A 52‐year‐old male patient without any medical history presented to the hospital with dizziness of 2 weeks' duration. He was afebrile, with blood pressure 140/80, respiratory rate 14, and pulse rate 35. Cardiac examination was normal. The patient had 2 + reflexes with 5/5 strength in all extremities, and cranial nerves were grossly intact. Complete blood count and comprehensive metabolic panel were all within normal limits. EKG showed sinus bradycardia without conduction delays. Cardiac echocardiogram showed ejection fraction of 60%, normal wall motion, and no valvular abnormalities. The patient was evaluated by electrophysiology and subsequently underwent pacemaker placement. Afterwards, he continued to have dizziness, and had seizure activity for the first time. An MRI of the brain showed no intracranial pathology. Lumbar puncture was performed with opening pressure of 40 cm H2O. CSF results were: glucose 33, protein 199, and 133 nucleated cells. CSF cultures grew Cryptococcus neoformans. Further testing revealed that the patient was HIV positive.
Many efforts are being made to reduce the annual number of new HIV infections and transmission rate. Often, patients with HIV infection visit health‐care settings for years before being tested or diagnosed with HIV. The goal of screening is to identify patients with undiagnosed HIV so that timely treatment is provided and transmission is prevented. In our practice, we frequently see patients who are newly diagnosed with HIV, yet who have seen many physicians prior to their diagnoses without undergoing testing. HIV can be diagnosed with the use of effective, inexpensive tests, and well‐established evidence proves that screening for HIV infection is cost effective. CDC recommends routine screening for HIV in all patients aged 13‐64 years unless prevalence of undiagnosed HIV infection in their patients has been documented to be <0.1%. Despite screening recommendations, clinicians may not screen patients for whom they have low suspicion. For example, if the patient described above had been tested for HIV prior to his hospital presentation, Cryptococcus meningitis could have been prevented. In addition, knowing that the patient was HIV positive would have broadened our differential of bradycardia to include increased intracranial pressure. Increased intracranial pressure can cause bradycardia and hypertension and is referred to as the Cushing response. In this case, the patient underwent unnecessary placement of pacemaker.
A key benefit of HIV screening is that HIV+ individuals can begin lifesaving therapy leading to improved health outcomes, including slower clinical progression and reduced mortality. The aim of this case is to increase clinicians' awareness about the importance of HIV screening, which has potential individual as well as public health implications. This case also demonstrates the importance of including intracranial pressure in the differential for bradycardia.