Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections

Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.^1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.^4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.⁸ However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.

Are histopathological findings of diagnostic value in native valve endocarditis?

BACKGROUND

Optimal management of infective endocarditis (IE) depends on the early detection of IE-causing pathogens and on appropriate antimicrobial and surgical therapy. The current guidelines of the European Society of Cardiology (ESC) recommend histopathological examination as the gold standard for diagnosing IE Habib et al. (Eur Heart J 30:2369-2413, 2005). We hypothesize that histopathological findings do not provide additional information relevant to clinical decision-making.

METHODS

We retrospectively reviewed a cohort of patients who had undergone surgery for native valve endocarditis (NVE) at the University Hospital Regensburg between September 1994 and February 2005. All episodes of intraoperatively confirmed endocarditis during this period were included in the study. Data were retrieved from surgical records, microbiological and histopathological reports, and medical files of the treating as well as admitting hospital. Pathogens were correlated with the site of manifestation of the affected heart valve and with clinical and histopathological findings.

RESULTS

A total of 163 episodes of NVE were recorded and entered into our study for analysis. The valves affected were the aortic valve (45 %), the mitral valve (28 %), the aortic and mitral valve (22 %), and other valves (5 %). IE-causing pathogens were Staphylococcus aureus (22 %), viridans streptococci (18 %), enterococci (10 %), streptococci other than Streptococcus viridans (9 %), coagulase-negative staphylococci (5 %), miscellaneous pathogens (4 %), and culture-negative endocarditis (33 %). Infection with S. aureus was associated with high rates of sepsis, septic foci, and embolic events, while patients with enterococcal IE showed the highest rate of abscesses. Mortality rate in all subgroups was low without significant differences. However, histopathological findings correlated poorly with the pathogen involved and showed only few significant associations that were without clinical relevance.

CONCLUSIONS

The clinical presentation of IE depends on the pathogen involved. Among the episodes of NVE examined, the histopathological examination of resected heart valves did not show any pathogen-specific morphological patterns and therefore did not provide any additional information of clinical value. Based on our findings, we recommend complementary cultures of the resected materials (valve tissue, thrombotic material, pacer wire) and implementation of molecular diagnostic methods (e.g., broad-range PCR amplification techniques) instead of histopathological analyses of resected valve tissue.

Redescription of Heligmosomoides neopolygyrus, Asakawa and Ohbayashi, 1986 (Nematoda: Heligmosomidae) from a Chinese rodent, Apodemus peninsulae (Rodentia: Muridae); with comments on Heligmosomoides polygyrus polygyrus (Dujardin, 1845) and related species in China and Japan

Heligmosomoides neopolygyrus, Asakawa and Ohbayashi, 1986 (Nematoda, Heligmosomoidea) is redescribed from Apodemus peninsulae from Rangtang, Sichuan, China. A morphological review of the Heligmosomoides spp. belonging to the "polygyrus line" proposed by Asakawa (1988) is made using new characters. This enabled us to distinguish two subspecies in Mus musculus (Heligmosomoides polygyrus bakeri from Japan and H. p. polygyrus from China) and two valid species in Apodemus spp. (H. neopolygyrus from Japan (in A. peninsulae) and from China (in A. agrarius) and H. asakawae from China (in A. uralensis)). Three parasite species of A. agrarius and A. peninsulae, previously identified by Asakawa et al. (1993) as H. neopolygyrus, are considered to be Heligmosomoides incertae sedis. This is the first report of H. neopolygyrus in A. peninsulae from China.

Description of a new species of Heligmosomoides (Nematoda: Heligmosomidae) parasitic in Microtus limnophius (Rodentia: Cricetidae) from Rangtang, Sichuan, China

Heligmosomoides craigi n. sp. (Nematoda: Heligmosomoidea) is described from Microtus limnophilus Büchner, 1889 (Rodentia: Cricetidae) from Rangtang, Sichuan, China. It is related to H. protobullosus Asakawa, 1987 and H. longispiculum Tokobaev & Erkulov, 1966 both parasites of Microtus spp. from Japan and USSR, respectively by the following features: a ratio of spicule length/body length of more than 45% and rays 9 shorter than rays 10. The new species is differentiated by rays 8 being closed to rays 6 and 19-22 cuticular ridges versus 14 in H. protobullosus (synlophe not described in H. longispiculum). H. longicirratus (Schulz, 1954) also a parasite of Microtus sp. from the USSR is the most closely related species based on the number of cuticular ridges (20) and the ratio of spicule length/body length (48% versus 50%). There are no illustrations of this species and the female has not been described; for that reason, it is not possible to compare it accurately with our specimens.

