Difficulties in diagnosing atypical primary HIV-1 infection

Casseb, Jorge Simão do Rosário; Caterino-de-Araujo, Adele

doi:10.1590/S0036-46651994000300015

Abstracts

Several cases of primary HIV-1 infection are not identified, either because the diagnosis is not suspected or because they test negative for HIV-1 antibody. This work presents an uncommon case of primary HIV-1 infection in an young parenteral drug abuser man, who presented symptoms of acute hepatitis. During the initial acute phase the serum sample of the patient tested negative for the presence of antibodies against several viruses, including HIV-1. Nevertheless, the diagnosis of primary HIV-1 infection was suspected by using an alternative method for"in vitro" induced antibody production (IVIAP), and confirmed by p24 antigen serum positivity and seroconversion in serial plasma samples of the patient. The authors suggest the use of the IVIAP and others complementary assays to help the diagnosis of acute HIV-1 infection in persons at high risk conditions.

Muitos casos de infecção primária pelo HIV não são identificados devido a dificuldades em seu diagnóstico clínico e laboratorial. Este trabalho relata um caso atípico de infecção primária pelo HIV em um usuário de drogas intravenosas que apresentou como primeira manifestação clínica, quadro agudo de hepatite. A pesquisa de anticorpos dirigidos contra vários vírus inclusive o HIV, resultou negativa, na primeira análise do soro do paciente. No entanto, o diagnóstico de infecção primária pelo HIV foi sugerido inicialmente utilizando um novo método laboratorial alternativo para a pesquisa destes anticorpos, denominado IVIAP (in vitro induced antibody production). A infecção HIV foi confirmada pela antigenemia p24 na mesma amostra de sangue e aparecimento de anticorpos específicos em amostras sequenciais de soro do paciente. Os autores deste trabalho sugerem a potencial utilização da IVIAP e de outros exames laboratoriais complementares para o diagnóstico de infecção primária aguda pelo HIV, em populações expostas a situação de risco para adquirir a infecção.

Infecção primária pelo HIV; Diagnóstico

RELATO DE CASO

Dificuldades no diagnóstico de infecção primária atípica por HIV-1. Relato de um caso

Difficulties in diagnosing atypical primary HIV-1 infection: case report

Jorge Simão do Rosário Casseb^I; Adele Caterino-de-Araujo^II

^IMédico Infectologista do Instituto de Infectologia Emílio Ribas, Pós-Graduando da Disciplina de Alergia e Imunopatologia da FMUSP, São Paulo, SP, Brasil

^IIPesquisadora Científica do Instituto Adolfo Lutz, São Paulo, SP, Brasil

^{Endereço para correspondência} Endereço para correspondência: Adele Catenino-de-Araujo Instituto Adolfo Lutz, Seção de Inmunologia Av. Dr. Arnaldo, 355, 11º andar CEP 01246-902, São Paulo, SP, Brasil

RESUMO

Muitos casos de infecção primária pelo HIV não são identificados devido a dificuldades em seu diagnóstico clínico e laboratorial. Este trabalho relata um caso atípico de infecção primária pelo HIV em um usuário de drogas intravenosas que apresentou como primeira manifestação clínica, quadro agudo de hepatite. A pesquisa de anticorpos dirigidos contra vários vírus inclusive o HIV, resultou negativa, na primeira análise do soro do paciente. No entanto, o diagnóstico de infecção primária pelo HIV foi sugerido inicialmente utilizando um novo método laboratorial alternativo para a pesquisa destes anticorpos, denominado IVIAP (in vitro induced antibody production). A infecção HIV foi confirmada pela antigenemia p24 na mesma amostra de sangue e aparecimento de anticorpos específicos em amostras sequenciais de soro do paciente. Os autores deste trabalho sugerem a potencial utilização da IVIAP e de outros exames laboratoriais complementares para o diagnóstico de infecção primária aguda pelo HIV, em populações expostas a situação de risco para adquirir a infecção.

Unitermos: Infecção primária pelo HIV; Diagnóstico.

SUMMARY

Several cases of primary HIV-1 infection are not identified, either because the diagnosis is not suspected or because they test negative for HIV-1 antibody. This work presents an uncommon case of primary HIV-1 infection in an young parenteral drug abuser man, who presented symptoms of acute hepatitis. During the initial acute phase the serum sample of the patient tested negative for the presence of antibodies against several viruses, including HIV-1. Nevertheless, the diagnosis of primary HIV-1 infection was suspected by using an alternative method for"in vitro" induced antibody production (IVIAP), and confirmed by p24 antigen serum positivity and seroconversion in serial plasma samples of the patient. The authors suggest the use of the IVIAP and others complementary assays to help the diagnosis of acute HIV-1 infection in persons at high risk conditions.

