Light at the end of the TUNEL: HIV-associated thrombotic microangiopathy

history of hypertension that might have been identified during his care for the noted infections. The patient’s chief complaints were nausea and vomiting. He had more long-standing symptoms of generalized weakness, malaise, and chronic headache. He disclosed a list of current and/or recent medications that included rifabutin, ethambutol, clarithromycin, nelfinavir, stavudine, lamivudine, trimethoprimsulfamethoxazole, loratadine, and amlodipine. Compliance had been a concern, and the patient recently had initiated a selfimposed drug holiday. At presentation, his physical examination was noteworthy for a blood pressure of 180/120 mm Hg; heart rate ranging from 84 to 112 beats/min; and temperature, 96.9 F. The remainder of the physical examination was noncontributory. Laboratory values obtained at presentation included a serum creatinine of 9.5 mg/dL; BUN, 86 mg/dL; uric acid, 7.6 mg/dL; CASE PRESENTATION sodium, 135 mEq/L; potassium, 4.7 mEq/L; chloride, 106 mEq/L; A 45-year-old man with long-standing HIV infection pretotal CO2, 18 mEq/L; total protein, 6.1 g/dL; albumin, 2.3 g/dL; sented to the emergency room at his local medical center. total bilirubin, 0.6 mg/dL; glucose, 104 mg/dL; and calcium, 8.2 Complications of his HIV infection in the past had consisted mg/dL. Urinalysis revealed 1 blood and 3 protein; microof numerous opportunistic infections including toxoplasmosis, scopic examination of the urine sediment showed 6 to 8 white pneumocystis pneumonia, cytomegalovirus retinitis, chronic blood cells and 4 to 8 red blood cells/high-power field and no vertebral osteomyelitis resulting from infection with an atypical casts. More quantitative assessment of the degree of proteinmycobacterial organism (M. avium intracellulare), and rectal uria was not performed. Urine cultures grew no organisms. A herpes. He had received multiple combinations of anti-retrocomplete blood count revealed a hematocrit of 26.3%; hemoviral therapy for his primary infection as well as therapies globin, 8.8 g/dL; and white blood cell count, 3600/mm, with directed more specifically to the various infections he had en75% neutrophils, 14% lymphocytes, 7% monocytes, 3% eosincountered. Other specific details of his HIV infection history ophils, and 1% band forms. The platelet count was 76,000/ such as blood counts, lymphocyte subsets, and measurements mm. A peripheral blood smear revealed red cell macrocytosis of viremia were unavailable. Other than complications of his and schistocytes. HIV infection, the patient’s medical history included a renal Therapy aimed at achieving acute control of the patient’s stone that underwent successful basket retrieval five years preblood pressure was instituted, but the serum creatinine and viously and extraction of a cataract approximately seven BUN did not improve over the subsequent two days. Because months prior to the current presentation. He had had renal of issues related to the recently recognized renal insufficiency insufficiency (serum creatinine of approximately 2.0 mg/dL) and the desire to exclude treatable causes of renal failure and approximately one year prior to the current presentation, but plan for institution of dialysis, a renal biopsy was performed he declined further workup at that time. The patient reportedly and referred to the University of Washington for evaluation. had normal blood pressure at that time and reportedly had no