Acute HIV Infection Presenting Research Articles

Cryptococcal meningitis: an unusual presentation of primary HIV infection

Acute HIV infection presenting as severe opportunistic disease is a very uncommon event associated with more rapid HIV progression and higher mortality. We describe the case of a patient with cryptococcal meningitis in the setting of primary HIV infection.

Acute HIV Discovered During Routine HIV Screening With HIV Antigen-Antibody Combination Tests in 9 US Emergency Departments

Newer combination HIV antigen-antibody tests allow detection of HIV sooner after infection than previous antibody-only immunoassays because, in addition to HIV-1 and -2 antibodies, they detect the HIV-1 p24 antigen, which appears before antibodies develop. We determine the yield of screening with HIV antigen-antibody tests and clinical presentations for new diagnoses of acute and established HIV infection across US emergency departments (EDs). This was a retrospective study of 9 EDs in 6 cities with HIV screening programs that integrated laboratory-based antigen-antibody tests between November 1, 2012, and December 31, 2015. Unique patients with newly diagnosed HIV infection were identified and classified as having either acute HIV infection or established HIV infection. Acute HIV infection was defined as a repeatedly reactive antigen-antibody test result, a negative HIV-1/HIV-2 antibody differentiation assay, or Western blot result, but detectable HIV ribonucleic acid (RNA); established HIV infection was defined as a repeatedly reactive antigen-antibody test result and a positive HIV-1/HIV-2 antibody differentiation assay or Western blot result. Theprimary outcomes were the number of new HIV diagnoses and proportion of patients with laboratory-defined acute HIV infection. Secondary outcomes compared reason for visit and the clinical presentation of acute HIV infection. In total, 214,524 patients were screened for HIV and 839 (0.4%) received a new diagnosis, of which 122 (14.5%) were acute HIV infection and 717 (85.5%) were established HIV infection. Compared with patients with established HIV infection, those with acute HIV infection were younger, had higher RNA and CD4 counts, and were more likely to have viral syndrome (41.8% versus 6.5%) or fever (14.3% versus 3.4%) as their reason for visit. Most patients with acute HIV infection displayed symptoms attributable to acute infection (median symptom count 5 [interquartile range 3 to 6]), with fever often accompanied by greater than or equal to 3 other symptoms (60.7%). ED screening using antigen-antibody tests identifies previously undiagnosed HIV infection at proportions that exceed the Centers for Disease Control and Prevention's screening threshold, with the added yield of identifying acute HIV infection in approximately 15% of patients with a new diagnosis. Patients with acute HIV infection often seek ED care for symptoms related to seroconversion.

Acute HIV infection presenting as hemophagocytic lymphohistiocytosis: case report and review of the literature

BackgroundHemophagocytic lymphohistiocytosis (HLH) is an uncommon systemic inflammatory condition that can result from infections, autoimmune diseases and malignancies. It is a rarely reported life threatening complication of an acute HIV infection, with only ten documented case reports per our literature search. We present a case of HLH secondary to acute HIV infection with a negative HIV antibody-based assay and high plasma viral load.Case presentationA 45 year old male with a past medical history of well controlled hypertension presented with fever, dizziness and non-bloody diarrhea. Initial lab work revealed a new thrombocytopenia, marked renal failure and an elevated creatine kinase, ferritin, lactate dehydrogenase and D-dimer. A bone marrow biopsy revealed HLH. As part of the work up for thrombocytopenia, a rapid HIV antibody based assay was done and was negative. The sample was later routinely tested with a fourth generation antigen/antibody assay as per local protocol and was strongly positive. The plasma RNA viral load was >10,000,000 copies /mL confirming the diagnosis of an acute HIV infection. The patient was urgently started on antiretroviral therapy and recovered.ConclusionThis case illustrates a diagnostic approach to HLH which is an uncommon but life threatening multisystem disease, requiring the involvement of a multidisciplinary team of experts. Following any diagnosis of HLH, rapid identification and treatment of the underlying condition is critical. A negative rapid HIV antibody test can be misleading in the context of early HIV infection and the additional use of fourth generation antigen/antibody test or plasma RNA viral load may be required within the right clinical context for diagnosis.

Transverse myelitis and acute HIV infection: a case report

BackgroundMost HIV infected patients will develop some sort of neurologic involvement of the disease throughout their lives, usually in advanced stages. Neurologic symptoms may occur in acute HIV infection but myelopathy in this setting is rare. Up until this date, only two cases of transverse myelitis as a manifestation of acute HIV infection have been reported in the literature. Therapeutic approach in these patients is not well defined.Case presentationA 35 year-old male Caucasian recently returned from the tropics presented to our hospital with urinary retention and acute paraparesis. After extensive diagnostic workup he was diagnosed with acute HIV infection presenting as transverse myelitis. Full neurologic recovery was observed without the use of anti-retroviral therapy.ConclusionAcute spinal cord disorders are challenging, as they present a wide array of differential diagnosis and may lead to devastating sequelae. Timely and rigorous diagnostic workup is of the utmost importance when managing these cases. Clinicians should be aware of the protean manifestations of acute HIV infection, including central nervous system involvement, and have a low threshold for HIV screening.