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Full text available only in PDF format.

Recebido para publicação em 19/03/1993.

Aceito para publicação em 07/02/1994.

1. ALLAIN, J.P.; PAUL, D.A.; LAURIAN, Y. & SENN, D. - Serological markers in early stages of human immunodeficiency virus infection in haemophiliacs. Lancet, 2: 1233-1236, 1986.
2. BOOTMAN, J.S. & KITCHIN, P.A. - An international collaborative study to assess a set of reference reagents for HIV-1 PCR. J. virol. Meth., 37: 23-42, 1992.
3. BORKOWSKY, W.; KRASINSKI, K.; POLLACK, H. et al. - Early diagnosis of human immunodeficiency virus infection in children 6 months of age: comparison of polymerase chain reaction, culture, and plasma antigen capture techniques. J. infect. Dis., 166: 616-619, 1992.
4. BUSCH, M.P.; AMAD, Z.; SHEPPARD, H.W. & LANG, W. - Primary HIV-1 infection. New Engl. J. Med., 325: 733, 1991.
5. CARNE, C.A.; AMITH, A.; ELKINGTON, S.G. et al. - Acute encephalopathy coincident with seroconversion for anti-HTLV-III. Lancet, 2: 1206-1208, 1985.
6. CATERINO-DE-ARAUJO, A. - Rapid "in vitro" detection of HIV-1-specifíc antibody secretion by cells culture with virus antigens. Mem. Inst. Oswaldo Cruz, 87: 239-247, 1992.
7. CATERINO-DE-ARAUJO, A. - Produçăo induzida de anticorpos "in vitro": novo método para o diagnóstico de infecçăo perinatal pelo vírus da iniunodefîcięncia humana. Săo Paulo, 1993. (Tese de Doutorado - Instituto de Cięncias Biomédicas da Universidade de Săo Paulo).
8. CATERINO-DE-ARAUJO, A.; CASSEB, J.S.R.; GRUMACH, A.S. & MARQUES, H.H.S. - Utilizaçăo da técnica de secreçăo de anticorpos anti-HIV-1, em cultura de células mononucleares estimulada com antígenos virais como método auxiliar no diagnóstico de AIDS pediátrico. In: CONGRESSO BRASILEIRO DE PEDIATRIA, 27., Porto Alegre, 1991. Resumos. p. 124.
9. CATERINO-DE-ARAUJO, A.; CASSEB, J.S.R.; MARQUES, H.H.S. & GRUMACH, A.S. - A prospective study of infants born to HIV-1 seropositive women using an "in vitro" induced HIV-specific antibodies production. In: INTERNATIONAL CONFERENCE ON AIDS, 8., Amsterdam, 1992. Abstracts. PA17.
10. CATERINO-DE-ARAUJO, A.; SANTOS-FORTUNA, E.; CASSEB, J.S.R.; GRUMACH, A.S. & MARQUES, H.H.S. - IVIAP: um novo método para detectar infecçăo pelo HIV. In: CONGRESSO DE LA ASOCIACIÓN LATINO AMERICANA DE INMUNOLOGIA, 3., Santiago, 1993. Resumos. p. 91.
11. CATERINO-DE-ARAUJO, A.; SANTOS-FORTUNA, E. & GRUMACH, A.S. - An alternative method for "in vitro" production of HIV-1-specific antibodies. Braz. J. med. biol. Res., 24: 797-799, 1991.
12. CATERINO-DE-ARAUJO, A.; SANTOS-FORTUNA, E. & KIMURA, R.T. - Pesquisa de anticorpos específicos para o virus da imunodefícięncia humana (HIV-1) e do antígeno de superfície da hepatite B (AgHBs) em amostras de líquido cefalorraquidiano (LCR). In: ENCONTRO NACIONAL DE VIROLOGIA, 5., Săo Lourenço, 1990. Resumos. p. 83.
13. CATERINO-DE-ARAUJO, A.; SANTOS-FORTUNA, E.; SOUZA, A.M.C. et al. - AIDS: valor prognóstico da pesquisa de antígeno e de anticorpos específicos para proteínas e glicoproteínas do HLV-1 no soro. In: CONGRESSO DA SOCIEDADE BRASILEIRA DE MEDICINA TROPICAL, 27., Uberaba, 1991. Resumos. p. 47.
14. CELUM, C.L.; COOMBS, R.W.; LAFFERTY, W. et al. - Indeterminate human immunodeficiency virus type 1 western blots: seroconversion risk, specificity of supplemental tests, and an algorithm for evaluation. J. infect. Dis., 164: 656-664, 1991.
15. CLARK, S.; SAAG, M.S.; DECKER, W.D. et al. - High titers of cytopathic virus in plasma of patients with symptomatic primary HIV-1 infection. New Engl. J. Med., 324: 954-960, 1991.
16. COOPER, D.A.; MACLEAN, P.; FILAYSON, R. et al. - Acute AIDS retrovirus infection. Definition of a clinical illness associated with seroconvertion. Lancet, 1: 537-540, 1985.
17. COOPER, D.A.; TINDALL, B.; WILSON, E.J.; IMRIE, A.A. & PENNY, R. - Characterization of T lymphocyte response during primary infection with human immunodeficiency virus. J. infect. Dis., 157: 889-896, 1988.
