Otilia Benea

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).

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).

Efficacy and safety of darunavir (Prezista(®)) with low-dose ritonavir and other antiretroviral medications in subtype F HIV-1 infected, treatment-experienced subjects in Romania: a post-authorization, open-label, one-cohort, non-interventional, prospective study.

INTRODUCTION The aim of the study was to assess the safety and efficacy of darunavir (Prezista(®)) used in subtype F human immunodeficiency virus - type 1 (HIV-1) infected, antiretroviral therapy (ART)-experienced patients in Romania in routine clinical practice. METHODS This was a post-authorization, open-label, one-cohort, non-interventional, prospective study conducted at multiple sites in Romania to assess efficacy (CD4 cell count, viral load, and treatment compliance) and safety ([serious] adverse events, clinical laboratory evaluation, and vital signs) of darunavir in combination with low-dose ritonavir (DRV/r) and other antiretroviral (ARV) medications in subtype F HIV-1 infected subjects in naturalistic settings. Seventy-eight subjects were recruited by 9 investigational sites and received 600/100 mg DRV/r twice daily. RESULTS Treatment with DRV/r administered with other ARV medications resulted in the expected, statistically relevant improvement of CD4 cell count and viral load in subjects eligible for such treatment. In addition, adherence to treatment was high and the treatment-emergent safety profile observed during this study was consistent with the established safety profile of darunavir. CONCLUSION DRV/r administered in combination with other ARV medications in subtype F HIV-1 infected subjects in naturalistic settings proved to be an effective and safe treatment in Romania. TRIAL REGISTRATION NCT01253967.

Kaposi Sarcoma in HIV Infected Patients

Abstract Objective: The aim of the study was to describe clinical and laboratory characteristics in HIV-infected patients with Kaposi sarcoma (KS). Methods: We retrospectively studied data on HIV-infected patients hospitalized in one tertiary care hospital in Bucharest, Romania, in whom Kaposi Sarcoma was diagnosed, between January 2008 and November 2013. Results: We identified 27 HIV-infected patients diagnosed with KS within 6 years. They had a median age of 42 years old and a median CD4 cell count of 101 cells per mm3 at the time of KS diagnosis. All patients received antiretroviral therapy (ART), with 18 patients (66%) already on ART at the time of KS diagnosis. Most patients (59%) were classified as ACTG poor-risk and 56% as Mitsuyasu stage I. The overall prognosis was poor, with 41% mortality, in a median time span of 6 months, significantly correlated with gastrointestinal involvement (p=0.019), poor-risk KS in ACTG classification (p<0.001) and stage IV Mitsuyasu (p=0.006). Conclusion: KS remains an important cause of morbidity and mortality in patients with HIV infection, especially in late presenters.

Short-term evaluation of immediately-treated patients with acute HIV infection, recently diagnosed in the National Institute for Infectious Diseases "Prof. Dr. Matei Balş", Bucharest, Romania

Methods All newly-diagnosed HIV-infected adults (>18 yo) in the last 18 months (01.2013-06.2014) in an infectious diseases hospital were considered. The including criteria for AHI group were: detectable HIV-RNA or positive antigen/antibody combination assays in the setting of a negative/indeterminate HIV Western blot. AHI group was classified accordingly to Fiebig stages and was further evaluated regarding CD4 count and viral load (VL) at diagnosis, at 3 and 6 months. ART initiation and the regimen were also registered.

HIV low-level persistent viremia under new antiretroviral regimens: what we have learned up to this point?

Methods A cohort, retrospective study was conducted in Adult Clinic I of the National Institute for Infectious Diseases “Prof. Dr. Matei Bals”, Bucharest, over a 6 year-period (01.2008-12.2013). The main inclusion criteria were: HIV-positive patients stable on ART (>6 months) at their first regimen, good adherence and absence of other medication susceptible for drug-drug interactions with ART. We recorded the demographical data (age/gender), the HIV transmission route, CDC stage, the baseline immune-virological status (CD4 count, HIV-VL and genotypic mutations) and ART regimen. There were also registered subsequently CD4 count and HIV-VL (biannually taken). We then analyzed the management of the patients found with LLV: maintaining the current ART regimen and close monitoring, ART intensification or ART switch. LLV was defined as VL >50 and <1000 copies/mL in at least 2 determinations over a 24 week-period, after at least 24 weeks of stable ART. Results Of 61 patients screened, 35 met the inclusion criteria. The median age was 38 years, (IQR, 32-51) and 71.4% (n = 25) were male. According to 1993 CDC classification, 42.8% (n = 15) were A2 and 22.8% (n = 8) were C3. Sixty percent (n = 21) were heterosexually infected. The median baseline CD4 count was 292 cells/cmm (IQR, 179-376), and median VL was 5.1 log10 copies/mL (IQR, 4.4-5.4). Two patients had detectable baseline mutations. All ART regimens contained 2 NRTI plus one as following: boosted-lopinavir (11 patients), efavirenz (10 patients), boosted-darunavir (6 patients), boostedatazanavir (5 patients) and raltegravir (3 patients). Of 11 patients (31.4%) who had detectable VL at 6 months, 5 met the LLV definition criteria. Their median VL was 267 copies/mL and the median CD4 count was 551/cmm. None of them had had baseline mutations. They didn’t have changes in the current ART regimen, except one patient in whom we increased darunavir dose to 1200 mg/ day. At 12 months their median CD4 count raised to 743/cmm and the median VL declined to 150 copies/mL.

