Giuliano Stagni

Impact of Treatment With Protease Inhibitors on Aortic Stiffness in Adult Patients With Human Immunodeficiency Virus Infection

Background—The role of antiretroviral therapy in acceleration of atherosclerosis in patients with human immunodeficiency virus (HIV) infection is controversial. We hypothesized that aortic stiffness, an early marker of arteriosclerosis, may be increased in HIV patients treated with protease inhibitors. Methods and Results—In 32 HIV-infected patients treated with protease inhibitors and 32 age-, sex-, and blood pressure–matched HIV-uninfected control subjects, we obtained aortic pulse wave velocity and central aortic pressure waveform, from which aortic augmentation was calculated. HIV patients had a higher aortic pulse wave velocity (7.6±1.1 versus 6.8±1.2 m×s−1, P=0.015) and aortic augmentation (6.8±5 versus 4.6±4 mm Hg, P=0.037) than control subjects. Age and HIV infection (both P<0.05) independently predicted aortic pulse wave velocity when a consistent number of cardiovascular risk factors was simultaneously controlled for. The cumulative duration of treatment was a predictor of aortic pulse wave velocity, each 5 years of treatment duration being independently related to a 1.35 m×s−1 increase in pulse wave velocity. Conclusions—Aortic stiffness is increased in HIV-positive individuals receiving antiretroviral therapy including a protease inhibitor. Pulse wave velocity increases with longer exposure to protease inhibitors. We hypothesize that arteriosclerosis is a side effect of antiretroviral treatment including a protease inhibitor.

Antibody responses and HIV-1 viral load in HIV-1-seropositive subjects immunised with either the MF59-adjuvanted influenza vaccine or a conventional non-adjuvanted subunit vaccine during highly active antiretroviral therapy.

OBJECTIVE To study immunological and virological parameters in HIV-1-seropositive adults treated with highly active antiretroviral therapy (HAART) for at least 7 months after immunisation with MF59-adjuvanted (FLUAD, Chiron, Siena, Italy) or with non-adjuvanted (AGRIPPAL, Chiron) trivalent influenza vaccine. DESIGN Blood samples, collected before and after vaccination, were analysed for the presence of antibodies against the vaccine antigens, for number of CD4+ T lymphocytes and HIV-1 RNA levels. RESULTS Forty-four volunteers received FLUAD and 40 AGRIPPAL influenza vaccine. Thirty days after vaccination both adjuvanted and non-adjuvanted vaccines induced significant increases of anti-influenza virus antibodies. However, antibody titres found in volunteers receiving adjuvanted vaccine were in general significantly higher when compared with those found in the non-adjuvanted vaccine group. The requirements of the European Commission of influenza vaccine for a non-elderly adult population were always met by recipients of the adjuvanted vaccine, even in those with the lowest CD4+ cell counts (<200 cells/mmc). The subjects receiving the non-adjuvanted vaccine failed to met these requirements. The CD4+ T lymphocytes and plasma HIV-1 RNA levels remained stable in the long term, both in people receiving adjuvanted or non-adjuvanted vaccine. CONCLUSION MF59-adjuvanted influenza induced a significant higher immune responses as compared with conventional vaccine in HIV-seropositive HAART-treated patients. Both vaccines were safe regarding HIV RNA viral replication and loss of CD4+ T lymphocytes.

