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McAlpine L, Zubair AS, Joseph P, Spudich S. Case-Control Study of Individuals With Small Fiber Neuropathy After COVID-19. Neurol Neuroimmunol Neuroinflamm 2024; 11:e200244. [PMID: 38630952 DOI: 10.1212/nxi.0000000000200244] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/19/2024]
Abstract
OBJECTIVES To report a case-control study of new-onset small fiber neuropathy (SFN) after COVID-19 with invasive cardiopulmonary exercise testing (iCPET). SFN is a critical objective finding in long COVID and amenable to treatment. METHODS A retrospective chart review was conducted on patients seen in the NeuroCOVID Clinic at Yale who developed new-onset SFN after a documented COVID-19 illness. We collected demographics, symptoms, skin biopsy, iCPET testing, treatments, and clinical response to treatment or no intervention. RESULTS Sixteen patients were diagnosed with SFN on skin biopsy (median age 47, 75% female, 75% White). 92% of patients reported postexertional malaise characteristic of myalgic encephalomyelitis/chronic fatigue syndrome (ME/CFS), and 7 patients underwent iCPET, which demonstrated neurovascular dysregulation and dysautonomia consistent with ME/CFS. Nine patients underwent treatment with IVIG, and 7 were not treated with IVIG. The IVIG group experienced significant clinical response in their neuropathic symptoms (9/9) compared with those who did not receive IVIG (3/7; p = 0.02). DISCUSSION Here, we present preliminary evidence that after COVID-19, SFN is responsive to treatment with IVIG and linked with neurovascular dysregulation and dysautonomia on iCPET. A larger clinical trial is indicated to further demonstrate the clinical utility of IVIG in treating postinfectious SFN. CLASSIFICATION OF EVIDENCE This study provides Class III evidence. It is a retrospective cohort study.
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Affiliation(s)
- Lindsay McAlpine
- From the Department of Neurology (L.M., A.S.Z., S.S.), and Department of Pulmonology (P.J.), Yale University School of Medicine, New Haven, CT
| | - Adeel S Zubair
- From the Department of Neurology (L.M., A.S.Z., S.S.), and Department of Pulmonology (P.J.), Yale University School of Medicine, New Haven, CT
| | - Phillip Joseph
- From the Department of Neurology (L.M., A.S.Z., S.S.), and Department of Pulmonology (P.J.), Yale University School of Medicine, New Haven, CT
| | - Serena Spudich
- From the Department of Neurology (L.M., A.S.Z., S.S.), and Department of Pulmonology (P.J.), Yale University School of Medicine, New Haven, CT
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Wang M, Yoon J, Reisert H, Das B, Orlinick B, Chiarella J, Halvas EK, Mellors J, Pang AP, Barakat LA, Fikrig M, Cyktor J, Kluger Y, Spudich S, Corley MJ, Farhadian SF. HIV-1-infected T cell clones are shared across cerebrospinal fluid and blood during ART. JCI Insight 2024; 9:e176208. [PMID: 38587074 DOI: 10.1172/jci.insight.176208] [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] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Accepted: 02/27/2024] [Indexed: 04/09/2024] Open
Abstract
The central nervous system HIV reservoir is incompletely understood and is a major barrier to HIV cure. We profiled people with HIV (PWH) and uninfected controls through single-cell transcriptomic and T cell receptor (TCR) sequencing to understand the dynamics of HIV persistence in the CNS. In PWH on ART, we found that most participants had single cells containing HIV-1 RNA, which was found predominantly in CD4 central memory T cells, in both cerebrospinal fluid (CSF) and blood. HIV-1 RNA-containing cells were found more frequently in CSF than blood, indicating a higher burden of reservoir cells in the CNS than blood for some PWH. Most CD4 T cell clones containing infected cells were compartment specific, while some (22%) - including rare clones with members of the clone containing detectable HIV RNA in both blood and CSF - were found in both CSF and blood. These results suggest that infected T cells trafficked between tissue compartments and that maintenance and expansion of infected T cell clones contributed to the CNS reservoir in PWH on ART.
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Affiliation(s)
- Meng Wang
- Program in Computational Biology and Bioinformatics, Yale University, New Haven, Connecticut, USA
| | | | | | | | | | - Jennifer Chiarella
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Elias K Halvas
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - John Mellors
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Alina Ps Pang
- Department of Medicine, Division of Infectious Diseases, Weill Cornell Medicine, New York City, New York, USA
| | | | | | - Joshua Cyktor
- Department of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Yuval Kluger
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Serena Spudich
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael J Corley
- Department of Medicine, Division of Infectious Diseases, Weill Cornell Medicine, New York City, New York, USA
| | - Shelli F Farhadian
- Section of Infectious Diseases, and
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, USA
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Ocampo FF, Sacdalan C, Pinyakorn S, Paudel M, Wansom T, Poltubtim N, Sriplienchan S, Phanuphak N, Paul R, Hsu D, Colby D, Trautmann L, Spudich S, Chan P. Neuropsychiatric and Laboratory Outcomes of Hepatitis C Treatment in an Early-Treated HIV Cohort in Thailand. Res Sq 2024:rs.3.rs-4186965. [PMID: 38645141 PMCID: PMC11030515 DOI: 10.21203/rs.3.rs-4186965/v1] [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] [Subscribe] [Scholar Register] [Indexed: 04/23/2024]
Abstract
Background Hepatitis C virus (HCV) coinfection may further compromise immunological and cognitive function in people with HIV (PWH). This study compared laboratory and neuropsychiatric measures across the periods of HCV seroconversion and direct-acting antiviral (DAA) therapy with sustained virologic response (SVR) among PWH who initiated antiretroviral therapy (ART) during acute HIV infection (AHI) and acquired HCV after 24 weeks of ART. Methods Participants from the RV254 AHI cohort underwent paired laboratory and neuropsychiatric assessments during regular follow-up. The former included measurements of CD4 + and CD8 + T-cell counts, HIV RNA, liver enzymes, and lipid profiles. The latter included the Patient Health Questionnaire-9 (PHQ-9), Distress Thermometer (DT), and a 4-test cognitive battery that evaluated psychomotor speed, executive function, fine motor speed and dexterity. The raw scores in the battery were standardized and averaged to create an overall performance (NPZ-4) score. Parameters of HCV-coinfected participants were compared across HCV seroconversion and DAA treatment groups. Results Between 2009 and 2022, 79 of 703 RV254 participants acquired HCV after ≥ 24 weeks of ART; 53 received DAA, and 50 (94%) achieved SVR. All participants were Thai males (median age: 30 years); 34 (68%) denied past intravenous drug use, and 41 (82%) had a history of other sexually transmitted infections during follow-up. Following SVR, aspartate transferase (AST) and alanine transaminase (ALT) decreased (p < 0.001), while total cholesterol, low-density lipoprotein, and triglycerides increased (p < 0.01). The median CD4+/CD8 + ratio increased from 0.91 to 0.97 (p = 0.012). NPZ-4 improved from 0.75 to 0.91 (p = 0.004). The median DT score increased from 1.7 to 2.7 (p = 0.045), but the PHQ-9 score remained unchanged. Conclusion HCV coinfection is common in this group of high-risk PWH, highlighting the need for regular screening, early diagnosis, and treatment. There was a modest improvement in the CD4+/CD8 + T-cell ratio and cognitive performance after DAA therapy in patients who achieved SVR. Future studies should examine potential neuropsychiatric impacts during early HCV infection as well as the longer-term neuropsychiatric outcomes after DAA treatment with SVR.
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Chan P, Moreland S, Sacdalan C, Kroon E, Colby D, Sriplienchan S, Pinyakorn S, Phanuphak N, Jagodzinski L, Valcour V, Vasan S, Paul R, Trautmann L, Spudich S. Cerebrospinal fluid pleocytosis is associated with HIV-1 neuroinvasion during acute infection. AIDS 2024; 38:373-378. [PMID: 37916464 PMCID: PMC10842649 DOI: 10.1097/qad.0000000000003777] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Accepted: 10/26/2023] [Indexed: 11/03/2023]
Abstract
OBJECTIVE HIV-1 invades the brain within days post-transmission. This study quantitated cerebrospinal fluid (CSF) white blood cell count (WBC) and investigated whether it associated with plasma and CSF HIV-1 RNA during untreated acute HIV infection (AHI). DESIGN Seventy participants underwent lumbar puncture during Fiebig stages I-V AHI. METHOD WBC and HIV-1 RNA with a lower limit of quantification (LLQ) of 80 copies/ml were measured in CSF. RESULTS Sixty-nine (99%) participants were men, with a median age of 26. Their blood CD4 + and CD8 + T-cell counts were 335 [interquartile range (IQR) 247-553) and 540 (IQR 357-802) cells/μl, respectively. Forty-five (64%) were in Fiebig stages III-V whereas 25 (36%) were in Feibig stages I-II. Fifty-two (74%) experienced acute retroviral syndrome. Median plasma and CSF HIV-1 RNA were 6.10 (IQR 5.15-6.78) and 3.15 (IQR 1.90-4.11) log 10 copies/ml, respectively. Sixteen (23%) CSF samples had HIV-1 RNA below LLQ. Median CSF WBC was 2.5 (IQR 1-8) cells/μl. CSF pleocytosis (WBC >5) was observed in 33% and was only present in CSF samples with detectable HIV-1 RNA. The frequencies of CSF pleocytosis during Fiebig stages III-V and among CSF samples of higher viral load (>1000 copies/ml) were 42 and 45%, respectively. Pleocytosis independently associated with CSF HIV-1 RNA in multivariate analysis [adjusted coefficient: 0.79, 95% confidence interval (CI) 0.41-1.14), P < 0.001] and a lower plasma to CSF HIV-1 RNA ratio ( P < 0.001). CONCLUSION CSF pleocytosis was present in one-third of participants with AHI. It associated with higher CSF HIV-1 RNA and a lower plasma to CSF HIV-1 RNA ratio, suggesting a potential association with HIV-1 neuroinvasion.
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Affiliation(s)
- Phillip Chan
- Department of Neurology
- Yale Center for Brain and Mind Health, Yale University School of Medicine, New Haven, CT
| | - Sarah Moreland
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Carlo Sacdalan
- SEARCH Research Foundation
- Faculty of Medicine, Chulalongkorn University
| | - Eugene Kroon
- SEARCH Research Foundation
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - Donn Colby
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | | | - Suteeraporn Pinyakorn
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | | | - Linda Jagodzinski
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
| | - Victor Valcour
- Memory and Aging Center, Department of Neurology, University of California San Francisco, CA
| | - Sandhya Vasan
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Robert Paul
- Faculty of Psychological Sciences, Missouri Institute of Mental Health, University of Missouri-St. Louis, St. Louis, MO, USA
| | - Lydie Trautmann
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, MD, USA
| | - Serena Spudich
- Department of Neurology
- Yale Center for Brain and Mind Health, Yale University School of Medicine, New Haven, CT
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Holroyd KB, Han WM, Apornpong T, Trautmann L, Gatechompol S, Hiransuthikul A, Ubolyam S, Sacdalan C, Sriplienchan S, Kanaprach R, Kerr S, Avihingsanon A, Spudich S, Chan P. Framingham risk score based vascular outcomes in acute versus chronic HIV cohorts after 6 years of ART. HIV Med 2024. [PMID: 38383057 DOI: 10.1111/hiv.13621] [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: 12/15/2023] [Accepted: 02/05/2024] [Indexed: 02/23/2024]
Abstract
INTRODUCTION Immune dysregulation persists in people with HIV (PWH) on antiretroviral therapy (ART) and may lead to accelerated vascular ageing and cardiovascular disease (CVD). While delayed time to initiation of ART has been linked to worse cardiovascular outcomes, the effect of ART initiation during acute infection on these outcomes is not well understood. METHODS Participants were enrolled from the SEARCH010/RV254 acute HIV (AHI) and HIV-NAT chronic HIV (CHI) cohorts in Thailand. Participants with 6-year follow-up and viral suppression (viral load < 50 copies/μL) at follow-up were included. Both unmatched cohorts and age and gender-matched cohorts were analysed. Demographics, HIV laboratories, and cardiovascular risk factors from enrolment and 6-year follow-up were obtained from electronic records. Framingham Risk Score (FRS), vascular age (VA), vascular age deviation (VAD), and 10-year atherosclerotic cardiovascular disease (ASCVD) risk were calculated from previously published equations. Vascular outcomes in AHI and CHI cohorts were compared, and univariable and multivariable linear regression analyses were used to investigate risk factors associated with worse vascular scores. RESULTS In all, 373 AHI participants and 608 CHI participants were identified. AHI participants were of younger age, had a higher prevalence of syphilis and a lower prevalence of prior hepatitis B, tuberculosis, diabetes, and hypertension. Higher CD4 T-cell and lower CD8 T-cell counts were seen in the AHI cohort at enrolment and 6-year follow-up. In all participants, the AHI cohort had a lower median FRS (p < 0.001) and VA (p < 0.001), but higher VAD (p < 0.001). However, in matched cohorts, no differences were found in FRS-based outcomes. In all participants, higher VAD after 6 years of ART was associated with higher body mass index (p < 0.001) and higher CD4 count (p < 0.001), which persisted in multivariable analysis. When FRS components were analysed individually, CD4 count was associated only with male sex and cholesterol. CONCLUSIONS We did not identify differences in FRS-based vascular outcomes at 6 years in matched cohorts of participants who started ART during AHI versus CHI. We identified a correlation between higher CD4 count and worse FRS-based vascular outcomes, which may be driven by underlying metabolic risk factors. Further study is needed to confirm these findings and evaluate underlying mechanisms.
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Affiliation(s)
| | - Win Min Han
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Kirby Institute, UNSW Sydney, Sydney, New South Wales, Australia
| | | | - Lydie Trautmann
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine Inc., Bethesda, Maryland, USA
| | - Sivaporn Gatechompol
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Center of Excellence in Tuberculosis, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Akarin Hiransuthikul
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Department of Preventive and Social Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sasiwimol Ubolyam
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Center of Excellence in Tuberculosis, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Carlo Sacdalan
- SEARCH Research Foundation, Bangkok, Thailand
- Research Affairs, Chulalongkorn University, Bangkok, Thailand
| | | | | | - Stephen Kerr
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Anchalee Avihingsanon
- HIV-NAT, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Center of Excellence in Tuberculosis, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Serena Spudich
- Department of Neurology, Yale University, New Haven, Connecticut, USA
- Yale Center for Brain and Mind Health, Yale University, New Haven, Connecticut, USA
| | - Phillip Chan
- Department of Neurology, Yale University, New Haven, Connecticut, USA
- Yale Center for Brain and Mind Health, Yale University, New Haven, Connecticut, USA
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Albalawi YA, Shull T, Virdi AK, Subra C, Mitchell J, Slike BM, Jian N, Krebs SJ, Sacdalan C, Ratnaratorn N, Hsu DC, Phanuphak N, Spudich S, Trautmann L, Al-Harthi L. CD4 dim CD8 bright T cells are inversely associated with neuro-inflammatory markers among people with HIV. AIDS 2024; 38:1-7. [PMID: 37792358 PMCID: PMC10715695 DOI: 10.1097/qad.0000000000003743] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 08/24/2023] [Accepted: 09/19/2023] [Indexed: 10/05/2023]
Abstract
OBJECTIVE HIV-associated neuroinflammation persists in the brain despite suppressive combination antiretroviral therapy (cART). We evaluated associations between a subset of CD8 + T cells, termed CD4 dim CD8 bright T cells, and soluble markers of immune activation and/or neuroinflammation in the cerebrospinal fluid (CSF) and plasma of people with HIV (PWH). DESIGN Fifteen cART-naive PWH were enrolled and underwent blood draw, lumbar puncture for CSF collection, and neuropsychological tests at week 0 (pre-cART) and 24 weeks after cART initiation. METHODS CSF and peripheral blood T cells were evaluated with flow cytometry and soluble markers of immune activation were measured by multiplex and singleplex assays. Spearman bootstrap correlation coefficients with 10 000 resamples were computed and reported with corresponding 95% confidence intervals (CIs) for each marker of interest and T-cell type. RESULTS The frequency of CSF CD4 dim CD8 bright T cells at week 0 was inversely related with CSF neopterin. In contrast, at week 24, CSF CD4 - CD8 + T cells were positively correlated with CSF s100β, a marker of brain injury. In the blood, at week 0, CD4 dim CD8 bright T cells were inversely correlated with MCP-1, IP-10, IL-8, IL-6, G-CSF, and APRIL and positively correlated with plasma RANTES and MMP1. At week 0, the frequency of blood CD4 - CD8 + were positively correlated with CRP and BAFF. CONCLUSION CD4 dim CD8 bright T cells are associated with some anti-inflammatory properties, whereas CD4 - CD8 + T cells may contribute to inflammation and injury. Assessing the contrast between these two cell populations in neuroHIV may inform targeted therapeutic intervention to reduce neuroinflammation and associated neurocognitive impairment.
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Affiliation(s)
- Yasmeen A. Albalawi
- Department of Microbial Pathogens and Immunity, Rush University Medical Center, Chicago, Illinois, USA
- Department of Biology, College of Science, Jouf University, Sakaka, Aljouf, Saudi Arabia
| | - Tanner Shull
- Department of Microbial Pathogens and Immunity, Rush University Medical Center, Chicago, Illinois, USA
- Division of Epidemiology and Biostatistics, University of Illinois Chicago, School of Public Health, Chicago, Illinois
| | - Amber K. Virdi
- Department of Microbial Pathogens and Immunity, Rush University Medical Center, Chicago, Illinois, USA
| | - Caroline Subra
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Julie Mitchell
- Vaccine and Gene Therapy Institute, Oregon Health & Science University, Beaverton, Oregon, USA
| | - Bonnie M. Slike
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Ningbo Jian
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Shelly J. Krebs
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
| | - Carlo Sacdalan
- SEARCH Research Foundation
- Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Denise C. Hsu
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | | | - Serena Spudich
- Department of Neurology, Yale University, New Haven, Connecticut, USA
| | - Lydie Trautmann
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Lena Al-Harthi
- Department of Microbial Pathogens and Immunity, Rush University Medical Center, Chicago, Illinois, USA
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Farhadian SF, Reisert HD, McAlpine L, Chiarella J, Kosana P, Yoon J, Spudich S. Self-Reported Neuropsychiatric Post-COVID-19 Condition and CSF Markers of Neuroinflammation. JAMA Netw Open 2023; 6:e2342741. [PMID: 37948085 PMCID: PMC10638645 DOI: 10.1001/jamanetworkopen.2023.42741] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/02/2023] [Indexed: 11/12/2023] Open
Abstract
This case-control study assesses cerebrospinal fluid markers of neuroinflammation and blood-brain barrier disruption in individuals with post–COVID-19 condition who reported neuropsychiatric symptoms.
