A 38-year-old man comes to an urgent care center with sore throat and malaise for 3 days. He also has pain during swallowing. His past medical history is significant for mild intermittent asthma, gastroesophageal reflux disease, and irritable bowel syndrome. His irritable bowel syndrome manifests as abdominal pain and diarrhea several times a year. He has had multiple male sexual partners over the last 10 years. He recently returned from a trip to Europe to visit friends.
Examination shows pharyngeal erythema and shallow, tender ulcers on buccal mucosa. The remainder of the examination is unremarkable. Point-of-care testing for group A streptococcus is negative. Symptomatic therapy with acetaminophen and mouthwash is prescribed. The patient returns 2 days later due to persistent sore throat, fatigue, and new rash. He also reports poor appetite and 2 episodes of diarrhea. Physical examination shows a fine macular rash on his trunk, hands, and feet.
Which of the following is the most likely diagnosis?

Question

A 38-year-old man comes to an urgent care center with sore throat and malaise for 3 days.  He also has pain during swallowing.  His past medical history is significant for mild intermittent asthma, gastroesophageal reflux disease, and irritable bowel syndrome.  His irritable bowel syndrome manifests as abdominal pain and diarrhea several times a year.  He has had multiple male sexual partners over the last 10 years.  He recently returned from a trip to Europe to visit friends.
Examination shows pharyngeal erythema and shallow, tender ulcers on buccal mucosa.  The remainder of the examination is unremarkable.  Point-of-care testing for group A streptococcus is negative.  Symptomatic therapy with acetaminophen and mouthwash is prescribed.  The patient returns 2 days later due to persistent sore throat, fatigue, and new rash.  He also reports poor appetite and 2 episodes of diarrhea.  Physical examination shows a fine macular rash on his trunk, hands, and feet.
Which of the following is the most likely diagnosis?

Quizplus · Accepted Answer

The patient has a persistent sore throat, new-onset rash, and diarrhea with a previously negative rapid strep test. He most likely has acute HIV. Acute HIV presents with "flu-like" symptoms, including fever, headache, fatigue, sore throat, nausea, diarrhea, and enlarged lymph nodes. Sore throat may be persistent and is often mistaken for other viral illnesses. The rash is macular with some papular features and typically appears on the trunk and face. The appearance of a rash signifies seroconversion, so HIV testing at this point is appropriate. (Choice A) Sore throat would be a very unusual extraintestinal manifestation of Crohn's disease, making this diagnosis unlikely. (Choice B) Gonococcal pharyngitis usually presents in association with genitourinary symptoms but can also occur by itself. The rash associated with disseminated gonococcal infection is commonly associated with joint or tendon pain, is more peripheral (rather than truncal), and varies from maculopapular to pustular. This patient's lack of joint pain or genitourinary symptoms makes gonorrhea unlikely. (Choice D) Infectious mononucleosis typically presents in patients age <21 and can cause a sore throat with malaise and lymphadenopathy. Rash is seen in <5% of patients, but it is almost always (>70%) seen if the "cillin" antibiotics are given. (Choice E) Infectious diarrhea caused by toxin-mediated bacteria such as Escherichia coli can lead to complications such as hemolytic uremic syndrome. However, these patients do not typically have a sore throat and macular rash. Educational objective: HIV may present in its acute phase as a flu-like illness and as a cause of persistent sore throat. When a rash is present, HIV enzyme-linked immunosorbent assay testing is sensitive with a lower rate of false negatives. __________ References: Acute primary HIV infection (http://www.ncbi.nlm.nih.gov/pubmed/21646465) Acute HIV-1 Infection (http://www.ncbi.nlm.nih.gov/pubmed/21591946)

A 38-Year-Old Man Comes to an Urgent Care Center with Sore