Barbara Belfiori

HIV type 1 infection, and not short-term HAART, induces endothelial dysfunction.

Objective:Ischemic cardiovascular events increasingly occur during long-lasting HIV infection and are attributed either to the infection itself or to the use of HAART. Endothelial dysfunction and platelet activation are markers of atherosclerosis. Our aim was to assess whether patients with chronic HIV infection present endothelial dysfunction and whether this is the consequence of infection or of HAART. Design:Fifty-six HIV-infected patients were studied in a retrospective cohort study before and 3, 6, 12 and 24 months after starting HAART with protease inhibitors (n = 28) or nonnucleoside reverse transcriptase inhibitors (n = 28), and compared with 28 age-matched and sex-matched healthy controls, and with 10 naive HIV-infected patients studied at diagnosis and after 12 months of untreated infection. Methods:Soluble endothelial and platelet activation markers were measured in plasma by flow cytometry. Results:Soluble P-selectin, soluble vascular cell adhesion molecule-1, monocyte chemoattractant protein-1 and von Willebrand factor were significantly higher in HIV-infected patients than in healthy controls, whereas soluble CD40 ligand and tissue type plasminogen activator were within normal range. During follow-up, soluble vascular cell adhesion molecule-1, monocyte chemoattractant protein-1 and von Willebrand factor but not soluble P-selectin decreased progressively, without significant differences between protease inhibitors and nonnucleoside reverse transcriptase inhibitors treatment. In naive, untreated patients, increased plasma markers of endothelial dysfunction were confirmed at diagnosis, with no changes upon follow-up. Conclusion:Chronic HIV infection, and not its pharmacological treatment, induces alterations of markers of endothelial function. Short-term treatment with HAART reduces some markers of endothelial dysfunction, with no differences between protease inhibitors and nonnucleoside reverse transcriptase inhibitors.

Management of Hepatitis B Virus Reactivation in Patients with Hematological Malignancies Treated with Chemotherapy

Introduction:Hepatitis B virus (HBV) reactivation is a majorcause of morbidity and mortality in patients with hematologicalmalignancies who receive cytotoxic chemotherapy. Wehave therefore carried out a prospective observational studyout to assess the incidence, prevalence, and clinical course ina cohort of these patients.Methods:HBV and HCV markers and liver function indiceswere monitored prospectively in 318 consecutive patients(171 males, 147 females; mean age 57 years) with hematologicalmalignancies, who had been referred to the HematologyDivision, Perugia University, between October 2005and March 2007 and followed up for at least 6 months.Results:At diagnosis, 32 patients (10%) had received HBVvaccination; 30 were responders. At least one HBV marker waspositive in 70/318 patients (22%): 14 (20%) were HBsAg-positive(HBV surface antigen-positive), 13 (19%) were only anti-HBc positive (antibodies to HB core antigen), and 43(61%)were anti-HBc and anti-HBs positive. Twelve HBsAg+ patientsreceived nucleoside/nucleotide analogs (adefovir [six patients],lamivudine [four], and combined adefovir/lamivudine[two non-responders to lamivudine]). After 6 months oftherapy, HBV-DNA was negative and transaminases were normalin nine of these 12 patients (adefovir [six], lamivudina[two], adefovir + lamivudina [one]). Seroreversion wasachieved in 3/13 patients (23%) who were only anti-HBc positive;all were on rituximab therapy and received adefovir.Seroreversion was not observed in any of the 43 patients whowere anti-HBc- and anti-HBs positive.Conclusions:Essential to the management of patients withhematological malignancies undergoing chemotherapy aresurveillance and prophylaxis of HBV infection together withprompt administration of nucleoside/nucleotide analogs incases of reactivation and/or seroreversion.

Primary brain abscess with Nocardia farcinica in an immunocompetent patient

In this paper, we describe a case of an immunocompetent patient with cerebral nocardiosis. The onset was with loss of strength, paresthesia and focal epilepsy of the left arm. MRI showed on T2-weighted sequences a hyperintense central area of pus surrounded by a well-defined hypointense capsule and surrounding edema; on T1-weighted sequences a hypointense necrotic cavity with ring enhancement following administration of intravenous gadolinium. The patient underwent surgical excision of the abscess but culture from the specimen was negative. After 40 days of empirical antimicrobial therapy he developed neurological deterioration with focal epilepsy. A new MRI documented an enlargement of the hypointense lesion in the right frontal-parietal region. A second craniotomy with drainage of the abscess was performed; cultures yielded Nocardia farcinica. Therapy with trimethoprim/sulfamethoxazole, amikacin and meropenem was given for 35 days, and clinical and radiological improvement was observed. Home therapy was done with oral trimethoprim/sulfamethoxazole. Currently, 5 months from the second surgery, the patient can walk with support and no new episodes of epilepsy occurred. Side effects were absent from therapy. The MRI appearance of the brain lesion has improved, with a decrease in size, surrounding edema and ring enhancement.

