Clinical manifestations of AIDS in the era of pneumocystis prophylaxis. Multicenter AIDS Cohort Study

Intravitreal therapy-success stories and challenges

Intravitreal injections have revolutionized the treatment of various sight-threatening diseases of the posterior segment of the eye. Initially explored for treatment of bacterial endophthalmitis, intravitreal injections rapidly expanded to combat retinal vascular disease in particular. Especially anti-vascular endothelial growth factor agents have emerged as a cornerstone of intravitreal therapy, targeting neovascular age-related macular degeneration and diabetic macular edema as important examples. Advances continue, with novel therapies such as complement inhibitors now available as treatment for geographic atrophy secondary to non-neovascular age-related macular degeneration, offering hope for a previously untreatable condition. Pioneering approaches such as the port delivery system and intravitreal gene therapy aim to improve treatment efficacy while minimizing patient burden. Despite notable successes, challenges for intravitreal therapies persist, including ocular and systemic complications and high treatment burden. Future research endeavors aim to address these challenges and enhance treatment outcomes. This comprehensive review critically evaluates the efficacy, safety, and cost-effectiveness of intravitreal injections, delving into emerging trends and future directions.

Epidemiology and risk factors of community-acquired pneumonia in patients with different causes of immunosuppression

Immunosuppression constitutes a significant risk for community-acquired pneumonia (CAP). Nevertheless, specific causes of immunosuppression and their relevance for incidence, etiology and prognosis of CAP are insufficiently investigated.We conducted a population-based cohort study within a statutory health insurance in Germany from 2015 to 2018. CAP was retrieved by ICD-10-GM codes. Episodes of immunosuppression were identified by coded conditions (hematologic neoplasms, stem cell or organ transplantation, neutropenia, HIV, primary immunosuppressive syndromes) or treatments (immunosuppressants, antineoplastic drugs, systemic steroids). Endpoints were defined as occurrence of CAP (primary), hospitalization, 30-day mortality and CAP associated with rare pathogens. Our analysis utilized the Andersen-Gill model adjusted for sex, age, level of long-term care, vaccination status, community type and comorbidities.942,008 individuals with 54,781 CAPs were included (hospitalization 55%, 30-day mortality 14.5%). 6% of individuals showed at least one episode of immunosuppression during the study period with systemic steroids (39.8%) and hematologic neoplasms (26.7%) being most common. Immunosuppression was recorded in 7.7% of CAPs. Besides classical risk factors such as age and level of long-term care, immunosuppressed patients were most prone to CAP (HR 2.4[2.3-2.5]) and consecutive death (HR 1.9[1.8-2.1]). Organ and stem cell transplantation (HR 3.2[2.6-4.0] and 2.8[2.1-3.7], respectively), HIV (HR 3.2[1.9-5.4]) and systemic steroids (> 20 mg prednisone daily dose equivalent (HR 2.7[2.4-3.1])) showed the highest risk for contracting CAP. CAP by rare pathogens was strongly associated with immunosuppression (HR 17.1[12.0-24.5]), especially HIV (HR 34.1[7.6-153]) and systemic steroids (HR 8.2[4.6-14.8]).Our study elucidates the relevance of particular immunosuppressive conditions including systemic steroids for occurrence and prognosis of CAP.

Cryo-electron microscopy structures of capsids and in situ portals of DNA-devoid capsids of human cytomegalovirus

The portal-scaffold complex is believed to nucleate the assembly of herpesvirus procapsids. During capsid maturation, two events occur: scaffold expulsion and DNA incorporation. The portal-scaffold interaction and the conformational changes that occur to the portal during the different stages of capsid formation have yet to be elucidated structurally. Here we present high-resolution structures of the A- and B-capsids and in-situ portals of human cytomegalovirus. We show that scaffolds bind to the hydrophobic cavities formed by the dimerization and Johnson-fold domains of the major capsid proteins. We further show that 12 loop-helix-loop fragments-presumably from the scaffold domain-insert into the hydrophobic pocket of the portal crown domain. The portal also undergoes significant changes both positionally and conformationally as it accompanies DNA packaging. These findings unravel the mechanism by which the portal interacts with the scaffold to nucleate capsid assembly and further our understanding of scaffold expulsion and DNA incorporation.

Pneumocystis Pneumonia With Multiple Centrilobular Pulmonary Nodules and Lack of Ground-Glass Attenuation on High-Resolution Computed Tomography

Pneumocystis jirovecii pneumonia (PCP) typically presents with diffuse ground-glass attenuation (GGA) in both lungs on high-resolution CT (HRCT). While other radiological features, including cysts and air-space consolidation, may be found, the absence of GGA has a high negative predictive value for PCP in patients with AIDS. We report a case of PCP in a male patient who visited our hospital with a subacute, non-productive cough. He had never been diagnosed with an HIV infection. Although his HRCT scan revealed multiple centrilobular nodules without GGA, Pneumocystis jirovecii was detected in the bronchoalveolar lavage (BAL), and no other additional pathogens were identified. The patient was diagnosed with PCP associated with AIDS after a high plasma HIV-RNA titer and low CD4+ cell count were confirmed. Physicians need to be aware of this atypical radiological presentation of PCP associated with AIDS.

High prevalence of gastrointestinal manifestations among Cytomegalovirus end-organ disease in the combination antiretroviral era

BACKGROUND

Cytomegalovirus (CMV) end-organ disease (EOD) continues to pose a significant risk to patients with advanced HIV disease despite decreased incidence with combination anti-retroviral therapy (ART) and lower mortality with effective anti-CMV therapy. Subclinical CMV shedding may also contribute to ongoing inflammation and non-infectious comorbidities.

METHODS

We examined the occurrence of CMV EOD and CMV shedding in a cohort of patients participating in a prospective observational study of severely immunosuppressed (CD4 ≤100 cells/μl), ART-naïve, HIV-1 infected adult participants.

RESULTS

We studied 206 participants, of whom 193 (93.7%) were CMV IgG positive. Twenty-five participants (12.1%) developed confirmed CMV EOD. At baseline, 47 (22.8%) had CMV viremia detectable by PCR in the absence of clinical disease (CMV viremia). The remaining 134 (65%) had neither CMV EOD nor CMV viremia detected at baseline. Five participants with CMV EOD (2.4% of total cohort, 20% of CMV EOD) met AIDS Clinical Trials Group criteria for CMV immune reconstitution inflammatory syndrome (IRIS). Only one-third of CMV EOD patients had retinitis, while two-thirds presented with histologically confirmed gastrointestinal illness. CMV viremia was associated with higher percentages of activated CD8+ T cells even after HIV suppression.

CONCLUSION

The manifestations of CMV EOD in advanced HIV disease before and after initiation of ART may be more diverse than previously described, with high incidence of gastrointestinal illness. Recognition and treatment of unusual clinical presentations of CMV infection remains important in reducing morbidity and mortality from HIV co-infections.

