Sergio Babudieri

Severe liver disease associated with prolonged exposure to antiretroviral drugs

Background: Liver damage is frequently seen in HIV-positive subjects, often resulting from coinfection with hepatitis B and/or C viruses (HCV), alcohol abuse, etc. However, the etiology of liver disease still remains unknown for a small subset of individuals. Methods: Cryptogenic liver disease (CLD) was defined as persistently elevated aminotransferases levels in the absence of hepatitis C and/or B viruses replication and of other common causes of liver disease (alcohol, medications, etc). We identified cases initially meeting this definition by examining all HIV-positive subjects attended during the year 2004 in 2 large HIV clinics in Spain. Their clinical charts were retrospectively reviewed, and their assessment completed when needed to rule out other less frequent causes of liver disease. The stage of liver fibrosis was assessed by liver biopsy and/or elastography. To assess which factors could be associated with CLD, HIV-positive controls were chosen and matched by age, gender, and CD4 status. Results: CLD was diagnosed in 17 (0.5%) out of 3200 HIV-positive patients. Their mean age was 43 years, 82.4% were male, and 76% had acquired HIV through homosexual relationships. The mean time from HIV diagnosis was >15 years, and all patients had been exposed to antiretroviral therapy. Nevirapine, stavudine, and didanosine were the drugs more frequently used by this subset of patients. None of them had liver function test abnormalities before initiating antiretroviral therapy. Advanced liver fibrosis (F3-F4 Metavir scores) was recognized in 10 (58.8%) individuals, and 9 (52.9%) had developed symptomatic liver complications, including ascites (8), portal thrombosis (6), variceal bleeding (5), and encephalopathy (2). In the case-control analysis, prolonged didanosine exposure was the only independent predictor of developing CLD in this population. Conclusions: CLD is an uncommon condition in HIV-positive individuals and might be associated with prolonged didanosine exposure. It may evolve causing severe liver complications, with variceal bleeding and portal thrombosis being particularly frequent.

Long-term efficacy of interferon alpha-2b and lamivudine in combination compared to lamivudine monotherapy in patients with chronic hepatitis B. An Italian multicenter, randomized trial

BACKGROUND/AIMS To evaluate the therapeutic efficacy of interferon alpha-2b and lamivudine in combination compared to lamivudine monotherapy in patients with chronic hepatitis B. METHODS One hundred and fifty-one patients were randomly assigned to receive either recombinant interferon alpha-2b (nine million units three times per week) and lamivudine (100 mg/daily per os) for 24 weeks or lamivudine alone (100 mg/daily per os) for 52 weeks. Patients were followed up for a further 48 weeks. RESULTS Sustained HBeAg seroconversion with undetectable serum levels of HBV DNA was observed in 25 of 76 patients (33%) treated with the combination therapy and in 11 of 75 patients (15%) treated with monotherapy (P=0.014). Histological improvement defined as a reduction of at least two points in the inflammation score as compared with pretreatment score was observed in 35 of 76 patients (46%) treated with combination therapy and in 20 of 75 patients (27%) treated with monotherapy (P=0.021). Both therapeutic regimens were well tolerated. CONCLUSIONS Six-month treatment with interferon alpha-2b and lamivudine in combination appeared to increase the rate of sustained HBeAg seroconversion compared to 1-year lamivudine monotherapy. However, the potential benefit of combining lamivudine and interferon should be investigated further in studies with different regimens of combination therapy.

Incidence of Neutropenia and Infections During Combination Treatment of Chronic Hepatitis C with Pegylated Interferon Alfa-2a or Alfa-2b Plus Ribavirin

Background:Combination therapy with pegylated interferon (peginterferon) plus ribavirin is associated with several side effects, including neutropenia and infection.Aims:To evaluate the incidence of neutropenia and infection between all consecutive patients with hepatitis C who were treated in two centers with peginterferon-alfa-2a and peginterferon-alfa-2b, in combination with ribavirin and actively monitored for occurrence of any infection. Methods:A total of 319 consecutive patients with chronic hepatitis C received once-weekly peginterferon alfa-2b at a weight-adjusted dose (n = 162) or peginterferon alfa-2a at a flat dose (n = 157), plus ribavirin.Results:Neutropenia was observed in 53 patients overall (17%). There were 73 infections in 73 subjects (23% of the treated population); 4/73 required hospitalization. Infections included respiratory infections (n = 23), cellulitis (n = 17), dental abscesses (n = 13), gastroenteric infections (n = 2), and other types of infections (n = 18). The incidence of all infections was significantly associated with age, especially over 60 years (p < 0.01) but not with neutropenia or type of pegylated interferon.Conclusions:During the treatment with pegylated interferons and ribavirin, we did not find a correlation between neutropenia and infections. This result provides a support for the notion that current guidelines for pegylated interferons dose reduction in the treatment of chronic hepatitis C for hematologic toxicity could be overly strict.

