Selected Abstracts

The Royal Society of Medicine Press produce, as a regular feature of the Journal, a selection of abstracts from 60 of the leading journals which regularly publish in the field of sexually transmitted infections and HIV. The aim is to inform readers of recent advances, which they may otherwise have overlooked. The articles included are personal selections made by Dr W W Dinsmore (Editor) and myself. We hope that this will provide a valuable service.

Early clinical experience of dolutegravir in an HIV cohort in a larger teaching hospital

Dolutegravir (DTG) is the third HIV integrase inhibitor (INI) available for prescription in Belfast since July 2014. It has shown high virological efficacy in both treatment-naïve and -experienced patients. We carried out a retrospective case chart analysis of HIV-1-positive adults commenced on DTG between July 2014 and September 2015. Patients were identified from records as either treatment-naïve or antiretroviral therapy (ART) experienced. Outcomes included: (1) virological response (HIV-1 RNA viral load at 0, 4, 8 and 12 weeks), (2) immunological response (CD4+ cell count at 0, 4, 8 and 12 weeks) and (3) tolerability (side effects and discontinuation). The main exclusion criteria were patients transferring care already established on DTG from other treatment centres or inadequate follow-up information (defined as attendance at <50% of clinical and serological follow-up visits). One hundred and fifty-seven commenced DTG out of 823 patients on ART; 106 (68%) were switched to DTG from another regimen, and 51 (32%) were ART-naïve. One naïve and 14 treatment-experienced patients were excluded from the analysis due to failure to attend clinical follow-up. Analysis of HIV-1 RNA viral load (HIV-1 VL) was divided into three groups: 50 new starters, 68 suppressed at switch and 24 not suppressed at switch. New starters: Baseline median HIV-1 RNA VL 71,259 copies/mL (19,536_Q25-196,413_Q75); 73% were virally undetectable (HIV-1 RNA VL <70 copies/mL) by week 4. Switching patients: Of those with an HIV-1 RNA undetectable viral load prior to switching, two were detectable with a mean viral load of 443,730 copies/mL after four weeks. Of the 24 patients detectable at switch (median HIV-1 VL 2212 [311_Q25-43,467_Q75]), 10 were detectable after four weeks. For those with a recordable viraemia, the median HIV-1 VL reduced to 376 (220_Q25-1181_Q75). At week 12, four patients were detectable with a median VL of 12,390 (567_Q25-52,285_Q75). Overall, 56 (35%) reported side effects; 40 (25%) reported either difficulty with low mood, anxiety or sleep disturbance. Sixteen (10%) discontinued DTG, with 13 (8%) due to intolerable side effects. DTG is a useful drug in naïve or switch patients. It has the potential to effectively suppress the viral load within the first four weeks of treatment and thus reduces infectiousness. Within the cohort, DTG was generally well tolerated but side effects such as low mood, anxiety and sleep disturbance were high, with 8% of patients discontinuing treatment.

Selected Abstracts

The Royal Society of Medicine Press produce, as a regular feature of the Journal, a selection of abstracts from 60 of the leading journals which regularly publish in the field of sexually transmitted infections and HIV. The aim is to inform readers of recent advances, which they may otherwise have overlooked. The articles included are personal selections made by Dr W W Dinsmore (Editor) and myself. We hope that this will provide a valuable service.

Are we missing mumps epididymo-orchitis?

Mumps epididymo-orchitis has not been recorded as a cause of testicular symptoms without systemic features (including parotitis). The aim of the present study was to assess if we were missing cases in the genitourinary clinic during a previous outbreak of mumps in the community. During a prospective pilot study from November 2005 to February 2006, all patients presenting with symptoms or signs of epididymo-orchitis were studied. These patients were assessed for previous exposure to mumps virus or vaccine, and any current evidence of systemic illness. All patients included had a full sexual health screen (loop test, chlamydia polymerase chain reaction [PCR], gonorrhoea culture, HIV and Venereal Disease Research Laboratory [test]/ Treponema pallidum particle agglutination assay), urinary tract infection excluded by urinalysis and mid-stream specimen of urine (MSSU) and mumps serology (Immunoglobulin M [IgM] and Immunoglobulin G [IgG]) performed.

