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Buccheri R, Benard G. Opinion: Paracoccidioidomycosis and HIV Immune Recovery Inflammatory Syndrome. Mycopathologia 2017; 183:495-498. [PMID: 29159660 DOI: 10.1007/s11046-017-0230-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Accepted: 11/16/2017] [Indexed: 11/29/2022]
Abstract
Two distinct patterns of immune recovery inflammatory syndrome (IRIS) are recognized, paradoxical and unmasking IRIS. Here we raise some concerns regarding the first case of neuroPCM-IRIS published to date, as recently proposed by Almeida and Roza (Mycopathologia 177:137-141, 2017) for a patient originally described by Silva-Vergara et al. (Mycopathologia 182:393-396, 2014), taking in account the different case definitions for IRIS and the cases of neuroparacoccidioidomycosis already described in the literature. We are concerned that data from the case report have been misinterpreted and that no regard has been given to the possibility that the development of manifestations of neuroPCM after starting antiretroviral therapy and antifungal treatments could represent the predicted course of a missed neuroPCM diagnosis at presentation whose treatment failed. We hypothesize that diagnosis of the neuroPCM would not have been missed if careful screening for opportunistic infection of the central nervous system was performed prior to antiretroviral therapy initiation. Currently, there is no definitive diagnostic test for IRIS and diagnostic suspicion, as well as its management, are based on image studies and non-specific clinical signs and symptoms of inflammation. IRIS remains a diagnosis of exclusion, after considering drug toxicity, microbiologic treatment failure and the expected course of newly or previously diagnosed opportunistic infections.
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Affiliation(s)
- Renata Buccheri
- Instituto de Infectologia Emílio Ribas, São Paulo, Brazil. .,Laboratory of Medical Investigation Unit #53, Medical School and Tropical Medicine Institute, University of São Paulo Medical School, Avenida Doutor Arnaldo, 455. Cerqueira Cesar, São Paulo, SP, Brazil.
| | - Gil Benard
- Laboratories of Medical Investigation Units #53 and #56, Medical School and Tropical Medicine Institute, University of São Paulo Medical School, Avenida Doutor Arnaldo 455, São Paulo, SP, Brazil
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Aldous AM, Castel AD, Parenti DM. Prevalence and trends in transmitted and acquired antiretroviral drug resistance, Washington, DC, 1999-2014. BMC Res Notes 2017; 10:474. [PMID: 28893321 PMCID: PMC5594524 DOI: 10.1186/s13104-017-2764-9] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 08/31/2017] [Indexed: 11/29/2022] Open
Abstract
Background Drug resistance limits options for antiretroviral therapy (ART) and results in poorer health outcomes among HIV-infected persons. We sought to characterize resistance patterns and to identify predictors of resistance in Washington, DC. Methods We analyzed resistance in the DC Cohort, a longitudinal study of HIV-infected persons in care in Washington, DC. We measured cumulative drug resistance (CDR) among participants with any genotype between 1999 and 2014 (n = 3411), transmitted drug resistance (TDR) in ART-naïve persons (n = 1503), and acquired drug resistance (ADR) in persons with genotypes before and after ART initiation (n = 309). Using logistic regression, we assessed associations between patient characteristics and transmitted resistance to any antiretroviral. Results Prevalence of TDR was 20.5%, of ADR 40.5%, and of CDR 45.1% in the respective analysis groups. From 2004 to 2013, TDR prevalence decreased for nucleoside and nucleotide analogue reverse transcriptase inhibitors (15.0 to 5.5%; p = 0.0003) and increased for integrase strand transfer inhibitors (INSTIs) (0.0–1.4%; p = 0.04). In multivariable analysis, TDR was not associated with age, race/ethnicity, HIV risk group, or years from HIV diagnosis. Conclusions In this urban cohort of HIV-infected persons, almost half of participants tested had evidence of CDR; and resistance to INSTIs was increasing. If this trend continues, inclusion of the integrase-encoding region in baseline genotype testing should be strongly considered.
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Affiliation(s)
- Annette M Aldous
- Department of Epidemiology and Biostatistics, The George Washington University, Milken Institute School of Public Health, Washington, DC, 20037, USA
| | - Amanda D Castel
- Department of Epidemiology and Biostatistics, The George Washington University, Milken Institute School of Public Health, Washington, DC, 20037, USA
| | - David M Parenti
- Division of Infectious Diseases, The George Washington University School of Medicine, 2150 Pennsylvania Avenue, NW, Washington, DC, USA.
