This case highlights an AIDS-defining illness as the initial presentation of HIV. Objectives include recognizing clinical features that prompt HIV testing and navigating legal considerations for reporting when patients lack capacity.

A 70 year-old male with systemic sarcoidosis, hypertension, atrial fibrillation, complete heart block with a biventricular-pacemaker, and recent admission for altered mental status (AMS) presented from a nursing facility for recurrent AMS and fever. He was unresponsive and intubated on arrival. Last known normal was 48 hours prior, with baseline orientation x2. Workup from his admission approximately one week prior included CT head which showed vasogenic edema in the left frontal and right parieto-occipital regions, lumbar puncture (LP) with negative CSF cytology and meningitis panel, and inguinal lymph node biopsy with benign histology. MRI could not be obtained due to his pacemaker. He was discharged after mentation improved with treatment of a urinary tract infection (UTI).

On re-admission, CT head showed stable vasogenic edema. LP was initially deferred due to stable CT findings and recent neurologic workup, but then pursued after focal seizure-like activity developed on hospital day 3. HIV screen was positive for HIV-1 (negative 6 years prior) and CD4 count was 78. CSF testing showed Toxoplasma gondii. Treatment for HIV and cerebral toxoplasmosis were initiated. Mandated HIV reporting was complicated by inability to obtain sexual history or consent for disclosure. Following Illinois law, disclosure was made to his power-of-attorney. Contact tracing and reporting were managed by the State Health Department.

Late presentation of HIV with AIDS-defining illness is diagnostically challenging, especially when risk factors cannot be assessed and imaging is limited. A lower threshold for HIV testing in AMS may expedite treatment and improve outcomes. Physician awareness of local HIV reporting laws is imperative, as circumstances may require nuanced legal and ethical considerations.