Avaliação dos efeitos colaterais da nevirapina em gestantes HIV positivo em Hospital Universitário do sul do Brasil / Evaluation of the adverse effects of nevirapine in HIV-infected pregnant women in a South Brazilian University Hospital

OBJETIVO: avaliar a freqüência de efeitos advesos com o uso da nevirapina e suas correlações em gestantes infectadas pelo vírus da imunodeficiência humana (HIV). MÉTODOS: estudo retrospectivo foi realizado entre janeiro de 2003 e dezembro de 2006, incluindo todas as mulheres que utilizaram nevirapina durante a gestação. Os critérios de exclusão foram: início da nevirapina antes da gestação; presença de enzimas hepáticas basais aumentadas e dados incompletos de bioquímica hepática no prontuário. Os parâmetros avaliados foram idade, duração de exposição à nevirapina, idade gestacional no início da medicação, semanas de seguimento, carga viral, contagem de CD4 e dosagens de transaminases. A incidência de efeitos adversos hepáticos e/ou cutâneos foi determinada e correlacionada com a contagem de CD4. As análises estatísticas foram realizadas utilizando o teste exato de Fisher e o teste t de Student quando apropriado. A significância estatística foi estabelecida quando p<"0,05. RESULTADOS: cento e cinqüenta e sete gestantes foram incluídas nos critérios estabelecidos. Trinta e uma mulheres (19,7 por cento) apresentaram toxicidade cutânea e/ou hepática. Rash cutâneo foi responsável por 77,4 por cento das toxicidades e anormalidade da função hepática por 22,6 por cento. Hepatotoxicidades graus 1, 2 e 3 foram observadas em 0,6, 2,5 e 1,3 por cento, respectivamente. Contagem de CD4, carga viral e dosagem de transaminases basais foram similares em gestantes com e sem reação induzida pela nevirapina. A contagem de CD4 média foi de 465,4 e 416,6 células/µL em mulheres com e sem efeitos colaterais, respectivamente (p=0,3). Todas as pacientes que apresentaram hepatotoxicidade apresentavam contagem de CD4 prévia ao tratamento superior a 250 células/µL. CONCLUSÕES: a incidência de eventos adversos com nevirapina em nosso estudo foi alta, mas a maioria deles foi cutâneo. Não houve correlação entre a alta contagem de CD4 e os eventos adversos quando se analisou conjuntamente as reações cutâneas e hepáticas; entretanto, a hepatotoxicidade ocorreu apenas em gestantes com contagem de CD4 > 250 células/µL.

PURPOSE: The aim of this article is to evaluate the use of nevirapine HIV-infected pregnant women in our service. METHODS: a retrospective study was performed between January 2003 and December 2006 analysing all women prescribed nevirapine in pregnancy. Exclusion criteria included: (1) women who started nevirapine before pregnancy, (2) patients with abnormal baseline liver enzymes, and (3) women with incomplete liver biochemistry data. Evaluated parameters included age, weeks of exposure to nevirapine, gestational age in the begginning of medication, weeks of follow-up, viral load, CD4 cells count and serum aminotransferase levels. The incidence of adverse hepatic and/or cutaneous effects was determined and correlated to the CD4 cells count. Statistical analysis were performed using Fisher’s exact test and t-Student test when appropriate, with a statistical significance level of p<0,05. RESULTS: one hundred fifty-seven women met the inclusion criteria. Thirty-one (19.7 percent) presented cutaneous and/or hepatic toxicity. Skin rash accounted for 77.4 percent of toxicities and liver function abnormalities were noted in 22.6 percent of women exhibiting toxicities. Grade 1, 2 and 3 hepatotoxicities were observed in 0.6, 2.5 and 1.3 percent, respectively. Baseline CD4 counts, viral loads and transaminases were similar in pregnant women with nevirapine adverse effects and those without reaction. Median absolute CD4 cell counts were 465.4 and 416.6 cells/µL in women with and without side effects, respectively (p=0.3). All patients who experienced hepatotoxicity had pretreatment CD4 counts superior to 250 cells/µL. CONCLUSIONS: The incidence of adverse events with nevirapine in our study was high, but most of them were cutaneous. There was no correlation between high CD4 counts and adverse events when analysing both cutaneous and hepatic reactions; nevertheless, hepatotoxicity occurred only in pregnant women with CD4 counts >250 cells/µL.

