Arthralgias and cryoglobulinemia during protease inhibitor therapy in a patient infected with human immunodeficiency virus and hepatitis C virus

We present the case of a woman who had a chronic infection with human immunodeficiency virus (HIV) and hepatitis C virus (HCV). She developed severe polyarthralgias associated with type II mixed cryoglobulinemia during therapy with an HIV-1 protease inhibitor. This therapy resulted in a dramatic increase in her CD4+ T cell count, from 70/mm3 to 567/mm3, which was composed of a high proportion (88%) of naive CD45RA+ CD62L+ cells, together with a recovery of her CD4+ T cell reactivity to antigenic stimulation. This may suggest that rapid recovery of immune competence in the CD4+ T helper subset might participate in the development of immunopathologic events such as this patient's cryoglobulinemia.

Virological and immunological data of AIDS patients treated by passive immunotherapy (transfusions of plasma rich in HIV-1 antibodies)

BACKGROUND AND OBJECTIVES

In human immunodeficiency virus (HIV) infections, passive immunotherapy can be carried out through infusions of virus-inactivated plasma from symptomless HIV-infected persons with abundant HIV antibodies.

MATERIALS AND METHODS

We carried out a prospective, randomized, double-blind, controlled, passive immunotherapy study, which compared two groups. One received plasma rich in HIV antibodies, the other a standard seronegative plasma.

RESULTS

Measurement of the plasma HIV RNA load showed in both groups a significant decrease in the mean viral copy number at the end of the first month, followed by an increase at the third month. Beyond the third months, a significant decrease in viral load was observed only in the treatment group. A significant difference in favor of the treatment group was observed for plasma viremia by HIV culture. For the cytokines involved in the viral replication and for the immune activation markers such as neopterin and beta 2-microglobulin, the biological analysis in plasma failed to show a significant difference in either group. Clinically, the treatment group benefited by delay in the appearance of the first AIDS-defining event and reduction in the cumulative incidence of such events.

CONCLUSION

One possible interpretation is that passive immunotherapy affects plasma viral load, but there is no evidence that HIV-specific antibodies are exclusively responsible for the observed effects.

Quantitation of passively acquired human immunodeficiency virus (HIV) antibodies in AIDS patients transfused with a plasma that is rich in HIV antibodies

BACKGROUND

Passive immunotherapy in human immunodeficiency virus (HIV) infection is based on transfusions of plasma that is rich in HIV antibodies.

STUDY DESIGN AND METHODS

To verify whether the clearance of transfused antibodies will maintain an elevated titer of specific antibodies between biweekly transfusions of plasma, the titers of anti-HIV-1 in plasma and in transfusion recipients were measured. Samples from 12 recipients were analyzed by automated scanning of Western blot, before transfusion and at Days 2, 7, and 14 after transfusion.

RESULTS

The p24 antibody became detectable or higher than the baseline after transfusion and remained detectable until the second transfusion. Anti-p24 titers were variable and dependent on the antibody titer of the transfused plasma and the baseline p24 antigen titer.

CONCLUSION

Biweekly transfusion of plasma with a high anti-HIV titer maintains a high anti-p24 titer between transfusions in AIDS patients treated with passive immunotherapy.

Early bactericidal activity of rifabutin versus that of placebo in treatment of disseminated Mycobacterium avium complex bacteremia in AIDS patients

Rifabutin, 600 mg/day, was compared with a placebo in the early treatment of culture-proven Mycobacterium avium bacteremia in patients with AIDS. Following 14 days' treatment, bacteriological success, defined as a negative culture or a reduction in the number of CFU of M. avium organisms per milliliter of blood by a factor of > or = 0.5 log from the baseline, was observed in 7 of 10 (70%) evaluable rifabutin patients and in 1 of 13 (8%) evaluable placebo patients (P = 0.002). Rifabutin is active against M. avium as a single agent and can make a significant contribution to combination regimens for the treatment of disseminated M. avium infection in AIDS patients.

