HIV-1 drug resistance surveillance in antiretroviral treatment-naive individuals from a reference hospital in Guatemala, 2010-2013

The recent expansion of antiretroviral treatment (ART) coverage in middle/low-income countries has been associated with increasing prevalence of HIV pre-ART drug resistance (PDR). We assessed PDR prevalence, patterns, and trends in Guatemala. Blood samples from 1,084 ART-naive individuals, enrolled from October 2010 to December 2013 at the Roosevelt Hospital in Guatemala City, were obtained. PDR was evaluated using the WHO mutation list for transmitted drug resistance (TDR) surveillance. An overall PDR prevalence of 7.3% (95% CI 5.8-9.0%) was observed for the whole study period. TDR to nonnucleoside reverse transcriptase inhibitors (NNRTI) was the highest (4.9%, p<0.001), followed by nucleoside RT inhibitors (1.8%) and protease inhibitors (1.0%). No significant trends in PDR prevalence were observed during the study period. However, higher NNRTI PDR levels were found in individuals with >500 and 350-500 CD4(+) T cells/μl (7.4% and 8.7%, respectively) compared to individuals with <350 CD4(+) T cells/μl (3.7%; p=0.039 and p=0.007, respectively), as well as a tendency of higher levels of NNRTI transmitted drug resistance (DR) in individuals with recent infection determined by HIV incidence tests (9.7%), suggesting increasing trends in time. Clusters of viruses with NNRTI PDR suggesting complex transmission networks were observed. No associations between PDR and demographic variables were found. PDR in Guatemala remains at an intermediate level. Nevertheless, we have shown evidence suggesting increasing trends in NNRTI PDR, which need to be taken into account in national HIV management policies.

Geographic and temporal trends in the molecular epidemiology and genetic mechanisms of transmitted HIV-1 drug resistance: an individual-patient- and sequence-level meta-analysis

BACKGROUND

Regional and subtype-specific mutational patterns of HIV-1 transmitted drug resistance (TDR) are essential for informing first-line antiretroviral (ARV) therapy guidelines and designing diagnostic assays for use in regions where standard genotypic resistance testing is not affordable. We sought to understand the molecular epidemiology of TDR and to identify the HIV-1 drug-resistance mutations responsible for TDR in different regions and virus subtypes.

METHODS AND FINDINGS

We reviewed all GenBank submissions of HIV-1 reverse transcriptase sequences with or without protease and identified 287 studies published between March 1, 2000, and December 31, 2013, with more than 25 recently or chronically infected ARV-naïve individuals. These studies comprised 50,870 individuals from 111 countries. Each set of study sequences was analyzed for phylogenetic clustering and the presence of 93 surveillance drug-resistance mutations (SDRMs). The median overall TDR prevalence in sub-Saharan Africa (SSA), south/southeast Asia (SSEA), upper-income Asian countries, Latin America/Caribbean, Europe, and North America was 2.8%, 2.9%, 5.6%, 7.6%, 9.4%, and 11.5%, respectively. In SSA, there was a yearly 1.09-fold (95% CI: 1.05-1.14) increase in odds of TDR since national ARV scale-up attributable to an increase in non-nucleoside reverse transcriptase inhibitor (NNRTI) resistance. The odds of NNRTI-associated TDR also increased in Latin America/Caribbean (odds ratio [OR] = 1.16; 95% CI: 1.06-1.25), North America (OR = 1.19; 95% CI: 1.12-1.26), Europe (OR = 1.07; 95% CI: 1.01-1.13), and upper-income Asian countries (OR = 1.33; 95% CI: 1.12-1.55). In SSEA, there was no significant change in the odds of TDR since national ARV scale-up (OR = 0.97; 95% CI: 0.92-1.02). An analysis limited to sequences with mixtures at less than 0.5% of their nucleotide positions—a proxy for recent infection—yielded trends comparable to those obtained using the complete dataset. Four NNRTI SDRMs—K101E, K103N, Y181C, and G190A—accounted for >80% of NNRTI-associated TDR in all regions and subtypes. Sixteen nucleoside reverse transcriptase inhibitor (NRTI) SDRMs accounted for >69% of NRTI-associated TDR in all regions and subtypes. In SSA and SSEA, 89% of NNRTI SDRMs were associated with high-level resistance to nevirapine or efavirenz, whereas only 27% of NRTI SDRMs were associated with high-level resistance to zidovudine, lamivudine, tenofovir, or abacavir. Of 763 viruses with TDR in SSA and SSEA, 725 (95%) were genetically dissimilar; 38 (5%) formed 19 sequence pairs. Inherent limitations of this study are that some cohorts may not represent the broader regional population and that studies were heterogeneous with respect to duration of infection prior to sampling.

CONCLUSIONS

Most TDR strains in SSA and SSEA arose independently, suggesting that ARV regimens with a high genetic barrier to resistance combined with improved patient adherence may mitigate TDR increases by reducing the generation of new ARV-resistant strains. A small number of NNRTI-resistance mutations were responsible for most cases of high-level resistance, suggesting that inexpensive point-mutation assays to detect these mutations may be useful for pre-therapy screening in regions with high levels of TDR. In the context of a public health approach to ARV therapy, a reliable point-of-care genotypic resistance test could identify which patients should receive standard first-line therapy and which should receive a protease-inhibitor-containing regimen.

Influence of quinacrine and chloroquine on the in vitro 3'-azido-3'-deoxythymidine antiretroviral effect

Background

Antimalarials quinacrine (Qc) and chloroquine (Cq) intercalate DNA, potentiate the activity of other drugs and have lysosomotropic, anti-inflammatory and antiviral activities that could increase the effect of the 3′-azido-3′-deoxythymidine (AZT) antiretroviral agent. The aim of the current study was to evaluate if Qc and Cq could improve the in vitro effect of the antiretroviral AZT agent.

Findings

Inhibition of viral replication in human immunodeficiency virus (HIV)_SF33-infected peripheral blood mononuclear cells treated with Qc or Cq, alone or combined with a low dose of AZT was measured. Viral replication increased with Qc and decreased with high doses of Cq. The increase of replication caused by Qc was reversed by AZT. Neither Qc nor Cq significantly changed the antiviral activity of AZT.

Conclusion

Cq does not potentiate the effect of AZT, but it is effective by itself at high doses. The rise of HIV replication by Qc could be deleterious in HIV endemic regions, where it is used as antimalarial. The mechanisms associated to this phenomenon must be identified.