Prevalence of HBV, HDV and HCV hepatitis markers in HIV-positive patients

Since HIV infection could condition the natural history of parenterally transmitted viral hepatitis (HBV, HCV, HDV), with possibly differing effects in different risk groups, we decided to retrospectively examine sera from a cohort of 637 HIV seropositive patients in different stages of infection, seen from 1985 to 1992, to study the prevalence and temporal course of these infections. Virological markers of HBV, HCV and HDV were determined by ELISA and RIBA methods. The severity of HIV infection was higher in homosexuals than in drug addicts. Prevalence of antiHBc antibodies was 82% in drug addicts and 77% in homosexuals, whereas antiHCV antibodies prevalence was 72% in drug addicts and only 7% in homosexuals (p<0.000001). When only antiHBc-positive patients were considered, there was a significant difference in antiHBs antibodies between drug addicts (DA) and homosexuals (OR for DA 0.29, 95% CI 0.08/0.83,p=0.02), suggesting that drug addicts are less able to produce a protective response. This fact cannot be explained by the severity of HIV infection (which was higher among the homosexual group) and suggests some immunodepressive effect of drug abuse. Delta infection was only detected in the drug addict group, and the prevalence was low. Finally, we cannot confirm the interference of HCV infection with the speed of HBsAg clearance: in this study the prevalence of HBsAg was almost the same in HCV-positive and negative patients.

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.

Is estimated cardiovascular risk higher in HIV-infected patients than in the general population?

Cardiovascular disease (CVD) is an increasing concern for human immunodeficiency virus (HIV)-infected patients, and risk assessment is recommended in routine HIV care. The absolute cardiovascular risk in an individual is determined by several factors, and various algorithms may be applied. To date, few comparisons of HIV patients with persons of the same age from the general population have been conducted. We hypothesized that the calculated risk of CVD may be increased in HIV patients. The probability for acute coronary events within 10 y (Framingham Risk Score) and the probability for fatal cardiovascular disease (SCORE algorithm) were assessed in 403 consecutive HIV-positive subjects free from overt cardiovascular disease, as well as in 96 age- and gender-matched control subjects drawn from the general population living in the same geographical area. The average 10-y risk for acute coronary events (Framingham Risk Score) was 7.0%±5% in HIV subjects and 6.3%±5% in the control group (p =0.32). The 10-y estimated risk for cardiovascular mortality (SCORE algorithm) was 1.23%±2.3% and 0.83%±0.9%, respectively (p =0.01). The main contributor to the increased CVD risk was the high proportion of smokers, but not an increase in cholesterol level. In conclusion, a limited increase in estimated risk of CVD was found in HIV-infected patients compared to the general population. In HIV-infected individuals other factors of less value in the general population and not included in any cardiovascular algorithm might be important. In our patients intervention to modify traditional risk factors should be addressed primarily towards modifying smoking habits.

Interferon-Alpha Is Effective in the Treatment of HIV-1–Related, Severe, Zidovudine-Resistant Thrombocytopenia: A Prospective, Placebo-controlled, Double-Blind Trial

