Liver toxicity and risk of discontinuation in HIV/hepatitis C virus-coinfected patients receiving an etravirine-containing antiretroviral regimen: influence of liver fibrosis

OBJECTIVES

The aim of the study was to establish the risk of liver toxicity in HIV/hepatitis C virus (HCV)-coinfected patients receiving etravirine, according to the degree of liver fibrosis.

METHODS

A prospective cohort study of 211 HIV-infected patients initiating an etravirine-containing regimen was carried out. HCV coinfection was defined as a positive HCV RNA test, and baseline liver fibrosis was assessed by transient elastography. Hepatotoxicity was defined as clinical symptoms, or an aspartate aminotransferase (AST) or alanine aminotransferase (ALT) value > 5-fold higher than the upper limit of normal if baseline values were normal, or 3.5-fold higher if values were altered at baseline.

RESULTS

Overall, 145 patients (69%) were HCV coinfected, with a lower nadir (165 versus 220 cells/μL, respectively; p = 0.03) and baseline (374 versus 498 cells/μL, respectively; p = 0.04) CD4 count than monoinfected patients. Etravirine was mainly used with two nucleoside reverse transcriptase inhibitors (129; 61%) or with a boosted protease inhibitor (PI) (28%), with no significant differences according to HCV serostatus. Transient elastography in 117 patients (81%) showed a median (range) stiffness value of 8.25 (3.5-69) kPa, with fibrosis stage 1 in 43 patients (37%) and fibrosis stage 4 in 28 patients (24%). During an accumulated follow-up time of 449.3 patient-years (median 548 days), only one patient with advanced fibrosis (50.8 kPa) had grade 3-4 liver toxicity (0.7%). Transaminases changed slightly, with no significant differences compared with baseline fibrosis, and nine and six patients had grade 1 and 2 transaminase increases, respectively. Also, HCV coinfection was not associated with a higher risk of discontinuation (25% discontinued versus 21% of monoinfected patients; p = 0.39, log-rank test) or virological failure (8% versus 12%, respectively; p = 0.4).

CONCLUSIONS

Our data suggest that etravirine is a safe option for HIV/HCV-coinfected patients, including those with significant liver fibrosis.

Trends on epidemiological, virological, and clinical features among newly diagnosed HIV-1 persons in Northwest Spain over the last 10 years

To describe temporal trend and characteristics of newly HIV-diagnosed patients in a medical care area in Northwest Spain over the last 10 years. All newly diagnosed patients for HIV-infection from 2004 to 2013 at a reference medical care area in Northwest of Spain were identified. Epidemiological, virological, immunological, and clinical data, as well as HIV genotype and drug resistance information were recorded. A total of 565 newly HIV-diagnosed patients were identified. The number of new cases increased in the last 5 years (66 cases/year). Overall, 53.1% had a median CD4 counts < 350 cells/µl and 33.6% had an AIDS defining criteria. Non-B variants were found in 34.4% of patients being subtype F (25.8%) the most common non-B subtype. The rate of transmitted drug resistance (TDR) over the study period was 3.7%, but a decreased to 2.6% was observed in the last 5 years. The most prevalent TDR mutations were: T215 revertants (1.5%), K219QENR (1.2%), for NRTIs; K103N (1.9%), for NNRTIs; L90M (0.3%), for PIs. Overall, 73.2% of patients started antiretroviral treatment and 9.9% of patients died during follow-up. The number of newly HIV diagnosed patients increased since year 2009. There is a high prevalence of late diagnosis (53%) and 33% had an AIDS defining criteria. Interestingly, the most prevalent non-B subtype in our population was F (25.8%). These findings support the need to facilitate the access for HIV testing to reduce the rate of late HIV diagnosis, improve the clinical outcome and prevent HIV transmission.

Outcome of HCV/HIV-coinfected liver transplant recipients: a prospective and multicenter cohort study

Eighty-four HCV/HIV-coinfected and 252-matched HCV-monoinfected liver transplant recipients were included in a prospective multicenter study. Thirty-six (43%) HCV/HIV-coinfected and 75 (30%) HCV-monoinfected patients died, with a survival rate at 5 years of 54% (95% CI, 42-64) and 71% (95% CI, 66 to 77; p = 0.008), respectively. When both groups were considered together, HIV infection was an independent predictor of mortality (HR, 2.202; 95% CI, 1.420-3.413 [p < 0.001]). Multivariate analysis of only the HCV/HIV-coinfected recipients, revealed HCV genotype 1 (HR, 2.98; 95% CI, 1.32-6.76), donor risk index (HR, 9.48; 95% CI, 2.75-32.73) and negative plasma HCV RNA (HR, 0.14; 95% CI, 0.03-0.62) to be associated with mortality. When this analysis was restricted to pretransplant variables, we identified three independent factors (HCV genotype 1, pretransplant MELD score and centers with <1 liver transplantation/year in HIV-infected patients) that allowed us to identify a subset of 60 (71%) patients with a similar 5-year prognosis (69%[95% CI, 54-80]) to that of HCV-monoinfected recipients. In conclusion, 5-year survival in HCV/HIV-coinfected liver recipients was lower than in HCV-monoinfected recipients, although an important subset with a favorable prognosis was identified in the former.

Long-term prognosis of HIV-infected patients with Kaposi sarcoma treated with pegylated liposomal doxorubicin

INTRODUCTION

Incidence of Kaposi sarcoma (KS) in human immunodeficiency virus (HIV)-infected persons has dramatically decreased in the highly active antiretroviral therapy era. However, this tumor still represents the most common cancer in this population.

