thromboembolic complications have been described in hiv infected patients with higher incidence seen in patients with active opportunistic infections ( oi ) or malignancy , and in patients with acquired immunodeficiency syndrome ( aids ) . various abnormalities predisposing to hypercoagulable state have been reported in aids patients including the presence of antiphospholipid antibodies , lupus anticoagulant , deficiencies of proteins c and s , heparin cofactor ii , and antithrombin and use of protease inhibitors . though more than one thrombotic episode has been reported in adults , it has rarely been reported in children . we report an hiv infected boy who had three thromboembolic episodes in a matter of 6 months and finally succumbed to the disease . a six - year- old hiv infected boy on 2 drug antiretroviral therapy ( art ) consisting of zidovudine ( azt ) and lamivudine ( 3tc ) for the past 3 years presented with tuberculous meningitis and pulmonary tuberculosis ( tb ) in december 2004 . on investigation , he was also found to have cardiomyopathy ( left ventricular dilation with hypertrophy ) on echocardiography , elevated liver transaminases , anemia , elevated , basal ganglia calcifications on ct of brain and normal kidney sizes on ultrasound of abdomen ( right kidney = 7.9  4.1 cm , left kidney = 7.7  3.7 cm ) and normal renal function tests . his birth history was uneventful . on examination , he was malnourished ( weight = 12 kg ) , had oral thrush , clubbing and hypertension . his urine examination showed no proteinuria and ultrasound colour doppler of renal vessels was normal . he was started on antituberculous therapy ( att ) ; art was shifted to azt , didanosine ( ddi ) and efavirenz ( efv ) . after 3 months in march 2005 , he was again hospitalized with convulsion and hypertension . his csf was normal , sputum for acid fast bacilli was negative and chest x - ray had normalized . hemoglobin had also increased to 16.7 g / dl , and esr was 15 mm at end of 1 h. liver transaminases were decreasing ( sgot = 97 iu / l , sgpt = 39 iu / l ) . however , ultrasound of kidneys showed small left kidney ( left kidney = 5.2  1.8 cm , right kidney = 9.9  4.2 cm ) . renal function tests were normal and urine examination was also normal and serum toxoplasma igg was positive . he was treated with sulfadiazine- pyrimethamine for 6 weeks and hypertension was controlled with increasing dose of nifedipine . thus , he was determined to have renal hypertension most likely due to renal artery stenosis . the child was discharged and after 2 months he presented with right - sided hemiplegia and uncontrolled hypertension in may 2005 . mri of brain showed old and new infarcts with angiography showing no flow beyond left middle cerebral artery . the child was advised left - sided nephrectomy in view of non functioning kidney and uncontrolled hypertension , which parents refused . thrombotic workup in form of anticardiolipin antibodies ( acla ) , antiphospholipid antibodies ( apla ) , lupus anticoagulant were negative in this child . protein c , protein s and antithrombin iii levels could not be done due to nonaffordability . decrease in natural anticoagulants such as protein c and protein s has been found in hiv infected patients without a thrombotic episode . it appears that cd4 counts < 200/ mm , presence of opportunistic infections , aids - related neoplasms or autoimmune disorder associated with hiv such as autoimmune hemolytic anemia ( aiha ) may predispose to thrombosis . in our patient , though cd4 counts were normal , the child did have advanced hiv disease , had ois in form of tuberculosis and suspected cns toxoplasmosis which could have predisposed him to thrombosis . though his apla , acla were negative , we could not do his protein c and protein s level which would have helped to determine the cause of his recurrent thrombosis . earlier we had reported a child with aps and cerebral infarct , but recurrent thrombosis inspite of anticoagulation is rarely seen as was seen in our patient . in adults on art with protease inhibitor , found that out of 28 adult male homosexuals with aids , who had thrombotic episodes , six patients had two thrombotic events . these patients had either deep vein thrombosis , pulmonary thromboembolism or renal vein thrombosis . however , our patient had renal artery thrombosis , followed by middle cerebral artery thrombosis and subsequently hepatic vein thrombosis which has never been reported earlier . though anticoagulants and/or aspirin have been used to prevent recurrent thrombosis , in our patient inspite of warfarin , the child had a recurrent thrombosis that proved to be fatal . our patient initially presented with hypertension , subsequently developed small non - functioning kidney due to renal artery stenosis and proteinuria though he had normal renal function tests on blood examination . these include hiv - associated nephropathy ( hivan ) , hiv - related immune complex disease , nephropathy secondary to antiretroviral therapy ( art ) or antibiotics , thrombotic microangiopathy , and diseases related to common comorbidities such as opportunistic infections . the broad spectrum of clinical presentation includes acute renal failure ( arf ) , nephrotic syndrome , progressive chronic renal dysfunction , proteinuria , tubular function abnormalities and electrolyte disturbances . proteinuria is believed to be the earliest and most consistent clinical finding for the diagnosis of hiv - associated nephropathy . however , our patient presented with hypertension and only later in the disease developed proteinuria suggestive that renal involvement was due to vasculopathy rather than renal involvement of hiv per se . in adults , hypertension in hiv infected patients has been found to be related to increasing age , longer duration of hiv , higher body mass index , and diabetes , with a trend for african american ethnicity . we did not get any information on renal artery stenosis in hiv infected children , but postulate that it may be related to thrombotic tendency with hiv infection as the child subsequently had thrombosis in cerebral vessels and also the hepatic veins . further studies to elucidate the mechanisms underlying this abnormal hemostatic phenomenon , factors predisposing to recurrent thrombosis are required . thus , clinicians caring for hiv infected children should be aware of thromboembolic disease as a possible complication of aids .