Cytomegalovirus cell tropism and clinicopathological characteristics in gastrointestinal tract of patients with HIV/AIDS

BACKGROUND

Cytomegalovirus (CMV) has been recognized as one of the frequently occurring opportunistic infections (OIs) reported in the patients having human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS). In addition, it has been identified as the factor leading to gastrointestinal (GI) tract disorder among HIV/AIDS population. CMV exhibits broad cell tropism in different organs. This study evaluated the CMV cell tropism and clinicopathological characteristics of CMV infection in the different GI regions in HIV/AIDS cases.

METHODS

Using nucleic acid in situ hybridization (ISH), CMV was detected in the gastrointestinal mucosal biopsy samples. The paraffin-embedded samples were stained with hematoxylin and eosin (HE) and immunohistochemistry (IHC), respectively.

RESULTS

A total of 32 HIV/AIDS patients were enrolled in this study. Fourteen of these patients underwent gastroscopy, while the remaining eighteen received colonoscopy. CMV-infected cells were observed at 46 GI sites. Among them, the colon was the region with the highest susceptibility to GI CMV infection (n = 12, 26.1%). The CMV giant cell inclusion bodies were detected in epithelial cells and mesenchymal cells, including histiocytes, smooth muscle cells, fibroblasts, and endothelial cells. In the duodenum, there were markedly more positive epithelial cells than mesenchymal cells (p = 0.033). In contrast, in the esophagus (p = 0.030), cardia (p = 0.003), rectum (p = 0.019), colon (p < 0.001), and cecum (p < 0.001), there were notably less positive epithelial cells than mesenchymal cells. The expression levels of PDGFRα and Nrp2 in the mesenchymal cells were higher than the epithelial cells in cardia, cecum, colon, sigmoid, and rectum, especially in the areas with ulcers. However, Nrp2 in the epithelial cells was higher than that in the duodenum. Moreover, the positive CMV DNA in peripheral blood was related to the CMV-positive cell count, as well as the ulceration in GI tract (p = 0.035 and 0.036, respectively).

CONCLUSIONS

The colon has been identified as the GI site with the highest susceptibility to CMV infection. There are different CMV-infected cells in the different sites of the GI that relate to the expression level of PDGFRα and Nrp2. CMV DNA positive in the blood is related to the positive CMV cell count, as well as ulceration in the GI tract.

Compartmentalized T cell profile in the lungs of patients with HIV-1-associated pulmonary Kaposi sarcoma

Pulmonary Kaposi sarcoma (pKS) caused by Human herpesvirus 8 (HHV-8) is a devastating form of KS in patients with advanced acquired immunodeficiency syndrome (AIDS) and is associated with increased morbidity and mortality. Blood T cells play a central role in the response of HIV-1 and HHV-8. However, little information is available on T cells in the alveolar space of HIV-1-associated pKS patients.Therefore, we examined CD8+ and CD4+ T cells in the alveolar space in comparison with the blood of patients with pKS. We recruited 26 HIV-1 positive patients with KS, including 15 patients with pKS. Bronchoalveolar lavage (BAL) cells and blood mononuclear cells were analyzed for T cell memory phenotypes, surface markers associated with exhaustion, and intracellular cytokine staining (ICS) using flow cytometry. HIV-1 and HHV-8 viral loads were measured in plasma by quantitative PCR.BAL T cells showed reduced inflammatory capacities and significantly diminished polyfunctionality compared to blood T cells from patients with pKS. This was not accompanied by increased expression of exhaustion markers, such as TIM-3 and PD-1.More importantly, we found a negative correlation between the production of MIP1-β and TNF-α in T cells in BAL and blood, indicating compartmentalised immune responses to pKS and accentuated chronic HIV-1/HHV-8 pathogenesis via T cells in the lungs of people with pKS.

Integrative Multi-Omics Reveals Serum Markers of Tuberculosis in Advanced HIV

Tuberculosis (TB) accounts for disproportionate morbidity and mortality among persons living with HIV (PLWH). Conventional methods of TB diagnosis, including smear microscopy and Xpert MTB/RIF, have lower sensitivity in PLWH. Novel high-throughput approaches, such as miRNAomics and metabolomics, may advance our ability to recognize subclinical and difficult-to-diagnose TB, especially in very advanced HIV. We conducted a case-control study leveraging REMEMBER, a multi-country, open-label randomized controlled trial comparing 4-drug empiric standard TB treatment with isoniazid preventive therapy in PLWH initiating antiretroviral therapy (ART) with CD4 cell counts <50 cells/μL. Twenty-three cases of incident TB were site-matched with 32 controls to identify microRNAs (miRNAs), metabolites, and cytokines/chemokines, associated with the development of newly diagnosed TB in PLWH. Differentially expressed miRNA analysis revealed 11 altered miRNAs with a fold change higher than 1.4 or lower than -1.4 in cases relative to controls (p<0.05). Our analysis revealed no differentially abundant metabolites between cases and controls. We found higher TNFα and IP-10/CXCL10 in cases (p=0.011, p=0.0005), and higher MDC/CCL22 in controls (p=0.0072). A decision-tree algorithm identified gamma-glutamylthreonine and hsa-miR-215-5p as the optimal variables to classify incident TB cases (AUC 0.965; 95% CI 0.925-1.000). hsa-miR-215-5p, which targets genes in the TGF-β signaling pathway, was downregulated in cases. Gamma-glutamylthreonine, a breakdown product of protein catabolism, was less abundant in cases. To our knowledge, this is one of the first uses of a multi-omics approach to identify incident TB in severely immunosuppressed PLWH.

Self-collected and clinician-collected anal swabs show modest agreement for HPV genotyping

BACKGROUND & AIM

Women with HIV/HPV coinfection and cervical lesions are at increased risk of developing HPV related anal cancer. Self-collection of anal swabs may facilitate HPV molecular testing in anal cancer screening, especially in high-risk groups, and yet it is not adequately studied. We evaluated level of agreement between self-collected anal swabs (SCAS) and clinician-collected anal swabs (CCAS) when used for HPV genotyping. We also described the anal HPV genotype distribution and HIV/HPV coinfection.

METHODS

We performed a cross sectional study with participants from a visual-inspection-with-acetic-acid and cervicography (VIAC) clinic, in Harare, Zimbabwe. In a clinic setting, the women aged ≥18 years provided anal swabs in duplicate; first CCAS and then SCAS immediately after. HPV detection and genotyping were performed using next generation amplicon sequencing of a 450bp region of the HPV L1 gene. Level of agreement of HPV genotypes between CCAS and SCAS was calculated using the kappa statistic. McNemar tests were used to evaluate agreement in the proportion of genotypes detected by either method.

RESULTS

Three-hundred women provided 600 samples for HPV genotyping. HPV genotypes were detected in 25% of SCAS and in 22% of CCAS. The most common genotypes with CCAS were HPV52, HPV62 and HPV70 and with SCAS were HPV62, HPV44, HPV52, HPV53 and HPV68. Total HPV genotypes detected in CCAS were more than those detected in SCAS, 32 versus 27. The agreement of HPV genotypes between the two methods was 0.55 in kappa value (k). The test of proportions using McNemar gave a Chi-square value of 0.75 (p = 0.39). Multiple HPV infections were detected in 28/75 and 29/67 women for CCAS and SCAS respectively.

CONCLUSIONS

SCAS and CCAS anal swabs showed moderate agreement, with no statistically significant difference in the proportion of genotypes detected by either methods. Although the differences between the two methods were not statistically significant, CCAS detected more HPV genotypes than SCAS and more HPV infections were detected in SCAS than in CCAS. Our data suggest that self-collected anal swabs can be used as an alternative to clinician-collected anal swabs for HPV genotyping.

Ambulatory induction phase treatment of cryptococcal meningitis in HIV integrated primary care clinics, Yangon, Myanmar

BACKGROUND

Cryptococcal meningitis (CM) is a common HIV-associated opportunistic-infection worldwide. Existing literature focusses on hospital-based outcomes of induction treatment. This paper reviews outpatient management in integrated primary care clinics in Yangon.

METHOD

This retrospective case note review analyses a Myanmar HIV-positive patient cohort managed using ambulatory induction-phase treatment with intravenous amphotericin-B-deoxycholate (0.7-1.0 mg/kg) and oral fluconazole (800 mg orally/day).

