A 23-year-old college student comes to the student health center due to 2 weeks of "not feeling well." She has not attended classes for the past several days due to myalgia and fatigue. The patient has also had intermittent fever, headache, dry cough, and malaise. Due to weak appetite and frequent episodes of diarrhea, she has lost a significant amount of weight over the same period. The patient has also had excessive dandruff and scaly facial rash despite using the same shampoo and cosmetic products as before. In the last several months, she has experienced numerous psychosocial stressors, including working 3 jobs to keep up with her finances. Which of the following additional history is most likely to be helpful in reaching the diagnosis in this patient?

Question

A 23-year-old college student comes to the student health center due to 2 weeks of "not feeling well."  She has not attended classes for the past several days due to myalgia and fatigue.  The patient has also had intermittent fever, headache, dry cough, and malaise.  Due to weak appetite and frequent episodes of diarrhea, she has lost a significant amount of weight over the same period.  The patient has also had excessive dandruff and scaly facial rash despite using the same shampoo and cosmetic products as before.  In the last several months, she has experienced numerous psychosocial stressors, including working 3 jobs to keep up with her finances.  Which of the following additional history is most likely to be helpful in reaching the diagnosis in this patient?

Quizplus · Accepted Answer

Explanation: This young patient has a wide range of nonspecific symptoms and has had significant weight loss; she requires evaluation for acute HIV. Acute HIV is marked by dramatic viremia 2-4 weeks after viral acquisition prior to the onset of HIV-specific humoral immunity. Patients may have few or no symptoms or may develop a mononucleosis-like illness that includes fever, lymphadenopathy, weight loss, sore throat, myalgias, diarrhea, and headache. Although these manifestations are nonspecific, prolonged symptoms or the presence of mucocutaneous ulcers or generalized rash should always raise suspicion for HIV. This patient should give a detailed sexual history including number of partners, condom use, sex for money, men who have sex with men, and sexually transmitted diseases. A prior or current history of intravenous drug use should also be noted. Diagnosis of acute HIV is typically made with a combination of fourth-generation HIV test and HIV viral load. Although less common in acute HIV, seborrheic dermatitis (eg, dandruff, scaly facial rash) occurs frequently in patients with HIV. (Choice A) Rheumatic diseases such as systemic lupus erythematosus (SLE) can closely resemble acute HIV, and family history is positive in up to 15% of cases. However, sudden weight loss and diarrhea are less prominent features of new-onset SLE. In addition, sexual history is likely to rapidly identify if this patient is at risk of acute HIV, whereas family history may or may not be positive for rheumatic disease. (Choice B) Poor nutrition may result in vitamin deficiency and/or weight loss but is unlikely to cause such prominent, acute symptoms (eg, intermittent fevers). (Choice C) Occupational exposure to some cleaners, oxidizing agents, or radiation can sometimes lead to generalized illness; however, acute HIV infection is far more likely to cause vague, nonspecific symptoms and weight loss. (Choice D) This patient is under great stress working 3 jobs; however, her cluster of symptoms across many organ systems likely represents acute HIV. A psychiatric history is not indicated at this time. Educational objective: Young patients who present with vague, nonspecific symptoms should be evaluated for acute HIV infection with a detailed sexual history and inquiry of intravenous drug use. If suspicion remains, patients should receive a fourth-generation HIV test and a HIV viral load.

A 23-Year-Old College Student Comes to the Student Health Center