Hepatitis E virus co-infection in HIV-infected patients in Foggia and Naples in southern Italy

BACKGROUND

Hepatitis E virus (HEV) infection represents an emerging infection in developed countries and is thought to be a zoonotic infection. It has recently been described as a new causative agent of acute and chronic hepatitis in immunosuppressed subjects, including HIV-infected patients. The aim of this study was to assess the sero-virological prevalence of HEV in HIV patients and in the general population as control group.

METHODS

A prospective and observational cohort study was carried out in two hospitals in southern Italy. The seroprevalence of HEV was determined in a cohort of 959 subjects, 509 (53%) of whom were HIV-positive patients and 450 were from the general population. Serum samples were tested for anti-HEV antibodies; repeatedly positive results were confirmed by a Western blot assay. In positive patients HEV RNA and genotypes were also determined.

RESULTS

A total of 46 (4.8%) of the 959 serum samples examined were reactive to anti-HEV Ig and confirmed by Western blotting. The prevalence of HEV antibodies (IgG and/or IgM) was 2.7% in the control group and 6.7% in HIV-infected patients. Anti-HEV IgM was found in 6/46 (13.0%) of the anti-HEV Ig-positive serum samples, in 5/34 HIV patients and in 1/12 of the general population. No HIV-infected patient presented chronic hepatitis with HEV infection alone.

CONCLUSIONS

This study indicates a higher circulation of HEV in HIV-infected patients, whereas a low prevalence of HEV antibodies in the general Italian population was shown. Chronic hepatitis with HEV alone was absent, while it was present in subjects with HIV-HEV, co-infected with hepatitis B virus (HBV) and/or hepatitis C virus (HCV).

Relation of epicardial fat and alanine aminotransferase in subjects with increased visceral fat

BACKGROUND

Increased visceral adipose tissue (VAT) is a risk factor for an unfavorable cardio-metabolic profile and fatty liver. Individuals with human immunodeficiency virus (HIV) on highly active antiretroviral therapy (HAART) can be associated with metabolic syndrome (MS) and higher visceral fat. However, the potential link between cardiac adiposity, emerging index of visceral adiposity, and fatty liver is still unexplored.

OBJECTIVE

To evaluate whether echocardiographic epicardial adipose tissue, index of cardiac adiposity, could be related to serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) activity, surrogate markers of fatty liver, in HIV-infected patients with (HIV+MS+) and without HAART-associated MS (HIV+MS-).

METHODS AND PROCEDURES

This was a cross-sectional observational study on 57 HIV+MS+ patients, 52 HIV+MS- and 57 HIV-negative subjects with MS (HIV-MS+), as control group. Epicardial fat thickness and intra-abdominal VAT were obtained by echocardiography and magnetic resonance imaging (MRI), respectively. Serum ALT and AST activity, plasma adiponectin levels, and MS biochemical parameters were measured.

RESULTS

Echocardiographic epicardial fat thickness was correlated with MRI-VAT (r = 0.83, P < 0.01), AST/ALT ratio (r = 0.77, P < 0.01), ALT (r = 0.58, P < 0.01), AST (r = 0.56, P < 0.01), and adiponectin (r = -0.45, P < 0.01) in HIV+MS+. MRI-VAT and AST/ALT ratio were the best correlates of epicardial fat thickness (r (2) = 0.45, P < 0.01).

DISCUSSION

This study shows for the first time a clear relationship of epicardial fat, index of cardiac and visceral adiposity, and serum ALT and AST activity, markers of fatty liver, in subjects with increased visceral adiposity and cardio-metabolic risk. This correlation seems to be independent of overall adiposity and rather function of excess visceral adiposity.

Relation of subepicardial adipose tissue to carotid intima-media thickness in patients with human immunodeficiency virus

Patients infected with human immunodeficiency virus (HIV) are at increased risk for subclinical atherosclerosis. Whether increased cardiac adiposity may be related to HIV subclinical atherosclerosis is still unexplored. The objective of this study was to evaluate whether echocardiographically determined subepicardial adipose tissue, an index of cardiac adiposity, is related to carotid intima-media thickness (IMT), an index of subclinical atherosclerosis, in HIV-infected patients receiving highly active antiretroviral therapy. Echocardiographic epicardial fat thickness and ultrasonographic IMT were measured in 103 consecutive HIV-infected Caucasian subjects receiving highly active antiretroviral therapy. Echocardiographic subepicardial adipose tissue showed an excellent correlation with IMT (r = 0.92, p <0.01). Multiple regression analysis showed that IMT was best predicted by epicardial fat thickness (r(2) = 0.81, p <0.01). In conclusion, this study suggests, for the first time, that epicardial adipose tissue, an index of cardiac adiposity, may be significantly related to subclinical atherosclerosis in HIV-infected patients.

Epicardial adipose tissue is related to carotid intima-media thickness and visceral adiposity in HIV-infected patients with highly active antiretroviral therapy-associated metabolic syndrome

BACKGROUND

High cardiovascular risk and accelerated atherosclerosis are associated with human immunodeficiency virus (HIV). Recently, the use of highly active antiretroviral therapy (HAART) for the treatment of HIV infection is correlated with the development of HAART-associated metabolic syndrome and lipodystrophy (LDS). Detection of epicardial fat thickness, new index of visceral adiposity in non HIV-infected patients, might be important as diagnostic tool in HIV-infected patients on HAART.

OBJECTIVE

Primary objective of this study was to evaluate whether echocardiographic epicardial adipose tissue is related to visceral adipose tissue (VAT) and Carotid Intima-Media Thickness (IMT), index of atherosclerosis in HIV-infected patients on HAART with LDS.

DESIGN

We studied 60 consecutive HIV-infected subjects with HAART-associated metabolic syndrome and LDS and 45 HIV-infected subjects on HAART without LDS.

MAIN OUTCOMES MEASURES

Epicardial fat thickness and IMT were measured by ultrasonography in both study and control groups. Magnetic resonance imaging (MRI) was used to calculate VAT in HIV-infected subjects on HAART with LDS.

RESULTS

Epicardial adipose tissue thickness showed an excellent correlation with MRI-VAT (r=0.85; P<0.001) and IMT (r=0.78;P<0.001) in HIV-infected patients on HAART-with LDS. Multiple regression analysis showed that epicardial fat thickness was best predicted by MRI-VAT and IMT (R2=0.57, p<0.001 and p<0.01, respectively). HIV-infected patients with HAART-associated metabolic syndrome and LDS showed higher epicardial fat thickness and IMT (8 vs 6.5 mm; 0.71 vs 0.66 mm, respectively, p<0.01 for both) than HIV-infected subjects on HAART without LDS.

