Eruption of human immunodeficiency virus seroconversion

A 34-year-old Caucasian man, previously in excellent health, was admitted to Mount Sinai Hospital in September 1996 with an acute illness, including high fevers, malaise, sore throat, and a mucocutaneous eruption. On examination, he had a temperature of 38.5 °C. Cutaneous findings included a severe seborrheic dermatitis and an exanthem characterized by multiple erythematous macules and papules, some with a hemorrhagic center, distributed on the trunk and proximal extremities (Fig. 1). Subtle palmar petechiae were noted. The mouth contained an enanthem with palatal petechiae and a well- circumscribed erosion (Fig. 2). Koplik's spots were not present. Hepatosplenomegaly and lymphadenopathy were absent. Complete blood count revealed a white blood count of 2600 with a differential of 46% polymorphonuclear cells, 25% bands, 25% lymphocytes, and 4% monocytes. His hemoglobin was 11 g/dL and his platelet count was 90,000. A lymphopenia (0.7 (normal range 1.0-4.5 x 1000)) and an elevated PTT were also present. The routine biochemistry profile was within normal limits. Monospot was negative. There were no antibodies to hepatitis B or C, Coxsackie virus, Epstein-Barr virus, measles, herpes, toxoplasmosis, or cytomegalovirus antigen. The patient was immune to measles. Rapid plasma reagin (RPR) was nonreactive. Two months prior to presentation, human immunodeficiency virus (HIV) antibody testing was negative. A biopsy specimen from a lesion on the upper part of the chest demonstrated a mild interface dermatitis (Fig. 3), consistent with a drug reaction or viral exanthem. Acid fast, Dieterle, and Gram stains of the biopsy specimen failed to reveal microorganisms. Serological testing for HIV DNA by polymerase chain reaction (PCR) was positive. PCR testing for HIV RNA recorded in excess of 7 million copies/mm³. Triple antiretroviral therapy with Saquinavir, AZT, and 3TC was initiated. The eruption cleared completely within one week of its onset. Six weeks later, seroconversion to HIV antibody positivity occurred. Eight weeks after starting therapy, the patient experienced severe nausea and vomiting and became icteric, and all medications were withdrawn. The patient recovered and has not experienced any further illness in 1 year of follow-up.