Awareness of the risk of occupational transmission of HIV to health care workers dates back to December 1984, when the first case of needlestick-transmitted HIV infection was reported [1]. From December 1984 through September 1997, a total of 94 documented cases and 170 possible cases of occupational transmission of HIV to health care workers were reported worldwide. However, individuals with other types of jobs also risk occupational exposure to bloodborne infection. We report the case of a policeman in whom both HIV and hepatitis C virus (HCV) seroconversion were clearly documented after he was involved in a bloody fight while making an arrest.
A 52-year-old policeman (patient A) presented with a positive HIV result on EIA. Ten weeks previously, he had developed an acute mononucleosis-like syndrome. Acute HIV-1 infection was confirmed by means of gradual Western blot positivity. His CD4+ lymphocyte count was 399 × 109 cells/L, and his plasma level of HIV type 1 (HIV-1) RNA was 503,200 copies/mL. Alanine aminotransferase activity was slightly elevated. No antibodies to HCV were detected, and the patient was immune to hepatitis B virus (HBV). Three weeks later, HCV seroconversion was diagnosed (by means of EIA, recombinant immunoblot assay, and plasma HCV RNA positivity). The patient's sex partner was seronegative for both viruses, and the patient denied having had another sex partner during the previous 6 months. He had never received blood transfusions and had never been an injection drug user. However, he disclosed that, 3 weeks before the onset of his illness, he had punched a man in the teeth while making an arrest. Although he had noticed 2 wounds on his hand, which was covered with blood, he did not wash his hand immediately after the incident. Within a few days after the arrest, he developed lymphangitis that required antibiotic treatment.
The man who received the punch (patient B) was known to be infected with HIV-1, human T lymphotropic virus type 1 (HTLV-1), HBV, and HCV, but patient B declined all treatment. Six months after the incident, patient B's CD4+ lymphocyte count was 552 × 109 cells/L, his plasma level of HIV-1 RNA was 52,900 copies/mL, and his plasma level of HCV RNA (Amplicor HCV Monitor; Roche Diagnostics, Branchburg, NJ) was 132,052 copies/mL.
The strains of HIV and HCV that infected the 2 patients were compared. Viruses were isolated from the plasma of patient A at 4 months after the incident and from patient B at 6 months after the incident. Both HCV strains were determined to be genotype 2a. Nucleotide sequencing of the amplification product of the V3 region of HIV and the NS5b region of HCV revealed, respectively, 98.7% and 100% identity for the strains infecting the 2 patients. Fifteen months after the fight, the serological results of HTLV-1 testing were still negative.
Simultaneous transmission of either HIV and HCV or HIV and HBV from a single source has been previously described [2, 3]; however, to our knowledge, this is the first proven case of HIV-HCV coinfection that occurred as the result of a blow with the fist. Although HIV is probably infrequently transmitted via this route, this case raises the question of whether prophylaxis should be used after potential exposure to HIV during a bloody fight with an HIV-infected (or possibly HIV-infected) individual, as is recommended after other types of potential exposure to HIV, especially among individuals with frequent occupational exposure to HIV (e.g., police and fire department employees, etc.) [4]. Similarly, the risk of transmission of HCV infection during violent incidents should be taken into account.
References
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