Because of the COVID19 pandemic, you are practicing medicine by telemedicine. You are presented a case of a previously healthy 35-year-old single man who presented with a 5-day illness characterized by the onset of fever, lassitude, generalized myalgias, and a diffuse splotchy non-pruritic erythematous rash (see photo below). You are told he has generalized adenopathy but no hepatosplenomegaly. His physical is otherwise normal.
What is your diagnosis, what test(s) would you order to confirm your suspicions, and what treatment, if any, do you recommend?
DIAGNOSIS: Acute HIV-1 infection. About 80% of patients with acute HIV infection are symptomatic with a flu-like illness. In descending order of frequency from 80% to 20%, common symptoms include fever, myalgias and fatigue, headache, pharyngitis, GI symptoms, rash, weight loss, and arthraligias. Highly infected individuals may present with a variety of neurological manifestations, including stroke, Guillain-Barré syndrome, meningitis, encephalitis, and myelitis. Rashes are usually diffuse, erythematous and maculopapular as seen in the presented case. In addition to a rash, physical examination may reveal generalized adenopathy and mucosal ulcers.
Patients with suspected HIV infection should have blood drawn for a 4th generation HIV-1 p24 antigen-based immunoassay, which if positive, needs to be confirmed by a Western-Blot assay. Positive patients should have CD4+ T cell and viral counts and be placed on standard treatment.