Nevirapine-induced side effects in pregnant women: experience of a brazilian university hospital

Nevirapine-based therapy is associated with increased frequency of adverse events among HIV-infected pregnant women. The aim of this article was to evaluate the incidence of adverse effects in HIV-infected women who started nevirapine during pregnancy. A retrospective study was performed in our center between January 2003 and December 2006 analyzing all women prescribed nevirapine during pregnancy. Women presenting any risk factor for hepatotoxicity were excluded from the analysis. Patients were divided into two groups according to the presence or absence of adverse effects, and a correlation to CD4 counts was performed. Liver function abnormality was graded according to the Division of AIDS toxicity guidelines. A total of 170 women initiated nevirapine during pregnancy, but only 133 were included in the study. Twenty-seven women (20.3 percent) presented adverse effects, skin rash accounting for 77.8 percent (21/27 women) and liver function abnormalities for 22.2 percent (6/27) of the cases. Baseline CD4 counts, viral loads and transaminases were similar in both groups. All nevirapine side effects were developed in less than seven weeks. Four of 31 women with CD4 counts <250 cells/µL (12.9 percent) and 23 of 102 women with CD4 counts ≥250 cells/µL (22.5 percent) developed adverse events. All patients who experienced hepatotoxicity had pretreatment CD4 counts >250cells/µL. The incidence of adverse events with nevirapine in our study was high, but most of them were cutaneous. There was no correlation between high CD4 counts and adverse events when analyzing both cutaneous and hepatic reactions; nevertheless, hepatotoxicity occurred only in pregnant women with CD4 counts ≥250cells/µL.

Bilateral peripheral facial palsy secondary to lymphoma in a patient with HIV/AIDS: a case report and literature review

Neurological complications represent one of the most important causes of morbidity and mortality in patients with HIV/AIDS. However, peripheral neuropathy comprises only 5 to 20 of the total neurological complications and facial nerve palsy, especially when it is bilateral, is a less common manifestation. Peripheral facial palsy has been considered as a possible neurological complication of the early stage of HIV infection but the number of reported cases in the literature is limited. Histological findings of nervous tissue in peripheral facial palsy at an early stage of HIV infection include a degenerative and not suppurative inflammatory process, but its etiology remains obscure. Peripheral facial palsy in the late stage of HIV infection is characterized by an advanced immunological deficit and generally it is secondary to an opportunistic infection of the CNS, such as neurotoxoplasmosis and lymphoma. However, this peripheral attack of the facial nerve is not very common at this late stage of HIV infection. Bilateral peripheral facial palsy as a complication of non-Hodgkin s lymphoma is considered an extremely rare entity. There are no published reports of bilateral peripheral facial palsy secondary to lymphomas or other neoplasms of the CNS in immunosuppressed patients. Non-Hodgkin s lymphoma (NHL) has been considered a late and relatively common manifestation of HIV infection, but an exact cause for the higher incidence of this malignant neoplasm in HIV/AIDS patients is still uncertain.

Response of HIV/AIDS patients to Hepatitis B recombinant vaccine

Studies have demonstrated that HIV infection negatively affects the immune response to hepatitis B vacine. The present study evaluated the seroconversions to the recombinant vaccine against hepatitis B applied in HIV patients. Twenty-two patients were included in the study group all with confirmed HIV infection and with negative serum markers to hepatitis B. The control group was composed of 18 healthy individuals with negative markers for hepatitis B. All subjects were vaccinated with 20µg of ENGERIX B at 0,1 and 6 months (3 doses). The antibody response was quantitatively assessed 1 month after the third dose of recombinant vaccine. CD4 T lymphocyte counts were also performed in those beginning vaccination. Of 22 patients in the study group, only 10 (45.5 percent) responded to vaccination with protective levels (over 10 µlU/ml). In the control group, all of the subjects responded (p=0.005). Seventeen patients in the study group had their CD4 lymphocytes measured. The results suggested a direct relationship between the level of CD4 lymphocyte counts and response to the vaccine. The rate of response to hepatite B recombinant vaccine with 3 doses of 20µg of HBsAg in patients infected by the human immunodeficiency virus was significantly lower than in the control group. Patients with low CD4 T lymphocyte counts are likely to have an inadequate response to the current method of hepatitis B vaccination.

Cutaneous leishmaniosis coinfection in AIDS patients: Case report and literature review

A fatal case of mucosal leishmaniasis in a patient with AIDS is presented. Seventeen cases of L. brasiliensis coinfection in AIDS patients in Brazil have been presented at the meetings of The Brazilian Society of Infectious Diseases. As in the case presented here, 4 cases with mucosal involvement also had negative delayed type hypersensitivity reactions to leishmania antigens. This lack of immunologic responsiveness, the invasive nature of the infection, and the poor response to therapy indicate that the combination of these infections should be viewed as a new disease entity.