1
|
O’Connor LF, Byrne M, Baskaran A, Andersen EW, Horberg MA, Benator DA, Lucar J, Denyer RV, Lee R, Castel AD, Monroe AK. Characterizing Indicators of Engagement in HIV-Associated Healthcare and Clinical Outcomes among People with HIV and Mpox in Washington, DC: A Nested Case-Control Study of the DC Cohort. Pathogens 2024; 13:117. [PMID: 38392854 PMCID: PMC10892472 DOI: 10.3390/pathogens13020117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 01/19/2024] [Accepted: 01/25/2024] [Indexed: 02/25/2024] Open
Abstract
The high proportion of people with HIV (PWH) in the 2022-2023 mpox outbreak has raised questions surrounding the association between HIV and mpox. The objectives of this study were to evaluate the association between engagement in HIV-associated healthcare and mpox diagnosis, as well as to characterize cases of mpox among PWH. The DC Cohort is a longitudinal cohort of PWH in Washington, DC. We conducted a 5:1 (controls:cases) nested case-cohort study on male participants, matching age and care site. Cases were participants with an identified mpox diagnosis. Conditional logistic regression was used to assess the impact of indicators of engagement in HIV-associated healthcare on mpox diagnosis. We identified 70 cases of mpox in DC Cohort participants randomly matched to 323 controls, for a total of 393 participants included in the analysis. Study participants were primarily non-Hispanic Black (72.3%) with a median age of 41 (IQR: 36, 50). There was no association between engagement in care and mpox diagnosis; however, low CD4 was associated with increased odds of mpox diagnosis (aOR: 4.60 (95% CI: 1.23, 17.11)). Among a cohort of PWH, engagement in care was not associated with mpox diagnosis, suggesting that the overrepresentation of PWH among mpox cases is not due to surveillance bias.
Collapse
Affiliation(s)
- Lauren F. O’Connor
- Milken Institute School of Public Health, The George Washington University, Washington, DC 20052, USA
| | - Morgan Byrne
- Milken Institute School of Public Health, The George Washington University, Washington, DC 20052, USA
| | - Anuja Baskaran
- Milken Institute School of Public Health, The George Washington University, Washington, DC 20052, USA
| | - Elisabeth W. Andersen
- Milken Institute School of Public Health, The George Washington University, Washington, DC 20052, USA
| | - Michael A. Horberg
- Kaiser Permanente Mid-Atlantic Permanente Medical Group, Rockville, MD 20852, USA
| | - Debra A. Benator
- District of Columbia Veterans Affairs Medical Center, Washington, DC 20422, USA
- School of Medicine & Health Sciences, The George Washington University, Washington, DC 20037, USA
| | - Jose Lucar
- School of Medicine & Health Sciences, The George Washington University, Washington, DC 20037, USA
| | - Rachel V. Denyer
- District of Columbia Veterans Affairs Medical Center, Washington, DC 20422, USA
- School of Medicine & Health Sciences, The George Washington University, Washington, DC 20037, USA
| | - Rachel Lee
- District of Columbia Veterans Affairs Medical Center, Washington, DC 20422, USA
- School of Medicine & Health Sciences, The George Washington University, Washington, DC 20037, USA
| | - Amanda D. Castel
- Milken Institute School of Public Health, The George Washington University, Washington, DC 20052, USA
| | - Anne K. Monroe
- Milken Institute School of Public Health, The George Washington University, Washington, DC 20052, USA
| |
Collapse
|
2
|
Denyer R, Zemskova J, Benator DA. HIV treatment with dolutegravir and doravirine: rationale for selection and clinical outcomes in a highly treatment experienced population. Int J STD AIDS 2022; 33:1073-1077. [DOI: 10.1177/09564624221116533] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Dolutegravir and doravirine are individually safe and effective antiretroviral therapy (ART) components, but their combined use has not been studied in clinical trials and is not recommended in HIV treatment guidelines. We noted persons with HIV (PWH) receiving dolutegravir with doravirine at our Washington, DC, infectious disease clinic and undertook a service evaluation to understand why providers selected this ART, whether HIV virologic suppression was achieved and identify adverse effects of concomitant use. Case registry and prescriptions data identified 21 PWH receiving concomitant dolutegravir and doravirine with mean follow-up 576.1 days (range 413–751); frequent reasons for switching were multiple ART resistance (57.1%), proton pump inhibitor usage (28.6%) and renal failure (28.6%), with 52.4% switched from protease inhibitor or cobicistat-boosted regimens. Dolutegravir with doravirine alone was prescribed for 60%, and additional ART in 40%. During 12 months follow-up mean CD4 was 585.9 (baseline 570.7) with undetectable viral load in 77.8% (baseline 66.7%). No discontinuations for drug-related adverse events or virologic failure occurred. Dolutegravir with doravirine was well tolerated in small numbers of highly treatment experienced PWH at our clinic, achieving virologic suppression in most. Establishing the efficacy and safety of dolutegravir with doravirine for HIV treatment in randomized trials remains important.
Collapse
Affiliation(s)
- Rachel Denyer
- Infectious Diseases Section, DC Veterans Affairs Medical Center, Washington, DC, USA
- Division of Infectious Diseases, The George Washington University, Washington, DC, USA
| | - Julie Zemskova
- Infectious Diseases Section, DC Veterans Affairs Medical Center, Washington, DC, USA
- Division of Infectious Diseases, The George Washington University, Washington, DC, USA
| | - Debra A Benator
- Infectious Diseases Section, DC Veterans Affairs Medical Center, Washington, DC, USA
- Division of Infectious Diseases, The George Washington University, Washington, DC, USA
| |
Collapse
|
3
|
Denyer R, Zemskova J, Beatty D, Benator DA. 1009. Dolutegravir and Doravirine in Combination: When Standard Antiretroviral Regimens are Unacceptable. Open Forum Infect Dis 2020. [PMCID: PMC7777508 DOI: 10.1093/ofid/ofaa439.1195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
A drug-drug interaction study between dolutegravir and doravirine in healthy volunteers found no evidence of untoward interaction. Whilst we hypothesize that the combination would be safe and effective, there is no supportive clinical data. We aimed to assess the rationale for use of dolutegravir and doravirine in combination and clinical outcomes among persons with HIV infection (PWH) receiving care at the Washington DC VAMC.