Thrombocytopenia is relatively common in patients infected with human immunodeficiency virus type 1 (HIV-1), and it occurs in patients belonging to all major risk groups, such as homosexuals, intravenous drug users, and hemophiliacs [1-3]. Thrombocytopenia occurs in 5% to 15% of asymptomatic patients; 6% to 24% of these patients have serious thrombocytopenia (counts < 30 109/L [2, 4]) and clinical bleeding [2, 4, 5]. The general consensus is to not treat patients with less severe thrombocytopenia because of the low risk for bleeding and the possibility of spontaneous remissions [6-9]. However, the treatment of severe thrombocytopenia is mandatory in view of the frequent, serious bleeding manifestations [2, 4, 5]. The mechanism of HIV-1related thrombocytopenia is not completely understood but immunologic mechanisms (antiplatelet antibodies or circulating immune complexes, or both) and megakaryocyte viral infection may play a role [10]. Although the response to treatment of HIV-1related thrombocytopenia does not appear to differ substantially from that observed in adults with idiopathic chronic thrombocytopenia, there are limitations when using conventional therapeutic approaches. Steroids and other immunosuppressive agents (for example, vincristine, cyclophosphamide) [11, 12] can facilitate the development of opportunistic infections or can lead to the flaring up of infectious hepatitis, which is often present in these patients [13, 14]; steroids have also been reported to accelerate the progression of Kaposi sarcoma [15, 16]. Splenectomy enhances the risk for subsequent infection, especially severe sepsis [17], and in some patients a late relapse of thrombocytopenia may occur [18]. High-dose intravenous immunoglobulins represent an effective treatment in most patients, but the effect is short-lasting in almost all of them, and the high costs and the need for intravenous administration limit their use [9, 19]. Finally, alternative approaches, such as dapsone [20], protein A immunoadsorption [21], or anti-rhesus factor IgG [19], have been tested in limited series and uncontrolled studies (or both). It is now well established that zidovudine (azidothymidine) can effectively enhance the platelet count of patients with HIV-1related thrombocytopenia. A remission of thrombocytopenia during zidovudine administration has been shown in several case series [22-24] and in one placebo-controlled, prospective clinical study [25]. However, between 30% and 40% of patients with thrombocytopenia are resistant to full-dose (1000 mg/d) zidovudine treatment [23, 24, 26, 27]. It is not clear that higher doses of zidovudine affect thrombocytopenia [28, 29]; in addition, higher doses are potentially toxic [30]. Some anecdotal reports and small, uncontrolled case series have recently suggested that interferon- can correct the thrombocytopenia of patients with HIV-1 infection [9, 14, 31-33], even in patients not responding to zidovudine treatment [31, 33]. However, no studies have analyzed, under carefully controlled conditions, the efficacy, toxicity, and kinetics of the response to interferon- in patients with zidovudine-resistant, HIV-1related thrombocytopenia. We tested whether interferon- can increase the platelet count in patients with zidovudine-resistant, HIV-1related severe thrombocytopenia and assessed the kinetics of the interferon- effects and the possible toxicity of interferon in association with zidovudine in a randomized, placebo-controlled clinical study. Methods Selection of Patients Patients were considered eligible for the study if they were seropositive for HIV-1 by the enzyme-linked immunosorbent assay and the Western-blot technique and had a platelet count less than 25 109/L on at least two occasions separated by more than 2 weeks. In addition, thrombocytopenia had to be refractory to a 1-month course of full-dose (1000 mg/d) zidovudine treatment and to previous therapeutic attempts with one of the following: corticosteroids, splenectomy, vincristine, danazol, high-dose intravenous IgG, or anti-ID immunoglobulins. The main exclusion criteria were pregnancy or breast-feeding; the acquired immunodeficiency syndrome; concomitant serious diseases not related to HIV-1 infection (cardiomyopathy, seizure, stroke, psychosis); presence of antinuclear, anti-smooth-muscle, antimitochondrial, or anti-liver-kidney microsome 1 antibodies; and granulocyte counts less than 1 109/L or hemoglobin levels less than 80 g/L. Women of childbearing potential were advised to practice effective methods of birth control. Assessment before study included a medical history, physical examination, electrocardiogram, chest radiograph, and the following laboratory tests: measurement of hemoglobin, hematocrit, mean corpuscular volume, leukocyte count, differential leukocyte count, platelet count, serum glucose, blood urea nitrogen, serum creatinine, bilirubin, aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, serologic tests for