Frequency of post treatment control varies by antiretroviral therapy restart and viral load criteria

Clinical trials including an analytical treatment interruption (ATI) are vital for evaluating the efficacy of novel strategies for HIV remissions. We briefly describe an interactive tool for predicting viral rebound timing in ATI trials and the impact of posttreatment controller (PTC) definitions on PTC frequency estimates. A 4-week viral load threshold of 1000 cps/ml provides both high specificity and sensitivity for PTC detection. PTC frequency varies greatly based on the definition of a PTC.

Myocardial Steatosis Among Antiretroviral Therapy-Treated People With Human Immunodeficiency Virus Participating in the REPRIEVE Trial

BACKGROUND

People with human immunodeficiency virus (PWH) face increased risks for heart failure and adverse heart failure outcomes. Myocardial steatosis predisposes to diastolic dysfunction, a heart failure precursor. We aimed to characterize myocardial steatosis and associated potential risk factors among a subset of the Randomized Trial to Prevent Vascular Events in HIV (REPRIEVE) participants.

METHODS

Eighty-two PWH without known heart failure successfully underwent cardiovascular magnetic resonance spectroscopy, yielding data on intramyocardial triglyceride (IMTG) content (a continuous marker for myocardial steatosis extent). Logistic regression models were applied to investigate associations between select clinical characteristics and odds of increased or markedly increased IMTG content.

RESULTS

Median (Q1, Q3) IMTG content was 0.59% (0.28%, 1.15%). IMTG content was increased (> 0.5%) among 52% and markedly increased (> 1.5%) among 22% of participants. Parameters associated with increased IMTG content included age (P = .013), body mass index (BMI) ≥ 25 kg/m2 (P = .055), history of intravenous drug use (IVDU) (P = .033), and nadir CD4 count < 350 cells/mm³ (P = .055). Age and BMI ≥ 25 kg/m2 were additionally associated with increased odds of markedly increased IMTG content (P = .049 and P = .046, respectively).

CONCLUSIONS

A substantial proportion of antiretroviral therapy-treated PWH exhibited myocardial steatosis. Age, BMI ≥ 25 kg/m2, low nadir CD4 count, and history of IVDU emerged as possible risk factors for myocardial steatosis in this group.

CLINICAL TRIALS REGISTRATION

NCT02344290; NCT03238755.

Treatment Trends and Outcomes in Healthcare-Associated Pneumonia

BACKGROUND

The American Thoracic Society and Infectious Diseases Society of America guidelines for management of healthcare-associated pneumonia (HCAP), first published in 2005, have been controversial regarding the selection of empiric broad-spectrum antibiotics, whether the criteria for HCAP predicts the likelihood of infection with multidrug resistant organisms, and whether HCAP patients have improved outcomes when treated with empiric broad-spectrum antibiotics.

METHODS

A retrospective cohort study at 488 US hospitals from July 2007 to November 2011. Patients who met criteria for HCAP were included. Guideline-concordant antibiotics were assessed based on guideline recommendations. We assessed changes in hospital rates of concordant antibiotic use over time and their correlation with outcomes.

RESULTS

Among 149,963 patients with HCAP, 19.6% received fully guideline-concordant antibiotics, 21.7% received partially concordant antibiotics, and 58.9% received discordant antibiotics. Guideline concordance increased over time. Rates of fully or partially concordant antibiotics varied across hospitals (median 36.4%; interquartile range 25.8%-49.1%). Among patients who received discordant antibiotics, 81.5% were treated according to community-acquired pneumonia (CAP) guidelines. On average, the rate of guideline concordance increased by 2.2% per 6-month interval, while hospital level rates of mortality, excess length of stay, and progression to respiratory failure did not change.

CONCLUSIONS

In this large, nationally representative cohort, only 1 in 5 patients with risk factors for HCAP received treatment that was fully in accordance with guidelines, and many received CAP therapy instead. At the hospital level, increases in the use of concordant antibiotics were not associated with declines in mortality, excess length of stay, or progression to respiratory failure.

Toxoplasma encephalitis in an HIV-infected patient on highly active antiretroviral therapy despite sustained immune response

Toxoplasma encephalitis (TE) is usually diagnosed in advanced stages of HIV infection when the CD4+ count is <100–200 cells/µl. A 55-year-old woman with HIV/AIDS, well controlled on antiretroviral therapy (ART), CD4+ count in the 300 cells/μl range for >1 year presented with acute onset of headache, nausea and vomiting. She had been on her current ART regimen consisting of raltegravir, co-formulated emtricitabine/tenofovir and etravirine for three years and had been off Pneumocystis prophylaxis for 10 months (trimethoprim-sulfamethoxazole). Brain MRI showed multiple ring-enhancing, supratentorial and infra-tentorial parenchymal lesions suspicious for metastases. She had no other evidence of metastatic disease in her body. The possibilities of TE and primary CNS lymphoma were considered but deemed unlikely given the high CD4+ count. A brain biopsy demonstrated Toxoplasma tachyzoites. There was no evidence of lymphoma or carcinoma. Anti-toxoplasma treatment yielded good initial clinical and radiographic responses. While on TE maintenance therapy, she developed similar symptoms. Repeat MRI showed progression of lesions. Further work-up including CSF Epstein-Barr virus PCR and SPECT Th 201 imaging was not conclusive for CNS lymphoma. The patient’s clinical condition deteriorated and she died. We postulate that functional immunological dysfunction is a possible mechanism by which our patient developed TE despite demonstrating sustained immune response on ART.

Similar efficacy of raltegravir when used with or without a protease inhibitor in treatment-experienced patients

BACKGROUND

Patients with multiclass-resistant HIV-1 have limited treatment options. Raltegravir, an inhibitor of integrase, has shown excellent efficacy when used with protease inhibitors (Pis) in patients with drug-resistant HIV-1. Limited data are available however about the outcomes when using raltegravir without Pis in this population.

METHODS

Medical records of subjects who received raltegravir as part of the Merck EAP study 0518 were reviewed and abstracted at participating sites. Eligibility criteria included HIV positivity, age ≥ 16 years, limited or no treatment options due to resistance or intolerance to multiple antiretroviral regimens, detectable viremia on current treatment regimen, and documented resistance to at least one drug in each antiretroviral class (PI, NNRTI, and nucleoside analogue). Demographic, clinical, and laboratory data were collected locally using a standardized collection form. Genotypic susceptibility scores (GSS) were determined from the most recent genotypic resistance test available prior to the initiation of raltegravir. The main objective was to compare virologic results in patients who received raltegravir with a PI versus those who received raltegravir without a PI.

RESULTS

Four hundred forty-two subjects were evaluated from the respective sites in the EAP trial, of whom 340 were evaluable. The baseline mean HIV RNA was 4.6 log copies/ mL, and the mean CD4 cell count was 159 cells/μL. The median number of total and new antiretroviral agents in the background regimen was 4 and 2, respectively. Among the 254 patients who received a PI, the most common PI used was darunavir (89%). Etravirine was commonly used in both groups: 39% of the PI group and 67% of the non-PI group. At week 12, 67% of PI patients and 64% of non-PI patients achieved HIV RNA <75 copies/mL and 85% and 86%, respectively, achieved HIV RNA <400 copies/mL GSS, which was similar in both groups at baseline, predicted achieving an HIV RNA of <400 and 75 copies/mL at week 12 (P < .05).

CONCLUSIONS

In treatment-experienced patients, the combination of raltegravir with a regimen not containing a PI (used with etravirine in two-thirds of patients) had similar virologic activity when compared to more standard regimens using raltegravir with a PI. The main determinant of efficacy was the number of active drugs as measured by GSS. These data expand the potential utility of raltegravir in patients with multidrug-resistant HIV.

Evidence for subpopulations of Listeria monocytogenes with enhanced invasion of cardiac cells

Cardiac infections caused by the foodborne bacterium Listeria monocytogenes represent a significant but poorly studied facet of disease. It is not known whether L. monocytogenes cardiac infections stem solely from host susceptibility, or whether bacterial isolates exist that exhibit a tropism for cardiac tissue. Here we examine the cardio-invasive capacity of a recent L. monocytogenes cardiac case strain (07PF0776) as well as nine additional outbreak and clinical isolates. Mice infected with the cardiac isolate 07PF0776 had 10-fold more bacteria recovered from heart tissue than those infected with L. monocytogenes strain 10403S, a well-characterized clinical isolate originally obtained from a human skin lesion. Additional L. monocytogenes isolates exhibited varied capacities to colonize the hearts of mice; however, those with the highest efficiency of mouse cardiac invasion also demonstrated the highest levels of bacterial invasion in cultured myoblast cells. Our findings strongly suggest that subpopulations of L. monocytogenes strains have acquired an enhanced ability to target and invade the myocardium.

