Iulia Niculescu

Characteristics of late presenters in Bucharest

Late presentation is associated with increased healthcare costs, rates of HIV transmission and poor outcome. In Romania, in 2012, one third of individuals with new HIV diagnosis were late presenters (LP).

Toxoplasmosis: a rare cause of IRIS in HIV infected patients. Case series

Results Three patients, one male and 2 women, aged 55 years old, respectively 41 and 42 year-old, all 3 diagnosed concomitantly with HIV infection (as very late presenters) and cerebral toxoplasmosis, with a CD4 count of 6, 6 and 7/cmm respectively, viral loads (VL) of 254,000, 57,000 and 156,000 copies/mL respectively, and CSF viral load below the plasmatic VL in all 3 cases. We recorded minimal abnormalities of CSF analysis regarding the number of cells and biochemical exams; all had positive PCR for Toxoplasma gondii in the CSF and positive serology (IgG). All 3 had intracerebral lesions (abscesses) and all were biopsied at the neurosurgery department for diagnostic purpose before knowing their HIV-positive status. They received high doses of oral trimethoprim/sulfamethoxazole (T/S) for toxoplasmosis and antiretroviral therapy in the first 2 weeks after the diagnosis. They repeated cerebral imagery (MRI) after 3 weeks of T/S and had no regression of the size of lesions (although with the decreasing of perilesional edema) and new lesions, in two cases without having corresponding symptoms; in all 3 cases the CD4 count increased in the first month more than 100%. The search for another cause for the augmentation of their brain lesions was negative. Maintaining the same medication, the next imagery exams showed improvement in 2 out of 3 cases, in which the outcome was favorable with almost complete neurological recovery. In the remaining case the evolution was unfavorable (death).

Epidemic dispersion of HIV and HCV in a population of co-infected Romanian injecting drug users

Co-infections with HIV and HCV are very frequent among people who inject drugs (PWID). However, very few studies comparatively reconstructed the transmission patterns of both viruses in the same population. We have recruited 117 co-infected PWID during a recent HIV outbreak in Romania. Phylogenetic analyses were performed on HIV and HCV sequences in order to characterize and compare transmission dynamics of the two viruses. Three large HIV clusters (2 subtype F1 and one CRF14_BG) and thirteen smaller HCV transmission networks (genotypes 1a, 1b, 3a, 4a and 4d) were identified. Eighty (65%) patients were both in HIV and HCV transmission chains and 70 of those shared the same HIV and HCV cluster with at least one other patient. Molecular clock analysis indicated that all identified HIV clusters originated around 2006, while the origin of the different HCV clusters ranged between 1980 (genotype 1b) and 2011 (genotypes 3a and 4d). HCV infection preceded HIV infection in 80.3% of cases. Coincidental transmission of HIV and HCV was estimated to be rather low (19.65%) and associated with an outbreak among PWID during detention in the same penitentiary. This study has reconstructed and compared the dispersion of these two viruses in a PWID population.

Co-infections and co-morbidities among injecting drug users versus sexually infected patients in Bucharest

After the 2008 introduction of new psychoactive substances (NPS) in Romania, the number of newly diagnosed HIV infections showed significant increase among injecting drug users (IDUs). Our objective was to analyze the differences between co‐infections related to the HIV infection, based on the way of transmission (IDUs versus sexually infected).

NGS combined with phylogenetic analysis to detect HIV-1 dual infection in Romanian people who inject drugs

Dual HIV infections are possible and likely in people who inject drugs (PWID). Thirty-eight newly diagnosed patients, 19 PWID and 19 heterosexually HIV infected were analyzed. V2V3 loop of HIV-1 env gene was sequenced on the NGS platform 454 GSJunior (Roche). HIV-1 dual/multiple infections were identified in five PWID. For three of these patients, the reconstructed variants belonged to pure F1 subtype and CRF14_BG strains according to phylogenetic analysis. New recombinant forms between these parental strains were identified in two PWID samples. NGS data can provide, with the help of phylogenetic analysis, important insights about the intra-host sub-population structure.

