A 29-year-old man presents with fever and generalised lymphadenopathy 3 weeks after returning from a beach holiday in South East Asia.
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1. What do you include in the differential diagnosis?
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Malaria should be excluded but is unlikely because of the incubation period and associated lymphadenopathy
Fever and lymphadenopathy is associated with Epstein–Barr virus, cytomegalovirus, rubella and an HIV seroconversion illness. Bacterial infections that could cause this include brucellosis, cat scratch disease and tuberculosis.
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2. What questions would you ask him?
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A detailed sexual history should be taken, specifically to find out if he has had unprotected sex with male or female partners while on holiday. He should also be asked about animal contact and consumption of undercooked animal products and dairy products, such as unpasteurised milk or cheese.
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3. His HIV screening test is negative - what do you do?
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An HIV ELISA/Western blot test is often negative during the acute seroconversion period of infection but becomes positive over the next 3 months. However NAAT to detect HIV RNA (viral load) will be positive in patients with acute HIV infection. The lymphocyte count may be lower than normal. You should also measure the CD4 count, which may be low but usually improves 1–2 months after acute infection. The HIV test should be repeated after 12 weeks to exclude infection
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4. If a patient reports a known exposure what precautions might you take?
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Postexposure prophylaxis can be offered to people who have had unprotected sexual contact or a needle-stick injury from a known or potential HIV-positive source. This is most effective when given as close as possible to the time of exposure, preferably within 30 minutes.
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5. What other blood-borne viruses might a patient such as this have been exposed to?
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Hepatitis B and C are both prevalent in SE Asia and associated with transmission following sexual contact. He should be offered hepatitis B vaccine and testing for hepatitis C with counselling.
