M.H. Snow

HIV viral suppression in the era of antiretroviral therapy

Altogether 42 million people worldwide have been infected with HIV, and 12 million have died over the last 20 years. Effective antiretroviral therapy has lead to sustained HIV viral suppression and immunological recovery in patients who have been infected with the virus. The incidence of AIDS has declined in the Western world with the introduction of effective antiretroviral therapy. Questions on When to start treatment?, What to start with?, How to monitor patients?, remain heavily debated. Adherence to antiretroviral treatment remains the cornerstone of effective treatment, and failure to adhere is the strongest predictor of virological failure. Long term therapy can lead to metabolic complications. Resource poor countries are dealing with difficult issues such as mother to child prevention of HIV transmission. Other treatment options are now available, with the recent introduction of fusion inhibitors, second generation non-nucleoside reverse transcriptase inhibitors, and nucleotide reverse transcriptase inhibitors to clinical practice.

Pancreatic exocrine insufficiency in HIV‐positive patients

We describe the management of a cohort of eight HIV‐positive patients on antiretroviral medication with evidence of pancreatic insufficiency consisting of chronic diarrhoea and a low faecal elastase measurement.

Unilateral recurrent acute retinal necrosis syndrome caused by cytomegalovirus in an immune-competent adult

Purpose To report an immune-competent patient with unilateral recurrent acute retinal necrosis syndrome caused by cytomegalovirus, and to highlight the importance of diagnostic vitreous biopsy and specific antiviral therapy in this condition. Methods Case report. Results A 75-year-old man with good general health had two episodes of acute retinal necrosis syndrome affecting his left eye. Vitreous biopsy was performed in each episode, and polymerase chain reaction analysis on the vitreous specimen was positive for cytomegalovirus and negative for varicella zoster virus and herpes simplex virus 1 and 2. On each occasion, investigations indicated past cytomegalovirus infection but no evidence of a systemic reactivation. No indication of immunodeficiency was found over a 2-year follow-up period. His management, which included systemic and intravitreal antiviral therapy, is discussed. Conclusions To the authors’ knowledge, only two other cases of acute retinal necrosis syndrome caused by cytomegalovirus have been reported previously in immune-competent patients. This case illustrates the importance of vitreous biopsy for viral polymerase chain reaction studies in cases of acute retinal necrosis syndrome, in order to direct appropriate antiviral treatment. It also illustrates the role of an intravitreal antiviral drug that is effective against all three herpetic viruses.

Oral cancer, fever of unknown origin, and listeriosis

Listeriosis is a rare cause of fever of unknown origin in patients with oral cancer. We report two patients who, because of pain and discomfort, ate large quantities of soft cheeses; this caused listeriosis and fever. Both cases responded to high doses of amoxycillin.

Neurocysticercosis in pregnancy.

SIR — We note with interest the recent description of neurocysticercosis in the UK and the recommendations for treatment.1 We would like to describe a rare presentation of this condition in pregnancy. A 35-year-old lady born in the UK, of Indian parents presented with witnessed primary generalized seizures. She is vegetarian. Her elder sister had tuberculosis 20 years ago. Seven months previously, she had travelled to India for 2 weeks. Physical examination was unremarkable and there were no lateralizing neurological signs or impairment of consciousness. Contrast CT of the brain revealed a single ring-enhancing lesion in the right frontal lobe. She was commenced on dexamethasone 4 mg tds, ranitidine 150 mg bd and carbamezepine 200 mg bd. She had a positive pregnancy test. After appropriate counselling MRI of the brain was arranged and this showed a 1.5 × 1.5-cm ring enhancing mass lesion in the right parasagittal area. Serology for toxoplasma and cryptococcosis were negative as was her Heaf test. Cysticercosis serology by immunofluorescence, immunoblot and on ELISA were all negative. The EEG was normal. She underwent a stereotactic biopsy of the lesion which showed a cysticercosis cyst with a scolex and rostellum and muscular suckers. There was no calcification and the features being compatible with a recent cysticercosis lesion, she was commenced on praziquantel 50 mg/kg/day in three divided doses for 15 days together with continuing steroid cover. The carbamazepine, was subsequently changed to lamotrigine as she developed drug-related hepatitis. Three weeks after the biopsy, repeat CT of the brain, after appropriate foetal shielding, showed considerable improvement of the lesion. She had no further problems with her pregnancy and delivered a normal male baby in June of 2000. A repeat CT at 12 weeks has shown further resolution of the right frontal lesion. The lamotrigine has recently been stopped with no recurrence of fits. There are three reports of successful treatment of cystercercosis in pregnancy. There has been one report of maternal mortality associated with this condition. This was after ventriculitis and secondary obstructive hydrocephalus.2,3 Neurocysticercosis is a recognised cause of first time convulsions in pregnant patients. It should be considered in the differential diagnosis of seizure at the time of presentation. Patients may be initially controlled on anticonvulsive medications. If they are not controlled on antiepileptic drugs alone, praziquantel should be considered during pregnancy. A clear decrease is seen in the number of neurocysticerci in the brain and improvement in seizure disorder has been demonstrated with anticysticidal treatment.4 Albendazole, though previously thought to be contraindicated in pregnancy has been used without any foetal sideeffects.5 There are recent data to suggest that there are no adverse pregnancy outcomes linked with albendazole. No adverse pregnancy outcomes were recorded in 184 women treated with albendazole for intestinal helminths in the first trimester.6 If seizures are well controlled, antihelminthic treatment can be withheld until postpartum. 4 There is insufficient evidence to determine whether cysticidal therapy is of any clinical benefit to patients with neurocysticercosis. However, more patients remain seizure-free when treated with cysticidal drugs.7 In our case in retrospect the patient could have been managed without anti-helminthic therapy as there appears to have been a single cyst that may have been killed by the biopsy procedure.

Pneumocystis carinii Pneumonia after Thoracic Duct Ligation and Leakage

A case of Pneumocystis carinii pneumonia was induced through immunosuppression following thoracic duct ligation. The patient initially presented with an esophageal adenocarcinoma, which was totally resected. She is human immunodeficiency virus-negative and not undergoing immunosuppressive treatment.