Atul K. Patel

Safety and antiretroviral effectiveness of concomitant use of rifampicin and efavirenz for antiretroviral-naive patients in India who are coinfected with tuberculosis and HIV-1.

ObjectiveTo study the safety and antiretroviral effectiveness of concomitant use of rifampicin and efavirenz for antiretroviral-naïve patients in India who are coinfected with tuberculosis (TB) and HIV-1. Design and MethodsThe study was an observational longitudinal cohort investigation. HIV-1–infected patients with CD4 cell counts of ≤200/μL who attended the Infectious Disease Clinic of Sterling Hospital (Ahmedabad, India) from June 2001 to December 2002 were recruited for the study. Patients were divided in 2 groups: group A, patients with active TB (n = 126); and group B, patients without TB (n = 129). Group A patients were given efavirenz with 2 nucleoside reverse transcriptase inhibitors along with rifampicin-containing anti-TB treatment. Group B patients were treated for presenting opportunistic infections and started therapy with efavirenz plus 2 nucleoside reverse transcriptase inhibitors. The nucleoside reverse transcriptase inhibitors were either zidovudine and lamivudine (n = 30) or stavudine and lamivudine (n = 225). Patients self-funded their investigations and medications (antiretroviral, anti-TB, and other opportunistic infection–related agents). Indian generic medications were used. ResultsEfavirenz-based highly active antiretroviral therapy with rifampicin for HIV/TB-coinfected patients resulted in an immunologic response that was comparable with that of the group not receiving rifampicin. Median CD4 cell counts at baseline, 3 months, 6 months, and 9 months in group A were 84/μL (range, 5–200/μL), 225/μL (range, 26–528/μL), 251/μL (range, 65–775/μL), and 275/μL (range, 61–611/μL), respectively, and in group B, these values were 118/μL (range, 2–200/μL), 244/μL (range, 38–881/μL), 294/μL (range, 23–1322/μL), and 295/μL (range, 26–991/μL), respectively. The overall increase in CD4 cell count was greater in group A than in group B at 9 months (190 vs. 176/μL, respectively). Patients in both groups tolerated the therapy well; the adverse effects profile was comparable except that group A patients had a higher incidence of hepatitis than group B patients (13.49% vs. 0, respectively; P < 0.0001). ConclusionClinical and immunologic benefits are comparable for patients receiving efavirenz-based antiretroviral therapy with or without rifampicin.

Exophiala dermatitidis endocarditis on native aortic valve in a postrenal transplant patient and review of literature on E. dermatitidis infections.

Atul K. Patel, Ketan K. Patel, Prakash Darji, Rachna Singh, M. R. Shivaprakash and Arunaloke Chakrabarti Infectious Diseases Clinic, Vedanta Institute of Medical Sciences, Ahmedabad, India, Department of Nephrology and Renal Transplant, Sterling Hospital, Ahmedabad, India and Division of Mycology, Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India

Tenofovir-associated renal dysfunction in clinical practice: An observational cohort from western India.

BACKGROUND Tenofovir (TDF) is preferred nucleoside reverse transcriptase inhibitors (NRTI) for the treatment of human immunodeficiency virus infection because of its potency and safety. Renal toxicity with TDF use is low and comparable with other NRTI in clinical trials, but there are many case studies and small case series of renal dysfunction with TDF. MATERIALS AND METHODS This is an observational longitudinal cohort of patients started on a TDF-based regimen from January 2007 to April 2010. Patients were evaluated at baseline and with every follow-up visit for serum creatinine and calculated creatinine clearance (Cockroft-Gault formula). In addition to this, the patients were also subjected to test for serum potassium, phosphorous and urine examinations as and when indicated. Renal dysfunction was defined as rise in serum creatinine to more than the upper level of normal (>1.2 mg%). RESULTS Of 1,271 patients started on a TDF-containing antiretroviral treatment (ART) 83 (6.53%) developed renal dysfunction, of which 79 had impaired serum creatinine and five had Fanconis syndrome. Renal dysfunction was more common with boosted a protease inhibitor (PI) (9.44%)-based regimen as compared to a non- nucleoside reverse transcriptase inhibitors (NNRTI) (5.01%)-based regimen (P = 0.003). The mean decline in creatinine clearance from baseline was 22.27 ml/min. The median time to develop renal dysfunction was 154 (15-935) days. Serum creatinine returned to normal in all the patients after stopping TDF. Five patients presented with features suggestive of Fanconis syndrome without alteration in serum creatinine. CONCLUSION TDF-based treatment is associated with mild but reversible renal dysfunction. Patients receiving PI/r are at a higher risk of renal dysfunction compared to those receiving NNRTI-based ART. Clinicians should be adviced to have intensive renal monitoring, including creatinine clearance, urine examination, K+ and phosphate levels at baseline and during treatment with TDF.

