[Question #13476] Cervical Lymph nodes and low lymph count

1 months ago

I was on PEP and tested negative 91 days after exposure, which was about 9 weeks after completing PEP.

I was finally putting this behind me and starting to move on with my life, but I recently encountered a situation that triggered a relapse in my worries.

Ten days after receiving my result, I went to the emergency room due to a possible head injury after losing consciousness. They ordered a cervical CT scan and other lab tests, including a CBC.

The alarming findings were a few prominent upper cervical lymph nodes and a cystic thyroid lymph node. The CBC showed a low lymphocyte count of about 1.3 (reference range: 1.5–4.5), representing 11% of total white cells. The overall WBC count was 10.8, with neutrophils at 80%.

Now I’m freaking out about these findings—could it be possible that I still have HIV despite everything? I strictly followed the CDC guidelines, testing 12 weeks post-exposure for a final result (I tested at 13 weeks). In my mind swollen lymph node = HIV or Cancer or TB.

Should I undergo further investigation for HIV infection? I haven’t had any exposures since the initial incident that required PEP.

1 months ago

There was no fever, no rash over all the body. Exposure was relatively low risk, partial condom slippage, and unprotected oral.
I am really really worried about this. Also the panel I did at 91 days, included the following:

Neisseria gonorrhoeae DNA (PCR)

Chlamydia trachomatis DNA (PCR)

HIV P24 Ag & Abs (Combo test)

Trichomonas vaginalis DNA (PCR)

Mycoplasma genitalium DNA (PCR)

Ureaplasma urealyticum DNA (PCR)

Ureaplasma parvum DNA (PCR)

Mycoplasma hominis DNA (PCR)

RPR (Syphilis) and TPHA

HBsAg (Hepatitis B)

HCV Abs (Hepatitis C)

All either non-reactive or not detected

1 months ago

I have read some case reports where seroconversion occurred past 3 months. (doi: 10.1016/j.ajic.2012.05.016. Epub 2012 Oct 22.)

This makes me worried that PEP may have failed.

H. Hunter Handsfield, MD

1 months ago

Welcome to the forum. Thanks for your confidence in our services.

First, HIV is not likely to be a cause of only a very few enlarged lymph nodes. There must be over a hundred other far more likely causes. Second and perhaps more important, the HIV tests override all other considerations. No matter how high the risk of HIV at the time of exposure, and no matter what symptoms are present -- even symptoms that are typical for HIV or ARS -- the test results are to be believed and your results prove with 100% certainty you don to have HIV. It is impossible to have HIV symptoms and test negative. You also can rely on the negative results on all those other tests (many of which are not even sexually transmitted and should not have been done anyway).

In the case you cite, the exposed person lacked antibody to HIV but tested positive on the HIV RNA PCR test. You probably had that test in addition to the HIV AgAb test you mention. If not, you could discuss this with your doctors and have a PCR if not yet done. If it already has been negative, you can rest easy knowing you don't have HIV and that other condition(s) explain the minor lymph nodes and lymphocyte count. But have a PCR now if not done previously.

I hope these comments are helpful. Let me know if anything isn't clear.

HHH, MD

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1 months ago

I haven't taken an HIV PCR test. I asked my doctor about my 6-week post-PEP test, and she explained it's stored for follow-up on reactive cases to confirm results and determine viral load for treatment. She also mentioned that it is more prone to false positives if there's another viral infection, and even if I do it, I still need to confirm it with a 4th-generation test. I took my last test at a private lab that offers a comprehensive STD panel, and I chose that option. I haven't done any HIV PCR test. The HIV NAT test is very expensive, and I assumed that a 4th-generation test would be enough. Can I wait longer and just repeat a 4th-generation test instead of an HIV PCR test? If so, how long should I wait—3 months or 5 months post-PEP?

1 months ago

Sorry for the repeated sentence typo.

1 months ago

Forgot to mention that during that incident, I had food poisoning. I fell out of bed when I woke up in the middle of the night to vomit.
Could it explain the CBC?

1 months ago

I also had a CBC test about 3 weeks post-PEP, which showed a normal lymphocyte count(2.3 abs count).

Is the principle of the ag/ab test able to detect ag if there are no antibodies produced, and vice versa?

