Virological Failure in HIV to Triple Therapy With Dolutegravir-Based Firstline Treatment: Rare but Possible

We describe a case of virological failure during initial treatment with tenofovir disoproxil fumarate/emtricitabine/dolutegravir twice daily, with concomitant rifampin treatment of staphylococcal infection, selection of R263K + E157Q, and low plasma dolutegravir levels. Using rifampin together with dolutegravir may require closer follow-up, and, if possible, plasma dolutegravir levels should be monitored.

Prevalence and distribution of hepatitis C virus genotypes in Spain during the 2000-2015 period (the GEHEP 005 study)

We report the largest study on the prevalence and distribution of HCV genotypes in Spain (2000-2015), and we relate them with clinical, epidemiological and virological factors. Patients from 29 hospitals in 10 autonomous communities (Andalusia, Aragon, Castilla-Leon, Catalonia, Galicia, Canary Islands, Madrid Community, Valencian Community, Murcia Region and Basque Country) have been studied. Annual distribution of HCV genotypes and subtypes, as well as gender, age, transmission route, HIV and/or HBV coinfection, and treatment details were recorded. We included 48595 chronically HCV-infected patients with the following characteristics: median age 51 years (IQR, 44-58), 67.9% male, 19.1% HIV-coinfected, 23.5% HBV-coinfected. Parenteral transmission route was the most frequent (58.7%). Genotype distribution was 66.9% GT1 (24.9% subtype 1a and 37.9% subtype 1b), 2.8% GT2, 17.3% GT3, 11.4% GT4 and 0.1% GT5 and 0.02% GT6. LiPA was the most widely HCV genotyping test used (52.4%). HCV subtype 1a and genotypes 3 and 4 were closely associated with male gender, parenteral route of infection and HIV and HBV coinfection; in contrast, subtype 1b and genotype 2 were associated with female gender, nonparenteral route and mono-infection. Age was related to genotype distribution, and different patterns of distribution and biodiversity index were observed between different geographical areas. Finally, we describe how treatment and changes in transmission routes may have affected HCV genotype prevalence and distribution patterns. We present the most recent data on molecular epidemiology of hepatitis C virus in Spain. This study confirms that genotype distributions vary with age, sex, HIV and HBV coinfection and within geographical areas and epidemiological groups.

Protein substitutes for phenylketonuria in Europe: access and nutritional composition

BACKGROUND/OBJECTIVES

Protein substitutes (PS) are an essential component in the dietary management of phenylketonuria (PKU). PS are available as phenylalanine-free amino-acid mixtures (AAM), glycomacropeptide-based PS (GMP) and large neutral amino acids (LNAA). There is a lack of information regarding their availability in different countries and comparison of their nutritional composition is limited. The objectives of this study were to identify the number of PS available in different European countries and Turkey and to compare their nutritional composition.

SUBJECTS/METHODS

Members of the European Nutritionist Expert Panel on PKU (ENEP) (Portugal, Spain, Belgium, Italy, Germany, Netherlands, United Kingdom, Denmark and Turkey) provided data on PS available in each country. The nutritional composition of PS available in Portugal was analyzed.

RESULTS

The number of PS available in each country varied from 30 (Turkey) to 105 (Germany), with a median of 64. GMP was available only in Portugal, whereas LNAA was an option in Portugal, Italy, Turkey and Denmark. Some PS were designed for weaning. Many PS did not contain added fat and fiber. GMP contained the highest carbohydrate (CHO) and energy content as well as higher LNAA content compared with AAM. Only one AAM contained added fructo-oligosaccharides and galacto-oligosaccharides. AAM designed for the first year of life had the highest CHO, fat and LNAA contribution. Liquid AAM had lower CHO and fat contents compared with powdered AAM, but contained higher LNAA.

CONCLUSIONS

There was widely dissimilar numbers of PS available in different countries. Nutritional composition of different PS was variable and should be considered before prescription.

Urine and plasma metabolites predict the development of diabetic nephropathy in individuals with Type 2 diabetes mellitus

AIMS

Early detection of individuals with Type 2 diabetes mellitus or hypertension at risk for micro- or macroalbuminuria may facilitate prevention and treatment of renal disease. We aimed to discover plasma and urine metabolites that predict the development of micro- or macroalbuminuria.