Methods
A quality improvement initiative utilized the clinical case registry to identify all PWH receiving both dolutegravir and doravirine. We conducted chart review to examine (a) the reasons for switch from other ART to dolutegravir and doravirine, and comorbidities, HIV resistance mutations or drug interactions precluding the use of standard ART, (b) adverse events or side effects and (c) achievement of virologic suppression.
Results
A case registry search revealed 21 individuals receiving combination dolutegravir doravirine from 2018–2020 (Table 1 and Figure 1). Side effects were not noted except one patient developed mild diarrhea that improved with continuation of therapy. Four patients were hospitalized during the follow-up period for reasons unrelated to the medications. One patient who was admitted to the ICU with shock and multi-organ failure was switched on admission but died four days later and therefore was not included in the analysis of viral outcome (Table 2). One patient had cardiac arrest following missed dialysis, hyperkalemia and rectal hemorrhage from metastatic rectal cancer.
Table 1: Patient Demographics.
Figure 1: Reasons for Switching to Dolutegravir with Doravirine.
Table 2: Virologic Control Before and After Switching to Dolutegravir with Doravirine.
Conclusion
In an era of abundant ART options, we identified a subset of older PWH whose treatment options are defined by extensive comorbidities, viral resistance, and medication interactions or toxicities. Doravirine is attractive for this population as it can be used in renal impairment, moderate hepatic impairment, is unaffected by timing of meals, and (unlike rilpivirine) has no interaction with proton pump inhibitors. Dolutegravir is included in NRTI-sparing regimens that HHS guidelines suggest should be considered in older PWH, especially with CKD. We found that dolutegravir with doravirine is well tolerated, and achieves virologic suppression in the majority of PWH, indicating this combination is useful when other ART options cannot be used.
Disclosures
All Authors: No reported disclosures
Collapse
Affiliation(s)
- Rachel Denyer
- Washington DC VAMC/The George Washington University, Washington, District of Columbia
| | - Julie Zemskova
- The George Washington University, Washington, District of Columbia
| | - Daniel Beatty
- The George Washington University, Washington, District of Columbia
| | | |
Collapse
|
4
|
Wallace DE, Horberg MA, Benator DA, Greenberg AE, Castel AD, Monroe AK, Happ LP. Diabetes mellitus control in a large cohort of people with HIV in care-Washington, D.C. AIDS Care 2020; 33:1464-1474. [PMID: 32811173 DOI: 10.1080/09540121.2020.1808160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
With more effective antiretroviral therapy (ART), people with HIV (PWH) are living longer and have more chronic diseases, including diabetes mellitus (DM). The prevalence of DM has been estimated in PWH previously, however there is less research regarding DM control. Our objectives were to determine the prevalence of DM and DM control and determine factors associated with DM control in a large urban cohort of PWH in care. We examined DC Cohort participants aged ≥18 years old to determine DM prevalence and to assess DM control (HbA1c measurement <7.0%). Demographic, clinical, and HIV-related factors associated with DM control were identified using multivariate logistic regression. The cohort of 5876 participants was predominantly male (71.3%), Non-Hispanic Black (78.1%) and had a median age of 52.0 years. DM prevalence was 17.4% (1023/5876). Among participants with recent HbA1c data available (39.9%) the proportion with DM control was 60.0% (245/408). In multivariate analysis, higher BMI (aOR: 0.47; 95% CI 0.28, 0.79) and use of non-insulin DM medication (aOR 0.43, 95% CI 0.25, 0.73) or insulin (aOR 0.010, 95% CI 0.04,0.24) compared to no medication use. Our findings suggest that individuals on medication for their DM likely need enhanced support to reach their treatment goals.
Collapse
Affiliation(s)
- David E Wallace
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC, USA
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - Debra A Benator
- Division of Infectious Disease, Veterans Affairs Medical Center, Washington, DC, USA.,Department of Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Alan E Greenberg
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC, USA
| | - Amanda D Castel
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC, USA
| | - Anne K Monroe
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC, USA
| | - Lindsey Powers Happ
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC, USA
| | -
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC, USA
| |
Collapse
|
5
|
Levy ME, Monroe AK, Horberg MA, Benator DA, Castel AD. Is low-level viraemia associated with serum lipid profiles among HIV controllers? HIV Med 2020; 21:e14-e16. [PMID: 32311819 DOI: 10.1111/hiv.12856] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/12/2020] [Indexed: 11/28/2022]
Affiliation(s)
- M E Levy
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC, USA
| | - A K Monroe
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC, USA
| | - M A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD, USA
| | - D A Benator
- Infectious Diseases Section, Veterans Affairs Medical Center, Washington, DC, USA.,George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - A D Castel
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC, USA
| | | |
Collapse
|
6
|
Levy ME, Monroe AK, Horberg MA, Benator DA, Molock S, Doshi RK, Powers Happ L, Castel AD. Pharmacologic Treatment of Psychiatric Disorders and Time With Unsuppressed HIV Viral Load in a Clinical HIV Cohort. J Acquir Immune Defic Syndr 2019; 82:329-341. [PMID: 31356466 PMCID: PMC6791752 DOI: 10.1097/qai.0000000000002138] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
OBJECTIVE To evaluate associations of mood, anxiety, stress-/trauma-related, and psychotic disorders, both treated and untreated, with duration of unsuppressed HIV viral load (VL) among persons living with HIV (PLWH). SETTING The DC Cohort, an observational clinical cohort of PLWH followed from 2011 to 2018 at 14 sites in Washington, DC. METHODS Among PLWH ≥18 years old who received primary care at their HIV clinic, we determined in a time-updated manner whether participants had diagnoses and pharmacologic prescriptions for mood, anxiety, stress-/trauma-related, and/or psychotic disorders. Associations between psychiatric disorders/treatments and the proportion of subsequent days with VL ≥200 copies/mL were assessed using multivariable Poisson regression with generalized estimating equations. RESULTS Among 5904 participants (median age 51; 70% men; 82% Black), 45% had ≥1 psychiatric disorder, including 38% with mood disorders (50% treated), 18% with anxiety or stress-/trauma-related disorders (64% treated), and 4% with psychotic disorders (52% treated). Untreated major depressive disorder (adjusted rate ratio = 1.17; 95% confidence interval: 1.00 to 1.37), untreated other/unspecified depressive disorder (1.23; 1.01 to 1.49), untreated bipolar disorder (1.39; 1.15 to 1.69), and treated bipolar disorder (1.25; 1.02 to 1.53) (vs. no mood disorder) predicted more time with VL ≥200 copies/mL. Treated anxiety disorders (vs. no anxiety disorder) predicted less time (0.78; 0.62 to 0.99). Associations were weaker and nonsignificant for treated depressive disorders (vs. no mood disorder) and untreated anxiety disorders (vs. no anxiety disorder). CONCLUSIONS PLWH with depressive and bipolar disorders, particularly when untreated, spent more time with unsuppressed VL than PLWH without a mood disorder. Treatment of mood disorders may be important for promoting sustained viral suppression.