Differential partial activation phenotype and production of tumour necrosis factor-α by conventional dendritic cells in response to lipopolysaccharide in HIV+ viraemic subjects and HIV+ controllers

HIV(+) subjects are reported to have increased soluble CD14 (sCD14) in plasma, an indicator of microbial translocation. We evaluated if microbial translocation has a differential impact on the activation and function of conventional dendritic cells (cDC) from viraemic HIV(+) subjects and HIV(+) controllers (CTs). The HIV(+) subjects were classified into two groups according to their plasma viral load (pVL): CT and viraemic. Subjects without HIV were included as controls (HIV(-) ). The frequencies and phenotypes of cDC from these subjects were evaluated by multi-parameter flow cytometry. In addition, peripheral blood mononuclear cells (PBMCs) were stimulated with lipopolysaccharide (LPS) or single-stranded RNA40 (ssRNA40), the phenotype of the cDC and the intracellular production of tumour necrosis factor (TNF)-α by the cDC were evaluated by flow cytometry. We observed a partial activation phenotype for the cDC in the viraemic subjects and CTs ex vivo and after LPS activation, which showed differences in the expression of CD40 and CD86. Furthermore, in response to LPS the cDC from the viraemic subjects produced more TNF-α compared to the cDC from CTs. Interestingly, the percentage of TNF-α(+) cDC was found to be correlated positively with the pVL. The partial activation of cDC and the over-production of TNF-α in response to LPS in viraemic HIV(+) subjects might be related to the increased chronic activation observed in these subjects. In contrast, cDC from CTs seem to have a regulated response to LPS, indicating that they respond differently to chronic immune activation. These results may have implications in the development of HIV therapies and vaccines using DC.

Intralesional bevacizumab in patients with human immunodeficiency virus-associated Kaposi's sarcoma in the upper airway

OBJECTIVES/HYPOTHESIS

The aim of this study was to evaluate the efficacy and safety of intralesional bevacizumab, a monoclonal antibody against vascular endothelial growth factor, in patients with human immunodeficiency virus (HIV)-associated Kaposi's sarcoma of the upper airway receiving antiretroviral therapy.

STUDY DESIGN

A pilot randomized, open, phase II study.

METHODS

HIV-infected patients with Kaposi's sarcoma lesions of the upper airway in the T0 stage were randomized to receive antiretroviral therapy alone or antiretroviral therapy with intralesional bevacizumab. The primary end point was the assessment of changes in tumor size according to the Response Evaluation Criteria In Solid Tumors (RECIST); the secondary end point was safety.

RESULTS

Of the 14 patients with Kaposi's sarcoma included in the study, seven were assigned to the bevacizumab group and seven to the control group. The median age was 30.5 years (interquartile range [IQR], 24.7-38.2). Four patients (28.5%) had >150 CD4 T cells/mm(3). Nine patients had lesions in the oral cavity; three patients had pharyngeal disease; one patient had laryngeal involvement; and one patient had oral cavity, pharyngeal, and laryngeal involvement. Four patients had complete response (28.5%), two had partial response, six had stable disease, and two had progressive disease. The median time to complete response was 13 weeks (IQR, 7.5-36.5). No statistical differences between groups were observed (P = .124). In the bevacizumab group, one patient had a grade I adverse event, and another patient had a grade II adverse event.

CONCLUSIONS

Intralesional administration of bevacizumab was well tolerated but had no impact on upper respiratory tract Kaposi's sarcoma lesions of HIV-infected patients.

Proposed clinical case definition for cytomegalovirus-immune recovery retinitis

BACKGROUND

Cytomegalovirus (CMV) retinitis has been extensively described in patients with advanced or late human immunodeficiency virus (HIV) disease under ineffective treatment of opportunistic infection and antiretroviral therapy (ART) failure. However, there is limited information about patients who develop active cytomegalovirus retinitis as an immune reconstitution inflammatory syndrome (IRIS) after successful initiation of ART. Therefore, a case definition of cytomegalovirus-immune recovery retinitis (CMV-IRR) is proposed here.

METHODS

We reviewed medical records of 116 HIV-infected patients with CMV retinitis attending our institution during January 2003-June 2012. We retrospectively studied HIV-infected patients who had CMV retinitis on ART initiation or during the subsequent 6 months. Clinical and immunological characteristics of patients with active CMV retinitis were described.

RESULTS

Of the 75 patients under successful ART included in the study, 20 had improvement of CMV retinitis. The remaining 55 patients experienced CMV-IRR; 35 of those developed CMV-IRR after ART initiation (unmasking CMV-IRR) and 20 experienced paradoxical clinical worsening of retinitis (paradoxical CMV-IRR). Nineteen patients with CMV-IRR had a CD4 count of ≥50 cells/µL. Six patients with CMV-IRR subsequently developed immune recovery uveitis.

CONCLUSIONS

There is no case definition for CMV-IRR, although this condition is likely to occur after successful initiation of ART, even in patients with high CD4 T-cell counts. By consequence, we propose the case definitions for paradoxical and unmasking CMV-IRR. We recommend close follow-up of HIV-infected patients following ART initiation.

Human immunodeficiency virus type 1 (HIV-1) subtype B epidemic in Panama is mainly driven by dissemination of country-specific clades

The Human immunodeficiency virus type-1 (HIV-1) subtype B is the most predominant clade in Central America; but information about the evolutionary history of this virus in this geographic region is scarce. In this study, we reconstructed the spatiotemporal and population dynamics of the HIV-1 subtype B epidemic in Panama. A total of 761 HIV-1 subtype B pol sequences obtained in Panama between 2004 and 2013 were combined with subtype B pol sequences from the Americas and Europe. Maximum Likelihood phylogenetic analyses revealed that HIV-1 subtype B infections in Panama derived from the dissemination of multiple founder viruses. Most Panamanian subtype B viruses (94.5%) belong to the pandemic viral strain proposed as originated in the US, whereas others (5.5%) were intermixed among non-pandemic Caribbean strains. The bulk (76.6%) of subtype B sequences from Panama grouped within 12 country-specific clades that were not detected in other Central American countries. Bayesian coalescent-based analyses suggest that most Panamanian clades probably originated between the early 1970s and the early 1980s. The root location of major Panamanian clades was traced to the most densely populated districts of Panama province. Major Panamanian clades appear to have experienced one or two periods of exponential growth of variable duration between the 1970s and the 2000s, with median growth rates from 0.2 to 0.4 year⁻¹. Thus, the HIV-1 subtype B epidemic in Panama is driven by the expansion of local viral strains that were introduced from the Caribbean and other American countries at an early stage of the AIDS pandemic.

Molecular epidemiology of HIV-1 in Panama: origin of non-B subtypes in samples collected from 2007 to 2013

Phylogenetic studies have suggested that the HIV-1 epidemic in the Americas is mainly dominated by HIV subtype B. However, countries of South America and the Caribbean have recently reported changes in their circulating HIV-1 genetic profiles. The aim of this study was to characterize the molecular profile of the HIV-1 epidemic in Panama by the analysis of 655 polymerase gene (pol) sequences that were obtained from HIV-infected Panamanians diagnosed between 1987 and 2013. Blood samples were collected from recently infected, antiretroviral drug-naïve and treatment-experienced subjects since mid-2007 to 2013. Viral RNA from plasma was extracted and sequences of HIV protease and reverse transcriptase genes were obtained. Bootscanning and phylogenetic methods were used for HIV subtyping and to trace the putative origin of non-B subtype strains. Our results showed that HIV-1 infections in Panama are dominated by subtype B (98.9%). The remaining 1.1% is represented by a diverse collection of recombinant variants including: three URFs_BC, one CRF20_BG, and one CRF28/29_BF, in addition to one subtype F1 and one subtype C, none of which were previously reported in Panama. The non-B subtype variants detected in Panama were probably introduced from Brazil (subtype F1 and CRF28/29_BF), Cuba (CRF20_BG), Dominican Republic (URFs_BC) and India (subtype C). Panama is the geographical vertex that connects the North with South America and the Caribbean through trade and cultural relations, which may explain the observed introductions of non-B subtype HIV-1 variants from both the Caribbean and South America into this Central American country.

