Anna Maria Cattelan

Regression of AIDS-related Kaposi's sarcoma following antiretroviral therapy with protease inhibitors: biological correlates of clinical outcome

The clinical response of AIDS-related Kaposis sarcoma (KS) to highly active antiretroviral therapy (HAART), a combination of human immunodeficiency virus type 1 (HIV-1) protease and reverse transcriptase inhibitors, was studied in 11 patients, all but one with progressive KS. CD4+ cell counts, plasma HIV-1 RNA levels, and antibody titres to lytic ORF65 and latency-associated human herpes virus type 8 (HHV-8) proteins were determined in sequential samples. Six complete and three partial clinical responses were achieved in a median time of 6 and 3 months, respectively, and confirmed after a median time of 16 months on HAART. 2 patients showed disease progression. A consistent decrease in HIV-1 RNA levels, paralleled by an increase in CD4+ cell counts, was observed in all patients who showed complete or partial clinical response; HIV-1 RNA levels remained persistently high in the two patients who progressed, despite a change in HAART. HHV-8 antibody titres were generally higher in patients with mucosal/visceral involvement compared with patients with limited disease; a decrease in ORF65 antibody titre was significantly associated with a clinical response. These results indicate that HAART is effective for AIDS-related KS; the clinical response correlates with a decrease in plasma HIV-1 RNA levels, an increase in CD4+ lymphocytes, and a decrease in antibodies to ORF65 HHV-8 protein.

Dynamics of Epstein-Barr virus in HIV-1-infected subjects on highly active antiretroviral therapy.

Objective Patients infected with HIV-1 are at high risk of developing Epstein–Barr virus (EBV)-associated lymphoproliferative disorders. This study evaluated the impact of highly active antiretroviral therapy (HAART) on EBV infection. Methods To measure EBV content in peripheral blood lymphocytes (PBL) and in plasma, we set up a quantitative analysis using the real-time PCR. EBV latent membrane protein 1 (LMP1) expression was determined by reverse transcriptase-PCR. Results EBV levels were determined in 33 HIV-1- and EBV-coinfected patients at the start of HAART, and during therapy. At baseline, EBV content in PBL samples ranged from 8 to 14 532 copies/μg DNA. EBV levels transiently increased in nine out of 17 patients in whom HIV-1 plasmaviraemia declined to undetectable levels (virological response) and CD4 cell counts increased (immunological response), while they remained fairly stable or decreased in the other eight virological and immunological responders, and in seven patients who showed a virological response only. Of interest, a significant increase in EBV load was observed in five out of nine patients who showed an increase in CD4 cell counts but lack of HIV-1 suppression during HAART. This EBV increase was accompanied by the detection of both LMP1 transcripts in PBL and EBV DNA in plasma, and was paralleled by an increase in immunoglobulin levels, a marker of B-cell stimulation. Conclusions These findings suggest that peripheral immune reconstitution during HAART without a reduction in HIV-1 replication may increase B-cell stimulation and the number of EBV-infected B cells.

