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Aiman W, Ali MA, Grewal N, Bethel N, Savopoulos AA, Guron G. A Case of Deep Venous Thrombosis in an HIV-Infected Patient despite Therapeutic Anticoagulation. Int J Hematol Oncol Stem Cell Res 2024; 18:206-209. [PMID: 38868809 PMCID: PMC11166488 DOI: 10.18502/ijhoscr.v18i2.15379] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 03/24/2024] [Indexed: 06/14/2024] Open
Abstract
Patients with human immunodeficiency virus (HIV) infection have an increased likelihood of venous thromboembolism (VTE) owing to factors such as acquired protein C and S deficiency, antiphospholipid antibody syndrome, and heightened levels of pro-inflammatory cytokines. This case report highlights an exceptionally uncommon occurrence of deep venous thrombosis in an HIV-infected patient receiving a therapeutic dose of enoxaparin. This underscores the need for cautious consideration of the risk of VTE in HIV-infected individuals, even with preventive or therapeutic anticoagulant treatment. Further research is recommended to investigate HIV as a potential risk factor of prophylactic anticoagulation.
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Affiliation(s)
- Wajeeha Aiman
- Saint Michael’s Medical Center, New York College of Medicine, Newark, NJ, USA
| | | | - Navjot Grewal
- Saint Michael’s Medical Center, New York College of Medicine, Newark, NJ, USA
| | - Nyan Bethel
- Saint Michael’s Medical Center, New York College of Medicine, Newark, NJ, USA
| | | | - Gunwant Guron
- Saint Michael’s Medical Center, New York College of Medicine, Newark, NJ, USA
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2
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Crane HM, Nance RM, Ruderman SA, Haidar L, Tenforde MW, Heckbert SR, Budoff MJ, Hahn AW, Drumright LN, Ma J, Mixson LS, Lober WB, Barnes GS, McReynolds J, Attia EF, Peter I, Moges T, Bamford L, Cachay E, Mathews WC, Christopolous K, Hunt PW, Napravnik S, Keruly J, Moore RD, Burkholder G, Willig AL, Lindstrom S, Whitney BM, Saag MS, Kitahata MM, Crothers KA, Delaney JAC. Venous Thromboembolism Among People With HIV: Design, Implementation, and Findings of a Centralized Adjudication System in Clinical Care Sites Across the United States. J Acquir Immune Defic Syndr 2024; 95:207-214. [PMID: 37988634 PMCID: PMC11151789 DOI: 10.1097/qai.0000000000003339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Accepted: 08/30/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND People with HIV (PWH) are at increased risk for venous thromboembolism (VTE). We conducted this study to characterize VTE including provoking factors among PWH in the current treatment era. METHODS We included PWH with VTE between 2010 and 2020 at 6 sites in the CFAR Network of Integrated Clinical Systems cohort. We ascertained for possible VTE using diagnosis, VTE-related imaging, and VTE-related procedure codes, followed by centralized adjudication of primary data by expert physician reviewers. We evaluated sensitivity and positive predictive value of VTE ascertainment approaches. VTEs were classified by type and anatomic location. Reviewers identified provoking factors such as hospitalizations, infections, and other potential predisposing factors such as smoking. RESULTS We identified 557 PWH with adjudicated VTE: 239 (43%) had pulmonary embolism with or without deep venous thrombosis, and 318 (57%) had deep venous thrombosis alone. Ascertainment with clinical diagnoses alone missed 6% of VTEs identified with multiple ascertainment approaches. DVTs not associated with intravenous lines were most often in the proximal lower extremities. Among PWH with VTE, common provoking factors included recent hospitalization (n = 134, 42%), infection (n = 133, 42%), and immobilization/bed rest (n = 78, 25%). Only 57 (10%) PWH had no provoking factor identified. Smoking (46%), HIV viremia (27%), and injection drug use (22%) were also common. CONCLUSIONS We conducted a robust adjudication process that demonstrated the benefits of multiple ascertainment approaches followed by adjudication. Provoked VTEs were more common than unprovoked events. Nontraditional and modifiable potential predisposing factors such as viremia and smoking were common.
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Affiliation(s)
- Heidi M Crane
- Department of Medicine, University of Washington, Seattle, WA
| | - Robin M Nance
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Lara Haidar
- Department of Pharmacy, University of Manitoba, Manitoba, CA
| | - Mark W Tenforde
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Matthew J Budoff
- Department of Medicine, Lundquist Institute at Harbor-UCLA, Torrance, CA
| | - Andrew W Hahn
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Jimmy Ma
- Department of Medicine, University of Washington, Seattle, WA
| | - L S Mixson
- Department of Medicine, University of Washington, Seattle, WA
| | - William B Lober
- Department of Medicine and Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Gregory S Barnes
- Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Justin McReynolds
- Clinical Informatics Research Group, University of Washington, Seattle, WA
| | - Engi F Attia
- Department of Medicine, University of Washington, Seattle, WA
| | - Inga Peter
- Department of Genetics, Mount Sinai University, New York NY
| | - Tesfaye Moges
- Department of Medicine, University of California, San Diego, CA
| | - Laura Bamford
- Department of Medicine, University of California, San Diego, CA
| | - Edward Cachay
- Department of Medicine, University of California, San Diego, CA
| | | | | | - Peter W Hunt
- Department of Medicine, University of California, San Francisco, CA
| | - Sonia Napravnik
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Jeanne Keruly
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Richard D Moore
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Greer Burkholder
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL
| | - Amanda L Willig
- Department of Medicine, University of Alabama Birmingham, Birmingham, AL
| | - Sara Lindstrom
- Department of Genetics, University of Washington, Seattle, WA; and
| | | | - Michael S Saag
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - Mari M Kitahata
- Department of Medicine, University of Washington, Seattle, WA
| | | | - Joseph A C Delaney
- Department of Medicine, University of Washington, Seattle, WA
- Department of Medicine, University of Manitoba, Manitoba, CA
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3
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Kubo T, Kawaratani H, Yoshiji H. Severe superior mesenteric vein thrombosis after COVID-19 mRNA vaccination. Clin Case Rep 2023; 11:e7354. [PMID: 37215973 PMCID: PMC10196657 DOI: 10.1002/ccr3.7354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Revised: 03/14/2023] [Accepted: 05/02/2023] [Indexed: 05/24/2023] Open
Abstract
Venous thrombosis is a rare occurrence following the administration of the COVID-19 mRNA vaccine. The occurrence of superior mesenteric vein (SMV) is even more rare. SMV thrombosis should be considered as a differential diagnosis in patients who develop abdominal pain after COVID-19 mRNA vaccination.
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Affiliation(s)
- Takahiro Kubo
- Department of GastroenterologyNara Medical UniversityKashiharaJapan
| | | | - Hitoshi Yoshiji
- Department of GastroenterologyNara Medical UniversityKashiharaJapan
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4
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Laraghy M, McCullough J, Gerrard J, Stroebel A, Winearls J. Venoarterial extracorporeal membrane oxygenation for cardiac support in human immunodeficiency virus-positive patients: a case report and review of a multicentre registry. J Cardiothorac Surg 2023; 18:109. [PMID: 37029414 PMCID: PMC10080512 DOI: 10.1186/s13019-023-02191-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 03/26/2023] [Indexed: 04/09/2023] Open
Abstract
BACKGROUND Human immunodeficiency virus (HIV) is associated with increased risk of heart failure via multiple mechanisms both in patients with and without access to highly active antiretroviral therapy (HAART). Limited information is available on outcomes among this population supported on Venoarterial Extracorporeal Membrane Oxygenation (VA ECMO), a form of temporary mechanical circulatory support. METHODS We aimed to assess outcomes and complications among patients with HIV supported on VA ECMO reported to a multicentre registry and present a case report of a 32 year old male requiring VA ECMO for cardiogenic shock as a consequence of his untreated HIV and acquired immune deficiency syndrome (AIDS). A retrospective analysis of the Extracorporeal Life Support Organization (ELSO) registry data from 1989 to 2019 was performed in HIV patients supported on VA ECMO. RESULTS 36 HIV positive patients were reported to the ELSO Database who received VA ECMO during the study period with known outcomes. 15 patients (41%) survived to discharge. No significant differences existed between survivors and non-survivors in demographic variables, duration of VA ECMO support or cardiac parameters. Inotrope and/or vasopressor requirement prior to or during VA ECMO support was associated with increased mortality. Survivors were more likely to develop circuit thrombosis. The patient presented was supported on VA ECMO for 14 days and was discharged from hospital day 85. CONCLUSIONS A limited number of patients with HIV have been supported with VA ECMO and more data is required to ascertain the indications for ECMO in this population. HIV should not be considered an absolute contraindication to VA ECMO as they may have comparable outcomes to other patient groups requiring VA ECMO support.
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Affiliation(s)
- Matthew Laraghy
- Intensive Care, Gold Coast University Hospital, Gold Coast, QLD, Australia.
| | - James McCullough
- Intensive Care, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - John Gerrard
- Infectious Diseases and Immunology, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - Andrie Stroebel
- Cardiothoracic Surgery, Gold Coast University Hospital, Gold Coast, QLD, Australia
| | - James Winearls
- Intensive Care, Gold Coast University Hospital, Gold Coast, QLD, Australia
- School of Medicine, University of Queensland, St. Lucia, QLD, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- St Andrew's War Memorial Hospital, Brisbane, QLD, Australia
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5
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Akinosoglou K, Kolosaka M, Schinas G, Delastic AL, Antonopoulou S, Perperis A, Marangos M, Mouzaki A, Gogos C. Association of Antiretroviral Therapy with Platelet Function and Systemic Inflammatory Response in People Living with HIV: A Cross-Sectional Study. Microorganisms 2023; 11:microorganisms11040958. [PMID: 37110381 PMCID: PMC10144397 DOI: 10.3390/microorganisms11040958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2022] [Revised: 04/03/2023] [Accepted: 04/04/2023] [Indexed: 04/29/2023] Open
Abstract
People living with HIV (PLWHIV) present an increased risk of adverse cardiovascular events. We aimed to assess whether antiretroviral therapy (ART) pharmacologically enhances platelet reactivity and platelet activation intensity, and explore the potential association with underlying inflammatory status. This was a cross-sectional cohort study carried out among PLWHIV on diverse ART regimens. Platelet reactivity and activation intensity were assessed using the bedside point-of-care VerifyNow assay, in P2Y12 reaction units (PRU), measurements of monocyte-platelet complexes, and P-selectin and GPIIb/IIIa expression increase, following activation with ADP, respectively. Levels of major inflammatory markers and whole blood parameters were also evaluated. In total, 71 PLWHIV, 59 on ART and 22 healthy controls, were included in this study. PRU values were significantly elevated in PLWHIV compared to controls [Mean; 257.85 vs. 196.67, p < 0.0001], but no significant differences were noted between ART-naïve or ART-experienced PLWHIV, or between TAF/TDF and ABC based regimens, similar to systemic inflammatory response. However, within-group analysis showed that PRUs were significantly higher in ABC/PI vs ABC/INSTI or TAF/TDF + PI patients, in line with levels of IL-2. PRU values did not correlate strongly with CD4 counts, viral load, or cytokine values. P-selectin and GPIIb/IIIa expression increased following ADP activation and were significantly more prominent in PLWHIV (p < 0.005). Platelet reactivity and platelet activation intensity were shown to be increased in PLWHIV, but they did not appear to be related to ART initiation, similar to the underlying systemic inflammatory response.
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Affiliation(s)
- Karolina Akinosoglou
- Department of Internal Medicine, University General Hospital of Patras, 26504 Patras, Greece
- Medical School, University of Patras, 26504 Patras, Greece
- Division of Infectious Diseases, Department of Internal Medicine, University of Patras, 26504, Patras, Greece
| | - Martha Kolosaka
- Department of Internal Medicine, University General Hospital of Patras, 26504 Patras, Greece
| | - George Schinas
- Medical School, University of Patras, 26504 Patras, Greece
| | - Anne-Lise Delastic
- Laboratory of Immuno-Hematology, Medical School, University of Patras, 26504 Patras, Greece
| | - Stefania Antonopoulou
- Laboratory of Immuno-Hematology, Medical School, University of Patras, 26504 Patras, Greece
| | - Angelos Perperis
- Department of Cardiology, University General Hospital of Patras, 26504 Patras, Greece
| | - Markos Marangos
- Department of Internal Medicine, University General Hospital of Patras, 26504 Patras, Greece
- Medical School, University of Patras, 26504 Patras, Greece
- Division of Infectious Diseases, Department of Internal Medicine, University of Patras, 26504, Patras, Greece
| | - Athanasia Mouzaki
- Medical School, University of Patras, 26504 Patras, Greece
- Laboratory of Immuno-Hematology, Medical School, University of Patras, 26504 Patras, Greece
| | - Charalambos Gogos
- Department of Internal Medicine, University General Hospital of Patras, 26504 Patras, Greece
- Medical School, University of Patras, 26504 Patras, Greece
- Division of Infectious Diseases, Department of Internal Medicine, University of Patras, 26504, Patras, Greece
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Zerangian N, Erabi G, Poudineh M, Monajjem K, Diyanati M, Khanlari M, Khalaji A, Allafi D, Faridzadeh A, Amali A, Alizadeh N, Salimi Y, Ghane Ezabadi S, Abdi A, Hasanabadi Z, ShojaeiBaghini M, Deravi N. Venous thromboembolism in viral diseases: A comprehensive literature review. Health Sci Rep 2023; 6:e1085. [PMID: 36778773 PMCID: PMC9900357 DOI: 10.1002/hsr2.1085] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2022] [Revised: 12/25/2022] [Accepted: 01/19/2023] [Indexed: 02/09/2023] Open
Abstract
Venous thromboembolism (VTE) is known to be a common respiratory and/or cardiovascular complication in hospitalized patients with viral infections. Numerous studies have proven human immunodeficiency virus infection to be a prothrombotic condition. An elevated VTE risk has been observed in critically ill H1N1 influenza patients. VTE risk is remarkably higher in patients infected with the Hepatitis C virus in contrast to uninfected subjects. The elevation of D-dimer levels supported the association between Chikungunya and the Zika virus and the rise of clinical VTE risk. Varicella-zoster virus is a risk factor for both cellulitis and the consequent invasive bacterial disease which may take part in thrombotic initiation. Eventually, hospitalized patients infected with the coronavirus disease of 2019 (COVID-19), the cause of the ongoing worldwide pandemic, could mainly suffer from an anomalous risk of coagulation activation with enhanced venous thrombosis events and poor quality clinical course. Although the risk of VTE in nonhospitalized COVID-19 patients is not known yet, there are a large number of guidelines and studies on thromboprophylaxis administration for COVID-19 cases. This study aims to take a detailed look at the effect of viral diseases on VTE, the epidemiology of VTE in viral diseases, and the diagnosis and treatment of VTE.