Twenty-three patients met inclusion criteria. Their ages ranged from 16 to 50 years, average 30.8 years. All had symptoms of these, 18 had testicular pain, eight swelling, (four had both pain and swelling) and three also had dysuria. On examination, 12 had tenderness, seven swelling, (two both tenderness and swelling) and six had no signs. Seventeen denied history of mumps, one patient had a record of vaccination and five described fever. None had parotid swelling. Three patients were chlamydia PCR positive, two had candida cultured, three had non-specific urethritis (>10 polymorphonuclear leucocyte/high powered field) and 13 had negative sexually transmitted infection screen (one known HIV-positive). Three had positive IgM mumps serology and two were IgG-positive.

It is important to include mumps in the differential of epididymo-orchitis and to be aware of outbreaks in the community that may present with genital symptoms, as the management and partner notification will be different.

Clinical care versus ethical obligations: HIV-1 and -2 co-infection with hepatitis B in a pregnant Jehovah's Witness

Co-infection with HIV-1 and -2 is rare, even in west Africa. We present the case of a 38-year-old pregnant Jehovah's Witness presenting late in pregnancy with triple infection with HIV-1, HIV-2 and hepatitis B virus. There was a successful outcome in averting vertical transmission despite objections to management based on religious and cultural beliefs.

Managing vaccines: defining the remit of primary care and specialist HIV clinics in the delivery of immunization to individuals with HIV infection

The British HIV Association (BHIVA) has published guidelines for immunization of HIV-infected adults. A chart review of 200 HIV-infected patients diagnosed was conducted to determine shortcomings in previous practice and determine which vaccines should routinely be given in specialist HIV clinics and which might be able to be delegated to primary care clinics. Data were collected on administration of three categories of vaccinations: (1) vaccines used in all individuals with chronic disease (pneumococcal, influenza, swine flu H1N1); (2) targeted vaccinations used in non-immune individuals with HIV who are at risk of exposure (hepatitis A and hepatitis B); (3) routine vaccines traditionally delivered to the whole population (measles/mumps/rubella [MMR], diphtheria/tetanus/pertussis and meningitis C/ACWY). Pneumococcal vaccine was delivered to 54% of eligible patients, 52% of eligible individuals completed a full hepatitis B programme of vaccination and 21% (42/200) were naturally immune; hepatitis A vaccine was delivered to 36% of eligible individuals. With increasing demands on resources, it seems likely that HIV services will have to harness resources of primary care in vaccine programmes in relation to routine vaccines. By improving communication between primary and secondary care mistakes with live vaccination decisions could be avoided; HIV services should continue to perform targeted and chronic disease vaccines, i.e. for category 1 and category 2 vaccines.

Acute hepatitis B: the limits of maintaining patient confidentiality

Household contacts of hepatitis B (HBV) are at risk of infection, and guidelines advise vaccination of these contacts in addition to sexual partners (along with traditional high-risk groups). We present a case of intrafamilial transmission of acute hepatitis B virus (HBV) following failure to self-disclose status to family members. Complex confidentiality issues can arise following a diagnosis of HBV infection.

A case of multidrug resistance in the central nervous system

HIV-1 infection may persist in the central nervous system (CNS) despite antiretroviral therapy. We present a case of severe cognitive decline in a man with HIV-1 infection on a fully active regimen for five years. All infective causes were excluded. Despite fully suppressed virus in the blood, HIV RNA in the cerebrospinal fluid measured 3.52 log(10) RNA copies/mL and genotyping of this sample showed an extensive pattern of resistance. This suggested that either the antiretroviral agents were not adequately penetrating the CNS or the CNS had resistant virus as a result of adherence problems. This case highlights the possibility that drug-resistant mutations may develop in the CNS compartment while plasma virus remains suppressed.