RESULTS

Seventy-six patients were diagnosed between 2010 and 2017. The median age of patients diagnosed was 35 years, 63% were male and 33 (45%) were on concurrent treatment for tuberculosis. The median CD4 count was 60 at the time of diagnosis. Amphotericin-B-deoxycholate infusions precipitated 56 episodes of toxicity, namely hypokalaemia, nephrotoxicity, anaemia, febrile reactions, phlebitis, observed in 44 patients (58%). One-year survival (86%) was higher than existing hospital-based treatment studies.

CONCLUSION

Ambulation of patients in this cohort saved 1029 hospital bed days and had better survival outcomes when compared to hospital-based studies in other resource constrained settings.

Generation of Liposomes to Study the Effect of Mycobacterium Tuberculosis Lipids on HIV-1 cis- and trans-Infections

Tuberculosis (TB) is the leading cause of death among HIV-1-infected individuals and Mycobacterium tuberculosis (Mtb) co-infection is an early precipitate to AIDS. We aimed to determine whether Mtb strains differentially modulate cellular susceptibility to HIV-1 infection (cis- and trans-infection), via surface receptor interaction by their cell envelope lipids. Total lipids from pathogenic (lineage 4 Mtb H37Rv, CDC1551 and lineage 2 Mtb HN878, EU127) and non-pathogenic (Mycobacterium bovis BCG and Mycobacterium smegmatis) Mycobacterium strains were integrated into liposomes mimicking the lipid distribution and antigen accessibility of the mycobacterial cell wall. The resulting liposomes were tested for modulating in vitro HIV-1 cis- and trans-infection of TZM-bl cells using single-cycle infectious virus particles. Mtb glycolipids did not affect HIV-1 direct infection however, trans-infection of both R5 and X4 tropic HIV-1 strains were impaired in the presence of glycolipids from M. bovis, Mtb H37Rv and Mtb EU127 strains when using Raji-DC-SIGN cells or immature and mature dendritic cells (DCs) to capture virus. SL1, PDIM and TDM lipids were identified to be involved in DC-SIGN recognition and impairment of HIV-1 trans-infection. These findings indicate that variant strains of Mtb have differential effect on HIV-1 trans-infection with the potential to influence HIV-1 disease course in co-infected individuals.

The clinical characteristics and outcome of cryptococcal meningitis with AIDS in a tertiary hospital in China: an observational cohort study

BACKGROUND

Despite the profound impact of antiretroviral therapy in the control of AIDS mortality, central nervous system opportunistic infections remains a significant burden in AIDS patients. This retrospective study aims to elucidate the clinical characteristics, outcome and risk factors of cryptococcal meningitis (CM) poor prognosis in AIDS patients from a tertiary hospital in China.

METHODS

Clinical data from 128 patients admitted in Beijing Ditan Hospital, Capital Medical University from November 2008 to November 2017 was collected. The cohort was stratified based on treatment outcome (effective 79%, and ineffective 21%), and Multivariate Logistic regression analysis used to identify risk factors of poor disease prognosis.

RESULTS

Age, incidence of cerebral infarction, the proportion of consciousness disorder, and fasting plasma glucose was higher in the ineffective treatment group than the effective treatment group. The duration of treatment in the induction period of the ineffective group was significantly shorter than that of the effective group. Multivariate Logistic regression analysis indicated that the occurrence of cerebral hernia and consciousness disorder were risk factors for the prognosis of AIDS patients with CM infection, while the duration of treatment in the induction period was a indicative of a better prognosis in AIDS with CM infection complications. Finally, shunt decompression therapy correlated with a better disease outcome.

CONCLUSIONS

This retrospective study exposes the main risk factors associated with worse disease prognosis in AIDS patients with CM infection complications.

Insufficient tuberculosis treatment leads to earlier and higher mortality in individuals co-infected with HIV in southern China: a cohort study

BACKGROUND

Tuberculosis (TB) and Acquired Immune Deficiency Syndrome (AIDS) are leading causes of death globally. However, little is known about the long-term mortality risk and the timeline of death in those co-infected with human immunodeficiency virus (HIV) and Mycobacterium tuberculosis (MTB). This study sought to understand the long-term mortality risk, factors, and the timeline of death in those with HIV-Mycobacterium tuberculosis (MTB) coinfection, particularly in those with insufficient TB treatment.

METHODS

TB-cause specific deaths were classified using a modified 'Coding of Cause of Death in HIV' protocol. A longitudinal cross-registration-system checking approach was used to confirm HIV/MTB co-infection between two observational cohorts. Mortality from the end of TB treatment (6 months) to post-treatment year (PTY) 5 (60 months) was investigated by different TB treatment outcomes. General linear models were used to estimate the mean mortality at each time-point and change between time-points. Cox's proportional hazard regressions measured the mortality hazard risk (HR) at each time-point. The Mantel-Haenszel stratification was used to identify mortality risk factors. Mortality density was calculated by person year of follow-up.

RESULTS

At the end point, mortality among patients with HIV/MTB coinfection was 34.7%. From the end of TB treatment to PTY5, mortality and loss of person years among individuals with TB treatment failure, missing, and adverse events (TBFMA) were significantly higher than those who had TB cure (TBC) and TB complete regimen (TBCR). Compared to individuals with TBC and with TBCR, individuals with TBFMA tended to die earlier and their mortality was significantly higher (HRTBFMA-TBC = 3.0, 95% confidence interval: 2.5-3.6, HRTBFMA-TBCR = 2.9, 95% CI: 2.5-3.4, P < 0.0001). Those who were naïve to antiretroviral therapy, were farmers, had lower CD4 counts (≤200 cells/μL) and were ≥ 50 years of age were at the highest risk of mortality. Mortality risk for participants with TBFMA was significantly higher across all stratifications except those with a CD4 count of ≤200 cells/μL.

CONCLUSIONS

Earlier and long-term mortality among those with HIV/MTB co-infection is a significant problem when TB treatment fails or is inadequate.

Surgical outcomes and prognostic factors following vitrectomy in acquired immune deficiency syndrome patients with cytomegalovirus retinitis-related retinal detachment

To determine the surgical outcomes and prognostic factors of cytomegalovirus (CMV) retinitis-related retinal detachment (RD) in acquired immune deficiency syndrome (AIDS) patients following vitrectomy.A retrospective charts review was carried out on AIDS patients who were diagnosed with CMV retinitis-related RD and treated with vitrectomy between 2002 and 2016. The main outcome measures were the rates of primary anatomical success and final visual acuity (VA) success defined as postoperative VA ≥20/200. Kaplan-Meier curves on the time to retinal redetachment were performed. Multivariate logistic regression models based on a directed acyclic graph were used to identify independent factors associated with achieving VA success.Forty five AIDS patients (52 eyes) were included. Over a mean follow-up period of 41.7 months, primary anatomical success was achieved in 44 eyes (84.6%) and VA success was achieved in 34 eyes (65.4%). Receiving highly active antiretroviral therapy (HAART) prior to RD (adjusted odds ratio [aOR]=4.9, P = .043), better preoperative VA (aOR = 4.3, P = .006), undergoing vitrectomy within 3 months (aOR=6.7, P = .008), absence of optic atrophy (aOR=58.1, P < .001), and absence of retinal redetachment (aOR=38.1, P = .007) increased the odds of achieving final VA success.Vitrectomy provided favorable anatomical reattachment in AIDS patients with CMV retinitis-related RD. Majority of patients was able to retain functional vision postoperatively. The use of HAART and early vitrectomy increased the probability of achieving both anatomical and VA success.

Incidence and predictors of tuberculosis occurrence among adults on antiretroviral therapy at Debre Markos referral hospital, Northwest Ethiopia: retrospective follow-up study

BACKGROUND

In resource limited settings, Tuberculosis (TB) is a major cause of morbidity and mortality among patients on antiretroviral treatment. Ethiopia is one of the 30 high TB burden countries. TB causes burden in healthcare system and challenge the effectiveness of HIV care. This study was to assess incidence and predictors of Tuberculosis among adults on antiretroviral therapy at Debre Markos Referral Hospital, Northwest Ethiopia, 2019.

