Alexander Wong

CIHR Canadian HIV Trials Network Coinfection and Concurrent Diseases Core Research Group: 2016 Updated Canadian HIV/Hepatitis C Adult Guidelines for Management and Treatment.

Background. Hepatitis C virus (HCV) coinfection occurs in 20–30% of Canadians living with HIV and is responsible for a heavy burden of morbidity and mortality. Purpose. To update national standards for management of HCV-HIV coinfected adults in the Canadian context with evolving evidence for and accessibility of effective and tolerable DAA therapies. The document addresses patient workup and treatment preparation, antiviral recommendations overall and in specific populations, and drug-drug interactions. Methods. A standing working group with HIV-HCV expertise was convened by The Canadian Institute of Health Research HIV Trials Network to review recently published HCV antiviral data and update Canadian HIV-HCV Coinfection Guidelines. Results. The gap in sustained virologic response between HCV monoinfection and HIV-HCV coinfection has been eliminated with newer HCV antiviral regimens. All coinfected individuals should be assessed for interferon-free, Direct Acting Antiviral HCV therapy. Regimens vary in content, duration, and success based largely on genotype. Reimbursement restrictions forcing the use of pegylated interferon is not acceptable if optimal patient care is to be provided. Discussion. Recommendations may not supersede individual clinical judgement. Treatment advances published since December 2015 are not considered in this document.

Disparities in direct acting antivirals uptake in HIV-hepatitis C co-infected populations in Canada

Direct acting antivirals (DAAs) have revolutionized hepatitis C (HCV) treatment with >90% cure rates even in real‐world studies, giving hope that HCV can be eliminated. However, for DAAs to have a population‐level impact on the burden of HCV disease, treatment uptake needs to be expanded. We investigated temporal trends in HCV treatment uptake and evaluated factors associated with second‐generation DAA initiation and efficacy among key HIV‐HCV co‐infected populations in Canada.

Hematospermia in a returned traveler

Hematospermia is a common complaint among patients seen in outpatient urology clinics. The differential diagnosis is broad and includes inflammatory, infectious, neoplastic, structural, systemic, and traumatic causes. The most common infectious causes are uropathogens and sexually transmitted infections. However, with increasing global travel, physicians must maintain a high clinical suspicion for pathogens not endemic to their region, including Echinococcus, Mycobacterium tuberculosis, and Schistosoma.1 We present a case of hematospermia in a traveler returning from Eastern Africa with exposure to Lake Malawi. The patients microscopic analysis of semen was positive for Schistosoma haematobium, revealing a rare presentation of S. haematobium infection.

Real-world impact of direct acting antiviral therapy on health-related quality of life in HIV/Hepatitis C co-infected individuals

Clinical trial results of direct acting antivirals (DAAs) for the treatment of hepatitis C virus (HCV) have shown improvements in health‐related quality of life (HR‐QoL). However, the extent to which these results are broadly generalizable to real‐world settings is unknown. We investigated the real‐world impact of oral DAA therapy on HR‐QoL among individuals coinfected with HIV/HCV. We used data from the Canadian HIV/HCV Co‐Infection Cohort Study that prospectively follows 1795 participants from 18 centres. Since 2007, clinical, lifestyle, and HR‐QoL data have been collected biannually through self‐administered questionnaires and chart review. HR‐QoL was measured using the EQ‐5D instrument. Participants initiating oral DAAs, having at least one visit before treatment initiation and at least one visit after DAA treatment response was ascertained, were included. Successful treatment response was defined as a sustained viral response (SVR). Segmented multivariate linear mixed models were used to evaluate the impact of SVR on HR‐QoL, controlling for pretreatment trends. 227 participants met our eligibility criteria, 93% of whom achieved SVR. Before treatment, the EQ‐5D utility index decreased 0.6 percentage‐point/y (95% CI, −0.9, −0.3) and health state was constant over time. The immediate effect of SVR resulted in an increase of 2.3‐units (−0.1, 4.7) in patients’ health state and 2.0 percentage‐point increase (−0.2, 4.0) in utility index. Health state continued to increase post‐SVR by 1.4 units/y (−0.9, 3.7), while utility trends post‐SVR plateaued over the observation period. Overall using real‐world data, we found modest improvements in HR‐QoL following SVR, compared to previously published clinical trials.

