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Rodrigues Alves N, Barão C, Mota C, Costa L, Proença RP. Immune recovery uveitis: a focus review. Graefes Arch Clin Exp Ophthalmol 2024; 262:2703-2712. [PMID: 38381160 PMCID: PMC11271330 DOI: 10.1007/s00417-024-06415-y] [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: 07/30/2023] [Revised: 12/23/2023] [Accepted: 02/11/2024] [Indexed: 02/22/2024] Open
Abstract
Immune recovery uveitis (IRU) is an intraocular inflammation that typically occurs as part of immune reconstitution inflammatory syndrome (IRIS) in the eye. Typically, it affects human immunodeficiency virus (HIV)-infected patients with recognized or unrecognized cytomegalovirus (CMV) retinitis who are receiving highly active antiretroviral therapy (HAART). IRU is a common cause of new vision loss in these patients, and it manifests with a wide range of symptoms and an increased risk of inflammatory complications, such as macular edema. Recently, similar IRU-like responses have been observed in non-HIV individuals with immune reconstitution following immunosuppression of diverse etiologies, posing challenges in diagnosis and treatment. This review provides an updated overview of the current literature on the epidemiology, pathophysiology, biomarkers, clinical manifestations, diagnosis, differential diagnosis, and treatment strategies for IRU.
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Affiliation(s)
- Nuno Rodrigues Alves
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal.
| | - Catarina Barão
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
| | - Catarina Mota
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
| | - Lívio Costa
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Rita Pinto Proença
- Department of Ophthalmology, Unidade Local de Saúde de São José, Centro Hospitalar Universitário Lisboa Central, Rua José António Serrano, 1150-199, Lisbon, Portugal
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Lu L, Ma Y, Cong Y, Zhou B, Chen Y, Niu J, He Y, Cao W, Li T. Comorbidity of Myasthenia gravis and Graves' disease as immune reconstitution-associated autoimmune disease in HIV infection: A case report and literature review. HIV Med 2024; 25:398-403. [PMID: 37990629 DOI: 10.1111/hiv.13584] [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: 09/14/2023] [Accepted: 11/05/2023] [Indexed: 11/23/2023]
Abstract
BACKGROUND Comorbidity of Myasthenia gravis (MG) and Graves' disease (GD) in treated HIV-infected individuals has rarely been described and little study has been done on the link between HIV-related immune reconstitution and autoimmune diseases occurring post antiretroviral therapy. CASE PRESENTATION Here we report on a 33-year-old Chinese man with HIV infection who had been virologically suppressed since 2018. The patient was diagnosed with GD and was treated in 2020. Early in 2022, he developed fluctuating weakness and fatigue involving the bilateral extraocular muscles and limbs. With a positive neostigmine test, he was considered to have MG, but showed a poor response to oral medication. After multiple failed medication attempts, a thymectomy was finally performed to resolve his symptoms. The consecutive onset of immunological events may have partially resulted from immune reconstitution after viral control. CONCLUSIONS This is a rare case of HIV-related immune reconstitution-associated autoimmune disease (IRAD) with comorbidity of MG and GD which was reported initially. Cooperation with multidisciplinary teams is essential to avoid misdiagnosis and to promote the overall health of HIV-infected patients.
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Affiliation(s)
- Lianfeng Lu
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yanan Ma
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Cong
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Baotong Zhou
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yeye Chen
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Jingwen Niu
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yun He
- Department of Infectious Diseases, The Third People's Hospital of Shenzhen: Second Affiliated Hospital of Southern University of Science and Technology, Shenzhen, China
| | - Wei Cao
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Taisheng Li
- Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
- Department of Basic Medical Sciences, School of Medicine, Tsinghua University, Beijing, China
- State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
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Lee CY, Lin YP, Lin CY, Chen TC, Kuo SH, Lo SH, Wang SF, Lu PL. Trends and the associated factors of optimal immunological response and virological response in late anti-retroviral therapy initiation HIV cases in Taiwan from 2009 to 2020. J Infect Public Health 2024; 17:339-348. [PMID: 38194765 DOI: 10.1016/j.jiph.2023.12.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 11/22/2023] [Accepted: 12/28/2023] [Indexed: 01/11/2024] Open
Abstract
BACKGROUND Late cART initiation (CD4 count ≤200 cells/μL or AIDS-defining opportunistic illnesses [AOIs] at cART initiation) impedes CD4 count recovery and virologic suppression after cART initiation. However, studies to evaluate trends of and modifiable factors for optimal immunological response (IR) and virological response (VR) in people living with HIV (PLWH) with late cART initiation with the current HIV treatment strategies are limited. METHODS We retrospectively identified 475 PLWH with late cART initiation in 2009-2020. Patients were grouped based on the presence of IR (CD4 count ≥200 cells/μL) or VR (plasma viral load [PVL] ≤ 50 copies/mL) within 18 months after cART initiation (403 [84.8%] IR(+) and 72 [15.2%] IR(-); 422 [88.8%] VR(+) and 53 [11.2%] VR(-)). We used Joinpoint regression to identify IR (+) and VR(+) proportion changes. RESULTS From 2009 to 2020, the proportion of IR(+) patients remained unchanged (75% to 90%, P = 0.102), whereas that of VR(+) patients increased significantly (75% to 95%, P = 0.007). No join point was identified for either IR(+) or VR(+), and the annual percentage change was 0.56% (nonsignificant) and 1.35% (significant) for IR(+) and VR(+), respectively. Compared to IR(-) patients, IR(+) patients were more likely to have a higher pre-cART PVL, to start with a first-line INSTI-based regimen, or to start cART within 14 days of HIV diagnosis but were less likely to have chronic kidney disease, composite AOIs, or a lower pre-cART CD4 count. Compared to VR(-) patients, VR(+) patients were more likely to start a single-tablet regimen but were less likely to have a higher pre-cART PVL. CONCLUSIONS Our study identified several modifiable factors for optimal IR (rapid cART initiation and INSTI-based regimen initiation) and for optimal VR (STR initiation) among late initiators, which may guide early treatment modifications to reduce their AIDS-defining event incidence and mortality.
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Affiliation(s)
- Chun-Yuan Lee
- Graduate Institute of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC; M.Sc. Program in Tropical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Yi-Pei Lin
- Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC; M.Sc. Program in Tropical Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Chun-Yu Lin
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC
| | - Tun-Chieh Chen
- School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Shin-Huei Kuo
- Department of Internal Medicine, Kaohsiung Municipal Ta-Tung Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Shih-Hao Lo
- Department of Internal Medicine, Kaohsiung Municipal Siaogang Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Sheng-Fan Wang
- Center for Tropical Medicine and Infectious Disease, Kaohsiung Medical University, Kaohsiung, Taiwan , ROC; Department of Medical Laboratory Science and Biotechnology, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Department of Medical Research, Kaohsiung Medical University Hospital, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC
| | - Po-Liang Lu
- School of Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Division of Infectious Diseases, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan, ROC; School of Post-Baccalaureate Medicine, College of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan, ROC; Center for Liquid Biopsy and Cohort Research, Kaohsiung Medical University, Taiwan, ROC.
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Geteneh A, Andualem H, Belay DM, Kiros M, Biset S. Immune reconstitution inflammatory syndrome, a controversial burden in the East African context: a systematic review and meta-analysis. Front Med (Lausanne) 2023; 10:1192086. [PMID: 37636563 PMCID: PMC10450628 DOI: 10.3389/fmed.2023.1192086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/18/2023] [Indexed: 08/29/2023] Open
Abstract
Introduction It is well established that starting antiretroviral therapy (ART) increases a patient's life expectancy among HIV-positive individuals. Considering the HIV pandemic, the major concern is initiation of ARTs to the large segment of HIV infected population, not adverse events from immune restoration. The prevalence of HIV-associated immune reconstitution inflammatory syndrome (IRIS) is poorly estimated due to Africa's underdeveloped infrastructure, particularly in Eastern Africa. Therefore, this study compiled data regarding the magnitude and associated factors of IRIS in the context of Eastern Africa. Methods The electronic databases such as Google Scholar, PubMed, Web of Science, and free Google access were searched till 5 June 2021, and the search was lastly updated on 30 June 2022 for studies of interest. The pooled prevalence, and associated factors with a 95% confidence interval were estimated using the random effects model. The I2 and Egger's tests were used for heterogeneity and publication bias assessment, respectively. Results The development of HIV-associated IRIS in Eastern Africa was estimated to be 18.18% (95% CI 13.30-23.06) in the current review. The two most common predictors of IRIS associated with Eastern Africa were the lower pre-ART CD4 T-cell count of 50 cells/μl and the low baseline body mass index level. Therefore, attention should be focused on the early detection and care of HIV-associated IRIS to reduce the morbidity and death caused by IRIS.
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Affiliation(s)
- Alene Geteneh
- Department of Medical Laboratory Science, College of Health Sciences, Woldia University, Woldia, Ethiopia
| | - Henok Andualem
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Demeke Mesfin Belay
- Department of Pediatrics and Child Health Nursing, College of Health Sciences, Debre Tabor University, Debre Tabor, Ethiopia
| | - Mulugeta Kiros
- Department of Medical Laboratory Science, College of Medicine and Health Sciences, Aksum University, Aksum, Ethiopia
| | - Sirak Biset
- Department of Medical Microbiology, School of Biomedical and Laboratory Sciences, College of Medicine and Health Sciences, University of Gondar, Gondar, Ethiopia
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Comparison of Virological Efficacy of DTG/ABC/3TG and B/F/TAF Regimens and Discontinuation Patterns in Persons Living with Advanced HIV in the Era of Rapid ART: A Retrospective Multicenter Cohort Study. Infect Dis Ther 2023; 12:843-861. [PMID: 36520332 PMCID: PMC10017888 DOI: 10.1007/s40121-022-00734-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2022] [Accepted: 11/17/2022] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION International treatment guidelines recommend the rapid initiation of antiretroviral therapy (ART) with bictegravir (B)/emtricitabine (F)/tenofovir alafenamide (TAF) and dolutegravir (DTG)-based regimens for treatment-naïve persons living with HIV (PLWH) irrespective of their disease stage. However, we lack evidence of the virological efficacy, virological failure, and tolerability of coformulated B/F/TAF and DTG/ABC/3TC regimens in persons living with advanced HIV (PLWAH; defined as persons with a CD4+ count of < 200 cells/μL or an AIDS-related opportunistic illness [AOI] at or before ART initiation) in the era of rapid ART. METHODS This retrospective multicenter study enrolled treatment-naïve PLWAH initiating ART with coformulated DTG/ABC/3TC or B/F/TAF in 2019-2020. Viral suppression at week 48 was analyzed using FDA snapshot analysis. Between-regimen differences in time to viral suppression (< 50 copies/mL), virological failure, and regimen discontinuation were examined using a Cox proportional hazards model. Analysis was also performed using time to regimen discontinuation due to adverse reactions (ARs) as the outcome. RESULTS We enrolled 162 patients, including 61.1% on DTG/ABC/3TC and 38.9% on B/F/TAF. At week 48 after ART initiation, 73.47% on DTG/ABC/3TC and 85.71% on B/F/TAF achieved viral suppression (P = 0.178). We identified no between-regimen differences in time to viral suppression or virological failure, regardless of pre-ART viral load. Compared with the DTG/ABC/3TC group, regimen discontinuation was less prevalent in the B/F/TAF group (adjusted hazard ratio = 0.23, 95% CI 0.06-0.85, P = 0.027). The main reason for discontinuation in both groups was ARs (61.9% in the DTG/ABC/3TC and 50% in the B/F/TAF, P = 0.877), of which skin manifestations were the most common in both groups (61.5% in the DTG/ABC/3TC and 50% in the B/F/TAF, P = 0.756). DTG/ABC/3TC, same-day ART prescription, and AOI were risk factors for AR or virological failure-related regimen discontinuation. CONCLUSION In the real world, the risk of regimen discontinuation was higher in PLWAH on coformulated DTG/ABC/3TC than in those on B/F/TAF, with no difference in viral suppression or virological failure. Given the findings concerning the effect of same-day ART prescription and AOIs on AR or virological failure-related regimen discontinuation, individualized approaches to PLWAH are necessary.
