Virological factors associated with outcome of dual maraviroc/raltegravir therapy (ANRS-157 trial)

OBJECTIVES

ROCnRAL ANRS-157 was a single-arm study designed to evaluate a switch to a maraviroc (300 mg twice a day) plus raltegravir (400 mg twice a day) regimen in virologically suppressed HIV-1-infected patients (ClinicalTrials.gov: NCT01420523). The aim of this work was to investigate the factors associated with virological failure (VF) (5/44 patients) or virological rebound defined as one viral load (VL) >50 copies/mL or VL >1 copy/mL.

METHODS

At baseline (BL), ultradeep sequencing (UDS) of DNA gp120 V3 and integrase regions and quantification of HIV DNA were performed in PBMCs. Tropism, VL, BL ultrasensitive HIV RNA VL, BL HIV DNA VL, subtype, age, ethnicity, transmission group, AIDS status, nadir CD4 and BL CD4 cell count, time since HIV diagnosis, duration of ART and suppressed viraemia, VL zenith, CD4/CD8 ratio and BL CD8 cell count were investigated as potential factors associated with virological rebound.

RESULTS

The proportion of patients with VL <1 copy/mL did not evolve over time. Among the 44 included patients, 3 had minority X4-tropic viruses determined by UDS at BL and one of them presented VF. Minority resistant variants in the integrase gene were detected at BL at two positions (E138 and G140) for three patients who did not have VF. Among all studied factors, none was associated with virological rebound.

CONCLUSIONS

Maraviroc plus raltegravir failed to maintain virological suppression in virologically suppressed HIV-1-infected patients. However, neither minority viral variants nor ultrasensitive viraemia was found to be a predictive factor of VF or virological rebound in this context.

The features of infectious diseases departments and anti-infective practices in France and Turkey: a cross-sectional study

The aim of this study was to assess the infectious diseases (ID) wards of tertiary hospitals in France and Turkey for technical capacity, infection control, characteristics of patients, infections, infecting organisms, and therapeutic approaches. This cross-sectional study was carried out on a single day on one of the weekdays of June 17-21, 2013. Overall, 36 ID departments from Turkey (n = 21) and France (n = 15) were involved. On the study day, 273 patients were hospitalized in Turkish and 324 patients were followed in French ID departments. The numbers of patients and beds in the hospitals, and presence of an intensive care unit (ICU) room in the ID ward was not different in both France and Turkey. Bed occupancy in the ID ward, single rooms, and negative pressure rooms were significantly higher in France. The presence of a laboratory inside the ID ward was more common in Turkish ID wards. The configuration of infection control committees, and their qualifications and surveillance types were quite similar in both countries. Although differences existed based on epidemiology, the distribution of infections were uniform on both sides. In Turkey, anti-Gram-positive agents, carbapenems, and tigecycline, and in France, cephalosporins, penicillins, aminoglycosides, and metronidazole were more frequently preferred. Enteric Gram-negatives and hepatitis B and C were more frequent in Turkey, while human immunodeficiency virus (HIV) and streptococci were more common in France (p < 0.05 for all significances). Various differences and similarities existed in France and Turkey in the ID wards. However, the current scene is that ID are managed with high standards in both countries.

[Tetanus complicated with sepsis on major haemoglobinopathy]

Rapporter un cas de tétanos compliqué de septicémie chez un enfant souffrant d'une hémoglobinopathie majeure. Enfant de 9 ans drépanocytaire (SC), non vacciné contre le tétanos, a été admis au CHU YO pour raideur de la nuque, difficulté à l'ouverture de la bouche et hyperthermie. L'examen à son admission notait un syndrome infectieux avec une hyperthermie (température à 39°1C), Pouls = 100/mn, Fréquence cardiaque = 100batt/mn, fréquence respiratoire = 30cycles/mn, poids =22Kg, un trismus, une contracture des muscles para vertébraux, des paroxysmes toniques à la palpation (stade II de Mollaret), un syndrome méningé. L'examen n'avait pas retrouvé une porte d'entrée. La ponction lombaire avait ramené un liquide céphalo rachidien clair; l'hémogramme avait montré une hyperleucocytose à 10 200/mm³, et l'hémoculture a permis d'isoler Staphylococcus aureus. Sous antibiothérapie et sous sédatifs, l’évolution a été favorable. Les porteurs d'hémoglobinopathie majeure sont plus exposés aux infections. La physiopathologie de ces infections s'explique par l'immunodépression et les troubles de la phagocytose. Un dépistage précoce de ces hémoglobinopathies, un bon suivi et une bonne couverture vaccinale des enfants drépanocytaires sont essentiels pour prévenir le tétanos et ses complications.