Structural basis for genome packaging, retention, and ejection in human cytomegalovirus

How the human cytomegalovirus (HCMV) genome—the largest among human herpesviruses—is packaged, retained, and ejected remains unclear. We present the in situ structures of the symmetry-mismatched portal and the capsid vertex-specific components (CVSCs) of HCMV. The 5-fold symmetric 10-helix anchor—uncommon among known portals—contacts the portal-encircling DNA, which is presumed to squeeze the portal as the genome packaging proceeds. We surmise that the 10-helix anchor dampens this action to delay the portal reaching a “head-full” packaging state, thus facilitating the large genome to be packaged. The 6-fold symmetric turret, latched via a coiled coil to a helix from a major capsid protein, supports the portal to retain the packaged genome. CVSCs at the penton vertices—presumed to increase inner capsid pressure—display a low stoichiometry, which would aid genome retention. We also demonstrate that the portal and capsid undergo conformational changes to facilitate genome ejection after viral cell entry.

Human cytomegalovirus (HCMV) is the prototypical member of the β-herpesvirinae subfamily and the leading viral cause of congenital infections that can lead to birth defects and it can also cause life-threatening disease in immunocompromised individuals. Here, the authors present the in-situ cryo-EM structures of the symmetry-mismatched portal and the capsid vertex-specific components (CVSCs) of HCMV and discuss the mechanistic implications for genome package, retention and ejection.

Development of a Vaccine against Human Cytomegalovirus: Advances, Barriers, and Implications for the Clinical Practice

Human cytomegalovirus (hCMV) is one of the most common causes of congenital infection in the post-rubella era, representing a major public health concern. Although most cases are asymptomatic in the neonatal period, congenital CMV (cCMV) disease can result in permanent impairment of cognitive development and represents the leading cause of non-genetic sensorineural hearing loss. Moreover, even if hCMV mostly causes asymptomatic or pauci-symptomatic infections in immunocompetent hosts, it may lead to severe and life-threatening disease in immunocompromised patients. Since immunity reduces the severity of disease, in the last years, the development of an effective and safe hCMV vaccine has been of great interest to pharmacologic researchers. Both hCMV live vaccines-e.g., live-attenuated, chimeric, viral-based-and non-living ones-subunit, RNA-based, virus-like particles, plasmid-based DNA-have been investigated. Encouraging data are emerging from clinical trials, but a hCMV vaccine has not been licensed yet. Major difficulties in the development of a satisfactory vaccine include hCMV's capacity to evade the immune response, unclear immune correlates for protection, low number of available animal models, and insufficient general awareness. Moreover, there is a need to determine which may be the best target populations for vaccine administration. The aim of the present paper is to examine the status of hCMV vaccines undergoing clinical trials and understand barriers limiting their development.

Transcriptional analysis of immune response genes during pathogenesis of cytomegalovirus retinitis in mice with murine acquired immunodeficiency syndrome

Human cytomegalovirus (HCMV) is an opportunistic human herpesvirus that causes a sight-threatening retinitis in immunosuppressed patients, especially those with AIDS. Using an established model of experimental murine cytomegalovirus (MCMV) retinitis in mice with retrovirus-induced immunodeficiency (MAIDS), we have been attempting to define with greater clarity the immunologic mechanisms that contribute to the progression of AIDS-related HCMV retinitis in the unique immunosuppressive setting of HIV infection. Toward this end, we provide herein a comprehensive assessment of immune response gene expression during the onset and development of MAIDS-related MCMV retinitis employing NanoString nCounter. In so doing, we analyzed and compared the intraocular expressions of 561 immune response genes within MCMV-infected eyes of groups of healthy mice, MCMV-infected mice with MAIDS of 4 weeks' (MAIDS-4) duration, and MCMV-infected eyes of mice with MAIDS of 10 weeks' (MAIDS-10) duration. These animal groups show a progression of retinal disease from absolute resistance to retinitis development in healthy mice to the development of classic full-thickness retinal necrosis in MAIDS-10 mice but through an intermediate stage of retinal disease development in MAIDS-4 mice. Our findings showed that increased susceptibility to MCMV retinitis during the progression of MAIDS is associated with robust upregulation or downregulation of a surprisingly large number of immune response genes that operate within several immune response pathways often unique to each animal group. Analysis of 14 additional immune response genes associated with programmed cell death pathways suggested involvement of necroptosis and pyroptosis during MAIDS-related MCMV retinitis pathogenesis. Use of the NanoString nCounter technology provided new and unexpected information on the immunopathogenesis of retinitis within MCMV-infected eyes of mice with retrovirus-induced immunosuppression. Our findings may provide new insights into the immunologic events that operate during the pathogenesis of AIDS-related HCMV retinitis.

Cytomegalovirus-Mediated T Cell Receptor Repertoire Perturbation Is Present in Early Life

Human cytomegalovirus (CMV) is a highly prevalent herpesvirus, particularly in sub-Saharan Africa, where it is endemic from infancy. The T cell response against CMV is important in keeping the virus in check, with CD8 T cells playing a major role in the control of CMV viraemia. Human leukocyte antigen (HLA) B*44:03-positive individuals raise a robust response against the NEGVKAAW (NW8) epitope, derived from the immediate-early-2 (IE-2) protein. We previously showed that the T cell receptor (TCR) repertoire raised against the NW8-HLA-B*44:03 complex was oligoclonal and characterised by superdominant clones, which were shared amongst unrelated individuals (i.e., "public"). Here, we address the question of how stable the CMV-specific TCR repertoire is over the course of infection, and whether substantial differences are evident in TCR repertoires in children, compared with adults. We present a longitudinal study of four HIV/CMV co-infected mother-child pairs, who in each case express HLA-B*44:03 and make responses to the NW8 epitope, and analyse their TCR repertoire over a period spanning more than 10 years. Using high-throughput sequencing, the paediatric CMV-specific repertoire was found to be highly diverse. In addition, paediatric repertoires were remarkably similar to adults, with public TCR responses being shared amongst children and adults alike. The CMV-specific repertoire in both adults and children displayed strong fluctuations in TCR clonality and repertoire architecture over time. Previously characterised superdominant clonotypes were readily identifiable in the children at high frequency, suggesting that the distortion of the CMV-specific repertoire is incurred as a direct result of CMV infection rather than a product of age-related "memory inflation." Early distortion of the TCR repertoire was particularly apparent in the case of the TCR-β chain, where oligoclonality was low in children and positively correlated with age, a feature we did not observe for TCR-α. This discrepancy between TCR-α and -β chain repertoire may reflect differential contribution to NW8 recognition. Altogether, the results of the present study provide insight into the formation of the TCR repertoire in early life and pave the way to better understanding of CD8 T cell responses to CMV at the molecular level.

Treatment of Toxoplasmosis: Historical Perspective, Animal Models, and Current Clinical Practice

Primary Toxoplasma gondii infection is usually subclinical, but cervical lymphadenopathy or ocular disease can be present in some patients. Active infection is characterized by tachyzoites, while tissue cysts characterize latent disease. Infection in the fetus and in immunocompromised patients can cause devastating disease. The combination of pyrimethamine and sulfadiazine (pyr-sulf), targeting the active stage of the infection, is the current gold standard for treating toxoplasmosis, but failure rates remain significant. Although other regimens are available, including pyrimethamine in combination with clindamycin, atovaquone, clarithromycin, or azithromycin or monotherapy with trimethoprim-sulfamethoxazole (TMP-SMX) or atovaquone, none have been found to be superior to pyr-sulf, and no regimen is active against the latent stage of the infection. Furthermore, the efficacy of these regimens against ocular disease remains uncertain. In multiple studies, systematic screening for Toxoplasma infection during gestation, followed by treatment with spiramycin for acute maternal infections and with pyr-sulf for those with established fetal infection, has been shown to be effective at preventing vertical transmission and minimizing the severity of congenital toxoplasmosis (CT). Despite significant progress in treating human disease, there is a strong impetus to develop novel therapeutics for both the acute and latent forms of the infection. Here we present an overview of toxoplasmosis treatment in humans and in animal models. Additional research is needed to identify novel drugs by use of innovative high-throughput screening technologies and to improve experimental models to reflect human disease. Such advances will pave the way for lead candidates to be tested in thoroughly designed clinical trials in defined patient populations.