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Affiliation(s)
- Nasibeh Zerangian
- Health Education and Health Promotion, Department of Health Education and Health Promotion, School of HealthMashhad University of Medical SciencesMashhadIran
| | - Gisou Erabi
- Student Research CommitteeUrmia University of Medical SciencesUrmiaIran
| | | | - Kosar Monajjem
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | - Maryam Diyanati
- Student Research CommitteeRafsanjan University of Medical SciencesRafsanjanIran
| | - Maryam Khanlari
- Student Research CommitteeTabriz University of Medical SciencesTabrizIran
| | | | - Diba Allafi
- Student Research CommitteeUrmia University of Medical SciencesUrmiaIran
| | - Arezoo Faridzadeh
- Department of Immunology and Allergy, School of MedicineMashhad University of Medical SciencesMashhadIran,Immunology Research CenterMashhad University of Medical SciencesMashhadIran
| | - Arian Amali
- Student Research Committee, Paramedical DepartmentIslamic Azad University, Mashhad BranchMashhadIran
| | - Nilufar Alizadeh
- Doctor of Medicine (MD), School of MedicineIran University of Medical SciencesTehranIran
| | - Yasaman Salimi
- Student Research CommitteeKermanshah University of Medical SciencesKermanshahIran
| | - Sajjad Ghane Ezabadi
- Student's Scientific Research Center, School of MedicineTehran University of Medical SciencesTehranIran
| | - Amir Abdi
- Student Research Committee, School of Medicine, Tehran Medical SciencesIslamic Azad UniversityTehranIran
| | - Zahra Hasanabadi
- Doctor of Medicine (MD), School of MedicineQazvin University of Medical ScienceQazvinIran
| | - Mahdie ShojaeiBaghini
- Medical Informatics Research Center, Institute for Futures Studies in HealthKerman University of Medical SciencesKermanIran
| | - Niloofar Deravi
- Student Research Committee, School of MedicineShahid Beheshti University of Medical SciencesTehranIran
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7
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The role of immune status, viral co-infections and paraproteinemia in development of venous thromboembolism in HIV. Blood Coagul Fibrinolysis 2022; 33:473-475. [PMID: 36409924 DOI: 10.1097/mbc.0000000000001136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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8
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Chakra MA, Roux S, Peyromaure M, Delongchamps NB, Bailly H, Duquesne I. An unusual presentation of penile Mondor's disease in an HIV-positive patient. Ann R Coll Surg Engl 2022; 104:e258-e260. [PMID: 35639369 PMCID: PMC9685967 DOI: 10.1308/rcsann.2022.0034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2022] [Indexed: 11/03/2023] Open
Abstract
Penile Mondor's disease (PMD), or thrombosis of the dorsal vein, is an under-reported benign condition. Its aetiology is poorly understood. Clinically, it presents as a palpable cord in the dorsal vein of the penis, with pain or local discomfort, especially during erection. PMD may be diagnosed based on the medical history and physical examination. Management of the condition is conservative, with practitioners opting for various strategies including sexual/masturbatory abstinence, localised anticoagulant topical therapy and oral nonsteroidal anti-inflammatory drugs. In many cases, PMD will resolve within 4-8 weeks of presentation. Thrombectomy and resection of the superficial penile vein are applied surgically in patients refractory to the medical treatment. We describe the case of a 33-year-old patient known to have HIV who presented for severe painful dorsal induration and swelling of the proximal third of the penis. The patient had no recent history of sexual intercourse, penile trauma or other well-known risk factors for PMD. The physical examination was unequivocal, so a Doppler ultrasound was performed. A diagnosis of PMD was made and conservative treatment was prescribed. During a follow-up visit after 6 weeks, the patient had no symptoms and physical examination did not reveal anything pathological.
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Affiliation(s)
- MA Chakra
- Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, France
| | - S Roux
- Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, France
| | - M Peyromaure
- Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, France
| | - NB Delongchamps
- Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, France
| | - H Bailly
- Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, France
| | - I Duquesne
- Cochin Hospital, Assistance Publique-Hôpitaux de Paris, Paris Descartes University, France
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9
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Luu B, Ruderman S, Nance R, Delaney JAC, Ma J, Hahn A, Heckbert SR, Budoff MJ, Crothers K, Mathews WC, Christopolous K, Hunt PW, Eron J, Moore R, Keruly J, Lober WB, Burkholder GA, Willig A, Chander G, McCaul ME, Cropsey K, O'Cleirigh C, Peter I, Feinstein M, Tsui JI, Lindstroem S, Saag M, Kitahata MM, Crane HM, Drumright LN, Whitney BM. Tobacco smoking and binge alcohol use are associated with incident venous thromboembolism in an HIV cohort. HIV Med 2022; 23:1051-1060. [PMID: 35343038 PMCID: PMC9515244 DOI: 10.1111/hiv.13309] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 01/27/2022] [Accepted: 03/14/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND People with HIV (PWH) are at increased risk of cardiovascular comorbidities and substance use is a potential predisposing factor. We evaluated associations of tobacco smoking and alcohol use with venous thromboembolism (VTE) in PWH. METHODS We assessed incident, centrally adjudicated VTE among 12 957 PWH within the Centers for AIDS Research Network of Integrated Clinical Systems (CNICS) cohort between January 2009 and December 2018. Using separate Cox proportional hazards models, we evaluated associations of time-updated alcohol and cigarette use with VTE, adjusting for demographic and clinical characteristics. Smoking was evaluated as pack-years and never, former, or current use with current cigarettes per day. Alcohol use was parameterized using categorical and continuous alcohol use score, frequency of use, and binge frequency. RESULTS During a median of 3.6 years of follow-up, 213 PWH developed a VTE. One-third of PWH reported binge drinking and 40% reported currently smoking. In adjusted analyses, risk of VTE was increased among both current (HR: 1.44, 95% CI: 1.02-2.03) and former (HR: 1.44, 95% CI: 0.99-2.07) smokers compared to PWH who never smoked. Additionally, total pack-years among ever-smokers (HR: 1.10 per 5 pack-years; 95% CI: 1.03-1.18) was associated with incident VTE in a dose-dependent manner. Frequency of binge drinking was associated with incident VTE (HR: 1.30 per 7 days/month, 95% CI: 1.11-1.52); however, alcohol use frequency was not. Severity of alcohol use was not significantly associated with VTE. CONCLUSIONS Current smoking and pack-year smoking history were dose-dependently associated with incident VTE among PWH in CNICS. Binge drinking was also associated with VTE. Interventions for smoking and binge drinking may decrease VTE risk among PWH.
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Affiliation(s)
- Brandon Luu
- Northern Ontario School of Medicine, Thunder Bay, Ontario, Canada
| | | | - Robin Nance
- University of Washington, Seattle, Washington, USA
| | - Joseph A C Delaney
- University of Washington, Seattle, Washington, USA
- University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jimmy Ma
- University of Washington, Seattle, Washington, USA
| | - Andrew Hahn
- University of Washington, Seattle, Washington, USA
| | | | | | | | | | | | - Peter W Hunt
- University of California, San Francisco, California, USA
| | - Joseph Eron
- University of North Carolina, Chapel Hill, North Carolina, USA
| | | | | | | | | | - Amanda Willig
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | | | - Karen Cropsey
- University of Alabama at Birmingham, Birmingham, Alabama, USA
| | | | - Inga Peter
- Mount Sinai Hospital, New York, New York, USA
| | | | | | | | - Michael Saag
- University of Alabama at Birmingham, Birmingham, Alabama, USA
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10
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Coagulation Parameters in Human Immunodeficiency Virus Infected Patients: A Systematic Review and Meta-Analysis. AIDS Res Treat 2022; 2022:6782595. [PMID: 35492260 PMCID: PMC9050251 DOI: 10.1155/2022/6782595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 04/05/2022] [Indexed: 11/23/2022] Open
Abstract
Background Coagulation abnormalities are common complications of human immunodeficiency virus (HIV) infection. Highly active antiretroviral treatment (HAART) decreased the mortality of HIV but increased coagulopathies. HIV-related thrombocytopenia, prolonged prothrombin time (PT), activated partial thromboplastin time (APTT), and high D-dimer level commonly manifested in patients with HIV. Thus, this study is aimed to compare coagulation parameters of HAART-treated and HAART-naïve HIV-infected patients with HIV-seronegative controls. Methods A systematic literature search was conducted using the databases PubMed/MEDLINE, Embase, Web of Science, and Google Scholar of studies published until July 2021. The primary outcome of interest was determining the pooled mean difference of coagulation parameters between HIV-infected patients and seronegative controls. The Joana Briggs Institute (JBI) critical appraisal tool was used for quality appraisal. Statistical analyses were performed using Stata11.0 software. The statistical results were expressed as the effect measured by standardized mean difference (SMD) with their related 95% confidence interval (CI). Results A total of 7,498 participants (1,144 HAART-naïve patients and 2,270 HAART-treated HIV-infected patients and 3,584 HIV-seronegative controls) from 18 studies were included. HIV-infected patients (both on HAART and HAART-naive) exhibited significantly higher levels of PT than HIV-seronegative controls (SMD = 0.66; 95% CI: 0.53–0.80 and SMD = 1.13; 95% CI: 0.60–2.0, respectively). The value of APTT was significantly higher in patients with HIV on HAART than in seronegative controls. However, the values of PLT count, APTT, and fibrinogen level were significantly higher in seronegative controls. Besides, the level of fibrinogen was significantly higher in HAART-treated than treatment-naïve patients (SMD = 0.32; 95%CI: 0.08, 0.57). Moreover, the level of APTT and PT had no statistical difference between HAART and HAART-naïve HIV-infected patients. Conclusions This study identified that HIV-infected patients are more likely to develop coagulation abnormalities than HIV-seronegative controls. Therefore, coagulation parameters should be assessed regularly to prevent and monitor coagulation disorders in HIV-infected patients.
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11
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12
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Elevated Risk of Venous Thromboembolism in People Living with HIV. Viruses 2022; 14:v14030590. [PMID: 35336997 PMCID: PMC8955815 DOI: 10.3390/v14030590] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Accepted: 03/06/2022] [Indexed: 11/16/2022] Open
Abstract
Human immunodeficiency virus (HIV) has been generally considered as a highly adaptive and rapidly evolving virus. It still constitutes a major public health problem all over the world despite an effective outcome in the prevention and reversal of the development and prognosis by using antiretroviral therapy. The salient question lies in the more frequent emergence of a series of comorbidities along with the prolongation of the life, which deeply affects the survival in such group. Venous thromboembolism (VTE) has been recognized to be the third most common cardiovascular condition within people living with HIV (PWH). In terms of its mechanism of action, the occurrence of VTE is quite multifactorial and complex in HIV. Prior exploration concerning the etiology of VTE in PWH identifies general, disease-specific, and miscellaneous factors for explaining its occurrence and development. VTE has constituted an important role in PWH and may increase its all-cause mortality. Therefore, it is quite necessary to understand VTE from the following aspects of epidemiology, pathophysiology, molecular mechanisms, and therapeutic interventions so as to balance the risks and benefits of anticoagulation and optimize corresponding treatment.
