Acute encephalopathy and multi-organ involvement with rhabdomyolysis during primary HIV infection

Human Immunodeficiency Virus (HIV) Masquerading as Myopathy and Rhabdomyolysis

Human immunodeficiency virus (HIV) characteristically presents as a mononucleosis-like prodrome; rhabdomyolysis as a sole manifestation remains a rare finding from infection to seroconversion. A young male with a vague sexual history presented with myopathy progressing rapidly to rhabdomyolysis and renal failure. Acute HIV rarely presents with classic features, and rhabdomyolysis seems to manifest more in younger patients. Our case also demonstrates the importance of keeping a strong suspicion for HIV in the right setting despite false-negative results in the pre-seroconversion phase. The variability in HIV presentation and stigma of sexual history taking represents a diagnostic challenge. The astute clinician must be privy to these peculiarities to formulate a prompt diagnosis.

Severe Rhabdomyolysis as an Unusual Presentation of Primary Human Immunodeficiency Virus Infection

Rhabdomyolysis is characterized by muscle necrosis and leakage of toxic intracellular contents into the circulatory system. It is most commonly caused by trauma, physical exertion, drugs, toxins, and a variety of infections; only rarely is it associated with acute human immunodeficiency virus (HIV) infection alone. The severity of illness ranges from asymptomatic elevations in serum muscle enzymes to life-threatening electrolyte imbalances and acute kidney injury. High HIV viral load is associated with higher muscle breakdown that increases the incidence of severe acute kidney injury and sometimes the need for renal replacement therapy. The introduction of highly active antiretroviral therapy (HAART) revolutionized the treatment of HIV infection and increased the life expectancy of such patients by suppressing viral replication. Myopathy is one of the neuromuscular manifestations of HIV. It can occur either as a result of a complication of HIV itself or as a result of medicines used to control HIV. Muscle involvement of HIV infection ranges from asymptomatic muscle enzyme elevation to severe, HIV-associated polymyositis or pyomyositis. Here we report a case of acute retroviral syndrome presenting as severe non-traumatic rhabdomyolysis.

Blinded by Zika? A missed HIV diagnosis that resulted in optic neuropathy and blindness: a case report

Background

Typical symptoms of an acute human immunodeficiency virus (HIV) infections like fever and rash are not specific and can be caused by a multitude of other pathogens, such as Zika or rickettsiosis. Up to 30% of primary HIV infection do not present with the typical flu-like symptoms and thus represent a diagnostic challenge. In this report, we describe a rare case of optic neuropathy as the initial presentation of primary HIV infection, which resulted in irreversible blindness. To our knowledge, only four cases of optic neuropathy resulting from a recent HIV seroconversion have been reported.

Case presentation

In January 2015, a 72-year-old man presented with a rash, fever and diffuse myalgias after returning from a fortnight in Cuba. In the context of the current polemic, Zika was considered likely. A diagnostic work-up, including dengue fever and Zika, was negative. Symptoms resolved spontaneously. In March, the patient experienced a sudden loss of vision first on one, a few days later on the other eye. Magnetic resonance imaging showed optic nerve enhancement suggesting neuritis. Numerous infective causes were sought and the patient was diagnosed with HIV. Corticosteroids and antiretroviral therapy were initiated but vision did not improve. Four weeks later an optic atrophy developed. After more than a year of follow-up the patient remains blind. Stored serum from January revealed a detectable viremia with a negative Western blot assay, typical of acute HIV infection.

Conclusions

Optic neuritis is a rare complication of early HIV infection. Only four others cases have been described, some of which recovered their vision after the administration of corticosteroids and/or ARV treatment. The balance between ischemic and neuroimmune processes may play a role in recovery. Delayed diagnosis, due to an unjustified focus on the Zika virus may have contributed to the tragic outcome.

