Case Report

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American Journal of Emergency Medicine

journal homepage: www. elsevier. com/ locate/ajem

American Journal of Emergency Medicine 34 (2016) 760.e3-760.e5

Rhabdomyolysis as presenting feature of acute HIV-1 seroconversion in a pediatric patient

Abstract

Acute rhabdomyolysis is a rare phenomenon in the emergency set- ting almost exclusively associated with trauma, drugs, and recent upper respiratory and gastrointestinal infection. Rare reports in the lit- erature have highlighted adult patients presenting with rhabdomyoly- sis as 1 component in a constellation of symptoms in acute HIV-1 seroconversion; however, there are few reports of rhabdomyolysis as the sole presenting symptom. This case highlights the importance of in- vestigating HIV and other sexually transmittED diseases in Pediatric cases of rhabdomyolysis in the emergency care setting.

Acute rhabdomyolysis is a rare phenomenon in the emergency set- ting almost exclusively associated with trauma, drugs, and recent upper respiratory and gastrointestinal infection [1]. Rare reports in the literature have highlighted adult patients presenting with rhabdomyol- ysis as 1 component in a constellation of symptoms in acute HIV-1 sero- conversion; however, there are few reports of rhabdomyolysis as the sole presenting symptom [2]. This case highlights the importance of in- vestigating HIV and other sexually transmitted diseases in pediatric cases of rhabdomyolysis in the emergency care setting.

Acute human immunodeficiency represents the period from infec- tion to seroconversion and is important because it represents a rapidly growing viral reservoir irreparably harming the host immune system; during this time, patients are thought to be most contagious and are typically unaware of their infection [3]. An estimated 70% of individuals with acute HIV-1 seroconversion may experience a pronounced flu-like prodrome including high fever, headache, malaise, myalgia, and phar- yngitis with coexistent lymphadenopathy [4]. However, many patients may experience atypical manifestations of acute HIV. Early identifica- tion of HIV is critical in prevention of disease transmission, and early treatment may critically influence a favorable disease course [5].

We present a case of a 15-year-old Adolescent boy who has sex with males with medical history significant for seizure disorder and depression who presented to the emergency department with 2-day acute onset of worsening debilitating myalgia. He reported declining urine output dur- ing the previous several days and concurrent darkening of his tea- colored urine. He had recently run away from home and was homeless for the prior 10 days. He vomited one time and but denied fever, nausea, diarrhea, and recent weight loss at the time of presentation.

Further history revealed that the patient had no sick contacts, denied travel, received childhood vaccines on schedule, and had not sustained any trauma. Previous medications included levetiracetam, sertraline, and hydroxyzine, but patient discontinued these on his own 2 weeks prior. He revealed that he had used alcohol and marijuana intermittent- ly in the past, but not in the past 6 months. He denied lifetime

intravenous drug use. His last reported sexual contact was greater than 1 year before presentation, and he reported inconsistent past con- dom use. He also indicated that he received a negative HIV test within the past 3 months from a community health clinic.

On admission, the patient was in moderate-to-severe pain but fully alert and oriented. On physical examination, temperature was 39.3?C; blood pressure, 108/61; pulse, 75 beats per minute; respiratory rate, 23 breaths per minute; and oxygen saturation, 100% on room air. Lower limbs showed no edema. Exquisite tenderness to palpation was elicited over the muscles of the thighs, lower legs, gluteals, and chest most prominently. Cervical chain and inguinal lymphadenopathy was appreciated bilaterally. Cardiovascular examination revealed normal S1 and S2. Chest was clear to auscultation. Head, eyes, ears, and throat examination was unremarkable. No organomegaly or cutaneous find- ings were appreciated.

Initial laboratory analyses revealed Creatine Kinase of 604820 (ref- erence, 39-195); D-dimer of 2.55 (reference, 0.00-0.45); elevated trans- aminases and lactate dehydrogenase levels; elevated hemoglobin, hematocrit, and glucose; hyponatremia, hypochlorhydria, and hypocal- cemia; and elevated blood urea nitrogen and creatinine. Urinalysis showed cloudy, amber urine with 42 white blood cells (reference, 0- 4), protein of 100 (reference, 0), and large red blood cells (reference, negative). urine drug screen was negative. Subsequent forensic screen- ing for elusive illicit drugs including Synthetic cannabinoids, ?- hydroxybutyric acid, and sedative hypnotics were negative.

Initial HIV 1/2 was nonreactive, whereas subsequent laboratory in- vestigations revealed reactive HIV-1 on fourth-generation screening. Western blot was confirmatory. HIV-1 RNA viral load was 660000. Ab- solute CD4 + was 199. This leads us to conclude that the patient was experiencing acute HIV seroconversion. Serologies for hepatitis A, B, and C; influenza A and B; Epstein-Barr virus; mycoplasma antibody and immunoglobulin A; coxsackie B antibodies (types 1-6); streptococ- cal A antigen; rapid plasma regain; gonorrhea; and chlamydia were all negative. Cytomegalovirus immunoglobulin G was positive, but viral load was not present. Quantiferon gold for tuberculosis was negative. Based on these findings, we concluded that the patient was experienc- ing Severe rhabdomyolysis due to acute HIV-1.

Despite being treated with aggressive hydration, his CPK continued to climb peaking at 894480 (Fig. 1). In addition, his renal function con- tinued to decline with his blood urea nitrogen peaking at 50 and his cre- atinine peaking at 11.2 (Fig. 2). The patient was started on dialysis receiving treatments daily on hospital days 2 to 6. It was reduced to 3 times weekly as his creatine kinase and renal function normalized (dial- ysis initiation depicted graphically.)

Acute renal failure is a relatively common manifestation of advanced HIV disease [6] but is uncommon in acute HIV. Rhabdomyolysis as the

0735-6757/(C) 2015

760.e4 J. Gagnon et al. / American Journal of Emergency Medicine 34 (2016) 760.e3-760.e5

Fig. 1. Creatine Kinase.

presenting feature of acute HIV leading to nephropathy has been ob- served only rarely in adults [7-9]. Furthermore, the literature shows al- most no observed cases in adolescents [10]. This case illustrates the importance of investigating HIV in pediatric cases presenting with acute rhabdomyolysis without obvious inciting factors. Early detection of HIV in this population will serve to streamline effective treatment both acutely and chronically and can serve to protect transmission to noninfected individuals [11].

Jason Gagnon, MD, MA, MPH Ohio State University Wexner Medical Center, Columbus, OH 43210 Corresponding author. Tel.: +1 617 901 0350

E-mail address: [email protected]

Harold Katner, MD

Mercer University School of Medicine, Macon, GA

S. Brent Core, MD, PharmD, MBA

Mayo Clinic, Rochester, MN

Jean Dozier, MD Chintan Patel, MD Chanty Davis, MD

Mercer University School of Medicine, Macon, GA

http://dx.doi.org/10.1016/j.ajem.2015.08.031

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   Fig. 2. Creatine Kinase.

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