Șerban Benea

Muco-cutaneous manifestations in HIV infection/AIDS

The HIV/AIDS infection is an important public health problem in Romania. The aim of this study was to evaluate the main muco-cutaneous manifestations and their frequency in patients with HIV infection/AIDS in Romania. The study was performed beginning 1988 among 400 patients with HIV infection/AIDS who attended Scarlat Longhin Clinical Hospital for Dermatology, Victor Babes Clinical Hospital of Infectious Diseases and Matei Bals National Institute for Infectious Diseases Bucharest, Romania. The patients were clinically examined; mycological examination (KOH exam, cultures) was necessary in 216 cases and histological examination was performed in 32 cases. The subjects were classified in all stages of disease. The age of patients included in the study ranged from 6 months to 82 years. Muco-cutaneous manifestations were present in 76% of patients. The main muco-cutaneous manifestations registered were infections - 283 cases (oral and/or genital candidiasis - 179 cases; molluscum contagiosum - 53 cases; warts - 37 cases; tinea - 36 cases; sexually transmitted infections - 107 cases: herpes simplex genitalis - 33 cases, urethritis - 31 cases, condylomata acuminata - 29 cases, syphilis - 17 cases; herpes zoster - 28 cases; scabies - 12 cases; intertrigo - 11 cases; hairy leukoplakia - 4 cases; acute retroviral infection - 2 cases; disseminated cryptococcosis - 2 cases; bacillary angiomatosis, ganglionar tuberculosis - 1 case each), xerosis - 172 cases, papular eruptions - 87 cases, seborrheic dermatitis - 57 cases, atopic dermatitis - 24 cases, drug reactions - 21 cases, cancers - 20 cases (Kaposi sarcoma - 16 cases, basal cell carcinoma - 4 cases), psoriasis - 7 cases. Muco-cutaneous manifestations in HIV infection/AIDS are frequent and polymorphous. They can occur at any point in time, but their frequency and severity are increasing as HIV infection progresses. Dermatological examination is an important step in evaluation of patients HIV-positive.

Comparison of Kaposi disease outlines in patients with and without HIV infection in two tertiary care hospitals in Bucharest, Romania

Methods A retrospective study on KD was performed in two academic centers, tertiary-care hospitals with national addressability in Romania. Two groups were comparatively studied: HIV-infected patients diagnosed in the National Institute for Infectious Diseases “Prof.Dr. Matei Bals” (HIV-positive group), and non-HIV patients diagnosed in the first Clinic of Dermatology, Colentina Clinical Hospital (HIV-negative group). The statistical analysis was performed using IBM SPSS Statistics v.22 (Chicago, USA).

Difficulties in controlling HIV and TB infections in multi-experienced patients

The treatment of extra pulmonary tuberculosis in HIV infected patients experienced to antiretroviral therapy raises major issues of adherence, drug interactions, side effects and limited antiretroviral alternatives. This is the case of a 24 year old woman from countryside, most probably infected in 1989. She was diagnosed with HIV infection in 2000 after repeated admissions in hospital for pneumonia. She started ART when diagnosed with a favorable evolution: CD4 cell count increased from 200 to 674 cells/cmm, and HIV RNA levels became undetectable. She turned 18 in 2008 and refused to take her treatment for almost two years. She returned to the hospital in April 2010 with a CD4 cell count of 140 cells/cmm. She started again antiretroviral therapy with ABC+3TC+FPV/r. In April 2013 she is admitted with night sweats, chills and fever. At that time her CD4 cell count was 144 cells/cmm and had 461,000 copies/mL RNA-HIV. Her chest XR showed right pleural effusion, widened mediastinum and the CT revealed infiltrative-like lesion at subcarinal and retrocarinal level. Biopsy was performed and she was diagnosed with ganglionary tuberculosis. She started anti-TB treatment HRZE 7/7 and the ART was changed to ABC+RAL+T20. The anti-TB regimen is changed after three months to rifampicin and isoniazid 7/7 because she accused arthralgias, tingling of the extremities, blurred vision and decreased visual acuity. She was diagnosed with hyperuricemia (pyrazinamide) and optic and peripheral neuritis (ethambutol). New visit at the clinic for fatigability, after 7 months of antiretroviral therapy with ABV+RAL+T20. The CD4 cell count was 9 cells/cmm and RNA-HIV was 61,000 copies/mL. She admits taking 1 cp of Raltegravir BID, but denies any other adherence problem. The resistance test showed evidence of resistance to some NRTIs, to all NNRTIs, to RAL and no resistance to PIs. The tropism test showed that maraviroc can be used. We have excluded relapse of tuberculosis and other diseases associated. The ART was changed again to TDF+DRV/r+MRV and the anti-TB treatment is change to isoniazid and moxifloxacin. Adherence can be an important issue when treating patients for long periods of time. Other important issues are the drug-drug interactions (rifampicin – PIs) and the increased side effects which may lead to loss of good friends (Raltegravir). The poor outcome for this patient may be due to poor HIV and tuberculosis control.