Severe Hepatic Failure Related to Nevirapine Treatment

markable. Laboratory evaluations were significant for a leukocyte count of 1,500/mm (normal value, 4,500–11,000/mm) and macrocytic anemia (hematocrit, 30%; hemoglobin level, 9.8 g/dL; mean corpuscular volume, 104.6 fL). The absolute neutrophil and lymphocyte counts were 870 and 600/mm, respectively. The blood urea nitrogen level was 34 mg/dL (normal value, 7–22 mg/dL), and the creatinine level was 1.8 mg/dL (normal value, 0.6–1.3 mg/dL). Blood cultures were negative. Direct fluorescent antibody staining of fluid from one of the vesicles was positive for HSV, and viral cultures subsequently yielded HSV. A punch biopsy of one of the lesions revealed epidermal ulceration with florid viral cytopathic changes consistent with herpesvirus infection. Secondary bacterial colonization was noted. The patient was treated with intravenous acyclovir (5 mg/kg three times a day), and there was subsequent resolution of the lesions with scarring. Ecthyma refers to a cutaneous infection resembling impetigo but affecting areas deeper in the skin. The lesions are characterized by localized, well-demarcated, erythematous plaques with ulceration that reaches the dermis. Therefore, the lesions often have a central eschar and cause scarring [1]. Ecthyma is almost always secondary to streptococcal and staphylococcal infections, in particular Streptococcus pyogenes infection; therefore, treatment for ecthyma generally consists of oral antimicrobials that are active against S. pyogenes and Staphylococcus aureus. However, mucormycosis [2, 3], molluscum contagiosum [4], cutaneous diphtheria [5], and gonococcal infections [6] have all been associated with ecthyma-like cutaneous eruptions. Review of the literature with use of MEDLINE revealed no previously reported cases of an ecthyma-like presentation of HSV infection. On the basis of nomenclature, ecthyma should be distinguished from two similarly named conditions, ecthyma gangrenosum and contagious ecthyma. Ecthyma gangrenosum is a life-threatening condition secondary to bacterial septicemia with gram-negative bacteria, in particular Pseudomonas aeruginosa. It is characterized by well-demarcated, indurated, weeping, necrotic eschars in areas rich in apocrine glands. Contagious ecthyma, also known as orf, is a parapoxvirus infection of the skin acquired from sheep that is characterized by ulcerated erythematous nodules with white halos. A history of contact with sheep is almost invariably present. This case presents a novel manifestation of HSV infection in immunocompromised hosts. Other such manifestations include painful ulcerative lesions of the genitalia, perianal area, and lips and follicular facial lesions [7]. Moreover, HSV infections should be considered in the differential diagnosis of ecthyma-like skin lesions in immunocompromised patients, and biopsies and virological studies should be performed to exclude HSV infections.

Recent Advances in the Treatment of AIDS-Related Kaposi’s Sarcoma

Kaposi’s sarcoma (KS) is the most common malignancy associated with HIV infection and is considered an AIDS defining condition by the US Centers of Disease Control Guidelines. Several advances in the treatment of AIDS-related KS have been achieved over the past few years, even though a gold standard therapy for KS has not yet been defined and treatment must be tailored to individual needs. Since the availability of highly active antiretroviral therapy (HAART), a dramatic clinical response has been documented in patients with KS, making HAART an essential approach in the management of KS in most, if not all, patients with AIDS-related KS. However, in case of aggressive, visceral, and/or life-threatening KS, more complex therapeutic schedules have to be taken into account, including chemotherapy, radiotherapy, and/or immunotherapy. In general, systemic treatment for KS is limited to widespread, symptomatic disease, whereas local interventions are indicated for minimal, cosmetically troublesome lesions.Among new cytotoxic agents, liposomal anthracyclines and paclitaxel are highly effective molecules for KS and have been approved by the US Food and Drug Administration (FDA) as first-line and second-line monotherapy, respectively, for advanced KS. Furthermore, a greater understanding of the pathogenesis of KS has lead to the development of an array of new experimental agents.Many antiangiogenic agents such as AGM 1470 (TNP 470), thalidomide, and glufanide disodium (IM 862) have produced encouraging responses in patients with KS and large clinical trials are in progress. Retinoic acids may also block neoangiogenesis as well as proliferation of KS cells in vitro, and they have been used either systemically or topically with a high response rate. Thus, a topical compound 0.1% alitretinoin gel was approved in 1999 by the FDA for the treatment of skin lesions associated with KS.Human chorionic gonadotropin, a hormonal agent, has shown a strong inhibitory activity in KS cells, but its role in the regression of KS lesions is not clear.Finally, the identification of a novel γ-herpesvirus, human herpesvirus-8, as a causative agent for KS, together with novel antiangiogenic compounds, such as metalloproteinase inhibitors, may offer promising targets for the therapy of KS.

Human immunodeficiency virus type 1 modulates telomerase activity in peripheral blood lymphocytes.

