Exuberant case of erythema elevatum diutinum in a patient infected with HIV and hepatitis B virus

Abstract Erythema elevatum diutinum is a small vessel vasculitis which is benign, rare, and chronic. It is clinically characterized by violaceous, brown, or yellowish plaques, nodules, and papules. It has been associated with autoimmune, infectious, and neoplastic processes. The following case describes a patient with hepatitis B virus and human immunodeficiency virus with CD4 count < 200 mm3, HIV-seropositive for 16 years, and diagnosed with hepatitis B virus at the hospital. The patient was treated with oral dapsone 100 mg/day, showing regression after seven months of treatment. The authors found three cases in the literature of association of erythema elevatum diutinum, human immunodeficiency virus, and hepatitis B virus.

Aging, neurocognitive impairment and adherence to antiretroviral therapy in human immunodeficiency virus-infected individuals

ABSTRACT Background/objective: There is an increasing number of older patients with human immunodeficiency virus infection due to the success of antiretroviral therapy, the improved prognosis and life expectancy of patients, and the higher number of new infections among older individuals. The main objective of the present study was to compare the characteristics of older human immunodeficiency virus patients with those of younger patients. Materials and methods: We conducted a cross-sectional study with human immunodeficiency virus-infected patients who were treated at the Specialized Care Service (Serviço de Assistência Especializada) for human immunodeficiency virus/AIDS in the city of Pelotas, South Brazil. Sociodemographic information as well as data on human immunodeficiency virus infection and treatment were collected. All participants underwent psychiatric and neurocognitive assessments, and their adherence to antiretroviral therapy was evaluated. Results: A total of 392 patients participated in the study, with 114 patients aged 50 years and older. The characteristics showing significant differences between older and younger human immunodeficiency virus-infected patients included race/ethnicity, comorbidities, duration and adherence to antiretroviral therapy, currently undetectable viral load, and cognitive impairment. Compared to younger patients, older patients were at higher risk of exhibiting cognitive impairment [OR 2.28 (95% CI: 1.35-3.82, p = 0.002)] and of having increased adherence to antiretroviral therapy [OR 3.11 (95% CI: 1.67-5.79, p < 0.001)]. Conclusions: The prevalence of neurocognitive impairment remained high in human immunodeficiency virus-infected patients despite antiretroviral therapy. In the present study, the prevalence of this type of impairment was significantly higher in patients aged ≥50 years, most likely due to aging, human immunodeficiency virus infection, and a possible synergistic effect between these factors. Despite this higher prevalence, older patients exhibited higher rates of adherence to antiretroviral therapy and of undetectable human immunodeficiency virus viral load.

Depressive symptoms in HIV-infected patients treated with highly active antiretroviral therapy / Sintomas depressivos em pacientes infectados pelo HIV tratados por terapia antiretroviral altamente ativa

INTRODUCTION: The prevalence of depressive disorders in HIV-infected patients ranges from 12% to 66% and is undiagnosed in 50% to 60% of these patients. Depression in HIV-infected individuals may be associated with poor antiretroviral treatment (ART) outcomes, since it may direct influence compliance. OBJECTIVE: To assess the presence of symptoms and risk factors for depression in patients on ART. METHODS: Cross-sectional study. Certified interviewers administered questionnaires and the Beck Depression Inventory (BDI), and participants' self-reported compliance to ART. Clinical and laboratory variables were obtained from clinical records. Patients with BDI > 12 were defined as depressed. RESULTS Out of the 250 patients invited to participate, 246 (98%) consented. Mean age was 41 ± 9.9 years; most were male (63%). Income ranged from 0-14 Brazilian minimum wages. AIDS (CDC stage C) had been diagnosed in 97%, and 81% were in stable immune status. One hundred ninety-one (78%) reported compliance, and 161 (68%) had undetectable viral loads. The prevalence of depressive symptoms was 32% (95% CI 26-40). In multivariate analysis, depressive symptoms were significantly associated with income (prevalence ratio [PR] = 0.85; 95% CI 0.74-0.97; p = 0.02). CONCLUSIONS: Depressive symptoms are frequent in patients on ART, and are associated with low income.

