"A Rare Manifestation of Human Immunodeficiency Virus Masquerading as R" by Amira Al-Nabolsi, Faizan Faizee et al.
 

A Rare Manifestation of Human Immunodeficiency Virus Masquerading as Refractory Cardiogenic Shock

Document Type

Conference Proceeding

Publication Date

5-2025

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Human Immunodeficiency Virus (HIV) infection commonly manifests with an acute seroconversion syndrome followed by asymptomatic progression until immunological deterioration leads to opportunistic infections. Direct end-organ involvement, particularly cardiac manifestations, represents an atypical initial presentation. HIV-associated cardiomyopathy has historically been documented in advanced disease with CD4 counts below 200 cells/µL. We describe an unusual case of cardiogenic shock as the presenting manifestation of newly diagnosed HIV infection in a patient with preserved CD4 counts but markedly elevated viral load. A 28-year-old man presented to the emergency department with progressive dyspnea. Two weeks prior, he was diagnosed with community-acquired pneumonia and completed a seven-day course of doxycycline without clinical improvement. Upon presentation, vital signs were significant for tachycardia (147 beats/minute). Laboratory evaluation revealed acute kidney injury (creatinine 1.69 mg/dL), transaminitis (AST 145 U/L, ALT 110 U/L), and elevated BNP (1,869 pg/mL). Initial chest radiography demonstrated worsening multifocal pneumonia. His clinical status rapidly deteriorated, developing acute encephalopathy with increased work of breathing, necessitating emergent endotracheal intubation. Post-intubation computed tomography of the chest revealed diffuse bilateral airspace disease. Point-of-care echocardiography demonstrated severe biventricular systolic dysfunction with left ventricular ejection fraction of 10-15%, global hypokinesis, severe left ventricular dilation (end-diastolic diameter 6.8 cm), and right ventricular dysfunction with TAPSE measuring 12mm. The patient developed cardiogenic shock requiring vasopressor support and subsequent Impella placement and continuous renal replacement therapy for oliguric renal failure. Comprehensive infectious disease workup revealed HIV-1 positivity with CD4 count of 238 cells/µL and viral load exceeding 3 million copies/mL. Given the clinical presentation, empiric treatment for pneumocystis pneumonia was initiated with trimethoprim-sulfamethoxazole. Despite stabilization with the Impella device, the patient demonstrated persistent severe left ventricular dysfunction necessitating transition to a durable left ventricular assist device (HeartMate 3™). He then achieved hemodynamic stability with recovery of renal function. The pathophysiology of HIV-associated cardiomyopathy traditionally correlates with advanced immunosuppression, yet this case demonstrates severe myocardial dysfunction in the setting of relatively preserved cellular immunity with extreme viral burden. This suggests that viral burden may play a direct role in myocardial injury, independent of immunological status. Successful management with mechanical circulatory support demonstrates the potential reversibility of HIV-associated cardiomyopathy with appropriate intervention and viral load suppression. This case emphasizes the importance of considering HIV in the differential diagnosis of unexplained cardiomyopathy in young patients and demonstrates that significant end-organ dysfunction can occur at CD4 counts considered relatively protective in the setting of high viral loads.

Volume

211

First Page

A3927

Comments

American Thoracic Society (ATS) International Conference, May 16-21, 2025, San Francisco, CA

Last Page

A3927

DOI

10.1164/ajrccm.2025.211.Abstracts.A3927

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