METHODS

Institution based retrospective follow up study was conducted among adults on ART newly enrolled from 2014 to 2018 at Debre Markos Referral Hospital. Simple random sampling technique was used to select patients chart. Data was entered to EPI- INFO version 7.2.2.6 and analyzed using Stata 14.0. Tuberculosis incidence rate was computed and described using frequency tables. Both bivariable and multivariable Cox proportional hazard models was fitted to identify predictors of TB.

RESULTS

Out of the 536 patients chart reviewed, 494 patient records were included in the analysis. A total of 62 patients developed new TB cases during the follow up period of 1000.22 Person Years (PY); which gives an overall incidence rate of 6.19 cases per 100 PY (95% CI: 4.83-7.95). The highest rate was seen within the first year of follow up. After adjustment base line Hemoglobin < 10 g/dl (AHR = 5.25; 95% CI: 2.52-10.95), ambulatory/bedridden patients at enrolment (AHR = 2.31; 95% CI: 1.13-4.73), having fair or poor ART adherence (AHR = 3.22; 95% CI: 1.64-6.31) were associated with increased risk of tuberculosis whereas taking Isoniazid Preventive Therapy (IPT) (AHR = 0.33; 95% CI: 0.12-0.85) were protective factors of TB occurrence.

CONCLUSION

TB incidence was high among adults on ART especially in the first year of enrollment to ART. Low hemoglobin level, ambulatory or bedridden functional status, non-adherence to ART and IPT usage status were found to be independent predictors. Hence, continuous follow up for ART adherence and provision of IPT has a great importance to reduce the risk of TB.

Parvovirus B19 DNA detection in treatment-naïve HIV anemic patients in Lagos, Nigeria: a case control study

BACKGROUND

Parvovirus B19 (B19) has tropism for cells of the erythroid lineage, which may lead to transient inhibition of erythropoiesis. Several studies and case reports suggested that B19 infection may contribute significantly to severe chronic anemia in HIV infected persons.

OBJECTIVE

To detect parvovirus B19 DNA in treatment-naïve HIV patients.

METHODS

This was a case control retrospective study. One hundred nineteen anemic and 81 non-anemic treatment-naïve HIV infected patients participated in the study at the Lagos University Teaching Hospital, Lagos, Nigeria. Polymerase chain reaction was used to detect B19 DNA.

RESULTS

Out of 200 patients analysed, 13(6.5%) had parvovirus B19 DNA. Eight HIV patients with anemia had B19 DNA while five non-anemic HIV patients had B19 DNA. This suggests that the presence of B19 DNA in the blood of HIV positive individuals may contribute to anemia because the majority (61.5%) who were positive for B19 DNA had anemia as compared to the non-anemic control group (38.5%).

CONCLUSION

This study shows that the presence of B19 DNA in anemic HIV infected patients is not associated with chronic anaemia in HIV infection because no significant association exist.

Runaway Kaposi Sarcoma-associated herpesvirus replication correlates with systemic IL-10 levels

KSHV-associated inflammatory cytokine syndrome (KICS) is caused by Kaposi's sarcoma-associated herpesvirus (KSHV). KICS is associated with high-level, systemic replication of KSHV. This study characterized the clinical and virologic features of a KICS patient over time. Additionally, it compared the cytokine profiles of the KICS case to Kaposi's sarcoma (KS) (n = 11) and non-KS (n = 6) cases. This KICS case presented with elevated levels of KSHV and IL-10, as expected. Surprisingly, this case did not have elevated levels of IL-6 or human immunodeficiency virus 1 (HIV-1). Nevertheless, treatment with anti-IL6 receptor antibody (tocilizumab) reduced KSHV viral load and IL-10. The KSHV genome sequence showed no significant changes over time, except in ORF24. Phylogenetic analysis established this isolate as belonging to KSHV clade A and closely related to other US isolates. These findings suggest IL-10 as potential biomarker and therapy target for KICS.

Integrating HCV testing with HIV programs improves hepatitis C outcomes in people who inject drugs: A cluster-randomized trial

BACKGROUND & AIMS

There have been calls to integrate HCV testing into existing services, including harm reduction and HIV prevention and treatment, but there are few empirical trials to date. We evaluated the impact of integrating HCV testing/education into integrated care centers (ICCs) delivering HIV services to people who inject drugs (PWID) across India, using a cluster-randomized trial.

METHODS

We compared ICCs with usual care in the PWID stratum (12 sites) of a 22-site cluster-randomized trial. In 6 sites, ICCs delivering HIV testing, harm reduction, other preventive services and linkage to HIV treatment were scaled from opioid agonist therapy centers and operated for 2 years. On-site rapid HCV antibody testing was integrated after 1 year. To assess impact, we conducted baseline and evaluation surveys using respondent-driven sampling (RDS) across the 12 sites (n = 11,993 recruited at baseline; n = 11,721 recruited at evaluation). The primary outcome was population-level self-reported HCV testing history.

RESULTS

At evaluation, HCV antibody prevalence ranged from 7.2-76.6%. Across 6 ICCs, 5,263 ICC clients underwent HCV testing, of whom 2,278 were newly diagnosed. At evaluation, PWID in ICC clusters were 4-fold more likely to report being tested for HCV than in usual care clusters, adjusting for baseline testing (adjusted prevalence ratio [aPR] 3.69; 95% CI 1.34-10.2). PWID in ICC clusters were also 7-fold more likely to be aware of their HCV status (aPR 7.11; 95% CI 1.14-44.3) and significantly more likely to initiate treatment (aPR 9.86; 95% CI 1.52-63.8).

CONCLUSIONS

We provide among the first empirical data supporting the integration of HCV testing into HIV/harm reduction services. To achieve elimination targets, programs will need to scale-up such venues to deliver comprehensive HCV services. CLINICALTRIALS.

GOV IDENTIFIER

NCT01686750.

LAY SUMMARY

Delivering hepatitis C virus (HCV) testing to people who inject drugs (PWID) in places where they also have access to HIV prevention and treatment services is an effective way to improve uptake of HCV testing among communities of PWID. To achieve the World Health Organization's ambitious elimination targets, integrated programs will need to be scaled up to deliver comprehensive HCV services.

Neurological disorders in HIV in Africa: a review

BACKGROUND

Neurological disorders in HIV infection are a common cause of morbidity and mortality. The aim of this paper is to provide a narrative overview of up to date information concerning neurological disorders affecting HIV infected persons in Africa.

METHODS

Seminal research concerning neurological disorders among HIV-infected adults in sub-Saharan Africa from prior to 2000 was combined with an in-depth search of PubMed to identify literature published from 2000 to 2017. The following Mesh terms were used. "Nervous System Diseases" "HIV Infections" and "Africa South of the Sahara" and "Seizures" or "Spinal Cord Diseases" or "Peripheral Nervous System Diseases" or "AIDS Dementia Complex" or "Opportunistic Infections" or "Immune Reconstitution Inflammatory Syndrome" or "Stroke". Only those articles written in English were used. A total of 352 articles were identified, selected and reviewed and 180 were included in the study. These included case series, observational studies, interventional studies, guidelines and reviews with metanalyses. The author also included 15 publications on the subject covering the earlier phase of the HIV epidemic in Africa from 1987 to 1999 making a total of 195 references in the study. This was combined with extensive personal experience diagnosing and treating these neurological disorders.

RESULTS

Neurological disorders were common, typically occurring in WHO stages III/IV. These were in three main categories: those arising from opportunistic processes mostly infections, direct HIV infection and autoimmunity. The most common were those arising from direct HIV infection occurring in >50%. These included HIV-associated neurocognitive dysfunction (HAND), neuropathy and myelopathy. Opportunistic infections occurred in >20% and frequently had a 6-9-month mortality rate of 60-70%. The main causes were cryptococcus, tuberculosis, toxoplasmosis and acute bacterial meningitis. Concurrent systemic tuberculosis occurred in almost 50%.

CONCLUSION

Neurological disorders are common in HIV in Africa and the main CNS opportunistic infections result in high mortality rates. Strategies aimed at reducing their high burden, morbidity and mortality include early HIV diagnosis and anti-retroviral therapy (ART), screening and chemoprophylaxis of main opportunistic infections, improved clinical diagnosis and management and programme strengthening.

