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Clinical Summary

Establishing the diagnosis of primary HIV infection is very important from a public health perspective. Patients are highly infectious during acute HIV secondary to an enormous viral load in both blood and genital secretions. Such patients may be unaware that they are infected and therefore may put others at risk. 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 include fever, swollen lymph nodes, sore throat, myalgias/arthralgias, diarrhea, nausea/vomiting, weight loss, headache, mucocutaneous lesions, and a generalized maculopapular rash located over the face, neck, and trunk. This 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.

Emergency Department Treatment and Disposition

Historically, HIV testing has rarely been performed in the emergency department setting owing to the difficulty of obtaining consent, lack of resource availability, lack of time for counseling and most importantly, uncertain follow-up for linking infected patients to treatment and long-term care. However, there are presently multiple examples of emergency department screening programs that have shown promise in the early detection of HIV infection. Emergency physicians should take a careful history for HIV risk factors and should be cautious but honest in entertaining this diagnosis. Patients should be educated about disease transmission and referred for prompt follow up and further outpatient testing and evaluation.

Figure 20.1.

Primary HIV Infection. A maculopapular rash is seen in over half of persons with symptomatic acute HIV infection. This less typical papular/vesicular rash was present in a patient with primary HIV infection. (Photo contributor: Gregory K. Robbins, MD, MPH.)


  1. Maintain a high degree of clinical suspicion for acute HIV infection, especially when patients present with mononucleosis-like symptoms, unexplained rash, mucocutaneous ulcers or lymphadenopathy, and aseptic meningitis.

  2. Ensure proper follow up for patients in whom the diagnosis of acute HIV infection is entertained.

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

Clinical Summary

Oral hairy leukoplakia (OHL) is a disease of the lingual squamous epithelium caused by the Epstein-Barr virus. OHL generally affects the lateral portion of the tongue, although the floor of the mouth, palate, or buccal mucosa may also be involved. The lesions are described as white corrugated plaques that, unlike Candida, cannot be scraped from the surface to which ...

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