A 36-year-old man comes to the office due to a month of diarrhea, nausea, and abdominal cramps. He has also had night sweats, arthralgias, and weight loss of 6.8 kg (15 lb) during this period. Pink, oval lesions developed on the patient's upper chest, neck, and face at the beginning of the illness but have now resolved. Temperature is 38.2 C (100.8 F), blood pressure is 112/74 mm Hg, pulse is 104/min, and respirations are 16/min. Nontender lymphadenopathy is present in the cervical and inguinal lymph nodes. There are no joint effusions or skin lesions. The abdomen is soft and nontender with no organomegaly. Which of the following is the best next step in evaluation of this patient?

Question

A 36-year-old man comes to the office due to a month of diarrhea, nausea, and abdominal cramps.  He has also had night sweats, arthralgias, and weight loss of 6.8 kg (15 lb) during this period.  Pink, oval lesions developed on the patient's upper chest, neck, and face at the beginning of the illness but have now resolved.  Temperature is 38.2 C (100.8 F), blood pressure is 112/74 mm Hg, pulse is 104/min, and respirations are 16/min.  Nontender lymphadenopathy is present in the cervical and inguinal lymph nodes.  There are no joint effusions or skin lesions.  The abdomen is soft and nontender with no organomegaly.  Which of the following is the best next step in evaluation of this patient?

Quizplus · Accepted Answer

11ec25c8_d1b3_0595_bc81_8b34263cc2a6_MD0003_00 This patient's subacute gastrointestinal symptoms (eg, diarrhea, nausea, cramps), systemic manifestations (eg, fever, weight loss, night sweats, arthralgias), lymphadenopathy, and transient rash should raise suspicion for acute HIV infection. Although many early cases are minimally symptomatic, patients frequently develop several weeks of nonspecific symptoms such as fever, sore throat, myalgias/arthralgias, headache, diarrhea, weight loss, and diffuse lymphadenopathy shortly after transmission. Two notable clues (not always present) are painful oral ulcerations and/or oval, pink/red macular lesions that usually develop soon after acute illness and last approximately a week. Because the manifestations of HIV are often vague and nonspecific, providers should have a low bar for HIV testing, particularly given the public health implications. Although most new cases arise in individuals with traditional HIV risk factors (eg, intravenous drug use, incarceration, receptive anal intercourse, multiple sexual partners), patients frequently do not fully disclose their social history; therefore, the absence of risk factors should not preclude testing. (Choice A) Systemic lupus erythematosus frequently presents with arthralgias, fever, weight loss, and lymphadenopathy. Although rash is common, it is usually present on the cheeks (malar) and lasts for the duration of the flare. Furthermore, women are much more likely to be affected than men, and gastrointestinal symptoms are less common. (Choice B) Whipple disease and inflammatory bowel disease can cause abdominal pain, diarrhea, weight loss, and arthralgias but are not typically associated with lymphadenopathy or transient oval-shaped skin rash (Whipple disease is linked with hyperpigmentation, and ulcerative colitis is linked with erythema nodosum/pyoderma gangrenosum). In addition, HIV testing is noninvasive and should be performed prior to invasive tests such as colonoscopy. (Choice D) Lymph node biopsy can diagnose lymphoma, which frequently presents with fever, night sweats, weight loss, and nontender lymphadenopathy. However, gastrointestinal manifestations are somewhat uncommon, and the presence of a transient rash would be atypical. In addition, noninvasive testing (eg, HIV testing) is generally performed prior to more invasive tests such as lymph node biopsy. (Choice E) Tissue transglutaminase antibodies can indicate celiac disease, which usually presents with weight loss, diarrhea, and malabsorption (eg, steatorrhea). Although arthralgias can occur, this patient's lymphadenopathy, fever, night sweats, and transient rash make this diagnosis less likely. Educational objective: Acute HIV infection often causes a mononucleosis-like syndrome consisting of fever, night sweats, lymphadenopathy, arthralgias, and diarrhea. Important diagnostic clues include oral ulcerations and a transient rash (oval, red, macular lesions). Providers should have a low threshold for HIV testing even when traditional HIV risk factors are absent. References: Diagnosis and initial management of acute HIV infection. (http://www.ncbi.nlm.nih.gov/pubmed/20507048)

A 36-Year-Old Man Comes to the Office Due to a Month