OBJECTIVES

The objectives of this study were to evaluate long-term prognosis of HIV-infected patients with KS who had received pegylated liposomal doxorubicin (PLD) and, more specifically, to assess tumor relapse rate, mortality, and cause of death in these subjects.

DESIGN

This study was a retrospective review of all patients with KS who had received PLD in centers belonging to the Caelyx/KS Spanish Group. Kaplan-Meier analysis and univariate and multivariate Cox-regression analysis were used to assess the rate of and factors associated with relapse and death through January 2006.

RESULTS

A total of 98 patients received PLD from September 1997 through June 2002. Median follow-up after initiation of treatment was 28.7 months (interquartile range, 6.6-73.2 months); during follow-up, 29 patients died (a mortality rate of 14.6% per year). In 9 patients (31%), the cause of death was related to the appearance of other tumors (including 7 lymphomas, 1 gastrointestinal adenocarcinoma, and 1 tongue epidermoid cancer). Death caused by progression of KS occurred in 3 cases. Death risk was inversely related to CD4(+) cell counts at the end of follow-up (hazard ratio for every increase in CD4(+) cell count of 100 cells/microL, 0.7; 95% confidence interval, 0.5-0.9). A relapse study was performed for 61 patients who had complete or partial response to PLD and who attended a control visit after treatment completion. After a median follow-up of 50 months (interquartile range, 17.2-76 months), 8 patients (13%) had experienced relapse; 5 of these patient experienced relapse within the first year after stopping PLD. The only factor that was independently related to risk of relapse was having a CD4(+) cell count >200 cells/microL at baseline (hazard ratio, 6.2; 95% confidence interval, 1.2-30). Lower CD4(+) cell count at the end of follow-up was marginally associated with relapse (hazard ratio for every increase in CD4(+) cell count of 100 cells/microL, 0.7; 95% confidence interval, 0.6-1.01).

CONCLUSIONS

Treatment of KS with PLD in HIV-infected patients is followed by a low relapse rate, with most relapses occurring during the first year after stopping chemotherapy. However, the mortality rate in this population was high, in part because of an unexpectedly high incidence of other tumors, mainly lymphomas.

Assessment of climatic and orographic conditions on the infection by Calicophoron daubneyi and Dicrocoelium dendriticum in grazing beef cattle (NW Spain)

From February 2003 to March 2004, 1148 faecal samples from autochthonous Rubia Gallega cattle breed were collected in 170 farms from Lugo (NW Spain), in order to find out the prevalence and intensity of egg-excretion by Calicophoron daubneyi and Dicrocoelium dendriticum, and the possible influence of external factors as annual mean temperature and rainfall, altitude and mean slope. Twenty-six percent (95% CI 19%, 33%) and the 18% (12, 24) of the farms were infected with rumen and lancet flukes. C. daubneyi egg-output (Me=24) was found in 13% (11, 15) of the individual samples. Six percent (5, 7) of the animals in the study had low D. dendriticum eggs (Me=8). By estimating the odds ratio values it was shown that the highest probability of infection by C. daubneyi was in pastures with a mean slope of less than 13% (OR=1.9) and situated under 600 m (OR=1.6). Annual mean rainfall and temperature were not identified as risk factors for the infection with rumen flukes. Mountainous pastures with a mean slope of higher than 25% (OR=5.8) and situated over 600 m (OR=24.6) where precipitation was high (>1000 mm; OR=7) and temperature low (<11 degrees C; 2.8) had involved the highest risk of infection by D. dendriticum. Because of the prevalences found in this study, employment of suitable management practices with strategic treatments with efficacious anthelmintics are needed to reduce the presence of both trematodes and to increase the health status of grazing beef cattle.

Immunodiagnosis of current fasciolosis in sheep naturally exposed to Fasciola hepatica by using a 2.9kDa recombinant protein

A 2.9 kDa recombinant-Fasciola hepatica protein (FhrAPS) was employed to estimate the prevalence of fasciolosis in sheep maintained under field conditions. For this purpose, 340 samples with known status in relation to fasciolosis by using a direct-ELISA and the coprological sedimentation were used. These samples were analysed by using an indirect-ELISA (iELISA) and the FhrAPS recombinant protein and excretory/secretory antigens (FhES) of this trematode. Current fasciolosis (CF) was named when results were positive to antigenemia and/or coprology. Out of 198 sheep with current fasciolosis, 68% were positive to the FhrAPS-ELISA test and 53% to the FhES. We observed 14% of the CF-neg sheep were positive to the FhrAPS, whereas this percentage was 52% with the FhES. A significant correlation between FhrAPS and current fasciolosis was obtained (r2=0.513, p=0.001). We concluded that the FhrAPS provides a more suitable antigen than FhES for developing field trials to know the prevalence of early and current fasciolosis.

