Prevention and treatment of opportunistic infections in HIV-infected adults and adolescents: Updated Guidelines from the Centers for Disease Control and Prevention, National Institutes of Health, and HIV Medicine Association of the Infectious Diseases Society of America

Solid organ transplant-related central nervous system infections

PURPOSE OF REVIEW

Central nervous system (CNS) infections in solid organ transplant (SOT) recipients may present atypical or nonspecific symptoms. Due to a wider range of infectious agents compared with immunocompetent hosts, diagnosis is challenging. This review categorizes CNS infections in SOT recipients by cause.

RECENT FINDINGS

New studies have reported new data on the epidemiology and the risk factors associated with each specific pathogen described in this review. Additionally, we included the treatment recommendations.

SUMMARY

The latest findings give us an insight into the different pathogens causing infectious neurologic complications in SOT recipients.

Does the Recovery of Respiratory Viruses Impact Pulmonary Function at Baseline and 1-, 6-, and 12-Month Follow-Up in People Living with HIV and Pneumonia?

The frequency of respiratory viruses in people living with HIV (PLHIV) and their impact on lung function remain unclear. We aimed to determine the frequency of respiratory viruses in bronchoalveolar lavage and induced sputum samples in PLHIV and correlate their presence with lung function. A prospective cohort of adults hospitalized in Medellín between September 2016 and December 2018 included three groups: group 1 = people diagnosed with HIV and a diagnosis of community-acquired pneumonia (CAP), group 2 = HIV, and group 3 = CAP. People were followed up with at months 1, 6, and 12. Clinical, microbiological, and spirometric data were collected. Respiratory viruses were detected by multiplex RT-PCR. Sixty-five patients were included. At least 1 respiratory virus was identified in 51.9%, 45.1%, and 57.1% of groups 1, 2 and 3, respectively. Among these, 89% of respiratory viruses were detected with another pathogen, mainly Mycobacterium tuberculosis (40.7%) and Pneumocystis jirovecii (22.2%). The most frequent respiratory virus was rhinovirus (24/65, 37%). On admission, 30.4% of group 1, 16.6% of group 2, and 50% of group 3 had airflow limitation, with alteration in forced expiratory volume at first second in both groups with pneumonia compared to HIV. Respiratory viruses are frequent in people diagnosed with HIV, generally coexisting with other pathogens. Pulmonary function on admission was affected in patients with pneumonia, improving significantly in the 1st, 6th, and 12th months after CAP onset.

Re-estimation of the burden of serious fungal diseases in Uganda

Background

It is of utmost importance to monitor any change in the epidemiology of fungal diseases that may arise from a change in the number of the at-risk population or the availability of local data.

Objective

We sought to update the 2015 publication on the incidence and prevalence of serious fungal diseases in Uganda.

Methods

Using the Leading International Fungal Education methodology, we reviewed published data on fungal diseases and drivers of fungal diseases in Uganda. Regional or global data were used where there were no Ugandan data.

Results

With a population of ~45 million, we estimate the annual burden of serious fungal diseases at 4,099,357 cases (about 9%). We estimated the burden of candidiasis as follows: recurrent Candida vaginitis (656,340 cases), oral candidiasis (29,057 cases), and esophageal candidiasis (74,686 cases) in HIV-infected people. Cryptococcal meningitis annual incidence is estimated at 5553 cases, Pneumocystis pneumonia at 4604 cases in adults and 2100 cases in children. For aspergillosis syndromes, invasive aspergillosis annual incidence (3607 cases), chronic pulmonary aspergillosis (26,765 annual cases and 63,574 5-year-period prevalent cases), and prevalence of allergic bronchopulmonary aspergillosis at 75,931 cases, and severe asthma with fungal sensitization at 100,228 cases. Tinea capitis is common with 3,047,989 prevalent cases. For other mycoses, we estimate the annual incidence of histoplasmosis to be 646 cases and mucormycosis at 9 cases.

Conclusion

Serious fungal diseases affect nearly 9% of Ugandans every year. Tuberculosis and HIV remain the most important predisposition to acute fungal infection necessitating accelerated preventive, diagnostic, and therapeutic interventions for the management of these diseases.

Antibiotic prophylaxis in immunosuppressed patients - Missed opportunities from trimethoprim-sulfamethoxazole allergy label

Trimethoprim-sulfamethoxazole (TMP-SMX) is a broad spectrum antibiotic in use for more than 50 years. It has an important indication as first line agent in the prophylaxis of opportunistic infections, particularly Pneumocystis jirovecii pneumonia (PJP), in immunosuppressed patients. For those who have a history of allergy or severe intolerance to TMP-SMX, pentamidine, dapsone or atovaquone may be substituted; however there is evidence that TMP-SMX offers superior coverage for PJP, toxoplasmosis, and nocardiosis. Compared to pentamidine, it has the added benefit of cost-effectiveness and self-administration as opposed to required hospital attendance for administration. Many patients who report a history of allergy or adverse reaction to TMP-SMX (or "sulfur allergy") will be found not to be allergic; and even those who are allergic may be able to be desensitized. The evaluation and, where appropriate, removal of TMP-SMX allergy label enables the use of TMP-SMX for prophylaxis against opportunistic infections. This is a cost-effective intervention to optimize antimicrobial prescribing and reduce the risk of opportunistic infections in immunosuppressed patients.

Use of nanoparticles, a modern means of drug delivery, against cryptosporidiosis

Cryptosporidium is a primary cause of waterborne epidemics, despite being previously considered only an opportunistic pathogen. The disease is associated with significant economic losses in humans and animals that are brought on by diarrhea, which frequently causes dehydration. Contact with diseased people or animals, as well as polluted water, is the major cause of infection. Different drugs are used to control the parasites. Nitazoxanide (NTZ), which is an anti-protozoan and anti-viral drug, can be used to control helminths, viruses, and protozoan parasites as a broad-spectrum antibiotic and has been approved by the food and drug authority (FDA). However, the problem is the development of resistance over a period of time in these parasites. Nanoparticles have received significant attention as possible anti-parasitic agents in recent years. By directing medications to specific cellular locations, targeted drug delivery minimizes the side effects of medications. Nanoparticles have demonstrated effectiveness against different Cryptosporidium species. Nanoparticles loaded with NTZ are found to be an effective remedy for C. parvum in young ones and decrease the oocyst count shed in the stools. Additionally, silver nanoparticles have proven to be effective against C. parvum by releasing silver ions that breach the cell wall of the oocyst, causing the escape of intracellular contents and the destruction of sporozoites within the oocyst. Implementing tiny particles for the purification of consuming water from Cryptosporidium is an economical and environmentally sustainable process. However, the use of nanoparticles in medicine requires more research.

Case report: A toxoplasmic encephalitis in an immunocompromised child detected through metagenomic next-generation sequencing

There exist numerous pathogens that are capable of causing infections within the central nervous system (CNS); however, conventional detection and analysis methods prove to be challenging. Clinical diagnosis of CNS infections often depends on clinical characteristics, cerebrospinal fluid (CSF) analysis, imaging, and molecular detection assays. Unfortunately, these methods can be both insensitive and time consuming, which can lead to missed diagnoses and catastrophic outcomes, especially in the case of infrequent diseases. Despite the application of appropriate prophylactic regimens and evidence-based antimicrobial agents, CNS infections continue to result in significant morbidity and mortality in hospital settings. Metagenomic next-generation sequencing (mNGS) is a novel tool that enables the identification of thousands of pathogens in a target-independent manner in a single run. The role of this innovative detection method in clinical pathogen diagnostics has matured over time. In this particular research, clinicians employed mNGS to investigate a suspected CNS infection in a child with leukemia, and unexpectedly detected Toxoplasma gondii.

Case

A 3-year-old child diagnosed with T-cell lymphoblastic lymphoma was admitted to our hospital due to a 2-day history of fever and headache, along with 1 day of altered consciousness. Upon admission, the patient's Glasgow Coma Scale score was 14. Brain magnetic resonance imaging revealed multiple abnormal signals. Due to the patient's atypical clinical symptoms and laboratory test results, determining the etiology and treatment plan was difficulty.Subsequently, the patient underwent next-generation sequencing examination of cerebrospinal fluid. The following day, the results indicated the presence of Toxoplasma gondii. The patient received treatment with a combination of sulfamethoxazole (SMZ) and azithromycin. After approximately 7 days, the patient's symptoms significantly improved, and they were discharged from the hospital with oral medication to continue at home. A follow-up polymerase chain reaction (PCR) testing after about 6 weeks revealed the absence of Toxoplasma.

