Swollen lymph nodes during PEP

Dear Doctor,

I had a possible exposure about 3 weeks ago and I have few questions that I hope you can help me with. The exposure was mainly mutual oral sex however, there was a period of anal/penile rubbing and my question is regarding this part. I am worried if there was a penetration during rubbing without me noticing it. My partner claimed that he is negative yet I know that he had few partners before me. I talked with HIV specialist and he put me on PEP (combivir+Kaletra) for 28 days which I started at ~65 hours. My adherence to the regime is extremely strict. In addition to the usual digestive side effects, I did not experience any other problem until last week. At 1.5 week mark I started to have a throat discomfort which is still around (more like a post nasal drip rather than sore throat) and stiff neck. This made me check my glands everyday and around 2 weeks mark I found one small bump at back of my right neck. I developed swollen nodes on my left armpit (1-2mm) around 2.5 week and this made me visit my doctor. He said that this is not worrisome since I’m on very potent PEP and this should stop virus from replicating, therefore ARS is not possible. Since then I have developed more swollen nodes: 2 on my left neck(2-3mm each), 2 on my right neck, and larger than normal nodes (1-2mm) on my right armpit. I have absolutely no fever or rashes. I know that symptoms are always poor indicators but:

1- Can this be due to PEP failure?
2- Is the size of nodes consistent with ARS?
3- Is it possible to experience ARS without fever?
4- Is it possible that PEP reduces the severity of symptoms? thus no fever.
5- What other conditions other than HIV and mono (infected few years ago) can cause generalized swollen glands?

Thanks for your help.

[Edward W Hook, MD]

Welcome to the Forum. i will make some comments related to the exposure you describe, as well as the symptoms you are experiencing.  I have read the interchanges you have had on the HIV Prevention Community and have to say that I agree with Lizzie Lou and Teak.  If you had seen me, I would not have given you PEP as the cost and side effects far out way the likelihood that you were exposed to HIV or, if you were, that you would become infected.  In addition, I must say, I am very impressed that you or your doctor can feel 2-3 mm (less than 1/4 inch) lymph nodes.  I know of no other clinician who could do so reliably.  I would also add that the precise effectiveness of PEP is unknown- we believe that in persons who take it that HIV acquisition if very, very rare but precisely how rare is still being defined in scientific studies.

Finally, I would add that the thoughts as to whether or not this might be a PEP failure is something that you and your doctor heed to work out.  He/she could do specific tests if they likelihood of PEP failure was high.  From your story however, I think it is most unlikely.

Now on  to your specific questions:

1.  See above- very unlikely that you needed PEP at all and if you needed it, unlikely that your symptoms represent a failure.  It sounds to me like you have a plain old, every day, non-HIV sore throat.
2.  See above.  No, they are not.  
3.  The ARS is a non-specific viral syndrome of which fever is a part.  Many persons get HIV without fever. Thus the idea that you have "partial" ARS is hard to deal with.  Here on this site we have said again and again that to worry about symptoms of the sort you have is a complete and total waste of time for most people.  I would extend that generalization to you.
4.  Unknown- under study.  Remember, not everyone who gets HIV develops ARS symptoms.
5.  The list is enormous and beyond the scope of this site.  Start with the myriad viruses that can cause sore throat and  extend from there.

Once again, that you have HIV, even if you had not taken PEP is tiny.  With PEP it become vanishingly rare.  The issues you raise here are really things that you need to (and should expect to be able to) discuss with the doctor who put you on PEP.  Try not to worry.  EWH

[redwsam]

Thank you very much for your comforting comments. They were the best thing that I could've read. I will try to not focus on this for now until the 3-month test.

[redwsam]

Hi again Doctor. I have two more questions and I promise that these are my last questions and I won't bother you again as I am trying to move on. To be clearer, regarding my exposure, even though it is highly unlikely, I am worried about unnoticed penetration for 20-30 seconds. Also more lymph nodes are swollen today (including chest/breast area) yet their size is still less than 1/4inch. Okay now back to the questions: first, since during seroconversion, lymph nodes become activated, is it possible to say that swollen lymph nodes happen in all patients regardless of ARS? In other words are swollen lymph nodes alone a part of ARS? and my second question is about my PEP regime (Kaletra+Combivir). In your opinion, is this a good combination? In particular, is it useful against the drug-resistant strains of virus?

As I said, these are my final questions and I will not bother you again. I will be appreciated if you can answer them. Thanks.

[Edward W Hook, MD]

The drugs you are on for PEP are highly active and would be expected to be effective.

Lymph node swelling is non-specific.  I am not sure what you mean by "activated in all patients".  No need to clarify however.  There is virtually no chance your lymph node swelling is due to HIV.

Please no more questions. There will be no more answers.  EWH