A 31-year-old man comes to the office due to a week of fever, night sweats, sore throat, malaise, and extreme fatigue. He has no prior medical conditions and takes no medications. The patient has had multiple sexual partners over his lifetime and uses condoms inconsistently. Temperature is 38 C (100.4 F), blood pressure is 110/80 mm Hg, pulse is 92/min, and respirations are 20/min. Physical examination shows multiple shallow ulcers on the oropharyngeal mucosa, and the tonsils are enlarged and hyperemic. Cervical and axillary lymphadenopathy is present, and there is a generalized, erythematous, maculopapular skin rash. HIV testing shows the following results: Which of the following best explains this patient's laboratory findings?

Question

A 31-year-old man comes to the office due to a week of fever, night sweats, sore throat, malaise, and extreme fatigue.  He has no prior medical conditions and takes no medications.  The patient has had multiple sexual partners over his lifetime and uses condoms inconsistently.  Temperature is 38 C (100.4 F), blood pressure is 110/80 mm Hg, pulse is 92/min, and respirations are 20/min.  Physical examination shows multiple shallow ulcers on the oropharyngeal mucosa, and the tonsils are enlarged and hyperemic.  Cervical and axillary lymphadenopathy is present, and there is a generalized, erythematous, maculopapular skin rash.  HIV testing shows the following results:  Which of the following best explains this patient's laboratory findings?

Quizplus · Accepted Answer

11ec160b_3833_737a_9249_f338992608ef_MD0001_00 Most patients infected with HIV develop mononucleosis-like symptoms (eg, fever, diffuse lymphadenopathy, malaise, myalgia, sore throat, and headache) 2-4 weeks after inoculation (acute retroviral syndrome). The presence of oropharyngeal ulcers and a diffuse maculopapular rash are important diagnostic clues. Acute retroviral syndrome is associated with extremely high levels of viral replication (~5 million copies/mL) as the cell-mediated and humoral antibody response against the virus is not yet fully activated. Therefore, laboratory results during this period usually show evidence of HIV in the plasma (positive viral load and p24 antigen) with a negative serologic response (negative HIV-1/HIV-2 antibody). This is referred to as the "window period," as patients are infected with HIV but HIV antibody screening tests may be negative (newer screening tests incorporate testing for HIV p24 antigen and are more sensitive in early infection). The humoral response to HIV typically develops 6-8 weeks after initial infection. At this time, anti-HIV antibodies in the serum neutralize circulating virus, which reduces viral load and leads to resolution of acute retroviral symptoms. Most patients then enter a long asymptomatic period until diminished CD4 counts open the door to opportunistic infections. (Choice B) Antibodies against HIV surface glycoproteins (eg, gp120) help neutralize circulating virus and reduce viral load. However, HIV surface glycoproteins display a high degree of antigenic variation, which prevents the formation of a completely effective antibody response. (Choices C and E) Patients with HIV develop immunosuppression primarily due to impairments in the cell-mediated immune response. Although the humoral immune response is also impaired, patients are able to generate anti-HIV antibodies that partially neutralize the virus. It is very rare that a patient with HIV will be too immunodeficient to seroconvert. (Choice D) Acute retroviral syndrome is marked by an extremely high rate of viral replication. Although antibodies eventually form, the response is delayed because the humoral immune response takes several weeks to fully develop. Educational objective: Initial HIV infection is often associated with mononucleosis-like symptoms (eg, fever, lymphadenopathy, sore throat) 2-4 weeks after transmission. Important diagnostic clues are oropharyngeal ulcers and a diffuse maculopapular rash. As the humoral antibody response is not fully activated early in infection, laboratory results typically show HIV in the serum (positive viral load and p24 antigen) but negative HIV serology.

A 31-Year-Old Man Comes to the Office Due to a Week