AB1052 SYSTEMIC LUPUS ERYTHEMATOSUS IN CONTEXT OF HUMAN IMMUNODEFICIENCY VIRUS INFECTION: A CLINICAL CONUNDRUM
Authors: Ankita Singh, Anjani Gummadi, Laxmi Makam, Deepti Suri, Anju Gupta, Pandiarajan Vignesh, Ankur Jindal, Amit Rawat, Surjit Singh
Journal: Annals of the Rheumatic Diseases (2019)

<h3>Background</h3> Systemic lupus erythematosus (SLE) and Human immunodeficiency virus (HIV) infection can occasionally coexist in a patient (1). Also, in rare scenarios, the clinical symptomatology and laboratory tests of these diseases can masquerade each other (2). <h3>Objectives</h3> To describe diagnostic and therapeutic dilemmas of coexistent SLE and HIV <h3>Methods</h3> We analyzed case records of 2 patients with childhood SLE who had the clinical conundrum of HIV infection as well <h3>Results</h3> <b>Case 1-</b> An 11-year-boy presented with large joint arthralgia, fever and respiratory distress for 4 days. On examination he had pallor, oral thrush,and onycomycosis. A malar rash was also noted. Systemic examination revealed consolidation in right lung and hepatosplenomegaly. Investigations showed severe anemia and lymphopenia. HIV serology was strongly reactive and CD4 counts were low (49 cells/µl). In view of malar rash he was investigated for SLE and anti-nuclear antibody (ANA) by indirect immunoflorescence (IIF) was 4+ homogenous with rim enhancement. Anti double stranded DNA (dsDNA) antibody titer was 1200 IU/ml, serum complements were low (C3- &lt;28 mg/dl; C4-10 mg/dl) and direct Coombs test for IgG was positive. Antiphospholipid antibody titers were elevated (Anticardiolipin antibody- Ig G: 695 U/L; anti b2 glycoprotein antibody Ig G: 3177 U/L). Blood culture grew Streptococcus pneumoniae. He was started on ceftriaxone and amphotericin, however, he had an acute neurological worsening (raised intracranial pressure) during hospital stay. A diagnosis of concomitant HIV infection and neuropsychiatric SLE was considered in this child. Pulse methylprednisolone was given, but he soon succumbed to the complications. <b>Case 2:</b> An 8-year-old girl was admitted with fever for 6 months and cough and respiratory distress for 15 days. On examination she had anascarca, oral ulcers, hyperpigmented macules over face and crepitations in right lung fields. Her HIV ELISA was intermediate reactive. Considering a clinical possibility of secondary immunodeficiency due to HIV infection she was managed with broad spectrum antimicrobials while awaiting confirmatory tests for HIV infection. She went on to develop hypertension and nephritis. ANA was 4+ homogenous, low complements and elevated anti dsDNA. Further tests for confirmation of HIV infection showed CD4 counts - 421 cells/µl, negative HIV viral loads, negative HIV DNA PCR and p24 antigen was negative, so it was considered that the intermediate reactivity of HIV serology was false positive. Subsequently she was given immunosuppression (methylprednisolone pulse and cyclophosphamide) to which she transiently responded however she developed acute intracranial bleed during hospital stay and died. <h3>Conclusion</h3> These cases highlight the fact that serological tests can be difficult to interpret in patients with overlapping manifestations of HIV infection and SLE. However, early diagnosis and prompt therapy is imperative. <h3>References</h3> [1] Burton J, Vera JH, Kapembwa M. HIV and systemic lupus erythematosus: the clinical and diagnostic dilemmas of having dual diagnosis. Int J STD AIDS. 2010 Dec;21(12):845–6. [2] Carugati M, Franzetti M, Torre A, Giorgi R, Genderini A, Strambio de Castilla F, et al. Systemic lupus erythematosus and HIV infection: a whimsical relationship. Reports of two cases and review of the literature. Clin Rheumatol. 2013 Sep;32(9):1399–405. <h3>Disclosure of Interests</h3> None declared