Professionnels en établissements de santé infectés par le SARS-CoV-2 : le bilan après deux ans de pandémie

Introduction

Les professionnels travaillant en établissements de santé (PES) sont exposés au risque d'infection par le SARS-CoV-2. Une enquête a été mise en place afin d'objectiver l'impact de la pandémie dans cette population spécifique.

Matériels et méthodes

Un web questionnaire a été proposé mi-avril 2020 à tous les établissements de santé (ES) publics ou privés. Les ES volontaires saisissent de manière hebdomadaire le nombre de nouveaux cas de PES infectés et les décès attribuables. La région, la catégorie professionnelle, le service sont également recueillis. Les proportions de PES infectés ont été estimées en rapportant le nombre de cas aux données de la Statistique annuelle des établissements de santé 2019.

Résultats

1 450 des 3 636 ES ont participé au moins une fois à l'enquête, à savoir 74,7% des PES salariés en France. Au cours de la 5^ème vague, 337 ES ont participé à l'enquête soit 20,7 % des PES salariés en France. Du 1^er Mars 2020 au 15 Février 2022, 118 340 PES, correspondant à 12,1 % des PES exerçant dans les ES participants ont été infectés par le SARS-CoV2, avec 19 décès attribuables. La répartition hebdomadaire du nombre de cas montre 5 pics de contamination enregistrés durant les 5 vagues épidémiques successives, le 5^e pic étant le plus important.

Parmi ces PES, 62,8 % des cas étaient des soignants dont 22 % d'infirmiers et 18 % d'aides-soignants. Rapportés aux effectifs globaux par catégorie professionnelle dans ces ES, les aides-soignants et les kinésithérapeutes étaient les professions les plus infectées (respectivement 12,8 et 12,2 pour 100 professionnels travaillant dans les ES participants). Les PES contaminés travaillaient principalement dans des services de MCO (42,3 %) ou médicotechniques (25,4 %). Des disparités régionales dans la proportion de PES infectés étaient observées au cours des différentes vagues. Lors de la 5^ème vague, la Guadeloupe et l'Occitanie sont les régions où les PES sont les plus touchés par la COVID-19.

Conclusion

Cette enquête montre les mêmes tendances temporelles et géographiques qu'en population générale. L'augmentation du nombre de cas chez les PES lors de la 5^ème vague est en lien avec la diffusion rapide du variant Omicron. La participation des ES a varié au cours du temps. Malgré un protocole d'enquête reposant sur la déclaration volontaire, plus de 130 ES (20 % des PES salariés) participent régulièrement à l'enquête et permettent de considérer que ces résultats donnent une bonne estimation de la dynamique de contamination des PES. Bien que l'objectif de cette étude n'était pas de déterminer les circonstances de contamination, il semble que les professions ayant des contacts fréquents et prolongés avec les patients (aides-soignants, kinésithérapeutes) sont proportionnellement les plus touchées.

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[HIV prevention with PrEP: Challenges and prospects]

Pre-exposure prophlaxis (PrEP) is the use of antiretroviral drugs by uninfected people to prevent human immunodeficiency virus (HIV) infection. PrEP is used by people who are at substantial risk of being exposed to HIV. Numerous clinical trials have confirmed its effectiveness in reducing HIV acquisition and PrEP has been approved and allowed in several countries including France. However, PrEP uptake remains low as concerns about increase in sexual risk behaviour with PrEP use in the wake of a growing epidemic of sexually transmitted infections, and fear of drug resistance have been expressed. As a result, the difference between the proportion of people on PrEP and the proportion of people who would be very likely to use PrEP if they could access it -otherwise known as the PrEP gap- remains high. Nowadays, studies continue to explore long-term effects of PrEP as well as expand the array of available technologies and regimens.

Contexte de contamination des professionnels de santé par la COVID-19 : résultats préliminaires

Introduction

Afin de documenter les circonstances des contaminations par le SARS-CoV-2, une enquête nationale a été conduite auprès des professionnels de santé.