Evolution of Intravitreal Therapy for Retinal Diseases-From CMV to CNV: The LXXIV Edward Jackson Memorial Lecture

PURPOSE

To present the evolution of intravitreal therapy for retinal diseases and its impact on clinical practice.

DESIGN

Retrospective literature review and personal perspective.

METHODS

Retrospective literature review and personal perspective.

RESULTS

Pharmacotherapeutic advances in retinal disease have been remarkable over the last 25 years. Almost all of the new drugs developed have required intravitreal administration to be highly effective, leading to an exponential increase in the annual number of intravitreal injections given. The use of intravitreal antibiotic injections to treat endophthalmitis, usually on a one-time basis, first familiarized ophthalmologists with this method of drug delivery. Ganciclovir was the first widely available, relatively inexpensive compounded drug that was used for repeat intravitreal injection to treat a chronic retinal disease, followed by triamcinolone for diabetic macular edema and bevacizumab for neovascular age-related macular degeneration. Ganciclovir was formulated for sustained-release drug delivery to avoid frequent intravitreal injections, a goal that has been more elusive for anti-VEGF drugs. Political obstacles encountered while conducting some of the trials to evaluate these treatments were substantial. Addressing the issues they raised led to important national policy changes that will impact the conduct of future clinical trials. The first comparative efficacy trial of intravitreal therapies was the Comparison of AMD Treatments Trials (CATT). The primary results from CATT and the many publications that followed continue to shape the use of intravitreal therapy today.

CONCLUSION

Intravitreal therapy has proven highly effective for the treatment of many retinal diseases. The treatment burden for patients from numerous injections, the cost to health care systems, and the impact on workflows in clinical practice have been substantial. Efforts to develop effective intravitreal therapies with reduced treatment burden and cost are ongoing.

Atomic structure of the human cytomegalovirus capsid with its securing tegument layer of pp150

Herpesviruses possess a genome-pressurized capsid. The 235-kilobase genome of human cytomegalovirus (HCMV) is by far the largest of any herpesvirus, yet it has been unclear how its capsid, which is similar in size to those of other herpesviruses, is stabilized. Here we report a HCMV atomic structure consisting of the herpesvirus-conserved capsid proteins MCP, Tri1, Tri2, and SCP and the HCMV-specific tegument protein pp150-totaling ~4000 molecules and 62 different conformers. MCPs manifest as a complex of insertions around a bacteriophage HK97 gp5-like domain, which gives rise to three classes of capsid floor-defining interactions; triplexes, composed of two "embracing" Tri2 conformers and a "third-wheeling" Tri1, fasten the capsid floor. HCMV-specific strategies include using hexon channels to accommodate the genome and pp150 helix bundles to secure the capsid via cysteine tetrad-to-SCP interactions. Our structure should inform rational design of countermeasures against HCMV, other herpesviruses, and even HIV/AIDS.

Refractory acute respiratory failure due to Pneumocystis jiroveci (PCP) and Cytomegalovirus (CMV) pneumonitis: A case report and review of literature

BACKGROUND

Opportunistic infections with Pneumocystis jiroveci pneumonia (PCP) are common in patients with HIV (human immunodeficiency virus) and are encountered once the CD4 count decreases below 200 cells/mm3. Cytomegalovirus (CMV) tends to cause disease once the CD4 count drops below 50 cells/mm3. CMV pneumonitis is not common in this population. However, detecting its presence in broncho-alveolar lavage (BAL) fluid has been associated with increased morbidity and mortality. The role of antiviral therapy against CMV remains unclear.

CASE PRESENTATION

We report a newly diagnosed HIV patient with a CD4 count of 44 cells/mm3 presenting with acute respiratory failure secondary to PCP that failed to respond to 3 weeks of standard therapy with trimethoprim-sulfamethoxazole and corticosteroids. He was later diagnosed to have a CMV co-infection causing pneumonitis with BAL cytology findings showing CMV cytopathic effects and PCP. Plasma CMV DNA PCR was 17,424 copies/mL. He responded well after introduction of intravenous ganciclovir.

CONCLUSION

The presence of histopathologic changes demonstrating viral cytopathic effects on BAL cytology along with a high plasma CMV DNA PCR should raise the specificity for diagnosing CMV pneumonitis. True PCP and CMV pneumonitis can occur, and the addition of antiviral therapy with ganciclovir may benefit such patients in the right clinical scenario.

COMPARISON OF VISUAL PROGNOSIS AND CLINICAL FEATURES OF CYTOMEGALOVIRUS RETINITIS IN HIV AND NON-HIV PATIENTS

PURPOSE

To compare the visual prognosis and clinical features of cytomegalovirus (CMV) retinitis between HIV and non-HIV patients.

METHODS

Retrospective cross-sectional study on patients diagnosed with CMV retinitis. Depending on the presence of HIV infection, best-corrected visual acuity (VA) and clinical feature of CMV retinitis were analyzed. The clinical characteristics associated with poor visual prognosis after antiviral treatment were also identified.

RESULTS

A total of 78 eyes (58 patients) with CMV retinitis were included in this study: 21 eyes and 57 eyes in HIV and non-HIV patients, respectively. Best-corrected VA was not significantly different between HIV and non-HIV patients. The rate of foveal involvement, retinal detachment, involved zone, and mortality did not significantly differ between the two groups. Visual acuity after antiviral treatment was significantly worse (pretreatment logarithm of the minimal angle of resolution best-corrected VA, 0.54 ± 0.67 [Snellen VA, 20/63]; posttreatment logarithm of the minimal angle of resolution best-corrected VA, 0.77 ± 0.94 [Snellen VA, 20/125]; P = 0.014). Poor visual prognosis was significantly associated with Zone 1 involvement, retinal detachment, and a poor general condition.

CONCLUSION

The overall visual prognosis and the clinical features of CMV retinitis do not differ between HIV and non-HIV patients. The visual prognosis of CMV retinitis still remains quite poor despite advancements in antiviral treatment. This poor prognosis after antiviral treatment is associated with retinal detachment during follow-up, Zone 1 involvement, and the poor general condition of the patient.

Cytomegalovirus Vaccines: Current Status and Future Prospects

Congenital human cytomegalovirus (HCMV) infection can result in severe and permanent neurological injury in newborns, and vaccine development is accordingly a major public health priority. HCMV can also cause disease in solid organ transplant (SOT) and hematopoietic stem-cell transplant (HSCT) recipients, and a vaccine would be valuable in prevention of viremia and end-organ disease in these populations. Currently there is no licensed HCMV vaccine, but progress toward this goal has been made in recent clinical trials. A recombinant HCMV glycoprotein B (gB) vaccine has been shown to have some efficacy in prevention of infection in young women and adolescents, and has provided benefit to HCMV-seronegative SOT recipients. Similarly, DNA vaccines based on gB and the immunodominant T-cell target, pp65 (ppUL83), have been shown to reduce viremia in HSCT patients. This review provides an overview of HCMV vaccine candidates in various stages of development, as well as an update on the current status of ongoing clinical trials. Protective correlates of vaccine-induced immunity may be different for pregnant woman and transplant patients. As more knowledge emerges about correlates of protection, the ultimate licensure of HCMV vaccines may reflect the uniqueness of the target populations being immunized.