Low prevalence of primary HIV resistance in western Massachusetts

Most studies of primary antiretroviral (ARV) resistance have been conducted in large metropolitan areas with reported rates of 8% to 25%. We collected data on 99 HIV-1-infected antiretroviral-naive patients from several sites in Springfield, MA, who underwent genotypic resistance assay between 2004 and 2008. Only major resistance mutations per International AIDS Society-USA (IAS-USA) drug resistance mutations list were considered. The prevalence of resistance was 5% (5 of 99). Three patients had one nonnucleoside reverse transcriptase inhibitor (NNRTI) mutation: 103N, 103N, and 190A, 1 patient had a protease inhibitor (PI) mutation: 90M; and 1 patient had 3-class resistance with NNRTI: 181C, 190A, PI: 90M, and nucleoside analogue reverse transcriptase inhibitor (NRTI): 41L, 210W. Mean time from HIV diagnosis to resistance testing was shorter in patients with resistance versus those without: 9 (range 0.3-42 months) versus 27 (range 0.1-418 months), P = .11. There was a trend to lower mean CD4 count in those with resistance, 170 versus 318 cells/mm(3), P = .06. No differences were noted in gender, age, HIV risk category, or HIV RNA level. The low prevalence of primary resistance may be explained by differences in demographic and risk factors or may reflect the time from infection to resistance testing. Our findings emphasize the importance of continued resistance surveillance.

Antibiotic therapy and treatment failure in patients hospitalized for acute exacerbations of chronic obstructive pulmonary disease

CONTEXT

Guidelines recommend antibiotic therapy for acute exacerbations of chronic obstructive pulmonary disease (COPD), but the evidence is based on small, heterogeneous trials, few of which include hospitalized patients.

OBJECTIVE

To compare the outcomes of patients treated with antibiotics in the first 2 hospital days with those treated later or not at all.

DESIGN, SETTING, AND PATIENTS

Retrospective cohort of patients aged 40 years or older who were hospitalized from January 1, 2006, through December 31, 2007, for acute exacerbations of COPD at 413 acute care facilities throughout the United States.

MAIN OUTCOME MEASURES

A composite measure of treatment failure, defined as the initiation of mechanical ventilation after the second hospital day, inpatient mortality, or readmission for acute exacerbations of COPD within 30 days of discharge; length of stay, and hospital costs.

RESULTS

Of 84,621 patients, 79% received at least 2 consecutive days of antibiotic treatment. Treated patients were less likely than nontreated patients to receive mechanical ventilation after the second hospital day (1.07%; 95% confidence interval [CI], 1.06%-1.08% vs 1.80%; 95% CI, 1.78%-1.82%), had lower rates of inpatient mortality (1.04%; 95% CI, 1.03%-1.05% vs 1.59%; 95% CI, 1.57%-1.61%), and had lower rates of readmission for acute exacerbations of COPD (7.91%; 95% CI, 7.89%-7.94% vs 8.79%; 95% CI, 8.74%-8.83%). Patients treated with antibiotic agents had a higher rate of readmissions for Clostridium difficile (0.19%; 95% CI, 0.187%-0.193%) than those who were not treated (0.09%; 95% CI, 0.086%-0.094%). After multivariable adjustment, including the propensity for antibiotic treatment, the risk of treatment failure was lower in antibiotic-treated patients (odds ratio, 0.87; 95% CI, 0.82-0.92). A grouped treatment approach and hierarchical modeling to account for potential confounding of hospital effects yielded similar results. Analysis stratified by risk of treatment failure found similar magnitudes of benefit across all subgroups.

CONCLUSION

Early antibiotic administration was associated with improved outcomes among patients hospitalized for acute exacerbations of COPD regardless of the risk of treatment failure.

Comparative effectiveness of macrolides and quinolones for patients hospitalized with acute exacerbations of chronic obstructive pulmonary disease (AECOPD)

BACKGROUND

Meta-analyses of randomized trials have found that antibiotics are effective in acute exacerbations of chronic obstructive pulmonary disease (AECOPD), but there is insufficient evidence to guide antibiotic selection. Current guidelines offer conflicting recommendations.

OBJECTIVE

To compare the effectiveness of macrolides and quinolones for AECOPD DESIGN: Retrospective cohort study using logistic regression, propensity score-matching, and grouped treatment models.

SETTING

A total of 375 acute care hospitals throughout the United States.

PATIENTS

Age > or =40 years and hospitalized for AECOPD.

INTERVENTION

Macrolide or quinolone antibiotic begun in the first 2 hospital days.

MEASUREMENTS

Treatment failure (defined as the initiation of mechanical ventilation after hospital day 2, inpatient mortality, or readmission for AECOPD within 30 days), length of stay, and hospital costs.

RESULTS

Of the 19,608 patients who met the inclusion criteria, 6139 (31%) were treated initially with a macrolide and 13,469 (69%) with a quinolone. Compared to patients treated initially with a quinolone, those who received macrolides had a lower risk of treatment failure (6.8% vs. 8.1%; P < 0.01), a finding that was attenuated after multivariable adjustment (odds ratio [OR], 0.89; 95% confidence interval [CI], 0.78-1.01), and disappeared in a grouped-treatment analysis (OR, 1.01; 95% CI, 0.75-1.35). There were no differences in adjusted length of stay (ratio, 0.98; 95% CI, 0.97-1.00) or adjusted cost (ratio, 1.00; 95% CI, 0.99-1.02). After propensity score-matching, antibiotic-associated diarrhea was more common with quinolones (1.2% vs. 0.6%; P < 0.001).

CONCLUSIONS

Macrolide and quinolone antibiotics are associated with similar rates of treatment failure in AECOPD; however, macrolides are less frequently associated with diarrhea.

Neurocognitive effects of treatment interruption in stable HIV-positive patients in an observational cohort

OBJECTIVE

Prior studies have shown improved neurocognition with initiation of antiretroviral treatment (ART) in HIV. We hypothesized that stopping ART would be associated with poorer neurocognitive function.

METHODS

Neurocognitive function was assessed as part of ACTG 5170, a multicenter, prospective observational study of HIV-infected subjects who elected to discontinue ART. Eligible subjects had CD4 count >350 cells/mm(3), had HIV RNA viral load <55,000 cp/mL, and were on ART (>or=2 drugs) for >or=6 months. Subjects stopped ART at study entry and were followed for 96 weeks with a neurocognitive examination.

RESULTS

A total of 167 subjects enrolled with a median nadir CD4 of 436 cells/mm(3) and 4.5 median years on ART. Significant improvements in mean neuropsychological scores of 0.22, 0.39, 0.53, and 0.74 were found at weeks 24, 48, 72, and 96 (all p < 0.001). In the 46 subjects who restarted ART prior to week 96, no significant changes in neurocognitive function were observed.

CONCLUSION

Subjects with preserved immune function found that neurocognition improved significantly following antiretroviral treatment (ART) discontinuation. The balance between the neurocognitive cost of untreated HIV viremia and the possible toxicities of ART require consideration.

CLASSIFICATION OF EVIDENCE

This study provides Class III evidence that discontinuing ART is associated with an improvement in 2 neuropsychological tests (Trail-Making Test A & B and the Wechsler Adult Intelligence Scale-Revised Digit Symbol subtest) for up to 96 weeks. Resuming ART was not associated with a decline in these scores for up to 45 weeks.

Choriocarcinoma in an AIDS patient--relapsing but not fatal

Choriocarcinoma is associated with high mortality in immunocompromised patients, in contrast to a good prognosis in immunocompetent individuals. Respiratory failure due to metatstatic choriocarcinoma is associated with high mortality in any patient. We report a case of a woman with AIDS that survived metastatic choriocarcinoma and respiratory failure. We also observed that in contrast to some in vitro studies, the markedly elevated levels of beta-subunit of human chorionic gonadotropin in this patient did not have any apparent inhibitory effect on viral replication.

