Correspondence

Acute Immunosuppression with HIV Seroconversion

N Engl J Med 1993; 328:288-289January 28, 1993

Article

To the Editor:

Acute immunosuppression with opportunistic infection immediately after human immunodeficiency virus (HIV) seroconversion is believed not to occur. Here is one such case.

On September 16, 1991, a 31-year-old, heterosexual white man without risk factors for the acquired immunodeficiency syndrome was admitted with an influenza-like syndrome of fever, mouth sores, odynophagia, rectal pain and bleeding, and weakness. Laboratory tests revealed a white-cell count of 2300 per cubic millimeter, a platelet count of 52,000 per cubic millimeter, and a hematocrit of 49 percent. Colonoscopy showed diffuse edema, erythema, mucosal friability, and whitish plaque-like lesions in the rectum. Rectal biopsy confirmed cytomegalovirus (CMV) colitis with characteristic CMV inclusion bodies in the vascular endothelium, as well as the lamina propria (Figure 1Figure 1Rectal-Biopsy Specimen from a Patient with CMV Colitis.). Immunoperoxidase staining for CMV was positive. The HIV enzyme immunoassay performed by a reference laboratory on September 17 was nonreactive. On September 20 a polymerase-chain-reaction assay for HIV DNA was positive, and a p24 antigen test was reactive at 101 pg per milliliter. On September 25 the HIV enzyme immunoassay was repeatedly reactive. Changes in CD4 and CD8 cell counts are shown in Table 1Table 1Laboratory Findings in the Case Patient.. On October 3 the man was readmitted for “falling spells” due to peripheral neuropathy (confirmed by electromyography), which persisted and disabled him. Proctitis was improved, and a rectal-biopsy specimen was now negative for CMV colitis.

Acute HIV infection is known to present with an influenza-like illness1,2. Acute immunosuppression, however, has so far been seen to occur only after a prolonged disease-free seropositive interval or after a prolonged period of constitutional symptoms3,4. This patient appears to have had acute HIV seroconversion with acute immunosuppression and CMV colitis. I know of one other report5 of simultaneous CD4 and CD8 suppression with acute HIV infection, but the immunosuppression resolved spontaneously without any opportunistic infection or disability.

Acute HIV seroconversion in the patient described here is suggested by the initially negative HIV-antibody test and the positive polymerase-chain-reaction and p24 antigen tests, leading to the repeatedly reactive enzyme immunoassay. The patient appears to have mounted the antibody response during this time. It is further supported by the rapidly evolving CD4 and CD8 changes and the clinical influenza-like illness. The hypothesis of acute CMV infection is supported serologically by a 10-fold increase in the CMV IgG titer, from 0.15 on September 18 to 1.56 on October 5. CMV and HIV may be interactive in their pathogenesis, however. There is also the possibility of fortuitous acquisition of both infections at about the same time.

Immunologic data concerning acute seroconversion have thus far shown an inverted CD4:CD8 ratio resulting from an increase in CD8 lymphocytes and no substantial CD4 lymphocytopenia1,3-5. This patient had marked CD4 lymphocytopenia, which explains the susceptibility to opportunistic infection with CMV, although the CD4:CD8 ratio was still normal. In the presence of CD8 lymphocytopenia, the CD4:CD8 ratio may not be low (which is usually considered a reliable indicator in this disease).

Kaushal K. Gupta, M.D.
11206 Airline Dr., Houston, TX 77037

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Citing Articles (7)

Citing Articles

1. 1

   Alex Studemeister. (2011) Cytomegalovirus Proctitis: A Rare and Disregarded Sexually Transmitted Disease. Sexually Transmitted Diseases 38:9, 876-878
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2. 2

   K.-W. Hong, S. I. Kim, Y. J. Kim, S. H. Wie, Y. R. Kim, J.-H. Yoo, N. I. Han, M. W. Kang. (2011) Acute cytomegalovirus pneumonia and hepatitis presenting during acute HIV retroviral syndrome. Infection 39:2, 155-159
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3. 3

   Alex Padiglione, Eman Aleksic, Martyn French, Alicia Arnott, Kim M. Wilson, Emma Tippett, Matthew Kaye, Lachlan Gray, Anne Ellett, Megan Crane, David E. Leslie, Sharon R. Lewin, Alan Breschkin, Chris Birch, Paul R. Gorry, Dale A. McPhee, Suzanne M. Crowe. (2010) Extremely prolonged HIV seroconversion associated with an MHC haplotype carrying disease susceptibility genes for antibody deficiency disorders. Clinical Immunology 137:2, 199-208
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4. 4

   B. Kreft, A. Oehme, C. Lübbert, W.C. Marsch, A.S. Kekulé. (2010) 37-jähriger Patient mit Fieber, Durchfall und Lymphknotenschwellung. Der Internist 51:8, 1050-1052
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5. 5

   Patrick J Lillie, Gavin D Barlow, Peter J Moss, Mirella J Parsonage, Kate Adams, Hiten K Thaker. (2007) HIV seroconversion complicated by Mycobacterium kansasii infection. AIDS 21:5, 650-652
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6. 6

   J. V. Nicholas, P. J. Skidmore, D. P. Dooley. (2002) Esophageal Ulceration Due to Cytomegalovirus Infection in a Patient with Acute Retroviral Syndrome. Clinical Infectious Diseases 34:1, e14-e15
   CrossRef

7. 7

   Emanuel N. Vergis, John W. Mellors. (2000) NATURAL HISTORY OF HIV-1 INFECTION. Infectious Disease Clinics of North America 14:4, 809-825
   CrossRef