Letters to the Editor
Diagnostic Testing for HIV Infection
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Am Fam Physician. 2003 Jul 15;68(2):224.
to the editor: I would like to point out a minor, but potentially significant, error in the article “Lymphadenopathy and Malignancy”1 in American Family Physician. The authors appropriately include primary human immunodeficiency virus (HIV) infection in the differential diagnosis of lymphadenopathy. However, in Table 1they list “HIV antibody” as the diagnostic test of choice.
It has been reported that between 40 and 70 percent of patients experience diffuse lymphadenopathy following primary HIV infection. However, patients will not seroconvert until about 22 to 27 days postexposure.2 Thus, the standard HIV enzyme-linked immunosorbent assay (ELISA) will be negative if performed during the period of acute infection. The recommended test to obtain in this setting is an HIV RNA level by either polymerase chain reaction or branched DNA. Serologic testing for p24 antigen also may be used, but the reported sensitivity is only about 75 to 90 percent. In the majority of cases, the HIV RNA level will be exceedingly high (more than 100,000 copies per mL) and thus confirm the diagnosis. These patients can then be promptly referred for consideration of treatment with antiretroviral agents, concurrent with the current recommendations of the U.S. Public Health Service treatment guidelines.3Risk-reduction counseling also can be addressed during this time because there are epidemiologic studies suggesting that a significant amount of HIV transmission occurs from persons with early infection.4
1. Bazemore AW, Smucker DR. Lymphadenopathy and malignancy. Am Fam Physician. 2002;66:2103–10.
2. Kahn JO, Walker BD. Acute human immunodeficiency virus type 1 infection. N Engl J Med. 1998;339:33–9.
3. Dybul M, Fauci AS, Bartlett JG, Kaplan JE, Pau AK. Guidelines for using antiretroviral agents among HIV-infected adults and adolescents. Recommendations of the Panel on Clinical Practices for Treatment of HIV. MMWR Recomm Rep. 2002;51(RR-7):1–55.
4. Hecht FM, Busch MP, Rawal B, Webb M, Rosenberg E, Swanson M, et al. Use of laboratory tests and clinical symptoms for identification of primary HIV infection. AIDS. 2002;24:1119–29.
editor's note: A copy of this letter was sent to the authors of “Lymphadenopathy and Malignancy,” who declined to reply.
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