Also known as acute retroviral syndrome

Primary HIV infection can vary significantly between patients. with some experiencing a mild febrile illness while others experience a severe, mononucleosis-like viral syndrome

The time between infection and onset of symptoms is variable, with incubation time lasting several weeks to months. During acute infection, there is a high degree of viral replication followed by widespread infection of CD4+ T-lymphocytes. The T-lymphocyte count may drop transiently, which is often normal in early HIV infections unless patients present with signs of opportunistic infection. Initial laboratory evaluation indudes the use of a fourth generation HIV test, which tests for HIV p24 antigen and antibodies combined with direct measurement of the HIV viral load using reverse transcription polymerase chain reaction. It is common in early HIV infection for patients to have a negative fourth generation test but a high viral load; this is known as the window period. The window period varies depending on the kind of test used, induding viral testing, though viral testing generally has the shortest window period and is therefore the most reliable test to detect infection.

Although many early cases are minimally symptomatic, patients frequently develop several weeks of nonspecific symptoms such as fever, sore throat, myalgias/arthralgias, headache, diarrhea, weight loss, and diffuse lymphadenopathy shortly after transmission.  Two notable clues (not always present) are painful oral ulcerations and/or oval, pink/red macular lesions that usually develop soon after acute illness and last approximately a week.

Because the manifestations of HIV are often vague and nonspecific, providers should have a low bar for HIV testing, particularly given the public health implications.  Although most new cases arise in individuals with traditional HIV risk factors (eg, intravenous drug use, incarceration, receptive anal intercourse, multiple sexual partners), patients frequently do not fully disclose their social history; therefore, the absence of risk factors should not preclude testing.

Once the diagnosis is made, laboratory studies should be sent for mutational analysis and genotyping, but this should not delay the immediate institution of treatment with antiretroviral therapy. Therapy typically includes a combination of al least three different drugs from at least two different antiretroviral classes

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(Choice D)  Lymph node biopsy can diagnose lymphoma, which frequently presents with fever, night sweats, weight loss, and nontender lymphadenopathy.  However, gastrointestinal manifestations are somewhat uncommon, and the presence of a transient rash would be atypical.  In addition, noninvasive testing (eg, HIV testing) is generally performed prior to more invasive tests such as lymph node biopsy.

(Choice C) HIV antibody testing is used in the setting of potential acute retroviral syndrome, though in the window period, may be falsely negative. The window period can be as many as 18 to 24 days from the time of e)(posure for antibody testing. While it can give insight into whether the patient has been previously exposed to HIV virus and in some cases can be positive, it does not provide information about the current severity of infection and is less accurate than assessing the viral load. Because of this, it is most appropriate to obtain a viral load at this time