Analysis of the IgG antibody response against Paramphistomidae trematoda in naturally infected cattle. Application to serological surveys

The IgG antibody response to Calicophoron daubneyi (Digenea: Paramphistomidae) excretory/secretory antigens was evaluated in naturally infected cattle from Lugo (Galicia, NW Spain) by using an ELISA procedure. Two studies were conducted, first a survey in 524 cattle separated into three groups according to age, G-1 (0-2 years old), G-2 (3-5 years old) and G-3 (> 6 years old). In the second study, three groups of cattle were employed: G-I, naturally infected; G-T, naturally infected and treated with oxyclozanide plus levamisole (Nilzan Plus); G-C, cattle maintained in a farm where C. daubneyi has never diagnosed. Variations on egg-output and haematic parameters (erythrocytes, haematocrite, leukocytes and lymphocytes) were also analyzed. The ELISA procedure showed that 61.2% of the cattle in the first study had been exposed to the trematode, but only 10.1% passed eggs in the feces. Age-association with egg-output was shown but not with the IgG values. In the second experiment, the administration of the anthelmintic reduced significantly the IgG kinetic levels and the C. daubneyi-egg-output was suppressed during 12 weeks in the G-T group. The values of red cells, haematocrite, leukocytes and lymphocytes increased significantly in the treated cattle 5 weeks after chemotherapy; however, new reduction after week 5 was recorded, as results of the challenge of these cattle. This is the first investigation in which evaluation of the IgG humoral response against C. daubneyi in cattle has been carried out. We proved that a notable IgG response in naturally infected cattle is induced, and can be detected by using an ELISA procedure. The IgG antibodies did not increase after challenge infection. Our results proved an important percentage of cattle were exposed to this trematode in the area of study and suitable measures for preventing this relationship must be considered.

Toxocara canis larvae viability after disinfectant-exposition

The effect of three routinely used disinfectants on the embryonary development of Toxocara canis eggs was evaluated both in vivo and in vitro. In the in vitro experiment, T. canis eggs were treated with the ethanol, sodium hypochlorite, and one commercial mix of benzalconium chloride and formaldehyde, and the embryonary development was assessed. After a period of 24 days incubation, ethanol was the best disinfectant because it prevented the development of the T. canis larvae 2 in the eggs, and sodium hypochlorite caused degeneration in 50% eggs. By using the commercial mix, 25% T. canis eggs developed to 2nd stage larvae. In the in vivo experiment, the embryonated eggs treated with the disinfectants were inoculated to mice, and their brain tissues were examined for larval presence on the 24th day postinfection. In addition, a control group was set up for comparison with the infected groups. No injury or T. canis larvae were observed in mice infected with sodium hypochlorite-treated eggs, opposite to that recorded in the animals infected with the commercial disinfectant-treated eggs. These results showed that both ethanol and sodium hypochlorite are very appropriate because of their full efficacy against infective T. canis eggs. Disinfection of kennels, animal shelters, cages, and veterinary clinics with one of these products to eliminate T. canis eggs and to avoid contamination is strongly recommended.

Prevalences of gastrointestinal parasites in sheep and parasite-control practices in NW Spain

A coprological survey to know the presence of gastro-intestinal nematode parasites infecting sheep was done in Galicia (NW Spain), an area with Atlantic climate where sheep production is replacing cattle due to the Agricultural Community Politics of the European Union. From September 2001 to November 2002, 1710 faecal samples were randomly collected from 49 sheep farms and examined by using the flotation technique to determine the prevalence of gastro-intestinal nematode parasites. The sheep-level prevalence was 100%, and the genera identified were Chabertia, Cooperia, Haemonchus, Nematodirus, Oesophagostomum, Teladorsagia, Trichostrongylus and Trichuris spp. A questionnaire was distributed to the farmers (at the same time as sampling) about parasite-control practices during the year before sampling (2000). Ninety percent (95% CI 81%, 98%) of the farmers said they used antiparasitic drugs occasionally, but none of them asked for a coprological analysis prior to the treatment and the efficacy of the drugs was never evaluated. A higher median EPG was observed in the treated sheep (163) than in the untreated ones (26). Chemotherapy was the only parasite-control practice. Flocks that treated according to the farmer's previous experience had higher median EPG (236) than other flocks (185 following the prescription of their veterinary clinician and 232 based on the commercial agent's counsel). Typically, one benzimidazole-treatment per year was applied in autumn and non-veterinary counsel was used. Sheep treated with imidotiazoles had lower EPG (144) than other drugs (164 for the benzimidazoles and 166 for the macrocyclic lactones). We found a higher median EPG in the sheep receiving two treatments/year (175) than in those treated only once per year (156). These results suggest lack of knowledge about worm-control strategies and anthelmintic use or unwillingness to apply such knowledge.

A 2.9 kDa Fasciola hepatica-recombinant protein based ELISA test for the detection of current-ovine fasciolosis trickle infected

The suitability of an enzyme linked immunosorbent assay (ELISA) test with a 2.9 kDa Fasciola hepatica-recombinant protein (FhrAPS) for diagnosing early and current-ovine fasciolosis was analyzed, and compared to that obtained by using a direct ELISA for detecting F. hepatica-circulating FhES antigens and to the coprological sedimentation for fluke egg quantitation. Fourteen Gallega autochthonous breed sheep were experimentally infected with metacercariae by a trickle system (small repetitive infections) and divided into two groups: G-I represented a primary infection for 34 weeks; G-R, animals with primary infection and reinfected 18 w.a.p.i. Seven sheep were left uninfected as the control group (G-C). Serum IgG antibody values against the FhrAPS rose rapidly by 1st w.a.p.i. in all infected sheep. Antibody levels in those with primary infection (G-I, G-C) peaked at 10 weeks, diminishing slightly and levelling from 16 to 34 weeks. Those with primary infection reinfected at 18 weeks had a rebound effect with the highest values observed. Circulating F. hepatica-ES antigens were detected by the 1st w.a.p.i. in all infected groups peaking at 6 weeks, decreasing rapidly to uninfected control values by 10 weeks of infection. Faecal egg-output started 11 weeks after primary infection. An increase in the IgG antibody as well as antigen responses to the FhrAPS and to anti-FhES from the 18 w.a.p.i. was recorded in G-T and G-R after the challenge infection. Antibody levels remained high whereas antigenemia values diminished after 6 weeks. A positive significant correlation between the IgG response against the FhrAPS and the F. hepatica circulating antigens (r2 = 0.428, p = 0.001) was obtained. In conclusion, our standardized diagnostic ELISA for fasciolosis based on the detection of IgG responses to the FhrAPS would be a valuable tool to diagnosis early and current F. hepatica-infections in sheep.

