Expert: John Thai, M.D. - 10/2/2007

Question
Dear Dr. Thai,
I very much need your professional opinion. I'm far from home (US), working for the peace corp in rural Romania. I'm concerned about possibly having contracted HIV.  My problem is that my provincial doctors here are not knowledgeable about HIV nor do they speak English very well. I hope you can help me, as I've been reduced to playing doctor on myself, yet know very little about HIV/testing.

My situation is this: one-time unprotected vaginal intercourse with woman of unknown HIV status four months ago while on holiday in Holland. I've since had many ARS symptoms these past four months. One-month post-exposure I had a very painful sore throat (unable to swallow food/liquids), followed a few days later by an outbreak of white ulcers in my mouth. The Romanian ENT doctor who examined me at that time ordered an HIV test (negative 6 weeks post-exposure), plus a microbiological test: Candida sp. - negative. Enterobacter cloacae 10 ^ 3

Following this I've had a cold/flu lasting 10 days in summer; various transient minor skin rashes and red spots; generalized itchy skin; random swollen lymph glands; quite severe nerve tingling/burning in my feet, hands, legs and face; and constant eye floaters that started a month ago and persist today.

In addition to possible ARS symptoms, there are abnormalities in my CBC and Liver Tests that also seem 'HIV-suspicious'. CBC done one month post-exposure: low wbc 4.2 (4.1 - 10.5 range) high lymphocytes 43.3 (25 - 40) platelets 295 (130 to 440).
Liver Enzymes: low AP 71 (98 - 280) but normal AST 23 (0 - 38) ALT 35 (0 - 40) GGT 46 (11 - 50) .

CBC done three months post-exposure: wbc 5.8 (4.1 10.5) lym 34.6 (25 40) lower platelets 202 (130 440) ; Hep B/C tests done four months post-exposure: HbeAg and Anti-HCV non-reactive.
Liver enzymes: AST 23 (0 to 40) ALT 34 (0 to 55) but very high GGT 60 (0 - 35).

But here's the thing: My HIV tests to date been negative:

Repeatedly negative HIV test results over 4 months on three different (blood drawn) second-generation HIV 1/2 (ab-only) tests negative. My latest test this week: second-generation Abbott AXSym HIV 1/2 (ab-only test) negative at 17 weeks (120 days) post-exposure. At 110 days post-exposure: RNA PCR test for HIV-1 (Roche v.1.5) no virus detected. DNA PCR tests are not available here.

My questions:

1. Would you agree that my CBC/Liver test abnormalities are suspicious for ARS?

2. Because the HIV tests here in Romania are older, second-generation tests, should I keep testing out to 6 months, despite the fact that Western countries say 3-months is conclusive? My doctors here said I don't need retesting, but given my ongoing symptoms I'm confused.

3. Because my exposure was in multi-cultural Holland, where HIV-2 infection rates I assume would be higher than in Romania (where there is no immigration from African countries), is it possible I have a HIV-2 strain that is undetectable on Romania's older, second generation tests, and therefore if I had such a HIV-2 strain I could never get a true negative test result here?

4. Do you think I should travel to a Western European country and do a 4th generation HIV test?

Although I'm HIV negative out to 17 weeks, the ongoing symptoms (especially constant, severe eye-floaters) keep me concerned, preventing me from fully focusing on the job at hand, which is to help people in need here. Thanks you in advance for answering my questions.
Sincerely,
Bill  

Answer
Hi Bill,

Acute Retroviral Syndrome (ARS, aka Acute HIV syndrome) is a concomitant of various symptoms which correlates an early immune response to a foreign body attacking and overloading the immune system. This may include oral thrush, pharyngitis, reactivation of herpes, generalized rashes, anemia, or low platelets. However, WBC is not usually affected in ARS.

Your entire medical history is more evident of infectious mononucleosis (EBV - epstein-barr virus) and not HIV. A monospot test will confirm it. Other tests are EBV IgM VCA titers. It usually decreases in after 3-6 months from date of infection but may persist in low titer for up to a year. EBV IgG VCA antibodies will begin to rise around 4-6 months and remain elevated for life.

My reasons for EBV include:

1. skin rashes with red spots
2. pharyngitis
3. decrease wbc, but not-significantly lower
4. mild decrease in platelets - you need to know what's your PT/PTT/INR levels
5. mild neuropathy - tingling sensation of extremities

Ophthalmic changes is not common in EBV. Thus, I do recommend that you get tested for CMV - cytomegalovirus as it also may produce the same symptoms and lab results. CMV is known to cause ophthalmic changes. Thus, immediate treatment is necessary to prevent blindness.

HIV test should be perform 3 months from your initial contact with her. Then again 1 month after that. Then 6 months and 1 year.

Not sure why you've elected to test for HBeAg. In order to rule out viral hepatitis B, you need to test for the surface antigen - HBsAg and antibodies - HBsAb. HBeAg is to determine infectivity.

I can't comment on Romania medical care as I have no knowledge of their medical system and it is highly unethical.

So let's answer your questions:

1. Would you agree that my CBC/Liver test abnormalities are suspicious for ARS?

--> No. More evident for EBV and CMV

2. Because the HIV tests here in Romania are older, second-generation tests, should I keep testing out to 6 months, despite the fact that Western countries say 3-months is conclusive? My doctors here said I don't need retesting, but given my ongoing symptoms I'm confused.

--> Should not make a difference as the method used internationally is western-blot analysis. US has more technologically advanced machinery to quicken the process... but human errors do occur anywhere you go.

3. Because my exposure was in multi-cultural Holland, where HIV-2 infection rates I assume would be higher than in Romania (where there is no immigration from African countries), is it possible I have a HIV-2 strain that is undetectable on Romania's older, second generation tests, and therefore if I had such a HIV-2 strain I could never get a true negative test result here?

--> Again, the testing methods should not be indifferent. You can always purchase a HIV-1/2 rapid test and have it shipped overnight to London or US for testing. You will get your results over the phone.

4. Do you think I should travel to a Western European country and do a 4th generation HIV test?

--> I cannot answer this as it is illegal in the US to provide management advisory without properly taking a full medical history and physical examination of an individual.


Again, have the physicians there rule out EBV and CMV. CMV needs proper treatment. If you are infected with EBV, it will cause you problems for approximately 6 months or longer. You should refrain from strenuous physical activity for the first 3 weeks of illness and get well rested for the next few months. And most importantly, you should avoid exposing other people to your body secretions (i.e. no kissing, don't share towels, drinks, etc) because the virus remains actively infectious for months (up to 6 months) after initial infection.


Regards,

John Thai, MD