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13
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Analysis of the Coagulation Profile in Children with HIV Infection-Effect of Disease and Anti Retroviral Therapy. Indian J Hematol Blood Transfus 2022; 38:132-137. [PMID: 35125721 PMCID: PMC8804129 DOI: 10.1007/s12288-021-01440-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2021] [Accepted: 04/25/2021] [Indexed: 01/03/2023] Open
Abstract
The pathogenesis of hypercoagulability in HIV infection is multifactorial and usually more than one factor is responsible for a thromboembolic episode. The present study was conducted to evaluate the effect of HIV infection and antiretroviral therapy on various coagulation parameters in paediatric patients. Forty two newly diagnosed paediatric patients with HIV infection who were enrolled at the Anti-Retro viral Therapy (ART) centre of Kalawati Saran Children's Hospital were included in the study. The patients were grouped into 4 clinical stages according to the WHO clinical staging of HIV disease. Coagulation tests [PT, aPTT, fibrinogen, D-Dimer and coagulation inhibitors i.e. Protein C (PC), Protein S (PS) and antithrombin III (AT III), Lupus anticoagulant (LA) and Anti phospholipid antibody (APLA)] were performed in all the patients at the time of diagnosis and repeated after 6 months. All the patients were started on antiretroviral therapy within 2 months of their diagnosis. At the time of diagnosis, prolonged PT and aPTT were observed in 30.9% and 23% of the cases respectively. Hyperfibinogenemia was seen in 11.9% of patients. D-Dimer was raised in 83.3% of patients. PS, PC & AT activities were reduced in 90.4%, 42.8% & 11.9% of cases respectively. A reduction in the PC and AT activity was seen from clinical stage 1 to 4, but the change was not statistically significant. On follow up after 6 months, a statistically significant reduction in the level of fibrinogen and D-Dimer was seen. Even though there was improvement in the activity of all the coagulation inhibitor after 6 months, statistically significant improvement was seen only for PS. The current study shows that HIV produces a hypercoagulable state in children. Raised d-dimer level and deficiency of natural anticoagulants contribute to the thrombophilic state.
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Christopher C, Nwogoh B, Akaba K, igwilo H, Abang R. Plasminogen Activator Inhibitor 1 (PAI-1) and Haematologic Parameters in HIV- Positive Patients on Protease Inhibitor-Based HAART Regimen: A Case-Control Study. Clin Appl Thromb Hemost 2022; 28:10760296221126176. [DOI: 10.1177/10760296221126176] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Background: Human immunodeficiency virus (HIV) infection is associated with an increased risk of hypercoagulability and treatment with antiretroviral agents especially protease inhibitors has also been reported to contribute to this risk. Altered fibrinolytic activity is reported as a mechanism of increased thrombotic risk in HIV patients on therapy. However, this has not been investigated in our environment. Objective: To evaluate and compare PAI-1 levels as a marker of thrombotic risk in HIV-infected persons on PI-based HAART regimen with those on non-PI-based therapy and to correlate PAI-1 with haematological parameters. Methods: This was a comparative cross-sectional study conducted at the University of Calabar Teaching Hospital (UCTH), Calabar, Cross River State. A total of 125 subjects including 45 HIV-positive patients on PI-based HAART regimen, 42 HIV-positive patients on non-PI-based HAART regimen and 38 Controls. The controls include 18 HIV-positive therapy naïve patients and 20 HIV-negative controls. PAI 1 and blood counts were estimated using standard methods. Data were analyzed using the IBM version of the statistical package for social sciences (SPSS) version 22. Statistical significance was set at 0.05. Result: The median PAI-1 level was significantly increased in patients on PI-based HAART regimen (p = 0.004). The blood counts did not differ significantly between patients on PI and non-PI-based HAART regimens (p > 0.05). There were no significant correlations between PAI-1 levels and blood counts (p > 0.05). Conclusion: PAI-1 level is elevated in HIV patients on PI-based HAART regimen. However, the association with thrombotic events could not be established in the study.
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Affiliation(s)
| | - Benedict Nwogoh
- Department of Haematology, University of Benin Teaching Hospital, Benin, Nigeria
| | - Kingsley Akaba
- Haematology and Blood Transfusion, University of Calabar, Calabar, Nigeria
| | - Hilary igwilo
- Department of Haematology, University of Calabar, Calabar, Nigeria
| | - Roger Abang
- Department of Psychiatry, Federal Neuro-Psychiatric Hospital Calabar, Calabar, Nigeria
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15
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Tang YF, Wang Y, Xue TJ, Liu G, Chen Q, Zhao W, Liu YY, Chen RQ, Chen L, Liu J. Clinical Characteristics of HIV-Infected Patients with Venous Thromboembolism and Different CD4+ T Lymphocyte Levels. J Inflamm Res 2022; 15:613-620. [PMID: 35115809 PMCID: PMC8805832 DOI: 10.2147/jir.s346200] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 12/23/2021] [Indexed: 11/23/2022] Open
Abstract
Objective Methods Results Conclusion
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Affiliation(s)
- Yan-Fen Tang
- Department of Respiratory, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
- Clinical Key Department of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
- Correspondence: Yan-Fen Tang Department of Respiratory, Beijing Ditan Hospital, Capital Medical University, No. 8, Jingshun Dongjie, Chaoyang District, Beijing, 100015, People’s Republic of ChinaTel +86 10 84322963Fax +86 10 84322146 Email
| | - Yu Wang
- Department of Respiratory, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
- Clinical Key Department of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
| | - Tian-Jiao Xue
- Department of Respiratory, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
- Clinical Key Department of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
| | - Gang Liu
- Department of Respiratory, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
- Clinical Key Department of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
| | - Qi Chen
- Department of Respiratory, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
- Clinical Key Department of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
| | - Wen Zhao
- Department of Respiratory, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
- Clinical Key Department of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
| | - Yan-Yan Liu
- Department of Respiratory, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
- Clinical Key Department of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
| | - Rong-Qian Chen
- Department of Respiratory, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
- Clinical Key Department of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
| | - Li Chen
- Department of Respiratory, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
- Clinical Key Department of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
| | - Jing Liu
- Department of Respiratory, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
- Clinical Key Department of Infectious Diseases, Beijing Ditan Hospital, Capital Medical University, Beijing, 100015, People’s Republic of China
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International Normalized Ratio (INR) Increases amongst Two Patients Living with HIV on Warfarin after Being Switched from a Nevirapine to a Dolutegravir-Based Antiretroviral Regimen. Case Rep Infect Dis 2021; 2021:9384663. [PMID: 34745671 PMCID: PMC8570848 DOI: 10.1155/2021/9384663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Accepted: 10/21/2021] [Indexed: 11/17/2022] Open
Abstract
The increased use of dolutegravir-based regimens in the treatment of HIV is unmasking drug interactions, particularly in patients who were previously on nevirapine. Nevirapine is an enzyme inducer and increases the dosing requirements for cytochrome P450 enzyme substrates including warfarin. Upon discontinuing nevirapine, close monitoring of drugs with narrow therapeutic indices is paramount since dosing requirements may significantly reduce, increasing the probability of toxicity development. We present two cases describing interactions experienced by patients living with HIV, while transitioning from nevirapine to dolutegravir-based HIV regimens. The first case describes a 70-year-old man living with HIV and diabetes, while the second case describes a 60-year-old woman living with HIV. They were diagnosed with unprovoked deep vein thrombi, and while receiving treatment with warfarin, their HIV medication regimen was changed from lamivudine, zidovudine, nevirapine, and septrin to lamivudine, tenofovir, dolutegravir, and septrin. During the weeks following this switch, warfarin requirements decreased resulting in supratherapeutic INRs. With the continued promotion of dolutegravir-based HIV regimens as the preferred option for the treatment of HIV in President's Emergency Plan for AIDS Relief (PEPFAR) supported HIV treatment programs in Africa, clinicians must be aware of the potentially life-threatening consequences of switching antiretroviral regimens. It is hoped that a greater awareness of this potential side effect could lead to increased monitoring and prevention of the consequences of drug interactions.
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Moodley P, Martinson NA, Joyimbana W, Otwombe KN, Abraham P, Motlhaoleng K, Naidoo VA, Variava E. Venous thromboembolic disease in adults admitted to hospital in a setting with a high burden of HIV and TB. Afr J Thorac Crit Care Med 2021; 27:10.7196/AJTCCM.2021.v27i3.155. [PMID: 34761207 PMCID: PMC8573812 DOI: 10.7196/ajtccm.2021.v27i3.155] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2021] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND HIV and tuberculosis (TB) independently cause an increased risk for venous thromboembolic disease (VTE): deep vein thrombosis (DVT) and/or pulmonary embolism (PE). Data from high HIV and TB burden settings describing VTE are scarce. The Wells' DVT and PE scores are widely used but their utility in these settings has not been reported on extensively. OBJECTIVES To evaluate new onset VTE, compare clinical characteristics by HIV status, and the presence or absence of TB disease in our setting. We also calculate the Wells' score for all patients. METHODS A prospective cohort of adult in-patients with radiologically confirmed VTE were recruited into the study between September 2015 and May 2016. Demographics, presence of TB, HIV status, duration of treatment, CD4 count, viral load, VTE risk factors, and parameters to calculate the Wells' score were collected. RESULTS We recruited 100 patients. Most of the patients were HIV-infected (n=59), 39 had TB disease and 32 were HIV/TB co-infected. Most of the patients had DVT only (n=83); 11 had PE, and 6 had both DVT and PE. More than a third of patients on antiretroviral treatment (ART) (43%; n=18/42) were on treatment for <6 months. Half of the patients (51%; n=20/39) were on TB treatment for <1 month. The median (interquartile range (IQR)) DVT and PE Wells' score in all sub-groups was 3.0 (1.0 - 4.0) and 3.0 (2.5 - 4.5), respectively. CONCLUSION HIV/TB co-infection appears to confer a risk for VTE, especially early after initiation of ART and/or TB treatment, and therefore requires careful monitoring for VTE and early initiation of thrombo-prophylaxis.
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Affiliation(s)
- P Moodley
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - N A Martinson
- Perinatal HIV Research Unit, SAMRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg,
South Africa
- NRF/DST Centre of Excellence in Biomedical TB Research, Johannesburg, South Africa
- Center for TB Research, Johns Hopkins University Baltimore, USA
| | - W Joyimbana
- Perinatal HIV Research Unit, SAMRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg,
South Africa
| | - K N Otwombe
- Perinatal HIV Research Unit, SAMRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg,
South Africa
| | - P Abraham
- Perinatal HIV Research Unit, SAMRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg,
South Africa
| | - K Motlhaoleng
- Perinatal HIV Research Unit, SAMRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg,
South Africa
| | - V A Naidoo
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
| | - E Variava
- Department of Internal Medicine, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Perinatal HIV Research Unit, SAMRC Soweto Matlosana Collaborating Centre for HIV/AIDS and TB, University of the Witwatersrand, Johannesburg,
South Africa
- Department of Internal Medicine, Klerksdorp Tshepong Hospital Complex, South Africa
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Okudo J, Civelli VF, Narang VK, Johnson RH, Khan N, Andruszko B, Heidari A. A Rare Case of Cryptococcus gattii Meningitis in Advanced HIV Disease, Sagittal Thrombosis, and Immune Reconstitution Syndrome, Resolved With Isavuconazonium. J Investig Med High Impact Case Rep 2021; 8:2324709620959880. [PMID: 32935587 PMCID: PMC7498974 DOI: 10.1177/2324709620959880] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Cryptococcus gattii is a species that has received more
recognition in the recent past as distinct from Cryptococcus neoformans.
C gattii is known to cause meningeal disease in both
immunocompetent and immunosuppressed hosts. Patients may be clinically
asymptomatic until immunosuppressive conditions occur such as corticosteroid
treatment or an HIV infection. HIV-associated cryptococcal infections are most
often due to C neoformans. C gattii is found in a minority.
Speciation and subtyping of Cryptococcus are not always
accomplished. In many parts of the world, there is no availability for
speciation of Cryptococcus. Travel history may provide a clue
to the most probable species. This case demonstrates a case of C
gattii meningitis with a multiplicity of complications. These
include advanced HIV disease secondary to nonadherence, immune reconstitution
inflammatory syndrome, and superior sagittal sinus thrombosis. The patient
represented diagnostic and therapeutic dilemmas over time. Headache was the
primary symptom in cryptococcal meningitis, immune reconstitution inflammatory
syndrome, and superior sagittal sinus thrombosis. All are discussed in detail as
potential etiologies for the primary disease. Isavuconazonium is a relatively
new broad-spectrum antifungal azole that was used as salvage therapy.
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Mucheleng'anga LA, Telendiy V, Hamukale A, Shibemba AL, Zumla A, Himwaze CM. COVID-19 and Sudden Unexpected Community Deaths in Lusaka, Zambia, Africa - A Medico-Legal Whole-Body Autopsy Case Series. Int J Infect Dis 2021; 109:160-167. [PMID: 34320461 PMCID: PMC8255190 DOI: 10.1016/j.ijid.2021.07.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 06/30/2021] [Accepted: 07/01/2021] [Indexed: 01/06/2023] Open
Abstract
Background Data from Africa regarding sudden and unexpected COVID-19 community deaths and underlying pathological, demographic, and co-morbidity features require definition. Methods We performed a case series of COVID-19-related deaths seen at Forensic Post-Mortem examination of sudden and unexpected Community Deaths in Lusaka, Zambia, Africa. Whole-body Post-Mortem examinations were performed according to Standard Operating Procedures. Patient demographics, history, co-morbidities, pathological gross and microscopic findings, and cause(s) of death were recorded. Variables were grouped as frequencies and percentages. Comparison of data was made with autopsy findings of hospital COVID-19 deaths. Findings Of 21 COVID-19 decedents, 14/21 (66.7%) were male; 18/21, (85.7%) were below 55 years of age (mean age, 40 ± 12.3; range, 20-73). The median duration of symptoms was 1 day (range 0-2); 9/21 (42.9%) had co-morbidities, with hypertension and obesity being the most common. Main post-mortem findings were diffuse alveolar damage (DAD) (80.9%), saddle and shower emboli (38.1%, respectively), and pneumonia (14.3%). Pulmonary thromboembolism (76.2%), DAD (14.3%), and SARS-CoV-2 pneumonia (9.5%) were common causes of death. Conclusions COVID-19 is an important cause of death to consider in forensic investigations of sudden and unexpected community deaths. Risk factors for the younger age of COVID-19 deaths and thromboembolism need to be identified.