Isolation of Clostridium difficile from human jejunum: identification of a reservoir for disease?

The possibility that the small intestine may represent a reservoir for Clostridium difficile was studied, using segments of human jejunum collected at necropsy. Our results (three of 100 specimens positive for C difficile culture) support the hypothesis that C difficile can be found in human jejunum and that it adheres to the normal mucosa as a resident bacterium. These findings suggest that gastrointestinal disease caused by C difficile has an endogenous origin.

Identification of HIV patients with active pulmonary tuberculosis using urine based polymerase chain reaction assay

BACKGROUND Despite the increased dissemination of tuberculosis among HIV infected patients, the diagnosis is difficult to establish. Traditional microbiological methods lack satisfactory sensitivity. We have developed a highly sensitive and specific nested polymerase chain reaction (PCR) capable of detecting Mycobacterium tuberculosis DNA in urine specimens and have used this test to examine urine specimens from HIV patients with active pulmonary tuberculosis. METHODS Urine specimens from 13 HIV infected patients with microbiologically proven active pulmonary tuberculosis, 10 AIDS patients with non-tuberculous mycobacterial infection (documented by blood culture), 53 AIDS patients with no evidence of mycobacterial disease, and 80 healthy subjects (25 with positive skin test to purified protein derivative) were tested forM tuberculosis using PCR, acid fast staining (AFS), and culture. RESULTS Of the urine specimens from patients with active tuberculosis, all tested positive by PCR, two by culture, and none by AFS. No reactivity was observed in urine specimens from patients with non-tuberculous mycobacterial infection. Of the 53 AIDS patients without mycobacterial infection, one had a positive urine PCR. Normal subjects were all negative. CONCLUSIONS Urine based nested PCR for M tuberculosis may be a useful test for identifying HIV patients with pulmonary tuberculosis.

Enzyme Biosensors for Biomedical Applications: Strategies for Safeguarding Analytical Performances in Biological Fluids.

Enzyme-based chemical biosensors are based on biological recognition. In order to operate, the enzymes must be available to catalyze a specific biochemical reaction and be stable under the normal operating conditions of the biosensor. Design of biosensors is based on knowledge about the target analyte, as well as the complexity of the matrix in which the analyte has to be quantified. This article reviews the problems resulting from the interaction of enzyme-based amperometric biosensors with complex biological matrices containing the target analyte(s). One of the most challenging disadvantages of amperometric enzyme-based biosensor detection is signal reduction from fouling agents and interference from chemicals present in the sample matrix. This article, therefore, investigates the principles of functioning of enzymatic biosensors, their analytical performance over time and the strategies used to optimize their performance. Moreover, the composition of biological fluids as a function of their interaction with biosensing will be presented.

Acute hepatitis C: A 24-week course of pegylated interferon alpha-2b versus a 12-week course of pegylated interferon alpha-2b alone or with ribavirin

Therapy of acute hepatitis C (AHC) has not yet been standardized and several issues are still unresolved. This open, randomized, multicenter trial aimed to assess the efficacy and safety of a 24‐week course of pegylated IFN (Peg‐IFN) alpha‐2b versus a 12‐week course of Peg‐IFN alpha‐2b alone or with ribavirin (RBV) in AHC patients. One hundred and thirty HCV acutely infected patients who did not spontaneously resolve by week 12 after onset were consecutively enrolled and randomized to receive Peg‐IFN alpha‐2b monotherapy (1.5 μg/kg/week) for 24 or 12 weeks (arm 1, n = 44 and arm 2, n = 43, respectively) or in combination with RBV (10.6 mg/kg/day) for 12 weeks (arm 3, n = 43). The primary endpoint was undetectable HCV RNA at 6‐month posttreatment follow‐up (sustained virological response; SVR). All patients were followed for 48 weeks after therapy cessation. HCV RNA levels were determined by real‐time polymerase chain reaction (limit of detection: 15 IU/mL) at the central laboratory at baseline, week 4, end of treatment, and 6 and 12 months posttreatment. Using an intent‐to‐treat analysis, overall SVR rate was 71.5%. In particular, an SVR was achieved in 31 of 44 (70.5%), 31 of 43 (72.1%), and 31 of 43 (72.1%) patients in arms 1, 2, and 3, respectively (P = 0.898). Sixteen patients (12.3%) prematurely discontinued therapy or were lost to follow‐up; thus, sustained response rates with per‐protocol analysis were 81.6%, 81.6%, and 81.6% for patients in arms 1, 2, and 3 respectively. With multivariate analysis, virologic response at week 4 of treatment was an independent predictor of SVR. Peg‐IFN alpha‐2b was well tolerated. Conclusion: Peg‐IFN alpha‐2b induces a high SVR in chronically evolving AHC patients. Response rates were not influenced by combination therapy or treatment duration. (Hepatology 2014;59:2101‐2109)

