Infection for PLAB 1

A 27 year old man has a fever, a widespread maculopapular rash, a sore throat, mouth ulcers and tender cervical lymphadenopathy for five days. He had unprotected sex with a new partner three weeks ago. His Monospot is negative. He feels systemically unwell but is haemodynamically stable. What is the SINGLE most likely diagnosis?

1. Infectious mononucleosis (including Epstein-Barr virus) Fever, sore throat and lymphadenopathy with atypical lymphocytes, and it is the classic mimic of seroconversion. A seroconversion illness three weeks after unprotected sex with a negative Monospot makes an HIV test necessary.
2. Cerebral toxoplasmosis Focal neurology and headache with ring-enhancing lesions on imaging, at a CD4 below 100. A seroconversion illness three weeks after unprotected sex with a negative Monospot raises it.
3. Human immunodeficiency virus (HIV) correct Correct. A glandular-fever-like illness with rash and mouth ulcers, a negative Monospot, and a clear recent exposure. Acute seroconversion is the diagnosis most often missed because it looks like a viral sore throat.
4. Seroconversion illness Fever, maculopapular rash, pharyngitis, mouth ulcers and lymphadenopathy two to four weeks after exposure. A seroconversion illness three weeks after unprotected sex with a negative Monospot describes it.
5. Pneumocystis pneumonia Progressive breathlessness with a dry cough and marked desaturation on exertion, out of proportion to a near-normal chest film. A seroconversion illness three weeks after unprotected sex with a negative Monospot points to it.

The point: Offer an HIV test far more widely than feels necessary: to everyone registering with a GP or admitted in a high-prevalence area, to anyone with an indicator condition, and to anyone who asks. A fourth-generation combined antigen-antibody test detects infection from about four weeks, and it is repeated at twelve weeks after a specific exposure to exclude it. Seroconversion is a glandular-fever-like illness with fever, rash, sore throat and lymphadenopathy, and it is the moment the diagnosis is most often missed. Start antiretroviral therapy in everyone regardless of CD4 count, and the CD4 count then defines the risk of opportunistic infection: Pneumocystis pneumonia below 200, with prophylaxis at that threshold, and cerebral toxoplasmosis and cryptococcal disease lower still. Post-exposure prophylaxis is started within 72 hours and pre-exposure prophylaxis is offered to those at ongoing risk. Consent is the patient's alone, and results are confidential.

Source: BHIVA — Guidelines for the routine investigation and monitoring of adult HIV-1-positive individuals British HIV Association · tier 2, specialty society or college

A 27 year old man has a fever, a widespread maculopapular rash, a sore throat, mouth ulcers and tender cervical lymphadenopathy for five days. He had unprotected sex with a new partner three weeks ago. His Monospot is negative. He feels systemically unwell but is haemodynamically stable. What is the SINGLE most appropriate initial investigation?

1. Screen for coinfection and other sexually transmitted infections Hepatitis B, hepatitis C, syphilis and the rest, because they cluster and change management. A seroconversion illness three weeks after unprotected sex with a negative Monospot makes it worthwhile.
2. Chest radiograph and induced sputum For respiratory symptoms, though the film is frequently near-normal in Pneumocystis pneumonia. A seroconversion illness three weeks after unprotected sex with a negative Monospot makes it appropriate.
3. CD4 count and HIV viral load The CD4 stages the immunodeficiency and predicts opportunistic infection; the viral load guides treatment response. A seroconversion illness three weeks after unprotected sex with a negative Monospot makes them essential.
4. HIV RNA (viral load) in suspected seroconversion correct Correct. At three weeks the antigen-antibody test may still be negative, but the viral load is very high in acute infection and detects it before antibodies appear.
5. Repeat the test at 12 weeks after a specific exposure The window period means a negative test before twelve weeks does not exclude infection after a known exposure. A seroconversion illness three weeks after unprotected sex with a negative Monospot makes the timing matter.

The point: Offer an HIV test far more widely than feels necessary: to everyone registering with a GP or admitted in a high-prevalence area, to anyone with an indicator condition, and to anyone who asks. A fourth-generation combined antigen-antibody test detects infection from about four weeks, and it is repeated at twelve weeks after a specific exposure to exclude it. Seroconversion is a glandular-fever-like illness with fever, rash, sore throat and lymphadenopathy, and it is the moment the diagnosis is most often missed. Start antiretroviral therapy in everyone regardless of CD4 count, and the CD4 count then defines the risk of opportunistic infection: Pneumocystis pneumonia below 200, with prophylaxis at that threshold, and cerebral toxoplasmosis and cryptococcal disease lower still. Post-exposure prophylaxis is started within 72 hours and pre-exposure prophylaxis is offered to those at ongoing risk. Consent is the patient's alone, and results are confidential.

Source: BHIVA — Guidelines for the routine investigation and monitoring of adult HIV-1-positive individuals British HIV Association · tier 2, specialty society or college

A 27 year old man has a fever, a widespread maculopapular rash, a sore throat, mouth ulcers and tender cervical lymphadenopathy for five days. He had unprotected sex with a new partner three weeks ago. His Monospot is negative. He feels systemically unwell but is haemodynamically stable. What is the SINGLE most appropriate immediate management?

1. Pyrimethamine and sulfadiazine for cerebral toxoplasmosis Empirical treatment with a response confirming the diagnosis, alongside steroid for mass effect. A seroconversion illness three weeks after unprotected sex with a negative Monospot makes it appropriate.
2. Start antiretroviral therapy regardless of CD4 count Everyone is treated now, whatever the CD4. Starting in acute infection also reduces the size of the viral reservoir, and a seroconversion illness three weeks after unprotected sex with a negative Monospot here points elsewhere.
3. Post-exposure prophylaxis within 72 hours A 28 day course after a significant exposure, and the sooner it is started the more effective it is. A seroconversion illness three weeks after unprotected sex with a negative Monospot makes the clock the point.
4. Refer to the HIV specialist service correct Correct. Diagnosis, staging and treatment are led by the specialist team, who also handle partner notification confidentially.
5. Notify partners with the patient's consent Through the specialist service, and it is confidential and consensual rather than mandatory disclosure. A seroconversion illness three weeks after unprotected sex with a negative Monospot makes it careful.

The point: Offer an HIV test far more widely than feels necessary: to everyone registering with a GP or admitted in a high-prevalence area, to anyone with an indicator condition, and to anyone who asks. A fourth-generation combined antigen-antibody test detects infection from about four weeks, and it is repeated at twelve weeks after a specific exposure to exclude it. Seroconversion is a glandular-fever-like illness with fever, rash, sore throat and lymphadenopathy, and it is the moment the diagnosis is most often missed. Start antiretroviral therapy in everyone regardless of CD4 count, and the CD4 count then defines the risk of opportunistic infection: Pneumocystis pneumonia below 200, with prophylaxis at that threshold, and cerebral toxoplasmosis and cryptococcal disease lower still. Post-exposure prophylaxis is started within 72 hours and pre-exposure prophylaxis is offered to those at ongoing risk. Consent is the patient's alone, and results are confidential.

Source: BHIVA — Guidelines for the routine investigation and monitoring of adult HIV-1-positive individuals British HIV Association · tier 2, specialty society or college