Matériels et méthodes

Un questionnaire a été mis en ligne le 17 avril 2020. Pouvait être inclus tout professionnel de santé (IDE, aide-soignant, médecin, kiné, technicien de laboratoire, pharmacien, manipulateur radio, brancardier, psychologue, diététicien, dentiste…) pour lequel un diagnostic de COVID-19 a été posé, quel que soit son mode d’exercice (établissement de santé, libéral, établissement médicosocial…).

Les données collectées portaient sur l’activité, le type de tâches réalisées, le port de protections et l’existence d’éventuels contacts avec des cas (professionnels, extra-professionnels), dans les 2 semaines précédant la date de début des symptômes.

Résultats

Entre le 17 avril et le 9 juin 2020, 2129 questionnaires ont été renseignés. Les infirmiers (678), les médecins (477), et les aides-soignants (296) étaient les catégories les plus représentées. Ils exerçaient en établissements de santé (ES) pour 1446 d’entre eux et 403 en ville ; les autres répondeurs exerçaient dans le secteur médicosocial. La répartition géographique des déclarants se rapprochait des résultats du recensement national des cas de contamination limité au personnel soignant en ES. Dans les deux semaines précédant leurs symptômes, 287/2129 (13,5 %) des déclarants avaient exercé dans le cadre d’un intérim ou d’un renfort en établissement de santé. Lors des entretiens avec les patients (en face à face, à moins d’un mètre), 416/1446 (29 %) des soignants en ES, et 217/403 (53 %), en ville, ne portaient jamais de masque. En ville, 169/403 (42 %) des soignants contaminés réalisaient des visites à domicile. Parmi les 870/1146 (76 %) soignants qui ont déclaré avoir participé à des réunions de travail, 558/870 (64 %) ne portaient jamais de masque ou en portaient parfois à cette occasion. En salle de repos, lors des pauses, 1235/1446 (85 %) soignants ne portaient pas de masque ou le portaient occasionnellement. Six cent trois (28 %) répondeurs ont déclaré avoir été en contact, sans masque, avec un collègue ayant une infection confirmée à COVID-19, pendant ses symptômes ou durant les précédentes 72 h. En dehors de leur activité professionnelle, 278/2129 (13 %) professionnels contaminés ont été en contact avec au moins un cas suspecté ou confirmé d’infection à COVID-19.

Conclusion

Cette enquête reposait sur la participation volontaire des soignants ayant eu une COVID-19. Les résultats préliminaires montrent un défaut d’utilisation des mesures de protection parmi les tâches réalisées, notamment pour les professionnels de ville, quelle qu’en soit la raison. La reconnaissance d’un contact extra-professionnel paraît faible. En revanche, le rôle de la contamination entre soignants sur leur lieu d’exercice paraît être un déterminant important de la contamination des soignants.

[Cerebral infarction and tuberculosis: case report and literature review]

INTRODUCTION

Although tuberculous meningitis is an uncommon presentation of tuberculosis, it still remains one of the deadliest forms of this disease. In this context, the occurrence of a cerebral infarct is an aggravating factor.

OBSERVATION

A 48-year-old Asian man presented himself in the emergency room for dysarthria and dysphagia of progressive onset. Cerebral CT showed a recent ischemic defect of the right internal capsule. Lumbar puncture showed meningitis with low sugar levels. Pulmonary micronodules on the thoracic CT suggested tuberculosis, which was confirmed by a broncho-alveolar lavage. Anti-tuberculosis treatment and early corticosteroid resulted in an improvement of the patient's state.

CONCLUSION

Cerebral infarctions in patients with tuberculous meningitis are events that cannot be underestimated in terms of frequency or severity. Their poor prognosis is partly the result of insufficiently defined management, which combines anti-tuberculosis treatment and early corticosteroid therapy.

[Nasopharyngeal carriage of SARS-CoV-2 among health personnel with symptoms suggestive of COVID-19 in a University Hospital in the Paris suburbs]

Introduction

Une consultation dédiée aux professionnels de santé symptomatiques a été ouverte au début de l'épidémie de COVID-19, afin de répondre aux besoins spécifiques de cette population. L'objectif de ce travail était d'estimer la fréquence du portage nasopharyngé du SARS-Cov-2 chez les personnels de santé symptomatiques suspects de COVID-19, et de déterminer les facteurs associés à ce portage.