Collapse
Affiliation(s)
- Matthew E Levy
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC
| | - Anne K Monroe
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC
| | - Michael A Horberg
- Mid-Atlantic Permanente Research Institute, Kaiser Permanente Mid-Atlantic States, Rockville, MD
| | - Debra A Benator
- Infectious Diseases Section, Veterans Affairs Medical Center, Washington, DC
- George Washington University School of Medicine and Health Sciences, Washington, DC
| | - Sherry Molock
- Department of Psychology, The George Washington University, Washington, DC
| | - Rupali K Doshi
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC
| | - Lindsey Powers Happ
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC
| | - Amanda D Castel
- Department of Epidemiology, Milken Institute School of Public Health at the George Washington University, Washington, DC
| |
Collapse
|
7
|
Powers Happ LJ, Monroe AK, Young HA, Ma Y, Greenberg AE, Benator DA, Horberg MA, Castel A. 342. The Impact of Glycemic Control on CD4 Cell Count in Persons Living with HIV and Diabetes Mellitus—Washington, DC. Open Forum Infect Dis 2019. [PMCID: PMC6809343 DOI: 10.1093/ofid/ofz360.415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Among persons living with HIV (PLWH) with type 2 diabetes mellitus (DM) there is limited research on the effect of DM control on CD4 count. Current guidelines recommend that PLWH with DM maintain a hemoglobin A1c (HbA1c) <7%. This analysis examined the impact of HbA1c on trends in CD4 count among PLWH receiving care in Washington, DC. Methods We used data from the DC Cohort, a longitudinal observational cohort of patients receiving HIV care at 14 clinics between 2011–2018. Participants with DM on an ongoing antiretroviral regimen with ≥1 year of follow-up, ≥2 HbA1c results, and ≥2 CD4 count results were included. Participants were compared based on the most recent HbA1c result categorized into one of three control levels control: strict, HbA1c < 7.5%; moderate, HbA1c between 7.5–9.0%; and uncontrolled, HbA1c >9.0%. All statistical tests were performed within the framework of the linear mixed-effects (LME) model. The rates of increase in CD4 count by DM control were compared using an LME model with random slopes and random intercepts, adjusted for sex, BMI, nadir CD4, a history of AIDS, or cancer diagnosis. Results Among 554 participants (median age 53.5; 70.8% male; 82.7% Black), there were 5,138 total CD4 count measurements. In unadjusted analysis, participants with moderate or uncontrolled HbA1c had higher mean CD4 counts over the follow-up period than those with strict HbA1c control (strict: 690 cells/μL, moderate: 712 cells/μL uncontrolled: 711 cells/μL; P = 0.0156 strict vs. moderate, 0.049 strict vs. uncontrolled). All DM control groups had a similar temporal increase over time in CD4 count (P = 0.46). In multivariate analysis, only moderate vs. strict control showed a significant difference in CD4 count (mean difference=18.1; P = 0.02). Results showed CD4 count change was not affected by the duration of HIV diagnosis or diabetes diagnosis. See Table 1 for additional results. Conclusion PLWH and DM with moderate HbA1c control had higher CD4 counts than those with strict HbA1c control and similar CD4 counts compared with those with uncontrolled HbA1c levels, while the rate of increase in CD4 count was similar in the three groups. These results show that moderate DM control may benefit CD4 count, which should be considered when revising DM control guidelines for PLWH. ![]()
Disclosures All authors: No reported disclosures.
Collapse
Affiliation(s)
| | | | | | - Yan Ma
- The George Washington University, Washington, DC
| | - Alan E Greenberg
- George Washington University Milken Institute School of Public Health, Washington, DC
| | | | | | | |
Collapse
|
8
|
Cohn DL, El Sadr WM, Abrams DI, Neaton JD, Benator DA, Vernon AA. In Memoriam, Fred Gordin, MD, 1951–2018. Clin Infect Dis 2018. [DOI: 10.1093/cid/ciy338] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- David L Cohn
- Denver Public Health, University of Colorado School of Medicine, New York
| | - Wafaa M El Sadr
- ICAP at Columbia University, Mailman School of Public Health, New York, New York
| | - Donald I Abrams
- Zuckerberg San Francisco General Hospital and Trauma Center, University of California at San Francisco
| | - James D Neaton
- Coordinating Centers for Biometric Research, University of Minnesota School of Public Health, Minneapolis
| | - Debra A Benator
- Washington VA Medical Center, The George Washington University School of Medicine and Health Sciences, D.C
| | - Andrew A Vernon
- Division of TB Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia
| |
Collapse
|
9
|
Lucar J, Hart R, Rayeed N, Terzian A, Weintrob A, Siegel M, Parenti DM, Squires LE, Williams R, Castel AD, Benator DA. Sexually Transmitted Infections Among HIV-Infected Individuals in the District of Columbia and Estimated HIV Transmission Risk: Data From the DC Cohort. Open Forum Infect Dis 2018; 5:ofy017. [PMID: 29479550 PMCID: PMC5804762 DOI: 10.1093/ofid/ofy017] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 01/16/2018] [Indexed: 11/14/2022] Open
Abstract
Background Washington, DC, has one of the highest rates of HIV infection in the United States. Sexual intercourse is the leading mode of HIV transmission, and sexually transmitted infections (STIs) are a risk factor for HIV acquisition and transmission. Methods We evaluated the incidence and demographic factors associated with chlamydia, gonorrhea, and syphilis among HIV-infected persons enrolled at 13 DC Cohort sites from 2011 to 2015. Using Poisson regression, we assessed covariates of risk for incident STIs. We also examined HIV viral loads (VLs) at the time of STI diagnosis as a proxy for HIV transmission risk. Results Six point seven percent (451/6672) developed an incident STI during a median follow-up of 32.5 months (4% chlamydia, 3% gonorrhea, 2% syphilis); 30% of participants had 2 or more STI episodes. The incidence rate of any STIs was 3.8 cases per 100 person-years (95% confidence interval [CI], 3.5-4.1); age 18-34 years, 10.8 (95% CI, 9.7-12.0); transgender women, 9.9 (95% CI, 6.9-14.0); Hispanics, 9.2 (95% CI, 7.2-11.8); and men who have sex with men (MSM), 7.7 (95% CI, 7.1-8.4). Multivariate Poisson regression showed younger age, Hispanic ethnicity, MSM risk, and higher nadir CD4 counts to be strongly associated with STIs. Among those with an STI, 41.8% had a detectable VL within 1 month of STI diagnosis, and 14.6% had a VL ≥1500 copies/mL. Conclusions STIs are highly prevalent among HIV-infected persons receiving care in DC. HIV transmission risk is considerable at the time of STI diagnosis. Interventions toward risk reduction, antiretroviral therapy adherence, and HIV virologic suppression are critical at the time of STI evaluation.