INTRODUÇÃO:A prevalência de transtornos depressivos em pacientes infectados pelo HIV varia de 12% a 66% e não é diagnosticada em 50% a 60% desses pacientes. A depressão em indivíduos HIV positivo pode se associar a resultados fracos do tratamento antirretroviral (TAR) porque pode influenciar diretamente a aderência ao regime. OBJETIVO: Avaliar a presença de sintomas e de fatores de risco de depressão em pacientes em TAR. MÉTODOS: Estudo em corte transverso. Entrevistadores certificados administraram questionários e o Beck Depression Inventory (BDI), e os participantes fizeram o autorrelato da aderência ao TAR. Variáveis clínicas e laboratoriais foram obtidas dos prontuários clínicos. Os pacientes com escore ao BDI > 12 foram definidos como deprimidos. RESULTADOS: Dos 250 pacientes convidados a participar, 246 (98%) concordaram. A média de idade foi de 41 ± 9,9 anos; a maioria dos pacientes era do sexo masculino (63%). A renda variou de 0-14 salários mínimos brasileiros. A AIDS (estágio C dos CDC) havia sido diagnosticada em 97% e 81% estavam em estado imune estável. Dos pacientes, 191 (78%) relataram aderência e 161 (68%) tinham carga viral não detectável. A prevalência dos sintomas depressivos foi de 32% (IC 95% 26-40). Em análise multivariada, os sintomas depressivos se associaram significativamente à renda (razão de prevalência [RP] = 0,85, IC 95% 0,74-0,97; p = 0,02). CONCLUSÕES: Os sintomas depressivos são frequentes em pacientes em TAR e se associam a uma renda baixa.

Prevalência de alterações hematológicas em mulheres com HIV/AIDS assistidas em serviço especializado: relato de série de casos / Prevalence of haematological disorders in women with HIV/Aids:series of cases in a specialized service

Alterações hematológicas estão entre as principais comorbidades da infecção pelo HIV e podem comprometer drasticamente o curso da doença. Anemia e leucopenia são geralmente causadas por inadequada produção devido à supressão medular pelo HIV, que produz citocinas e altera a microestrutura medular. Plaquetopenia é causada por destruição imuno-mediada das plaquetas em associação à inadequada produção destas. Este trabalho objetiva relatar a prevalência de anemia, leucopenia e plaquetopenia nas pacientes HIV positivas atendidas pelo Serviço de Atendimento Especializado (SAE) de Pelotas, RS, e mostrar a importância do pedido regular de hemograma com plaquetas nos pacientes tratados pelo HIV. Métodos: Relato de série de casos em que foram analisados 115 eritrogramas, 112 leucogramas e 99 contagem de plaquetas das pacientes do SAE. Esses exames foram inseridos em um banco de dados e os valores de referência foram usados de acordo com o determinado pela OMS. Resultado: 56,5% das pacientes foram consideradas anêmicas, enquanto que 34,8% eram leucopênicas. Plaquetopenia foi observado em 8,1% das pacientes, e a associação anemia mais leucopenia esteve presente em 18,9% das mulheres atendidas pelo SAE. Conclusão: Assim como descrito na literatura, anemia é a alteração hematológica mais frequente em pacientes HIV positivos. As desordens leucopenia e plaquetopenia também são relevantes. Devido a alta prevalência dessas alterações, tem grande importância o pedido de hemograma com plaquetas nas pacientes HIV positivas e o dever do médico em saber reconhecer e tratar as alterações hematológicas, bem como seus sintomas.

Hematological changes are among the major co-morbidities of HIV infection and may dramatically affect the course of the disease. Anemia and leukopenia are usually caused by inadequate production due to bone marrow suppression by HIV, which produces cytokines and alters the marrow microstructure. Thrombocytopenia is caused by immune-mediated destruction of platelets, in association with inadequate production of these. This paper aims to report the prevalence of anemia, leukopenia and thrombocytopenia in HIV positive patients served by the Specialized Treatment Unit (SAE) in Pelotas, RS, and show the importance of requesting regular blood tests with platelets counts in patients with HIV. Methods: Case series in which we examined 115 RBC counts, 112 WBC counts and 99 platelet counts of patients from SAE. These tests were entered into a database and reference values were used as determined by the WHO. Results: 56.5% of patients were considered anemic, while 34.8% were leukopenic. Thrombocytopenia was observed in 8.1% of patients, and the association anemia-leukopenia was present in 18.9% of the women treated in the SAE. Conclusion: Anemia was the most frequent hematological change in this series. While relevant, leukopenia and thrombocytopenia occurred to a lesser frequency.

