A 36-year-old man presents to his general practitioner (GP) complaining of a fever and generalized aching in muscles around the back and legs. At first he thought that this was probably influenza but the symptoms have now been present for 9 or 10 days. For 3 days he had diarrhoea but this has settled now. He has complained of a sore mouth over the last week or so which has made it difficult to eat, but he has not felt very hungry during this time and thinks he may have lost a few kilograms in weight. Around the time that the symptoms started he noticed a mild erythematous rash over his chest and abdomen but this has faded. He has visited the practice occasionally in the past for minor complaints. He has been to the practice to obtain vaccinations for visits to Vietnam and Thailand over the last 3 years. His last travel abroad was 3 months ago. He smokes 10 cigarettes daily, drinks 20–30 units of alcohol weekly and takes no illicit drugs. He had no other relevant medical or family history. He works as a solicitor. He is single and lives alone. He has had a number of heterosexual and homosexual relationships in the past. Twelve months ago he had an HIV test which was negative.
Examination He had a temperature of 38°C. Pulse rate was 94/min, respiratory rate 16/min and blood pressure 124/78mmHg. There were no abnormalities in the cardiovascular or respiratory system. On examination of the mouth there were two ulcers in the oral mucosa, 5–10mm in diameter. There were a number of palpable cervical lymph nodes on both sides of the neck, which were a little tender. There were no other nodes and no enlargement of liver or spleen. There were no rashes on the skin.
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Normal Haemoglobin 14.8g/dL 13.7–17.7g/dL Mean corpuscular volume (MCV) 87fL 80–99fL White cell count 7.4 109/L 3.9–10.6 109/L Neutrophils 5.1 109/L 1.8–7.7 109/L Lymphocytes 2.0 109/L 0.6–4.8 109/L Platelets 332 109/L 150–440 109/L Sodium 144mmol/L 135–145mmol/L Potassium 4.4mmol/L 3.5–5.0mmol/L Urea 5.9mmol/L 2.5–6.7mmol/L Creatinine 73amol/L 70–120amol/L Bilirubin 13mmol/L 3–17mmol/L Alkaline phosphatase 121IU/L 30–300IU/L Alanine aminotransferase 25IU/L 5–35IU/L A 36-year-old man presents to his general practitioner (GP) complaining of a fever and generalized aching in muscles around the back and legs. At first he thought that this was probably influenza but the symptoms have now been present for 9 or 10 days. For 3 days he had diarrhoea but this has settled now. He has complained of a sore mouth over the last week or so which has made it difficult to eat, but he has not felt very hungry during this time and thinks he may have lost a few kilograms in weight. Around the time that the symptoms started he noticed a mild erythematous rash over his chest and abdomen but this has faded. He has visited the practice occasionally in the past for minor complaints. He has been to the practice to obtain vaccinations for visits to Vietnam and Thailand over the last 3 years. His last travel abroad was 3 months ago. He smokes 10 cigarettes daily, drinks 20–30 units of alcohol weekly and takes no illicit drugs. He had no other relevant medical or family history. He works as a solicitor. He is single and lives alone. He has had a number of heterosexual and homosexual relationships in the past. Twelve months ago he had an HIV test which was negative.
Examination He had a temperature of 38°C. Pulse rate was 94/min, respiratory rate 16/min and blood pressure 124/78mmHg. There were no abnormalities in the cardiovascular or respiratory system. On examination of the mouth there were two ulcers in the oral mucosa, 5–10mm in diameter. There were a number of palpable cervical lymph nodes on both sides of the neck, which were a little tender. There were no other nodes and no enlargement of liver or spleen. There were no rashes on the skin.
Normal Haemoglobin 14.8g/dL 13.7–17.7g/dL Mean corpuscular volume (MCV) 87fL 80–99fL White cell count 7.4 109/L 3.9–10.6 109/L Neutrophils 5.1 109/L 1.8–7.7 109/L Lymphocytes 2.0 109/L 0.6–4.8 109/L Platelets 332 109/L 150–440 109/L Sodium 144mmol/L 135–145mmol/L Potassium 4.4mmol/L 3.5–5.0mmol/L Urea 5.9mmol/L 2.5–6.7mmol/L Creatinine 73amol/L 70–120amol/L Bilirubin 13mmol/L 3–17mmol/L Alkaline phosphatase 121IU/L 30–300IU/L Alanine aminotransferase 25IU/L 5–35IU/L
ANSWER
This seems likely to be an infective problem which has gone on for over a week. The length of the history makes influenza unlikely. The other positive features are the cervical lymphadenopathy and the oral ulceration. The temperature is still up and there has been a rash which has resolved. The blood results are all normal including the test for glandular fever (infectious mononucleosis) which was a reasonable diagnosis with these features. The previous homosexual contact increases the possibility of sexually transmitted infections. It is possible that travel to Vietnam and Thailand may have been associated with high-risk sexual exposure. He is known to have had a negative HIV test 12 months ago. However, it is quite possible that this might be an HIV seroconversion illness. In around half of those who acquire the virus this occurs within 4–6 weeks of acquisition. Although the HIV test will still be negative, this can be diagnosed by finding the presence of the HIV virus or its p24 antigen in the blood. He should have been counselled about precautions to reduce the risk of transmission of sexually transmitted diseases at the time of the HIV testing 12 months before. The picture might fit for secondary syphilis which occurs 6–8 weeks after the primary lesion. However, in that case the rash would often be more extensive and the lymph nodes are not usually tender. A serological test for syphilis should certainly be performed. Other viral illnesses are possible. Hepatitis may present with this more general prodrome but the normal liver function tests make this much less likely. Lymphoma can present with lymphadenopathy and fever but the oral ulceration and the rash are not typical of lymphoma. If the serological tests proved negative, lymph node biopsy might be considered. In this case, tests for an HIV viraemia were positive. Antiretroviral treatment at the time of known or high-risk exposure is useful in reducing the risk of infection. At this stage, treatment is supportive with explanation and arrangements for monitoring of viral load.