Activation of NK cells is associated with HIV-1 disease progression

The main predictor of HIV-1 disease progression is CD8(+) T cell activation, characterized by elevated expression of CD38 and HLA-DR. NK cells are also activated in viremic HIV-1-infected individuals. However, the relationship between NK cell activation and HIV-1 disease progression remains undefined. We characterized NK cell activation and its association with disease progression in treatment of naive HIV-1-infected individuals, who naturally maintained low/undetectable viremia (elite and viremic controllers), compared with progressors and AIDS subjects, and treated individuals. Our results show that CD38 expression on NK cells, predominantly in the cytotoxic CD56(dim)CD16(+) subset, is associated with HIV-1 disease progression (CD4(+) T cell count and pVL), T cell activation (percentage of CD38(+)HLA-DR(+) T cells), sCD14, inflammation, and innate immune activation. Moreover, NK cell activation is increased in HIV-1-infected subjects progressing to AIDS but not in elite and viremic controllers. ART partially reduces the proportion of activated NK cells. Furthermore, our results show that individuals, who naturally control viremia, maintain low levels of innate immune activation similar to those of uninfected controls.

Xpert MTB/RIF for diagnosis of tuberculous cervical lymphadenitis in HIV-infected patients

OBJECTIVES/HYPOTHESIS

The World Health Organization endorsed the Xpert MTB/RIF assay for the diagnosis of pulmonary tuberculosis (TB), but there is limited information about the utility of this assay for the diagnosis of TB lymphadenitis. Therefore, the objective of this study was to assess the diagnostic accuracy of Xpert MTB/RIF assay in HIV-infected patients with palpable cervical lymph nodes.

STUDY DESIGN

Prospective, diagnostic test study.

METHODS

Consecutive patients with cervical lymphadenopathy were prospectively enrolled between January 2011 and March 2013. Lymph node specimens were obtained through fine-needle aspiration or excisional biopsy. Mycobacterial culture was considered as the gold standard.

RESULTS

Mycobacterium TB was cultured from 15 of 68 specimens (22.05%), and 53 specimens had negative cultures (77.94%). The sensitivity of Xpert MTB/RIF was 100% (95% CI, 74.65%-100%), and the specificity was 100% (95% CI, 91.58%-100%). Smear microscopy had a lower diagnostic performance.

CONCLUSION

Although based on a limited sample size, our study indicates that Xpert MTB/RIF is a useful method for the diagnosis of cervical TB lymphadenitis in HIV-infected patients, regardless of the bacillary load in smear-positive samples or the CD4 T cell count. The sensitivity, specificity, positive predictive value, and negative predictive value were similar to gold-standard culture.

LEVEL OF EVIDENCE

N/A.

Oropharyngeal syphilis among patients infected with human immunodeficiency virus

OBJECTIVES

There has been a reemergence of syphilis among men who have sex with men over the past decade, especially in patients infected with human immunodeficiency virus (HIV). This study was aimed at describing the oropharyngeal manifestations of secondary syphilis in HIV-infected patients. We also sought to determine the clinical risk factors for the development of oropharyngeal syphilitic lesions in patients with secondary syphilis.

METHODS

We performed an observational, comparative, retrospective study of HIV-infected patients who were admitted to a tertiary referral center in Mexico City and who had syphilis according to the criteria of the US Centers for Disease Control and Prevention.

RESULTS

We identified 44 patients with syphilis, 31 of whom had secondary syphilis and 9 of whom had oropharyngeal manifestations. Lesions involving the anterior tonsillar pillar were the most common, observed in 5 patients; and tongue lesions were observed in 3 patients. In the patients with secondary syphilis, multivariate analysis showed that the development of oropharyngeal lesions was not associated with age, CD4 and CD8 cell counts, or HIV RNA viral load.

CONCLUSIONS

The present work shows that oropharyngeal manifestations of secondary syphilis and overlapping stages of syphilis are frequent in HIV-infected patients. To the best of our knowledge, this is the first comparative study of the oropharyngeal manifestations of syphilis in HIV-infected patients.

Transient expansion of activated CD8(+) T cells characterizes tuberculosis-associated immune reconstitution inflammatory syndrome in patients with HIV: a case control study

BACKGROUND

CD4(+) T cell activation indicators have been reported to be a common phenomenon underlying diverse manifestations of immune reconstitution inflammatory syndrome (IRIS). However, we have found that a high frequency of circulating CD8(+) T cells is a specific risk factor for mycobacterial IRIS. Therefore, we investigated whether CD8(+) T cells from patients who develop TB IRIS were specifically activated.

METHODS

We obtained PBMCs from HIV+ patients prior to and 4, 8, 12, 24, 52 and 104 weeks after initiating antiretroviral therapy. CD38 and HLADR expression on naive, central memory and effector memory CD8(+) and CD4(+) T cells were determined by flow cytometry. Absolute counts and frequencies of CD8(+) T cell subsets were compared between patients who developed TB IRIS, who developed other IRIS forms and who remained IRIS-free.

RESULTS

TB IRIS patients showed significantly higher counts of naive CD8(+) T cells than the other groups at most time points, with a contraction of the effector memory subpopulation occurring later in the follow-up period. Activated (CD38(+) HLADR(+)) CD8(+) T cells from all groups decreased with treatment but transiently peaked in TB IRIS patients. This increase was due to an increase in activated naive CD8(+) T cell counts during IRIS. Additionally, the CD8(+) T cell subpopulations of TB IRIS patients expressed HLADR without CD38 more frequently and expressed CD38 without HLADR less frequently than cells from other groups.

CONCLUSIONS

CD8(+) T cell activation is specifically relevant to TB IRIS. Different IRIS forms may involve different alterations in T cell subsets, suggesting different underlying inflammatory processes.