METHODS

Patients with Type 2 diabetes (n = 90) and hypertension (n = 150) were selected from the community-cohort 'Prevention of REnal and Vascular End-stage Disease' (PREVEND) and the Steno Diabetes Center for this case-control study. Cases transitioned in albuminuria stage (from normo- to microalbuminuria or micro- to macroalbuminuria). Controls, matched for age, gender, and baseline albuminuria stage, remained in normo- or microalbuminuria stage during follow-up. Median follow-up was 2.9 years. Metabolomics were performed on plasma and urine. The predictive performance of a metabolite for albuminuria transition was assessed by the integrated discrimination index.

RESULTS

In patients with Type 2 diabetes with normoalbuminuria, no metabolites discriminated cases from controls. In patients with Type 2 diabetes with microalbuminuria, plasma histidine was lower (fold change = 0.87, P = 0.02) and butenoylcarnitine was higher (fold change = 1.17, P = 0.007) in cases vs. controls. In urine, hexose, glutamine and tyrosine were lower in cases vs. controls (fold change = 0.20, P < 0.001; 0.32, P < 0.001; 0.51, P = 0.006, respectively). Adding the metabolites to a model of baseline albuminuria and estimated glomerular filtration rate metabolites improved risk prediction for macroalbuminuria transition (plasma integrated discrimination index = 0.28, P < 0.001; urine integrated discrimination index = 0.43, P < 0.001). These metabolites did not differ between hypertensive cases and controls without Type 2 diabetes.

CONCLUSIONS

Type 2 diabetes-specific plasma and urine metabolites were discovered that predict the development of macroalbuminuria beyond established renal risk markers. These results should be confirmed in a large, prospective cohort.

Molecular characterization of enteroviruses associated with neurological infections in Spain, 2008

In order to investigate the etiology of viral neurological infections in Spain, a national study was performed in 2008. The results obtained have been published. Enteroviruses were the most frequent cause of the aseptic meningitis and infant febrile syndromes. The present report supplements the previous study with the genotyping of the detected enteroviruses. Typing was by amplification of partial VP1 region and sequencing in 70 (53%) of the 132 available cerebrospinal fluid samples positive for enteroviruses. Twelve different genotypes within the B species were identified. Echovirus 4 was predominant (24%), followed by echovirus 30 (19%), echovirus 9 (17%), and echovirus 6 (14%). In summary, a co-circulation of several enterovirus types associated with meningitis in children under 15 years old was observed. Although infrequently detected, echovirus 4 was the predominant genotype identified due to an aseptic meningitis outbreak which occurred in the Canary Islands in 2008.

Viral infections of the central nervous system in Spain: a prospective study

The aim of the study was to determine the incidence of viruses causing aseptic meningitis, meningoencephalitis, and encephalitis in Spain. This was a prospective study, in collaboration with 17 Spanish hospitals, including 581 cases (CSF from all and sera from 280): meningitis (340), meningoencephalitis (91), encephalitis (76), febrile syndrome (7), other neurological disorders (32), and 35 cases without clinical information. CSF were assayed by PCR for enterovirus (EV), herpesvirus (herpes simplex [HSV], varicella-zoster [VZV], cytomegalovirus [CMV], Epstein-Barr [EBV], and human herpes virus-6 [HHV-6]), mumps (MV), Toscana virus (TOSV), adenovirus (HAdV), lymphocytic choriomeningitis virus (LCMV), West Nile virus (WNV), and rabies. Serology was undertaken when methodology was available. Amongst meningitis cases, 57.1% were characterized; EV was the most frequent (76.8%), followed by VZV (10.3%) and HSV (3.1%; HSV-1: 1.6%; HSV-2: 1.0%, HSV non-typed: 0.5%). Cases due to CMV, EBV, HHV-6, MV, TOSV, HAdV, and LCMV were also detected. For meningoencephalitis, 40.7% of cases were diagnosed, HSV-1 (43.2%) and VZV (27.0%) being the most frequent agents, while cases associated with HSV-2, EV, CMV, MV, and LCMV were also detected. For encephalitis, 27.6% of cases were caused by HSV-1 (71.4%), VZV (19.1%), or EV (9.5%). Other positive neurological syndromes included cerebellitis (EV and HAdV), seizures (HSV), demyelinating disease (HSV-1 and HHV-6), myelopathy (VZV), and polyradiculoneuritis (HSV). No rabies or WNV cases were identified. EVs are the most frequent cause of meningitis, as is HSV for meningoencephalitis and encephalitis. A significant number of cases (42.9% meningitis, 59.3% meningoencephalitis, 72.4% encephalitis) still have no etiological diagnosis.