CONCLUSION

Echocardiographic assessment of epicardial fat may have the potential to be a simple and reliable marker of visceral adiposity and increased cardiovascular risk in HIV-infected patients with HAART-associated metabolic syndrome and LDS.

Lopinavir/Ritonavir or Efavirenz plus two Nucleoside Analogues as First-Line Antiretroviral Therapy: A Non-Randomized Comparison

Background

Although efavirenz (EFV) and lopinavir/ritonavir (LPV/r) are both recommended antiretroviral agents for combination therapy in drug-naive HIV-infected patients, no randomized comparison of their efficacy and tolerability is available yet. A multi-cohort prospective observational comparative study was performed.

Methods

Efficacy was examined comparing time to virological failure, CD4 recovery and clinical progression. Tolerability was examined comparing time to treatment discontinuation for any reason and for toxicity and time to liver enzymes or lipid alterations. Survival analysis was conducted by an intent-to-treat principle using the Kaplan–Meier method, and standard and weighted Cox regression models.

Results

A total of 674 antiretroviral-naive patients starting a two nucleoside reverse transcriptase inhibitor regimen plus either EFV ( n=481) or LPV/r ( n=193) were examined. At baseline, patients starting LPV/r had higher HIV RNA and lower CD4+ T-cell counts. There was no difference in the adjusted hazards of virological failure (LPV/r versus EFV relative hazard [RH] 1.16, 95% confidence intervals [CI]: 0.58–2.32, P=0.67), CD4 recovery (RH=0.93, 95% CI: 0.66–1.30, P=0.66), clinical progression (RH=1.64, 95% CI: 0.70–3.84, P=0.25), drug discontinuation for toxicity (RH=0.92, 95% CI: 0.51–1.64, P=0.76) and for any reason, and rates of liver enzyme and total/low density lipoprotein (LDL) cholesterol elevation. In contrast, the rate of triglycerides elevations (>1 NCEP Adult Treatment Panel III category increase) was higher in the LPV/r group (RH=1.69, 95% CI: 1.14–2.50; P=0.01). Models weighted for the inverse of conditional probability of receiving either drug applied to the efficacy endpoints yielded similar results. CD4 recovery with both drugs was also similar in the lowest CD4 strata.

Conclusions

Our analysis suggests similar efficacy and tolerability for EFV- or LPV/r-based first-line antiretroviral regimens. LPV/r was associated with higher rates of hypertriglyceridaemia.

Lopinavir/ritonavir or efavirenz plus two nucleoside analogues as first-line antiretroviral therapy: a non-randomized comparison

BACKGROUND

Although efavirenz (EFV) and lopinavir/ ritonavir (LPV/r) are both recommended antiretroviral agents for combination therapy in drug-naive HIV-infected patients, no randomized comparison of their efficacy and tolerability is available yet. A multi-cohort prospective observational comparative study was performed.

METHODS

Efficacy was examined comparing time to virological failure, CD4 recovery and clinical progression. Tolerability was examined comparing time to treatment discontinuation for any reason and for toxicity and time to liver enzymes or lipid alterations. Survival analysis was conducted by an intent-to-treat principle using the Kaplan-Meier method, and standard and weighted Cox regression models.

RESULTS

A total of 674 antiretroviral-naive patients starting a two nucleoside reverse transcriptase inhibitor regimen plus either EFV (n = 481) or LPV/r (n = 193) were examined. At baseline, patients starting LPV/r had higher HIV RNA and lower CD4+ T-cell counts. There was no difference in the adjusted hazards of virological failure (LPV/r versus EFV relative hazard [RH] 1.16, 95% confidence intervals [CI]: 0.58-2.32, P = 0.67), CD4 recovery (RH = 0.93, 95% CI: 0.66-1.30, P = 0.66), clinical progression (RH = 1.64, 95% CI: 0.70-3.84, P = 0.25), drug discontinuation for toxicity (RH = 0.92, 95% CI: 0.51-1.64, P = 0.76) and for any reason, and rates of liver enzyme and total/low density lipoprotein (LDL) cholesterol elevation. In contrast, the rate of triglycerides elevations (> 1 NCEP Adult Treatment Panel III category increase) was higher in the LPV/r group (RH = 1.69, 95% CI: 1.14-2.50; P = 0.01). Models weighted for the inverse of conditional probability of receiving either drug applied to the efficacy endpoints yielded similar results. CD4 recovery with both drugs was also similar in the lowest CD4 strata.

CONCLUSIONS

Our analysis suggests similar efficacy and tolerability for EFV- or LPV/r-based first-line antiretroviral regimens. LPV/r was associated with higher rates of hypertriglyceridaemia.

Evolution of HVR-1 Quasispecies after 1-Year Treatment in HIV/HCV-Coinfected Patients According to the Pattern of Response to Highly Active Antiretroviral Therapy

Hepatitis C virus (HCV) variability is mainly attributed to the ability of the virus to respond to host immune pressure, acting as a driving force for the evolution of quasispecies. This study was aimed at studying the changes in HVR-1 heterogeneity and the evolution of HCV quasispecies in HIV/HCV-coinfected patients according to the pattern of response to highly active antiretroviral therapy (HAART).

Sixteen HIV/HCV-coinfected patients harbouring HCV genotype 1 and who had been on HAART for at least 1 year, 8 showing increasing CD4+T-cell counts (immunological responders) and 8 showing a stable or decreasing CD4+ T-cell counts (immunological non-responders), were selected from a prospective cohort study.

After 1 year of HAART, 11 patients showed HIV viral load <2.6 log10 cp/ml (virological responders), and 5 showed HIV viral load above this value (virological non-responders). Plasma samples, collected before starting therapy and after 1 year of HAART, underwent clonal sequence analysis for HVR-1 region of HCV. Non-synonymous/synonymous substitutions ratio (Ka/Ks), aminoacidic complexity (normalized Shannon entropy) and diversity (p-distance), were considered as parameters of quasispecies heterogeneity. After 1 year of HAART, heterogeneity of HVR-1 quasispecies significantly decreased in virological non-responders, whereas the heterogeneity tended to increase in virological responders. The differences in the evolution were less stringent, when considering immunological response. On the other hand, profound qualitative modifications of HVR-1 quasispecies were observed only in patients with both immunological and virological HAART response.

On the whole, these findings suggest that, in patients undergoing HAART, the extent of HCV variability and the evolution of HVR-1 quasispecies is influenced by the pattern of response to antiretroviral therapy.

