Klaudija Višković

Arterial stiffness evaluation in HIV-positive patients: A multicenter matched control study

OBJECTIVE The purpose of this article is to assess the differences, if any, in the values of carotid artery stiffness parameters between HIV-infected subjects without known cardiovascular disease (CVD) or carotid artery plaques and HIV-uninfected control subjects matched for sex, age, body mass index, and other CVD risk factors (i.e., hypertension, hypercholesterolemia, diabetes, and cigarette smoking). Arterial stiffness is emerging as a predictor of CVD risk. By recording the blood pressure, an automated echo-tracking system implemented in ultrasound equipment allows evaluation of arterial stiffness. SUBJECTS AND METHODS Fifty-four HIV-infected patients without a history of CVD were closely matched for sex, age, body mass index, and CVD risk factors to 54 HIV-uninfected control subjects on an individual basis. Ultrasound studies of carotid artery stiffness parameters were performed using ultrasound equipment with a linear broadband high-frequency transducer. Carotid intima-media thickness was also measured. Repeatability between operators was assessed. Nonparametric Mann-Whitney U test, chi-square statistics, Fisher exact test, Pearson correlation coefficient, and intraclass correlation coefficient were used for statistical analysis. A p value less than 0.05 was considered statistically significant. RESULTS Except for arterial compliance in HIV-infected subjects, arterial stiffness parameters were correlated with age in both groups. Compared with matched control subjects, HIV-infected subjects showed lower arterial compliance parameter values (0.95 [interquartile range, 0.78-1.23] vs 0.76 [interquartile range, 0.62-1.00]; p = 0.0009), whereas other parameters were similar. Repeatability between operators was good. CONCLUSION HIV-infected subjects have an arterial compliance significantly lower than that of control subjects. The impairment of carotid artery distensibility may contribute to subclinical atherosclerosis.

Comparison of four international cardiovascular disease prediction models and the prevalence of eligibility for lipid lowering therapy in HIV infected patients on antiretroviral therapy.

Aim To compare four cardiovascular disease (CVD) risk models and to assess the prevalence of eligibility for lipid lowering therapy according to the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, European AIDS Clinical Society Guidelines (EACS), and European Society of Cardiology and the European Atherosclerosis Society (ESC/EAS) guidelines for CVD prevention in HIV infected patients on antiretroviral therapy. Methods We performed a cross-sectional analysis of 254 consecutive HIV infected patients aged 40 to 79 years who received antiretroviral therapy for at least 12 months. The patients were examined at the HIV-treatment centers in Belgrade and Zagreb in the period February-April 2011. We compared the following four CVD risk models: the Framingham risk score (FRS), European Systematic Coronary Risk Evaluation Score (SCORE), the Data Collection on Adverse Effects of Anti-HIV Drugs study (DAD), and the Pooled Cohort Atherosclerotic CVD risk (ASCVD) equations. Results The prevalence of current smoking was 42.9%, hypertension 31.5%, and hypercholesterolemia (>6.2 mmol/L) 35.4%; 33.1% persons were overweight, 11.8% were obese, and 30.3% had metabolic syndrome. A high 5-year DAD CVD risk score (>5%) had substantial agreement with the elevated (≥7.5%) 10-year ASCVD risk equation score (kappa = 0.63). 21.3% persons were eligible for statin therapy according to EACS (95% confidence intervals [CI], 16.3% to 27.4%), 25.6% according to ESC/EAS (95% CI, 20.2% to 31.9%), and 37.9% according to ACC/AHA guidelines (95% CI, 31.6 to 44.6%). Conclusion In our sample, agreement between the high DAD CVD risk score and other CVD high risk scores was not very good. The ACC/AHA guidelines would recommend statins more often than ESC/EAS and EACS guidelines. Current recommendations on treatment of dyslipidemia should be applied with caution in the HIV infected population.

