History HIV clinical display in the acute stage is variable plus some Icilin of its virological and immunological factors aren’t completely understood. seen as a an impaired HIV- antibody creation and a 12?month timeframe to attain an undetectable viral insert despite no proof level of resistance. Conclusions This case survey apart from explaining an unusual scientific presentation of the acute HIV infections as hemophagocytic symptoms provides useful details that might lead for understanding some simple issues in severe HIV infection specifically the dynamics of virological and immunological factors after antiretroviral therapy initiation. Electronic supplementary materials The online edition of this content (doi:10.1186/s12879-016-1945-9) contains supplementary materials which is open to certified users. 2 particle agglutination assay cryptococcal antigen CMV CMV and antigen viral insert in bloodstream also harmful. Upper body X-Ray abdominal ultrasound upper body and abdominal CT scan didn’t reveal relevant abnormality. Antiretroviral therapy (Artwork) was began on 11th July with tenofovir/emtricitabine and atazanavir/ritonavir. The individual preserved fever but acquired no focal symptoms. Asymptomatic intensifying liver organ enzymes elevation was noted (aspartate aminotransferase/alanine aminotransferase (AST/ALT): 153/80UI/L; alkaline phosphatase (ALK) 321UI/L total bilirubin 3.89?mg/dL). The outcomes of genotypic level of resistance test became obtainable and exposed no significant mutations that could confer resistance either to protease or reverse transcriptase inhibitors. TAGLN At 7th day time ritonavir was/ritonavir was switched to raltegravir?(Fig. 1). Despite this liver cytolysis/cholestasis continued worsening (Fig.?2) and was accompanied by aggravated pancytopenia. Fig. 2 Liver enzymes development Lactate dehydrogenase (LDH) and Beta-2 microglobulin were elevated: 1872?mg/dL (Normal <225?mg/dL) and 4750?mg/dL (Normal?Icilin resistance test was repeated and again no relevant mutations were recognized. At 5?weeks of therapy fever and asthenia persisted with no other symptoms. At 6th week viral weight increased to 268.211cp/mL (Fig.?1). Esophageal candidiasis and cytomegalic reactivation without organ involvement were recorded and treated. A group decision was to optimize ART to tenofovir/emtricitabine?+?darunavir/ ritonavir?+?etravirine (TDF/FTC?+?DRV/r?+?ETV) (Fig.?1). The patient was on Daily Observed Therapy. A third genotypic resistance test was performed and again no relevant or fresh mutations were found using different interpretation algorithms: Stanford HIVdb and HIV REGA algorithms (version 8.0.2; available at http://www.rega.kuleuven.be/cev/). An additional file explains this Icilin in more detail [Observe Additional file 2]. INNO-LIA? HIV I/II test was repeated and an indeterminate result was acquired once again with the same reactivity rating for gp41..