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In a recent issue of AIDS Clinical Care, Rosenberg et al make a plea for practitioner recognition of primary HIV infection and the acute retroviral syndrome. Why is this of import to primary care physicians? We are often the patient’s first encounter with the medical system, and recent data suggest that rapid diagnosis of these conditions may well improve patient prognosis. A theoretical advantage of early initiation of antiretroviral therapy is that viral production is slowed, helping the immune system fight infection before the viral load becomes too unwieldy. Preliminary clinical data bear this out as well. In an ongoing trial of 24 patients placed on triple drug therapy within 90 days of HIV infection, none have any detectable viral load at 4-16 months of treatment.1
Primary HIV infection is defined as the time between initial HIV exposure and the development of measurable HIV antibody. Typically, HIV antibody is not measurable until 6-10 weeks after acute exposure. Once the virus gains entry, there is a tremendous viremic response with a heavy viral burden. A rapid fall in CD4 cell count occurs, followed by a disproportionate rise in the CD8 cell count. Over the ensuing month, the CD4 count rebounds, although it never achieves its pre-infection level. For the majority of patients, this period of heavy viremia and aggressive immune response manifests itself clinically. Most patients develop clinical symptoms within 5-30 days of acute HIV exposure, typically 14 days post exposure. They develop a mononucleosis-like syndrome termed the acute retroviral syndrome. Symptoms include fever, fatigue, myalgias, and sore throat. Physical exam findings include lymphadenopathy, oral ulcers, macular rash, and pharyngitis. Occasionally, patients may present with genital or rectal ulcers, neurologic symptoms, or thrombocytopenia. The clinical spectrum is highly variable, and the differential diagnosis includes acute CMV, Epstein Barr infection, syphilis, and acute toxoplasmosis.
Retrospective data suggest that many HIV patients recall an acute viral syndrome, and many state that they felt ill enough to seek medical attention. How often in our clinical practice do we consider the acute retroviral syndrome when evaluating patients with viral symptoms? Not only can most centers measure viral load at the onset of exposure, they can also measure qualitative HIV-DNA. We no longer need to wait for the development of HIV antibody before we initiate antiretroviral therapy, and this may give the patient a several month advantage to fight the viral load.
How does this affect our practice? We need to do adequate routine screening for high-risk behaviors. When patients present with significant viral symptoms and physical exam features suggestive of a mononucleosis-like syndrome, add the acute retroviral syndrome to your differential diagnosis. Timely diagnosis of this entity is of crucial importance to the individual patient and, from a public health standpoint, to the community at large. (Dr. Heilpern is Assistant Professor of Medicine, Emory University School of Medicine, Atlanta.)
1. Markowitz M, et al. Recent HIV infection treated with AZT, 3TC and a potent protease inhibitor. Fourth Conference on Retroviruses and Opportunistic Infections (abstract). Washington DC, January 1997.