Molecular characterization of the predominant influenza A(H1N1)pdm09 virus in Mexico, December 2011-February 2012

When the A(H1N1)pdm09 pandemic influenza virus moved into the post-pandemic period, there was a worldwide predominance of the seasonal influenza A(H3N2) and B viruses. However, A(H1N1)pdm09 became the prevailing subtype in the 2011-2012 influenza season in Mexico and most of Central America. During this season, we collected nasopharyngeal swabs of individuals presenting with influenza-like illness at our institution in Mexico City. Samples were tested for seasonal A(H3N2) and B influenza viruses, as well as A(H1N1)pdm09 by real-time reverse transcription-polymerase chain reaction. Of 205 samples tested, 46% were positive to influenza, all of them A(H1N1)pdm09. The clinical characteristics of patients showed a similar pattern to the 2009 pandemic cases. Using next generation sequencing, we obtained whole genome sequences of viruses from 4 different patients, and in 8 additional viruses we performed partial Sanger sequencing of the HA segment. Non-synonymous changes found in the Mexican isolates with respect to the prototype isolate H1N1 (A/California/04/2009) included HA S69T, K163R and N260D unique to 2012 Mexican and North American isolates and located within or adjacent to HA antigenic sites; HA S143G, S185T, A197T and S203T previously reported in viruses from the 2010-2011 season, located within or adjacent to HA antigenic sites; and HA E374K located in a relevant site for membrane fusion. All Mexican isolates had an oseltamivir-sensitive genotype. Phylogenetic analysis with all 8 influenza gene segments showed that 2012 Mexican sequences formed a robust, distinct cluster. In all cases, 2012 Mexican sequences tended to group with 2010-2011 Asian and European sequences, but not with 2009 Mexican sequences, suggesting a possible recent common ancestor between these latter regions and the 2012 Mexican viruses. It remains to be defined if these viral changes represent an important antigenic drift that would enable viral immune evasion and/or affect influenza vaccine effectiveness.

Crusted scabies-associated immune reconstitution inflammatory syndrome

BACKGROUND

Despite the widely accepted association between crusted scabies and human immunodeficiency virus (HIV)-infection, crusted scabies has not been included in the spectrum of infections associated with immune reconstitution inflammatory syndrome in HIV-infected patients initiating antiretroviral therapy.

CASE PRESENTATION

We report a case of a 28-year-old Mexican individual with late HIV-infection, who had no apparent skin lesions but soon after initiation of antiretroviral therapy, he developed an aggressive form of crusted scabies with rapid progression of lesions. Severe infestation by Sarcoptes scabiei was confirmed by microscopic examination of the scale and skin biopsy. Due to the atypical presentation of scabies in a patient responding to antiretroviral therapy, preceded by no apparent skin lesions at initiation of antiretroviral therapy, the episode was interpreted for the first time as "unmasking crusted scabies-associated immune reconstitution inflammatory syndrome".

CONCLUSION

This case illustrates that when crusted scabies is observed in HIV-infected patients responding to antiretroviral therapy, it might as well be considered as a possible manifestation of immune reconstitution inflammatory syndrome. Patient context should be considered for adequate diagnosis and treatment of conditions exacerbated by antiretroviral therapy-induced immune reconstitution.

Human endogenous retrovirus expression is inversely associated with chronic immune activation in HIV-1 infection

Human endogenous retroviruses (HERV) are remnants of ancestral retroviral infections integrated into the germ line, and constitute approximately 8% of the genome. Several autoimmune disorders, malignancies, and infectious diseases such as HIV-1 are associated with higher HERV expression. The degree to which HERV expression in vivo results in persistent inflammation is not known. We studied the association of immune activation and HERV-K expression in 20 subjects with chronic, untreated progressive HIV-1 infection and 10 HIV-1 negative controls. The mean HERV-K gag and env RNA expression level in the HIV-1 infected cohort was higher than in the control group (p = 0.0003), and was negatively correlated with the frequency of activated CD38+HLA-DR+CD4+ T cells (Rho = -0.61; p = 0.01) and activated CD38+HLA-DR+CD8+ T cells (Rho = -0.51; p = 0.03). Although HIV-infected persons had higher levels of HERV-K RNA expression (as expected), the level of RNA expression was negatively associated with level of T cell activation. The mechanism for this unexpected association remains to be defined.

Oropharyngeal Syphilis among HIV-Infected Patients

Objective: This study was aimed at describing oropharyngeal manifestations of secondary syphilis in HIV-infected patients. We also sought to determine the clinical risk factors for the development of oropharyngeal syphilitic lesions in patients with HIV and secondary syphilis.

Method: We conducted a case-control study in HIV-infected patients at a tertiary referral center in Mexico City. All HIV-infected patients admitted at our center during the period between November 2009 and February 2012 who fulfilled the CDC criteria for syphilis were included in this case control study.

Results: We identified 35 cases of syphilis; 17 patients had secondary syphilis, and 9 had oropharyngeal manifestations. Lesions involving the anterior tonsillar pillar were the most common, observed in 5 patients; and tongue lesions were observed in 3 patients. Multivariate analysis showed that the development of oropharyngeal lesions was independently associated with age, CD3, CD4, and CD8 cell counts and HIV RNA viral load.

Conclusion: The present work shows that oropharyngeal manifestations of secondary syphilis are frequent in HIV-infected patients.

Head and neck manifestations of the immune reconstitution syndrome in HIV-infected patients: a cohort study

OBJECTIVE

To describe head and neck manifestations of immune reconstitution inflammatory syndrome (IRIS) in a cohort of HIV-infected patients receiving combined antiretroviral therapy (cART). After initiation of cART, some HIV-infected patients present a paradoxical worsening and clinical deterioration due to pathological inflammatory reactions to infectious or noninfectious antigens, a condition known as IRIS.

STUDY DESIGN

Prospective study with a follow-up period of 6 to 24 months.

SETTING

Tertiary referral center in Mexico City.

METHODS

Our cohort was integrated by 165 patients who had started cART within the past 2 months prior to study entry. Patients underwent a complete ear, nose, and throat examination (ENT). Laboratory tests (hematology and blood chemistry), cultures from body fluids, and biopsies were performed.

RESULTS

Of the 165 patients studied, 21 (12.7%) presented IRIS in the head and neck region. Kaposi sarcoma was the most common presentation, observed in 7 patients. Tuberculosis-associated IRIS was observed in 6 patients with scrophulas, lymph node enlargement, or retropharyngeal abscess. Other manifestations included herpes simplex I infection and unilateral vocal fold palsy secondary to Mycobacterium avium intracelulare paratracheal abscess and scrophulas, as well as cervical lymph node histoplasmosis and facial palsy.

CONCLUSIONS

To our knowledge, this is the first prospective study describing the different manifestations of IRIS in the head and neck region.

Intralesional cidofovir in severe juvenile respiratory papillomatosis

Recurrent respiratory papillomatosis causes significant morbidity among affected children and usually requires frequent surgeries. We present a prospective case series including nine children at a Mexican tertiary referral center. All enrolled patients had severe disease that had required at least four surgical procedures, with a median of 6. Two children had tracheobronchial involvement, one had lung parenchymal disease, and one had a tracheostomy performed during his first surgery.

OBJECTIVE

To assess the efficacy of intralesional cidofovir in lowering the surgery rate.

STUDY DESIGN

Prospective case series.

SETTING

Tertiary referral center in Mexico City.

METHODS

Nine Mexican children with severe disease were enrolled. Intralesional cidofovir was applied after surgical debulking at a concentration of 5 mg/mL with a four to six week interval.

RESULTS

Six of the nine patients had a notable decrease in the rate of surgeries, with three patients remaining disease-free with follow up ranging from 1.8 to 3.3 years. No patient demonstrated laboratory abnormalities. Two patients showed moderate and mild dysplasia on papilloma biopsy distinguished by a lack of epithelial maturation with no mitoses or cellular atypia. Two patients died several months after the last injection.

CONCLUSIONS

Intralesional cidofovir appears to be effective in the treatment of recurrent respiratory papillomatosis, although further studies are required to determine its safety.

