HIVAN

Today, Dr. Plavsky reviewed an interesting case of a middle aged gentleman with HIV not on HAART therapy who presented with AMS, found to have severe hypertension, anemia, thrombocytopenia, AKI, proteinuria and MRI brain evidence of diffuse white matter lesions. Ultimately after ruling out PML and other infectious etiologies, it was felt that the patient had HIV-associated nephropathy leading to hypertension and PRES, although no kidney biopsy was able to be obtained.

HIVAN.png

Learning Points:

  1. We reviewed a very broad ddx for altered mental status, which was even more broad in our patient as he was immunosuppressed and susceptible to opportunitistic infections (toxoplasmosis, HSV/VZV/CMV) and AIDS-associated tumors. This DDx included infection, metabolic derangements (electrolytes, endocrine disturbances, hypo/erglycemia, etc.), drugs/toxins, brain disorders (CNS infxn, seizures, trauma, psychiatric disorders), among others.
  2. Dr. Plavsky reviewed HIV-associated nephropathy including presentation (hematuria, proteinuria, hypertension, rapid declinen in eGFR, and edema), biopsy results (collapsing form of FSGS), and treatment options (reducing HIV replication through HAART and slowing progression of kidney disease with ACEI/ARBs). She reviewed a retrospective cohort study by Szczech that showed time to dialysis was shorter with HIVAN compared to lesions other than HIVAN, highlighting the importance of obtaining a kidney biopsy.
  3. TTP was brought up as well given the patient's thrombocytopenia, anemia, acute kidney injury, subjective fever, and AMS/neurologic abnormalities. Interestingly, a retrospective analysis published in JAMA by Burrus showed that 48% of patients having TTP who had acute abnormalities on brain MRI had PRES. Was this actually the unifying diagnosis? Intriguing indeed! What do you think? Comment below!