Multiclass HCV resistance to direct-acting antiviral failure in real-life patients advocates for tailored second-line therapies

Despite the excellent efficacy of direct‐acting antivirals (DAA) reported in clinical trials, virological failures can occur, often associated with the development of resistance‐associated substitutions (RASs). This study aimed to characterize the presence of clinically relevant RASs to all classes in real‐life DAA failures.

Activation of MSRV-Type Endogenous Retroviruses during Infectious Mononucleosis and Epstein-Barr Virus Latency: The Missing Link with Multiple Sclerosis?

The etiology of multiple sclerosis (MS) is still unclear. The immuno-pathogenic phenomena leading to neurodegeneration are thought to be triggered by environmental (viral?) factors operating on predisposing genetic backgrounds. Among the proposed co-factors are the Epstein Barr virus (EBV), and the potentially neuropathogenic HERV-W/MSRV/Syncytin-1 endogenous retroviruses. The ascertained links between EBV and MS are history of late primary infection, possibly leading to infectious mononucleosis (IM), and high titers of pre-onset IgG against EBV nuclear antigens (anti-EBNA IgG). During MS, there is no evidence of MS-specific EBV expression, while a continuous expression of HERV-Ws occurs, paralleling disease behaviour. We found repeatedly extracellular HERV-W/MSRV and MSRV-specific mRNA sequences in MS patients (in blood, spinal fluid, and brain samples), and MRSV presence/load strikingly paralleled MS stages and active/remission phases. Aim of the study was to verify whether HERV-W might be activated in vivo, in hospitalized young adults with IM symptoms, that were analyzed with respect to expression of HERV-W/MSRV transcripts and proteins. Healthy controls were either EBV-negative or latently EBV-infected with/without high titers of anti-EBNA-1 IgG. The results show that activation of HERV-W/MSRV occurs in blood mononuclear cells of IM patients (2Log10 increase of MSRV-type env mRNA accumulation with respect to EBV-negative controls). When healthy controls are stratified for previous EBV infection (high and low, or no anti-EBNA-1 IgG titers), a direct correlation occurs with MSRV mRNA accumulation. Flow cytometry data show increased percentages of cells exposing surface HERV-Wenv protein, that occur differently in specific cell subsets, and in acute disease and past infection. Thus, the data indicate that the two main links between EBV and MS (IM and high anti-EBNA-1-IgG titers) are paralleled by activation of the potentially neuropathogenic HERV-W/MSRV. These novel findings suggest HERV-W/MSRV activation as the missing link between EBV and MS, and may open new avenues of intervention.