Epidemiology of tuberculosis on Gran Canaria: a 4 year population study using traditional and molecular approaches

BACKGROUND

In recent years several population based studies using restriction fragment length polymorphism (RFLP) analysis have shown a higher rate of recent transmission of tuberculosis than previously thought. This study was undertaken to determine the transmission patterns of tuberculosis and the potential causes of recent transmission on the island of Gran Canaria (Spain).

METHODS

The strains of all patients diagnosed with tuberculosis confirmed by culture between 1 January 1993 and 31 December 1996 were typed by RFLP using the insertion sequence IS6110. A cluster was defined as two or more isolates with an identical RFLP pattern. Epidemiological linkage through contact tracing was investigated.

RESULTS

Of the total of 719 patients, 153 (21.3%) were excluded because there was inadequate bacterial DNA for genotyping (n=129) or the isolates of Mycobacterium tuberculosis had less than five copies of IS6110 (n=24). The isolates from 409 patients (72.3%) were grouped into 78 different clusters with an estimated 58.5% of the cases being due to recent transmission. Young age was the only significant predictor of clustering. Only in 147 (35.9%) of the 409 patients belonging to a cluster could an epidemiological link be found. 111 patients (19.6%) were identified as having had previous contact with a tuberculosis patient and 81 of them (72.9%) belonged to a cluster. The three largest clusters included 75, 49 and 20 patients, respectively.

CONCLUSION

Recent transmission is frequent among patients with tuberculosis on Gran Canaria and could be associated with certain aspects of control measures. Some of the clusters described in the study could be due to the prevalence of particular strains of M tuberculosis on the island.

Epidemiological evidence of the spread of a Mycobacterium tuberculosis strain of the Beijing genotype on Gran Canaria Island

Molecular epidemiological studies suggest that particular Mycobacterium tuberculosis strains have an enhanced capacity to spread within a community. One strain, the Beijing genotype, has been associated with outbreaks in a number of communities throughout the world. IS6110 restriction fragment length polymorphism (RFLP) analysis was performed on M. tuberculosis isolates from 566 of the 721 patients (78.5%) diagnosed with tuberculosis (TB) on Gran Canaria Island from 1993 to 1996, as well as 35% of isolates from 1991-1992 (85 strains). RFLP identification of the family of strains of the Beijing genotype was confirmed by spoligotyping. Medical records of all patients were reviewed and epidemiological links were identified. Of 566 M. tuberculosis isolates from 1993 to 1996 with RFLP available, 72% belonged to clusters. The largest contained 75 cases and was caused by a strain of the Beijing genotype that was introduced to the island in 1993. It was found in 10 patients in 1993 (5.5%), 12 in 1994 (8.1%), 18 in 1995 (16.4%), and 35 in 1996 (27.1%). Epidemiological linkage was confirmed for 68% of cases. This study has demonstrated rapid dissemination of this strain of the Beijing genotype. This genotype might play an important role in the future of the worldwide tuberculosis epidemic.

Exogenous reinfection with tuberculosis on a European island with a moderate incidence of disease

The frequency and determinants of exogenous reinfection and of endogenous reactivation of tuberculosis in patients previously treated are poorly understood. In Gran Canaria Island, Spain, between 1991 and 1996, 962 tuberculosis cases were confirmed by culture. Drug susceptibility testing was performed on available bacterial isolates and IS6110-based RFLP genotyping was carried out. Twenty-three patients (2.4%) had two positive cultures separated by at least 12 mo, 18 of whom had bacterial DNA available for genotypic analysis. The initial and final isolates from eight (44%) were different genotypes, indicating exogenous reinfection. Six of them were retreated after cure and two retreated after default. Six were HIV seronegative and two were HIV seropositive. Endogenous reactivation was seen in the remaining 10 patients of whom eight were retreated after default and two after cure. Three of the eight (38%) being retreated after default developed multidrug resistance. One genotype was responsible for a second episode of tuberculosis in five cases, three exogenous reinfections and two endogenous reactivations. In the context of a moderate incidence of tuberculosis, exogenous reinfection is an important cause of TB recurrence, even in HIV-seronegative patients.

