A 51‐year‐old man presented with a 1‐week history of back pain and fevers. He attributed the back pain to heavy lifting at his new job, but did not have an explanation for the fever. He denied intravenous drug use or symptoms suggestive of malignancy. On the day following admission, he noted a severe right‐sided headache and photophobia. He also noted poor oral intake in the previous month, leading to a 10‐pound weight loss. His vital signs were normal, and he was afebrile on presentation. He had lymphadenopathy in the bilateral posterior cervical, right axillary, and bilatera femoral chains. TTiere was no point tenderness in any portion of his spine. A CBC revealed a white blood cell count of 2000 cells/μL, platelets of 90,000 cells/μL, and a normal hemoglobin concentration. A peripheral smear revealed the presence of large platelets and Pelgar‐Huet cells. The hepatitis C antibody was reactive; all cultures showed no growlh. A lumbar puncture was normal. Serology for HIV‐1 and ‐2 was negative. A lymph node biopsy failed to confirm the diagnosis of lymphoma. He was discharged with an anticipated lymph node excisional biopsy. Five days after discharge, however, the HIV PCR was found to be positive, with 6,190,000 copies/mL
Hospitalists are often the first health professionals to provide care to patients with suspected HIV. The most common symptoms at presentation are fever and fatigue. Other common symptoms include rash, headache, lymphadenopathy. pharyngitis, myalgias, gastrointestinal symptoms, night sweats, leukopenia, and thrombocytopenia. Based on CDC recommendations, acute HIV should be considered in anyone with any combination of the above symptoms, regardless of whether the patient is part of the traditional at‐risk populations. Symptoms generally do not last longer than fourteen days and rarely occur 6 or more weeks after initial exposure. The traditional HIV diagnostic tests, ELISA and Western blots, dc not become positive for 3 or 4 weeks after exposure, and some patients can remain negative for up to 3 months to a year.
Acule HIV syndrome is often mistaken for infectious mononucleosis, influenza, streptococcal pharyngitis, or viral hepatitis. Though there was concern for myelodysplasia syndrome, the suppression of 2 cell lines and the irregularities on his peripheral blood smear increased the pretest probability for HIV, prompting a direct discussion with the patients primary care provider who followed up on his positive viral load. The hospitalist must be aware of the lack of sensitivity of early HIV screening tests. Although viral loads are more specific, the result of this test frequently returns after the hospital course. For this reason, it is important for the hospitalist to integrate Ihis consideration into the transitions of care communication with the patient's primary care physician.
M. Smith, none.
To cite this abstract:Smith M. Staying the Course. Abstract published at Hospital Medicine 2010, April 8-11, Washington, D.C. Abstract 356. Journal of Hospital Medicine. 2010; 5 (suppl 1). https://www.shmabstracts.com/abstract/staying-the-course/. Accessed December 11, 2019.