Characteristics of HIV antiretroviral regimen and treatment adherence

The relationship between characteristics of HIV antiretroviral regimens and treatment adherence was studied in adolescent and adult patients who underwent antiretroviral therapy from January 1998 to September 2000, at the Service for Specialized Assistance in Pelotas. The patients were interviewed on two occasions, and the use of antiretrovirals during the previous 48 hours was investigated by a self-report. Adherence was defined as use of 95 percent or more of the prescribed medication. Social-demographic variables were collected through direct questionnaires. The antiretroviral regimen and clinical data were copied from the patients' records. Associations between the independent variables and adherence were analyzed by means of logistic regression. The multivariate analysis included characteristics of the antiretroviral regimens, social-demographic variables, as well as perception of negative effects, negative physiological states, and adverse effects of the treatment. Among the 224 selected patients, 194 participated in our study. Their ages varied from 17 to 67 years; most patients were men, with few years of schooling and a low family income. Only 49 percent adhered to the treatment. Adherence to treatment regimens was reduced when more daily doses were indicated: three to four doses (odds ratio of adherence to treatment (OR)=0.47, 95 percent confidence interval (CI) 0.22-1.01) and five to six (OR=0.24, 95 percent CI 0.09-0.62); two or more doses taken in a fasting state (OR=0.59, 95 percent CI 0.11-0.68), and for patients who reported adverse effects to the treatment (OR=0.39, 95 percent CI 0.19-0.77). Most of the regimens with more than two daily doses of medication included at least one dose apart from mealtimes. The results suggest that, if possible, regimens with a reduced number of doses should be chosen, with no compulsory fasting, and with few adverse effects. Strategies to minimize these effects should be discussed with the patients

Predictors of undetectable plasma viral load in HIV-positive adults receiving antiretroviral therapy in Southern Brazil

Factors associated with undetectable viral load (<80 copies/ml) were investigated among non-pregnant adults in antiretroviral treatment in a specialized service for HIV/AIDS in Southern Brazil. Use of antiretrovirals was investigated in two interviews (one month interval). Clinical data were collected from the clinical records; viral load previous to adherence measurement was defined the viral load previous to the first interview; the final viral load, the viral load subsequent to the second interview (interval between measures approximately 6 months). Undetectable final viral load occurred in 48 of the patients and was positively associated with levels of treatment adherence (p<0.001), being 19 for less than 60 of adherence and about 60 for adherence greater than 80. In the multivariate model, the odds of undetectable final viral load was four times greater for 80-94 and > or =95 of adherence (CI 95 1,80-13,28; CI 95 1,73-9,53), compared with less than 60 adherence; it was greater for less than 6 months in treatment (OR = 3.37; CI 95 1.09-10.46); and smaller for viral load previous to adherence measurement 5.2 log10 (OR = 0.19; CI95 0.06-0.58), adjusted for these variables and sex, age, clinical status, current immune status, group of drugs and interval between the two measurements of viral load. The crude odds were lower for age 16-24 years and use of Nucleoside Analog Reverse Transcriptase Inhibitors only, but these effects were not significant in the multivariate model. There was no evidence of effect of sex, clinical status, current immune status, and changes in treatment regimen. Treatment adherence gave the largest effect. Motivational interventions directed at adherence may improve treatment effectiveness.

Desenvolvimento de uma escala de auto-eficácia para adesão ao tratamento anti-retroviral / Development of a scale of self-efficacy for adherence to antiretroviral therapy

Uma escala de expectativa de auto-eficácia para seguir prescriçäo anti-retroviral em situaçöes difíceis (21 itens) foi desenvolvida pela análise do conteúdo de entrevistas com pacientes que estavam em tratamento ou que o abandonaram. A consistência interna e a validade de construto foram examinadas em 60 sujeitos que freqüentaram ambulatório para pacientes em estágios avançados da doença (hospital-dia). Um escore de expectativa de auto-eficácia para adesäo ao tratamento foi derivado do primeiro componente da análise de componentes principais. A média do escore foi 0,25 para os sujeitos aderentes e -0,33 para os näo-aderentes ao tratamento (teste t, p = 0,046). A chance de adesäo duplicou quando o escore de expectativa de auto-eficácia era maior em uma unidade (OR = 2,07; IC95 por cento = 1,002 a 4,26). A consistência interna foi alta (alfa de Cronbach = 0.96). A escala demonstrou validade de construto e confiabilidade para medir auto-eficácia para tratamento anti-retroviral nesses pacientes