Baseline HIV-1 tropism prediction in advanced immune suppressed patients: evidence of CXCR4 viruses in IDUs infected with recombinant forms

Until 2011, the main risk factor for the spread of HIV-1 in Romanian adult population was heterosexual contact. More recently, the number of HIV-1 new cases among IDUs significantly increased. This new subepidemic is characterized by circulation of particular forms of infective strains (CRF14_BG), high prevalence of HCV co-infections and infective endocarditis. Genotypic methods are currently used for testing viral tropism in HIV infected patients. Deep sequencing proved to have much higher sensitivity than population sequencing in detecting minority - CXCR4 tropic viruses. Previous studies suggested that the presence of CXCR4 phenotype at baseline is frequently associated with a faster disease progression. The aim of the study was to evaluate the viral tropism at the moment of HIV diagnostic in IDU patients. We have analyzed sequences from 19 IDUs that presented low CD4 counts (<200 cells/cmm) and/or CDC stage C when HIV-1 infection was diagnosed. They were compared with strains from 24 heterosexuals diagnosed at the same time with the IDUs were included in the study. RT PCR was performed to amplify the V3 loop. Population sequencing was done using BigDye chemistry and 3500 Genetic Analyzer. Deep-sequencing was performed on the GS Junior 454 sequencing platform and AVA software was used to analyze the output sequences. The tropism prediction was assessed by geno2pheno[coreceptor] bioinformatic algorithm and subtyping with REGA tool version 2.0. The IDU group was mainly infected with recombinant forms: CRF14_BG and recombinants between F1 and CRF14_BG (68.4%, 13/19); the heterosexuals had F1 subtype viruses (95.8%, 23/24). CXCR4 tropism was associated with IDUs and in particular with CRF14_BG (p=0.0027). All the CRF14_BG were X4 by population sequencing. Furthermore, when tested with deep sequencing the viral populations of CRF14_BG samples were exclusively X4 (no minority R5 populations). Dual tropic (CCR5 and CXCR4) populations were more frequent in F1 samples isolated from heterosexuals and predicted as X4 by population sequencing. We found concordance between the predictions of the two methods. In the heterosexual group both techniques predicted mainly CCR5 viruses. CXCR4 tropic CRF14_BG viruses were very common in IDUs at baseline. This may contribute to faster disease progression in this population than in heterosexuals infected with the F1 CCR5 tropic strains.

Variation in CD4 cell count among IDUs versus sexually-infected HIV-positive naïve patients in Romania

Since 2011 Romania is experiencing a dramatic increase of newly diagnosed HIV infections among injecting drug users (IDUs), mainly linked to the introduction of new psychoactive substances (NPS) on the Romanian market, their use being related to higher levels of risk behavior compared to opioid abuse. There is no sufficient data showing the natural course of HIV in subjects infected through IDU – the majority are ART-naive due to recently acquired infection (many are asymptomatic and have a CD4 cell count over 350 cells/cmm) and poor adherence. Our objective was to determine if IDUs have a faster decline in CD4 cells than sexually-infected patients. We performed a retrospective study, including ART-naive HIV-positive patients diagnosed between January 2011 and June 2013 at the National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, who had 2 subsequent CD4 cell count determinations over a timespan of 6-24 months and a baseline CD4 count higher than 350 cells/cmm. Among 1,248 newly diagnosed patients, 234 met these inclusion criteria. The data were statistically analyzed using SPSS version 17 (independent sample t-test, Mann-Whitney test, linear regression; the significance level was set at 0.05). The majority (80%, 187/234) were men and the median age was 29 years (15-76). More than half of the patients (138; 59%) were former or active IDUs, with low socioeconomic status, most of them injecting both opioids and NPS and 55 (40%) of them were in detention at the moment of HIV diagnosis. Among them, 98% were coinfected with HCV, as opposed to only 21% of the sexually-infected patients. Subtype analysis was performed for 64 patients and revealed the following subtypes and circulating recombinant forms (CRF): 50 F1, 3 B, 10 CRF14_BG and 1 CRF14_F. There was no significant difference of CD4 cell count between the two groups at baseline (p=0.55). The median variation of CD4 cells in IDUs was 150 and 42 in the non IDUs group. IDUs had a statistically significant CD4 cell decline (p=0.01). HCV coinfection was also correlated with a faster decline in CD4 cells (p <0.001). The more rapid decline of CD4 cells among IDUs could be explained by direct effect of drugs, differences in the virulence of the HIV strains circulating among IDUs and HCV coinfection. These data highlight the importance of carefully monitoring IDUs with HIV infection and of initiating ART earlier in this risk group.