Raltegravir as functional monotherapy leads to virological failure and drug resistance in highly treatment-experienced HIV-infected patients

The objective of this study was to evaluate the development of resistance to raltegravir (RAL) in patients with viraemia between 40 and 400 copies/ml. All HIV-1-infected patients with multidrug-resistant virus, plasma HIV-1 RNA >1000 copies/ml and starting RAL were enrolled in this observational study and followed up until week 48. Sixty-seven patients with median plasma HIV-1 RNA at 4.3 log(10) copies/ml and CD4 at 177 cells/mm(3) were included. At week 24, 43 achieved full viral suppression (FVS; plasma HIV-1 RNA <40 copies/ml), 18 had incomplete viral suppression (IVS; plasma HIV-1 RNA 40-<or=400 copies/ml) and 6 experienced virological failure (VF; plasma HIV-1 RNA >400 copies/ml). At week 48, all the FVS were sustained, 16 of the IVS patients retained a plasma HIV-1 RNA <400 copies/ml and only 2 of the IVS at week 24 experienced VF. No RAL resistance was detected in the persistent low viraemia. In contrast, integrase mutation was detected in 6 of the patients with VF. A genotypic sensitivity score equal to 0 was associated with plasma HIV-1 RNA >40 copies/ml at week 24 (OR 20.9, 95% CI 2.0-215.1) and with RAL resistance (OR 14.2, 95% CI 2.1-94.7). This study confirmed the high efficacy of a RAL-containing regimen under routine clinical conditions in infections caused by multidrug-resistant virus. If persistent low viraemia is observed over more than 48 weeks without the emergence of resistance, RAL should never be given as functional monotherapy, as it is associated with a maximal risk of VF and the emergence of RAL resistance.

Discordance between cerebral spinal fluid and plasma HIV replication in patients with neurological symptoms who are receiving suppressive antiretroviral therapy

OBJECTIVE

We report data on 11 patients with neurological symptoms and human immunodeficiency virus (HIV) cerebrospinal fluid (CSF) viremia contrasting with suppressed plasma HIV RNA during receipt of combined antiretroviral therapy.

DESIGN

We retrospectively identified instances of central nervous system (CNS) symptoms in patients who had been receiving stable combination antiretroviral therapy. Discordance between plasma and CSF HIV RNA levels was defined by any detectable CSF HIV RNA level >200 copies/mL while plasma levels were <50 copies/mL or by a CSF HIV RNA level that was 1 log greater than the plasma HIV RNA level.

RESULTS

Eleven patients had experienced acute or subacute neurological symptoms. All but one patient had CSF pleocytosis and/or elevated protein levels. The median CSF HIV RNA level was 880 copies/mL (range, 558-12,885 copies/mL). Patients had been receiving stable combination antiretroviral therapy for a median of 13 months (range, 10-32 months). Eight of 11 patients had a plasma HIV RNA level <50 copies/mL, and 3 had plasma HIV RNA blips with their CSF HIV RNA level >1 log higher than their plasma HIV RNA level. Resistance-associated mutations were detected in 7 of 8 CSF HIV RNA genotypic strains. The median number of resistance-associated mutations was 6 (range, 2-8) to nucleoside reverse-transcriptase inhibitors and 3 (range, 1-9) to protease inhibitors. One patient had a virus harboring nonnucleoside reverse-transcriptase inhibitor mutations. The median central nervous system penetration-effectiveness (CPE) rank was 2 (range, 1-3), and 5 patients had a CPE 1.5. After antiretroviral therapy optimization based on genotypes and CPE, all patients clinically improved, with normalization of CSF.

CONCLUSIONS

Despite successful suppression of plasma viremia with antiretroviral therapy, HIV may replicate in CSF, with development of CSF HIV resistance resulting in acute or subacute neurological manifestations.

