(581) When Things Are Not What They Appear to Be, It May Be New HIV

Introduction: We present a case of a patient with routine appendicitis, who had a critically ill postoperative course secondary to newly diagnosed acute retroviral syndrome (ARS).

Description: A 32-year-old man presented with 4 days of fever, nausea, vomiting, diarrhea, anorexia, and abdominal pain. Initial labs were without leukocytosis but showed mild acute kidney injury and mildly elevated liver enzymes. Imaging was consistent with acute appendicitis, and he underwent an uncomplicated laparoscopic appendectomy. Postoperatively, he suffered a cardiac arrest secondary to hemorrhagic shock from staple line bleeding, requiring emergent surgery. He continued to clinically deteriorate with 3-pressor shock, respiratory failure, stress cardiomyopathy with a reduced ejection fraction of 30%, severe rhabdomyolysis (creatine kinase >40,000), acute renal failure requiring dialysis, acute liver failure, and disseminated intravascular coagulation. His shock recovered within 3 days, but he had a disproportionate hyperinflammatory state with persistent rhabdomyolysis from possible myositis, retiform purpura with hemorrhagic bullae and pancreatitis. An expanded workup was initiated with a wide differential for sepsis, autoimmune process, or hemophagocytic lymphohistiocytosis with an H score of 187 points. Ultimately, it was discovered that he had a new diagnosis of acute HIV with a positive HIV antigen, negative HIV antibody, 19 million copies/mL of HIV-1 RNA, CD4 count 259 cells/μL and CD4% of 17%. Antiretroviral therapy (ART) was started, and he had clinical improvement with complete cardiologic and renal recovery.

Discussion: ARS is typically characterized by flu-like symptoms. However, a prior case report demonstrated appendicitis as an atypical initial presentation of ARS. In the early stages of infection, the HIV virus replicates rapidly in gut-associated lymphoid tissue, including the appendix. Although rare, it is not implausible that appendicitis may be the first sign of a primary HIV infection. Overall, HIV patients have a higher prevalence of appendicitis when compared to the general population. Those who are ART-naïve or with CD4 count < 200 cells/μL have a higher perioperative mortality, often due to sepsis. Our patient’s ARS likely contributed to his unexpected critical illness after appendectomy.