Analysis of the humoral immune response to Oestrus ovis in ovine

Antibody responses (IgG, IgM and IgA) against Oestrus ovis were analyzed in sheep and in first year grazing lambs from Sardinia (Italy) by an indirect-enzyme-linked immunoassay test and L2 O. ovis excretory/secretory antigens. Serum samples from 208 sheep were obtained prior to be slaughtered, and then heads were removed and cut open along their longitudinal axis to collect the parasites from the nasal cavities, turbinates and sinus. Besides this, blood samples were monthly collected from the lambs of G-1 (maintained under field conditions) and the lambs of G-2 (kept housed since birth to avoid Oestrus infestations) throughout a year. In the sheep, a positive significant correlation was observed between the number of first instar O. ovis larvae and the values of IgM, and between the second instar larvae and the IgG optical densities. In the lambs, all classes of antibodies increased significantly from July in G-1. The highest values of IgG were reached in September (IgG) and decreased in November-December. The IgM response peaked in November, and very low values of IgA were observed during the study. Matching these data with chronobiology of O. ovis in this region, we conclude that the first infection occurs on May, stimulating the production of humoral antibodies. The reduction of the IgG antibody levels starting from October means the beginning of the diapause while the IgM response seems to be associated to the presence of L1 in the nasal cavities. The data obtained led us to forecast an early treatment of the ovine on June-July, which should keep away from the maturation of O. ovis L1 larvae, avoiding the development of clinical lesions and interrupting the life cycle of this parasite.

Comparison of Oestrus ovis metabolic and somatic antigens for the immunodiagnosis of the zoonotic myasis oestrosis by immunoenzymatic probes

Control of zoonosis implies reduction of infected animal hosts, and the first measure consists of a suitable and accurate detection test. An experimental study for determining the most appropriate antigen (metabolic or somatic) to be used in the detection of the oestrosis (Oestrus ovis) zoonotic myasis by means of immunoenzymatic probes was carried out. A flock of 23 uninfected goats was maintained under field conditions to allow their infection in Sassari (Sardinia, Italy). Caprine were bled monthly and serum samples processed by means of an iELISA. After comparing these results to the chronobiology of O. ovis, we proved that the IgG humoral response against the metabolic antigens increased only during the period of real risk of infestation (when adults fly, from May to September), whereas the absorbances against the somatic products were positive from the beginning of the study (in January, prior to infection). We concluded that the excretory/secretory products are most useful and suitable for the immunodiagnosis of oestrosis in goats, because a direct relation between the development of O. ovis and the IgG humoral response is possible, allowing a more accurate diagnostic.

Consensus conference on chronic viral hepatitis and HIV infection: updated Spanish recommendations

Chronic hepatitis B and C represent a leading cause of morbidity and mortality among human immunodeficiency virus (HIV)-infected patients worldwide. New treatment options against both hepatitis B (HBV) and C (HCV) viruses have prompted us to update previous recommendations for the management of coinfected individuals. Fifteen topics (nine related to HCV, five to HBV and one to both viruses) were selected for this purpose. A panel of Spanish experts in the field was invited to review these areas and propose specific recommendations, which were scored according to the Infectious Disease Society of America (IDSA) grading system. These guidelines represent a comprehensive and updated overview on the management of hepatitis B and C in HIV-infected patients.

Prevalence of natural ovine fasciolosis shown by demonstrating the presence of serum circulating antigens

The prevalence of fasciolosis in sheep (Galicia, Northwest Spain) kept under field conditions was determined by using a sandwich-enzyme-linked immunosorbent assay (sELISA). Serum Fasciola hepatica circulating antigens were captured by means of a rabbit polyclonal IgG antibody to F. hepatica excretory/secretory products. Results were compared to those obtained by faecal sedimentation and an indirect ELISA (iELISA) and excretory/secretory antigens. Prevalences were 39.1% by sELISA, 30.4% by faecal sedimentation and 56% by iELISA; 83.3% of the sheep were positive to any one of the three tests. We observed that 59.5% of the sheep examined had active fasciolosis, 29.1% (117) had antigenaemia, 20.4% (82) passed eggs, and 40 (10%) were positive to both probes. We conclude that there is a high prevalence of fasciolosis in sheep from the studied region, and that the combination of sELISA and coprological sedimentation is extremely helpful for demonstrating current fasciolosis, so its application can be strongly recommended for epidemiological surveys.