CD4+ T-cell decline after the interruption of antiretroviral therapy in ACTG A5170 is predicted by differential expression of genes in the ras signaling pathway

Patterns of expressed genes examined in cryopreserved peripheral blood mononuclear cells (PBMCs) of seropositive persons electing to stop antiretroviral therapy in the AIDS Clinical Trials Group Study A5170 were scrutinized to identify markers capable of predicting the likelihood of CD4+ T-cell depletion after cessation of antiretroviral therapy (ART). A5170 was a multicenter, 96-week, prospective study of HIV-infected patients with immunological preservation on ART who elected to interrupt therapy. Study entry required that the CD4 count was greater than 350 cells/mm(3) within 6 months of ART initiation. Median nadir CD4 count of enrollees was 436 cells/mm(3). Two cohorts, matched for clinical characteristics, were selected from A5170. Twenty-four patients with an absolute CD4 cell decline of less that 20% at week 24 (good outcome group) and 24 with a CD4 cell decline of >20% (poor outcome group) were studied. The good outcome group had a decline in CD4+ Tcell count that was 50% less than the poor outcome group. Significance analysis of microarrays identified differential gene expression (DE) in the two groups in data obtained from Affymetrix Human FOCUS GeneChips. DE was significantly higher in the poor outcome group than in the good outcome group. Prediction analysis of microarrays (PAM-R) identified genes that classified persons as to progression with greater than 80% accuracy at therapy interruption (TI) as well as at 24 weeks after TI. Gene set enrichment analysis (GSEA) identified a set of genes in the Ras signaling pathway, associated with the downregulation of apoptosis, as significantly upregulated in the good outcome group at cessation of ART. These observations identify specific host cell processes associated with differential outcome in this cohort after TI.

Safety and efficacy of posaconazole in the long-term treatment of azole-refractory oropharyngeal and esophageal candidiasis in patients with HIV infection

PURPOSE

To evaluate safety and efficacy of long-term posaconazole in HIV-infected patients with azole-refractory oropharyngeal candidiasis and/or esophageal candidiasis.

METHOD

In this noncomparative, open-label study, participants received oral posaconazole 400 mg twice daily (bid) for 3 months. Enrolled patients (N = 100) included 60 from a previous 1-month acute study of posaconazole and 40 posaconazole-naïve participants. Participants with a clinical response could be followed untreated for up to 1 month afterwards. Participants who relapsed during follow-up, showed improvement at the end of 3 months of treatment (EOT), or were cured but likely to benefit from further therapy could continue on posaconazole 400 mg bid for up to 12 months.

RESULTS

In the modified intent-to-treat population, clinical response (cure or improvement) occurred in 85.6% (77/90) at EOT. The results were similar in the previously treated participants and the posaconazole-naïve participants, 88.1% (52/59) and 80.6% (25/31), respectively. Posaconazole was well-tolerated, showing a similar safety profile during the 3-month study period and during suppressive therapy. The most frequently reported treatment-related adverse event was vomiting (4/100, 4%) during the early follow-up period (on or before day 105) and elevated hepatic enzymes (3/51, 6%) during the long-term follow-up (after day 105).

CONCLUSION

Oral posaconazole 400 mg bid demonstrated long-term safety, tolerability, and efficacy, offering a long-term, suppressive treatment option for HIV-infected participants with azole-refractory mucosal candidiasis.

Prospective comparison of methicillin-susceptible and methicillin-resistant community-associated Staphylococcus aureus infections in hospitalized patients

BACKGROUND

We sought to determine the proportion of community-associated Staphylococcus aureus infections due to methicillin-resistant S. aureus (CA-MRSA) at a large county hospital. In addition, we sought to identify the demographic and clinical risk factors associated with CA-MRSA infection.

METHODS

Patients were prospectively enrolled if they were admitted to Parkland Hospital and had a positive culture for S. aureus isolated within 72 h of admission. The patients were interviewed using a standardized data questionnaire. Data collected included patient demographics, clinical history, as well as health care and non-health care associated MRSA risk factors. Bacterial susceptibilities were verified through review of microbiology laboratory and pharmacy records. Isolates were tested for Panton-Valentine leukocidin (PVL) gene, SCCmec type, and for inducible clindamycin resistance.

RESULTS

One hundred and ninety-eight patients were interviewed prospectively, of which eight had colonization without active infection. One hundred and nineteen patients were infected with MRSA and 71 patients were infected with methicillin-susceptible S. aureus (MSSA). Patients with MRSA were more likely to be African-American and unemployed. Patients with MRSA most commonly presented with a skin or soft tissue infection (SSTI): 69% versus 45%, p=0.0012, while patients with MSSA were more likely to have infection of the respiratory tract: 11% versus 3%, p=0.02. Patients with MRSA were more likely to have used antibiotics in the past six months, been homeless, have a history of incarceration, have abused alcohol and have a history of infection with MRSA. In multivariate analysis, African-American race, antibiotics in the past six months, and a history of being homeless were associated with MRSA infection. Only 11 of 119 (9%) MRSA patients did not have at least one of these risk factors. PVL gene was present in 72 of 74 (97%) MRSA isolates and SCCmec type IV was present in 63 of 75 (84%) MRSA isolates.

CONCLUSIONS

The majority of patients hospitalized with community-associated S. aureus infections were due to MRSA, most of which involved an SSTI. African-American race, recent antibiotics and past homeless status predicted infection with MRSA; however, no clinical profile could reliably exclude MRSA. Clinicians should be aware of the increasing prevalence of CA-MRSA.

Interruption of antiretroviral treatment in HIV-infected patients with preserved immune function is associated with a low rate of clinical progression: a prospective study by AIDS Clinical Trials Group 5170

BACKGROUND

We sought to determine the safety of treatment interruption (TI) and to identify parameters that would define patients with human immunodeficiency virus (HIV) for whom TI is safer.

METHODS

AIDS Clinical Trials Group 5170 was a multicenter, 96-week-long, prospective study of HIV-infected patients receiving antiretroviral therapy (ART) who had CD4(+) cell counts >350 cells/mm(3) and who underwent TI.

RESULTS

A total of 167 patients were enrolled. The median nadir in CD4(+) cell count was 436 cells/mm(3). The initial decrease (i.e., during the first 8 weeks) in CD4(+) cell count after ART interruption was 20 cells/mm(3)/week; the subsequent decrease was 2.0 cells/mm(3)/week until week 96. Both the CD4(+) cell count before enrollment and the increase in CD4(+) cell count during ART predicted early decrease; later decrease was predicted by the level of interleukin-7 at enrollment. A Centers for Disease Control and Prevention (CDC) diagnosis of a category B or C event was made for 2 and 2 patients, respectively (all had CD4(+) cell counts >350 cells/mm(3)). At week 96, 17 patients had CD4(+) cell counts < or =250 cells/mm(3), and 46 patients had resumed ART; 5 patients died (unrelated to HIV or acquired immunodeficiency syndrome). In a multivariate analysis, a higher nadir in CD4(+) cell count (>400 cells/mm(3)), a lower HIV load (<50 copies/mL) at the time of TI, and an HIV load < or =22,000 copies/mL before ART predicted a longer time to the primary end point (CDC category B or C event, death, CD4(+) cell count < or =250 cells/mm(3), or resumption of ART).

CONCLUSION

Disease progression after TI was low in this cohort. A higher nadir in CD4(+) cell count, a lower HIV load before ART, and an HIV load < or =50 copies/mL at the time of TI predicted a longer time to the primary end point.

The Werner Syndrome Helicase Is a Cofactor for HIV-1 Long Terminal Repeat Transactivation and Retroviral Replication

The Werner syndrome helicase (WRN) participates in DNA replication, double strand break repair, telomere maintenance, and p53 activation. Mutations of wrn cause Werner syndrome (WS), an autosomal recessive premature aging disorder associated with cancer predisposition, atherosclerosis, and other aging related symptoms. Here, we report that WRN is a novel cofactor for HIV-1 replication. Immortalized human WRN(-/-) WS fibroblasts, lacking a functional wrn gene, are impaired for basal and Tat-activated HIV-1 transcription. Overexpression of wild-type WRN transactivates the HIV-1 long terminal repeat (LTR) in the absence of Tat, and WRN cooperates with Tat to promote high-level LTR transactivation. Ectopic WRN induces HIV-1 p24(Gag) production and retroviral replication in HIV-1-infected H9(HIV-1IIIB) lymphocytes. A dominant-negative helicase-minus mutant, WRN(K577M), inhibits LTR transactivation and HIV-1 replication. Inhibition of endogenous WRN, through co-expression of WRN(K577M), diminishes recruitment of p300/CREB-binding protein-associated factor (PCAF) and positive transcription elongation factor b (P-TEFb) to Tat/transactivation response-RNA complexes, and immortalized WRN(-/-) WS fibroblasts exhibit comparable defects in recruitment of PCAF and P-TEFb to the HIV-1 LTR. Our results demonstrate that WRN is a novel cellular cofactor for HIV-1 replication and suggest that the WRN helicase participates in the recruitment of PCAF/P-TEFb-containing transcription complexes. WRN may be a plausible target for antiretroviral therapy.

