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Pianist still worried

Aug 8, 2008

Hi Dr. Bob, You responded to my original question last November ( Unfortunately I am still highly symptomatic, with chronic and significant neurologic complaints (dizzy, disoriented, and what feels like pressure from the inside of my skull), mild pain in my liver area, and chronic fatigue among other things.

My high-risk exposure was May 2007, and I recently tested negative for HIV1 and HIV2 with Elisa tests. This takes me out to 14 months. I also tested negative for hepatitis B and C out to 7 months. What concerns me are the following lab results:

Dec 2007: ALT 59 Jan 2008: ALT 49 Mar 2008: ALT 42 April 2008: CD4 376, CD4% 41, CD4:CD8 1.43 July 2008: CD4 273, CD4% 34.1, CD4:CD8 1.15 July 2008: ALT 58

I have had a liver ultrasound and an abdominal CT scan, both of which were unremarkable with the exception of some small low densities in the right lobe of my liver. I dont drink alcohol and have a healthy diet. I am more concerned with my T cell counts. It seems that something is decimating my immune system. My questions are the following:

1) Is it possible that I am an extremely late seroconverter, or that I have a rare strain of HIV not being picked up by standard EIA tests?

2) What is your opinion, based on my description and lab results above? I would appreciate your comments on both my liver as well as my immune system.

3) I am planning on repeating the lymphocyte subset analysis in October. In the event that my numbers continue to drop, would your opinion change?

Thank you SO much! Mike

Response from Dr. Frascino

Hi Mike,

For all the reasons I detailed in my initial response to you (see below), I do not believe you are HIV infected. Your risk was negligible at best and your undetectable PCR DNA and NAT at four months and negative HIV-1 and HIV-2 ELISA tests out to 14 months are definitive and conclusive. HIV is not your problem. However, that leaves us with your moderately depressed absolutely CD4 cell count and lingering symptoms. I unfortunately cannot diagnose the cause over the Internet. However, I continue to believe your visit with Korean Sex Worker and fears about possible HIV infection are complete red herrings. I would advise you see a board-certified clinical immunologist to evaluate your depressed CD4 count. There are other conditions, such as idiopathic CD4 lymphocytopenia (ICL), which could cause this abnormality. I'll reprint some information about ICL below.

To respond to your specific questions:

1. No, I do not believe you are a late seroconverter or that you have a rare strain of HIV.

2. Your CD4 counts are moderately depressed and it's difficult for me to comment about your liver, based only on results of a single liver enzyme. Your ALT is mildly elevated. As you mentioned, the liver ultrasound and abdominal CT scan are normal.

3. No, my opinion wouldn't change.

Finally, since I know you are a Martha Argerich fan, I have tickets to see her in San Francisco this season and I highly recommend her new recording of the Shostakovich piano concerto.

Keep me posted on what the clinical immunologist finds, OK Mike?

Good luck!

Dr. Bob

freaked out pianist - $100 donation made Nov 6, 2007

Hi Dr. Bob, Ive just made a contribution to your AIDS Foundation (ref# ETHE1D4AE017), and would encourage your other readers who are financially able to do the same. I have been living in hell for the past six months, and would greatly appreciate your sage advice. Please bear with my rather long-winded history.

In May of this year, I made the unfortunate choice to visit a sex worker. The girl was Korean and, judging from her poor English, has not been in this country for very long. Although I used a condom for vaginal intercourse, Im pretty sure that it was slipping around a bit due to the use of lubrication and the fact that I wasnt completely aroused. At any rate, I wasnt able to ejaculate inside and she eventually climbed off. I noticed that the condom, although still on my penis, was only covering to about one inch past the glans. She removed the condom and soon after brought me to orgasm with a hand job and the use of lubrication.

The very next day, I started experiencing symptoms which lasted for one week. These included: achy chest and arms, headaches, and a throbbing feeling on both sides of my neck. One week post exposure I had an STD panel including an hiv EIA, all negative. I experienced no symptoms for the next six weeks. Seven weeks post exposure, I started experiencing the following symptoms: a noticeably yellow tongue, extreme fatigue, weak and achy muscles, diarrhea, and frequent burping. These symptoms have all been more or less chronic and have continued to this day, six months post exposure.

I had a CBC with differential at 3 months, which showed low lymphocytes (13%) and high neutrophils (80%), with a total WBC of 4800. I had a repeat CBC at 3.5 months, which again showed low lymphocytes (15.7%) and relatively high neutrophils (74%), with a total WBC of 5300. I had a PCR DNA test as well as a pooled NAT test done at 4 months, both non-reactive. In addition, I recently (6 months post exposure) had an hiv 1/2 rapid test done, which was negative. My questions/comments are the following:

1) How risky would you consider my encounter, considering there was most likely vaginal fluid on the shaft of my penis when she gave me a hand job.