The Survival Experience of Older and Younger Adults with AIDS

Older people with HIV infection die faster than younger counterparts, but it is notknown whether age-associated survival is changing over time. The authors used theCenters for Disease Control data set of adult cases of AIDS reported from January 1,1981, to December 31, 1994, to study age-associated differences in survival by yearof diagnosis. A total of 433,354 adults with AIDS were reported during this interval.Of these, 10.3% were younger than age 50. In 1983-1984, median survival for olderand younger people was 153 versus 274 days, respectively. By 1991-1992, mediansurvival had improved for both groups-396 and 731 days, respectively. However,the relative and absolute gap in survival grew. While a substantially larger proportionof older adults died within 90 days of diagnosis, the overall trend of an increasingage-associated gap in survival remained when these were excluded from the analysis.Older and younger people with AIDS have achieved prolonged survival, but theage-associated gap in survival has grown.

Association of CMV-Specific T Cell-Mediated Immunity with CMV DNAemia and Development of CMV Disease in HIV-1-Infected Individuals

BACKGROUND

Among HIV-1-infected individuals, cytomegalovirus (CMV) reactivation and disease occur in the setting of advanced immunosuppression. The value of a standardized assessment of CMV-specific T-cell mediated immunity by the CMV QuantiFERON assay (CMV-QFT) has not yet been thoroughly investigated in HIV-1-infected subjects.

METHODS

Prospective, longitudinal study in 153 HIV-1-infected subjects with a CD4+ T cell count < 350/μL who simultaneously underwent CMV-QFT, CMV serology testing and CMV-DNA quantification. Factors associated with CMV-QFT were evaluated. Clinical screening for CMV manifestations was then performed every 3 months.

RESULTS

Among the 141 CMV IgG-seropositive individuals the CMV-QFT assay yielded reactive results in 84% (118/141), negative results in 15% (21/141) and indeterminate (negative mitogen IFN-gamma response) results in 1% (2/141) of subjects. The mean actual CD4+ T cell count was significantly higher in CMV-QFT reactive subjects, when compared to CMV-QFT non-reactive individuals (183 ± 102 vs. 126 ± 104 cells/μL, P = 0.015). A significantly lower proportion of CMV-QFT reactive vs. non-reactive patients displayed CMV DNAemia > 100 copies/mL (23% (27/118) vs. 48% (11/23), P = 0.02). Furthermore, a statistically significant inverse association between mitogen IFN-gamma response and CMV-DNAemia > 1000 copies/mL was observed (P < 0.001). During the observational period, 5 CMV end-organ manifestations were observed. In three of the CMV cases the CMV-QFT yielded indeterminate results.

CONCLUSIONS

While CMV-QFT reactivity indicates CMV-specific immunity, indeterminate results due to negative mitogen IFN-gamma response might reflect HIV-1-induced immunodeficiency. Thus, dependency upon CD4+ T cell count should be considered when interpreting CMV-QFT results.

Ocular Manifestations of Acquired Immunodeficiency Syndrome

Purpose

To investigate the patterns and risk factors of the ocular manifestations of acquired immunodeficiency syndrome (AIDS) and their correlation with CD4+ count in the era of highly active antiretroviral therapy (HAART).

Methods

This retrospective study examined 127 AIDS patients who presented to Soonchunhyang University Hospital. Data were collected from patient interviews, clinical examinations, and laboratory investigations. Ophthalmologic examinations included the best-corrected visual acuity, intraocular pressure, anterior segment and adnexal examination, and dilated fundus examination.

Results

Of the 127 patients with AIDS, 118 were on HAART and 9 were not. The mean CD4+ count was 266.7 ± 209.1 cells/µL. There were ocular manifestations in 61 patients (48.0%). The incidence of anterior segment manifestations was higher than posterior segment manifestations at 28.3% and 19.7%, respectively. The mean CD4+ count was significantly (p < 0.05) lower in the patients with posterior versus anterior segment ocular manifestations. The most common ocular manifestation was retinal microvasculopathy (15.0%), followed by keratoconjunctivitis sicca (14.2%), conjunctival microvasculopathy (9.4%), cytomegalovirus retinitis (3.1%), herpes zoster ophthalmicus (2.4%), and blepharitis (1.6%). Retinal microvasculopathy and cytomegalovirus retinitis were common in patients with CD4+ counts <200 cells/µL, while keratoconjunctivitis sicca and conjunctival microvasculopathy were common in patients with CD4+ counts of 200 to 499 cells/µL. There was a significant (p < 0.05) association between ocular manifestation and CD4+ count or age.

Conclusions

The introduction of HAART has changed the landscape of ocular presentations in patients with AIDS. In this study, anterior segment and external ocular manifestations occurred more frequently than posterior segment manifestations. Also, the mean CD4+ count was significantly lower in patients with posterior segment ocular manifestations versus anterior segment ocular manifestations. We found that CD4+ count and age >35 years were independent risk factors for developing ocular manifestations.

Outcomes of cytomegalovirus retinitis-related retinal detachment surgery in acquired immunodeficiency syndrome patients in an Asian population

Background

This study reports the surgical outcomes of acquired immunodeficiency syndrome (AIDS) patients with Cytomegalovirus retinitis (CMVR) -related retinal detachments(RD) in an Asian population.

Methods

Review of CMVR characteristics, surgical outcomes and complications in 19 eyes with CMVR-related RD that underwent surgery from January 2000 to June 2011.

Results

CMVR was inactive in 73.7% of the eyes at time of surgery. Anatomical success was achieved in 14 eyes. Seven eyes (36.8%) had improvement of two or more lines in visual acuity (VA) and 8 eyes (42.1%) maintained VA. Thirteen eyes presented with worse than 6/120 vision, with 30.8% of them achieving ambulatory vision or better. Five eyes had re-detachments. Median durations from CMVR and immune recovery uveitis (IRU) diagnoses to RD were 2.7 and 1.0 months respectively.

Conclusions

Surgery for CMVR-related RD is associated with good anatomical outcomes with most eyes maintaining or having improved vision. CMVR lesion size of <50% retinal area is associated with better outcomes. Eyes with CMVR and IRU require close monitoring for RD.

Chest computed tomography findings in HIV-infected individuals in the era of antiretroviral therapy

BACKGROUND

Chest radiographic abnormalities were common in HIV-infected individuals in the pre-combination antiretroviral therapy era, but findings may differ now due to a changing spectrum of pulmonary complications.

METHODS

Cross-sectional study of radiographic abnormalities in an HIV-infected outpatient population during the antiretroviral therapy era. Demographics, chest computed tomography, and pulmonary function tests were obtained in HIV-infected volunteers without acute respiratory illness from the University of Pittsburgh HIV/AIDS clinic. Overall prevalence of radiographic abnormalities and potential risk factors for having any abnormality, nodules, or emphysema were evaluated using univariate and multivariable analyses.