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Affiliation(s)
| | - Viktor Telendiy
- Ministry of Home Affairs, Office of the State Forensic Pathologist, Nationalist Road, Lusaka, Zambia
| | | | - Aaron Lunda Shibemba
- University Teaching Hospitals, Department of Pathology and Microbiology, Nationalist Road, Lusaka, Zambia
| | - Alimuddin Zumla
- Division of Infection and Immunity, University College London; NIHR Biomedical Research Centre, UCL Hospitals NHS Foundation Trust, London, UK, and UNZA-UCLMS R&D Program, Lusaka, Zambia
| | - Cordelia Maria Himwaze
- Ministry of Home Affairs, Office of the State Forensic Pathologist, Nationalist Road, Lusaka, Zambia; University Teaching Hospitals, Department of Pathology and Microbiology, Nationalist Road, Lusaka, Zambia
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20
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Gatechompol S, Avihingsanon A, Putcharoen O, Ruxrungtham K, Kuritzkes DR. COVID-19 and HIV infection co-pandemics and their impact: a review of the literature. AIDS Res Ther 2021; 18:28. [PMID: 33952300 PMCID: PMC8097669 DOI: 10.1186/s12981-021-00335-1] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 04/08/2021] [Indexed: 01/08/2023] Open
Abstract
Coronavirus disease 2019 (COVID-19) was first detected in December 2019. In March 2020, the World Health Organization declared COVID-19 a pandemic. People with underlying medical conditions may be at greater risk of infection and experience complications from COVID-19. COVID-19 has the potential to affect People living with HIV (PLWH) in various ways, including be increased risk of COVID-19 acquisition and interruptions of HIV treatment and care. The purpose of this review article is to evaluate the impact of COVID-19 among PLWH. The contents focus on 4 topics: (1) the pathophysiology and host immune response of people infected with both SARS-CoV-2 and HIV, (2) present the clinical manifestations and treatment outcomes of persons with co-infection, (3) assess the impact of antiretroviral HIV drugs among PLWH infected with COVID-19 and (4) evaluate the impact of the COVID-19 pandemic on HIV services.
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21
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Rakhra A, Kiefer LE, Busireddy KR, Sankaraneni R. Cerebral Venous Sinus Thrombosis in an Immunocompetent HIV Patient. Cureus 2021; 13:e13694. [PMID: 33833915 PMCID: PMC8019322 DOI: 10.7759/cureus.13694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/03/2021] [Indexed: 11/05/2022] Open
Abstract
Cerebral venous sinus thrombosis (CVST) is an uncommon manifestation in patients with the human immunodeficiency virus (HIV) due to the virus's prothrombotic state. Our case involves a 41-year-old Hispanic male with a past medical history of HIV on bictegravir/emtricitabine/tenofovir/alafenamide (Biktarvy), hyperlipidemia, post-traumatic stress disorder, hypogonadism with the cessation of testosterone injections one month prior, and generalized anxiety disorder who presented with retro-orbital headache, intermittent bilateral blurry vision, and flashing lights in the lower lateral left eye for one week. Vitals signs and laboratory studies were within normal limits aside from new iron deficiency anemia. Neurological exam was unremarkable. Computed tomography (CT) of the head showed evidence of a subacute cerebral infarct with hemorrhagic transformation in the right superior parietal lobe. Magnetic resonance imaging (MRI) of the brain with contrast revealed a small thrombosed cortical vein with surrounding hemorrhage and edema in the same location, in addition to a partial thrombosis of the adjacent superior sagittal sinus, which was confirmed by magnetic resonance venogram (MRV). Although cerebral angiography was performed, no intervention was attempted for the partially occluded sagittal sinus. HIV viral load was undetectable with a robust cluster of differentiation (CD) 4 count on therapy. The patient was treated with strict blood pressure control, a statin, and a heparin drip. He remained stable and was discharged on enoxaparin injections with bridging to warfarin. In summary, appropriate lab testing, imaging, and high clinical suspicion are required for proper diagnosis and treatment of venous thromboembolism (VTE) or CVST in an HIV-positive patient.
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Affiliation(s)
- Amandeep Rakhra
- Internal Medicine, Creighton University School of Medicine, Omaha, USA
| | - Luke E Kiefer
- Neurology, Creighton University School of Medicine, Omaha, USA
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22
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Identification of two different coagulation phenotypes in people living with HIV with undetectable viral replication. Sci Rep 2021; 11:4383. [PMID: 33623050 PMCID: PMC7902813 DOI: 10.1038/s41598-021-83731-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2020] [Accepted: 01/28/2021] [Indexed: 12/11/2022] Open
Abstract
Altered coagulation has been reported in people living with HIV (PLWH) with ongoing viral replication and may predispose to cardiovascular diseases. However, less is known about coagulation in PLWH with undetectable viral replication. In a cross-sectional observational study, we investigated whether HIV infection with undetectable viral replication is independently associated with activated partial thromboplastin time (APTT) and coagulation factor II-VII-X concentrations out of reference. Logistic regression analyses were used to assess the association of HIV infection with APTT and coagulation factor II-VII-X, after adjusting for age, sex, smoking status, alcohol consumption, BMI, diabetes and hsCRP. 936 PLWH with undetectable viral replication from the Copenhagen Co-morbidity in HIV infection study (COCOMO-study) and 2955 uninfected controls were included. Higher prevalence of short APTT was found in PLWH compared to controls (13.5% vs. 7.6%, P < 0.001). Furthermore, higher prevalence of low coagulation factor II-VII-X was found in PLWH than in controls (9.6% vs. 7.4%, P = 0.022). HIV was independently associated with short APTT (adjusted odds ratio (aOR) 2.3 (95% CI 1.7-2.9), P < 0.001) and low coagulation factor II-VII-X (aOR 1.4 (95% CI 1.0-1.9), P = 0.046). Few participants among PLWH and controls had both short APTT and low coagulation factor II-VII-X, 2.1% vs. 0.8%, respectively. We found evidence of both procoagulant (short APTT) and anticoagulant (low coagulation factor II-VII-X) alterations in PLWH with undetectable viral replication, and our findings suggest that two different coagulation phenotypes exist in participants with treated HIV infection.
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23
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Danzi GB, Galeazzi G, Robba D, Muri M. Disseminated Arterial and Venous Thrombosis: An Unusual Combination. Am J Med 2021; 134:e117-e118. [PMID: 32828725 DOI: 10.1016/j.amjmed.2020.07.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 07/09/2020] [Accepted: 07/09/2020] [Indexed: 11/16/2022]
Affiliation(s)
| | | | - Debora Robba
- Division of Cardiology, Ospedale di Cremona, Cremona, Italy
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24
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Agrati C, Mazzotta V, Pinnetti C, Biava G, Bibas M. Venous thromboembolism in people living with HIV infection (PWH). Transl Res 2021; 227:89-99. [PMID: 32693031 DOI: 10.1016/j.trsl.2020.07.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Revised: 07/14/2020] [Accepted: 07/15/2020] [Indexed: 10/23/2022]
Abstract
The risk of venous thromboembolism (VTE) and of recurrent VTE remain elevated in people living with HIV compared to controls still with contemporary antiretroviral therapy (ART). The pathophysiology of VTE in HIV is multi factorial and includes an interplay among traditional risk factors, HIV-specific factors, behavioral factors, exposure to ART and other therapies, coinfections, and co-morbidities.
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Affiliation(s)
- Chiara Agrati
- Cellular Immunology and Pharmacology Laboratory, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy
| | - Valentina Mazzotta
- The Clinical and Research Department, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy
| | - Carmela Pinnetti
- The Clinical and Research Department, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy
| | - Gianluigi Biava
- The Clinical and Research Department, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy
| | - Michele Bibas
- The Clinical and Research Department, National Institute for Infectious Diseases 'Lazzaro Spallanzani'-IRCCS, Rome, Italy.
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25
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Ruiz-Padilla AJ, Ruiz-Noa Y, Del Rocio Ibarra-Reynoso L, Lazo-de-la-Vega-Monroy ML, Alonso-Castro AJ, Sánchez-Barajas M, Alvarez-Alvarez RM, Del Carmen Preciado-Puga M. FGF21 and its Relationship with Inflammatory and Metabolic Parameters in HIV Patients after Antiretroviral Treatment. Curr HIV Res 2020; 18:308-314. [PMID: 32684151 DOI: 10.2174/1570162x18666200719235625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/19/2020] [Accepted: 07/30/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND Fibroblast Growth Factor 21 (FGF21) serum levels are associated with insulin resistance and metabolic syndrome in HIV patients. OBJECTIVE To quantify FGF21 levels in HIV patients using antiretroviral therapy (ART) and to analyze a possible association between serum FGF21 levels and lipid profile, levels of proinflammatory cytokines, and atherogenic risk factors. MATERIALS AND METHODS Twenty patients with HIV infection, who received ART in a scheme consisting of Tenofovir/Emtricitabine+Lopinavir/Ritonavir, were enrolled in this study. The serum levels of FGF21, inflammatory parameters (IL-6 and IL-1β), glucose, cholesterol, triglycerides, and insulin were determined at baseline and after 36 weeks of treatment. The homeostatic model assessment for insulin resistance (HOMA-IR) and the atherogenic risk factor were also calculated. RESULTS After 36 weeks, serum FGF21 levels decreased significantly (p=0.011), whereas IL-6 levels (r=0.821, p=0.0001) and the CD4+ T cell count (r=0.446, p=0.048), showed a positive correlation with the decrease in FGF21 levels. There was an increase in total cholesterol (r=-0.483, p=0.031), LDL (r=-0.496, p=0.026), VLDL (r=-0.320, p=0.045), and the atherogenic index factor (r=-0.539, p=0.014), these values showed a negative correlation with FGF21 levels. CONCLUSION The decrease of serum FGF21 levels due to ART is associated with the alteration in lipid profile and an increased risk for cardiovascular diseases. These variations are predictors of inflammatory status in HIV patients using antiretroviral therapy.
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Affiliation(s)
- Alan Joel Ruiz-Padilla
- Departamento de Farmacia, División de Ciencias Exactas e Ingenierías, Universidad de Guanajuato, Campus
Guanajuato- Guanajuato, Guanajuato, México
| | - Yeniley Ruiz-Noa
- Departamento de Ciencias Médicas División de Ciencias de la Salud, Universidad de Guanajuato, Campus León, León, Guanajuato, México
| | - Lorena Del Rocio Ibarra-Reynoso
- Departamento de Ciencias Médicas División de Ciencias de la Salud, Universidad de Guanajuato, Campus León, León, Guanajuato, México
| | | | - Angel Josabad Alonso-Castro
- Departamento de Farmacia, División de Ciencias Exactas e Ingenierías, Universidad de Guanajuato, Campus
Guanajuato- Guanajuato, Guanajuato, México
| | - Mauricio Sánchez-Barajas
- Departamento de Ciencias Médicas División de Ciencias de la Salud, Universidad de Guanajuato, Campus León, León, Guanajuato, México,Departamento de Medicina Interna, Hospital General de Zona/MF 21, León, Guanajuato, México
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A case of pulmonary infarction induced by undiagnosed HIV. Respir Med Case Rep 2020; 31:101293. [PMID: 33251107 PMCID: PMC7683264 DOI: 10.1016/j.rmcr.2020.101293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2020] [Revised: 11/04/2020] [Accepted: 11/04/2020] [Indexed: 11/23/2022] Open
Abstract
A 25-year-old Chinese man visited our institution due to fever and left chest pain. A chest CT showed infiltrative shadows with pleural effusion. Despite antibiotics treatment, his symptoms gradually worsened. The contrast CT showed deterioration of infiltrative shadows with thromboembolism in pulmonary arteries, suggesting pulmonary infarction. Thereafter, his HIV test turned out to be positive. His symptoms and radiological findings improved after initiation of an anticoagulant therapy. No known risk factors for thromboembolism were identified except HIV infection. The possibility of pulmonary thrombosis should be noted when the HIV patient with acute chest pain and pneumonia-like infiltrative shadow is seen.