2) Although Im pretty confident I dont have hiv-1 subtype B, I have read a lot of information about the prevalence of hiv-1 subtype CRF01_AE amongst the hiv+ hetero community in Korea, as well as its increased transmission risk in comparison with subtype B. Ive also read that the PCR DNA and NAT tests are optimized in this country to detect subtype B, and are generally not as effective in picking up other types. How concerned should I be that my tests have missed non-B subtypes?

3) Im going to have another CBC soon. In the event that I continue to have lymphocytopenia, would you recommend that I see an infectious disease specialist and be tested for CD4% and PCR RNA viral load? I wouldnt be so freaked out if it werent for my abnormal CBCs and continuing symptoms.

Thank you SO much for your advice. I appreciate your great sense of humor, compassion, and wisdom. I have spent much time reading comments from doctors on this and other forums, and have come to the conclusion that this is indeed a very rare combination. Please stay healthy and continue the amazing work that you do. By the way, Im a fellow pianist. Have you listened to Martha Argerichs recording of Schumanns Fantasie? Its unbelievable.

Thanks again, Tickler of the ivories

Response from Dr. Frascino

Hello Tickler of the Ivories,

First, thank you for your donation to The Robert James Frascino AIDS Foundation ( and your very kind comments. Both are warmly appreciated.

Next, you can't judge how long a person has been in the U.S. based on poor English skills. Using that criterion, Dubya would be a recent unschooled immigrant. Of course even a recent unschooled immigrant could do a better job of communicating (and running this country) than Dubya, but that's another story.

So, on to your problem or, more accurately, non-problem!

Regarding risk, your condom may have slipped, but the business end of your tallywhacker remained latex enshrined. Therefore your HIV risk was negligible at best.

As for symptoms, whatever you experienced beginning "the very next day" and lasting for one week could not have been HIV related. ARS (acute retroviral syndrome) symptoms take weeks to become manifest following primary HIV infection.

The symptoms that showed up at week seven are not suggestive of or worrisome for HIV ARS.

Your laboratory results also do not suggest HIV in any way shape or form! Your negative HIV-1/HIV-2 at six months plus your negative PCR DNA and NAT at four months are absolutely definitive and conclusive. The mild (and resolving) CBC abnormalities are not suggestive of HIV!

To respond to your specific queries:

1. Vaginal fluid on the shaft of the penis is not a risk for HIV. The virus can not penetrate intact skin. The shaft of the penis is covered with skin. The mucous membrane, which can absorb HIV, is limited to the urethra (pee hole).

2. Your chances of contracting a non-B subtype from the activities you describe and not have it be detected by the testing you've had to date are nonexistent.

3. Your CBC abnormalities are absolutely not related to HIV, because you do not have HIV! I can't diagnose the exact cause over the internet, but these types of mild abnormalities are extremely common and often resolve spontaneously with time. Don't perseverate on an illness you could not possibly have. Proceeding on with PCR RNA, CD4 subset analysis and infectious disease consultation is not warranted! Save your money. Buy all of Martha Argerich's CDs instead. It's a much better and more worthwhile investment.

Regarding the 88s, yes, Argerich is phenomenal. I've seen her perform several times and it's been magical.

Now stop worrying and yell WOO-HOO, OK? And get back to the piano and practice that Fantasy. The second movement's triumphal march (in E flat) has some very tricky jumps in the coda.

Be well. Stay well. (You are indeed well!)

Dr. Bob

ICL Jul 1, 2007

I have a question about the definition of Idiopathic CD4 Lymphocytopenia (ICL). First off I know about the qualification of less than 300 cd4 count ( or less than 20%) on two or more occasions and being HIV negative.

One thing I want to know is does the person also have to have an AIDS defining disease or can they be clinicly asymptomatic?

Also is the less than 300 T cell count (or under 20%) mandatory? In other words if a person had an AIDS defining disease(lets say chronic TB), was HIV negative, but had a T-cell count of 650 would he qualify as ICL or would he be just a TB patient?

Thanks for your help, Daniel

Response from Dr. Frascino

Hi Daniel,

The case-definition criteria for ICL include:

1. CD4 count less than 300 or CD4% less than 20% on two or more measurements.

2. Lack of evidence of HIV infection.

3. Absence of alternative explanations for the CD4-cell lymphocytopenia, including Sjgren's syndrome, sarcoidosis, radiation, atopic dermatitis, collagen vascular disease, steroid therapy or lymphoma.

Please note, transient unexplained decreases in CD4 cells may occur in healthy persons.

To answer your specific questions:

1. No, a person does not need an AIDS-defining disease to have ICL. They need only to meet the three criteria listed above.

2. Is a count of less than 300 or less than 20% mandatory? Yes, it's the first criterion listed above.

3. A person with TB and CD4 count of 650 would have TB, not ICL, because she didn't meet this first criterion above. (I should also point out that TB is only considered to be an AIDS-defining illness in folks who definitively have HIV infection.)

Dr. Bob

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