Risk factors for immune reconstitution inflammatory syndrome under combination antiretroviral therapy can be aetiology-specific

In order to discriminate general from aetiology-specific risk factors for immune reconstitution inflammatory syndrome (IRIS), we followed up, during six months, 99 patients with advanced HIV infection commencing antiretroviral therapy (ART) without active opportunistic infections or evident inflammation. IRIS predictors were determined by univariate analysis using clinical data from 76 ART-responding patients either completing follow-up or developing IRIS, and by multivariate analysis of inflammation, disease progression and nutrition status variables. We identified 23 primary IRIS events (30.3%). Univariate predictors for all IRIS events were higher platelet counts and lower CD4/CD8 ratio, whereas subclinical inflammation was the multivariate predictor. Platelets, alkaline phosphatase levels and %CD8 T-cells in univariate analysis also predicted mycobacteria-associated IRIS independently, remaining elevated during follow-up. Herpesvirus IRIS was predicted by platelets and inflammation. Indicators of advanced HIV disease and subclinical inflammation jointly predict IRIS, and some are specific of the underlying microbial aetiology, possibly explaining previous reports.

Short communication: preferential concentration of hydroxychloroquine in adenoid tissue of HIV-infected subjects

Hydroxychloroquine (HCQ) anti-HIV activity is well documented. To evaluate its distribution in lymphoid tissues, which are considered sanctuaries of HIV reservoirs and targets of early massive depletion of CD4(+) T cells, we assessed HCQ concentrations in adenoid tissue and plasma of HIV-infected subjects. A daily oral dose of 400 or 800 mg of HCQ was administered to eight HIV-infected subjects for 8 days. HCQ concentrations were measured in plasma and adenoid tissue by high-performance liquid chromatography. Mean concentrations of HCQ in adenoid tissue of subjects treated with 400 and 800 mg were 87,210 +/- 17,817 and 167,472 +/- 93,793 ng/g, respectively. In plasma, these values corresponded to 329 +/- 133 and 278 +/- 68 ng/g, respectively. HCQ concentrations were significantly higher in adenoid tissue than in plasma in both groups. The potential use of HCQ as adjuvant in the therapy of HIV deserves to be explored, as the drug accumulates in relevant tissues for HIV replication and immunopathogenesis.

Endoscopic assessment of adenoid size is an indicator of tissue virologic response to highly active antiretroviral therapy

OBJECTIVE

To compare human immunodeficiency virus viral load (HIVVL) in plasma versus the adenoid HIVVL during highly active antiretroviral therapy (HAART).

DESIGN

Adenoid biopsies were taken basally and after 3 and 6 months of treatment. Also, the adenoid diameter by simple endoscopy was measured, and its correlation with adenoid HIVVL was calculated.

SETTING AND PATIENTS

A public tertiary care human immunodeficiency virus (HIV) hospital research centre. Twenty-seven antiretroviral-naive HIV-infected patients, with a mean age of 34.7 years, were included in the study.

MAIN OUTCOME MEASURE

Correlation between adenoid diameter and plasma and tissue HIVVL.

RESULTS

At 3 months, although plasma HIVVL reduced by almost 5 log to a level below 1 log, adenoid HIVVL only decreased 2.36 log, remaining well over 4 log. At 6 months, plasma HIVVL further decreased to 0.205 log, but adenoid HIVVL remained at 2.424 log. Adenoid diameter also decreased over time, with means at 8.52, 5.61, and 4 mm, respectively. It significantly correlated with plasma and adenoid viral load, but the correlation was higher with the biopsies.

CONCLUSION

HIVVL in adenoid tissue is more resilient to HAART than plasma VL and may need more than 6 months to reach asymptomatic levels. Nevertheless, simple endoscopic measurement of the adenoid diameter is a good indicator of viral load decrease in this tissue.

Identification of oral candidosis, hairy leukoplakia and recurrent oral ulcers as distinct cases of immune reconstitution inflammatory syndrome

Oral lesions such as candidosis, hairy leukoplakia (HL) and oral ulcers are strikingly absent in the numerous reports of immune reconstitution inflammatory syndrome (IRIS). To document oral manifestations attributable to immune reconstitution, we conducted a longitudinal follow-up of a cohort of HIV+ individuals starting highly active antiretroviral therapy (HAART) and completing oral pathology follow-up up to 12 weeks after treatment initiation. HIV-infected patients had oral examinations, CD4+ T-cell count and viral load determinations performed at baseline, and at weeks 4, 8 and 12 after HAART initiation. Among individuals with satisfactory viral response and recovery of ≥50 CD4+ T-cell/µL, eight patients complied with strict IRIS criteria: two developed clinical signs of oral candidosis (OC), two oral ulcers, three HL and one Kaposi's sarcoma. CD4+ T-cell counts at symptom onset suggested no remaining immune suppression. Our findings show that cases of OC, HL and recurrent ulcers can be instances of IRIS.

APOBEC3G mRNA expression in exposed seronegative and early stage HIV infected individuals decreases with removal of exposure and with disease progression

Background

APOBEC3G is an antiretroviral factor that acts by inducing G to A mutations. In this study, we examined the expression of APOBEC3G in uninfected HIV-1 exposed individuals at the time of their partner's diagnosis and one year later. We then compared this expression with that of infected individuals at different disease stages. APOBEC3G mRNA was measured in PBMCs from three groups: healthy controls with no known risk factor to HIV infection (n = 26), exposed uninfected individuals who had unprotected sex with their HIV+ partners for at least 3 months (n = 37), and HIV infected patients at various disease stages (n = 45), including 8 patients with low HIV viral loads < 10,000 copies/mL (LVL) for at least 3 years. Additionally, we obtained sequences from the env, gag, pol, nef, vif and the LTR of the patients' virus.

Results

Exposed uninfected individuals expressed higher APOBEC3G than healthy controls (3.86 vs. 1.69 relative expression units), and their expression significantly decreased after a year from the HIV diagnosis and subsequent treatment of their partners. Infected individuals showed a positive correlation (Rho = 0.57, p = 0.00006) of APOBEC3G expression with CD4+ T cell count, and a negative correlation with HIV viremia (Rho = -0.54, p = 0.00004). The percentage of G to A mutations had a positive correlation (Rho = 0.43, p = 0.0226) with APOBEC3G expression, and it was higher in LVL individuals than in the other patients (IQR 8.27 to 9.64 vs. 7.06 to 8.1, p = 0.0084). Out of 8 LVLs, 3 had hypermutations, and 4 had premature stop codons only in viral vif.

Conclusion

The results suggest that exposure to HIV may trigger APOBEC3G expression in PBMCs, in the absence of infection. Additionally, cessation of exposure or advanced disease is associated with decreased APOBEC3G expression.

[A new therapeutic strategy to control HIV? The PD1 molecule and its role in inhibiting cellular immune responses]

CD8+ T cells are crucial in protecting against viral infections by secreting antiviral factors and lysing infected cells. The loss of these functions is a hallmark of various chronic viral infections. In HIV chronic infection, CD8+ T cells develop this exhausted phenotype and their protection capacities diminish. Recently, it has been shown that a co-inhibitory molecule called PD-1 plays an important role on this exhausted phenotype. These findings open up the possibility of research targeted to develop therapeutic interventions that may restore CD8+ T cell function in chronic HIV infection.