Do lagomorphs play a relay role in the evolution of the Trichostrongyuna nematodes?

In order to confirm or refute the relay role of lagomorphs in the evolution of the Trichostrongylina (Nematoda), the following points were studied by summarizing previous works on the subject: the chronology of the life cycles (27 conducted in natural hosts, lagomorphs, ruminants or arvicolin rodents; 14 in experimental hosts); the parasitic phase in the experimental host and the adaptation involved; the migration of the parasites into the tissues of the host; the morphogenesis of larval stages and molecular phylogeny. These data confirm, in their entirety, that lagomorphs may be considered as "relay" hosts in the evolution of the Trichostrongylina.

Additional molecular evidence to support a sister taxon relationship between Heligmosomoidea and Molineoidea nematodes (Trichostrongylina)

Sequences of the first and second internal transcribed spacers of the ribosomal DNA were used to infer the evolutionary relationships of 19 species of parasitic nematode belonging to three superfamilies, Trichostrongyloidea, Molineoidea and Heligmosomoidea, within the sub-order Trichostrongylina. Analyses using maximum parsimony, maximum likelihood and neighbor-joining methods revealed strong statistical support for monophyly of each superfamily as defined on morphological criteria. Furthermore, in most analyses, there was also strong support for a sister taxon relationship between the Molineoidea and Heligmosomoidea, which supports the findings of a previous study based on partial LSU rDNA sequence data.

Development of Nematodirus spathiger (Nematoda, Molineoidea) in the rabbit and comparison with other Nematodirus spp parasites of ruminants

The morphogenesis and chronology of the life cycle of Nematodirus spathiger (Railliet, 1896), a parasite of ruminants, were studied in detail in an experimental host. Twenty-four worm-free rabbits were each infected per os with N. spathiger larvae and were killed at 12 h after infection (12 HAI) and every day from 1 DAI to 23 DAI. By 12 HAI, all the larvae were exsheathed and present in the small intestine. The third moult occurred between 4 DAI and 5 DAI. The last moult occurred between 13 DAI and 16 DAI. The prepatent period lasted 21-24 days. The distribution of N. spathiger along the small intestine of the rabbit was assessed. The chronology of the life cycles was compared for various Nematodirus spp from ruminants in their natural hosts and in the rabbit (N. battus, N. spathiger).

["Tingling feet," forgetfulness, and progressive personality changes in a 63-year-old patient]

A 63-year-old female was admitted to the hospital with leg and forearm paresthesias. We found progressive ataxia, dementia, and psychosocial deterioration. The clinical symptoms, the neurologic and psychiatric abnormalities together with the inflammatory cerebrospinal fluid alteration and the cerebral magnetic resonance imaging changes suggested a paraneoplastic etiology. It was confirmed by paraneoplastic antineuronal antibodies in the patient's serum and the histological diagnosis of a small cell bronchial carcinoma. The prognosis of patients with paraneoplastic symptoms is the better the earlier a diagnosis is established and antitumor therapy is initiated.

Development of Trichostrongylus colubriformis and Trichostrongylus vitrinus, parasites of ruminants in the rabbit and comparison with Trichostrongylus retortaeformis

The parasitic phase of development of both Trichostrongylus colubriformis and Trichostrongylus vitrinus, parasites of ruminants, was studied in detail in the rabbit. In T. colubriformis, the third moult appeared by 4 days after infection (DAI) and the last moult occurred between 10 and 11 DAI. In T. vitrinus, the third moult occurred between 8 and 11 DAI and the last one between 12 and 15 DAI. The prepatent period lasted 16-17 days for T. colubriformis and 20 days for T. vitrinus. The chronology of the life cycles and the distribution of the parasites along the small intestine for various Trichostrongylus spp. from lagomorphs and ruminants in the natural host or in the experimental host were compared. All of these biological parameters indicated a lower level of adaptation of T. vitrinus compared to the other species of Trichostrongylus. The results are fully compatible with the evolutionary scheme based on morphological analyses.