Effectiveness of low-dose indinavir/ritonavir at 400/100 mg twice a day with 2 nucleoside reverse transcriptase inhibitors in nonnucleoside reverse transcriptase inhibitor-experienced HIV-infected patients in India: 1-year follow-up.

There are an estimated 5 million HIV-infected people in India. The nonnucleoside reverse transcriptase inhibitor (NNRTI)-based combination antiretroviral therapy (cART) is the first-line therapy for HIV-infected patients in India and in the developing world. And unlike in developed countries there are limited options available for patients who failed on first-line cART in developing countries. Low-dose indinavir (IDV)/ritonavir at 400/100 mg BID with 2 nucleoside reverse transcriptase inhibitors (NRTIs) is the most cost-effective boosted protease inhibitor (PI)-based regimen in India; therefore it deserves a study. Indinavir as cART at standard dosages (800 mg TID) had proven efficacy and benefits. Unboosted IDV has been replaced by ritonavir-boosted IDV (IDV/r) because of the complex dosing schedule food interaction and toxicities related to unfavorable pharmacokinetics. Ritonavir at 100 mg BID along with IDV improves the pharmacokinetics of IDV and allows dose reduction and convenient twice-a-day administration without dietary restrictions. (excerpt)

Brain abscess due to Cladophialophora bantiana: a review of 124 cases.

Brain abscess caused by Cladophialophora bantiana is a rare disease associated with high mortality due to delay in diagnosis and absence of standardized therapy. We reviewed 124 culture proven C. bantiana brain abscess cases; 103 cases published in English literature during 1952 through 2014 and 21 unpublished cases from our reference center. The majority (57.3%) of the patients was from Asian countries especially from India (62/124, 50%). The diagnosis of the cases was delayed with mean duration 115 days after developing symptoms. The disease was nearly equally distributed in immunocompetent and immunosuppressed hosts but associated with significantly higher mortality (77.1%) in later group. Complete excision of brain lesion in immunocompetent host led to significantly better survival (43.7%). Though all commercially available antifungal drugs have been used in these patients, amphotericin B deoxycholate or lipid preparations were most commonly (62.83%) prescribed agent. None of the drugs used was found to be independently associated with improved outcome. In vitro antifungal susceptibility testing of 13 isolates of our center, demonstrated good activity to voriconazole, posaconazole, and itraconazole, but these triazoles were prescribed in only 29.2% patients. Increased awareness with early suspicion of the disease, and aggressive medical and surgical approach in treating these patients may improve the outcome.

Immune Reconstitution Visceral Leishmaniasis Presented as Hemophagocytic Syndrome in a Patient With AIDS From a Nonendemic Area: A Case Report

Visceral Leishmaniasis (VL) is endemic in the Ganges and Brahmaputra plains of India. Leishmaniasis/HIV coinfection is on the rise in India and may pose a real diagnostic and therapeutic challenge. HIV-related immunosuppression increases the risk of reactivating leishmaniasis by 100 to 1000 times and it also increases the risk of drug resistant leishmaniasis. Immune reconstitution VL is not very well reported in literature. Hemophagocytosis is known to occur with various infectious agents like viruses, bacteria, and parasites, but is rare to occur with leishmaniasis. Here the authors describe a case of VL presenting as immune reconstitution disease and hemophagocytosis in an HIV infected patient coming from a nonendemic area.

Immune Reconstitution Syndrome Presenting With Cerebral Varicella Zoster Vasculitis in HIV-1-Infected Patient: A Case Report

Neurologic dysfunction complicating HIV infection may occur in up to 70% of AIDS patients. The advent of highly active antiretroviral therapy has reduced central nervous system opportunistic infections. Immune reconstitutions after highly active antiretroviral therapy also lead to atypical presentations of neurologic opportunistic infections. We report a man who developed an encephalitic illness 10 months after institution of highly active antiretroviral therapy and improvement in his CD4 count. Varicella zoster vasculitis involving the brain was suspected. Acyclovir therapy resulted in complete clinical and radiologic recovery. Symptomatic reactivation of varicella zoster infection within the encephalon during therapeutic immunologic reconstitution is rare and should be suspected, especially in patients with neurologic syndrome consistent with encephalitis with recent history of herpes zoster and multiple, discrete areas of infarct or demyelination on brain magnetic resonance imaging. The clinical and neuroradiologic features of this condition and its relevance to the immune reconstitution syndrome are discussed.