Cornering HIV: taking advantage of interactions between selective pressures

Adaptive immune responses, cellular restrictive factors and antiretroviral drugs, target multiple regions in the Human Immunodeficiency Virus (HIV) proteome, imposing diverse pressures to viral adaptation. However, the virus is remarkably able to escape from these pressures as mutations are selected. In many cases these mutants have diminished viral fitness. We propose that the concerted action of strategically placed agents and pressures in a host can limit HIV variation capacity while inhibiting its replication. These mechanisms would corner HIV by selecting conflicting adaptive mutations, each having a disadvantage in face of another selective pressure. This would keep the virus unable to efficiently escape the suppressive effects of selective pressures. Cornering between antiretroviral drugs and cytotoxic T lymphocytes may explain recent observations, and can be predicted and used in viral control strategies. This idea can be extended to numerous other identified sites in the viral genome that confer selective pressures. We describe these other sites and how they could be induced to interact in prophylactic or therapeutic cornering strategies, as well as their experimental verifications. Cornering would control HIV infection better than current strategies, focused on few, albeit important, sites in the HIV genome.

Influenza: forecast for a pandemic

Recently, great speculation about a possible influenza pandemic has been made. However, the facts supporting the possibility of this threat are less discussed. During the last decade highly pathogenic strains of avian influenza virus, including the H5N1 subtype, crossed the species barriers from birds to humans and caused fatal disease. The Z strain of H5N1 subtype is characterized by pathogenicity to a larger number of animal species and by resistance to the older class of antiviral drugs. At present, two out of three general conditions for the onset of a pandemic have been met; namely, the emergence of a new virus and its ability to replicate in humans causing serious illness. Should the virus achieve efficient human-to-human transmission, the next influenza pandemic might occur. This review addresses these biological and epidemiological aspects of influenza in the context of history and characteristics of previous epidemics, as well as concrete actions that can be undertaken considering current understanding of influenza pathogenesis, treatment, and control possibilities.

CD8+ cell noncytotoxic anti-HIV response: restoration by HAART in the late stage of infection

Highly active antiretroviral therapy (HAART) is currently the best HIV infection management strategy. However, its effects on the CD8+ T cell noncytotoxic anti-HIV response (CNAR) are not well known. We investigated if HAART has different effects on CNAR in patients at the intermediate and late stages of HIV infection. Untreated healthy HIV-infected subjects with a mean CD4+ T cell count of 606 cells/microl were examined as a reference group. Plasma viral load, CD4+ T cell count, and CNAR activity were measured at baseline and regular intervals for at least 48 weeks following initiation of HAART. Baseline CNAR activity in all subjects correlated inversely with viral load and directly with CD4 T+ cell counts. The level of CNAR in the latestage group was significantly lower than in the intermediate-stage and the healthy reference group (p < 0.01). Following initiation of HAART, substantial increases in CD4+ T cell counts and decreases in viral loads were observed in both groups, indicating treatment success. CNAR activity was found to be increased significantly during HAART, but only in the late-stage group (p < 0.01). This increase in CD8+ cell function was seen within 4 weeks of treatment initiation and resulted in levels of CNAR activity almost equal to those observed in the healthy reference subjects. Our findings suggest a beneficial effect on CNAR in those individuals with reduced activity, typically in late-stage infection.

Microcyntm: a novel super-oxidized water with neutral pH and disinfectant activity

A new super-oxidized water (SOW) product, Microcyn, was tested for in vitro antimicrobial and antiviral activities. The effectiveness of this neutral-pH SOW at killing Staphylococcus aureus, Escherichia coli, Pseudomonas aeruginosa, Salmonella typhi and Candida albicans in pure culture was evaluated. One millilitre (approximately 10(8)colony-forming units/mL) of each micro-organism was subjected to 9 mL Microcyn or sterile water at room temperature for 30s. Under these conditions, a log(10) reduction factor of 8 in the level of all pathogens occurred in the treatment samples. In addition, results of tests with three batches of Microcyn exposed to Bacillus atrophaeus spores for 5 min demonstrated complete inactivation of the spores within 2-3 min (log(10) reduction factor >4). The effectiveness of Microcyn in reducing human immunodeficiency virus-1 (HIV-1) on hard surfaces (glass) was also evaluated in compliance with Environmental Protection Agency requirements for virucidal claims. After exposure of the tested surfaces to Microcyn for 5 min without agitation, there was a log(10) reduction factor >3 in the viral load as measured by both cytopathic effect and antigen p24 of HIV-1 production in MT-2 cultures. Microcyn activity against adenoviral vector type 5 was also analysed under simulated laboratory in-use conditions with viral suspensions. In order to increase the sensitivity of the test, the fluorescent light emitted by AdGFP-infected cells was measured with the use of a flow cytometer. A log(10) reduction factor >3 in the viral load was achieved after a 5-min exposure to Microcyn under these strict conditions. These results show that Microcyn exerts a wide antimicrobial spectrum with major advantages over acidic SOWs, including neutral pH, lower free active chlorine (51-85 ppm) and long shelf life (1 year).

Molecular mechanisms involved in the pathogenesis of septic shock

Pathogenesis of the development of sepsis is highly complex and has been the object of study for many years. The inflammatory phenomena underlying septic shock are described in this review, as well as the enzymes and genes involved in the cellular activation that precedes this condition. The most important molecular aspects are discussed, ranging from the cytokines involved and their respective transduction pathways to the cellular mechanisms related to accelerated catabolism and multi-organic failure.

Lower incidence and severity of cytomegalovirus-associated immune recovery uveitis in HIV-infected patients with delayed highly active antiretroviral therapy

An analysis of clinical records after the introduction of highly active antiretroviral therapy (HAART) in Mexico showed a lower prevalence and severity of immune recovery uveitis when HIV-infected patients started HAART after completing cytomegalovirus retinitis treatment than when treatments were concomitant. The findings suggest a protective role of delaying HAART until cytomegalovirus retinitis is controlled.

