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Physician to physician- desperate for your advice, best question you will ever have
Aug 29, 2003

Dr. Bob,

This is at least my 4th time writing to you. Please refer to my last e-mail for a more descriptive account of my situation. I will briefly summarize what has happened to me: I am an otherwise healthy physician in my mid 30s with a baseline TLC of 3700 over 2 years ago. Last fall I went to a "lingerie model" who masterbated for me and then within a minute took her finger which was covered with her vaginal secretions and fingered my ass up to the prostate. Four days later I developed a sore throat and 7 days post exposure a temperature of 99.7. I ordered a cd4 and HIV RNA on myself on day 9, and my cd4 came back at 288 (30) with the HIV- RNA negative. For the next 3 months I would have a Tmax of 99.5 in the afternoon. I have had 3 negative ELISAs out to 5.5 months, as well as numerous negative HIV-DNA, HIV-RNA, and p24 ag. However, my cd4 has ranged from the 288 to around 550, with the cd4 ranging from 30-36, and the cd4/cd8 ranging from 1.1 to 1.24 out to 7 months. I have seen an infectious disease specialist who attributes the low lymphocyte counts to stress, but I am unconvinced that stress alone could drop my TLC from 3700 to the 1000s. I am concerned that I have a rare strain or group that is not being picked up by any available test. Should I go to the CDC for additional testing? Believe me, I am completely rational, take care of many HIV patients myself, and am scared to death of my low cd4s. Please do not be afraid to answer this question and if you respond I would love to make a meaningful donation to your foundation.

Sincerely, worried physician

Response from Dr. Frascino

Hello Worried Physician,

I'm sorry, but I have no way of referencing your previous e-mail, which I'm sure is now buried among thousands of others. So I'll try to address the concerns you raise here.

I wonder a bit what type of physician you happen to be. First off, why are you ordering tests on yourself? I remember being taught by an old and crusty (but wizened) physician in medical school that "any physician who tries to diagnose and treat themselves has a fool for a patient and an idiot for a doctor." I think his point, though not elegantly stated, is indeed valid. We must not try to be our own physician.

So, let's look at your case rationally. Your exposure is masturbation and possibly having vaginal secretions on a finger that tickled your prostate. The risk of HIV transmission from this type of activity is nearly nonexistent. Your question sounds remarkably similar to several others that I have received, where the questioner was concerned that this activity carried essentially the same HIV transmission risk level as unprotected anal sex. This, of course, is certainly not the case.

Next, your symptoms. As a physician, I'm sure you realize that a "T max of 99.5" or even 99.7 is not at all significant. Also, a "sore throat" combined with this minimal temperature elevation is not suggestive of HIV seroconversion or acute retroviral syndrome. Again, this makes me wonder about your medical training and expertise.

Now, on to your laboratory tests. First off, you ordered the wrong tests. HIV RNA (PCR) should not be used as a screening test for HIV due to the possibility of false positive results. Second, why order a CD4 count 9 days after a possible HIV exposure? This makes absolutely no sense whatsoever. You have had "numerous negative HIV-DNA, HIV-RNA, p24 Ag, and ELISA tests out to 5.5 months". Again, I have to ask why? A single ELISA at 3 months would have been conclusive to establish your negative status. Your repeatedly negative (and excessive) HIV testing confirms and re-confirms your HIV-negative status. Of this, there can be no question. Rare strain? No, absolutely not.

Now, what about those CD4 counts? As a physician (are you really a physician?), you should be well aware that CD4 cells are involved in many things other than HIV disease. The normal CD4 circulating population in the peripheral blood can vary quite dramatically, reflecting what's going on with one's immune defenses. For instance, the "sore throat" you were experiencing at the time of your initial CD4 test may well have been a routine viral infection (not HIV), as most of these cases tend to be. These very common viral syndromes can transiently depress CD4 counts. Your count is now 550. That's normal. Could stress alter your immune counts? Yes, to some degree, but a drop in TLC from 3200 to 1000 is more likely to be a transient viral infection.

Should you go to the CDC for additional testing? Absolutely not.

You claim to be "completely rational." If so, then look at the facts rationally. 1. Risk exposure nearly nonexistent. 2. Excessive HIV testing (PCR, p24 Ag, and ELISA's) all negative. 3. Symptoms not suggestive of HIV. 4. Infectious Diseases specialist's opinion stress, not HIV.

"Rationally," what does that add up to? A "rare strain" or "very common anxiety?" You admit to being "scared to death of your low CD4's." Your CD4's aren't the problem; being "scared to death" is.

I don't know if you're really a physician or not (I have my doubts), but I hope you'll take this physician's advice and seek some counseling. You are clearly demonstrating an irrational fear of a disease you could not possibly have. If you truly do "take care of many HIV patients" yourself, I can only hope you show better judgment in their cases.

Good luck.

Dr. Bob



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