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A 32-year-old homosexual man comes to the clinic complaining of cold symptoms. He describes diffuse myalgias, fevers, sore bumps in his neck, rash, and fever blisters, lasting for about a week. Before this episode he has been in good health, and generally takes care of himself. He reports practicing safe sex, has had hepatitis A and B vaccinations, and 1 month ago had negative HIV and hepatitis C screening tests. Vital signs today are blood pressure 134/90 mm Hg, pulse 105/min, respirations 24/min, and temperature 38.3 C (101 F). Head and neck examination reveals bloodshot conjunctiva and small, shallow, sharply demarcated ulcers in the oral mucosa, a nonexudative pharyngitis, and tender cervical lymphadenopathy. A diffuse, patchy erythematous rash is present over the patient™s thorax. The rest of the exam, including genitourinary exam, is within normal limits. Which of the following tests is most likely to reveal this patient™s underlying condition?
A. Hepatitis B and C screening panels
B. Heterophile test for Epstein-Barr virus
C. Herpes virus (HSV) screen
D. HIV RNA viral load test
E. Rapid plasma reagin (RPR) test
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The correct answer is D. Primary HIV infection, or acute seroconversion syndrome, often manifests as a mononucleosis-type illness and can occur as quickly as 2 to 4 weeks after HIV inoculation. Although there are no specific signs, mucocutaneous lesions in the presence of HIV risk factors should prompt one to consider the diagnosis. The viral load is extremely high at this time, and then plummets as the immune system temporarily brings the infection under control. Although most patients with acute seroconversion syndrome are unfortunately missed, identifying these patients is of extreme importance. During this time the viral load is extremely high, making these unaware patients very infectious. Further, there is evidence that in primary HIV infection, early treatment may improve outcome. Because antibody formation and detection may lag the symptoms of primary infection, HIV viral load testing is the recommended testing modality as opposed to the traditional ELISA and Western blot.
Hepatitis B and C (choice A) have a variety of extrahepatic manifestations. However, they do not normally cause this symptom complex. Further, this patient has hepatitis B immunity.
An infection with the Epstein-Barr virus (choice B) can present in this manner, though the overall symptom complex and epidemiology are much more suggestive of primary HIV infection.
Herpes virus (choice C) can cause oral ulcerations, though vesicular labial lesions are more common. The fluid from a vesicular lesion may be sent for culture and immunofluorescence examination.
Any disease presentation can present as syphilis. However, this patient does not have the classic signs of syphilis, either the chancre of primary syphilis or the papular, full-body rash (including palms and soles) of secondary syphilis. As such, an RPR (choice E) is not the most urgent test in this patient.
