Interesting Clinical Questions

2019

Question: I have a patient who was referred to me with a new diagnosis of HIV. When previously tested, the HIV antibody/antigen test came back positive however the viral load was negative. She presented with some risk factors for contracting the virus and had been sexually active with a man who, after breaking up with her, was acting ‘weird’. She was suspicious of his behavior and consequently got tested for HIV with a 4th generation test which came back positive. The patient reports having been tested multiple other times, as she is in the military, all of which came back negative. On meeting this patient and hearing her history I repeated all testing. The HIV antigen/antibody came back negative and the viral load was undetectable. I also ordered a proviral assay which is pending. Is there anything else you recommend I do?

Answer: There is nothing more I would recommend. The first 4th generation test was most likely a false positive which we have seen in our clinic as well. After a HIV 4th generation test comes back positive additional testing in needed to confirm or invalidate the results, which was done for your patient. Read this article for more information on false positive HIV tests.

Question: I have a patient from Malawi who is newly diagnosed with HIV and started medication about two weeks ago. He currently has a CD4 count of 200 cells/µL and reports a history of seizures. An MRI was taken of his brain and showed multiple ‘cystic’ lesions; all serologic tests and toxoplasmosis came back negative. Neurosurgery biopsied a lesion and the pathology results came back as follows:

Brain biopsy:

• Necrotizing granulomatous inflammation with microabscess formation
• Special stains for microorganisms are negative

Quantiferon TB gold, all cultures, AFB smear, and fungal tests came back negative. The patient looks healthy and reports feeling fine. Should I treat empirically for TB and fungal infections? Do you have any other suggestions or recommendations?

Answer: I would be concerned for Neurocysticercosis. Does he fit into this syndrome? Use this link to review the guidelines.