Case Presentation: A 22 year old man with no past medical history presented to our emergency department with three weeks of nausea, vomiting and abdominal pain. He also reported subjective fevers, hematochezia, hematemesis, oral ulcers, gum bleeding, dark colored urine and 30 pound weight loss over the past month. The patient was not forthcoming with his social history yet ultimately reported having male and female sexual partners, but none within the past three years. On examination, vitals were normal, he had right lower quadrant abdominal tenderness and rectal exam revealed red colored stool without visible hemorrhoids. Labs were significant for serum creatinine of 1.9 mg/dl, BUN of 44 mg/dl, indirect hyperbilirubinemia, transaminitis, LDH of 2100 u/L, reticulocyte count of 0.5%, hemoglobin of 13.9 g/dl, WBC 7.3 K/UL, platelets 114 K/UL, elevated ESR and CRP levels. A chart review showed that a previous HIV screening test done five days earlier was reported as positive, however a confirmatory test was nonreactive. CT abdomen was unremarkable. A HIV RNA level was then ordered, which was a send out lab at that time. In the interim, a complete anemia work up showed significantly decreased glucose-6-phosphate-dehydrogenase levels, ferritin greater than 7500 ng/ml as well as evidence of worsening hemolysis. On day seven of admission, he began to have high grade fevers. Bacterial and fungal cultures were negative. The final HIV RNA PCR result returned on hospital day 24 and was greater than two million copies/uL. Once told the results, he admitted to unprotected sexual intercourse one week prior to the onset of symptoms. He was started on antiretroviral therapy with gradual improvement of his symptoms.
Discussion: The Centers for Disease Control recommends screening suspected HIV patients with fourth generation combination antibody antigen assay followed by HIV 1&2 differentiations assays which has been validated by several studies to increase the sensitivity and specificity of HIV screening to nearly 100% for chronic HIV infection (1). However, the merits of the current confirmatory test cannot be generalized to include the confirmation of acute HIV infection as it is only able to identify early infection in 80% of patients (1). Furthermore, acute HIV typically presents with non-specific, constitutional symptoms. Given these limitations, testing for acute HIV with HIV RNA PCR relies heavily on patient history, but can be complicated by both an uncooperative patient as well as laboratory turnaround time. In our index case, the HIV RNA PCR did not return for 24 days. This delay in diagnosis was associated with prolonged hospital stay and increased exposure to invasive and non-invasive tests leading to increased costs and anxiety for the patient.
Conclusions: In conclusion, performing concurrent HIV RNA viral load test with confirmatory tests in patients with a high index of suspicion for acute HIV has the possibility to decrease diagnostic uncertainties, reduced medical waste and most importantly, decrease time to initiation of treatment.