A MAN NEWLY DIAGNOSED WITH HIV REFUSES TO INFORM HIS SPOUSE. C. Gibbs 1 , J. Tsui 1 ; 1 Emory University, Atlanta, GA (Tracking ID #74714) LEARNING OBJECTIVES: 1.) To appreciate a care giver's ethical and legal responsibilities when partner notification is refused by a newly diagnosed patient; 2.) To identify various partner notification strategies and weigh their advantages and disadvantages. CASE INFORMATION: A 36 year-old man presented to the emergency room complaining of fatigue, shortness of breath, severe dyspnea on exertion, and cough worsening over several weeks. The patient had no significant past medical history and denied tobacco, alcohol, or IV drug use. He denied any previous history of blood-product transfusions.He stated he had been in a monogamous marriage for the ten years and had had no other sexual partners. Further, the patient reported a negative HIV test three years ago. Chest X-ray revealed bilateral patchy opacifications without any focal consolidation. Laboratory results were significant for a WBC of 5.1, an LDH of 514, and an ABG of 7.46/39/55. The patient was admitted for communityacquired pneumonia and started on ceftriaxone and doxycycline; however, given his clinical picture, the patient's sputum was sent for silver stain. It returned positive for pneumocystis carinii. The patient's medications were changed to trimethoprim/sulfamethoxazole and prednisone, and he was counseled about the likelihood of immunocompromise. At this point, the patient agreed to HIV testing. He subsequently tested positive for HIV and had a CD4 count of 26. Patient education regarding HIV infection and AIDS was initiated. The patient acknowledged the possibility that his wife may have been infected and agreed that she should be notified. Initially, he wished to talk with her himself (self-referral). After a few days, it was discovered that the patient had not disclosed his HIV status to his wife. With much encouragement and further education, he agreed to a dual referral approach involving a healthcare provider being present when he notified his wife. However, when the appointed meeting day arrived, the patient once again refused. Patient education and support continued. As the patient's discharge approached, the medicine team feared that the patient's wife would never be informed of his seropositive status and her potential risk. These concerns were discussed with the patient and he was informed that if he did not notify his wife, the medicine team would act according to state and federal laws and notify her of her HIV exposure and need for testing. The patient informed his wife within 24 hours. IMPLICATIONS/DISCUSSION: This case demonstrates various approaches to partner notification and deals with the ethical and legal decisions physicians are forced to make when newly diagnosed HIV patients refuse to participate. Partner notification strategies can be classified into three basic categories: self-referral, dual referral, and provider referral. Each approach has its own advantages and disadvantages. Regardless of the strategy chosen, the patient's rights to autonomy, trust, confidentiality, and safety must be respected while balancing the physician's moral and legal responsibility to patients' partner(s), children, and community. Healthcare providers must recognize their responsibilities, know their federal and state laws, and act according to individual cases. A 50 year old African American man with no significant past medical history presented to the office with malaise, weakness, anorexia, watery diarrhea and mild headache of 2 days duration. He was treated conservatively for presumed viral gastroenteritis, until he presented to the emergency room 2 days later with increasingly severe frontal headache and fevers. Physical examination was remarkable for a temperature of 39.6 deg C and nuchal rigidity, but no focal neurological signs or impaired sensorium. Laboratory studies included a WBC count of 8800, and cerebrospinal fluid analysis which demonstrated a CSF WBC count of 150/mm3 with a differential of 11% neutrophils, 88% lymphocytes, 1% monocytes, and a CSF-protein level of 117 mg/dl. CSF gram stain was negative. The patient was admitted and placed on empiric ampicillin and cefrtriaxone. Blood cultures and CSF bacterial, fungal and protozoal studies remained negative. The patient slowly defervesced and his headache improved, and he was discharged to home. Notably, this case occurred at a time when public awareness of West Nile Virus infection in Allegheny County, Pennsylvania was just emerging; the virus had been isolated in several dead birds in the area, although there had been no reported cases of human infection. During the hospitalization, serum was therefore sent for West Nile Virus serologic testing. Following discharge, results of IgM and IgG antibody ELISA assays subsequently returned positive, and were later confirmed by plaque reduction neutralization test (PRNT). The patient gradually improved, although notably after developing a transient morbilliform rash on his chest, back and arms, observed during outpatient follow-up approximately one week after discharge. IMPLICATIONS/DISCUSSION: West Nile Virus infection is a mosquito-borne arboviral illness that is commonest in the United States in late summer and early fall. One of the early clues to an epidemic is the presence of dead birds in the surroundings. Infection is most often asymptomatic, and clinical illness is generally mild, presenting with constitutional symptoms much like those of other viral syndromes. Among patients with more serious CNS illness, isolated meningitis Ð such as occurred in our patient Ð is relatively less common than encephalitis or meningoencephalitis. Treatment is supportive, and advanced age is the biggest risk factor for severe neurologic disease. This case illustrates the need to consider West Nile Virus infection, however, in cases of aseptic meningitis occurring in endemic areas.Diagnosis is by serum or CSF IgM antibodies to West Nile Virus; first-line testing is by ELISA assay, and positive results are generally confirmed by the more specific PRNT.