Méthodes

Étude descriptive des caractéristiques cliniques et épidémiologiques des consultants, conduite du 5 mars au 17 avril 2020. Le recueil des données cliniques et des résultats du test RT-PCR a été conduit à l'aide de formulaires standardisés.

Résultats

Des 522 consultants, 308 exerçaient à l'Hôpital et 214 à l'extérieur. Ils avaient des formes bénignes de COVID-19 et des signes cliniques non spécifiques à l'exception de l'agueusie/anosmie, significativement plus fréquente chez ceux avec RT-PCR positive. Le taux de positivité de la RT-PCR était globalement de 38 %, sans différence significative selon la profession, supérieur chez les consultants extérieurs (47 % versus 31 %). À l'hôpital, ce taux était significativement moindre pour les personnels symptomatiques des secteurs de soins, comparé aux personnels des plateaux techniques et laboratoires (24 %, versus 45 %, p = 0,006 et 54 %, p < 0,001, respectivement), mais ne différait pas entre personnels des unités COVID et des autres secteurs de soins (30 % versus 28 %). Parmi les consultants extérieurs, les taux de positivité des personnels des EHPAD et des libéraux (53 % et 55 % respectivement) étaient plus du double de celui du personnel soignant hospitalier (24 %, p < 0,001).

Conclusions

Ces données confirment l'impact fort du COVID-19 sur les professionnels de santé. Les taux de positivité plus élevés chez les professionnels symptomatiques exerçant en dehors de l'hôpital, comparativement à ceux exerçant à l'hôpital, pourraient s'expliquer en partie par une pénurie en équipements de protection et par des difficultés d'accès au diagnostic virologique, qui étaient plus importants en dehors de l'hôpital quand l'épidémie a commencé.

[Splenic abscesses: From diagnosis to therapy]

Splenic abscess is septic collection which occurs after haematogenous spread or local dissemination. Splenic abscess is an uncommon and rare condition, more frequently affecting male and immunocompromised patients. There are no guidelines regarding its diagnosis and management. Computed tomography (CT) scan is highly sensitive and specific (95% and 92%, respectively) in the diagnosis of splenic abscess. Diagnosis is based on blood cultures which are positive in 24 to 80% of cases. Bacterial growth culture of abscess after drainage is more efficient (50-80%) and can be performed after surgery or percutaneous drainage under imaging, including CT scan. Microorganisms involved are frequently enterobacteriaceae, gram-positive cocci and anaerobes. This particular ecology leads to an empiric broad-spectrum antibiotic therapy, with a variable duration, from 10days to more than one month. Management remains very close to the one applied in case of liver abscesses. The role of splenectomy in the prevention of recurrence remains controversial. We reviewed the literature regarding splenic abscesses, from diagnosis to therapy.

HSV-2 meningoencephalitis in an immunocompetent young man: what is the pathogenesis and what is the treatment?

Herpes simplex encephalitis is rarely caused by herpes simplex virus type 2 (HSV-2) after the neonatal period. The pathogenesis of HSV-2 encephalitis is not known and its treatment has not been discussed. We report a case of mild meningoencephalitis secondary to HSV-2 primary infection after sexual risk behaviour in a healthy young man. The diagnosis was established upon clinical, biological and electroencephalographic criteria. Aciclovir treatment led to rapid clinical improvement. This case highlights HSV-2 as a rare cause of meningoencephalitis, and questions the management of this rare manifestation of HSV-2 infection.

Management of accidental exposure to HIV: the COREVIH 2011 activity report

BACKGROUND

Post-exposure prophylaxis (PEP) relies on procedures allowing quick access to treatment in case of accidental exposure to viral risk (AEV). Occupational blood exposure (OBE) affects mainly caregivers; these accidents are monitored and assessed by the inter-regional center for nosocomial infections (C-CLIN), occupational physicians, and infection control units. They are classified apart from sexual exposure for which there is currently no monitoring.