Spatially targeted screening to reduce tuberculosis transmission in high-incidence settings

As the leading infectious cause of death worldwide and the primary proximal cause of death in individuals living with HIV, tuberculosis remains a global concern. Existing tuberculosis control strategies that rely on passive case-finding appear insufficient to achieve targets for reductions in tuberculosis incidence and mortality. Active case-finding strategies aim to detect infectious individuals earlier in their infectious period to reduce onward transmission and improve treatment outcomes. Empirical studies of active case-finding have produced mixed results and determining how to direct active screening to those most at risk remains a topic of intense research. Our systematic review of literature evaluating the effects of geographically targeted tuberculosis screening interventions found three studies in low tuberculosis incidence settings, but none conducted in high tuberculosis incidence countries. We discuss open questions related to the use of spatially targeted approaches for active screening in countries where tuberculosis incidence is highest.

Intravitreal and Systemic Foscarnet in the Treatment of Aids-Related Cmv Retinitis

Cytomegalovirus retinitis is the most frequent ocular opportunistic infection in AIDS patients. Untreated, it is always a progressive and destructive disease of the retina that results in blindness. Specific treatment is therefore mandatory to halt the progression of the retinal lesions. The authors report their experience in the treatment of CMV retinitis with foscarnet in 25 AIDS patients; the drug is an analog of pyrophosphate, virostatic against all herpes-class viruses including CMV. Foscarnet was successful in halting the progression of CMV retinitis during induction treatment (180 mg/kg/day) by either a TID (three times a day) or a BID (twice a day) regimen, and in healing retinal lesions during maintenance (90 mg/kg/day) in 14 out of 19 patients. Five patients had a relapse of retinitis during maintenance. In these patients a brief course of intravitreal foscarnet, in association with the lowest dosage of the drug administered systematically (90 mg/kg/day), was effective in healing the retinal lesions. The main systemic side effects, such as renal impairment and electrolytic disturbances, were observed only during the induction treatment, and only in one case was it necessary to stop the therapy.

The effect of HIV infection and HCV viremia on inflammatory mediators and hepatic injury-The Women's Interagency HIV Study

Hepatitis C virus infection induces inflammation and while it is believed that HIV co-infection enhances this response, HIV control may reduce inflammation and liver fibrosis in resolved or viremic HCV infection. Measurement of systemic biomarkers in co-infection could help define the mechanism of inflammation on fibrosis and determine if HIV control reduces liver pathology. A nested case-control study was performed to explore the relationship of systemic biomarkers of inflammation with liver fibrosis in HCV viremic and/or seropositive women with and without HIV infection. Serum cytokines, chemokines, growth factors and cell adhesion molecules were measured in HIV uninfected (HIV-, n = 18), ART-treated HIV-controlled (ARTc, n = 20), uncontrolled on anti-retroviral therapy (ARTuc, n = 21) and elite HIV controllers (Elite, n = 20). All were HCV seroreactive and had either resolved (HCV RNA-; <50IU/mL) or had chronic HCV infection (HCV RNA+). In HCV and HIV groups, aspartate aminotransferase to platelet ratio (APRI) was measured and compared to serum cytokines, chemokines, growth factors and cell adhesion molecules. APRI correlated with sVCAM, sICAM, IL-10, and IP-10 levels and inversely correlated with EGF, IL-17, TGF-α and MMP-9 levels. Collectively, all HCV RNA+ subjects had higher sVCAM, sICAM and IP-10 compared to HCV RNA-. In the ART-treated HCV RNA+ groups, TNF-α, GRO, IP-10, MCP-1 and MDC were higher than HIV-, Elite or both. In ARTuc, FGF-2, MPO, soluble E-selectin, MMP-9, IL-17, GM-CSF and TGF-α are lower than HIV-, Elite or both. Differential expression of soluble markers may reveal mechanisms of pathogenesis or possibly reduction of fibrosis in HCV/HIV co-infection.

Genotypic distribution of HHV-8 in AIDS individuals without and with Kaposi sarcoma: Is genotype B associated with better prognosis of AIDS-KS?

AIDS-associated Kaposi's sarcoma (AIDS-KS) caused by human herpes virus 8 (HHV-8) is the most severe and resistant form of KS tumor. Our aim was to verify whether there is an association between HHV-8 variability and development of AIDS-KS in Brazil by comparing the HHV-8 variability between individuals without and with KS. Saliva samples and blood, when available, were analyzed by polymerase chain reaction (PCR) techniques for detection of the fragments of ORF K1 of HHV-8, which were then genotyped and analyzed regarding the genetic variability. Our study described 106 positive cases for HHV-8 in the saliva from 751 AIDS patients without previous KS. In addition, we performed a phylogenetic analysis of HHV-8 in 34 of the 106 AIDS patients without KS and in 33 of the 37 patients with active KS. The distribution of HHV-8 genotypes A, B, C, and F in AIDS individuals was indistinguishable by comparing non-KS and KS groups, as well as regarding ethnicity. Considering the KS group, genotype B was associated with better prognosis of KS tumor. Interestingly, we found a particular profile of diversity within clade C and 2 recombinant patterns of HHV-8 in the saliva of AIDS individuals without KS. We emphasize the need to achieve standard genotyping protocol for ORF K1 amplification, thus allowing for substantial detection of HHV-8 variants. Our findings can shed light on the role of HHV-8 variability in the pathogenesis of AIDS-KS.

Cytomegalovirus Co-infection in AIDS-associated Oral Kaposi’s Sarcoma

The increasing appearance of AIDS-associated oral Kaposi’s sarcoma (KS) in South Africa may be ascribed to the later start of the HIV epidemic, more patients reaching stages III and IV, and the inaccessibility of most patients to anti-retroviral therapy. The objective of this study was to demonstrate cytomegalovirus (CMV) co-infection in oral KS and to consider its possible significance. We reviewed 20 cases of oral KS in known HIV-positive patients without active CMV disease. HHV8 PCR and CMV immunohistochemistry were performed. HHV8 DNA was present in all cases. CMV inclusions were detected in five cases. The significance of CMV co-infection in oral KS is unclear. The inclusions suggest active infection, although there is no evidence to support CMV in the pathogenesis of KS. Nonetheless, it is vital that physicians be alerted to active CMV infection, so that timely intervention and careful observation can be instituted, ensuring early diagnosis and treatment.

Conceptual Emergence of Human Herpesvirus 8 (Kaposi’s Sarcoma-associated Herpesvirus) as an Oral Herpesvirus

Recognition of the various clinico-epidemiologic forms of Kaposi’s sarcoma, a disease putatively caused by an infectious agent, did not provide ready clues as to how that agent might be transmitted, although fecal and sexual routes were implicated. Application of serologic and genome-detection assays, and cell-culture studies following the identification of human herpesvirus 8 as the causative agent now implicate that virus as one that is orally shed. While oral transmission of the virus might account for the viral endemicity in Africa and Mediterranean countries, why it is particularly prevalent among male homosexuals in the West remains more difficult to explain. Such explanation may be sought from behavioral studies into the role saliva plays in sexual interactions.

Oral EBV and KSHV Infection in HIV

The gamma herpesviruses, Kaposi’s-sarcoma-associated herpesvirus (KSHV) and Epstein-Barr virus (EBV), are tightly associated with the development of AIDS-associated oral disease and malignancy during immune suppression. The objective of this investigation was to characterize oral infection and pathogenesis in healthy and immune-suppressed individuals. To characterize oral EBV and KSHV infection, we examined throat washings and oral epithelial cells from HIV-positive and HIV-negative individuals. Quantitative/real-time polymerase-chain-reaction (PCR) assays, transmission electronmicroscopy, immunostaining, and sequence analysis were used to identify viral infection. Virus was isolated from throat-wash samples and was used to infect epithelial and lymphoid cell lines. We detected EBV and KSHV in the oral cavity in healthy and immune-suppressed individuals. Viral strain analysis of KSHV K1 in multiple clones from the oral cavities of healthy persons and immunosuppressed patients detected several strains previously detected in KS lesions, with minor strain variation within individuals. Immunoelectron microscopy for multiple viral antigens detected consistent expression of viral proteins and oral epithelial specimens. In oral epithelial cells infected with wild-type KSHV in vitro, the K8.1 glycoprotein associated with lytic KSHV infection was detected in both primary and telomerase immortalized oral epithelial cultures by 24 hours post-infection. Virions were detected, subsequent to infection, by scanning electron microscopy. Oral epithelial cells were also infected in vitro with wild-type EBV originating from throat washes. Analysis of these data suggests that, like EBV, KSHV infection is present in the oropharynx of healthy individuals, is transmissible in vitro, and may be transmitted by saliva.