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Tuberculosis-Associated Immune Reconstitution Inflammatory Syndrome-An Extempore Game of Misfiring with Defense Arsenals. Pathogens 2023; 12:pathogens12020210. [PMID: 36839482 PMCID: PMC9964757 DOI: 10.3390/pathogens12020210] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 01/21/2023] [Accepted: 01/28/2023] [Indexed: 01/31/2023] Open
Abstract
The lethal combination involving TB and HIV, known as "syndemic" diseases, synergistically act upon one another to magnify the disease burden. Individuals on anti-retroviral therapy (ART) are at risk of developing TB-associated immune reconstitution inflammatory syndrome (TB-IRIS). The underlying inflammatory complication includes the rapid restoration of immune responses following ART, eventually leading to exaggerated inflammatory responses to MTB antigens. TB-IRIS continues to be a cause of morbidity and mortality among HIV/TB coinfected patients initiating ART, and although a significant quantum of knowledge has been acquired on the pathogenesis of IRIS, the underlying pathomechanisms and identification of a sensitive and specific diagnostic marker still remain a grey area of investigation. Here, we reviewed the latest research developments into IRIS immunopathogenesis, and outlined the modalities to prevent and manage strategies for better clinical and diagnostic outcomes for IRIS.
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Wang Y, Yang J, Wen Y. The Peculiarity of Infection and Immunity Correlated with Guillain-Barré Syndrome in the HIV-Infected Population. J Clin Med 2023; 12:jcm12030907. [PMID: 36769555 PMCID: PMC9917483 DOI: 10.3390/jcm12030907] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 01/05/2023] [Accepted: 01/16/2023] [Indexed: 01/26/2023] Open
Abstract
Guillain-Barré syndrome (GBS) can occur at all stages of human immunodeficiency virus (HIV) infection. HIV, cytomegalovirus (CMV), and varicella zoster virus (VZV) are the main infectious agents in HIV-positive GBS cases. These cases include acute and chronic HIV infection, immune reconstitution inflammatory syndrome (IRIS) shortly after anti-retroviral therapy (ART), those with ART interruption, or those with cerebrospinal fluids (CSF) HIV escape. The mechanisms are involved in both humoral and cellular immunities. Demyelinating and axonal neuropathies are the main pathological mechanisms in GBS. Presentation and prognosis are identical to those in patients without HIV infection. Typical or atypical clinical manifestations, CSF analysis, electrophysiological and pathological examination, and antiganglioside antibody detection can help diagnose GBS and classify its various subtypes. Intravenous immunoglobulin and plasma exchange have been used to treat GBS in HIV-positive patients with a necessary ART, while ganciclovir or foscarnet sodium should be used to treat ongoing CMV- or VZV-associated GBS. Steroids may be beneficial for patients with IRIS-related GBS. We reviewed HIV-positive cases with GBS published since 2000 and summarized their features to highlight the necessity of HIV testing among patients with GBS. Moreover, the establishment of a multidisciplinary team will guarantee diagnostic and therapeutic advantages.
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Affiliation(s)
- Yanli Wang
- Department of Infectious Diseases, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Jun Yang
- Neurology Department, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
| | - Ying Wen
- Department of Infectious Diseases, The First Affiliated Hospital of China Medical University, Shenyang 110001, China
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Gillespie SL, Chinen J, Paul ME. Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome. Clin Immunol 2023. [DOI: 10.1016/b978-0-7020-8165-1.00041-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/08/2023]
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Lawal IO, Abubakar S, Ankrah AO, Sathekge MM. Molecular Imaging of Tuberculosis. Semin Nucl Med 2023; 53:37-56. [PMID: 35882621 DOI: 10.1053/j.semnuclmed.2022.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/05/2022] [Indexed: 01/28/2023]
Abstract
Despite the introduction of many novel diagnostic techniques and newer treatment agents, tuberculosis (TB) remains a major cause of death from an infectious disease worldwide. With about a quarter of humanity harboring Mycobacterium tuberculosis, the causative agent of TB, the current efforts geared towards reducing the scourge due to TB must be sustained. At the same time, newer alternative modalities for diagnosis and treatment response assessment are considered. Molecular imaging entails the use of radioactive probes that exploit molecular targets expressed by microbes or human cells for imaging using hybrid scanners that provide both anatomic and functional features of the disease being imaged. Fluorine-18 fluorodeoxyglucose (FDG) is the most investigated radioactive probe for TB imaging in research and clinical practice. When imaged with positron emission tomography interphase with computed tomography (PET/CT), FDG PET/CT performs better than sputum conversion for predicting treatment outcome. At the end of treatment, FDG PET/CT has demonstrated the unique ability to identify a subset of patients declared cured based on the current standard of care but who still harbor live bacilli capable of causing disease relapse after therapy discontinuation. Our understanding of the pathogenesis and evolution of TB has improved significantly in the last decade, owing to the introduction of FDG PET/CT in TB research. FDG is a non-specific probe as it targets the host inflammatory response to Mycobacterium tuberculosis, which is not specifically different in TB compared with other infectious conditions. Ongoing efforts are geared towards evaluating the utility of newer probes targeting different components of the TB granuloma, the hallmark of TB lesions, including hypoxia, neovascularization, and fibrosis, in TB management. The most exciting category of non-FDG PET probes developed for molecular imaging of TB appears to be radiolabeled anti-tuberculous drugs for use in studying the pharmacokinetic characteristics of the drugs. This allows for the non-invasive study of drug kinetics in different body compartments concurrently, providing an insight into the spatial heterogeneity of drug exposure in different TB lesions. The ability to repeat molecular imaging using radiolabeled anti-tuberculous agents also offers an opportunity to study the temporal changes in drug kinetics within the different lesions during treatment.
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Affiliation(s)
- Ismaheel O Lawal
- Division of Nuclear Medicine and Molecular Imaging, Department of Radiology and Imaging Sciences, Emory University, Atlanta, GA; Department of Nuclear Medicine, University of Pretoria, Pretoria, Gauteng, South Africa.
| | - Sofiullah Abubakar
- Department of Radiology and Nuclear Medicine, Sultan Qaboos Comprehensive Cancer Care and Research Center, Muscat, Oman
| | - Alfred O Ankrah
- Department of Nuclear Medicine, University of Pretoria, Pretoria, Gauteng, South Africa; National Center for Radiotherapy Oncology and Nuclear Medicine, Korle Bu Teaching Hospital, Accra, Ghana; Medical Imaging Center, Department of Nuclear Medicine and Molecular Imaging, University Medical Center Groningen, Groningen, The Netherlands
| | - Mike M Sathekge
- Department of Nuclear Medicine, University of Pretoria, Pretoria, Gauteng, South Africa; Nuclear Medicine Research Infrastructure (NuMeRI), Steve Biko Academic Hospital, Pretoria, South Africa
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Alsulami S, Alotaibi SN, Damfu N, Aljefri DM, Altayib HA, Alharbi M. Efficacy and Safety of Bictegravir-Based Regimen in Pregnant Women Living with HIV: A Case Report. J Int Assoc Provid AIDS Care 2022; 21:23259582221146110. [PMID: 36529886 PMCID: PMC9772963 DOI: 10.1177/23259582221146110] [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] [Indexed: 12/23/2022] Open
Abstract
Bictegravir (BIC) is included in international guidelines as the first line of therapy for patients living with Human Immunodeficiency Virus (HIV), either as initial therapy or as a replacement for patients with prior antiretroviral therapy (ART). Due to limited efficacy and safety data, BIC is currently not recommended during pregnancy. Data on the safety and efficacy of BIC during pregnancy were unavailable at the time of drug approval. In our case, BIC/TAF/FTC was effective in suppressing viral load (VL) in pregnancy, and there were no reported safety issues for the mother or the baby.
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Affiliation(s)
- Shaimaa Alsulami
- Department of Pharmaceutical Care Services, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia,Shaimaa Alsulami, Department of Pharmaceutical Care Services, King Fahd Armed Forces Hospital, Jeddah, Saudi Arabia.
| | - Sultan N. Alotaibi
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Nader Damfu
- Department of Infection Prevention and Control, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | - Doaa M. Aljefri
- Department of Pharmaceutical Care Services, King Abdulaziz Medical City, Jeddah, Saudi Arabia
| | | | - Maher Alharbi
- Department of Infectious Diseases, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia,Department of Infection Prevention and Control, King Abdulaziz Medical City, Ministry of National Guard Health Affairs, Jeddah, Saudi Arabia,King Abdullah International Medical Research Center, Jeddah, Saudi Arabia,King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
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Mendes JC, Ceccato MDGB, Reis AMM, Costa AMGD, Pantuzza LLN, Furtado dos Santos S, Crepalde-Ribeiro K, Silveira MR. Active Pharmacovigilance Project on the safety profile of Dolutegravir in Brazil. AIDS Care 2022; 35:729-738. [PMID: 35578399 DOI: 10.1080/09540121.2022.2062289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
A quantitative descriptive study based on Brazilian Active Pharmacovigilance of Dolutegravir (DTG) Project was performed to describe the adverse drug reactions (ADRs) to DTG reported and to evaluate the noncompleteness of data from DTG active pharmacovigilance in Brazil. ADRs and clinical and individual data were obtained from information from the Pharmacovigilance Questionnaire from April 2017 to August 2019. The reported ADRs were classified using the Medical Dictionary for Regulatory Activities (MedDRA). In the evaluated period, 249,066 individuals using DTG participated in the active pharmacovigilance of DTG, with 3472 (1.39%) reporting ADRs at least once. A total of 6312 ADRs were reported, of which 57.56% were persistent and 81.46% were not serious according to the individuals' reports. Most of the reported ADRs were gastrointestinal, neurological and psychiatric. ADRs related to neural tube defects and serious neuropsychiatric ADRs have been reported. Completion of more than half of the fields in the Pharmacovigilance Questionnaire was excellent. The frequency of ADR was low in relation to the number of people living with HIV (PLHIV) using DTG in Brazil, which suggests good tolerability and safety of DTG. The DTG active pharmacovigilance database in Brazil showed good data completeness.
