CASE 1

A 26-year old woman attending medicine OPD clinic presents with fever, rash, night sweats, severe fatigue,
headache, diarrhea, pharyngitis, arthralgia, and myalgia. She confessed to having an unprotected sexual
intercourse with an acquaintance three weeks ago. History taking ruled out occupational exposure to blood
or body fluids, or needle sharing. On clinical examination, Lymphadenopathy involving cervical lymph nodes
were observed but hepato-splenomegaly were absent. Macular itchy lesions were also noted on the trunk
and limbs. Complete blood count revealed thrombocytopenia, anemia, leukopenia, lymphopenia, and
monocytosis. Rapid tests for Malaria, Enteric Fever and Hepatitis B were negative.

Q1. What is the likely clinical diagnosis?

Ans. It is likely to be Acute HIV infection. This condition is also known as acute HIV syndrome, acute HIV
illness, seroconversion illness, or acute retroviral syndrome. Differential diagnosis includes infectious
mononucleosis, cytomegalovirus mononucleosis, viral upper respiratory tract infection, toxoplasmosis,
rubella, secondary syphilis, drug reactions, and viral hepatitis.

Q2. Which tests are to be performed as a part of laboratory diagnosis?

Ans. At this stage of the illness, viral RNA and HIV antigen can be demonstrated along with a negative
antibody test. Therefore, the tests to be performed are RT-PCR for HIV RNA, and P24 antigen detection.
HIV viral load can be estimated by using quantitative polymerase chain reaction testing or branched DNA
assays. P24 antigen in blood can be detected by ELISA test. Any of the rapid antibody screening test can
also be performed. Estimation of CD4:CD8 ratio by flow-cytometry is helpful.

Q3. Describe the principles of these tests and their likely findings.

Ans. In acute HIV infection, the RNA levels in the blood plasma become detectable as early as 10 (mean 13-
28) days after infection. In patients with acute HIV infection, RNA levels typically rise above 100,000 copies
per mL. Low viral loads (particularly 1,000 RNA copies per mL or less) in a person with suspected acute HIV
infection may indicate a false-positive result. In acute HIV infection, the p24 core protein becomes
detectable in blood by 14-15 (mean 18-34) days after infection. Its level falls as antibodies arise. Fourth
generation ELISA can detect both the antigen and antibody to HIV. The HIV antibody test result is invariably
negative or indeterminate during primary infection as antibodies become detectable by 25 (mean 22–37)
days after detection. The period between the infection and seroconversion is known as the window period.
In acute HIV infection the CD4:CD8 ratio is inversed (less than 1), which returns to normal (> 1) as the
immune response clears the virus.

In this case, the patient sample is likely to be positive for HIV RNA with high loads, positive for P24 HIV
antigen, a negative HIV-1/2 antibody test.

Q4. What is the normal course of this disease?

Ans. There are three stages of HIV infection: Acute HIV Infection, chronic asymptomatic phase, and AIDS.
The acute infection stage usually lasts for three to six weeks and terminates with the appearance of an
immune response to HIV. The chronic infection phase may last for seven to 10 years. The progression of
the disease to AIDS depends on several variables such as the host’s susceptibility to the virus, genetic
makeup, immune function and the presence of co-infections. Finally, the disease enters into the AIDS stage,
which is characterized by profound immune suppression, frequent opportunistic infections, and
malignancies. The CD4 count is usually less than 200 cells/mm3 and declines progressively. Clinical AIDS is
defined as a CD4 cell count of less than 200/mm3 and/or the appearance of AIDS defining illnesses. This
stage may last for one to three years and results in death without the intervention of Anti-Retroviral
Treatment (ART).