Intestinal migrations of Trichostrongylus retortaeformis (Trichostrongylina, Trichostrongylidae) in the rabbit

Observations were made on histological sections of the stomach and small intestine of seven rabbits infected with Trichostrongylus retortaeformis and from one uninfected control rabbit. At 12h post-infection, larvae were found in the small intestine. At first, only a few larvae were observed entering the mucosa through capillaries of the stroma of villi; the majority of larvae remained in the intestinal lumen, within mucus of the crypts. We consider that the presence of the worms in the stroma is the result of a larval migration. From a phyletic point of view, this migration is interpreted as an ancestral memory of the pulmonary migration seen in the primitive Strongylida.

Life cycle of Trichostrongylus retortaeformis in its natural host, the rabbit (Oryctolagus cuniculus)

The chronology of the life cycle of Trichostrongylus retortaeformis (Zeder, 1800) (Nematoda, Trichostrongyloidea) is studied in its natural host Oryctolagus cuniculus. The free living period lasted 5 days at 24 degrees C. Worm-free rabbits were each infected per os with T. retortaeformis larvae. Rabbits were killed at 12 h post-infection (p.i.) and every day from one day to 13 days p.i. By 12 h p.i., all the larvae were exsheathed and in the small intestine. The third moult occurred between 3 and 5 days p.i. and the last moult between 4 and 7 days p.i. The prepatent period lasted 12 to 13 days. The patent period lasted five and a half months. The four known life cycles of species of Trichostrongylus in ruminants were compared with that of T. retortaeformis. No significant difference was found except in the duration of the prepatent period. These similarities in the life cycles confirm the previously formulated hypotheses on the relationship between the parasites of the two host groups (Durette-Desset, 1985).

The life cycle of Ohbayashinema erbaevae (Nematoda, Heligmosomoidea, Heligmosomidae) in Ochotona rufescens rufescens (Ochotonidae)

The morphogenesis and the chronology of the life cycle of Ohbayashinema erbaevoe Durette-Desset et al, 2000, a parasite of Ochotona daurica from Buriatia were studied in detail in an experimental host, Ochotona rufescens rufescens. Worm-free pikas were each infected per os with O. erbaevae larvae and were killed at one day post infection (DPI 1) and every 12 hours from 1.5 to 8 days post infection. By DPI 1, all the larvae were exsheathed and in the small intestine. The third moult occurred in 2.5-3.0 days. The last moult occurred in 4.0-4.5 days. The prepatent period was eight days and the patent period lasted between two and 12 weeks. The distribution of O. erbaevae along the small intestine of the pikas was assessed. For each experiment, a morphological description of the different stages of the life cycle was provided. The morphogenesis and the chronology of the life cycle of O. erbaevae appear to be identical with those of two other genera of the family of the Heligmosomidae, Heligmosomum Railliet & Henry, 1909 and Heligmosomoides Hall, 1916. They confirm that the three genera belong to the same family. The presence of an abortive posterior genital branch in the female of O. erbaevae, which represents the posterior part of the genital primordium of the didelphic females, supports the systematic position of the genus Ohbayashinema between the didelphic genus Citellinema Hall, 1916 and the monodelphic genera Heligmosomum and Heligmosomoides.

Morphogenesis and distribution of Trichostrongylus retortaeformis in the intestine of the rabbit

The morphogenesis and the distribution along the digestive tract of Trichostrongylus retortaeformis(Zeder, 1800) (Nematoda) were studied in detail in one of its natural hosts, Oryctolagus cuniculus. Worm-free rabbits were each infected with T. retortaeformis larvae and were killed at 12 h post-infection (HPI) and on each day from 1 to 15 days post-infection (DPI). The distribution of worm populations along the small intestine was assessed. At the different dates of infection, more than 80% of the population was recovered from the first third of the intestine with more than 50% occurring in the first 30 cm. For each date, morphological descriptions of the different stages of the life cycle were also provided. In addition, adult worms collected from naturally infected rabbits from France were redescribed.