[Antigenemia and real time polymerase chain reaction for diagnosis of cytomegalovirus disease in HIV infected adults]

BACKGROUND

Cytomegalovirus (CMV) infection is frequent in HIV adults. It is unknown usefulness of quantitative methods for diagnosing the CMV disease in Chilean patients.

AIM

To determine the performance of antigenemia and real time polymerase chain reaction (rtPCR) in the diagnosis of CMV disease in Chilean HIV adults.

METHOD

Detection of CMV by viral isolation (AVR), antigenemia and quantitative rtPCR in HIV adults.

RESULTS

The 102 adults with suspected CMV disease had lower LTCD4 count and higher HIV viral load than 77 patients without suspicion (p < 0.05). Antigenemia and PCR were positive in 47 (46.1%) and 37 (36.3%) adults with clinical suspicion and in 2 (2.6%) and 4 (5.2%) of 77 without suspicion. The sensitivity, specificity, positive and negative predictive value of antigenemia and RPCtr were 92%, 80%, 72% and 95% and 72%, 95%, 92% and 80%, respectively. The cutoff values were ≥ lcell (+) and ≥ 5.5 log10 copies/2 x 10(6) cells. CMV was isolated in 6/179 patients (3.4%), all symptomatic.

CONCLUSION

Positivity of antigenemia and rtPCR are similar for diagnosing CMV disease in Chilean HIV adults. AVR is inappropriate as a gold standard for its low performance.

Herpes zoster as an immune restoration disease in AIDS patients during therapy including protease inhibitors

A prospective study to evaluate the incidence of herpes zoster (HZ) as an immune restoration disease in patients with AIDS during highly active antiretroviral therapy (HAART) was conducted in a series of 115 patients diagnosed with AIDS initiated on HAART between 1 January 2000 and 31 July 2001. Of these, a single dermatomal HZ episode occurred in 14 (12%) patients within one and 15 months of HAART (median eight months). The HZ patients were similar to the non-HZ patients in age, sex, and HIV transmission risk factor, but had a more advanced disease. Compared with the baseline values, the viral loads significantly ( P<0.01) decreased, while the mean CD4+ T-cell counts increased by almost four-fold ( P<0.01) in both groups at the time of the HZ episode (or equivalent in non-HZ), but remained below 400/mL in the HZ patients. HZ during HAART is an immunopathological consequence of the improvement of the host immune response, correlating with the beginning of immune restoration.

The association between HPV, intraepithelial lesions and HIV-1 shedding in anogenital specimens in two contrasting populations: Senegalese women and American MSM

In light of observational evidence showing an association between human papillomavirus (HPV) and HIV acquisition risk, the potential of HPV vaccination as a HIV prevention strategy is being considered. However, the relationship between HPV and HIV infectiousness is unclear. In this analysis, the relationship between HPV and anogenital HIV shedding (a proxy for transmissibility) was assessed in two diverse populations: HIV-infected Senegalese women and American men who have sex with men (MSM). Data from two longitudinal studies with similar protocols were analysed. In both studies, anogenital specimens underwent cytologic, HPV DNA, and HIV-1 RNA testing. Analyses utilised multivariable generalised estimating equations that controlled for age, hormonal contraceptive use (women only), plasma viral load, CD4 count and treatment status. Among Senegalese women, cervical lesions were significantly associated with the detection of HIV RNA (aRR = 1.16 [1.05, 1.28]) and log10 cervicovaginal fluids viral load (adjusted β = 0.56 [0.12, 1.01]). No association was detected between HPV (of any type) and cervicovaginal HIV shedding (aRRDetection = 0.90 [0.77, 1.06]; βQuantity = -0.31 [-0.78, 0.16]). Among MSM, having multiple HPV infections (versus no HPV infection) was associated with anal HIV shedding (aRRDetection = 1.05 [1.01, 1.09]; βQuantity = 0.11 [0.01, 0.21]). Anal lesions were not associated with anal HIV shedding (aRRLESIONS = 0.99 [0.96, 1.03], βLESIONS = -0.05 [-0.13, 0.03]). Although HPV and intraepithelial lesions were associated with anogenital HIV shedding in crude analyses, the measures of effect were attenuated in adjusted analyses. Our data suggest that the prevention of HPV through vaccination is unlikely to substantially affect HIV infectiousness among persons living with HIV.

Human herpesvirus 8 (HHV-8) detected by nested polymerase chain reaction (PCR) in HIV patients with or without Kaposi's sarcoma. An analytic cross-sectional study

CONTEXT AND OBJECTIVE

Kaposi's sarcoma (KS) is a common neoplastic disease in AIDS patients. The aim of this study was to evaluate the frequency of human herpesvirus 8 (HHV-8) infection in human immunodeficiency virus (HIV)-infected patients, with or without KS manifestations and correlate HHV-8 detection with KS staging.

DESIGN AND SETTING

Analytic cross-sectional study conducted in a public tertiary-level university hospital in Ribeirão Preto, São Paulo, Brazil.

METHODS

Antibodies against HHV-8 lytic-phase antigens were detected by means of the immunofluorescence assay. HHV-8 DNA was detected in the patient samples through a nested polymerase chain reaction (nested PCR) that amplified a region of open reading frame (ORF)-26 of HHV-8.

RESULTS

Anti-HHV-8 antibodies were detected in 30% of non-KS patients and 100% of patients with KS. Furthermore, the HHV-8 DNA detection rates observed in HIV-positive patients with KS were 42.8% in serum, 95.4% in blood samples and 100% in skin biopsies; and in patients without KS, the detection rate was 4% in serum. Out of the 16 serum samples from patients with KS-AIDS who were classified as stage II, two were positive (12.5%); and out of the 33 samples from patients in stage IV, 19 (57.6%) were positive.

CONCLUSION

We observed an association between HHV-8 detection and disease staging, which was higher in the serum of patients in stage IV. This suggests that detection of HHV-8 DNA in serum could be very useful for clinical assessment of patients with KS and for monitoring disease progression.

High seropositivity of IgG and IgM antibodies against cytomegalovirus (CMV) among HIV-1 seropositive patients in Ilorin, Nigeria

BACKGROUND

Human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) is a major public health problem in sub-saharan Africa. Cytomegalovirus (CMV) has been reported to enhance HIV replication and accelerate the progression of HIV infection to AIDS.

OBJECTIVE

This study reports on the high seropositivity of immunoglobulin (Ig) G and M antibodies against CMV and the risk factors for CMV infection among HIV/AIDS patients in Ilorin, Nigeria.

METHOD

A total of 180 consented HIV-1 seropositive patients (age-range 16-56 years; 108 females and 72 males) were consecutively recruited. Socio-demographic/behavioral data and 5 ml blood samples were collected from each patient. Plasma of each sample was assayed for anti-CMV IgG/IgM using a CMV IgG and IgM Enzyme Linked ImmunoSorbent Assay (ELISA) kit.

RESULTS

Twenty (11.1%) of the 180 HIV-1 seropositive subjects were positive for anti-CMV IgM antibody while 169(93.9%) were positive for anti-CMV IgG antibody. Age, marital status, number of sexual partners, CD4 cells counts and previous history of blood transfusion were the main correlates of CMV seropositivity among these patients. However, occupation, sex, highly active antiretroviral therapy (HAART) were not statistically associated with CMV seropositivity in this study.

CONCLUSION

This study has shown that greater percentages of HIV-1 seropositive patients had active CMV infection. It has further shown that CMV is hyperendemic in HIV-1 seropositive patients in Ilorin, Nigeria.

