Case 1: a 38-year old female patient, diagnosed with HIV infection in 2008, presented with complaints of intermittent high grade fever associated with chills and rigor for one month to a local hospital. This was associated with loss of appetite and generalized weakness. She was transfused two units of packed RBC. She was receiving an antiretroviral regimen consisting of tenofovir, lamivudine and efavirenz. Her CD4 count was 85/mul and the viral load was 56, 670 copies/mul. With a diagnosis of virological failure, she was shifted to an atazanavir/ritonavir based regimen. She was referred to us with persistent fever. On examination, she was febrile with a pulse rate of 120/min and a respiratory rate of 25/min. She had icterus and her jugular venous pressure was elevated. Chest examination revealed decreased bilateral breath sounds and bi-basal crepitations. On abdominal examination hepatosplenomegaly was present. The baseline laboratory evaluation revealed pancytopenia and hyperbilirubinemia (Hemoglobin- 5.9 gm/dl, total leucocyte count- 1500/cu.mm, platelet count- 18,000/cu.mm and bilirubin- 3.3gm/dl). Peripheral smear showed dimorphic hypochromic anemia with a corrected reticulocyte count of 1%. Vitamin B12 and folic acid levels were normal. Lactate dehydrogenase (LDH) levels were elevated (1154 U/l). Blood culture was sterile for bacteria, fungi and non-tubercular mycobacteria. Contrast enhanced computed tomography (CECT) scan of chest and abdomen revealed hepatosplenomegaly (liver-16.8 cm, spleen-13.4cm) and multiple enlarged non-necrotic lymph nodes in mesentery, para-aortic and inguinal region. A whole body Fluorodeoxy glucose positron emission tomography (FDGPET) scan revealed hypermetabolic bilateral supraclavicular, internal mammary lymph nodes and abdominal lymph nodes. There was avid uptake in liver, spleen and bone marrow also. The biopsy from supraclavicular lymph node showed reactive hyperplasia. Staining for acid fast bacilli, GeneXpert and Mycobacterial growth indicator tube (MGIT) culture for Mycobacterium tuberculosis were negative. A bone marrow biopsy was done which showed 60-70% cellularity. It was negative for geneXpert and Cytomegalovirus (CMV) polymerase chain reaction (PCR) assay. Also, pp65 antigen detection test in blood for CMV and rk39-antibody test for visceral leishmaniasis was negative. With a presumptive diagnosis of tuberculosis, modified anti-tubercular therapy (ATT) (levofloxacin, ethambutol and amikacin) was started as the patient had elevated bilirubin level. There was no response even after one month of ATT. Introduction of rifampicin and isoniazid was attempted but the bilirubin levels rose to 9.5g/dl. Clarithromycin was empirically added to cover for Mycobacterium avium complex (MAC) infection. On further investigations, she was found to have a triglyceride levels of 435 mg/dl, fibrinogen levels of 500 mg/dl, ferritin levels of >2000 ng/ml and decreased NK cell activity. With a diagnosis of Haemophagocytic lymphohistiocytosis (HLH), dexamethasone at a dose of 16 mg per day was started. The fever and pancytopenia improved in a week's time (Hemoglobin- 7.4gm/dl, total leucocyte count- 5300/cu.mm, platelet count- 50,000/cu.mm). The patient was doing well but she started getting dyspneic fifteen days after the initiation of steroids. Chest X-ray revealed consolidation in the right middle lobe. With a diagnosis of hospital acquired pneumonia, she was started on cefoperazone sulbactam, but she succumbed to her illness after two days.