In vivo platelet activation and platelet hyperreactivity in abacavir-treated HIV-infected patients

Abacavir (ABC) has been associated with ischaemic cardiovascular events in HIV-infected patients, but the pathogenic mechanisms are unknown. Aim of our study was to assess whether ABC induces in vivo platelet activation and ex vivo platelet hyper-reactivity. In a retrospective, case-control study, in vivo platelet activation markers were measured in 69 HIV-infected patients, before starting therapy and after 6-12 months of either ABC (n=35) or tenofovir (TDF) (n=34), and compared with those from 20 untreated HIV-infected patients. A subgroup of patients was restudied after 28-34 months for ex vivo platelet reactivity. In vivo platelet activation markers were assessed by ELISA or flow cytometry, ex vivo platelet reactivity by light transmission aggregometry (LTA) and PFA-100®. Thein vitro effects of the ABC metabolite, carbovir triphosphate, on aggregation and intra-platelet cGMP were also studied. sPLA2, sPsel and sGPV increased significantly 6-12 months after the beginning of ABC, but not of TDF or of no treatment. Ex vivo platelet function studies showed enhanced LTA, shorter PFA-100® C/ADP closure time and enhanced platelet expression of P-sel and CD40L in the ABC group. The intake of ABC blunted the increase of intraplatelet cGMP induced by nitric oxide (NO) and acutely enhanced collagen-induced aggregation. Preincubation of control platelets with carbovir triphosphate in vitro enhanced platelet aggregation and blunted NO-induced cGMP elevation. In conclusion, treatment with ABC enhances in vivo platelet activation and induces platelet hyperreactivity by blunting the inhibitory effects of NO on platelets. These effects may lead to an increase of ischaemic cardiovascular events.

Peginterferon plus Ribavirin for chronic hepatitis C in opiate addicts on methadone/buprenorphine maintenance therapy

BACKGROUND In developed countries hepatitis C is prevalently transmitted by intravenous drug users (IDUs). The problems associated with management of HCV hepatitis in these patients have, in the past, discouraged treatment. AIM To evaluate efficacy, safety and tolerability of a standard Peginterferon (Peg-IFN) alpha-2b or alpha-2a plus Ribavirin treatment in IDUs who were receiving methadone or buprenorphine. METHODS A multi-centre prospective observational study performed from September 2003 to September 2006 in Central Italy (Umbria and Marches regions). A shared care model of HCV management was used which integrated a multidimensional, multidisciplinary approach. RESULTS Sixty-five subjects were evaluated and 52 satisfied inclusion criteria. Forty-five completed treatment (25 with Peg-IFN alpha-2b, 20 with Peg-IFN alpha-2a), a total of 37 showed a biochemical/virological response at the end of treatment (ITT 71.1%), 26 had a sustained virological response (ITT 50%; 38.4% of cases genotype 1-4, 61.6% genotype 3-2). CONCLUSIONS The results indicate that patients on maintenance treatment with methadone/buprenorphine can be treated for HCV. The success rate was fairly good; tolerability and side effects were similar to those reported in non-IDU patients. Close cooperation with specialists in drug addiction and psychiatrists is however essential for success.

Reactivation of hepatitis B virus replication due to cytotoxic therapy: a five-year prospective study.

BACKGROUND AND AIMS In hepatitis B virus (HBV) carriers receiving chemotherapy, the risk of reactivation is high, particularly if rituximab is given alone or in combination with steroids. The aim of this study was to assess the incidence, prevalence, and clinical course of HBV infection in a cohort of patients with hematological malignancies receiving cytotoxic therapy as well as to propose a strategy for managing HBV reactivation. METHODS This is a prospective observational study. All consecutive patients with hematological malignancies receiving intravenous cytotoxic chemotherapy between October 2005 and June 2010 and followed up for at least six months were enrolled in the study. Viral hepatitis markers and liver function indexes were monitored prospectively. RESULTS We enrolled 478 patients, including 263 males (55%) and 465 (97.3%) Italians. Non-Hodgkins lymphoma was the most frequent diagnosis (66%). At least one HBV marker was positive in 96 patients (20%): 21 (4.4%) patients were HBsAg positive, 17 (3.5%) were anti-HBc positive, and 58 (12.1%) were anti-HBc/anti-HBs positive. All but one HBsAg-positive patient received therapy with nucleoside/nucleotide analogs prior to chemotherapy. All but three reached complete virological suppression at six months from the start of treatment. Of the 17 HBsAg-negative/anti-HBc-positive patients, three (18%) had reactivation with seroreversion. All three obtained viral suppression with adefovir. Regarding the 58 anti-HBc/anti-HBs-positive patients, two (3.4%) experienced seroreversion and were treated successfully with nucleoside analogs; both were taking rituximab. No severe ALT flares were observed during or after antiviral therapy. CONCLUSION Our data suggest that pre-treatment screening of patients at risk of viral reactivation yields benefit and therefore should be practiced by clinicians treating patients with malignancies.

