Document Type
Conference Proceeding
Publication Date
5-3-2024
Abstract
We present a case involving a 36-year-old male with a complex medical history, including hypertension, hyperlipidemia, cerebrovascular accident (CVA), and Hypertrophic Obstructive Cardiomyopathy (HOCM). The patient presented with a week-long history of chest, lower extremity, and back pain, tingling, and a history of recurrent falls. The initial presentation, combined with his history of ICD placement in 2019, led to investigations for Acute Coronary Syndrome (ACS) and ICD malfunction. The patient's initial laboratory workup, which included a comprehensive drug screen, was unremarkable except for mild normocytic anemia and elevated protein levels. CT scans of the head and spine and X-rays of the limbs were normal. The cardiac workup confirmed HOCM on echocardiography. Elevated protein and gamma globulins were found as part of the emergency department workup. The broad differential diagnosis at this point included multiple myeloma, given the patient's history of muscle and bone pain, and chronic infections such as bacterial endocarditis, Lyme disease, HIV, and syphilis. However, his blood cultures remained consistently negative, and the gammopathy was found to be polyclonal. Ultimately, the patient was diagnosed as HIV-positive. Additional findings included evidence of prior Hepatitis B Virus (HBV) infection and a recent primary Epstein-Barr Virus (EBV) infection with no active symptoms of an infection. Complicating the case further, during the gammopathy workup, the patient was found to have an Erythrocyte Sedimentation Rate (ESR) of 111 mm/hr (with normal CRP), positive ANA with titers 1:640, positive anti-dsDNA, false-positive syphilis, and positive antiphospholipid syndrome antibodies. These findings suggested a potential diagnosis of Systemic Lupus Erythematosus (SLE). However, after further questioning and examination by our hospital's rheumatologists, the patient did not meet the criteria for SLE diagnosis as he lacked any clinical signs of the disease, such as arthritis, nephritis, or serositis. Close follow-up was recommended to monitor for development of disease. The patient's management was complicated by his inability to provide accurate identification or contact information for relatives, thus hindering comprehensive healthcare provision. Unfortunately, our infectious disease specialists did not initiate antiretroviral treatment due to fears of poor outpatient follow-up. In this complex case, the patient's reluctance to disclose information resulted in significant challenges in managing and initiating antiretroviral therapy for HIV-1. His unique combination of conditions required a holistic, multidisciplinary approach, reinforcing the importance of a wide-ranging differential diagnosis in patients with diverse symptoms. This case underscores the need for innovative approaches in managing patients with complicated, overlapping diagnoses, especially when these are further complicated by issues related to poor follow-up or compliance.
Recommended Citation
Karageorgiou I, Schimmel N, Marchese P, Khatoon T. Navigating clinical uncertainty: a convergence of HIV, positive ANA, and genetic cardiomyopathy. Presented at: American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter 2024 Resident and Medical Student Day; 2024 May 3; Troy, MI
Comments
American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter 2024 Resident and Medical Student Day, May 3, 2024, Troy, MI