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Snopkova S, Matyskova M, Havlickova K, Jarkovsky J, Svoboda M, Zavrelova J, Svacinka R, Penka M, Husa P. Increasing procoagulant activity of circulating microparticles in patients living with HIV. Med Mal Infect 2019; 50:555-561. [PMID: 31611134 DOI: 10.1016/j.medmal.2019.09.013] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Revised: 03/01/2019] [Accepted: 09/17/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVES HIV-infected individuals are at higher risk of non-AIDS diseases associated with procoagulant status. Microparticles are elevated in disorders associated with thrombosis (e.g., cardiovascular diseases). We investigated the association between microparticle levels in untreated and treated HIV-infected subjects, and determined the association with immune status, viral replication, and duration of antiretroviral therapy. PATIENTS AND METHODS We included 144 HIV-infected subjects, including 123 on antiretroviral therapy (ART) and 21 before treatment initiation. A control group of 40 HIV-negative healthy adults matched for age and sex was used for comparison of microparticle levels. Treated subjects were divided into five groups depending on the period of antiretroviral exposure. Statistically significant differences were determined by Kruskal-Wallis test and Chi2 test. The relation between microparticles and other parameters was assessed using Spearman's coefficient of correlation. RESULTS Microparticle levels were significantly higher in treated and untreated HIV-infected subjects than in non-HIV-infected controls (P<0.001). The microparticle level was similar between the groups on treatment (P=0.913). No association between the microparticle level and CD4+ count, CD4+/CD8+ ratio, number of HIV-1 RNA copies, or duration of exposure to antiretroviral treatment was observed. CONCLUSION Increased levels of microparticles may be due to processes independent of viral replication and CD4+ cell count, and microparticle release might persist even during viral suppression by antiretroviral treatment. Elevated microparticle levels might occur in response to other triggers.
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Affiliation(s)
- S Snopkova
- Department of infectious diseases, Faculty hospital Brno and Faculty of medicine, Masaryk University Brno, Jihlavska 340/20, 62500 Brno, Czech Republic.
| | - M Matyskova
- Department of hematology, Faculty hospital Brno and Faculty of medicine, Masaryk University Brno, Jihlavska 340/20, 62500 Brno, Czech Republic
| | - K Havlickova
- Department of infectious diseases, Faculty hospital Brno and Faculty of medicine, Masaryk University Brno, Jihlavska 340/20, 62500 Brno, Czech Republic
| | - J Jarkovsky
- Institute of biostatistics and analyses, Faculty of medicine, Masaryk University Brno, Kamenice 126/3, 62500 Brno, Czech Republic
| | - M Svoboda
- Institute of biostatistics and analyses, Faculty of medicine, Masaryk University Brno, Kamenice 126/3, 62500 Brno, Czech Republic
| | - J Zavrelova
- Department of hematology, Faculty hospital Brno and Faculty of medicine, Masaryk University Brno, Jihlavska 340/20, 62500 Brno, Czech Republic
| | - R Svacinka
- Department of infectious diseases, Faculty hospital Brno and Faculty of medicine, Masaryk University Brno, Jihlavska 340/20, 62500 Brno, Czech Republic
| | - M Penka
- Department of hematology, Faculty hospital Brno and Faculty of medicine, Masaryk University Brno, Jihlavska 340/20, 62500 Brno, Czech Republic
| | - P Husa
- Department of infectious diseases, Faculty hospital Brno and Faculty of medicine, Masaryk University Brno, Jihlavska 340/20, 62500 Brno, Czech Republic
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Howard JFB, Rokx C, Smit C, Wit FWNM, Pieterman ED, Meijer K, Rijnders B, Bierman WFW, Tichelaar YIGV. Incidence of a first venous thrombotic event in people with HIV in the Netherlands: a retrospective cohort study. Lancet HIV 2019; 6:e173-e181. [PMID: 30777727 DOI: 10.1016/s2352-3018(18)30333-3] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 10/12/2018] [Accepted: 11/15/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND The risk of venous thrombotic events is elevated in people with HIV, but overall risk estimates and estimates specific to immune status and antiretroviral medication remain i mprecise. In this study, we aimed to estimate these parameters in a large cohort of people with HIV in the Netherlands. METHODS In this retrospective cohort study, we used the Dutch ATHENA cohort to estimate crude, age and sex standardised, and risk period-specific incidences of a first venous thrombotic event in people with HIV aged 18 years or older attending 12 HIV treatment centres in the Netherlands. Crude and standardised incidences were compared with European population-level studies of venous thrombotic events. We used time-updated Cox regression to estimate the risk of a first venous thrombotic event in association with HIV-specific factors (CD4 cell count, viral load, recent opportunistic infections, antiretroviral medication use) adjusted for traditional risk factors for venous thrombotic events. FINDINGS With data collected from Jan 1, 2003, to April 1, 2015, our study cohort included 14 389 people with HIV and 99 762 person-years of follow-up, with a median follow-up of 7·2 years (IQR 3·3-11·1). During this period, 232 first venous thrombotic events occurred, yielding a crude incidence of 2·33 events per 1000 person-years (95% CI 2·04-2·64) and an incidence standardised for age and sex of 2·50 events per 1000 (2·18-2·82). CD4 counts less than 200 cells per μL were independently associated with higher risk of a venous thrombotic event: adjusted hazard ratio (aHR) 3·40 (95% CI 2·28-5·08) relative to counts of 500 cells per μL. A high viral load (aHR 3·15, 95% CI 2·00-5·02; >100 000 copies per mL vs <50 copies per mL) and current or recent opportunistic adverse events (2·80, 1·77-4·44) were also independently associated with higher risk of a venous thrombotic event. There were no associations between any specific antiretroviral drugs and risk of a venous thrombotic event. Rates associated with pregnancy (9·4, 95% CI 4·6-17·3), malignancy (16·7, 10·6-25·1), and hospitalisation (24·4, 19·1-30·6) were lower than primary thromboprophylaxis thresholds suggested by the respective guidelines. INTERPRETATION Our findings support neither prescribing primary outpatient thromboprophylaxis nor avoiding any type of antiretroviral medication in people with HIV at high risk of a venous thrombotic event. FUNDING Dutch Ministry of Health, Welfare and Sport.
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Affiliation(s)
- Jaime F Borjas Howard
- Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands.
| | - Casper Rokx
- Section of Infectious Diseases, Department of Internal Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Colette Smit
- HIV Monitoring Foundation, Amsterdam, Netherlands
| | - Ferdinand W N M Wit
- HIV Monitoring Foundation, Amsterdam, Netherlands; Department of Global Health and Division of Infectious Diseases, Amsterdam University Medical Centres, University of Amsterdam, Amsterdam, Netherlands
| | - Elise D Pieterman
- Section of Infectious Diseases, Department of Internal Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Karina Meijer
- Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Bart Rijnders
- Section of Infectious Diseases, Department of Internal Medicine, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Wouter F W Bierman
- Department of Internal Medicine, Infectious Diseases Service, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Y I G Vladimir Tichelaar
- Department of Haematology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
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Swart L, Schapkaitz E, Mahlangu JN. Thrombotic thrombocytopenic purpura: A 5-year tertiary care centre experience. J Clin Apher 2018; 34:44-50. [PMID: 30536422 DOI: 10.1002/jca.21673] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 10/10/2018] [Accepted: 10/15/2018] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Thrombotic thrombocytopenic purpura (TTP) is associated with high mortality if not managed timeously with therapeutic plasma exchange (TPE). TTP secondary to human immunodeficiency virus (HIV) infection is unique to sub-Saharan Africa. The management and outcome of TTP in the era of improved access to therapy has not been described. METHODS The present study describes the clinical presentation, treatment, therapeutic endpoints, and outcome of TTP patients at the Charlotte Maxeke Johannesburg Academic Hospital, South Africa. The inpatient and outpatient records of 41 consecutive adults with TTP were reviewed between 2012 and 2016. Patients were classified according to aetiology and treatment response. RESULTS TTP was the initial presenting feature of HIV infection in 78.0%, and 12.5% were noncompliant with antiretroviral therapy (ART). Most study patients were of black ethnicity (95%) and female gender (78.1%). Treatment included initial TPE (87.8%), plasma infusion (78.1%), antiretroviral therapy (78.3%), corticosteroids (61.0%) intensive care admission (41.5%), renal dialysis (12.2%), and other immunosuppressive agents (4.9%). The median (range) number of TPEs was 10.0 (7.0-15.0). A high rate of refractory disease (63.4%) was reported. Haemoglobin, platelet count, lactate dehydrogenase, red cell distribution width, and creatinine were reliable therapeutic end-points (P < .05). The relapse rate was 9.8% and the mortality rate was 29.3%. CONCLUSION The high mortality rate emphasises the importance of early diagnosis, referral, and appropriate management of TTP. Anti-retroviral therapy and adherence monitoring are essential to TTP management associated with HIV. Future studies to identify patients at risk for refractory disease are indicated.
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Affiliation(s)
- Léanne Swart
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, National Health Laboratory Service, University of the Witwatersrand, Johannesburg, South Africa
| | - Elise Schapkaitz
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, National Health Laboratory Service, University of the Witwatersrand, Johannesburg, South Africa
| | - Johnny N Mahlangu
- Department of Molecular Medicine and Haematology, Faculty of Health Sciences, National Health Laboratory Service, University of the Witwatersrand, Johannesburg, South Africa
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Kamuren Z, Kigen G, Keter A, Maritim A. Characteristics of patients with thromboembolic disorders on warfarin therapy in resource limited settings. BMC Health Serv Res 2018; 18:723. [PMID: 30231891 PMCID: PMC6145184 DOI: 10.1186/s12913-018-3537-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Accepted: 09/12/2018] [Indexed: 11/28/2022] Open
Abstract
Background Warfarin is a drug with narrow therapeutic index used in the management of thromboembolic disorders. Several factors affect its plasma concentrations with a resultant risk of toxicity. We examined the database of patients on warfarin therapy in order to establish the factors that affect the stability of INR and correlated them to clinical outcomes in resource limited settings. Methods We analysed retrospective data of patients admitted to adult medical wards at Moi Teaching and Referral Hospital (MTRH) in 2015. Inclusion criteria were patients with thromboembolic and related disorders and on warfarin treatment. Derived data included demographics, indications for warfarin use, co-prescribed drugs, co-morbidities, INR measurements, duration of hospital stay and clinical outcomes. Descriptive statistics were used to summarize the data. Pearson’s correlation coefficient was used to assess relationships between duration of hospitalization and number of INR tests. Regression splines were used to capture INR trends during the follow up period. Data was analysed using R v. 3.3.1. Results A total of 310 patients had thromboembolic disorders, out of which 63 met the study criteria. The median age was 48 years, while the mean number of INR measurements was once every four days. Majority of patients did not achieve stable INR values, with only two having consecutive INR values within therapeutic goal. Patients who died had high INR levels. The median duration of hospital stay was 9 days (IQR: 7.0, 16.5). There was a significant correlation between length of stay in hospital and the number of times that INR were measured (Corr = 0.667, p < 0.001). The two most common indications for warfarin were DVT (64.4%) and atrial fibrillation (24.7%). All the patients had one or more comorbid conditions except for 11 with DVT alone, with cardiovascular diseases and infections being the most frequent, and on concomitant medications, majority of which are known to interact with warfarin. Conclusions It was difficult to achieve stable INR under the prevailing conditions despite the frequent tests. The potential factors that may have contributed to the fluctuations include drug-drug interactions, frequency of INR tests, comorbidities and the short duration of hospital stay.
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Affiliation(s)
- Zipporah Kamuren
- Department of Pharmacology and Toxicology, Moi University School of Medicine, P.O. Box 4606, Eldoret, 30100, Kenya.
| | - Gabriel Kigen
- Department of Pharmacology and Toxicology, Moi University School of Medicine, P.O. Box 4606, Eldoret, 30100, Kenya
| | - Alfred Keter
- Academic Model Providing Access to Healthcare, P.O. Box 4606, Eldoret, 30100, Kenya
| | - Alice Maritim
- Department of Pharmacology and Toxicology, Moi University School of Medicine, P.O. Box 4606, Eldoret, 30100, Kenya
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Tsabedze N, Vachiat A, Zachariah D, Manga P. A New Face of Cardiac Emergencies: Human Immunodeficiency Virus-Related Cardiac Disease. Cardiol Clin 2018; 36:161-170. [PMID: 29173676 DOI: 10.1016/j.ccl.2017.09.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The human immunodeficiency virus epidemic is a major health challenge of the twenty-first century as the transition from infectious complications to noncommunicable disease becomes more evident. These patients may present to the emergency department with a variety of cardiovascular diseases, such as acute coronary syndromes, heart failure, pericardial disease, infective endocarditis, venothromboembolism, and other conditions. Increased awareness is needed among health care professionals to enhance adequate identification and promote prompt management of these patients.
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Affiliation(s)
- Nqoba Tsabedze
- Division of Cardiology, Department of Internal Medicine, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg 2000, South Africa
| | - Ahmed Vachiat
- Division of Cardiology, Department of Internal Medicine, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg 2000, South Africa
| | - Don Zachariah
- Division of Cardiology, Department of Internal Medicine, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg 2000, South Africa
| | - Pravin Manga
- Division of Cardiology, Department of Internal Medicine, Faculty of Health Sciences, University of Witwatersrand, 7 York Road, Parktown, Johannesburg 2000, South Africa.