Passive immunotherapy in AIDS: a double-blind randomized study based on transfusions of plasma rich in anti-human immunodeficiency virus 1 antibodies vs. transfusions of seronegative plasma

A randomized double-blind controlled trial was conducted to determine the efficacy of passive immunotherapy in the treatment of symptomatic human immunodeficiency virus (HIV) infection. This trial included 86 symptomatic patients randomized to receive plasma rich in anti-HIV-1 antibody or standard seronegative plasma. Each patient in both groups received a 300-ml infusion every 14 days over a 1-year period, and every 28 days thereafter, in addition to zidovudine and other conventional prophylactic treatments. Plasma donors were selected among symptomless seropositive individuals with a CD4 lymphocyte count > or = 400 x 10(6) cells per liter, a negative p24 antigen assay, and a high concentration of anti-p24 antibody. The plasmas were heat-inactivated before infusion. During the study period (day 28-day 365) scheduled by the protocol, clinical benefit from passive immunotherapy was observed in delaying the appearance of the first AIDS-defining event (P < 0.009) and reducing the cumulative incidence of such events, which was estimated 3-fold higher in the control group compared to the treatment group. Seven deaths occurred in the treatment group vs. 11 in the control group (P = 0.27). A total of 47 patients died or exhibited new AIDS-defining events, 18 in the treatment group and 29 in the control group (P = 0.009). No clinical benefit was observed after the 1-year period with infusions performed every 4 weeks. These results indicate a favorable effect of passive immunotherapy on the evolution of advanced AIDS.

Vapreotide, a somatostatin analogue, in cryptosporidiosis and other AIDS-related diarrhoeal diseases

OBJECTIVE

To evaluate the efficacy and tolerance of vapreotide, a new somatostatin analogue, in the treatment of refractory AIDS-related diarrhoea.

DESIGN

An open, non-comparative pilot trial.

SETTING

The trial was conducted in 10 medical centres in France.

PATIENTS, PARTICIPANTS

Thirty-four AIDS patients with chronic diarrhoea unresponsive to conventional antidiarrhoeal therapy were enrolled. Cryptosporidiosis was diagnosed in 21 out of 30 evaluable patients. Mean number of stools prior to therapy was 10.1 +/- 4.9 per day (range, 3-20 stools per day).

INTERVENTION

After initial baseline studies, patients received subcutaneous vapreotide at escalating doses of 400 (23 patients) or 500 micrograms (seven patients), between two and six times daily.

MAIN OUTCOME MEASURES

Efficacy was assessed after 14 days of therapy, when it was found to be effective. Responders were offered the opportunity to continue receiving therapy.

RESULTS

Four patients demonstrated a complete response and 12 a partial response with greater than 50% reduction in daily stool emission. Fourteen patients did not respond to doses up to 2400 micrograms/day. Patients with conditions other than cryptosporidiosis had a significantly higher probability of response (P = 0.013), as did those with milder diarrhoea (less than 10 stools per day). Median duration of response was 1.5 months (range, 0.5-5 months); relapse occurred in five out of eight responders despite maintenance therapy. Toxicity was minimal.

CONCLUSIONS

We conclude that AIDS patients with diarrhoea not caused by Cryptosporidium may benefit from vapreotide therapy.

Passive immunotherapy in AIDS: a randomized trial of serial human immunodeficiency virus-positive transfusions of plasma rich in p24 antibodies versus transfusions of seronegative plasma

To assess the place of passive immunotherapy in the treatment of AIDS, a randomized study was conducted that evaluated the safety and short-term efficacy of serial transfusions of human immunodeficiency virus type 1 (HIV-1) seropositive plasma in 18 patients. Heat-inactivated anti-HIV antibody-rich plasma was compared with seronegative fresh-frozen seronegative plasma given in addition to zidovudine and other conventional prophylactic treatments. Seven transfusions every 2 weeks of immune plasma significantly reduced (2 vs. 8, P = .016) the number of opportunistic infections. Antigenemia became undetectable. When transfusions were stopped, positive p24 antigenemia returned at a level higher than before treatment and was correlated with a severe clinical deterioration, suggesting a rebound effect. This trial suggests that passive immunotherapy is promising in AIDS treatment. It confirms also that plasma donation does not affect donors' CD4 cell count over a 1-year period. In patients with severe immunodeficiency, special attention should be paid to withdrawal of an effective therapy as virologic relapse may be explosive and poorly tolerated.

