Acute hiv case studies
However, patient 3 maintained a high viral load and was started on triple-drug antiretroviral therapy. None of the patients were started on antiretroviral therapy during the acute retroviral syndrome phase of PHI, which is currently recommended in US treatment guidelines. A year-old woman presented to the emergency room with confusion, stiff neck, fever, headache, and sore throat that had lasted for over 2 weeks. She had no prior relevant medical or surgical history, no medications, and no "sick contacts.
Landmark Acute HIV Infection Cohort Study Concludes | MHRP | Military HIV Research Program
A CT of the head showed no acute changes and the chest x-ray was clear. Initially, she was empirically treated with ceftriaxone and acyclovir for presumptive diagnosis of bacterial meningitis and herpes simplex encephalitis. She markedly improved by day 5 when acyclovir was stopped. She was discharged on day 9 with diagnosis of possible "partially treated bacterial meningitis. The HIV serology was positive. CD4 cell counts and viral load were not obtained. The patient was seen at a clinic 3 months after being discharged from the hospital.
A more thorough history revealed that she was engaged in a heterosexual relationship with a new partner "who was sick" 3 months prior to the onset of her symptoms. A year-old bisexual man presented to the emergency department complaining of progressive headaches, confusion, myalgia, vivid nightmares, and diarrhea. For many years he had traveled extensively throughout sub-Saharan Africa and had recently spent 2 years in Madagascar.
He had returned to the United States 1 month before admission. Once home, he developed diffuse myalgia and malaise. Stool analysis showed hookworm and Entamoeba histolytica, and he was treated with mebendazole and metronidazole 1 week before admission. During that week, he developed flu-like symptoms of fever, chills, cough, and persistent diarrhea.
Three days before admission, he developed a stiff neck, headaches, confusion, and vivid nightmares. Within the past 6 months, he had been sexually active with 4 partners, all in Africa. He reported 1 episode of gonococcal urethritis within the past 2 months. He did not use condoms consistently. His last HIV serologic test, 3 months earlier, had been negative. His neck was supple, without lymphadenopathy.
Funduscopic examination was normal, but he had a visual field defect in the left eye. The only other notable finding was a faint maculopapular rash over his trunk and extremities.
Landmark Acute HIV Infection Cohort Study Concludes
His complete blood count CBC results were normal. On the fifth hospital day, the patient's fever, rash, headaches, visual field defect, and other symptoms resolved spontaneously without treatment. All cultures remained negative. He was discharged to the HIV outpatient clinic for follow-up and eventual treatment.
His plasma p24 antigen became undetectable. One year later the patient remained asymptomatic. Volunteers with confirmed HIV-1 infection were enrolled in the long-term follow-up phase. Full details of the study design and statistical analysis plan are provided in the protocol. Volunteers with HIV-1 infection were referred to a local care provider for treatment, including antiretroviral therapy.
Diagnosis and Management of Acute HIV Infection
Counseling regarding HIV risk reduction was provided every 3 months and informally during small-volume blood collections. Condoms and lubricants were provided to participants at the study sites. The study team encouraged care providers to initiate treatment promptly if the volunteers had clinically significant symptoms of acute retroviral syndrome, were pregnant, or met national guidelines for the initiation of antiretroviral therapy.
Plasma was diluted in a ratio in phosphate-buffered saline pH, 7. HIV serologic testing with the use of standard diagnostic methods was performed at screening, every 6 months, and during the second part of the surveillance phase see the Supplementary Appendix , available at NEJM. HIV-1 subtyping was performed as described previously see the Supplementary Methods section in the Supplementary Appendix. Viral RNA levels below the lower limit of quantitation were imputed by dividing the limit of quantitation by two.
The viral upslope was calculated from the date of the last negative sample to the peak viral load, excluding data from participants for whom the period between the last negative sample and the first sample that was positive for HIV-1 RNA was more than 10 days. The early nadir in the HIV-1 RNA viral load was defined as the lowest viral load after the peak viral load through day Viral downslope was calculated from the peak viral load to the early nadir viral load.
The viral-load set point was defined as the average viral load of all samples collected before antiretroviral therapy was administered between days 42 and among participants in whom at least two viral-load values were measured during this period. Results of physical examinations and reported clinical symptoms are described according to the study visit and per patient.
Data on participants were censored at the initiation of antiretroviral therapy. We performed an exploratory analysis of viral-load dynamics in acute HIV-1 infection without prespecified hypotheses.
Regional differences in viral loads in East Africa and Thailand were evaluated with the use of Wilcoxon rank-sum tests. We used Wilcoxon signed-rank test to assess changes from baseline. Log-transformed viral RNA dynamics during the first year were assessed with the use of regression splines with participant-specific intercepts and slopes. Lymphocyte data were assessed with the use of repeated-measures models with adjustment for region and study visit.
Details of the statistical analysis are provided in the Supplementary Methods section in the Supplementary Appendix. All analyses were performed with the use of SAS software, version 9. Single false reactive results on qualitative nucleic acid testing were common, but acute HIV infection was confirmed in all participants who had two consecutive plasma samples that were reactive for HIV-1 RNA on qualitative nucleic acid testing.
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Among participants with acute infection, peak viremia could be accurately defined in 54 participants who had at least two samples in which testing for HIV-1 RNA was reactive and enzyme immunoassay was nonreactive. Four of these participants were excluded from virologic and immunologic analyses because they received early antiretroviral therapy ART. From June through June , a total of volunteers were screened Figure 1 and of high-risk participants Most participants with acute HIV-1 infection in the three African sites were heterosexual women, whereas most participants with acute infection from Thailand were homosexual men or transgender women.
To accurately define peak viremia, we restricted the analysis to the 50 participants in whom at least two large-volume blood samples showed detectable HIV-1 RNA and a nonreactive enzyme immunoassay, who had had at least one study visit before detection of viral RNA, and who had quantitative HIV-1 RNA data.
Analysis of the viral-load set point in 45 participants who had not received antiretroviral treatment required two blood samples obtained after day In these participants, a median of 4 days range, 2 to days occurred between the last negative sample and the first sample that was reactive for HIV-1 RNA. Longitudinal viral-load values are plotted against the number of days since the first blood sample was reactive for HIV-1 RNA in 33 participants from East Africa and 17 from Thailand who had two or more blood samples that were nonreactive on enzyme immunoassay EIA and were reactive on nucleic acid testing.
Day 0 is the day of the first positive nucleic acid test. The box-and-whisker plots show the median, interquartile range, and range for each variable.
runneeqadroughnean.gq The vertical box plots show peak and nadir viral loads, and the horizontal box plots show the number of days from the first reactive result on nucleic acid testing to the peak viral load, to reactivity on the EIA, and to the nadir viral load. Median values are shown for each variable. Figure 2 shows HIV-1 viremia during the first days of HIV-1 infection, including the median days to the peak viral load, enzyme immunoassay reactivity, and early nadir viral load. The median initial viral RNA level was 4. A third-generation enzyme immunoassay was reactive at a median of 14 days range, 8 to The median early nadir viral RNA level, 4.
The median viral-load RNA set point was 4. Five participants were excluded because of missing viral-load data or the initiation of antiretroviral therapy.