Long-Term Follow-up of a Cohort of HIV-Infected Patients Who Discontinued Maintenance Therapy for Cytomegalovirus Retinitis

PURPOSE

To determine the long-term safety of discontinuation of maintenance therapy for cytomegalovirus retinitis (CMVR) and to identify predictors for relapse.

METHOD

This was a prospective cohort study. Patients with treated CMVR who responded to HAART were followed by ophthalmologic assessment, markers for CMV replication (blood and urine cultures, CMV antigenemia, CMV DNA by PCR), and in vitro lymphoproliferative responses to CMV and other antigens after discontinuation of CMVR maintenance therapy.

RESULTS

23 patients were followed a median of 34 (range, 5-61) months. Median CD4 count was 321/mm3 at enrollment and 395/mm3 at last follow-up. HIV RNA was <50 copies/mL in 78% of patients at enrollment and 65% at last follow-up. One CMVR reactivation occurred at 12 months at a CD4 count of 395/mm3 (21%) and HIV RNA <50 copies/mL. Urine cultures were a poor predictive marker for reactivation. Other CMV replication markers had good negative predictive value. 96% of patients had a good lymphoproliferative response to CMV antigen in vitro.

CONCLUSION

Maintenance therapy for CMVR can safely be discontinued in patients who have responded to HAART. Combining our results with the published literature, the risk of reactivation is estimated at 0.016 per person year of follow-up. Markers to predict relapse and the need for re-initiation of maintenance therapy are not yet identified.

[THE DYNAMICS OF THE INCIDENCE OF OPPORTUNISTIC INFECTIONS AND SOMATIC DISEASES HIV-INFECTED PATIENTS WHO RECEIVED INPATIENT TREATMENT IN 2006-2011]

To the article a brief historical review and modern data are driven about the state of HIV-infection in the Odessa area, morbidity of HIV is analysed--the infected patients, passing treatment in stationary section of the Odessa regional centre from a prophylaxis and fight against AIDS during the last six year, drawn conclusion about efficiency of introduction of potent antiretroviral therapy.

Leishmaniasis as a Manifestation of Immune Reconstitution Inflammatory Syndrome (IRIS) in HIV-Infected Patients: A Literature Review

INTRODUCTION

After the onset of highly active antiretroviral therapy (HAART), some HIV-infected patients present a severe inflammation in response to a latent or a previously treated opportunistic pathogen termed immune reconstitution inflammatory syndrome (IRIS). Few reports of tegumentary and visceral leishmaniasis have been described in association with IRIS.

METHODS

A systematic literature review of IRIS in association with leishmaniasis identified 34 reported cases.

RESULTS AND DISCUSSION

The majority of these occurred in males 4 months following the onset of HAART. The mean CD4 count before HAART was 94 ± 77 cells/mm³ increasing to 5 times the initial value between the onset of HAART and IRIS presentation. Visceral leishmaniasis and post-kala-azar dermal leishmaniasis were the most commonly reported clinical manifestations, followed by tegumentary leishmaniasis and uveitis.

CONCLUSIONS

Commonly found characteristics included cutaneous involvement, regardless of Leishmania species; appearance of lesions unrelated to time of probable Leishmania infection; rapid recovery of CD4 count following HAART; and rapid progression.

Cellular immune responses in HIV-negative immunodeficiency with anti-interferon-γ antibodies and opportunistic intracellular microorganisms

Background

Cell-mediated immunity plays a crucial role in resistance to intracellular infection. We previously reported antibodies against interferon-gamma (IFN-γ) in HIV− negative (HIV−) patients with acquired immunodeficiency presenting with repeated episodes of disseminated infection caused by uncommon opportunistic intracellular fungal, bacterial, and viral pathogens. This follow-up study aimed to investigate cellular immune responses in these unusual patients.

Methods

Twenty HIV− patients presenting with ≥2 episodes of culture- or histopathologic-proven opportunistic infections were enrolled along with age- and sex-matched controls comprised of 20 HIV+ patients plus 20 healthy adults. Monocyte phenotyping and intracellular cytokine production were determined by staining with specific antibodies followed by flow cytometry. Anti-interferon-γ antibodies were measured by enzyme-linked immunosorbent assay, and inducible nitric oxide synthase by reverse-transcription polymerase chain reaction.

Results

There were no differences among cases, HIV+, and healthy controls in the percentage of monocytes, or CD68 and HLA-DR expression on their surfaces. FcR1 (CD119) expression on monocytes was significantly higher in cases than in HIV+ (p<0.05) and healthy controls (p<0.01), suggesting the presence of activated monocytes in the circulation. Interleukin (IL)-2 and tumor necrosis factor (TNF)-α production in CD4 cells were significantly lower in cases than in healthy controls (p<0.01 and p<0.001, respectively). CD8 production of TNF-α among cases was significantly lower than that of healthy controls (p<0.05).

Conclusion

Immunodeficiency in HIV− individuals with repeated infections with intracellular pathogens may be associated with one or more of the abnormal immune responses reflected by the reduced production of both IL-2 by CD4 T cells and TNF-α by CD4 T cells and CD8 T cells, as well as presence of anti-IFN-γ antibody, as previously reported.

[Peculiarities of bronchopulmonary pathology in HIV-patients]

The causes of hospitalization of HIV-infected patients during of medical treatment in a multidisciplinary health care setting (Military Medical Academy) are analyzed. Leading causes of death in medical institutions among patients with HIV are diseases, which are not associated with HIV infection: burns, combined injuries, toxic substances poisoning. It was found that HIV infection worsens prognosis for patients hospitalized with respiratory diseases and leads to earlier development of nosocomial infections, exacerbation of bronchopulmonary diseases and short-term mortality.

Prevalence and gB genotype distribution of human cytomegalovirus among HIV sero-negative and HIV sero-positive orphans in Thailand

BACKGROUND

Human Cytomegalovirus (HCMIV infects humans in all geographic areas. Polymorphisms ofglycoprotein B (gB) have been usedforgenotypic characterization of HCMV However information of gB genotyping of HCMV in Thailand is not clearly known especially in children.

MATERIAL AND METHOD

A cross-sectional study was conducted to assess HCMV infection in 236 HIV seronegative and HIV seropositive children who attended an orphanage in Nonthaburi, Thailand by nested-PCR technique using urine specimens. HCMV gB genotypes were determined by restrictionfragment length polymorphism (RFLP), andDNA sequencing technique.

RESULTS

Sixty-one percent (144/236) of the samples were HCMV positive, which consisted of 66.1% (37/56) of the HIV seropositive children and 59.4% (107/180) of the HIVsero-negative children. Multivariate analysis showed that children who living in one particular room were independently associated with HCMVinfection. Genotypic analysis revealed that the most prevalent genotype in these children was gB1; 85.4% (111/130) followed by gB3; 4.6% (6/130), gB2 and gB4 each at 2.3% (3/130). Mixed gB genotypes were identified in 5.4% (7/130) of the samples.

CONCLUSION

HCMV infection, in particular gB1 genotype was commonly ident fled among these Thai orphans. Living in one particular room was associated with getting the infection. To prevent the transmission of HCMV infection in this setting, improvement in hygienic behavior ofchildcare workers should be focused.

No association of cryptococcal antigenemia with poor outcomes among antiretroviral therapy-experienced HIV-infected patients in Addis Ababa, Ethiopia

Introduction

There are limited data on clinical outcomes of ART-experienced patients with cryptococcal antigenemia. We assessed clinical outcomes of a predominantly asymptomatic, ART-experienced cohort of HIV+ patients previously found to have a high (8.4%) prevalence of cryptococcal antigenemia.

Methods

The study took place at All Africa Leprosy, Tuberculosis and Rehabilitative Training Centre and Black Lion Hospital HIV Clinics in Addis Ababa, Ethiopia. A retrospective study design was used to perform 12-month follow-up of 367 mostly asymptomatic HIV-infected patients (CD4<200 cells/µl) with high levels of antiretroviral therapy use (74%) who were previously screened for cryptococcal antigenemia. Medical chart abstraction was performed approximately one year after initial screening to obtain data on clinic visit history, ART use, CD4 count, opportunistic infections, and patient outcome. We evaluated the association of cryptococcal antigenemia and a composite poor outcome of death and loss to follow-up using logistic regression.