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Affiliation(s)
- Shelli F. Farhadian
- Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
- Center for Brain and Mind Health, Yale University, New Haven, Connecticut
| | - Hailey D. Reisert
- Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Lindsay McAlpine
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Jennifer Chiarella
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Priya Kosana
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut
| | - Jennifer Yoon
- Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut
| | - Serena Spudich
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
- Center for Brain and Mind Health, Yale University, New Haven, Connecticut
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Letendre SL, Chen H, McKhann A, Roa J, Vecchio A, Daar ES, Berzins B, Hunt PW, Marra CM, Campbell TB, Coombs RW, Ma Q, Swaminathan S, Macatangay BJC, Morse GD, Miller T, Rusin D, Greninger AL, Ha B, Alston-Smith B, Robertson K, Paul R, Spudich S. Antiretroviral Therapy Intensification for Neurocognitive Impairment in Human Immunodeficiency Virus. Clin Infect Dis 2023; 77:866-874. [PMID: 37183889 PMCID: PMC10506779 DOI: 10.1093/cid/ciad265] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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] [Received: 02/28/2023] [Revised: 04/23/2023] [Accepted: 04/27/2023] [Indexed: 05/16/2023] Open
Abstract
BACKGROUND Neurocognitive impairment (NCI) in people with HIV (PWH) on antiretroviral therapy (ART) is common and may result from persistent HIV replication in the central nervous system. METHODS A5324 was a randomized, double-blind, placebo-controlled, 96-week trial of ART intensification with dolutegravir (DTG) + MVC, DTG + Placebo, or Dual - Placebo in PWH with plasma HIV RNA <50 copies/mL on ART and NCI. The primary outcome was the change on the normalized total z score (ie, the mean of individual NC test z scores) at week 48. RESULTS Of 357 screened, 191 enrolled: 71% male, 51% Black race, 22% Hispanic ethnicity; mean age 52 years; mean CD4+ T-cells 681 cells/µL. Most (65%) had symptomatic HIV-associated NC disorder. Study drug was discontinued due to an adverse event in 15 (8%) and did not differ between arms (P = .17). Total z score, depressive symptoms, and daily functioning improved over time in all arms with no significant differences between them at week 48 or later. Adjusting for age, sex, race, study site, efavirenz use, or baseline z score did not alter the results. Body mass index modestly increased over 96 weeks (mean increase 0.32 kg/m2, P = .006) and did not differ between arms (P > .10). CONCLUSIONS This is the largest, randomized, placebo-controlled trial of ART intensification for NCI in PWH. The findings do not support empiric ART intensification as a treatment for NCI in PWH on suppressive ART. They also do not support that DTG adversely affects cognition, mood, or weight.
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Affiliation(s)
| | - Huichao Chen
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Ashley McKhann
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jhoanna Roa
- DLH Corporation, Silver Spring, Maryland, USA
| | - Alyssa Vecchio
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Eric S Daar
- Lundquist Institute at Harbor–University of California–Los Angeles Medical Center, Torrance, California, USA
| | | | - Peter W Hunt
- University of California–San Francisco, San Francisco, California, USA
| | - Christina M Marra
- University of Washington School of Medicine, Seattle, Washington, USA
| | | | - Robert W Coombs
- University of Washington School of Medicine, Seattle, Washington, USA
| | - Qing Ma
- University at Buffalo, Buffalo, New York, USA
| | | | | | | | | | - David Rusin
- DLH Corporation, Silver Spring, Maryland, USA
| | | | - Belinda Ha
- ViiV Healthcare Ltd, Research Triangle Park, North Carolina, USA
| | | | - Kevin Robertson
- University of North Carolina, Chapel Hill, North Carolina, USA
| | - Robert Paul
- University of Missouri, St. Louis, Missouri, USA
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9
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Schiess N, Kulo V, Anand P, Bearden DR, Berkowitz AL, Birbeck GL, Cervantes-Arslanian A, Chan P, Chishimba LC, Chow FC, Elicer I, Fleury A, Kinikar A, Kvalsund M, Mateen FJ, Mbonde AA, Meyer ACL, O'Carroll CB, Ogunniyi A, Patel AA, Rubenstein M, Siddiqi OK, Spudich S, Tackett SA, Thakur KT, Vora N, Zunt J, Saylor DR. Consensus Competencies for Postgraduate Fellowship Training in Global Neurology. Neurology 2023; 101:357-368. [PMID: 36997322 PMCID: PMC10449442 DOI: 10.1212/wnl.0000000000207184] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [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: 09/18/2022] [Accepted: 01/27/2023] [Indexed: 04/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Use a modified Delphi approach to develop competencies for neurologists completing ≥1 year of advanced global neurology training. METHODS An expert panel of 19 United States-based neurologists involved in global health was recruited from the American Academy of Neurology Global Health Section and the American Neurological Association International Outreach Committee. An extensive list of global health competencies was generated from review of global health curricula and adapted for global neurology training. Using a modified Delphi method, United States-based neurologists participated in 3 rounds of voting on a survey with potential competencies rated on a 4-point Likert scale. A final group discussion was held to reach consensus. Proposed competencies were then subjected to a formal review from a group of 7 neurologists from low- and middle-income countries (LMICs) with experience working with neurology trainees from high-income countries (HICs) who commented on potential gaps, feasibility, and local implementation challenges of the proposed competencies. This feedback was used to modify and finalize competencies. RESULTS Three rounds of surveys, a conference call with United States-based experts, and a semistructured questionnaire and focus group discussion with LMIC experts were used to discuss and reach consensus on the final competencies. This resulted in a competency framework consisting of 47 competencies across 8 domains: (1) cultural context, social determinants of health and access to care; (2) clinical and teaching skills and neurologic medical knowledge; (3) team-based practice; (4) developing global neurology partnerships; (5) ethics; (6) approach to clinical care; (7) community neurologic health; (8) health care systems and multinational health care organizations. DISCUSSION These proposed competencies can serve as a foundation on which future global neurology training programs can be built and trainees evaluated. It may also serve as a model for global health training programs in other medical specialties as well as a framework to expand the number of neurologists from HICs trained in global neurology.
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Affiliation(s)
- Nicoline Schiess
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Violet Kulo
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Pria Anand
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - David R Bearden
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Aaron L Berkowitz
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Gretchen L Birbeck
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Anna Cervantes-Arslanian
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Phillip Chan
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Lorraine Chishimba Chishimba
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Felicia C Chow
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Isabel Elicer
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Agnes Fleury
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Aarti Kinikar
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Michelle Kvalsund
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Farrah J Mateen
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Amir A Mbonde
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Ana-Claire L Meyer
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Cumara B O'Carroll
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Adesola Ogunniyi
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Archana A Patel
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Michael Rubenstein
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Omar K Siddiqi
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Serena Spudich
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Sean A Tackett
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Kiran T Thakur
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Nirali Vora
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Joseph Zunt
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle
| | - Deanna R Saylor
- From the Department of Neurology (N.S., A.-C.L.M., D.R.S.), Johns Hopkins University School of Medicine; Department of Health Professions Education (V.K.), University of Maryland, Baltimore, MD; Department of Neurology (P.A., A.C.-A.), Boston University and Boston Medical Center, MA; Department of Child Neurology (D.R.B.), University of Rochester Medical Center, NY; Department of Educational Psychology (D.R.B.), University of Zambia, Lusaka; Department of Neurology (A.L.B., F.C.C.), University of California, San Francisco; Department of Neurology (G.L.B., M.K.), University of Rochester Medical Center, NY; University of Zambia School of Medicine (G.L.B., M.K., O.K.S.), Lusaka; SEARCH (P.C.), Institute of HIV Research and Innovation, Bangkok, Thailand; University Teaching Hospital (L.C.C., D.R.S.), Lusaka, Zambia; Hospital Dr. Sótero del Río (I.E.), Clínica Las Condes, Santiago, Chile; Instituto de Investigaciones Biomédicas (A.F.), Universidad Nacional Autónoma de México; Instituto Nacional de Neurología y Neurocirugía (A.F.), Secretaria de Salud, Mexico City, Mexico; Department of Paediatrics and Neonatology (A.K.), B.J. Government Medical College, Pune, India; Department of Neurology (F.J.M., A.A.M.), Massachusetts General Hospital, Boston; Department of Internal Medicine (A.A.M.), Mbarara University of Science and Technology, Uganda; Department of Neurology (C.B.O.C.), Mayo Clinic Arizona, Scottsdale; Department of Medicine (A.O.), College of Medicine, University of Ibadan, Nigeria; Department of Child Neurology (A.A.P.), Boston Children's Hospital, MA; Department of Neurology (M.R.), University of Pennsylvania Perelman School of Medicine, Philadelphia; Department of Neurology (O.K.S.), Beth Israel Deaconess Medical Center, Boston, MA; Department of Neurology (S.S.), Yale School of Medicine, New Haven, CT; Department of Internal Medicine (S.A.T.), Johns Hopkins Bayview Medical Center, Baltimore, MD; Department of Neurology (K.T.T.), Columbia University Medical Center, New York, NY; Department of Neurology (N.V.), Stanford University Medical School, Palo Alto, CA; and Department of Neurology (J.Z.), University of Washington School of Medicine, Seattle.
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10
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Bolzenius J, Sacdalan C, Ndhlovu LC, Sailasuta N, Trautmann L, Tipsuk S, Crowell TA, Suttichom D, Colby DJ, Phanuphak N, Chan P, Premeaux T, Kroon E, Vasan S, Hsu DC, Valcour V, Ananworanich J, Robb ML, Ake JA, Pohl KM, Sriplienchan S, Spudich S, Paul R. Brain volumetrics differ by Fiebig stage in acute HIV infection. AIDS 2023; 37:861-869. [PMID: 36723491 PMCID: PMC10079583 DOI: 10.1097/qad.0000000000003496] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE People with chronic HIV exhibit lower regional brain volumes compared to people without HIV (PWOH). Whether imaging alterations observed in chronic infection occur in acute HIV infection (AHI) remains unknown. DESIGN Cross-sectional study of Thai participants with AHI. METHODS One hundred and twelve Thai males with AHI (age 20-46) and 18 male Thai PWOH (age 18-40) were included. Individuals with AHI were stratified into early (Fiebig I-II; n = 32) and late (Fiebig III-V; n = 80) stages of acute infection using validated assays. T1-weighted scans were acquired using a 3 T MRI performed within five days of antiretroviral therapy (ART) initiation. Volumes for the amygdala, caudate nucleus, hippocampus, nucleus accumbens, pallidum, putamen, and thalamus were compared across groups. RESULTS Participants in late Fiebig stages exhibited larger volumes in the nucleus accumbens (8% larger; P = 0.049) and putamen (19%; P < 0.001) when compared to participants in the early Fiebig. Compared to PWOH, participants in late Fiebig exhibited larger volumes of the amygdala (9% larger; P = 0.002), caudate nucleus (11%; P = 0.005), nucleus accumbens (15%; P = 0.004), pallidum (19%; P = 0.001), and putamen (31%; P < 0.001). Brain volumes in the nucleus accumbens, pallidum, and putamen correlated modestly with stimulant use over the past four months among late Fiebig individuals ( P s < 0.05). CONCLUSIONS Findings indicate that brain volume alterations occur in acute infection, with the most prominent differences evident in the later stages of AHI. Additional studies are needed to evaluate mechanisms for possible brain disruption following ART, including viral factors and markers of neuroinflammation.
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Affiliation(s)
| | - Carlo Sacdalan
- SEARCH, Institute of HIV Research and Innovation, Bangkok, Thailand
| | - Lishomwa C Ndhlovu
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York City, New York
| | - Napapon Sailasuta
- Department of Tropical Medicine, Medical Microbiology & Pharmacology, University of Hawaii, Hawaii
| | - Lydie Trautmann
- Vaccine and Gene Therapy Institute, Oregon Health and Science University, Beaverton, Oregon
| | - Somporn Tipsuk
- SEARCH, Institute of HIV Research and Innovation, Bangkok, Thailand
| | - Trevor A Crowell
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | | | - Donn J Colby
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | | | - Phillip Chan
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Thomas Premeaux
- Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York City, New York
| | - Eugène Kroon
- SEARCH, Institute of HIV Research and Innovation, Bangkok, Thailand
| | - Sandhya Vasan
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Denise C Hsu
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Victor Valcour
- Department of Neurology, University of California, San Francisco, California, USA
| | - Jintanat Ananworanich
- Department of Global Health, Amsterdam University Medical Centers, University of Amsterdam, and Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Merlin L Robb
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc., Bethesda, Maryland
| | - Julie A Ake
- Vaccine and Gene Therapy Institute, Oregon Health and Science University, Beaverton, Oregon
| | - Kilian M Pohl
- Department of Psychiatry and Behavioral Sciences, Stanford University, Stanford, California, USA
| | | | - Serena Spudich
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Robert Paul
- University of Missouri, St. Louis, St. Louis, Missouri, USA
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11
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Joseph SB, Gianella S, Burdo TH, Cinque P, Gisslen M, Letendre S, Nath A, Morgello S, Ndhlovu LC, Spudich S. Biotypes of Central Nervous System Complications in People With Human Immunodeficiency Virus: Virology, Immunology, and Neuropathology. J Infect Dis 2023; 227:S3-S15. [PMID: 36930640 PMCID: PMC10022721 DOI: 10.1093/infdis/jiac370] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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] [Received: 06/21/2022] [Indexed: 03/18/2023] Open
Abstract
Despite viral suppression with antiretroviral therapy (ART), people with human immunodeficiency virus (HIV) continue to experience central nervous system (CNS) complications, primarily in the form of mild cognitive impairment and mental health disorders (eg, depression, anxiety, other neuropsychiatric problems). The multifactorial pathogenesis and heterogeneity of mechanisms likely underlying CNS complications must be addressed in the development of preventive interventions and effective treatments. The biotyping approach has previously been useful to define phenotypes of other CNS diseases based on underlying mechanisms and could be translated to the field of neuroHIV. The purpose of the Biotype Workshop series, and the Virology, Immunology and Neuropathology Working Group in particular, is to capitalize on current and new technologies and guide future research efforts using the wealth of available immunological, virologic, and neuropathological data collected from people with HIV on and off ART.
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Affiliation(s)
- Sarah B Joseph
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina, USA
| | - Sara Gianella
- Department of Medicine, Division of Infectious Disease and Global Public Health, University of California, San Diego, La Jolla, California, USA
| | - Tricia H Burdo
- Department of Microbiology, Immunology and Inflammation, Center for NeuroVirology and Gene Editing, Lewis Katz School of Medicine, Temple University, Philadelphia, Pennsylvania, USA
| | - Paola Cinque
- Unit of Infectious Diseases, San Raffaele Scientific Institute, Milano, Italy
| | - Magnus Gisslen
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Scott Letendre
- Department of Medicine, Division of Infectious Disease and Global Public Health, University of California, San Diego, La Jolla, California, USA
| | - Avindra Nath
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Susan Morgello
- Departments of Neurology, Neuroscience, and Pathology, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Lishomwa C Ndhlovu
- Department of Medicine, Division of Infectious Diseases, Brain and Mind Research Institute, Weill Cornell Medicine, New York, New York, USA
| | - Serena Spudich
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
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12
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Chan P, Yoon B, Colby D, Kroon E, Sacdalan C, Sriplienchan S, Pinyakorn S, Ananworanich J, Valcour V, Vasan S, Hsu D, Phanuphak N, Paul R, Spudich S. Immunological, Cognitive, and Psychiatric Outcomes After Initiating Efavirenz- and Dolutegravir-based Antiretroviral Therapy During Acute Human Immunodeficiency Virus Infection. Clin Infect Dis 2023; 76:e718-e726. [PMID: 35687498 PMCID: PMC9907536 DOI: 10.1093/cid/ciac466] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 05/27/2022] [Accepted: 06/03/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Efavirenz (EFV)- and dolutegravir (DTG)-based antiretroviral therapy (ART) is the former and current recommended regimen for treatment-naive individuals with human immunodeficiency virus type 1 (HIV-1). Whether they impact the immunological and neuropsychiatric profile differentially remains unclear. METHODS This retrospective analysis included 258 participants enrolled during acute HIV-1 infection (AHI). Participants initiated 1 of 3 ART regimens during AHI: EFV-based (n = 131), DTG-based (n = 92), or DTG intensified with maraviroc (DTG/MVC, n = 35). All regimens included 2 nucleoside reverse-transcriptase inhibitors and were maintained for 96 weeks. CD4+ and CD8+ T-cell counts, mood symptoms, and composite score on a 4-test neuropsychological battery (NPZ-4) were compared. RESULTS At baseline, the median age was 26 years, 99% were male, and 36% were enrolled during Fiebig stage I-II. Plasma viral suppression at weeks 24 and 96 was similar between the groups. Compared with the EFV group, the DTG group showed greater increments of CD4+ (P < .001) and CD8+ (P = .015) T-cell counts but a similar increment of CD4/CD8 ratio at week 96. NPZ-4 improvement was similar between the 2 groups at week 24 but greater in the DTG group at week 96 (P = .005). Depressive mood and distress symptoms based on the Patient Health Questionnaire and distress thermometer were similar between the 2 groups at follow-up. Findings for the DTG/MVC group were comparable to those for the DTG group vs the EFV group. CONCLUSIONS Among individuals with AHI, 96 weeks of DTG-based ART was associated with greater increments of CD4+ and CD8+ T-cell counts and improvement in cognitive performance.
