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Healthcare exposure - need specialist advice
Sep 11, 2007

Dear Dr Bob, I am an intern who got stuck while trying to place a central line in a severly ill pt during a code (which the pt did not survive). The pt was cachectic, had very poor prior healthcare, and on this hospitalization was diagnosed with systemic CMV, HSVII encephalitis, and pulmonary Aspergilossis, with some questionable acid fast bacilli on staining - many of the Aids deficining conditions. His WBC count was only 1 and his absolute lymphocyte count 0.1x10^9. This pt was also on high dose steroids for a probable diagnosis of Lupus for the past 1 yr. After getting stuck we sent off the basic labs: Hep C Ab - negative, and Hiv1 Ab - negative using the Genetic Systems HIV-1 PLUS O EIA (which I think is a 3rd generation test), and HIV2 Ab- negative. Therefore no PEP was started. However I am now very woried about the possibility of a False negatie in late stage HIV, especially given the pt's poor immunological and immunosuppresed status. Pt had never had HIV RNA or CD4 testing done, but had had 2 more HIV serologies done within the last year which were negative (one early this month, and one in Aug 2006 during which times he had a similar WBC profile). My question is how common is serorevesion in end stage AIDS pts, and the likelyhood of that being the case with this pt given his 3 different HIV negative serologies at 2 different institutions. Are my fears justified or should I just move on. BTW I'm way past the PEP window now , this incident happened 15 days ago. Thanks for your help. -Desperate intern

Response from Dr. Frascino

Hello Desperate Intern,

Is sero-reversion "common" in end-stage AIDS? No, it is not common, but it can happen.

Do I think the patient you described had AIDS? No, I do not believe he did. However, he was obviously critically ill with multiple infections, most likely resulting from his neutropenia and high-dose steroid-induced immunosuppression. I agree with the recommendation not to start PEP based on the patient's three negative HIV serologies and clinical picture. Although in light of the high-dose steroids, I would also have checked a DNA PCR. But, since you are now well beyond the PEP window, all of this is moot. I would suggest you get HIV tested per the occupational-exposure guidelines, but I see no reason for you to be excessively worried about this incident. I'm quite confident your definitive HIV tests will be negative, OK?

Good luck.

Dr. Bob



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