18. DAAR, E.S.; MOUDGH, T.; MEYER, R.D. & HO, D. - Transient high levels of viremia in patients with primary human immunodeficiency virus type 1 infection. New Engl. J. Med., 324: 961-964, 1991.
19. DE ROSSI, A.; ADES, A.E.; MAMMANO, F. et al. - Antigen detection, virus culture, polymerase chain reaction, and "in vitro" antibody production in the diagnosis of vertically transmitted HIV-1 infection. AIDS, 5: 15-20, 1991.
20. ELLAURIE, M.; CALVELLI, T.A. & RUBINSTEIN, A. - Immune complexes in pediatric human immunodeficiency virus infection. Amer. J. Dis. Child., 144: 1207-1209, 1990.
21. GAINES, H.; ALBERT, J.; VON SYDOW, M. et al. - HIV antigenaemia and virus isolation from plasma during primary HIV infection. Lancet, 1: 1317-1318, 1987.
22. GOUDSMITH, J.; LANGE, J.M.A.; PAUL, D.A. & DAWSON, G.J. - Antigenemia and antibody titers to core and envelope antigens in AIDS, AIDS-related complex, and subclinical human immunodeficiency virus infection. J. infect. Dis., 155: 558-560, 1987.
23. LAURENCE, J.C. - HIV antigenaemia and virus isolation from plasma during primary HIV infection. Lancet, 1: 1317-1318, 1987.
24. LELIE, P.M.; REESINK, H.W. & HUISMAN, J.G. - Earlier detection of HIV and second-generation antibody assays. Lancet, 2: 343, 1987.
25. LEVY, A.J.; MACKEWICZ, C.E. & WALKER, C.M. - Primary HIV-1 infection. New Engl. J. Med., 325: 734, 1991.
26. LINDHARDT, B.O.; LAURITZEN, E.; ULRICH, K. et al. - Serological markers of primary HIV infection. Scand. J. infect Dis., 21: 491-496, 1989.
27. OKSENHENDLER, M.D.; HARZIC, M.; ROUX, J.M.; RABIAN, C. & CLAUVEL, J.P. - HIV infection with seroconversion after a superficial needlestick injury to the finger. New Engl. J. Med., 3: 582, 1986.
28. OU, C.Y.; KWORK, S.; MITCHELL, S.W. et al. - DNA amplification for detection of HIV-1 in DNA of peripheral blood mononuclear cells. Science, 239: 295-297, 1988.
29. PALOMBA, E.; GAY, V.; MARTINO, M.D. et al. - Early diagnosis of human immunodeficiency virus infection in infants by detection of free and complexed p24 antigen. J. infect. Dis., 165: 394-395, 1992.
30. PATON, P.; POLY, H.; GONNAUD, P.M. et al. - Acute meningoradiculitis concomitant with seroconversion to human immunodeficincy virus type 1. Res. Virol., 141: 427-433, 1990.
31. PEDERSEN, C.; LINDHART, B.O.; JENSEN, B.L. et al. - Clinical course of primary HIV infection: consequences for subsequent course of infection. Brit. med. J., 299: 154-157, 1989.
32. RANKI, A.; KROHN, M.; ALLAIN, J.P. et al. - Long latency precedes overt seroconversion in sexually transmitted human immunodeficiency virus infection. Lancet, 2: 589-593, 1987.
33. SAMUEL, D.; CASTAING, D.; ADAM, R. et al. - Fatal acute HIV infection with aplastic anaemia, transmitted by liver graft. Lancet, 1: 1221-1222, 1988.
34. SCARLATTI, G.; LOMBARDI, V.; PLEBANI, A. et al. - Polymerase chain reaction, virus isolation and antigen assay in HIV-1-antibody-positive mothers and their children. AIDS, 5: 1173-1178, 1991.
35. SIMMONDS, P.; LAISON, F.A.L.; CUTHBERT, R. et al. - HIV antigen and antibody detection: variable responses to infection in the Edinburg haemophiliac cohort. Brit. med. J., 296: 593-598, 1988.
36. SINICCO, A.; PALESTRO, G.L; CARAMELLO, P. et al.- Acute HIV-1 infection. Clinical and biological study of 12 patients. J. Acquir. Immune Defic. Syndr., 3: 260-265, 1990.
37. ULSTRUP, J.C.; SKAUG, K.; FIGENSCHAU, K.J. et al. - Sensitivity of Western blotting (compared with ELISA and immunofluorescence) during seroconversion after HTLV-III infection. Lancet, 1: 1151-1152, 1986.
38. VALLE, S. - Febrile pharyngitis as the primary sign of HIV infection in a cluster of cases linked by sexual contact. Scand. J. infect. Dis., 19: 13-17, 1987.
39. VON SYDOW, M.; GAINES, H.; SONNERBORG, A. et al. - Antigen detection in primary HIV infection. Brit. med. J., 196: 238-240, 1988.
40. WALKER, C.M.; MOODY, D.J.; STITES, D.P. & LARRY, J.A. - CD8+ lymphocytes can control HIV infection in vitro by suppressing virus replication. Science, 234: 1563-1566, 1986.

