Acute HIV-1 Infection Presenting as Oral Aphthosis

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Acute HIV-1 Infection Presenting as Oral
Aphthosis
L. Parker Gregg, MDResident, Department of
Internal Medicine, University of Washington
She returned the next day with expansion of her
rash to the extremities, including a macule on
the palm of her right hand (figure 2). Not only
were the lesions increasing in number and
expanding in territory, but she also developed
profound oral aphthosis (figure 3) that had
abruptly worsened over the preceding 24 hours. On
her face and arms were multiple discrete
erythematous macules up to 1.5 cm in diameter
that were slightly tender to palpation but
non-pruritic. She had temperatures as high as
39.3C, but vital signs were otherwise stable and
within normal limits. A complete blood count was
normal with a differential showing a neutrophilic
predominance and absolute lymphocyte count at the
lower limit of normal. Blood chemistries and
lactate level were normal. Syphilis IgG antibody
was negative.
Workup included an HIV 4th generation
antigen/antibody test, which returned positive
with a negative Multispot Ab test. This result
was interpreted as presumptively positive for p24
antigen. Western blot assay was indeterminant for
HIV-1 but positive for p24, and an HIV-1 RNA
assay yielded 2,471,000 copies/mL with a CD4
count of 481 cells/microL.
She is a mother of two who has never used IV
drugs, is monogamous with her husband, and has no
other behavioral risk factors for acquisition of
HIV-1. However, she worries that her husband is
unfaithful to her. Her acute symptoms resolved
after several days, and she was discharged from
the hospital on antiretroviral therapy to be
followed in the Acute HIV Clinic.