Results

Overall, 323 (88%) patients were alive, 8 (2%) dead, and 36 (10%) lost to follow-up. Among the 31 patients with a positive cryptococcal antigen test (titers ≥1∶8) at baseline, 28 were alive (all titers ≤1∶512), 1 dead and 2 lost to follow-up (titers ≥1∶1024). In multivariate analysis, cryptococcal antigenemia was not predictive of a poor outcome (aOR = 1.3, 95% CI 0.3–4.8). A baseline CD4 count <100 cells/µl was associated with an increased risk of a poor outcome (aOR 3.0, 95% CI 1.4–6.7) while an increasing CD4 count (aOR 0.1, 95% CI 0.1–0.3) and receiving antiretroviral therapy at last follow-up visit (aOR 0.1, 95% CI 0.02–0.2) were associated with a reduced risk of a poor outcome.

Conclusions

Unlike prior ART-naïve cohorts, we found that among persons receiving ART and with CD4 counts <200 cells/µl, asymptomatic cryptococcal antigenemia was not predictive of a poor outcome.

Oral human papillomavirus infection and head and neck cancers in HIV-infected individuals

PURPOSE OF REVIEW

HIV-infected individuals are living longer due to effective antiretroviral therapy and may therefore have a greater opportunity to develop human papillomavirus (HPV)-associated malignancies. This review describes the risk factors and burden of oral HPV infection and HPV-associated head and neck cancer (HNC) among HIV-infected individuals.

RECENT FINDINGS

Oral HPV infection is commonly detected in HIV-infected individuals and is elevated among those with a higher number of lifetime oral sexual partners, current tobacco use and immunosuppression. There are limited data on the natural history of oral HPV, but initial studies suggest that the majority of infections clear within 2 years. Although HIV-infected individuals are at a much higher risk of most HPV-associated cancers than the general population, studies suggest HIV-infected individuals have a more modest 1.5-4-fold greater risk for HPV-associated HNC.

SUMMARY

HIV-infected individuals are living longer, have a high prevalence of oral HPV infection and have many of the currently determined risk factors for HPV-associated HNC.

High levels of divergent HIV-1 quasispecies in patients with neurological opportunistic infections in China

Despite the fact that the survival of people infected with human immunodeficiency virus (HIV) has improved worldwide because of the increasingly powerful and highly active antiretroviral therapy, opportunistic infections (OIs) of the central nervous system (CNS) remain a serious burden. HIV-1 is capable of entering the CNS through infected peripheral monocytes, but its effect on OIs of CNS remains unclear. In this study, we investigated the characteristics of HIV-1 in acquired immunodeficiency syndrome (AIDS) patients with CNS OIs. A total of 24 patients with CNS OIs and 16 non-CNS OIs (control) cases were selected. These AIDS patients were infected with HIV-1 by paid blood donors in China. HIV-1 loads in plasma and cerebrospinal fluid (CSF) were detected using RT-PCR, and the C2-V5 region of HIV-1 envelope gene was amplified from viral quasispecies isolated from CSF using nested PCR. The CSF HIV-1 load of CNS OIs was higher than that of non-CNS OIs, but plasma HIV-1 load of CNS OIs was not higher than that of non-CNS OIs. The nucleotide sequence of C2-V5 region of the HIV-1 quasispecies isolated from the CSF of CNS OIs had a high diversity, and the HIV-1 quasispecies isolated from the CSF of CNS OIs revealed R5 tropism as 11/25 charge rule. These results suggest that high levels of divergent HIV-1 quasispecies in the CNS probably contribute to opportunistic infections.

Immunohistological characterization of spinal TB granulomas from HIV-negative and -positive patients

Tuberculosis (TB) is mainly a disease of the lungs, but Mycobacterium tuberculosis (Mtb) can establish infection in virtually any organ in the body. Rising rates of extrapulmonary (EP) TB have been largely associated with the HIV epidemic, as patients co-infected with HIV show a four-fold higher risk of EPTB. Spinal TB (Pott's Disease), one of the most debilitating extrapulmonary forms of disease, is difficult to diagnose and can cause deformity and/or neurological deficits. This study examined the histopathology and distribution of immune cells within spinal TB lesions and the impact of HIV on pathogenesis. The overall structure of the spinal granulomas resembled that seen in lung lesions from patients with pulmonary TB. Evidence of efficient macrophage activation and differentiation were detectable within organized structures in the spinal tissue, irrespective of HIV status. Interestingly, the granulomatous architecture and macroscopic features were similar in all samples examined, despite a reversal in the ratio of infiltrating CD4 to CD8 T cells in the lesions from HIV-infected patients. This study provides a foundation to understand the mechanism of tissue destruction and disease progression in Spinal TB, enabling the future development of novel therapeutic strategies and diagnostic approaches for this devastating disease.

[Enteropathogens responsible for gastrointestinal disorders in HIV patients]

Gastrointestinal disorders or GID are debilitating conditions common in individuals infected by the human immunodeficiency virus (HIV), capable of leading to death. Numerous etiological agents and pathophysiological mechanisms have been involved in this status. Although the use of highly active antiretroviral therapy (HAART) in many countries has greatly reduced the prevalence of gastrointestinal infections, enteric pathogens such as bacteria, parasites, fungi and viruses may still act as opportunist agents in these patients. Cytomegalovirus, adenovirus, calicivirus, astrovirus, rotavirus, enterovirus, picobirnavirus and some more recently described, like bocavirus and Aichi virus, have been detected in HIV patients. However, except for cytomegalovirus, which is an established etiological agent of GID in these patients, the role of the other viruses remains unclear. Several species of Cryptosporidium, microsporidia, Salmonella, atipical mycobacteria and Campylobacter jejuni, have also been recognized as important causes of GID in HIV patients. The progressive incorporation of increasingly sensitive immunological and molecular assays for antigen, antibody and pathogens detection from faeces, has improved the diagnosis of diarrhea and contributed to clarify the etiological significance of some microorganisms in immunocompetent patients. In Venezuela, some information is available about the prevalence of enteric pathogens in immunocompromised patients infected with HIV. The identification of the etiologic agent responsible for this condition may be useful for the management and treatment of these patients, for whom viral enteritis is a disease, which reduces their quality of life and causes a high public health spending.

Predictive clinical factors in the diagnosis of gastrointestinal Kaposi's sarcoma and its endoscopic severity

BACKGROUND

The diagnosis of gastrointestinal (GI) involvement in Kaposi's sarcoma (KS) is important to make because the need for treatment depends on the extent of the disease. Moreover, severe GI lesions can cause serious complications. Endoscopy with biopsy is an extremely useful method to diagnose GI-KS. However, determining the indications for endoscopy is difficult because KS can occur without GI symptoms or cutaneous KS. This study sought to clarify predictive clinical factors for GI-KS and its severity on endoscopy.

METHODOLOGY/PRINCIPAL FINDINGS

A total of 1,027 HIV-infected patients who underwent endoscopy were analyzed. Sexual behavior, CD4 count, HIV RNA, history of highly active antiretroviral therapy (HAART), GI symptoms, and cutaneous KS were assessed. Endoscopic severity including bulky tumor, ulceration, and number of lesions were evaluated. Thirty-three patients had GI-KS and 46 patients cutaneous KS. Among the GI-KS patients, 78.8% (26/33) had no GI symptoms and 24.2% (8/33) had no cutaneous KS. Univariate analysis identified men who have sex with men (MSM), CD4 <100 cells/µL, HIV RNA ≥10,000 copies/mL, no history of HAART, and cutaneous KS were significantly associated with GI-KS. Among these factors, cutaneous KS was closely related to GI-KS on multivariable analysis. Among patients without cutaneous KS, MSM and CD4 count <100 cells/µL were the only independent clinical factors related to GI-KS. Bulky tumor was significantly associated with CD4 <100 cells/µL and large number of lesions was significantly associated with HIV-RNA ≥10,000 copies/mL.

CONCLUSIONS

To diagnose GI-KS, clinical factors need to be considered before endoscopy. The presence of GI symptoms is not useful in predicting GI-KS. MSM and CD4 count <100 cells/µL are predictive factors among patients without cutaneous KS. Caution should be exercised especially in patients with low CD4 counts or high HIV viral loads as they are more likely to develop severe GI-KS lesions.