Thermal, kinetic, spectroscopic studies and anti-microbial, anti-tuberculosis, anti-oxidant properties of clioquinol and benzo-coumarin derivatives mixed complexes with copper ion

A series of six Cu(II) complexes of clioquinol with benzo-coumarin derivatives have been synthesized. Physico-chemical, spectroscopic, and thermal properties of the complexes have been studied on the basis of infrared spectra, mass spectra, NMR spectra, electronic spectra, elemental analyses, and thermogravimetric analyses. The kinetic parameters such as order of reaction (n), energy of activation (Ea), entropy (S*), pre-exponential factor (A), enthalpy (H*), and Gibbs free energy (G*) have been calculated using Freeman-Carroll method. All the compounds were screened for their anti-bacterial activity against Escherichia coli, Pseudomonas aeruginosa, Streptococcus pyogenes, Bacillus subtilis, and anti-fungal activity against Candida albicans and Aspergillus niger. Ferric-reducing anti-oxidant power of all complexes were measured. Also the compounds against Mycobacterium tuberculosis shows clear enhancement in the anti-tubercular activity upon copper complexation.Graphical abstractStructural, spectroscopic, and biological aspects of ligands and its metal complexes have been studied on the basis of mass spectra, NMR, FT-IR spectrophotometry, and elemental analyses. Thermal behavior and kinetic properties of complexes were discussed. The structure of compounds has been monitored for their in vitro anti-microbial, anti-oxidant, and anti-tuberculosis activity.

Transfusion Associated Graft Versus Host Disease Following Whole Blood Transfusion from an Unrelated Donor in an Immunocompetent Patient

Graft-versus-host disease (GVHD) is a well-known complication of allogeneic bone marrow transplantation. Transfusion associated graft-versus-host disease (TA-GVHD) is much less common and nearly uniformly fatal complication of blood transfusion. The risk factors underlying the development of TA- GVHD are incompletely defined, but it is commonly seen in individuals with congenital or acquired immunodeficiency, transfusions from blood relatives, intrauterine transfusions and HLA-matched platelet transfusions. Diagnosis of TA-GVHD may be difficult at a time due to rarity in occurrence and overlapping clinical features with various infections and drug reactions. We describe a case of transfusion-associated GVHD that occurred after transfusion of whole blood from unrelated donor in an immunocompetent patient.

Clinical outcome of novel H1N1 (Swine Flu)-infected patients during 2009 pandemic at tertiary referral hospital in western India

Background: The first case of 2009 pandemic influenza A (H1N1) virus in Gujarat, India, was reported in August 2009. Oseltamivir was used for treatment of pandemic influenza in India. We discuss the clinical characteristics and outcome of the hospitalized patients with H1N1 infection during 2009 pandemic influenza season. Materials and Methods: Hospitalized patient with laboratory-confirmed H1N1 flu during August 2009 to February 2010 were included in this retrospective study. Data were collected from hospital ICU charts. Patients discharged from hospital were considered cured from swine flu. Data analysis was performed using CDC software EPI Info v3.5.3. Both univariate and multivariate analyses were conducted. Results: A total of 63 patients were included in the study, of them 41 (65%) males and 22 (35%) females. Median age was 34 (3-69) years and median duration of symptoms before hospitalization was 5 (2-20) days. Common presenting symptoms include fever 58 (92.06%), cough 58 (92.06%), breathlessness 38 (60.31%), common cold 14 (22.22%), vomiting 12 (19.04%), weakness 9 (14.28%), throat pain 7 (11.11%), body ache 5 (7.93%), and chest pain 4 (6.34%). Co-morbidities were seen in 13 (20.63%) patients. Steroids were used in 39 (61.90%) patients, and ventilatory support was required in 17 (26.98%) patients. On presentation chest x-ray was normal in 20 (31.74%) patients, while pulmonary opacities were seen in 43 (68.26%) patients. Forty-seven (74.60%) patients were cured and discharged from hospital, 14 (22.22%) patients died, and 2 (3.17%) patients were shifted to other hospital. Ventilatory requirement, pneumonia, and co-morbidities were the independent predictors of mortality, while age, sex, and steroid use were not associated with increased mortality. Conclusion: 2009 pandemic influenza A had the same clinical features as seasonal influenza except vomiting. Mortality rate was high in 2009 H1N1-infected patients with pneumonia, co-morbid conditions, and patients who required ventilatory support.