Posaconazole for the Treatment of Azole-Refractory Oropharyngeal and Esophageal Candidiasis in Subjects with HIV Infection

BACKGROUND

We evaluated the efficacy and safety of oral posaconazole for human immunodeficiency virus (HIV)-infected subjects with oropharyngeal candidiasis (OPC) and/or esophageal candidiasis (EC) who were clinically refractory to treatment with oral fluconazole or itraconazole.

METHODS

Subjects with confirmed OPC or EC who did not improve after receiving standard courses of fluconazole or itraconazole treatment were eligible for study enrollment. Subjects received either oral posaconazole (400 mg twice daily) for 3 days followed by oral posaconazole (400 mg once daily) for 25 days (regimen A; 103 patients) or oral posaconazole (400 mg twice daily) for 28 days (regimen B; 96 patients). The primary end point was cure or improvement after 28 days. Primary efficacy analyses were performed on the subset of treated subjects with refractory disease (e.g., baseline culture positive for fluconazole- or itraconazole-resistant Candida species or persistent or progressive clinical signs or symptoms consistent with treatment failure).

RESULTS

Of the modified intent-to-treat population, 132 (75%) of 176 subjects achieved a clinical response to posaconazole treatment. Clinical response rates were similar between regimen A recipients (75.3%) and regimen B recipients (74.7%). Clinical responses occurred in 67 (73%) of 92 subjects with baseline isolates resistant to fluconazole, 49 (74%) of 66 subjects with baseline isolates resistant to itraconazole, and 42 (74%) of 57 subjects with isolates resistant to both. Clinical response was achieved in 32 (74.4%) of 43 subjects with endoscopically documented EC. The most common treatment-related adverse events were diarrhea (11%), neutropenia (7%), flatulence (6%), and nausea (6%). Eight subjects (4%) discontinued therapy as a result of a treatment-related adverse event.

CONCLUSIONS

Posaconazole offers a safe and effective treatment option for HIV-infected subjects with azole-refractory OPC and/or EC.

Cryptococcal immune reconstitution inflammatory syndrome: report of four cases in three patients and review of the literature

Immune reconstitution inflammatory syndromes (IRIS) in patients with AIDS are characterized by atypical manifestations of opportunistic pathogens in patients experiencing improvement in CD4 cell counts following receipt of highly active anti-retroviral therapy (HAART). We report four cases of IRIS due to Cryptococcus neoformans in three patients and review the literature of cryptococcal IRIS in AIDS (an additional 21 episodes). The IRIS presentation was lymphadenitis in all three patients; one patient also had meningeal IRIS. Combining our patients with the literature review revealed the following IRIS presentations: lymphadenitis (n=14), central nervous system (CNS) IRIS (n=10): meningitis in six and mass lesions in four, and pulmonary cavities (n=1). The median CD4 count of cases at the time of initial cryptococcal diagnosis and prior to the start of HAART was 25 cells/microl and the median HIV viral load was 439,053 copies/ml. At time of presentation of the IRIS, the median CD4 count had increased by 197 cells/microl. The median time from initial cryptococcal diagnosis and the start of HAART to the IRIS was 11 months (range 7 weeks to 3 years) and 7 months (range <2 weeks to 22 months), respectively. Patients with CNS IRIS tended to have shorter intervals from initiation of HAART to presentation compared to patients with lymphadenitis: median 3.5 months compared to 7 months. In 24 of 25 cases, the clinical manifestations of the IRIS resolved (range: days to months). Only four patients were given anti-inflammatory medications: corticosteroids in two and non-steroidal anti-inflammatory drugs in two, thus precluding assessment of efficacy. Patients with cryptococcal disease who initiate HAART are at risk for cryptococcal IRIS.

Treatment failure resulting from resistance of Staphylococcus aureus to daptomycin

Daptomycin, a new cyclic lipopeptide, was recently approved for the treatment of infections by gram-positive organisms, including infections with methicillin-resistant Staphylococcus aureus (MRSA). A patient infected with infected with MRSA developed resistance to daptomycin after prolonged exposure, which resulted in clinical failure. Clinicians should be aware of the possibility of daptomycin resistance and should consider routine testing for daptomycin susceptibility.

A Multicenter Randomized Trial Evaluating Posaconazole versus Fluconazole for the Treatment of Oropharyngeal Candidiasis in Subjects with HIV/AIDS

BACKGROUND

Oropharyngeal candidiasis is the most common opportunistic infection among persons infected with human immunodeficiency virus (HIV). Use of some agents is hampered by lack of efficacy, emergence of resistance, adverse events, and need for intravenous administration. Posaconazole is an extended-spectrum triazole with potent in vitro activity against Candida species, including Candida albicans, Candida glabrata, and Candida krusei (including fluconazole-resistant strains).

METHODS

This multicenter, randomized, evaluator-blinded study of subjects with HIV infection and oropharyngeal candidiasis compared efficacy of posaconazole with that of fluconazole. Subjects received either 200 mg of posaconazole or fluconazole oral suspension on day 1, followed by 100 mg/day for 13 days. The primary study end point--clinical success (cure or improvement) on day 14--was evaluated for 329 subjects. Durability of clinical success was evaluated on day 42.

RESULTS

Three hundred fifty subjects received posaconazole (n = 178) or fluconazole (n = 172). Clinical success occurred in 155 (91.7%) of 169 posaconazole recipients and in 148 (92.5%) of 160 fluconazole recipients (95% confidence interval, -6.61% to 5.04%), indicating that posaconazole was not inferior to fluconazole. On day 14, mycological success was 68% in both arms, but by day 42, significantly more posaconazole recipients than fluconazole recipients continued to have mycological success (40.6% vs. 26.4%; P=.038). Fewer posaconazole recipients than fluconazole recipients experienced clinical relapse (31.5% vs. 38.2%). Adverse events were similar between treatment arms.

CONCLUSIONS

Results demonstrate that posaconazole was as effective as fluconazole in producing a successful clinical outcome. However, posaconazole was more effective in sustaining clinical success after treatment was stopped.

HIV-1 Tat interactions with p300 and PCAF transcriptional coactivators inhibit histone acetylation and neurotrophin signaling through CREB

The human immunodeficiency virus type-1 (HIV-1) infects microglia, macrophages, and astrocytes in the central nervous system (CNS) and may cause severe neurological diseases, such as AIDS-related dementias or progressive encephalopathies, as a result of CNS inflammation and neurotrophin signaling defects associated with expression of viral antigens and HIV-1 replication in the brain. The HIV Tat protein can be endocytosed by surrounding uninfected cells; interacts with transcriptional coactivators/acetyltransferases, p300/CREB-binding protein, and p300/CREB-binding protein-associated factor (PCAF); and induces neuronal apoptosis. Since nerve growth factor (NGF) receptor and brain-derived neurotrophic factor receptor signaling through CREB requires p300 and PCAF histone acetyltransferases, we sought to determine whether HIV-1 Tat coactivator interactions interfere with neurotrophin receptor signaling in neuronal cells. Here, we demonstrate that Tat-coactivator interactions inhibit NGF- and brain-derived neurotrophic factor-responsive CRE trans-activation and neurotrophin protection against apoptosis in PC12 and IMR-32 neuroblastoma cells. Purified recombinant Tat or Tat-derived synthetic peptides, spanning p300- and PCAF-binding sequences, inhibit histone H3/H4 acetylation in vitro. A Tat mutant, TatK28A/K50A, defective for binding p300 and PCAF, neither repressed NGF-responsive CRE transactivation nor inhibited histone acetylation. HIV-1 Tat interacts in PCAF complexes in post-mortem CNS tissues from donor neuro-AIDS patients, as determined by fluorescence resonance energy transfer immunoconfocal microscopy. Importantly, these findings suggest that HIV-1 Tat-coactivator interactions may contribute to neurotrophin signaling impairments and neuronal apoptosis associated with HIV-1 infections of the CNS.

