A 32-year-old man comes to the clinic with a week of sore throat, fatigue, and malaise. He has had several episodes of diarrhea but no abdominal pain. His past medical history is unremarkable. The patient reports several new sexual partners in the last 6 months. Last year, screening tests for HIV, syphilis, gonorrhea, and chlamydia were all negative.
His temperature is 38.2 C (100.8 F), blood pressure is 120/60 mm Hg, pulse is 88/min, and respirations are 16/min. Physical examination shows pharyngeal erythema and shallow, tender ulcers on the buccal mucosa and the posterior pharynx. There is a fine macular rash on his trunk, hands, and feet.
Serum HIV RNA levels are markedly elevated.
Which of the following is the best next step in management of this patient?

Question

A 32-year-old man comes to the clinic with a week of sore throat, fatigue, and malaise.  He has had several episodes of diarrhea but no abdominal pain.  His past medical history is unremarkable.  The patient reports several new sexual partners in the last 6 months.  Last year, screening tests for HIV, syphilis, gonorrhea, and chlamydia were all negative.
His temperature is 38.2 C (100.8 F), blood pressure is 120/60 mm Hg, pulse is 88/min, and respirations are 16/min.  Physical examination shows pharyngeal erythema and shallow, tender ulcers on the buccal mucosa and the posterior pharynx.  There is a fine macular rash on his trunk, hands, and feet.
Serum HIV RNA levels are markedly elevated.
Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec193a_9866_95f3_853d_ff703168aeab_MD0002_00 This patient has fever, pharyngitis, and malaise. This mononucleosis-like illness is consistent with acute HIV infection (acute retroviral syndrome), confirmed by the patient's high HIV viral load. Acute retroviral syndrome is caused by the rapid expansion of virus in a naïve host and is characterized by high viral load and a rapidly falling CD4 count. After 1-2 months, the immune system controls the viral replication, leading to normalization of CD4 counts and decline of the viral load. Generally, patients with acute retroviral syndrome are not aware of their infection. This lack of awareness, combined with the high viral loads, renders these patients highly infectious. Therefore, for both clinical and public health reasons, combination antiretroviral therapy is recommended. Treatment is offered regardless of CD4 count, which may fall precipitously during acute HIV infection. (Choices B and C) Treatment is recommended for all patients with HIV infection, including acute infection. Symptomatic treatment alone is not appropriate. Treatment should include at least 3 effective agents to minimize the risk of developing antiviral resistance. (Choice D) A CD4 count should be obtained when HIV infection is confirmed. However, waiting for the CD4 count before starting therapy is unnecessary as treatment is required regardless of the level. (Choice E) Resistance testing is recommended for all patients initiating antiretroviral therapy. For patients with acute HIV syndrome, Department of Health and Human Services guidelines state explicitly that treatment should not be delayed pending the results, as the antiretroviral regimen can be modified if needed. Educational objective: Acute HIV infection should be considered in patients who have an acute viral illness and risk factors for HIV infection. Diagnosis is made by HIV-RNA polymerase chain reaction testing as HIV antibody testing may be negative. Treatment with combination antiretroviral therapy is recommended. __________ References: Antiretroviral treatment of adult HIV infection. (http://www.ncbi.nlm.nih.gov/pubmed/20639566) Acute HIV-1 infection. (http://www.ncbi.nlm.nih.gov/pubmed/21591946)

A 32-Year-Old Man Comes to the Clinic with a Week