A 23 year old male presented himself to an urgent care center with urethral disc

Question

A 23 year old male presented himself to an urgent care center with urethral discharge and a red rash on his feet and forearms. He stated that he had had unprotected sex with a prostitute within the past 2 weeks. He was treated empirically for chlamydia, gonorrhea(GC), and Rocky Mountain spotted fever (RMSF). The following laboraty tests were ordered: Chlamydia/GD PCR; RPR; serology testing for RMSF; hepatitis B, C; and HIV. All test results were negative except for Chlamydia PCR. Fourteen days later, the patient presents to an infectious disease clinic with a headache, a fever of 38.1 °C. nausea and vomiting, myalgia, 2 weeks of fatique and mouth ulcers, and a 10 lb weight loss within the past 3 weeks. Laboratory tests at this time reveal the patient is lymphocytopenic, and his liver function enzymes are slightly elevated.

What is the most likely diagnosis of this patient: chlamydia, HIV, HSV, syphilis, hepatitis B or C?

What laboratory test would you like repeated on the second visit, and why?

What molecular test could have been ordered on the patient’s first visit that may have likely been able to provide a diagnosis for him?

Explanation / Answer

The most likely diagnosis of the patient is HIV. HIV infects the CD4+ T lymphocytes and destroys them. This results in a reduction in the peripheral blood lymphocyte count and this condition is termed as lymphocytopenia. Infection with HIV results in weight loss and also the liver function enzymes will be elevated.

Serology testing can be repeated on the second visit to detect for the presence of HIV antibodies in the patient’s serum. In a person infected with HIV, production of antibodies to HIV antigens occurs 6 weeks to 3 months after infection. This period is known as the window period, the time period between HIV infection and the production of antibodies in the infected person. This is the reason why serology testing can be repeated on the second visit.

Reverse transcriptase polymerase chain reaction (RT-PCR) molecular testing could have been ordered on the patient’s first visit to provide a diagnosis for him. Since HIV is an RNA virus RT-PCR could have been performed in the first visit to accurately confirm the infection.

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