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Di Stefano M, D'Andrea G, Zoboli F, Faleo G, Fasano M, Martinelli D, Margaglione M, Santantonio TA, Fiore JR. Preliminary Data From the Study of Coagulative Profile of HIV Infected Individuals Suggest a Role For Point Mutations in the Gene in Protein S Deficiency in Individuals Undergoing Highly Antiretroviral Therapy. Open AIDS J 2018; 12:6-10. [PMID: 29576814 PMCID: PMC5850486 DOI: 10.2174/1874613601812010006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2017] [Revised: 12/22/2017] [Accepted: 01/21/2018] [Indexed: 12/13/2022] Open
Abstract
Background: HIV infection is a known prothrombotic condition but factors involved are still controversial. A role for antiretrovirals, especially protease inhibitors, was advocated. Objectives: The study aimed to analyze the levels of anticoagulant proteins in virally suppressed HIV-infected subjects treated with different anti-retroviral regimens. Materials and Methods: Forty-four patients were included in the study. C and PS, D-Dimers and Fibrinogen levels were determined as well as APC-resistance. PROS1 gene was sequenced in a group of patient. Results: Twelve of the 44 subjects (27%) showed reduced levels of PS, while lower levels of PC were found only in 2 patients (4,5%). No difference in the mean values of PC and PS was found stratifying the study population by antiretroviral regimen administrated (p>0.05). Three patients had higher levels of D-Dimer concentrations and in two of these patients, an association between higher D-Dimer values and lower levels of PS was observed; but however no correlation was found by statistical analysis. PROS1 gene analysis was performed in 26 of the 44 HIV-1 patients and the subjects with low levels of PS had mutation in the fifteen exon of PROS 1 gene. While among individuals with normal levels, this mutation was observed only in 8/18 (44%) of the cases (p=0,0072). Conclusion: The majority of patients with low PS levels also had mutations in the fifteen exon of PROS 1 gene. Genetic determinants, deserving further investigations, rather than antiretrovirals might cause PS deficiency in HIV-1 positive patients.
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Affiliation(s)
- Mariantonietta Di Stefano
- Department of Clinical and Experimental Medicine, Section of Infectious Diseases, University of Foggia, Viale L. Pinto 71131 Foggia, Italy.,Medical Genetics, University of Foggia, Viale L. Pinto 71131 Foggia, Italy
| | - Giovanna D'Andrea
- Medical Genetics, University of Foggia, Viale L. Pinto 71131 Foggia, Italy
| | - Fabio Zoboli
- Department of Clinical and Experimental Medicine, Section of Infectious Diseases, University of Foggia, Viale L. Pinto 71131 Foggia, Italy
| | - Giuseppina Faleo
- Department of Clinical and Experimental Medicine, Section of Infectious Diseases, University of Foggia, Viale L. Pinto 71131 Foggia, Italy
| | - Massimo Fasano
- Department of Clinical and Experimental Medicine, Section of Infectious Diseases, University of Foggia, Viale L. Pinto 71131 Foggia, Italy
| | - Domenico Martinelli
- Department of Medical Sciences, Section of Hygiene, University of Foggia, Apulia Regional Epidemiological Observatory, Viale L. Pinto 71131 Foggia, Italy
| | | | - Teresa A Santantonio
- Department of Clinical and Experimental Medicine, Section of Infectious Diseases, University of Foggia, Viale L. Pinto 71131 Foggia, Italy
| | - Josè R Fiore
- Department of Clinical and Experimental Medicine, Section of Infectious Diseases, University of Foggia, Viale L. Pinto 71131 Foggia, Italy
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Vululi ST, Bugeza S, Zeridah M, Ddungu H, Openy AB, Frank M, Parkes-Ratanshi R. Prevalence of lower limb deep venous thrombosis among adult HIV positive patients attending an outpatient clinic at Mulago Hospital. AIDS Res Ther 2018; 15:3. [PMID: 29370816 PMCID: PMC5784710 DOI: 10.1186/s12981-018-0191-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2017] [Accepted: 01/12/2018] [Indexed: 11/24/2022] Open
Abstract
Background Deep venous thrombosis (DVT) and its major complication pulmonary embolism (PE) are collectively known as venous thromboembolism. In Uganda, the prevalence of DVT among HIV patients has not been previously published. The aim of the study was to determine the prevalence and sonographic features of lower limb deep venous thrombosis among HIV positive patients on anti-retroviral treatment (ART). Methods This was a cross sectional study in which HIV positive patients on ART were recruited from an out-patient HIV clinic at Mulago National Referral Hospital. Patients were randomly selected and enrolled until a sample size of 384 was reached. Study participants underwent compression and Doppler ultrasound studies of both lower limb deep veins using Medison Sonoacer7 ultrasound machine. Resuts We found a prevalence of DVT of 9.1% (35 of 384 participants) among HIV patients on ART. The prevalence of latent (asymptomatic) DVT was 2.3%. Among 35 patients with DVT, 42.8% had chronic DVT; 31.1% had acute DVT and the rest had latent DVT. Among the risk factors, the odds of occurrence of DVT among patients with prolonged immobility were 4.81 times as high as in those with no prolonged immobility (p = 0.023; OR = 4.81; 95% CI 1.25–18.62). Treatment with second line anti-retroviral therapy (ART) including protease inhibitors (PIs) was associated with higher odds of DVT occurrence compared with first line ART (p = 0.020; OR = 2.38; 95% CI 1.14–4.97). The odds of DVT occurrence in patients with a lower CD4 count (< 200 cells/µl) were 5.36 times as high as in patients with CD4 counts above 500 cells/µl (p = 0.008). About 48.6% patients with DVT had a low risk according to Well’s score. Conclusion DVT was shown in nearly 10% of HIV patients attending an out-patient clinic in an urban setting in Uganda. Risk factors included protease inhibitors in their ART regimen, prolonged immobility, and low CD4 count (< 200 cells/µl). Clinicians should have a low threshold for performing lower limb Doppler ultrasound scan examination on infected HIV patients on ART who are symptomatic for DVT. Therefore, clinicians should consider anti-coagulant prophylaxis and lower deep venous ultrasound screening of patients who are on second line ART regimen with low CD4 cell counts and/or with prolonged immobility or hormonal contraception.
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Abstract
Infection with the human immunodeficiency virus (HIV), and subsequent treatment with antiretroviral therapy (ART), is often associated with perturbations in lipid profiles. Furthermore, persistent inflammation, in spite of suppression of viral replication by ART, likely contributes to modifications in lipid composition and function, exacerbating risk for development of cardiovascular disease (CVD). Increased levels of several pro-inflammatory lipid species, including oxidized low-density lipoprotein (LDL) and high-density lipoprotein (HDL), have been measured in HIV-infected persons and are associated with markers of immune activation. The mechanisms linked to this bidirectional relationship in which inflammation increases lipid levels and promotes their modification, and these modified lipid species perpetuate inflammatory processes, require further investigation. Treatment with statins and other lifestyle modifications, including improvement in dietary intake and exercise, are critical to reducing CVD risk. Well-designed clinical trials that take into account the complex relationships among lipids and inflammation within persons infected with HIV need to be considered.
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Affiliation(s)
- Nicholas T Funderburg
- School of Health and Rehabilitation Sciences, Division of Medical Laboratory Science, Ohio State University, 453 W. 10th Ave., 535A Atwell Hall, Columbus, OH, 43210, USA
| | - Nehal N Mehta
- Section of Inflammation and Cardiometabolic Diseases, National Heart, Lung and Blood Institute, Bethesda, MD, 20892, USA.
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M N, R J, Bhat M, Christopher R, P S. Profile of 26 HIV Seropositive individuals with Cerebral Venous Thrombosis. J Neurol Sci 2017; 378:69-74. [PMID: 28566183 DOI: 10.1016/j.jns.2017.04.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2017] [Revised: 04/10/2017] [Accepted: 04/17/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND HIV infection has been found to be prothrombotic condition. However, venous thromboembolism associated with HIV is restricted to peripheral vasculature with few reports of cerebral venous thrombosis (CVT). OBJECTIVE To examine the clinical manifestations of CVT among HIV seropositive individuals and explore the possible etiological factors. METHODS AND RESULTS It is a prospective study of 26 (M:F-18:8) patients of CVT associated with HIV seropositive status. Their age and duration of illness was 33.8±6.8years and 11.3±8.5days respectively. Headache and vomiting was the most common symptom followed by seizures. Drowsiness with GCS (Glasgow coma score) ranging from 9-14 was present in two-thirds of the patients. Serum homocysteine was elevated in 70% of patients. Vitamin B12 was low in 12.5% and insufficient levels in 25%. 88.5% of the patients recovered completely to GCS 15/15 in 2-7days during follow up; 11.5% patients expired during the acute state. CONCLUSION This study represents the largest series of CVT in HIV seropositive individuals. There is increased risk of thrombosis due to elevated homocysteine and low Vitamin B12. They have better sensorium inspite of extensive radiological involvement.
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Affiliation(s)
- Netravathi M
- Department of Neurology, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore 560029, India.
| | - Jaychandran R
- Department of Neurology, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore 560029, India
| | - M Bhat
- Department of Neuroimaging & Interventional Neuroradiology (NIIR), National Institute of Mental Health & Neurosciences (NIMHANS), India
| | - R Christopher
- Department of Neurochemistry, National Institute of Mental Health & Neurosciences (NIMHANS), India
| | - Satishchandra P
- Department of Neurology, National Institute of Mental Health & Neurosciences (NIMHANS), Bangalore 560029, India
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Ramlakhan R, Andronikou S, Rajkumar A. The prevalence and radiological findings of pulmonary embolism in HIV-positive patients referred for computed tomography pulmonary angiography in the Western Cape of South Africa. Cardiovasc J Afr 2017; 28:221-228. [PMID: 28218770 PMCID: PMC5642032 DOI: 10.5830/cvja-2016-083] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 09/21/2016] [Indexed: 11/06/2022] Open
Abstract
Aim: To provide imaging data and report associations between human immunodeficiency virus (HIV), tuberculosis (TB) and pulmonary embolism (PE) in a South African population that underwent computed tomography pulmonary angiography (CTPA) for suspected PE. Methods: A validated Qanadli severity scoring system for PE was used for 164 CTPA scans, and parenchymal, pleural and cardiovascular complications were reported. Serological confirmation of HIV testing and microbiological confirmation of TB were recorded. Results: Prevalence of PE in the CTPA population was 26% (95% CI: 19.67–33.65%). HIV-positive prevalence in patients with PE was 67% (95% CI: 48.17–82.04%), however it was not statistically significantly different when compared with the patients without PE (p = 1). HIV-positive patients had more extensive partial thrombus in the right middle lobe (p = 0.045), but no other differences when compared with HIV-negative patients. TB prevalence in patients with PE was 57% (95% CI: 34.49–76.81%). This was statistically significantly different when compared with the patients without PE (p = 0.073 at the 10% level). Prevalence of TB co-morbidity in the HIV-positive group with proven PE was 71% (95% CI: 41.90– 91.61%), however there was no statistically significant difference in comparison with the HIV-negative patients with TB and PE (p= 0.305). Conclusion: The high number of patients presenting for CTPA who were HIV infected (and also infected with TB) highlights that PE evaluation should include severity/extent of the disease, as these patients may have more severe disease in specific lung lobes. The use of a validated scoring system, such as the Qanadli score, when reporting PE may have a profound effect on patient risk stratification, management and prognosis and would also provide a system for collecting larger volumes of data for analysis.
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Affiliation(s)
- Raksha Ramlakhan
- Department of Radiology, Groote Schuur Hospital and University of Cape Town, South Africa.
| | - Savvas Andronikou
- Department of Paediatric Radiology, University of Bristol and the Bristol Royal Hospital for Children, Bristol, United Kingdom and Department of Radiology, University of Cape Town, South Africa
| | - Ashmitha Rajkumar
- Department of Radiology, Mitchell's Plain Hospital, Mitchells Plain, Cape Town, South Africa
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Jackson BS, Mokoena T. Comparison of the therapeutic dose of warfarin in HIV-infected and HIV-uninfected patients: a study of clinical practice. BMJ Open 2017; 7:e013709. [PMID: 28179414 PMCID: PMC5306524 DOI: 10.1136/bmjopen-2016-013709] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND People infected with HIV are prone to venous thrombosis. Treatment of thrombosis is primarily with warfarin. No studies have addressed the effects of HIV infection on warfarin dose. The aims of this study were to determine whether the therapeutic dose of warfarin and induction time to therapeutic dose in HIV-infected patients differ from that in HIV-uninfected patients. METHODS A prospective and retrospective descriptive study of induction time to therapeutic warfarin dose, as well as of ambulant therapeutic warfarin dose, was performed. HIV-infected and HIV-uninfected patients being treated after deep venous thrombosis with or without pulmonary embolism were compared. Sex and use of antiretroviral drugs (ARVs) were also compared in the groups. RESULTS 234 patients were entered into the study. Induction time to therapeutic warfarin dose did not differ between the 2 groups. The mean therapeutic dose of warfarin was higher in the HIV-infected than the HIV-uninfected group: 6.06 vs 5.72 mg/day, but this was not statistically significant (p=0.29). There was no difference in therapeutic warfarin dose between ARV-naïve groups-HIV-uninfected and HIV-infected patients not on ARVs. CONCLUSIONS There appears to be little effect of HIV infection on warfarin dosing. Warfarin therapy should be administered conventionally in HIV-infected patients.
