A 24-year-old man comes to the clinic because he "feels terrible and can barely get out of bed." Two days ago, he started feeling feverish and sweaty. He then developed persistent headache, fatigue, sore throat, and aching in his muscles and joints. The patient has no chronic medical issues and takes no medications. He has been sexually active with 2 women over the past few months and rarely uses condoms. The patient smokes a pack of cigarettes and drinks 2-4 alcoholic beverages daily. Temperature is 38.6 C (101.5 F), blood pressure is 130/88 mm Hg, pulse is 94/min, and respirations are 16/min. The patient is ill-appearing with flushed, damp skin. An erythematous maculopapular rash is present on his face, trunk, palms, and soles. Oropharyngeal examination shows a shallow, tender ulcer with white exudate on the posterior oropharynx. Several enlarged, discrete, mobile lymph nodes are present in the cervical, axillary, and occipital regions. Lung auscultation is unremarkable, and heart sounds are normal. The abdomen is soft, nontender, and nondistended with no hepatosplenomegaly. Laboratory results are as follows: Which of the following is the most likely cause of this patient's current symptoms?

Question

A 24-year-old man comes to the clinic because he "feels terrible and can barely get out of bed."  Two days ago, he started feeling feverish and sweaty.  He then developed persistent headache, fatigue, sore throat, and aching in his muscles and joints.  The patient has no chronic medical issues and takes no medications.  He has been sexually active with 2 women over the past few months and rarely uses condoms.  The patient smokes a pack of cigarettes and drinks 2-4 alcoholic beverages daily.  Temperature is 38.6 C (101.5 F), blood pressure is 130/88 mm Hg, pulse is 94/min, and respirations are 16/min.  The patient is ill-appearing with flushed, damp skin.  An erythematous maculopapular rash is present on his face, trunk, palms, and soles.  Oropharyngeal examination shows a shallow, tender ulcer with white exudate on the posterior oropharynx.  Several enlarged, discrete, mobile lymph nodes are present in the cervical, axillary, and occipital regions.  Lung auscultation is unremarkable, and heart sounds are normal.  The abdomen is soft, nontender, and nondistended with no hepatosplenomegaly.  Laboratory results are as follows:  Which of the following is the most likely cause of this patient's current symptoms?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c174_a3e2_8f63_579eb6645d05_MD0005_00 This patient with a history of multiple sexual partners and rare condom use likely has acute retroviral syndrome due to a recently acquired HIV infection. Although many patients are asymptomatic, dramatic early elevations in viral load often result in transient manifestations 2-4 weeks after inoculation. Symptoms can closely resemble infectious mononucleosis and commonly include fever, nontender lymphadenopathy, sore throat, headache, fatigue, and myalgia. Two distinctive features are a painful mucocutaneous ulcer (shallow, discrete, white base) and a generalized maculopapular rash that may include the palms and soles. Laboratory testing often shows leukopenia and thrombocytopenia. Diagnosis is made with a combination of fourth-generation HIV serologic testing (HIV antigen plus HIV-1/HIV-2 antibody) and HIV viral load. Treatment with antiretroviral therapy (after resistance testing) reduces the reservoir of latent HIV and the risk of transmission to other individuals. (Choice B) Herpes simplex virus can cause fever, fatigue, and headache; however, patients typically have multiple ulcerating lesions and tender lymphadenopathy (unlike this patient). In addition, diffuse rash is uncommon. (Choice C) Infectious mononucleosis (Epstein-Barr virus, cytomegalovirus) can cause fever, lymphadenopathy, fatigue, and sore throat. Mucocutaneous ulceration and a maculopapular rash that includes the palms and soles are quite uncommon. (Choice D) Influenza often manifests with fever, fatigue, myalgias, sore throat, and headache. However, influenza is a respiratory infection typically associated with respiratory tract symptoms such as cough and nasal congestion (unlike this patient). (Choice E) Secondary syphilis can cause fever, headache, nontender lymphadenopathy, fatigue, and a maculopapular rash that includes the palms and soles. A single, painful mucocutaneous lesion would be atypical (syphilitic chancres are nontender and a marker of primary syphilis). Educational objective: Acute retroviral syndrome may occur 2-4 weeks after HIV infection. Symptoms are often nonspecific and include fever, nontender lymphadenopathy, sore throat, headache, fatigue, and myalgia. Suspicion should be raised in those with a painful mucocutaneous lesion or widespread maculopapular rash (that may include the palms and soles).

A 24-Year-Old Man Comes to the Clinic Because He "Feels