[Epidemiologic study of infection by hepatitis C virus in a hemodialysis unit]

OBJECTIVE

To analyze the prevalence of infection, the frequency of HCV genotypes and the epidemiology characteristics among the patients in hemodialysis treatment in one 25 years old hospital hemodialysis center and one 15 years old secondary unit by a transversal cross-section study in 1998.

PATIENTS AND METHODS

171 hemodialyzed-patients were studied. Patients sera were analyzed by the presence of HCV antibodies anti-VHC by a enzymoimmunoassay (Abbott Cientifica) and the presence of antibodies was confirmed by a line immunoassay (Inno-LIA HCV AbIII) and by the presence of VHC-RNA by reverse transcriptase PCR (Cobas Amplicor HCV). Genotypes were determinate by reverse hybridization (Inno-LIA HCV III).

RESULTS

Fifty (29.2%) of the patients were HCV antibody positive. Forty-five (26.3%) were HCV-RNA positive, all of them with antibodies positive. The distribution of genotypes was: 1b, 34 (75.5%); 4f, 4 (8.9%); 1a, 3 (6.7%); 1, 3 (6.7%) and 1 case could not be typed (2.2%). In 14 patients (28.0%), seroconversions were documented Twenty-one patients (42.0%) were diagnosed when the routine tests were available and 15 patients (30.0%) were diagnosed pre-dialysis. The multivariate analysis showed that the risk of HCV infection was greater for patients who had been more 8 years on dialysis (OR: 6.22; 95% CI: 1.24-31.07).

CONCLUSIONS

Data presented indicate that the prevalence of HCV infections in our hemodialysis units and the number of seroconversions were high and the HCV subtype 1b was more frequent; because of this, the screening by both serological and molecular methods is necessary, at least twice a year, to identify all the infected patients. Besides, we think that is necessary to increase the control of the completion of the Universal Precautions.

[Usefulness of detecting Mycobacterium tuberculosis by genome amplification in the diagnosis of childhood pulmonary tuberculosis]

OBJECTIVE

To evaluate the polymerase chain reaction in the diagnosis of pulmonary tuberculosis in children.

PATIENTS AND METHODS

135 samples (68 sputum and 67 gastric aspirates) of 72 patients under 15 years old with suspected tuberculosis and a negative acid-fast stain were included in the study. In all the samples an acid-fast stain and culture in Lowestein-Jensen with and without piruvate were performed. Also, a specific detection of Mycobacterium tuberculosis complex (MT) was made by PCR (Amplicor-MT-Roche Diagnostic). Tuberculosis was certainly diagnosed when M. tuberculosis was isolated or clinical evidence of tuberculosis in positive-PCR cases with negative culture was achieved.

RESULTS

Ten samples of six patients were positive culture. Four of these samples were positive PCR. In addition, two samples of two patients with negative culture were positive PCR. Both patients had a clinical diagnosis of pulmonary tuberculosis with effective anti-tuberculosis treatment, one of them had also another positive PCR and culture sample. The results of sensitivity, specificity, positive predictive value and negative predictive value by patient according to the reference methodology were 57.1, 100, 100 and 95.4%, respectively, and by sample 66.6%, 100, 100 and 96.8%, respectively. Other 15 patients presented pulmonary tuberculosis with negative PCR and culture; so the sensitivity of the culture and the PCR regarding a clinical diagnosis were 27.3% (6/22) and 18% (4/22) respectively.

CONCLUSION

Due to the diagnosis by culture takes a long time and the low percentage of samples of pediatric patients with positive acid-fast rain stain, the PCR would be useful in order to achieve quickly and specific diagnosis of tuberculosis in a high-prevalence population.