Fetal death as a result of placental immune reconstitution inflammatory syndrome

A 26-year-old woman was HIV-1 diagnosed at 11 weeks of pregnancy (CD4 = 7/mm(3), HIV-1 RNA = 108,000 copies/mL) with immunity against toxoplasmosis (Toxoplasma IgG = 1800 UI/mL). A fetal death was diagnosed 7 weeks after starting HAART (CD4 = 185/mm(3), HIV-1 RNA = 391 copies/mL) with a positive Toxoplasma PCR on fetal tissues and amniotic fluid. The absence of severe toxoplasmic foetopathy, the very exaggerated and atypical placental inflammation and the immune restoration context led to the diagnosis of placental IRIS associated with Toxoplasma gondii reactivation. This outcome remains undescribed and could represent an issue in resource-limited settings where HIV-pregnant patients are often severely immunodeficient and infected with opportunistic pathogens.

Persistent high nevirapine blood level with DRESS syndrome 12 days after interruption of antiretroviral therapy

Nevirapine is an antiretroviral agent associated with drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. Such a case in an immunocompetent woman recently treated with nevirapine for postexposure HIV prophylaxis is reported here. Despite a period of 12 days after interruption of treatment, a high blood level of nevirapine was still observed.

Skin and soft tissue infections in returning travelers

Skin and soft tissue infections (SSTI) are a leading cause of cutaneous problems in travelers. Sixty travelers who presented with an SSTI were prospectively included over a 20-month period. Bacterial analysis and research for Panton-Valentine leukocidine (PVL) were performed according to clinical and bacterial presentation. The SSTI appeared abroad in 73% and were predominantly localized on lower limbs (75%). The main clinical forms were impetigo (35%) and cutaneous absess (23%). Insect bites were significantly associated with impetigo and ecthyma. Methicillin-susceptible Staphylococcus aureus (MSSA) was identified in 15 patients (43%), Group A Streptococcus (GAS) in 12 patients (34%), and an association of both in 8 (23%) among the 35 patients for whom bacteria were identified. The MSSA producing PVL were found in 4 patients. Travelers should be advised on how to prevent arthropod exposure and susceptibility testing should be recommended considering that methicillin-resistant S. aureus (MRSA) is increasingly reported, although not identified in our study.

Impact of gag mutations on selection of darunavir resistance mutations in HIV-1 protease

OBJECTIVES

To search for genetic factors in the protease and gag regions (NC-p1/TFP-p6/p6pol) involved in selection of darunavir resistance mutations.

PATIENTS AND METHODS

We analysed 48 protease inhibitor (PI)-experienced HIV-infected patients experiencing darunavir treatment failure. Viral genotyping at baseline and months 3 and 6 was used to assess the selection of mutations in the protease and gag regions conferring resistance to PIs.

RESULTS

There were no genotypic differences in the studied gag region between baseline and the latest available rebound isolates. There was an association between the presence of the mutation A431V in the gag sequence and the selection of the L76V mutation in the protease sequence in the latest available rebound. The I437T/V mutation in gag and the L76V mutation in the protease were associated with a lower risk of selecting darunavir resistance mutations.

CONCLUSIONS

In these PI-treated patients experiencing treatment failure of a darunavir-containing regimen, we showed that mutations in the gag region NC-p1/TFP-p6/p6pol may influence the selection of darunavir resistance mutations; in particular, the I437T/V gag mutation that confers resistance to PIs reduces the selection of such mutations. Virus with L76V in protease or I437T/V in gag may be already resistant to darunavir and, therefore, no additional resistance mutations need to be selected.

Chagas disease, France

Chagas Disease, France

Chagas disease (CD) is endemic to Latin America; its prevalence is highest in Bolivia. CD is sometimes seen in the United States and Canada among migrants from Latin America, whereas it is rare in Europe. We report 9 cases of imported CD in France from 2004 to 2006.

