Medical Mystery of the Week

 You have recieved your COVID19 immunizations and are practicing traditional medicine.
 Your case is a 63 year-old woman who presented with fever, chills, myalgias, headache, sore throat, odynophagia, and mild confusion of two weeks duration.
      On your exam, her temperature is 38.9°C, pulse 96 beats per minute, blood pressure 160/80 mm Hg, and respirations 20 breaths per minute. Her body mass index is 29.9. Pertinent findings include a small tender lymph node in the left posterior cervical chain. On neurologic examination she is alert and oriented but unable to perform simple calculations, to list the days of the week in reverse order, or to follow two-step commands. The rest of your exam is unremarkable.
      Her pertinent lab findings include a wbc count of 3700 with 2290 neutrophils, 1320 lymphocytes, and 60 monocytes, a SGPT of 280 U/l, a SGOT of 235 U/l, an alkaline phosphatase of 205 U/l, and a lactic dehydrogenase of 466 U/l. Her CSF is clear and colorless with 201 mg/dl protein, 43 mg/dl glucose, and 73 wbc/ul (65% lymphocytes, 29% plasma cells, 6% monocytes). No organisms are seen on Gram's stain.
      A chest x-ray is read as normal. A CT of the abdomen with IV contrast shows prominent gastrohepatic, periportal, periaortic, and inguinal lymph nodes. A MRI of her head shows multifocal patchy hyperintensities in the cerebral white matter bilaterally.
      What is your diagnosis, what test(s) would you order to confirm your suspicions, and what treatment, if any, do you recommend?
DIAGNOSIS: Acute human immunodeficiency virus type 1 infection.
      Although the majority of HIV infections in the United States occur in men who have sex with men, in 2018, 19% of new cases were reported in heterosexual women with 60% of these occurring in women older than 35 years of age. The presented case had unprotected sex with a new male partner 1 week before the onset of symptoms.
      Patients with acute HIV infection often present with diffuse lymphadenopathy and neurological manifestations including "aseptic" meningitis and/or encephalitis (∼10%). Chronic infection with HIV can cause a variety of neurologic manifestations including dementia, chronic meningitis, autonomic neuropathy, and vacuolar myelopathy.
      Passage of  HIV-infected macrophages through the blood brain barrier plays a pivotal role both in initiating and in sustaining CNS infection.
      Current antiretroviral therapies (ARTs) have drastically reduced the incidence of CNS complications; however, a minimal viral replication can persist and cause neurocognitive deficits in treated individuals.
      The diagnosis of HIV infection is established by performing a HIV-1 nucleic acid assay (RNA copies/ml)(positive by day 10 - coincides with onset of symptoms), a HIV p24 antigen-assay (positive ∼day 17), and HIV antibody assays (positive ∼day 22). Antigen assays are  confirmed by HIV-1 and HIV-2 lateral flow immunochromographic assays. The presented case had a HIV-1 RNA viral load of 8,420,000 copies/ml plasma and developed antibodies to four HIV-1 antigens.
      The patient  was treated with a daily bictegravir-emtrictabine-tenofir comination pill. Her symptoms resolved shortly after starting retroviral therapy. Her case demonstrates the importance of obtaining a sexual history on all patients.
      Cited article: Goldstein, R.H., Mehan, W.A., Hutchison, B., Robbins, G.K. Case 24-2021: A 63-year-old woman with fever, sore throat, and confusion. N.E.J.M. 385;7:641-648.