High Incidence of Non-B and Recombinant HIV-1 Strains in Newly Diagnosed Patients in Galicia, Spain: Study of Genotypic Resistance

The objectives of this study are to describe the incidence of non-B and recombinant HIV-1 strains in newly diagnosed HIV-1 infections in Galicia, northwest of Spain, during a 2-year period (May 2000 to June 2002), and the frequency of resistance-associated mutations in reverse transcriptase (RT) and protease (PR) genes, analysing the polymorphisms more frequently detected in non-B and recombinant viruses. All newly diagnosed HIV-1-infected patients attending the nine public hospitals of the seven main cities of Galicia were included in this study. RT, PR and V3 regions from HIV-1 RNA plasma were amplified and sequenced, being the corrected sequences sent to the Stanford HIV RT and Protease Sequence Database. Nineteen of 85 patients (22.3%) were infected by non-B or recombinant viruses: three subtype C, two G, one F1, one Dpol/A1V3, five CRF02_AG, one CRF14_BG, five BGpol/BV3 and one UKpol/UV3 (U, unknown fragment). Eleven of these 19 patients (57.9%) were foreign individuals living in Galicia infected through heterosexual contact, and the other eight (42.1%) were Spanish intravenous drug users who had shared injection equipment. Five of 85 patients (5.9%), all infected with B subtype viruses, showed resistance-associated mutations in RT (M184V, M41L, L210W, T215Y/D and K219Q). In one patient (1.2%) infected with a subtype G strain, resistance-associated mutations in PR (K20I+M36I+M46I+V82I) were detected. In subtype B viruses resistance mutations in PR were not detected. Several polymorphisms in RT: D123S, Q174K, D177E, T200A, V245Q, and PR: I13V, K20I, M36I, R41K, H69K, L89M were detected more frequently in non-B and recombinants than in B strains ( P<0.01 to P<0.001). This study reports a high incidence (22.3%) of newly diagnosed patients infected by different non-B and recombinant HIV-1 strains, in a geographical area of Spain, showing also a high frequency of polymorphisms in RT and PR genes.

[GB virus C: lack of association with transaminases levels, CD4 and HIV viral load in aids patients]

OBJECTIVE

To study the prevalence of GBV-C-RNA in sera of HIV-infected patients and determine whether differences in immunological condition and hepatic disease exist between GBV-C positive and negative patients.

METHODS

The presence of GBV-C-RNA was determined in sera of 222 HIV-positive patients by semi-automated RT-PCR. A comparison of GBV-C-RNA positive and negative patients was made by studying a series of clinical and analytical parameters. This same comparison was made in particular between those coinfected with HCV and GBV-C and those who only presented GBV-C.

RESULTS

Prevalence of GBV-C-RNA was 28.8%. The most frequent hepatotropic virus was HCV, appearing in 71.6% of cases. Coinfection with HCV and HGV was present in 17% and 8.6% only had GBV-C. Patients positive for GBV-C-RNA showed clinical and analytical characteristics similar to those found in GBV-C-RNA negative patients. Among the HCV-GBV-C coinfected and those presenting HGV as the only virus it was observed that the coinfected group presented alterations in transaminases and predominance of parenteral transmission as a risk factor for HIV, whereas the GBV-C group presented normal transaminases and predominance of sexual transmission. No differences were perceived in mean CD4 and HIV-RNA values in both groups.

CONCLUSIONS

Being positive for GBV-C in HIV-positive patients does not influence the presence of hepatic disease that in these patients is frequently accompanied by coinfection with other hepatotropic viruses. Moreover, it does not seem to influence the viremia of the HIV nor the CD4 cell counts.

Influence of age and breed on natural bovine fasciolosis in an endemic area (Galicia, NW Spain)

An analysis was undertaken of the effect of breed and age on bovine fasciolosis using antibody and antigen detection ELISAs. A total of 84.3% of the 1284 serum samples examined had positive antibody values and 20.4% exhibited antigenaemia. The seroprevalence of antibodies in crossbred cattle was higher than that in autochthonous Rubia Gallega, Friesian or Brown Swiss cows. The highest percentage antigenaemia occurred in the Brown Swiss cattle, but the breed differences were not statistically significant. Cattle aged 3-5 years had the highest antibody and circulating antigen prevalence and the age differences were significant. It was concluded that the apparent influence of breed was probably closely associated with the husbandry system. The autochthonous Rubia Gallega may be better adapted to fasciolosis as its percentage of antigenaemia was the lowest.

Time-course analysis of coproantigens in rats infected and challenged with Fasciola hepatica

The influence of a challenge infection during an acute or chronic primary infection on Fasciola hepatica-coproantigen kinetics was established in rats. Egg-output and IgG humoral responses were also established. Two primary-infected groups were reinfected at different periods, one 4 weeks after primary infection (w.p.i.) (acute phase) and the other 11 w.p.i. (chronic phase). Another group remained without reinfection as a control. Coproantigens were first detected in the group challenged on acute fascioliasis. The highest values of coproantigens were recorded in the group reinfected during acute fascioliasis and the lowest in the group challenged during chronic fascioliasis. The IgG responses to F. hepatica excretory/secretory antigens increased after reinfection. Neither the egg output nor the parasitic burden were significantly different among the three infected groups. Our results indicate that the time of challenge affects the kinetics of coproantigens. Thus, challenge during acute fascioliasis favours the migration of the juvenile flukes from the primary infection to the bile ducts, and is responsible for the earlier presence of coproantigens in these animals. The possible relationship between coproantigen detection and T1 and T2 tegumentary antigens is discussed.

Interferon-alpha plus ribavirin for 12 months increases the sustained response rates in chronic hepatitis C relapsers

BACKGROUND

The effectiveness and tolerability of combination therapy for 12 months have not been evaluated sufficiently in chronic hepatitis C relapsers to interferon.

