Alessandra Salotti

The combination of FRAX and Ageing Male Symptoms scale better identifies treated HIV males at risk for major fracture.

Osteoporosis and hypogonadism are common in men with HIV infection. Ageing Male Symptoms (AMS) scale measures symptoms related to hypogonadism. FRAX provides 10‐year probability of major fractures. We investigated the role of AMS scale combined with FRAX without bone mineral density (BMD), in identifying HIV men with bone fragility.

Long-term IFN-γ and IL-2 response for detection of latent tuberculosis infection in healthcare workers with discordant immunologic results

Discordant results between the interferon-gamma release assays (IGRAs) and tuberculin skin test (TST) are common in latent tuberculosis infection (LTBI). We evaluated whether the measurement of IFN-γ and interleukin (IL)-2T-cell responses, after prolonged Mycobacterium tuberculosis-specific antigen stimulation, can be used as adjunctive biomarker for LTBI detection in subjects with discordant results between TST and QuantiFERON-Gold In-Tube (QFT). 196 healthcare workers were screened for LTBI and in 90 of those participants, the QFT was repeated after 18 h, and IFN-γ/IL-2 immune response was measured after 72 h long-term stimulation. Of the 196 patients, 34 had positive, 155 negative, and 7 indeterminate QFT results. Discordant TST+/QFT- results were found in 29 (14.7%) patients, of whom 6 (20.6%) were Bacillus Calmette-Guerin (BCG) vaccinated. None of 23 non-BCG vaccinated subjects showed a specific IFN-γ immune response after 18 h nor 72 h of incubation, whereas 3/23 (13.04%) discordant subjects produced a specific long-term IL-2 response, which might reflect a LTBI status. In LTBI group (TST+/QFT+) both cytokine levels were increased after long-term in comparison to short-term stimulation. No significant long-term IFN-γ/IL-2 secretion was detected in control group (TST-/QFT-). Taken together, our data showed that the 87% of discordant patients who did not respond to the long-term assay, as controls subjects, were judged LTBI negative. The use of classic QFT and long-term IL-2 response may have a potential role to clarify the LTBI status in individuals in whom the diagnosis of LTBI is uncertain due to the discordance of the available diagnostic tests, such as TST and IGRA.

Levofloxacin and Tobramycin for Severe Bacterial Keratouveitis

Abstract Purpose: To report on clinical features and outcome of severe bacterial keratouveitis. Methods: Twenty patients with severe bacterial keratouveitis treated with topical tobramycin and levofloxacin and oral levofloxacin were included. Main outcome measures were ulcers location, bacterial isolates, risk factors, visual prognosis. Results: Centrally located ulcer/abscess was present in 65% of patients. Contact lens (CL) wear was the most common risk factor (70%). Bacterial isolates were observed in 58% of patients, none resistant to tobramycin and levofloxacin. Pseudomonas aeruginosa was found in 47% of positive cases and in 64% of CL wearers. After therapy, the mean visual acuity improved significantly (p < 0.0001), particularly in contact lens wearers (p = 0.04) and in patients younger than 60 years old (p < 0.001). Conclusions: Pseudomonas aeruginosa is the most frequent cause of bacterial keratouveitis and CL wear the most common risk factor. Topical tobramycin and levofloxacin and oral levofloxacin are effective in the treatment of bacterial keratouveitis.

Long-Term Treatment With Raltegravir is Associated with Lower Triglycerides and Platelets Count in the Older HIV+ Population: Results from the Ral-Age Study