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Affiliation(s)
- Jullye Campos Mendes
- Programa de Pós Graduação em Medicamentos e Assistência Farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Maria das Graças Braga Ceccato
- Programa de Pós Graduação em Medicamentos e Assistência Farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Departamento de Farmácia Social, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Adriano Max Moreira Reis
- Programa de Pós Graduação em Medicamentos e Assistência Farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Departamento de Produtos Farmacêuticos, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Lais Lessa Neiva Pantuzza
- Programa de Pós Graduação em Medicamentos e Assistência Farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Simone Furtado dos Santos
- Programa de Pós Graduação em Medicamentos e Assistência Farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Kennedy Crepalde-Ribeiro
- Programa de Pós Graduação em Medicamentos e Assistência Farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Micheline Rosa Silveira
- Programa de Pós Graduação em Medicamentos e Assistência Farmacêutica, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Departamento de Farmácia Social, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
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Pinnetti C, Cimini E, Vergori A, Mazzotta V, Grassi G, Mondi A, Forbici F, Amendola A, Grisetti S, Baldini F, Candela C, Casetti R, Campioni P, Capobianchi MR, Agrati C, Antinori A. Use of Pembrolizumab for Treatment of Progressive Multifocal Leukoencephalopathy in People Living with HIV. Viruses 2022; 14:v14050970. [PMID: 35632711 PMCID: PMC9146231 DOI: 10.3390/v14050970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 04/28/2022] [Accepted: 05/02/2022] [Indexed: 02/04/2023] Open
Abstract
Progressive Multifocal Leukoencephalopathy (PML) is a demyelinating disease occurring in advanced HIV infection, caused by the reactivation of poliomavirus JC (JCV). The use of pembrolizumab for treatment is based on the inhibition of programmed cell death protein 1 (PD-1), potentially improving the anti JCV-specific response. We used pembrolizumab with combined antiretroviral treatment (cART) on a compassionate-use basis. At each administration, clinical evaluation, MRI and laboratory testing, including CD3, CD4, CD8, PD-1 markers, HIV-RNA and JCV-DNA in cerebrospinal fluid (CSF)/plasma pairs, were performed. The JCV-specific T cell response was analysed by Elispot assay. This study included five HIV patients: four male, median age 43 years (29–52), median CD4 and CD8 count 150 (15–158) and 973 (354–1250) cell/mm3, respectively; median JCV-DNA and HIV-RNA in CSF/plasma pairs 9.540/1.503 cps/mL and 2.230/619 cp/mL, respectively. Overall, patients received between two and seven doses of pembrolizumab. After treatment, we observed JCV-DNA reduction and PD-1 down-regulation both in CSF and in plasma (high in circulating CD4 and CD8 at baseline), which remained stable at low levels in all patients. Three out of five patients showed stability of clinical picture and neuroimaging, while two others died. More data are needed in order to identify predictors of response to therapy.
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Affiliation(s)
- Carmela Pinnetti
- HIV/AIDS Unit, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (V.M.); (A.M.); (S.G.); (F.B.); (C.C.); (A.A.)
- Correspondence: (C.P.); (A.V.); Tel.: +39-0655170482 (C.P. & A.V.); Fax: +39-0655170477 (C.P. & A.V.)
| | - Eleonora Cimini
- Cellular Immunology and Pharmacology Laboratory, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (E.C.); (G.G.); (R.C.); (C.A.)
| | - Alessandra Vergori
- HIV/AIDS Unit, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (V.M.); (A.M.); (S.G.); (F.B.); (C.C.); (A.A.)
- Correspondence: (C.P.); (A.V.); Tel.: +39-0655170482 (C.P. & A.V.); Fax: +39-0655170477 (C.P. & A.V.)
| | - Valentina Mazzotta
- HIV/AIDS Unit, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (V.M.); (A.M.); (S.G.); (F.B.); (C.C.); (A.A.)
| | - Germana Grassi
- Cellular Immunology and Pharmacology Laboratory, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (E.C.); (G.G.); (R.C.); (C.A.)
| | - Annalisa Mondi
- HIV/AIDS Unit, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (V.M.); (A.M.); (S.G.); (F.B.); (C.C.); (A.A.)
| | - Federica Forbici
- Laboratory of Virology, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (F.F.); (A.A.); (M.R.C.)
| | - Alessandra Amendola
- Laboratory of Virology, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (F.F.); (A.A.); (M.R.C.)
| | - Susanna Grisetti
- HIV/AIDS Unit, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (V.M.); (A.M.); (S.G.); (F.B.); (C.C.); (A.A.)
| | - Francesco Baldini
- HIV/AIDS Unit, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (V.M.); (A.M.); (S.G.); (F.B.); (C.C.); (A.A.)
| | - Caterina Candela
- HIV/AIDS Unit, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (V.M.); (A.M.); (S.G.); (F.B.); (C.C.); (A.A.)
| | - Rita Casetti
- Cellular Immunology and Pharmacology Laboratory, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (E.C.); (G.G.); (R.C.); (C.A.)
| | - Paolo Campioni
- Radiology Unit, National Institute for Infectious Diseases Lazzaro Spallanzani IRCCS, 00149 Rome, Italy;
| | - Maria Rosaria Capobianchi
- Laboratory of Virology, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (F.F.); (A.A.); (M.R.C.)
| | - Chiara Agrati
- Cellular Immunology and Pharmacology Laboratory, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (E.C.); (G.G.); (R.C.); (C.A.)
| | - Andrea Antinori
- HIV/AIDS Unit, National Institute for Infectious Diseases, Lazzaro Spallanzani IRCCS, 00149 Rome, Italy; (V.M.); (A.M.); (S.G.); (F.B.); (C.C.); (A.A.)
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Tang S, Zhao N, Wang LY, Wen Y. Frosted branch angiitis due to cytomegalovirus-associated unmasking immune reconstitution inflammatory syndrome: a case report and literature review. BMC Infect Dis 2021; 21:613. [PMID: 34174839 PMCID: PMC8236202 DOI: 10.1186/s12879-021-06311-4] [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: 12/31/2020] [Accepted: 06/10/2021] [Indexed: 11/20/2022] Open
Abstract
Background Cytomegalovirus (CMV) retinitis is a common opportunistic infection in patients with acquired immunodeficiency syndrome. The common funduscopic manifestations are haemorrhagic necrotising variety and granular variety. Frosted branch angiitis (FBA), as a special form, when it occurred after antiretroviral therapy(ART), could possibly be associated with immune reconstitution. We report a case of FBA secondary to CMV infection-associated unmasking immune reconstitution inflammatory syndrome (IRIS). Case presentation A 27-year-old man with human immunodeficiency virus infection developed FBA after 35 days of ART. The left Aqueous humour (AqH) tested positive for CMV DNA, and the patient was diagnosed with CMV retinitis. The degree of intraocular inflammation was reflected by increased levels of interleukin (IL)-6 and IL-8 in AqH. After anti-CMV treatment and continuous ART for several months, his FBA and vision significantly improved. CMV DNA became undetectable in the left AqH, and the IL-6 and IL-8 levels in AqH decreased. Conclusion FBA could be a sign of CMV-associated unmasking IRIS. Anti-CMV treatment alone or combination with steroid treatment may be administered, depending on the changes in CMV DNA load and immunologic profile of AqH.
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Affiliation(s)
- Shi Tang
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, China
| | - Ning Zhao
- Department of Ophthalmology, The First Affiliated Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Li Yang Wang
- Department of Gastroenterology, The sixth People's Hospital of Shenyang, Shenyang, Liaoning Province, China
| | - Ying Wen
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, No. 155, Nanjing North Street, Heping District, Shenyang, 110001, Liaoning Province, China.
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Wen Y, Wang MC, Zhou Y, Lin XY, Hou G, Yin Y. Immune reconstitution inflammatory syndrome associated with Pneumocystis pneumonia in a patient with AIDS. J Int Med Res 2021; 48:300060520946544. [PMID: 32851886 PMCID: PMC7457674 DOI: 10.1177/0300060520946544] [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: 11/17/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) after starting antiretroviral treatment for human immunodeficiency virus (HIV) infection has a wide variety of causes. Delayed diagnosis and treatment of IRIS is fatal. We report a case of a 21-year-old man with HIV infection and Pneumocystis jirovecii pneumonia. The patient presented with fever and dyspnea with deterioration of pulmonary infiltrations 5 days after starting antiretroviral treatment. We reached the diagnosis of IRIS based on radial endobronchial ultrasound (EBUS)-guided lung biopsy. In conclusion, radial EBUS-guided lung biopsy via bronchoscopy is a valuable and minimally invasive technique for the rapid diagnosis of IRIS-associated Pneumocystis jirovecii pneumonia.
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Affiliation(s)
- Ying Wen
- Department of Infectious Disease, First Hospital of China Medical University, Shenyang, China
| | - Meng-Chan Wang
- Department of Pulmonary and Critical Care Medicine, First Hospital of China Medical University, Shenyang, China
| | - Ying Zhou
- Department of Infectious Disease, First Hospital of China Medical University, Shenyang, China
| | - Xu-Yong Lin
- Department of Pathology, First Affiliated Hospital and College of Basic Medical Sciences, Shenyang, China
| | - Gang Hou
- Department of Pulmonary and Critical Care Medicine, First Hospital of China Medical University, Shenyang, China
| | - Yan Yin
- Department of Pulmonary and Critical Care Medicine, First Hospital of China Medical University, Shenyang, China
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Wang Y, Lin X, Wen Y. Organizing pneumonia-presenting acute respiratory distress syndrome because of paradoxical tuberculosis-immune reconstitution disease? AIDS 2021; 35:351-354. [PMID: 33394677 DOI: 10.1097/qad.0000000000002752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Yu Wang
- Department of Infectious Diseases
| | - XuYong Lin
- Pathology Department, The First Hospital of China Medical University, Shenyang, Liaoning Province, China
| | - Ying Wen
- Department of Infectious Diseases
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16
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Wang Y, Zhao N, Yang J, Wen Y. Case Report: Orbital Myositis and Myasthenia Gravis as Symptoms of Immune Reconstitution Inflammatory Syndrome in a Patient With Human Immunodeficiency Virus Infection. Front Immunol 2020; 11:595068. [PMID: 33381117 PMCID: PMC7768007 DOI: 10.3389/fimmu.2020.595068] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2020] [Accepted: 11/05/2020] [Indexed: 12/15/2022] Open
Abstract
We present a case of a 37-year-old man with HIV infection who had been on antiretroviral therapy for one year. He was admitted to our hospital with red and swollen eyes, acute onset progressive exophthalmos, and intermittent diplopia endured for 7 days. His symptoms, exam, and imaging led to a diagnosis of immune reconstitution inflammatory syndrome associated orbital myositis. His symptoms improved considerably after glucocorticoid therapy. Following a reduction in the oral prednisone dose, he re-presented with left ptosis, which rapidly progressed to bilateral ptosis. Diagnostic testing led to the diagnosis of immune mediated myasthenia gravis. Treatment with pyridostigmine bromide, prednisone, and tacrolimus was initiated. One month later, the patient's symptoms improved significantly. There was a probable association between his symptoms and autoimmune immune reconstitution inflammatory syndrome. This report highlights the importance of recognizing autoimmune disorders in human immunodeficiency virus-infected patients undergoing antiretroviral therapy. Orbital myositis and myasthenia gravis in human immunodeficiency virus-infected patients correlate closely with immunity status following a marked increase in CD4+ T cell counts.
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Affiliation(s)
- Yanli Wang
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Ning Zhao
- Department of Ophthalmology, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Jun Yang
- Neurology Department, The First Affiliated Hospital of China Medical University, Shenyang, China
| | - Ying Wen
- Infectious Diseases Department, The First Affiliated Hospital of China Medical University, Shenyang, China
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Levine A, Sacktor N, Becker JT. Studying the neuropsychological sequelae of SARS-CoV-2: lessons learned from 35 years of neuroHIV research. J Neurovirol 2020; 26:809-823. [PMID: 32880873 PMCID: PMC7471564 DOI: 10.1007/s13365-020-00897-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Revised: 08/11/2020] [Accepted: 08/18/2020] [Indexed: 01/14/2023]
Abstract
The virology of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) and the human immune response to the virus are under vigorous investigation. There are now several reports describing neurological symptoms in individuals who develop coronavirus disease 2019 (COVID-19), the syndrome associated with SARS-CoV-2 infection. The prevalence, incidence, and clinical course of these symptoms will become clearer in the coming months and years through epidemiological studies. However, the long-term neurological and cognitive consequence of SARS-CoV-2 infection will remain conjectural for some time and will likely require the creation of cohort studies that include uninfected individuals. Considering the early evidence for neurological involvement in COVID-19 it may prove helpful to compare SARS-CoV-2 with another endemic and neurovirulent virus, human immunodeficiency virus-1 (HIV-1), when designing such cohort studies and when making predictions about neuropsychological outcomes. In this paper, similarities and differences between SARS-CoV-2 and HIV-1 are reviewed, including routes of neuroinvasion, putative mechanisms of neurovirulence, and factors involved in possible long-term neuropsychological sequelae. Application of the knowledge gained from over three decades of neuroHIV research is discussed, with a focus on alerting researchers and clinicians to the challenges in determining the cause of neurocognitive deficits among long-term survivors.