A case of hospital-acquired GNB infection - P. aeruginosa meningoencephalitis post laparoscopic cholecystectomy for biliary pancreatitis, complicated with portal vein branch thrombosis and intracerebral ischemic and hemorrhagic lesions

Case report We present the case of a female patient admitted to our clinic with a suspicion of acute bacterial meningoencephalitis, one month after a laparoscopic cholecystectomy. During the first 48 hours she presented generalized seizures, 5-6 daily, with a duration that ranged from 30 to 60 seconds, that responded to medical therapy. The CSF cultures and the pulmonary tract secretions both tested positive for P. aeruginosa. The antibiotic regimen consisted of iv meropenem, colistin and ciprofloxacin for 7 days, then meropenem and ciprofloxacin for 21 days. The evolution and the treatment decisions were complicated by the discovery on the cerebral MRI of bilateral frontal ischemic and hemorrhagic lesions and a portal vein branch thrombosis. The patient registered almost complete cognitive and motor recovery, and is continuing the kinetotherapy.

Surveillance of mother to child transmission of HIV in Romania, a 12 years’ experience in the National Institute for Infectious Diseases “Prof. Dr. Matei Balş”

Surveillance of mother to child transmission of HIV in Romania, a 12 years’ experience in the National Institute for Infectious Diseases “Prof. Dr. Matei Bals” Mariana Mărdărescu, Cristina Petre, Adrian Streinu-Cercel, Sorin Petrea, Ruxandra Neagu-Drăghicenoiu, Rodica Ungurianu, Ana Maria Tudor, Alina Cibea, Delia Vlad, Mihai Mitran, Otilia Benea, Dan Oțelea, Carmen Crăciun, Tatiana Colțan, Marieta Iancu, Ionel Ionel, Alexandra Mărdărescu

Factors associated with poor outcome in right heart endocarditis

Results Males predominated (64.2%), patients in the age group 20-39 years (83%), those from urban areas (81%) and unemployed persons (69.8%). The infection was localized to the tricuspid valves – 42 cases, tricuspid valves plus left heart – 6 cases, right atrial wall – 3 cases, pulmonary valve – 1 case, right atrial device – 1 case. The main risk factor for right endocarditis was as IV drug use (86.8%). 87% of patients had HCV infection and 52.2% were HIV infected. Blood cultures were positive in 73.6% of cases. Staphylococcus aureus was the most frequently isolated (73.7%), type MSSA in 51.3% of cases. Under treatment with antibiotics, anticoagulants, diuretics evolution was towards improvement in 52.8% of cases and 18.9% for death. Factors associated with risk of poor outcome were: the presence of tricuspid murmurs (from 8/10 deaths vs. 13/43 survivors, p=0.003; OR=9.231, 95%CI: 1.71949.55), the occurrence of embolic complications (4/10 deaths vs. 5/43 survivors, p=0.03; OR=5.067, 95%CI: 1.05224.39), the presence of multiple pulmonary microabscesses (8/10 patients vs. 14/43, p=0.004; OR=8.286, 95%CI: 1.55144.26), tricuspid vegetations larger than 10 mm (7/10 deaths vs. 5/43 survivors, p=0.0002; OR=17.73, 95%CI: 3.431-91.66), the association of HIV infection with elevated HIV-RNA and severe immune deficiency with CD4 below 200 cells/cmm.

What is the correct therapeutic approach in patients with advanced HIV infection associated with ≥ 3 AIDS defining illness?

Case report We present a case of a 29 years old patient, MSM, confirmed with HIV infection in 2007 but who do not accept the diagnosis and returns to our service in 2013. He was diagnosed with generalized Kaposi sarcoma (extensive skin lesions, sores in the mouth and cavum, lung injury; the clinical diagnosis was confirmed by skin biopsy and lung CT), cerebral toxoplasmosis (specific to brain MRI image with anti-toxoplasma IgG positive), disseminated tuberculosis (positive blood cultures for M tuberculosis) and genital herpes with large lesions and necrotic component, at a CD4 = 2 cells/cmm. Treatment was complex, for getting every opportunistic infection; because of the complexity of the case and the hematologic associated events (severe leucopenia, anemia and thrombocytopenia) has not been discussed the specific therapy for Kaposi’ sarcoma. After 6 weeks of antinfectious treatment and correction of associated metabolic and hematological disorders, the antiretroviral therapy with Abacavir, Epivir and Raltegravir was introduced. Without developing immune reconstitution syndrome the evolution was unfavorable to death. Conclusion We discuss the correct therapeutic approach for the treatment of AIDS-defining diseases associated and the proper management of this type of patient.