Correspondence

Mother-to-Infant Transmission of the Human Immunodeficiency Virus during Primary Infection

N Engl J Med 1999; 341:1548November 11, 1999

Article

To the Editor:

The efficacy of antiretroviral-drug therapy in preventing mother-to-infant transmission of the human immunodeficiency virus (HIV) has led to the recommendation of universal testing of pregnant women as early as possible after conception.1 However, this strategy precludes the identification of women who acquire HIV infection later in pregnancy, including women who are infected during the peripartum period. Either scenario can result in erroneous exclusion of infant HIV infection, as has been documented for congenital syphilis.2 Early identification of infants with HIV infection is important for the initiation of prophylaxis against Pneumocystis carinii pneumonia and antiretroviral-drug therapy. We report a case of perinatal HIV infection that occurred during the period in which the mother was seronegative and that was further distinguished by the infant's rapid progression to AIDS and death without the development of detectable HIV antibodies.

A two-month-old girl was admitted to the hospital for failure to thrive. She had been born at term after a pregnancy complicated by syphilis during the first trimester. At that time, the mother and three of her partners had a negative result on an enzyme-linked immunosorbent assay for HIV antibodies. At admission, the infant was 10 g above birth weight; otherwise, the findings on physical examination were normal. The workup for failure to thrive was negative. Tests for HIV antibodies were negative in stored umbilical-cord serum as well as during hospitalization and seven weeks later. Eight weeks after admission, the infant had fever and respiratory failure. Severe lymphopenia was found, with an absolute CD4 count of 135 cells per cubic millimeter. HIV antibody tests remained negative, but tests for HIV DNA (by the polymerase chain reaction) and p24 antigen in plasma were positive, and the level of plasma HIV type 1 RNA was 32 million copies per milliliter. Despite maximal supportive care, the infant died. Autopsy revealed P. carinii pneumonia and disseminated cytomegalovirus infection. HIV antibodies were detected in the mother's serum at the time of the infant's death. The mother admitted to having had multiple sexual partners throughout pregnancy but said that she had not had symptoms of primary HIV infection before delivery.

The negative serologic tests early in pregnancy and in cord serum and the positive test in the mother post partum suggest maternal infection near the time of delivery. Seronegative HIV infection has been reported in rare cases in both adults and children and is usually associated with rapid progression of disease. This case highlights the need for repeated testing of pregnant women who are at high risk and the need for the use of direct virologic methods in infants with seronegative tests but clinical presentations suggestive of HIV infection.

Brian A. Van Tine
George M. Shaw, M.D., Ph.D.
Grace Aldrovandi, M.D.
University of Alabama at Birmingham, Birmingham, AL 35294

2 References

1. 1

   Stoto MA, Almario DA, McCormick MC, eds. Reducing the odds: preventing perinatal transmission of HIV in the United States. Washington, D.C.: National Academy Press, 1999.
   

2. 2

   Dorfman DH, Glaser JH. Congenital syphilis presenting in infants after the newborn period. N Engl J Med 1990;323:1299-1302
   Full Text | Web of Science | Medline

Citing Articles (4)

Citing Articles

1. 1

   Marine Karchava, Wendy Pulver, Lou Smith, Sean Philpott, Timothy J. Sullivan, Judith Wethers, Monica M. Parker. (2006) Prevalence of Drug-Resistance Mutations and Non-Subtype B Strains Among HIV-Infected Infants From New York State. JAIDS Journal of Acquired Immune Deficiency Syndromes 42:5, 614-619
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2. 2

   Karen P. Beckerman. 2005. Identification, Evaluation, and Care of the Human Immunodeficiency Virus–Exposed Neonate. , 475-494.
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3. 3

   Monica M. Parker, Nancy Wade, Robert M. Lloyd,, Guthrie S. Birkhead, Brian K. Gallagher, Babu Cheku, Timothy Sullivan, Jill Taylor. (2003) Prevalence of Genotypic Drug Resistance Among a Cohort of HIV-Infected Newborns. JAIDS Journal of Acquired Immune Deficiency Syndromes 32:3, 292-297
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4. 4

   BLUMA G. BRENNER, MARK A. WAINBERG. (2000) The Role of Antiretrovirals and Drug Resistance in Vertical Transmission of HIV-1 Infection. Annals of the New York Academy of Sciences 918:1, 9-15
   CrossRef