The effect of human immunodeficiency virus type 1 (HIV-1) on telomerase activity in peripheral blood lymphocytes (PBL) was examined. Telomerase is an enzyme that is involved in mechanisms that control cell life span and replicative potential. HIV-1 reduced telomerase activity in in vitro-infected PBL and impaired enzyme activation upon cell stimulation. Telomerase activity was significantly lower in PBL from 23 HIV-1-infected patients than in PBL from healthy donors and significantly increased during highly active antiretroviral therapy (HAART) in 10 patients who had both a virological and an immunological response and in 5 and 8 patients with a virological or an immunological response, respectively. Further analyses of fractionated cells revealed that telomerase activity increased mainly in CD4(+) lymphocytes. Overall, these findings demonstrate that HIV-1 infection down-modulates telomerase activity and suggest that both the HIV-1 decline and immunorestoration in response to HAART contribute to increased telomerase activity in CD4(+) lymphocytes.

Association between diarrhea and quality of life in HIV-infected patients receiving highly active antiretroviral therapy

Diarrhea is a common symptom that many HIV patients experience either as a consequence of HIV infection or of highly active antiretroviral therapy (HAART). A multicenter, prospective observational study was conducted in 11 AIDS clinics in Italy to determine the effect of diarrhea on health-related quality of life among patients receiving HAART. The study enrolled 100 consecutive HIV positive patients who had diarrhea while on HAART. For each enrolled patient a control patient with matching disease stage who did not have diarrhea was identified using existing data from another prospective observational study conducted in 34 AIDS clinics (including the 11 in current study). Quality of life was measured by MOS-HIV Health Survey (MOS-HIV). Paired t-test and multiple regression analysis were used to compare the quality of life among patients with and without diarrhea. Mean patient age was 40 ± 7 years; 69% were male. Mean CD4 cell count was 342 ± 239 cells/mm3; 59% had AIDS. Of the cases, 49 patients had severe diarrhea ( > 5 bowel movements or > 3 watery per day) and 46 patients had moderate diarrhea (3–5 bowel movements). Compared to matched control patients, cases experiencing diarrhea while on HAART had significantly lower MOS-HIV scores in all domains. The significant adverse effect of diarrhea on quality of life should be considered when choosing the appropriate antiretroviral drugs regimen.

Epstein-Barr Virus load and immune activation in Human Immunodeficiency Virus type 1-infected patients

BACKGROUND Patients infected with HIV-1 are at high risk of developing Epstein-Barr Virus (EBV)-related diseases. Chronic immune activation is a hallmark of HIV-1 pathogenesis and may play a role in B-cell stimulation and expansion of EBV-infected cells. OBJECTIVES The aim of the study was to define the relationship between parameters of immune activation and EBV load in HIV-1-infected subjects. STUDY DESIGN A total of 156 HIV-1-infected patients were studied. EBV types 1 and 2 were quantified on peripheral blood mononuclear cells by multiplex real-time PCR. Plasma levels of cytokines and lipopolysaccharide (LPS) were determined by immunoenzymatic assays. B-cell activation was analyzed by flow cytometry. RESULTS EBV-DNA was detected in 114 patients, and in all but 3 was EBV type 1. The median [interquartile] EBV-DNA load was 43[1-151] copies/10(5) PBMC. EBV-DNA load was higher in patients with detectable HIV-1 plasma viremia, despite good immunological status (CD4>500 cells/μl), than in patients with undetectable HIV-1 plasma viremia regardless of immunological status (46[5-136] copies/10(5) cells vs 17[1-56] copies/10(5) cells, p=0.008). Patients with high EBV-DNA load (>median value) had higher levels of LPS and proinflammatory cytokines (IL-6, IL-10 and TNF-α) than patients with low EBV load. Furthermore, percentages of activated B-cells correlated with EBV-DNA load (r(s)=0.754; p<0.001). CONCLUSIONS Overall, these findings indicate a strong association between HIV-1 viremia, markers of immune activation and EBV load and suggest that persistence of HIV-1 viremia and immune activation, regardless of peripheral CD4 cell depletion/repopulation, may favor expansion of EBV-infected cells and onset of EBV-related malignancies.

Diagnosis of infected total knee arthroplasty with anti-granulocyte scintigraphy: the importance of a dual-time acquisition protocol.