[The importance of polymerase chain reaction in the diagnosis of enterovirus infections of the central nervous system in children. Clinico-epidemiologic characteristics]

BACKGROUND

To compare the diagnosis utility of a reverse transcription-polymerase chain reaction (RT-PCR) for detection of enteroviral RNA in cerebrospinal fluid (CSF) in comparison to viral culture for central nervous system infections in pediatric population and to know the clinic epidemiological characteristics of this infection.

METHODS

From June to December of 1997, 116 CSF samples of children were included in the study. The samples were inoculated in MRC-5 and HEP-2 and the enterovirus RNA was detected with AMPLICOR-Enterovirus (Roche Diagnostic System). The virus were typed by neutralization.

RESULTS

36 samples were positive (30 were positive for RT-PCR and 6 for RT-PCR and viral culture). The media time in detect the CPE was 4.8 days. The viruses found were four echovirus 6, one echovirus 30 and one echovirus 7. Fifteen children were under 6 months (93.3% under two months) and 21 children over 6 months with a media age of 81 months (range, 38-160 months). In over 6 months old children, the most frequent clinical presentation was meningitis aseptic syndrome with pleocytosis and in under 6 months old ones was fever and only 60% of these children had pleocytosis. The evolution was good in all the cases.

CONCLUSIONS

AMPLICOR-Enterovirus is a sensitive method for the diagnosis of enteroviral meningitis. The clinical manifestations are different with the age and due to the absence of neurological symptoms and pleocytosis in the patients under two months, we think that it is necessary to study the presence of enterovirus with genetic amplification methods in this population of patients.

[Prevalence of hepatitis C virus genotypes: epidemiology and histologic characteristics]

OBJECTIVE

To analyse the prevalence of HCV genotypes among patients from Gran Canaria and the relation with the routes of viral transmission, date of primoinfection and severity of hepatic lesion.

PATIENTS AND METHODS

179 patients were studied. In 61 patients the date of exposure was determinate. Liver biopsies were obtained in 139 patients. Genotypes were determinate by reverse hybridisation using InnoLiPA genotyping kit (Innogenetics).

RESULTS

The distribution of genotypes was: 1b, 114 (63.7%), 1a, 30 (16.7%); 1, 17 (9.5%); 3a, 7 (3.9%); 4c/4d, 6 (3.3%); 2, 1 (0.5%); 2a/2c, 2 (1.1%), 3, 1 (0.5%) and 4f, 1 (0.5%). We did not find any case of coinfection with a second genotype. In univariable analysis, we found statistically differences in sex (78.9% of women infected with genotype 1b compared with 55.1% of men, p < 0.01 and 31.6% of men infected with 1a, 3a and 4c/4d compared with 15.7% of women, p < 0.01) and age (median age in genotype 1b 45 +/- 12 years vs 36 +/- 9 years in the other genotypes, p < 0.01). HCV subtypes 1a and 3a were predominant in patients IVDA (47.6% and 23.85% respectively) and 1b in blood transfusion receptors (71.2%) (p < 0.01). In 40.2% of the patients, the sources of infection were unknown. In the multivariable logistical regression analysis we found the only factor influencing the genotypes distribution was the transmission mechanism (p < 0.001) and sex and age are relationated with the transmission mode. The media infection duration in patients infected with 1b was 22 +/- 11 years vs 9 +/- 6 years in the other genotypes. We found differences in the liver histologic findings and the age of the patient, but not in the different genotypes.

CONCLUSIONS

Our study reflects the higher frequency of HCV subtype 1b in our area and a different prevalence of genotypes in relation to mode of transmission. Our results suggest that in our media the liver damage seems to be directly influenced by the age of the patient, but not influenced by HCV genotype.