Collapse
Affiliation(s)
- Jose Lucar
- Division of Infectious Diseases, The George Washington University Medical Center, Washington, DC.,Infectious Diseases Section, Veterans Affairs Medical Center, Washington, DC.,Division of Infectious Diseases, University of Mississippi Medical Center, Jackson, Mississippi
| | | | | | | | - Amy Weintrob
- Division of Infectious Diseases, The George Washington University Medical Center, Washington, DC.,Infectious Diseases Section, Veterans Affairs Medical Center, Washington, DC
| | - Marc Siegel
- Division of Infectious Diseases, The George Washington University Medical Center, Washington, DC
| | - David M Parenti
- Division of Infectious Diseases, The George Washington University Medical Center, Washington, DC
| | - Leah E Squires
- Infectious Diseases Section, Veterans Affairs Medical Center, Washington, DC.,Department of Psychology, The George Washington University, Washington, DC
| | - Rush Williams
- Infectious Diseases Section, Veterans Affairs Medical Center, Washington, DC.,Columbia Health, Columbia University in the City of New York, New York, New York
| | | | - Debra A Benator
- Division of Infectious Diseases, The George Washington University Medical Center, Washington, DC.,Infectious Diseases Section, Veterans Affairs Medical Center, Washington, DC
| | | |
Collapse
|
10
|
Badal-Faesen S, Firnhaber C, Kendall MA, Wu X, Grinsztejn B, Escada RODS, Fernandez M, Hogg E, Sanne I, Johnson P, Alland D, Mazurek GH, Benator DA, Luetkemeyer AF. Impact of Larger Sputum Volume on Xpert ® MTB/RIF Assay Detection of Mycobacterium tuberculosis in Smear-Negative Individuals with Suspected Tuberculosis. J Clin Med 2017; 6:jcm6080078. [PMID: 28783093 PMCID: PMC5575580 DOI: 10.3390/jcm6080078] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2017] [Revised: 07/20/2017] [Accepted: 07/31/2017] [Indexed: 11/22/2022] Open
Abstract
As a strategy to improve the sensitivity of nucleic acid-based testing in acid-fast bacilli (AFB) negative samples, larger volumes of sputum (5–10 mL) were tested with Xpert® MTB/RIF from 176 individuals with smear-negative sputum undergoing tuberculosis evaluation. Despite larger volumes, this strategy had a suboptimal sensitivity of 50% (4/8).
Collapse
Affiliation(s)
- Sharlaa Badal-Faesen
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg 2092, South Africa.
| | - Cynthia Firnhaber
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg 2092, South Africa.
| | - Michelle A Kendall
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health Boston, Boston, MA 02115, USA.
| | - Xingye Wu
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health Boston, Boston, MA 02115, USA.
| | - Beatriz Grinsztejn
- Instituto Nacional de Infectologia Evandro Chagas-INI-Fiocruz, Rio de Janeiro 21.045-900, Brazil.
| | | | - Michel Fernandez
- Pulmonary and Critical Care Department, Baylor Scott and White Hospital, Temple, TX 76508, USA.
| | - Evelyn Hogg
- Social & Scientific Systems, Inc., Silver Spring, MD 20910, USA.
| | - Ian Sanne
- Clinical HIV Research Unit, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg 2092, South Africa.
| | | | - David Alland
- Division of Infectious Disease, Rutgers-New Jersey Medical School, 185 South Orange Avenue, Newark, NJ 07103, USA.
| | - Gerald H Mazurek
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA.
| | - Debra A Benator
- The Veterans Affairs Medical Center, The George Washington University, Washington, DC 20422, USA.
| | - Anne F Luetkemeyer
- Division of HIV, Infectious Diseases and Global Medicine, Zuckerberg San Francisco General, University of California, San Francisco, CA 94110, USA.
| |
Collapse
|
11
|
Johnson MG, Stout JE, Benator DA, Whitworth WC, Holland DP. Medium matters: modeling the impact of solid medium performance on tuberculosis trial sample size requirements. Int J Tuberc Lung Dis 2017; 20:600-4. [PMID: 27084812 DOI: 10.5588/ijtld.15.0570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Two-month solid medium culture conversion is a commonly used, if suboptimal, endpoint for phase 2 anti-tuberculosis treatment trials. OBJECTIVE AND DESIGN To model the effect of the performance characteristics (sensitivity and contamination rate) of solid medium on required sample size for a two-arm clinical trial with 85% true (gold standard) culture conversion in the control and 95% in the experimental arm. RESULTS Increasing sensitivity and decreasing contamination reduced the sample size from 239 subjects/arm (60% sensitivity, 30% contamination) to 138 subjects/arm (95% sensitivity, 1% contamination). CONCLUSION Optimizing solid medium has significant potential to reduce sample size and increase the efficiency of tuberculosis clinical trials.
