HIV Presentation

1. General
   1. Primary infection may be asymptomatic
   2. Acutely infected patient is high risk of transmission
2. Signs and Symptoms: Typical presentation:
   1. Mononucleosis-like illness
   2. Occurs 2-3 weeks after exposure in up to 90% of patients
   3. Precedes seroconversion by 10-21 days
   4. Self limited
   5. Medical attention sought in 20-30% of patients
3. Signs and symptoms: Acute Retroviral Syndrome
   1. Fever (low-grade <102) occurs in 80-90%
      1. Fever over 102 with rigors suggests occult infection
   2. Fatigue (70-90%)
   3. Erythematous Maculopapular Rash (40-80%)
      1. Face and Trunk
      2. Extremities involving palms and soles
   4. Headache (32-70%)
   5. Generalized Lymphadenopathy (40-70%)
   6. Pharyngitis (50-70%)
   7. Myalgia or arthralgia (50-70%)
   8. Gastrointestinal symptoms (30-60%)
      1. Nausea or Vomiting
      2. Diarrhea
   9. Hepatosplenomegaly (14%)
   10. Night Sweats (50%)
   11. Oral Aphthous Ulcers or Thrush (10-20%)
   12. Genital Ulcers (5-15%)
   13. Neurologic symptoms (12%)
       1. Aseptic Meningitis (25%)
       2. Peripheral Neuropathy
       3. Facial palsy
       4. Guillain-Barre Syndrome
       5. Brachial Neuritis
       6. Cognitive Impairment
       7. Psychosis
   14. Malaise
   15. Anorexia
   16. Weight loss (70%)
   17. Wasting Syndrome
       1. Unexplained weight loss of >10% usual body weight
4. Associated Conditions: Other presentations in early HIV
   1. Fungal
      1. Vaginal Candidiasis
      2. Onychomycosis
      3. Thrush
   2. Dermatologic
      1. Seborrhea
      2. Shingles
5. Evaluation: Initial Goals
   1. What is the current risk of HIV progression?
      1. Based on CD4 Count and HIV Viral Load
      2. Are Antiretrovirals indicated at this point?
   2. What is the current risk of opportunistic infection?
      1. Based on CD4 Count and comorbid conditions
      2. Is prophylaxis or screening indicated?
         1. See HIV Prophylaxis of Secondary Infection
   3. What symptoms are present related to HIV status?
   4. Identify comorbid conditions related to HIV Infection
   5. Identify health maintenance needs (e.g. Pap Smear)
6. Imaging: Chest XRay Indications
   1. Pulmonary symptoms on presentation or
   2. Tuberculin Skin Test positive
7. Labs: HIV Diagnosis
   1. Protocol
      1. Start with HIV ELISA Test and HIV RNA Load
      2. HIV positive if
         1. HIV ELISA Test positive or
         2. HIV RNA >10,000
      3. HIV equivocal (HIV ELISA negative and HIV RNA <10,000)
         1. Retest HIV RNA Load in 1-2 weeks
   2. HIV ELISAAntibody Test
      1. Positive 3-8 weeks from infection
      2. Often negative initially in acute onset
   3. HIV Activity Tests
      1. HIV RNA Load Test (100% sensitive, 97.4% Specific)
         1. Positive at 11-12 days from infection
         2. Higher rate of false positives
         3. Low counts (<10,000) are often false positives
      2. p24 Antigen (88.7% sensitive, 100% Specific)
         1. Positive at 14-15 days from infection (falls within 6-8 weeks)
         2. Higher rate of false negatives
      3. References
         1. (2001) Ann Intern Med 134:25-29
8. Labs: Initial labs at time of diagnosis
   1. Labs often abnormal at diagnosis
      1. Complete Blood Count with Platelet Count
         1. Thrombocytopenia (45%)
         2. Leukopenia (40%)
      2. Liver Function Tests
         1. Hepatic enzyme (transaminase) levels may be elevated
   2. Baseline labs prior to starting medications
      1. Serum Creatinine
      2. Serum Glucose