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Affiliation(s)
- Phillip Chan
- South East Asia Research Collaboration in HIV, Institute of HIV Research and Innovation, Bangkok, Thailand
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Bohyung Yoon
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland, USA
| | - Donn Colby
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland, USA
| | - Eugène Kroon
- South East Asia Research Collaboration in HIV, Institute of HIV Research and Innovation, Bangkok, Thailand
| | - Carlo Sacdalan
- South East Asia Research Collaboration in HIV, Institute of HIV Research and Innovation, Bangkok, Thailand
| | - Somchai Sriplienchan
- South East Asia Research Collaboration in HIV, Institute of HIV Research and Innovation, Bangkok, Thailand
| | - Suteeraporn Pinyakorn
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland, USA
| | - Jintanat Ananworanich
- Department of Global Health, Amsterdam University Medical Centers, Amsterdam Institute for Global Health and Development, University of Amsterdam, Amsterdam, The Netherlands
| | - Victor Valcour
- Department of Neurology, Memory and Aging Center, University of California–San Francisco, San Francisco,California, USA
| | - Sandhya Vasan
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland, USA
| | - Denise Hsu
- US Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Inc, Bethesda, Maryland, USA
| | - Nittaya Phanuphak
- South East Asia Research Collaboration in HIV, Institute of HIV Research and Innovation, Bangkok, Thailand
| | - Robert Paul
- Faculty of Psychological Sciences, Missouri Institute of Mental Health, University of Missouri-St. Louis, St. Louis, Missouri, USA
| | - Serena Spudich
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
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13
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Kincer LP, Joseph SB, Gilleece MM, Hauser BM, Sizemore S, Zhou S, Di Germanio C, Zetterberg H, Fuchs D, Deeks SG, Spudich S, Gisslen M, Price RW, Swanstrom R. Rebound HIV-1 in cerebrospinal fluid after antiviral therapy interruption is mainly clonally amplified R5 T cell-tropic virus. Nat Microbiol 2023; 8:260-271. [PMID: 36717718 PMCID: PMC10201410 DOI: 10.1038/s41564-022-01306-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [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: 05/05/2022] [Accepted: 12/14/2022] [Indexed: 02/01/2023]
Abstract
HIV-1 persists as a latent reservoir in people receiving suppressive antiretroviral therapy (ART). When ART is interrupted (treatment interruption/TI), rebound virus re-initiates systemic infection in the lymphoid system. During TI, HIV-1 is also detected in cerebrospinal fluid (CSF), although the source of this rebound virus is unknown. To investigate whether there is a distinct HIV-1 reservoir in the central nervous system (CNS), we compared rebound virus after TI in the blood and CSF of 11 participants. Peak rebound CSF viral loads vary and we show that high viral loads and the appearance of clonally amplified viral lineages in the CSF are correlated with the transient influx of white blood cells. We found no evidence of rebound macrophage-tropic virus in the CSF, even in one individual who had macrophage-tropic HIV-1 in the CSF pre-therapy. We propose a model in which R5 T cell-tropic virus is released from infected T cells that enter the CNS from the blood (or are resident in the CNS during therapy), with clonal amplification of infected T cells and virus replication occurring in the CNS during TI.
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Affiliation(s)
- Laura P Kincer
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Sarah Beth Joseph
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC HIV Cure Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Maria M Gilleece
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Biogen, Research Triangle Park, NC, USA
| | - Blake M Hauser
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Ragon Institute of MGH, MIT and Harvard, Cambridge, MA, USA
| | - Sabrina Sizemore
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Shuntai Zhou
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Clara Di Germanio
- Vitalant Research Institute, San Francisco, CA, USA
- Department of Laboratory Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, UK
- UK Dementia Research Institute at UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, China
| | - Dietmar Fuchs
- Division of Biological Chemistry, Biocenter, Innsbruck Medical University, Innsbruck, Austria
| | - Steven G Deeks
- Division of HIV, Infectious Diseases, and Global Medicine, Zuckerberg San Francisco General Hospital, University of California San Francisco, San Francisco, CA, USA
| | - Serena Spudich
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Magnus Gisslen
- Department of Infectious Diseases, Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Infectious Diseases, Gothenburg, Sweden
| | - Richard W Price
- Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Ronald Swanstrom
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
- Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
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14
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Renedo D, Leasure AC, Acosta J, Young RT, Alhanti B, Mac Grory B, Spudich S, Messe S, Reeves M, Hassan AE, Schwamm LH, Matouk C, Sheth KN, Falcone GJ. Abstract WP130: Intracerebral Hemorrhage Outcomes And Trends During The Covid-19 Pandemic. An Observational Study Of 61,417 Cases. Stroke 2023. [DOI: 10.1161/str.54.suppl_1.wp130] [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: 02/05/2023]
Abstract
Background:
Patients with ischemic stroke have worse outcome if there is concomitant coronavirus 2019 (COVID-19) infection. We hypothesize that patients with intracerebral hemorrhage (ICH) during the pandemic era had worse outcomes than ICH patients during the pre-pandemic period, and that concomitant COVID-19 in ICH patients is associated with worse outcome.
Methods:
We analyzed data from Get With The Guidelines® Stroke. We implemented a two-stage design: first, we compared outcomes for ICH patients pre-pandemic (admitted between March 2019 and February 2020) with outcomes for ICH patients admitted during the pandemic (from March 2020 to February 2021); second, we compared outcomes of ICH patients with and without COVID-19 infection admitted during the pandemic (from March 2020 to February 2021). We used multivariable logistic regression adjusted by age, sex, race/ethnicity, and clinical covariates for in-hospital mortality and poor functional outcome using the modified Rankin Scale (mRS) at discharge (mRS >= 4) and a for length of stay (LOS).
Results:
The first stage included 62,743 pre-pandemic and 64,681 intra-pandemic ICH cases 64,681. ICH patients during the pandemic had worse outcomes, including higher modified rankin scale (mRS) (OR 1.10, CI 1.06-1.14) and higher mortality (OR 1.04, CI 1.01-1.07). The second stage included 60,091 COVID-19-negative and 1,326 COVID-19-positive ICH patients. Patients with concomitant COVID-19 infection had worse outcomes, including higher LOS (RR 1.32, CI 1.25-1.39), high mRS (OR 1.68, CI 1.40-2.01), and increased mortality (OR 1.50, CI 1.33-1.71).
(Table).
Conclusion:
When comparing pre- and intra-pandemic cases of ICH, critically ill stroke patients admitted during the pandemic had worse outcomes. When comparing COVID-19 positive and negative ICH cases that happened during the pandemic, those with the infection had worse clinical outcomes. COVID-19 infection is an independent risk factor for poor outcomes in ICH.
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15
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Paul R, Cho K, Bolzenius J, Sacdalan C, Ndhlovu LC, Trautmann L, Krebs S, Tipsuk S, Crowell TA, Suttichom D, Colby DJ, Premeaux TA, Phanuphak N, Chan P, Kroon E, Vasan S, Hsu D, Carrico A, Valcour V, Ananworanich J, Robb ML, Ake JA, Sriplienchan S, Spudich S. Individual Differences in CD4/CD8 T-Cell Ratio Trajectories and Associated Risk Profiles Modeled From Acute HIV Infection. Psychosom Med 2022; 84:976-983. [PMID: 36162059 PMCID: PMC9553252 DOI: 10.1097/psy.0000000000001129] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 07/27/2022] [Indexed: 12/04/2022]
Abstract
OBJECTIVE We examined individual differences in CD4/CD8 T-cell ratio trajectories and associated risk profiles from acute HIV infection (AHI) through 144 weeks of antiretroviral therapy (ART) using a data-driven approach. METHODS A total of 483 AHI participants began ART during Fiebig I-V and completed follow-up evaluations for 144 weeks. CD4+, CD8+, and CD4/CD8 T-cell ratio trajectories were defined followed by analyses to identify associated risk variables. RESULTS Participants had a median viral load (VL) of 5.88 copies/ml and CD4/CD8 T-cell ratio of 0.71 at enrollment. After 144 weeks of ART, the median CD4/CD8 T-cell ratio was 1.3. Longitudinal models revealed five CD4/CD8 T-cell ratio subgroups: group 1 (3%) exhibited a ratio >1.0 at all visits; groups 2 (18%) and 3 (29%) exhibited inversion at enrollment, with normalization 4 and 12 weeks after ART, respectively; and groups 4 (31%) and 5 (18%) experienced CD4/CD8 T-cell ratio inversion due to slow CD4+ T-cell recovery (group 4) or high CD8+ T-cell count (group 5). Persistent inversion corresponded to ART onset after Fiebig II, higher VL, soluble CD27 and TIM-3, and lower eosinophil count. Individuals with slow CD4+ T-cell recovery exhibited higher VL, lower white blood cell count, lower basophil percent, and treatment with standard ART, as well as worse mental health and cognition, compared with individuals with high CD8+ T-cell count. CONCLUSIONS Early HIV disease dynamics predict unfavorable CD4/CD8 T-cell ratio outcomes after ART. CD4+ and CD8+ T-cell trajectories contribute to inversion risk and correspond to specific viral, immune, and psychological profiles during AHI. Adjunctive strategies to achieve immune normalization merit consideration.
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16
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Le LT, Price RW, Gisslén M, Zetterberg H, Emu B, Fabre R, Christian P, Andersen S, Spudich S, Vassallo M. Correlation between CD4/CD8 ratio and neurocognitive performance during early HIV infection. HIV Med 2022; 24:442-452. [PMID: 36134890 DOI: 10.1111/hiv.13411] [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] [Received: 05/13/2022] [Accepted: 09/05/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION CD4/CD8 ratio is a marker of immune activation in HIV infection and has been associated with neurocognitive performance during chronic infection, but little is known about the early phases. The aim of this study was to examine the relationship between blood CD4/CD8 ratio and central nervous system endpoints in primary HIV infection (PHI) before and after antiretroviral treatment (ART). METHODS This was a retrospective analysis of the Primary Infection Stage CNS Events Study (PISCES) cohort. We longitudinally assessed blood and cerebrospinal fluid (CSF) markers of inflammation, immune activation and neuronal injury, and neuropsychological testing performance (NPZ4, an average of three motor and one processing speed tests, and a summarized total score, NPZ11, including also executive function, learning and memory) in ART-naïve participants enrolled during PHI. Spearman correlation and linear mixed models assessed the relationships between the trajectory of CD4/CD8 ratio over time and neurocognitive performance, blood and CSF markers of immune activation and neuronal injury. RESULTS In all, 109 PHI participants were enrolled. The mean CD4/CD8 ratio decreased with longer time from infection to starting treatment (p < 0.001). Every unit increase in NPZ4 score was independently associated with a 0.15 increase in CD4/CD8 ratio (95% CI: 0.002-0.29; p = 0.047), whereas no correlation was found between CD4/CD8 ratio and NPZ11. Among the cognitive domains, only a change in processing speed was correlated with CD4/CD8 ratio over time (p = 0.03). The trajectory of the CD4/CD8 ratio was negatively correlated with change in CSF neurofilament light chain (p = 0.04). CONCLUSIONS The trajectory of CD4/CD8 ratio was independently associated with motor/psychomotor speed performance, suggesting that immune activation is involved in brain injury during the early stages of the infection.
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Affiliation(s)
- Leah T Le
- Department of Neurology, Yale School of Medicine, Yale University New Haven, New Haven, Connecticut, USA
| | - Richard W Price
- Department of Neurology, University of California at San Francisco School of Medicine, San Francisco, California, USA
| | - Magnus Gisslén
- Department of Infectious Diseases at Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Region Västra Götaland, Sahlgrenska University Hospital, Department of Infectious Diseases, Gothenburg, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry at Institute of Neuroscience and Physiology, University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK.,UK Dementia Research Institute at UCL, London, UK.,Hong Kong Center for Neurodegenerative Diseases, Hong Kong, China
| | - Brinda Emu
- Department of Infectious Diseases and Pathology, Yale School of Medicine, Yale University New Haven, Connecticut, USA
| | - Roxane Fabre
- Department of Public Health, Nice University Hospital, Université Côte d'Azur, Nice, France
| | - Pradier Christian
- Department of Public Health, Nice University Hospital, Université Côte d'Azur, Nice, France
| | - Signe Andersen
- Department of Infectious Diseases, Nice University Hospital, Université Côte d'Azur, Nice, France
| | - Serena Spudich
- Department of Neurology, Yale School of Medicine, Yale University New Haven, New Haven, Connecticut, USA.,Center foor Neuroepidemiology and Clinical Neurological Research, Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Matteo Vassallo
- Department of Internal Medicine/Infectious Diseases, Cannes General Hospital, Cannes, France.,Unité de Recherche Clinique Cote d'Azur (UR2CA), URRIS, Centre Hospitalier Universitaire Pasteur 2, Nice, France
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17
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Killingsworth L, Spudich S. Neuropathogenesis of HIV-1: insights from across the spectrum of acute through long-term treated infection. Semin Immunopathol 2022; 44:709-724. [PMID: 35882661 PMCID: PMC10126949 DOI: 10.1007/s00281-022-00953-5] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [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] [Received: 01/29/2022] [Accepted: 05/20/2022] [Indexed: 01/16/2023]
Abstract
This review outlines the neuropathogenesis of HIV, from initial HIV entry into the central nervous system (CNS) to chronic infection, focusing on key advancements in the last 5 years. Discoveries regarding acute HIV infection reveal timing and mechanisms of early HIV entry and replication in the CNS, early inflammatory responses, and establishment of genetically distinct viral reservoirs in the brain. Recent studies additionally explore how chronic HIV infection is maintained in the CNS, examining how the virus remains in a latent "hidden" state in diverse cells in the brain, and how this leads to sustained pathological inflammatory responses. Despite viral suppression with antiretroviral therapy, HIV can persist and even replicate in the CNS, and associate with ongoing neuropathology including CD8 + T-lymphocyte mediated encephalitis. Crucial investigation to advance our understanding of the immune mechanisms that both control viral infection and lead to pathological consequences in the brain is necessary to develop treatments to optimize long-term neurologic health in people living with HIV.
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Affiliation(s)
- Lauren Killingsworth
- Department of Neurology, Yale University School of Medicine, 300 George Street, Room 8300c, New Haven, CT, 06520, USA
| | - Serena Spudich
- Department of Neurology, Yale University School of Medicine, 300 George Street, Room 8300c, New Haven, CT, 06520, USA.
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18
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Ulfhammer G, Edén A, Antinori A, Brew BJ, Calcagno A, Cinque P, De Zan V, Hagberg L, Lin A, Nilsson S, Oprea C, Pinnetti C, Spudich S, Trunfio M, Winston A, Price RW, Gisslén M. Cerebrospinal Fluid Viral Load Across the Spectrum of Untreated Human Immunodeficiency Virus Type 1 (HIV-1) Infection: A Cross-Sectional Multicenter Study. Clin Infect Dis 2022; 75:493-502. [PMID: 34747481 PMCID: PMC9427147 DOI: 10.1093/cid/ciab943] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2021] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND The aim of this large multicenter study was to determine variations in cerebrospinal fluid (CSF) HIV-RNA in different phases of untreated human immunodeficiency virus type 1 (HIV-1) infection and its associations with plasma HIV-RNA and other biomarkers. METHODS Treatment naive adults with available CSF HIV-RNA quantification were included and divided into groups representing significant disease phases. Plasma HIV-RNA, CSF white blood cell count (WBC), neopterin, and albumin ratio were included when available. RESULTS In total, 1018 patients were included. CSF HIV-RNA was in median (interquartile range [IQR]) 1.03 log10 (0.37-1.86) copies/mL lower than in plasma, and correlated with plasma HIV-RNA (r = 0.44, P < .01), neopterin concentration in CSF (r = 0.49, P < .01) and in serum (r = 0.29, P < .01), CSF WBC (r = 0.34, P < .01) and albumin ratio (r = 0.25, P < .01). CSF HIV-RNA paralleled plasma HIV-RNA in all groups except neuroasymptomatic patients with advanced immunodeficiency (CD4 < 200) and patients with HIV-associated dementia (HAD) or opportunistic central nervous system (CNS) infections. Patients with HAD had the highest CSF HIV-RNA (in median [IQR] 4.73 (3.84-5.35) log10 copies/mL). CSF > plasma discordance was found in 126 of 972 individuals (13%) and varied between groups, from 1% in primary HIV, 11% in neuroasymptomatic groups, up to 30% of patients with HAD. CONCLUSIONS Our study confirms previous smaller observations of variations in CSF HIV-RNA in different stages of HIV disease. Overall, CSF HIV-RNA was approximately 1 log10 copies/mL lower in CSF than in plasma, but CSF discordance was found in a substantial minority of subjects, most commonly in patients with HAD, indicating increasing CNS compartmentalization paralleling disease progression.
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Affiliation(s)
- Gustaf Ulfhammer
- Correspondence: G. Ulfhammer, Dept. of Infectious Diseases, Sahlgrenska Academy, University of Gothenburg, SE-416 85 Gothenburg, Sweden ()
| | - Arvid Edén
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Infectious Diseases, Gothenburg, Sweden
| | | | - Bruce J Brew
- Departments of Neurology and Immunology, Peter Duncan Neurosciences Unit St Vincent’s Centre for Applied Medical Research, St Vincent’s Hospital, University of New South Wales and University of Notre Dame, Australia
| | - Andrea Calcagno
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | | | | | - Lars Hagberg
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Infectious Diseases, Gothenburg, Sweden
| | - Amy Lin
- Stanford University School of Medicine, Department of Biomedical Data Science, Palo Alto, California, USA
| | - Staffan Nilsson
- Mathematical Sciences, Chalmers University of Technology, Gothenburg, Sweden
| | - Cristiana Oprea
- Carol Davila University of Medicine and Pharmacy, Victor Babes Clinical Hospital for Infectious and Tropical Diseases, Bucharest, Romania
| | - Carmela Pinnetti
- National Institute of Infectious Diseases L. Spallanzani, Rome, Italy
| | | | - Mattia Trunfio
- Unit of Infectious Diseases, Department of Medical Sciences, University of Torino, Torino, Italy
| | | | - Richard W Price
- University of California at San Francisco, San Francisco, California, USA
| | - Magnus Gisslén
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Region Västra Götaland, Sahlgrenska University Hospital, Department of Infectious Diseases, Gothenburg, Sweden
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19
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Chan P, Spudich S. Investigating vascular diseases in people living with HIV by nuclear imaging. J Nucl Cardiol 2022; 29:1576-1582. [PMID: 33884573 DOI: 10.1007/s12350-021-02613-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 03/11/2021] [Indexed: 10/21/2022]
Affiliation(s)
- Phillip Chan
- SEARCH, Institute of HIV Research and Innovation, Bangkok, Thailand
| | - Serena Spudich
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA.