Collapse
Affiliation(s)
- M G Johnson
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - J E Stout
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA
| | - D A Benator
- Infectious Diseases Section, Veterans Affairs Medical Center and the George Washington University Medical Center, Washington DC, USA
| | - W C Whitworth
- Clinical Research Branch, Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, USA
| | - D P Holland
- Division of Infectious Diseases and International Health, Duke University Medical Center, Durham, North Carolina, USA; Division of Infectious Diseases, Emory University, Atlanta, Georgia, USA
| |
Collapse
|
12
|
Luetkemeyer AF, Firnhaber C, Kendall MA, Wu X, Mazurek GH, Benator DA, Arduino R, Fernandez M, Guy E, Johnson P, Metchock B, Sattler F, Telzak E, Wang YF, Weiner M, Swindells S, Sanne IM, Havlir DV, Grinsztejn B, Alland D. Evaluation of Xpert MTB/RIF Versus AFB Smear and Culture to Identify Pulmonary Tuberculosis in Patients With Suspected Tuberculosis From Low and Higher Prevalence Settings. Clin Infect Dis 2016; 62:1081-8. [PMID: 26839383 DOI: 10.1093/cid/ciw035] [Citation(s) in RCA: 59] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2015] [Accepted: 11/13/2015] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The Xpert MTB/RIF (Xpert) assay is a rapid nucleic acid amplification test widely used in settings of high tuberculosis prevalence to detect tuberculosis as well asrpoBmutations associated with rifampin resistance. Data are needed on the diagnostic performance of Xpert in lower-prevalence settings to inform appropriate use for both tuberculosis detection and the need for respiratory isolation. METHODS Xpert was compared to 2 sputum samples, each evaluated with acid-fast bacilli (AFB) smear and mycobacterial culture using liquid and solid culture media, from participants with suspected pulmonary tuberculosis from the United States, Brazil, and South Africa. RESULTS Of 992 participants enrolled with evaluable results, 22% had culture-confirmed tuberculosis. In 638 (64%) US participants, 1 Xpert result demonstrated sensitivity of 85.2% (96.7% in participants with AFB smear-positive [AFB(+)] sputum, 59.3% with AFB smear-negative [AFB(-)] sputum), specificity of 99.2%, negative predictive value (NPV) of 97.6%, and positive predictive value of 94.9%. Results did not differ between higher- and low-prevalence settings. A second Xpert assay increased overall sensitivity to 91.1% (100% if AFB(+), 71.4% if AFB(-)), with specificity of 98.9%. In US participants, a single negative Xpert result predicted the absence of AFB(+)/culture-positive tuberculosis with an NPV of 99.7%; NPV of 2 Xpert assays was 100%, suggesting a role in removing patients from airborne infection isolation. Xpert detected tuberculosis DNA and mutations associated with rifampin resistance in 5 of 7 participants with rifampin-resistant, culture-positive tuberculosis. Specificity for rifampin resistance was 99.5% and NPV was 98.9%. CONCLUSIONS In the United States, Xpert testing performed comparably to 2 higher-tuberculosis-prevalence settings. These data support the use of Xpert in the initial evaluation of tuberculosis suspects and in algorithms assessing need for respiratory isolation.
Collapse
Affiliation(s)
- Anne F Luetkemeyer
- Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, University of California
| | - Cynthia Firnhaber
- Clinical HIV Research Unit Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand Right to Care, Johannesburg, South Africa
| | - Michelle A Kendall
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Xingye Wu
- Center for Biostatistics in AIDS Research, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Gerald H Mazurek
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Debra A Benator
- Infectious Diseases Section, Veterans Affairs Medical Center and The George Washington University, Washington D.C
| | - Roberto Arduino
- Department of Internal Medicine, Division of Infectious Diseases, The University of Texas Health Science Center at Houston
| | - Michel Fernandez
- University of North Texas Health Science Center, Tarrant County Health Department, Fort Worth
| | - Elizabeth Guy
- Section of Pulmonary Critical Care and Sleep Medicine, Baylor College of Medicine, Ben Taub General Hospital, Houston, Texas
| | | | - Beverly Metchock
- Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Fred Sattler
- Division of Infectious Diseases, Keck School of Medicine of USC, Los Angeles, California
| | - Edward Telzak
- St. Barnabus Hospital Health System, Albert Einstein College of Medicine, Bronx, New York
| | - Yun F Wang
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, Georgia
| | - Marc Weiner
- Department of Medicine, University of Texas Health Science Center, Veterans Administration Medical Center, San Antonio
| | - Susan Swindells
- Internal Medicine/Infectious Diseases, University of Nebraska Medical Center, Lincoln
| | - Ian M Sanne
- Right to Care, Johannesburg, South Africa Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - Diane V Havlir
- Division of HIV, Infectious Diseases and Global Medicine, San Francisco General Hospital, University of California
| | - Beatriz Grinsztejn
- Infectious Diseases Department, Instituto de Pesquisa Clinica Evandro Chagas Fiocruz, Fundacao Oswaldo Cruz, Rio de Janeiro, Brazil
| | - David Alland
- Division of Infectious Disease, Rutgers New Jersey Medical School, Newark
| | | |
Collapse
|
13
|
Laake AM, Liappis AP, Guy E, Kerr G, Benator DA. Tuberculosis reactivation in hepatocellular carcinoma: association with transarterial chemoembolization. Infect Dis (Lond) 2015; 47:267-70. [PMID: 25688446 DOI: 10.3109/00365548.2014.989540] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Transarterial chemoembolization (TACE) is an important therapeutic option for patients with hepatocellular carcinoma (HCC). We discuss five patients with HCC and tuberculosis (TB) reactivation following TACE. Screening patients for latent TB infection at diagnosis of cirrhosis or HCC should be considered because of the immunosuppression inherent in both the diseases and their treatments.
