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HCW needs help
Sep 11, 2007

Dear Dr Conway, I am an intern who got stuck while trying to place a central line in a severly ill patient during a code (which the patient did not survive). The patient was cachectic, had very poor prior healthcare, and on this hospitalization was diagnosed with systemic CMV, HSV II encephalitis, and pulmonary Aspergilosis, with some questionable acid fast bacilli on staining - many of the AIDS defining 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 HIV 1 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 negative 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 patients, and the likelihood of that being the case with this patient 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. Conway

Seroreversion in late stage AIDS (a false negative HIV antibody test) is uncommon. If it does occur, it is a very late event. As such, the negeative test in this patient that was done last year is a valid indicator that the person was not infected and rules out HIV infection. I would just move on at this stage, if I were you.



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