A previously healthy 35–year–old male patient presented with 2 weeks history of fatigue and a maculopapular rash over his back, torso, extremities and face. He had flu–like symptoms and rinorrhea just before the rash. One week before the admission, patient developed a gradually worsening symmetric lower extremity swelling. He described his urine as being frothy and foamy. At presentation, he was normotensive, afebrile. Physical exam showed bilateral eyelids and facial swelling, as well as moderate upper extremities and severe lower extremities pitting edema. Skin showed a maculopapular rash with areas of confluence over the back, torso, upper and lower extremities affecting hands and feet but no palms neither soles. Blood testing showed normal leukocytes, lymphopenia and hemoglobin of 5.0 g/dL. Biochemical testing revealed an impressive and worrisome creatinine level of 7.0 mg/dL, BUN of 63 mg/dL and albumin of 1.0 g/dL. He also had hypercholesterolemia and hypertriglyceridemia compatible with a nephrotic syndrome. Ultrasound showed increased cortical echogenicity. CT scan showed enlarged kidneys. Serology for viral hepatitis and autoimmune work up were negative. With so much surprise to the patient and the primary team HIV was positive, with a CD4 < 5 cells/ml and HIV viral load of 114490 copies/ml. Patient was started urgently on antiretroviral therapy (ART). A kidney biopsy was done and it showed collapsing, focal and segmental glomerulosclerosis typical for HIV nephropathy. The anemia was thought to be too severe for this degree of renal disease. The reticulocyte count was low. Parvovirus B19 infection was suspected due his profound immunosuppression. IgM and confirmatory PCR testing were positive. Due to worsening of his kidney function (cretinine of 8.5 mg/dL) patient was started on dialysis. After 4 weeks, there was improvement of creatinine to 1.7 mg/dl and hemoglobin to 11.7 g/dl. Dialysis was stopped and patient was continued on ART, ACE inhibitor and prednisone. After 4 months, his CD4 count improved to 150 cells/ml, with an undetectable HIV viral load and with a stable kidney function (creatinine between 1.5 and 1.7 mg/dl).
HIV nephropathy (HIVAN) is one of the indications or urgent initiation of ART at the time of diagnosis. ART should not be withheld from patients simply because of the severity of their renal dysfunction. Addition of ACEI, ARBs, and/or prednisone should be considered in patients with HIVAN if ART alone does not result in improvement of renal function. Dialysis should not be withheld for patients with HIV infection. Renal transplantation may be considered at centers with adequate experience. Recent reports document resolution of human parvovirus B19–related pure red blood cell aplasia in HIV–infected patients with ART.
HIVAN and Parvovirus B–19 pure red blood cell aplasia are conditions in which the most important element for successful clinical resolution is the initiation of antiretroviral therapy.