      3. Lipid profile (affected by Protease Inhibitors)
      4. Urinalysis
   3. HIV staging labs
      1. CD4 Count
      2. Plasma HIV RNA level or Viral load
         1. See Protocol above
         2. Obtain 2 assays at 1-2 weeks apart
      3. Genotypic Antiretroviral Resistance Testing
         1. Test at baseline to direct Antiretrovirals
   4. Screen for infections prior to Immunization
      1. Hepatitis B Surface Antigen (HBsAg)
      2. Hepatitis A Serology (xHAV IgG)
   5. Screen for comorbid illness and immunity
      1. Hepatitis C Antibody (xHCV)
      2. Rapid Plasma Reagin (RPR)
      3. Toxoplasmosis IgG
      4. Cytomegalovirus IgG (CMV IgG)
      5. Neisseria gonorrhoeae PCR
      6. Chlamydia trachomatis PCR
      7. Tuberculin Skin Test (PPD)
         1. Five mm is positive in HIV patients
      8. Varicella IgG (VZV IgG)
         1. Test before post-exposure prophylaxis
9. Monitoring
   1. CD4 Count and HIV Viral Load
      1. Asymptomatic patients: every 4-6 months
      2. Symptomatic patients: every 3-4 months
   2. Annual screening
      1. PPD Skin Test and Chest XRay
      2. Pap Smear
   3. Other annual tests depending on risks
      1. Rapid Plasma Reagin (RPR)
      2. Gonorrhea Antigen
      3. Chlamydia Antigen
      4. Hepatitis C Serology
   4. Periodic comorbidity screening depending on risks
      1. Complete Blood Count with Platelets
      2. Urinalysis
      3. Chemistry panel (renal and liver function)
   5. Testing if CD4 Count <100 cells/mm3
      1. Acid fast bacteria Blood Culture for MAI Complex
      2. Dilated Funduscopic Exam for CMV q3-6 months
10. Differential Diagnosis
    1. HIV related disease
       1. Occult infection (especially if CD4 Count< 200 cells)
       2. Anti-microbial agents (Drug Reaction in HIV)
          1. Most frequent cause of Drug Induced Fever
    2. Most Common
       1. Epstein-Barr Virus infection (Mononucleosis)
       2. Influenza
       3. Severe Streptococcal Pharyngitis
       4. Viral Gastroenteritis
       5. Viral upper respiratory tract infection
    3. Less Common
       1. Drug Reaction
       2. Primary Herpes Simplex Virus Infection
       3. Viral Hepatitis
       4. Secondary Syphilis
    4. Least Common
       1. Aseptic Meningitis
       2. Primary Cytomegalovirus infection (CMV)
       3. Toxoplasmosis
       4. Rubella
       5. Brucellosis
       6. Measles
       7. Malaria
       8. Typhoid
11. Management
    1. See HIV Course
    2. See HIV Treatment Strategy
    3. Consult with HIV specialist to start management
    4. Starting Antiretrovirals is usually not urgent
    5. Initial agents should be chosen carefully
       1. Best response to therapy is with the first attempt
       2. Informed consent for longterm compliance is critical
12. Prevention: Strategies at diagnosis
    1. See HIV Prophylaxis of Secondary Infection
    2. High risk of transmission (10 fold increased risk)
       1. Peak viremia occurs with Acute Retroviral Syndrome
    3. See Immunization in HIV
       1. Pneumovax (try to give when CD4 Count >200)
       2. Hepatitis B Vaccine (if HBsAg negative)
       3. Hepatitis A Vaccine (if risks)
       4. Influenza Vaccine annually
       5. Routine Tetanus vaccine (Tdap or Td)
       6. Consider Hib Vaccine
13. References
    1. Chu (2010) Am Fam Physician 81(10): 1239-44
    2. Daar (2008) Curr Opin Hiv AIDS 3(1): 10-5
    3. Daar (2001) Ann Intern Med 134:25-9
    4. Khalsa (2006) Am Fam Physician 73:271-80
    5. Niu (1993) J Infect Dis 168:1490-501
    6. Perlmutter (1999) Am Fam Physician 60(2):535-542