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Fig. 5 | AIDS Research and Therapy

Fig. 5

From: Cytomegalovirus and disseminated histoplasmosis-related hemophagocytic lymphohistiocytosis syndrome in an HIV-patient late presenter with IRIS: a case report

Fig. 5

After ART initiation, the patient began with fever, chills, lower lip ulceration, and diarrhea 12 days prior to hospitalization (gray arrow). On day 0, the patient was diagnosed with sepsis, pancytopenia, AKI (KDIGO III), and IRIS; blood tests, Chest X-ray, and CT scan studies were performed. On day 1, empirical treatment for severe PCP and disseminated histoplasmosis was initiated; also, the patient started with hemorrhage, and blood transfusions (platelets, plasmapheresis, and red blood cells) were administered, which continued intermittently until day 43 (red arrow). On day 2, hemophagocytosis and H. capsulatum were reported in a BMA. On day 9, support was requested to InIVIH, and samples were collected for NK cells cytotoxic assays. On day 13, low NK cells cytotoxic activity was confirmed (purple arrow), and a 3-day immunoglobulin treatment was provided. On day 40, severe epistaxis and hematochezia required massive transfusions (10 units in less than 24 h; indicated by a blood droplet); empirical ganciclovir was provided while test results were reported. On day 43, CMV infection was confirmed. After 62 days and 83 blood transfusions, the patient was discharged with undetectable HIV viral load, 10 CD4+ T cells count, and normal blood tests (blue arrow). During all this time, ART treatment was not suspended nor modified (green arrow). The yellow arrow indicates the process of HLS diagnosis. Created with BioRender. AKI: Acute Kidney Injury; AMB: Amphotericin B; ART: Antiretroviral Therapy; BMA: Bone Marrow Aspiration; CMV: Citomegalovirus; CT: Computed Tomography; DXM: Dexametasone; HLS: Hemophagocytic Lymphohistiocytosisi Syndrome; IRIS: Inmmune Reconsitution Inflammatory Syndrome; I.V: Intravenous; IVIg: intravenous gamma Immunoglobulin; Methyl-PDN: Methylprednisolone; PCP: Pneumocystis jiroveci Pneumonia; PDN: prednisone; P.O: oral administration; TMP-SMX: trimethoprim/sulfamethoxazole

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