Postgrad Med J: first published as 10.1136/pgmj.67.783.92 on 1 January 1991. Downloaded from

Postgrad Med J (1991) 67, 92 - 93 © The Fellowship of Postgraduate Medicine, 1991

A typhus-like illness caused by acute HIV seroconversion M. Gary Brook, Amanda Barnes, Gordon C. Cook and David C.W. Mabey Department ofClinical Tropical Medicine, The Hospital For Tropical Diseases, 4 St Pancras Way, London NW) OPE, UK.

Summary: A patient is described in whom an acute human immunodeficiency vwirus seroconversion illness occurred following a trip to southern Africa. The presentation was strikingly similar to that of African tick typhus and could only be distinguished by serological testing.

Introduction The worldwide incidence of heterosexually trans- ofhis illness; the rash and ulcers disappeared 2 and mitted human immunodeficiency virus (HIV) 5 days later, respectively. Subsequent investiga- infection' and the scale of foreign travel are both tions showed him to be HIV-1 p24 antigen positive increasing. The following case illustrates one con- and anti-HIV-I and -II antibody negative during sequence of these developments. this episode; 2 months later the anti-HIV-1 antibody test became positive. Investigations for all other likely pathogens including rickettsiae, Case report arboviruses, cytomegalovirus and enteroviruses by copyright. were negative. A 27 year old Europid man was admitted with a 2 day history offever and a rash of 1 day's duration. These symptoms had developed immediately after return from a 5 month visit to Zimbabwe, Bots- wana and South Africa. He had spent a great deal of this time in rural areas, suffering frequent insect bites, until just before his return. He also admitted to vaginal intercourse with several women but http://pmj.bmj.com/ using condoms on each occasion. His last sexual contact was 10 days before this illness. On examin- ation he was febrile (39°C), had multiple small palatal ulcers, a generalized erythematous maculo- papular rash (Figure 1), bilateral inguinal lymph- adenopathy and a 5 mm diameter non-tender ulcer of the glans penis. A clinical diagnosis of tick typhus in addition to primary syphilis seemed on September 24, 2021 by guest. Protected likely. Initial laboratory investigations included a total white blood cell count of2.2 x I09/l (29% lympho- cytes) and a platelet count of (85 x 109/l); dark ground microscopy of the penile ulcer exudate revealed Treponema pallidum. Treponema pallidum haemagglutination assay (excluding secondary syphilis), a malaria film of peripheral blood and monospot test for Epstein-Barr virus were nega- tive. A 10 day course ofprocaine penicillin (600 mg intramuscularly daily) was prescribed for his pri- mary syphilis. He became afebrile on the fifth day Correspondence: M.G. Brook, M.R.C.P., Coppetts Wood Hospital, Coppetts Road, London N1OIJN, UK. Accepted: 9 July 1990 Figure 1 The rash on the second day. Postgrad Med J: first published as 10.1136/pgmj.67.783.92 on 1 January 1991. Downloaded from

CLINICAL REPORTS 93

Discussion The association of high fever, lymphadenopathy, undergo a seroconversion illness (CDC stage 1) and a generalized maculo-papular rash in a man vary from rare to very common.3'4 A glandular who has recently returned from rural southern fever-like illness, which may include a rash, is the Africa strongly suggests tick typhus; this can only most frequently recognized manifestation of this be confirmed retrospectively by a serological test.2 event.4'5 The sexual history and co-existent primary syphilis We suggest that an HIV seroconversion illness led us, however, to suspect other sexually transmit- should be considered in the differential diagnosis of ted diseases. The final diagnosis was established by any acute febrile condition which is accompanied a HIV-l p24 antigen assay; this test is not available by a maculo-papular rash in a sexually active adult in the majority of African countries. Estimates of travelling to or living in the tropics. the proportion of HIV-1 infected patients who

References 1. Chin, J. & Mann, J. Global surveillance and forecasting of 4. Tindall, B., Barker, S., Donovan, B. et al. Characterisation of AIDS. Bull WHO 1989, 67: 1-7. the acute clinical illness associated with human immunode- 2. Woodward, T.E. Rickettsial diseases. In: Weatherall, D.J., ficiency virus infection. Arch Intern Med 1988, 148: 945-949. Ledingham, J.C. & Warrell, D.A. (eds) Oxford Textbook of 5. Gaines, H., Von-Sydow, M., Pehrson, P.O. & Lundbergh, P. Medicine, Vol. 2. Oxford University Press, Oxford, 1987, Clinical picture of primary HIV infection presenting as a pp. 341-355. glandular-fever-like illness. Br Med J 1988, 297: 1363-1368. 3. Weber, J.N., Wadsworth, J., Rogers, L.A. et al. Three-year prospective study of HTLV-III/LAV infection in homosexual men. Lancet 1986, 1: 1179-1182. by copyright. http://pmj.bmj.com/ on September 24, 2021 by guest. Protected