Hepatitis C- and Human Immunodeficiency Virus-Induced Hypersensitivity Vasculitis

Abstract

A 49-year-old Caucasian man with a history of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) was evaluated for fevers, rash, and arthritis. The patient’s medical history was notable for HIV (diagnosed in 1994; last CD4 count of 500 and viral load >10,000). He was not on anti-retroviral therapy for the last year due to liver function abnormalities but had no history of opportunistic infections, he was infected with HCV (viral load greater than 3.5 million, untreated), and also carried diagnoses of hypertension, insulin-dependent diabetes mellitus, paroxysmal atrial fibrillation (not on anticoagulation), depression, and a recent negative purified protein derivative test. He had no known drug allergies. His home medications included detemir, atenolol, humulin, and lisinopril. He had a 90-pack year smoking history, as well as previous alcohol and heroin abuse (which he quit in 1999). He was living with his girlfriend, and on disability. Five months prior to this evaluation the patient was hospitalized for gross hematuria, fevers to 39°C, and nonbloody diarrhea. During the hospitalization, he developed asymmetric arthritis and a petechial rash. On physical examination, his blood pressure was 170/80 mmHg, he had synovitis of both wrists, proximal interphalangeal (PIP) joints bilaterally, and the left ankle. The rash was flat, nonblanching, purpuric, and worst over his extremities, flank, and shawl area, sparing his palms and soles. His work-up was negative for cryoglobulins; rheumatoid factor (RF); antimyeloperoxidase; and antiproteinase 3 antibodies, antiRo (SSA) and anti-La (SSB) antibodies, anti-nuclear antibody (ANA), and anti-double-stranded DNA antibody (dsDNA; Table 1). Complement levels were normal. Hepatitis B serologies were negative. Computerized axial tomography scan (CT scan) of the abdomen and pelvis (without contrast) showed hepatosplenomegaly. Renal ultrasound was negative for hydronephrosis. He was treated with intravenous (IV) Solumedrol 60 mg every 8 h and IV fluids, with resolution of his fever, rash, and arthritis as well as return of his creatinine to his baseline level. A renal biopsy was scheduled but the patient eloped from the hospital before the renal biopsy could be performed. The patient was seen in nephrology clinic 1 month after discharge; repeat cryoglobulins were positive with 2% precipitate and he had 4 g of proteinuria on a spot urine protein to creatinine ratio. HSSJ (2010) 6: 102–107 DOI 10.1007/s11420-009-9141-8