Differences in nocturnal basal and rhythmic prolactin secretion in untreated compared to treated HIV‐infected men are associated with CD4+ T‐lymphocytes

The existence of decreased hypothalamic dopaminergic tone in HIV-infected men has been suggested. In a cross-sectional study, we determined 12 h nocturnal basal and pulsatile prolactin (PRL) release levels (by blood sampling every 10 min) and their correlation with CD4+ T cells in seven volunteer HIV-negative, healthy men (group 1), and 21 normoprolactinemic, euthyroid, HIV-infected men divided into 3 groups (each group = 7): (i) group 2, asymptomatic HIV-infected stage A1 men, untreated; (ii) group 3, AIDS stage C3 without active opportunistic infections, untreated; and (iii) group 4, previously stage C3 after at least 6 months of successful highly active antiretroviral therapy. Serum PRL was measured by radioimmunoanalysis and the results were analysed by waveform-independent deconvolution analysis. CD4+ T lymphocytes were measured by flow cytometry and viral load by a nucleic acid sequence-based amplification assay. No differences were detected in the first two groups. In the third group, however, 100% of prolactin secretion was found to be pulsatile with a shorter secretory burst duration (P = 0.04), and a greater circulating half-life and pulse amplitude (P < or = 0.04). Group 4 had the greatest basal prolactin secretion (P < or = 0.04), and a shorter secretory burst duration (P = 0.04 vs group 2), circulating half-life (P = 0.01 vs group 3) and intersecretory burst interval (P = 0.06 vs group 1). PRL approximate entropy was similar among all groups. Linear correlations existed between CD4+ T cell counts and PRL secretory burst half duration (r = 0.62, P = 0.002) and amplitude (r = -0.63, P = 0.001), and in circulating serum half-life (r = - 0.61, P = 0.002) in HIV-infected groups. Viral load showed no correlations. It is suggested that differential changes in nocturnal prolactin secretion among HIV-infected men occurred while maintaining the normal coordinate feedback and/or feedforward control within the lactotropic axis. These changes may represent an adaptative mechanism to sustain, by different means, the maximal physiologic PRL production to stimulate the highest cellular immune response and/or reconstitution in attempting to survive.

[Genetic determinant factors of resistance to HIV infection and of control of progression to AIDS: implications on pathogenesis and therapeutic approaches for the eradication of HIV. A review]

In this review, we describe and discuss the genetic factors that, up to some point, determine resistance to the infection and control the progression of the disease in HIV-infected individuals. Genetic factors may account for non-progression or slow progression of the disease in some of so called long-term non progressors HIV-infected individuals. In general, this group shows no symptoms for more than 10 years, while their circulating T CD4+ cells levels remain stable and they usually have a low virus load. Even though non-progression and rapid progression phenomenon are still not fully understood, there probability exists that some class I and class II MHC alleles are associated with a greater or smaller risk to develop AIDS. Class I HLA-B*35 and Cw*04 alleles are the ones commonly associated with the rapid transition of the infection into AIDS. In contrast, heterozygosity for class I HLA alleles and, particularly, the absence of HLA-B*35 and Cw*04 may contribute to non-progression. Studies which set forward other HLA alleles as possibly taking part of the pathogenic mechanism of non-progression are also described; although, relevant methodological problems can be noticed. Furthermore, this review explains and discusses allelic variations for some of the components of the chemokine receptors family, particularly the genes which codify for CCR5 and CCR2 and other genetic factors such as the SDF1-3'. A variant of the alpha SDF1 chemokine gene that have been associated with AIDS' slow progression or non-progression in HIV-infected individuals. As a whole, the factors described in this review are those that influence the natural history of the disease due to HIV and give an example of what genetic or multigenetic influence can have over the pattern of evolution of HIV infection. Finally, we mention the possible implications that the identification of the genetic markers has in the pathogenesis of HIV disease and in the development of the new therapeutic strategies to control or eliminate HIV.

Antibody and cellular immune responses in breakthrough infection subjects after HIV type 1 glycoprotein 120 vaccination

HIV-specific antibodies and CD8+ T cell antiviral responses were evaluated in three human immunodeficiency virus 1 (HIV-1) gp120 vaccine recipients who later became infected with HIV-1. Titers of neutralizing antibody to the HIV-1(SF2) vaccine isolate were boosted, but titers of antibody to the autologous infecting viruses were never high and required at least 6 months after HIV infection to develop. Similarly, a marginal noncytotoxic CD8+ T cell antiviral response was observed only in one of the three vaccinees 3 months after HIV-1 infection. The infecting virus isolates had several amino acid substitutions in the HIV-1 envelope V3 region but were similar to other regional HIV-1 clade B isolates. Viral loads were similar to those of other HIV-1-infected individuals who had not been vaccinated and transient CD4+ T cell declines were observed in each person, suggesting that the vaccine was not effective at controlling these prognostic markers early in infection.

Virological and immunological features of long-term human immunodeficiency virus-infected individuals who have remained asymptomatic compared with those who have progressed to acquired immunodeficiency syndrome

Infection with the human immunodeficiency virus (HIV) leads to a decrease in CD4(+) T cells and disease progression within a decade of seroconversion. However, a small group of infected people, despite being infected by HIV for 10 or more years, remain clinically asymptomatic and have stable CD4(+) cell counts without taking antiretroviral medication. To determine why these individuals, known as long-term survivors (LTS), remain healthy, the hematological profiles, viral load and properties, HIV coreceptor genotype, and anti-HIV immune responses of these people were compared with those of individuals who have progressed to disease (Progressors) over the same time period. Unlike Progressors, LTS have a low circulating viral load and a low number of HIV-infected cells. These differences in the levels of the viral load were not associated with a dominant biologic viral phenotype, varying growth kinetics of the virus, mutation in the cellular CCR5 gene, or the presence of neutralizing antibodies. Importantly, the difference in viral load could be explained by the enhanced ability of CD8(+) cells from LTS to suppress HIV replication.

Human immunodeficiency virus-2 infection in baboons is an animal model for human immunodeficiency virus pathogenesis in humans

OBJECTIVE

To assess disease progression in baboons (Papio cynocephalus) that were infected with two human immunodeficiency virus-2 (HIV-2) isolates.

METHODS

Eight baboons were inoculated intravenously with either HIV-2UC2 or HIV-2UC14 and were followed for a 2- to 7-year period of observation.

RESULTS

Six of 8 baboons showed lymphadenopathy and other signs of HIV-related disease, 3 of 8 baboons had an acute phase CD4+ T-cell decline, and 2 of 5 baboons infected with the HIV-2UC2 isolate progressed to an acquired immunodeficiency syndrome-like disease. Human immunodeficiency virus-2-specific pathology in lymphatic tissues included follicular lysis, vascular proliferation, and lymphoid depletion. Both neutralizing antibodies and a CD8+ T-cell antiviral response were associated with resistance to disease.

CONCLUSIONS

Disease progression and the development of acquired immunodeficiency syndrome in HIV-2-infected baboons have similarities to human HIV infections.

Transient virus infection and pathogenesis of a new HIV type 2 isolate, UC12, in baboons

We have previously shown that baboons (Papio cynocephalus) can be persistently infected with HIV-2 and some baboons progress to an AIDS-like disease with a CD4+ T cell decline, cachexia, alopecia, and Kaposi's sarcoma-like fibromatosis. In this study, we found that a new virus isolate, HIV-2UC12, replicated to high levels in baboon peripheral blood mononuclear cells (PBMCs) in vitro. Three baboons were subsequently inoculated and had plasma viral RNA loads that peaked between 15,000 and 7000 copies/ml at 2 weeks postinfection. Virus was isolated from the PBMCs for up to 6 months. Although PBMCs were subsequently virus culture negative, virus could be recovered from the spleen, lymph nodes, and tonsils, indicating that HIV-2 was sequestered within these lymphoid tissues. HIV-2-associated pathology included follicular lysis, vascular proliferation, and lymphoid depletion. This study indicated that HIV-2UC12 infection in baboons can cause HIV-associated pathological abnormalities within the lymphatic tissues and that the high level of HIV-2UC12 replication in vitro was not predictive of replication in vivo.