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Affiliation(s)
- Andrew Levine
- Department of Neurology David Geffen School of Medicine, University of California, Los Angeles, CA, 90095, USA.
| | - Ned Sacktor
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, 21205, USA
| | - James T Becker
- Departments of Psychiatry, Neurology, and Psychology, University of Pittsburgh, Pittsburgh, PA, 15260, USA
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18
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Ramírez-Amador V, Patton LL, Naglik JR, Nittayananta W. Innovations for prevention and care of oral candidiasis in HIV-infected individuals: Are they available?-A workshop report. Oral Dis 2020; 26 Suppl 1:91-102. [PMID: 32862535 DOI: 10.1111/odi.13391] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Oral candidiasis (OC) is the most prevalent HIV-related oral lesion in patients on combined anti-retroviral therapy (cART) or without cART. Management is challenged in some patients by development of resistance to azole drugs, such as fluconazole. Recent scientific knowledge about OC pathogenesis, the role of OC in the immune reconstitution inflammatory syndrome (IRIS), the relationship of OC with the microbiome, and novelties in OC treatment was discussed in an international workshop format. Literature searches were conducted to address five questions: (a) Considering the pathogenesis of Candida spp. infection, are there any potential therapeutic targets that could be considered, mainly in HIV-infected individuals resistant to fluconazole? (b) Is oral candidiasis part of IRIS in HIV patients who receive cART? (c) Can management of the oral microbiome reduce occurrence of OC in patients with HIV infection? (d) What are the recent advances (since 2015) regarding plant-based and alternative medicines in management of OC? and (e) Is there a role for photodynamic therapy in management of OC in HIV-infected patients? A number of the key areas where further research is necessary were identified to allow a deeper insight into this oral condition that could help to understand its nature and recommend alternatives for care.
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Affiliation(s)
- Velia Ramírez-Amador
- Department of Health Care, Master´s Course in Oral Pathology and Oral Medicine, Universidad Autónoma Metropolitana-Xochimilco, México City, Mexico
| | - Lauren L Patton
- Division of Craniofacial and Surgical Care, Adams School of Dentistry University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Julian R Naglik
- Centre for Host-Microbiome Interactions, Faculty of Dentistry, Oral & Craniofacial Sciences, King's College London, London, UK
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Gonzalez-Cao M, Martinez-Picado J, Rosell R. Safety of Anti-PD-L1 Inhibition in HIV-1-Infected Patients With Cancer-Reply. JAMA Oncol 2020; 6:1810-1811. [PMID: 32910172 DOI: 10.1001/jamaoncol.2020.3400] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Maria Gonzalez-Cao
- Translational Cancer Research Unit, Instituto Oncológico Dr Rosell, Dexeus University Hospital, Barcelona, Spain
| | | | - Rafael Rosell
- Translational Cancer Research Unit, Instituto Oncológico Dr Rosell, Dexeus University Hospital, Barcelona, Spain.,Institute for Health Science Research Germans Trias i Pujol (IGTP), Badalona, Spain
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AbdullGaffar B, Bashir M. Patterns of Mycobacterium avium-intracellulare complex infection in duodenal endoscopic biopsies in HIV/AIDS patients. Ann Diagn Pathol 2020; 49:151638. [PMID: 33069083 DOI: 10.1016/j.anndiagpath.2020.151638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Revised: 09/01/2020] [Accepted: 09/27/2020] [Indexed: 11/25/2022]
Abstract
Mycobacterium avium-intracellulare complex (MAIC) is a nontuberculous opportunistic infection in immunocompromised patients. Involvement of the gastrointestinal tract (GIT) is usually part of a disseminated disease in AIDS patients with a low CD4 count, however with standard antiretroviral therapy (ART), a localized presentation is more likely. It can affect any part of the GIT, mostly the duodenum and typically as patches. Incomplete or refractory ART for HIV-strains, therapy-related side effects, noncompliant or incomplete treatment to previous MAIC infections, superimposed complications and comorbid opportunistic infections may result in atypical clinical, endoscopic and histopathologic manifestations. We performed a retrospective review study retrieving cases of MAIC in duodenal endoscopic biopsy. We found five cases of MAIC in HIV/AIDS patients. They were males with an average age of 40-years. They showed different histopathologic features, variable patterns of MAIC-histiocytic infiltrates, and varying intensity of intracellular acid-fast positive bacilli. Enterocytes vacuolization and transepithelial elimination were also observed. Three cases were associated with cytomegalovirus and cryptococcal infections. A case was complicated by lymphangiectasia-associated protein-losing enteropathy. Initially, three cases were morphologically missed. Ziehl-Neelsen stain helped reach the correct diagnosis. Pathologists have an important role in patients' management by guiding clinicians to the correct diagnosis. Pathologists should be aware of these different histopathologic manifestations, their potential pitfalls, look for certain helpful clues complemented with multiple levels and special stains. In particular, AFB stains are mandatory in all mucosal biopsy specimens from HIV/AIDS patients regardless of their appearances.
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Affiliation(s)
| | - Mohamed Bashir
- Gastroenterology Unit, Rashid Hospital, Dubai, United Arab Emirates
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21
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Laberko A, Yukhacheva D, Rodina Y, Abramov D, Konovalov D, Radygina S, Shelikhova L, Pershin D, Kadnikova O, Maschan M, Maschan A, Balashov D, Shcherbina A. BCG-Related Inflammatory Syndromes in Severe Combined Immunodeficiency After TCRαβ+/CD19+ Depleted HSCT. J Clin Immunol 2020; 40:625-636. [PMID: 32377975 DOI: 10.1007/s10875-020-00774-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Accepted: 03/22/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION The live-attenuated BCG vaccine is known to cause disseminated Mycobacterium bovis infection in patients with severe combined immunodeficiency (SCID). However, BCG-related post-hematopoietic stem cell transplantation (HSCT) immune reconstitution inflammatory syndromes, similar to those described in patients with HIV infections, are less-known complications of SCID. PATIENTS AND METHODS We reported on 22 BCG-vaccinated SCID patients who had received conditioned allogeneic HSCT with TCRαβ+/CD19+ graft depletion. All BCG-vaccinated patients received anti-mycobacterial therapy pre- and post-HSCT. Post-transplant immunosuppression consisted of tacrolimus in 10 patients and of 8 mg/kg tocilizumab (d-1, + 14, + 28) and 10 mg/kg abatacept (d-1, + 5, + 14, + 28) in 11 patients. RESULTS Twelve patients, five of whom had BCG infection prior to HSCT, developed BCG-related inflammatory syndromes (BCG-IS). Five developed early BCG-IS with the median time of manifestation 11 days after HSCT, corresponding with a dramatic increase of CD3+TCRγδ+ in at least two patients. Early BCG-IS was noted in only one out of 11 patients who received tocilizumab/abatacept and 4 out of 11 patients who did not. Seven patients developed late BCG-IS which corresponded to T cell immune recovery; at the time of manifestation (median 4.2 months after HSCT), the median number of CD3+ cells was 0.42 × 109/ and CD3+CD4+ cells 0.27 × 109/l. In all patients, late BCG-IS was controlled with IL-1 or IL-6 inhibitors. CONCLUSION BCG-vaccinated SCID patients undergoing allogeneic HSCT with TCRαβ+/CD19+ graft depletion are at an increased risk of early and late BCG-IS. Anti-inflammatory therapy with IL-1 and IL-6 blockade is efficient in the prevention of early and treatment of late BCG-IS.
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Affiliation(s)
- Alexandra Laberko
- Department of Immunology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, 1, Samory Mashela str., Moscow, Russia, 117997.
| | - Daria Yukhacheva
- Department of Immunology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, 1, Samory Mashela str., Moscow, Russia, 117997
| | - Yulia Rodina
- Department of Immunology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, 1, Samory Mashela str., Moscow, Russia, 117997
| | - Dmitriy Abramov
- Department of Pathology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, 1, Samory Mashela str., Moscow, Russia, 117997
| | - Dmitriy Konovalov
- Department of Pathology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, 1, Samory Mashela str., Moscow, Russia, 117997
| | - Svetlana Radygina
- Department of Hematopoietic Stem Cell Transplantation, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, 1, Samory Mashela str., Moscow, Russia, 117997
| | - Larisa Shelikhova
- Department of Hematopoietic Stem Cell Transplantation, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, 1, Samory Mashela str., Moscow, Russia, 117997
| | - Dmitry Pershin
- Laboratory of Hematopoietic Stem Cell Transplantation and Immunotherapy, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, 1, Samory Mashela str., Moscow, Russia, 117997
| | - Olga Kadnikova
- Phtisiology Consultant, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, Moscow, Russia
| | - Michael Maschan
- Department of Hematopoietic Stem Cell Transplantation, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, 1, Samory Mashela str., Moscow, Russia, 117997
| | - Alexei Maschan
- Department of Hematopoietic Stem Cell Transplantation, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, 1, Samory Mashela str., Moscow, Russia, 117997
| | - Dmitry Balashov
- Department of Hematopoietic Stem Cell Transplantation, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, 1, Samory Mashela str., Moscow, Russia, 117997
| | - Anna Shcherbina
- Department of Immunology, Dmitry Rogachev National Medical Center of Pediatric Hematology, Oncology and Immunology, 1, Samory Mashela str., Moscow, Russia, 117997
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Barbier F, Mer M, Szychowiak P, Miller RF, Mariotte É, Galicier L, Bouadma L, Tattevin P, Azoulay É. Management of HIV-infected patients in the intensive care unit. Intensive Care Med 2020; 46:329-342. [PMID: 32016535 PMCID: PMC7095039 DOI: 10.1007/s00134-020-05945-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2019] [Accepted: 01/20/2020] [Indexed: 12/19/2022]
Abstract
The widespread use of combination antiretroviral therapies (cART) has converted the prognosis of HIV infection from a rapidly progressive and ultimately fatal disease to a chronic condition with limited impact on life expectancy. Yet, HIV-infected patients remain at high risk for critical illness due to the occurrence of severe opportunistic infections in those with advanced immunosuppression (i.e., inaugural admissions or limited access to cART), a pronounced susceptibility to bacterial sepsis and tuberculosis at every stage of HIV infection, and a rising prevalence of underlying comorbidities such as chronic obstructive pulmonary diseases, atherosclerosis or non-AIDS-defining neoplasms in cART-treated patients aging with controlled viral replication. Several patterns of intensive care have markedly evolved in this patient population over the late cART era, including a steady decline in AIDS-related admissions, an opposite trend in admissions for exacerbated comorbidities, the emergence of additional drivers of immunosuppression (e.g., anti-neoplastic chemotherapy or solid organ transplantation), the management of cART in the acute phase of critical illness, and a dramatic progress in short-term survival that mainly results from general advances in intensive care practices. Besides, there is a lack of data regarding other features of ICU and post-ICU care in these patients, especially on the impact of sociological factors on clinical presentation and prognosis, the optimal timing of cART introduction in AIDS-related admissions, determinants of end-of-life decisions, long-term survival, and functional outcomes. In this narrative review, we sought to depict the current evidence regarding the management of HIV-infected patients admitted to the intensive care unit.
