A 57-year-old HIV-infected male patient with a CD4 count of 333  cells/microL and a suppressed HIV viral load presented with fever,  abdominal pain, nausea and vomiting. His antiretroviral therapy  was a combination tablet consisting of emtricitabine, tenofovir and  efavirenz. The patient was pyrexial with rigors and had scleral icterus.  A chest examination revealed scattered crepitations. He had no  palpable lymphadenopathy or hepatosplenomegaly
A presumptive diagnosis of pulmonary tuberculosis (TB) was made,  and he was started on standard TB treatment as well as amoxicillin/ clavulanic acid for an underlying CAP. A sputum TB polymerase chain  reaction test was negative. TB treatment was discontinued after 3 weeks  owing to a poor clinical response and persistent fever. Other causes for  the persistent fever were investigated and none were found. The patient  fullfilled four of the Histiocyte Society HLH Study Group diagnositc  criteria. Within 24 hours of treatment according to the HLH-94  protocol, the fever subsided and he was discharged after completing the  8-week induction course. The only identifiable trigger for HLH was the  underlying HIV infection. He remained well after 3 years of follow-up.