Endereço para correspondência:

Adele Catenino-de-Araujo

Instituto Adolfo Lutz, Seção de Inmunologia

Av. Dr. Arnaldo, 355, 11º andar

CEP 01246-902, São Paulo, SP, Brasil

Publication Dates

Publication in this collection
20 Sept 2006
Date of issue
June 1994

History

Accepted
07 Feb 1994
Received
19 Mar 1993

This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License.

[1] 1. ALLAIN, J.P.; PAUL, D.A.; LAURIAN, Y. & SENN, D. - Serological markers in early stages of human immunodeficiency virus infection in haemophiliacs. Lancet, 2: 1233-1236, 1986.

[2] 2. BOOTMAN, J.S. & KITCHIN, P.A. - An international collaborative study to assess a set of reference reagents for HIV-1 PCR. J. virol. Meth., 37: 23-42, 1992.

[3] 3. BORKOWSKY, W.; KRASINSKI, K.; POLLACK, H. et al. - Early diagnosis of human immunodeficiency virus infection in children 6 months of age: comparison of polymerase chain reaction, culture, and plasma antigen capture techniques. J. infect. Dis., 166: 616-619, 1992.

[4] 4. BUSCH, M.P.; AMAD, Z.; SHEPPARD, H.W. & LANG, W. - Primary HIV-1 infection. New Engl. J. Med., 325: 733, 1991.

[5] 5. CARNE, C.A.; AMITH, A.; ELKINGTON, S.G. et al. - Acute encephalopathy coincident with seroconversion for anti-HTLV-III. Lancet, 2: 1206-1208, 1985.

[6] 6. CATERINO-DE-ARAUJO, A. - Rapid "in vitro" detection of HIV-1-specifíc antibody secretion by cells culture with virus antigens. Mem. Inst. Oswaldo Cruz, 87: 239-247, 1992.

[7] 7. CATERINO-DE-ARAUJO, A. - Produçăo induzida de anticorpos "in vitro": novo método para o diagnóstico de infecçăo perinatal pelo vírus da iniunodefîcięncia humana. Săo Paulo, 1993. (Tese de Doutorado - Instituto de Cięncias Biomédicas da Universidade de Săo Paulo).

