Aphthous esophagitis as an atypical manifestation of a primary HIV-infection

History: A 56-year-old patient from Burkina Faso (Western Africa), living in Switzerland for 12 years, was referred to hospital because of acute onset of severe painful swallowing. He returned from a 3-week visit to his home country 4 weeks prior to admission. Clinical findings and investigations: Whereas clinical and radiological findings were normal, routine laboratory testing showed increased parameters of infection. Endoscopy revealed an aphthous esophagitis, suggesting a viral infection. Biopsy confirmed an active erosive esophagitis. Herpes simplex, cytomegalovirus and candida could not be detected in the biopsy specimens (immunohistochemistry, microbiology) and in serum. Both, the anti-HIV screening-test and the Western blot antibody test for HIV-1 and HIV-2 were negative on admission. Because of the persistent suspicion for an underlying HIV Infection, a combined HIV p24-antigen/ antibody-test was performed, showing an indeterminate result. Following PCR-based tests for HIV-RNA on days 5 and 12 showed 86 100 and 103 700 HIV-1 RNA copies/ml plasma, respectively, revealing the diagnosis of primary HIV-1 infection. Subsequent serological testing (WB) finally documented HIV-1 antibody seroconversion, showing indeterminate and positive results on days 5 and 19, respectively. Treatment and course: Within 5 days all signs of Infection returned to normal and as documented by endoscopy on day 12, the esophagitis healed up spontaneously. As the patient intended to go back to his home country and the CD4 cell count was 615 x 10(6)/l, no antiviral therapy was initiated. Conclusion: This case report is the first demonstrating an atypical symptomatic primary HIV-Infection prior to seroconversion, which presented itself exclusively as an aphthous esophagitis with no symptoms of the classic acute retroviral syndrome. Therefore, each clinical suspicion of an underlying HIV-infection should be followed up carefully, even if the patient presents with unusual symptoms.