PRIMARY HIV INFECTION

[Anonymous]

 Differential Diagnosis

Formerly considered to be similar to a mononucleosis-like viral syndrome, primary HIV infection does present with some unique features. Perhaps the most distinctive physical manifestation is the skin rash, which is rarely found in primary presentations of mononucleosis, toxoplasmosis, and cytomegalovirus infection. The rashes of rubella and roseola do not affect palms and soles. Other considerations in the differential diagnosis include hepatitis A or B, disseminated gonococcal infection, drug reactions, and secondary syphilis.

Emergency Department Treatment and Disposition

HIV testing is rarely performed in the ED owing to the difficulty of obtaining informed consent, lack of time for thorough counseling, and uncertain follow-up. Moreover, the diagnosis of acute HIV infection is difficult to make with standard serologic tests. Emergency physicians should take a careful history for HIV risk factors and should be cautious but honest in entertaining this diagnosis. Patients should be educated about safe sex and referred for further outpatient testing and evaluation. Prompt follow-up is critical, since immediate antiviral therapy is indicated for persons with acute HIV infection.

Clinical Pearls

1. Although historically HIV infection has been seen predominately in patients who belong to high-risk groups, the epidemiology is changing. When any sexually active patient presents to the ED with an acute, severe febrile illness, acute HIV infection should be included in the differential diagnosis.

2. Consider acute HIV infection as a potential etiology in patients with aseptic meningitis, pharyngitis, or a maculopapular rash.

3. Ensure proper follow-up for patients in whom the diagnosis of acute HIV infection is entertained.