Clinical Communications: Adult| Volume 57, ISSUE 4, e113-e116, October 2019

Acute HIV Infection in a Patient with Repeat HIV Antibody/Antigen Negative Results Presenting at an Urban Emergency Department: A Case Report

Published:September 06, 2019DOI:



      It is not uncommon for patients with human immunodeficiency virus (HIV) infections to visit the emergency department (ED) during seroconversion. However, patients with newly acquired HIV may not have a reactive screening result. We report a case of a patient who initially screened reactive on a fourth generation HIV test and subsequently nonreactive twice, but ultimately had positive viral load tests.

      Case Report

      A 41-year-old woman experiencing symptoms of a sore throat, odynophagia, and back and flank pain for 5 days presented to the ED. The patient had a reactive HIV screen but negative confirmatory antibody test. The ED provider ordered a HIV viral load, informed the patient, and discharged with oral antibacterial agent. The patient returned the next day and after review of Visit 1 results, the ED provider ordered a second HIV screen, which had a nonreactive result. Another HIV viral load order was placed. The patient was discharged and returned a third time, 4 days after initial presentation. On this visit she was admitted, and the initial HIV viral load result returned positive.

      Why Should an Emergency Physician Be Aware of This?

      We report a case of a patient who initially screened reactive on a fourth generation HIV screening and then twice nonreactive on the same screening test, ultimately having positive viral loads. The most probable explanation for her series of atypical HIV results is that the patient presented during the p24 seroconversion window, which is graphically conveyed in Figure 1. If her first screening had been performed during the window, no further test would have been performed to rule out HIV, contributing to misdiagnosis. ED providers need to be aware that, at some time points during seroconversion from “negative” to “positive”, patients recently infected with HIV and manifesting prodromal symptoms may nonetheless have a negative screening result.


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        • Delgado M.K.
        • Acosta C.D.
        • Ginde A.A.
        • et al.
        National survey of preventive health services in US emergency departments.
        Ann Emerg Med. 2011; 57: 104-108
        • Cohen M.S.
        • Gay C.L.
        • Busch M.P.
        • et al.
        The detection of acute HIV infection.
        J Infect Dis. 2010; 202: S270-S277
        • Branson B.M.
        • Owen M.S.
        • Wesolowski L.G.
        • et al.
        Laboratory testing for the diagnosis of HIV infection: updated recommendations.
        Centers for Disease Control and Prevention and Association of Public Health Laboratories, Atlanta, GA2014
        • Muthukumar A.
        • Alatoom A.
        • Burns S.
        • et al.
        Comparison of 4th generation HIV antigen/antibody combination assay with 3rd generation HIV antibody assays for the occurrence of false-positive and false-negative results.
        Lab Med. 2015; 46: 84-89
        • Branson B.M.
        • Handsfield H.H.
        • Lampe M.A.
        • et al.
        Revised recommendations for HIV testing of adults, adolescents, and pregnant women in health-care settings.
        MMWR Recomm Rep. 2006; 55: 1-17
        • Patel P.
        • Bennett B.
        • Sullivan T.
        • et al.
        Rapid HIV screening: missed opportunities for HIV diagnosis and prevention.
        J Clin Virol. 2012; 54: 42-47
        • Chavez P.
        • Wesolowski L.
        • Patel P.
        • Delaney K.
        • Owen S.M.
        Evaluation of the performance of the Abbott ARCHITECT HIV Ag/Ab Combo Assay.
        J Clin Virol. 2011; 52: S51-S55
        • Spivak A.M.
        • Brennan T.P.
        • O’Connell K.A.
        • et al.
        A case of seronegative HIV-1 infection.
        J Infect Dis. 2010; 201: 341-345
        • Gurtler L.
        • Muhlbacher A.
        • Michl U.
        • et al.
        Reduction of the diagnostic window with a new combined p24 antigen and human immunodeficiency virus anti-body-screening assay.
        J Virol Methods. 1998; 75: 27-38
        • Speers D.
        • Phillips P.
        • Dyer J.
        Combination assay detecting both human immunodeficiency virus (HIV) p24 antigen and anti-HIV antibodies open a second diagnostic window.
        J Clin Microbiol. 2005; 43: 5397-5399
        • Meier T.
        • Knoll E.
        • Henkes M.
        • et al.
        Evidence for a diagnostic window in fourth generation assays for HIV.
        J Clin Virol. 2001; 23: 113-116
        • Kabamba M.B.
        • Vandercam B.
        • Bodeus M.
        • et al.
        An HIV seroconversion case: an unequal performance of combined antigen/antibodies assays.
        AIDS. 2002; 16: 127-128

      Linked Article

      • False Negative Human Immunodeficiency Virus Rapid Test: Lessons to Remember
        Journal of Emergency MedicineVol. 59Issue 1
        • Preview
          The article by Wilson et al. in the October 2019 article of the Journal exploring the probability of false negative human immunodeficiency virus (HIV) serologic testing at various time points during the window period is both interesting and informative (1). Regarding their article, we would like to highlight on the influencing factors for limitations of the currently available tests and awareness of these among counselors and other health care providers.
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