A patient arrives at the Er with the following symptoms: High fever, headache, s

Question

A patient arrives at the Er with the following symptoms: High fever, headache, severe body ache, and congestion. You suppose it is influenza since it is flu season and the patient was not vaccinated. In a subsequent visit 15 days later, the symptoms progressed as follows: all the symptoms above, plus sore indicating HPV all over the body. As a physician, you suspect that the patient is HIV positive.

What hypothesis can you formulate regarding the order of infection of all three viruses (with rationale)?

How can you test both the presence and order of infection of all three viruses?

Explanation / Answer

The probable order of infection of all the three viruses are HPV followed by HIV and lastly the Flu virus.

The rationale behind this hypothesis is that people having a STD (Sexually Transmitted Disease; HPV is one of the common sexually transmitted virus) may have a sore or break in the skin; this allows the HIV to enter the body (Normal or unbroken skin is a good barrier to HIV). Once the patient is infected by HIV, his immune system - mainly the cell-mediated immunity (HIV infects the CD4+ T Helper cells predominantly) became weaker gradually, leaving the patient vulnerable to opportunistic infections, in this case- the Flu virus. Also, on the onset of HIV infection, affected people develop flu-like symptoms.

DETECTION OF THE PRESENCE OF THE VIRUSES:

HPV: HPV infection is a subclinical infection i.e. it does not manifest the symptoms readily upon infection. So, testing for HPV is difficult. Generally presence of genital warts may be an indication of HPV infection,- this is followed by a Pap test (Detection of cervical cancer) or a DNA detection test. A swab of cells are taken from the cervix ( in case of females) and the DNA from the cells are extracted and analyzed for the presence of HPV DNA.

HIV: Presence of HIV can be detected by ELISA. If the patient is infected by HIV, then presence of anti-HIV antibodies are being detected by ELISA. Patient blood samples are added to microplate wells coated with HIV antigen, incubated and then washed. Next, wells are incubated with enzyme conjugate ( Antibodies specific for anti-HIV conjugated with HorseRadish Peroxidase enzyme), washed, and treated with appropriate chromogenic substrate (ABTS) that changes to green if patient's serum is positive for HIV antibody.

Influenza virus: It can be detected by RT-PCR methods, where the mRNA (transcriptome) of the cells of the upper respiratory tract of the patient is isolated, subjected to reverse transcription & then screened for the presence of Influenza virus specific nucleic acid via PCR with specific designed primers.

Order of viruses acquired-

On the onset of HIV infection, affected people develop flu-like symptoms; at that time, large number of viruses are being produced in the body- so a large viral anti-titre detected in ELISA for HIV may indicate the recent acquiring of the HIv and the subsequent flu.

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