Hepatic encephalopathy as an unusual late complication of transjugular intrahepatic portosystemic shunt insertion for non-cirrhotic portal hypertension caused by nodular regenerative hyperplasia in an HIV-positive patient on highly active antiretroviral therapy

Transjugular intrahepatic portosystemic shunt (TIPS) is an artificially created conduit between the portal and systemic vascular system in the liver performed percutaneously via radiological guidance. It is used mainly in conditions causing portal hypertension and its resulting complications. It reduces portal pressure by diverting portal blood flow into the systemic circulation. Hepatic encephalopathy is the most common complication following TIPS insertion and tends to present fairly early. We describe a case of hepatic encephalopathy as an unusual late complication of TIPS insertion (first presenting six years after) for non-cirrhotic portal hypertension caused by nodular regenerative hyperplasia in an HIV-positive patient on highly active antiretroviral therapy.

Transmission of HIV-1 infection due to a fist fight

Summary

We report a case of HIV-1 infection transmission caused by a fist fight between brothers. A 30-year-old Caucasian UK resident man developed ‘flu-like illness with symptoms of lethargy and weakness. Persistent lymphadenopathy six months later lead to HIV antibody testing, which was positive. Of note, his 37-year-old brother, who was HIV antibody-positive since August 2000, was taking HAART (combivir and nevaripine) with CD4 350 × 106/L (16%) with viral load 4800 copies/mL (log 2.58). A bloody fight had occurred between them four weeks prior to onset of symptoms. Phylogenetic analysis was undertaken. Analysis of the pol gene region indicated that samples from both brothers belonged to the subtype C clade of HIV-1, and that the sequences were closely related to one another. Exposure risk data are extremely useful in helping counsel patients prior to HIV-testing but, as this case illustrates, does not cover all situations.

Patient assessment of anogenital warts and the success of treatment with home applied therapy

Home treatment with podophyllotoxin or imiquimod are commonly prescribed therapies for anogenital warts. It is important to ascertain if patients are locating all lesions for treatment and if they know when they are clear of them. We set out to assess patients' ability to determine the number and location of their genital warts and compare their observation with that of their examining doctor or nurse. Following instruction on the use of home treatment and being given an instruction leaflet patients were reviewed in four weeks' time. One hundred and fifty-five patients enrolled in the study--31% (48) male, 69% (107) female. At initial assessment 62.5% (30) of male patients and 59.8% (64) of female patients underestimated the extent of their disease: 10.5% (5) of male patients and 10.3% (11) of female patients overestimated their disease burden with some mistaking skin tags for genital warts. At review 29.4% (5) of male patients and 44.4% (20) of female patients still underestimated the extent of their infection. Patients undertaking home treatment for warts not only need detailed instruction on its use but should be reviewed to assess the success of treatment.

Histoplasmosis as a presentation of human immunodeficiency virus infection

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Genital schistosomiasis

Schistosomiasis is the most serious helminthic infection in the United Kingdom. Female genital schistosomiasis affects 9-13 million women worldwide, mainly in areas where Schistosoma haematobium is endemic. With increasing tourism to these areas, this diagnosis is being encountered more frequently in the West. We present 2 cases of vulval schistosomiasis that were presented to our department in 1999 and 2000.

Selected Abstracts

The Royal Society of Medicine Press produce, as a regular feature of the Journal, a selection of abstracts from 60 of the leading journals which regularly publish in the field of sexually transmitted infections and HIV. The aim is to inform readers of recent advances, which they may otherwise have overlooked. The articles included are personal selections made by the Editor and myself. We hope that this will provide a valuable service.

Selected Abstracts

The Royal Society of Medicine Press produce, as a regular feature of the Journal, a selection of abstracts from 60 of the leading journals which regularly publish in the field of sexually transmitted infections and HIV. The aim is to inform readers of recent advances, which they may otherwise have overlooked. The articles included are personal selections made by Dr W. W. Dinsmore (Editor) and myself. We hope that this will provide a valuable service.

A case of pneumocystis pneumonia after cessation of secondary prophylaxis

Improvement in the immunological and virological profile of HIV-infected population during the era of highly active antiretroviral therapy (HAART), has allowed guidelines on discontinuation of Pneumocystis carinii pneumonia (PCP) prophylaxis to be published. A case of a 37-year-old homosexual man, who had sustained CD4 count over 200 cells/microl for 2 years while on secondary prophylaxis for PCP, who then developed PCP after cessation of prophylaxis, is presented. This case emphasizes the need for close monitoring of patients who discontinued secondary PCP prophylaxis with respiratory symptoms.