METHODS

Data was extracted from the COREVIH (steering committee for the prevention of HIV infection) 2011 activity reports (AR), available online. Data collection was performed using a standardized grid.

RESULTS

Twenty-four out of 28 AR were available online. Nine thousand nine hundred and twenty AEV were reported, 44% of OBE, and 56% of sexual and other exposures. PEP was prescribed in 8% of OBE and in 77% of sexual exposures. The type of PEP was documented in 52% of the cases. Follow-up was poorly documented.

CONCLUSION

AR provide an incomplete and heterogeneous review of exposure management without any standardized data collection. The difficulties encountered in data collection and monitoring are due to differences in care centers (complex patient circuits, multiple actors) and lack of common dedicated software. Sexual exposures account for 50% of AEV and most are treated; but they are incompletely reported and consequently not analyzed at the regional or national level. A typical AR collection grid is being studied in 2 COREVIH, with the objective to improve collection and obtain useful national data.

[Tubular renal acidosis]

Renal tubular acidosis (RTAs) are a group of metabolic disorders characterized by metabolic acidosis with normal plasma anion gap. There are three main forms of RTA: a proximal RTA called type II and a distal RTA (type I and IV). The RTA type II is a consequence of the inability of the proximal tubule to reabsorb bicarbonate. The distal RTA is associated with the inability to excrete the daily acid load and may be associated with hyperkalaemia (type IV) or hypokalemia (type I). The most common etiology of RTA type IV is the hypoaldosteronism. The RTAs can be complicated by nephrocalcinosis and obstructive nephrolithiasis. Alkalinization is the cornerstone of treatment.

Survival after neuroAIDS: association with antiretroviral CNS Penetration-Effectiveness score

OBJECTIVE

We examined if the CNS Penetration-Effectiveness (CPE) score of antiretroviral drugs was associated with survival after a diagnosis of HIV-related encephalopathy, progressive multifocal leukoencephalopathy (PML), cerebral toxoplasmosis, or cryptococcal meningitis.

METHODS

Using data from the FHDH-ANRS CO4, we compared the survival of 9,932 HIV-infected patients diagnosed with a first neurologic AIDS-defining event in the pre-combination antiretroviral therapy (cART) (1992-1995), early cART (1996-1998), or late cART (1999-2004) periods. Follow-up was subdivided (CPE < 1.5 and CPE ≥ 1.5), and relative rates (RR) of death were estimated using multivariable Poisson regression models.

RESULTS

In the pre-cART and early cART periods, regimens with CPE ≥ 1.5 were associated with lower mortality after HIV-related encephalopathy (RR 0.64; 95% confidence interval [CI] 0.47-0.86 and RR 0.45; 95% CI 0.35-0.58) and after PML (RR 0.79; 95% CI 0.55-1.12 and RR 0.45; 95% CI 0.31-0.65), compared to regimens with CPE < 1.5, while in the late cART period there was no association between the CPE score and the mortality. A higher CPE score was also associated with a lower mortality in all periods after cerebral toxoplasmosis (RR 0.68, 95% CI 0.56-0.84) or cryptococcal meningitis (RR 0.50, 95% CI 0.34-0.74). Whatever the neurologic event, these associations were not maintained after adjustment on updated plasma HIV-RNA (missing, <500, ≥500 copies/mL) with RR ranging from 0.82 (95% CI 0.36-1.91) to 1.02 (0.69-1.52).

CONCLUSION

At the beginning of the cART era, the CPE score was of importance for survival after severe neurologic event, while in the late cART period, the additional effect of CPE score vanished with more powerful antiretroviral regimens associated with plasma viral load control.

[Cushing's syndrome induced by combined treatment with inhaled fluticasone and oral ritonavir]

INTRODUCTION

Fluticasone is a corticosteroid drug which is used in inhaled and nasal formulations for the treatment of asthma and allergic rhinitis. It is metabolized in the liver by the cytochrome P450. Ritonavir, an inhibitor of the HIV protease, also acts as an inhibitor of several isoenzymes of the P450 cytochrome. This property explains the many drug interactions observed with this agent.