Management of travelers with fever and exanthema, notably dengue and chikungunya infections

Febrile exanthema frequently presents as an acute condition in travelers. Sixty-two travelers who presented with febrile exanthema were prospectively included over a 20-month period. Diagnostic tests were performed according to clinical presentation and risk exposures. Symptoms occurred after return in 56% of these travelers, and the median interval between return and symptom onset was 2 days. The 3 main travel destinations were the Indian Ocean (35%), Africa (21%), and Asia (18%). The 3 main etiologies were chikungunya (35%), dengue (26%), and African tick bite fever (ATBF) (10%). Travel to the Indian Ocean and South Africa was significantly associated with respectively chikungunya and ATBF. Arthralgias were significantly more frequent in chikungunya than in dengue, whereas leucopenia, neutropenia, and thrombopenia were significantly more frequent in dengue. Travelers presenting with febrile exanthema should therefore be screened for arboviral infections according to the area visited.

Antibiothérapie de la phase primaire de la borréliose de Lyme

OBJECTIVE

The aim of this article is to provide clinicians with guidelines for the antibiotherapy of early-localized Lyme disease. The outcome measures are the clearance of erythema migrans and associated symptoms of early localized Lyme disease and the prevention rate of late complications, with a low risk of adverse effects. Design. The reviewed studies were selected by Medline with the keywords: "erythema migrans, treatment". Sixteen studies comparing treatment or duration of treatment were analyzed.

RESULTS

Amoxicillin, doxycycline, and cefuroxim axetil are equally efficacious for early-localized Lyme disease. Azithromycin is an alternative. Most patients respond completely and less than 10% fail to respond. All antibiotics are associated with a low frequency of adverse effects, with the exception of Jarisch Herxheimer reaction which occurs in about 15% of the patients.

CONCLUSIONS

We recommend treating adults with amoxicillin (50 mg/kg/day in 3 intakes) or doxycycline (100 mg bid) for 14 days (erythema migrans) to 21 days (early localized Lyme disease with associated symptoms). For children, we recommend amoxicillin (50 mg/kg/day in 3 intakes) or doxycycline (4 mg/kg/day in 2 intakes, maximum 100 mg/dose) above 8 years of age. Cefuroxim axetil (500 mg twice daily for adults or 30 mg/kg/day in 2 intakes, maximum 500 mg/dose, for children), and azithromycin (500 mg/day for adults and 20 mg/kg/day for children for 7-10 days) are second line treatment.

Genetic diversity and drug resistance mutations in HIV type 1 from untreated patients in Bamako, Mali

OBJECTIVE

To determine the genetic diversity of HIV-1 reverse transcriptase (RT) and protease sequences and the presence of mutations linked to antiretroviral (ARV) resistance in treatment-naive, HIV-1-infected individuals living in Mali.

METHODS

Ninety-eight samples from ARV drug-naive, HIV-1-infected patients were collected in one clinical centre in Bamako, Mali in 2005. RT and protease genes were sequenced in order to perform phylogenetic and resistance analyses.

RESULTS

The most prevalent subtype was CRF02-AG (75% of cases), followed by the CRF06-cpx subtype (20%). Intersubtype recombinants between CRF02-AG, CRF01-AE and CRF06-cpx were also described in 5% of cases. After 4 years of ARV use in Mali, two previously untreated individuals (2%; 95% CI: 0.00-4.77%) were found to have resistant viruses, one with a single nucleoside mutation and one with K103N non-nucleoside reverse transcriptase inhibitor resistance mutation. No evidence of transmitted protease inhibitor resistance mutations was found.

CONCLUSION

These data provide direct evidence for the circulation of HIV-1 isolates containing resistance mutations in treatment-naive patients in Mali. Since ARV use in Mali began, more than 5000 patients have started treatment, mostly with Triomune (stavudine/lamivudine/nevirapine). The resistance-associated mutations detected in the present study are consistent with this treatment regimen. Continued surveillance will be required to monitor the emergence of ARV resistance in this country.

Genetic Diversity and Drug Resistance Mutations in HIV type 1 from Untreated Patients in Bamako, Mali

Objective

To determine the genetic diversity of HIV-1 reverse transcriptase (RT) and protease sequences and the presence of mutations linked to antiretroviral (ARV) resistance in treatment-naive, HIV-1-infected individuals living in Mali.

Methods

Ninety-eight samples from ARV drug-naive, HIV-1-infected patients were collected in one clinical centre in Bamako, Mali in 2005. RT and protease genes were sequenced in order to perform phylogenetic and resistance analyses.