Assessment of Ultrasound for Use in Detecting Lipoatrophy in HIV-Infected Patients Taking Combination Antiretroviral Therapy

The aim of this study was evaluation of ultrasound (US) as a tool for the assessment of lipoatrophy in a population of HIV-infected patients. We enrolled a convenience sample of 151 HIV-infected Caucasian participants (males, 79%) who were treated for at least 1 year with combination antiretroviral therapy (CART) in Zagreb, Croatia. US measurements of subcutaneous fat thickness were done over the malar, brachial, and crural region. We determined sensitivity and specificity of US as a diagnostic tool for lipoatrophy using receiver-operating curves and concordant patient and clinician assessment as our reference for the presence of lipoatrophy. HIV was acquired through heterosexual contact in 50% of participants and by sex between men in 42%. The mean current CD4 cell count was 503.1 cells=mm3 (standard deviation [SD] = 250.8). Seventy-seven (51%) participants were treated with stavudine and 91 (64%) with a protease inhibitor for at least 6 months. Nineteen (13%)participants had lipoatrophy in at least one anatomic site. Sensitivity of US ranged from 67%-71%, specificity from 65%-71%, positive and negative predictive values ranged from 11%-20% and 96-97%, respectively. US diagnosed lipoatrophy was more frequently found in patients with a history of stavudine treatment and in females. Patients with lipoatrophy had a longer duration of CART than those without lipoatrophy. US is a useful tool in ruling out the presence of clinical lipoatrophy in patients on CART. Using this objective measure of subcutaneous fat may be useful in helping clinicians make decisions about changing therapy.

Ultrasound measurements of carotid intima-media thickness and plaque in HIV-infected patients on the Mediterranean diet

Aim To evaluate the influence of food habits, specifically adherence to the Mediterranean diet, on carotid intima-media thickness (CIMT) and the presence of plaques in HIV-infected patients taking antiretroviral therapy (ART) and non-HIV-infected participants and to determine if HIV infection contributes independently to subclinical atherosclerosis. Methods We conducted a cross-sectional study of 110 HIV-infected patients on ART and 131 non-HIV-infected participants at the University Hospital for Infectious Diseases in Zagreb, Croatia, from 2009-2011. CIMT measurement and determination of carotid plaque presence was detected by ultrasound. Adherence to the Mediterranean diet was assessed by a 14-point food-item questionnaire. Subclinical atherosclerosis was defined by CIMT≥0.9 mm or ≥1 carotid plaque. Results In HIV-infected patients, subclinical atherosclerosis was associated with older age (P < 0.001; Mann-Whitney test), higher body mass index (P = 0.051; Mann-Whitney test), hypertension (P < 0.001; χ2 test), and a lower Mediterranean diet score (P = 0.035; Mann-Whitney test), and in non-HIV-infected participants with older age (P < 0.001; Mann-Whitney test) and hypertension (P = 0.006; χ2 test). Multivariate analysis showed that decreased adherence to the Mediterranean diet was associated with higher odds of subclinical atherosclerosis (odds ratio [OR] 2.28, 95% confidence interval [CI] 1.10-4.72, P = 0.027) as was current smoking (OR 2.86, 95% CI 1.28-6.40), hypertension (OR 3.04, 95% CI 1.41-6.57), and male sex (OR 2.35, 95% CI 0.97-5.70). There was a significant interaction of age and HIV status, suggesting that older HIV-infected patients had higher odds of subclinical atherosclerosis than controls (OR 3.28, 95% CI 1.24-8.71, P = 0.017 at the age of 60 years). Conclusion We confirmed the association between lower adherence to the Mediterranean diet and increased risk of subclinical atherosclerosis and found that treated HIV infection was a risk factor for subclinical atherosclerosis in older individuals.

Cardiovascular markers of inflammation and serum lipid levels in HIV-infected patients with undetectable viraemia

Successfully treated HIV‐infected patients may still have an increased risk for cardiovascular morbidity and mortality, which might be related not only to traditional risks, but also to inflammation and dyslipidemia induced by HIV and/or antiretroviral therapy [ 1 , 2 ]. We examined the relationship of serum lipid levels with plasma biomarkers of inflammation using a composite inflammatory burden score (IBS) from the following seven markers of inflammation: CD40L, tPA, MCP‐1, IL‐8, IL‐6, hCRP and P‐selectin.

