Human Immunodeficiency Virus Book

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HIV PresentationAka: Acute Retroviral Syndrome, Acute HIV Infection, HIV New Diagnosis

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  1. General
    1. Primary infection may be asymptomatic
    2. Acutely infected patient is high risk of transmission
    3. Typical presentation:
      1. Mononucleosis-like illness
      2. Occurs 2-3 weeks after exposure
      3. Precedes seroconversion by 10-21 days
      4. Self limited
      5. Medical attention sought in 20-30% of patients
  2. 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
  3. Associated Conditions: Other presentations in early HIV
    1. Fungal
      1. Vaginal Candidiasis
      2. Onychomycosis
      3. Thrush
    2. Dermatologic
      1. Seborrhea
      2. Shingles
  4. 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)
  5. Labs: HIV Diagnosis
    1. HIV Screening (HIV ELISA Antibody Test)
      1. Often negative initially in acute onset
    2. Consider HIV Activity Test
      1. HIV RNA Test (100% sensitive, 97.4% Specific)
        1. Higher rate of false positives
        2. Low counts (<10,000) are often false positives
      2. p24 Antigen (88.7% sensitive, 100% Specific)
        1. Higher rate of false negatives
      3. References
        1. (2001) Ann Intern Med 134:25
  6. 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. Elevated Liver Function Tests
        1. Hepatic enzyme levels
    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. Viral load (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. Tuberculin Skin Test (PPD)
        1. Five mm is positive in HIV patients
      6. Varicella IgG (VZV IgG)
        1. Test before post-exposure prophylaxis
  7. 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
  8. 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. Other Infectious Disease
      1. Aseptic Meningitis
      2. Primary Cytomegalovirus infection (CMV)
      3. Drug Reaction
      4. Epstein-Barr Virus infection (Mononucleosis)
      5. Viral Hepatitis
      6. Primary Herpes Simplex Virus Infection
      7. Influenza
      8. Severe Streptococcal Pharyngitis
      9. Secondary Syphilis
      10. Toxoplasmosis
      11. Rubella
      12. Brucellosis
      13. Malaria
  9. 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
  10. Prevention strategies at diagnosis
    1. See HIV Prophylaxis of Secondary Infection
    2. 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. Consider Influenza Vaccine
      5. Consider Hib Vaccine
  11. References
    1. Daar (2001) Ann Intern Med 134:25
    2. Khalsa (2006) Am Fam Physician 73:271
    3. Niu (1993) J Infect Dis 168:1490
    4. Perlmutter (1999) Am Fam Physician 60(2):535

Acute HIV infection (C0343752)

ConceptsDisease or Syndrome (T047)
EnglishAcute HIV infection, Acute human immunodeficiency virus infection, Acute human immunodeficiency virus seroconversion illness
Spanishinfección aguda por HIV, infección aguda por VIH, infeccion aguda por HIV, infeccion aguda por VIH
CreditsDerived from the NIH UMLS (Unified Medical Language System)



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