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20
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Farhadian SF, Lindenbaum O, Zhao J, Corley MJ, Im Y, Walsh H, Vecchio A, Garcia-Milian R, Chiarella J, Chintanaphol M, Calvi R, Wang G, Ndhlovu LC, Yoon J, Trotta D, Ma S, Kluger Y, Spudich S. HIV viral transcription and immune perturbations in the CNS of people with HIV despite ART. JCI Insight 2022; 7:e160267. [PMID: 35801589 PMCID: PMC9310520 DOI: 10.1172/jci.insight.160267] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 05/13/2022] [Indexed: 01/12/2023] Open
Abstract
People with HIV (PWH) on antiretroviral therapy (ART) experience elevated rates of neurological impairment, despite controlling for demographic factors and comorbidities, suggesting viral or neuroimmune etiologies for these deficits. Here, we apply multimodal and cross-compartmental single-cell analyses of paired cerebrospinal fluid (CSF) and peripheral blood in PWH and uninfected controls. We demonstrate that a subset of central memory CD4+ T cells in the CSF produced HIV-1 RNA, despite apparent systemic viral suppression, and that HIV-1-infected cells were more frequently found in the CSF than in the blood. Using cellular indexing of transcriptomes and epitopes by sequencing (CITE-seq), we show that the cell surface marker CD204 is a reliable marker for rare microglia-like cells in the CSF, which have been implicated in HIV neuropathogenesis, but which we did not find to contain HIV transcripts. Through a feature selection method for supervised deep learning of single-cell transcriptomes, we find that abnormal CD8+ T cell activation, rather than CD4+ T cell abnormalities, predominated in the CSF of PWH compared with controls. Overall, these findings suggest ongoing CNS viral persistence and compartmentalized CNS neuroimmune effects of HIV infection during ART and demonstrate the power of single-cell studies of CSF to better understand the CNS reservoir during HIV infection.
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Affiliation(s)
- Shelli F. Farhadian
- Department of Medicine, Section of Infectious Diseases, and
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ofir Lindenbaum
- Program in Applied Mathematics, and
- Interdepartmental Program in Computational Biology and Bioinformatics, Yale University, New Haven, Connecticut, USA
| | - Jun Zhao
- Interdepartmental Program in Computational Biology and Bioinformatics, Yale University, New Haven, Connecticut, USA
- Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Michael J. Corley
- Department of Medicine, Division of Infectious Diseases, and
- Feil Family Brain & Mind Institute, Weill Cornell Medicine, New York, New York, USA
| | - Yunju Im
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Hannah Walsh
- Department of Medicine, Section of Infectious Diseases, and
| | - Alyssa Vecchio
- University of North Carolina-Chapel Hill, Chapel Hill, North Carolina, USA
| | - Rolando Garcia-Milian
- Bioinformatics Support Program, Cushing/Whitney Medical Library, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jennifer Chiarella
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Rachela Calvi
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Guilin Wang
- Yale Center for Genome Analysis, Yale University, New Haven, Connecticut, USA
| | - Lishomwa C. Ndhlovu
- Department of Medicine, Division of Infectious Diseases, and
- Feil Family Brain & Mind Institute, Weill Cornell Medicine, New York, New York, USA
| | - Jennifer Yoon
- Department of Medicine, Section of Infectious Diseases, and
| | - Diane Trotta
- Department of Immunobiology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Shuangge Ma
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Yuval Kluger
- Program in Applied Mathematics, and
- Interdepartmental Program in Computational Biology and Bioinformatics, Yale University, New Haven, Connecticut, USA
- Department of Pathology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Serena Spudich
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
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21
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Abstract
PURPOSE OF REVIEW This review focuses on the cerebrospinal fluid (CSF) findings in connection to the central nervous system (CNS) reservoir in treatment-naïve and virally suppressed PLWH, followed by the findings in CSF HIV-1 escape and analytical treatment interruption studies. RECENT FINDINGS Compared to chronic infection, initiating antiretroviral therapy (ART) during acute HIV-1 infection results in more homogeneous longitudinal benefits in the CNS. Viral variants in CSF HIV-1 escape are independently linked to infected cells from the systemic reservoir and in the CNS, highlighting the phenomenon as a consequence of different mechanisms. HIV-infected cells persist in CSF in nearly half of the individuals on stable ART and are associated with worse neurocognitive performance. Future studies should probe into the origin of the HIV-infected cells in the CSF. Examining the capacity for viral replication would provide new insight into the CNS reservoir and identify strategies to eradicate it or compensate for the insufficiency of ART.
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Affiliation(s)
- Phillip Chan
- SEARCH, Institute of HIV Research and Innovation, Bangkok, Thailand
| | - Serena Spudich
- Department of Neurology and Center for Neuroepidemiology and Clinical Neurological Research, Yale University, New Haven, CT, USA.
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22
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Abstract
[Figure: see text].
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Affiliation(s)
| | - Avindra Nath
- National Institute of Neurological Diseases and Stroke, National Institutes of Health, Bethesda, MD, USA
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23
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Kincer LP, Schnell G, Swanstrom R, Miller MB, Spudich S, Eron JJ, Price RW, Joseph SB. HIV-1 is Transported into the Central Nervous System by Trafficking Infected Cells. Pathog Immun 2022; 7:131-142. [PMID: 36865569 PMCID: PMC9973728 DOI: 10.20411/pai.v7i2.524] [Citation(s) in RCA: 5] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 11/24/2022] [Indexed: 01/25/2023] Open
Abstract
Background In this work, we carried out a cross-sectional study examining HIV-1 and HCV free virus concentrations in blood and cerebrospinal fluid (CSF) to determine whether HIV-1 enters the central nervous system (CNS) passively as virus particles or in the context of migrating infected cells. If virions migrate freely across the blood-cerebrospinal fluid barrier (BCSFB) or the blood-brain barrier (BBB) then HCV and HIV-1 would be detectable in the CSF at proportions similar to that in the blood. Alternatively, virus entry as an infected cell would favor selective entry of HIV-1. Methods We measured HIV-1 and HCV viral loads in the CSF and blood plasma of 4 co-infected participants who were not on antiviral regimens for either infection. We also generated HIV-1 env sequences and performed phylogenetic analyses to determine whether HIV-1 populations in the CSF of these participants were being maintained by local replication. Results While CSF samples taken from all participants had detectable levels of HIV-1, HCV was not detectable in any of the CSF samples despite participants having HCV concentrations in their blood plasma, which exceeded that of HIV-1. Further, there was no evidence of compartmentalized HIV-1 replication in the CNS (Supplementary Figure 1). These results are consistent with a model where HIV-1 particles cross the BBB or the BCSFB within infected cells. In this scenario, we would expect HIV-1 to reach the CSF more readily because the blood contains a much greater number of HIV-infected cells than HCV-infected cells. Conclusions HCV entry into the CSF is restricted, indicating that virions do not freely migrate across these barriers and supporting the concept that HIV-1 is transported across the BCSFB and/or BBB by the migration of HIV-infected cells as part of an inflammatory response or normal surveillance.
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Affiliation(s)
- Laura P Kincer
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.,UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Gretja Schnell
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Ronald Swanstrom
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.,UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Melissa B Miller
- Department of Pathology & Laboratory Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Serena Spudich
- Division of Neurological Infections and Global Neurology, Department of Neurology, Yale University, New Haven, CT
| | - Joseph J Eron
- Division of Infectious Diseases, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Richard W Price
- Department of Neurology, University of California at San Francisco, San Francisco, CA
| | - Sarah B Joseph
- Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, NC.,UNC Center for AIDS Research, University of North Carolina at Chapel Hill, Chapel Hill, NC.,Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Chapel Hill, NC
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24
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Sharma V, Creegan M, Tokarev A, Hsu D, Slike BM, Sacdalan C, Chan P, Spudich S, Ananworanich J, Eller MA, Krebs SJ, Vasan S, Bolton DL. Cerebrospinal fluid CD4+ T cell infection in humans and macaques during acute HIV-1 and SHIV infection. PLoS Pathog 2021; 17:e1010105. [PMID: 34874976 PMCID: PMC8683024 DOI: 10.1371/journal.ppat.1010105] [Citation(s) in RCA: 8] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2021] [Revised: 12/17/2021] [Accepted: 11/10/2021] [Indexed: 12/30/2022] Open
Abstract
HIV-1 replication within the central nervous system (CNS) impairs neurocognitive function and has the potential to establish persistent, compartmentalized viral reservoirs. The origins of HIV-1 detected in the CNS compartment are unknown, including whether cells within the cerebrospinal fluid (CSF) produce virus. We measured viral RNA+ cells in CSF from acutely infected macaques longitudinally and people living with early stages of acute HIV-1. Active viral transcription (spliced viral RNA) was present in CSF CD4+ T cells as early as four weeks post-SHIV infection, and among all acute HIV-1 specimens (N = 6; Fiebig III/IV). Replication-inactive CD4+ T cell infection, indicated by unspliced viral RNA in the absence of spliced viral RNA, was even more prevalent, present in CSF of >50% macaques and human CSF at ~10-fold higher frequency than productive infection. Infection levels were similar between CSF and peripheral blood (and lymph nodes in macaques), indicating comparable T cell infection across these compartments. In addition, surface markers of activation were increased on CSF T cells and monocytes and correlated with CSF soluble markers of inflammation. These studies provide direct evidence of HIV-1 replication in CD4+ T cells and broad immune activation in peripheral blood and the CNS during acute infection, likely contributing to early neuroinflammation and reservoir seeding. Thus, early initiation of antiretroviral therapy may not be able to prevent establishment of CNS viral reservoirs and sources of long-term inflammation, important targets for HIV-1 cure and therapeutic strategies. Neurological pathologies are associated with HIV-1 infection and remain common in the ongoing AIDS epidemic. Despite the advent of successful viremia suppression by anti-retroviral therapy, increased life expectancies and co-morbidities have led to higher prevalence of milder forms of neurocognitive dysfunction. How HIV-1 causes neurocognitive dysfunction is currently unclear, though it is widely believed that viral replication within the central nervous system (CNS) prior to therapy triggers these detrimental processes. The appearance of HIV-1 in the cerebrospinal fluid during the earliest stages of infection suggests that these processes may begin very early. Here, we use novel techniques to probe cells for viral infection during the first few weeks of infection in the CNS of humans and animals to determine the source of this virus. We found HIV-1 replication in T cells in the cerebrospinal fluid during this early window. In addition, infected T cells were present at similar frequencies in the CNS and other anatomic compartments, suggesting equilibration of T cell infection levels across these sites and potential for establishment of long-term reservoirs in the CNS. Our study provides new insights to the early events of viral entry and replication in the CNS with implications for subsequent viral persistence and neuronal injury.
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Affiliation(s)
- Vishakha Sharma
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
| | - Matthew Creegan
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
| | - Andrey Tokarev
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
| | - Denise Hsu
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
- Department of Retrovirology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Bonnie M. Slike
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
| | - Carlo Sacdalan
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - Phillip Chan
- Institute of HIV Research and Innovation, Bangkok, Thailand
| | - Serena Spudich
- Department of Neurology, Yale University, New Haven, Connecticut, United States of America
| | - Jintanat Ananworanich
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
| | - Michael A. Eller
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
| | - Shelly J. Krebs
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
| | - Sandhya Vasan
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
- Department of Retrovirology, Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Diane L. Bolton
- Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, United States of America
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, United States of America
- * E-mail:
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25
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Peng TJ, Jasne AS, Simonov M, Abdelhakim S, Kone G, Cheng YK, Rethana M, Tarasaria K, Herman AL, Baker AD, Yaghi S, Frontera JA, Sansing LH, Falcone GJ, Spudich S, Schindler J, Sheth KN, Sharma R. Prior Stroke and Age Predict Acute Ischemic Stroke Among Hospitalized COVID-19 Patients: A Derivation and Validation Study. Front Neurol 2021; 12:741044. [PMID: 34675873 PMCID: PMC8524436 DOI: 10.3389/fneur.2021.741044] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/06/2021] [Indexed: 11/17/2022] Open
Abstract
Objectives: Our objective was to identify characteristics associated with having an acute ischemic stroke (AIS) among hospitalized COVID-19 patients and the subset of these patients with a neurologic symptom. Materials and Methods: Our derivation cohort consisted of COVID-19 patients admitted to Yale-New Haven Health between January 3, 2020 and August 28, 2020 with and without AIS. We also studied a sub-cohort of hospitalized COVID-19 patients demonstrating a neurologic symptom with and without an AIS. Demographic, clinical, and laboratory results were compared between AIS and non-AIS patients in the full COVID-19 cohort and in the sub-cohort of COVID-19 patients with a neurologic symptom. Multivariable logistic regression models were built to predict ischemic stroke risk in these two COVID-19 cohorts. These 2 models were externally validated in COVID-19 patients hospitalized at a major health system in New York. We then compared the distribution of the resulting predictors in a non-COVID ischemic stroke control cohort. Results: A total of 1,827 patients were included in the derivation cohort (AIS N = 44; no AIS N = 1,783). Among all hospitalized COVID-19 patients, history of prior stroke and platelet count ≥ 200 × 1,000/μL at hospital presentation were independent predictors of AIS (derivation AUC 0.89, validation AUC 0.82), irrespective of COVID-19 severity. Among hospitalized COVID-19 patients with a neurologic symptom (N = 827), the risk of AIS was significantly higher among patients with a history of prior stroke and age <60 (derivation AUC 0.83, validation AUC 0.81). Notably, in a non-COVID ischemic stroke control cohort (N = 168), AIS patients were significantly older and less likely to have had a prior stroke, demonstrating the uniqueness of AIS patients with COVID-19. Conclusions: Hospitalized COVID-19 patients who demonstrate a neurologic symptom and have either a history of prior stroke or are of younger age are at higher risk of ischemic stroke.
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Affiliation(s)
- Teng J Peng
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Adam S Jasne
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Michael Simonov
- Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, United States
| | - Safa Abdelhakim
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Gbambele Kone
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Yee Kuang Cheng
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Melissa Rethana
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Karan Tarasaria
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Alison L Herman
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Anna D Baker
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Shadi Yaghi
- Department of Neurology, New York University Langone Health, New York, NY, United States.,Department of Neurology, Brown University School of Medicine, Providence, RI, United States
| | - Jennifer A Frontera
- Department of Neurology, New York University Langone Health, New York, NY, United States
| | - Lauren H Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Guido J Falcone
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Serena Spudich
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Joseph Schindler
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Kevin N Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Richa Sharma
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
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26
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Weiss JJ, Calvi R, Naganawa M, Toyonaga T, Farhadian SF, Chintanaphol M, Chiarella J, Zheng MQ, Ropchan J, Huang Y, Pietrzak RH, Carson RE, Spudich S. Preliminary In Vivo Evidence of Reduced Synaptic Density in Human Immunodeficiency Virus (HIV) Despite Antiretroviral Therapy. Clin Infect Dis 2021; 73:1404-1411. [PMID: 34050746 PMCID: PMC8528400 DOI: 10.1093/cid/ciab484] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND Synaptic injury is a pathological hallmark of neurological impairment in people living with human immunodeficiency virus (HIV, PLWH), a common complication despite viral suppression with antiretroviral therapy (ART). Measurement of synaptic density in living humans may allow better understanding of HIV neuropathogenesis and provide a dynamic biomarker for therapeutic studies. We applied novel synaptic vesical protein 2A (SV2A) positron emission tomographic (PET) imaging to investigate synaptic density in the frontostriatalthalamic region in PLWH and HIV-uninfected participants. METHODS In this cross-sectional pilot study,13 older male PLWH on ART underwent magnetic resonance imaging (MRI) and PET scanning with the SV2A ligand [11C]UCB-J with partial volume correction and had neurocognitive assessments. SV2A binding potential (BPND) in the frontostriatalthalamic circuit was compared to 13 age-matched HIV-uninfected participants and assessed with respect to neurocognitive performance in PLWH. RESULTS PLWH had 14% lower frontostriatalthalamic SV2A synaptic density compared to HIV-uninfected (PLWH: mean [SD], 3.93 [0.80]; HIV-uninfected: 4.59 [0.43]; P = .02, effect size 1.02). Differences were observed in widespread additional regions in exploratory analyses. Higher frontostriatalthalamic SV2A BPND associated with better grooved pegboard performance, a measure of motor coordination, in PLWH (r = 0.61, P = .03). CONCLUSIONS In a pilot study, SV2A PET imaging reveals reduced synaptic density in older male PLWH on ART compared to HIV-uninfected in the frontostriatalthalamic circuit and other cortical areas. Larger studies controlling for factors in addition to age are needed to determine whether differences are attributable to HIV or comorbidities in PLWH. SV2A imaging is a promising biomarker for studies of neuropathogenesis and therapeutic interventions in HIV.
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Affiliation(s)
- Julian J Weiss
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Rachela Calvi
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Mika Naganawa
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Takuya Toyonaga
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Shelli F Farhadian
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
- Department of Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Jennifer Chiarella
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ming-Qiang Zheng
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Jim Ropchan
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Yiyun Huang
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Robert H Pietrzak
- Department of Psychiatry, Yale School of Medicine, New Haven, Connecticut, USA
- US Department of Veteran Affairs National Center for Posttraumatic Stress Disorder, Clinical Neurosciences Division, VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - Richard E Carson
- Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut, USA
| | - Serena Spudich
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
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27
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Spudich S. Neurological complications of HIV infection. J Neurol Sci 2021. [DOI: 10.1016/j.jns.2021.118040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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28
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Corley MJ, Sacdalan C, Pang APS, Chomchey N, Ratnaratorn N, Valcour V, Kroon E, Cho KS, Belden AC, Colby D, Robb M, Hsu D, Spudich S, Paul R, Vasan S, Ndhlovu LC. Abrupt and altered cell-type specific DNA methylation profiles in blood during acute HIV infection persists despite prompt initiation of ART. PLoS Pathog 2021; 17:e1009785. [PMID: 34388205 PMCID: PMC8386872 DOI: 10.1371/journal.ppat.1009785] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 03/22/2021] [Revised: 08/25/2021] [Accepted: 07/06/2021] [Indexed: 02/06/2023] Open
Abstract
HIV-1 disrupts the host epigenetic landscape with consequences for disease pathogenesis, viral persistence, and HIV-associated comorbidities. Here, we examined how soon after infection HIV-associated epigenetic changes may occur in blood and whether early initiation of antiretroviral therapy (ART) impacts epigenetic modifications. We profiled longitudinal genome-wide DNA methylation in monocytes and CD4+ T lymphocytes from 22 participants in the RV254/SEARCH010 acute HIV infection (AHI) cohort that diagnoses infection within weeks after estimated exposure and immediately initiates ART. We identified monocytes harbored 22,697 differentially methylated CpGs associated with AHI compared to 294 in CD4+ T lymphocytes. ART minimally restored less than 1% of these changes in monocytes and had no effect upon T cells. Monocyte DNA methylation patterns associated with viral load, CD4 count, CD4/CD8 ratio, and longitudinal clinical phenotypes. Our findings suggest HIV-1 rapidly embeds an epigenetic memory not mitigated by ART and support determining epigenetic signatures in precision HIV medicine. Trial Registration:NCT00782808 and NCT00796146. The epigenetic marker, DNA methylation, plays a key role regulating the immune system during host-pathogen interactions. Using cell-type specific DNA methylation profiling, we explored whether epigenetic changes occurred soon after HIV infection and following early treatment with anti-HIV drugs. Acute infection was associated with early DNA methylation changes in purified monocytes and CD4+ T cells isolated from blood. In monocytes, rapid anti-HIV treatment minimally restored DNA methylation changes associated with infection and unexpectedly had no impact in CD4+ T cells. DNA methylation patterns before treatment informed long term clinical outcomes including CD4+ T cell counts and favorable clinical phenotypes. These findings identify candidates for consideration in epigenome editing approaches in HIV prevention, treatment, and cure strategies.
