Management of HIV/AIDS
With the advances in antiretroviral therapy and increased life expectancy of
patients with HIV infection, the emergency physician must also consider noninfectious pathologies in the differential diagnosis.
New clinical data from EDs also support the increased utility of fourth-generation testing. A recent study by Geren et al11 found that in a nontargeted opt-out screening program with a fourth-generation antibody/antigen test, nearly one fourth of undiagnosed HIV patients had acute infections that would not have been diagnosed using older testing methods.11 The results of this single study may not be generalizable, but they point out that routine testing of ED patients could lead to a substantial increase in the diagnosis of acute HIV infections and have a considerable impact on the recognition of HIV/AIDS infections that would otherwise go undiagnosed.
Advances in the ability to detect HIV infection should prompt clinicians to inquire about the testing methodologies available at their institutions. If fourth-generation testing is not available, and there is a clinical suspicion for early HIV infection, an RNA assay should be obtained.
The HIV-Positive Individual in the ED
Prior to the advent of HAART in 1995, the practice of emergency medicine required extensive knowledge of the recognition and treatment of opportunistic and nonopportunistic infections associated with HIV infection. Post-HAART, as patients with HIV live longer, and are exposed to antiretroviral therapy for extended periods, complaints unrelated to opportunistic infections are becoming more common. These complaints may be related to HIV infection and therapy, such as mental health disorders associated with chronic disease and side effects from antiretroviral therapy. Further, as HIV-infected individuals live longer, non-HIV related complaints common in the general population, such as CVD and oncologic disease, are increasingly relevant. To make matters even more challenging for the EP, antiretroviral therapy itself is associated with hyperlipidemia, hyperglycemia, truncal obesity, and a 26% increased relative risk of myocardial infarction (MI) per year.12
Patients with HIV presenting to the ED may have additional high risk social and medical factors with implications for care and follow-up. One retrospective single-center study of HIV-positive individuals found increased ED utilization was associated with lower income and higher viral load. Further, these patients sought care mainly for complaints unrelated to their HIV status. The most common diagnoses were ill-defined symptoms, injuries, and musculoskeletal disorders.13
Five Categories of HIV-related Presentations
HIV-positive individuals may present to the ED with complaints unrelated to their HIV status. However, amongst those with HIV-related presentations, it may be helpful to consider five basic categories: (1) HIV seroconversion syndrome; (2) opportunistic infections; (3) primary HIV-related diseases; (4) immune reconstitution syndrome; and (5) antiretroviral medication-related complaints.
HIV Seroconversion Syndrome
Seroconversion syndrome usually presents within the 3 to 4 weeks after HIV infection, and generally persists for 2 to 3 weeks. This seroconversion is accompanied by flu-like symptoms in at least 50%, and possibly up to 90%, of individuals. More than 50% will have at least one of the following symptoms: lymphadenopathy, fever, pharyngitis, rash, or myalgias. Additionally, there may be mucocutaneous lesions on the oral cavity and genitals. Other common symptoms include diarrhea, headache, nausea and vomiting, weight loss, thrush, and neurological symptoms such as aseptic meningitis, meningoencephalitis, facial palsy, and Guillain-Barré syndrome.
Seroconversion syndrome is often accompanied by a distinctive maculopapular, nonpruritic, erythematous rash on the face and trunk. The rash can affect the extremities including the palms and soles. The presence of this rash should trigger the consideration of HIV infection.
A diagnosis of HIV at seroconversion benefits the individual because it results in earlier treatment, but it additionally has a substantial public health impact. At this phase, viral loads are extremely high, and the patient is highly infectious. Individuals with acute HIV infection are thought to account for 7% to 50% of HIV transmission worldwide.14-16
Opportunistic Infections and Primary HIV-related Diseases
Evaluation of the HIV-infected patient in the ED should be tailored to the individual complaint, with modifications for the relative immune status of the individual. It is advisable to consider the level of immune impairment, prior exposure to infectious agents, and the use of prophylactic therapy. A complete review of the opportunistic and primary HIV-related diseases in the contemporary ED is outside the scope of this review; however, several of the major considerations and most common diseases will be discussed.
In a patient with fever or other symptoms consistent with infection, basic diagnostic testing such as a complete blood count, metabolic panel, liver function tests, urinalysis, and chest radiography may need to be supplemented to account for opportunistic infections. Blood and urine cultures may need to include fungal and mycobacterial cultures as well as aerobic and anaerobic culture. Serologic testing for syphilis, toxoplasma, coccidiodes, and cryptococcal antigen may be merited. If abdominal pain or diarrhea are reported, stool should be examined for parasites and their ova. When evaluating headache or any neurological complaints, the clinician should maintain a lower threshold for obtaining a computed tomography (CT) scan and lumbar puncture in immunocompromised patients.