Superinfection with human immunodeficiency virus type 2 can reactivate virus production in baboons but is contained by a CD8 T cell antiviral response

An animal model was used to assess whether resistance to superinfection by human immunodeficiency virus (HIV) can exist in vivo. Asymptomatic baboons (Papio cynocephalus), previously infected with HIV-2, were first challenged with homologous virus (HIV-2UC2 or HIV-2UC14) and later with heterologous virus (HIV-2UC12). After both virus inoculations, either resistance to viral infection or a transient viremia was observed. The original virus was recovered in 3 baboons, suggesting that reactivation of a latent infection occurred on heterologous challenge and that HIV-2 superinfection is blocked by processes established during prior infection. Antibody titers measured by ELISA and virus neutralization remained at low levels. However, suppression of HIV-1 replication was observed with CD8 T cells and filtered cell culture supernatants. The soluble factor involved was not a beta-chemokine. This resistance to HIV superinfection appears to be mediated at least in part by CD8 T cells that suppress virus production.

Effects of thalidomide on HIV-associated wasting syndrome: a randomized, double-blind, placebo-controlled clinical trial

OBJECTIVE

To evaluate the efficacy of thalidomide in treating wasting syndrome in patients with advanced HIV disease, and to assess the effects of thalidomide on circulating CD4+ T cells, and on HIV viral burden in peripheral blood mononuclear cells (PBMC).

DESIGN

Randomized, double-blind placebo-controlled clinical trial.

SETTING

Public tertiary care hospital in Mexico City.

PATIENTS

Twenty-eight adults with advanced HIV disease being treated with antiretroviral therapy, and who had received antiretrovirals for at least 6 months, who did not have an active opportunistic infection, and who had 10% weight loss in the previous 6 months.

INTERVENTIONS

Patients received thalidomide (100 mg by mouth, four times daily) or a matching placebo for the duration of the study (12 weeks).

MAIN OUTCOME MEASURES

The main clinical endpoint for efficacy of thalidomide was weight gain or no progression of wasting. Secondary endpoints were Karnofsky performance status, CD4+ cell counts, and HIV viral burden in PBMC.

RESULTS

Both groups were comparable in their baseline status. Therapeutic failure occurred in 10 out of 14 patients from the placebo group and in three out of 14 from the thalidomide group (P = 0.021). Weight gain occurred in one patient on placebo and in eight given thalidomide. The Karnofsky index was significantly higher by the end of the study in the thalidomide group (P = 0.003). Mild and transient somnolence and erythematous macular skin lesions were significantly more common in the thalidomide group. CD4+ T cell counts and HIV viral burden in PBMC did not change in either group.

CONCLUSIONS

Results suggest that thalidomide not only impeded but also reverted the wasting syndrome, preserving the Karnofsky index in patients with advanced HIV disease. Thalidomide, at the dosage used in this study, had no effect on peripheral CD4+ T cells nor on HIV viral burden in PBMC.

Cyclospora cayetanensis infection in patients with and without AIDS: biliary disease as another clinical manifestation

We describe patients with and without AIDS who had Cyclospora cayetanensis infection; these patients were seen at a tertiary care teaching hospital in Mexico City because of diarrheal disease. C. cayetanensis was detected by examination of fresh fecal preparations and acid-fast staining of fecal smears; the presence of other bacteria and parasites was excluded by standard methods. Fecal specimens from 12 patients contained C. cayetanensis. The overall mean duration of illness was 94 days. Seven of the 12 patients had AIDS; these patients presented with more weight loss than did patients without AIDS (P = .04). The patients with AIDS also tended to have a more prolonged illness. Two patients with AIDS had biliary disease that resolved when they received therapy with trimethoprim-sulfamethoxazole for cyclospora infection; the excretion of oocysts also ceased. Our data confirm that C. cayetanensis causes diarrhea in humans and a significant weight loss in patients with AIDS. In addition, Cyclospora could be involved in biliary disease in patients with AIDS.

[Care for the patient with AIDS]

New concepts regarding the medical care of AIDS patients are described in this paper. Currently, new pharmacologic agents and their combinations with zidovudine are being evaluated in clinical trials to determine their efficacy in the treatment of HIV-infected patients. Nevertheless, zidovudine is still the mainstay of therapy in AIDS patients. Significant findings regarding monotherapy, combination therapy, and immunotherapy for the treatment of HIV infection are also discussed. There is considerable controversy on the optimal time to initiate therapy with antiretroviral agents. The clinician's decision to initiate antiretroviral therapy should consider the expectations of patients in the context of relative benefits and potential toxicities of therapy. The clinician must be aware that rigid universal therapy guidelines for all patients may not be appropriate. Currently available drugs are only palliative and the development of innovative therapeutic strategies for early intervention is indispensable on the basis of recent knowledge of the extremely complex pathogenesis of HIV infection. At present time, the medical care of AIDS patients should be individualized and done in the context of the patient-physician relationship for therapeutic and nontherapeutic decisions.

[Pathogenesis of human immunodeficiency virus infection]

The immunopathogenic mechanisms of the human immunodeficiency virus infection and the precise events that are involved in the clinical latency period are extremely complex and remain unknown. Thus, at the present time, there is no way to prevent or revert the disease, though several and innovative forms of treatment have been developed and different clinical trials on immunization have been conducted. In this review, we describe the molecular biology of HIV-1, the dynamic interactions between HIV and the host, particularly in the clinical latency period, and the factors that induce viral expression. The consequences of HIV infection are influenced by the immunological state of the host, especially by the subtype 1 of CD4+ T cells. The subsequent reaction of the host immune system, with neutralizing antibodies and strong CD8+ T cells response, contain temporarily the course of HIV infection. However, the HIV generates strategies in order to face, evade, and destroy direct or indirectly the immune system. The virus is then activated and replicates without control, producing the progression to AIDS, and inevitably leading to the death. Only the understanding of the pathogenic mechanisms could offer definitive alternative treatment or control of HIV infection.

[T CD4+ cell counts and their use in the management of patients with HIV-1]

The hallmark of the HIV-1 infection is the progressive depletion of the circulating CD4+ T cells. The prophylactic, therapeutic and prognosis criteria of the HIV-1 infected patients are based on the measurement of these cells. However, there are serious analytical and biological variations in the count of CD4+T cells. The factors that influence the measurement of the circulating levels of CD4+T cells and its consequences in the clinical management of the HIV-1 infected patients are described in this update. In addition, some recommendations are suggested to reduce these variations.

Major recurrent oral ulcers in AIDS: report of three cases

We report the cases of three AIDS patients who developed major recurrent oral ulcers with severe odynophagia and weight loss. The patients were treated successfully with systemic steroids. Within the first week of prednisone therapy (40 mg/day), the symptoms improved and the lesions entirely healed. We suggest, on the bases of recent literature, that superantigens and the cytokine network could be involved and they should be considered in the immunopathogenic mechanisms of this type of ulcers.