[Question #13435] Concerned about viral exanthem rash / ARS?
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1 months ago
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I had a nude massage in Thailand. Masseuse might have made contact her vagina over my penis (sitting on my penis) possible contact vaginal fluids. I fingered her and might have touched my penis afterwards, might touched with my urethra accidentally (worst case). No penetration.
Day 10 - Low-grade fever
Day 11 - Headache. It went away after Advil.
Day 12 - Rash on my face and got one or two small dark red/brownish spots on my palm side of my fingertips later in the day.
Day 13 - Rash spread to my neck, chest, back, arms and thighs. Finger spots disappeared. Looked like Rubella or Zika - small flat bright red spots all over, no bumps.
Day 14 - Rash remained, no other symptoms.
Day 15 - Rash gone.
No itch, except in the shower.
Was diagnosed with "non specific viral exanthem" on day 13 at the hospital.
Symptoms closely resemble Rubella but I got the MMR vaccine. Zika / Rubella are rare in Thailand.
Day 34 - rapid antibody blood test - (not sure if 2nd IgG only or 3rd IgG/IgM). Negative.
Can ARS rash manifest in this way (face first, spreading to rest of the body)?
Would the test have come back positive, even if it was a 2nd gen rapid test, after 24 days from symptom onset / 21 days from rash onset?
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1 months ago
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I also wanted to add that I understand that this would be classified as a low-risk exposure but I am concerned about the timing and primarily the rash as it closely resembles the ARS rash and it was accompanied by a fever. I've read that rash and mouth ulcers have the highest the predictive value for primary HIV infection.
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1 months ago
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I forgot to mention that the rash faded away in the same order it appeared (i.e. Day 14 - Rash was no longer on my face but still on my neck, chest, arms, legs). Wanted to add that in case it can help indicate what may be the cause, assuming it's not ARS (hopefully!!!)
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Edward W. Hook M.D.
1 months ago
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Welcome to our forum. Thank you for your questions.
I agree with you that your exposure was virtually no risk however also understand how the timing of your symptom onset could be concerning. I am confident you are aware that contact with genital secretions, whether directly with your masseuse‘s Vagina rubbed over your penis or through transfer of genital secretions on your hands is not associated with risk for acquisition of HIV. As you also know, the symptoms of the HIVARS are mimiced by many other non-STI, community acquired viral infections. In fact when studies of patients with symptoms, similar to yours have been performed, over 99% of at risk persons with such symptoms have something other than HIV. In addition, in persons with HIVARS fourth generation combination, HIV antigen/antibody tests are always positive because the symptoms are a result of the interaction of the virus, detected as HIV antigen with antibodies produced in response to infection. Your negative test for HIV antibodies more than 30 days following your exposure is strong evidence that this is not the ARS although as mentioned above, a fourth generation Test is preferred.
The rash of the ARS typically occurs on the back and trunk and does not start on the face.
I am confident that the issue describe was not due to HIV although I understand that you might choose to test one more time to prove this to yourself. If you do, my advice would be to seek a fourth generation test. No matter where you are in the world, such tests should be readily available.
I hope this information is helpful. EWH.
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1 months ago
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Thanks for the response Dr.
Are you saying that there could be a chance that the symptoms mentioned could possibly be due to ARS and the antibody test could have missed it or are you suggesting the 4th gen test purely out of reassurance?
Given the low risk nature of the exposure, it’s the symptoms and timing that got me concerned. If these symptoms hadn’t happened, I wouldn’t have alarmed.
Purely from a time since symptoms perspective, if these symptoms had been ARS, would 24 days after onset / 22 days after rash be enough time for a rapid antibody test to return a reliable result that eliminates the chance that the symptoms are a result of ARS?
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Edward W. Hook M.D.
1 months ago
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In science and medicine you can never say never, just as you cannot say you won’t be struck by a meteorite from space however my confidence that your symptoms were not the ARS is at about the same level. The symptoms are compatible with the ARS but there is virtually no chance that they were given the information you have provided.
The onset of antibody production is quite variable however if your symptoms were the ARS the antibody test you took would have been positive.
I am confident that your symptoms were not the ARS. EWH
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1 months ago
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Thanks for the quick reply, Dr.
Can you clarify when you say onset of antibody production is quite variable, if are you referring to the time from exposure or symptoms?
In your clinical experience, and as well as that of your colleagues, have you seen anyone take 3+ weeks after symptom onset to test positive for antibodies?
Lastly, I've read through a number of responses on the forum and noticed that Dr. HHH has typically takes a much firmer stance when it comes to symptoms vs. time to test positive (for antibody) where you tend to emphasize the Ag/Ab test more.
"ARS symptoms are caused not by HIV itself, but by the immune response to it. Therefore, the HIV antibody tests are always positive in presence of ARS symptoms."
"The symptoms of initial HIV infection (acute retroviral syndrome, ARS) are not due to the virus itself but the immune response to it. The immune response is reflected in antibody. Therefore, it is not possible to have HIV symptoms and negative HIV antibody tests."
" It is impossible to have HIV symptoms without positive antibody. It is the immune response to the virus (measured by antibody) that causes symptoms, not the virus itself. "
Is this due to just to differences in styles or perhaps different real-life experience w/ patients? Not trying to ruffle any feathers but just want to get better clarity into my specific situation.
Can you clarify when you say onset of antibody production is quite variable, if are you referring to the time from exposure or symptoms?
In your clinical experience, and as well as that of your colleagues, have you seen anyone take 3+ weeks after symptom onset to test positive for antibodies?
Lastly, I've read through a number of responses on the forum and noticed that Dr. HHH has typically takes a much firmer stance when it comes to symptoms vs. time to test positive (for antibody) where you tend to emphasize the Ag/Ab test more.
"ARS symptoms are caused not by HIV itself, but by the immune response to it. Therefore, the HIV antibody tests are always positive in presence of ARS symptoms."
"The symptoms of initial HIV infection (acute retroviral syndrome, ARS) are not due to the virus itself but the immune response to it. The immune response is reflected in antibody. Therefore, it is not possible to have HIV symptoms and negative HIV antibody tests."
" It is impossible to have HIV symptoms without positive antibody. It is the immune response to the virus (measured by antibody) that causes symptoms, not the virus itself. "
Is this due to just to differences in styles or perhaps different real-life experience w/ patients? Not trying to ruffle any feathers but just want to get better clarity into my specific situation.
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Edward W. Hook M.D.
1 months ago
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You are seeing differences in our style as differences in our assessments. Dr. Handsfield and I are in agreement on this issue of symptoms and the onset of antibody production. ON AVERAGE, it takes 3-4 weeks for antibodies to be produced but it is variable and can take up to 8 weeks for an antibody only test to provide conclusive results. The quotes you include describe the FACT than the symptoms of the ARS are due to the interaction of HIV antigens (the virus) AND the antibodies produced in response to the infection.
This completes this thread. EWH
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