Acute HIV Infection in a Critically Ill 15-Year-Old Male

A 15-year-old previously healthy male presented with fever, vomiting, diarrhea, malaise, and altered mental status. In the emergency department, the patient appeared acutely ill, was febrile, tachycardic, hypotensive, and slow to respond to commands. He was quickly transferred to the ICU where initial evaluation revealed elevated white blood cell count and inflammatory markers, coagulopathy, abnormal liver function, and renal failure. Head computed tomography, cerebrospinal fluid studies, and blood cultures were negative. He was quickly stabilized with intravenous fluids and broad-spectrum antibiotics. When his mental status improved, the patient consented to HIV testing and was found to be negative using laboratory-based and rapid third-generation HIV type 1 (HIV-1)/HIV type 2 antibody assays. The specimen was subsequently shown to be positive for HIV by a newly licensed fourth-generation antigen/antibody test. HIV-1 Western blot performed on this sample was negative, but molecular testing for HIV-1 RNA 4 days later was positive and confirmed the screening result. The patient was later determined to have a viral load of 5 624 053 copies/mL and subsequently admitted to unprotected receptive anal intercourse 2 weeks before admission. This case demonstrates an atypically severe presentation of acute HIV infection with important lessons for pediatricians. It highlights the need to consider acute HIV infection in the differential diagnosis of the critically ill adolescent and for appropriate testing if acute infection is suspected. This case also illustrates the shortcomings of testing adolescents based only on reported risk and supports Centers for Disease Control and Prevention and American Academy of Pediatrics recommendations for routine testing.

Hemophagocytic Lymphohistiocytosis: An Unusual Initial Presentation of Acute HIV Infection

To the Editor: Hemophagocytic lymphohistiocytosis (HLH) has been described in HIV-infected patients who developed opportunistic infections or malignancies.1,2 The hypercytokinemia triggered by malignancy or coinfection with human herpesvirus-8 or other opportunistic infections and the generalized defects in T-cell and natural killer (NK) cell cytotoxicity in HIV-infected patients are characteristic immunologic features of HLH,3,4 which explains the predisposition to HLH in patients with HIV infection. HLH could also be one of the manifestations of acute HIV infection,5-8 although it has rarely been described to date.9 Here, we present 3 cases of HLH as the initial presentation of acute HIV infection and review the literature.5-8 Detailed clinical characteristics of the 7 cases of HLH of patients with acute HIV infection, including our 3 cases, are shown in Table 1.Table 1: Clinical Characteristics of 7 Patients With Acute HIV Infection and HLHOf the 7 patients diagnosed with acute HIV infection and HLH, 4 were homosexual men. Their median age was 27 years (range: 18-31 years). The presenting symptoms of acute HIV infection were fever (100%), generalized or localized lymphadenopathy (100%), sore throat (86%), and skin rashes (71%). Hepatomegaly or splenomegaly (100%) was detected by physical examination or image studies (see Table 1). Five patients had oroesophageal candidiasis. Severe complications were found in 3 patients: 2 patients developed encephalopathy;6,7 1 had renal failure, acute pancreatitis, and pancreatic panniculitis;7 and 1 had blurred vision.8 Laboratory data showed leukopenia (median value = 2200 cells/μL, range: 1400-10,085 cells/μL), anemia (median value = 12.2 g/dL, range: 9-15.7 g/dL), thrombocytopenia (median value = 175,000 cells/μL, range: 99,000-184,000 cells/μL), hyperferritinemia (median value = 10,817.5 ng/dL, range: 2227-29,893 ng/dL), and elevated lactate dehydrogenase (LDH) levels (median = 1483 U/L, range: 989-4769 U/L). The CD4 lymphocyte counts of the 7 patients were low at the time acute HIV infection was diagnosed, with a median count of 247 cells/μL (range: 63-500 cells/μL), and the median CD8 count was 1302 cells/μL (range: 364-1617 cells/μL). Plasma HIV RNA load was available in 4 patients, with a median value of 5.88 log10 copies/mL by reverse transcriptase-polymerase chain reaction (RT-PCR; range: 5.72-5.88 log10 copies/mL). Histiocytosis with hemophagocytosis was demonstrated in biopsies of the bone marrow or lymph nodes. Acute HIV infection has long been a difficult diagnosis to make because of its nonspecific symptoms.9 Compared with the patients previously described and reviewed, who had opportunistic infections or malignancies at the diagnosis of HLH,1,2 all 7 patients with acute HIV infection and HLH had fever, generalized or localized lymphadenopathy, and hepatomegaly or splenomegaly at presentation. Less hypertriglyceridemia and higher CD4 counts were noted. All patients survived after supportive care was instituted. Although some of them had received immunomodulating agents, such as intravenous immunoglobulin (3 patients) and steroids (2 patients), the benefit of these agents in the treatment of HLH associated with acute HIV infection remains unclear. Our experience and our review of the literature suggest that hemophagocytosis could be one of the initial presentations of acute HIV infection. Hsin-Yun Sun Mao-Yuan Chen Chi-Tai Fang Szu-Min Hsieh Chien-Ching Hung Shan-Chwen Chang *Department of Internal Medicine,, National Taiwan University Hospital and National Taiwan University College of Medicine,, Tapei, Taiwan; and, †Department of Parasitology, National Taiwan University College of Medicine, Taipei, Taiwan

Acute HIV Infection presenting as cytomegalovirus mononucleosis in a young woman

Acute HIV Infection presenting as cytomegalovirus mononucleosis in a young woman