Conclusion

This case highlights the potential of mNGS as an effective method for detecting toxoplasmic encephalitis (TE). Since mNGS can identify thousands of pathogens in a single run, it may be a promising detection method for investigating the causative pathogens of central nervous system infections with atypical features.

Severe efavirenz associated neurotoxicity: A retrospective cohort study

Background

Efavirenz (EFV) is associated with neuropsychiatric symptoms. Severe neurotoxicity has been reported but the clinical phenotype and risk factors are poorly defined.

Objectives

To characterise clinical presentations, risk factors and outcomes to help clinicians recognise severe neurotoxicity earlier.

Method

The authors retrospectively identified adults with supratherapeutic EFV concentrations (> 4 mg/L) obtained during routine clinical care in Cape Town, South Africa. Clinical and laboratory data at the time of EFV quantification were extracted from medical records. Logistic regression was performed to identify associations with neuropsychiatric symptoms, and with severe neurotoxicity.

Results

Eighty one patients were included; 62 with neuropsychiatric manifestations (most frequently ataxia [n = 20] and psychomotor slowing [n = 24]); and 19 with hepatotoxicity. Overall, 28 (34.6%) were male, 49 (60.5%) had concomitant isoniazid exposure, and median EFV concentration was 12.1 mg/L (interquartile range [IQR]: 6.6-20.0). Neuropsychiatric symptoms were associated with longer duration of EFV therapy, adjusted odds ratio (aOR) 1.3/180-day increment (95% confidence interval [CI]: 1.0-1.7); higher EFV concentrations, aOR 1.2/1 mg/L increase (95% CI: 1.0-1.4) and isoniazid exposure, aOR 8.2 (95% CI: 2.5-26.7). Severe neuropsychiatric symptoms occurred in 47 (75%) patients at a median of 5.9 months (IQR: 2.1-40.8) after EFV initiation. Severe symptoms odds were 1.2-fold higher (95% CI: 1.1-1.4) per 1 mg/L increase in EFV concentration. Symptoms resolved completely within 1 month in 25 (76%) patients with severe neurotoxicity who discontinued EFV.

Conclusion

A concentration-effect relationship for severe neurotoxicity exists, which occurred late and resolved in most patients after EFV discontinuation.

Contribution

The authors highlighted clinical heterogeneity and morbidity of EFV-associated neurotoxicity.

Lifetime prevalence and adherence rate of cervical cancer screening among women living with HIV: a systematic review and meta-analysis

INTRODUCTION

Women living with HIV (WLWH) are more likely to develop cervical cancer. Screening and available healthcare can effectively reduce its incidence and mortality rates. We aimed to summarize the lifetime prevalence and adherence rate of cervical cancer screening among WLWH across low- and middle-income countries (LMICs), and high-income countries (HICs).

METHODS

We systematically searched PubMed, Web of Science and Embase for studies published between database inception and 2 September 2022, without language or geographical restrictions. Those reporting the lifetime prevalence and/or adherence rate of cervical cancer screening among WLWH were included. Pooled estimates across LMICs and HICs were obtained using DerSimonian-Laird random-effects models. When the number of eligible studies was greater than 10, we further conducted stratified analyses by the World Health Organization (WHO) region, setting (rural vs. urban), investigation year, screening method, type of cervical cancer screening programme, age and education level.

RESULTS

Among the 63 included articles, 26 provided data on lifetime prevalence, 24 on adherence rate and 13 on both. The pooled lifetime prevalence in LMICs was 30.2% (95% confidence interval [CI]: 21.0-41.3), compared to 92.4% in HICs (95% CI: 89.6-94.6). The pooled adherence rate was 20.1% in LMICs (95% CI: 16.4-24.3) and 59.5% in HICs (95% CI: 51.2-67.2).

DISCUSSION

There was a large gap in cervical cancer screening among WLWH between LMICs and HICs. Further analysis found that those in LMICs had higher lifetime prevalence in subgroups with urban settings, with older age and with higher education levels; and those in HICs had higher adherence in subgroups with younger age and with higher education levels.

CONCLUSIONS

Cervical cancer screening among WLWH falls considerably short of the WHO's goal. There should be continuous efforts to further increase screening among these women, especially those residing in the rural areas of LMICs and with lower education levels.

A Rare Complication of Herpes Zoster Ophthalmicus (HZO)

Retrobulbar optic neuritis is a rare complication of herpes zoster ophthalmicus (HZO). We report a case of a 27-year-old man who presented with a progressive left blurring of vision for one week. A history of vesicular rashes in the left trigeminal nerve area preceded his condition. On examination, we noted that his left eye visual acuity was hand movement, and his optic nerve function was reduced. Findings from examining the anterior segment and intraocular pressure were unremarkable. The fundus examination results were normal. A blood investigation was positive for human immunodeficiency virus (HIV). MRI showed hyperintense features of the intraorbital segment of the optic nerve in the T2-weighted image. An abnormal high signal on a T2 weighted image may be present, which may be a clue for varicella zoster associated complications, such as HZO-related optic neuritis. Therefore, a diagnosis of retrobulbar optic neuritis was made, and antiviral treatment was initiated. He received two weeks of IV acyclovir and switched to the oral route for one month. After the completion of the treatment, his visual acuity remained the same.

A Case of Severe Pneumocystis Pneumonia in an HIV-Negative Patient Successfully Treated with Oral Atovaquone

Currently, atovaquone is not recommended for treating severe Pneumocystis jirovecii pneumonia (PCP) due to insufficient evidence in clinical studies. This report describes a case of severe PCP in a human immunodeficiency virus (HIV)-negative immunosuppressed patient who was successfully treated with oral atovaquone and corticosteroids. A 63-year-old Japanese woman complained of fever and dyspnea for 3 days. She had been treated with oral prednisolone (30 mg/day) for interstitial pneumonia for 3 months without PCP prophylaxis. Although we could not confirm P. jirovecii from the respiratory specimen, a diagnosis of PCP was indicated by marked elevation of serum beta-D-glucan levels and bilateral ground-glass opacities in the lung fields. Based on the arterial blood gas test results (alveolar-arterial oxygen difference >45 mmHg), the disease status of PCP was defined as severe. Trimethoprim-sulfamethoxazole (SXT) is the first-line drug for treating severe PCP. However, given the patient's history of SXT-induced toxic epidermal necrolysis, she was administered atovaquone instead of SXT. Her clinical symptoms and respiratory condition gradually improved, with a 3-week treatment showing a good clinical course. Previous clinical studies on atovaquone have only been conducted in HIV-positive patients with mild or moderate PCP. Accordingly, the clinical efficacy of atovaquone for severe PCP cases or PCP in HIV-negative patients remains unclear. There is a rising incidence of PCP among HIV-negative patients, given the increasing number of patients receiving immunosuppressive medications; moreover, atovaquone has less severe side effects than SXT. Therefore, there is a need for further clinical investigation to confirm the efficacy of atovaquone in cases of severe PCP, especially among HIV-negative patients. In addition, it also remains unclear whether corticosteroids are beneficial for severe PCP in non-HIV patients. Thus, the use of corticosteroids in cases of severe PCP in non-HIV patients should also be investigated.

Pneumocystis pneumonia in COVID-19 patients: A comprehensive review

The admitted patients of intensive care units with coronavirus disease 2019 (COVID-19) meet the challenges of subsequent infections. Opportunistic fungal infections such as Pneumocystis pneumonia (PCP) are among the important factors in the context of COVID-19 patients affecting illness severity and mortality. We reviewed the literature on COVID-19 patients with PCP to identify features of this infection. Although studies confirmed at least the presence of one immunosuppressive condition in half of PCP patients, this disease can also occur in immunocompetent patients who developed the immunosuppressive condition during Covid-19 treatment. The major risk factors associated with COVID-19 patients with PCP can be considered low lymphocyte counts and corticosteroid therapy. Diagnostic and treatment options are complicated by the overlapping clinical and radiologic characteristics of PCP and COVID-19 pneumonia. Therefore, physicians should comprehensively evaluate high-risk patients for PCP prophylaxis.

