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.