Neurological involvement in patients with acute/recent HIV-1 infection. A case-control study

Primary HIV-1 infection is a relevant period for its virological and epidemiological consequences. Most patients present a symptomatic disease that can be potentially serious, but neurological involvement during primary HIV-1 infection has been poorly studied. The aim of this study was to describe the characteristics and outcomes of primary HIV-1 infection patients presenting neurological symptoms and to compare them with primary HIV-1 infection patients without neurological involvement. Retrospective case-control study (1:3) comparing primary HIV-1 infection patients with and without neurological involvement enrolled in the Acute/Recent Hospital Clinic PHI Cohort between 1997 and 2016. Matching criteria included age (±10 years), gender, year of diagnosis (±4 years), and Fiebig stage. The conditional logit model was used for comparisons. Fourteen out of 463 patients (3.02%) enrolled in the Acute/Recent Hospital Clinic PHI Cohort between 1997 and 2016 presented neurological symptoms. 28.5% of cases presented as meningitis and 71.5% as meningoencephalitis. Cerebrospinal fluid showed non-specific findings, including pleocytosis with lymphocyte predominance and increased protein levels. All cases required hospitalisation, whereas only 19% of the controls did. No other pathogen was identified in any case, but five patients initiated empirically antimicrobial treatment for other aetiologies until diagnosis was confirmed. CD4/CD8 ratio was significantly lower (p = 0.039) and plasmatic viral load significantly higher in the case group, compared to controls (p = 0.028). Risk factors, HIV-1 tropism, subtype distribution, and prescribed ART regimens were comparable between cases and controls. After 6 months on ART, 92% of cases had undetectable viral load, similar to controls, and CD4/CD8 ratio became also comparable between groups. All cases recovered rapidly with ART and were discharged without sequels. Neurological involvement during primary HIV-1 infection is unusual but serious, always requiring hospitalisation. Diagnosis is difficult because of the wide range of symptoms and similarities with other viral aetiologies. Neurological manifestations during primary HIV-1 infection are associated with a lower CD4/CD8 ratio and with a higher viral load than controls. Immediate ART initiation and rapid viral load decrease are required, allowing complete clinical recovery.

Acute HIV-1 infection presenting with fulminant encephalopathy

Human immunodeficiency virus (HIV)-1 directly affects the nervous system, causes distinct neurological symptoms, and indirectly results in opportunistic infections, which include herpes virus simplex (HSV)-1, HSV-2, varicella zoster virus, and cytomegalovirus encephalitis caused by immunodeficiency. Early HIV-1 invasion of the central nervous system is also possible, and acute encephalopathy is a potentially lethal complication. We encountered a case of fulminant encephalopathy as a primary presentation of acute HIV-1 infection, in which highly active antiretroviral treatment resulted in a full clinical recovery. This case highlights the importance of considering acute HIV-1 infection in the differential diagnosis of reversible encephalopathy.

Neurologic signs and symptoms frequently manifest in acute HIV infection

OBJECTIVE

To determine the incidence, timing, and severity of neurologic findings in acute HIV infection (pre-antibody seroconversion), as well as persistence with combination antiretroviral therapy (cART).

METHODS

Participants identified with acute HIV were enrolled, underwent structured neurologic evaluations, immediately initiated cART, and were followed with neurologic evaluations at 4 and 12 weeks. Concurrent brain MRIs and both viral and inflammatory markers in plasma and CSF were obtained.

RESULTS

Median estimated HIV infection duration was 19 days (range 3-56) at study entry for the 139 participants evaluated. Seventy-three participants (53%) experienced one or more neurologic findings in the 12 weeks after diagnosis, with one developing a fulminant neurologic manifestation (Guillain-Barré syndrome). A total of 245 neurologic findings were noted, reflecting cognitive symptoms (33%), motor findings (34%), and neuropathy (11%). Nearly half of the neurologic findings (n = 121, 49%) occurred at diagnosis, prior to cART initiation, and most of these (n = 110, 90%) remitted concurrent with 1 month on treatment. Only 9% of neurologic findings (n = 22) persisted at 24 weeks on cART. Nearly all neurologic findings (n = 236, 96%) were categorized as mild in severity. No structural neuroimaging abnormalities were observed. Participants with neurologic findings had a higher mean plasma log10 HIV RNA at diagnosis compared to those without neurologic findings (5.9 vs 5.4; p = 0.006).

CONCLUSIONS

Acute HIV infection is commonly associated with mild neurologic findings that largely remit while on treatment, and may be mediated by direct viral factors. Severe neurologic manifestations are infrequent in treated acute HIV.

Primary HIV infection presenting as limbic encephalitis and rhabdomyolysis

Recognising the initial clinical presentation of acute HIV infection could enable earlier initiation of antiretroviral therapy and appropriate counselling to reduce the risk of transmission to others. Herein, we describe an unusual case of acute HIV infection presenting as limbic encephalitis and rhabdomyolysis.