AIMS

To evaluate the sustained response to interferon plus ribavirin for 12 months in chronic hepatitis C relapsers.

METHODS

We included 55 chronic hepatitis C relapsers in a 12-month treatment protocol with interferon (3 MU thrice weekly) plus ribavirin (1-1.2 g/day). The effectiveness was evaluated using serum aminotransferase and hepatitis C virus RNA levels, alanine aminotransferase normalization and viraemia clearance after 12 months, defining the end-of-treatment response, and 6 months after completion of therapy, defining the sustained response. Adverse effects were recorded.

RESULTS

End-of-treatment response and sustained response were achieved in 47 (85%) and 37 (67%) patients, respectively; there were 10 (21%) relapsers after combination therapy. Predictive factors of sustained response included the genotype (non-1 95% vs. 1 48%; P < 0.001), lower viraemia (503 917 +/- 553 230 vs. 901 393 +/- 548 267 copies/mL; P < 0.005), higher alanine aminotransferase levels (137 +/- 75 vs. 103 +/- 41 IU/L; P < 0.05) and a lower gamma-glutamyl transpeptidase/alanine aminotransferase ratio (0.30 +/- 0.23 vs. 0.49 +/- 0.39; P < 0.05). Tolerance to therapy was good, with no withdrawals.

CONCLUSIONS

Interferon plus ribavirin treatment for 12 months in chronic hepatitis C relapsers yields high sustained response rates and is well tolerated. The sustained response is related to a non-1 genotype, lower baseline viraemia, higher alanine aminotransferase level and a lower gamma-glutamyl transpeptidase/alanine aminotransferase ratio.

Drug resistance in patients experiencing early virological failure under a triple combination including indinavir

OBJECTIVE

To assess the pattern of drug resistance mutations selected in HIV-1-infected patients failing a first line triple combination therapy including indinavir.

PATIENTS AND METHODS

Plasma samples from 87 patients collected at the time of the first virological rebound (> 50 HIV-RNA copies/ml) were examined for the presence of drug-resistant genotypes.

RESULTS

The mean level of plasma viraemia at rebound was 7824 HIV-1 RNA copies/ml in 73 subjects with good compliance, whereas it was 359,460 HIV-1 RNA copies/ml in 14 patients who admitted to poor adherence. Genetic sequence analysis yielded results for 51 (70%) of the patients having good adherence. More than half of them (26/51, 51%) carried primary mutations associated with resistance to nucleoside analogues. In contrast, primary protease inhibitor resistance mutations were recognized less frequently (14/51, 27%; P < 0.05). Moreover, in 23 (45%) patients there was no evidence of drug-resistant viruses at all. The most frequent drug-resistant genotypes in the reverse transcriptase gene were at codons 184 (n = 19), 215 (n = 14) and 41 (n = 8), whereas for the protease they were at codons 46 (n = 10), 82 (n = 9) and 90 (n = 7). No resistance genotypes were found among non-compliant patients.

CONCLUSION

The overall rate of drug-resistant HIV genotypes was 38% (28/73) in patients with good adherence and who were experiencing a first virological failure under a triple combination regimen including indinavir; resistance to nucleoside analogues was more frequent than resistance to indinavir. Therefore, treatment intensification in those patients without resistance, or a selective substitution of nucleosides in those with resistance limited to these compounds, might be justified.

Effect of fasciolicides on the antigenaemia in sheep naturally infected with Fasciola hepatica

A study was developed to evaluate the influence of triclabendazole (Fasinex) and netobimin (Hapasil) the antigenaemia in sheep naturally infected with Fasciola hepatica during 16 weeks. A sandwich-ELISA (enzyme-linked immunosorbent assay) using a rabbit polyclonal IgG antibody to F. hepatica antigens was employed and the data obtained were compared to those from coprological and indirect-ELISA techniques. Triclabendazole reduced the values of circulating antigens at weeks 2-4 post-treatment and faecal output at weeks 2-8 post-treatment, but antibodies showed positive values until the end of the study. Netobimin did not reduce circulating antigens of the trematode nor egg-excretion; and IgG antibodies did not decrease throughout the study.

Interferon alfa-2b plus ribavirin for chronic hepatitis C patients who have not responded to interferon monotherapy

BACKGROUND

The role of combination therapy is poorly defined in chronic hepatitis C patients who are non-responders to interferon.

AIM

To assess the efficacy, safety and tolerance of interferon alfa-2b plus ribavirin in chronic hepatitis C patients who do not respond to interferon monotherapy.

METHODS

A total of 127 non-responder patients with chronic hepatitis C received 3 mU t.i.w. of interferon alfa-2b plus 1000-1200 mg ribavirin daily for 48 weeks. Effects of therapy were evaluated by serum aminotransferases and hepatitis C virus (HCV) RNA levels.

RESULTS

Twenty-nine (23%) patients had an end-of-treatment response. Six months after treatment, 20 (16%) patients were sustained responders. Early loss of HCV RNA was the strongest predictor of a sustained response (P < 0.0001). Remission was also more frequent in patients with genotype 1b (P < 0.02), elevated alanine aminotransferase (P < 0.03) and low gamma glutamiltranspeptidase (P < 0.002). Treatment was discontinued in 21 (17%) patients: in 14 for intolerance and in seven due to side-effects.

CONCLUSIONS

Combination therapy with interferon plus ribavirin produced a sustained response in 16% of chronic hepatitis C patients who were non-responders to interferon. This combination was safe and well tolerated.