Response to Haart and Gb Virus Type C Coinfection in a Cohort of Antiretroviral-Naive HIV-Infected Individuals

The prognostic role of GB virus type C (GBV-C) viraemia in HIV-infected subjects treated with highly active antiretroviral therapy (HAART) is still undefined, The aim of this analysis is to assess the relationship between GBV-C infection and response to antiretroviral therapy among HIV-infected subjects initiating HAART when antiretroviral-naive.

A prospective, observational study of 400 HIV-infected patients with measurements of GBV-C RNA, hepatitis C virus (HCV) antibodies and HCV RNA determined from plasma stored prior to HAART initiation, Time to virological (achieving HIV RNA ≤500 copies/ml) and immunological success (a CD4+ count increase of ≥200cells/μl), and the time to virological relapse (confirmed HIV RNA >500 copies/ml) were assessed by Kaplan-Meier methods and Cox proportional hazard regression model.

Of the subjects, 117 (29.3%) were GBV-C positive and, overall, 351 (87.8%) patients achieved virological success, After controlling for a number of confounders including HCV RNA, GBV-C viraemic patients experienced a significantly lower risk of HIV rebound than those who were GBV-C negative [relative hazard (RH)=0.56, 95% CI: 0.34–0.93, P=0.03], Conversely, the probability of achieving initial virological success or CD4+ count response after HAART did not differ between GBV-C-negative and -positive subjects, These results suggest that GBV-C coinfection may play a role in determining the rate of HIV rebound possibly by competing with HIV replication after HIV load has been successfully suppressed by HAART.

Variability in the Interpretation of Transmitted Genotypic HIV-1 Drug Resistance and Prediction of Virological Outcomes of the Initial Haart by Distinct Systems

High level HIV-1 drug resistance in recently infected treatment-naive individuals correlates with sub-optimal virological responses to highly active antiretroviral therapy (HAART). To determine whether genotypic HIV-1 drug resistance in chronic naive patients, as interpreted by various systems, could predict the virological outcomes of HAART, isolates from patients enrolled in a prospective observational cohort (ICoNA) prior to treatment start were genotyped. Genotypic susceptibility scores (GSS) assigned to the initial HAART regimens using the interpretations of pre-therapy resistance mutations by 13 systems were related to virological outcomes. Of 415 patients, 42 (10%) had at least one major resistance mutation. According to the different interpretations, 1.9–20.5% of patients had some level of resistance to at least one drug in the initial regimen. In multivariable analysis, GSS from two systems significantly predicted the time to virological success: Rega 5.5, for each unit increase in GSS adjusted relative hazard (RH) 1.86 [95% confidence intervals (95% CI): 1.15–3.02] and hivresistanceWeb v3, RH 1.87 (95% CI: 1.00–3.48). With three other systems, GSS showed a trend towards a significant prediction of success: Retrogram 1.6, RH 2.33 (95% CI: 0.98–5.53), Menéndez 2002, RH 2.36 (95% CI: 0.97–5.72) and Stanford hivdb, RH 2.06 (95% CI: 0.94–4.49). Genotypic resistance testing coupled with adequate interpretation in chronic naive patients can usefully identify those at risk of sub-optimal virological response to HAART.

The Management of Hepatitis B Virus/HIV-1 Co-Infected Patients Starting Their First Haart Regimen. Treating Two Infections for the Price of One Drug?

We examined the impact of a lamivudine-containing highly active antiretroviral therapy (HAART) regimen on 164 hepatitis B virus/HIV co-infected individuals starting their first HAART. Lamivudine-treated patients (accounting for 73% of the study population) showed a significantly lower level of alanine aminotransferase over follow-up [–81.1 mU/ml mean difference; 95% confidence intervals (95% CI): –30.3; –131.7, P=0.003] and a significantly reduced risk of liver-related morbidity/mortality [Relative hazard (RH)=0.07; 95% CI: 0.01–0.38, P=0.002] than those starting a lamivudine sparing-regimen.

Good safety profile and efficacy of leucocyte interferon-alpha in combination with oral ribavirin in treatment-naive patients with chronic hepatitis C: a multicentre, randomised, controlled study

BACKGROUND

The differential tolerability profile of various interferon (IFN)-alpha preparations used in combination with ribavirin for the treatment of chronic hepatitis C needs to be elucidated. Approximately 8% of patients receiving recombinant IFNalpha-2b plus ribavirin discontinue treatment because of adverse events. Human leucocyte IFNalpha is deemed to have a better safety profile than recombinant IFNalpha. We therefore compared the safety profile and efficacy of ribavirin combined with leucocyte IFNalpha or with recombinant IFNalpha-2b in treatment-naive patients with chronic hepatitis C.

STUDY DESIGN

We randomised 423 patients to either leucocyte IFNalpha 3MU three times weekly plus ribavirin (210 patients) or the same dose of recombinant IFNalpha-2b plus ribavirin (213 patients). Patients were treated for 24 weeks and followed-up for a further 48 weeks. The primary endpoint was the safety profile of the two therapies; the secondary endpoint was the rate of sustained response.

RESULTS

In patients receiving leucocyte IFNalpha, the total number of adverse events was lower than in the group receiving recombinant IFNalpha (259 vs 441 patients), and the percentage of patients discontinuing treatment because of adverse events or laboratory abnormalities was significantly reduced (4% vs 11%; p = 0.013). Sustained response was observed in 47% of patients receiving leucocyte IFNalpha plus ribavirin and in 44% of patients receiving IFNalpha-2b plus ribavirin.

CONCLUSIONS

Both therapeutic regimens were effective in inducing a sustained response in naive patients. However, the safety profile of leucocyte IFNalpha plus ribavirin was more favourable than that observed with the administration of recombinant IFNalpha-2b plus ribavirin, suggesting that leucocyte IFNalpha may be an alternative option in patients with reduced tolerability to other IFNs.

An open-label, prospective, observational study of the incidence of coronary artery disease in patients with hiv infection receiving highly active antiretroviral therapy

BACKGROUND

The association of highly active antiretroviral therapy (HAART) regimens that include protease inhibitors (PIs) with metabolic and somatic disorders has raised concerns about the possibility of an increased risk of coronary artery disease (CAD) in patients with HIV infection.

OBJECTIVE

The aim of this study was to assess the incidence of CAD in previously untreated HIV infected outpatients who received reverse transcriptase inhibitors with or without PIs.