11C, 12C and 13C-Cyanation of Electron-Rich Arenes via Organic Photoredox Catalysis

As a non-invasive imaging technology, positron emission tomography (PET) plays a crucial role in personalized medicine, including early diagnosis, patient screening, and treatment monitoring. The advancement of PET research depends on the discovery of new PET agents, which requires the development of simple and efficient radiolabeling methods in many cases. As bioisosteres for halogen and carbonyl moieties, nitriles are important functional groups in pharmaceutical and agrochemical compounds. Here, we disclose a mild organophotoredox-catalyzed method for efficient cyanation of a broad spectrum of electron-rich arenes, including abundant and readily available veratroles and pyrogallol trimethyl ethers. Notably, the transformations not only are compatible with various affordable 12C and 13C-cyanide sources, but also could be applied to carbon-11 synthons to incorporate [11C]nitriles into arenes. The aryl [11C]nitriles can be further derivatized to [11C]carboxylic acids, [11C]amides, and [11C]alkyl amines. The newly developed reaction can serve as a powerful tool for generating new PET agents.

HIV treatment, antiretroviral adherence and AIDS mortality in people who inject drugs: a scoping review

BACKGROUND

People who inject drugs (PWID) are a key population for the prevention and care of HIV infection.

METHODS

This scoping review covers recent (post-2010) systematic reviews on engagement of PWID in sequential stages of HIV care from uptake, to achieving viral suppression, and to avoiding AIDS-related mortality.

RESULTS

We found that data on engagement of PWID into antiretroviral therapy (ART) were particularly scarce, but generally indicated very low engagement in ART. Studies of adherence and achieving viral suppression showed varying results, with PWID sometimes doing as well as other patient groups. The severity of social, medical and psychiatric disability in this population poses significant treatment challenges and leads to a marked gap in AIDS mortality between PWID and other population groups.

CONCLUSIONS

Given the multi-level barriers, it will be difficult to reach current targets (UNAIDS fast-track targets of 95-95-95) for ART for PWID in many locations. We suggest giving priority to reducing the likelihood that HIV seropositive PWID will transmit HIV to others and reducing morbidity and mortality from HIV infection and from other comorbidities.

Disseminated Talaromyces marneffei infection after renal transplantation: A case report and literature review

We reported a 31-year-old man who received renal transplantation for more than 2 years. He was admitted to our hospital on 9 March 2022 due to intermittent diarrhea accompanied by leukopenia for more than 1 month. The patient successively developed high fever, cough, anemia, weight loss, gastrointestinal bleeding, and liver function impairment. Computed tomography (CT) revealed a slight inflammation in the lower lobes of both lungs, enlargement of the lymph nodes in the retroperitoneal and the root of mesenteric areas, and hepatosplenomegaly. Talaromyces marneffei was detected by metagenomics next-generation sequencing (mNGS) in blood and bronchoalveolar lavage fluid, and the pathogen was subsequently verified by blood culture. After endoscopic hemostatic therapy and antifungal therapy with voriconazole and amphotericin B cholesteryl sulfate complex, the patient was successfully discharged. Oral voriconazole was given regularly after discharge. Diarrhea, fever, enlargement of the lymph nodes, and endoscopic evidence of erosion may indicate intestinal T. marneffei infection. Although the mortality of T. marneffei infection after renal transplantation is very high, timely and effective antifungal therapy with amphotericin B cholesteryl sulfate complex is still expected to improve its prognosis.

Candida albicans can foster gut dysbiosis and systemic inflammation during HIV infection

Candida albicans (C. albicans) is a ubiquitous fungal commensal component of the human microbiota, and under certain circumstances, such as during an immunocompromised state, it may initiate different types of infection. Moreover, C. albicans continuously and reciprocally interacts with the host immune system as well as with other elements of the gut microbiota, thus contributing significantly to both gut homeostasis and host immunity. People living with HIV (PLWH), including those receiving antiretroviral therapy, are characterized by a depletion of CD4 + T-cells and dysbiosis in their gut. C. albicans colonization is frequent in PLWH, causing both a high prevalence and high morbidity. Gut barrier damage and elevated levels of microbial translocation are also fairly common in this population. Herein, we take a closer look at the reciprocity among C. albicans, gut microbiota, HIV, and the host immune system, thus throwing some light on this complex interplay.

Study on the mechanisms of action of berberine combined with fluconazole against fluconazole-resistant strains of Talaromyces marneffei

Talaromyces (Penicillium) marneffei (T. marneffei) is a thermally dimorphic fungus that can cause opportunistic systemic mycoses. Our previous study demonstrated that concomitant use of berberine (BBR) and fluconazole (FLC) showed a synergistic action against FLC-resistant T. marneffei (B4) in vitro. In this paper, we tried to figure out the antifungal mechanisms of BBR and FLC in T. marneffei FLC-resistant. In the microdilution test, the minimum inhibitory concentration (MIC) of FLC was 256 μg/ml before FLC and BBR combination, and was 8 μg/ml after combination, the partial inhibitory concentration index (FICI) of B4 was 0.28. After the treatments of BBR and FLC, the studies revealed that (i) increase reactive oxygen species (ROS), (ii) reduce ergosterol content, (iii) destroy the integrity of cell wall and membrane, (iv) decrease the expression of genes AtrF, MDR1, PMFCZ, and Cyp51B however ABC1 and MFS change are not obvious. These results confirmed that BBR has antifungal effect on T. marneffei, and the combination with FLC can restore the susceptibility of FLC-resistant strains to FLC, and the reduction of ergosterol content and the down-regulation of gene expression of AtrF, Mdr1, PMFCZ, and Cyp51B are the mechanisms of the antifungal effect after the combination, which provides a theoretical basis for the application of BBR in the treatment of Talaromycosis and opens up new ideas for treatment of Talaromycosis.

A comprehensive clinical guide for Pneumocystis jirovecii pneumonia: a missing therapeutic target in HIV-uninfected patients

INTRODUCTION

Pneumocystis jirovecii is an opportunistic, human-specific fungus that causes Pneumocystis pneumonia (PCP). PCP symptoms are nonspecific. A patient with P. jirovecii and another lung infection faces a diagnostic challenge. It may be difficult to determine which of these agents is responsible for the clinical symptoms, preventing effective treatment. Diagnostic and treatment efforts have been made more difficult by the rising frequency with which coronavirus 2019 (COVID-19) and PCP co-occur.

AREAS COVERED

Herein, we provide a comprehensive review of clinical and pharmacological recommendations along with a literature review of PCP in immunocompromised patients focusing on HIV-uninfected patients.

EXPERT OPINION

PCP may be masked by identifying co-existing pathogens that are not necessarily responsible for the observed infection. Patients with severe form COVID-19 should be examined for underlying immunodeficiency, and co-infections must be considered as co-infection with P. jirovecii may worsen COVID-19's severity and fatality. PCP should be investigated in patients with PCP risk factors who come with pneumonia and suggestive radiographic symptoms but have not previously received PCP prophylaxis. PCP prophylaxis should be explored in individuals with various conditions that impair the immune system, depending on their PCP risk.

High Blood Cytomegalovirus Load Suggests Cytomegalovirus Retinitis in HIV/AIDS Patients: A Cross-Sectional Study

PURPOSE

To clarify the cut off value of blood CMV load to indicate CMV retinitis and its relationships with ocular features.

METHODS

Patients were divided into non-CMV and CMV retinitis groups. A logistic regression model was applied to estimate the association of each variable with CMV retinitis. Spearman correlation was used to estimate the correlation between the blood and aqueous CMV load.

RESULTS

Blood CMV load higher than 4log₁₀ (OR, 6.897; CI: 2.813-16.910; P < .001) was the major predictor of CMV retinitis. Blood CMV load wasn't different between the initial and early stage (P = .066). No correlation was observed between the blood and aqueous CMV load (P = .083, r = 0.228).

CONCLUSIONS

Blood CMV load higher than 4log₁₀ is an important predictor for CMV retinitis in HIV/AIDS patients, but it couldn't indicate the ocular features. Ophthalmologic screening is still necessary.Abbreviations: CMV: Cytomegalovirus; CMVR: Cytomegalovirus retinitis; HIV: Human Immunodeficiency Virus; AIDS: Acquired Immune Deficiency Syndrome; ART: Antiretroviral therapy; EOD: End-organ diseases; PCR: Polymerase Chain Reaction; OR: Odds Ratio; CI: 95% Confidence Interval; IQR: Interquartile range.