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Affiliation(s)
- François Barbier
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France.
| | - Mervin Mer
- Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, South Africa
- Division of Critical Care and Pulmonology, Department of Medicine, Charlotte Maxeke Johannesburg University Hospital, Johannesburg, South Africa
| | - Piotr Szychowiak
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
| | - Robert F Miller
- Research Department of Infection and Population Health, University College London, London, UK
| | - Éric Mariotte
- Medical Intensive Care Unit, Saint-Louis University Hospital, APHP, Paris, France
| | - Lionel Galicier
- Department of Clinical Immunology, Saint-Louis University Hospital, APHP, Paris, France
| | - Lila Bouadma
- Medical and Infectious Diseases Intensive Care Unit, Bichat-Claude Bernard University Hospital, APHP, Paris, France
- Paris Diderot University, IAME-UMR 1137, INSERM, Paris, France
| | - Pierre Tattevin
- Infectious Diseases and Medical Intensive Care Unit, Pontchaillou University Hospital, Rennes, France
| | - Élie Azoulay
- Medical Intensive Care Unit, Saint-Louis University Hospital, APHP, Paris, France.
- ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic, Sorbonne-Paris Cité, CRESS), INSERM, Paris Diderot University, Paris, France.
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Gouel-Cheron A, Nason M, Rupert A, Sheikh V, Robby G, Fahle GA, Sereti I. Cardiovascular Biomarker Profile on Antiretroviral Therapy Is Not Influenced by History of an IRIS Event in People With HIV and Suppressed Viremia. Open Forum Infect Dis 2020; 7:ofaa017. [PMID: 32016127 PMCID: PMC6991617 DOI: 10.1093/ofid/ofaa017] [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: 10/28/2019] [Accepted: 01/09/2020] [Indexed: 11/13/2022] Open
Abstract
Immune reconstitution inflammatory syndrome (IRIS) is characterized by release of proinflammatory cytokines and tissue inflammation occurring early after antiretroviral therapy (ART) initiation. The role of previous IRIS events in persistent chronic inflammation in people with HIV is currently unclear. In this retrospective analysis of 143 participants who maintained suppression of HIV viremia, we compared biomarkers related to inflammation, coagulation, and cardiovascular risk after 3 years on ART in participants with and without a history of IRIS. There was no evidence of higher levels of persistent chronic inflammation in people with HIV who had a history of an IRIS event. ClinicalTrials.gov Identifier . NCT00286767.
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Affiliation(s)
- Aurelie Gouel-Cheron
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, USA
- Département d’Anesthésie et Réanimation Chirurgicale, Université de Paris, Groupe Hospitalier Bichat Claude Bernard, Assistance Publique Hôpitaux de Paris, Paris, France
- Unit of Antibodies in Therapy and Pathology, Pasteur Institut, UMR INSERM, Paris, France
| | - Martha Nason
- Biostatistics Research Branch, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Rockville, Maryland, USA
| | - Adam Rupert
- Leidos Biomedical Research Inc., NCI Campus at Frederick, Frederick, Maryland, USA
| | - Virginia Sheikh
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Greg Robby
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Gary A Fahle
- Department of Laboratory Medicine, Clinical Center (CC), National Institutes of Health, Bethesda, Maryland, USA
| | - Irini Sereti
- Laboratory of Immunoregulation, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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24
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Ramos-E-Silva M, Secchin P, Trope B. The life-threatening eruption in HIV and immunosuppression. Clin Dermatol 2019; 38:52-62. [PMID: 32197749 DOI: 10.1016/j.clindermatol.2019.10.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Immunosuppressed patients frequently have skin diseases of mild to moderate intensity. Diagnosis as well as treatment should be performed early to avoid important complications for these patients. Skin eruptions are among these problems. Life-threatening eruptions in HIV and other types of immunosuppression range from acute retroviral syndrome to drug eruptions; immune reconstitution inflammatory syndrome; infection by virus, protozoan, bacteria, or fungi; inflammatory and immune dermatoses; and neoplasia. All of these are discussed in this group of patients.
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Affiliation(s)
- Marcia Ramos-E-Silva
- The Sector of Dermatology and Post-Graduation Course in Dermatology, University Hospital and School of Medicine, Federal University of Rio de Janeiro, Brazil.
| | - Pedro Secchin
- The Sector of Dermatology and Post-Graduation Course in Dermatology, University Hospital and School of Medicine, Federal University of Rio de Janeiro, Brazil
| | - Beatriz Trope
- The Sector of Dermatology and Post-Graduation Course in Dermatology, University Hospital and School of Medicine, Federal University of Rio de Janeiro, Brazil
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25
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Cevaal PM, Bekker LG, Hermans S. TB-IRIS pathogenesis and new strategies for intervention: Insights from related inflammatory disorders. Tuberculosis (Edinb) 2019; 118:101863. [PMID: 31561185 DOI: 10.1016/j.tube.2019.101863] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 09/10/2019] [Accepted: 09/12/2019] [Indexed: 12/29/2022]
Abstract
In almost one in five HIV/tuberculosis (TB) co-infected patients, initiation of antiretroviral therapy (ART) is complicated by TB immune reconstitution inflammatory syndrome (TB-IRIS). Corticosteroids have been suggested for treatment of severe cases, however no therapy is currently licensed for TB-IRIS. Hence, there is a strong need for more specific therapeutics, and therefore, a better understanding of TB-IRIS pathogenesis. Immune reconstitution following ART is a precariously balanced functional restoration of adaptive immunity. In those patients predisposed to disease, an incomplete activation of the innate immune system leads to a hyper-inflammatory response that comprises partially overlapping innate, adaptive and effector arms, eventually leading to clinical symptoms. Interestingly, many of these pathological mechanisms are shared by related inflammatory disorders. We here describe therapeutic strategies that originate from these other disciplines and discuss their potential application in TB-IRIS. These new avenues of interventions range from final-phase treatment of symptoms to early-phase prevention of disease onset. In conclusion, we propose a novel approach for the discovery and development of therapeutics, based on an updated model of TB-IRIS pathogenesis. Further experimental studies validating the causal relationships in the proposed model could greatly contribute to providing a solid immunological basis for future clinical trials on TB-IRIS therapeutics.
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Affiliation(s)
- Paula M Cevaal
- Amsterdam UMC, University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam Public Health Research Institute, Paasheuvelweg 25, 1105, BP Amsterdam, the Netherlands.
| | - Linda-Gail Bekker
- Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa
| | - Sabine Hermans
- Amsterdam UMC, University of Amsterdam, Department of Global Health, Amsterdam Institute for Global Health and Development, Amsterdam Public Health Research Institute, Paasheuvelweg 25, 1105, BP Amsterdam, the Netherlands; Desmond Tutu HIV Centre, Institute for Infectious Disease and Molecular Medicine, University of Cape Town, Anzio Rd, Observatory, 7925, Cape Town, South Africa
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26
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Azoulay É, de Castro N, Barbier F. Critically Ill Patients With HIV: 40 Years Later. Chest 2019; 157:293-309. [PMID: 31421114 DOI: 10.1016/j.chest.2019.08.002] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/25/2019] [Accepted: 08/04/2019] [Indexed: 01/27/2023] Open
Abstract
The development of combination antiretroviral therapies (cARTs) in the mid-1990s has dramatically modified the clinical presentation of critically ill, HIV-infected patients. Most cART-treated patients aging with controlled HIV replication are currently admitted to the ICU for non-AIDS-related events, mostly bacterial pneumonia and exacerbation of comorbidities, variably affected by chronic HIV infection (COPD, cardiovascular diseases, or solid neoplasms). Today, Pneumocystis jirovecii pneumonia, cerebral toxoplasmosis, TB, and other severe opportunistic infections only occur in patients with unknown viral status, limited access to cART, viral resistance, or compliance issues. Acute respiratory failure, neurological disorders, and sepsis remain the main conditions that lead HIV-infected patients to the ICU, although admissions for liver diseases or acute kidney injury are increasing. Case fatality dropped substantially over the past decades, reaching figures of HIV-uninfected critically ill patients with similar demographic characteristics, comorbidities, and level of organ dysfunctions. Several other facets of critical care management have evolved in this population, including diagnostic procedures, cART management at the acute phase of critical illness, and ethical considerations. The goal of this narrative review was to depict the current evidence and emerging challenges for the management of critically ill, HIV-infected patients, almost 40 years following the onset of the AIDS epidemic.
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Affiliation(s)
- Élie Azoulay
- Medical Intensive Care Unit, Saint-Louis Hospital, APHP, Paris, France; ECSTRA, SBIM, and the Saint-Louis Hospital, APHP, Paris, France.
| | - Nathalie de Castro
- Department of Infectious Diseases, Saint-Louis Hospital, APHP, Paris, France
| | - François Barbier
- Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France
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27
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Herrera Vazquez O, Romo ML, Fleury A. Neurocysticercosis and HIV Infection: what can we learn from the published literature? ARQUIVOS DE NEURO-PSIQUIATRIA 2019; 77:357-365. [PMID: 31189001 DOI: 10.1590/0004-282x20190054] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Accepted: 02/11/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE Infections caused by the human immunodeficiency virus (HIV) and by the larvae of Taenia solium (i.e., cysticercosis) are still widespread in many developing countries. Both pathologies modify host immune status and it is possible that HIV infection may modulate the frequency and pathogeny of cysticercosis of the central nervous system (i.e., neurocysticercosis [NCC]). To describe published cases of NCC among HIV-positive patients and to evaluate whether the characteristics of NCC, including frequency, symptoms, radiological appearance, and response to treatment differed between HIV-positive and HIV-negative patients. METHODS Forty cases of NCC/HIV co-infected patients were identified in the literature. Clinical and radiological characteristics, as well as response to treatment, were compared with non-matching historical series of NCC patients without HIV infection. RESULTS Most of these patients had seizures and multiple vesicular parasites located in parenchyma. Clinical and radiological characteristics were similar between HIV-positive and HIV-negative patients with NCC, as well as between immunocompromised and non-immunocompromised HIV-positive patients. CONCLUSION Our review did not reveal clear interactions between HIV and NCC. This may be partially due to the small number of cases and reliance on published research. A systematic, multi-institutional effort aiming to report all the cases of this dual pathology is needed to confirm this finding and to clarify the possible relationship between both pathogens.
