HCW exposure
Posted: Sep 11, 2007
QUESTION:
Dear Dr Wohl,
I am an intern who got stuck while trying to place a central line in a severly ill pt during a code (which the pt did not survive). The pt was cachectic, had very poor prior healthcare, and on this hospitalization was diagnosed with systemic CMV, HSVII encephalitis, and pulmonary Aspergilossis, with some questionable acid fast bacilli on staining - many of the Aids deficining conditions. His WBC count was only 1 and his absolute lymphocyte count 0.1x10^9. This pt was also on high dose steroids for a probable diagnosis of Lupus for the past 1 yr.
After getting stuck we sent off the basic labs: Hep C Ab - negative, and Hiv1 Ab - negative using the Genetic Systems HIV-1 PLUS O EIA (which I think is a 3rd generation test), and HIV2 Ab- negative. Therefore no PEP was started. However I am now very woried about the possibility of a False negatie in late stage HIV, especially given the pt's poor immunological and immunosuppresed status. Pt had never had HIV RNA or CD4 testing done, but had had 2 more HIV serologies done within the last year which were negative (one early this month, and one in Aug 2006 during which times he had a similar WBC profile). My question is how common is serorevesion in end stage AIDS pts, and the likelyhood of that being the case with this pt given his 3 different HIV negative serologies at 2 different institutions. Are my fears justified or should I just move on. BTW I'm way past the PEP window now , this incident happened 15 days ago. Thanks for your help.
-Desperate intern
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RESPONSE FROM: 
I understand your concern and hopefully at the time you received some advice regarding PEP from someone who knew what they were talking about.
I know of no hard and fast numbers regarding loss of HIV antibodies and agree that repeated HIV antibody negative tests are very reassuring. However, there is a risk of a false negative as you fear - but I would say that risk under these circumstances seems real small.
Although you are indeed past the window for HIV medications as PEP I would try and press for an HIV RNA PCR to be done on stored blood. A sympathetic ID doc at your institution may be able to convince the lab to add this on to an upcoming PCR run. I think you can also justify this on the basis of workman's compensation as there is a small but real risk of the HIV antibody test being negative during very advanced HIV.
I suspect the PCR will be negative but the peace of mind will be worth it.
DW
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