METHODS

In this open-label, multicenter, prospective, observational trial, previously untreated and asymptomatic HIV-infected Italian patients were followed to assess the incidence of CAD (primary end point) according to the HAART regimen they received: 2 nucleoside analogue reverse transcriptase inhibitors (NRTIs) in combination with PIs (group PI+) or 1 non-nucleoside reverse transcriptase inhibitor in combination with 2 NRTIs (group PI-). Patients underwent clinical examination and laboratory testing every 4 months.

RESULTS

A total of 1551 HIV-infected patients (994 [64%] men; median age, 35 years; range, 22-50 years) were followed for a median 36 months (range, 34-42 months). The cumulative annual incidence of CAD-related events was 9.8/1000 in group PI+ and 0.8/1000 in group PI- (P < 0.001). The annual incidence of myocardial infarction was 5.1/1000 in group PI+ and 0.4/1000 in group PI- (P < 0.001). Independent of patient age, the incidence of CAD was greater among men (P < 0.001) and patients who smoked >20 cigarettes per day (P < 0.001). Lipodystrophy and metabolic alterations were observed in 62% of patients in group PI+ and in 4% of patients in group PI- (P < 0.001). Of 23 patients receiving PIs who developed CAD, 17 (73.9%) had lipodystrophy and all 23 had hypertriglyceridemia and hypercholesterolemia.

CONCLUSIONS

According to our findings, HAART that includes PIs may accelerate the onset of CAD-related events in young, male, heavy smokers who develop metabolic disorders and lipodystrophy during therapy. Patients with increased coronary risk should receive careful cardiac monitoring if treated with PIs.

Time to discontinuation of the first highly active antiretroviral therapy regimen: a comparison between protease inhibitor- and non-nucleoside reverse transcriptase inhibitor-containing regimens

Data from a cohort of HIV-positive individuals who were antiretroviral naive at enrollment were analysed to estimate the probability of discontinuing the first highly active antiretroviral therapy (HAART) regimen, comparing protease inhibitor- and non-nucleoside reverse transcriptase-containing regimens. Of the 2002 individuals who began HAART, 857 (42.8%) discontinued their first regimen. No statistically significant difference was found in the time to discontinuation by specific type of regimen, either when considered overall or by specific reason.

Evaluation of long-term efficacy of interferon alpha-2b and ribavirin in combination in naive patients with chronic hepatitis C: an Italian multicenter experience. Ribavirin-Interferon in Chronic Hepatitis Italian Group Investigators

BACKGROUND/AIMS

A combination of interferon alpha and ribavirin has been suggested to reach a higher rate of sustained virological response in patients with chronic hepatitis C than monotherapy. In this study we assessed the long-term efficacy of this combination therapy in the treatment of selected Italian naive chronic hepatitis C patients compared to interferon alpha monotherapy.

METHODS

We enrolled 428 naive patients who were randomly assigned to receive either recombinant interferon alpha-2b and ribavirin for 24 weeks or interferon alpha-2b alone for 48 weeks. The primary end-point of the study was the rate of sustained virological response. Serum HCV RNA levels were determined before treatment; during treatment at weeks 12 and 24 in the patients receiving the combination therapy; at weeks 12, 24, 36 and 48 in the patients receiving monotherapy; and after therapy at weeks 12, 24 and 48 in the patients in both study groups.

RESULTS

Sustained virological response was observed in 43% of the patients treated with combination therapy and in 14% of the patients treated with monotherapy. Logistic regression analysis showed that sustained response was associated with the combination therapy, with HCV genotype other than 1b, with an HCV viral load of 3x10(6) copies/ml or less, with an inflammation score of 7 or less, and with an estimated duration of disease of 10 years or less.

CONCLUSIONS

A 24-week treatment course with interferon alpha-2b and ribavirin offers a greater chance of sustained virological response compared to treatment with interferon alpha-2b alone for 48 weeks, and may be indicated as initial therapy in such patients.

Clinical course of cardiomyopathy in HIV-infected patients with or without encephalopathy related to the myocardial expression of tumour necrosis factor-alpha and nitric oxide synthase

OBJECTIVE

To define whether the development of encephalopathy influences the clinical course of HIV-associated cardiomyopathy (HIV-DCM) in relation to the myocardial expression of tumour necrosis factor-alpha (TNF-alpha) and inducible nitric oxide synthase (iNOS).

DESIGN

Prospective study.

SETTING

University hospitals and AIDS centres.

METHODS

115 HIV-infected patients with echocardiographic diagnosis of HIV-associated cardiomyopathy (34 with encephalopathy and 81 without encephalopathy) were followed for a mean of 24 +/- 3.2 months. All patients underwent endomyocardial biopsy for determination of myocardial immunostaining intensity of TNF-alpha and iNOS. Cerebrospinal fluid (CSF) from patients with encephalopathy was examined for the presence of viruses. Patients underwent clinical examination every 3 months and echocardiographic examination every 6 months. The intensity of TNF-alpha and iNOS immunostaining was also evaluated on postmortem cerebral tissue of patients who died of congestive heart failure (CHF).

RESULTS

A greater impairment of echocardiographic parameters was observed in patients with HIV-associated cardiomyopathy after development of encephalopathy. These parameters tended to worsen progressively during the follow-up period and were inversely correlated with HIV-1 viral load, CD4 cell count, mini mental status score and the intensity of myocardial and cerebral TNF-alpha and iNOS staining. CSF specimens were available in 29 patients with encephalopathy. HIV-1 sequences were detected in CSF of all these patients with cytomegalovirus sequences in two. The mortality rate for CHF was greater among patients with encephalopathy (73% versus 12%).

CONCLUSIONS

The development of encephalopathy has an adverse effect on the clinical course of HIV-associated cardiomyopathy. In the relationship between cardiomyopathy and encephalopathy, the activation of iNOS by TNF-alpha may have a significant pathogenetic role in HIV disease.

Intravenous recombinant interferon-beta versus interferon-alpha-2b and ribavirin in combination for short-term treatment of chronic hepatitis C patients not responding to interferon-alpha. Multicenter Interferon Beta Italian Group Investigators

BACKGROUND

Little is known about the therapeutic role of intravenous interferon-beta in chronic hepatitis C patients unresponsive to a previous treatment with interferon-alpha.

METHODS

Two hundred interferon-alpha non-responders were randomized to receive either intravenous recombinant interferon-beta or interferon-alpha-2b and ribavirin for 12 weeks. The responders in both groups were followed up for a further 48 weeks.