Results

The most prevalent subtype was CRF02-AG (75% of cases), followed by the CRF06-cpx subtype (20%). Intersubtype recombinants between CRF02-AG, CRF01-AE and CRF06-cpx were also described in 5% of cases. After 4 years of ARV use in Mali, two previously untreated individuals (2%; 95% CI: 0.00–4.77%) were found to have resistant viruses, one with a single nucleoside mutation and one with K103N non-nucleoside reverse transcriptase inhibitor resistance mutation. No evidence of transmitted protease inhibitor resistance mutations was found.

Conclusion

These data provide direct evidence for the circulation of HIV-1 isolates containing resistance mutations in treatment-naive patients in Mali. Since ARV use in Mali began, more than 5,000 patients have started treatment, mostly with Triomune (stavudine/lamivu-dine/nevirapine). The resistance-associated mutations detected in the present study are consistent with this treatment regimen. Continued surveillance will be required to monitor the emergence of ARV resistance in this country.

Foscarnet Salvage Therapy for Patients with Late-Stage HIV Disease and Multiple Drug Resistance

Objective

To evaluate the efficacy of foscarnet on HIV infection in patients with late-stage HIV disease and multiple drug resistance.

Methods

Three drugs experienced patients with plasma viral load (pVL) >50,000 copies/ml and CD4+ T-cell counts <100/mm3 were eligible for this open-label, single-arm, add-on pilot study. Foscarnet induction therapy consisted of 5 g intravenously twice daily for 6 weeks, in addition to a stable antiretroviral regimen. Patients with at least 1 log10 decrease in pVL at week 6 (W6), were given foscarnet 5 g intravenously twice daily on two consecutive days each week. Primary endpoint was the virological response rate at W6.

Results

Eleven patients were enrolled with a median baseline pVL at 5.16 log10 copies/ml, median CD4+ T-cell count at 10/mm3 and median number of mutations of 9, 2 and 12 associated with resistance to nucleoside reverse transcriptase inhibitors (NRTIs), non-NRTIs and protease inhibitors, respectively. One patient discontinued foscarnet at W2 because of renal toxicity. In an intent-to-treat analysis, the median change in pVL from baseline was -1.99 log10 copies/ml at W2 and -1.79 log10 copies/ml at W6. Eight out of eleven patients had a fall in pVL of at least 1 log10 at W6, and six started maintenance therapy. The median fall in pVL after 12 weeks of maintenance therapy was -0.85 log10 copies/ml in the four patients who reached W12, and the median increase of CD4+ T-cell count was 60/mm3.

Conclusion

In patients with HIV mutations conferring resistance to all antiretroviral drug classes, foscarnet markedly reduced plasma HIV load and improved immunological status.

Foscarnet salvage therapy for patients with late-stage HIV disease and multiple drug resistance

OBJECTIVE

To evaluate the efficacy of foscarnet on HIV infection in patients with late-stage HIV disease and multiple drug resistance.

METHODS

Three drugs experienced patients with plasma viral load (pVL) > 50,000 copies/ml and CD4+ T-cell counts < 100/mm3 were eligible for this open-label, single-arm, add-on pilot study. Foscarnet induction therapy consisted of 5 g intravenously twice daily for 6 weeks, in addition to a stable antiretroviral regimen. Patients with at least 1 log10 decrease in pVL at week 6 (W6), were given foscarnet 5 g intravenously twice daily on two consecutive days each week. Primary endpoint was the virological response rate at W6.

RESULTS

Eleven patients were enrolled with a median baseline pVL at 5.16 log10 copies/ml, median CD4+ T-cell count at 10/mm3 and median number of mutations of 9, 2 and 12 associated with resistance to nucleoside reverse transcriptase inhibitors (NRTIs), non-NRTIs and protease inhibitors, respectively. One patient discontinued foscarnet at W2 because of renal toxicity. In an intent-to-treat analysis, the median change in pVL from baseline was -1.99 log10 copies/ml at W2 and -1.79 log10 copies/ml at W6. Eight out of eleven patients had a fall in pVL of at least 1 log10 at W6, and six started maintenance therapy. The median fall in pVL after 12 weeks of maintenance therapy was -0.85 log10 copies/ml in the four patients who reached W12, and the median increase of CD4+ T-cell count was 60/mm3.

CONCLUSION

In patients with HIV mutations conferring resistance to all antiretroviral drug classes, foscarnet markedly reduced plasma HIV load and improved immunological status.