Marco Trevenzoli

Severe Hepatic Failure Related to Nevirapine Treatment

markable. Laboratory evaluations were significant for a leukocyte count of 1,500/mm (normal value, 4,500–11,000/mm) and macrocytic anemia (hematocrit, 30%; hemoglobin level, 9.8 g/dL; mean corpuscular volume, 104.6 fL). The absolute neutrophil and lymphocyte counts were 870 and 600/mm, respectively. The blood urea nitrogen level was 34 mg/dL (normal value, 7–22 mg/dL), and the creatinine level was 1.8 mg/dL (normal value, 0.6–1.3 mg/dL). Blood cultures were negative. Direct fluorescent antibody staining of fluid from one of the vesicles was positive for HSV, and viral cultures subsequently yielded HSV. A punch biopsy of one of the lesions revealed epidermal ulceration with florid viral cytopathic changes consistent with herpesvirus infection. Secondary bacterial colonization was noted. The patient was treated with intravenous acyclovir (5 mg/kg three times a day), and there was subsequent resolution of the lesions with scarring. Ecthyma refers to a cutaneous infection resembling impetigo but affecting areas deeper in the skin. The lesions are characterized by localized, well-demarcated, erythematous plaques with ulceration that reaches the dermis. Therefore, the lesions often have a central eschar and cause scarring [1]. Ecthyma is almost always secondary to streptococcal and staphylococcal infections, in particular Streptococcus pyogenes infection; therefore, treatment for ecthyma generally consists of oral antimicrobials that are active against S. pyogenes and Staphylococcus aureus. However, mucormycosis [2, 3], molluscum contagiosum [4], cutaneous diphtheria [5], and gonococcal infections [6] have all been associated with ecthyma-like cutaneous eruptions. Review of the literature with use of MEDLINE revealed no previously reported cases of an ecthyma-like presentation of HSV infection. On the basis of nomenclature, ecthyma should be distinguished from two similarly named conditions, ecthyma gangrenosum and contagious ecthyma. Ecthyma gangrenosum is a life-threatening condition secondary to bacterial septicemia with gram-negative bacteria, in particular Pseudomonas aeruginosa. It is characterized by well-demarcated, indurated, weeping, necrotic eschars in areas rich in apocrine glands. Contagious ecthyma, also known as orf, is a parapoxvirus infection of the skin acquired from sheep that is characterized by ulcerated erythematous nodules with white halos. A history of contact with sheep is almost invariably present. This case presents a novel manifestation of HSV infection in immunocompromised hosts. Other such manifestations include painful ulcerative lesions of the genitalia, perianal area, and lips and follicular facial lesions [7]. Moreover, HSV infections should be considered in the differential diagnosis of ecthyma-like skin lesions in immunocompromised patients, and biopsies and virological studies should be performed to exclude HSV infections.

Cellular proviral HIV-DNA decline and viral isolation in naïve subjects with 500 × 106/l CD4 cells treated with highly active antiretroviral therapy

ObjectiveTo evaluate the decay rate of cellular proviral HIV-DNA and viral replication in patients receiving highly active antiretroviral therapy (HAART) in the very early phase of infection.MethodsThirty-four patients treated with HAART and retrospectively selected for progressive decline of plasma

Hypersensitivity Syndrome (DRESS) and Meningoencephalitis Associated with Nevirapine Therapy

The DRESS (drug rash with eosinophilia and systemic symptoms) syndrome is a serious condition that has been reported in association with various drugs, such as allopurinol, sulfonamides and aromatic anticonvulsants. Recently the condition has been described in HIV-infected patients taking antiretroviral agents. We report the first case, to our knowledge, of DRESS syndrome complicated by meningoencephalitis associated with nevirapine therapy.The DRESS (drug rash with eosinophilia and systemic symptoms) syndrome is a serious condition that has been reported in association with various drugs, such as allopurinol, sulfonamides and aromatic anticonvulsants. Recently the condition has been described in HIV-infected patients taking antiretroviral agents. We report the first case, to our knowledge, of DRESS syndrome complicated by meningoencephalitis associated with nevirapine therapy.

Unusual, rapidly growing ulcerative genital mass due to herpes simplex virus in a human immunodeficiency virus-infected woman.