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Affiliation(s)
- Michael J. Corley
- Department of Medicine, Division of Infectious Diseases, Weill Cornell Medicine; New York, New York, United States of America
| | - Carlo Sacdalan
- Institute of HIV Research and Innovation; Bangkok, Thailand
- SEARCH, South East Asia Research Collaboration in HIV; Bangkok, Thailand
| | - Alina P. S. Pang
- Department of Medicine, Division of Infectious Diseases, Weill Cornell Medicine; New York, New York, United States of America
| | - Nitiya Chomchey
- Institute of HIV Research and Innovation; Bangkok, Thailand
- SEARCH, South East Asia Research Collaboration in HIV; Bangkok, Thailand
| | | | - Victor Valcour
- Memory and Aging Center, University of California San Francisco; San Francisco, California, United States of America
| | - Eugene Kroon
- Institute of HIV Research and Innovation; Bangkok, Thailand
- SEARCH, South East Asia Research Collaboration in HIV; Bangkok, Thailand
| | - Kyu S. Cho
- Missouri Institute of Mental Health University of Missouri; St. Louis, Missouri, United States of America
| | - Andrew C. Belden
- Missouri Institute of Mental Health University of Missouri; St. Louis, Missouri, United States of America
| | - Donn Colby
- Institute of HIV Research and Innovation; Bangkok, Thailand
- SEARCH, South East Asia Research Collaboration in HIV; Bangkok, Thailand
| | - Merlin Robb
- Armed Forces Research Institute of Medical Sciences; Bangkok, Thailand
- Henry M. Jackson Foundation for the Advancement of Military Medicine; Bethesda, Maryland, United States of America
| | - Denise Hsu
- Armed Forces Research Institute of Medical Sciences; Bangkok, Thailand
- Henry M. Jackson Foundation for the Advancement of Military Medicine; Bethesda, Maryland, United States of America
| | - Serena Spudich
- Department of Neurology, Yale University; New Haven, Connecticut, United States of America
| | - Robert Paul
- Missouri Institute of Mental Health University of Missouri; St. Louis, Missouri, United States of America
| | - Sandhya Vasan
- Henry M. Jackson Foundation for the Advancement of Military Medicine; Bethesda, Maryland, United States of America
- US Military HIV Research Program; Silver Spring, Maryland, United States of America
| | - Lishomwa C. Ndhlovu
- Department of Medicine, Division of Infectious Diseases, Weill Cornell Medicine; New York, New York, United States of America
- * E-mail:
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29
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Abstract
A 52-year-old woman with HIV and recent antiretroviral therapy non-adherence presented with a 5-day history of widespread painful vesicular skin lesions. Direct fluorescent antibody testing of the skin lesions was positive for varicella zoster virus (VZV). On day 3, she developed profound right upper extremity weakness. MRI of the brain and cervical spine was suggestive of VZV myelitis. Lumbar puncture was positive for VZV PCR in the cerebrospinal fluid (CSF) and CSF HIV viral load was detected at 1030 copies/mL, indicating 'secondary' HIV CSF escape. She was treated with intravenous acyclovir for 4 weeks and subsequent oral therapy with famciclovir then valacyclovir for 6 weeks. She also received dexamethasone. The patient had an almost full recovery at 6 months. Myelitis is a rare complication of reactivated VZV infection that can have atypical presentation in immunocompromised patients. Such 'secondary' HIV CSF escape should be considered in immunosuppressed patients with concomitant central nervous system infection.
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Affiliation(s)
- Julian J Weiss
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA.,Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Serena Spudich
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lydia Barakat
- Infectious Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
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30
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Liu R, Yeh YHJ, Varabyou A, Collora JA, Sherrill-Mix S, Talbot CC, Mehta S, Albrecht K, Hao H, Zhang H, Pollack RA, Beg SA, Calvi RM, Hu J, Durand CM, Ambinder RF, Hoh R, Deeks SG, Chiarella J, Spudich S, Douek DC, Bushman FD, Pertea M, Ho YC. Single-cell transcriptional landscapes reveal HIV-1-driven aberrant host gene transcription as a potential therapeutic target. Sci Transl Med 2021; 12:12/543/eaaz0802. [PMID: 32404504 DOI: 10.1126/scitranslmed.aaz0802] [Citation(s) in RCA: 57] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 10/29/2019] [Accepted: 04/17/2020] [Indexed: 12/22/2022]
Abstract
Understanding HIV-1-host interactions can identify the cellular environment supporting HIV-1 reactivation and mechanisms of clonal expansion. We developed HIV-1 SortSeq to isolate rare HIV-1-infected cells from virally suppressed, HIV-1-infected individuals upon early latency reversal. Single-cell transcriptome analysis of HIV-1 SortSeq+ cells revealed enrichment of nonsense-mediated RNA decay and viral transcription pathways. HIV-1 SortSeq+ cells up-regulated cellular factors that can support HIV-1 transcription (IMPDH1 and JAK1) or promote cellular survival (IL2 and IKBKB). HIV-1-host RNA landscape analysis at the integration site revealed that HIV-1 drives high aberrant host gene transcription downstream, but not upstream, of the integration site through HIV-1-to-host aberrant splicing, in which HIV-1 RNA splices into the host RNA and aberrantly drives host RNA transcription. HIV-1-induced aberrant transcription was driven by the HIV-1 promoter as shown by CRISPR-dCas9-mediated HIV-1-specific activation and could be suppressed by CRISPR-dCas9-mediated inhibition of HIV-1 5' long terminal repeat. Overall, we identified cellular factors supporting HIV-1 reactivation and HIV-1-driven aberrant host gene transcription as potential therapeutic targets to disrupt HIV-1 persistence.
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Affiliation(s)
- Runxia Liu
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, CT 06519, USA
| | - Yang-Hui Jimmy Yeh
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, CT 06519, USA
| | - Ales Varabyou
- Department of Computer Science, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Jack A Collora
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, CT 06519, USA
| | - Scott Sherrill-Mix
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - C Conover Talbot
- Institute for Basic Biomedical Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Sameet Mehta
- Yale Center for Genome Analysis, Yale University, New Haven, CT 06519, USA
| | - Kristen Albrecht
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, CT 06519, USA
| | - Haiping Hao
- Institute for Basic Biomedical Sciences, Johns Hopkins School of Medicine, Baltimore, MD 21205, USA
| | - Hao Zhang
- Department of Molecular Microbiology and Immunology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD 21205, USA
| | - Ross A Pollack
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Subul A Beg
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Rachela M Calvi
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06519, USA
| | - Jianfei Hu
- Vaccine Research Center, National Institute of Health, Bethesda, MD 20892, USA
| | - Christine M Durand
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Richard F Ambinder
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA
| | - Rebecca Hoh
- Department of Medicine, University of California, San Francisco, CA 94110, USA
| | - Steven G Deeks
- Department of Medicine, University of California, San Francisco, CA 94110, USA
| | - Jennifer Chiarella
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06519, USA
| | - Serena Spudich
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06519, USA
| | - Daniel C Douek
- Vaccine Research Center, National Institute of Health, Bethesda, MD 20892, USA
| | - Frederic D Bushman
- Department of Microbiology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
| | - Mihaela Pertea
- Department of Computer Science, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD 21218, USA.,Department of Biomedical Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD 21218, USA
| | - Ya-Chi Ho
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, CT 06519, USA.
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31
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Song E, Bartley CM, Chow RD, Ngo TT, Jiang R, Zamecnik CR, Dandekar R, Loudermilk RP, Dai Y, Liu F, Sunshine S, Liu J, Wu W, Hawes IA, Alvarenga BD, Huynh T, McAlpine L, Rahman NT, Geng B, Chiarella J, Goldman-Israelow B, Vogels CB, Grubaugh ND, Casanovas-Massana A, Phinney BS, Salemi M, Alexander JR, Gallego JA, Lencz T, Walsh H, Wapniarski AE, Mohanty S, Lucas C, Klein J, Mao T, Oh J, Ring A, Spudich S, Ko AI, Kleinstein SH, Pak J, DeRisi JL, Iwasaki A, Pleasure SJ, Wilson MR, Farhadian SF. Divergent and self-reactive immune responses in the CNS of COVID-19 patients with neurological symptoms. Cell Rep Med 2021; 2:100288. [PMID: 33969321 PMCID: PMC8091032 DOI: 10.1016/j.xcrm.2021.100288] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 03/03/2021] [Accepted: 04/22/2021] [Indexed: 12/17/2022]
Abstract
Individuals with coronavirus disease 2019 (COVID-19) frequently develop neurological symptoms, but the biological underpinnings of these phenomena are unknown. Through single-cell RNA sequencing (scRNA-seq) and cytokine analyses of cerebrospinal fluid (CSF) and blood from individuals with COVID-19 with neurological symptoms, we find compartmentalized, CNS-specific T cell activation and B cell responses. All affected individuals had CSF anti-severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies whose target epitopes diverged from serum antibodies. In an animal model, we find that intrathecal SARS-CoV-2 antibodies are present only during brain infection and not elicited by pulmonary infection. We produced CSF-derived monoclonal antibodies from an individual with COVID-19 and found that these monoclonal antibodies (mAbs) target antiviral and antineural antigens, including one mAb that reacted to spike protein and neural tissue. CSF immunoglobulin G (IgG) from 5 of 7 patients showed antineural reactivity. This immune survey reveals evidence of a compartmentalized immune response in the CNS of individuals with COVID-19 and suggests a role of autoimmunity in neurologic sequelae of COVID-19.
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Affiliation(s)
- Eric Song
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Christopher M. Bartley
- Hanna H. Gray Fellow, Howard Hughes Medical Institute, Chevy Chase, MD, USA
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Ryan D. Chow
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | - Thomas T. Ngo
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA
| | - Ruoyi Jiang
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Colin R. Zamecnik
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Ravi Dandekar
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Rita P. Loudermilk
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Yile Dai
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Feimei Liu
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Sara Sunshine
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA, USA
| | - Jamin Liu
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA, USA
- University of California, Berkeley—University of California, San Francisco Gradate Program in Bioengineering, Berkeley, CA, USA
| | - Wesley Wu
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Isobel A. Hawes
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
- Biomedical Sciences Graduate Program, University of California, San Francisco, San Francisco, CA, USA
| | - Bonny D. Alvarenga
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Trung Huynh
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Lindsay McAlpine
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Nur-Taz Rahman
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Bertie Geng
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | | | - Benjamin Goldman-Israelow
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
- Bioinformatics Support Program, Cushing/Whitney Medical Library, Yale University School of Medicine, New Haven, CT, USA
| | - Chantal B.F. Vogels
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Nathan D. Grubaugh
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Arnau Casanovas-Massana
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Brett S. Phinney
- Proteomics Core Facility, UC Davis Genome Center, University of California, Davis, Davis, CA 95616, USA
| | - Michelle Salemi
- Proteomics Core Facility, UC Davis Genome Center, University of California, Davis, Davis, CA 95616, USA
| | - Jessa R. Alexander
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Juan A. Gallego
- Institute for Behavioral Science, The Feinstein Institute for Medical Research, Manhasset, NY, USA
- Division of Psychiatry Research, The Zucker Hillside Hospital, Glen Oaks, NY, USA
- Department of Psychiatry, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Todd Lencz
- Institute for Behavioral Science, The Feinstein Institute for Medical Research, Manhasset, NY, USA
- Division of Psychiatry Research, The Zucker Hillside Hospital, Glen Oaks, NY, USA
- Department of Psychiatry, Zucker School of Medicine at Hofstra/Northwell, Hempstead, NY, USA
| | - Hannah Walsh
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Anne E. Wapniarski
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Subhasis Mohanty
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | - Carolina Lucas
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Jon Klein
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Tianyang Mao
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Jieun Oh
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Aaron Ring
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Serena Spudich
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Albert I. Ko
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Steven H. Kleinstein
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
- Interdepartmental Program in Computational Biology and Bioinformatics, Yale University, New Haven, CT, USA
| | - John Pak
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Joseph L. DeRisi
- Department of Biochemistry and Biophysics, University of California, San Francisco, San Francisco, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Akiko Iwasaki
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
- Department of Molecular, Cellular, and Developmental Biology, Yale School of Medicine, New Haven, CT, USA
- Howard Hughes Medical Institute, Chevy Chase, MD, USA
| | - Samuel J. Pleasure
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Michael R. Wilson
- Weill Institute for Neurosciences, University of California, San Francisco, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - Shelli F. Farhadian
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
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32
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Gisslen M, Keating SM, Spudich S, Arechiga V, Stephenson S, Zetterberg H, Di Germanio C, Blennow K, Fuchs D, Hagberg L, Norris PJ, Peterson J, Shacklett BL, Yiannoutsos CT, Price RW. Compartmentalization of cerebrospinal fluid inflammation across the spectrum of untreated HIV-1 infection, central nervous system injury and viral suppression. PLoS One 2021; 16:e0250987. [PMID: 33983973 PMCID: PMC8118251 DOI: 10.1371/journal.pone.0250987] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Accepted: 04/16/2021] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVE To characterize the evolution of central nervous system (CNS) inflammation in HIV-1 infection applying a panel of cerebrospinal fluid (CSF) inflammatory biomarkers to grouped subjects representing a broad spectrum of systemic HIV-1 immune suppression, CNS injury and viral control. METHODS This is a cross-sectional analysis of archived CSF and blood samples, assessing concentrations of 10 functionally diverse soluble inflammatory biomarkers by immunoassays in 143 HIV-1-infected subjects divided into 8 groups: untreated primary HIV-1 infection (PHI); four untreated groups defined by their blood CD4+ T lymphocyte counts; untreated patients presenting with subacute HIV-associated dementia (HAD); antiretroviral-treated subjects with ≥1 years of plasma viral suppression; and untreated elite controllers. Twenty HIV-1-uninfected controls were included for comparison. Background biomarkers included blood CD4+ and CD8+ T lymphocytes, CSF and blood HIV-1 RNA, CSF white blood cell (WBC) count, CSF/blood albumin ratio, CSF neurofilament light chain (NfL), and CSF t-tau. FINDINGS HIV-1 infection was associated with a broad compartmentalized CSF inflammatory response that developed early in its course and changed with systemic disease progression, development of neurological injury, and viral suppression. CSF inflammation in untreated individuals without overt HAD exhibited at least two overall patterns of inflammation as blood CD4+ T lymphocytes decreased: one that peaked at 200-350 blood CD4+ T cells/μL and associated with lymphocytic CSF inflammation and HIV-1 RNA concentrations; and a second that steadily increased through the full range of CD4+ T cell decline and associated with macrophage responses and increasing CNS injury. Subacute HAD was distinguished by a third inflammatory profile with increased blood-brain barrier permeability and robust combined lymphocytic and macrophage CSF inflammation. Suppression of CSF and blood HIV-1 infections by antiretroviral treatment and elite viral control were associated with reduced CSF inflammation, though not fully to levels found in HIV-1 seronegative controls.
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Affiliation(s)
- Magnus Gisslen
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Infectious Diseases, Region Västra Götaland, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Sheila M. Keating
- Vitalant Research Institute (formerly Blood Systems Research Institute), San Francisco, CA, United States of America
| | - Serena Spudich
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States of America
| | - Victor Arechiga
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States of America
| | - Sophie Stephenson
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States of America
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, Queen Square, London, United Kingdom
- UK Dementia Research Institute at UCL, London, United Kingdom
| | - Clara Di Germanio
- Vitalant Research Institute (formerly Blood Systems Research Institute), San Francisco, CA, United States of America
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Gothenburg, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Dietmar Fuchs
- Institute of Biological Chemistry, Innsbruck Medical University, Innsbruck, Austria
| | - Lars Hagberg
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Philip J. Norris
- Vitalant Research Institute (formerly Blood Systems Research Institute), San Francisco, CA, United States of America
| | - Julia Peterson
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States of America
| | - Barbara L. Shacklett
- Department of Medical Microbiology and Immunology, University of California Davis, Davis CA, United States of America
| | - Constantin T. Yiannoutsos
- Department of Biostatistics, Indiana University R.M. Fairbanks School of Public Health, Indianapolis, IN, United States of America
| | - Richard W. Price
- Department of Neurology, University of California San Francisco, San Francisco, CA, United States of America
- * E-mail:
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33
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Handoko R, Colby DJ, Kroon E, Sacdalan C, de Souza M, Pinyakorn S, Prueksakaew P, Munkong C, Ubolyam S, Akapirat S, Chiarella J, Krebs S, Sereti I, Valcour V, Paul R, Michael NL, Phanuphak N, Ananworanich J, Spudich S. Determinants of suboptimal CD4 + T cell recovery after antiretroviral therapy initiation in a prospective cohort of acute HIV-1 infection. J Int AIDS Soc 2021; 23:e25585. [PMID: 32949118 PMCID: PMC7507109 DOI: 10.1002/jia2.25585] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 06/18/2020] [Accepted: 07/01/2020] [Indexed: 01/19/2023] Open
Abstract
Introduction Up to 30% of individuals treated with antiretroviral therapy (ART) during chronic HIV fail to recover CD4 counts to >500 cells/mm3 despite plasma viral suppression. We investigated the frequency and associations of suboptimal CD4 recovery after ART started during acute HIV infection (AHI). Methods Participants who started ART in Fiebig I to V AHI with ≥48 weeks of continuous documented HIV‐RNA < 50 copies/mL were stratified by CD4 count at latest study visit to suboptimal immune recovery (SIR; CD4 < 350 cells/mm3), intermediate immune recovery (IIR; 350 ≤ CD4 < 500) and complete immune recovery (CIR; CD4 ≥ 500). Clinical and laboratory parameters were assessed at pre‐ART baseline and latest study visit. Additional inflammatory and neurobehavioral endpoints were examined at baseline and 96 weeks. Results Of 304 participants (96% male, median 26 years old) evaluated after median 144 (range 60 to 420) weeks of ART initiated at median 19 days (range 1 to 62) post‐exposure, 3.6% (n = 11) had SIR and 14.5% (n = 44) had IIR. Pre‐ART CD4 count in SIR compared to CIR participants was 265 versus 411 cells/mm3 (p = 0.002). Individuals with SIR or IIR had a slower CD4 rate of recovery compared to those with CIR. Timing of ART initiation by Fiebig stage did not affect CD4 count during treatment. Following ART, the CD8+T cell count (p = 0.001) and CD4/CD8 ratio (p = 0.047) were lower in SIR compared to CIR participants. Compared to the CIR group at week 96, the combined SIR and IIR groups had higher sCD14 (p = 0.008) and lower IL‐6 (p = 0.04) in plasma, without differences in neuropsychological or psychiatric indices. Conclusions Despite immediate and sustained treatment in AHI, suboptimal CD4 recovery occurs uncommonly and is associated with low pre‐ART CD4 count as well as persistent low CD8 count and CD4/CD8 ratio during treatment.
