Acute Retroviral Syndrome

Acute Retroviral Syndrome is the symptomatic presentation of acute human immunodeficiency virus infection



 • Presents as a mononucleosis/flu type of syndrome with a constellation of nonspecific symptoms

 • >50,000 HIV infections occur annually in the US

 • 10 to 60% - No symptoms

 • Time: 2-4 weeks from exposure to symptoms

 • May last days or weeks

 • Virus infects wide variety of tissues, seeds the lymphoid organs

 • Symptoms of primary HIV typically begin within 28 days of infection



Acute Retroviral Syndrome Symptoms:

 • Headache (45%)

 • Fever (75%)

 • Encephalopathy (25%)

 • Fatigue (68%)

 • Lymphadenopathy (39%)

 • Photophobia (24%)

 • Mouth ulcers

 • Sore throat (40%)

 • Night sweats (28%)

 • Skin rash (48%)

 • Hepatomegaly - Liver enzyme elevation

 • Nausea, vomiting, diarrhea (27%)

 • Myalgias, Arthralgias (49%)

 • Weight loss (>5 lb; 2.5 kg) (32%)



Atypical Presentations:

 • Opportunistic infections - rare during transient CD4 lymphopenia of early HIV infection 

	- Most common: Oral and esophageal candidiasis

 • Central nervous system manifestations



Labs:

 • CD4+ T-cell count can decrease (<200 cells per microliter or <14%), in which case opportunistic infections can develop

 • Viral RNA level ↑

 • Leukocyte-lymphocyte subset counts ↓

 • Liver enzymes ↑

 • Mild anemia

 • Thrombocytopenia



Neuro - Aseptic Meningitis:

 • >1 in 10 patients have symptoms

 • Severe headache, meningismus

 • Photophobia

 • Lymphocytic pleocytosis on cerebrospinal fluid



DDX:

 • Epstein-Barr virus (EBV)

 • Cytomegalovirus (CMV)

 • Toxoplasmosis

 • Rubella

 • Syphilis

 • New onset SLE

 • Disseminated gonococcal infection

 • Viral hepatitis



Diagnosis:

Fourth-generation HIV-1/2 Immunoassay

 • Detects both HIV antibody and HIV p24 antigen

 • Identify acute/early infection in up to 80% of patients

 • HIV-1 p24 core Ag - Detects 17-20 days after exposure

 • Antibodies to HIV-1 and HIV-2

 • HIV-1 RNA viral load

Confirmatory Tests:

 • HIV-1/HIV-2 differentiation immunoassay

 • If differentiation IA is indeterminant - then an HIV Nucleic Acid test is necessary



Eclipse Phase:

 • The short interval following HIV acquisition in which no diagnostic test is capable of detecting HIV for 10-12 days.

 • HIV RNA is the first test to detect HIV (10 days after initial HIV-1 acquisition,)

 • 17-20 days after exposure: HIV p24 antigen detected

 • 21 to 25 days after exposure, HIV-1 or HIV-2 antibodies can be detected (IgG/IgM-sensitive HIV-1 antibody test)



Treatment:

 • ART to slow HIV disease progression by slowing CD4 decline and reducing HIV RNA levels.



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