A 36 year-old male came in to the ED with 2 day history of painful itchy rash on the left side of the neck and face. The patient denied any fever or chills. The patient also denied any past medical, surgical or family history as well as any alcohol, drugs or tobacco use. The patient was diagnosed in the ED as having shingles vs contact dermatitis and was discharged home on oral Benadryl.
1 month later, the same patient was brought in by his family to the ED again with severe dyspnea and fever. On admission, he was tachycardic (125), feverish (38.4), tachypnic (32), and hypoxic (87 on room air). On physical exam, the patient had decreased breath sounds on both lung bases and vesicular rash on left side of neck. Initial labs showed pancytopenia (RBCs 3.96L, WBC 2.7L, Platelets 74L), severe acidosis (pH of 6.9) and elevated lactic acid (1.61). Urine was positive for methamphetamines. CXR showed dense right lower lobe pneumonia. Patient was intubated for respiratory failure and admitted to the ICU.
Unfortunately the patient rapidly deteriorated into septic shock (with resistant hypotension on 2 pressors, IV antibiotics and IV fluids), bacteremia, multiple electrolyte abnormalities and acute renal failure and was started on hemodialysis. HIV serology was ordered and came back positive for HIV-1 with undetected CD-4 T cell count (3.1%). Patient rapidly deteriorated and expired 4 days later due to severe hypotension and asystole that didn’t respond to resuscitative measures
Infection with the human immunodeficiency virus (HIV) has literally exploded over the past three decades to become the worst epidemic of the twentieth century. The AIDS epidemic now ranks alongside the influenza pandemic of the early 1900s in terms of fatalities. The major modes of acquiring HIV infection are sexual, parenteral and perinatal transmission.
HIV targets dendritic cells, macrophages, and CD4+ T cells, all are cellular immunity key players. Therefore, HIV can present with many other coinfections as cryptococcal meningitis chronic viral hepatitis and shingles, as in our patient’s case.
A 36 year-old male presented with shingles rash 1 month before being newly diagnosed with HIV infection. The patient’s course was rapidly complicated by respiratory failure, septic shock and renal failure and died after 4 days of admission to the ICU.
This case shows that AIDS -the full blown dreaded endpoint of HIV infection- can present with other coinfections like shingles. In young patients presenting with any rash suspicious of shingles, HIV should be considered and further testing is mandatory. It’s much easier to control HIV infection than to treat AIDS, and so early detection and management with ARTs is key in improving the QOL of these patients and controlling the HIV pandemic.