CASE REPORT

We report two cases of Cushing's syndrome with adrenal insufficiency associated with the combined administration of oral low dose ritonavir and moderate to high dose inhaled fluticasone.

CONCLUSION

These observations highlight the fact that the combined administration of fluticasone and ritonavir must be avoided as well as the combined administration of fluticasone and other inhibitors of the cytochrome P450.

[Evaluation of amoxicillin-clavulanic acid prescriptions in a teaching hospital of Parisian suburb]

OBJECTIVE

Prospective study of amoxicillin-clavulanic acid (amox-clav) prescriptions in the medical departments of a teaching hospital that prescribes this antibiotic very often.

DESIGN

From April to May 2004, each patient treated by amox-clav was included. Data were collected (age, sex, past diseases, associated-diseases, reason for hospitalization, prior antibiotic therapy, date of amox-clav prescription, indication for amox-clav prescription, other associated antibiotics, nosocomial or community-acquired infection, site of infection, bacteriologic samples and bacterial identification, treatment duration and status of the physician). Data were analysed by a muldisciplinary group and compared with a referential used for antibiotic prescriptions in our hospital.

RESULTS

One hundred and two medical files were analysed. Seventy-one percent of amox-clav prescriptions were in adequation with the referential. Combination of three criteria (indication of antibiotic therapy, choice of amox-clav and of an antibiotic combination) showed that 58 (57%) was acceptable, 29 (28%) was debatable and 15 (15%) was unacceptable. Unacceptable prescriptions were often made by a junior. The majority of inadequate antibiotic prescriptions referred to acute pulmonary infections. Antibiotic combinations were often inadequate and treatment duration was too long. The quality of the prescription was more accurate when made by a senior.

CONCLUSION

An effort should be made in our teaching hospital to optimize antibiotic prescriptions.

Tuberculosis treatment duration in France: From guidelines to daily practice

BACKGROUND

Guidelines for tuberculosis (TB) recommend 6 months of treatment except for meningeal TB, where a 9- to 12-month course may be preferred.

METHODS

In order to assess whether practices in France are in agreement with those guidelines, we performed an anonymous audit of the policy of French physicians, focusing on TB treatment duration and corticosteroid use according to the TB presentation.

RESULTS

Sixty-six completed forms were analyzed. Reported treatment duration was usually 6 months for pulmonary TB (91% of physicians) and miliary TB (45%), 9 months for pulmonary TB in HIV-infected patients (42%) and for TB lymphadenitis (57%), and 12 months for TB meningitis (79%) and osteo-articular TB (65%). Corticosteroid use was systematic for meningitis (80%) and pericarditis (65%).

CONCLUSION

This study reveals discrepancies between guidelines and daily practice for TB treatment duration in France: We observed a very high reported rate of unnecessary, prolonged treatment for most extrapulmonary TB.

[Use of nitrates in hospitalised elderly patients aged 65 and over]

BACKGROUND

Nitrates are frequently prescribed drugs, although their indications are limited. We studied nitrates' prescription in elderly patients hospitalised in the internal medicine ward of a French teaching hospital.

METHODS

Hospitalised patients aged 65 years and more and receiving nitrates in their usual treatment were identified prospectively. A standardised questionnaire was used during a structured medical interview conducted by the same physician for all patients. Informations regarding nitrates' prescription were studied according to the actual recommendations for their use: angina in patients with contraindication to betablockers, acute myocardial infarction and acute pulmonary oedema.

RESULTS

Among 256 hospitalised elderly patients, 49 (19% [IC95%: 15-25]) were under nitrates therapy, because of either angina pectoris, heart failure or unknown reason. Cardiologists prescribed nitrates in accordance with guidelines significantly more frequently than non-cardiologists. Transdermal treatment was used in 69% of patients.