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Affiliation(s)
| | - Donn J Colby
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,United States Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - Eugène Kroon
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Carlo Sacdalan
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Mark de Souza
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Suteeraporn Pinyakorn
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,United States Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | | | | | | | - Siriwat Akapirat
- Armed Forces Research Institute of Medical Sciences, US Army Medical Directorate, Bangkok, Thailand
| | | | - Shelly Krebs
- United States Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Irini Sereti
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Victor Valcour
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - Robert Paul
- Missouri Institute of Mental Health, University of Missouri-St. Louis, St. Louis, MO, USA
| | - Nelson L Michael
- United States Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | | | - Jintanat Ananworanich
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,United States Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
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34
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McAlpine LS, Zubair AS, Maran I, Chojecka P, Lleva P, Jasne AS, Navaratnam D, Matouk C, Schindler J, Sheth KN, Chun H, Lee AI, Spudich S, Sharma R, Sansing LH. Ischemic Stroke, Inflammation, and Endotheliopathy in COVID-19 Patients. Stroke 2021; 52:e233-e238. [PMID: 33966492 PMCID: PMC8140646 DOI: 10.1161/strokeaha.120.031971] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Supplemental Digital Content is available in the text. Reports indicate an increased risk of ischemic stroke during coronavirus disease 2019 (COVID-19) infection. We aimed to identify patients with COVID-19 and ischemic stroke and explore markers of inflammation, hypercoagulability, and endotheliopathy, a structural and functional disturbance of the vascular endothelium due to a stressor.
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Affiliation(s)
- Lindsay S McAlpine
- Department of Neurology (L.S.M., A.S.Z., I.M., P.C., P.L., A.S.J., D.N., J.S., K.N.S., S.S., R.S., L.H.S.), Yale University School of Medicine, New Haven, CT
| | - Adeel S Zubair
- Department of Neurology (L.S.M., A.S.Z., I.M., P.C., P.L., A.S.J., D.N., J.S., K.N.S., S.S., R.S., L.H.S.), Yale University School of Medicine, New Haven, CT
| | - Ilavarasy Maran
- Department of Neurology (L.S.M., A.S.Z., I.M., P.C., P.L., A.S.J., D.N., J.S., K.N.S., S.S., R.S., L.H.S.), Yale University School of Medicine, New Haven, CT
| | - Pola Chojecka
- Department of Neurology (L.S.M., A.S.Z., I.M., P.C., P.L., A.S.J., D.N., J.S., K.N.S., S.S., R.S., L.H.S.), Yale University School of Medicine, New Haven, CT
| | - Paul Lleva
- Department of Neurology (L.S.M., A.S.Z., I.M., P.C., P.L., A.S.J., D.N., J.S., K.N.S., S.S., R.S., L.H.S.), Yale University School of Medicine, New Haven, CT
| | - Adam S Jasne
- Department of Neurology (L.S.M., A.S.Z., I.M., P.C., P.L., A.S.J., D.N., J.S., K.N.S., S.S., R.S., L.H.S.), Yale University School of Medicine, New Haven, CT
| | - Dhasakumar Navaratnam
- Department of Neurology (L.S.M., A.S.Z., I.M., P.C., P.L., A.S.J., D.N., J.S., K.N.S., S.S., R.S., L.H.S.), Yale University School of Medicine, New Haven, CT
| | - Charles Matouk
- Department of Neurosurgery (C.M.), Yale University School of Medicine, New Haven, CT
| | - Joseph Schindler
- Department of Neurology (L.S.M., A.S.Z., I.M., P.C., P.L., A.S.J., D.N., J.S., K.N.S., S.S., R.S., L.H.S.), Yale University School of Medicine, New Haven, CT
| | - Kevin N Sheth
- Department of Neurology (L.S.M., A.S.Z., I.M., P.C., P.L., A.S.J., D.N., J.S., K.N.S., S.S., R.S., L.H.S.), Yale University School of Medicine, New Haven, CT
| | - Hyung Chun
- Department of Internal Medicine, Section of Cardiovascular Medicine (H.C.), Yale University School of Medicine, New Haven, CT
| | - Alfred I Lee
- Department of Internal Medicine, Section of Hematology (A.I.L.), Yale University School of Medicine, New Haven, CT
| | - Serena Spudich
- Department of Neurology (L.S.M., A.S.Z., I.M., P.C., P.L., A.S.J., D.N., J.S., K.N.S., S.S., R.S., L.H.S.), Yale University School of Medicine, New Haven, CT
| | - Richa Sharma
- Department of Neurology (L.S.M., A.S.Z., I.M., P.C., P.L., A.S.J., D.N., J.S., K.N.S., S.S., R.S., L.H.S.), Yale University School of Medicine, New Haven, CT
| | - Lauren H Sansing
- Department of Neurology (L.S.M., A.S.Z., I.M., P.C., P.L., A.S.J., D.N., J.S., K.N.S., S.S., R.S., L.H.S.), Yale University School of Medicine, New Haven, CT.,Department of Immunobiology (L.H.S.), Yale University School of Medicine, New Haven, CT
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35
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Chan P, Colby DJ, Kroon E, Sacdalan C, Pinyakorn S, Paul R, Robb M, Valcour V, Ananworanich J, Marra C, Spudich S. Clinical and laboratory impact of concomitant syphilis infection during acute HIV. HIV Med 2021; 22:502-511. [PMID: 33728759 DOI: 10.1111/hiv.13079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/24/2020] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Cognitive impairment has been reported in people living with HIV-1 (PLWH) with prior syphilis, while PLWH who present with incident syphilis have reduced blood CD4 T-lymphocyte and elevated HIV-1 RNA levels. However, the clinical, virological and neurocognitive effects of syphilis during acute HIV-1 (AHI) remain unknown. METHODS Pre-antiretroviral therapy laboratory outcomes and neurocognitive performance in a four-test battery in the SEARCH10/RV254 AHI cohort were compared according to syphilis status, determined by serum Treponema pallidum haemagglutination (TPHA), Venereal Disease Research Laboratory (VDRL) and syphilis treatment history. Impaired cognitive performance was defined as having z-scores ≤ -1 in at least two tests or ≤ -2 in at least one test. RESULTS Out of 595 AHI participants (97% male, median age of 26 years and estimated duration of HIV-1 infection of 19 days), 119 (20%) had history of syphilis (TPHA-positive), of whom 51 (9%) had untreated syphilis (TPHA-positive/VDRL-positive/without prior treatment). Compared with those without syphilis (TPHA-negative), individuals with untreated syphilis had higher CD8 T-lymphocyte levels but not higher plasma HIV-1 RNA or lower CD4 T-lymphocyte levels. Taking into account estimated duration of HIV-1 infection (P < 0.001), and later Fiebig stages (III-V) (P < 0.001), those with untreated syphilis had higher CD8 T-lymphocyte levels (P = 0.049). Individuals with any syphilis (TPHA-positive), but not untreated syphilis, had higher odds of impaired cognitive performance than those without (P = 0.002). CONCLUSIONS During AHI, individuals with any history of syphilis (TPHA-positive) had poorer cognitive performance than those without syphilis. However, syphilis was not associated with worsened HIV disease measures as described in chronic infection.
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Affiliation(s)
- P Chan
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - D J Colby
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - E Kroon
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - C Sacdalan
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - S Pinyakorn
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - R Paul
- Missouri Institute of Mental Health, University of Missouri-St Louis, St Louis, MO, USA
| | - M Robb
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA
| | - V Valcour
- Memory and Aging Center, Department of Neurology, University of California San Francisco, San Francisco, CA, USA
| | - J Ananworanich
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,Department of Global Health, University of Amsterdam, Amsterdam, The Netherlands
| | - C Marra
- Department of Neurology, University of Washington, Seattle, WA, USA
| | - S Spudich
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
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36
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Abstract
PURPOSE OF REVIEW Over 70 million people worldwide, including those with neurodegenerative disease (NDD), have been diagnosed with coronavirus disease 2019 (COVID-19) to date. We review outcomes in patients with NDD and COVID-19 and discuss the hypothesis that due to putative commonalities of neuropathogenesis, COVID-19 may unmask or trigger NDD in vulnerable individuals. RECENT FINDINGS Based on a systematic review of published literature, patients with NDD, including dementia, Parkinson's disease, and multiple sclerosis (MS) make up a significant portion of hospitalized COVID-19 patients. Such patients are likely to present with altered mental status or worsening of their preexisting neurological symptoms. Patients with NDD and poor outcomes often have high-risk comorbid conditions, including advanced age, hypertension, diabetes, obesity, and heart/lung disease. Patients with dementia including Alzheimer's disease are at higher risk for hospitalization and death, whereas those with preexisting Parkinson's disease are not. MS patients have good outcomes and disease modifying therapies do not increase the risk for severe disease. Viral infections and attendant neuroinflammation have been associated with the pathogenesis of Alzheimer's disease, Parkinson's disease, and MS, suggesting that COVID-19 may have the potential to incite or accelerate neurodegeneration. SUMMARY Since patients with Alzheimer's disease are at higher risk for hospitalization and death in the setting of COVID-19, additional precautions and protective measures should be put in place to prevent infections and optimize management of comorbidities in this vulnerable population. Further studies are needed to determine whether COVID-19 may lead to an increased risk of developing NDD in susceptible individuals.
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Affiliation(s)
- Lindsay S McAlpine
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
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37
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Song E, Bartley CM, Chow RD, Ngo TT, Jiang R, Zamecnik CR, Dandekar R, Loudermilk RP, Dai Y, Liu F, Hawes IA, Alvarenga BD, Huynh T, McAlpine L, Rahman NT, Geng B, Chiarella J, Goldman-Israelow B, Vogels CB, Grubaugh ND, Casanovas-Massana A, Phinney BS, Salemi M, Alexander J, Gallego JA, Lencz T, Walsh H, Lucas C, Klein J, Mao T, Oh J, Ring A, Spudich S, Ko AI, Kleinstein SH, DeRisi JL, Iwasaki A, Pleasure SJ, Wilson MR, Farhadian SF. Exploratory neuroimmune profiling identifies CNS-specific alterations in COVID-19 patients with neurological involvement. bioRxiv 2020:2020.09.11.293464. [PMID: 32935102 PMCID: PMC7491516 DOI: 10.1101/2020.09.11.293464] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
One third of COVID-19 patients develop significant neurological symptoms, yet SARS-CoV-2 is rarely detected in central nervous system (CNS) tissue, suggesting a potential role for parainfectious processes, including neuroimmune responses. We therefore examined immune parameters in cerebrospinal fluid (CSF) and blood samples from a cohort of patients with COVID-19 and significant neurological complications. We found divergent immunological responses in the CNS compartment, including increased levels of IL-12 and IL-12-associated innate and adaptive immune cell activation. Moreover, we found increased proportions of B cells in the CSF relative to the periphery and evidence of clonal expansion of CSF B cells, suggesting a divergent intrathecal humoral response to SARS-CoV-2. Indeed, all COVID-19 cases examined had anti-SARS-CoV-2 IgG antibodies in the CSF whose target epitopes diverged from serum antibodies. We directly examined whether CSF resident antibodies target self-antigens and found a significant burden of CNS autoimmunity, with the CSF from most patients recognizing neural self-antigens. Finally, we produced a panel of monoclonal antibodies from patients' CSF and show that these target both anti-viral and anti-neural antigens-including one mAb specific for the spike protein that also recognizes neural tissue. This exploratory immune survey reveals evidence of a compartmentalized and self-reactive immune response in the CNS meriting a more systematic evaluation of neurologically impaired COVID-19 patients.
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Affiliation(s)
- Eric Song
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Christopher M. Bartley
- Hanna H. Gray Fellow, Howard Hughes Medical Institute, Chevy Chase, MD, USA
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Ryan D. Chow
- Department of Genetics, Yale School of Medicine, New Haven, CT, USA
| | - Thomas T. Ngo
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Psychiatry, University of California, San Francisco, CA, USA
| | - Ruoyi Jiang
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Colin R. Zamecnik
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Ravi Dandekar
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Rita P. Loudermilk
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Yile Dai
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Feimei Liu
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Isobel A. Hawes
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, CA, USA
- Biomedical Sciences Graduate Program, University of California, San Francisco, CA, USA
| | - Bonny D. Alvarenga
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Trung Huynh
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Lindsay McAlpine
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Nur-Taz Rahman
- Bioinformatics Support Program, Cushing/Whitney Medical Library, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Bertie Geng
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
| | | | - Benjamin Goldman-Israelow
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
- Bioinformatics Support Program, Cushing/Whitney Medical Library, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Chantal B.F. Vogels
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Nathan D. Grubaugh
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Arnau Casanovas-Massana
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Brett S. Phinney
- Proteomics Core Facility, UC Davis Genome Center, University of California, Davis, CA 95616, USA
| | - Michelle Salemi
- Proteomics Core Facility, UC Davis Genome Center, University of California, Davis, CA 95616, USA
| | - Jessa Alexander
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Juan A. Gallego
- Institute for Behavioral Science, The Feinstein Institute for Medical Research, Manhasset, New York, USA
- Division of Psychiatry Research, The Zucker Hillside Hospital, Glen Oaks, New York, USA
- Department of Psychiatry, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York USA
| | - Todd Lencz
- Institute for Behavioral Science, The Feinstein Institute for Medical Research, Manhasset, New York, USA
- Division of Psychiatry Research, The Zucker Hillside Hospital, Glen Oaks, New York, USA
- Department of Psychiatry, Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York USA
| | - Hannah Walsh
- Bioinformatics Support Program, Cushing/Whitney Medical Library, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Carolina Lucas
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Jon Klein
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Tianyang Mao
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Jieun Oh
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Aaron Ring
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
| | - Serena Spudich
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
| | - Albert I. Ko
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, USA
| | - Steven H. Kleinstein
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
- Department of Pathology, Yale School of Medicine, New Haven, CT, USA
- Interdepartmental Program in Computational Biology and Bioinformatics, Yale University, New Haven, CT, USA
| | - Joseph L. DeRisi
- Department of Biochemistry and Biophysics, University of California, San Francisco, CA, USA
- Chan Zuckerberg Biohub, San Francisco, CA, USA
| | - Akiko Iwasaki
- Department of Immunobiology, Yale School of Medicine, New Haven, CT, USA
- Department of Molecular, Cellular, and Developmental Biology, Yale School of Medicine, New Haven, CT, USA
- Howard Hughes Medical Institute, Chevy Chase, MD, USA
| | - Samuel J. Pleasure
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Michael R. Wilson
- Weill Institute for Neurosciences, University of California, San Francisco, CA, USA
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Shelli F. Farhadian
- Department of Neurology, Yale School of Medicine, New Haven, CT, USA
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, USA
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Peluso MJ, Colby DJ, Pinyakorn S, Ubolyam S, Intasan J, Trichavaroj R, Chomchey N, Prueksakaew P, Slike BM, Krebs SJ, Jian N, Robb ML, Phanuphak P, Phanuphak N, Spudich S, Ananworanich J, Kroon E. Liver function test abnormalities in a longitudinal cohort of Thai individuals treated since acute HIV infection. J Int AIDS Soc 2020; 23:e25444. [PMID: 31953919 PMCID: PMC6968973 DOI: 10.1002/jia2.25444] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2019] [Accepted: 12/04/2019] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Liver disease is a common cause of non-AIDS morbidity and mortality in people living with HIV (PLHIV), but the prevalence and significance of liver function test (LFT) abnormalities in early HIV infection is unknown. This study aimed to characterize LFTs in a large cohort of participants with acute HIV infection initiating immediate antiretroviral therapy (ART) and examine the association between LFTs and biomarkers of HIV infection and inflammation. METHODS We measured LFTs at the time of HIV diagnosis and at 4, 12, 24 and 48 weeks after ART initiation in 426 Thai individuals with acute HIV infection from 2009 to 2018. A subset of individuals had data available at 96 and 144 weeks. We excluded individuals with concomitant viral hepatitis. Alanine aminotransferase (ALT) was the primary outcome of interest; values greater than 1.25 times the upper limit of normal were considered elevated. Analyses utilized descriptive statistics, non-parametric tests and multivariate logistic regression. RESULTS Sixty-six of the 426 individuals (15.5%) had abnormal baseline ALT levels; the majority (43/66, 65.5%) had Grade 1 elevations. Elevated baseline ALT correlated with Fiebig stages III to V (p = 0.001) and baseline HIV RNA >6 log10 copies/mL (p = 0.012). Baseline elevations resolved by 48 weeks on ART in 59 of the 66 individuals (89%). ALT elevations at 24 and 48 weeks correlated with Fiebig stages I to II at diagnosis (p < 0.001), baseline plasma HIV RNA levels <6 log10 copies/mL (p < 0.001), abnormal baseline ALT (p < 0.001), baseline CD4 >350 cells/μL (p = 0.03) and older age (p = 0.03). Individuals initiating efavirenz-based regimens were more likely to have elevated ALT levels at 48 weeks compared with those on non-efavirenz-based regimens (p = 0.003). CONCLUSIONS One in six people with acute HIV infection have elevated LFTs. Clinical outcomes with ART started in acute HIV are generally good, with resolution of ALT elevations within 48 weeks on ART in most cases. These results suggest a multifactorial model for hepatic injury involving a combination of HIV-associated and ART-associated processes, which may change over time.