SIR, Mycosis fungoides (MF) is characterized by clonal helper ⁄ memory (CD4+ CD45RO+) T-cells in the epidermis, whereas follicular mucinosis or alopecia mucinosis has perifollicular T-cell infiltrates and may clinically resemble alopecia areata. Bexarotene is the first retinoid X receptor (RXR)-selective retinoid shown to be effective for cutaneous T-cell lymphoma. Bexarotene has recently been shown to induce T-cell apoptosis in vitro. Although bexarotene oral and topical gel are effective for MF, this is the first report, to our knowledge, of reversal of associated alopecia. Five patients with alopecia secondary to MF or follicular mucinosis were observed among a cohort of over 90 patients receiving bexarotene therapy at the M.D. Anderson Cancer Center. Their demographic data, degree of hair loss, skin biopsy results and drug administration are shown in Table 1. The location of the hair loss was confined to the scalp in four patients and to the extremities in a fifth. All of the skin biopsy specimens revealed atypical CD4+ CD8+ perifollicular lymphocytic infiltrates, and two showed mucin deposits consistent with follicular mucinosis. Three patients had scaling with negative fungal cultures. Patients with early stage MF were treated with topical bexarotene therapy and advanced stage patients with oral bexarotene. The MF as well as the alopecia improved in all five patients, irrespective of the route of delivery. Hair regrowth began within 2–9 months and full regrowth was evident by 1Æ5 years. Patient 1. A 77-year-old Native American woman presented with a 3-month history of a single patch of alopecia accompanied by pruritus and mild tenderness, generalized xerosis, fatigue and a 4Æ5-kg unintentional weight loss. Asthma and childhood eczema were noted. There was a 4 · 5 cm alopecia areata-like lesion with scaling on the scalp (Fig. 1a) and macular erythema of less than 1%. An atypical CD4+ CD8– clonal lymphocytic infiltrate and mucin deposits were present in the follicular epithelium. After applying 1% bexarotene gel daily to the leg and scalp lesions, partial hair regrowth was present at 3 months (Fig. 1b), with full regrowth of terminal grey hair covering the former patch of alopecia at 5 months (Fig. 1c). Patient 2. A 64-year-old Hispanic man with dermatitis for 30 years developed generalized exfoliative erythroderma, patchy alopecia, and a skin biopsy consistent with MF. He had increased fatigue, chills, night sweats and intense pruritus. On examination, he had generalized exfoliative erythroderma and lymphadenopathy. On the scalp, multiple round alopecia areata lesions, patches of white hair, and exclamation point hairs were observed (Fig. 2a,b). An atypical CD4+ CD8+ dermal infiltrate with epidermotropism and a clonal T-cell receptor gene rearrangement were observed in

Splenic Infarct During Infectious Mononucleosis

We present a case of splenic infarct during infectious mononucleosis in a 17-y-old boy. The patients condition improved without the need for surgery.We present a case of splenic infarct during infectious mononucleosis in a 17-y-old boy. The patients condition improved without the need for surgery.

Recovery of Long-term Natural Protection Against Reactivation of CMV Retinitis in AIDS Patients Responding to Highly Active Antiretroviral Therapy

OBJECTIVES To see whether in severely immunosuppressed AIDS patients (with prior Cytomegalovirus retinal disease) who have significant increases in CD4+ lymphocytes following the initiation of highly active antiretroviral therapy (HAART) anti-Cytomegalovirus (CMV) maintenance therapy can be withdrawn with no subsequent progression of CMV retinitis. METHODS Eight patients with AIDS and one or more previous episodes of CMV retinitis interrupted anti-CMV maintenance therapy following the successful beginning of HAART. CD4 cell counts and HIV-RNA were monitored monthly while measurement of CMV antigenemia and ophthalmoscopy were carried every 2 weeks thereafter. RESULTS The HAART recipients in whom anti-CMV maintenance therapy had been interrupted had measureable increases of CD4+ T lymphocytes, substantial control of both HIV-RNA and CMV viraemia and did not show recurrence of retinitis during a mean follow-up of 98.4 weeks (range 78-120, SD 15.2). CONCLUSIONS Anti-CMV maintenance therapy can be interrupted with no subsequent progression of retinal damage over a long time in patients with AIDS who successfully respond to HAART with a significant increase in CD4 cell count.

Esophageal Cryptococcosis in a Patient With AIDS

TO THE EDITOR: Cryptococcus neoformans infection generally provokes meningitis in highly immunodepressed HIV-infected patients with very low CD4 cell counts (usually ,100/ml). Cryptococcal esophagitis has been described only in one non–HIV-infected patient with Job’s syndrome (1). We have observed a similar case in one patient with AIDS. This 35-yr-old man, HIV-infected from 1985, had cryptococcal meningitis in 1993 and was on fluconazole 600 mg daily since. After 25 months of highly active antiretroviral therapy (HAART), which included, in the last 9 months, stavudine, lamivudine, and nelfinavir, in July 1998 he presented with fever and weight loss but no dysphagia; CD4 cells were 281/ ml (13.7%), CD4/CD8 ratio was 0.28, HIVRNA copies (Chiron Quantiplex assay) were ,500/ml, and cryptococcal latex agglutination test was positive at a 1:2.048 dilution both in blood and cerebrospinal fluid (CSF). Cryptococcus neoformans however was not grown from CSF. A lymphoma was suspected and a cerebral, chest, and abdominal CT scan performed; the only relevant finding was thickness of the lower esophageal wall. Esophageal endoscopy revealed, in addition, multiple ulcers of the upper estremity. Biopsies were performed and histological examination showed massive cryptococcal infiltration of both the ulcers and the lower esophageal mucosa (Fig. 1). The patient was treated with liposomal amphotericin B (Abelcet, Wyeth-Lederle), 2.8 g total dose in 2 wk, followed by fluconazole 600 mg daily; 11 wk later endoscopy showed complete healing of the esophageal lesions. HAART has modified the natural history of several AIDS-related opportunistic disorders (2) but did not appear thus far to have changed the clinical manifestations of Cryptococcus neoformans infection, which are thought to be restricted to meningeal, pulmonary, or skin involvement. The case presented suggests that powerful and effective antiretroviral therapy can be associated with a highly unusual localization of cryptococcal infection and that this can occur despite fluconazole secondary prophylaxis. Cryptococcal localization should be included in the differential diagnosis of esophageal lesions in patients with