A man came to the office a while back.  He had been feeling unwell for several days.  He had fevers, a sore throat, and swollen glands–a common set of complaints.  In the ER, he tested negative for strep throat, and was given motrin.  A few days later at the office, he tested negative for strep again, and a rapid test for mono was negative.  He was sent home with motrin again…

Two weeks later he still had fevers, but now had a rash as well.  It was mostly on his trunk and consisted of discrete red bumps ranging from 0.5 to 1 cm in diameter.  It itched a little.

This was too long to have a fever, and the usual suspects were ruled out, so we spent a bit more time going over things.

He had a job as a laborer, with exposure to various food products, no exposures to animals, and no one else around him was ill.  He sleeps with men, but reportedly uses protection.  He denied drug use.  He hadn’t traveled recently.

His throat was red, with enormous tonsils, and swollen glands in his neck.   His liver and spleen were not enlarged.  The rash was as described.  The usual laboratory tests were unremarkable.

I pulled my resident aside for a chat.  He wasn’t sure what to make of it, so I asked him to present the data to me anew.

Male, sleeps with men, rash, fever, swollen glands, sore throat, no strep and no mono.  Hmm…

These days, young doctors aren’t as familiar with this particular set of symptoms, but if you trained in the 80s or 90s, especially in a big city, a red flag goes up– “Acute Retroviral Syndrome”, or the immediate illness following infection with the human immunodeficiency virus.

At this stage of infection, the usual antibody test is not useful, so if you really suspect it, you must send a test for actual virus in the blood.  His took much longer than usual to come back–the viral load was too high to measure and had to be diluted and rechecked.  This is fairly typical of early HIV infection.

So we had to tell him the bad news–but it comes with good news that we didn’t have 20 years ago.  Now, with proper treatment, he can expect to live a very long time.  There are many problems with current HIV therapy, but they don’t measure up to the problems we had before the advent of modern HIV drug therapy, when a diagnosis was a death sentence.

It was my resident’s first time telling someone very bad news, but not his last.  The news is obviously worse for the patient, but giving bad news takes a toll on health care providers.  It takes a chunk out of you each time you tell someone they have cancer, they are going to die, they have a serious disease, their loved one is very ill; as these chunks fall away, so can a doctor’s humanity.  It’s a tough balance, keeping your humanity and keeping yourself intact.  Next time your doctor seems a little distracted, if you’re not terribly ill, consider cutting them a little slack–you don’t know who was in the exam room before you.