Progressive outer retinal necrosis presenting as cherry red spot

PURPOSE

To report a case of progressive outer retinal necrosis (PORN) presenting as a cherry red spot.

METHODS

Case report.

RESULTS

A 53-year-old woman with recently diagnosed HIV and varicella-zoster virus (VZV) aseptic meningitis developed rapid sequential vision loss in both eyes over 2 months. Her exam showed a "cherry red spot" in both maculae with peripheral atrophy and pigmentary changes, consistent with PORN. Due to her late presentation and the rapid progression of her condition, she quickly developed end-stage vision loss in both eyes.

CONCLUSIONS

PORN should be considered within the differential diagnosis of a "cherry red spot." Immune-deficient patients with a history of herpetic infection who present with visual loss warrant prompt ophthalmological evaluation.

AIDS related Kaposi's sarcoma presenting with palatal and eyelid nodule

Kaposi sarcoma is a low-grade vascular neoplasm associated with Human Herpesvirus-8 (HHV8) infection. Although India has a large HIV infected population, Kaposi's sarcoma is rare and only 12 cases of AIDS related Kaposi's sarcoma from India have been reported in the published literature to our knowledge. The 50% of total cases in India has been reported from Mumbai. The incidence of AIDS related Kaposi's sarcoma is increasing as more than 50% of the cases are reported in 2008 to 2010.

SUMMARY

We report a case of 26-year-old, HIV seropositive, Indian male with multiple, non-blanching, purplish blue nodular swellings in the palate and right upper eye lid. Similar lesions were also present on the face and the extremities. On the basis of clinical and histopathological examination, a diagnosis of AIDS related Kaposi's sarcoma was made.

Mycobacterium tuberculosis and human immunodeficiency virus coinfection in a tertiary care hospital in Midwestern Brazil

Infection with human immunodeficiency virus (HIV) increases the risk of tuberculosis (TB), and HIV TB coinfection is associated with higher mortality. This study aimed to characterize patients coinfected with Mycobacterium tuberculosis and HIV in a reference centre for cases involving complications or drug resistance in TB. This retrospective cohort study was conducted at a Hospital for Tropical Diseases in the state of Goiás, Midwestern Brazil. Patients' medical records were reviewed between January 2008 and December 2009. Sixty-one cases of TB/HIV coinfection were evaluated, and 54 HIV-seronegative TB cases were selected as controls. The prevalence of TB HIV coinfected patients in 2008/2009 was 23%. Coinfection was more prevalent in men (75.4%), with a mean age of 37.1 years. Pulmonary disease (50.8%) was the most frequent clinical form of TB in coinfected patients, followed by disseminated disease (32.8%). Anaemia, malnutrition and low levels of CD4 T lymphocytes were found in about 80% of coinfected patients. Bilateral pulmonary infiltrates were the most common radiographic finding in coinfected patients (51.8%), and pulmonary cavitation was the rarest event (5.4%). The mortality rate was 2.8 times higher in the TB HIV coinfected group (39.3%) than in TB patients without HIV (18.5%). Actions targeting the TB HIV-coinfected population, based on national and international recommendations, are necessary to improve prognosis and outcomes in TB and HIV infection in the institution.

H1N1-associated acute retinitis

PURPOSE

To present the first reported case of bilateral H(1)N(1)-associated acute retinitis and its successful treatment.

DESIGN

Interventional case report.

METHODS

A 41-year-old HIV-positive male presented with acute vision loss, panuveitis, and retinitis. A diagnostic and therapeutic vitrectomy with intravitreal injection of vancomycin and ganciclovir and endolaser was performed. One month later, the patient returned with similar symptoms in the fellow eye and underwent the same procedure.

RESULTS

ELISA immunoassay revealed H(1)N(1) antibodies in both the vitreous and serum. PCR for herpes viruses included HSV, CMV, and VZV. Bacterial and fungal cultures were negative. On 1-year follow-up, the vision remained 20/20 in both eyes without evidence of recurrent inflammation.

CONCLUSIONS

H(1)N(1) should be included in the differential diagnosis of any patient with a history of recent influenza A (H(1)N(1)) infection and acute retinitis. H(1)N(1) may carry a better prognosis than other viruses causing acute retinitis.

Impact of detectable human cytomegalovirus DNAemia on viro-immunological effectiveness of HAART in HIV-infected patients naive to antiretroviral therapy

Our objective was to explore whether positive human cytomegalovirus (HCMV) DNAemia at baseline impaired CD4+ T-cell increase after 1 year of HAART. A sub-study of a randomized clinical trial in selected patients with <200 cell/mm CD4+ at baseline was conducted. Six out of 30 patients had detectable HCMV DNAemia at baseline, all reaching HCMV suppression at week 52 after HAART (only 1 of them was treated with valgancyclovir). No significant differences were found between patients with detectable or undetectable HCMV DNAemia in terms of CD4+ T-cell increase and HIV RNA response to HAART. Although some data may favor HCVM pre-emptive therapy to decrease immune activation, our results do not indicate that this practice may increase CD4+ T-cell count after HAART. At the same time, HAART proved effective in reducing HCMV DNAemia without the need for a specific therapy.

Computational and serologic analysis of novel and known viruses in species human adenovirus D in which serology and genomics do not correlate

In November of 2007 a human adenovirus (HAdV) was isolated from a bronchoalveolar lavage (BAL) sample recovered from a biopsy of an AIDS patient who presented with fever, cough, tachycardia, and expiratory wheezes. To better understand the isolated virus, the genome was sequenced and analyzed using bioinformatic and phylogenomic analysis. The results suggest that this novel virus, which is provisionally named HAdV-D59, may have been created from multiple recombination events. Specifically, the penton, hexon, and fiber genes have high nucleotide identity to HAdV-D19C, HAdV-D25, and HAdV-D56, respectively. Serological results demonstrated that HAdV-D59 has a neutralization profile that is similar yet not identical to that of HAdV-D25. Furthermore, we observed a two-fold difference between the ability of HAdV-D15 and HAdV-D25 to be neutralized by reciprocal antiserum indicating that the two hexon proteins may be more similar in epitopic conformation than previously assumed. In contrast, hexon loops 1 and 2 of HAdV-D15 and HAdV-D25 share 79.13 and 92.56 percent nucleotide identity, respectively. These data suggest that serology and genomics do not always correlate.

JC virus-associated central nervous system diseases in HIV-infected patients in Brazil: clinical presentations, associated factors with mortality and outcome

INTRODUCTION

Several presentations of neurologic complications caused by JC virus (JCV) in human immunodeficiency virus (HIV)-infected patients have been described and need to be distinguished from the "classic" form of progressive multifocal leukoencephalopathy (PMl). The objectives of this study were: 1) to describe the spectrum and frequency of presentations of JCV-associated central nervous system (CNS) diseases; 2) identify factors associated with in-hospital mortality of patients with JCV-associated CNS disease; and 3) to estimate the overall mortality of this population.

MATERIAL AND METHODS

This was a retrospective study of HIV-infected patients admitted consecutively for JCVassociated CNS diseases in a referral teaching center in São Paulo, Brazil, from 2002 to 2007. All patients with laboratory confirmed JCV-associated CNS diseases were included using the following criteria: compatible clinical and radiological features associated with the presence of JCV DNA in the cerebrospinal fluid. JCV-associated CNS diseases were classified as follows: 1) classic PMl; 2) inflammatory PMl; and 3) JC virus granule cell neuronopathy (GCN).

RESULTS

We included 47 cases. JCV-associated CNS diseases were classified as follows: 1) classic PMl: 42 (89%); 2) inflammatory PMl: three (6%); and 3) JC virus GCN: four (9%). Nosocomial pneumonia (p = 0.003), previous diagnosis of HIV infection (p = 0.03), and imaging showing cerebellar and/or brainstem involvement (p = 0.02) were associated with in-hospital mortality. overall mortality during hospitalization was 34%.

CONCLUSIONS

Novel presentations of JCV-associated CNS diseases were observed in our setting; nosocomial pneumonia, previous diagnosis of HIV infection, and cerebellar and/or brainstem involvement were associated with in-hospital mortality; and overall mortality was high.