Neurosyphilis remains a severe manifestation of syphilis, particularly in individuals living with HIV, where atypical presentations and treatment challenges are more common. Although ceftriaxone is considered an alternative to penicillin G, emerging reports suggest possible therapeutic failure in immunocompromised hosts. We describe a 63-year-old man with well-controlled HIV infection who developed seizures and altered mental status. Cerebrospinal fluid analysis confirmed neurosyphilis, and he was treated with high-dose intravenous ceftriaxone (2 g twice daily) for ten days. Despite therapy, neurological symptoms persisted, and repeat investigations showed ongoing inflammation. Ceftriaxone was replaced with intravenous doxycycline (100 mg twice daily), resulting in rapid clinical improvement within 72 hours. Follow-up cerebrospinal fluid studies and imaging demonstrated complete resolution of inflammatory changes. The patient completed a 28-day doxycycline course with sustained recovery. This case underscores the potential for ceftriaxone failure in HIV-associated neurosyphilis and supports considering doxycycline as an effective alternative in refractory cases.

Toxoplasma gondii encephalitis is a common but serious opportunistic infection in people living with human immunodeficiency virus (PLHIV), particularly those with advanced disease and low CD4 counts. Its classical manifestations include fever, altered mental status, seizures and focal neurological signs. Movement disorders are a less common consequence, with hemichorea-hemiballismus (HCHB) representing a rare but striking manifestation. We describe a 36-year-old man with advanced HIV disease who had defaulted on treatment. He presented with bizarre, involuntary movements of his left upper and lower limbs. His serum Toxoplasma IgG was positive, and brain imaging revealed a basal ganglia lesion leading to the presumptive diagnosis of cerebral toxoplasmosis. He was treated with anti-toxoplasmosis and anti-dyskinetic medications, achieving both clinical and radiological resolution after one month of therapy. A high clinical suspicion for Toxoplasma gondii encephalitis should be maintained in patients with advanced HIV disease who present with rare manifestations such as movement disorders. Timely management, guided by serology and brain imaging, is essential to improve treatment outcomes.

Biktarvy, a once-daily combination of bictegravir, emtricitabine, and tenofovir alafenamide (TAF), is a highly effective antiretroviral therapy for HIV management. Although well-tolerated, rare but serious complications such as lactic acidosis can occur, particularly in patients on nucleoside reverse transcriptase inhibitors. We present the case of a 36-year-old male with HIV/AIDS and chronic kidney disease, who was admitted with altered mental status and acute hypoxic respiratory failure. Imaging confirmed atypical pneumonia. Initial labs revealed elevated lactate and creatinine. He was treated with broad-spectrum antibiotics, and after clinical improvement, Biktarvy was resumed. Within 24 h, his lactate spiked to 21.8 mmol/L. Suspecting TAF-induced lactic acidosis, Biktarvy was discontinued. Continuous renal replacement therapy, along with L-carnitine and thiamine, was initiated based on a literature review. The patient's condition improved significantly. Upon discharge, lactate and creatinine returned to baseline. At outpatient follow-up, he remained clinically stable on Dolutegravir-Rilpivirine and Entecavir.

BackgroundThis study aimed to identify people living with HIV (PLWH) with tuberculosis (TB) co-infection, explore their demographic and clinical characteristics, and determine predictors of early mortality within 6 months of TB diagnosis.MethodsA cross-sectional study was conducted in a tertiary referral center in Türkiye of PLWH diagnosed with TB between 2004 and 2023. Demographic, clinical, and laboratory data were reviewed, and statistical analyses were performed to identify early mortality predictors.ResultsAmong 1541 PLWH, 62 (4%) had TB, and 23 (37%) died within 6 months. TB presentations were pulmonary (44%), extrapulmonary (27%), and both (29%). Predictors significantly associated with early mortality included lymphopenia (p = 0.009), a CD4 + T lymphocyte count ≤50 cells/mm3 (p = 0.015), anemia (p = 0.009), and thrombocytopenia (p = 0.034), particularly platelet counts below 150,000/mm3 (p = 0.001). Clinical predictors also included symptoms such as fever (p = 0.017), anorexia (p = 0.012), weight loss (p = 0.012), and altered mental status (p = 0.043). Additionally, receiver operating characteristic (ROC) analysis demonstrated that CD4 + T lymphocyte count ≤50 cells/mm3 (AUC = 0.76, p = 0.039) and platelet count <150,000/mm3 (AUC = 0.71, p = 0.034) were significant predictive cutoffs for early mortality. TB culture positivity was high (84%), while PCR positivity was low (15%). Opportunistic infections were seen in 11% of cases.ConclusionsHigh early mortality among people living with HIV/TB co-infection is associated with advanced immunosuppression and hematological abnormalities. These results highlight the importance of early HIV detection and close clinical monitoring to reduce mortality.

