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INTRODUCTION

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Kaposi Sarcoma. Multiple KS lesions surrounding the nipple of this patient with advanced HIV. (Photo contributor: Seth W. Wright, MD.)

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The authors would like to acknowledge the special contributions of J. Michael Ballister, MD, Roderick Morrison, MD, Shane Cline, MD, and Michael Krentz, MD, for their excellent work on prior editions of this chapter.

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PRIMARY HIV INFECTION

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Clinical Summary

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Establishing a definitive diagnosis in the earliest stage of HIV infection can have significant impact on the patient’s outcome and may serve a public health function as well. Patients are highly infectious during acute seroconversion and may be unaware that they are infected. It is believed that a significant number of the new cases of HIV infection occurring in the United States are acquired from acutely infected individuals. Identifying acute seroconverters could offer the opportunity to discuss transmission reduction behavior. Clinical illness accompanies primary HIV infection in approximately two-thirds of patients. The usual time from HIV exposure to the development of symptoms is approximately 10 to 20 days, with average symptom duration of 1.5 to 2 weeks. The most common symptoms following seroconversion mimic a typical viral syndrome and may include mucocutaneous lesions and a generalized maculopapular rash located over the face, neck, and trunk. The rash is seen in over 50% of persons with symptomatic primary HIV infection. The lesions are typically small, well circumscribed, erythematous, nonpruritic, and nontender. Less frequently, patients may demonstrate neurologic signs and symptoms consistent with meningoencephalitis, myelopathy, and peripheral neuropathy. If obtained, laboratory studies may show lymphopenia and thrombocytopenia.

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Management and Disposition

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Although rapid HIV testing has become feasible in most emergency department (ED) settings, the diagnosis of acute infection cannot rely solely on rapid antibody-based tests. If the possibility of acute seroconversion is entertained, then a discussion should take place with the patient regarding level of risk behavior. If acute HIV is suspected, HIV-1 ribonucleic acid (RNA) quantitative polymerase chain reaction (PCR) is the appropriate diagnostic test. Patients who are acutely seroconverting should have extremely high levels of HIV RNA. Importantly, a negative HIV antibody test does not rule out HIV infection in these cases. During the “window period” of acute HIV infection, antibodies against the HIV virus have not yet formed and may not be detected for 8 to 10 weeks. If acute HIV is suspected or confirmed, patients should be educated about disease transmission and referred for prompt follow-up and further outpatient testing and evaluation.

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Pearls

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  1. Maintain a high degree of clinical suspicion for acute primary HIV infection, especially when sexually active patients or patients who use intravenous drugs present with mononucleosis-like symptoms, unexplained rash, mucocutaneous ulcers, lymphadenopathy, or aseptic meningitis.

  2. Obtain an HIV RNA quantitative PCR (and not just an HIV ...

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