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Affiliation(s)
- Omar Herrera Vazquez
- Instituto de Investigaciones Biomédicas, Unidad de Neuroinflamación, UNAM, Ciudad de México, México.,Instituto Nacional de Neurología y Neurocirugía, Clínica de Neurocisticercosis. Ciudad de México, México
| | - Matthew L Romo
- School of Public Health, Li Ka Shing Faculty of Medicine, The University of Hong Kong. Hong Kong
| | - Agnès Fleury
- Instituto de Investigaciones Biomédicas, Unidad de Neuroinflamación, UNAM, Ciudad de México, México.,Instituto Nacional de Neurología y Neurocirugía, Clínica de Neurocisticercosis. Ciudad de México, México
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28
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Bolles K, Woc-Colburn L, Hamill RJ, Hemmige V. Ordering Patterns and Costs of Specialized Laboratory Testing by Hospitalists and House Staff in Hospitalized Patients With HIV at a County Hospital: An Opportunity for Diagnostic Stewardship. Open Forum Infect Dis 2019; 6:ofz158. [PMID: 31205970 PMCID: PMC6557192 DOI: 10.1093/ofid/ofz158] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 03/23/2019] [Indexed: 01/17/2023] Open
Abstract
Background Inpatient HIV care often requires specialized laboratory testing with which practitioners may not be familiar. In addition, computerized physician order entry allows for ordering tests without understanding test indications, but it can also provide a venue for education and diagnostic stewardship. Methods All charts of HIV-positive patients hospitalized at a tertiary care public safety net hospital in Houston, Texas, between January 1, 2014, and June 30, 2014, were reviewed for a set list of laboratory tests. Appropriateness of test ordering was assessed by 2 providers. Cost estimates for each test were obtained from Medicaid and a national nonprofit health care charge database. Results A total of 274 HIV-positive patients were admitted 429 times in the 6-month study period. During the study period, 45% of the study laboratory tests ordered were not indicated. A total of 532 hepatitis serologies were ordered, only 52% of which were indicated. Overall, 71 serum qualitative cytomegalovirus (CMV) polymerase chain reactions (PCRs) and eight CMV quantitative PCRs were ordered, with most (85%) qualitative PCRs ordered for nonspecific signs of infection (eg, fever). Other tests ordered without clear indications included Aspergillus IgE (7), serum Epstein-Barr virus (EBV) PCR (5), parvovirus serology (7), and Toxoplasma IgM (18). Overall, the estimated laboratory cost of inappropriate testing over the study period was between $14 000 and $92 000, depending on which cost database was used. Conclusions Many tests ordered in HIV-positive inpatients do not have indications, representing a substantial source of health care waste and cost and potentially leading to inappropriate treatment. Opportunities exist to decrease waste through education of trainees and hospitalists and through implementation of diagnostic stewardship via the electronic medical record.
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Affiliation(s)
- Kathryn Bolles
- Department of Medicine, University of Washington, Seattle, Washington
| | - Laila Woc-Colburn
- Division of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas
| | - Richard J Hamill
- Division of Infectious Diseases, Department of Medicine, Baylor College of Medicine, Houston, Texas.,Medical Care Line, Section of Infectious Diseases, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Vagish Hemmige
- Division of Infectious Diseases, Montefiore Medical Center, Bronx, New York
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29
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Yang S, Li M, Cheng J, Wan G, Zhou Y, Jia H, Wei H, Song R, Sheng L, Wang H, Wang L, Hua W. Diagnostic determination of Norovirus infection as one of the major causes of infectious diarrhea in HIV patients using a multiplex polymerase chain reaction assay. Int J STD AIDS 2019; 30:550-556. [PMID: 30722749 DOI: 10.1177/0956462418824912] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Although infectious diarrhea is one of the most common complications in human immunodeficiency virus (HIV)-infected patients, robust diagnostic methods for determining potential pathogens are still limited in the clinic. Norovirus, a type of calicivirus, has been shown to be the most common cause of gastroenteritis. Here, we used multiplex polymerase chain reaction as a diagnostic tool to verify Norovirus as the diarrhea-related pathogen in HIV-infected patients with unknown etiological information. Stool specimens obtained from 81 HIV-infected patients with diarrhea were analyzed by BioFire FilmArray Gastrointestinal (GI) panel. Among 26 HIV-infected patients with unknown etiological information, we detected Norovirus in 14 stool specimens of these patients with 100% sensitivity and specificity as confirmed by reverse transcription polymerase chain reaction (RT-PCR), and one specimen showed both Norovirus and enterotoxigenic Escherichia coli infection. Among the remaining 55 patients with verified Clostridium difficile infection, nine patients also detected positive for Norovirus infection. In conclusion, using FilmArray GI panel and RT-PCR, we determined that Norovirus infection as one of the main pathogens responsible for diarrhea in HIV patients.
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Affiliation(s)
- Siyuan Yang
- 1 The Laboratory of Infectious Diseases Centre, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Min Li
- 2 Clinical Laboratory of Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Jingwei Cheng
- 2 Clinical Laboratory of Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Gang Wan
- 3 Medical Information Department, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Yunao Zhou
- 4 Department of Research and Education, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hongyu Jia
- 2 Clinical Laboratory of Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Hongshan Wei
- 5 Department of Gastroenterology, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Rui Song
- 6 Department of Infectious Disease, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Linjun Sheng
- 2 Clinical Laboratory of Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Huizhu Wang
- 2 Clinical Laboratory of Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Linghang Wang
- 7 Department of Emergency, Beijing Ditan Hospital, Capital Medical University, Beijing, China
| | - Wenhao Hua
- 2 Clinical Laboratory of Beijing Ditan Hospital, Capital Medical University, Beijing, China
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30
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Vidal JE. HIV-Related Cerebral Toxoplasmosis Revisited: Current Concepts and Controversies of an Old Disease. J Int Assoc Provid AIDS Care 2019; 18:2325958219867315. [PMID: 31429353 PMCID: PMC6900575 DOI: 10.1177/2325958219867315] [Citation(s) in RCA: 66] [Impact Index Per Article: 13.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Revised: 06/14/2019] [Accepted: 06/28/2019] [Indexed: 01/06/2023] Open
Abstract
Cerebral toxoplasmosis is the most common cause of expansive brain lesions in people living with HIV/AIDS (PLWHA) and continues to cause high morbidity and mortality. The most frequent characteristics are focal subacute neurological deficits and ring-enhancing brain lesions in the basal ganglia, but the spectrum of clinical and neuroradiological manifestations is broad. Early initiation of antitoxoplasma therapy is an important feature of the diagnostic approach of expansive brain lesions in PLWHA. Pyrimethamine-based regimens and trimethoprim-sulfamethoxazole (TMP-SMX) seem to present similar efficacy, but TMP-SMX shows potential practical advantages. The immune reconstitution inflammatory syndrome is uncommon in cerebral toxoplasmosis, and we now have more effective, safe, and friendly combined antiretroviral therapy (cART) options. As a consequence of these 2 variables, the initiation of cART can be performed within 2 weeks after initiation of antitoxoplasma therapy. Herein, we will review historical and current concepts of epidemiology, diagnosis, and treatment of HIV-related cerebral toxoplasmosis.
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Affiliation(s)
- José Ernesto Vidal
- Departamento de Neurologia, Instituto de Infectologia Emílio Ribas, São
Paulo, Brazil
- Departamento de Moléstias Infecciosas e Parasitárias, Hospital das Clínicas
HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, São Paulo, Brazil
- Laboratório de Investigação Médica em Protozoologia, Bacteriologia e
Resistência Antimicrobiana (LIM 49), Instituto de Medicina Tropical, Universidade de São
Paulo, São Paulo, Brazil
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31
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Emu B, Fessel J, Schrader S, Kumar P, Richmond G, Win S, Weinheimer S, Marsolais C, Lewis S. Phase 3 Study of Ibalizumab for Multidrug-Resistant HIV-1. N Engl J Med 2018; 379:645-654. [PMID: 30110589 DOI: 10.1056/nejmoa1711460] [Citation(s) in RCA: 130] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Ibalizumab, a humanized IgG4 monoclonal antibody, blocks the entry of human immunodeficiency virus type 1 (HIV-1) by noncompetitive binding to CD4. METHODS In this single-group, open-label, phase 3 study, we enrolled 40 adults with multidrug-resistant (MDR) HIV-1 infection in whom multiple antiretroviral therapies had failed. All the patients had a viral load of more than 1000 copies of HIV-1 RNA per milliliter. After a 7-day control period in which patients continued to receive their current therapy, a loading dose of 2000 mg of ibalizumab was infused; the viral load was quantified 7 days later. Through week 25 of the study, patients received 800 mg of ibalizumab every 14 days, combined with an individually optimized background regimen including at least one fully active agent. The primary end point was the proportion of patients with a decrease in viral load of at least 0.5 log10 copies per milliliter from baseline (day 7) to day 14. RESULTS A total of 31 patients completed the study. The mean baseline viral load was 4.5 log10 copies per milliliter, and the mean CD4 count was 150 per microliter. Of the 40 patients in the intention-to-treat population, 33 (83%) had a decrease in viral load of at least 0.5 log10 copies per milliliter from baseline (P<0.001 for the comparison with the control period). The mean viral-load decrease was 1.1 log10 copies per milliliter. During the control period, 1 patient, who received the optimized background regimen prematurely, had a decrease in viral load of 0.5 log10 copies per milliliter. At week 25, patients who had received ibalizumab plus an optimized background regimen had a mean decrease of 1.6 log10 copies per milliliter from baseline; 43% of the patients had a viral load of less than 50 copies per milliliter, and 50% had a viral load of less than 200 copies per milliliter. Among 10 patients who had virologic failure or rebound, in vitro testing identified 9 who had a lower degree of susceptibility to ibalizumab than at baseline. The most common adverse event was diarrhea (in 20% of patients). Four patients died from causes related to underlying illnesses; 1 had a serious adverse event (the immune reconstitution inflammatory syndrome) that was deemed to be related to ibalizumab therapy. CONCLUSIONS In patients with MDR HIV-1 infection who had advanced disease and limited treatment options, ibalizumab had significant antiviral activity during a 25-week study. Evidence of the emergence of diminished ibalizumab susceptibility was observed in vitro in patients who had virologic failure. (Funded by the Orphan Products Clinical Trials Grants Program of the Food and Drug Administration and TaiMed Biologics; TMB-301 ClinicalTrials.gov number, NCT02475629 .).
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Affiliation(s)
- Brinda Emu
- From the Yale School of Medicine, New Haven, CT (B.E.); Kaiser Foundation Research Institute (J.F.) and Quest Clinical Research (S. Win), San Francisco; Schrader Clinic, Houston (S.S.); Georgetown University, Washington, DC (P.K.); Nova Southeastern University, Ft. Lauderdale, FL, and Florida International University, Miami (G.R.); TaiMed Biologics, Irvine, CA (S. Weinheimer, S.L.); and Theratechnologies, Montreal (C.M.)
| | - Jeffrey Fessel
- From the Yale School of Medicine, New Haven, CT (B.E.); Kaiser Foundation Research Institute (J.F.) and Quest Clinical Research (S. Win), San Francisco; Schrader Clinic, Houston (S.S.); Georgetown University, Washington, DC (P.K.); Nova Southeastern University, Ft. Lauderdale, FL, and Florida International University, Miami (G.R.); TaiMed Biologics, Irvine, CA (S. Weinheimer, S.L.); and Theratechnologies, Montreal (C.M.)
| | - Shannon Schrader
- From the Yale School of Medicine, New Haven, CT (B.E.); Kaiser Foundation Research Institute (J.F.) and Quest Clinical Research (S. Win), San Francisco; Schrader Clinic, Houston (S.S.); Georgetown University, Washington, DC (P.K.); Nova Southeastern University, Ft. Lauderdale, FL, and Florida International University, Miami (G.R.); TaiMed Biologics, Irvine, CA (S. Weinheimer, S.L.); and Theratechnologies, Montreal (C.M.)
| | - Princy Kumar
- From the Yale School of Medicine, New Haven, CT (B.E.); Kaiser Foundation Research Institute (J.F.) and Quest Clinical Research (S. Win), San Francisco; Schrader Clinic, Houston (S.S.); Georgetown University, Washington, DC (P.K.); Nova Southeastern University, Ft. Lauderdale, FL, and Florida International University, Miami (G.R.); TaiMed Biologics, Irvine, CA (S. Weinheimer, S.L.); and Theratechnologies, Montreal (C.M.)
