Michael P. Mullen

Infection with multidrug resistant, dual-tropic HIV-1 and rapid progression to AIDS: a case report

BACKGROUND Rapid progression to AIDS after acute HIV-1 infection, though uncommon, has been noted, as has the transmission of multidrug resistant viruses. Here, we describe a patient in whom these two factors arose concomitantly and assess the effects. METHODS We did a case study of a patient with HIV-1 seroconversion. We genotyped the virus and host genetic markers by PCR and nucleotide sequencing. To ascertain the drug susceptibility of our patients HIV-1 we did phenotypic studies with the PhenoSense assay. We assessed viral coreceptor use via syncytium formation in vitro and with a modified PhenoSense assay. FINDINGS Our patient seems to have been recently infected by a viral variant of HIV-1 resistant to multiple classes of antiretroviral drugs. Furthermore, his virus population is dual tropic for cells that express CCR5 or CXCR4 coreceptor. The infection has resulted in progression to symptomatic AIDS in 4-20 months. INTERPRETATION The intersection of multidrug resistance and rapid development of AIDS in this patient is of concern, especially in view of his case history, which includes high-risk sexual contacts and use of metamfetamine. The public health ramifications of such a case are great.

Linezolid-associated toxic optic neuropathy: a report of 2 cases.

We describe 2 cases in which the prolonged use of linezolid to treat complicated methicillin-resistant Staphylococcus aureus infections was followed by acutely developed blurred vision and progressive loss of vision and color perception during the ensuing few weeks. Both patients received a diagnosis of toxic optic neuropathy, and linezolid therapy was stopped. The patients experienced an initial rapid partial improvement and a subsequent gradual, almost complete, recovery over many months.

Infections associated with hickman catheters in patients with acquired immunodeficiency syndrome

PURPOSE Hickman catheters are frequently used as convenient long-term venous access in patients with acquired immunodeficiency syndrome (AIDS). These patients seem to be at increased risk for bacterial infections of intravenous devices. The aim of our study was to determine the frequency of Hickman catheter infection in patients with AIDS as compared with that in other patients. PATIENTS AND METHODS We analyzed the records of 69 patients who underwent 71 consecutive Hickman catheter placements during a one-year study period. RESULTS Forty-six Hickman catheters were inserted in 44 patients with AIDS, and 25 Hickman catheters were placed in 25 other patients. There were 18 infections: 16 occurred in patients with AIDS, and two developed in the control group (p less than 0.05). The 16 infections in AIDS were as follows: five exit site, five septicemias, two tunnel, one septic phlebitis, and three probable Hickman catheter-related. Staphylococcus aureus was responsible for 14 cases (87%); Staphylococcus epidermidis was responsible for four cases (25%). Mean onset of infection was 32 days, but seven patients were diagnosed in the first eight days after Hickman catheter insertion. Fever occurred in all patients with early infection, leukopenia was present only in three; infusion of parenteral nutrition did not increase the risk. Two early infections were fatal. The rate of Hickman catheter infection in patients with AIDS was 0.47 per 100 catheter days, as compared with 0.09 in the control group. CONCLUSION Our findings underscore the need for using Hickman catheters only when absolutely indicated in patients with AIDS, since the risk of serious infectious complications appears to be high.

Telaprevir in the Treatment of Acute Hepatitis C Virus Infection in HIV-Infected Men

