# Lost and Found: Misdiagnosis of AIDS-Related Bone Marrow Suppression As Neutropenic Fever and Benign Ethnic Neutropenia in a Patient With Congenital HIV

## TL;DR

A patient with untreated congenital HIV showed severe neutropenia and fever, which were misdiagnosed until AIDS-related bone marrow suppression was identified.

## Contribution

This case highlights a new phenotype of HIV patients with delayed AIDS complications due to ART discontinuation and low healthcare literacy.

## Key findings

- Untreated HIV can lead to severe neutropenia and pancytopenia due to bone marrow suppression.
- Misdiagnosis is common when neutropenia is attributed to benign ethnic neutropenia or co-infections like tuberculosis.
- Non-adherence to ART and poor healthcare literacy contribute to delayed diagnosis of AIDS-related complications.

## Abstract

Neutropenia is a relatively uncommon but notable secondary effect of HIV infection. While the various hematopoietic effects of HIV and AIDS are well-described in the literature, high-quality evidence directly linking neutropenia with mortality in HIV-infected patients remains limited. The multifactorial etiology of neutropenia complicates its diagnosis, particularly when it occurs secondary to HIV. We present the case of a 35-year-old African American male with congenital HIV, who presented with severe neutropenia accompanied by a fever in the context of untreated HIV. The initial differential diagnosis was broad, including benign ethnic neutropenia (given the patient’s African American ethnicity), tuberculosis (given the potential for anti-tuberculosis therapy to cause neutropenia and its commonality as a co-infection in HIV patients), sepsis-related neutropenia, and AIDS-related bone marrow suppression. However, through further workup, it became apparent that HIV-related bone marrow suppression ultimately led to pancytopenia. This case highlights how HIV patient non-adherence to antiretroviral therapy (ART) and hematologic abnormalities complicate the diagnosis of hematopoietic abnormalities from HIV. It also discusses how vertical transmission and abrupt ART discontinuation create a new phenotype of HIV patients with delayed presentations of AIDS-related complications. This patient’s presentation also provides insight into the consequences of untreated HIV following the self-discontinuation of long-term HIV management therapy due to low healthcare literacy and loss of follow-up. The patient's clinical course, laboratory findings, imaging studies, and treatment outcomes are discussed, emphasizing the need for timely diagnosis and a multidisciplinary approach to care while exploring potential barriers to care in different social contexts.