hepatitis B and C, prothrombin time, activated partial thromboplastin time, bleeding time, and urinalysis. Fifteen consecutive patients satisfying the criteria for entry into the study were enrolled between April and October 1992 in four centers belonging to four different hospitals in Central Northern Italy. Written, informed consent was obtained from each patient before enrollment in the study; the study protocol was approved by the Ethics Committee of the Umbria Region. Treatment Patients were enrolled in a double-blind, crossover, placebo-controlled, randomized study in which they were treated with either subcutaneous lymphoblastoid interferon- (Wellferon, Burroughs Wellcome, Italy) or 1 mL of subcutaneous saline solution (placebo). Therapy was administered to the patients in hospital by specially trained nurses. The treatment code was known only to the nurse, and the doctors, nurses involved in patient management, and the patients were all blinded to the study code. All patients received subcutaneous injections of placebo or interferon-, 3 million units, three times a week for 4 weeks. During the following 4 weeks, they did not receive any injections (washout period); they were then switched to the opposite treatment for another 4 weeks. After treatment discontinuation, patients were followed for a final 4-week period (washout period). Patients were randomly assigned to either sequence of the crossover design. The study lasted 16 weeks; during this time patients were seen weekly for clinical evaluations including a physical examination, a review of subjective complaints, and standard hematologic tests including platelet counts. All patients received, throughout the study period, zidovudine therapy at 200 mg three times a day. Bleeding times, immune studies, and p24 antigen, hematologic, renal, and hepatic tests were done at weeks 0, 4, 8, 12, and 16. Evaluation Criteria The primary end point, established before the beginning of the study, was the variation in the number of circulating platelets. A secondary end point was the clinical response to interferon- treatment, defined as follows: 1) complete response: platelet count more than 100 109/L; 2) partial response: platelet count more than 50 109/L and less than 100 109/L; 3) failure: platelet count less than 50 109/L. A cut-off level of 50 109 platelets/L was chosen to define treatment failure because conventionally hemorrhage is rare when counts are greater than this limit. Other secondary end points included the bleeding time, p24 antigen levels in serum, CD4 and CD8 counts, 2-microglobulin levels in serum, and platelet-associated IgG. Laboratory Data Platelet counts were determined on ethylenediaminetetraacetic acid-anticoagulated venous blood samples by using electronic particle counters (Coulter Counter, STKR, Hialeah, Florida for the four centers). Platelet counts were measured on each patient using the same instrument throughout the study. Bleeding time was carried out according to Mielke and colleagues [34] by the use of a standardized template (Simplate II, General Diagnostics, Morris Plains, New Jersey). The registration of the bleeding time was followed for a maximum of 30 minutes; when the bleeding time exceeded 30 minutes, it was considered to be equal to 30 minutes for the statistical analysis. CD4 and CD8 lymphocyte counts were determined by two-color flow cytometry using monoclonal antibodies (Leu 2-3+, Leu 2+3-; Leu 4+Dr-; Becton Dickinson, Franklin, New Jersey) on whole blood samples. Serum p24 core antigen was determined by enzyme immune assay (New England Nuclear, du Pont, Rockville, Maryland); the least detectable amount with this assay is 4.4 pg/mL of serum. Serum 2-microglobulin was assayed by enzyme immune assay (Behring, Scoppito, Italy). Serum platelet antibodies were detected with the indirect platelet suspension immunofluorescence test [35]. Determinations of hemoglobin, complete blood counts, serum glucose, blood urea nitrogen, creatinine, liver function tests (aspartate aminotransferase, alanine aminotransferase, alkaline phosphatase, -glutamyltranspeptidase, and total bilirubin), prothrombin time, and activated partial thromboplastin times were carried out according to standard procedures. Data Collection and Statistical Analysis All investigators, nurses, and laboratory personnel involved in patient and sample management were blinded to treatment groups until all end points were determined at the end of the study. First-order carryover identifies the residual effect of a given treatment at the time of the second baseline (before the beginning of the second treatment), whereas second-order carry-over indicates any residual effect of the first treatment at the time of the second treatment. Data required by the study protocol were collected and recorded in case report forms by the investigators at each of the participating centers. The case report forms were then submitted to clinical research personnel at the

