Signs & Symptoms

Acute HIV Infection

In an estimated 40% to 90% of individuals, HIV seroconversion is associated with a clinical syndrome known as acute (or primary) HIV infection or acute retroviral syndrome. Many patients with acute HIV infection are symptomatic and seek medical care but are not diagnosed.9 In one prospective study, 95% of individuals with symptoms at the time of seroconversion sought medical care, but only one-fourth were diagnosed at the first visit.9 Despite this, acute HIV infection is rarely diagnosed partly because the signs and symptoms are nonspecific. The onset of illness associated with acute HIV infection occurs after viral transmission and symptoms are believed to correlate with peak viremia, which is often in excess of 1 million viral copies/mL.10 Common symptoms include fever, rash, lymphadenopathy, nonexudative pharyngitis and myalgias/arthralgias11 (Table 1).

Table 1. Acute HIV Infection: Frequency of Associated Signs and Symptoms

Data from Daar et al.11

Exam findings in acute or primary HIV infection are often nonspecific. Most often, the rash is reminiscent of a viral exanthem with erythematous maculopapular lesions on the face and trunk, although many types of lesions have been described. Headache with or without cerebrospinal fluid pleocytosis, myalgia, and gastrointestinal symptoms are also common. Although not present in all patients, oral or genital ulcers can be an important diagnostic clue. Laboratory abnormalities, specifically leukopenia, thrombocytopenia, and elevated transaminase levels, are not uncommon. Opportunistic infections such as mucocutaneous candidiasis and P jiroveci pneumonia may manifest during acute HIV infection as a result of transient but dramatic CD4+ cell count depletion caused by a high viremia level.11

The symptoms of acute HIV infection are self-limited and most likely correlate with viremia. After reaching high levels, the viral load declines to a steady state or set point, and the CD4+ count recovers. HIV-1 specific cytotoxic T lymphocytes are present in high titer and appear to play an important role in controlling viral replication. The magnitude of the viral set point and the severity of initial symptoms predict disease progression. Whether early antiretroviral treatment changes an individual’s disease course remains unclear.9 However, antiretroviral therapy is now recommended in all HIV-infected individuals, including those with early or acute HIV infection.12,13 Recognition of this syndrome has implications for HIV transmission and public health.

Chronic HIV Infection

A number of historical details, findings on physical examination, and laboratory abnormalities should prompt testing to identify persons with established HIV infection. As expected, these findings are more prominent in patients with more advanced disease. Often, the initial diagnosis of HIV infection is made when the patient develops an AIDS indicator condition (Table 2).14 However, the astute clinician can often detect signs and symptoms of HIV infection earlier in the course of disease, allowing access to appropriate therapy and prophylaxis before significant illness develops.

Table 2. AIDS-indicator conditions

Data from Centers for Disease Control.14

A history of certain illnesses can also be suggestive of HIV infection. Infections such as active tuberculosis, recurrent community-acquired pneumonia, esophageal candidiasis, undifferentiated interstitial lung disease, and either multidermatomal herpes zoster or zoster in younger adults should lead to HIV testing. Neoplastic diseases such as B-cell lymphoma, severe anal or cervical dysplasia, or invasive carcinoma and Kaposi sarcoma are indications for HIV testing, as is idiopathic dilated cardiomyopathy. The evaluation of fever of unknown origin or unexplained weight loss should always include an HIV test, even in older patients without identified risk factors.

Various findings on physical examination may suggest coexisting HIV infection. Examination of the skin can be particularly revealing. Seborrheic dermatitis or molluscum contagiosum are common in early disease as is psoriasis. Oral candidiasis can be seen typically with CD4+ counts below 200 cells/mm3.15 Generalized lymphadenopathy is common. Recurrent or severe lesions of herpes simplex virus may be indicative of underlying HIV infection. Neurologic findings such as unexplained peripheral neuropathy or dementia are also suggestive.

On laboratory evaluation, idiopathic thrombocytopenia, unexplained anemia, neutropenia, and/or leukopenia are frequent, early clues to underlying HIV infection. An elevated total protein level or globulin fraction is also suggestive.

< Introduction | Diagnosis >