[8] 8. CATERINO-DE-ARAUJO, A.; CASSEB, J.S.R.; GRUMACH, A.S. & MARQUES, H.H.S. - Utilizaçăo da técnica de secreçăo de anticorpos anti-HIV-1, em cultura de células mononucleares estimulada com antígenos virais como método auxiliar no diagnóstico de AIDS pediátrico. In: CONGRESSO BRASILEIRO DE PEDIATRIA, 27., Porto Alegre, 1991. Resumos. p. 124.

[9] 9. CATERINO-DE-ARAUJO, A.; CASSEB, J.S.R.; MARQUES, H.H.S. & GRUMACH, A.S. - A prospective study of infants born to HIV-1 seropositive women using an "in vitro" induced HIV-specific antibodies production. In: INTERNATIONAL CONFERENCE ON AIDS, 8., Amsterdam, 1992. Abstracts. PA17.

[10] 10. CATERINO-DE-ARAUJO, A.; SANTOS-FORTUNA, E.; CASSEB, J.S.R.; GRUMACH, A.S. & MARQUES, H.H.S. - IVIAP: um novo método para detectar infecçăo pelo HIV. In: CONGRESSO DE LA ASOCIACIÓN LATINO AMERICANA DE INMUNOLOGIA, 3., Santiago, 1993. Resumos. p. 91.

[11] 11. CATERINO-DE-ARAUJO, A.; SANTOS-FORTUNA, E. & GRUMACH, A.S. - An alternative method for "in vitro" production of HIV-1-specific antibodies. Braz. J. med. biol. Res., 24: 797-799, 1991.

[12] 12. CATERINO-DE-ARAUJO, A.; SANTOS-FORTUNA, E. & KIMURA, R.T. - Pesquisa de anticorpos específicos para o virus da imunodefícięncia humana (HIV-1) e do antígeno de superfície da hepatite B (AgHBs) em amostras de líquido cefalorraquidiano (LCR). In: ENCONTRO NACIONAL DE VIROLOGIA, 5., Săo Lourenço, 1990. Resumos. p. 83.

[13] 13. CATERINO-DE-ARAUJO, A.; SANTOS-FORTUNA, E.; SOUZA, A.M.C. et al. - AIDS: valor prognóstico da pesquisa de antígeno e de anticorpos específicos para proteínas e glicoproteínas do HLV-1 no soro. In: CONGRESSO DA SOCIEDADE BRASILEIRA DE MEDICINA TROPICAL, 27., Uberaba, 1991. Resumos. p. 47.

[14] 14. CELUM, C.L.; COOMBS, R.W.; LAFFERTY, W. et al. - Indeterminate human immunodeficiency virus type 1 western blots: seroconversion risk, specificity of supplemental tests, and an algorithm for evaluation. J. infect. Dis., 164: 656-664, 1991.

[15] 15. CLARK, S.; SAAG, M.S.; DECKER, W.D. et al. - High titers of cytopathic virus in plasma of patients with symptomatic primary HIV-1 infection. New Engl. J. Med., 324: 954-960, 1991.

[16] 16. COOPER, D.A.; MACLEAN, P.; FILAYSON, R. et al. - Acute AIDS retrovirus infection. Definition of a clinical illness associated with seroconvertion. Lancet, 1: 537-540, 1985.

[17] 17. COOPER, D.A.; TINDALL, B.; WILSON, E.J.; IMRIE, A.A. & PENNY, R. - Characterization of T lymphocyte response during primary infection with human immunodeficiency virus. J. infect. Dis., 157: 889-896, 1988.

[18] 18. DAAR, E.S.; MOUDGH, T.; MEYER, R.D. & HO, D. - Transient high levels of viremia in patients with primary human immunodeficiency virus type 1 infection. New Engl. J. Med., 324: 961-964, 1991.

[19] 19. DE ROSSI, A.; ADES, A.E.; MAMMANO, F. et al. - Antigen detection, virus culture, polymerase chain reaction, and "in vitro" antibody production in the diagnosis of vertically transmitted HIV-1 infection. AIDS, 5: 15-20, 1991.

[20] 20. ELLAURIE, M.; CALVELLI, T.A. & RUBINSTEIN, A. - Immune complexes in pediatric human immunodeficiency virus infection. Amer. J. Dis. Child., 144: 1207-1209, 1990.

[21] 21. GAINES, H.; ALBERT, J.; VON SYDOW, M. et al. - HIV antigenaemia and virus isolation from plasma during primary HIV infection. Lancet, 1: 1317-1318, 1987.