RESULTS

At week 12 a biochemical and virologic response was documented in 42% of the patients treated with interferon-beta and in 22% of the patients treated with combination therapy. A sustained response was observed in 21% of the patients treated with interferon-beta and in 13% of those treated with combination therapy, with similar differences on intention-to-treat analysis.

CONCLUSIONS

Short-term treatment with intravenous interferon-beta seems to offer a chance for sustained response in a subset of interferon-alpha non-responders. The role of long-term therapy in these patients still remains to be explored.

Intensity of myocardial expression of inducible nitric oxide synthase influences the clinical course of human immunodeficiency virus-associated cardiomyopathy. Gruppo Italiano per lo Studio Cardiologico dei pazienti affetti da AIDS (GISCA)

BACKGROUND

Increased levels of tumor necrosis factor-alpha (TNF-alpha) and inducible nitric oxide synthase (iNOS) have been reported in patients with dilated cardiomyopathy. We investigated the myocardial expression of TNF-alpha and iNOS in patients with HIV-associated cardiomyopathy (HIV-DCM) compared with patients with idiopathic dilated cardiomyopathy (IDCM).

METHODS AND RESULTS

Endomyocardial biopsy specimens from 82 HIV-DCM and 80 IDCM patients were processed for determination of the immunostaining intensity of TNF-alpha and iNOS and for virological examination. Negative controls were derived from autopsy myocardium specimens from 32 HIV-negative patients without known heart disease. The mortality rate for congestive heart failure between groups according to the intensity of iNOS staining was also evaluated. The mean intensity of both TNF-alpha and iNOS staining was greater in patients with HIV-DCM (0.81 and 1.007, respectively) than in patients with IDCM (0.44 and 0.49, respectively) and controls (0.025 and 0.027, respectively). The staining intensity of both TNF-alpha and iNOS was inversely correlated with CD4 count. The staining intensity of iNOS was greater in HIV-DCM patients with HIV/coxsackievirus B3 (CVB3) or with HIV/cytomegalovirus coinfection than in IDCM patients showing infection with CVB3 and adenovirus alone. The staining intensity of iNOS correlated to mortality rate, because it was higher in HIV-DCM patients and, in particular, in those with an optical density unit >1.

CONCLUSIONS

Cytokine activation seems to play a significant pathogenetic role in both HIV-DCM and IDCM. In HIV-DCM patients, the state of immunodeficiency may favor the selection of viral variants of increased pathogenicity, influencing the clinical course of cardiomyopathy by enhancement of the inflammatory process.

Interferon alpha-2B and ribavirin in combination for patients with chronic hepatitis C who failed to respond to, or relapsed after, interferon alpha therapy: a randomized trial

PURPOSE

To assess the efficacy of interferon alpha-2b and ribavirin in combination in the treatment of patients with chronic hepatitis C who had either failed to respond to therapy with interferon alpha (nonresponders), or who had relapsed after interferon therapy (relapsers).

SUBJECTS AND METHODS

Four hundred patients with chronic hepatitis C (200 nonresponders and 200 relapsers) were randomly assigned in equal numbers to receive either subcutaneous administration of recombinant interferon alpha-2b (3 million units three times per week) and ribavirin (1,000 to 1,200 mg/daily orally) or interferon alpha-2b alone (6 million units three times per week). Both ribavirin and interferon alpha-2b were given for 24 weeks. The patients were then followed for an additional 24 weeks.

RESULTS

At the end of the treatment period, normalization of serum alanine aminotransferase levels and absence of hepatitis C virus RNA were seen in 21% of nonresponders and in 39% of relapsers who were treated with interferon alpha-2b and ribavirin, compared with 5% of nonresponders (P = 0.001) and 9% of relapsers treated with interferon alpha-2b alone (P <0.001). At the end of follow-up, 14% of nonresponders and 30% of relapsers treated with the combination therapy had a sustained response, compared with 1% of nonresponders (P = 0.001) and 5% of relapsers treated with interferon alpha alone (P <0.001).

CONCLUSIONS

A 24-week course of treatment with interferon alpha-2b and ribavirin offers a chance of sustained response, whereas retreatment with interferon alpha-2b alone does not give satisfactory results. The role of long-term therapy in inducing prolonged remission remains to be explored.

Hepatocellular mitochondrial alterations in patients with chronic hepatitis C: ultrastructural and biochemical findings

OBJECTIVE

Hepatitis C virus (HCV) infection is associated with increased lipoperoxidation, which may lead to interference with mitochondrial function with possible depletion of mitochondrial DNA (mtDNA). We correlated the ultrastructural findings of liver biopsy specimens with the lipoperoxidation markers and contents of mtDNA in chronic hepatitis C (CHC) patients with a different HCV genotype.

METHODS

Liver biopsy samples obtained from 75 CHC patients were processed for histological and electron microscopic examination. Twenty-two subjects without known liver disease served as controls. Hepatic glutathione in its reduced (H-GSH) and oxidized (H-GSSG) forms were determined from biopsy specimens by high-performance liquid chromatography. Plasmatic and lymphocytic GSH and erythrocytic malonyldialdehyde (MDA) were also determined, along with the ratio between mtDNA and nuclear DNA (nDNA).

RESULTS

Ultrastructural alterations of the mitochondria were documented in 23 patients with genotype 1b, compared with 15 patients with genotype 2a/2c (p = 0.020) and seven patients with genotype 3a (p < 0.001). A significant depletion of H-GSH and lymphocytic GSH, an increase of H-GSSG and MDA, and a reduction of the mtDNA/nDNA ratio were documented in patients with genotype 1b, compared with patients with genotype 2a/2c and 3a and with controls.

CONCLUSIONS

In patients with genotype 1b frequent ultrastructural alterations of the mitochondria may be observed, and the depletion of mtDNA in these patients may represent the expression of a greater impairment of the process of oxidative phosphorylation. An increased production of free radicals in patients with genotype 1b may influence the evolution of the liver disease by enhancement of the cytopathic effect of HCV.

Serum ferritin and hepatic glutathione concentrations in chronic hepatitis C patients related to the hepatitis C virus genotype

BACKGROUND/AIMS

Increased serum ferritin is thought to be responsible for activation of glutathione turnover in patients with chronic hepatitis C. The aim of the study was to evaluate a possible correlation between levels of serum ferritin and concentrations of hepatic, plasmatic and lymphocytic glutathione in a selected cohort of chronic hepatitis C patients in relation to the hepatitis C virus genotype.