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Affiliation(s)
- Michael J Peluso
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, CA, USA
| | - Donn J Colby
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Suteeraporn Pinyakorn
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | | | - Jintana Intasan
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Rapee Trichavaroj
- Armed Forces Research Institute of Medical Sciences, Bangkok, Thailand
| | - Nitiya Chomchey
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | - Bonnie M Slike
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Shelly J Krebs
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Ningbo Jian
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Merlin L Robb
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | | | | | | | - Jintanat Ananworanich
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, MD, USA.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA.,The University of Amsterdam, Amsterdam, The Netherlands
| | - Eugène Kroon
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
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39
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McAlpine LS, Zubair AS, Moeller J, Baehring J, Spudich S. Lessons from a neurology consult service for patients with COVID-19. Lancet Neurol 2020; 19:806-807. [PMID: 32949536 PMCID: PMC7494315 DOI: 10.1016/s1474-4422(20)30316-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 08/19/2020] [Accepted: 08/20/2020] [Indexed: 10/28/2022]
Affiliation(s)
- Lindsay S McAlpine
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Adeel S Zubair
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Jeremy Moeller
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Joachim Baehring
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA
| | - Serena Spudich
- Department of Neurology, Yale University School of Medicine, New Haven, CT 06520, USA.
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40
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Joseph SB, Kincer LP, Bowman NM, Evans C, Vinikoor MJ, Lippincott CK, Gisslén M, Spudich S, Menezes P, Robertson K, Archin N, Kashuba A, Eron JJ, Price RW, Swanstrom R. Human Immunodeficiency Virus Type 1 RNA Detected in the Central Nervous System (CNS) After Years of Suppressive Antiretroviral Therapy Can Originate from a Replicating CNS Reservoir or Clonally Expanded Cells. Clin Infect Dis 2020; 69:1345-1352. [PMID: 30561541 DOI: 10.1093/cid/ciy1066] [Citation(s) in RCA: 47] [Impact Index Per Article: 11.8] [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: 08/06/2018] [Accepted: 12/12/2018] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND Human immunodeficiency virus type 1 (HIV-1) populations are detected in cerebrospinal fluid (CSF) of some people on suppressive antiretroviral therapy (ART). Detailed analysis of these populations may reveal whether they are produced by central nervous system (CNS) reservoirs. METHODS We performed a study of 101 asymptomatic participants on stable ART. HIV-1 RNA concentrations were cross-sectionally measured in CSF and plasma. In participants with CSF HIV-1 RNA concentrations sufficient for analysis, viral populations were genetically and phenotypically characterized over multiple time points. RESULTS For 6% of participants (6 of 101), the concentration of HIV-1 RNA in their CSF was ≥0.5 log copies/mL above that of plasma (ie, CSF escape). We generated viral envelope sequences from CSF of 3 participants. One had a persistent CSF escape population that was macrophage-tropic, partially drug resistant, genetically diverse, and closely related to a minor macrophage-tropic lineage present in the blood prior to viral suppression and enriched for after ART. Two participants (1 suppressed and 1 not) had transient CSF escape populations that were R5 T cell-tropic with little genetic diversity. CONCLUSIONS Extensive analysis of viral populations in 1 participant revealed that CSF escape was from a persistently replicating population, likely in macrophages/microglia, present in the CNS over 3 years of ART. CSF escape in 2 other participants was likely produced by trafficking and transient expansion of infected T cells in the CNS. Our results show that CNS reservoirs can persist during ART and that CSF escape is not exclusively produced by replicating CNS reservoirs.
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Affiliation(s)
- Sarah B Joseph
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Maryland
| | - Laura P Kincer
- Department of Microbiology and Immunology, University of North Carolina at Chapel Hill, Maryland
| | - Natalie M Bowman
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Maryland
| | - Chris Evans
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Maryland
| | - Michael J Vinikoor
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Maryland
| | - Christopher K Lippincott
- Division of Infectious Diseases, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Magnus Gisslén
- Department of Infectious Diseases, Sahlgrenska Academy at the University of Gothenburg, Sweden
| | - Serena Spudich
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Prema Menezes
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Maryland.,University of North Carolina Center for AIDS Research, University of North Carolina at Chapel Hill, San Francisco
| | - Kevin Robertson
- Department of Neurology, University of North Carolina at Chapel Hill, San Francisco
| | - Nancie Archin
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Maryland
| | - Angela Kashuba
- University of North Carolina Center for AIDS Research, University of North Carolina at Chapel Hill, San Francisco.,Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, San Francisco
| | - Joseph J Eron
- Division of Infectious Diseases, School of Medicine, University of North Carolina at Chapel Hill, Maryland.,University of North Carolina Center for AIDS Research, University of North Carolina at Chapel Hill, San Francisco
| | - Richard W Price
- Department of Neurology, University of California, San Francisco
| | - Ronald Swanstrom
- University of North Carolina Center for AIDS Research, University of North Carolina at Chapel Hill, San Francisco.,Department of Biochemistry and Biophysics, University of North Carolina at Chapel Hill
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41
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Hellmuth J, Muccini C, Colby DJ, Kroon E, de Souza M, Crowell TA, Chan P, Sacdalan C, Intasan J, Benjapornpong K, Tipsuk S, Puttamaswin S, Chomchey N, Valcour V, Sarnecki M, Tomaka F, Krebs SJ, Slike BM, Jagodzinski LL, Dumrongpisutikul N, Sailasuta N, Samboju V, Michael NL, Robb ML, Vasan S, Ananworanich J, Phanuphak P, Phanuphak N, Paul R, Spudich S. Central nervous system safety during brief analytic treatment interruption of antiretroviral therapy within four HIV remission trials: an observational study in acutely treated people living with HIV. Clin Infect Dis 2020; 73:e1885-e1892. [PMID: 32916708 DOI: 10.1093/cid/ciaa1344] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 05/04/2020] [Accepted: 09/09/2020] [Indexed: 01/22/2023] Open
Abstract
BACKGROUND The central nervous system (CNS) is a likely reservoir of HIV, vulnerable to viral rebound, inflammation, and clinical changes upon stopping antiretroviral therapy (ART). It is critical to evaluate the CNS safety of studies using analytic treatment interruption (ATI) to assess HIV remission. METHODS Thirty participants who started ART during acute HIV infection underwent CNS assessments across four ATI remission trials. ART resumption occurred with plasma viral load >1000 copies/mL. CNS measures included paired pre- vs. post-ATI measures of mood, cognitive performance, and neurologic examination, with elective cerebrospinal fluid (CSF) sampling, brain diffusion tensor imaging (DTI) and magnetic resonance spectroscopy (MRS). RESULTS Median participant age was 30 years old and 29/30 were male. Participants' median time on ART prior to ATI was 3 years, and ATI lasted a median of 35 days. Post-ATI, there were no differences in median mood scores or neurologic findings and cognitive performance improved modestly. During ATI, a low level of CSF HIV-1 RNA was detectable in six of 20 participants with plasma viremia, with no group changes in CSF immune activation markers or brain DTI measures. Mild worsening was identified in post-ATI basal ganglia total choline MRS, suggesting an alteration in neuronal membranes. CONCLUSION No adverse CNS effects were observed with brief, closely-monitored ATI in participants with acutely treated HIV, except a MRS alteration in basal ganglia choline. Further studies are needed to assess CNS ATI safety in HIV remission trials, particularly for studies using higher thresholds to restart ART and longer ATI durations.
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Affiliation(s)
- Joanna Hellmuth
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, California, USA
| | - Camilla Muccini
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Donn J Colby
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Eugène Kroon
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Mark de Souza
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA
| | - Trevor A Crowell
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Phillip Chan
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Carlo Sacdalan
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Jintana Intasan
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | - Somporn Tipsuk
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | - Nitiya Chomchey
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Victor Valcour
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, California, USA
| | | | - Frank Tomaka
- Janssen Research & Development LLC, Titusville, NJ, USA
| | - Shelly J Krebs
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Bonnie M Slike
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Linda L Jagodzinski
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | | | - Napapon Sailasuta
- Department of Tropical Medicine, Medical Microbiology and Pharmacology, University of Hawaii, Honolulu, Hawaii, USA
| | - Vishal Samboju
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, California, USA
| | - Nelson L Michael
- U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Merlin L Robb
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Sandhya Vasan
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA
| | - Jintanat Ananworanich
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, Maryland, USA.,U.S. Military HIV Research Program, Walter Reed Army Institute of Research, Silver Spring, Maryland, USA.,Department of Global Health, The University of Amsterdam, Amsterdam, The Netherlands
| | - Praphan Phanuphak
- SEARCH, The Thai Red Cross AIDS Research Centre, Bangkok, Thailand.,Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | | | - Robert Paul
- Missouri Institute of Mental Health, University of Missouri-St. Louis, MO, USA
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42
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Sheth KN, Mazurek MH, Yuen MM, Cahn BA, Shah JT, Ward A, Kim JA, Gilmore EJ, Falcone GJ, Petersen N, Gobeske KT, Kaddouh F, Hwang DY, Schindler J, Sansing L, Matouk C, Rothberg J, Sze G, Siner J, Rosen MS, Spudich S, Kimberly WT. Assessment of Brain Injury Using Portable, Low-Field Magnetic Resonance Imaging at the Bedside of Critically Ill Patients. JAMA Neurol 2020; 78:2769858. [PMID: 32897296 PMCID: PMC7489395 DOI: 10.1001/jamaneurol.2020.3263] [Citation(s) in RCA: 103] [Impact Index Per Article: 25.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Accepted: 07/17/2020] [Indexed: 01/17/2023]
Abstract
IMPORTANCE Neuroimaging is a key step in the clinical evaluation of brain injury. Conventional magnetic resonance imaging (MRI) systems operate at high-strength magnetic fields (1.5-3 T) that require strict, access-controlled environments. Limited access to timely neuroimaging remains a key structural barrier to effectively monitor the occurrence and progression of neurological injury in intensive care settings. Recent advances in low-field MRI technology have allowed for the acquisition of clinically meaningful imaging outside of radiology suites and in the presence of ferromagnetic materials at the bedside. OBJECTIVE To perform an assessment of brain injury in critically ill patients in intensive care unit settings, using a portable, low-field MRI device at the bedside. DESIGN, SETTING, AND PARTICIPANTS This was a prospective, single-center cohort study of 50 patients admitted to the neuroscience or coronavirus disease 2019 (COVID-19) intensive care units at Yale New Haven Hospital in New Haven, Connecticut, from October 30, 2019, to May 20, 2020. Patients were eligible if they presented with neurological injury or alteration, no contraindications for conventional MRI, and a body habitus not exceeding the scanner's 30-cm vertical opening. Diagnosis of COVID-19 was determined by positive severe acute respiratory syndrome coronavirus 2 polymerase chain reaction nasopharyngeal swab result. EXPOSURES Portable MRI in an intensive care unit room. MAIN OUTCOMES AND MEASURES Demographic, clinical, radiological, and treatment data were collected and analyzed. Brain imaging findings are described. RESULTS Point-of-care MRI examinations were performed on 50 patients (16 women [32%]; mean [SD] age, 59 [12] years [range, 20-89 years]). Patients presented with ischemic stroke (n = 9), hemorrhagic stroke (n = 12), subarachnoid hemorrhage (n = 2), traumatic brain injury (n = 3), brain tumor (n = 4), and COVID-19 with altered mental status (n = 20). Examinations were acquired at a median of 5 (range, 0-37) days after intensive care unit admission. Diagnostic-grade T1-weighted, T2-weighted, T2 fluid-attenuated inversion recovery, and diffusion-weighted imaging sequences were obtained for 37, 48, 45, and 32 patients, respectively. Neuroimaging findings were detected in 29 of 30 patients who did not have COVID-19 (97%), and 8 of 20 patients with COVID-19 (40%) demonstrated abnormalities. There were no adverse events or complications during deployment of the portable MRI or scanning in an intensive care unit room. CONCLUSIONS AND RELEVANCE This single-center series of patients with critical illness in an intensive care setting demonstrated the feasibility of low-field, portable MRI. These findings demonstrate the potential role of portable MRI to obtain neuroimaging in complex clinical care settings.
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Affiliation(s)
- Kevin N. Sheth
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Mercy H. Mazurek
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew M. Yuen
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Bradley A. Cahn
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Jill T. Shah
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Adrienne Ward
- Neuroscience Intensive Care Unit, Yale New Haven Hospital, New Haven, Connecticut
| | - Jennifer A. Kim
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Emily J. Gilmore
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Guido J. Falcone
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Nils Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Kevin T. Gobeske
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Firas Kaddouh
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - David Y. Hwang
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Joseph Schindler
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Lauren Sansing
- Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven, Connecticut
| | - Jonathan Rothberg
- Department of Genetics, Yale University School of Medicine, New Haven, Connecticut
- Hyperfine Research Inc, Guilford, Connecticut
| | - Gordon Sze
- Department of Radiology, Yale University School of Medicine, New Haven, Connecticut
| | - Jonathan Siner
- Division of Pulmonology and Sleep Medicine, Department of Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Matthew S. Rosen
- Athinoula A. Martinos Center for Biomedical Imaging, Massachusetts General Hospital, Charlestown
| | - Serena Spudich
- Division of Neurology Infections & Global Neurology, Department of Neurology, Yale University School of Medicine, New Haven, Connecticut
| | - W. Taylor Kimberly
- Division of Neurocritical Care, Department of Neurology, Massachusetts General Hospital, Boston
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43
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Kroon ED, Ananworanich J, Pagliuzza A, Rhodes A, Phanuphak N, Trautmann L, Mitchell JL, Chintanaphol M, Intasan J, Pinyakorn S, Benjapornpong K, Chang JJ, Colby DJ, Chomchey N, Fletcher JL, Eubanks K, Yang H, Kapson J, Dantanarayana A, Tennakoon S, Gorelick RJ, Maldarelli F, Robb ML, Kim JH, Spudich S, Chomont N, Phanuphak P, Lewin SR, de Souza MS. A randomized trial of vorinostat with treatment interruption after initiating antiretroviral therapy during acute HIV-1 infection. J Virus Erad 2020; 6:100004. [PMID: 33251022 PMCID: PMC7646672 DOI: 10.1016/j.jve.2020.100004] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 07/09/2020] [Accepted: 07/14/2020] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE AND DESIGN A randomized, open-label pilot study in individuals treated with antiretroviral therapy (ART) since acute HIV infection (AHI) with a regimen including a histone deacetylase inhibitor to induce HIV from latency and control HIV replication during subsequent treatment interruption (TI). METHODS Fifteen participants who initiated ART at AHI were randomized to vorinostat/hydroxychloroquine/maraviroc (VHM) plus ART (n = 10) or ART alone (n = 5). The VHM arm received three 14-day vorinostat cycles within 10 weeks before TI. ART was resumed for plasma viral load (VL) > 1,000 HIV RNA copies/mL. Primary outcome was proportion of participants on VHM + ART versus ART only with VL < 50 copies/mL for 24 weeks after TI. RESULTS Fifteen participants on ART (median: 178 weeks: range 79-295) enrolled. Two on VHM + ART experienced serious adverse events. Fourteen participants underwent TI; all experienced VL rebound with no difference in time between arms: VHM + ART (n = 9) median: 4 weeks and ART only (n = 5) median: 5 weeks. VHM induced a 2.2-fold increase in VL (p = 0.008) by single-copy HIV RNA assay after the first cycle. Neopterin levels increased significantly following the first two cycles. After VHM treatment, the frequencies of peripheral blood mononuclear cells harboring total HIV DNA and cell-associated RNA were unchanged. All participants achieved VL suppression following ART re-initiation. CONCLUSIONS Administration of VHM increased HIV VL in plasma, but this was not sustained. VHM did not impact time to viral rebound following TI and had no impact on the size of the HIV reservoir, suggesting that HIV reservoir elimination will require alternative treatment strategies.
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Affiliation(s)
| | - Jintanat Ananworanich
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- United States Military HIV Research Program, Bethesda, MD, USA
- Bill and Melinda Gates Medical Research Institute, Cambridge, MA, USA
| | - Amélie Pagliuzza
- Centre de Recherche du CHUM and Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montreal, Canada
| | - Ajantha Rhodes
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
- Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Center, Melbourne, Australia
| | | | - Lydie Trautmann
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- United States Military HIV Research Program, Bethesda, MD, USA
| | - Julie L. Mitchell
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- United States Military HIV Research Program, Bethesda, MD, USA
| | - Michelle Chintanaphol
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- Department of Neurology, Yale University School of Medicine, Yale University, New Haven, CT, USA
| | - Jintana Intasan
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Suteeraporn Pinyakorn
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- United States Military HIV Research Program, Bethesda, MD, USA
| | | | - J. Judy Chang
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
- Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Center, Melbourne, Australia
| | - Donn J. Colby
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Nitiya Chomchey
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | | | | | - Hua Yang
- Cooper Human Systems, Nashua, NH, USA
| | | | - Ashanti Dantanarayana
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
- Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Center, Melbourne, Australia
| | - Surekha Tennakoon
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
- Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Center, Melbourne, Australia
| | - Robert J. Gorelick
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, USA
| | - Frank Maldarelli
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
| | - Merlin L. Robb
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- United States Military HIV Research Program, Bethesda, MD, USA
| | - Jerome H. Kim
- International Vaccine Initiative, Seoul, Republic of Korea
| | - Serena Spudich
- Department of Neurology, Yale University School of Medicine, Yale University, New Haven, CT, USA
| | - Nicolas Chomont
- Centre de Recherche du CHUM and Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montreal, Canada
| | | | - Sharon R. Lewin
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
- Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Center, Melbourne, Australia
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Australia
| | | | - for the SEARCH 019 and RV254 Study Teams
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- The Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- United States Military HIV Research Program, Bethesda, MD, USA
- Bill and Melinda Gates Medical Research Institute, Cambridge, MA, USA
- Centre de Recherche du CHUM and Department of Microbiology, Infectiology and Immunology, Université de Montréal, Montreal, Canada
- The Peter Doherty Institute for Infection and Immunity, University of Melbourne and Royal Melbourne Hospital, Melbourne, Australia
- Peter MacCallum Cancer Centre, Victorian Comprehensive Cancer Center, Melbourne, Australia
- Department of Neurology, Yale University School of Medicine, Yale University, New Haven, CT, USA
- Cooper Human Systems, Nashua, NH, USA
- AIDS and Cancer Virus Program, Leidos Biomedical Research, Inc., Frederick National Laboratory for Cancer Research, Frederick, MD, USA
- Center for Cancer Research, National Cancer Institute, Bethesda, MD, USA
- International Vaccine Initiative, Seoul, Republic of Korea
- Department of Infectious Diseases, Alfred Health and Monash University, Melbourne, Australia
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Abstract
High rates of cognitive disorders in antiretroviral-treated people living with HIV have been described worldwide. The exact prevalence of such cognitive disorders is determined by the definitions used, and the presence of these cognitive disorders significantly impacts the overall wellbeing of people with HIV. With the cohort of people with HIV becoming increasingly older, and having high rates of comorbidities and concomitant medication use, rates of cognitive disorders are likely to increase. Conversely, interventions are being sought to reduce the size of the latent HIV reservoir. If successful, such interventions are likely to also reduce the HIV reservoir in the brain compartment, which could result in improvements in cognitive function and reduced rates of impairment.