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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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Kassaye SG, Grossman Z, Balamane M, Johnston-White B, Liu C, Kumar P, Young M, Sneller MC, Sereti I, Dewar R, Rehm C, Meyer W, Shafer R, Katzenstein D, Maldarelli F. Transmitted HIV Drug Resistance Is High and Longstanding in Metropolitan Washington, DC. Clin Infect Dis 2016; 63:836-843. [PMID: 27307507 PMCID: PMC4996138 DOI: 10.1093/cid/ciw382] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Accepted: 06/06/2016] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Washington, DC, has 2.5% human immunodeficiency virus (HIV) prevalence, 3.9% among African Americans. Antiretrovirals (ARTs) are the cornerstone for treatment and prevention. Monitoring changes in transmitted drug resistance (TDR) is critical for effective HIV care. METHODS HIV genotype data for individuals enrolled in research studies in metropolitan Washington, D.C., were used to identify TDR using the World Health Organization mutation list [Bennett DE, Camacho RJ, Otelea D, et al. Drug resistance mutations for surveillance of transmitted HIV-1 drug-resistance: 2009 update. PloS One 2009; 4:e4724]. HIV phylogenies were reconstructed using maximum likelihood and Bayesian methods. HIV transmission clusters were supported by 1000 bootstrap values >0.70 and posterior probability >0.95 of having a common ancestor. RESULTS Among 710 individuals enrolled in 1994-2013, the median age was 38.6 years, 46.2% were female, and 53.3% were African-American. TDR was 22.5% among 566 treatment-naive individuals; 15.8% had nucleoside/nucleotide reverse transcriptase inhibitor (NRTI) resistance, 9.8% had nonnucleoside reverse-transcriptase inhibitor (NNRTI) resistance, and 4.2% had protease inhibitor (PI) resistance. Single class TDR was 10.0%, 5.1%, and 1.6% to NRTIs, NNRTIs, and PIs. Dual TDR to PI and NRTI was seen in 1.6%, NRTI and NNRTI in 3.4%, and triple class TDR in 0.9%. TDR frequency decreased from 1994-2006 (27.1%) to 2007-2013 (19.4%; P = .02). Only 6/79 (7.6%) individuals within transmission clusters had evidence of TDR. DISCUSSIONS We identified high prevalence of TDR among HIV-infected individuals in metropolitan Washington, DC, regardless of gender. Active surveillance for TDR is needed to guide ART usage and analyses of risk group contributions to HIV transmission and resistance.
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Affiliation(s)
- Seble G Kassaye
- Department of Medicine, Georgetown University, Washington D.C
| | - Zehava Grossman
- Department of Epidemiology, Tel Aviv University, Israel
- HIV Dynamics and Replication Program, National Cancer Institute, Frederick, Maryland
| | - Maya Balamane
- Department of Medicine, Georgetown University, Washington D.C
| | | | - Chenglong Liu
- Department of Medicine, Georgetown University, Washington D.C
| | - Princy Kumar
- Department of Medicine, Georgetown University, Washington D.C
| | - Mary Young
- Department of Medicine, Georgetown University, Washington D.C
| | - Michael C Sneller
- Laboratory of Immunoregulation, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda
| | - Irini Sereti
- Laboratory of Immunoregulation, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda
| | | | - Catherine Rehm
- Laboratory of Immunoregulation, National Institutes of Allergy and Infectious Diseases, National Institutes of Health, Bethesda
| | | | - Robert Shafer
- Department of Medicine, Stanford University, California
| | | | - Frank Maldarelli
- HIV Dynamics and Replication Program, National Cancer Institute, Frederick, Maryland
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Brown CS, Smith CJ, Breen RAM, Ormerod LP, Mittal R, Fisk M, Milburn HJ, Price NM, Bothamley GH, Lipman MCI. Determinants of treatment-related paradoxical reactions during anti-tuberculosis therapy: a case control study. BMC Infect Dis 2016; 16:479. [PMID: 27600661 PMCID: PMC5013570 DOI: 10.1186/s12879-016-1816-4] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2016] [Accepted: 09/03/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Inflammatory response following initial improvement with anti-tuberculosis (TB) treatment has been termed a paradoxical reaction (PR). HIV co-infection is a recognised risk, yet little is known about other predictors of PR, although some biochemical markers have appeared predictive. We report our findings in an ethnically diverse population of HIV-infected and uninfected adults. METHODS Prospective and retrospective clinical and laboratory data were collected on TB patients seen between January 1999-December 2008 at four UK centres selected to represent a wide ethnic and socio-economic mix of TB patients. Data on ethnicity and HIV status were obtained for all individuals. The associations between other potential risk factors and PR were assessed in a nested case-control study. All PR cases were matched two-to-one to controls by calendar time and centre. RESULTS Of 1817 TB patients, 82 (4.5 %, 95 % CI 3.6-5.5 %) were identified as having a PR event. The frequency of PR was 14.4 % (18/125; 95 % CI 8.2-20.6 %) and 3.8 % (64/1692; 2.9-4.7) for HIV-positive and HIV-negative individuals respectively. There were no differences observed in PR frequency according to ethnicity, although the site was more likely to be pulmonary in those of black and white ethnicity, and lymph node disease in those of Asian ethnicity. In multivariate analysis of the case-control cohort, HIV-positive patients had five times the odds of developing PR (aOR = 5.05; 95 % CI 1.28-19.85, p = 0.028), whilst other immunosuppression e.g. diabetes, significantly reduced the odds of PR (aOR = 0.01; 0.00-0.27, p = 0.002). Patients with positive TB culture had higher odds of developing PR (aOR = 6.87; 1.31-36.04, p = 0.045) compared to those with a negative culture or those in whom no material was sent for culture. Peripheral lymph node disease increased the odds of a PR over 60-fold 4(9.60-431.25, p < 0.001). CONCLUSION HIV was strongly associated with PR. The increased potential for PR in people with culture positive TB suggests that host mycobacterial burden might be relevant. The increased risk with TB lymphadenitis may in part arise from the visibility of clinical signs at this site. Non-HIV immunosuppression may have a protective effect. This study highlights the difficulties in predicting PR using routinely available demographic details, clinical symptoms or biochemical markers.