The pp65 antigenaemia test as a predictor of cytomegalovirus-induced end-organ disease in patients with AIDS

Objective:To evaluate the predictive value of pp65 antigenaemia quantitative test for cytomegalovirus (CMV) end-organ disease in patients with advanced HIV infection. Design and patients:A prospective study in AIDS patients or HIV-infected subjects with CD4 count < 150 × 106/l or CD4 percentage < 10% was carried out. Patients with a history of CMV disease or positive viraemia or antigenaemia tests, and subjects under anti-herpes suppressive therapy were excluded. Clinical, ophthalmoscopic, biochemical and virological (antigenaemia test) evaluations were performed at baseline and every 1–3 months until the onset of CMV end-organ disease. Setting:Institutional tertiary care centre. Results:Forty-nine patients were evaluable for this study. End-organ disease was observed in 13 patients, 11 with at least one positive test, two with persistently negative assays. Thirteen patients without CMV disease had at least one positive test, whereas 23 always had negative tests. The 12-month Kaplan–Meier estimate of the incidence of CMV disease in our population was 30.9%, and was 75% in antigenaemia-positive subjects. The negative predictive value (NPV) of the test was 92%, and the positive predictive value (PPV) was 45.8%. However, the NPV of quantitative (> 20 cells) antigenaemia assay was 92.1%, and the PPV was 90.9%. Conclusions:The antigenaemia test is a quick, simple and easy to perform assay for diagnosing CMV infection. The NPV is fairly good, as is the PPV when the quantitative method (> 20 positive cells) is used. This test could be used as an alternative to polymerase chain reaction in order to select patients at higher risk of CMV disease who can be treated with pre-emptive anti-CMV therapy.

Acute fatal necrotizing hemorrhagic encephalitis caused by Epstein-Barr virus in a young adult immunocompetent man

Epstein-Barr Virus (EBV) encephalitis is a rare (<1%) and generally self-limited disease with few sequelae. This neurological complication has been reported almost exclusively in the course of acute primary infection and in paediatric patients. We describe a case of a young adult immunocompetent man who developed an acute fatal necrotizing haemorrhagic encephalitis as the only manifestation of an acute EBV infection. EBV-DNA was tested positive in several CSF samples by qualitative and quantitative PCR. Serological profile showed: absence of IgM against Viral Capsid Antigen (VCA) in three different consecutive samples, presence of IgG against VCA and IgG seroconversion for Epstein Barr Nuclear Antigen (EBNA). EBV-DNA was detected by qualitative PCR in autoptic brain material. Clinical course was not influenced by antiviral therapy with acyclovir. In conclusion to our knowledge, this is the only case of acute necrotizing haemorrhagic EBV encephalitis with a fatal outcome, in an adult immunocompetent man.

Clinical improvement of psoriasis in an AIDS patient effectively treated with combination antiretroviral therapy.

Psoriasis has been classified as a T-cell-mediated inflammatory disease. The paradoxical exacerbation of psoriasis in AIDS has not been fully explained. We describe a case of a 45-y-old male with AIDS whose coincidental psoriasis resolved following antiretroviral therapy. Dramatic improvement was seen 4 weeks after combination antiretroviral therapy including enfuvirtide was started. In advanced HIV disease psoriasis could represent a clinical index of progression of HIV disease. Several pathogenetic factors involved in the clinical manifestations of psoriasis in the HIV-infected population are discussed.

Role of antigenemia assay in the early diagnosis and prediction of human cytomegalovirus organ involvement in AIDS patients

The role of an antigenemia assay in the diagnosis and prediction of human cytomegalovirus (HCMV) disease in AIDS patients was evaluated. The clinical history of 62 patients with advanced HIV infection from whom a total of 248 blood samples were drawn and tested by the HCMV antigenemia assay was examined retrospectively. Between December 1992 and January 1994, 28 episodes of HCMV disease with organ involvement were recorded; the antigenemia assay was positive in 23 of them (82.1 %). In particular, this test was positive in 11 of 12 (91.6 %) first episodes and in 3 of 3 (100 %) recurrent episodes occurring in patients not receiving maintenance therapy. The same test was positive in 9 of 13 (69.2 %) recurrent episodes occurring in patients receiving maintenance therapy. The first occurrence of HCMV disease was always preceded by a positive antigenemia assay 2 and 4 months before diagnosis (in all 7 patients of the 7 for whom a blood sample was available before HCMV disease). A positive antigenemia test result was not always followed by organ involvement, but a high positive cell count (>100/200,000 polymorphonuclear leukocytes) strongly correlated with the appearance of HCMV disease in the following 1 to 3 months (100 % of cases). The antigenemia assay is a useful and reliable indirect method for the diagnosis and prediction of HCMV endorgan disease in severely and persistently immunocompromised AIDS patients.