Difficulties in the management of the meningitis with C. neoformans

The management of the meningitis with C. neoformans raises many problems: the choosing of the appropriate antifungal therapy, the prevention and/or the control of the complications, the correct management of the antiretroviral therapy. We report two cases with HIV infection same immunological and clinical stage, the first of them with relatively recent infection, the second with long-term infection (>20 years) and antiretroviral therapy experienced, but discontinued for 4 years, who developed the same opportunistic infection: cryptococcal meningitis. Although immunological status was similar in both patients, cerebrospinal fluid inflammatory response was stronger in patient infected latest; both had increased cerebrospinal fluid pressure, requiring repeated lumbar punctures. The antifungal treatment algorithm was applied according to guidelines, to availability of medications at that time and antifungal susceptibility testing results. Although the combination of fluconazole plus flucytosine is knowed as being clinically inferior to amphotericin B–based therapy, faster rate of cerebrospinal fluid sterilization was seen in patient with greater cerebrospinal fluid inflammatory response rather than in patient receiving antifungal therapy considered as “gold standard”. To avoiding the immune reconstitution syndrome, antiretroviral therapy was initiated in both cases after more than 4 weeks of therapy of opportunistic infection (after 2 weeks of sterilizing cerebrospinal fluid cultures); however, the patient with long-term HIV infection developed immune reconstitution syndrome after 21 days of initiating therapy. Choosing antiretroviral therapy was achieved in both cases according to guidelines, depending on the patient’s medical history (including previous regimens therapy) and drug interactions. Our cases illustrate that the same disease can have different solutions because the patient makes the difference.