Collapse
Affiliation(s)
- Ann M Laake
- From the Infectious Diseases Section, Medical Service, Veterans Affairs Medical Center , Washington, DC , USA
| | | | | | | | | |
Collapse
|
14
|
Gale HB, Rodriguez MD, Hoffman HJ, Benator DA, Gordin FM, Labriola AM, Kan VL. Progress realized: trends in HIV-1 viral load and CD4 cell count in a tertiary-care center from 1999 through 2011. PLoS One 2013; 8:e56845. [PMID: 23437255 PMCID: PMC3577700 DOI: 10.1371/journal.pone.0056845] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2012] [Accepted: 01/15/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND HIV-1 RNA and CD4 cell counts are important parameters for HIV care. The objective of this study was to assess the overall trends in HIV-1 viral load and CD4 cell counts within our clinic. METHODS Patients with at least one of each test performed by the Infectious Diseases Laboratory from 1999 through 2011 were included in this analysis. By adapting a novel statistical model, log(10) HIV-1 RNA means were estimated by month, and log(10)-transformed HIV-1 RNA means were estimated by calendar year. Geometric means were calculated for CD4 cell counts by month and calendar year. Log(10) HIV-1 RNA and CD4 cell count monthly means were also examined with polynomial regression. RESULTS There were 1,814 individuals with approximately 25,000 paired tests over the 13-year observation period. Based on each patient's final value of the year, the percentage of patients with viral loads below the lower limit of quantitation rose from 29% in 1999 to 72% in 2011, while the percentage with CD4 counts <200 cells/µL fell from 31% to 11%. On average annually, the mean HIV-1 RNA decreased by 86 copies/mL and the mean CD4 counts increased by 16 cells/µL. For the monthly means, the correlations (R(2)) from second-order polynomial regressions were 0.944 for log(10) HIV-1 RNA and 0.840 for CD4 cell counts. CONCLUSIONS Marked improvements in HIV-1 RNA suppression and CD4 cell counts were achieved in a large inner-city population from 1999 through 2011. This success demonstrates that sustained viral control with improved immunologic status can be a realistic goal for most individuals in clinical care.
Collapse
Affiliation(s)
- Howard B Gale
- Infectious Diseases Section, Medical Service, Veterans Affairs Medical Center, Washington, DC, USA.
| | | | | | | | | | | | | |
Collapse
|
15
|
Gale HB, Gitterman SR, Hoffman HJ, Gordin FM, Benator DA, Labriola AM, Kan VL. Is frequent CD4+ T-lymphocyte count monitoring necessary for persons with counts >=300 cells/μL and HIV-1 suppression? Clin Infect Dis 2013; 56:1340-3. [PMID: 23315315 DOI: 10.1093/cid/cit004] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Among patients infected with human immunodeficiency virus (HIV), those with HIV-1 RNA <200 copies/mL and CD4 counts ≥300 cells/µL had a 97.1% probability of maintaining durable CD4 ≥200 cells/µL for 4 years. When non-HIV causes of CD4 lymphopenia were excluded, the probability rose to 99.2%. Our data support less frequent CD4 monitoring during viral suppression.
Collapse
Affiliation(s)
- Howard B Gale
- Infectious Diseases Section, Medical Service, Veterans Affairs Medical Center, 50 Irving St NW, Washington, DC 20422, USA.
| | | | | | | | | | | | | |
Collapse
|
16
|
Reisen CA, Bianchi FT, Cohen-Blair H, Liappis AP, Poppen PJ, Zea MC, Benator DA, Labriola AM. Present and past influences on current smoking among HIV-positive male veterans. Nicotine Tob Res 2011; 13:638-45. [PMID: 21436293 DOI: 10.1093/ntr/ntr050] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Cigarette smoking has become an important influence of morbidity and mortality for HIV-positive individuals in the era of highly active antiretroviral therapy. Although smoking is common among military personnel and veterans, the lasting impact of military service on smoking at a later stage of life has not been examined. The current study investigated present and past influences on current smoking among HIV-positive male veterans. METHODS Participants were 200 HIV-positive men served by the Veterans Affairs Medical Center. A survey was administered via audio-enhanced computer-assisted self-interview, and additional information was extracted from the computerized patient record system. RESULTS Logistic regression was performed to test hypotheses concerning the participants' current situations as well as characteristics of their past military service. Having smokers in one's environment, being more depressed, and having used alcohol or drugs were associated with having smoked in the previous 30 days, whereas stronger endorsement of attitudes stating adverse effects of smoking was linked to lower likelihood of smoking. Neither having been in a military conflict nor the length of the military service was significantly related to current smoking. CONCLUSIONS Remote experiences in the military did not have a sustained effect on smoking behavior years later. Implications of this study for the development of smoking cessation programs targeting HIV-positive veterans include the importance of altering attitudes about tobacco, treating underlying depression, addressing social influence, decreasing substance use, and increasing awareness of the heightened vulnerability to a variety of negative consequences of smoking among infected individuals.
Collapse
Affiliation(s)
- Carol A Reisen
- Department of Psychology, George Washington University, 2125 G St. NW, Washington, DC 20052, USA.