It Is Safe to Stop Antiretroviral Therapy in Patients With Preantiretroviral CD4 Cell Counts >250 cells/??L

OBJECTIVE

To study clinical, immunologic, and virologic outcomes in patients who stop antiretroviral therapy (ART) with relatively preserved CD4 cell counts.

DESIGN AND METHODS

Patients with a documented CD4 cell count >250 cells/microL who stopped ART for any reason for at least 5 weeks were studied. Relevant clinical and laboratory data were collected using a standardized data collection form.

MAIN OUTCOME MEASURES

Patients were monitored for outcomes including Centers for Disease Control (CDC) category B or C events, time to restarting ART, and time to reaching a CD4 cell count of < or = 250 cells/microL.

RESULTS

A total of 107 patients were included. The median time on ART was 45 months and median number of antiretroviral medications was 4. The median pre-ART CD4 cell count and HIV viral load were 463 cells/microL and 4.35 log copies/mL, respectively. The median CD4 cell at time of ART stop was 739 cell/microL. The slope of the CD4 decrease was 65 cells/mo in the first 2 months, which was greater than the subsequent decline of 8 cells/mo thereafter (P < 0.01). Similarly the median viral load increase was 2.54 log copies/mL in the first 2 months after stopping and was unchanged after that point. Two patients experienced the retroviral rebound syndrome after ART cessation but no CDC category B or C events were observed during 10 months of follow-up. The median time from stopping ART to reaching the combined endpoint of CD4 <250 or restarting ART was 8.9 months. In multivariate analysis, pre-ART CD4 cell count >250 was protective of reaching the combined endpoint (odds ratio = 0.156, P = 0.03). Other predictors of reaching the combined endpoint in multivariate analysis were older age and number of prior ART agents. Patients who restarted ART had a favorable virologic and immunologic response.

CONCLUSIONS

Patients with relatively high CD4 cell counts prior to starting ART did well after stopping ART. Pre-ART CD4 cell count can be used to predict outcomes after ART cessation.

Safety of Discontinuation of Maintenance Therapy for Disseminated Histoplasmosis after Immunologic Response to Antiretroviral Therapy

We performed a prospective observational study to assess the safety of stopping maintenance therapy for disseminated histoplasmosis among human immunodeficiency virus infected patients after response to antiretroviral therapy. All subjects received at least 12 months of antifungal therapy and 6 months of antiretroviral therapy before entry. Negative results of fungal blood cultures, urine and serum Histoplasma antigen level of <4.1 units, and CD4+ T cell count of >150 cells/mm3 were required for eligibility. Thirty-two subjects were enrolled; the median CD4+ T cell count at study entry was 289 cells/mm3. No relapses of histoplasmosis occurred after a median duration of follow-up of 24 months. This corresponded to an observed relapse rate of 0 cases per 65 person-years. The median CD4+ T cell count at final study visit was 338 cells/mm3. Discontinuation of antifungal maintenance therapy appears to be safe for patients with acquired immunodeficiency syndrome with previously treated disseminated histoplasmosis and sustained immunologic improvement in response to antiretroviral therapy.

CMV pp65 antigen testing is of limited utility in the diagnosis of concomitant CMV disease in HIV-infected patients in the HAART era

BACKGROUND

There are limited data on the utility of the CMV pp65 antigen (Ag) test for the diagnosis of concomitant CMV end-organ disease (EOD) in HIV+ patients in the highly active antiretroviral therapy era.

OBJECTIVES

We sought to assess the predictive value of a single pp65 test for the diagnosis of concomitant CMV EOD in HIV-infected patients.

STUDY DESIGN

A review of all pp65 Ag tests conducted at a large county teaching hospital from January 1998 through July 1999 was conducted. A diagnosis of CMV EOD required histopathologic evidence (except for retinitis). Concomitant disease was defined as CMV EOD within 30 days of Ag test. Results were reported as number of Ag positive cells/300000 cells counted.

RESULTS

Two-hundred and thirty patient charts (308 antigen tests) were reviewed. The median follow-up time was 334 days. Thirty-two patients had a prior diagnosis of CMV EOD. The most common reasons for testing were fever (45), pneumonia (10), and monitoring for recurrent retinitis (8). Ag tests were positive (range 1-1042 cells) in 51 patients. Twelve patients were diagnosed with concomitant CMV EOD. A diagnosis other than CMV was made in a significant majority of patients (154). The mean initial pp65 level was significantly higher in patients with concomitant CMV EOD versus those without concomitant CMV: 314 cells versus 13 cells, P<0.0001. The overall sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were 67, 81, 16 and 98%, respectively. Using a 50-cell cutoff and including only patients with CMV symptoms and CD4<100, improved test accuracy: sensitivity, specificity, PPV, and NPV of 60, 91, 60, and 91%. The CD4 cell count but not the HIV viral load was predictive of CMV EOD.

CONCLUSIONS

The CMV pp65 Ag test is useful in excluding concomitant CMV disease, but has limited utility in the diagnosis of acute CMV disease. The highest test utility will be in patients with a high likelihood of CMV disease based on symptoms, and CD4 cell count.

Survival is prolonged by highly active antiretroviral therapy in AIDS patients with primary central nervous system lymphoma

OBJECTIVE

To determine the effects of highly active antiretroviral therapy (HAART) on survival in AIDS-related primary central nervous system lymphoma (PCNSL).

METHODS

Survival in consecutive patients with PCNSL at a large county teaching hospital from 1995 to 2001 were analyzed by the log rank test and Cox proportional hazards ratios (HR) were calculated for factors potentially affecting survival.

RESULTS

During the study period, 25 patients were diagnosed with PCNSL: 19 definite and 6 probable. At diagnosis, median CD4 cell count was 12 x 10(6) cells/l (range 1-151) and median HIV viral load was 5.3 log(10) copies/ml (range 3.9-5.9). Sixteen patients died (median survival 87 days; range, 0 to > 2112). Longer survival was noted for patients who received HAART after diagnosis [HR for death, 0.06; 95% confidence interval (CI), 0.01-0.48]. Six of seven HAART-treated patients were alive versus 0/18 untreated patients at a median follow-up time of 667 days (P = 0.0007 by log rank test). A survival benefit was seen for patients who had >/= 0.5 log(10) copies/ml decrease in HIV viral load after diagnosis (n = 6; HR, 0.07; 95% CI, 0.01-0.55) and for patients with a significant CD4 cell rebound (increase >/= 50 x 106 cells/l) in response to HAART (n = 6): all survived versus 0/19 survived (P = 0.0003). Cranial radiation therapy (n = 13) prolonged survival (HR, 0.20; 95% CI, 0.07-0.58). Median survival was only 29 days for 11 patients who received neither radiation nor HAART.

CONCLUSIONS

Receipt of HAART after diagnosis is associated with a significantly longer survival in patients with AIDS-related CNS lymphoma.

Changes in mortality related to human immunodeficiency virus infection: comparative analysis of inpatient deaths in 1995 and in 1999-2000

We conducted a retrospective chart review of human immunodeficiency virus (HIV)-infected patients who died in 1995 and in 1999-2000. We found an increase in the proportion of patients who died from an illness that was not related to acquired immunodeficiency syndrome (AIDS). Although there was a decrease in the prevalence of AIDS-defining illnesses, >85% of patients died with CD4 counts of <200 cells/microL. The leading cause of death was Pneumocystis carinii pneumonia (PCP). Nonadherence to therapy and new diagnosis of HIV infection were the leading reasons why patients were not receiving antiretroviral therapy. The leading causes of non-AIDS-related deaths in 1999-2000 were non-AIDS-defining infections and end-stage liver disease. At our hospital, PCP remains an important cause of death in the highly active antiretroviral therapy (HAART) era, possibly because >50% of HIV-infected patients who died were not receiving HAART. AIDS-defining illnesses continue to be a major cause of mortality in the HAART era in populations where access to care and adherence to HAART is limited.

Comparison of the effects of acute influenza infection and Influenza vaccination on HIV viral load and CD4 cell counts

PURPOSE

Influenza vaccination is recommended for HIV-infected patients, although the efficacy is not clear. Prior studies have yielded differing results with regard to the effects of influenza vaccination on HIV viral load and CD4 cell counts. The effects of acute influenza on HIV viral replication and CD4 cell counts have not been well described. We sought to assess the effect of influenza infection and vaccination on HIV viral load and CD4 cell counts.