Characteristics of Kaposi sarcoma in HIV-infected patients

Objective: to describe clinical and laboratory characteristics; to assess predictors for death in HIV-infected patients with Kaposi sarcoma (KS). We performed a retrospective study of HIV-infected patients diagnosed with KS in one infectious diseases hospital in Romania, between January 2008-November 2013. KS diagnosis was established on physical examination, skin biopsy, and for visceral involvement upper gastrointestinal endoscopy, bronchoscopy and computed tomography. KS was staged according to the AIDS Clinical Trials Group (ACTG) [1] and the Mitsuyasu classification system [2]. We identified 27 HIV-infected patients with KS. The median age was 42 years (IQR 34-52) and 18 (67%) were male. The median CD4 count at HIV diagnosis was 195 cells/cmm (IQR 55-313), while at KS diagnosis the median CD4 count was 101 cells/cmm (IQR 41-270). Eighteen (67%) patients had a CD4 count <200 cells/cmm. The median HIV viral load at the time of KS diagnosis was 120,000 copies/mL (IQR 316-328,522). HIV infection was diagnosed before KS in 19 patients (70%), with a median time between HIV and KS diagnosis of 7 months (IQR 0-58). The most frequent KS localization was the lower limb in 16 (59%) patients and 7 (26%) patients had disseminated KS. Oral, gastrointestinal and pulmonary involvements were seen in 10 (37%), 4 (15%) and 3 (11%) patients respectively. Concomitant opportunistic infections were diagnosed in 20 (74%), while other malignancies in 3 (12%) patients. According to the ACTG classification 16 (59%) patients had poor risk KS. Fifteen (56%), 6 (22%), 1 (4%) and 5 (18%) were in stage 1, 2, 3 and 4, respectively according to the Mitsuyasu classification. Six (22%) patients received specific KS treatment: three local radiotherapy and three systemic therapy (two with interferon; one with liposomal doxorubicin). The overall mortality was 41% with a median duration between KS diagnosis and death of 6 months (IQR 2-15). Gastrointestinal involvement (p=0.019), poor-risk KS in ACTG classification (p<0.001) and stage IV Mitsuyasu (p=0.006) were associated with death in univariate analysis. The mortality rate in this study was high, due to poor immunological status, extended KS and high incidence of opportunistic infections, but also due to the lack of specific systemic treatment.

Syphilitic encephalitis - a rare disease and a possible differential diagnosis of herpetic encephalitis.

Case report We present the case of a 41 year-old male, diagnosed with syphilitic encephalitis, in whom cerebral magnetic resonance imaging demonstrated preponderant involvement of bilateral temporal lobes, for this point of view raising differential diagnostic concerns with Herpes virus encephalitis. We also identified multiple encephalitis foci: hippocampus, lentiform nucleus, left thalamus, left midbrain, and bilateral occipital. The detection of herpes simplex virus DNA by PCR in CSF obtained at admission was negative. Furthermore, the subacute onset as a maniacal syndrome delayed the diagnostic, the patient being initially treated as psychiatric disorder in a Psychiatric Unit.

Initiating the antiretroviral therapy in treatment-naive patients.

Background The national guideline extends the recommendation for initiating antiretroviral therapy in HIV infected persons, regardless of baseline CD4 since 2013 but the choice of treatment regimens in our guide is determined by the CD4 levels. Objectives: analyzing ART regimens prescribed in newly HIV-infected patients, identifying the factors that influenced regimens choice and analyzing viro-immunological evolution under therapy.

A rapid progressive and fatal case of Non-Hodgkin’s lymphoma in a newly diagnosed HIV patient

Background Non-Hodgkin’s lymphoma (NHL) is one of the frequent and severe oncologic pathologies associated with HIV infection. Unlike in immunocompetent patients, this pathology manifests more aggressively in HIV-positive patients, frequently with severe systemic extranodal involvement, affecting the gastrointestinal tract, liver, bone marrow, central nervous system (CNS). Along extranodal involvement, the low level of CD4 at diagnosis, previous history of AIDS-defining illness, the NHL advanced stage, high LDH level and advanced age, are unfavorable prognostic factors for NHL associated with HIV infection.

Severe and prolonged febrile agranulocytosis under thyrosol

Background It is well known that patients with severe neutropenia are susceptible to bacterial infections, which may become lifethreatening. This hematologic disorder frequently occurs as an adverse effect of certain drug therapies. One of them, currently encountered in practice, is therapy with antithyroid drugs. An infective source is identified in average in 20-30% of febrile neutropenia episodes. Often the only infection proof is bacteremia, documented in 10-25% of patients.

Herpetic meningoencephalitis and neurosyphilis – a rare association

Background A sudden onset of symptoms that sums up confusion and memory loss, associated with the characteristic cerebral MRI changes: T2 hyperintensity in mediotemporal area, are usually highly evocative for herpetic meningoencephalitis. The medical literature data describe cases of patients with symptoms and MRI changes that are typical for this infectious pathology, but that proved to be in fact cases of neurosyphilis mimicking herpetic meningoencephalitis.