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Tackling HIV Testing Case 4

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Tackling HIV Testing Case 4
Case 4: July 2007
Mr X and Mr Y
1
Case 4: July 2007
• 26 year-old Caucasian man
• ‘Mr X’
2
Case 4: July 2007
Presents to ED at 18:00 with:
1-day history of:
• maculopapular rash to chest, face, arms and legs
3-day history of:
• headache
• neck stiffness
• photophobia
• diarrhoea and vomiting
• arthralgia
3
Case 4: July 2007
OE:
•
•
•
•
•
Pyrexia 39.8oC
Maculopapular rash over face, chest, limbs
Photophobic, no overt meningism
Routine bloods unremarkable
CT head / LP NAD
• Treated to cover bacterial meningitis
• Clinically improved and discharged home
• No HIV test performed
4
Case 4: July 2008
• 25 year-old British gay male
• ‘Mr Y’
5
Case 4: July 2008
Presents to ED with:
•
•
•
•
•
•
6
Headache
Neck stiffness
Fever
Maculopapular rash on face, chest, limbs
Nausea, vomiting
Cervical lymphadenopathy
Case 4: July 2008
History:
• Last sexual contact:
– Regular Male Partner of 3 months (no condoms)
• Previous contacts:
– Casual Male Partner 5 months ago (condoms)
– Casual Male Partner 8 months ago (condoms)
• HIV-1 antibody test negative 3 months earlier
7
Case 4: July 2008
Investigations:
• Routine bloods unremarkable
• HIV-1 antibody: weakly positive
• HIV-1 antibody (detuned):
suggestive of infection within 6 months
• HIV RNA viral load 1,000,000 copies/ml
• CD4 count 699 (9%)
8
Case 4: summary
• Both: viral type illness with meningism and rash
• Mr Y’s Regular Male Partner of 3 months = Mr X
• Mr X now tests positive for HIV
Diagnoses:
Mr Y: HIV seroconversion
Mr X: ??HIV seroconversion
9
Q: When could HIV testing have been
recommended in this scenario?
1. When Mr X was admitted with aseptic
meningitis without any apparent risk factors?
2. When Mr Y was admitted with aseptic
meningitis with a history of sex with other
men?
3. Should they have been referred on discharge
to GUM to see a trained counsellor before HIV
testing?
10
Who can test?
11
Who can test?
12
Who to test?
13
Who to test?
14
Who to test?
15
Q: What kind of tests should have been used
to diagnose seroconversion illness?
1. Rapid test?
2. 3rd generation antibody test?
3. 4th generation antigen/antibody test?
4. PCR (viral load)?
16
Which test to use?
17
Case 4: summary
• Both: viral type illness with meningism and rash
• Mr Y’s Regular Male Partner of 3 months = Mr X
• Mr X now tests positive for HIV
Diagnoses:
Mr Y: HIV seroconversion
Mr X: ??HIV seroconversion
Was Mr Y’s HIV infection preventable?
18
Learning Points
• Primary HIV Infection is easily missed – have a low index
of suspicion on presentation of PUO, meningism and rash
in adults
• During PHI viral load is extremely high making the patient
highly infectious
• Some patients may not disclose that they have put
themselves at risk of HIV infection in the past
• A perceived lack of risk should not deter you from offering
a test when clinically indicated
19
Key messages
• Antiretroviral therapy (ART) has transformed treatment of
HIV infection
• The benefits of early diagnosis of HIV are well recognised
- not offering HIV testing represents a missed opportunity
• UK guidelines recommend universal HIV testing for
patients from groups at higher risk of HIV infection
• Primary HIV Infection is a unique opportunity to diagnose
HIV as the patient’s next HIV-related presentation may be
at a late stage of infection
20
Also contains
UK National Guidelines for HIV
Testing 2008
from BASHH/BHIVA/BIS
Available from:
[email protected]
or 020 7383 6345
21
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