Examining 5-Year Cervical Cytology Progression Among Minority Women Living With HIV and Baseline Negative Cytology

OBJECTIVE

Women living with HIV (WLWH) have increased risk of human papillomavirus (HPV) infection, precancers, and invasive cervical cancers. This study aims to determine the rate of cervical cytologic progression and related factors in minority WLWH across 5 years.

MATERIALS AND METHODS

We used our HIV clinic database, complemented with a retrospective chart review to identify WLWH with a baseline negative cervical cytology between 2009 and 2012 and 5-year follow-up. Data included race/ethnicity, age, years living with HIV, AIDS status, viral load, history of smoking, drug use, and HPV status. Multivariate logistic regression tested progression of negative cytology to low-grade/high-grade squamous intraepithelial lesions (LGSIL/HGSIL).

RESULTS

Among 162 WLWH, 42% were African American, 30% non-Hispanic African Caribbean, and 26% Hispanic. At baseline, 21% had detectable viral load (>200 cp/mL), mean age was 44.8 (±11 years), and mean years living with HIV was 9.6 (±6.9). After 5 years, 19% of the cohort progressed to LGSIL/HGSIL. Human papillomavirus was detected consistently among women with cytologic changes (30% vs 7%, p < .01). Significant factors that predicted higher likelihood of progression to LGSIL/HGSIL were detection of HPV (adjusted odds ratios = 5.11 [1.31-19.93]; p = .02), and Centers for Disease Control and Prevention-defined AIDS status (adjusted odds ratios = 4.28 [1.04-17.63]; p = .04). Of the women who maintained negative cytology at 1 to 2 years (n = 102), 5 women (5%) progressed during the following 3 years before the recommended follow-up.

CONCLUSIONS

Human papillomavirus detection and AIDS status were significant factors predicting progression to LGSIL/HGSIL among minority WLWH. Providers screening WLWH for cervical intraepithelial neoplasia should carefully decide screening intervals for minority populations.

Considering humans as habitat reveals evidence of successional disease ecology among human pathogens

The realization that ecological principles play an important role in infectious disease dynamics has led to a renaissance in epidemiological theory. Ideas from ecological succession theory have begun to inform an understanding of the relationship between the individual microbiome and health but have not yet been applied to investigate broader, population-level epidemiological dynamics. We consider human hosts as habitat and apply ideas from succession to immune memory and multi-pathogen dynamics in populations. We demonstrate that ecologically meaningful life history characteristics of pathogens and parasites, rather than epidemiological features alone, are likely to play a meaningful role in determining the age at which people have the greatest probability of being infected. Our results indicate the potential importance of microbiome succession in determining disease incidence and highlight the need to explore how pathogen life history traits and host ecology influence successional dynamics. We conclude by exploring some of the implications that inclusion of successional theory might have for understanding the ecology of diseases and their hosts.

This study explores the analogy between ecological succession in terrestrial ecosystems and infections in a human-host landscape over time, showing how the ecosystem of long-term multi-pathogen dynamics within and among hosts may be a critical missing consideration in understanding epidemiology.

Pre-clinic study of radiopharmaceutical for Covid-19 inactivation: Dose distribution with Monte Carlo Simulation

Monte Carlo simulation method and Nuclear Medicine MIRD method were used to evaluate the effect of radiopharmaceuticals on Covid-19 disease. The mean absorbed organ dose in the target organ and gamma radiation emitter attenuation properties such as linear attenuation coefficients, energy absorption build-up factors (EABF), exposure build-up factors (EBF), and relative dose distributions (RDD) were examined. The results showed that radiopharmaceuticals containing gamma radiation emitters which are densely ionizing charged particles induced membrane damage and produced protein damage.

Etiology of meningitis among adults in three quaternary hospitals in Mozambique, 2016–2017: The role of HIV

Background

Meningitis remains an important cause of morbi-mortality in adults in sub-Saharan Africa. Data on the etiological investigation of meningitis in adults in Mozambique is limited and most studies were conducted in southern Mozambique. Identification of the etiology of meningitis in adults are crucial to guide prevention and treatments strategies. In this study, we determine the burden of fungal and bacterial meningitis among adults at the three largest hospitals in Mozambique.

Method

We performed analysis of data from the routine sentinel surveillance system for meningitis in Mozambique from January 2016 to December 2017. Cerebrospinal fluid (CSF) samples were collected from eligible adults (≥18 years old) who met World Health Organization (WHO) case definition criteria for Meningitis. All samples were tested by cryptococcal antigen (CrAg) lateral flow assay (LFA), culture and triplex real-time polymerase chain reaction (qPCR) assay and all patients were tested for human immunodeficiency virus (HIV) using the national algorithm for HIV testing.

Results

Retrospective analysis of 1501 CSF samples from adults clinically suspected of meningitis revealed that 10.5% (158/1501) were positive for bacterial and fungal meningitis. Of these 158 confirmed cases, the proportion of Cryptococcal meningitis and pneumococcal meningitis was38.6% (95% CI: 31.0% to 46.7%) and 36.7% (95% CI: 29.2% to 44.7%), respectively. The other bacterial agents of meningitis identified include Neisseria meningitidis (8.9%; 14/158), Escherichia coli (6.3%; 10/158), Haemophilus influenzae (5.1%; 8/158) and S. aureus (4.4%; 7/158), which represent (24.7%; 39/158) of the total confirmed cases.

Conclusion

Altogether, our findings show a high burden of Cryptococcal meningitis among adults in Mozambique, especially in people living with HIV, followed by pneumococcal meningitis. Our findings suggest that rollout of CrAg Lateral Flow Assay in the health system in Mozambique for early detection of cryptococcus neoformans is necessary to improve overall patient care.

Challenges in Serologic Diagnostics of Neglected Human Systemic Mycoses: An Overview on Characterization of New Targets

Systemic mycoses have been viewed as neglected diseases and they are responsible for deaths and disabilities around the world. Rapid, low-cost, simple, highly-specific and sensitive diagnostic tests are critical components of patient care, disease control and active surveillance. However, the diagnosis of fungal infections represents a great challenge because of the decline in the expertise needed for identifying fungi, and a reduced number of instruments and assays specific to fungal identification. Unfortunately, time of diagnosis is one of the most important risk factors for mortality rates from many of the systemic mycoses. In addition, phenotypic and biochemical identification methods are often time-consuming, which has created an increasing demand for new methods of fungal identification. In this review, we discuss the current context of the diagnosis of the main systemic mycoses and propose alternative approaches for the identification of new targets for fungal pathogens, which can help in the development of new diagnostic tests.

The implementation of the Kinyoun staining technique in a resource-limited setting is feasible and reveals a high prevalence of intestinal cryptosporidiosis in HIV patients

OBJECTIVES

In resource-limited settings, intestinal Cryptosporidia or coccidian infections are common causes of chronic diarrhoea, but usually remain undiagnosed by routine stool investigation. Here, the addition of the Kinyoun staining technique after stool concentration was evaluated as an easy and inexpensive method for diagnosis of intestinal parasitic infection in HIV-infected patients.

METHODS

This cross-sectional study investigated HIV-infected patients with diarrhoea and randomly selected HIV-infected patients without diarrhoea as controls. Stool samples were examined by wet mount microscopy and Kinyoun staining after stool concentration. Clinical, sociodemographic and behavioural data were collected. Statistical analysis was performed using Chi-squared test and multivariate regression analysis.

RESULTS

In total, 163 participants were included (62.0% female, mean age 38.2 [SD ±10.7] years). Diarrhoea was present in 52.1% (85/163). The prevalence of intestinal parasites was 18.4% (30/163). Cryptosporidia infections were more frequent among patients with diarrhoea (12.9% [11/85] vs. 1.3% [1/78], p=0.005) and in patients with CD4⁺ cell count <200 cells/µL (25.9% [7/27] vs. 3.7% [5/136], p=0.001). Risk factors for intestinal parasitic infections were diarrhoea and the habit of regularly eating uncooked food. Kinyoun staining was necessary for detection of cryptosporidiosis.