RESULTS

A majority of the 121 participants (55.4%) had a radiographic abnormality with the most common being emphysema (26.4%), nodules (17.4%), and bronchiectasis (10.7%). In multivariate models, age (odds ratio [OR] per year  = 1.07, 95% confidence interval [CI] 1.04-1.14, p<0.001), pneumonia history (OR  = 3.60, 95% CI  = 1.27-10.20, p = 0.016), and having ever smoked (OR  = 3.66, p = 0.013, 95% CI  = 1.31-10.12) were significant predictors of having any radiographic abnormality. Use of antiretroviral therapy, CD4 cell count, and HIV viral load were not associated with presence of abnormalities. Individuals with radiographic emphysema were more likely to have airway obstruction on pulmonary function tests. Only 85.8% participants with nodules had follow-up imaging resulting in 52.4% having stable nodules, 23.8% resolution of their nodules, 4.8% development of a new nodule, and 4.8% primary lung cancer.

CONCLUSIONS

Radiographic abnormalities remain common in HIV-infected individuals with emphysema, nodules, and bronchiectasis being the most common. Age, smoking, and pneumonia were associated with radiographic abnormalities, but HIV-associated factors did not seem to predict risk.

Multilocus microsatellite genotyping array for investigation of genetic epidemiology of Pneumocystis jirovecii

Pneumocystis jirovecii is a symbiotic respiratory fungus that causes pneumonia (PcP) in immunosuppressed patients. Because P. jirovecii cannot be reliably cultured in vitro, it has proven difficult to study and gaps in our understanding of the organism persist. The release of a draft genome for the organism opens the door for the development of new genotyping approaches for studying its molecular epidemiology and global population structure. We identified and validated 8 putatively neutral microsatellite markers and 1 microsatellite marker linked to the dihydropteroate synthase gene (dhps), the enzymatic target of sulfa drugs used for PcP prevention and treatment. Using these tools, we analyzed P. jirovecii isolates from HIV-infected patients from three geographically distant populations: Uganda, the United States, and Spain. Among the 8 neutral markers, we observed high levels of allelic heterozygosity (average He, 0.586 to 0.842). Consistent with past reports, we observed limited global population structuring, with only the Ugandan isolates showing minor differentiation from the other two populations. In Ugandan isolates that harbored mutations in dhps, the microsatellite locus linked to dhps demonstrated a depressed He, consistent with positive directional selection for sulfa resistance mutations. Using a subset of these microsatellites, analyses of individual and paired samples from infections in San Francisco, CA, showed reliable typeability within a single infection and high discriminatory power between infections. These features suggest that this novel microsatellite typing approach will be an effective tool for molecular-epidemiological investigations into P. jirovecii population structure, transmission, and drug resistance.

Restoration of CMV-specific-CD4 T cells with ART occurs early and is greater in those with more advanced immunodeficiency

Objectives

Restoration of Cytomegalovirus-specific-CD4 T cell (CMV-Sp-CD4) responses partly accounts for the reduction of CMV-disease with antiretroviral-therapy (ART), but CMV-Sp-CD4 may also drive immune activation and immunosenescence. This study characterized the dynamics of CMV-Sp-CD4 after ART initiation and explored associations with CD4 T cell recovery as well as frequency of naïve CD4 T cells at week 96.

Methods

Fifty HIV-infected, ART-naïve Thai adults with CD4 T cell count ≤350cells/µL and starting ART were evaluated over 96 weeks (ClinicalTrials.gov identifier NCT01296373). CMV-Sp-CD4 was detected by co-expression of CD25/CD134 by flow cytometry after CMV-antigen stimulation.

Results

All subjects were CMV sero-positive, 4 had quantifiable CMV-DNA (range 2.3-3.9 log₁₀ copies/mL) at baseline but none had clinically apparent CMV-disease. Baseline CMV-Sp-CD4 response was positive in 40 subjects. Those with CD4 T cell count <100cells/µL were less likely to have positive baseline CMV-Sp-CD4 response (P=0.003). Positive baseline CMV-Sp-CD4 response was associated with reduced odds of quantifiable CMV-DNA (P=0.022). Mean CD4 T cell increase at week 96 was 213 cells/µL. This was associated positively with baseline HIV-VL (P=0.001) and negatively with age (P=0.003). The frequency of CMV-Sp-CD4 increased at week 4 (P=0.008), then declined. Those with lower baseline CMV-Sp-CD4 (P=0.009) or CDC category C (P<0.001) had greater increases in CMV-Sp-CD4 at week 4. At week 96, CD4 T cell count was positively (P<0.001) and the frequency of CMV-Sp-CD4 was negatively (P=0.001) associated with the percentage of naïve CD4 T cells.

Conclusions

Increases in CMV-Sp-CD4 with ART occurred early and were greater in those with more advanced immunodeficiency. The frequency of CMV-Sp-CD4 was associated with reduced naïve CD4 T cells, a marker associated with immunosenescence.

Clinical review: Respiratory failure in HIV-infected patients--a changing picture

Respiratory failure in HIV-infected patients is a relatively common presentation to ICU. The debate on ICU treatment of HIV-infected patients goes on despite an overall decline in mortality amongst these patients since the AIDS epidemic. Many intensive care physicians feel that ICU treatment of critically ill HIV patients is likely to be futile. This is mainly due to the unfavourable outcome of HIV patients with Pneumocystis jirovecii pneumonia who need mechanical ventilation. However, the changing spectrum of respiratory illness in HIV-infected patients and improved outcome from critical illness remain under-recognised. Also, the awareness of certain factors that can affect their outcome remains low. As there are important ethical and practical implications for intensive care clinicians while making decisions to provide ICU support to HIV-infected patients, a review of literature was undertaken. It is notable that the respiratory illnesses that are not directly related to underlying HIV disease are now commonly encountered in the highly active antiretroviral therapy (HAART) era. The overall incidence of P. jirovecii as a cause of respiratory failure has declined since the AIDS epidemic and sepsis including bacterial pneumonia has emerged as a frequent cause of hospital and ICU admission amongst HIV patients. The improved overall outcome of HIV patients needing ICU admission is related to advancement in general ICU care, including adoption of improved ventilation strategies. An awareness of respiratory illnesses in HIV-infected patients along with an appropriate diagnostic and treatment strategy may obviate the need for invasive ventilation and improve outcome further. HIV-infected patients presenting with respiratory failure will benefit from early admission to critical care for treatment and support. There is evidence to suggest that continuing or starting HAART in critically ill HIV patients is beneficial and hence should be considered after multidisciplinary discussion. As a very high percentage (up to 40%) of HIV patients are not known to be HIV infected at the time of ICU admission, the clinicians should keep a low threshold for requesting HIV testing for patients with recurrent pneumonia.

Development of vaccines against burkholderia pseudomallei

Burkholderia pseudomallei is a Gram-negative bacterium which is the causative agent of melioidosis, a disease which carries a high mortality and morbidity rate in endemic areas of South East Asia and Northern Australia. At present there is no available human vaccine that protects against B. pseudomallei, and with the current limitations of antibiotic treatment, the development of new preventative and therapeutic interventions is crucial. This review considers the multiple elements of melioidosis vaccine research including: (i) the immune responses required for protective immunity, (ii) animal models available for preclinical testing of potential candidates, (iii) the different experimental vaccine strategies which are being pursued, and (iv) the obstacles and opportunities for eventual registration of a licensed vaccine in humans.