Internal transcribed spacer rDNA can be used to infer the phylogenetic relationships of species within the genus Nematodirus (Nematoda: molineoidea)

Sequences of the first internal transcribed spacer rDNA were characterised for four veterinary important species of gastrointestinal nematodes from the genus Nematodirus. The sequence data were combined with previously published data of the second internal transcribed spacer to determine whether these rDNA regions provided a suitable number of informative characters to determine the phylogenetic relationships of species within the genus. A total of 32 alignment positions of the first internal transcribed spacer data set and 33 characters from the second internal transcribed spacer data set were informative in phylogenetic analyses. Irrespective of whether the data from each spacer were analysed separately or combined, only one most parsimonious tree was produced, with the relationships of the four species fully resolved. In addition, several regions of conservatism in the first internal transcribed spacer sequence among the four Nematodirus species suggests that this rDNA region may also provide phylogenetic information for higher taxonomic levels within the Molineoidea.

Effect of antivenom on venom pharmacokinetics in experimentally envenomed rabbits: toward an optimization of antivenom therapy

Antivenomous immunotherapy is still used empirically. To improve the efficacy and safety of immunotherapy, we studied the effects of administering antivenom antibodies (F(ab')2) on the pharmacokinetics of the Vipera aspis venom in rabbits. Free venom levels were measured by enzyme-linked immunosorbent assay and total concentrations were quantified by measuring the radioactivity of trichloroacetic acid-precipitable radioiodinated venom. The intravenous infusion of 125 mg of antivenom 7 h after intramuscular injection with 700 microg x kg(-1) of V. aspis venom produced a redistribution of the venom antigens from the extravascular to the vascular space. Moreover, anti-venom antibodies were able to neutralize the totality of venom antigens in the vascular space, because no free plasma venom was detectable by enzyme-linked immunosorbent assay within 15 min after antivenom injection. Similar effects were obtained after injection of 25 mg of antivenom; however, the venom was only partially neutralized with lower doses (5 and 2.5 mg). We further established that intravenous injection is the most efficient route for antivenom administration, and we examined the effects of early and late immunotherapy. Finally, the efficacy of Fab antibodies was compared with that of F(ab')2; the plasma redistribution and the immunoneutralization of the venom were lower than those induced after injection of the same dose of F(ab')2. The difference between the effects of F(ab')2 and Fab could be explained by the differential pharmacokinetics of the two fragments.

Viper bites in France: clinical and biological evaluation; kinetics of envenomations

1. A second inquiry was conducted in France to collect more accurate epidemiological, clinical and biological data from patients hospitalized after a viper bite, as well as treatment that they received. Fifty-seven well documented cases were classified in four grades of increasing severity defined according to the clinical signs of envenomation. 2. Local and systemic signs of envenomation appeared during the first 3 h, but the severity of the envenomation was observed to increase during the 12-24 h following bites in 50% of moderate and severe cases. One fatal case was reported. Biological analysis revealed an hyperleukocytosis in patients with moderate and severe envenomations. 3. The average length of hospitalization was of 1.7 +/- 1.3 days for patients without signs of envenomation (grade 0) or presenting a minimal envenomation (grade 1), and statistically longer, 6.2 +/- 2.9 days, for patients presenting moderate (grade 2) or severe envenomation (grade 3). 4. Levels of venom antigens in serum samples regularly collected during hospitalization were determined by a sandwich ELISA test. The serum venom levels determined during the first 4 h following the bite correlated with the severity of the envenomation when the symptoms were determined at their worst, usually 12-24 h later. In fact, concentrations higher than 20 ng ml-1 predict a moderate or severe clinical evolution. 5. The pharmacokinetics of venom antigens was also investigated during human envenomations.(ABSTRACT TRUNCATED AT 250 WORDS)

