Acute HIV Infection in a Patient with Repeat HIV Antibody/Antigen Negative Results Presenting at an Urban Emergency...

It is not uncommon for patients with human immunodeficiency virus (HIV) infections to visit the emergency department (ED) during seroconversion. However, patients with newly acquired HIV may not have a reactive screening result. We report a case of a patient who initially screened reactive on a fourth generation HIV test and subsequently nonreactive twice, but ultimately had positive viral load tests.

A 41-year-old woman experiencing symptoms of a sore throat, odynophagia, and back and flank pain for 5 days presented to the ED. The patient had a reactive HIV screen but negative confirmatory antibody test. The ED provider ordered a HIV viral load, informed the patient, and discharged with oral antibacterial agent. The patient returned the next day and after review of Visit 1 results, the ED provider ordered a second HIV screen, which had a nonreactive result. Another HIV viral load order was placed. The patient was discharged and returned a third time, 4 days after initial presentation. On this visit she was admitted, and the initial HIV viral load result returned positive. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: We report a case of a patient who initially screened reactive on a fourth generation HIV screening and then twice nonreactive on the same screening test, ultimately having positive viral loads. The most probable explanation for her series of atypical HIV results is that the patient presented during the p24 seroconversion window, which is graphically conveyed in Figure 1. If her first screening had been performed during the window, no further test would have been performed to rule out HIV, contributing to misdiagnosis. ED providers need to be aware that, at some time points during seroconversion from "negative" to "positive", patients recently infected with HIV and manifesting prodromal symptoms may nonetheless have a negative screening result.