Imaging lung manifestations of HIV/AIDS

Advances in our understanding of human immunodeficiency virus (HIV) infection have led to improved care and incremental increases in survival. However, the pulmonary manifestations of HIV/acquired immunodeficiency syndrome (AIDS) remain a major cause of morbidity and mortality. Respiratory complaints are not infrequent in patients who are HIV positive. The great majority of lung complications of HIV/AIDS are of infectious etiology but neoplasm, interstitial pneumonias, Kaposi sarcoma and lymphomas add significantly to patient morbidity and mortality. Imaging plays a vital role in the diagnosis and management of lung of complications associated with HIV. Accurate diagnosis is based on an understanding of the pathogenesis of the processes involved and their imaging findings. Imaging also plays an important role in selection of the most appropriate site for tissue sampling, staging of disease and follow-ups. We present images of lung manifestations of HIV/AIDS, describing the salient features and the differential diagnosis.

Causes of early mortality in HIV-infected TB suspects in an East African referral hospital

BACKGROUND

Respiratory infections are a leading cause of death in Africa, especially among HIV-infected patients. Data on the etiology of fatal respiratory diseases are largely based on autopsy studies. We evaluated causes of pneumonia associated with early mortality among hospitalized HIV-infected patients in Kampala, Uganda.

METHODS

Prospective cohort study of HIV-infected patients admitted to Mulago Hospital, Kampala, with at least 2 weeks of cough. Consecutively enrolled patients with negative Ziehl Neelsen sputum smears for acid-fast bacilli underwent bronchoscopy with bronchoalveolar lavage and examination for mycobacteria (smear, solid culture), Pneumocystis jirovecii (Giemsa stain), and fungi (KOH mount, India ink stain, Sabouraud culture). Early mortality was defined as death before the 2-month follow-up visit.

RESULTS

Follow-up data were available for 353 (87%) of 407 patients enrolled. Of participants with follow-up data, 112 (32%) died within 2 months. Among patients with early mortality, a diagnosis was confirmed in 74 (66%), including tuberculosis (TB) (56%), cryptococcal pneumonia (1%), Pneumocystis pneumonia (3%), pulmonary Kaposi sarcoma (4%), and pneumonia caused by 2 or more disease processes (3%).

CONCLUSIONS

Mortality in HIV-infected TB suspects is high, with TB associated with the largest proportion of deaths. A significant proportion of patients die without a confirmed diagnosis.

Basal cortisol levels and correlates of hypoadrenalism in patients with human immunodeficiency virus infection

OBJECTIVE

To determine the frequency of occurrence of hypoadrenalism in patients with human immunodeficiency virus (HIV) infection and document the clinical correlates of hypoadrenalism for this group of patients.

SUBJECTS AND METHODS

A descriptive study was carried out on 66 hospitalized HIV patients in a semi-urban setting of South Africa. Hypoadrenalism was diagnosed based on a basal cortisol level of less than 400 nmol/l with or without overt signs and symptoms. Clinical and biochemical parameters of hypoadrenalism were compared between subjects with suboptimal and normal cortisol levels. Statistical analysis included Student's t test, χ(2) and Pearson's correlation coefficient tests.

RESULTS

The prevalence of hypoadrenalism was 27% with a high occurrence of contributory factors (cytomegalovirus infection in 100% and tuberculosis in 68.2% of the study subjects). Typical features of hypoadrenalism included: hyponatremia, 19.6%; hyperkalemia, 6.1%; mucosal hyperpigmentation, 12%, and loss of axillary hair, 15%. Comparison of clinical and biochemical parameters of hypoadrenalism did not show a correlation between CD4 count and cortisol levels (r = 0.1 and p = 0.3).

CONCLUSION

The prevalence of hypoadrenalism in our patients with HIV infection was high and the clinical features were comparable in subjects with normal and subnormal cortisol levels.

Antibody and cell-mediated immunity to Streptococcus pneumoniae: implications for vaccine development

It has long been assumed that children develop natural immunity to pneumococci via the acquisition of anticapsular antibodies, which confers serotype-specific immunity to the organism. This view has been further reinforced by the recent success of capsular polysaccharide conjugate vaccines in children in reducing colonization and disease caused by vaccine-type strains. Less clear, however, is whether this mechanism is responsible for the age-related gradual increased resistance to pneumococcal carriage and disease. Recent epidemiologic and experimental evidence point to the possibility that another mechanism may be involved. Here, an alternative possibility is presented, whereby it is proposed that acquired immunity to this common human pathogen is derived not only from natural acquisition of antibodies (capsular and noncapsular) that provides protection against invasive disease but also from the development of pneumococcus-specific CD4+ T(H)17 cells that reduces the duration of carriage and may also impact mucosal disease. This review focuses on the experimental and clinical evidence in support of this hypothesis. The implications for future vaccine development against Streptococcus pneumoniae are also discussed.

The Challenges of HIV Disease in the Intensive Care Unit

HIV/AIDS continues to be a significant world health issue. Patterns of referral to intensive care units (ICU) have changed in parallel with advances in treatment. Proven Pneumocystis therapy and the introduction of antiretroviral drugs have increased life expectancy. Lower respiratory tract infection predominates as a reason for ICU admission. Pneumocystis jirovecii, TB, fungi and bacterial infections rank highly as respiratory pathogens and should be considered potentially causative. Neurological pathology and severe sepsis commonly necessitate ICU admission in this population. The timing of highly active antiretroviral therapy (HARRT) remains controversial in critically ill patients. Therapy may be difficult due to associated drug interactions, lack of intravenous drug formulation and known toxic side effects. Improvement in survival may have resulted as much from general improvements in ICU care as from advances in highly active antiretroviral therapy, notably lung protective ventilation strategies and approaches to the early recognition and management of sepsis. HIV infection is now considered a chronic illness and should not be seen as a bar to ICU admission. Many HIV-positive patients present with non-HIV related illness and can be expected to make as good a recovery as non-infected patients.

Ocular immune reconstitution inflammatory syndromes

PURPOSE OF REVIEW

The aim of this article is to review the current literature concerning immune reconstitution inflammatory syndrome in relation to the eye. The definition, epidemiology, pathophysiology, risk factors, clinical features, diagnosis and treatment are discussed.

RECENT FINDINGS

Immune reconstitution inflammatory syndrome affecting the eye has been documented in association with cytomegalovirus retinitis following the introduction of highly active antiretroviral therapy in a large number of patients. This syndrome is referred to as immune recovery uveitis, which is presumed to be mediated by recovery of immune responses specific to residual cytomegalovirus antigen located in the eye. In addition to improved immunity itself, risk factors include a low CD4 T count at the time of initiation of highly active antiretroviral therapy and involvement of a larger proportion of retina. Immune recovery uveitis is a major cause of visual loss and morbidity among patients with AIDS who are receiving highly active antiretroviral therapy.

SUMMARY

Immune recovery uveitis is the most common form of immune reconstitution inflammatory syndrome in HIV-infected patients with cytomegalovirus retinitis who are receiving highly active antiretroviral therapy. Clear clinical definitions are required for ocular immune reconstitution inflammatory syndromes to avoid misclassification of other inflammatory conditions. A multidisciplinary approach is important in the diagnosis and management of immune recovery uveitis.