[22] 22. GOUDSMITH, J.; LANGE, J.M.A.; PAUL, D.A. & DAWSON, G.J. - Antigenemia and antibody titers to core and envelope antigens in AIDS, AIDS-related complex, and subclinical human immunodeficiency virus infection. J. infect. Dis., 155: 558-560, 1987.

[23] 23. LAURENCE, J.C. - HIV antigenaemia and virus isolation from plasma during primary HIV infection. Lancet, 1: 1317-1318, 1987.

[24] 24. LELIE, P.M.; REESINK, H.W. & HUISMAN, J.G. - Earlier detection of HIV and second-generation antibody assays. Lancet, 2: 343, 1987.

[25] 25. LEVY, A.J.; MACKEWICZ, C.E. & WALKER, C.M. - Primary HIV-1 infection. New Engl. J. Med., 325: 734, 1991.

[26] 26. LINDHARDT, B.O.; LAURITZEN, E.; ULRICH, K. et al. - Serological markers of primary HIV infection. Scand. J. infect Dis., 21: 491-496, 1989.

[27] 27. OKSENHENDLER, M.D.; HARZIC, M.; ROUX, J.M.; RABIAN, C. & CLAUVEL, J.P. - HIV infection with seroconversion after a superficial needlestick injury to the finger. New Engl. J. Med., 3: 582, 1986.

[28] 28. OU, C.Y.; KWORK, S.; MITCHELL, S.W. et al. - DNA amplification for detection of HIV-1 in DNA of peripheral blood mononuclear cells. Science, 239: 295-297, 1988.

[29] 29. PALOMBA, E.; GAY, V.; MARTINO, M.D. et al. - Early diagnosis of human immunodeficiency virus infection in infants by detection of free and complexed p24 antigen. J. infect. Dis., 165: 394-395, 1992.

[30] 30. PATON, P.; POLY, H.; GONNAUD, P.M. et al. - Acute meningoradiculitis concomitant with seroconversion to human immunodeficincy virus type 1. Res. Virol., 141: 427-433, 1990.

[31] 31. PEDERSEN, C.; LINDHART, B.O.; JENSEN, B.L. et al. - Clinical course of primary HIV infection: consequences for subsequent course of infection. Brit. med. J., 299: 154-157, 1989.

[32] 32. RANKI, A.; KROHN, M.; ALLAIN, J.P. et al. - Long latency precedes overt seroconversion in sexually transmitted human immunodeficiency virus infection. Lancet, 2: 589-593, 1987.

[33] 33. SAMUEL, D.; CASTAING, D.; ADAM, R. et al. - Fatal acute HIV infection with aplastic anaemia, transmitted by liver graft. Lancet, 1: 1221-1222, 1988.

[34] 34. SCARLATTI, G.; LOMBARDI, V.; PLEBANI, A. et al. - Polymerase chain reaction, virus isolation and antigen assay in HIV-1-antibody-positive mothers and their children. AIDS, 5: 1173-1178, 1991.

[35] 35. SIMMONDS, P.; LAISON, F.A.L.; CUTHBERT, R. et al. - HIV antigen and antibody detection: variable responses to infection in the Edinburg haemophiliac cohort. Brit. med. J., 296: 593-598, 1988.

[36] 36. SINICCO, A.; PALESTRO, G.L; CARAMELLO, P. et al.- Acute HIV-1 infection. Clinical and biological study of 12 patients. J. Acquir. Immune Defic. Syndr., 3: 260-265, 1990.

[37] 37. ULSTRUP, J.C.; SKAUG, K.; FIGENSCHAU, K.J. et al. - Sensitivity of Western blotting (compared with ELISA and immunofluorescence) during seroconversion after HTLV-III infection. Lancet, 1: 1151-1152, 1986.

[38] 38. VALLE, S. - Febrile pharyngitis as the primary sign of HIV infection in a cluster of cases linked by sexual contact. Scand. J. infect. Dis., 19: 13-17, 1987.

[39] 39. VON SYDOW, M.; GAINES, H.; SONNERBORG, A. et al. - Antigen detection in primary HIV infection. Brit. med. J., 196: 238-240, 1988.

[40] 40. WALKER, C.M.; MOODY, D.J.; STITES, D.P. & LARRY, J.A. - CD8+ lymphocytes can control HIV infection in vitro by suppressing virus replication. Science, 234: 1563-1566, 1986.

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