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How to complete my hiv workup?

Jul 29, 2012

Dear Dr. McGowan , I'm a 38 y male from the Middle East. Had a high-risk sexual encounter 2 years ago, followed by a negative Rapid EIA Blood-test done 3 months later. Since then have been relatively well except for a longer than usual URTI last winter. 11 weeks ago had an unexplained febrile disease, accompanied by drenching night sweats, moderate weight loss (from 73 to 68 kg) and oral thrush - lasting for 7 days in a row. Only after I had started a 10-day course of Azythromycin the high fever and night sweats faded away. The thrush, however, has remained ever since and does not respond well to Miconazole oral gel. In addition, I was able to regain only 2 kg (out of the 5 I had lost!). Alarmed by these highly suspicious symptoms I underwent two 4th generation ELISAs for HIV-1/2 and two PCR RNAs for HIV-1 (by Cobas TaqMan) which all came back negative and undetectable. Since there's no possibility to get a PCR DNA in my country (reserved only for newborns of HIV infected mothers) I ordered a CD4 count 6 weeks ago which showed: cd4 404 (ref 436-1394),cd4% 35 (ref 36-63), cd8 254 (ref 166-882), cd8% 22 (ref 15-40), cd4/cd8 1.59 (ref 1.5-3.3), CD 19% 7, CD56% 26. At the same time, serologies for other possible infections came back negative (CMV, HBV, HCV, HTLV-1, SYPHILIS, TOXO) or indicative for previous exposure (EBV). Decreasing PLT (from 200,000 to 144,000) and HDL (from 52 to 38) vs increasing Monocytes (up to 20% of total WBC) have also been documented. Based on all of these results I'm pretty sure I've got HIV, but now have to find a way to get it diagnosed asap. My questions: 1. What should be the next test to order? (I'll fly to Europe if needed..) 2. Would you recommend me to get tested for HIV-1 groups N and P as well (eventhough I haven't been intimate with someone from Africa)? 3. Is there justification for ordering a Resistance Test, as a last resort diagnostic tool? I don't want to lose precious time, and would like to start treatment as early as possible.Thank you for your time, G.

Response from Dr. McGowan

Dear G.

You do not need any further testing for HIV. That is clearly not the cause of your symptoms. All associated tests are negative. The CD4 count is NOT consistent with HIV infection. Lowered CD4 counts with HIV are associated with a relative drop in CD4 cells compared with CD8 cells, which you do not have (thanks for including all the counts). Also, it is not consistent with an "elite controller" with an undetectable viral load because those individuals have strong antibody responses and are HIV positive on the testing, which you are not.

So, work with your doctor to find out the cause of your symptoms, get a work up for tuberculosis, diabetes or perhaps an auto-immune cause of your symptoms. Would not focus time on HIV, which has been ruled out.

Good luck to you, Joe

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