Social history obtained upon admission revealed her current partner, and father of the baby, was a 50-year-old man with a history of incarceration, residence in shelters for the homeless, and prior hospitalizations for respiratory infection that was suspicious for tuberculosis. Initial workup of the mother in the ED at hospital no. 1 revealed elevated liver enzymes in the range of 400-500's, leukopenia, and maternal fever. HIV Elisa was negative and HIV RNA viral load was ordered. The patient was admitted to the hospital. To evaluate the patients' headache, neurology and infectious disease consults were requested and a lumbar puncture was performed. VDRL and Cryptosporidium test were ordered and were negative. The working diagnosis at this time was disseminated infection with Herpes simplex virus (HSV). The infectious disease physician recommended intravenous acyclovir for 10 days. On antiviral therapy day number five, the patient requested transfer to another private hospital (henceforth identified as hospital no. 2) where her obstetrician had admitting privileges. Of note, HIV viral load was still pending at time of transfer.
Upon arrival at hospital no. 2, a Maternal-Fetal medicine specialist from our teaching institution was consulted to evaluate the presumed disseminated HSV infection. Social history in the transferring note received from hospital no. 1 stated that the patient's partner was currently hospitalized with renal failure and end-stage AIDS. The plan at this time was to continue intravenous Acyclovir for the presumed disseminated HSV infection while HIV workup was in progress. Repeating HIV rapid screen test, HIV RNA viral load, and CD4 and CD8 counts were done, a PPD test was placed, and workup was ordered for elevated liver enzymes. Consultations with infectious disease and hepatology were requested. WBC on admission to hospital no. 2 was 4.3; Hepatitis A, B, C serologies, Human Granulocytic Ehrlichiosis IgG and IgM, and Toxoplasmosis IgG and IGM were negative. A right upper quadrant ultrasound was performed and ruled out any pathology. The PPD was read as negative. Blood cultures were negative. Rapid screen HIV test was again negative.
 Several days after admission to hospital no. 2, laboratory results were received from hospital no. 1, which were significant for HIV viral load being greater than 500,000 copies/mL and CD4 count of 227 cell/mm3. Thus the patient received the new diagnosis of acute HIV infection. She was started on an antiretroviral regimen of Combivir 150 mg/300 mg 1 tablet twice daily and Viracept 625 mg 2 tablets twice daily.
 On hospital day 6, her liver function tests decreased to an AST of 191, ALT of 365, and an alkaline phosphatase of 111. HIV RNA viral load that was obtained on admission to hospital no. 2 returned as 434,000 copies/mL. CD4 count was 323.9 cell/mm3. Her symptoms of fever and headache resolved and she was later discharged home without further complications or findings. Of note, laboratory studies as an outpatient at approximately 3 weeks later demonstrated a CD4 count of 447 cell/mm3 and a viral load of 869,000 copies/mL. Antiretroviral therapy was continued as outpatient. At 33 weeks and 5 days gestational age, her CD4 count was 177 cell/mm3 and viral load was 128 copies/mL.
The patient presented to hospital no. 2 at 37 weeks and 2 days in early labor complicated by chronic hypertension with superimposed preeclampsia. She was admitted for delivery. Based on the last viral load being less than 1,000 copies/mL, she was allowed a trial of vaginal delivery. She received a loading dose of zidovudine at 2 mg/kg followed by maintenance dosage of 1 mg/kg throughout labor. She also received magnesium sulfate for seizure prophylaxis. The viral load during this admission was 74 copies/mL. She underwent a low transverse cesarean section secondary to arrest of dilation and gave birth to a 4 pound 11 ounce infant girl with Apgar scores of 8 and 9 at one and five minutes, respectively. The patient was discharged on postoperative day number three without complications. The infant was negative for HIV infection at four months of life.