HIV infection should be detected as early as possible, because there are good treatment options today, and as otherwise there is a risk that the HIV virus is transmitted. However, an early diagnosis is not always easy. Acute HIV infection is often overlooked because of their non-specific symptoms. Chronic infection can last for years without symptoms. The following items will be identified based on clinical examples, the difficulties in the diagnosis and the risks of late diagnosis. Adjoining case reports (Box 1 and 2) are intended to illustrate how difficult may be the diagnosis of HIV infection. These two cases show that the symptoms of HIV infection can be very unspecific. Primarily, it is important to keep in mind. Case Study 1 Male patient, 58 years old Oral thrush, feels bad, losing weight: 20 kg Professional success, serious demeanor, civil Has children, but now lives by the wife separately and together with a man
In the spring of the first medical consultation, then multiply inpatient investigated without result Finally, after six months of HIV testing during office visits: positive At diagnosis 38 CD4 + / ul, viral load: 665 000 / ml Case Study 2 Male, 71 years Living in a rural area, is married Symptom onset in the summer with pain in the arms and legs, the patient attributes this to a poisoning Intermittent fevers, during inpatient investigations: Diagnostic “Feverish colds”, DD Food Allergy In November, through investigation in other clinic: chest X-ray, ultrasound of the abdomen, MRI skull, gastroscopy, colonoscopy, and bone marrow aspirate In the bone marrow aspirate is striking: 41 CD4 + / ul HIV test: positive Why it is important to detect a HIV infection at an early stage? To answer this question it is first helpful to look at the natural history of infection (see.
Fig. 1). At the beginning and at the end of the course of the viral load in the patient’s blood is very high. The level of CD4-positive leukocytes (helper cells) falls over time slowly until it finally to manifest immunodeficiency comes (AIDS). Early detection of infection is important for two reasons: Late diagnosis worsens the prognosis of the person concerned. Early diagnosis reduces the likelihood of further infections. 1. A late diagnosis worsens the prognosis of the person concerned The diagnosis “HIV infection” is made even today very late yet in many cases. Then the helper cells are often very low. According to current recommendations half of patients already need antiretroviral therapy at diagnosis. This leads initially often due to present opportunistic infections hospitalizations, which is associated with increased morbidity and mortality.
In addition, initially mean very low helper cell count often that no normalization of helper cell count can be achieved by antiretroviral therapy. This is particularly often in elderly patients. The fact that this unfortunately is the reality in Germany, numbers published by the Robert Koch Institute (see. Fig. 2). Following the current therapeutic recommendations in Europe, then patients with helper cell counts below 350 / ul in need of therapy . Considering the recommendations in the US or the latest WHO recommendations as a basis zoom, should already be initiating therapy with 500 / ul helper cells . The decrease in helper cells correlates roughly with the period of the disease, where there is considerable individual differences. If require therapy now already 50% of patients at diagnosis, this leads to the conclusion that the diagnosis is often made too late. 2. Early diagnosis reduces the likelihood of further infections As these individuals for many years without knowing a test nothing of their disease, the risk of transmission is increased to other people. It may be that are not taken adequate precautions during sexual contacts with non-knowledge of the infection.
On the other hand, is increased by the high viral load at the initial stage, the risk of infection. So here are two circumstances together: Affected are unaware of their infection and may not behave accordingly, thus giving the virus very “effective” on. If it is possible to diagnose the infection at an early stage by an HIV test, then can take steps to protect other people concerned. Through antiretroviral therapy, viral load can be reduced to below the detection limit and thus infectivity can be significantly reduced. GPs play a very important role: You can create awareness and offer the HIV test. When thinking about HIV? The HIV infection is clinically often very non-specific or not. Acute HIV infection presents itself as mononukleoseartiges disease. Typical symptoms include fever, fatigue, arthralgia. In about half the cases, a rash is added. These symptoms come now, however, in general practice very frequently. It is correspondingly difficult to detect the infection in the acute stage is. A mononukleoseartiges disease, a sensitive inquired risk anamnesis and frequent testing might help here.
In acute HIV infection is very important to remember that the antibody test will be negative in many cases. A definite exclusion can be assumed only about three months after the issue date of infection. In unclear cases, a virus direct detection are carried out by PCR. This is positively usually within two to three weeks. An HIV test after three months is recommended in any case. In the chronic stage, the infection is very long largely asymptomatic. One should think of an already occurred immunodeficiency certain markers diseases and symptoms. In the area of skin diseases which are for example a herpes zoster, a poorly treatable seborrheic dermatitis or Kaposi’s sarcoma. In the area of the oral cavity are not otherwise declared thrush (especially a thrush esophagitis) to call or oral hairy leukoplakia. But recurrent pneumococcal pneumonia or tuberculosis may indicate an immunodeficiency. How difficult can be the diagnosis, shows the Pneumocystis jirovecii pneumonia (PJP). Here at first lead only history and clinical (risk factors, dyspnea at rest) on. The auscultation is often normal and in the conventional chest X-ray recording is little to see or nothing.
Only a HR-CT of the chest often shows then a distinct findings. Furthermore, it should in newly diagnosed viral hepatitis and sexually transmitted diseases (such. As chlamydial infections, gonorrhea, syphilis and herpes simplex) an HIV test is recommended. The difficulty is again to think of these diseases, to ask the patient to risk factors and to perform specific tests. Moreover, the existence of very nonspecific symptoms should suggest HIV. These include unexplained prolonged diarrhea, as well as fatigue and tiredness and a generalized lymphadenopathy. In classic B symptoms with night sweats and weight loss, and fever of unknown origin HIV infection should always be included in the differential diagnosis. As evident from the case studies, it is better to test early and often. Many symptoms can thus be due to the HIV infection. It is important to always: One should think of HIV as a differential diagnosis. The practitioner is a particularly important role to play in the early detection of HIV infection. He has to know the advantage of many of his patients for years. That is however not necessarily mean that he knows everything about his patients.
The question to the patient, whether you can perform an HIV test, requires a lot of tact. Fortunately, the family physician is accustomed to such questions: Finally, the same applies to the question on the level of alcohol consumption or suicidality. A non-judgmental attitude will allow the patient to open up to the doctor. Gerd Geiss, Stuttgart MRCGP Specialist in internal medicine, specialist in general medicine Community practice Schwabstraße 59 70197 Stuttgart Competing interests: lecture fee from AbbVie, conference visits sponsored by AbbVie, Gilead Sciences, Janssen, ViiV Healthcare Published in: The Doctor, 2014; 36 (9) Page 44-48