DISCUSSION

In hospitalised patients aged 65 years and more who are prescribed nitrates in their usual treatment, at least one quarter have no recommended indication for its use. As almost one fifth of patients are receiving nitrates in their usual treatment, the medicoeconomic impact of these useless prescriptions could be significant. Nitrates prescribing can be optimized by following guidelines for their use, and restraining from prescribing the transdermal treatment which is more costly and without evidence-based clinical benefit compared to the oral route.

Medical and social differences between French and migrant patients consulting for the first time for HIV infection

The objectives of the study were to describe the medical and social characteristics of patients consulting for the first time after diagnosis of HIV-infection and to compare the medical and social characteristics between French and migrant patients. From 1 January 2001 to 31 December 2002, all consecutive adults consulting for the first time for HIV infection in two HIV outpatient clinics located in the western suburb of Paris, agreed to an interview based on an administered questionnaire regarding their medical and socioeconomic characteristics. Of the 203 patients (98 women, 105 men), one-third (n=70) was of French nationality. Delay (+/-SD) in access to HIV outpatient clinic after diagnosis was shorter in migrant than in French patients, respectively 7.6+/-29.6 months (median=0.5, range=0 to 196.6) and 23.8+/-51.4 months (median=0.9, range=0 to 199.7); p=0.005. There was no significant difference in the medical characteristics between the two groups of patients on their first consultation. However, most of the migrants were living in very poor socio-economic conditions with minimal resources thus sometimes delaying initiation of HAART. The development of social facilities for HIV-positive migrants should be a public health priority.

Impact of Newly Available Drugs on Clinical Progression in Patients with Virological Failure after Exposure to Three Classes of Antiretrovirals

Objective

To study the prognosis of HIV-infected patients with virological failure after exposure to three classes of antiretroviral drugs (ARVs).

Design

Cohort study. Setting: French Hospital Database on HIV.

Patients

Patients previously exposed to at least two nucleoside reverse transcriptase inhibitors (NRTIs), two protease inhibitors and one non-NRTI, with viral load (VL) values of >5000 copies/ml after the exposure criteria were met and a new treatment initiated between 1998 and 2001 with VL >5000 copies/ml.

Main outcome measures

Risk of new AIDS-defining-events (ADEs) or death from first introduction of a drug never used before occurring between 1998 and 2001 defined as baseline.

Results

The main baseline characteristics of the 1092 patients were: previous ADE in 49% of cases, median CD4 cell count 181 μl, median VL 4.9 log10 copies/ml, median duration of ARV therapy 5.0 years and previous exposure to a median of nine ARVs. The crude progression rates were 20.1/100 patient-years among patients included in 1998, 15.1 in 1999, 11.1 in 2000 and 8.6 in 2001. After adjustment for baseline characteristics, the calendar year of inclusion was associated with the risk of clinical progression ( P<0.001). When the types of newly available drugs used at baseline or during follow-up were introduced into the model, year of inclusion was no longer associated with the risk of clinical progression ( P=0.42), while exposure to amprenavir/r, lopinavir/r, abacavir or tenofovir was associated with a lower risk.

Conclusions

The clinical prognosis of heavily pretreated patients experiencing virological failure improved between 1998 and 2001, mainly thanks to the use of newly available drugs with more favourable resistance profiles.

Clinical significance of tolerant strains of streptococci in adults with infective endocarditis

OBJECTIVES

To compare the characteristics of patients with endocarditis due to tolerant and non-tolerant Streptococcus strains.

PATIENTS AND METHODS

A retrospective nine-year study was conducted in a single tertiary-care hospital. The study included 24 cases of streptococcal endocarditis with known beta-lactam minimal inhibitory and bactericidal concentrations.

RESULTS

Ten of the 24 patients concerned were infected with tolerant streptococcal strains, and 14 with non-tolerant strains. Bacterial tolerance was not associated with higher mortality or increased frequency of surgery. Fewer patients infected with tolerant than non-tolerant strains had serum bactericidal titers reaching success-predictive levels, and more of these experienced failure of initial antibiotic treatment and needed longer treatment.