Hepatitis C and HIV infection: biological, clinical, and therapeutic implications

As deaths from AIDS continue to decline in HIV-infected persons, liver disease is becoming an increasing cause of hospital admission and death in HIV-HCV co-infected persons. The problem is particularly relevant among intravenous drug users and haemophiliacs, most of whom are co-infected. Moreover, the risk of hepatotoxicity is higher with anti-HIV drugs among patients with chronic hepatitis C. Treatment with alpha-interferon provides a similar rate of response in non-severely immunosuppressed HIV-positive subjects as in HIV-negatives, and preliminary results from trials using the combination of interferon plus ribavirin in HIV-HCV co-infection look very promising for both rates of sustained response and safety.

Long-term re-treatment with interferon and ribavirin combination therapy in patients with chronic hepatitis C who are non-responders to interferon alone: a preliminary study

We evaluated the efficacy and tolerance of ribavirin and IFN-alpha combination therapy over 12 months in 28 patients who were non-responders to IFN-alpha alone. Of 24 patients who have finished the therapy, 6 (25%) obtained a complete response (normal ALT and negative HCV RNA) at the end of treatment and maintained a sustained response 27% (5/18).

[Community acquired pneumonia requiring admission to hospital. Etiology and follow-up of 366 cases]

An eighteen-month prospective study designed to determine the incidence, etiology and prognosis of community acquired pneumonia (CAP) in adults requiring admission to hospital.

METHODS

We studied 366 patients admitted to hospital after being diagnosed of CAP at the Emergency Room of a General Hospital. Standard laboratory methods were used for culture from blood and sputum, and serology tests for Legionella pneumophila. Mycoplasma pneumoniae, Chlamydia psittaci and Coxiella burnetti. Patients were evaluated until complete recovery, paying special attention to prognostic factors predictive of death.

RESULTS

An etiological diagnosis was established in 99 patients (27.6%). Legionella pneumophila was the most common pathogen accounting for 30 cases (8.2%), followed by Streptococcus pneumoniae with 26 cases. 26 patients died (mortality rate of 7%); factors predictive of death included pre-existing disease, tachypnea and elevated blood urea nitrogen level.

CONCLUSIONS

CAP represented 4.4% of admissions. Legionella pneumophila was the most frequently identified pathogen. If tachypnea and/or uremia are noted on admission, there is an increase in the risk of death.

[The efficacy of interferon alfa treatment in chronic hepatitis C in relation to the serum concentration of RNA-HCV and the viral genotype]

BACKGROUND

To determinate the viral variables (viremia and genotype) and patients variables (route and years of infection, histology, etc) related with response to the treatment with alpha intefferon in patients with chronic hepatitis C.

SUBJECTS AND METHODS

We have studied 50 patients with chronic hepatitis C that received an intefferon treatment during a year. In all them it was accomplished a hepatic biopsy before of the beginning of treatment and it was studied the viral load by quantitative PCR (Monitor, Roche) at the beginning of treatment, at four weeks and at the end of treatment. It was determined the HCV genotype by method INNO-LIPA (Boehringer Inghelheim).

RESULTS

8 patients (16%) achieved a complete sustained response during all the follow-up period (13.8 + 1.6 months); 8 patients responded but relapsed when the intefferon was interrupted and 34 patients not responded. The responders had lower viremia (p < 0.032) and HCV RNA negative at the fourth treatment week (p < 0.0082). The genotype 1b was the most frequent, the one which was presenting a smaller percentage of response and it was associated with a higher viremia. Cirrhotic patients were the worse responders. Ex-lDAs were better responders than the others groups, however this difference did not show statistics meaning.

CONCLUSIONS

A low pretreatment HCV-RNA level seems to be indicative of a sustained response to IFN, Whereas a high level seems to be indicative of a non sustained response to IFN. Negativization of HCV-RNA at week four is a good indicator of response to intefferon. Genotype 1b is the most frequent and the worse responder. To have 1b genotype, high pretreatment HCV-RNA level and to be viremic at four treatment seems to be indicative of non response.

[Interconversion of the results for erythrocyte zinc protoporphyrin expressed in different units]

As stated in a recent document of the National Committee for Clinical Laboratory Standards (NCCLS Document C42-P, April 1995), expression of the results of erythrocyte zinc protoporphyrin (ZPP) in different units is a main source of confusion which may hamper the wide use of this test. The possible inter-conversion of the ZPP values expressed as microgram/g Hb, microgram/dL blood and microgram/dL red cells was assessed. It was found that in all cases, despite a good correlation between these values (r > or = 0.939), the error of the estimation was higher than allowed by the American College of Pathologists criteria. Such findings show that ZPP values expressed in different units cannot be inter-converted as a function of the corresponding regression equation. Similarly, the use of hematofluorometers with an analogic-digital converter to express results as microgram ZPP/ dL blood might pose an additional source of error.