METHODS

The study considered 130 chronic hepatitis C patients and 23 control subjects. Hepatic glutathione was determined from biopsy liver specimens by high performance liquid chromatography. Total Iron Score was assessed by scoring iron separately within hepatocytes, sinusoidal cells and portal tracts. Blood samples were tested for determination of serum ferritin, and plasmatic and lymphocytic glutathione levels. Hepatic and erythocyte malonyldialdehyde were also determined along with peripheral blood mononuclear cell cytotoxic assay.

RESULTS

Patients with genotype 1b showed higher levels of serum ferritin compared to patients with genotype 2a/2c and 3a and to controls, along with a significant reduction of the concentrations of hepatic, plasmatic and lymphocytic glutathione and peripheral blood mononuclear cell cytotoxic activity. The levels of serum ferritin correlated significantly to Total Iron Score, to hepatic, plasmatic and lymphocytic glutathione, to hepatic and erythrocyte malonyldialdehyde and to peripheral blood mononuclear cell cytotoxic activity.

CONCLUSIONS

The levels of serum ferritin correlate significantly to lipoperoxidation markers in chronic hepatitis C patients. The increased production of free radicals with a reduced peripheral blood mononuclear cell cytotoxic activity may represent, especially in patients with genotype 1b, a factor underlying the resistance to interferon therapy and may influence the evolution of the liver disease by enhancement of the cytopathic effect of hepatitis C virus.

Interferon-alpha-2B and ribavirin in combination for chronic hepatitis C patients not responding to interferon-alpha alone: an Italian multicenter, randomized, controlled, clinical study

OBJECTIVE

The aim of the study was to assess the efficacy of interferon (IFN)-alpha-2b and ribavirin in combination in the treatment of chronic hepatitis C (CHC) patients unresponsive to a previous treatment with IFN-alpha-2b alone.

METHODS

We conducted a randomized study in 303 CHC patients. One hundred fifty-two patients received subcutaneous administration of recombinant IFN-alpha-2b (3 MU thrice weekly) and ribavirin (1000-1200 mg/daily per os), whereas 151 received IFN-alpha-2b alone (6 MU thrice weekly). Both ribavirin and IFN-alpha-2b were given for 24 wk, regardless of treatment response. Alanine aminotransferase (ALT) levels and HCV RNA titer were checked during the treatment period and for a further 24 wk.

RESULTS

Normal ALT levels were observed in 64.5% of the patients treated with IFN-alpha and ribavirin and in 22.6% of the patients treated with IFN-alpha alone. In the group of patients receiving IFN-alpha and ribavirin HCV RNA was not detectable in 40% of patients responders and remained undetectable in 44.2% of sustained responders. In the group of patients receiving IFN-alpha alone HCV RNA was not detectable in 24.2% of patients responders and remained not detectable in 33.3% of sustained responders.

CONCLUSIONS

A 24-wk treatment course with IFN-alpha and ribavirin given to patients with a previous lack of response to IFN-alpha alone offers a chance of a sustained biochemical and virological response, at least in a subset of such patients. The role of long-term therapy in inducing prolonged remission still remains to be explored.

Incidence of dilated cardiomyopathy and detection of HIV in myocardial cells of HIV-positive patients. Gruppo Italiano per lo Studio Cardiologico dei Pazienti Affetti da AIDS

BACKGROUND

Human immunodeficiency virus (HIV) infection is increasingly recognized as an important cause of dilated cardiomyopathy. However, the pathogenesis of the heart-muscle disease in the acquired immunodeficiency syndrome is unclear.

METHODS

We performed a prospective, long-term clinical and echocardiographic follow-up study of 952 asymptomatic HIV-positive patients to assess the incidence of dilated cardiomyopathy and to analyze the clinical variables associated with the development of cardiomyopathy. All patients with an echocardiographic diagnosis of dilated cardiomyopathy underwent endomyocardial biopsy for histologic, immunohistologic, and virologic assessment.

RESULTS

During a mean (+/-SD) follow-up period of 60+/-5.3 months, an echocardiographic diagnosis of dilated cardiomyopathy was made in 76 patients (8 percent), with a mean annual incidence rate of 15.9 cases per 1000 patients. The incidence of dilated cardiomyopathy was higher in patients with a CD4 count of less than 400 cells per cubic millimeter (as compared with a CD4 count of > or =400 cells per cubic millimeter) and in those who received therapy with zidovudine. A histologic diagnosis of myocarditis was made in 63 of the patients with dilated cardiomyopathy (83 percent). Inflammatory infiltrates were predominantly composed of CD3 and CD8 lymphocytes, with staining for major histocompatibility complex class I antigens in 71 percent of the patients. In the myocytes of 58 patients, HIV nucleic acid sequences were detected by in situ hybridization, and active myocarditis was documented in 36 of the 58. Among these 36 patients, 6 were also infected with coxsackievirus group B (17 percent), 2 with cytomegalovirus (6 percent), and 1 with Epstein-Barr virus (3 percent).

CONCLUSIONS

Dilated cardiomyopathy may be related either to a direct action of HIV on the myocardial tissue or to an autoimmune process induced by HIV, possibly in association with other cardiotropic viruses.

Cardiac involvement in the acquired immunodeficiency syndrome: a multicenter clinical-pathological study. Gruppo Italiano per lo Studio Cardiologico dei pazienti affetti da AIDS Investigators

The heart is frequently involved in the acquired immunodeficiency syndrome (AIDS). This study was planned to assess the prevalence of cardiac involvement in a large and selected population of patients who died of AIDS. Of 440 AIDS patients who underwent autopsy, cardiac involvement was documented in 82 patients. Dilated cardiomyopathy was found in 12 patients; lymphocytic interstitial myocarditis was documented in 30 patients, and in 10 of 12 patients with dilated cardiomyopathy. Inflammatory infiltrate was predominantly composed by CD3+ and CD8+ with a positive staining for major histocompatibility class I in 70% of the cases. Infective endocarditis was documented in 28 patients, pericardial effusion in 53 patients, myocardial Kaposi's sarcoma in 2 patients, myocardial B-cell immunoblastic lymphoma in 1 patient. Sequences of human immunodeficiency virus (HIV) nucleic acid were detected using the technique of in situ hybridization in the myocytes of 29 autopsy patients and in 25 of 29 patients with a positive hybridization signal an active myocarditis was documented. Among them, 7 presented a coinfection with Coxsakievirus group B, 2 with Epstein-Barr virus, and 1 with cytomegalovirus. HIV-associated cardiomyopathy may be related either to a direct action of HIV on the myocardial tissue or to an autoimmune process induced by HIV even in association with other cardiotropic viruses.