Changes in Dehydrodiferulic Acids and Peroxidase Activity against Ferulic Acid Associated with Cell Walls during Growth of Pinus pinaster Hypocotyl

Hydroxycinnamic acids associated with hypocotyl cell walls of dark-grown seedlings of Pinus pinaster Aiton were extracted with 1 N NaOH and identified by gas chromatography-mass spectrometry. The main hydroxycinnamic acid found was ferulic acid. Diferulic acid dehydrodimers were also found, with the 8,8-coupled isomer (compound 11) being the dehydrodiferulate present in the highest amount. However, the 5,5-coupled isomer, commonly referred to referred to as diferulic acid, was not detected. Two truxillic acids, 4-4[prime]-dihydroxy-3-3[prime]-dimethoxy-[alpha]-truxillic acids I and II, were tentatively identified. The 8,8-coupled dehydrodiferulic acid (compound 11) was the phenolic acid that showed the most conspicuous changes with hypocotyl age as well as along the hypocotyl axis. Peroxidase activity against ferulic acid was found in the apoplastic fluid as well as being ionically and covalently bound to the cell walls. The peroxidase activity increased with hypocotyl age as well as from the subapical toward the basal region of the hypocotyls. A key role in the cell-wall stiffening of 8,8 but not 5,5 dimerization of ferulic acid catalyzed by cell-wall peroxidases is proposed.

[Microbiological study of vulvovaginitis in premenarcheal girls]

BACKGROUND

A prospective microbiological study of the vaginal swab specimens from premenarcheal girls with clinical diagnosis of vulvovaginitis was done from the 1st of September 1991 to the 31st of August 1994.

PATIENTS AND METHODS

Vaginal secretions from premenarcheal girls with clinical findings were examined. Most important pathogenic agents were investigated and if there was an inflammatory reaction in the Gram stain and a heavy growth on culture, other potentially pathogenic agents were considered also.

RESULTS

In 70 (28.7%) of the 262 patients a potentially pathogenic microorganism was found: eight cases (3.0%) due to Streptococcus pyogenes, four cases (1.5%) due to Candida albicans. Only in one case Neisseria gonorrhoeae was isolated. Among the uncertain etiologic agents, Haemophilus influenzae was the most frequently isolated (7.6%). In 25 (12.6%) of the 198 patients Enterobius vermicularis ova were visualized.

CONCLUSIONS

Streptococcus pyogenes was the most frequently related organism with the vulvovaginitis syndrome among the traditionally established pathogens. The role of Haemophilus influenzae should be considered due to the high prevalence of isolation in this group of patients. We consider that differential diagnosis with Enterobius vermicularis infestation should be done in all cases.

[Gastroenteritis caused by adenoviruses 40/41: epidemiological and clinical aspects]

The 40/41 adenovirus plays an important role as the productive agent of gastroenteritis at a pediatric age according to recent studies. With the aim of evaluating the clinical-epidemiological importance of this agent in our medium a prospective study of the 40/41 adenovirus was carried out in 1,697 stools of children of under 14 years of age over a period of 2 years. An enzyme immunoassay technique with specific monoclonal antibodies was used for detection. The 40/41 adenovirus was the third cause of gastroenteritis following Salmonella sp. and rotavirus with a percentage of infection of 2.1%. In 87.1% of the patients in which it was detected the patients had an age of less than 24 months. A clear peak of infection was found in the months of September of the two years studied. The infection was of intrahospital origin in 46.2% of the patients. Most of the children presented a self-limited diarrheic picture. The evolution of the patients was good with adequate rehydration measures. The study of the 40/41 adenovirus is of indubitable interest with the aim of obtaining greater knowledge of its importance in the epidemiology and clinical manifestations of gastroenteritis.

[Gastroenteritis caused by verotoxin-producing Escherichia coli O157. Presentation of 2 cases]

Verotoxin-producing Escherichia coli strains have been associated with acute hemorrhagic colitis since 1982. We have systematically investigated this pathogen in our laboratory, in all stool samples submitted for culture during a fourteen month period, by using MacConkey sorbitol agar to isolate non sorbitol fermenting Escherichia coli strains. Coated latex particles with an antiserum against Escherichia coli O157 were used to detect O157 serogroup Escherichia coli. A completed serological study and verotoxin assay was performed in all positive strains. We have found two non-related cases of verotoxigenic Escherichia coli infection in two children. In one case, the main clinical picture was an acute hemorrhagic colitis and the other one was a diarrhea without presence of blood, with fever and vomiting. Both cases improved without antimicrobial treatment. No systemic complications appeared in any of the cases during the infection. The infection incidence was 0.07% of all positive stool cultures. The few documented cases of this infection in our country should encourage to investigate this pathogen in order to know its real incidence in our environment.