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Benator DA, Weiner MH, Burman WJ, Vernon AA, Zhao ZA, Khan AE, Jones BE, Sandman L, Engle M, Silva-Trigo C, Hsyu PH, Becker MI, Peloquin CA. Clinical Evaluation of the Nelfinavir-Rifabutin Interaction in Patients with Tuberculosis and Human Immunodeficiency Virus Infection. Pharmacotherapy 2007; 27:793-800. [PMID: 17542762 DOI: 10.1592/phco.27.6.793] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
STUDY OBJECTIVE To characterize the bidirectional interaction between twice-daily nelfinavir and twice-weekly rifabutin and isoniazid in patients with tuberculosis and human immunodeficiency virus (HIV) infection. DESIGN Prospective cohort study. SETTING Three clinical research centers. PATIENTS Seven patients with HIV-related tuberculosis. INTERVENTION Rifabutin 300 mg and isoniazid 15 mg/kg (maximum dose 900 mg) twice/week were administered for at least 2 weeks during the continuation phase of tuberculosis treatment. Antiretroviral therapy with nelfinavir 1250 mg twice/day and two nucleoside reverse transcriptase inhibitors was then added. MEASUREMENTS AND MAIN RESULTS Patients underwent blood sampling for pharmacokinetic analysis during the continuation phase of tuberculosis therapy and after a median of 21 days after the addition of antiretroviral treatment. When rifabutin was coadministered with nelfinavir, its area under the concentration-time curve from 0-21 hours (AUC(0-21)) increased 22% (geometric mean 5.01 microg.hr/ml [90% confidence interval (CI) 3.25-7.71] with nelfinavir vs 4.10 microg.hr/ml [90% CI 3.18-5.27] without nelfinavir; geometric mean ratio 1.22 [90% CI 0.78-1.92]). Also, the AUC(0-21) for the active metabolite, desacetylrifabutin, increased significantly (geometric mean ratio 3.46, 90% CI 1.84-6.47, p=0.009). In the presence of rifabutin, the pharmacokinetic parameters of nelfinavir and its principal metabolite M8 were similar to those of patients not taking rifabutin. No drug interaction between nelfinavir and isoniazid was detected. CONCLUSIONS Coadministration of rifabutin and isoniazid without dosage adjustment during twice-weekly tuberculosis therapy with nelfinavir-based antiretroviral therapy resulted in rifabutin exposures within the acceptable ranges for safety and efficacy. Therefore, this combination is an appropriate option for the simultaneous treatment of tuberculosis and HIV infection when tuberculosis therapy is given twice weekly.
Collapse
Affiliation(s)
- Debra A Benator
- Division of Infectious Diseases, Veterans Affairs Medical Center, Washington, D.C. 20422, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
18
|
Mullick CJ, Liappis AP, Benator DA, Roberts AD, Parenti DM, Simon GL. Syphilitic hepatitis in HIV-infected patients: a report of 7 cases and review of the literature. Clin Infect Dis 2004; 39:e100-5. [PMID: 15546070 DOI: 10.1086/425501] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2004] [Accepted: 07/14/2004] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND A recent resurgence of primary and secondary syphilis has been observed in certain population groups, particularly among persons infected with human immunodeficiency virus (HIV). Liver involvement is an infrequently recognized complication of early syphilis, with no previous reports among HIV-infected patients. METHODS We describe 7 cases of syphilitic hepatitis in HIV-positive individuals and review the literature. RESULTS At our institutions, all patients presented with a rash consistent with secondary syphilis. Each case was characterized by a conspicuous increase in serum alkaline phosphatase level (mean level +/- standard deviation, 905 +/- 523.6 IU/L) and milder elevations in serum transaminase levels. The mean CD4+ absolute T cell count was 317 cells/mm3, and the median rapid plasma reagin (RPR) titer was 1 : 128. There was a significant correlation between higher CD4+ cell counts and the RPR titers (R=0.93; P=.002). Symptomatic resolution and biochemical improvement, particularly a significant decrease in serum alkaline phosphatase levels (P=.02), occurred following antibiotic therapy. CONCLUSIONS Hepatic dysfunction is not uncommon in HIV-infected persons and is attributable to multiple causes. In the appropriate clinical setting, syphilitic hepatitis is an easily diagnosed and reversible etiology of liver dysfunction. The recognition of this entity will prevent unnecessary evaluation of abnormal liver enzyme levels in HIV-positive patients.
Collapse
Affiliation(s)
- C J Mullick
- Division of Infectious Diseases, Department of Medicine, George Washington University Medical Center, Washington, DC 20037, USA
| | | | | | | | | | | |
Collapse
|
19
|
Kumari P, Schechter GP, Saini N, Benator DA. Successful treatment of human immunodeficiency virus-related Castleman's disease with interferon-alpha. Clin Infect Dis 2000; 31:602-4. [PMID: 10987728 DOI: 10.1086/313979] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Multicentric Castleman's disease is an atypical lymphoproliferative disorder for which multiple chemotherapeutic regimens have been used without much success. Role of biological response modifiers like interferon used as a single agent is discussed in this case report.
Collapse
Affiliation(s)
- P Kumari
- Divisions of Infectious Diseases, Veterans Affairs Medical Center, and George Washington University Medical Center, Washington, DC 20422, USA.
| | | | | | | |
Collapse
|
20
|
Abstract
The nontuberculous mycobacteria are responsible for considerable morbidity in the immunocompromised and immunocompetent host, especially in the older patient with chronic fibrotic or cavitary disease of the lung. Mycobacterium szulgai is a slow growing mycobacterium infrequent in nature and man. Except from a snail and a tropical fish, it has been isolated only from humans and nearly always represents a true pathogen. Three-drug therapy using in vitro susceptibilities as a guide for 12 to 18 months increases the likelihood of success. We present a patient who developed M szulgai pulmonary infection 30 years after an episode of pulmonary tuberculosis. After successful therapy for his M szulgai infection, this patient developed chronic pulmonary histoplasmosis. We review the 25 years of clinical experience with this mycobacteria; particular emphasis is on the presentation and treatment of this very unusual infection.
Collapse
Affiliation(s)
- D A Benator
- Division of Infectious Diseases, Washington, DC Veterans Administration Medical Center, Washington DC 20422, USA
| | | | | |
Collapse
|
21
|
Abstract
The acquired immunodeficiency syndrome (AIDS) pandemic has led to greater understanding and respect for the pathogenic potential of non-tuberculous mycobacteria. Mycobacterium avium complex (MAC) has emerged as the most common systemic bacterial infection in AIDS, causing debilitating disseminated disease in late-stage HIV-infected patients. With the release of the macrolide antibiotics, clarithromycin and azithromycin, effective and well-tolerated therapeutic regimens for MAC have been developed which prolong survival and increase quality of life. The macrolides and rifabutin are also effective as preventive therapy for MAC in patients with AIDS. Mycobacterium kansasii, which causes pulmonary disease similar to tuberculosis as well as disseminated disease in AIDS, is treatable with isoniazid, rifampin and ethambutol. Clinical syndromes and therapeutic options for other non-tuberculous mycobacteria in AIDS are also reviewed.