Flumazenil for hepatic encephalopathy grade III and IVa in patients with cirrhosis: an Italian multicenter double-blind, placebo-controlled, cross-over study

The rationale for use of benzodiazepine receptor antagonists is based on the so-called benzodiazepine pathogenetic hypothesis of hepatic encephalopathy (HE). To assess the efficacy of flumazenil, a specific benzodiazepine receptor antagonist, in a large and selected population of cirrhotic patients with severe HE, we conducted a double-blind, placebo-controlled, cross-over trial on 527 cirrhotic patients with HE grade III and IVa admitted to Intensive Care Units over a 5-year period; among them, 265 (132 of grade III and 133 of grade IVa) received flumazenil, whereas 262 (130 of grade III and 132 of grade IVa) received placebo. Treatment was begun within 15 minutes of randomization; the response to treatment was assessed by neurological score and by continuous electroencephalographic (EEG) recordings. Improvement of the neurological score was documented in 17.5% of grade III patients treated with flumazenil and in 14.7% of grade IVa patients, compared, respectively, with 3.8% and 2.7% of the patients of both groups treated with placebo. Improvements in EEG tracings were observed in 27.8% of grade III patients and in 21.5% of grade IVa patients, compared, respectively, with 5% and 3.3% of the patients of both groups treated with placebo. Benzodiazepines were detected in the serum of 10 patients (4 in grade III group and 6 in grade IVa group). Flumazenil is beneficial only in a selected subset of cirrhotic patients with severe HE; the applicability of this treatment to unselected patients with severe HE still remains to be determined.

Flumazenil for hepatic coma in patients with liver cirrhosis: an Italian multicentre double-blind, placebo-controlled, crossover study

Several factors suggest that endogenous benzodiazepines and gamma-amino-butyric acid may be involved in pathophysiology of hepatic encephalopathy (HE). Contrasting opinions exist on the therapeutic efficacy of flumazenil in the treatment of HE. This study was planned to assess the efficacy of flumazenil by a double-blind, placebo-controlled, crossover design in a large and selected population of cirrhotic patients in stage 4a HE admitted to intensive care units over a 4-year period. Out of 236 patients selected for the study, 132 received flumazenil, whereas 131 patients received placebo. Improvement of the neurological score was documented in 31 patients (23%) of flumazenil group and in two patients (1.5%) of placebo group (p < 0.001) during the first study period, whereas during the crossover period, improvement of the neurological score was documented in seven patients (5.3%) of the flumazenil group and in none of the placebo group (p = 0.022). Improvements in EEG tracings were observed in 44 patients (33.3%) of flumazenil group and in five patients (3.8%) of placebo group (p < 0.001) during the first study period; during the crossover period, improvements in EEG tracings were observed in 10 patients (7.5%) of the flumazenil group and in two patients (1.5%) of the placebo group (p = 0.040). The presence of benzodiazepines was detected in the serum of three responders and in two non-responders. The presence of diazepam and NN-desmethyl diazepam was documented in two responders; prior intake of synthetic diazepam was later confirmed in these patients. The results of our study suggest that flumazenil is beneficial only in a selected subset of cirrhotic patients with severe HE; the applicability of this treatment to unselected patients with hepatic coma or to cirrhotic patients with less severe HE still remains to be determined.

Vagal system impairment in human immunodeficiency virus-positive patients with chronic hepatitis C: does hepatic glutathione deficiency have a pathogenetic role?

BACKGROUND

Both an autonomic impairment and a systemic depletion of reduced glutathione (GSH) may be documented in patients with chronic liver diseases and in human immunodeficiency virus (HIV)-positive patients.

METHODS

The coefficients of electrocardiographic R-R interval variation (CVc) were assessed in 125 patients with chronic hepatitis C (CHC) (65 HIV-positive and 60 HIV-negative) and in 61 healthy controls. The CVc values were correlated with hepatic (H-GSH), plasmatic (P-GSH), lymphocyte (L-GSH), and erythrocyte (E-GSH) concentrations of GSH and with erythrocyte malonyldialdehyde (MDA) levels.

RESULTS

Compared with healthy controls, in CHC patients the concentrations of H-GSH, P-GSH, L-GSH, and E-GSH were reduced, whereas MDA levels were increased with a statistically significant difference (P < 0.001). CVc was significantly reduced in patients with CHC (especially in those who were HIV-positive) and correlated significantly with the values of H-GSH, P-GSH, L-GSH, E-GSH, and MDA (P < 0.001).

CONCLUSIONS

A dysfunction of the cardiac vagal system may be detected in patients with CHC (especially in those who are HIV-positive); this abnormality may be related to a reduced response to oxidative stress because of a systemic depletion of GSH.

Effect of recombinant human granulocyte-macrophage colony-stimulating factor on HIV-related leukopenia: a randomized, controlled clinical study

OBJECTIVE

To assess the effect of granulocyte-macrophage colony-stimulating factor (GM-CSF) on white blood cell (WBC) count and on the rate of opportunistic infections in a large and selected population of leukopenic HIV-positive patients compared with non-treated controls.

DESIGN

Open-label, randomized, comparative clinical study.

SETTING

University hospitals and AIDS centres.

PATIENTS AND METHODS

One hundred and twenty-three leukopenic HIV-positive patients received recombinant human GM-CSF (300 microg subcutaneously daily for 1 week, and 150 microg subcutaneously two times weekly for 11 weeks thereafter); the control group comprised 121 non-treated leukopenic HIV-positive patients. A complete blood cell count with differential, platelet count, reticulocyte count, and CD4+ and CD8+ T-cell subset counts were performed in both patient groups at baseline and at weeks 1, 12 and 24.

RESULTS

The administration of GM-CSF resulted in a significant increase of WBC count in patients compared with non-treated controls. Total leukocyte count increased by 22% at week 1 and by 65% at week 12 compared with baseline levels; a 20% increase of total leukocyte count was still present at week 24. Increases of neutrophils, eosinophils and monocytes were responsible for the majority of the increase in WBC count. Opportunistic infections occurred in 61.7% of GM-CSF-treated patients and in 72% of the patients of the control group (relative risk, 0.86; 95% confidence interval, 0.72-1.03; P = 0.123). Mild flu-like side-effects were observed in most patients receiving GM-CSF, although they were not sufficiently severe to warrant withdrawal from the study.

CONCLUSIONS

GM-CSF was well tolerated and biologically active in leukopenic HIV-positive patients, with a significant, although time-limited, increase of WBC count compared with non-treated patients. The administration of this growth factor should be considered in ameliorating the myelosuppression observed with some cell-cycle-specific antiviral and anti-neoplastic agents.