Multicenter randomized, controlled study of intramuscular administration of interferon-beta for the treatment of chronic hepatitis C

The intramuscular administration of interferon-beta (IFN-beta) at a dosage of 6 million units three times per week for 6 months has been evaluated in 90 patients included in a multicenter, randomized, controlled trial for the treatment of chronic hepatitis C. Transaminase levels were significantly reduced in IFN-beta-treated patients (p = 0.015) and were significantly lower with respect to those of the untreated controls (p = 0.040 at 6 months). Four treated (8%) and one untreated (2.5%) patients had normal transaminase values after 6 months. At study end (12 months), three quarters of the IFN-beta-treated patients had sustained transaminase normalization, whereas the untreated case had relapsed. Hepatitis C viremia was cleared in 6 (12%) treated patients but in none of the untreated controls (p = 0.058). Side effects of IFN-beta were infrequent (a mild flu-like syndrome in < 10%, asthenia in 16%, anorexia in 8%, headaches and weight loss in 8%, and hair loss in 4%). Leukocyte and platelet counts decreased during IFN-beta treatment, but no dose modifications were necessary. Such decreases were not statistically significant when compared with the levels in the untreated controls. Intramuscular IFN-beta at the dosage used has little efficacy in the treatment of chronic hepatitis C. Because of IFN-beta tolerance, higher doses and alternate routes of injection might prove beneficial for the treatment of this disease.

Interferon alpha for the treatment of chronic hepatitis C in patients infected with human immunodeficiency virus. Hepatitis-HIV Spanish Study Group

Liver disease secondary to hepatitis C virus (HCV) infection is a rising cause of morbidity and mortality among individuals who have been infected parenterally with human immunodeficiency virus (HIV) such as injection drug users, hemophiliacs, and transfused patients. We analyzed both the efficacy of interferon (IFN) alpha therapy in these patients and the predictors of response to this agent. A total of 119 patients with chronic hepatitis C (90 of whom were infected with HIV and 29 of whom were not) were included in a multicenter, prospective, open, nonrandomized observational study. IFN-alpha was given subcutaneously in a dosage of 5 million units three times a week during a 3-month period; those patients who responded received a dose of 3 million units given subcutaneously three times a week for an additional 9 months. One hundred seven patients completed the study; the level of aminotransferases returned to normal and sera became negative (complete response) for HCV RNA in 26 (32.5%) of 80 HIV-infected patients and 10 (37.0%) of 27 non-HIV-infected patients (P = .666) after completion of the treatment. Two variables were independently associated with a response in HIV-infected patients: a CD4+ T lymphocyte count of > 500 x 10(6)/L and a baseline HCV viremia level of < 10(7) copies/mL. In the 12 months following treatment, relapses occurred in 30.8% of the HIV-infected patients and 12.5% of non-HIV-infected patients (P = .403).

[The treatment of chronic hepatitis C with interferon in patients infected with the human immunodeficiency virus. The Spanish Group for the Study of Viral Hepatitis in HIV+ Patients]

BACKGROUND

Alfa-interferon (aIFN) is widely recommended for the treatment of chronic hepatitis C (CHC). Hepatitis C virus (HCV) infection is very common in injecting drug users (IDUs), which in Spain represent the large number of HIV-infected persons. Interaction between human immunodeficiency virus (HIV) and HCV in coinfected patients might accelerate the clinical course of HCV-associated liver disease. The efficacy and safety of aIFN therapy in HIV-infected patients with CHC is not well known.

PATIENTS AND METHODS

In a multicenter, prospective, open, non randomized and partially controlled study, we compared the efficacy and safety of aIFN therapy in 119 patients with CHC, of whom 90 were HIV-positive and 29 HIV-negative. Interferon was started at 5 mega U tiw for 3 months, followed in responders by 3 megaU tiw for additional 9 months.

RESULTS

One hundred seven patients completed the study. A normalization of the aminotransferase values at the end of treatment (complete response, CR) was observed in 26/80 (32.5%) HIV-positive and 10/27 (37.0%) HIV-negative individuals (p = 0.666). Relapses at 12 months of stopping aIFN were seen in 30.8% of HIV-positive subjects and 12.5% of HIV-negatives (p = 0.403). Side effects were uncommon and did not have severity; only one patient required to stop the medication. However, 3 HIV-positive subjects treated with aIFN (3.5% of them) showed an irreversible fall of CD4+ T-cells below half the baseline values.

CONCLUSION

HIV-infected patients with CHC seems to respond to aIFN with a similar rate than HIV-negatives. Moreover, the drug is similarly well tolerated in both groups of patients, although a fall of CD4+ T-cells is an unusual side effect of particular relevance observed in HIV-infected patients.

[Immunoglobulins, beta-2 microglobulin and lymphocyte subpopulations in patients addicted to parenteral drugs (IVDA)]

Disorders in serum immunoglobulins, beta-2 microglobulin and lymphocyte subpopulations in parenterally drug-addict patients (PDAP) are analyzed. The study is divided in three parts. In the first one, a group of 33 HIV-negative PDAP without intercurrent diseases is compared with a control group of healthy non-addict persons. In the second part, the differences between a group of 58 HIV-negative PDAP and a group of 95 HIV-positive PDAP are studied. In the third part, the differences between the group of HIV-negative PDAP without associated procedures and a subgroup of HIV-positive patients including 31 asymptomatic carriers in phase II, are studied. No statistically significant differences were detected between the control group and the HIV-negative PDAP group. The HIV-positive PDAP group showed lymphocytes CD3, CD4 and a CD4/CD3 ratio statistically lower than the HIV-negative group, as well as a significant increase of the immunoglobulin IgG and beta-2 microglobulin. The same results were obtained when the subgroup of HIV-positive patients in phase II was compared with the group of HIV-negative PDAP without intercurrent diseases. According to these results, we conclude that the immunological disorders detected in PDAP patients seem to be more related with the infection by the human immunodeficiency virus and with other associated infections than with the drug-addiction itself.