[Question #5133] Risk assement

23 months ago
Dear doctors,

i had had a sexual encounter with a lady of unknown status and the condom broke twice. Both times i have noticed and replaced, but have no idea how long i was unprotected.

8 days after i rapidly developed fever at the evening — 37.8C. No other symptoms. In the next 5 days, fever was on and off, from none in the morning it would develop to 37.6—37.9 closer to the evening. 

I was active the whole week, not in bed. Within these 5 days, а yellow-green secretion started to run down in the back wall on my nose into the throat and i started develop coughing and my throat became irritated. After these 5 days, fever became persistent (37.6) and on the 8th day i went to see an emergency doctor. He performed x-ray on my chest (was clean) and blood test. The test showed higher CRP (43.0), higher Monocytes (11% and 1.29) and slightly lower Lymphocytes (19.3, with bottom border being 20). The doctor gave me antibiotics (cefpodoxime) for 7 days. 

In the next 4 days my respiratory problem worsened, fever as before on and off — usually none in the morning and then around 37.6—37.9 in the evening. I saw another internist who suggested i have any kind of viral infection (mono, etc.) and gave me Isoprinosine which i am taking for only one day now.

At day 10 i also developed two small ulcers in my mouth which lasted for a day or two

Its 12 days now from symptoms onset, and nothing seems to get better, despite the treatment. I have never had fever, that wouldn’t disappear for so long.  

What i didn’t and don’t have — headaches (only sometimes from too intensive coughing), any kind of sweats, fatigue, loss of appetite, rash, swollen lymphnodes. It’s only the fever and the nasal secretion/ cough issue.

My questions:
— given your experience is this situation suggesting ARS in any way, given my symptoms, blood test result and timing?

Please advice, a am extremely worried. I have to wait another two weeks to be able to perform a test and i will go crazy until then.

thank you
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
23 months ago
Welcome to the forum. Thanks for your question and your confidence in our services.

I certainly understand your concern about your symptoms and their timing with the sexual exposure. But the odds against HIV are very strong. Most likely this was a low risk exposure. Can you say more about your partner and her potential HIV risks and sexual lifestyle? But even if she has active, untreated HIV, the average transmission risk for a single episode of unprotected vaginal sex is around 1 in 2,500. So the odds against HIV are strong.

The symptoms of ARS are nonspecific -- meaning that they occur with innumerable other conditions. More than the detailed symptoms themselves, the pattern of symptoms is important -- and yours don't add up to a high likelihood of HIV. Among other things, ARS generally does not cause nasal congestion or dripping, and no cough. And as you suggest yourself, absnce of some symptoms -- especially skin rash, fever, and enlarged lymph nodes -- is pretty strong evidence against HIV as the cause. This sounds like respiratory virus infection -- worse and more prolonged than the average cold, but not alarming. Continued symptoms despite cefpodoxime only means it's not primarily a bacterial infection, but viral -- and no virus responds to antibiotics. They just have to run their course. (If I had to guess, I would suspect adenovirus, one of the more common of the prolonged respiratory viruses.)

Can I be 100% confident it isn't ARS? No. But it is extremely unlikely. In any case, you don't have to wait another 2 weeks to be tested for HIV. Discuss your concerns with your doctor and suggest he order a standard antigen-antibody ("due", "combo") HIV blood test. Although 2 weeks is early from the standpoint of the exposure, it almost always is positive within a week of onset of ARS symptoms. A negative result would not prove conclusively you don't have HIV, but it WOULD conclusively show that your symptoms are not caused by ARS. And depending on your doctor's perspective, s/he might order a nucleic acid amplification test (PCR, RNA test). At 2 weeks, a negative result will be nearly 100% conclusive. (If you're not confident of your own doctor's expertise, you ask for referral to an infectious diseases specialist or other provider experienced in HIV diagnosis and management.)

Bottom line:  Almost certainly you do not have HIV. I hope this information is helpful. Let me know if anything isn't clear.

23 months ago
Thank you Dr.  Handsfield, 

i really appreciate your detailed answer.

Bellow my comments and questions:

Can you say more about your partner and her potential HIV risks and sexual lifestyle? "
— She comes from a country which has one of highest HIV infection rate in Europe for 2018. On second hand she is a sporty person paying huge attention to her health, doesn't drink or smoke, eats only healthy food. She claims she has never had sex without a condom in her life, including when she was in a relationship. But, as  my example shows — condoms break, so no guarantee it hasn't happened before. I asked her to make a test herself, explaining my worries. She happily agreed to do so next week.

" And as you suggest yourself, absence of some symptoms -- especially skin rash, fever..."
— well, fever is exactly one of the two things (together with respiratory issues) i do complain about.

"Discuss your concerns with your doctor and suggest he order a standard antigen-antibody ("due", "combo") HIV"
— unfortunately the only test i have access to, right now, is an ELISA.

Few annoying, anxiety-driven questions:
— do my blood test results suggest anything ARS related? the higher CRP and Monocytes count?
— is a fever, jumping up and down between 37— 37.9 typical for ARS?
— would it make any sense to make an ELISA test next week, which would be 24 days from exposure? Would a negative result mean anything at 24 days?
If not, what is the earliest time you would suggest to have an ELISA if no other testing options are available?

Thank you in advance

H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
23 months ago
It sounds like your partner is not at high risk for HIV, regardless of her geographic origins. Good move to ask her to test; she can expect a negative result, in which case your worries are over.

Sorry I misread about fever, but it doesn't change my assessment or advice. Virtually all viral infections of the sort you have had will cause fever.

ELISA doesn't mean it's not an AgAb test. ELISA is a test technology, used in almost all lab-based HIV tests. Even if it's an antibody-only test, everyone with symptoms due to ARS more than a few days would have a positive result; a negative result at this time would be close to 100% reliable. And in any case, I cannot imagine any reputable lab that doesn't offer a range of different test types; it shouldn't be hard to arrange for an AgAb test. Or just wait for your partner's test result. 

Your blood test results are entirely compatible with just about any systemic viral infection. The fever pattern also doesn't mean anything in particular.

Don't overthink all this. Stop looking at minor nuances in symptoms, lab results, the nature of the exposure or anything else. The available info at this point comes to very strong evidence you don't have HIV.
23 months ago
Thank you Dr. Handsfield,

your answers were extremely helpful. I will follow your advices.

All the best.
H. Hunter Handsfield, MD
H. Hunter Handsfield, MD
23 months ago
Thanks for the thanks. That's why we're here. Take care and stay safe.---