ObjectiveTo evaluate clinical efficacy of a dual-time acquisition protocol consisting of early 4 h and delayed 20–24 h imaging with anti-granulocyte scintigraphy (LeukoScan) in the diagnosis of infection in painful total knee arthroplasty (TKA). Materials and methodsSeventy-eight consecutive patients with TKA (12 bilateral) were prospectively enrolled in the study from August 2004 to July 2005. All the patients had clinical and biochemical suspicious of infection, except for the 12 patients with bilateral painless prosthesis who had no signs and symptoms of loosening and/or infection and were considered as controls. TKA prostheses had been implanted 4 months to 9.5 years before our studies. Forty-three patients were on antibiotic therapy at the moment of scintigraphic examination, and treatment was not discontinued. All patients underwent LeukoScan examination by performing both early 4 h and delayed 20–24 h imaging. In addition to planar imaging SPECT was performed in 18 cases. A decrease in radiotracer uptake from early to delayed LeukoScan imaging was interpreted as an unspecific finding (negative for infection), while an increasing uptake was interpreted as a positive finding for the presence of infection. Three-phase 99mTc-MDP bone scan was also routinely performed by standard technique. Sensitivity and specificity of early and delayed LeukoScan imaging were calculated. ResultsSensitivity for early and delayed imaging were 92.7%, while specificity was 78.4% for early imaging and 100% for delayed imaging approach. SPECT imaging did not add any significant information as regard to specificity in our experience. Eight false positive early scans were correctly diagnosed as negative at delayed imaging. Three false negative results were recorded. Sensitivity and specificity were similar when patients were on or off antibiotic therapy. Imaging was negative in all 12 controls. ConclusionsOur results, based on a large group of patients, suggest that delayed LeukoScan imaging is important in identifying false positive results detect at early imaging. Thus, a dual-time, 4 h early and 20–24 h delayed LeukoScan imaging approach should be recommended to increase the diagnostic accuracy of the scintigraphy, with the exception of patients with a negative early LeukoScan examination, in whom the acquisition of delayed imaging appears unnecessary. In our experience, concomitant antibiotic therapy did not influence the diagnostic value of LeukoScan.

Different distribution of HIV type 1 genetic variants in European patients with distinct risk practices.

The use of two genetic markers has permitted the analysis of the distribution of two different human immunodeficiency virus type 1 (HIV-1) variants in patients of the homosexual (HO) and intravenous drug user (IDU) groups in distinct European countries. In Germany, Holland, and Italy the variants circulating in each risk group of HO and IDU patients were genetically distinguishable according to the genetic markers used. In contrast, in France and Spain, the same variant has been recovered from patients with different risk practices. These data highlight the diversity of the HIV-1 epidemic in Europe and the different patterns of HIV-1 variant distribution in European countries.

Oral human papillomavirus and human herpesvirus-8 infections among human immunodeficiency virus type 1-infected men and women in Italy

Background Oral human papillomavirus (HPV) and human herpesvirus-8 (HHV8) infections are sexually transmitted and respectively associated with the development of oropharyngeal carcinoma and Kaposi sarcoma. The aim of the study was to evaluate HPV prevalence and its possible correlation with HHV8 oral shedding, in relation to sex, human immunodeficiency virus (HIV) behavioral risk factor, and immune function. Methods The study population comprised 100 HIV-infected individuals divided into 3 groups: (1) 38 men who have sex with men (MSM), (2) 24 heterosexual men, and (3) 38 women. DNA was obtained from cells of unstimulated whole saliva. Human papillomavirus sequences were searched for by polymerase chain reaction (PCR) with MY09/MY11 primers or by nested PCR with GP5+/GP6+ primers as the second step. Typing was accomplished by restriction fragment length polymorphism analysis or by direct sequencing or by reverse line blot. Human herpesvirus-8 sequences were detected and quantified by nested PCR and real-time PCR, respectively. Results Oral HPV infection was present in 37 (prevalence, 37%) of 100 (13 with high-risk and 24 with low-risk types) patients; the most frequent types were HPV16, HPV6, HPV10, HPV61, HPV66, and HPV83. Human herpesvirus-8 DNA was detected in 46 (46%) of 100 subjects. Both infections had the highest prevalence among MSM and the lowest among women; women had a lower prevalence of high-risk HPV types than did both male groups (P = 0.05). An inverse correlation was observed with concomitant oral HHV8 infection (P = 0.007). Conclusions High prevalence of oral HPV and HHV8 infections was observed; MSM had the highest figures, despite better control of HIV infection.