Multiple organ failure during primary HIV infection reported

French doctors have reported a case of multiple organ failure in a young woman during primary HIV infection. The woman’s condition rapidly improved after the initiation of antiretroviral therapy. The report is published in the February 1^st edition of Clinical Infectious Diseases (now online).

The case involved a 16 year-old woman who presented with a four-day history of chills, fever, muscle pains and diarrhoea. Her temperature was over 40 degrees C and her blood pressure was 80/40mm Hg. There was nothing exceptional about the patient’s medical history – the only medication she was taking was an oral contraceptive. Nor was there anything to alert the treating physicians to the possibility of primary HIV infection, as the patient initially reported only one sexual partner of six months duration.

Tests on admission to hospital revealed that the patient was experiencing liver and kidney failure in addition to impaired cardiac function.

Three days after hospitalisation, the woman was tested for HIV and the results proved positive. She had a viral load of over 5,300,000 copies/ml. When told of the result, the patient said that she had had unprotected sex with an occasional sexual partner who had been diagnosed with HIV one month earlier.

Given the parlous state of the patient’s health, the treating physicians took the decision to initiate antiretroviral therapy with Kaletra, ddI and d4T. The patient’s condition improved dramatically and after a week of antiretroviral treatment she was discharged from hospital after a normal physical examination with normal liver, kidney and cardiac function.

After 45 days of HIV therapy, the woman’s viral load had fallen to below 50 copies/ml and her CD4 cell count had increased to 780 cells/mm³. Tests at this time for hepatitis A, B and C, syphilis and CMV were all negative. Three and a half years later, the patient was still taking antiretroviral therapy (efavirenz, ddI and 3TC), with sustained viral suppression and a CD4 cell count of over 1,000 cells/mm³.

“To our knowledge, this is the first report of acute liver failure during primary HIV infection”, write the investigators, who note that the multiple, serious conditions the patient presented with were “rather unusual.”

Diagnosing primary HIV infection can be difficult given the non-specific nature of the symptoms, assert the investigators, who note that a recent study showed that even though 85% of individuals experiencing an HIV seroconversion illness sought medical attention at the time, only 25% received a correct diagnosis.

The investigators add, “when patients present with unusual manifestations and do not report any significant risk factor, as in our patient, the diagnosis is frequently missed and may result in serious consequences.”

The authors also comment on the use of antiretroviral therapy during primary infection. Although they acknowledge that the routine initiation of HIV treatment at this time would be “controversial”, they write that their decision to start treatment in this patient was appropriate as “most physicians would treat patients presenting with life-threatening manifestations.”

They also point to research suggesting a public health benefit from treating primary HIV infection. At this time, viral load is at its peak and individuals newly infected with HIV are at their most infectious. Providing HIV treatment at this time “could provide a unique opportunity to abort rapid epidemiological spread in sexual networks.”

The authors conclude, “multiple organ failure may be added to the list of severe manifestations of acute HIV infection. Early initiation of combined antiretroviral treatment to control high viraemia seems to be the rational therapeutic intervention; in this case, the measure was followed by a dramatic improvement in the patient’s condition.”