Pharmacokinetics of Vipera aspis venom after experimental envenomation in rabbits

Toxicokinetic studies of Vipera aspis venom were performed in rabbits after experimental envenomation. Venom proteins with a molecular weight greater than 6 kDa (high-molecular weight proteins) and which reacted in enzyme-linked immunosorbent assay with specific antiviper venom Fab'2, were also responsible for the lethal potency and the capillary permeability increasing activity of the venom. Conversely, low-molecular weight proteins were not detected by enzyme-linked immunosorbent assay and were pharmacologically inactive. The toxicokinetics of both classes of venom components were studied, using high-molecular weight and low-molecular weight radiolabeled proteins as well as enzyme-linked immunosorbent assay. After intravenous injection, Vipera aspis venom in plasma followed a biexponential decline with a distribution half-life of 0.7 hr and an elimination half-life of 12 hr. The distribution volume was 1.2 l.kg-1 and the systemic clearance was 84 ml.hr-1.kg-1. Venom levels in plasma after intramuscular injection of three doses (300, 500 and 700 micrograms/kg) of venom increased within the few hours after the venom administration to reach maximal values proportional to the injected doses. They subsequently followed a monoexponential decline, with an apparent terminal half-life of 32.5 hr. Absorption was a kinetically complex process, rapid during the first 24 hr and continued at a slower rate over the subsequent 72 hr. Bioavailability of venom was about 65%, regardless of the administered dose, and less than 5% of venom injected was excreted by the renal route.

Quantitation of venom antigens from European vipers in human serum or urine by ELISA

We describe an enzyme-linked immunosorbent assay (ELISA) to quantitate venom antigens in human serum and urine, and thus to help evaluate the severity of envenomation due to viper bites. This assay, which is performed with commercially available polyclonal Fab'2s in a double-sandwich method, is rapid, simple, and specific for antigens of European vipers (Vipera aspis, Vipera berus, and Vipera ammodytes). No cross-reactivity was observed with other snake venoms or human serum proteins. It showed a good linear response over a wide range of concentrations of venom antigens (from 1 to 100 ng/mL). It was very sensitive, with detection limits of 7 and 2 ng/mL for Vipera aspis venom in serum and urine, respectively. This ELISA is also easily reproducible; the coefficients of variation determined at different concentrations of venom (50, 25, and 5 ng/mL) did not exceed 10% in serum and 14% in urine samples collected from different donors. This test was applied to determine the concentrations of venom in the serum of patients bitten by a viper in France and to follow its elimination as a function of time. The method is adaptable to other venoms by using other specific immunoglobulins.

Envenoming by viper bites in France: clinical gradation and biological quantification by ELISA

Viper bites are frequent in France but the evaluation of the severity of envenomings and consequently patient treatment has not yet been properly evaluated. The purpose of this study was to measure venom antigens in blood and/or urine of bitten patients and to establish a quantitative relationship with clinical observations. A prospective enquiry was conducted in 1990 in France to collect epidemiological, clinical and biological data from hospitals. Urine and blood samples were tested for their content of Vipera aspis venom antigens by a sandwich enzyme linked immunosorbent assay (ELISA). One hundred and two charts were analysed, from patients presenting documented viper bites. Oedema was the prominent local feature (81 cases). Systemic signs consisted of vomiting and/or diarrhoea (22 cases), slight or severe hypotension (15 cases), shock (2 cases) and bleeding (1 case). A relationship was observed between these systemic signs and the extent of the oedema, which permitted the establishment of a grading scale. Grade 0 (no envenoming) was identified by fang marks and absence of oedema and local reaction; grade 1 (mild envenoming) by local oedema and absence of systemic symptoms; grade 2 (moderate envenoming) by regional oedema and moderate systemic symptoms; and grade 3 (severe envenoming) by extensive oedema and severe systemic symptoms. Quantification of venom antigens in blood or urine of patients by ELISA revealed a significant correlation between clinical signs of envenoming and the level of venom antigens in blood or urine. This indicated that the ELISA test is a useful and predictive tool for clinically grading viper envenomings.