CONCLUSIONS

The results of this study strongly suggest that penicillin tolerance of the streptococci responsible for endocarditis has a clinical impact. Consequently, pending a larger prospective study addressing the problem of tolerance, it is clinically relevant to determine the minimal inhibitory and bactericidal penicillin concentrations for all streptococcal isolates causing endocarditis.

[Sulfasalazine neurotoxicity]

We report a case of seizures with acute encephalopathy in a female patient under sulfasalazine treatment for polyarthritis. Neurotoxicity secondary to sulfasalazine was suspected. This side effect has seldom been reported in the literature.

Long-term efficacy on Kaposi's sarcoma of highly active antiretroviral therapy in a cohort of HIV-positive patients. CISIH 92. Centre d'information et de soins de l'immunodéficience humaine

OBJECTIVE

To assess the efficacy of highly active antiretroviral treatment (HAART) on AIDS-Kaposi's sarcoma (KS).

DESIGN

Prospective cohort of patients followed for 24 months.

SETTING

Four referral hospitals of the West Paris metropolitan area.

PATIENTS/INTERVENTION

Thirty-nine AIDS-KS patients, 42 +/- 9 years old, who began HAART (HIV-protease inhibitor and two nucleoside analogues) between March and December 1996, were enrolled. One was lost to follow-up at month 12.

MAIN OUTCOME MEASURES

KS response, using criteria of the AIDS clinical trials group (ACTG), CD4 cell counts, and plasma HIV-RNA, assessed every 6 months. ACTG TIS staging of KS.

RESULTS

Eighteen patients had T1 KS and 21 T0 KS. One patient died from KS at month 6. KS improved progressively, with complete and partial response rates of 46% and 28% at month 24, respectively. Only six patients were still receiving systemic KS therapy at month 24. Complete response was observed in 10 of the 19 patients without systemic KS therapy at inclusion. Patients with complete response at month 24 had higher CD4 cell counts than others (465 +/- 343 versus 185 +/- 167 x 10(6)/l; P < 0.01), but the proportion of patients with HIV-1 RNA < 500 copies/ml was not significantly different. An increase in CD4 cell counts from inclusion to month 12 of > 150 x 10(6)/l [odds ratio (OR), 13.4; 95% confidence interval (CI), 2-82] and T0 KS at inclusion: [OR, 7; 95% CI, 1.1-42] were predictive of complete response at month 24.

CONCLUSIONS

HAART appears to have prolonged efficacy on AIDS-KS, even without specific KS therapy, and this effect appears to be linked to the restoration of immune function.

Lipodystrophy associated with protease inhibitors

Lipodystrophies, characterized by reduction of subcutaneous fat over part or all of the body surface, are uncommon. Their causes are unknown. Recently, lipodystrophy has been reported in human immunodeficiency virus (HIV)-infected patients taking protease inhibitors, which have been recommended since 1996 as standard therapy for HIV disease in combination with nucleoside analogues. In these cases, lipodystrophy consists of an association of peripheral lipoatrophy with central adiposity. We report four HIV-infected men on protease inhibitors who developed a disfiguring lipodystrophy. In three of them, the protease inhibitor was administered for a mean duration of 21.5 months (range 19-23) with good immunological and virological responses. Patient 4 had been treated for 2 years with successive combinations of protease inhibitors with nucleoside analogues without success. The four patients progressively developed an increase in abdominal girth associated with fat wasting of the face and legs. Two of them had recurrent paronychia of the great toes. Triglyceride levels were moderately increased in all patients, and one had a slightly increased cholesterol level. One patient had elevated glucose and insulin plasma levels during a glucose tolerance test. In two patients, a deep biopsy taken from the thigh showed thinning of the subcutaneous fat without other morphological changes. Computed tomographic scans of the face and abdomen confirmed the loss of almost all subcutaneous fat of the cheek and temporal regions, and abdominal perivisceral fat accumulation. For patients 1-3, the protease inhibitor was replaced by a non-nucleoside reverse transcriptase inhibitor. Nine months later, dysmorphic changes had not regressed, but lipid abnormalities had returned to normal and the paronychia had disappeared.