Impact of highly active antiretroviral therapy on ophthalmic manifestations in human immunodeficiency virus / acquired immune deficiency syndrome

Highly active antiretroviral therapy (HAART) has changed the face of human immunodeficiency virus (HIV) acquired immune deficiency syndrome (AIDS) by leading to dramatic decreases in HIV-related morbidity and mortality in the developed as well as developing world. Since the introduction of HAART, the incidence of ocular opportunistic infections causing retinitis has dramatically decreased, and clinicians should be aware of changes in the clinical presentation of ocular manifestations of HIV. As studies of HIV disease after the introduction of HAART continue to become available, more thorough descriptions of treated patients with ocular opportunistic infections will include side-effects and toxicities of therapy. This review focuses on the impact of HAART on the ocular manifestations of HIV.

Interleukin-17A mediates acquired immunity to pneumococcal colonization

Although anticapsular antibodies confer serotype-specific immunity to pneumococci, children increase their ability to clear colonization before these antibodies appear, suggesting involvement of other mechanisms. We previously reported that intranasal immunization of mice with pneumococci confers CD4+ T cell–dependent, antibody- and serotype-independent protection against colonization. Here we show that this immunity, rather than preventing initiation of carriage, accelerates clearance over several days, accompanied by neutrophilic infiltration of the nasopharyngeal mucosa. Adoptive transfer of immune CD4+ T cells was sufficient to confer immunity to naïve RAG1^−/− mice. A critical role of interleukin (IL)-17A was demonstrated: mice lacking interferon-γ or IL-4 were protected, but not mice lacking IL-17A receptor or mice with neutrophil depletion. In vitro expression of IL-17A in response to pneumococci was assayed: lymphoid tissue from vaccinated mice expressed significantly more IL-17A than controls, and IL-17A expression from peripheral blood samples from immunized mice predicted protection in vivo. IL-17A was elicited by pneumococcal stimulation of tonsillar cells of children or adult blood but not cord blood. IL-17A increased pneumococcal killing by human neutrophils both in the absence and in the presence of antibodies and complement. We conclude that IL-17A mediates pneumococcal immunity in mice and probably in humans; its elicitation in vitro could help in the development of candidate pneumococcal vaccines.

The bacterium Streptococcus pneumoniae (pneumococcus) causes serious disease in children and the elderly, including pneumonia and meningitis (inflammation of the brain). Carriage of pneumococcus in the nose is a necessary first step for most infections. As children age, they carry pneumococcus for shorter periods of time and their risk of disease decreases also. The mechanisms underlying this age-related decrease of carriage are not well understood. A deeper understanding of resistance to colonization would enable us to develop better pneumococcal vaccines. Using experimental mouse models, we show that repeated exposure to pneumococci leads to a subsequent reduction in duration of pneumococcal carriage, similar to what is observed in humans. We identify the immune cells that are responsible for this process, so-called T_H17 cells, which release a factor that enables human blood cells to kill pneumococcus more efficiently. We show that these T_H17 cells exist in adults and children, but not in newborn babies, which suggests that they may arise as a consequence of humans being exposed to pneumococcus. We describe an assay for the measurement of these cells in humans. Such an assay could facilitate the development of novel vaccines directed against pneumococcal carriage.

Poor predictive value of cytomegalovirus (CMV)-specific T cell assays for the development of CMV retinitis in patients with AIDS

BACKGROUND

We examined the potential clinical utility of using a cytomegalovirus (CMV)-specific T cell immunoassay to determine the risk of developing new-onset CMV retinitis (CMVR) in patients with acquired immunodeficiency syndrome (AIDS).

METHODS

CMV-specific T cell assays were performed by multiparameter flow cytometry using stored peripheral blood mononuclear cells that had been obtained in an observational study 2-6 months before new-onset CMVR was diagnosed in case patients (at a study visit during which a dilated ophthalmologic examination revealed no evidence of CMVR) and at the same study visit in control subjects (matched by absolute CD4(+) T cell count at entry) who did not subsequently develop retinitis during 1-6 years of study follow-up.

RESULTS

There were no significant differences in CMV-specific CD4(+) or CD8(+) T cell interferon-gamma or interleukin-2 expression in peripheral blood mononuclear cells from case patients and control subjects. Although there were trends toward lower percentages and absolute numbers of CMV-specific, cytokine-expressing CD8(+) T cells with a "late memory" phenotype (CD27(-)CD28(-)) as well as with an "early memory" phenotype (CD27(+)CD28(+)CD45RA(+)) in case patients than in control subjects, these differences were not statistically significant.

CONCLUSIONS

Many studies have reported that CMV-specific CD4(+) and CD8(+) T cell responses distinguish patients with active CMVR (i.e., who lack CMV-protective immunity) from those with inactive CMVR after immune restoration by antiretroviral treatment (i.e., who have CMV-protective immunity). However, the multiple CMV-specific immune responses we measured do not appear to have clinical utility for predicting the risk for patients with AIDS of developing new-onset CMVR with sufficient accuracy to be used in guiding therapeutic management.

Interleukin-17 in pulmonary host defense

Interleukin (IL)-17A and IL-17F are produced by a novel class of effector alphabeta T cells called Th17 cells as well as gammadelta T cells. alphabeta IL-17-producing T cells are controlled by the transcription factor RORgammat and develop independent of GATA-3, T-bet, Stat 4, and Stat 6. Effector molecules produced by these cells include IL-17A, IL-17F, and IL-22. IL-17A and IL-17F bind to IL-17 receptor (IL-17R) and receptor signaling is critical for host defense against extracellular bacteria by regulating chemokine gradients for neutrophil emigration into infected tissue sites as well as via regulation of host granulopoiesis. Furthermore, it has recently been shown that IL-17 and IL-22 regulate the production of antimicrobial proteins in epithelium. Although Th17 cells are important in mucosal host defense, in the setting of retained antigenic stimulation, such as in the setting of asthma or chronic infection, such as in cystic fibrosis, or in the setting of autoimmunity, these cells can mediate immunopathology.

Pneumocystis jiroveci Pneumonia

Pneumocystis pneumonia (PCP) is one of the most common pulmonary infections in persons with impaired cell-mediated immunity, and particularly those infected with human immunodeficiency virus (HIV).1–7 Pneumocystis was first described in the lungs of guinea pigs, during experiments on American trypanosomiasis by Carlos Chagas8 in 1909 and by Antonio Carinii9 in 1910. Both considered the cysts of Pneumocystis as part of the trypanosome’s life cycle. Shortly afterward the Delanoes10 found identical forms in the lungs of rats that had not been infected with trypanosomes and recognized the organism as a separate species. The name Pneumocystis carinii, was given to this organism as a generic name (Greek:pneumon, “lung”; kystis, “cyst”), honoring Carinii.11

The Many Faces of Pulmonary Nontuberculous Mycobacterial Infection

OBJECTIVE

The purpose of this article is to review clinical and radiologic manifestations of pulmonary nontuberculous mycobacterial infection.

CONCLUSION

Common and well-recognized patterns of infection include cavitary and bronchiectatic disease and infection in AIDS patients. Less common or well-recognized manifestations include nodules or masses mimicking malignancy, hypersensitivity pneumonitis, and others. Definitive diagnosis can be difficult and patterns may overlap. Timely diagnosis requires a high index of suspicion and knowledge of the spectrum of clinical and radiologic features.