Acute rhabdomyolysis associated with coadministration of levofloxacin and simvastatin in a patient with normal renal function

We report a rare case of severe acute rhabdomyolysis in association with coadministration of levofloxacin and simvastatin in a patient with normal renal function. A 70-year-old Caucasian male was treated due to community acquired pneumonia with levofloxacin in a dosage of 500 mg once and then twice a day. On the 8th day of hospitalization the patient presented with acute severe rhabdomyolysis requiring an intensive care support. After discontinuation of levofloxacin and concomitant medication with simvastatin 80 mg/day, clinical and laboratory effects were totally reversible. Up to now, levofloxacin has been reported to induce rhabdomyolysis mainly in patients with impaired renal function, as the medication has a predominant renal elimination. In our case renal function remained normal during the severe clinical course. According to a recent case report rhabdomyolysis was observed due to interaction of simvastatin and ciprofloxacin. To our best knowledge this is the first case of interaction between simvastatin and levofloxacin to be reported. This case emphasizes the need of close monitoring of creatine kinase in patients under more than one potentially myotoxic medication especially when patients develop muscle weakness.

Extreme elevation of ferritin and creatine kinase in primary infection with HIV-1

The diagnosis of primary HIV-1 infection can be challenging, especially in the absence of reported risks or when presenting features are unusual and uncommon. We report an atypical case of primary HIV-1 infection with HIV-1 subtype C in a 61-year old Caucasian man who presented with extreme hyperferritinaemia without iron overload and marked elevation of serum creatine kinase without rhabdomyolysis. In view of his symptomatic seroconversion and low baseline CD4+ T-lymphocyte count, the patient was treated promptly with combination antiretroviral therapy. Subsequently, he made good clinical improvement on treatment and no opportunistic infections were diagnosed at presentation or as part of a later immune reconstitution syndrome. This novel case highlights the importance of clinical suspicion of HIV and suggests that primary HIV-1 infection should be considered in patients presenting with severe hyperferritinaemia or markedly elevated creatine kinase levels. Further studies are required to explain the causative biological mechanisms underlying this rare presentation.

Symptomatic illness and low CD4 cell count at HIV seroconversion as markers of severe primary HIV infection

BACKGROUND

The risk/benefit of initiating ART in primary HIV infection (PHI) is unclear. The benefits are more likely to outweigh the risks in patients with severe PHI. An accepted definition of severe PHI is, however, lacking.

METHODS

CASCADE patients with HIV test interval <6 months were classified as severe and non-severe PHI based on whether the following traits were recorded in the first 6 months following seroconversion: severe specific pre-defined symptoms, central nervous system-implicated illness, and ≥1, ≥2 CD4<350 (and <500) cells/mm(3). For each definition, we used Kaplan-Meier curves and Cox survival models to compare time to AIDS/death, censoring at the earlier of last clinic visit or 1/1/1997, when combination antiretroviral therapy (cART) became available.

RESULTS

Among 1108 included patients mostly males (85%) infected through sex between men (71%), 366 were diagnosed with AIDS/died. The risk of AIDS/death was significantly higher for individuals with severe symptoms, those with ≥1 CD4<350 cells/mm(3) or ≥2 CD4 <500 cells/mm(3) in the first 6 months [aHR (95% confidence interval) 2.1 (1.4,3.2), 2.0 (1.5,2.7), and 2.3, (1.5-3.5) respectively]. Median [interquantile range] survival for patients with ≥2, ≥1 and no CD4<350 cells/mm(3) within 6 months of seroconversion was 3.9 [2.7,6.5], 5.4 [4.5,8.4] and 8.1 [4.3,10.3] years, respectively. The diagnosis of CNS-implicated symptoms was rare and did not appear to be prognostic.

CONCLUSION

One CD4 count <350 or two <500 cells/mm(3) within 6 months of seroconversion and/or severe illness in PHI may be useful early indicators of individuals at high risk of disease progression.

HIV and neurocognitive dysfunction

The spectrum of HIV-associated neurocognitive disorder (HAND) has been dramatically altered in the setting of widely available effective antiretroviral therapy (ART). Once culminating in dementia in many individuals infected with HIV, HAND now typically manifests as more subtle, though still morbid, forms of cognitive impairment in persons surviving long-term with treated HIV infection. Despite the substantial improvement in severity of this disorder, the fact that neurologic injury persists despite ART remains a challenge to the community of patients, providers and investigators aiming to optimize quality of life for those living with HIV. Cognitive dysfunction in treated HIV may reflect early irreversible CNS injury accrued before ART is typically initiated, ongoing low-level CNS infection and progressive injury in the setting of ART, or comborbidities including effects of treatment which may confound the beneficial reduction in viral replication and immune activation effected by ART.