Disseminated Exophiala dermatitidis causing septic arthritis and osteomyelitis

BackgroundExophiala dermatitidis is a melanized fungus isolated from many environmental sources. Infections caused by Exophiala species are typically seen in immunocompromised hosts and manifest most commonly as cutaneous or subcutaneous disease. Systemic infections are exceedingly rare and associated with significant morbidity and mortalityCase presentationA 28-year-old female originally from India presented with fevers, chills, weight loss and increasing back pain. She had a recent diffuse maculopapular rash that resulted in skin biopsy and a tentative diagnosis of sarcoidosis, leading to administration of azathioprine and prednisone. An MRI of her spine revealed a large paraspinal abscess requiring surgical intervention and hardware placement. Cultures from the paraspinal abscess grew a colony of dark pigmented mold. Microscopy of the culture revealed a melanized fungus, identified as Exophiala dermatitidis. Voriconazole was initially utilized, but due to relapse of infection involving the right iliac crest and left proximal humerus, she received a prolonged course of amphotericin B and posaconazole in combination and required 7 separate surgical interventions. Prolonged disease stability following discontinuation of therapy was achieved.ConclusionsDescribed is the first identified case of disseminated Exophiala dermatitidis causing osteomyelitis and septic arthritis in a patient on immunosuppressive therapy. A positive outcome was achieved through aggressive surgical intervention and prolonged treatment with broad-spectrum antifungal agents.

Comparison of atazanavir/ritonavir and darunavir/ritonavir based antiretroviral therapy for antiretroviral naïve patients

BackgroundAtazanavir/ritonavir and darunavir/ritonavir are common protease inhibitor-based regimens for treating patients with HIV. Studies comparing these drugs in clinical practice are lacking.MethodsWe conducted a retrospective cohort study of antiretroviral naïve participants in the Canadian Observational Cohort (CANOC) collaboration initiating atazanavir/ritonavir- or darunavir/ritonavir-based treatment. We used separate Fine and Gray competing risk regression models to compare times to regimen failure (composite of virologic failure or discontinuation for any reason). Additional endpoints included virologic failure, discontinuation due to virologic failure, discontinuation for other reasons, and virologic suppression.ResultsWe studied 222 patients treated with darunavir/ritonavir and 1791 patients treated with atazanavir/ritonavir. Following multivariable adjustment, there was no difference between darunavir/ritonavir and atazanavir-ritonavir in the risk of regimen failure (adjusted hazard ratio 0.76, 95% CI 0.56 to 1.03) Darunavir/ritonavir-treated patients were at lower risk of virologic failure relative to atazanavir/ritonavir treated patients (aHR 0.50, 95% CI 0.28 to 0.91), findings driven largely by high rates of virologic failure among atazanavir/ritonavir-treated patients in the province of British Columbia. Of 108 discontinuations due to virologic failure, all occurred in patients starting atazanavir/ritonavir. There was no difference between regimens in time to discontinuation for reasons other than virologic failure (aHR 0.93; 95% CI 0.65 to 1.33) or virologic suppression (aHR 0.99, 95% CI 0.82 to 1.21).ConclusionsThe risk of regimen failure was similar between patients treated with darunavir/ritonavir and atazanavir/ritonavir. Although darunavir/ritonavir was associated with a lower risk of virologic failure relative to atazanavir/ritonavir, this difference varied substantially by Canadian province and likely reflects regional variation in prescribing practices and patient characteristics.

Severe transient neutropenia with fever and abdominal pain in a 30-year-old man

A 30-year-old man presented to the emergency department with a 3-day history of fever, chills, nausea, vomiting, diarrhea and abdominal pain. The patient’s symptoms had progressed rapidly until he had a productive cough with yellow sputum, which led him to visit the emergency department. The