CONCLUSION

In our cohort, the prevalence of intestinal parasitic infection was high, especially after additional utilization of Kinyoun staining for detection of Cryptosporidia or intestinal coccidia. Considering its clinical relevance particularly in individuals at risk, the implementation of this technique should be considered in resource-limited settings.

A nomogram for predicting paradoxical immune reconstitution inflammatory syndrome associated with cryptococcal meningitis among HIV-infected individuals in China

Background

Cryptococcal meningitis (CM) associated immune reconstitution inflammatory syndrome (CM-IRIS) is the second most common complication in HIV-infected individuals with cryptococcal meningitis, with a reported mortality rate ranging from 8 to 30%. Given the devastating consequences of CM-IRIS related intracranial neuroinflammation and its challenging in diagnosis, we conducted a study to explore the risk factors and the occurrence of paradoxical CM-IRIS in HIV-infected patients, which is of great value for prevention and clinical management.

Methods

We conducted a retrospective cohort study to identify the indicators associated with paradoxical CM-IRIS among 86 HIV-infected patients with CM using univariate and multivariate cox analysis. A nomogram was constructed using selected variables to evaluate the occurrence of paradoxical CM-IRIS at 6 months and 12 months after ART initiation. The discrimination and calibration of the nomogram were assessed by concordance index (C-index) and calibration plots. Decision curves analysis (DCA) were used to evaluate clinical effectiveness of the nomogram. Subsequently, to help clinicians recognize patients at high risk faster, patients were divided into high-risk and low-risk groups according to the best cutoff point identified by X-tile.

Results

Of 86 AIDS patients with CM, 22.1% experienced paradoxical CM-IRIS at a median of 32 days after antiretroviral therapy (ART) initiation. The occurrence of paradoxical CM-IRIS was associated with age, ART initiation within 4 weeks of antifungal treatment, a four-fold increase in CD4 T cell counts, C-reactive protein levels, and hemoglobin levels independently. These five variables were further used to construct a predictive nomogram. The C-index (0.876) showed the favorable discriminative ability of the nomogram. The calibration plot revealed a high consistency between the predicted and actual observations. DCA showed that the nomogram was clinically useful. Risk stratification based on the total score of the nomogram showed well-differentiated in the high-risk and low-risk groups. Clinicians should pay attention to patients with total points high than 273.

Conclusions

We identified the predictive factors of paradoxical CM-IRIS and constructed a nomogram to evaluate the occurrence of paradoxical CM-IRIS in 6 months and 12 months. The nomogram represents satisfactory performance and might be applied clinically to the screening and management of high-risk patients.

Accuracy of Pneumocystis jirovecii Plasma Cell-Free DNA PCR for Noninvasive Diagnosis of Pneumocystis Pneumonia

Pneumocystis pneumonia (PCP) caused by Pneumocystis jirovecii is a serious infection in immunocompromised hosts which requires prompt diagnosis and treatment. The recommended specimen for diagnosis of PCP is bronchoalveolar lavage (BAL) fluid, which is invasive and may not be possible in unstable patients. The aim of this study was to evaluate the accuracy of noninvasive P. jirovecii plasma cell-free DNA (cfDNA) PCR using recently optimized preanalytical and analytical methods. Adult patients undergoing clinical testing for PCP with direct fluorescent antibody stain (DFA), respiratory PCR, and/or β-d-glucan were included in this study. Sensitivity and specificity P. jirovecii plasma cfDNA PCR was determined in PCP suspects categorized as proven and probable. A total of 149 patients were included in this study, of which 10 had proven and 27 had probable PCP. Most patients (95.9%, 143/149) were immunocompromised, including hematological malignancies (30.1%), bone marrow transplant (11.2%), solid organ transplantation (47.6%), and HIV/AIDS (4.2%). P. jirovecii plasma cfDNA PCR showed sensitivity and specificity of 100% (10/10; 95% confidence interval [CI], 69.2 to 100) and 93.4% (127/136; 95% CI, 87.8 to 96.9), and 48.6% (18/37; 95% CI, 31.9 to 65.6) and 99.1% (108/109; 95% CI, 94.9 to 100) in proven and proven/probable cases, respectively. P. jirovecii cell-free DNA PCR was similar in sensitivity but with substantially improved specificity over β-d-glucan (sensitivity, 60.0% [18/30; 95% CI, 40.6 to 77.3]); specificity, 66.7% [22/33; 95% CI, 48.2 to 82.0]) in patients with proven/probable PCP. Plasma cfDNA PCR offers a noninvasive testing option for early and accurate diagnosis of PCP, particularly in patients who cannot tolerate bronchoscopy.

AIDS at 40th: The progress of HIV treatment in Japan

Forty years have passed since the first five AIDS cases in Los Angeles were reported in 1981. Looking back at the history, these 40 years could be divided into 3 phases. During the first 15 years, when there was little efficacious therapy against HIV, clinical research was directed to develop diagnosis and treatment for opportunistic infections, mainly Pneumocystis jirovecii pneumonia. When combination antiretroviral therapy (cART) became available in 1996, taking cART had been troublesome to most patients following 10 years because some of them had severe side effects, diet restrictions, high pill burdens, drug interactions, etc. It was not easy for patients to keep high adherence and, therefore, the virus easily obtained drug resistance. Although the prognosis has been dramatically improved, patients had been still living with hard times during the second phase. Along with advancement of anti-retroviral drugs that have allowed simple treatment possible, their life expectancy has further improved and is reaching almost nearly the general population in the following 15 years. However, some patients have recently faced an additional load to treat life-related comorbidities and non-AIDS defining malignancies. The problem is that these diseases start to occur in the 40s- or 50s-year-old generations and that means HIV-infected persons are suffering from pre-mature aging. AIDS no longer signifies death. However, we still have a lot to improve for their quality of life.

Associations between presence of Bartonella species deoxyribonucleic acid and complete blood cell count and serum biochemical changes in client-owned cats

Background

Infection with Bartonella species is common in cats but reported effects of bacteremia on laboratory variables differ.

Objectives

Evaluate for associations between Bartonella bacteremia and CBC and serum biochemical changes in sick and healthy cats throughout the United States.

Animals

A total of 3964 client‐owned cats.

Methods

Retrospective cohort study using submissions to a commercial laboratory between 2011 and 2017. Serum biochemistry and CBC abnormalities (categorized as above or below reference intervals), age, and location (high‐ or low‐risk state for Ctenocephalides felis) in presumed healthy and sick cats were evaluated for associations with presence of Bartonella spp. DNA, detected by PCR. Univariate and multivariable logistic regression analyses were performed.

Results

Bartonella spp. DNA was amplified from 127 (3.2%) of 3964 cats; 126 (99.2%) of 127 were from high flea risk states and 121 (95.3%) of 127 were presumed sick. Fever of unknown origin was the most common PCR panel requested. In the multivariable analysis, neutrophilia, decreased ALP activity, clinical status (presumed sick), and young age (≤2 years) each were positively associated whereas neutropenia and hyperproteinemia both were negatively associated with Bartonella spp. bacteremia. Presence of Bartonella spp. DNA had no association with test results for other infectious disease agents.

Conclusions and Clinical Importance

In both healthy and sick cats, active Bartonella infections had minimal association with clinically relevant laboratory abnormalities. However, based on these results, in areas considered high risk for C. felis, active infection with Bartonella spp. is a reasonable differential diagnosis for cats presented with unexplained fever and neutrophilia, particularly if the cat is young.

Leishmania and its relationships with bacteria

Leishmaniasis is a zoonotic and neglected disease, which represents an important public health problem worldwide. Different species of Leishmania are associated with different manifestations, and a practical problem that can worsen the condition of hosts infected with Leishmania is the secondary infection caused by bacteria. This review aims to examine the importance and prevalence of bacteria co-infection during leishmaniasis and the nature of this ecological relationship. In the cases discussed in this review, the facilitation phenomenon, defined as any interaction where the action of one organism has a beneficial effect on an organism of another species, was considered in the Leishmania-bacteria interaction, as well as the effects on one another and their consequences for the host.

Stroke among highly active antiretroviral therapy-naive people living with the human immunodeficiency virus in China: a retrospective study of the characteristics, risk factors, and prognosis

BACKGROUND

We aimed to clarify the characteristics, risk factors, and prognosis of stroke among HAART-naive people living with HIV (PLWH) in China.

