Taha Mohamed Djirdeh, MD1, Nicole Gentile, MD2, Altaf Dawood, MBBS, MD2, Mario Affinati, MD3; 1Mercy Health System, Rockford, IL; 2Mercyhealth, Rockford, IL; 3Merchyhealth Rockford, Rockford, IL
Introduction: HIV is commonly associated with multiple complications. However, we present a patient with newly diagnosed HIV, pancreatitis, and concern for acute liver failure secondary to a rare phenomenon.
Methods: A 36 year old male with no PMH presented with poor appetite, malaise, and fatigue. He was diagnosed with HIV with CD4 count of 12 and a viral load of 1.3 million copies, started on HAART therapy and discharged. He was readmitted a few weeks later with generalized weakness, nausea, and jaundice. Labs demonstrated renal failure with creatinine of 12.2 (baseline 1.5) and potassium 8.4 for which he had urgent hemodialysis. In addition, his alkaline phosphatase was 228, ALT 135, AST 213, and total bilirubin of 12.4. INR was 2.1. Lipase was 252, triglycerides 1388, CD4 count 9. On admission, hemoglobin was 9.7gm/dL, platelet count 177X(10)3/uL and dropped to 6.1 gm/dL and 94 X(10)3/uL in the next couple days. Fibrinogen was 214mg/dL, ferritin level was 11,170. Therefore, bone marrow aspirate analysis was performed and showed hemophagocytosis of two RBC, a second histiocyte showed hemophagocytosis of 3 RBC, one of which was indenting the nucleus with 3 pyknotic cell nuclei in the cytoplasm of the histiocyte. With high concern for Hemophagocytic Lymphohistiocytosis (HLH), patient was transferred to a higher level of care for consideration of etoposide based treatment. This is an atypical presentation of HLH based on lack of fever and splenomegaly. HLH is a rare disease that may be diagnosed via molecular diagnosis or by clinically meeting 5 of 8 criteria including fever, splenomegaly, cytopenias, hypertriglyceridemia and/or hypofibrinogenemis, hemophagocytosis in bone marrow or spleen or lymph nodes, no malignancy, ferritin ≥500 µg/L, and soluble CD25 (i.e., soluble IL‐2 receptor) ≥2,400 U/ml. HLH is a syndrome of severe hyperinflammation secondary to abnormally activated macrophages and cytotoxic T cells. There is a genetic form and an aquired form triggered by infection or malignancy. HLH pathogenesis is secondary to excessive cytokine activity in the vascular system. Discussion: Overall HLH is associated with a poor prognosis with over 10% of patients with this condition dying in the span of 2 months secondary to DIC, neutropenia or multi-organ failure. The main treatment is to treat the underlying cause. In conclusion, we present a rare presentation of newly diagnosed HIV resulting in ALF and HLH demonstrating the importance of prompt disease recognition due to poor outcomes.
Disclosures: Taha Mohamed Djirdeh indicated no relevant financial relationships. Nicole Gentile indicated no relevant financial relationships. Altaf Dawood indicated no relevant financial relationships. Mario Affinati indicated no relevant financial relationships.