BACKGROUND There is an international epidemic of hepatitis C virus (HCV) infection among human immunodeficiency virus (HIV)-infected men who have sex with men. Sustained virologic response (SVR) rates with pegylated interferon and ribavirin treatment are higher in these men during acute HCV than during chronic HCV, but treatment is still lengthy and SVR rates are suboptimal. METHODS We performed a pilot study of combination therapy with telaprevir, pegylated interferon, and ribavirin in acute genotype 1 HCV infection in HIV-infected men. Men who were treated prior to the availability of, or ineligible for, telaprevir were the comparator group. The primary endpoint was SVR12, defined as an HCV viral load <5 IU/mL at least 12 weeks after completing treatment. RESULTS In the telaprevir group, 84% (16/19) of men achieved SVR12 vs 63% (30/48) in the comparator group. Among men with SVR, median time to undetectable viral load was week 2 in the telaprevir group vs week 4 in the comparator group, and 94% vs 53% had undetectable viral loads at week 4. Most patients (81%) who achieved SVR in the telaprevir group received ≤12 weeks of treatment and there were no relapses after treatment. The overall safety profile was similar to that known for telaprevir-based regimens. CONCLUSIONS Incorporating telaprevir into treatment of acute genotype 1 HCV in HIV-infected men halved the treatment duration and increased the SVR rate. Larger studies should be done to confirm these findings. Clinicians should be alert to detect acute HCV infection of HIV-infected men to take advantage of this effective therapy and decrease further transmission in this epidemic.

Extrapulmonary Pneumocystis Infection

Excerpt To the Editor:Extrapulmonary pneumocystosis has recently been reported in patients with the acquired immunodeficiency syndrome (AIDS) (1-5). This condition appears to be rare despite the hi...

High Rates of Anal High-Grade Squamous Intraepithelial Lesions in HIV-Infected Women Who Do Not Meet Screening Guidelines

Background. Human immunodeficiency virus (HIV)–infected women have a higher burden of anal high-grade squamous intraepithelial lesions (HSIL) and anal cancer (AC) compared with HIV-uninfected women. Guidelines for AC screening in this population are heterogeneous. Here we report outcomes and risk factors for anal HSIL following implementation of universal AC screening offered to all HIV-infected women. Methods. Data from women who underwent AC screening with anal cytology from April 2009 to July 2014 were analyzed. Routine clinical data included anal and cervical cytology, demographic/behavioral data, and high-resolution anoscopy (HRA) results. We evaluated the association of cytology with HRA results, and predictors of HSIL pathology, and compared rates of HSIL pathology among women meeting screening guidelines to those who did not. Results. Seven hundred forty-five HIV-infected women were screened with anal cytology. Thirty-nine percent had abnormal anal cytology on initial screen and 15% on secondary screen; 208 women underwent HRA following abnormal anal cytology. HSIL was found in 26% and 18% of anal biopsies following initial and secondary screening, respectively. One woman had AC. Cigarette smoking more than doubled HSIL risk. Among women who underwent AC screening despite not meeting existing guideline criteria, 21% and 10%, respectively, were found to have HSIL on biopsy. Neither meeting criteria for screening nor history of receptive anal sex was significantly associated with HSIL. Conclusions. Anal HSIL is common in HIV-infected women. Substantial numbers of HSIL would have been missed by strictly adhering to existing AC screening guidelines. These results support routine screening of all HIV-infected women regardless of human papillomavirus history or sexual practices.

Early-Onset Liver Fibrosis Due to Primary Hepatitis C Virus Infection Is Higher Over Time in HIV-Infected Men

To the Editor—We were pleased to read the recent report by Vogel et al [1] of their study undertaken in response to our findings of rapid onset fibrosis during primary hepatitis C virus (HCV) infection in human immunodeficiency virus (HIV)–infected men [2]. Their study, plus the recent publication of the liver biopsy results of Bottieau et al [3], seems to cement that this unexpected outcome is a true consequence of primary HCV infection in HIV-infected men. We disagree, however, that their results using transient elastography demonstrate a sharp decrease in the fibrosis progression rate (FPR) to a clinically unimportant level soon after the primary HCV infection period has waned.

Pneumocystis carinii in Bone Marrow

Excerpt To the editor:Despite the high frequency of lung infections caused byPneumocystis cariniiin immunosuppressed persons, extrapulmonary dissemination rarely occurs (1). Four cases ofP. carinii...