This Morning’s Grand Rounds
A patient with acute (primary) HIV infection with neurologic manifestion of clumsy left hand and demyelination on MRI (which clears over time, untreated).
Primary HIV (diagnosis, treatment, screening)
Best reference on primary HIV is full-text online, by Pilcher 2004 [1]. Treatment of acute disease is debated. The theoretical benefit is discussed. University of Cincinnati is participating in a trial looking at this question. Only 30% of patients with acute HIV were found to have symptoms in a recent North Carolina study [2].
ADEM (acute disseminated encephalomyelitis)
This acute inflammatory disorder of white matter is of uncertain etiology, possible autoimmune triggered by infection (as surmised in our case). Our case was self-limited (changes resolved onsubsequent MRI). Other case reports have suggested a role for prednisione or immune globulin. There have been no controlled series to guide therapy. ADEM has been reported in association with primary HIV.
References
Here are links to some online case reports (not associated with HIV) [3,4,5]. The library has copied references not available online, these are listed below.
1. Allen SH et al. Acute Demyelinating Encephalomyelitis (ADEM) in a patient with HIV infection. J Inf 2002:982
2. Narciso P. Acute disseminated encephalomyelitis as a manifestation of primary HIV infection. Neurology 2001;57:1493-1496
3. Hartung H and Grossman RI. ADEM—Distinct disease or part of the MS spectrum? Neurology 2001;56:1257-1260
4. Marchioni E et al. Postinfectious inflammatory disorders—subgroups based on prospective follow-up. Neurology 2005;65:1057
More on public health testing (finding acute HIV)
Pilcher’s group in the North Carolina department of health screened 100,000 people asking for HIV testing and public health clinics (including STD clinics) [2]. They found an HIV prevalence of 5.5/1000 (600 cases). To determine how many cases were “new” they used a “de-tuned”, less sensitive antibody test (lower antibody levels with new infection). This test suggested a prevalence of recent infection of 1/1000. Going further, they looked at those whose initial ELISA test was negative, and tested for RNA by amplification. They then found an additional 23 patients with acute (primary) HIV, for a prevalence of 0.2/1000. He points out that health departements would be a good screening ground to identify new disease. This might help reduce transmission. If treatment of primary disease proves beneficial this would also have implications for better detection.
Today Elie Klam will discuss a case mentioned here last year. Here are links to other recent references [1,2,3].
About half the population of adults have been infected (less in some parts of the world; more as age advances.) Such a high prevalence makes associations with other disease states difficult to prove. But the virus physiology & pathology make it suspect in rheumatologic conditions [2].