Abstract
A 23-year-old man was admitted to our hospital with severe thrombocytopaenia. He had unprotected sexual contact 6 weeks earlier. He was diagnosed with acute HIV infection by means of HIV RNA viral load testing and HIV-associated thrombocytopaenia. Although his thrombocytopaenia improved immediately with short-term dexamethasone therapy, this effect was not sustained after cessation of therapy. Antiretroviral therapy including raltegravir was initiated, and the patient recovered from severe thrombocytopaenia within several days. The findings from this case suggest that acute HIV infection should be suspected with unexplained thrombocytopaenia, and that antiretroviral therapy is the treatment of choice for severe HIV-associated thrombocytopaenia, even when in the early period following acquisition of the virus.
Introduction
The prognosis of patients with human immunodeficiency virus (HIV) infection has been dramatically improved by antiretroviral therapy (ART). However, because the number of newly infected patients is increasing, HIV is commonly encountered in clinical practice.
To prevent further transmission and disease progression, early diagnosis of HIV infection is crucial. However, early diagnosis is difficult, especially in the acute phase of infection, because of non-specific symptoms and signs. 1 We report a patient who presented with thrombocytopaenia associated with acute HIV infection, who received ART and whose thrombocytopaenia recovered immediately.
Case report
A 23-year-old Japanese man with an unremarkable medical history developed malaise, diarrhoea, and persistent fever. Two weeks later, he developed pruritus and a purpuric skin rash, at which time he visited a local hospital. A complete blood count was performed and the platelet count was 2.9 × 104/µL. Therefore, he presented to our hospital for further evaluation. A diagnostic work-up for thrombocytopaenia was performed, and an HIV screening test (chemiluminescent enzyme immunoassays) was found to be positive. The platelet count subsequently dropped to a level of 1.5 × 104/µL, at which time he was admitted to the hospital. He claimed that he had unprotected homosexual contact 3 weeks before the onset of initial symptoms.
Laboratory findings on admission.
APTT: activated partial thromboplastin time; AST: aspartate aminotransferase; ALT: alanine aminotransferase; LDH: lactate dehydrogenase; ALP: alkaline phosphatase, γ-GTP: gamma-glutamyl transpeptidase.
HIV-RNA was 6.9 × 104 copy/mL, but a Western blot assay for HIV-1 antibody was negative. These results suggested recent acquisition of the virus. Additionally, a BED EIA HIV-1 Incidence Test (Calypte Biomedical Corporation, OR, USA)
2
was performed, and the assay revealed recent HIV-1 seroconversion (optical density: 0.181). Based on these results, the patient was diagnosed with acute HIV-1 infection and associated thrombocytopaenia. The CD4-positive T cell count was low (163 cells/µL), but no opportunistic infection was diagnosed using serological and radiological investigations. With exacerbated thrombocytopaenia, major bleeding was a concern, and oral dexamethasone 40 mg/day was initiated on the 5th hospital day. This dose was used for 4 days, and the platelet count recovered immediately, but the effect was not sustained after cessation of the agent. Therefore, ART was started to control acute HIV infection and to treat the associated thrombocytopaenia. Genotypic testing for HIV-1 drug resistance showed no drug-resistant mutations. ART with raltegravir in combination with emtricitabine-tenofovir disoproxil was initiated with informed consent on the 15th hospital day. The patient recovered from severe thrombocytopaenia within several days after the initiation of ART (Figure 1). No side effects of ART were observed, and the patient was discharged from the hospital on the 22nd hospital day. One month after the initiation of ART, HIV viral load was undetectable (<20 copies/mL), and the platelet count was within the normal range.
Patient’s clinical course. Plt: platelet count; WB: Western blot analysis; DEX: dexamethasone; RAL: raltegravir; TDF/FTC: emtricitabine-tenofovir disoproxil combination.
Discussion
Establishing the diagnosis of acute HIV infection is crucial for the individual and for public health implications. Recognition and diagnosis of acute HIV infection are challenging because of the non-specific symptoms and the window period. 1 Therefore, a diagnosis of HIV can frequently be missed unless HIV is suspected. The findings in our case suggest that acute HIV infection should be included as a differential diagnosis of unexplained thrombocytopaenia.
Severe thrombocytopaenia, defined as a platelet count ≤5 × 104/µL, is estimated to occur in approximately 5% of HIV-infected patients. 3 In our patient, there were no other causes of thrombocytopaenia, such as infections due to other pathogens, drug adverse reactions, and haematological diseases, and he was diagnosed with primary HIV-associated thrombocytopaenia. Autoimmune mechanisms are likely to contribute to the aetiology of HIV-associated thrombocytopaenia, 4 and systemic corticosteroids are possibly a useful treatment. 5 However, short-term dexamethasone therapy is preferable because long-term prescription of corticosteroids may cause further immune disorders. In the present case, although the effect of dexamethasone was prompt, it was not sustained after cessation of therapy, and specific treatment directed against the underlying viral infection was required. 6
Initiation of ART during the early stage of HIV infection is controversial because few clinical data are available. Recently, guidelines suggest offering ART for acute HIV infection,7,8 while taking into account the potential benefits and the risks. Therefore, in our patient, the decision was made to initiate ART. The choice of antiretroviral regimen was guided by the results of drug resistance testing and a previous report that described a case of HIV-associated thrombocytopaenia that resolved with the addition of raltegravir. 9 Thrombocytopaenia was improved immediately in the patient, and this effect was persistent.
In conclusion, findings from our case suggest that acute HIV infection should be considered in the case of unexplained severe thrombocytopaenia and that ART is beneficial in this context.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.