Tuberculosis Screening before Anti–Hepatitis C Virus Therapy in Prisons

To the Editor: Prisons represent a crucial setting for tuberculosis (TB) control. Worldwide, reported TB rates for correctional system populations have been 10–100× higher than rates for the local civilian populations, and TB outbreaks with a high number of TB multidrug-resistant cases have been documented (1,2). Prisons are known as social and sanitary pathology reservoirs in which TB is often associated with chronic infectious diseases caused by HIV, hepatitis B virus (HBV), or hepatitis C virus (HCV) (2). HCV prevalence among inmates is 30%–40% (range 2%–58%), which is higher than that in the general population and is related to injection drug use (3). For these reasons, effective anti-HCV therapeutic approaches are recommended by national and international guidelines for decreasing illness, death rates, and reservoirs of infection in prisons (4,5). The standard of care for patients with chronic hepatitis C infection is represented by pegylated interferon-α (Peg-IFN) and ribavirin. These drugs determine complex antiviral, immunomodulatory, and antiproliferative actions, which can cause serious side effects such as leukopenia/neutropenia and alterations in the cytokine network (3). Although severe cellular immunodeficiency can often facilitate the development of many infections, only 4 clinical cases of TB in patients undergoing HCV antiviral therapy have been described in the literature (6–8), and only 1 of these was clearly described as a TB reactivation (7). We describe a case of pulmonary TB reactivation during therapy with Peg-IFN and ribavirin in a 44-year-old white male inmate, affected by genotype 1b/4a chronic hepatitis C. After prison admission in 2009, he underwent routine screening tests for infectious diseases, which indicated HCV antibody, HBV surface antibody, HBV core IgG antibody, and tuberculin skin test positivity. Results of chest radiograph and HIV screening were negative. His previous history involved injection drug use, smoking, and alcohol consumption. Anti-HCV therapy of directly observed administration of Peg-INF α-2a (180 µg/wk) and ribavirin (1,200 mg/d) was started. During therapy, the patient had only mild musculoskeletal pain and temporary irritability. During the 12th week of treatment, HCV-RNA decreased by 1 log10; therefore, the ribavirin dose was increased to 1,600 mg per day. Even after the therapy modification, no virologic suppression was found. Although during the 33rd week of therapy the patient had weakness, cough, and 2 episodes of hemoptysis, the results of a physical examination were unremarkable. Therapy was immediately discontinued. Sputum specimens collected on 3 consecutive days were positive for acid-fast bacilli. Nucleic acid amplification assays and cultures performed on mycobacteria growth indicator tube (Bactec MGIT; Becton Dickinson, Franklin Lakes, NJ, USA) and on Lowenstein-Jensen medium were positive for Mycobacterium tuberculosis isolates that later showed sensitivity to streptomycin, isoniazid, rifampin, and ethambutol. The patient was isolated at the Institute of Respiratory Diseases, University of Sassari–Faculty of Medicine, Sassari, Italy. A chest radiograph showed opacity in the upper right lung, and a high-resolution computed tomography scan (Figure) showed multiple lesions that were considered compatible with TB. CD4+ cell count (52.4%; 669 cells/mm3) was within reference range. Figure Computed tomography image of chest of patient with tuberculosis after anti–hepatitis C virus therapy. A parenchymal distortion 32 mm in diameter is shown in the upper right lung with initial central excavation 10 mm in diameter. Similar lesions ... TB treatment with rifampin, isoniazid, pyrazinamide, and ethambutol with pyridoxine was started. After 4 weeks of therapy, 3 sputum specimens were negative for acid-fast bacilli, but a bacterial culture was still positive; mycobacteria indicator growth tube culture was negative after 5 weeks. The interaction process between the IFN-α/β system and M. tuberculosis is not well known; nevertheless, Peg- IFN, alone and in combination with ribavirin, is considered potentially immunosuppressive (4,9). Immunodeficiency caused by Peg-IFNs and ribavirin may cause lower leukopenia/lymphopenia values than expected during anti-HCV treatment and may also lower CD4+ cell count and function (10). In the patient reported here, CD4+ cell count was within the reference range, and lung TB with excavations developed after 34 weeks of therapy. Before TB diagnosis, the patient had not shown any signs or symptoms of other infections and had not mentioned serious adverse effects from Peg-IFN and ribavirin treatment. However, the initial symptoms of TB and the common side effects of Peg-IFN therapy can be similar, which could have led to a delay in the diagnosis of TB. In conclusion, even if only a few cases of active TB have been reported in the literature, it is well known that standard anti-HCV treatment increases the risk for infections. A high proportion of patients with positive purified protein derivative results, isolation of >30% of multidrug-resistant strains of M. tuberculosis, and high prevalence of HCV antibody are concomitant among inmates. These data, together with current recommendations for increasing use of Peg-IFN and ribavirin in marginalized populations in correctional facilities, show the need to consider TB risk before starting HCV antiviral therapy. The management of simultaneous HCV and M. tuberculosis infections in prisons presents particular difficulties and pitfalls to overcome. In prisons, the clinical history of inmates should be carefully evaluated, a tuberculin skin test or Quantiferon TB in Tube test (Cellestis, Melbourne, Australia) should be performed, and, if those results are positive, a chest radiograph should be taken. Before receiving Peg-IFN, purified protein derivative–positive patients should receive anti-TB chemoprophylaxis. The case described here underscores the need for a careful and multidisciplinary evaluation of inmate patients for latent TB before administration of Peg-IFN and ribavirin therapy, thus avoiding reactivation.