[Passive immunotherapy in AIDS: transfusion of plasma rich in anti-p25 antibody (phase I trial)]

The present study is a therapeutic trial of phase I, based on the principle of passive immunotherapy in acquired immunodeficiency syndrome (AIDS). Eighteen patients with full blown AIDS (stage IV C2 of CDC) were subdivided into two groups: nine receiving every two weeks 300 ml of plasma collected from HIV-1 seropositive symptomless (stage II or III of CDC) individuals, and nine (control group) receiving 300 ml of seronegative plasma at the same rythm and for the same period. Each patient received seven transfusions. Clinical and biological results during the transfusional and post-transfusional periods are reported.

No evidence of frequent human immunodeficiency virus type 1 infection in seronegative at-risk individuals

The possible existence of human immunodeficiency virus type 1 (HIV-1) infection in asymptomatic seronegative at-risk individuals was investigated in a prospective study of 55 seronegative high-risk individuals (42 homosexual men and 13 heterosexual individuals) and 32 seronegative hemophiliacs treated with factor VIII or IX concentrates before viral inactivation by heat treatment and systematic screening of blood donations. Tests used include the polymerase chain reaction assay with three primer pairs (one in the gag region and two in the pol region) and tests for serum p24 antigen, anti-nef serology (Western blot), and five biologic markers frequently altered by HIV infection (CD4 lymphocyte count, serum beta 2-microglobulin and neopterin concentration, and serum IgG and IgA concentration). Although 91 of 92 HIV-1-seropositive persons were positive in testing with at least one primer pair, no positive result was observed in seronegative at-risk individuals or in 117 seronegative low-risk controls. No nef antibody was found in seronegative at-risk individuals or seronegative controls, but 44 (47%) of 92 HIV-1-seropositive persons had nef antibodies. These findings do not support the existence of frequent HIV-1 infection in seronegative at-risk individuals.

DNA amplification of HIV-1 in seropositive individuals and in seronegative at-risk individuals

We assessed the HIV-1 status of seropositive and seronegative at-risk individuals by the polymerase chain reaction. Fifty-four out of 55 HIV-1-seropositive samples scored positive. However, HIV-1 proviral DNA was not detected in 16 seronegative homosexuals, 20 seronegative polytransfused haemophiliacs and 20 seronegative thalassaemic children, 20 individuals with isolated and persistent anti-core antibodies and 74 seronegative blood donors. These data indicate that positive HIV-1 DNA is likely to be an exceptional phenomenon in HIV-seronegative people.

Treatment of AIDS-associated heart disease

Although the diagnosis of AIDS-associated heart disease is becoming routine, its treatment has not been reported except in anecdote. Also, it has been unclear whether the odds of successful treatment are altered because of the presence of cardiac involvement per se. This communication reports the authors' treatment of 18 patients with AIDS-associated heart disease. Their results are combined with the treatment results of all patients reported in the literature to date with AIDS-associated heart disease. Treatment success, defined as eradication of the organism and no relapse, was achieved in their patients with M. tuberculosis (M. tb), cardiac cryptococcosis, and Salmonella typhimurium. M. tb required emergency pericardiectomy (well tolerated in all patients), then administration of rifampin, isoniazid, and ethambutol. Cryptococcosis was treated acutely with amphotericin B and flucytosine, then with maintenance amphotericin B. The response, which included resolution of congestive heart failure, occurred within a week. Salmonella endocarditis was cured with administration of ampicillin and netilmicin for one month. When the patients' data were combined with those of patients from the literature, the authors found that the odds of successful treatment for tuberculous pericarditis were somewhat lower than if the tuberculosis was extracardiac (50% vs 67%). With cryptococcal heart disease, the odds of successful treatment were actually significantly better than when only extracardiac disease was present. The authors conclude that infectious forms of AIDS-associated heart disease are often treatable. Although some cardiac infections are less likely to respond to treatment if there is cardiac involvement, mostly the response to treatment is similar to the response with only extracardiac involvement.