ANSWER 78
This seems likely to be an infective problem which has gone on for over a week. The
length of the history makes influenza unlikely. The other positive features are the cervical
lymphadenopathy and the oral ulceration. The temperature is still up and there has been
a rash which has resolved. The blood results are all normal including the test for glandu-
lar fever (infectious mononucleosis) which was a reasonable diagnosis with these features.
The previous homosexual contact increases the possibility of sexually transmitted infec-
tions. It is possible that travel to Vietnam and Thailand may have been associated with
high-risk sexual exposure. He is known to have had a negative HIV test 12 months ago.
However, it is quite possible that this might be an HIV seroconversion illness. In around
half of those who acquire the virus this occurs within 4–6 weeks of acquisition. Although
the HIV test will still be negative, this can be diagnosed by finding the presence of the HIV
virus or its p24 antigen in the blood. He should have been counselled about precautions
to reduce the risk of transmission of sexually transmitted diseases at the time of the HIV
testing 12 months before.
The picture might fit for secondary syphilis which occurs 6–8 weeks after the primary
lesion. However, in that case the rash would often be more extensive and the lymph nodes
are not usually tender. A serological test for syphilis should certainly be performed.
Other viral illnesses are possible. Hepatitis may present with this more general prodrome but
the normal liver function tests make this much less likely. Lymphoma can present with lym-
phadenopathy and fever but the oral ulceration and the rash are not typical of lymphoma. If
the serological tests proved negative, lymph node biopsy might be considered.
In this case, tests for an HIV viraemia were positive. Antiretroviral treatment at the time
of known or high-risk exposure is useful in reducing the risk of infection. At this stage,
treatment is supportive with explanation and arrangements for monitoring of viral load.
- A seroconversion illness occurs in around 50 per cent of those acquiring HIV infection.
The severity varies. - In cases of known or high-risk exposure, such as needlestick injuries, an immediate
course of antiretroviral treatment is often indicated. Immediate advice should be sought.