Unexpected Cause of Fever in a Patient with Hiv/aids

1New York University School of Medicine, New York, NY

Meeting: Hospital Medicine 2014, March 24-27, Las Vegas, Nev.

Abstract number: 331

Case Presentation:

A 45 year old HIV+ Honduran man without previous diagnosis of AIDS presented with fever, shaking chills, malaise, nausea and diarrhea for 1 week. He reported 100% compliance with his anti‐retrovirals. Social history was significant for high risk sexual behaviors with other HIV+ individuals, methamphetamine use, and former alcohol abuse. He denied weight loss. Physical exam was significant for fever to 39.2 C, diaphoresis, and bilateral upper abdominal tenderness. No thrush, lymphadenopathy, or organomegaly was noted.

CBC showed a mild normocytic anemia (hemoglobin 13.4, MCV 92). Electrolytes were unremarkable. Liver function tests were significant for an alkaline phosphatase of 227. Albumin was 3.5. INR was 1.7. CD4 count was 122 (31%). HIV viral load was undetectable. Blood and urine cultures, as well as tests for multiple infectious organisms, were negative.

Ultrasound performed on arrival showed heterogeneous liver parenchyma with vague hypoechoic foci. MRI of the abdomen confirmed mild hepatomegaly with numerous nodules in both hepatic lobes, the largest measuring 8.5 x 5.1cm. Associated periportal and retroperitoneal lymphadenopathy had increased in size since last imaging from 3 years prior. The spleen was normal, measuring 12cm.

Ultrasound‐guided biopsy of a liver lesion revealed classic Hodgkin lymphoma with mixed cellularity and Epstein‐Barr virus‐positive cells. Bone marrow biopsy confirmed marrow involvement. Chest CT performed for staging showed no disease. Broad‐spectrum antibiotics started on admission were held after 48 hours without subsequent change in the patient’s clinical status. Hematology/oncology was consulted and initiated treatment with doxorubicin, bleomycin, vinblastine, and dacarbazine (ABVD).

Discussion:

Compared to those without the virus, HIV+ individuals have a 17‐fold increased risk of developing Hodgkin’s disease (HD). Though HD is classified as a non‐AIDS‐defining illness, lower CD4 counts appear to confer increased risk. This risk is not mitigated by antiretroviral therapy. Instead, as a consequence of immune reconstitution, initiation of therapy may actually precipitate disease.

HD tends to present more aggressively in HIV+ individuals. More than 70% of those affected will report “B” symptoms. A similar proportion present with extranodal disease. After the bone marrow, which is involved in up to 50% of cases, the liver is the most common extranodal site. Despite these typically poor prognostic factors, treatment response rates remain high. Surprisingly, HIV‐status does not affect survival.

Conclusions:

When an HIV+ patient presents with fever of unclear etiology and few localizing symptoms, non‐infectious causes—such as malignancy—must remain on the differential.

To cite this abstract:

Baghdadi J. Unexpected Cause of Fever in a Patient with Hiv/aids. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 331. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/unexpected-cause-of-fever-in-a-patient-with-hivaids/. Accessed March 31, 2020.

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