BACKGROUND Raltegravir (RAL) is considered one of the better-tolerated antiretroviral medications, due to limited side effects and minimal drug-drug interactions. Matherials and Methods: We retrospectively evaluated 96 HIV+, over 60 years old, experienced patients who had switched from any antiretroviral drug to raltegravir-based nuc-sparing or standard nucleoside-backbone regimens. A control group with patients aged under 60 years old was included. RESULTS The median age of the patients was 66 years (IQR 10.5) (77 M, 19 F); the median time horizon of follow-up was 4 years (IQR 5). HIV-RNA at baseline was undetectable for more than 6 months in most of the patients. Median CD4+ count was 453 cells/mmc (IQR 379). 49 patients had AIDS history. All the patients were assuming concomitant medications. No adverse effect attributed to the use of raltegravir was reported in the medical records. Only 2 patients presented virological failure, whereas viremic blips were observed in 10 patients. After switching to RAL-containing regimens triglycerides values showed a statistically significant reduction from a median value of 172 (IQR 105.5) mg/dl to 129 mg/dl (IQR 73) (p=0,0001). Switching to a standard regimens was associated with a marked reduction of triglycerides. Cholesterol levels were reduced at the time of follow-up (T2) but no significant modifications were observed when patients which had introduced drugs to treat dislypidemia were removed from the analysis; in contrast, triglycerides reduction was also confirmed in this sub-group. Patients presented higher levels of CD4+ at T2 and reduced platelet count [from 230 300/mmc (SD 123 527) to 197 125/mmc (SD 66 377), p=0,04]. Similar trends were observed in younger patients. CONCLUSION RAL-containing regimens are safe and highly effective in the older population. RALtreatment is associated with the reduction of triglycerides and platelets count in the older population.

Relapsing and disseminated VZV infection associated with post-zoster neuralgia in an HIV-infected patient

Sir: We describe a new case of postzoster neuralgia in a patient infected with human immunodeficiency virus (HIV) and with relapsing disseminated varicella-zoster virus (VZV) disease. The clinical presentation and course of post-zoster neuralgia vary greatly among patients [1]. Classically, burning pain sensation on the dermatome related to the previously infected nerve root(s) is the main clinical hallmark of the disease. However, the extent and severity of peripheral nerve involvement may determine the eventual prognosis of the disease [2, 3]. Among the less common clinical manifestations of post-zoster neuralgia is the relapse of painful clinical events. This can represent a troublesome disturbance, compromising the quality of life of these patients. In a number of previous reports, relapse of VZV disease and the related post-zoster neuralgia have never been described [1–4]. A 34-year-old HIV-seropositive, female drug user developed cutaneous herpes zoster on left side of the thorax and on the face associated with Ramsey-Hunt syndrome. The lesions were also present on both legs. Her CD4+ count was 21 cells/μl. Despite administration of acyclovir (4000 mg/daily), the patient developed neuralgia that was treated with carbamazepine. Because of the appearance of disseminated skin rash, the treatment was stopped and substituted with paracetamol-codeine with moderate improvement. After 6 months, the patient was hospitalized for a new episode of herpes zoster associated with fever and severe pain. The patient was given acyclovir (10 mg/kg day intravenously) in combination with specific anti-VZV human immunoglobulin, as recommended for specific secondary prophylaxis [5]. At the same time ketoprofen and paracetamolcodeine were administered. After discharge, the clinical condition of patient was stable until a persistent headache localized in the frontal region and associated with vomiting and rigor nucalis developed. For this reason the patient was again hospitalized. Simultaneously, vescicular lesions appeared on the face and on both legs. Computed tomography (CT) and magnetic resonance imaging (MRI) (Figs. 1, 2) of the brain gave negative results. Cytological analysis of the vescicular fluid revealed findings typical of herpes infection. The following therapy consisted of ketoprofen, paracetamol codeine and tramadol. Despite treatment, the clinical condition worsened and the patient died after a few weeks. To our knowledge, this is the first case showing the co-existence of relapsing and disseminated VZV infection in a patient with HIV disease and severe immunodeficiency that has been associated with a marked and intense pain resistant to any analgesic [6]. Interestingly, the occurrence of a severely painful syndrome, such as post-zoster neuralgia, may be putatively correlated to an compromised immune response in an HIV-infected patient. As previously hypothesized in another severe pain syndrome, the cluster headache associated with HIV or VZV infection [7, 8], the host immune deficiency may facilitate the onset and reappearance of post-zoster neuralgia or cluster headache [9]. In this clinical case