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Mr X and Mr Y

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  1. Case 4: July 2007 Mr X and Mr Y

  2. Case 4: July 2007 • 26 year-old Caucasian man • ‘Mr X’

  3. Case 4: July 2007 Presents to ED at 18:00 with: 1-day history of: • maculopapular rash to chest, face, arms and legs 3-day history of: • headache • neck stiffness • photophobia • diarrhoea and vomiting • arthralgia

  4. Case 4: July 2007 OE: • Pyrexia 39.8oC • Maculopapular rash over face, chest, limbs • Photophobic, no overt meningism • Routine bloods unremarkable • CT head / LP NAD • Treated to cover bacterial meningitis • Clinically improved and discharged home • No HIV test performed

  5. Case 4: July 2008 • 25 year-old British gay male • ‘Mr Y’

  6. Case 4: July 2008 Presents to ED with: • Headache • Neck stiffness • Fever • Maculopapular rash on face, chest, limbs • Nausea, vomiting • Cervical lymphadenopathy

  7. Case 4: July 2008 History: • Last sexual contact: • Regular Male Partner of 3 months (no condoms) • Previous contacts: • Casual Male Partner 5 months ago (condoms) • Casual Male Partner 8 months ago (condoms) • HIV-1 antibody test negative 3 months earlier

  8. Case 4: July 2008 Investigations: • Routine bloods unremarkable • HIV-1 antibody: weakly positive • HIV-1 antibody (detuned): suggestive of infection within 6 months • HIV RNA viral load 1,000,000 copies/ml • CD4 count 699 (9%)

  9. Case 4: summary • Both: viral type illness with meningism and rash • Mr Y’s Regular Male Partner of 3 months = Mr X • Mr X now tests positive for HIV Diagnoses: Mr Y: HIV seroconversion Mr X: ??HIV seroconversion

  10. Q: When could HIV testing have been recommended in this scenario? • When Mr X was admitted with aseptic meningitis without any apparent risk factors? • When Mr Y was admitted with aseptic meningitis with a history of sex with other men? • Should they have been referred on discharge to GUM to see a trained counsellor before HIV testing?

  11. Who can test?

  12. Who can test?

  13. Who to test?

  14. Who to test?

  15. Who to test?

  16. Q: What kind of tests should have been used to diagnose seroconversion illness? • Rapid test? • 3rd generation antibody test? • 4th generation antigen/antibody test? • PCR (viral load)?

  17. Which test to use?

  18. Case 4: summary • Both: viral type illness with meningism and rash • Mr Y’s Regular Male Partner of 3 months = Mr X • Mr X now tests positive for HIV Diagnoses: Mr Y: HIV seroconversion Mr X: ??HIV seroconversion Was Mr Y’s HIV infection preventable?

  19. Learning Points • Primary HIV Infection is easily missed – have a low index of suspicion on presentation of PUO, meningism and rash in adults • During PHI viral load is extremely high making the patient highly infectious • Some patients may not disclose that they have put themselves at risk of HIV infection in the past • A perceived lack of risk should not deter you from offering a test when clinically indicated

  20. Key messages • Antiretroviral therapy (ART) has transformed treatment of HIV infection • The benefits of early diagnosis of HIV are well recognised - not offering HIV testing represents a missed opportunity • UK guidelines recommend universal HIV testing for patients from groups at higher risk of HIV infection • Primary HIV Infection is a unique opportunity to diagnose HIV as the patient’s next HIV-related presentation may be at a late stage of infection

  21. Also contains UK National Guidelines for HIV Testing 2008 from BASHH/BHIVA/BIS Available from: enquiries@medfash.bma.org.uk or 020 7383 6345