METHODS

We selected HAART-naive PLWH admitted to Beijing Ditan Hospital, Capital Medical University, from 1 January 2009 to 31 December 2019. Demographic and clinical data were obtained by searching an anonymous electronic case system. Descriptive analysis and logistic regression and Cox proportional hazard models were used to determine the characteristics and predictors of stroke among all HAART-naive PLWH and evaluate the risk factors of mortality in HAART-naive PLWH with stroke.

RESULTS

Stroke was diagnosed in 105 cases (3.7%) of 2867 HAART-naive PLWH. Multivariate logistic regression indicated that age of 30-55 years (OR 1.903, 95% CI 1.005-3.603, p = 0.048), age of ≥ 55 years (OR 4.104, 95% CI 1.928-8.737, p < 0.001), and CD4 count of < 200 cells/µL (OR 2.005, 95% CI 1.008-3.985, p = 0.047) were associated with increased odds of stroke. Diabetes (OR 3.268, 95% CI 1.744-6.125, p < 0.001), hypertension (OR 2.301, 95% CI 1.425-3.717, p = 0.001), syphilis (OR 2.003, 95% CI 1.300-3.089, p = 0.002), and complicated AIDS-defining CNS diseases (OR 7.719, 95% CI 4.348-13.703, p < 0.001) were risk factors for stroke. Of the 105 stroke patients, 12 (11.4%) died during hospitalisation, and the risk factors for mortality among patients with stroke were age of > 65 years (AHR: 8.783, 95% CI 1.522-50.668, p = 0.015), complicated severe pneumonia (AHR: 3.940, 95% CI 1.106-14.029, p = 0.034), and AIDS-defining CNS diseases (AHR: 19.766, 95% CI 3.586-108.961, p = 0.001).

CONCLUSIONS

For HAART-naive people living with HIV (PLWH), stroke occurred in various age groups, and early screening for stroke, timely intervention for risk factors among patients in various age groups, and controlling the CD4 count are extremely important in reducing the burden of stroke.

Evidence for Implementation: Management of TB in HIV and Pregnancy

PURPOSE OF REVIEW

Pregnant people living with HIV (PLWH) are at especially high risk for progression from latent tuberculosis infection (LTBI) to active tuberculosis (TB) disease. Among pregnant PLWH, concurrent TB increases the risk of complications such as preeclampsia, intrauterine fetal-growth restriction, low birth weight, preterm-delivery, perinatal transmission of HIV, and admission to the neonatal intensive care unit. The grave impact of superimposed TB disease on maternal morbidity and mortality among PLWH necessitates clear guidelines for concomitant therapy and an understanding of the pharmacokinetics (PK) and potential drug-drug interactions (DDIs) between antitubercular (anti-TB) agents and antiretroviral therapy (ART) in pregnancy.

RECENT FINDINGS

This review discusses the currently available evidence on the use of anti-TB agents in pregnant PLWH on ART. Pharmacokinetic and safety studies of anti-TB agents during pregnancy and postpartum are limited, and available data on second-line and newer anti-TB agents used in pregnancy suggest that several research gaps exist. DDIs between ART and anti-TB agents can decrease plasma concentration of ART, with the potential for perinatal transmission of HIV. Current recommendations for the treatment of LTBI, drug-susceptible TB, and multidrug-resistant TB (MDR-TB) are derived from observational studies and case reports in pregnant PLWH. While the use of isoniazid, rifamycins, and ethambutol in pregnancy and their DDIs with various ARTs are well-characterized, there is limited data on the use of pyrazinamide and several new and second-line antitubercular drugs in pregnant PLWH. Further research into treatment outcomes, PK, and safety data for anti-TB agent use during pregnancy and postpartum is urgently needed.

Serological Evaluation of Toxoplasmosis and Related Risk Factors Among HIV+/AIDS Patients in Northern Iran

PURPOSE

Toxoplasma gondii is an important opportunistic intracellular protozoan parasite that can cause severe sequelae and even death in immunodeficient patients. This study aimed to evaluate the seroprevalence and risk factors of toxoplasmosis among HIV⁺/AIDS patients of the study area.

METHODS

A cross-sectional study was carried out on 121 registered HIV⁺/AIDS patients of behavioral diseases consultation center (BDCC) in Guilan province, north of Iran. Anti-Toxoplasma IgG and IgM antibodies were measured by ELISA technique in the serum samples. IgG avidity was measured for IgG- plus IgM-positive cases. Also, the relationship between T. gondii infection and related demographic and clinical characteristics were investigated.

RESULTS

Anti-T. gondii IgG and IgM antibodies were detected in 60.3 and 4.9% of patients, respectively. One case of acute toxoplasmosis (0.83%) was detected using an IgG avidity test. A significant correlation was observed between toxoplasmosis with age and marital status in these patients. The mean CD4⁺count of HIV⁺/AIDS patients was 549 ± 27 cells/µl. Viral load in 69.7% of the HIV patients was less than1000 copies/ml.

CONCLUSION

None of the T. gondii IgM-positive HIV patients received anti-Toxoplasma prophylaxis. This finding highlights the importance of T. gondii infection surveillance in HIV patients. Regarding the high prevalence of toxoplasmosis in the study population, educational efforts are recommended to prevent reactivation or acquiring primary infection and developing severe cases of toxoplasmosis in immunocompromised HIV⁺/AIDS patients.

Frequency and Characteristics of Patients Prescribed Antibiotics on Admission to Hospice Care

Background: Little is known about antibiotic prescribing on hospice admission despite known risks and limited evidence for potential benefits. Objective: To describe the frequency and characteristics of patients prescribed antibiotics on hospice admission. Design: Cross-sectional study. Subjects: Adult (age ≥18 years) decedents of a national, for-profit hospice chain across 19 U.S. states who died between January 1, 2017 and December 31, 2019. Measures: The primary outcome was having an antibiotic prescription on hospice admission. Patient characteristics of interest were demographics, hospice referral location, hospice care location, census region, primary diagnosis, and infectious diagnoses on admission. We used multivariable logistic regression to quantify associations between study variables. Results: Among 66,006 hospice decedents, 6080 (9.2%) had an antibiotic prescription on hospice admission. Fluoroquinolones (22%) were the most frequently prescribed antibiotic class. Patients more likely to have an antibiotic prescription on hospice admission included those referred to hospice care from the hospital (adjusted odds ratio [aOR] 1.13, 95% confidence interval [CI] 1.00-1.29) compared with an assisted living facility, those receiving hospice care in a private home (aOR 3.85, 95% CI 3.50-4.24), nursing home (aOR 3.65, 95% CI 3.24-4.11), assisted living facility (aOR 4.04, 95% CI 3.51-4.64), or hospital (aOR 2.43, 95% CI 2.18-2.71) compared with inpatient hospice, and those with a primary diagnosis of liver disease (aOR 2.23, 95% CI 1.82-2.74) or human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) (aOR 3.89, 95% CI 2.27-6.66) compared with those without these diagnoses. Conclusions: Approximately 9% of hospice patients had an antibiotic prescription on hospice admission. Patients referred to hospice from a hospital, those receiving care in a noninpatient hospice facility, and those with liver disease or HIV/AIDS were more likely to have an antibiotic prescription. These results may inform future antimicrobial stewardship interventions among patients transitioning to hospice care.

Toxoplasmosis Encephalitis: A Cross-Sectional Analysis at a U.S. Safety-Net Hospital in the Late cART Era

Despite decreasing incidence of toxoplasmosis encephalitis(TE) among people living with HIV(PLWH) in the late antiretroviral era, U.S. safety-net hospitals still see significant numbers of admissions for TE. Little is known about this population, their healthcare utilization and long-term outcomes. We conducted an 8-year retrospective review of PLWH with TE at a safety-net hospital. Demographics, clinical characteristics, treatments, readmissions, and outcomes were collected. We used chi-squared test to evaluate 6-month all-cause readmission and demographic/clinical characteristics. Of 38 patients identified, 79% and 40% had a new diagnosis of TE and HIV respectively. 59% had 6-month all-cause readmission. Social factors were associated with readmission (uninsured (p = 0.036), Spanish as primary language (p = 0.017), non-adherence (p = 0.030)) and not markers of clinical severity (ICU admission, steroid-use, concomitant infections, therapeutic adverse events). Despite high readmission rates, at follow-up, 60% had a complete response, 30% had a partial response. Improving TE outcomes requires focus on culturally competent, coordinated care.