SUBJECTS AND METHODS

All cases of influenza occurring in HIV-infected individuals over 3 years at a large county hospital were reviewed. For the year 1997-1998, data on all HIV clinic patients who were vaccinated for influenza were recorded prospectively. In order to assess the effects of influenza infection (Group I) and vaccination (Group II) on HIV viral load and CD4 cell counts, values from before and after influenza infection or vaccination were compared to each other and to a matched control group not vaccinated and without influenza infection (Group III).

RESULTS

Forty-three cases of influenza were diagnosed. Pre- and post-influenza viral load in Group I was not significantly different: 3.34 versus 3.49 log copies/ml (P=0.36). Viral load was unchanged in 22 of 37 patients, increased in ten patients and decreased in five patients. Similarly, pre- and post-vaccination viral load in Group II was not significantly different: 3.52 versus 3.66 log copies/ml (P=0.12). Thirty-four of 47 patients who received influenza vaccine had no significant change in viral load-viral load increased in ten patients and decreased in three patients. No significant CD4 cell count changes were noted following influenza infection or vaccination. In contrast, Group III patients experienced a small decline in viral load from 4.23 to 3.39 log copies/ml, P<0.05, while there was a trend towards an increase in CD4 cell counts (P=0.06).

CONCLUSIONS

Following influenza infection or vaccination, most patients did not have a significant increase in HIV viral load or decrease in CD4 cell count.

Prevalence of visual symptoms among patients with newly diagnosed cytomegalovirus retinitis

PURPOSE

To determine the prevalence and type of visual symptoms among human immunodeficiency virus (HIV)-positive patients with newly diagnosed cytomegalovirus (CMV) retinitis.

METHODS

The authors conducted a retrospective review of the charts of all HIV type 1-infected patients at Parkland Memorial Hospital (Dallas, TX) who had newly diagnosed CMV retinitis between July 1, 1993, and September 30, 1997. Information recorded included demographics, results of laboratory evaluations including CD4 cell count, visual symptoms at the time of diagnosis, and the zone and extent of retinal involvement at presentation. Visual symptoms in the patients with CMV retinitis were compared with those in a control group of HIV-positive patients who were screened for CMV retinitis but were not diagnosed with retinitis.

RESULTS

Of 183 eyes (138 patients), 83% (88% of patients) had visual symptoms at the time of diagnosis. The most common presenting symptoms were blurred vision (67% of patients), floaters (49%), flashes of light (16%), eye pain (7%), and scotomata (3%). Compared with the control group of patients without CMV retinitis, patients with CMV retinitis were more likely to have any eye symptoms (88% versus 53%, respectively) as well as blurred vision, floaters, and either blurred vision or floaters (P < 0.0001). Eyes with zone 1 retinal involvement had an 88% incidence of visual symptoms at the time of diagnosis compared with 77% of eyes with peripheral retinal involvement (zones 2 and 3) (P > 0.05). Patients with zone 1 disease were more likely to note blurred or decreased vision than were patients with zone 2 or 3 disease (75% versus 47%, respectively; P < 0.0001). Eyes with <25% retinal involvement had a 76% rate of visual symptoms, which was significantly lower than the 90% rate noted among eyes with >25% retinal involvement (P < 0.05).

CONCLUSIONS

Most HIV-infected patients with newly diagnosed CMV retinitis had visual symptoms at presentation regardless of the zone of retinal involvement. The incidence of visual symptoms correlated with the degree of retinal involvement.

Focal neurological disease in patients with acquired immunodeficiency syndrome

Focal neurological disease in patients with acquired immunodeficiency syndrome may be caused by various opportunistic pathogens and malignancies, including Toxoplasma gondii, progressive multifocal leukoencephalopathy (PML), cytomegalovirus (CMV), and Epstein-Barr virus-related primary central nervous system (CNS) lymphoma. Diagnosis may be difficult, because the findings of lumbar puncture, computed tomography (CT), and magnetic resonance imaging are relatively nonspecific. Newer techniques have led to improved diagnostic accuracy of these conditions. Polymerase chain reaction (PCR) of cerebrospinal fluid specimens is useful for diagnosis of PML, CNS lymphoma, and CMV encephalitis. Recent studies have indicated the diagnostic utility of new neuroimaging techniques, such as single-photon emission CT and positron emission tomography. The combination of PCR and neuroimaging techniques may obviate the need for brain biopsy in selected cases. However, stereotactic brain biopsy, which is associated with relatively low morbidity rates, remains the reference standard for diagnosis. Highly active antiretroviral therapy has improved the prognosis of several focal CNS processes, most notably toxoplasmosis, PML, and CMV encephalitis.

Linezolid-Induced anemia and thrombocytopenia

Linezolid, a fluorinated oxazolidinone, is the first of a new class of antimicrobials designed to target resistant gram-positive cocci. Hematologic adverse effects, including reversible thrombocytopenia, were reported during phase III comparator-controlled trials. A 66-year-old man developed sternal osteomyelitis due to methicillin-resistant Staphylococcus aureus after undergoing coronary artery bypass graft surgery. Methicillin-resistant S. aureus bacteremia developed after several surgical debridements and courses of vancomycin failed to improve the patient's condition. Oral linezolid 600 mg twice/day was begun; 17 days later, a complete blood count revealed that his hematocrit had decreased from 37.4% to 24.8%, and his platelet count had decreased from 234 x 10(3)/mm3 to 149 x 10(3)/mm3. Both values returned to normal after linezolid was discontinued. Complete blood counts should be monitored closely in patients taking linezolid, especially if therapy continues for more than 14 days.

Clinical manifestations of influenza in HIV-infected individuals

Although influenza vaccination is recommended for individuals with HIV infection, there are no data indicating an increased incidence or severity of influenza in this population. We sought to describe the clinical manifestations and morbidity of influenza in HIV-infected patients. All cases of influenza occurring in HIV-infected individuals over 3 years at a large county hospital were reviewed. Forty-three cases of influenza were diagnosed. Most patients presented with typical signs and symptoms of influenza, including cough (90%), myalgias (64%), and fever (52%). Sore throat and headache occurred in less than half of patients. The mean CD4 cell count and HIV viral load in patients with influenza was 340 cells/mm(3) and 3.34 log copies/ml, respectively. No significant differences in CD4 counts or viral loads were noted in patients with pneumonia (n=7) compared with patients without pneumonia (n=36), P>0.5. Six patients were hospitalized. One patient each had encephalitis and renal failure, although the relationship to influenza was not clear. No new or unusual clinical manifestations were observed. The rate of pulmonary complications was similar to other studies in HIV-negative patients; however, the hospitalization rate was higher than commonly seen in HIV-negative individuals.

Protease inhibitor therapy is associated with markedly prolonged time to relapse and improved survival in AIDS patients with cytomegalovirus retinitis

Prior to the use of highly active antiretroviral therapy (HAART), cytomegalovirus retinitis (CMV-R) in AIDS patients was characterized by multiple relapses and decreased survival. Recent data suggest that CMV-R in patients treated with HAART may remain relapse-free for long periods. We performed a study of the effects of HIV protease inhibitors (PIs) on the incidence of relapse and time to death in AIDS patients with CMV-R treated with anti-CMV therapy. Medical records of all AIDS patients with CMV-R at Parkland Memorial Health and Hospital System treated with anti-CMV agents were reviewed for date of diagnosis of CMV-R, date of CMV-R relapse, type and duration of anti-CMV therapy, and duration of PI therapy. Relapse rates in subjects treated with PIs were compared with the relapse rates in those who were not treated with PIs. The primary endpoint was the time to relapse and death as determined by Kaplan-Meier analysis. Multivariate analysis was performed by Cox proportional hazard model. One hundred and nine cases of CMV-R were identified in 75 patients. Median follow-up time was 247 days (range 31-1818 days). There were 0.54 relapses per 1000 patient days in the group treated with PIs compared with 1.83 relapses per 1000 patient days in the non-PI treatment group (relative risk [RR]=0.29, P<0.01). Time to relapse was increased in the PI treatment group compared with the non-PI treatment group (endpoint not reached vs 182 days, P<0.001, log-rank). Similarly, the time to relapse or death was increased in the PI group compared with the non-PI group (543 days vs 103 days, P<0.001, log-rank). Multivariate analysis utilizing the Cox proportional hazards model demonstrated that only PI therapy but not anti-CMV therapy was associated with decreased risk of CMV-R relapse or death. Only 3 patients with an undetectable HIV viral load and one patient with a CD4 count >120 cells/microl had a relapse. We conclude that patients with CMV-R treated with HAART containing a PI have increased time to relapse and have prolonged survival.