Collapse
Affiliation(s)
- A L French
- Department of Medicine, Rush Medical College, Chicago, Illinois, USA
| | | | | |
Collapse
|
22
|
Benator DA, Gordin FM. Nontuberculous mycobacteria in patients with human immunodeficiency virus infection. Semin Respir Infect 1996; 11:285-300. [PMID: 8976582] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Because of their often profound immune suppression, persons with HIV-infection are, increasingly, being identified as having morbidity related to mycobacteria. Indeed, mycobacterial disease is now the second most frequent cause of illness in AIDS patients receiving PCP prophylaxis with the majority of these patients in the United States having disease caused by M. avium complex (MAC). This section reviews the epidemiology, clinical presentation, treatment protocols, and prophylaxis strategies for MAC, as well as the other species of nontuberculosis mycobacteria being diagnosed in the setting of HIV infection. These organisms typically cause extrapulmonary, often disseminated disease in HIV infected persons, although pulmonary disease may occur. The prompt diagnosis and successful treatment of these infections can prolong the life and enhance its quality for affected patients with HIV coinfections.
Collapse
Affiliation(s)
- D A Benator
- Division of Infectious Diseases, Veterans Affairs Medical Center, Washington, DC 20422, USA
| | | |
Collapse
|
23
|
French AL, Beaudet LM, Benator DA, Levy CS, Kass M, Orenstein JM. Cholecystectomy in patients with AIDS: clinicopathologic correlations in 107 cases. Clin Infect Dis 1995; 21:852-8. [PMID: 8645829 DOI: 10.1093/clinids/21.4.852] [Citation(s) in RCA: 79] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
Abstract
The etiologic and clinical features of cholecystisis in infection due to human immunodeficiency virus (HIV) were studies retrospectively. The charts and histopathologic specimens of 136 HIV-infected patients who underwent cholecystectomy between February 1987 and May 1993 at a large tertiary care center were reviewed. Opportunistic pathogens infecting the 107 patients with AIDS included microsporidia (eight cases-- Enterocytozoon bieneusi in six and Septata intestinalis in two); cytomegalovirus alone (six cases); Cryptosporidium alone (eight cases); cytomegalovirus plus Cryptosporidum (15 cases); and Pneumocystis carinii and Isospora belli (one case each). In addition, histopathologic changes characteristic of Kaposi's sarcoma were seen in one case. Thirty-eight patients with AIDS had acalculous cholecystitis for which no etiologic agent was found. Twenty-eight AIDS patients had cholelithiasis, six with coexistent opportunistic gallbladder infection. In the 107 AIDS patients, no specific symptom was found to be predictive of opportunistic infection of the gallbladder, but such infection was significantly associated with an abnormal abdominal ultrasound (P = .017) and with nonvisualization of the gallbladder by radionucleotide biliary scan (P < .001).
Collapse
Affiliation(s)
- A L French
- Division of Infectious Diseases, Washington Hospital Center, D.C., USA
| | | | | | | | | | | |
Collapse
|
24
|
Guccion JG, Benator DA, Gibert CL, Dave HP. Disseminated toxoplasmosis and acquired immunodeficiency syndrome: diagnosis by transmission electron microscopy. Ultrastruct Pathol 1995; 19:95-9. [PMID: 7792954 DOI: 10.3109/01913129509014608] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
A 43-year-old, bisexual, black man with acquired immunodeficiency syndrome (AIDS), detected by CD4 lymphocyte criteria alone, presented with low-grade fever, chills, malaise, and watery diarrhea of 2 days' duration. Over the next 5 days, he developed a fulminant septicemia-like illness with progressive hypotension, disseminated intravascular coagulation, and very high serum lactic acid dehydrogenase (2,150 U/L) and serum creatine phosphokinase (5,395 U/L) levels, and died. The cause of this illness was not clinically apparent. A bone marrow biopsy performed on the day of his death revealed intracytoplasmic clusters of 3 microns long, oval, basophilic organisms, the exact nature of which was not evident by light microscopy. The diagnosis of disseminated toxoplasmosis (DT) was made only after electron microscopic study of the bone marrow revealed organisms with features typical of Toxoplasma gondii tachyzoites. These features included a multilayered pellicle, a pointed anterior end containing a conoid, up to nine rhoptries, sparse micronemes, and a posterior end containing a nucleus. Some of the organisms had divided by internal budding or endodyogeny. This case illustrates the value of transmission electron microscopy in making the diagnosis of DT.
Collapse
Affiliation(s)
- J G Guccion
- Pathology and Laboratory Medicine Service, Department of Veterans Affairs Medical Center, Washington, DC 20422, USA
| | | | | | | |
Collapse
|
25
|
Guccion JG, Benator DA, Zeller J, Termanini B, Saini N. Intestinal spirochetosis and acquired immunodeficiency syndrome: ultrastructural studies of two cases. Ultrastruct Pathol 1995; 19:15-22. [PMID: 7770958 DOI: 10.3109/01913129509014599] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Two cases of intestinal spirochetosis (IS) with acquired immunodeficiency syndrome are reported. In case 1, a 48-year-old homosexual black man presented with a 1-month history of alternating watery diarrhea and constipation, which dissipated following the removal of two colonic hyperplastic polyps containing IS. In case 2, a 26-year-old homosexual black man presented with a 3-month history of persistent bloody diarrhea and was found to have chronic shigellosis and IS. Pathologic findings of IS were similar in both cases. Basophilic fringes typical of IS covered the surfacing colonic epithelium and consisted of dense growths of spirochetes adherent to and oriented perpendicular to the plasma membranes of the surfacing epithelium. The spirochetes measured 3 to 5 microns in length and 0.2 micron in width, contained four to eight axial fibrils, and closely resembled Brachyspira aalborgi ultrastructurally. These cases are notable because the histopathologic changes of IS were more extensive than generally described. There was involvement of both the right colon and rectum by IS in case 2, and in both cases there was extension of the IS down into the crypts of Lieberkühn, spirochetal invasion of the colonic mucosa, and a conspicuous inflammatory response by macrophages in the underlying lamina propria.
Collapse
Affiliation(s)
- J G Guccion
- Pathology and Laboratory Medicine Service (113), Department of Veterans Affairs Medical Center, Washington, DC 20422, USA
| | | | | | | | | |
Collapse
|
26
|
Affiliation(s)
- D A Benator
- Section of Infectious Diseases, Washington Hospital Center, Washington, DC 20010
| | | | | | | | | |
Collapse
|