Five-year point prevalence survey of healthcare-associated infections and antimicrobial use in a Japanese university hospital

Background

Periodic point prevalence surveys (PPSs) provide a method for assessing changes in healthcare-associated infections (HAIs) and antimicrobial use over time. Following the introduction of an antimicrobial stewardship programme at Nagoya University Hospital (Aichi, Japan) a five-year PPS study was performed to highlight any epidemiological changes.

Methods

One-day PPSs were performed annually in July at Nagoya University Hospital. Data on patient characteristics, medical devices, active HAIs and antimicrobial use were collected using a standard data-collection form.

Results

A total of 4339 patients were included. Over the five-year study period the median patient age was 62 years, median duration of hospital admission was nine days, 9% of patients had an HAI and 35.2% received at least one antimicrobial. Overall there were 406 HAIs (95% confidence interval, 369-447) with surgical site infection, pneumonia and febrile neutropenia occurring most frequently. Enterobacterales were the most common pathogens (N = 78, 28.6%) and 32.1% were third-generation cephalosporin-resistant. Meropenem was the most frequently prescribed antimicrobial for HAIs. Surgical antimicrobial prophylaxis changed drastically, with shorter durations and a marked reduction in oral cephalosporin use. However, antimicrobials for medical prophylaxis gradually increased.

Conclusions

This five-year PPS study shows consistent data for patient background, HAIs and causative pathogens and highlights changes in antimicrobial use during the era of the National Action Plan on Antimicrobial Resistance. To describe the epidemiology of Japanese hospitals by PPS, multicentre PPSs including in community hospitals should be performed annually.

Case Report: Tropheryma whipplei Hide in an AIDS Patient With Pneumocystis Pneumonia

Introduction: Pneumocystis pneumonia (PCP) is one of the most common opportunistic infections in HIV-infected patients. However, coinfection with Tropheryma whipplei is infrequent in AIDS patients with PCP. Case Presentation: We report a 28-year-old male AIDS patient coinfected with T. whipplei and Pneumocystis jirovecii diagnosed in the bronchoalveolar lavage. After sulfamethoxazole-trimethoprim and meropenem treatment, the patient showed clinical improvement in 2 weeks. Conclusion: Clinicians need to be alert to the occurrence of T. whipplei infection in AIDS patients with PCP and timely diagnosis and antibacterial treatments are essential. This case may help clinicians for timely diagnosis of the coinfection of T. whipplei and P. jirovecii in AIDS patients.

Not all bad: Drug-induced interstitial pneumonia in DLBCL patients is potentially fatal but could be linked to better survival

BACKGROUND

Interstitial pneumonitis (IP), a fatal complication of DLBCL treatment, can bring great challenges to clinicians. We retrospectively investigated clinical characteristics and risk factors of previous IP patients, and analyzed their survival data.

METHODS

556 DLBCL patients receiving CHOP-like regimens were enrolled between 2013 and 2018 in Sichuan Cancer Hospital.

FINDINGS

The IP incidences were 4.9 % (27/556), 1.1 % (2/186), 5.2 % (10/191) and 8.4 % (15/179) in CHOP, R-CHOP and R-CDOP groups respectively (P = 0.005). When IP was diagnosed, monocyte and IL-6 were significantly higher while CD4 and CD4/CD8 significantly lower compared to baseline. 81.5 % (22/27) of IP patients were pathogen-negative with good response to glucocorticoid monotherapy. Only one patient died while the others recovered from IP and subsequently underwent previous chemotherapy. 19.2 % (5/26) of IP patients experienced IP recurrence, likely due to the reason of lower initial dose or faster withdrawal speed of glucocorticoid. Multivariate analysis identified male, in addition to G-CSF, rituximab and pegylated liposomal doxorubicin as risk factors. The 3-year PFS and OS were 74.1 % and 46.9 % respectively for patients with IP.

INTERPRETATION

We suggest that IL-6, monocyte and CD4 should be monitored closely, especially in R-CHOP/R-CDOP group. Sufficient initial dose and slow decrease of glucocorticoid based on radiographic remissions were critical strategies to reduce IP recurrence. We speculate that drug-induced immune imbalance could be trigger of developing IP, causing a lower intensity cytokine storm, resulting in a potential immunotherapy. This complication might bring benefit in patients' survival through a mechanism similar to PD-1.

Neurologic Infections in Patients on Immunomodulatory and Immunosuppressive Therapies

PURPOSE OF REVIEW

Both broadly immunosuppressive medications and selective immunomodulatory agents that act on particular components of the immune system are increasingly used in the treatment of neurologic and non-neurologic diseases. These therapies predispose patients to particular infections, some of which may affect the nervous system. Therefore, familiarity with the clinical and radiologic features of neurologic infections associated with specific immunomodulatory therapies is of importance for the practicing neurologist. This article reviews these neuroinfectious conditions, as well as other neurologic complications unique to transplant recipients and other patients who are immunocompromised.

RECENT FINDINGS

Diagnosis of infectious pathogens in patients who are immunocompromised may be particularly challenging because a decreased immune response can lead to atypical imaging or laboratory findings. Next-generation sequencing and other novel diagnostic modalities may improve the rate of early identification of neurologic infections in patients who are immunocompromised and ultimately ameliorate outcomes in this vulnerable population.

SUMMARY

A broad range of bacterial, viral, fungal, and parasitic infections of the nervous system can complicate solid organ and hematopoietic cell transplantation as well as other forms of immunocompromise. In addition to neurologic infections, such patients are at risk of neurotoxic and neuroinflammatory complications related to immunomodulatory and immunosuppressive therapies. Early recognition of infectious and noninfectious complications of immunocompromise is essential to guide appropriate treatment, which can include antimicrobial therapy and, in some cases, withdrawal of the predisposing medication with a transition to an alternative regimen.

Alsagaby S, Mir SA, Alaidarous M, Bin Dukhyil A, Alshehri B, Banawas S, Alturaiki W, Alharbi NK, Azad TA, Al Abdulmonem W. Seroprevalence of Viral Hepatitis B and C among Blood Donors in the Northern Region of Riyadh Province, Saudi Arabia

BACKGROUND

Hepatitis B and C viral infections, which are the most common cause of liver infection worldwide, are major health issues around the globe. People with chronic hepatitis infections remain at risk of liver cirrhosis and hepatic carcinoma, while also being a risk to other diseases. These infections are highly contagious in nature, and the prevention of hepatitis B and C transmission during blood transfusion is a major challenge for healthcare workers. Although epidemiological characteristics of hepatitis B and C infections in blood donors in Saudi Arabia have been previously investigated in multiple studies, due to targeted cohorts and the vast geographical distribution of Saudi Arabia, there are a lot of missing data points, which necessitates further investigations.

AIM OF THE STUDY

This study aimed to determine the prevalence of hepatitis B and hepatitis C viral infections among blood donors in the northern region of Riyadh, Saudi Arabia.

METHODS

To determine the given objectives, a retrospective study was performed which included data gathered from serological as well as nucleic acid test (NAT) screening of blood donors. Clinical data of 3733 blood donors were collected for a period of 2 years (from January 2019 to December 2020) at the blood bank of King Khalid General Hospital and the associated blood banks and donation camps in the region. Statistical analysis of the clinical data was performed using SPSS.

RESULTS

The blood samples of 3733 donors were analyzed to determine the seroprevalence of hepatitis B and C among the blood donors in the northern region of Riyadh, Saudi Arabia. Among the total of 3733 blood donors, 3645 (97.65%) were men and 88 (2.36%) were women. Most of the donors were younger than 27 years of age (n = 1494). The most frequent blood group in our study was O-positive (n = 1534), and the least frequent was AB-negative (n = 29). After statistically analyzing the clinical data, we observed that 7 (0.19%), 203 (5.44%) and 260 (6.96%) donor blood samples were positive for the HBV serological markers HBsAgs, HBsAbs and HBcAbs, respectively, and 12 (0.32%) blood samples reacted positively to anti-HCV antibodies. Moreover, 10 (0.27%) and 1 (0.027%) samples were NAT-HBV positive and NAT-HCV positive, respectively.