| | - Gary Richmond
- From the Yale School of Medicine, New Haven, CT (B.E.); Kaiser Foundation Research Institute (J.F.) and Quest Clinical Research (S. Win), San Francisco; Schrader Clinic, Houston (S.S.); Georgetown University, Washington, DC (P.K.); Nova Southeastern University, Ft. Lauderdale, FL, and Florida International University, Miami (G.R.); TaiMed Biologics, Irvine, CA (S. Weinheimer, S.L.); and Theratechnologies, Montreal (C.M.)
| | - Sandra Win
- From the Yale School of Medicine, New Haven, CT (B.E.); Kaiser Foundation Research Institute (J.F.) and Quest Clinical Research (S. Win), San Francisco; Schrader Clinic, Houston (S.S.); Georgetown University, Washington, DC (P.K.); Nova Southeastern University, Ft. Lauderdale, FL, and Florida International University, Miami (G.R.); TaiMed Biologics, Irvine, CA (S. Weinheimer, S.L.); and Theratechnologies, Montreal (C.M.)
| | - Steven Weinheimer
- From the Yale School of Medicine, New Haven, CT (B.E.); Kaiser Foundation Research Institute (J.F.) and Quest Clinical Research (S. Win), San Francisco; Schrader Clinic, Houston (S.S.); Georgetown University, Washington, DC (P.K.); Nova Southeastern University, Ft. Lauderdale, FL, and Florida International University, Miami (G.R.); TaiMed Biologics, Irvine, CA (S. Weinheimer, S.L.); and Theratechnologies, Montreal (C.M.)
| | - Christian Marsolais
- From the Yale School of Medicine, New Haven, CT (B.E.); Kaiser Foundation Research Institute (J.F.) and Quest Clinical Research (S. Win), San Francisco; Schrader Clinic, Houston (S.S.); Georgetown University, Washington, DC (P.K.); Nova Southeastern University, Ft. Lauderdale, FL, and Florida International University, Miami (G.R.); TaiMed Biologics, Irvine, CA (S. Weinheimer, S.L.); and Theratechnologies, Montreal (C.M.)
| | - Stanley Lewis
- From the Yale School of Medicine, New Haven, CT (B.E.); Kaiser Foundation Research Institute (J.F.) and Quest Clinical Research (S. Win), San Francisco; Schrader Clinic, Houston (S.S.); Georgetown University, Washington, DC (P.K.); Nova Southeastern University, Ft. Lauderdale, FL, and Florida International University, Miami (G.R.); TaiMed Biologics, Irvine, CA (S. Weinheimer, S.L.); and Theratechnologies, Montreal (C.M.)
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32
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Bolanos R, Martinez-Maza O, Zhang ZF, Hussain S, Sehl M, Sinsheimer JS, D'Souza G, Jenkins F, Wolinsky S, Detels R. Decreased levels of the serum inflammatory biomarkers, sGP130, IL-6, sCRP and BAFF, are associated with increased likelihood of AIDS related Kaposi's sarcoma in men who have sex with men. ACTA ACUST UNITED AC 2018; 4:45-59. [PMID: 33521162 PMCID: PMC7845762 DOI: 10.17980/2018.45] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
AIDS-related Kaposi’s sarcoma (AIDS-KS) risk remains substantially elevated compared with the general population, even among patients who receive effective combination antiretroviral therapy. This study investigated the role of inflammatory and immune activating biomarkers in AIDS-KS in men who have sex with men in the Multicenter AIDS Cohort study between 1984 and 2010. Concentrations of 24 serum biomarkers; IL-1β, IL-2, IL-6, IL-8, IL-10, IL-12p70, sGP130, sIL-2Rα, sIL-6R, eotaxin, MCP-1, MCP4, MIP 1β, TARC, BLC-BCA1, IP-10, GM-CSF, IFN-γ, BAFF, sCD14, CD27, sTNFR-2, sCRP, and TNF-α were tested longitudinally in 1,501 men. The concentrations of each biomarker were compared between AIDS-KS cases and controls at multiple time points, 0–1 years, 1–2 years, 2–3 year, 3–5 years and over 5 years, prior to KS diagnosis or study termination, using univariate non-parametric Kruskal-Wallis tests and logistic regression, adjusted for HBV and HCV co-infection, race/ethnicity, age at last visit, education, smoking and CD4+ cell count. In univariate analyses, concentrations of four markers were consistently higher in cases; sIL-2Rα, IP-10, sTNFR-2, MCP-1, and five were higher in controls; GM-CSF, IL-6, MIP-1β, sCRP, sGP130. In the adjusted models concentrations of four markers were significantly inversely associated with AIDS-KS risk including sGP130 (OR=0.14, 95% CI = 0.03–0.73, BAFF (OR=0.60, 95% CI =0.16–0.90), sCRP (OR=0.61, 95% CI = 0.43–0.87) and IL-6 (OR=0.51, 95% CI = 0.35–0.76). These results support a role for markers of immune activation and inflammation in AIDS-KS and may highlight pathways to be targeted for risk stratification or therapeutics.
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Affiliation(s)
- Rachel Bolanos
- Department of Epidemiology, Fielding School of Public Health, UCLA, Los Angeles, CA
| | - Otoniel Martinez-Maza
- Department of Epidemiology, Fielding School of Public Health, UCLA, Los Angeles, CA.,Departments of Obstetrics and Gynecology, and Microbiology, Immunology, and Molecular Genetics, David Geffen School of Medicine, UCLA, Los Angeles, CA.,Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA.,UCLA AIDS Institute, UCLA, Los Angeles, CA
| | - Zuo-Feng Zhang
- Department of Epidemiology, Fielding School of Public Health, UCLA, Los Angeles, CA.,Jonsson Comprehensive Cancer Center, UCLA, Los Angeles, CA
| | - Shehnaz Hussain
- Department of Epidemiology, Fielding School of Public Health, UCLA, Los Angeles, CA.,Department of Medicine and Comprehensive Cancer Center, Cedars-Sinai Medical Center, West Hollywood, CA
| | - Mary Sehl
- Department of Medicine, Division of Hematology/Oncology, AIDS Institute, UCLA, Los Angeles, California.,Biomathematics, David Geffen School of Medicine, UCLA, Los Angeles, California
| | - Janet S Sinsheimer
- Department of Human Genetics, UCLA, Los Angeles, California.,Biomathematics, David Geffen School of Medicine, UCLA, Los Angeles, California.,Department of Biostatistics, School of Public Health, UCLA, Los Angeles, California
| | - Gypsyarn D'Souza
- Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD
| | - Frank Jenkins
- University of Pittsburgh Cancer Institute, Pittsburgh, PA
| | - Steven Wolinsky
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago Illinois
| | - Roger Detels
- Department of Epidemiology, Fielding School of Public Health, UCLA, Los Angeles, CA
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Looking for fungi in all the right places: screening for cryptococcal disease and other AIDS-related mycoses among patients with advanced HIV disease. Curr Opin HIV AIDS 2017; 12:139-147. [PMID: 28134711 DOI: 10.1097/coh.0000000000000347] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
PURPOSE OF REVIEW As HIV treatment programmes scale up to meet the UNAIDS 90-90-90 goals, care must be taken to start antiretroviral treatment safely in patients with advanced disease (CD4 counts <200 cells/μl) who are simultaneously at risk for opportunistic infections and immune reconstitution inflammatory syndrome. Invasive fungal diseases pose a great threat at this critical time point, though the development of inexpensive and highly accurate rapid diagnostic tests has changed the approach HIV programmes are taking to reduce the high mortality associated with these opportunistic infections. This article summarizes recent advances and findings in fungal opportunistic infection diagnostics with a focus on screening to prevent cryptococcal meningitis. RECENT FINDINGS Cryptococcal antigen (CrAg) screening using a lateral flow assay platform is cost-effective and feasible to implement as either a laboratory reflex or point-of-care test. Recent CrAg screening pilots have elucidated the varying prevalence of cryptococcal antigenemia across geographic regions, which may aid programme planning. Evidence from recently completed clinical trials provides a strong motivation for the use of CrAg titer to refine treatment options for patients with subclinical cryptococcal disease. SUMMARY Although several operational barriers to programme effectiveness still need to be addressed, the utility of CrAg screening using inexpensive and accurate antigen assays has been demonstrated in real-world HIV programmes, paving the way for development and testing of other fungal opportunistic infection screening strategies and for an integrated advanced HIV disease testing package to reduce AIDS mortality and ensure safe antiretroviral treatment initiation.
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Matusz-Fisher A, Bodie W, Montgomery T. Immune Reconstitution Inflammatory Syndrome Presenting as Mycobacterium Avium Complex Lymphadenitis. J Gen Intern Med 2017; 32:712-713. [PMID: 28000104 PMCID: PMC5442004 DOI: 10.1007/s11606-016-3956-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Revised: 11/04/2016] [Accepted: 12/05/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Ashley Matusz-Fisher
- Department of Internal Medicine, Carolinas HealthCare System, Charlotte, NC, USA.
| | - Wesley Bodie
- Department of Internal Medicine, Carolinas HealthCare System, Charlotte, NC, USA
| | - Thomas Montgomery
- Department of Internal Medicine, Carolinas HealthCare System, Charlotte, NC, USA
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Nelson AM, Manabe YC, Lucas SB. Immune Reconstitution Inflammatory Syndrome (IRIS): What pathologists should know. Semin Diagn Pathol 2017; 34:340-351. [PMID: 28552210 DOI: 10.1053/j.semdp.2017.04.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Antiretroviral therapy has significantly improved the quality and length of life for those patients able to access effective and sustained treatment. The resulting restoration of the immune response is associated with a change in the clinical presentation of opportunistic infections, and the histologic reaction to pathogens. A complex combination of alterations in host response across the stages of HIV infection has been documented over the past 3 decades. The defects are seen in both acute and chronic phases of inflammation and involve innate and adaptive immunity. In advanced stages of HIV infection, the marked disruption of lymphoid tissue and loss of follicular dendritic cells limits the host's ability to process antigen and mount specific responses to pathogens. There are qualitative and quantitative defects in CD4 T cells due to HIV infection. The resulting indirect effects include loss of cytokine production, dysregulation of B-cell function, loss of cellular mediated immunity and "holes" in the immunologic repertoire that may not be restored with the use of antiretroviral therapy. Immune reconstitution allows the host to respond to and control infection, but a significant number of patients will have atypical inflammatory syndromes during the recovery period. We briefly discuss the impact of HIV infection on the immune system and give an overview of the spectrum of conditions attributed to the Immune Reconstitution Inflammatory syndrome (IRIS).