Hepatic glutathione deficiency in chronic hepatitis C: quantitative evaluation in patients who are HIV positive and HIV negative and correlations with plasmatic and lymphocytic concentrations and with the activity of the liver disease

OBJECTIVES

Reduced glutathione (GSH) is decreased in patients affected by chronic hepatitis C (CHC) as well as in patients who are HIV positive. Because the liver is the most important source of plasmatic GSH, we measured the concentrations of GSH in the liver (H-GSH) of patients with CHC who were either HIV positive or negative, correlating it to the concentrations of GSH in plasma (P-GSH) and in peripheral blood mononuclear cells (PBMCs) (L-GSH), to the replication activity of hepatitis C virus (HCV) in PBMCs, to the activity of the liver disease, and to the state of immunodeficiency in patients who were HIV positive.

METHODS

One hundred, five patients with serologically and histologically demonstrated CHC (55 HIV positive and 50 HIV negative) entered the trial. Fifty-one healthy individuals made up a control group for P-GSH and L-GSH concentrations. H-GSH concentration was determined by high performance liquid chromatography on liver specimens obtained by ultrasound-guided biopsy according to the method described by Reed et al. The concentrations of P-GSH and L-GSH were determined according to the method described by Suarez et al. The detection of HCV RNA strands in PBMCs was performed according to the method described by Qian et al. Histological findings and degree of fibrosis were scored according to the numerical scoring system proposed by Scheuer and by Knodell et al.

RESULTS

H-GSH, P-GSH, and L-GSH were significantly reduced in patients affected by CHC compared with healthy controls (p < 0.001). H-GSH and particularly L-GSH were more significantly reduced in patients who were HIV positive compared with those who were HIV negative (p < 0.001), without significant correlation with the values of the T cell subset CD4+. The reductions in H-GSH, P-GSH, and L-GSH were significantly correlated to the replication activity of HCV in PBMCs (p < 0.001) and to the grade of activity of the liver disease assessed by the values of ALT (p < 0.001) and by histological and fibrosis scores of CHC (p < 0.001). In both groups of patients with CHC, H-GSH, P-GSH, and L-GSH were more reduced in patients addicted to drugs than in patients who were not addicted.

CONCLUSIONS

In patients with CHC, particularly those who are HIV positive, a systemic depletion of GSH is present. This depletion may be a factor underlying the resistance to interferon therapy and, in patients who are HIV positive, to antiretroviral drugs, fostering HCV and/or HIV replication. This may represent the biological basis for GSH replacement therapy.

Clinical meaning of ventricular ectopic beats in the diagnosis of HIV-related myocarditis: a retrospective analysis of Holter electrocardiographic recordings, echocardiographic parameters, histopathological and virologic findings

Clinical-pathological studies have demonstrated that in 46-51% of AIDS patients a lymphocytic interstitial myocarditis can be found at autopsy. In > 80% of these patients no specific etiologic factor for myocarditis was found. This pathological finding is believed to be related to a specific pathogenetic action of HIV on myocardial tissue and it is called HIV-related myocarditis (HRM). In 15-30% of patients with lymphocytic interstitial myocarditis ventricular arrhythmias have been described. In order to assess the prevalence and the predictive value of ventricular ectopic beats (VEB) in the diagnosis of HRM, we performed a retrospective analysis of 24-hour Holter recordings, M-mode and two-dimensional echocardiographic and Doppler parameters and post-mortem myocardial histopathological and virologic findings on a selected sample of 35 NYHA functional class II patients died of AIDS. The patients were divided into two groups according to post-mortem histopathological findings of myocardium specimens: Group 1 (n = 19) including patients with histopathological findings consistent with diagnosis of HRM; Group 2 (n = 16), including patients without histopathological findings of myocarditis. Group 2 patients represented the control group. The retrospective analysis demonstrated a greater prevalence of VEB class IV and subclass IVb in Group 1 compared to Group 2 (p = 0.009 and p = 0.004, respectively). The other classes of VEB did not present a statistically significant difference between groups. VEB class IV presented a 81.2% diagnostic predictive value (subclass IVa: 50%; subclass IVb: 90.9%). Ejection fraction, kinetic score and Doppler E/A ratio, Ei Area, Ai Area and Ai Area/total Area ratio and isovolumetric relaxation time were significantly correlated to Lown's classes of VEB (p < 0.001) and to the values of CD+ cells (p < 0.001); on the other hand, VEB classes correlated significantly with the values of CD+ cells (p < 0.001). Syncytial cells and HIV p24 antigen in cultured myocytes were detected in 17 Group 1 patients (89.4%) and in 2 Group 2 patients (12.5%; p < 0.001). These results have demonstrated that in selected cases of AIDS patients specific classes of VEB may represent a simple and sensitive electrocardiographic marker of HRM. VEB classes correlate significantly with systolic and diastolic echocardiographic parameters and to the values of CD4+ cells. Furthermore, in patients with HRM a direct pathogenetic action of HIV may be assumed.

Fluconazole versus itraconazole for candida esophagitis in acquired immunodeficiency syndrome. Candida Esophagitis

BACKGROUNDS & AIMS

Contrasting opinions exist about the pharmacological treatment of esophageal candidiasis in patients with acquired immunodeficiency syndrome (AIDS). The aim of this study was to assess the long-term efficacy of fluconazole and itraconazole treatment.

METHODS

This study evaluated 2213 human immunodeficiency virus-positive patients at first episode of esophageal candidiasis diagnosed by endoscopy; 1105 received fluconazole and 1108 received itraconazole. The endoscopic and clinical response to treatment was assessed periodically until the end of the follow-up period (1 year).

RESULTS

At week 2, endoscopic cure occurred in 81.2% of patients treated with fluconazole and in 65.6% of patients treated with itraconazole (P < 0.001). Clinical cure was observed in 81.5% of patients treated with fluconazole and in 75.2% of patients treated with itraconazole (P < 0.001). At the end of the follow-up period, endoscopic and clinical cure were observed in 96% of patients treated with fluconazole and in 95.6% of patients treated with itraconazole (P = 0.788), with similar differences by intention-to-treat analysis (93.6% vs. 93.3%; P = 0.853). Treatment failure was observed in 22.3% of fluconazole-treated patients and in 26.6% of itraconazole-treated patients (P = 0.022).

CONCLUSIONS

Fluconazole and itraconazole are provided with good long-term therapeutic efficacy in the treatment of Candida esophagitis in patients with AIDS. Fluconazole is associated with a higher rate of cure than itraconazole in short-term treatment.