Osteonecrosis in HIV: a case-control study

BACKGROUND

Osteonecrosis (avascular necrosis) has been infrequently reported in HIV-infected patients. It is not known whether HIV itself is an independent risk factor for osteonecrosis.

METHODS

We identified 25 patients with osteonecrosis from 1984 to 1999 from a large county teaching hospital and two large practices in Dallas County that specialize in HIV-disease related therapy. A retrospective chart review was performed to evaluate potential risk factors for osteonecrosis. Each case was matched with two controls for HIV positive status and date of osteonecrosis diagnosis.

RESULTS

In the study, 22 of 25 (88%) case patients had at least one osteonecrosis risk factor compared with 24 of 50 (48%) controls, p =.003. The most common osteonecrosis risk factors were hyperlipidemia (32%), alcoholism (28%), pancreatitis (16%), corticosteroids (12%), and hypercoaguability (12%). Of the cases, 12% were idiopathic. Multiple joints were involved in 72% of cases. Four of the case patients compared with none of the controls received megesterol acetate before the diagnosis of osteonecrosis, p =.01. No significant differences were found between cases and controls with respect to liver function tests, testosterone levels, triglyceride levels, cholesterol levels, or CD4 cell counts. Saquinavir was independently associated with osteonecrosis, p <.05. However, no differences in overall use of protease inhibitors among cases and controls were noted: 79% versus 76%, respectively.

CONCLUSIONS

The increased incidence of osteonecrosis in HIV/AIDS may be due to an increased frequency of risk factors previously associated with osteonecrosis such as hyperlipidemia, corticosteroid use, alcohol abuse, and hypercoaguability. Use of protease inhibitors was not independently associated with osteonecrosis.

Peripherally inserted central catheters in patients with AIDS are associated with a low infection rate

We reviewed the medical records of all human immunodeficiency virus (HIV)-infected patients who had a peripherally inserted central catheter (PICC) placed during a 1-year period. Ninety-seven PICCs were inserted in 66 patients for 8337 catheter-days. Eighty of 97 catheters were used primarily to treat cytomegalovirus disease. The mean time to any complication was 150 days. The total complication rate was 6.1 per 1000 catheter-days. The total infection rate was 1. 3 per 1000 catheter-days, and the serious infection rate was 0.8 per 1000 catheter-days. The mean time to a serious infection was 310 days. The noninfectious complication rate was 4.6 per 1000 catheter-days. PICCs were associated with a low infection rate and a moderate mechanical complication rate, which compare favorably with historical rates seen in AIDS patients with other types of central venous access devices. PICCs are a reasonable alternative to other central venous access devices in patients with HIV or AIDS.

SPECT thallium-201 combined with Toxoplasma serology for the presumptive diagnosis of focal central nervous system mass lesions in patients with AIDS

OBJECTIVE

To determine the utility of brain thallium-201 single photon emission computerized tomography (Tl-201 SPECT) combined with Toxoplasma serology for the diagnosis of focal CNS lesions in patients with AIDS.

METHODS

Sixty-one consecutive HIV-infected patients with focal CNS lesion(s) on head computed tomography (CT) or MRI scan who underwent brain Tl-201 SPECT and serum Toxoplasma serology were evaluated, retrospectively. Thallium-201 uptake ratios were calculated by comparing lesion activity to contralateral scalp activity. Diagnoses were made by a combination of histology, serology, PCR, and empirical response to therapy. Toxoplasma serologies (IgG IFA) were compared in the patients with central nervous system (CNS) toxoplasmosis and those without CNS toxoplasmosis.

RESULTS

Fifty-six patients were evaluable and a definitive diagnosis was made in 38 patients: toxoplasmosis (17), lymphoma (14), PML (three), Aspergillus (one), tuberculoma (one), Cryptococcus (one), varicella-zoster virus (one). Patients with lymphoma had significantly higher lesion/contralateral scalp ratios compared to patients without lymphoma: 1.03 vs. 0.67, P < 0.05. Using a cut-off of 0.90 for the lesion/scalp uptake ratios (based on analysis of ROC curves) the sensitivity and specificity for the diagnosis of lymphoma were 86% and 83%, respectively. Serum Toxoplasma IgG titres were significantly higher in patients diagnosed with toxoplasmosis compared to those with a diagnosis other than toxoplasmosis, 1:5444 vs. 1:15, P < 0.05. Only one patient with confirmed toxoplasmosis had a Toxoplasma serology < 1:256, while no patients without toxoplasmosis (including all lymphoma patients) had serologies > 1:256.

CONCLUSIONS

In a series of HIV-infected patients, Tl-201 SPECT was able to accurately differentiate primary brain lymphoma from other causes of focal CNS lesions in most patients; however, both false positive and false negative results occurred. By combining Tl-201 SPECT with serum Toxoplasma IgG, diagnostic accuracy was improved.

Therapeutic developments in cytomegalovirus retinitis

The incidence of cytomegalovirus (CMV) retinitis in AIDS has declined significantly due to the use of highly active antiretroviral therapy (HAART). However, patients with HIV, especially those failing HAART, may still suffer with CMV retinitis, which can lead to significant loss of vision and blindness. Ganciclovir has traditionally been considered the recommended treatment for CMV retinitis; however, due to side effects and the possibility of developing viral resistance, other agents may be preferred in certain situations. Foscarnet, which has similar efficacy to ganciclovir but a different side effect profile, is more difficult to administer and is less well-tolerated. Intravenous cidofovir, which may be more effective than either iv. ganciclovir or foscarnet, can also be used as a first line agent; however, it is associated with toxicity (renal and ocular) and thus needs careful use. Local therapy for CMV retinitis has been a significant advance. The intraocular ganciclovir implant has the highest efficacy of the approved agents and is well-tolerated. Fomivirsen, an oligonucleotide injected intravitreally, is a newly approved agent which offers alternative treatment. Intravitreal ganciclovir or foscarnet, although not approved, have been used successfully in some patients especially those with recurrent or refractory disease. The development of new anti-CMV agents has been stalled by the decreased incidence of the disease. Valganciclovir, a prodrug of ganciclovir, offers excellent oral bioavailability and is the closest to approval of all the new anti-CMV drugs. High ganciclovir blood levels are achieved without the complications associated with the requirement for long-term iv. access. The monoclonal antibody (mAb) MSL-109, did not offer a significant advantage when added to traditional anti-CMV therapy. Development plans of other agents such as cyclic HPMPC and lobucavir have been put on hold by their respective manufacturers. Adefovir is a nucleotide analogue that possesses anti-CMV activity, but is currently only being pursued for the treatment of hepatitis B virus. Other compounds possessing significant anti-CMV activity, including BAY 38-4766 and GW1263W94 are still in the early stages of development.

Disseminated sporotrichosis with extensive cutaneous involvement in a patient with AIDS

Sporotrichosis most commonly presents as a localized, lymphocutaneous infection that follows trauma, such as an injury from a rose thorn. In patients infected with HIV, it may be widespread and disseminated. We describe a patient with AIDS who developed disseminated sporotrichosis, a rare opportunistic fungal infection that may affect these patients. The condition remained undiagnosed because of failure to recognize characteristic histopathologic findings and failure of clinicians to interface closely with the microbiology laboratory. The condition was difficult to treat, requiring systemic administration of amphotericin. While localized sporotrichosis is an innocuous disorder that responds well to therapy, in immunocompromised hosts, it is potentially life-threatening and may require prolonged therapy with potentially toxic medications such as amphotericin B. It is important that clinicians be aware of the presentation of this unusual opportunistic infection and that they maintain close communication with pathology and clinical microbiology laboratories to ensure that proper stains and cultures are performed to avoid potential misdiagnosis.

Sulfonamide-induced reactions in desensitized patients with AIDS--the role of covalent protein haptenation by sulfamethoxazole

BACKGROUND

Adverse reactions to sulfonamides cause significant morbidity in patients with AIDS. We have demonstrated previously a approximately 40 kd sulfamethoxazole (SMX)-substituted protein in the serum of some individuals treated with SMX.

OBJECTIVE

The purpose of this study was to examine patients with AIDS who had undergone SMX desensitization because of a prior history of SMX allergy for the presence of SMX-haptenated serum proteins and to determine whether these proteins, SMX-specific IgG antibodies, or both predict the development of subsequent clinical reactivity.