Characteristics of Kaposi sarcoma in HIV-infected patients

Objective: to describe clinical and laboratory characteristics; to assess predictors for death in HIV-infected patients with Kaposi sarcoma (KS). We performed a retrospective study of HIV-infected patients diagnosed with KS in one infectious diseases hospital in Romania, between January 2008-November 2013. KS diagnosis was established on physical examination, skin biopsy, and for visceral involvement upper gastrointestinal endoscopy, bronchoscopy and computed tomography. KS was staged according to the AIDS Clinical Trials Group (ACTG) [1] and the Mitsuyasu classification system [2]. We identified 27 HIV-infected patients with KS. The median age was 42 years (IQR 34-52) and 18 (67%) were male. The median CD4 count at HIV diagnosis was 195 cells/cmm (IQR 55-313), while at KS diagnosis the median CD4 count was 101 cells/cmm (IQR 41-270). Eighteen (67%) patients had a CD4 count <200 cells/cmm. The median HIV viral load at the time of KS diagnosis was 120,000 copies/mL (IQR 316-328,522). HIV infection was diagnosed before KS in 19 patients (70%), with a median time between HIV and KS diagnosis of 7 months (IQR 0-58). The most frequent KS localization was the lower limb in 16 (59%) patients and 7 (26%) patients had disseminated KS. Oral, gastrointestinal and pulmonary involvements were seen in 10 (37%), 4 (15%) and 3 (11%) patients respectively. Concomitant opportunistic infections were diagnosed in 20 (74%), while other malignancies in 3 (12%) patients. According to the ACTG classification 16 (59%) patients had poor risk KS. Fifteen (56%), 6 (22%), 1 (4%) and 5 (18%) were in stage 1, 2, 3 and 4, respectively according to the Mitsuyasu classification. Six (22%) patients received specific KS treatment: three local radiotherapy and three systemic therapy (two with interferon; one with liposomal doxorubicin). The overall mortality was 41% with a median duration between KS diagnosis and death of 6 months (IQR 2-15). Gastrointestinal involvement (p=0.019), poor-risk KS in ACTG classification (p<0.001) and stage IV Mitsuyasu (p=0.006) were associated with death in univariate analysis. The mortality rate in this study was high, due to poor immunological status, extended KS and high incidence of opportunistic infections, but also due to the lack of specific systemic treatment.

Clinical and epidemiologic features of community versus hospital-acquired Clostridium difficile infection

Methods We enrolled all CDI patients admitted to the Adults III department of the National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, Bucharest, between January – July 2014. Stool culture, toxin EIA and Cepheid Gene Xpert C. difficile test were used for CDI diagnosis. The subjects were divided into two groups: CA-CDI patients (Group 1) and HA-CDI patients (Group 2). Our objective was to describe the clinical, epidemiologic features and outcome of CA-CDI compared to hospital-associated CDIs (HA-CDI) including the ATLAS bedside severity scoring system. Statistical analyses were performed using SPSS Statistics package v.17.

Leptin dysfunction and the risk of dyslipidemia and metabolic syndrome in Romanian HIV-infected patients undergoing antiretroviral therapy

Leptin is a hormone secreted by the adipose tissue that may be associated in the general population with components of the metabolic syndrome (MS). Our objective was to test the association between dyslipidemia, MS presence and circulating leptin dysfunction in a cohort of HIV-infected non-diabetic patients undergoing combinant antiretroviral therapy (cART). We included HIV-infected non-diabetic consecutive patients undergoing cART, admitted to the National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, between 2008-2011. The diagnosis of MS was made using the International Diabetes and American Heart Association harmonized criteria from 2009. Circulating levels of leptin (BioSource EASIA) were measured. We enrolled 95 patients: 53 (55.8%) males (mean age=33.1±13.4 years) and 42 (44.2%) females (mean age=30.5±13.6 years). Most patients (72.5%) had undetectable HIV viral load; median CD4 count was 493.5 (IQR=422)/cmm. The median time from HIV diagnosis was 60 (IQR=73) months. The median time on cART was 58.5 (IQR=70) months, 53.8% of patients had experienced more than one cART regimen. The prevalence of MS was 17.1%. Elevated blood pressure, elevated waist circumference and abnormal fasting glucose prevalences were 30.3%, 17.1% and 6.5%, respectively. Median serum leptin was 1.89 (IQR=3.57) ng/mL. Circulating leptin dysfunction was present in almost half of patients, hypoleptinemia being more frequent (42.%) than hyperleptinemia (8.5%). Hypoleptinemia was more frequent in men (62.3%) comparative to women (17.1%), p=0.000. The prevalence of MS in patients with hypoleptinemia was 25.8% vs 10.8% in persons with normal leptin values (p=0.261). Hypoleptinemia was associated with elevated waist circumference (p=0.004) and abnormal fasting glucose (p=0.05) in women. More than half (65.6%) of men with hypoleptinemia had reduced HDL-cholesterol levels vs 29.4% in men with normal levels of leptin. As expected, hyperleptinemia was associated with the increase of body mass index, both in men (p=0.000) and women (p=0.05). In our cohort of young cART multiexperienced HIV patients leptin dysfunction was not significantly associated with MS presence. Leptin was correlated with several MS components (HDL-dyslipidemia, elevated circumference, abnormal fasting glucose) with significant gender differences, that suggests that leptin may play different roles in the regulation of glucose and lipid metabolism according to the sex.