Tuberculosis-Associated Immune Reconstruction Inflammatory Syndrome (TB-IRIS) in HIV-Infected Patients: Report of Two Cases and the Literature Overview

We describe two HIV-infected patients with tuberculosis-associated immune reconstruction inflammatory syndrome (TB-IRIS): one with “paradoxical” IRIS and the other with “unmasking” IRIS. TB-IRIS in HIV-infected subjects is an exacerbation of the symptoms, signs, or radiological manifestations of a pathogenic antigen, related to recovery of the immune system after immunosuppression. We focused on the radiological characteristics of TB-IRIS and the briefly literature review on this syndrome.

Prevalence and concordance of high cardiovascular disease scores in HIV/AIDS patients from Croatia and Serbia with four international algorithms

We evaluated cardiovascular risks in HIV‐infected patients from Croatia and Serbia and the eligibility for statin therapy as recommended by the 2013 American College of Cardiology/American Heart Association (ACC/AHA) guidelines, European AIDS Clinical Society (EACS) Guidelines and European Society of Cardiology and the European Atherosclerosis Society (ESC/EAS) guidelines for cardiovascular disease (CVD) prevention [ 1 – 3 ].

Acute pneumococcal myelitis in an adult patient.

Pneumococcal meningitis represents the most severe community-acquired bacterial meningitis. The disease is frequently associated with various complications. We present a case of pneumococcal meningitis in an immunocompetent adult patient treated with hypothermia. The disease course was complicated with severe myelitis and consequent paraplegia which is an extremely rare complication of pneumococcal disease.

Cardiovascular markers of inflammation and serum lipid levels in HIV-infected patients with undetectable viremia

Patients successfully treated for HIV infection still have an increased risk for cardiovascular morbidity and mortality, which might be related not only to traditional risks, but also to inflammation and dyslipidemia. We examined the relationship of serum lipid levels with plasma biomarkers of inflammation using a composite inflammatory burden score (IBS) based on individual (>75th percentile) measurements from the following seven markers: CD40L, tPA, MCP-1, IL-8, IL-6, hCRP and P-selectin. IBS was categorized as 0 (none of the biomarkers >75th percentile), 1, 2 and 3 or more scores. Correlations between the IBS and lipid parameters were examined by ordered logistic regression proportional odds models to estimate the odds of more elevated biomarkers. 181 male patients with undetectable HIV-viremia were included into the study. In the multivariate model, a one-unit increase (mmol/L) of total cholesterol and triglycerides was associated with a 1.41-fold (95% CI, 1.13–1.76) and 1.37-fold (95% CI, 1.18–1.60) increased odds of having a greater IBS, respectively. Those with an IBS score ≥1 compared to none had 2.14 (95% CI, 1.43–3.20) higher odds of having a one-unit increased total cholesterol/HDL-cholesterol ratio. In successfully treated HIV-infected persons dyslipidemia was associated with inflammation.

Successful Treatment of Disseminated Bacillus Calmette-Guérin Disease in an HIV-Infected Child with a Linezolid-Containing Regimen

Upon HIV infection diagnosis, an 8-month-old boy was transferred for evaluation of worsening respiratory distress requiring mechanical ventilation. Pneumocystis jirovecii pneumonia (PCP) was diagnosed; the boy also had a nonhealing ulcer at the site of vaccination with Statens Serum Institut (Danish strain) Bacillus Calmette-Guérin (BCG) vaccine and associated axillary lymphadenopathy. PCP treatment resulted in weaning from mechanical ventilation. Antimycobacterial treatment was immediately attempted but was discontinued because of hepatotoxicity. Over several months, he developed splenic lesions and then disseminated skin and cystic bone lesions. M. bovis was repeatedly cultured from both skin and bone lesions despite various multidrug antimycobacterial regimens which included linezolid. Eventually, treatment with a regimen of rifabutin, isoniazid, ethambutol, and linezolid led to definitive cure. Clinicians should consider a linezolid-containing regimen for treatment of severe disseminated BCG infection, especially if other drug regimens have failed. Although drug toxicity is a particular concern for young children, this patient received linezolid for 13 months without serious toxicity. This case also highlights the need for universal screening among pregnant women to prevent vertical transmission of HIV. Finally, routine immunization with BCG vaccine at birth should be questioned in countries with low and declining burden of tuberculosis.