Encephalitis in primary HIV infection: challenges in diagnosis and treatment

We report a case of primary HIV encephalitis, which initially presented as acute psychosis. Magnetic resonance imaging of the brain was suggestive of vasculitis and multiple infarctions, whereas a brain biopsy after six weeks of symptoms showed HIV encephalitis with microglial nodules, but no signs of vasculitis. We review previous reported cases and radiological findings in HIV encephalitis and discuss the role of antiretroviral therapy and steroids in its management.

Acute human immunodeficiency virus infection

The clinical spectrum of acute human immunodeficiency virus (HIV) infection, a common clinical syndrome, may range from asymptomatic to a severe illness. The purpose of this review is to increase awareness of this syndrome, which is rarely suspected and often missed in clinical care settings, and provide an informative reference for primary care providers. The diagnosis of acute HIV infection is important for both patient care and public health concerns. In this article, the epidemiology, pathophysiology, clinical presentation, diagnosis and treatment of acute HIV infection are reviewed.

[A case of primary human immunodeficiency virus infection with severe rhabdomyolysis without acute renal failure]

Subjects with primary human immunodeficiency virus (HIV) infection often have acute retroviral syndrome. Some develop rhabdomyolysis, which can lead to acute renal failure. A 21-year-old man admitted for consciousness disturbance was initially considered to have aseptic meningitis associated with primary HIV infection. On hospitalization day 3, he developed severe rhabdomyolysis with elevated serum creatine kinase (CK) of 218,100 IU/L with serum creatinine normal at 0.9 mg/dL. Following massive extracellular fluid infusion and urinary alkalinization, serum CK decreased smoothly, without renal failure. Severe rhabdomyolysis was concomitant with systemic inflammatory response syndrome (SIRS) only on admission day. Acute renal failure in those with rhabdomyolysis may be influenced by renal possibly due to SIRS and tubular damage from reactive oxygen species, rather than by tubular obstruction by myoglobin casts, although this depends on the extent of myolysis. Acute renal failure is prevented in those with primary HIV infection developing rhabdomyolysis, based on renal blood flow control, if condition causing SIRS do not become a complication.

HIV-associated dementia in the era of highly active antiretroviral therapy (HAART)

Neurological complications associated with HIV-1 are being recognized as a common disorder in AIDS patients, especially patients with HIV-associated dementia (HAD). However, our knowledge of the complicated pathogenesis and clinical symptoms of HAD is limited by an incomplete understanding of the biology of HIV-1 in the nervous system. Therefore, this review focuses on the pathogenesis of HAD in the context of novel highly active antiretroviral therapy (HARRT) regimens.

Impaired hemoglobin scavenging during an acute HIV-1 retroviral syndrome

BACKGROUND

We report a case of temporary impaired hemoglobin scavenging in a patient with an acute HIV-1 retroviral syndrome. The patient was presented at the emergency department in a severe inflammatory state, mimicking bacterial sepsis and/or hemophagocytic syndrome. The serum showed a hemolytic aspect. In contrast, serum haptoglobin concentration was not decreased.

METHODS

The hemolysis index was determined and the visual absorbance spectroscopy spectrum of the serum was studied. alpha1 microglobulin and hemopexin concentrations were determined in serum. The presence of circulating hemoglobin:haptoglobin complexes in serum and the saturation of the haptoglobin were investigated using starch gel electrophoresis followed by peroxidase staining. CD163 expression on peripheral blood monocytes was analyzed using flow cytometry.

RESULTS

A temporarily impaired hemoglobin scavenging was documented by an increased hemolysis index, absence of decreased haptoglobin levels, presence of circulating hemoglobin:haptoglobin complexes in serum and decreased hemopexin and alpha1 microglobulin concentrations.

CONCLUSIONS

A temporarily impaired hemoglobin scavenging was observed due to a transient CD163 pathway impairment following an acute HIV-1 retroviral syndrome. The patient improved clinically and biochemically after initiation of HIV-1 anti-retroviral therapy. The data suggest a transient HIV-1 mediated CD163 impairment, although a latent drug mediated block could not be ruled out completely.