Impact of Tenofovir Versus Abacavir on HIV-Related Endothelial Dysfunction

Ischemic cardiovascular events are a frequent complication of long-lasting HIV infection and have been attributed either to the infection itself or to antiretroviral therapy (ART). Some cohort studies suggested that in particular abacavir may be associated with an increased cardiovascular risk, but the pathogenic mechanisms remain unknown. Recently, abacavir use was significantly associated with incident cardiovascular disease in HIV-infected veterans and it was related to higher risk of acute myocardial infarction (AMI). Endothelial dysfunction is a central mechanism in atherosclerosis and a marker of cardiovascular risk. We have previously shown that HIVinfected patients present an endothelial dysfunction that tends to improve upon ART, suggesting that the infection itself rather than therapy is responsible for endothelial damage. In the present study we compared treatment with abacavir (ABC) and tenofovir (TDF) for their impact on endothelial dysfunction. In a retrospective, case-control study, plasma levels of soluble vascular cell adhesion molecule-1 (sVCAM-1) and monocyte chemoattractant protein-1 (MCP-1), two markers of endothelial dysfunction, were measured by flow cytometry using a bead-based assay (FlowCytomix, Bender MedSystems, Vienna, Austria) in 69 HIV-infected patients, before starting therapy and after 6–12 months of either ABC (n = 35, 18 females, age 44 – 12 years) or TDF (n = 34, 17 females, age 43 – 11 years). The two groups were similar for baseline immune-virologic status and all patients showed an increase of CD4 + count and a lowering of viral load after therapy, without differences between ABC and TDF. Twenty-one patients were recalled 28–34 months after the beginning of therapy (11 ABC and 10 TDF) for the measurement of peripheral vascular endothelial function by finger arterial pulse wave amplitude with the Endo-PAT2000 system, and of circulating endothelial cells (CECs) by flow cytometry. Two control groups were included: 20 HIV-infected patients (6 females, age 42 – 9 years), from whom blood samples were collected at diagnosis and after 6–12 months without therapy, and 10 healthy ageand gender-matched controls. All results are expressed as means – standard error of the mean (SEM). Differences between groups were assessed by using one-way analysis of variance (ANOVA) with the Kruskal-Wallis post hoc test, using the GraphPad Prism version 4.00 for Windows software (GraphPad, San Diego, CA). At diagnosis endothelial activation markers were significantly higher in HIV-infected patients than in healthy controls (sVCAM-1: 783 – 157 versus 518 – 53 ng/mL, p < 0.05; MCP-1: 293 – 22 versus 228 – 20 pg/mL, p < 0.05). After 6–12 months of treatment, sVCAM-1 and MCP-1 decreased significantly in the TDF group, although not to normal levels, but not in the ABC group, while in untreated patients endothelial dysfunction did not change, or even slightly worsened, at followup (Fig. 1A and B). Upon reevaluation after 28–34 months of treatment endothelial function, as assessed by peripheral arterial tonometry and CECs, was still significantly altered in HIV-infected patients as compared with healthy controls (Fig. 1C), with ABC-treated patients showing significantly higher CECs than controls and tendentially higher than TDF-treated patients (Fig. 1D); moreover, in ABC-treated but not in TDFtreated patients, CECs inversely correlated with endothelial function (Fig. 1E and F). Endothelial dysfunction detected by impaired peripheral arterial tonometry and increased CECs, two parameters not previously measured in HIV-infected patients, is a reliable marker of vascular damage and predicts late cardiovascular ischemic events. Therefore, our data confirm that chronic HIV-infection impairs endothelial function and show that antiretroviral treatment with TDF, but less with ABC, improves it. Very recent data showing that TDF selectively decreases the production of cardiovascular disease-related inflammatory cytokines are supportive of our conclusions. Whether persistent endothelial dysfunction in ABC-treated patients contributes to the suggested increased cardiovascular risk associated with ABC use needs to be assessed in prospective studies.

Role of platelet activation in the cardiovascular complications associated with HIV infection: differential effect of abacavir versus tenofovir

7‐11 November 2010, Tenth International Congress on Drug Therapy in HIV Infection, Glasgow, UK

Effect of age on response to and tolerability of highly active antiretroviral therapy: a case-control study

Methods All outpatients medical records of HIV-infected patients, newly diagnosed between 1 Jan. 2000 and 30 April 2008 at the Infectious Diseases Clinic of Perugia University Hospital, were reviewed. All patients were selected, and divided in two groups, according to age (<50 years>). Demographic data, HIV risk behaviours, stage of HIV disease (including CD4 cell count, HIV viral load), use of HAART, co-morbid conditions and tolerability of therapy were collected. When available, 6and 12-month data on CD4 cell count, HIV-RNA undetectability, side-effects and modification of treatments were collected as well. Data were analysed with t-test for continuous variables and chisquare for categorical variables; logistic regression was used for multivariate analysis.