Acute Human Immunodeficiency Virus Infection Presenting as Disseminated Gonococcal Infection

Offer Amir, MD, Vinh D. Nguyen, MD, Ben J. Barnett, MD


South Med J. 2003;96(3) 

In This Article


Gonorrhea is a common bacterial sexually transmitted disease, usually manifesting in men as acute urethritis.[1] The incubation period is typically 2 to 5 days but can be 10 days or more. Disseminated gonococcal infection (DGI) is a result of bacteremic spread of the organism, occurs in approximately 0.5 to 3% of infections, and usually presents clinically as an arthritis-dermatitis syndrome. Our patient did report a characteristic discrete papular rash, but this was resolved by the time of his presentation to the hospital; however, he never had signs or symptoms of arthritis or any other manifestation of DGI. Gonorrhea is a common diagnosis in HIV infected persons given their similar modes of transmission, and has been used as a marker of high risk behavior in this population.[2]

Acute HIV infection (also called primary HIV infection or PHI) has a similar incubation period as DGI.[3] The rate of transmission of HIV during a heterosexual encounter varies with the level of viral load in the infected partner, and in one large study, the rate of transmission from an infected female to a male partner was similar to that from an infected male to a female partner.[3a]Soon after the transmission event, there is a very rapid rise in HIV particles in the bloodstream, and widespread seeding of lymphoid tissues. For the first approximately 22 to 27 days, standard serologic tests such as ELISA for HIV-1 and -2 are negative and will miss the diagnosis of acute HIV infection. The diagnosis must be made by serum or plasma p24 antigen tests or by measurement of plasma HIV viral RNA, which will be extremely high. Therefore, if the diagnosis is not suspected, it will be very commonly missed in the clinical setting because the routine HIV test, the ELISA, has not yet turned positive in this situation.

The most common symptoms of acute HIV infection are fever, fatigue, rash, headache, pharyngitis, sweats, myalgias or arthralgias, and lymphadenopathy. Thrombocytopenia is observed in about 45% and leukopenia is seen in 40% of cases.[3] Our patient's symptoms, including the transient rash, were likely to be entirely due to the acute HIV infection, rather than DGI, and it was the leukopenia and thrombocytopenia that led us to perform the diagnostic test of HIV RNA viral load. The diagnosis of DGI was made by routine blood cultures and likely would have been undiagnosed had the patient not had those cultures done. Because there are few reported cohorts of patients with acute HIV infection, the incidence of other STD infections at the time of diagnosis with acute HIV infection is unknown. In addition, it is unknown whether the immunologic alterations induced by the acute retroviral syndrome would predispose a patient to DGI.

Acute HIV infection before seroconversion is a diagnosis not commonly made despite the fact that most patients with acute HIV are symptomatic. It can be confused with many other viral syndromes such as Epstein-Barr mononucleosis.[4] However, its diagnosis has large prognostic and therapeutic implications for the patient and for public health. A significant amount of the spread of HIV to new partners occurs during the acute HIV infection period, as the HIV viral load is extremely high, making transmission more efficient, and the source patient is not yet aware of his or her HIV positive status.[5] Furthermore, for the individual patient, early treatment with antiretroviral medications may confer substantial benefit in preserving specific cytotoxic CD8+ cell immune function against HIV-infected cells.[6] This very early treatment before seroconversion may then allow for novel strategies to control HIV infection that will potentially alter the natural history of HIV infection in that patient and allow for better immune control of the disease.[7] Such novel treatment strategies, for example antiretroviral drug treatment interruptions or structured intermittent therapy, are currently being evaluated in clinical trials for their efficacy in this unique patient population.