[Question #6838] HIV Risk or Not - Part 2

10 months ago

Hi,

 

First of all, hope you are safe during these difficult times with corona virus.

 

There are some developments that I am very concerned about and wanted to get your advice on.  Today is about 6 weeks post exposure and 2 weeks post completing PEP.  Recap of what has happened since my last post:

 

April 3 - had pain in my right hand (aching as well as shooting) and behind right knee.  Lasted only 2 days.  Did not think much of this.

 

April 10 – Had diarrhea in the morning and did not think much of it.  Took a nap after lunch and woke up about an hour later because of a lot of pain and stiffness in my right leg.  I have been at home under curfew for the last few days so no chance of straining it doing any activity.  The pain is below the anterior right knee –where the tendon goes into the tibia.  It hurts when I stand up or squat/sit down but not at rest or when I walk.  Also, from time to time, the area feels warm under the skin but not when I touch the skin.  It does not appear to be swollen either.

 

April 11/12 went to bed late and woke up at 6am with a heavy night sweat – my torso and head were very sweaty and my shirt was slightly damp.  I had the AC on at 21 degrees so the room was cool. 

 

April 12 (today) - The leg symptoms continue and I will find out if the night sweats do as well.  I did get a splotchy red rash on three places this morning – on the knee, where the tendon goes into the tibia, and a few inches below that as well.  But I had also put a hot water bottle there in the morning so not sure if its from that, but the rash is 95% gone after 5-6  hours

 

I am getting very worried now.  The night sweats and the arthralgia are things I have never gotten in my life.  Just seems against the odds to suddenly develop joint pain and night sweats out of the blue without going out and not being exposed to any other virus, bacteria, etc. due to curfew.

 

1.  Seems have to assume that my recollection of the events are not correct and I may have indeed had a risky exposure, and it is possible that PEP has failed and this is an atypical presentation of infection.  Would really appreciate your honest opinion if this sounds like a case of PEP failure.  Cant think of anything else that could cause all this especially sitting alone at home for so long.

 

2.  Could this pain be reactive arthritis or is it arthralgia? It seems like the joint is not involved and from what I’ve read, it seems more like enthesitis which is particular to reactive arthritis and apparently the protocol is to screen for hiv if one presents with a case of reactive arthritis as it is so common.

 

3.  Can one have night sweats without fever?  I don't recall having fever so far.

 

 

10 months ago
Hi Doctor,

I would also like to add (sorry but forgot to add this to the first question and hope you will not count this as the second question).  But I was just reading on medscape that erythema nodosum occurs with reactive arthritis.  And this looks exactly like what I had on my knee and shin.  I only noticed it today so not sure if it was there earlier.  But it has faded 95% but still slightly there.  Am very scared now


Edward W. Hook M.D.
Edward W. Hook M.D.
10 months ago
Welcome back to the forum although I’m sorry that you continue to worry about the events that you described in our original exchange. As I’ve already told you I would not have taken PEP following the encounter you described and if there had been risk, with PEP your risk for acquisition of infection would have become negligible.  

I am not discounting your symptoms. It sounds like something maybe going on however the symptoms and sequence of events you describe are not the least bit suggestive of HIV or any STI.  

Your lower extremity symptoms are somewhat suggestive of a tendinitis however if this were tendinitis you would also have discomfort on walking. I suspect the symptoms you’re describing are unrelated to the sexual encounter you described. They may however be related to your diarrheal illness. Indeed, reactive arthritis may follow diarrheal disease, particularly when it is caused by a bacteria called Campylobacter.  This point this is not a problem which can be easily sort it out online. A diagnosis of tendinitis or arthritis is most appropriately made by a trained clinician who is able to do a physical examination. I suggest you see your own doctor at this time to try to get this sorted out.

In answer to your specific questions:
1.  This sounds most unlikely to be a failure of your postexposure prophylaxis. Little you have described suggests HIV. If your symptoms were due to HIV, if you choose, you could get an HIV test which, if you had failed PEP and your symptoms were due to HIV, would certainly be positive. I suggest this not because I think HIV is likely but because I hope it would provide you with peace of mind.

2.  As noted above, a diagnosis of reactive arthritis should be made by a train clinician who has directly examined you.

3.  Night sweats are a non-specific symptom which can have many causes. Reflux esophagitis as well as any number of infections may cause this. Fever is not necessary for night sweats to occur.

Finally, like reactive arthritis a diagnosis of erythema nodosum  is something that should be made by a trained clinician. Not online and not to by patients themselves based on internet descriptions . Your concerns only reinforce my strong recommendation to seek a valuation by your own physician. I remain confident this is not HIV.  EWH


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10 months ago
Dear Dr. Hook,

Thank you for your reply.  I feel I may have written this in panic mode, so perhaps best I step back and approach this more logically.