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Affiliation(s)
- B S Jackson
- Department of Surgery, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa
| | - T Mokoena
- Department of Surgery, University of Pretoria and Steve Biko Academic Hospital, Pretoria, South Africa
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Kanyi J, Karwa R, Pastakia SD, Manji I, Manyara S, Saina C. Venous Thromboembolism Requiring Extended Anticoagulation Among HIV-Infected Patients in a Rural, Resource-Constrained Setting in Western Kenya. Ann Pharmacother 2017; 51:380-387. [PMID: 28056524 DOI: 10.1177/1060028016686106] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND HIV-infected patients are at an increased risk of developing venous thromboembolism (VTE), and minimal data are available to describe the need for extended treatment. OBJECTIVE To evaluate the frequency of and determine predictive risk factors for extended anticoagulation of VTE in HIV-infected patients in rural, western Kenya. METHODS A retrospective chart review was conducted at the Anticoagulation Monitoring Service affiliated with Moi Teaching and Referral Hospital and the Academic Model Providing Access to Healthcare. Data were collected on patients who were HIV-infected and receiving anticoagulation for lower-limb deep vein thrombosis. The need for extended anticoagulation, defined as receiving ≥7 months of warfarin therapy, was established based on patient symptoms or Doppler ultrasound-confirmed diagnosis. Evaluation of the secondary outcomes utilized a univariate analysis to identify risk factors associated with extended anticoagulation. RESULTS A total of 71 patients were included in the analysis; 27 patients (38%) required extended anticoagulation. The univariate analysis showed a statistically significant association between the need for extended anticoagulation and achieving a therapeutic international normalized ratio within 21 days in both the unadjusted and adjusted analysis. Patients with a history of opportunistic infections required an extended duration of anticoagulation in the adjusted analysis: odds ratio = 3.42; 95% CI = 1.04-11.32; P = 0.04. CONCLUSIONS This study shows that there may be a need for increased duration of anticoagulation in HIV-infected patients, with a need to address the issue of long-term management. Guideline recommendations are needed to address the complexity of treatment issues in this population.
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Affiliation(s)
- John Kanyi
- 1 Moi Teaching and Referral Hospital, Eldoret, Kenya.,2 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Rakhi Karwa
- 2 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,3 Purdue University College of Pharmacy, West Lafayette, IN, USA.,4 Moi University School of Health Sciences, Eldoret, Kenya
| | - Sonak Dinesh Pastakia
- 2 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya.,3 Purdue University College of Pharmacy, West Lafayette, IN, USA.,4 Moi University School of Health Sciences, Eldoret, Kenya
| | - Imran Manji
- 1 Moi Teaching and Referral Hospital, Eldoret, Kenya.,2 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Simon Manyara
- 1 Moi Teaching and Referral Hospital, Eldoret, Kenya.,2 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
| | - Collins Saina
- 2 Academic Model Providing Access to Healthcare (AMPATH), Eldoret, Kenya
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Diaz CM, Segura ER, Luz PM, Clark JL, Ribeiro SR, De Boni R, Eksterman L, Moreira R, Currier JS, Veloso VG, Grinsztejn B, Lake JE. Traditional and HIV-specific risk factors for cardiovascular morbidity and mortality among HIV-infected adults in Brazil: a retrospective cohort study. BMC Infect Dis 2016; 16:376. [PMID: 27503230 PMCID: PMC4977901 DOI: 10.1186/s12879-016-1735-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2016] [Accepted: 07/26/2016] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Antiretroviral therapy (ART) agents potentially associated with adverse metabolic profiles are commonly used in low- and middle-income countries. We assessed risk factors for cardiovascular disease (CVD)-related morbidity and mortality in a cohort of HIV-infected, ART-treated adults in Rio de Janeiro, Brazil. METHODS Hospital records and mortality data between 2000-2010 were examined for incident CVD-related ICD-10 and Coding of Death in HIV diagnoses among adults ≥18 years old on ART, enrolled in an observational cohort. Poisson regression models assessed associations between demographic and clinical characteristics and ART agent or class on CVD event risk. RESULTS Of 2960 eligible persons, 109 had a CVD event (89 hospitalizations, 20 deaths). Participants were 65 % male, 54 % white, and had median age of 37 and 4.6 years on ART. The median nadir CD4(+) T lymphocyte count was 149 cells/mm(3). The virologic suppression rate at the end of study follow-up was 60 %. In multivariable models, detectable HIV-1 RNA prior to the event, prior CVD, less time on ART, age ≥40 at study baseline, nadir CD4(+) T lymphocyte count ≤50 cells/mm(3), non-white race, male gender, and a history of hypertension were significantly associated with CVD event incidence (p < 0.05), in order of decreasing strength. In multivariate models, cumulative use of tenofovir, zidovudine, efavirenz and ritonavir-boosted atazanavir, darunavir and/or lopinavir were associated with decreased CVD event risk. Recent tenofovir and boosted atazanavir use were associated with decreased risk, while recent stavudine, nevirapine and unboosted nelfinavir and/or indinavir use were associated with increased CVD event risk. CONCLUSIONS Virologic suppression and preservation of CD4(+) T-lymphocyte counts were as important as traditional CVD risk factor burden in determining incident CVD event risk, emphasizing the overall benefit of ART on CVD risk and the need for metabolically-neutral first- and second-line ART in resource-limited settings.
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Affiliation(s)
- Chanelle M Diaz
- UCLA David Geffen School of Medicine, University of California, 11075 Santa Monica Blvd. St. 100, Los Angeles, 90025, CA, USA.,Montefiore University Hospital of Albert Einstein College of Medicine, Bronx, NY, USA
| | - Eddy R Segura
- UCLA David Geffen School of Medicine, University of California, 11075 Santa Monica Blvd. St. 100, Los Angeles, 90025, CA, USA
| | - Paula M Luz
- Fundação Oswaldo Cruz, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Jesse L Clark
- UCLA David Geffen School of Medicine, University of California, 11075 Santa Monica Blvd. St. 100, Los Angeles, 90025, CA, USA
| | - Sayonara R Ribeiro
- Fundação Oswaldo Cruz, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Raquel De Boni
- Fundação Oswaldo Cruz, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Leonardo Eksterman
- Fundação Oswaldo Cruz, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Rodrigo Moreira
- Fundação Oswaldo Cruz, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Judith S Currier
- UCLA David Geffen School of Medicine, University of California, 11075 Santa Monica Blvd. St. 100, Los Angeles, 90025, CA, USA
| | - Valdiléa G Veloso
- Fundação Oswaldo Cruz, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Beatriz Grinsztejn
- Fundação Oswaldo Cruz, Instituto Nacional de Infectologia Evandro Chagas, Rio de Janeiro, Brazil
| | - Jordan E Lake
- UCLA David Geffen School of Medicine, University of California, 11075 Santa Monica Blvd. St. 100, Los Angeles, 90025, CA, USA.
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Effect of antiretroviral therapy in thromboregulation through the hydrolysis of adenine nucleotides in platelets of HIV patients. Biomed Pharmacother 2016; 79:321-8. [PMID: 27044844 DOI: 10.1016/j.biopha.2016.02.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 07/08/2015] [Accepted: 02/23/2016] [Indexed: 01/16/2023] Open
Abstract
The human immunodeficiency virus (HIV) infection results in biochemical and vascular dysfunctions. The highly active antiretroviral therapy (HAART) markedly reduces mortality and opportunistic diseases associated with acquired immunodeficiency syndrome (AIDS). This increased survival time predisposes the development of cardiovascular diseases. Platelets present purinergic system ectoenzymes such as E-NTPDase, E-5'-nucleotidase and E-ADA on its surface. In view of this, the aim of this study was to evaluate the activity of these ectoenzymes in platelets as well as the platelet aggregation and lipid profile of patients with HIV infection and also patients receiving HAART. The results showed an increase in the E-NTPDase activity for ATP hydrolysis in the HIV group compared with the control group and the HIV/HAART group. When assessing the activity E-NTPDase hydrolysis to ADP, the results revealed an increase in activity in the HIV group when compared to the control group, and a decrease in activity when in the HIV/HAART group when compared to the control and HIV groups. The activity of E-5'-nucleotidase revealed an increase in AMP hydrolysis in the HIV group, as the results from control and HIV/HAART groups showed no statistical difference. Regarding the E-ADA activity, the HIV and HIV/HAART groups revealed a decreased deamination of adenosine when compared with the control group. Furthermore, we observed an increased platelet aggregation of HIV/HAART group compared with the control group. Thus, our results suggest that antiretroviral treatment against HIV has a significant effect on the activity of purinergic system ectoenzymes demonstrating that thromboregulation is involved in the process.
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Muyanja D, Muzoora C, Muyingo A, Muyindike W, Siedner MJ. High Prevalence of Metabolic Syndrome and Cardiovascular Disease Risk Among People with HIV on Stable ART in Southwestern Uganda. AIDS Patient Care STDS 2016; 30:4-10. [PMID: 26683587 DOI: 10.1089/apc.2015.0213] [Citation(s) in RCA: 58] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023] Open
Abstract
The objectives of this study were to determine the epidemiology and correlates of cardiovascular disease (CVD) risk among Ugandans on first-line antiretroviral therapy (ART). We conducted a cross-sectional study at an HIV clinic in southwestern Uganda. We enrolled adult patients on non-nucleoside-based ART regimens for a minimum of 2 years. We collected anthropometric and clinical measurements, smoking history, and blood for fasting lipid profile and blood sugar (FBS). Outcomes of interest were (1) presence of metabolic syndrome (at least two of the following: FBS >100 mg/dL, blood pressure of ≥130/85 mmHg, triglycerides ≥150 mg/dL, HDL <40 mg/DL, or waist circumference ≥94 cm in males or ≥80 cm in females); and (2) a Framingham score correlating to >5% 10-year CVD risk. Of the 250 participants enrolled, metabolic syndrome was detected in 145/250 (58%) of participants (62% in females and 50% in males). Forty-three participants (17%) had a Framingham risk correlating to a 5% or greater risk for CVD within 10 years (26% in males and 13% in females). In multivariate analyses, being female (AOR 3.13; 95% CI: 1.0-9.70; p = 0.04) and over 40 years of age (AOR 1.78; 95% CI: 1.00-3.17; p = 0.05) was independently associated with having metabolic syndrome. We found no independent risk factors for a Framingham risk score 10-year risk exceeding 5%, or associations between ART regimen and CVD risk profiles. We conclude that metabolic abnormalities are common among patients on first-line ART in rural Uganda, and appear to be more common in women than men.
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Affiliation(s)
- Daniel Muyanja
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Conrad Muzoora
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Anthony Muyingo
- Department of Internal Medicine, Mbarara University of Science and Technology, Mbarara, Uganda
| | - Winnie Muyindike
- Department of Internal Medicine, Mbarara Regional Referral Hospital, Mbarara, Uganda
| | - Mark J. Siedner
- Department of Infectious Disease and Center for Global Health, Massachusetts General Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Vishnu P, Aboulafia DM. Haematological manifestations of human immune deficiency virus infection. Br J Haematol 2015; 171:695-709. [PMID: 26452169 DOI: 10.1111/bjh.13783] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Early in the human immunodeficiency virus (HIV) epidemic, infected patients presented to medical attention with striking abnormalities in each of the major blood cell lineages. The reasons for these derangements remain complex and multifactorial. HIV infects multipotent haematopoietic progenitor cells and establish latent cellular reservoirs, disturbs the bone marrow microenvironment and also causes immune dysregulation. These events lead to cytokine imbalances and disruption of other factors required for normal haematopoiesis. Activation of the reticulo-endothelial system can also result in increased blood cell destruction. The deleterious effects of medications, including first and second generation anti-retroviral agents, on haematopoiesis were well documented in the early years of HIV care; in the current era of HIV-care, the advent of newer and less toxic anti-retroviral drugs have had a more beneficial impact on haematopoiesis. Due to impaired regulation of the immune system and potential side effects of one or more anti-retroviral agents, there is also an increase in coagulation abnormalities such as thromboembolism, and less frequently, acquired disorders of coagulation including thrombotic thrombocytopenic purpura, immune thrombocytopenic purpura and acquired inhibitors of coagulation. In this article we review the epidemiology and aetiology of select non-oncological haematological disorders commonly seen in people living with HIV-acquired immune deficiency syndrome.
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Affiliation(s)
- Prakash Vishnu
- Floyd & Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA, USA
| | - David M Aboulafia
- Floyd & Delores Jones Cancer Institute at Virginia Mason Medical Center, Seattle, WA, USA.,Division of Hematology, University of Washington, Seattle, WA, USA
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43
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Oxidized LDL Levels Are Increased in HIV Infection and May Drive Monocyte Activation. J Acquir Immune Defic Syndr 2015; 69:154-60. [PMID: 25647528 DOI: 10.1097/qai.0000000000000566] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND HIV infection is associated with increased cardiovascular risk, and this risk correlates with markers of monocyte activation. We have shown that HIV is associated with a prothrombotic monocyte phenotype, which can be partially mitigated by statin therapy. We therefore explored the relationship between oxidized low-density lipoprotein (oxLDL) particles and monocyte activation. METHODS We performed phenotypic analysis of monocytes using flow cytometry on fresh whole blood in 54 patients with HIV and 24 controls without HIV. Plasma levels of oxLDL, soluble CD14, IL-6, and soluble CD163 were measured by enzyme-linked immunosorbent assay. In vitro experiments were performed using flow cytometry. RESULTS Plasma levels of oxLDL were significantly increased in HIV infection compared with controls (60.1 units vs. 32.1 units, P < 0.001). Monocyte expression of the oxLDL receptors, CD36 and Toll-like receptor 4, was also increased in HIV. OxLDL levels correlated with markers of monocyte activation, including soluble CD14, tissue factor expression on inflammatory monocytes, and CD36. In vitro stimulation with oxLDL, but not to low-density lipoprotein, resulted in expansion of inflammatory monocytes and increased monocyte expression of tissue factor, recapitulating the monocyte profile we find in HIV disease. CONCLUSIONS OxLDL may contribute to monocyte activation, and further study in the context of HIV disease is warranted.