METHODS

Four patients with no history of allergy and in whom SMX prophylaxis was initiated and eight patients with AIDS who had undergone SMX desensitization because of prior allergy were evaluated. SMX-conjugated serum proteins were identified with an immunoblotting assay, and SMX-specific IgG antibodies were identified by ELISA inhibition.

RESULTS

One of the four patients receiving SMX prophylactic treatment demonstrated SMX-protein haptenation, none had detectable SMX-specific IgG antibodies, and none developed an SMX-associated reaction during the time in which they were followed. Of the eight patients who underwent SMX desensitization, six (75%) demonstrated SMX-protein haptenation, and three of these six (50%) subsequently developed SMX-induced cutaneous reactions. Only one of these six patients had detectable SMX-specific IgG antibodies. The two individuals who did not demonstrate SMX-protein haptenation have not developed a clinical reaction.

CONCLUSION

These preliminary data suggest that SMX haptenation, but not SMX-specific antibodies, may be important in the development of clinical sensitivity in patients with AIDS who have undergone SMX desensitization.

Nontunneled central venous catheters in patients with AIDS are associated with a low infection rate

Patients with AIDS frequently require long-term central venous access devices for intravenous (IV) therapy. We reviewed the medical records of all HIV-infected patients at a single large urban hospital who had a central venous catheter (CVC) placed during a 1-year period to assess the overall complication rate, infection rate, and the microbiology of infectious complications. One hundred fifty-six catheters were inserted in 87 patients for 11,041 catheter days. These catheters (142 of 156) were primarily nontunneled, nonimplantable CVCs (NT-CVCs), and analyses were limited to these. Of these catheters, 79% were primarily used to treat disease caused by cytomegalovirus (CMV). The complication rate for the NT-CVCs was 5.1/1000 catheter days with a mean time to any complication of 106 days. The total infection rate of the NT-CVCs was 2.8/1000 catheter days, and the serious infection rate (bacteremia) for the NT-CVCs was 1.4/1000 catheter days. The mean time to a serious infection was 407 days. None of the following parameters was associated with an increased infection rate: HIV risk factor, indication for catheter, medications received via catheter, number of catheter ports, anatomic site of catheter insertion, or the presence of neutropenia. NT-CVCs were associated with low complication and infection rates that were comparable with historical rates seen in AIDS patients with tunneled and totally implantable central venous access devices. NT-CVCs may be a safe, cost-effective alternative to other central venous access devices in patients with HIV/AIDS.

Catheter-related bacteremia due to Mycobacterium smegmatis

Rapidly growing mycobacteria have occasionally been reported to cause catheter-related infections. We report a case of a central venous catheter-related bacteremia, caused by Mycobacterium smegmatis, in a patient with cancer. Cultures of the catheter tip and blood cultures grew M smegmatis and Enterococcus faecalis. The patient responded to catheter removal and a 3-month course of antibiotics (doxycycline and ciprofloxacin). Based on our experience and the reported experience with other rapidly growing mycobacteria, M smegmatis catheter-related bacteremia should be treated with catheter removal and a course of appropriate antibiotics, based on in vitro susceptibility testing.

Human immunodeficiency virus infection in patients older than 50 years. A survey of primary care physicians' beliefs, practices, and knowledge

To assess primary care physicians' attitudes, knowledge, and practices with respect to the human immunodeficiency virus (HIV) in older patients, a prospective survey of a representative cohort of primary care physicians was conducted in Dallas County, Texas, a large metropolitan area. Three hundred thirty primary care physicians participated in the survey. Questions were asked regarding physician demographics, practice characteristics, and knowledge and practices with respect to HIV and the acquired immunodeficiency syndrome (AIDS) in patients older than 50 years. The responses of the following groups were compared: family practitioners vs internists, physicians younger than 40 years vs those aged 40 years and older, those who saw 5 or less vs more than 5 patients with HIV or AIDS per year, and those in private vs nonprivate practice. Most respondents (85.5%) reported having seen 10 or fewer patients with HIV or AIDS in the previous year. Most physicians (69.7%) reported that patients older than 50 years rarely or never asked questions concerning HIV or AIDS. Most physicians rarely or never discussed HIV or AIDS with patients older than 50 years (60.8%) and rarely or never discussed risk factor reduction (67.5%). Physicians were more likely to rarely or never ask patients older than 50 years compared with those younger than 30 years about HIV risk factors (40.0% vs 6.8%, P < .001). Physicians incorrectly rank ordered the most prevalent risk factors in patients older than 50 years. The correct order is (1) male-male sex, (2) intravenous drug use, (3) blood transfusion, and (4) heterosexual sex. Physicians aged 40 years and older were more likely to correctly identify the most prevalent risk factor (P = .03). Family practitioners were more likely to rarely or never ask older patients about risk factors for HIV (54.9% vs 28.9%, P = .007). Primary care physicians have inadequate knowledge concerning HIV and AIDS risk factors in older patients and insufficiently discuss HIV and AIDS with older patients. Physicians should counsel patients of all ages about HIV and AIDS.

Clinical significance of eosinophilia in HIV-infected individuals

PURPOSE

To assess the clinical significance of peripheral eosinophilia in HIV-infected individuals.

METHODS

In a retrospective case-control study we compared 42 HIV-infected patients (cases) with peripheral eosinophilia (absolute eosinophil count > 500 cells/mm3) with 84 HIV-infected controls without eosinophilia. Cases were matched to controls by date, and by CD4 cell count. Data on clinical parameters possibly associated with eosinophilia were collected and compared among cases and controls.

RESULTS

Eosinophilia was seen in patients with late-stage HIV disease (median CD4 cell count of 26 cells/mm3). Cases were more likely to be black (52% versus 18%, P = 0.0001), have pruritus (50% versus 20%, P = 0.002), and have a physician-documented rash (76% versus 52%, P = 0.02). Specific cutaneous diagnoses that were more prevalent in cases versus controls were eosinophilic folliculitis (24% versus 1% P = 0.0001), atopic dermatitis (14% versus 1%, P = 0.01), and prurigo nodularis (7% versus O, P = 0.07). Other parameters commonly associated with eosinophilia such as allergic reactions, parasitic infection, malignancy, and adrenal insufficiency were not found at higher incidence in cases.

CONCLUSIONS

Eosinophilia in AIDS patients is associated with cutaneous disease, but not with other conditions commonly associated with eosinophilia including parasitic infections, allergic reactions, or malignancy. Extensive work up for asymptomatic eosinophilia in patients with AIDS and cutaneous disease is not warranted.

The importance of comorbidity in HIV-infected patients over 55: a retrospective case-control study

PURPOSE

To study the impact of comorbidity on the course of HIV disease in older patients as compared to a matched cohort of younger patients.

METHODS

In a retrospective case-control study, we compared 43 HIV-infected patients > 55 years old to a randomly selected cohort of 86 patients < 45 years old, matched by date of HIV diagnosis. We collected data on non-HIV-related morbidity (as assessed by the Charlson comorbidity index), initiator of HIV testing, HIV stage at time of HIV diagnosis (TOHD), AIDS defining diagnoses, AIDS-related illnesses (ARI), observed AIDS-free interval, survival, and frequency of HIV-related and unrelated hospitalizations.

RESULTS

The older cohort was more likely to have had HIV testing initiated by a health care provider (36 of 36 versus 50 of 66, P = 0.003), and to have acquired HIV from a transfusion (5 of 43 versus 0 of 86, P = 0.001), had lower CD4 cell counts at TOHD (205 versus 429, P = 0.02), a shorter observed AIDS-free interval (24.0 versus 52.8 months, P = 0.0002) and a shorter survival (28.2 versus 58.9 months, P = 0.0002). The older cohort had more HIV-related (13.4 versus 9.2 per 100 patient-months, P = 0.024) and non-HIV-related hospitalizations (12.9 versus 8.1 per 100 patient-months, P = 0.0001). The comorbidity index was significantly higher in the older cohort (0.907 versus 0.198, P = 0.0001) and was a strong predictor of mortality, independent of age group (risk ratio = 1.38 per comorbidity point, P = 0.0003).

CONCLUSIONS

Older HIV-infected patients presented with more advanced disease, which may have been due to lack of HIV awareness in this population. Older patients had a shorter observed AIDS-free interval and shorter survival. In addition, they had more HIV- and non-HIV-related comorbidity. The more rapid course and decreased survival in the elderly may be related to the increase in comorbidity.