Unconventional therapies are frequently used by human immunodeficiency virus (HIV)-infected patients [1]. We describe a case in which an unconventional therapy contributed to a patient's death.

A 51-year-old man with the acquired immunodeficiency syndrome (AIDS), cytomegalovirus retinitis, and disseminated Mycobacterium avium complex infection, having read about the purported value of hydrogen peroxide therapy in human immunodeficiency virus (HIV) infection, injected 35% hydrogen peroxide into his subclavian vein catheter. He subsequently developed nausea, dark urine, hypotension, and tachycardia, and was hospitalized. He had a hemoglobin concentration of 33 g/L (previously, 81 g/L), a creatinine level of 310 mmol/L (normal, <110 mmol/L), and a lactate dehydrogenase level of 41.92 µkatal/L (normal, <3.33 µkatal/L). His urine was dark brown and tested strongly positive for blood and free hemoglobin. The peripheral smear showed poikilocytosis, eccentrocytosis, and many Heinz bodies (Figure 1). Treatment was initiated with intravenous fluids, urine alkalinization, and erythrocyte transfusions. Progressive renal insufficiency with multiple electrolyte abnormalities developed, and the patient died on the fifth hospital day.

View larger version (112K): [in this window] [in a new window]   Figure 1. Patient's peripheral blood smear showing morphology of Heinz-body hemolytic anemia. Panel A. Eccentrocyte. Panel B. "bite cell." Panel C. Remnant of erythrocyte membrane with denatured hemoglobin. Panel D. Unusually large Heinz-body inclusions. (Panels A, B, and C: May Greunwald-Giemsa stain; magnification, x 50; Panel D: Heinz-body stain; magnification, x 40.).

Many HIV-infected patients use some form of unconventional therapy (39% in one survey [1]), often without the knowledge of their physician. Acupuncture, massage, meditation, megavitamins, and many other therapies have been promoted as beneficial for HIV infection [2]. Hydrogen peroxide has also been touted for HIV infection and has been described as a "substance with ‘magical’ powers," found "at Lourdes, France" [3]. However, serious adverse effects from hydrogen peroxide "therapy" have been reported [4]. In our patient, Heinz body hemolytic anemia occurred when the oxidant stress of hydrogen peroxide infusion exceeded the protective capacity of the erythrocyte hexose monophosphate shunt system [5]. Hemoglobinuria with renal impairment and death subsequently developed. It behooves physicians caring for HIV-infected patients to routinely inquire about the use of unconventional therapies and to be aware of their potential toxicities.