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Acute Human Immunodeficiency Virus Syndrome in an Adolescent

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Acute Human Immunodeficiency Virus Syndrome in an Adolescent Acute Human Immunodeficiency Virus Syndrome in an Adolescent Mridula Aggarwal, MD, and Jeffrey Rein, MD ABSTRACT. Acute human immunodeficiency virus primary care physicians for adolescents who present (HIV) seroconversion illness is a difficult diagnosis to with a viral syndrome and appropriate risk factors. Pe- make because of its nonspecific and protean manifesta- diatrics 2003;112:e323–e324. URL: http://www.pediatrics. tions. We present such a case in an adolescent. A 15-year- org/cgi/content/full/112/4/e323; adolescent, human immu- old boy presented with a 5-day history of fever, sore nodeficiency virus, acute disease, seroconversion, diagnosis. throat, vomiting, and diarrhea. The patient also reported a nonproductive cough, coryza, and fatigue. The patient’s only risk factor for HIV infection was a history of unpro- ABBREVIATIONS. HIV, human immunodeficiency virus; PCR, tected intercourse with 5 girls. Physical examination was polymerase chain reaction. significant for fever, exudative tonsillopharyngitis, shotty cervical lymphadenopathy, and palpable purpura CASE REPORT on both feet. Laboratory studies demonstrated lym- 15-year-old boy without significant medical history pre- phopenia and mild thrombocytopenia. Hemoglobin, se- sented with a 5-day history of fever, sore throat, vomit- rum creatinine, and urinalysis were normal. The follow- ing, and diarrhea. The patient also reported a nonpro- Aductive nocturnal cough, coryza, and fatigue. His mother noted a ing day, the patient remained febrile. Physical examination revealed oral ulcerations, conjunctivitis, and pedal rash for 1 day. He denied recent travel, night sweats, ar- thralgias, dysuria and penile discharge, and sick contacts. On erythematous papules on the thorax; the purpura was physical examination, the patient was a thin, well-appearing boy unchanged. Serologies for hepatitis B, syphilis, HIV, and with a fever of 38.6°C, an ornamental stud through an otherwise Epstein-Barr virus were negative. Bacterial cultures of normal tongue, exudative tonsillopharyngitis, a supple neck, and blood and stool and viral cultures of throat and conjunc- shotty cervical lymphadenopathy. The cardiac, pulmonary, and tiva showed no pathogens. Coagulation profile and liver abdominal examinations were normal except for guaiac positive enzymes were normal. Within 1 week, all symptoms had brown stool with mild perianal excoriations. The patient had resolved. The platelet count normalized. Repeat HIV se- linear palpable purpura tracing the plantar-volar junction of both rology was positive, as was HIV DNA polymerase chain feet. Laboratory values included a leukocyte count of 3500 cells/ mm3 with 63% neutrophils, 25% lymphocytes with rare atypia, reaction. Subsequent HIV viral load was 350 000, and the 3 3 11% monocytes, and a platelet count of 100 000/mm . Hemoglo- CD4 lymphocyte count was 351/mm . HIV is the seventh bin, serum creatinine, and urinalysis were normal. leading cause of death among people aged 15 to 24 in the Although unaccompanied by his mother, the patient denied United States, and up to half of all new infections occur intravenous drug use, homosexual contact, and sex with prosti- in adolescents. Our patient presented with many of the tutes. He reported a lifetime history of unprotected intercourse typical signs and symptoms of acute HIV infection: fever, with 5 girls. fatigue, rash, pharyngitis, lymphadenopathy, oral ulcers, At follow-up examination the next day, the patient remained emesis, and diarrhea. Other symptoms commonly re- febrile, with persistent sore throat. The diarrhea had resolved. ported include headache, myalgias, arthralgias, aseptic Physical examination revealed resolution of tonsillopharyngitis, meningitis, peripheral neuropathy, thrush, weight loss, presence of several 2-mm ulcerations on the hard and soft palate, bilateral conjunctivitis, scattered erythematous, and blanching night sweats, and genital ulcers. Common seroconver- 5-mm papules on the thorax; the purpura was unchanged. Addi- sion laboratory findings include leukopenia, thrombocy- tional laboratory studies revealed negative serologies for hepatitis topenia, and elevated transaminases. The suspicion of A and B, syphilis, HIV, and Epstein-Barr virus; HIV DNA poly- acute HIV illness should prompt virologic and serologic merase chain reaction (PCR) and hepatitis C serology were un- analysis. Initial serology is usually negative. Diagnosis available. Bacterial cultures of blood and stool and viral cultures of therefore depends on direct detection of the virus, by throat and conjunctiva showed no pathogens. Throat culture dem- assay of viral load (HIV RNA), DNA polymerase chain onstrated ␤-hemolytic nongroup A streptococci, for which the reaction, or p24 antigen. Both false-positive and false- patient was treated. Coagulation profile and liver enzymes were negative results for these tests have been reported, fur- normal. Biopsy of a papule revealed lichenoid dermatitis, consis- tent with a viral exanthem. Blood counts were unchanged but for ther complicating early diagnosis. Pediatricians should a platelet count of 83 000/mm3. The erythrocyte sedimentation play an active role in identifying HIV-infected patients. rate was 17 mm/h. Our case, the first report of acute HIV illness in an During the following week, the patient’s fever, purpura, and adolescent, emphasizes that clinicians should consider papular rash resolved. The platelet count returned to normal. acute HIV seroconversion in the appropriate setting. Rec- Repeat HIV serology was positive, as was HIV DNA PCR. Subse- ognition of acute HIV syndrome is especially important quent HIV viral load was 350 000, and the CD4 lymphocyte count for improving prognosis and limiting transmission. It is was 351/mm3. imperative that we maintain a high index of suspicion as DISCUSSION HIV is the seventh leading cause of death among From the El Rio Health Center, Tucson, Arizona. people aged 15 to 24 in the United States.1 Although Received for publication Apr 17, 2003; accepted Jun 18, 2003. some HIV-related sexual risk behaviors among high Reprint requests to (M.A.) El Rio Health Center, 839 W. Congress St, 2 Tucson, AZ 85745. E-mail: [email protected] school students are decreasing, up to half of all new 3 PEDIATRICS (ISSN 0031 4005). Copyright © 2003 by the American Acad- infections occur in adolescents. emy of Pediatrics. This patient presented with a febrile, multisystem http://www.pediatrics.org/cgi/content/full/112/4/Downloaded from www.aappublications.org/newse323 byPEDIATRICS guest on September Vol. 25, 112 2021 No. 4 October 2003 e323 syndrome with a polymorphous eruption. In the ap- those at risk, such as sexually active adolescents.10,11 propriate setting, clinicians should always consider Recognition of acute HIV syndrome may be espe- acute HIV seroconversion. Our patient presented cially important. Early initiation of appropriate anti- with many of the typical signs and symptoms of retroviral therapy improves surrogate markers of acute HIV infection: fever, fatigue, pharyngitis, disease progression12 and should be considered for lymphadenopathy, oral ulcers, nausea, emesis, and all patients, optimally in a clinical trial.13 diarrhea. Although the rash of HIV seroconversion is classically described as a macular or morbilliform CONCLUSIONS eruption predominantly on the trunk, cutaneous vas- The nonspecific, mononucleosis-like symptoms of culitis has been described. Histopathology is consis- acute HIV infection make it an easy diagnosis to tent with a viral exanthem, as in this case.4 The miss. Data suggest that early diagnosis may affect 10-day time course of the patient’s illness is within morbidity and mortality. It is imperative that we the typical range of several days up to 10 weeks. maintain a high index of suspicion as physicians for Other symptoms commonly reported include head- adolescents who present with a viral syndrome and ache, myalgias, arthralgias, aseptic meningitis, pe- appropriate risk factors. ripheral neuropathy, thrush, weight loss, night REFERENCES sweats, and genital ulcers. Mucocutaneous ulcer- 5 1. Trends in HIV-related sexual risk behaviors among high school stu- ation is highly suggestive of acute HIV infection. dents—selected U.S. cities, 1991–1997. MMWR Morb Mortal Wkly Rep. These symptoms are similar to those of other ill- 1999;48:440–443 nesses such as infectious mononucleosis, acute hep- 2. Trends in sexual risk behaviors among high school students—United atitis, roseola and other viral illnesses, secondary States, 1991–2001. MMWR Morb Mortal Wkly Rep. 2002;51:856–859 3. Futterman D, Chabon B, Hoffman ND. HIV and AIDS in adolescents. syphilis, and toxoplasmosis. Of note in one study, 2% Pediatr Clin North Am. 2000;47:171–188 of heterophil antibody-positive blood samples were 4. Balslev E, Thomsen HK, Weisman K. Histopathology of acute human HIV RNA positive, with half of these representing immunodeficiency virus exanthema. J Clin Pathol. 1990;43:201–202 acute HIV infection.6 The common seroconversion 5. Kahn JO, Walker BD. Acute human immunodeficiency virus type 1 infection. N Engl J Med. 1998;339:33–39 laboratory findings of leukopenia and thrombocyto- 6. Rosenberg E, Caliendo AM, Walker BD. Acute HIV infection among penia were present in our patient. Another common patients tested for mononucleosis. N Engl J Med. 1999;340:969 abnormality, absent in this case, is elevation of he- 7. Rich JD, Merriman NA, Mylonakis E, et al. Misdiagnosis of HIV infec- patic enzymes.5 Our finding of atypical
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