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Affiliation(s)
- Colin Stewart Brown
- Hospital for Tropical Diseases, University College London Hospitals Foundation Trust, 235 Euston Road, London, NW1 2BU, UK.,UCL Division of Infection and Immunity, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | - Colette Joanne Smith
- Royal Free Campus, University College London, Rowland Hill Street, London, NW3 2PF, UK
| | | | | | - Rahul Mittal
- Royal Blackburn Hospital, Blackburn, Lancs, BB2 3LR, UK
| | - Marie Fisk
- Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK
| | - Heather June Milburn
- Guy's and St Thomas' Hospital NHS Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | - Nicholas Martin Price
- Guy's and St Thomas' Hospital NHS Trust, Westminster Bridge Road, London, SE1 7EH, UK
| | | | - Marc Caeroos Isaac Lipman
- Royal Free London NHS Foundation Trust, Pond Street, London, NW3 2QG, UK. .,UCL Respiratory, Division of Medicine, University College London, Rowland Hill Street, London, NW3 2PF, UK.
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Hsu E, Phadke VK, Nguyen MLT. Short Communication: Hyperthyroidism in Human Immunodeficiency Virus Patients on Combined Antiretroviral Therapy: Case Series and Literature Review. AIDS Res Hum Retroviruses 2016; 32:564-6. [PMID: 26887978 DOI: 10.1089/aid.2015.0374] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
We describe an HIV-infected patient initiated on combined antiretroviral therapy (cART) who subsequently developed immune restoration disease (IRD) hyperthyroidism-this case represents one of five such patients seen at our center within the past year. Similar to previous reports of hyperthyroidism due to IRD, all of our patients experienced a rapid early recovery in total CD4 count, but developed symptoms of hyperthyroidism on average 3 years (38 months) after beginning cART, which represents a longer time frame than previously reported. Awareness and recognition of this potential complication of cART, which may occur years after treatment initiation, will allow patients with immune restorative hyperthyroidism to receive timely therapy and avoid the long-term complications associated with undiagnosed thyroid disease.
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Affiliation(s)
- Emory Hsu
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia
| | - Varun K. Phadke
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
| | - Minh Ly T. Nguyen
- Division of Infectious Diseases, Emory University School of Medicine, Atlanta, Georgia
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Xie YL, Rosen LB, Sereti I, Barber DL, Chen RY, Hsu DC, Qasba SS, Zerbe CS, Holland SM, Browne SK. Severe Paradoxical Reaction During Treatment of Disseminated Tuberculosis in a Patient With Neutralizing Anti-IFNγ Autoantibodies. Clin Infect Dis 2015; 62:770-773. [PMID: 26646678 DOI: 10.1093/cid/civ995] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2015] [Accepted: 11/23/2015] [Indexed: 12/22/2022] Open
Abstract
Interferon-gamma (IFNγ) neutralizing autoantibodies are associated with disseminated nontuberculous mycobacterial infections. We report a previously healthy Thai woman with disseminated tuberculosis and high-titer IFNγ-neutralizing autoantibodies, who developed a severe inflammatory reaction during anti-tuberculosis treatment. IFNγ contributes to host control of tuberculosis but appears inessential for tuberculosis paradoxical reactions.
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Affiliation(s)
| | | | | | - Daniel L Barber
- Laboratory of Parasitic Diseases at the National Institute of Allergy and Infectious Diseases, National Institutes of Heath, Bethesda
| | - Ray Y Chen
- Laboratory of Clinical Infectious Diseases
| | | | - S Sonia Qasba
- Montgomery County Health Department, Silver Spring, Maryland
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