Drug resistance in Pneumocystis carinii: an emerging problem

Pneumocystis carinii pneumonia (PCP) is a frequent opportunistic infection in AIDS patients. Large numbers of HIV-infected individuals take prophylactic medications to prevent this illness. The development of drug resistance, while expected, cannot be monitored by classical means, since the organism cannot be cultivated in vitro. Two drug target genes, dihydropteroate synthase (DHPS) and cytochrome b, have been cloned and sequenced from human-derived P. carinii. Mutations leading to amino acid substitutions in the active sites of both proteins have been detected in patients receiving prophylaxis with sulfonamides and sulfones (DHPS inhibitors) and with atovaquone (cytochrome b inhibitor), suggesting that drug resistance may indeed be developing.

Human cytomegalovirus (CMV)-specific CD8+ T cell responses are reduced in HIV-infected individuals with a history of CMV disease despite CD4+ T cell recovery

Cytomegalovirus (CMV)-specific immunity was investigated in human immunodeficiency virus (HIV)-infected individuals. A case-control (1:2) study was performed with cases defined as having a history of CMV end-organ disease (n=15) and controls (n=30) matched by current CD4(+) T cell count. CMV-specific CD8(+) T cells responses were quantified using the high throughput Quantiferon-CMV test (Cellestis, Melbourne, Australia). 40/44 (91%) had a positive Quantiferon-CMV test and the magnitude of response to CMV peptides correlated significantly with response to mitogen (p<0.0001) but not with CD4(+) T cell count at the time of testing, CD4(+) T cell nadir or HIV viral load. Cases had a significantly lower Quantiferon-CMV test than controls but there was no significant difference in response to mitogen or other antigens. In individuals with a history of CMV disease, CMV-specific CD8(+) T cell responses are reduced even in the setting of CD4(+) T cell reconstitution.

Palatial erosion caused by Mycobacterium Avium complex in a human immunodeficiency virus infected child

Oral manifestations of Mycobacterium Avium complex (MAC) are rare and have only been described in adults. Here we report a 10-year-old female with advanced human immunodeficiency virus infection, who presented with disseminated MAC and an erosive left palate defect.

Cytomegalovirus disease in the era of highly active antiretroviral therapy (HAART)

Cytomegalovirus (CMV) infection was one of the most important opportunistic infections in HIV-infected patients before the introduction of highly active antiretroviral therapy (HAART), i.e. the combination of at least three antiretroviral drugs of different classes. Thereafter, life expectancy and quality of life increased dramatically with the persistent suppression of HIV viremia and a significant reduction in incidence of CMV disease. Nevertheless, evidence for a multitude of direct and indirect effects of CMV on HIV progression is accumulating. Even in the era of HAART, a considerable number of HIV-infected patients have a CD4 cell count below <100 mm(-3), which involves a high risk for CMV disease. The focus of the present review is on interpretation of test results, their predictive value for CMV disease, and guidance for the rational use of diagnostic assays in HIV-infected patients. Identification of patients at immediate risk for CMV disease may be accomplished by detection of CMV-DNA in leucocytes or plasma. Evidence is growing that CMV genotypes may be also relevant for the risk of CMV disease. Diagnosis of CMV disease requires in most instances demonstration of virus in biopsy specimen from the affected organ because presence of CMV in blood may not be causally related to symptoms observed. Clinical symptoms and patient characteristics are essential in the interpretation of laboratory test results and may guide the rational collection of clinical specimen and use of laboratory assays. As a consequence, a reliable diagnosis of CMV disease and early identification of patients at high risk for CMV disease requires an integrated interpretation of clinical and virological information.

Oxandrolone in the treatment of HIV-associated weight loss in men: a randomized, double-blind, placebo-controlled study

OBJECTIVE

To evaluate the efficacy and safety of oxandrolone in promoting body weight and body cell mass (BCM) gain in HIV-associated weight loss.

METHODS

Randomized, double-blind, placebo-controlled trial. Two hundred sixty-two HIV-infected men with documented 10% to 20% weight loss or body mass index < or =20 kg/m were randomized to placebo or to 20, 40, or 80 mg of oxandrolone daily. After 12 weeks, subjects were allowed to receive open-label oxandrolone at a dose of 20 mg for another 12 weeks.

RESULTS

Body weight increased in all groups, including the group receiving placebo, during the double-blind phase (1.1 +/- 2.7, 1.8 +/- 3.9, 2.8 +/- 3.3, and 2.3 +/- 2.9 kg in placebo and 20-, 40-, and 80-mg oxandrolone groups, respectively; all P < 0.014 vs. baseline). BCM increased from baseline in all groups (0.45 +/- 1.7, 0.91 +/- 2.2, 1.5 +/- 2.5, and 1.8 +/- 1.8 kg in placebo and 20-, 40-, and 80-mg oxandrolone groups, respectively). At 12 weeks, only the gain in weight at the 40-mg dose of oxandrolone and the gain in BCM at the 40- and 80-mg doses of oxandrolone were greater than those in the placebo group, however. Oxandrolone treatment was associated with significant suppression of sex hormone-binding globulin, luteinizing hormone, follicle-stimulating hormone, and total and free testosterone levels. Treatment was generally well tolerated but accompanied by significant increases in transaminases and low-density lipoprotein as well as decreases in high-density lipoprotein.

CONCLUSION

Oxandrolone administration is effective in promoting dose-dependent gains in body weight and BCM in HIV-infected men with weight loss.

Treatment of cytomegalovirus retinitis with oral valganciclovir in an acquired immunodeficiency syndrome patient unresponsive to combination antiretroviral therapy

BACKGROUND

Cytomegalovirus (CMV) retinitis was a much-feared visual complication of late-stage acquired immunodeficiency syndrome (AIDS) in the past. Its incidence has waned significantly owing to the benefits of potent antiretroviral combination therapy, which for many individuals has provided some degree of immune reconstitution and avoidance of opportunistic infections, particularly this blinding disease.

CASE REPORT

A 45-year-old white man with long-standing, multidrug-resistant human immunodeficiency virus (HIV) infection and severe immunodeficiency despite multiple antiretroviral drug regimens, presented to the eye clinic reporting decreased vision and spider web patterns in his left eye for the past week. Best-corrected visual acuity was 20/20 in the right (O.D.) and 20/25 in the left eye (O.S.). Dilated funduscopic examination of the left eye found vasculitis of the midperipheral inferonasal arcade in the midperiphery, with surrounding intraretinal hemorrhage and granular retinal necrosis. Diagnosis of cytomegalovirus retinitis was made, and the patient began induction therapy with oral valganciclovir 900 mg twice a day for 3 weeks. Maintenance therapy after retinitis stabilization was 900 mg every day until any observed recurrence of infection. Three months after complete resolution of the active retinitis, the patient returned to the clinic reporting new floaters of recent onset. A reactivation of the CMV retinitis warranted a reinduction with valganciclovir 900 mg orally twice a day for 3 weeks.

CONCLUSION

This case is illustrative of the efficacy and relative ease of administration of valganciclovir, the newest medication approved for treatment and maintenance of CMV retinitis. Despite his severe immunodeficiency, our patient tolerated the induction and maintenance therapy of oral valganciclovir well, and the CMV retinitis was stabilized and resolved with full recovery of visual acuity.