CONCLUSION

In the current study, low prevalence rates of HBV and HCV were observed in the blood donors. Statistical correlations indicated that both serological tests and NATs are highly effective in screening potential blood donors for HBV and HCV, which, in turn, prevents potential transfusion-transmitted hepatitis.

Progressive Multifocal Leukoencephalopathy in Children with Primary and Secondary Immune Deficiency

Progressive multifocal leukoencephalopathy (PML) is a fatal demyelinating disease of the central nervous system that is caused by John Cunningham virus (JCV). It occurs almost exclusively in immunosuppressed individuals, for example, patients with AIDS and hematological and lymphoreticular malignancies. In this article, we present a review of the literature and 2 case reports with PML. The first report examines a 15-year-old male (who presented with dedicator of cytokinesis 8 deficiency) who was diagnosed as having PML based on characteristic magnetic resonance imaging (MRI) lesions and a positive PCR for JCV in cerebrospinal fluid. He was transferred for bone marrow transplantation after stabilization with therapy of maraviroc and cidofovir. The second report examines a 6-year-old male who presented with encephalitis and was also diagnosed with AIDS. He was diagnosed with PML and started treatment with cidofovir. His clinical status and MRI findings deteriorated rapidly. In immunosuppressive patients who developed encephalopathy, JCV ought to be considered.

Predictors of Current CD4+ T-Cell Count Among Women of Reproductive Age on Antiretroviral Therapy in Public Hospitals, Southwest Ethiopia

Background

HIV/AIDS is one of the major global public health problems. CD4 is a glycoprotein found on the surface of different immune cells. CD4 cell counts determine the need for screening and prophylactic interventions against common opportunistic infections in those with advanced HIV disease. Thus, this study aimed to assess the predictors of current CD4⁺ T-cell count among women of reproductive age on antiretroviral therapy in public hospitals, southwest Ethiopia.

Methods

A cross-sectional study was conducted from February to April 2018. A total of 422 participants in the three public hospitals were selected using a systematic random sampling method. Linear regression analyses were used to determine the important predictors of current CD4⁺ T-cell count at p-values of <0.05.

Results

A total of 422 women with a median age of 37.00 years participated in this study. More than one in ten (12.8%) respondents experienced immunological failure. An increased current CD4⁺ T-cell count was observed among patients with a tertiary level of education [β = 56.45, 95% CI (3.5, 109.4)], baseline WHO clinical stage II [β = 44.06, 95% CI (5.3, 82.9)], initial regimen of AZT+3TC+EFV [β = 167.23, 95% CI (100.4, 234.1)], with increased baseline CD4⁺ T-cell count [β = 0.35, 95% CI (0.2, 0.5)], and with increased time duration on ART [β = 14.36, 95% CI (6.304, 22.4)]. On the other hand, the current CD4⁺ T-cell count was lowered among patients with poor baseline adherence, opportunistic infection, and viral load of ≥1000 by 181.06 cells/mm³, 101.62 cells/mm³, and 137.53 cells/mm³ compared to good baseline adherence, no opportunistic infection and undetectable viral load, respectively.

Conclusion

The immunological failure was relatively low. Maintaining adherence, early identification and treatment of opportunistic infections, and minimizing viral load to undetectable levels may further decrease immunological failure.

Talaromycosis marneffei of the Cervical Spine: An Unusual Infection

Talaromyces marneffei infection (TMI) causing vertebral osteomyelitis of the cervical spine is extremely rare. TMI in an HIV-uninfected patient is also unusual. This report presents the successful treatment of an HIV-uninfected TMI patient who underwent C6 and T1 vertebrectomies, bone grafting, and anterior cervical plating accompanied by antifungal therapy. A 63-year-old woman was diagnosed with adult-onset immune deficiency. She suddenly developed progressive neck pain without neurologic deficit. The plain radiographs and magnetic resonance imaging showed inflammation and abscess formation along the prevertebral area from C3-4 to T2-3 with vertebral body destruction. Intraoperative pus culture and tissue specimens were determined to be T marneffei. The patient was treated intravenously with amphotericin B deoxycholate for 4 weeks (0.6 mg/kg/d) and oral itraconazole (400 mg/d) for 12 months. Over a 2 consecutive year follow-up period, she achieved a full recovery with an absence of neck pain.

Moderate levels of 5-fluorocytosine cause the emergence of high frequency resistance in cryptococci

The antifungal agent 5-fluorocytosine (5-FC) is used for the treatment of several mycoses, but is unsuitable for monotherapy due to the rapid development of resistance. Here, we show that cryptococci develop resistance to 5-FC at a high frequency when exposed to concentrations several fold above the minimal inhibitory concentration. The genomes of resistant clones contain alterations in genes relevant as well as irrelevant for 5-FC resistance, suggesting that 5-FC may be mutagenic at moderate concentrations. Mutations in FCY2 (encoding a known permease for 5-FC uptake), FCY1, FUR1, UXS1 (encoding an enzyme that converts UDP-glucuronic acid to UDP-xylose) and URA6 contribute to 5-FC resistance. The uxs1 mutants accumulate UDP-glucuronic acid, which appears to down-regulate expression of permease FCY2 and reduce cellular uptake of the drug. Additional mutations in genes known to be required for UDP-glucuronic acid synthesis (UGD1) or a transcriptional factor NRG1 suppress UDP-glucuronic acid accumulation and 5-FC resistance in the uxs1 mutants.

Pathogenic fungi rapidly develop resistance to the antifungal agent 5-fluorocytosine (5-FC). Here, Chang et al. explore the mechanisms by which Cryptococcus develops 5-FC resistance at a high frequency, including mutations in several genes and altered levels of key metabolites.

Successful Treatment of Cryptococcal Meningitis and Cryptococcoma with Isavuconazole in a Patient Living with HIV

We describe the successful use of isavuconazole for treatment of an HIV-positive patient with cryptococcal meningitis following induction therapy with liposomal amphotericin B and flucytosine. Because the Cryptococcus neoformans isolate from cerebrospinal fluid had a borderline minimum inhibitory concentration of 8 mg/L, initial consolidation therapy was given with a daily dose of fluconazole 1200 mg based on area under the curve to minimum inhibitory concentration modelling data. Toxicity, and the radiological emergence of a cryptococcoma in the setting of immune reconstitution inflammatory syndrome, prompted a therapeutic switch to isavuconazole. Subsequent imaging after 19 weeks of isavuconazole shows a significant reduction in cryptococcoma size from 11 mm to complete resolution. The patient remains well after 210 days of therapy with a view to completion of treatment after 1 year.

HLA-mismatched allogeneic adoptive immune therapy in severely immunosuppressed AIDS patients

Severely immunosuppressed AIDS patients with recurrent opportunistic infections (OIs) represent an unmet medical need even in the era of antiretroviral therapy (ART). Here we report the development of a human leukocyte antigen (HLA)-mismatched allogeneic adaptive immune therapy (AAIT) for severely immunosuppressed AIDS patients. Twelve severely immunosuppressed AIDS patients with severe OIs were enrolled in this single-arm study. Qualified donors received subcutaneous recombinant granulocyte-colony-stimulating factor twice daily for 4-5 days to stimulate hematopoiesis. Peripheral blood mononuclear cells were collected from these donors via leukapheresis and transfused into the coupled patients. Clinical, immunological, and virological parameters were monitored during a 12-month follow-up period. We found AAIT combined with ART was safe and well-tolerated at the examined doses and transfusion regimen in all 12 patients. Improvements in clinical symptoms were evident throughout the study period. All patients exhibited a steady increase of peripheral CD4+ T cells from a median 10.5 to 207.5 cells/μl. Rapid increase in peripheral CD8+ T-cell count from a median 416.5 to 1206.5 cells/μl was found in the first 90 days since initiation of AAIT. In addition, their inflammatory cytokine levels and HIV RNA viral load decreased. A short-term microchimerism with donor cells was found. There were no adverse events associated with graft-versus-host disease throughout the study period. Overall, AAIT treatment was safe, and might help severely immunosuppressed AIDS patients to achieve a better immune restoration. A further clinical trial with control is necessary to confirm the efficacy of AAIT medication.