Case report:
Patient is a 34-year-old Caucasian male with a 5-year history of Human
immunodeficiency virus (HIV) infection, controlled on anti-retroviral
medications, who was admitted to the hospital for fever, nausea, and
muscle weakness.
The patient was in his usual state of health until 8 days prior to this
admission, when one morning patient began experiencing fever and nausea
upon waking up that morning. Patient fell getting out of bed as his legs
gave away from profound weakness in both legs which lasted for 15-20
minutes and improved but did not resolve until 3 hours later. He fell
once more that morning and developed pins and needle sensation in both
legs since then. Five days later when he went to work, he had 2 more
episodes of leg weakness with falls similar to the previous falls except
for bilateral arm weakness. Patient has a 5-year history of HIV and was
taking Efavirenz, Emtricitabine & Tenofovir (Atripla) but had never
been treated with a diuretic. Viral load had been undetectable on
Atripla and he was never diagnosed with an Acquired immunodeficiency
syndrome (AIDS) defining illness. On examination, heart rate was 64
beats/minute, BP 153/74 mmHg, respiratory rate 16 breaths per minute,
oxygen saturation 96% on room air. Pupillary reflexes were normal with
normal extra ocular movements. Upper extremity strength was 3/5
proximally and 5/5 distally. He had weakness in both hip flexors 2/5,
left worse than right, bilateral knee flexion and extension 3/5 but near
normal strength 4/5 in both ankles. Bilateral knee reflexes were
diminished. Rest of the physical examination was unremarkable. Patient
had CKD with baseline creatinine 1.6 mg/dL and normal potassium levels
prior. Initial labs on admission to the 1st hospital showed elevated WBC
count of 16,000 per microliter, hypokalemia of 1.6 mEq/L, and elevated
creatinine of 3.2 mg/dL. He had Lumbar puncture and received single dose
Vancomycin and Ceftriazone. He was given IV fluids with 20mEq potassium
and transferred to the 2nd hospital for further work-up and management.
Electrocardiogram showed normal sinus rhythm. Bedside chest X ray,
computerized tomography (CT) head without contrast, CT abdomen and
pelvis and magnetic resonance imaging (MRI) of thoracic and lumbar spine
were unremarkable. Pertinent labs are summarized in Table 1.