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Toxoplasmosis-associated IRIS involving the CNS: a case report with longitudinal analysis of T cell subsets. BMC Infect Dis 2017; 17:66. [PMID: 28086758 PMCID: PMC5237164 DOI: 10.1186/s12879-016-2159-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 12/22/2016] [Indexed: 12/13/2022] Open
Abstract
Background HIV-infected patients may present an unforeseen clinical worsening after initiating antiretroviral therapy known as immune reconstitution inflammatory syndrome (IRIS). This syndrome is characterized by a heightened inflammatory response toward infectious or non-infectious triggers, and it may affect different organs. Diagnosis of IRIS involving the central nervous system (CNS-IRIS) is challenging due to heterogeneous manifestations, absence of biomarkers to identify this condition, risk of long-term sequelae and high mortality. Hence, a deeper knowledge of CNS-IRIS pathogenesis is needed. Case presentation A 37-year-old man was diagnosed with AIDS and cerebral toxoplasmosis. Anti-toxoplasma treatment was initiated immediately, followed by active antiretroviral therapy (HAART) 1 month later. At 2 months of HAART, he presented with progressive hyposensitivity of the right lower limb associated with brain and dorsal spinal cord lesions, compatible with paradoxical toxoplasmosis-associated CNS-IRIS, a condition with very few reported cases. A stereotactic biopsy was planned but was postponed based on its inherent risks. Patient showed clinical improvement with no requirement of corticosteroid therapy. Routine laboratorial analysis was complemented with longitudinal evaluation of blood T cell subsets at 0, 1, 2, 3 and 6 months upon HAART initiation. A control group composed by 9 HIV-infected patients from the same hospital but with no IRIS was analysed for comparison. The CNS-IRIS patient showed lower percentage of memory CD4+ T cells and higher percentage of activated CD4+ T cells at HAART initiation. The percentage of memory CD4+ T cells drastically increased at 1 month after HAART initiation and became higher in comparison to the control group until clinical recovery onset; the percentage of memory CD8+ T cells was consistently lower throughout follow-up. Interestingly, the percentage of regulatory T cells (Treg) on the CNS-IRIS patient reached a minimum around 1 month before symptoms onset. Conclusion Although both stereotactic biopsies and steroid therapy might be of use in CNS-IRIS cases and should be considered for these patients, they might be unnecessary to achieve clinical improvement as shown in this case. Immunological characterization of more CNS-IRIS cases is essential to shed some light on the pathogenesis of this condition. Electronic supplementary material The online version of this article (doi:10.1186/s12879-016-2159-x) contains supplementary material, which is available to authorized users.
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Gatti-Mays ME, Manion M, Bowen LN, Brown GT, Danner RL, Khan O, Nath A, Battiwalla M, Barrett AJ, Ito S. Toxoplasmosis encephalitis with immune-reconstitution inflammatory syndrome in an allogeneic stem cell transplant patient: a case report. Bone Marrow Transplant 2016; 51:1622-1624. [PMID: 27643867 DOI: 10.1038/bmt.2016.230] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Affiliation(s)
- M E Gatti-Mays
- National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - M Manion
- National Institute of Allergy and Infection Disease, National Institutes of Health, Bethesda, MD, USA
| | - L N Bowen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - G T Brown
- National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - R L Danner
- Critical Care Medicine Department, National Institutes of Health Clinical Center, Bethesda, MD, USA
| | - O Khan
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - A Nath
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD, USA
| | - M Battiwalla
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - A J Barrett
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - S Ito
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Günthard HF, Saag MS, Benson CA, del Rio C, Eron JJ, Gallant JE, Hoy JF, Mugavero MJ, Sax PE, Thompson MA, Gandhi RT, Landovitz RJ, Smith DM, Jacobsen DM, Volberding PA. Antiretroviral Drugs for Treatment and Prevention of HIV Infection in Adults: 2016 Recommendations of the International Antiviral Society-USA Panel. JAMA 2016; 316:191-210. [PMID: 27404187 PMCID: PMC5012643 DOI: 10.1001/jama.2016.8900] [Citation(s) in RCA: 477] [Impact Index Per Article: 59.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
IMPORTANCE New data and therapeutic options warrant updated recommendations for the use of antiretroviral drugs (ARVs) to treat or to prevent HIV infection in adults. OBJECTIVE To provide updated recommendations for the use of antiretroviral therapy in adults (aged ≥18 years) with established HIV infection, including when to start treatment, initial regimens, and changing regimens, along with recommendations for using ARVs for preventing HIV among those at risk, including preexposure and postexposure prophylaxis. EVIDENCE REVIEW A panel of experts in HIV research and patient care convened by the International Antiviral Society-USA reviewed data published in peer-reviewed journals, presented by regulatory agencies, or presented as conference abstracts at peer-reviewed scientific conferences since the 2014 report, for new data or evidence that would change previous recommendations or their ratings. Comprehensive literature searches were conducted in the PubMed and EMBASE databases through April 2016. Recommendations were by consensus, and each recommendation was rated by strength and quality of the evidence. FINDINGS Newer data support the widely accepted recommendation that antiretroviral therapy should be started in all individuals with HIV infection with detectable viremia regardless of CD4 cell count. Recommended optimal initial regimens for most patients are 2 nucleoside reverse transcriptase inhibitors (NRTIs) plus an integrase strand transfer inhibitor (InSTI). Other effective regimens include nonnucleoside reverse transcriptase inhibitors or boosted protease inhibitors with 2 NRTIs. Recommendations for special populations and in the settings of opportunistic infections and concomitant conditions are provided. Reasons for switching therapy include convenience, tolerability, simplification, anticipation of potential new drug interactions, pregnancy or plans for pregnancy, elimination of food restrictions, virologic failure, or drug toxicities. Laboratory assessments are recommended before treatment, and monitoring during treatment is recommended to assess response, adverse effects, and adherence. Approaches are recommended to improve linkage to and retention in care are provided. Daily tenofovir disoproxil fumarate/emtricitabine is recommended for use as preexposure prophylaxis to prevent HIV infection in persons at high risk. When indicated, postexposure prophylaxis should be started as soon as possible after exposure. CONCLUSIONS AND RELEVANCE Antiretroviral agents remain the cornerstone of HIV treatment and prevention. All HIV-infected individuals with detectable plasma virus should receive treatment with recommended initial regimens consisting of an InSTI plus 2 NRTIs. Preexposure prophylaxis should be considered as part of an HIV prevention strategy for at-risk individuals. When used effectively, currently available ARVs can sustain HIV suppression and can prevent new HIV infection. With these treatment regimens, survival rates among HIV-infected adults who are retained in care can approach those of uninfected adults.
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Affiliation(s)
- Huldrych F Günthard
- University Hospital Zurich and Institute of Medical Virology, University of Zurich, Zurich, Switzerland
| | | | | | - Carlos del Rio
- Emory University Rollins School of Public Health and School of Medicine, Atlanta, Georgia
| | - Joseph J Eron
- University of North Carolina at Chapel Hill School of Medicine, Chapel Hill
| | | | - Jennifer F Hoy
- Alfred Hospital and Monash University, Melbourne, Australia
| | | | - Paul E Sax
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Rajesh T Gandhi
- Massachusetts General Hospital and Harvard Medical School, Boston
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Alby-Laurent F, Dollfus C, Ait-Oufella H, Rambaud J, Legrand O, Tabone MD, Hennequin C. Trichosporon
: another yeast-like organism responsible for immune reconstitution inflammatory syndrome in patients with hematological malignancy. Hematol Oncol 2016; 35:900-904. [DOI: 10.1002/hon.2309] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2015] [Revised: 04/08/2016] [Accepted: 04/27/2016] [Indexed: 11/12/2022]
Affiliation(s)
- Fanny Alby-Laurent
- Service d'Hémato-Oncologie Pédiatrique; AP-HP, Hôpital A. Trousseau; Paris France
- Service de Réanimation Pédiatrique; AP-HP, Hôpital A. Trousseau; Paris France
| | - Catherine Dollfus
- Service d'Hémato-Oncologie Pédiatrique; AP-HP, Hôpital A. Trousseau; Paris France
| | - Hafid Ait-Oufella
- Service de Réanimation Médicale; AP-HP, Hôpital St Antoine; Paris France
| | - Jerome Rambaud
- Service de Réanimation Pédiatrique; AP-HP, Hôpital A. Trousseau; Paris France
| | - Ollivier Legrand
- Service d'hématologie clinique et de thérapie cellulaire; AP-HP, Hôpital St Antoine; Paris France
| | | | - Christophe Hennequin
- Assistance Publique-Hôpitaux de Paris; Hôpital St Antoine, Service de Parasitologie-Mycologie; Paris France
- Inserm; U1135, CIMI-Paris; Paris France
- CNRS; ERL 8255, CIMI-Paris; Paris France
- Sorbonne Universités; UPMC Univ Paris 06, CR7, Centre d'Immunologie et des Maladies Infectieuses (CIMI-Paris); Paris France
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Suresh K, Semaan R, Arias S, Karakousis P, Lee H. Pleuropulmonary Kaposi Sarcoma in the Setting of Immune Reactivation. ACTA ACUST UNITED AC 2016; 6. [PMID: 27429861 PMCID: PMC4943458 DOI: 10.4172/2161-105x.1000352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
We present a case of a 26 year with history of HIV/AIDS who presented with a pleural effusion. Serial radiography, pleural fluid analysis as well as clinical symptoms revealed development of Kaposi Sarcoma related immune reconstitution inflammatory syndrome (KS-IRIS) in the setting of initiation of effective anti- retroviral therapy.
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Affiliation(s)
- Karthik Suresh
- Department of Medicine, Division of Pulmonary and Critical Care medicine, Johns Hopkins School of Medicine, Baltimore, USA
| | - Roy Semaan
- Department of Medicine, Division of Pulmonary and Critical Care medicine, Johns Hopkins School of Medicine, Baltimore, USA
| | - Sixto Arias
- Department of Medicine, Division of Pulmonary and Critical Care medicine, Johns Hopkins School of Medicine, Baltimore, USA
| | - Petros Karakousis
- Department of Medicine, Division of Infectious Diseases, Johns Hopkins School of Medicine, Baltimore, USA
| | - Hans Lee
- Department of Medicine, Division of Pulmonary and Critical Care medicine, Johns Hopkins School of Medicine, Baltimore, USA
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Narvid J, Rehani B, Talbott JF. Diagnostic Performance of Brain MRI in Immune Reconstitution Inflammatory Syndrome. J Neuroimaging 2015; 26:303-8. [PMID: 26360519 DOI: 10.1111/jon.12291] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2015] [Revised: 07/22/2015] [Accepted: 07/23/2015] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND AND PURPOSE Central nervous system immune reconstitution inflammatory syndrome (CNS-IRIS) significantly negatively impacts the human immunodeficiency virus (HIV)-infected population on combination antiretroviral therapy (cART). We sought to determine the diagnostic performance of several magnetic resonance imaging (MRI) features for CNS-IRIS in a cohort of HIV+ patients recently started on cART. METHODS Our radiologic database was searched from January 2003 to September 2014 retrospectively for patients diagnosed with HIV and worsening symptoms on cART. A total of 20 patients with HIV were identified; patients were classified as having CNS-IRIS on the basis of established clinical criteria (8 patients; 12 age- and sex-matched controls). Brain MR images were obtained at a single post-cART timepoint during hospitalization for acute neurologic deterioration and blindly interpreted by two experienced neuroradiologists for the presence of four variables: intrinsic T1 hyperintensity, marginal reduced diffusion, and marginal enhancement or perivascular enhancement. RESULTS Although each individual finding showed moderate predictive accuracy, the combination of MR findings demonstrated good test characteristics: sensitivity 88% (confidence interval [CI] 62-98), specificity 79% (58-93), positive predictive value 71% (44-90%), and negative predictive value 83% (CI 52-98%). In addition, this final diagnosis demonstrated good predictive accuracy, area under curve .78 (CI .63-.91), and moderate inter-reader agreement, κ = .55. CONCLUSIONS Our findings suggest that although each individual MR finding shows only moderate diagnostic performance, the combined assessment of experienced neuroradiologists has good predictive accuracy. The absence of any described MRI findings makes the diagnosis of CNS-IRIS highly unlikely.
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Affiliation(s)
- Jared Narvid
- Division of Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA
| | - Bhavya Rehani
- Division of Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA
| | - Jason F Talbott
- Division of Neuroradiology, Department of Radiology and Biomedical Imaging, University of California, San Francisco, CA
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