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Affiliation(s)
- Alan Winston
- Department of Infectious Disease, Imperial College London, London, UK; HIV Clinical Trials, Winston Churchill Wing, St Mary's Hospital, London, UK.
| | - Serena Spudich
- Department of Neurology, Yale University, New Haven, CT, USA
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Zubair AS, McAlpine LS, Gardin T, Farhadian S, Kuruvilla DE, Spudich S. Neuropathogenesis and Neurologic Manifestations of the Coronaviruses in the Age of Coronavirus Disease 2019: A Review. JAMA Neurol 2020; 77:1018-1027. [PMID: 32469387 PMCID: PMC7484225 DOI: 10.1001/jamaneurol.2020.2065] [Citation(s) in RCA: 601] [Impact Index Per Article: 150.3] [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] [Indexed: 12/15/2022]
Abstract
Importance Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in December 2019, causing human coronavirus disease 2019 (COVID-19), which has now spread into a worldwide pandemic. The pulmonary manifestations of COVID-19 have been well described in the literature. Two similar human coronaviruses that cause Middle East respiratory syndrome (MERS-CoV) and severe acute respiratory syndrome (SARS-CoV-1) are known to cause disease in the central and peripheral nervous systems. Emerging evidence suggests COVID-19 has neurologic consequences as well. Observations This review serves to summarize available information regarding coronaviruses in the nervous system, identify the potential tissue targets and routes of entry of SARS-CoV-2 into the central nervous system, and describe the range of clinical neurological complications that have been reported thus far in COVID-19 and their potential pathogenesis. Viral neuroinvasion may be achieved by several routes, including transsynaptic transfer across infected neurons, entry via the olfactory nerve, infection of vascular endothelium, or leukocyte migration across the blood-brain barrier. The most common neurologic complaints in COVID-19 are anosmia, ageusia, and headache, but other diseases, such as stroke, impairment of consciousness, seizure, and encephalopathy, have also been reported. Conclusions and Relevance Recognition and understanding of the range of neurological disorders associated with COVID-19 may lead to improved clinical outcomes and better treatment algorithms. Further neuropathological studies will be crucial to understanding the pathogenesis of the disease in the central nervous system, and longitudinal neurologic and cognitive assessment of individuals after recovery from COVID-19 will be crucial to understand the natural history of COVID-19 in the central nervous system and monitor for any long-term neurologic sequelae.
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Affiliation(s)
- Adeel S Zubair
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Lindsay S McAlpine
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Tova Gardin
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Shelli Farhadian
- Division of Infectious Disease, Department of Medicine, Yale School of Medicine, New Haven, Connecticut
- Division of Neurological Infections and Global Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Deena E Kuruvilla
- Division of Headache and Facial Pain, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
| | - Serena Spudich
- Division of Neurological Infections and Global Neurology, Department of Neurology, Yale School of Medicine, New Haven, Connecticut
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Jasne AS, Chojecka P, Maran I, Mageid R, Eldokmak M, Zhang Q, Nystrom K, Vlieks K, Askenase M, Petersen N, Falcone GJ, Wira CR, Lleva P, Zeevi N, Narula R, Amin H, Navaratnam D, Loomis C, Hwang DY, Schindler J, Hebert R, Matouk C, Krumholz HM, Spudich S, Sheth KN, Sansing LH, Sharma R. Stroke Code Presentations, Interventions, and Outcomes Before and During the COVID-19 Pandemic. Stroke 2020; 51:2664-2673. [PMID: 32755347 PMCID: PMC7446978 DOI: 10.1161/str.0000000000000347] [Citation(s) in RCA: 67] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Supplemental Digital Content is available in the text. Background: Anecdotal reports suggest fewer patients with stroke symptoms are presenting to hospitals during the coronavirus disease 2019 (COVID-19) pandemic. We quantify trends in stroke code calls and treatments at 3 Connecticut hospitals during the local emergence of COVID-19 and examine patient characteristics and stroke process measures at a Comprehensive Stroke Center (CSC) before and during the pandemic. Methods: Stroke code activity was analyzed from January 1 to April 28, 2020, and corresponding dates in 2019. Piecewise linear regression and spline models identified when stroke codes in 2020 began to decline and when they fell below 2019 levels. Patient-level data were analyzed in February versus March and April 2020 at the CSC to identify differences in patient characteristics during the pandemic. Results: A total of 822 stroke codes were activated at 3 hospitals from January 1 to April 28, 2020. The number of stroke codes/wk decreased by 12.8/wk from February 18 to March 16 (P=0.0360) with nadir of 39.6% of expected stroke codes called from March 10 to 16 (30% decrease in total stroke codes during the pandemic weeks in 2020 versus 2019). There was no commensurate increase in within-network telestroke utilization. Compared with before the pandemic (n=167), pandemic-epoch stroke code patients at the CSC (n=211) were more likely to have histories of hypertension, dyslipidemia, coronary artery disease, and substance abuse; no or public health insurance; lower median household income; and to live in the CSC city (P<0.05). There was no difference in age, sex, race/ethnicity, stroke severity, time to presentation, door-to-needle/door-to-reperfusion times, or discharge modified Rankin Scale. Conclusions: Hospital presentation for stroke-like symptoms decreased during the COVID-19 pandemic, without differences in stroke severity or early outcomes. Individuals living outside of the CSC city were less likely to present for stroke codes at the CSC during the pandemic. Public health initiatives to increase awareness of presenting for non-COVID-19 medical emergencies such as stroke during the pandemic are critical.
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Affiliation(s)
- Adam S Jasne
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Pola Chojecka
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Ilavarasy Maran
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Razaz Mageid
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Mohamed Eldokmak
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Qiang Zhang
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Karin Nystrom
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Kelsey Vlieks
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Michael Askenase
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Nils Petersen
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Guido J Falcone
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Charles R Wira
- Department of Emergency Medicine (C.R.W.), Yale University School of Medicine, New Haven, CT
| | - Paul Lleva
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Neer Zeevi
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Reshma Narula
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Hardik Amin
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Dhasakumar Navaratnam
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Caitlin Loomis
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - David Y Hwang
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Joseph Schindler
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Ryan Hebert
- Departments of Neurosurgery and of Radiology and Biomedical Imaging (R.H., C.M.), Yale University School of Medicine, New Haven, CT
| | - Charles Matouk
- Departments of Neurosurgery and of Radiology and Biomedical Imaging (R.H., C.M.), Yale University School of Medicine, New Haven, CT
| | - Harlan M Krumholz
- Department of Cardiology (H.M.K.), Yale University School of Medicine, New Haven, CT
| | - Serena Spudich
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Kevin N Sheth
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Lauren H Sansing
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
| | - Richa Sharma
- Department of Neurology (A.S.J., P.C., I.M., R.M., M.E., Q.Z., K.N., K.V., M.A., N.P., G.J.F., P.L., N.Z., R.N., H.A., D.N., C.L., D.Y.H., J.S., S.S., K.N.S., L.H.S., R.S.), Yale University School of Medicine, New Haven, CT
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Farhadian S, Glick LR, Vogels CBF, Thomas J, Chiarella J, Casanovas-Massana A, Zhou J, Odio C, Vijayakumar P, Geng B, Fournier J, Bermejo S, Fauver JR, Alpert T, Wyllie AL, Turcotte C, Steinle M, Paczkowski P, Dela Cruz C, Wilen C, Ko AI, MacKay S, Grubaugh ND, Spudich S, Barakat LA. Acute encephalopathy with elevated CSF inflammatory markers as the initial presentation of COVID-19. BMC Neurol 2020; 20:248. [PMID: 32552792 PMCID: PMC7301053 DOI: 10.1186/s12883-020-01812-2] [Citation(s) in RCA: 90] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 06/01/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND COVID-19 is caused by the severe acute respiratory syndrome virus SARS-CoV-2. It is widely recognized as a respiratory pathogen, but neurologic complications can be the presenting manifestation in a subset of infected patients. CASE PRESENTATION We describe a 78-year old immunocompromised woman who presented with altered mental status after witnessed seizure-like activity at home. She was found to have SARS-CoV-2 infection and associated neuroinflammation. In this case, we undertake the first detailed analysis of cerebrospinal fluid (CSF) cytokines during COVID-19 infection and find a unique pattern of inflammation in CSF, but no evidence of viral neuroinvasion. CONCLUSION Our findings suggest that neurologic symptoms such as encephalopathy and seizures may be the initial presentation of COVID-19. Central nervous system inflammation may associate with neurologic manifestations of disease.
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Affiliation(s)
- Shelli Farhadian
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, 06510, USA.
- Department of Neurology, Yale School of Medicine, New Haven, CT, 06510, USA.
| | - Laura R Glick
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Chantal B F Vogels
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Jared Thomas
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Jennifer Chiarella
- Department of Neurology, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Arnau Casanovas-Massana
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | | | - Camila Odio
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Pavithra Vijayakumar
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Bertie Geng
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - John Fournier
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Santos Bermejo
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Joseph R Fauver
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Tara Alpert
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Anne L Wyllie
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | | | | | | | - Charles Dela Cruz
- Department of Internal Medicine, Section of Pulmonary, Critical Care, and Sleep Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Craig Wilen
- Department of Laboratory Medicine, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Albert I Ko
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, 06510, USA
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | | | - Nathan D Grubaugh
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, 06510, USA
| | - Serena Spudich
- Department of Neurology, Yale School of Medicine, New Haven, CT, 06510, USA
| | - Lydia Aoun Barakat
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, CT, 06510, USA
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48
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Farhadian S, Glick LR, Vogels CBF, Thomas J, Chiarella J, Casanovas-Massana A, Zhou J, Odio C, Vijayakumar P, Geng B, Fournier J, Bermejo S, Fauver JR, Alpert T, Wyllie AL, Turcotte C, Steinle M, Paczkowski P, Cruz CD, Wilen C, Ko AI, MacKay S, Grubaugh ND, Spudich S, Aoun Barakat L. Acute encephalopathy with elevated CSF inflammatory markers as the initial presentation of COVID-19. Res Sq 2020:rs.3.rs-28583. [PMID: 32702723 PMCID: PMC7336693 DOI: 10.21203/rs.3.rs-28583/v1] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND COVID-19 is caused by the severe acute respiratory syndrome virus SARS-CoV-2. It is widely recognized as a respiratory pathogen, but neurologic complications can be the presenting manifestation in a subset of infected patients. CASE PRESENTATION We describe a 78-year old immunocompromised woman who presented with altered mental status after witnessed seizure-like activity at home. She was found to have SARS-CoV-2 infection and associated neuroinflammation. In this case, we undertake the first detailed analysis of cerebrospinal fluid (CSF) cytokines during COVID-19 infection and find a unique pattern of inflammation in CSF, but no evidence of viral neuroinvasion. CONCLUSION Our findings suggest that neurologic symptoms such as encephalopathy and seizures may be the initial presentation of COVID-19. Central nervous system inflammation may associate with neurologic manifestations of disease.
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49
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Philippi CL, Reyna L, Nedderman L, Chan P, Samboju V, Chang K, Phanuphak N, Ratnaratorn N, Hellmuth J, Benjapornpong K, Dumrongpisutikul N, Pothisri M, Robb ML, Ananworanich J, Spudich S, Valcour V, Paul R. Resting-state neural signatures of depressive symptoms in acute HIV. J Neurovirol 2020; 26:226-240. [PMID: 31989446 PMCID: PMC7261250 DOI: 10.1007/s13365-020-00826-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [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] [Received: 07/15/2019] [Revised: 09/23/2019] [Accepted: 01/16/2020] [Indexed: 02/07/2023]
Abstract
Depressive symptoms are often elevated in acute and chronic HIV. Previous neuroimaging research identifies abnormalities in emotion-related brain regions in depression without HIV, including the anterior cingulate cortex (ACC) and amygdala. However, no studies have examined the neural signatures of depressive symptoms in acute HIV infection (AHI). Seed-based voxelwise resting-state functional connectivity (rsFC) for affective seed regions of interest (pregenual ACC, subgenual ACC [sgACC], bilateral amygdala) was computed for 74 Thai males with AHI and 30 Thai HIV-uninfected controls. Group analyses compared rsFC of ACC and amygdala seed regions between AHI and uninfected control groups. Within the AHI group, voxelwise regression analyses investigated the relationship between depressive symptoms and rsFC for these affective seed regions. Group analyses revealed alterations in rsFC of the amygdala in AHI versus uninfected controls. Depressive symptoms associated with decreased rsFC between ACC regions and posterior cingulate/precuneus, medial temporal, and lateral parietal regions in AHI. Symptoms of depression also correlated to increased rsFC between ACC regions and lateral prefrontal cortex, sgACC, and cerebellum in AHI. Similar to the ACC, depressive symptoms associated with decreased rsFC between amygdala and precuneus. Of blood biomarkers, only HIV RNA inversely correlated with rsFC between posterior sgACC and left uncus. We found that depressive symptoms in AHI associate with altered rsFC of ACC and amygdala regions previously implicated in depression. Longitudinal research in this cohort will be necessary to determine whether these early alterations in rsFC of affective network regions are related to persistent depressive symptoms after combination antiretroviral therapy.
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Affiliation(s)
- Carissa L Philippi
- Department of Psychological Sciences, University of Missouri-St. Louis, St. Louis, MO, USA.
| | - Leah Reyna
- Department of Psychological Sciences, University of Missouri-St. Louis, St. Louis, MO, USA
| | - Laura Nedderman
- Department of Psychological Sciences, University of Missouri-St. Louis, St. Louis, MO, USA
| | - Phillip Chan
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
| | - Vishal Samboju
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA, USA
| | - Kevin Chang
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA, USA
| | | | | | - Joanna Hellmuth
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA, USA
| | | | | | - Mantana Pothisri
- Department of Radiology, Chulalongkorn University Medical Center, Bangkok, Thailand
| | - Merlin L Robb
- U.S. Military HIV Research Program, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
| | - Jintanat Ananworanich
- SEARCH, Thai Red Cross AIDS Research Centre, Bangkok, Thailand
- U.S. Military HIV Research Program, Silver Spring, MD, USA
- Henry M. Jackson Foundation for the Advancement of Military Medicine, Bethesda, MD, USA
- Department of Global Health, The University of Amsterdam, Amsterdam, The Netherlands
| | - Serena Spudich
- Department of Neurology, Yale University, New Haven, CT, USA
| | - Victor Valcour
- Memory and Aging Center, Department of Neurology, University of California, San Francisco, CA, USA
| | - Robert Paul
- Department of Psychological Sciences, University of Missouri-St. Louis, St. Louis, MO, USA
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Chan P, Goh O, Kroon E, Colby D, Sacdalan C, Pinyakorn S, Prueksakaew P, Reiss P, Ananworanich J, Valcour V, Spudich S, Paul R. Neuropsychiatric outcomes before and after switching to dolutegravir-based therapy in an acute HIV cohort. AIDS Res Ther 2020; 17:1. [PMID: 31907064 PMCID: PMC6945418 DOI: 10.1186/s12981-019-0257-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2019] [Accepted: 12/18/2019] [Indexed: 11/15/2022] Open
Abstract
Introduction Dolutegravir (DTG)-based antiretroviral therapy (ART) is currently the first-line treatment for people living with HIV. Neuropsychiatric adverse events (NP-AEs) have been reported with DTG but neuropsychiatric symptoms have not been systemically quantified using structured scales. This study examined mood and cognitive parameters before and after a planned transition from non-DTG to DTG-based ART within a longitudinal study of acute HIV infection (AHI). Methods RV254 AHI cohort participants on ≥ 24 weeks of ART initiated at AHI underwent sequential assessments before and after the switch including: (1) Patient Health Questionnaire-9 (PHQ-9), a 9-item survey (scores 0–27) that evaluates somatic and affective/cognitive symptoms of depression; (2) a 2-Questions screening that has been validated locally for depression; (3) Distress Thermometer (scores 0–10); and 4) administration of a 4-test neurocognitive battery sensitive to HIV. Results 254 individuals (95% male, median age 30) switched to a DTG-based regimen after a median 144 weeks of ART. Serial assessments were completed at a median of 19 weeks before and 37 weeks after DTG. There was a modest but statistically significant increase in PHQ-9 scores after DTG (pre-switch: 5 [IQR 1–7] vs. Post-switch: 5 [IQR 2–8], p = 0.009). The percentage of participants with at least moderate depression (PHQ-9 ≥ 10) increased from 10 to 16% (p = 0.006), but the frequency of moderate-severe depression (PHQ-9 ≥ 15) remained unchanged (3%). No volunteer reported NP-AEs within the study period. Somatic symptoms of depression increased more than cognitive/affective symptoms. Plasma viral suppression (HIV-1 RNA < 50; p = 0.005) and PHQ-9 ≥ 10 (p < 0.001) before switch were linked to lower PHQ-9 scores after DTG in multivariable analysis. Performance on all neuropsychological tests, except grooved pegboard test, improved modestly after DTG (all p < 0.05). Conclusion After a median duration of 37 weeks of DTG use, there was a modest increase in the higher quartile of PHQ-9. This increase was associated with a rise in moderate depression symptoms but not the more severe forms of depression on PHQ-9. No clinically relevant NP-AEs were reported. Pre-existing depression was not associated with subsequent worsening of symptoms after DTG. Cognitive test performance improved post-DTG but could be due to practice effect.
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