I was concerned about the symptoms because I have been in self-quarantine for the last 3 weeks.  As such, I have not undertaken any strenuous exercise nor have I gone out and been exposed to others and been potentially infected with any run of the mill bacterial/viral infection.  So, it seems that joint/ligament pain, night sweats, and rash is very strange in this setting unless we account for potential HIV.  Further, about 6 weeks ago after the initial expisode, I had prophylaxis of 2g Azithromycin and 800mg cefixime, so unlikely to have had any bacterial std.

Also, due to the quarantine/curfew here, it is not practical to visit a doctor/hospital except for emergencies.  Further, as of this morning:  (i) the rash has completely resolved, and (ii) the joint/ligament pain is more or less gone (80% improvement) so would not be much to show anyone at this point.  And I did not have any night sweats last night - just felt very hot several times during the night in a cold room, but I measured my temperature and it did not exceed 99.

Would appreciate if you could clarify the following:

1.  Why do you feel the symptoms are not suggestive of HIV?  I was under the impression that in ARS, arthralgia, night sweats, and rash are quite specific in the pantheon of ARS symptoms, and the timing is correct (i.e. 2 weeks post PEP completion had it failed). And given the self quarantine for 3 weeks, I'm confused as to how some other infection could be the cause of these symptoms as they are not normal run of the mill symptoms.

2.  I only had diarrhea one time, so not sure if this could be correlated.  In your experience, does Reactive Arthritis show up as ARS or during the later course of HIV infection?

3.  Regarding the acute onset of joint/ligament pain (in the absence of exercise) for a duration of 3 days, does it stand to reason that the most likely cause is viral?  And does the quick resolution this morning (along with resolution of rash and night sweats) point to ARS or tell us anything more?  Again, due to self quarantine, not sure how it could be related to another infection.

4.  Regarding the rash, it disappeared within 24 hours (provided it was not there before I noticed it).  It consisted of 2 red roundish spots on the shin (not raised) about 1 inch in diameter along with a 1.5 inch red arch shaped spot (not raised) on my knee.  This was all on the same leg that was paining and all blanched if pressed.  All three lesions were roughly in the same vertical line with a 3 inch gap between lesions.  Is it typical for ARS rash to be localized like this and be transient and go away so fast?  Does this sound like ARS rash?

5.  Yes, I think the only option is to test, so will do that.  Just praying that all these symptoms are completely unrelated and that the PEP medication worked!


Thanks!
Edward W. Hook M.D.
Edward W. Hook M.D.
10 months ago

Thanks for the additional information.  It does not change my assessment or advice however.  In response to your follow-up questions:

1.  High fever is always present in the ARS, the arthralgias are generalized, not localized  and the sore throat which typifies the ARS is quite severe.  NOTHIN you describe concerns me about the ARS. What is does suggest  however is that you are searching the internet for answers out of anxiety, something that makes my job harder as so much of what is on the internet is misleading.

2.  Typically the diarrheal illness which leads to reactive arthritis lasts several days.  Reactive arthritis is NOT part of the ARS (another interned fueled misperception!), it occurs after persons have well established HIV- typically month later and is a RARE manifestation of HIV, no matter what the internet says.

3.  Not necessarily.  Inactivity can lead to joint discomfort as well.  As I already said, evaluation of muscle and joint aches requires an examination.

4.  No, this sounds nothing like the rash of the ARS which is typically faint, generalized and most noticeable on the truck and back.

5.  I am confident that your test will be negative.  Further, I should point out that despite the COVID 19 pandemic, HIV testing remains widely available in most locations.  EWH

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10 months ago
Dear Dr. Hook,

I took the HIV Duo test, and the results were non-reactive - you were absolutely correct!  Would appreciate your thoughts on the following:

1.  The value of the test result was 0.25 and the range is <1 is non-reactive.  In the past, my test values have always been below 0.10.  Does it really matter what the specific value is as long as it is below 1, or does a higher value than what one normally gets signify potential increasing reactivity which could lead to a reactive result a few days/weeks later (if one is in the window period for example)?

2.  Does this definitively prove that any symptoms I had were not due to HIV?

3.  I took the test nearly 7 weeks from exposure (2 days short of 7 weeks to be exact) which is nearly 3 weeks after the last PEP dose.  Is this long enough for me to be assured I am HIV negative, or do I still need another test, and if so, when?  At this stage in the testing timeline, what would you estimate my odds for being HIV negative at?


Thanks so much for your help and advice!
Edward W. Hook M.D.
Edward W. Hook M.D.
10 months ago

1.  The test values can fluctuate on a day to day basis and are meaningless.  There is no significance to the fact that your negative value recently was slightly higher than previous negative values.  Both prove that there is no evidence of infection equally well.

2. Yes

3.  As I've already said, your risk of infection was vanishingly low even before you took PEP.  You need to believe your current results and stop worrying.  You DID NOT get HIV from the exposure you have described.  The possibility that you have HIV from the exposure you described is immeasurably low.

As you know, we provide up to three responses to each question and this is my 3rd response. Thus the thread will be closed now. I must warn you that should you return with further questions about this exposure or related to your lab values or PEP, the question may be deleted without a response and without return of your posting fee.  It is past time for you to move on.  I trust you will understand. EWH

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