H. Hunter Handsfield, MD

1 months ago

Thanks for the additional information, but it doesn't change my evaluation or advice. On one hand, I agree with your doctor that PCR testing isn't necessary; it is 100% certain you do not have HIV and something else explains your lymph nodes and the very minor variation in your lymphocyte count, which was not really abnormal anyway. I suggested PCR testing strictly for reassurance. You might discuss it again with your doctor; s/he might agree that reassuring you with the additional negative result is a good reason for a PCR test. In the meantime, I am completely certain you do not have HIV.---

1 months ago

Doctor Handsfield,

Could I please understand the rationale behind suggesting a PCR test for HIV after 3 months from exposure? (Are you suggesting these tests (4th gen) could have been falsely negative, even though it's 99.9% sensitive if done after the window period)

I also looked for the topic of people who are unable to produce antibodies to HIV; they are either immunocompromised, or they are on chemotherapy, which I'm not.

I reached out to an ID fellow specializing in Sexually Transmitted Infections (STIs) and HIV/AIDS, and he said:
"I'm not aware of infectious diseases doctors prescribing a PCR-RNA to diagnose HIV and if they do, they shouldn't.

PCR-RNA is a testing methodic that's been abused in recent years by anxious people due to the fact that it has a shorter conclusive window period compared to a combo 4th gen test.

But PCR-RNA should strictly be reserved to

screen donated blood units
screen viraemia of positive people on treatment

A 4th gen test, unlike PCR-RNA, is able to tell us if the patient has a newly acquired infection, a progressed infection and what type of antibodies (IgG, IgM, IgA) are detectable."

1 months ago

I'm really worried and lost sleep over this last night. Even if I went to my doctor, there’s a high chance she won’t prescribe PCR, and my insurance would likely refuse it, as Ag/Ab is the standard where I live. So I’d have to take that test out of pocket, which is very costly.

What's your take on my question in the previous post: "Can I wait longer and just repeat a 4th-generation test instead of an HIV PCR test? If so, how long should I wait—3 months or 5 months post-PEP?"

I'm really regretful that I stirred this topic. I don’t want to be that guy who overtests until getting a false positive and then has to go through multiple hoops to prove negativity (because I’ve seen that happen).

Is it safe to move on and trust my last results, or do you think I shouldn’t yet?
This is just a proposal, not a request. Can you add additional follow-up?
Disclosure (I'm a medical student, which is why you might see me probing on this topic; med school doesn't go into details about STDs, HIV, and PEP)

1 months ago

I feel really sorry for going back and forth on this topic. I let my anxiety slide. It was a regrettable experience that still haunts me to this day, and my mind keeps telling me, “HIV is going to show up sooner or later,” linking every trivial symptom to it.
I just wanted to put this last statement there.

H. Hunter Handsfield, MD

1 months ago

You're really into the weeds on this, although I'm glad to know you're a medical student -- and at one level congratulate you on attempting to understand the science beyond simple providers' advice. Most medical schools DO "go into details about STD, HIV and PEP," at least in the US, Western Europe and most industrialized countries. In any case you need to think analytically and objectively, which definitely is not reflected in irrational statements like "My mind keeps telling me HIV is going to show up sooner or later." It is not; and frankly from a psychological standpoint it is not normal to remain so uncertain and frightened after the repeated, science-based advice you have had from several providers and from this discussion.

As for the details of your questions, we do not provide medical care; our advice is general. All these details are more appropriate for the doctor or clinic that provided your PEP. You're just making more trouble and uncertainty for yourself by getting multiple opinions from different sources: as you are finding, attitudes and advice from expert providers can vary widely causing more confusion than help. (In my view based on 40 years experience, the ID fellow is wrong about not using PCR for diagnosis.) That said, it also is correct that your negative AgAb test at 3 months is conclusive. I see no reason for additional testing at all, except for its reassurance value.

You also have not given any information about the exposure that led to PEP. If you had a genuinely high risk exposure (like unprotected anal sex with another male partner, especially if he is known to have untreated HIV), it makes more sense to continue to ask your doctor/clinic about a confirmatory PCR test. If more like most exposures on this forum (e.g. unprotected vaginal sex with a female partner in North America or Europe) then you probably were at little or no risk of HIV anyway and PEP might not have been warranted.

That completes the two follow-up comments and replies included with each question and so ends this thread. I hope the discussion has been helpful. Best wishes and stay safe.

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