Cryptococcal meningoencephalitis is a grave and lethal form of an opportunistic infection usually occurring in immunocompromised patients (i.e., those with AIDS, organ transplant recipients, or those on immunosuppressive therapy) caused by Cryptococcus species, namely Cryptococcus neoformans, which has a worldwide distribution, or Cryptococcus gattii, which is predominantly found in tropical, subtropical, and temperate regions. Cryptococcus species are usually found in soil contaminated with bird or animal droppings in the form of cryptococcal spores. The former occurs predominantly in immunocompromised patients, affecting the central nervous system (CNS), while the latter occurs in immunocompetent patients, affecting the pulmonary system predominantly. Transmission occurs through these spores, which subsequently disseminate to the CNS through the hematogenous route. Manifestations include fever, headache, nausea, altered mental status, and meningismus in certain cases, potentially advancing to neurological problems such as elevated intracranial pressure, blindness, and seizures. Presentation in immunocompetent individuals is indolent, so diagnosis and treatment are delayed. Timely diagnosis and immediate treatment are essential to avert complications and mortality. Over the past few years, cryptococcal infection has seen an upward trend globally. Despite the availability of antifungal therapy, it has emerged as a significant public health concern, rendering it a therapeutically challenging case. Moreover, infrequent coinfections with bacteria or viruses might complicate therapy and prognosis. We hereby report a rare case of cryptococcal meningoencephalitis with herpes zoster coinfection occurring in an HIV patient with a normal CD4 count.

Salmonella urinary tract infections (UTIs) are rare and typically affect immunocompromised or anatomically predisposed individuals. While usually foodborne, transmission can also occur from pets or person to person. Symptoms mimic common UTIs and may present with or without prior gastrointestinal illness. We report the case of a 56-year-old HIV-positive male with poor medication compliance who presented with altered mental status and burning micturition. Urine and blood cultures revealed non-typhoidal Salmonella, prompting targeted antibiotic therapy. Treatment involves at least 14 days of antibiotics, with repeat urine cultures to ensure eradication. Rising antibiotic resistance necessitates awareness of local sensitivity patterns.

Dural venous sinus thrombosis (DVST) is characterized by thrombosis in the cerebral veins, the dural venous sinus, or both. Headache is the most common initial symptom. Patients can present with seizures, papilledema, focal neurological deficits, and mental status alteration. We describe a case of a young HIV-positive patient with a seizure disorder who presented with unrelenting headaches and breakthrough seizures and was diagnosed with thrombosis in the superior sagittal sinus extending to the left transverse and sigmoid sinuses with venous thrombosis in the left vein of Trolard. This case is highly relevant, reminding clinicians to keep a high index of suspicion for DVST in any patient with headache and neurological manifestations.

Coccidioidal meningitis is a rare yet life-threatening complication of disseminated Coccidioides infection, primarily affecting immunocompromised individuals. Coccidioides immitis and Coccidioides posadasii are dimorphic fungi endemic to the southwestern United States, where exposure to inhaled spores can lead to a range of clinical manifestations, including pulmonary and central nervous system (CNS) involvement. This report describes the case of a 27-year-old correctional officer with advanced human immunodeficiency virus (HIV) infection who presented with chronic headaches, altered mental status, and significant weight loss following his relocation from Arizona to Louisiana. Cerebrospinal fluid (CSF) analysis revealed slow-growing mold consistent with Coccidioides species, leading to the diagnosis of coccidioidal meningitis. This case emphasizes the importance of considering fungal meningitis in patients with compatible geographic exposure and immunosuppression.

This is an in-person escape room and procedure simulation activity based on complications of human immunodeficiency virus (HIV) in India, which was created by using local HIV management guidelines. Emergency Medicine (EM) trainees of all post-graduate levels are the target audience. This may also be used by trainees in other specialties, such as infectious disease or internal medicine, who require an understanding of HIV and its complications. This escape room can be completed in teams of varying sizes and is designed to be adaptable to local resource availability.