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Funderburg NT, Jiang Y, Debanne SM, Labbato D, Juchnowski S, Ferrari B, Clagett B, Robinson J, Lederman MM, McComsey GA. Rosuvastatin reduces vascular inflammation and T-cell and monocyte activation in HIV-infected subjects on antiretroviral therapy. J Acquir Immune Defic Syndr 2015; 68:396-404. [PMID: 25514794 PMCID: PMC4334694 DOI: 10.1097/qai.0000000000000478] [Citation(s) in RCA: 113] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
BACKGROUND Despite suppressive antiretroviral therapy (ART), increased levels of immune activation persist in HIV-infected subjects. Statins have anti-inflammatory effects and may reduce immune activation in HIV disease. METHODS Stopping Atherosclerosis and Treating Unhealthy bone with RosuvastatiN in HIV (SATURN-HIV) is a randomized, double-blind placebo-controlled trial assessing the effect of rosuvastatin (10 mg daily) on markers of cardiovascular risk and immune activation in ART-treated patients. T-cell activation was measured by expression of CD38, HLA-DR, and PD1. Monocyte activation was measured with soluble markers (sCD14 and sCD163) and by enumeration of monocyte subpopulations and tissue factor expression. Markers of systemic and vascular inflammation and coagulation were also measured. SATURN-HIV is registered on clinicaltrials.gov (identifier: NCT01218802). RESULTS Rosuvastatin, compared with placebo, reduced sCD14 (-10.4% vs 0.5%, P = 0.006), lipoprotein-associated phospholipase A2 (-12.2% vs -1.7%, P = 0.0007), and IP-10 (-27.5 vs -8.2%, P = 0.03) levels after 48 weeks. The proportion of tissue factor-positive patrolling (CD14CD16) monocytes was also reduced by rosuvastatin (-41.6%) compared with placebo (-18.8%, P = 0.005). There was also a greater decrease in the proportions of activated (CD38HLA-DR) T cells between the arms (-38.1% vs -17.8%, P = 0.009 for CD4 cells, and -44.8% vs -27.4%, P = 0.003 for CD8 cells). CONCLUSIONS Forty-eight weeks of rosuvastatin treatment reduced significantly several markers of inflammation and lymphocyte and monocyte activation in ART-treated subjects.
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Affiliation(s)
- Nicholas T. Funderburg
- School of Health and Rehabilitation Sciences, Division of Medical Laboratory
Science, Ohio State University, Columbus, OH, USA
| | - Ying Jiang
- Case Western Reserve University, Cleveland, OH, USA
| | | | - Danielle Labbato
- Case Western Reserve University, Cleveland, OH, USA
- University Hospitals Case Medical Center, Cleveland, OH, USA
- Rainbow Babies and Children’s Hospital, Cleveland, OH, USA
| | - Steven Juchnowski
- Harrington Heart & Vascular Institute, University Hospitals Case Medical
Center Cleveland, OH, USA
| | | | | | - Janet Robinson
- Case Western Reserve University, Cleveland, OH, USA
- University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Michael M. Lederman
- Case Western Reserve University, Cleveland, OH, USA
- University Hospitals Case Medical Center, Cleveland, OH, USA
| | - Grace A. McComsey
- Case Western Reserve University, Cleveland, OH, USA
- University Hospitals Case Medical Center, Cleveland, OH, USA
- Rainbow Babies and Children’s Hospital, Cleveland, OH, USA
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van den Dries LWJ, Gruters RA, Hövels-van der Borden SBC, Kruip MJHA, de Maat MPM, van Gorp ECM, van der Ende ME. von Willebrand Factor is elevated in HIV patients with a history of thrombosis. Front Microbiol 2015; 6:180. [PMID: 25814984 PMCID: PMC4356086 DOI: 10.3389/fmicb.2015.00180] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2014] [Accepted: 02/19/2015] [Indexed: 11/21/2022] Open
Abstract
Background: Arterial and venous thrombotic events are more prevalent in HIV infected individuals compared to the general population, even in the era of combination antiretroviral therapy. Although the mechanism is not fully understood, recent evidence suggests a role for chronic immune activation. Methods: We reviewed the Dutch National HIV registry database for HIV infected patients in Rotterdam with a history of arterial or venous thrombosis and calculated the incidence. We collected samples from patients with and without thrombosis and compared plasma levels of lipopolysaccharide (LPS), LPS binding protein (LBP), soluble CD14 (sCD14), and von Willebrand Factor antigen level (vWF). Results: During a 10-year period, a total of 60 documented events in 14,026 person years of observation (PYO) occurred, resulting in an incidence rate of 2.50, 2.21, and 4.28 for arterial, venous and combined thrombotic events per 1000 PYO, respectively. The vWF was elevated in the majority of study subjects (mean 2.36 SD ± 0.88 IU/ml); we found a significant difference when comparing venous cases to controls (mean 2.68 SD ± 0.82 IU/ml vs. 2.20 SD ± 0.77 IU/ml; p = 0.024). This difference remained significant for recurrent events (mean 2.78 SD ± 0.75; p = 0.043). sCD14 was positively correlated with LPS (r = 0.255; p = 0.003). Conclusion: The incidence of venous thrombosis was two-fold higher in HIV infected patients compared to age-adjusted data from general population cohort studies. We couldn't find a clear association between immune activation markers to either arterial or venous thrombotic events. We observed a marked increase in vWF levels as well as a correlation of vWF to first and recurrent venous thrombo-embolic events. These findings suggest that HIV infection is an independent risk factor for coagulation abnormalities and could contribute to the observed high incidence in venous thrombosis. This could be a reason to prolong anti-thrombotic treatment in HIV patients with a history of thrombosis.
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Affiliation(s)
| | - Rob A Gruters
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Netherlands
| | | | - Marieke J H A Kruip
- Division of Hematology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Netherlands
| | - Moniek P M de Maat
- Division of Hematology, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Netherlands
| | - Eric C M van Gorp
- Department of Viroscience, Erasmus MC, University Medical Center Rotterdam, Netherlands ; Division of Infectious Diseases, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Netherlands
| | - Marchina E van der Ende
- Division of Infectious Diseases, Department of Internal Medicine, Erasmus MC, University Medical Center Rotterdam, Netherlands
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Abstract
HIV infected patients are at increased risk for venous and arterial thromboembolic events. Multiple markers related to inflammation (IL-6, TNFrI, C-reative protein) and coagulation (tissue factor expression, FVIII, thrombin, fibrinogen and D-dimer levels) are increased in HIV infection, and several are predictive of thrombotic risk and mortality in HIV disease. The mechanisms behind the risk for abnormal coagulation in HIV infection have not been fully elucidated, but may be related to a chronic immune activation and inflammatory state in both untreated and treated HIV infection. The contribution of traditional risk factors, including smoking and dyslipidemia, overly represented in HIV infected patients, must also be considered when assessing thrombotic risk in this setting. Currently, several interventional studies are aimed at reducing inflammation and cardiovascular risk in HIV disease and may provide insights into the determinants of clotting events in HIV infected patients.
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Modi RA, McGwin G, Westfall AO, Powell DW, Burkholder GA, Raper JL, Willig JH. Venous thromboembolism among HIV-positive patients and anticoagulation clinic outcomes integrated within the HIV primary care setting. Int J STD AIDS 2014; 26:870-8. [PMID: 25414089 DOI: 10.1177/0956462414561033] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2014] [Accepted: 10/30/2014] [Indexed: 02/05/2023]
Abstract
The purpose of this study was to explore factors associated with venous thromboembolism (VTE) among a cohort of HIV-infected patients and to describe early outcomes of warfarin anticoagulation therapy treated in a pharmacist-based anticoagulation clinic (ACC). A nested case-control study was conducted using the University of Alabama at Birmingham 1917 HIV Clinic Cohort. Conditional logistic regression was used to estimate factors associated with VTE. Among HIV-infected VTE cases, ACC-managed patients were compared to primary care provider (PCP)-managed patients to determine Time within Therapeutic INR Range (TTR). CD4 < 200 cells/µl (OR = 4.50; 95% CI = 1.52, 13.37; p = 0.007) and prior surgical procedures (13.20; 1.56; 111.4; p = 0.018) demonstrated positive associations with VTE, whereas longer HIV duration demonstrated a negative association (0.87; 0.78, 0.98; p = 0.019). TTR was 56.2% among ACC-managed patients compared to 30.5% of PCP-managed patients (p = 0.174). Overall, prior surgical procedures and low CD4 count were associated with an increased risk of VTE among HIV-infected patients. Despite small sample size, patients managed in ACC tend to achieve greater proportion of TTR compared to those managed by PCPs, suggesting that this model of therapy may provide additional benefits to HIV-infected patients.
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Affiliation(s)
- Riddhi A Modi
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Gerald McGwin
- Department of Epidemiology, School of Public Health, UAB, Birmingham, AL, USA
| | | | - Deon W Powell
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA
| | - Greer A Burkholder
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA University of Alabama School of Medicine (UAB), Birmingham, AL, USA
| | - James L Raper
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA University of Alabama School of Medicine (UAB), Birmingham, AL, USA
| | - James H Willig
- Division of Infectious Diseases, University of Alabama at Birmingham (UAB), Birmingham, AL, USA University of Alabama School of Medicine (UAB), Birmingham, AL, USA
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Markers of coagulation and inflammation often remain elevated in ART-treated HIV-infected patients. Curr Opin HIV AIDS 2014; 9:80-6. [PMID: 24275673 DOI: 10.1097/coh.0000000000000019] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW Current antiretroviral therapies have dramatically changed the disease course of HIV infection. Although antiretroviral therapy is effective at decreasing viral replication and preserving CD4 T-cell numbers, low-level immune activation and inflammation persist in virally suppressed HIV-infected patients. This chronic immune activation/inflammation may contribute to an increased risk for venous and arterial thrombosis. RECENT FINDINGS Several markers of coagulation and inflammation are increased in HIV-infected patients. The Strategies for the Management of Antiretroviral Therapy study reported that plasma D-dimer levels, a marker of fibrinolysis, independently predicted morbidity in HIV-infected patients. Increased plasma and cell surface levels of the procoagulant tissue factor have also been reported in patients with HIV disease. Fibrinogen, von Willebrand factor, and P-selectin are likewise increased in plasma samples of HIV-infected patients; all of these markers suggest HIV-infection results in a procoagulant state. Treatment with antiretroviral therapy reduces, but does not always normalize, levels of biomarkers associated with inflammation and coagulation in HIV+ patients. SUMMARY HIV-infected patients are at greater risk for both venous and arterial thrombosis. Chronic immune activation and inflammation in these patients appears to contribute to coagulation risk. Antiretroviral therapy reduces viral replication, immune activation, and markers of coagulation, but these indices do not always return to normal, even after several years of viremic control.
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49
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Martinelli I, De Stefano V, Mannucci PM. Interaction between inherited thrombophilia and HIV infection: fact or fancy? Nat Rev Cardiol 2014; 11:321. [DOI: 10.1038/nrcardio.2013.211-c2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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50
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Abstract
Acquired thrombophilia is associated with an increased risk of venous thromboembolism (VTE). Antiphospholipid syndrome (APS) is the most prevalent acquired thrombophilia and is associated with both venous and arterial thromboses. Human immunodeficiency virus (HIV) is another form of acquired thrombophilia. Risk factors associated with VTE in this population include those related to the disease itself, host factors, and the pharmacotherapy for HIV. A significant proportion of VTE events occur in patients with malignancies. There is an increase in mortality associated with patients having cancer who experience VTE when compared to patients having cancer without VTE. Combination oral contraceptive (COC) use infers risk of thromboembolic events. The risk is dependent upon the presence of an underlying inherited thrombophilia, the estrogen dose, and generation of progestin. Patients at highest risk of VTE include those receiving high-dose estrogen and fourth-generation, progesterone-containing contraceptives. With the exception of APS, thrombophilia status does not alter the acute treatment of an initial VTE in nonpregnant patients.
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Affiliation(s)
- Emily M Armstrong
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, AL, USA Department of Internal Medicine, University of South Alabama, Mobile, AL, USA
| | - Jessica M Bellone
- Department of Pharmacy Practice, Concordia University Wisconsin School of Pharmacy, Mequon, WI, USA
| | - Lori B Hornsby
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, AL, USA Outpatient Clinic, Midtown Medical Center, Columbus, GA, USA
| | - Sarah Treadway
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, AL, USA Department of Family Medicine, University of South Alabama, Mobile, AL, USA
| | - Haley M Phillippe
- Department of Pharmacy Practice, Auburn University Harrison School of Pharmacy, Auburn, AL, USA Family Medicine-Huntsville Campus, University of Alabama School of Medicine, Huntsville, AL, USA
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