Guidelines for antiretroviral therapy in HIV-1 infected adults and adolescents: the recommendations of the Thai AIDS Society (TAS) 2008.

BACKGROUND: More than 100,000 patients have been treated, since the implementation of the National Universal Coverage for antiretroviral therapy (ART) in Thailand Although there are several comprehensive guidelines available internationally, there is a need to have guidelines that can be implemented in Thailand. MATERIAL AND METHOD: The guidelines were developed by a panel of 17 members who are the experts on HIV research and/or HIV patient care and appointed without incentive by the Thai AIDS Society (TAS). The recommendations were based on evidences from the published studies and availability of antiretroviral agents. Published studies that are relevant and applicable to Thailand in particular have been taken into consideration. RESULTS: The recommendations include: when to start ART; what to start; how to monitor the therapy; adverse effects and its management; diagnosis of treatment failure; and antiretroviral treatment options in patients with treatment failure. ART in special circumstances, i.e., patients with co-infection of tuberculosis or hepatitis B virus, is also included Appropriate level of CD4+ T-cell count to start ART among Thai patients has been considered carefully. The authors recommend to start ART at CD4+ T-cell count < 200 cells/mm3. CONCLUSION: ART should be initiated in adults and adolescents HIV-1 infected patients with a history of HIV-related illness or AIDS or with a CD4+ T-cell count <200 cells/mm3. For treatment-naive patients, the preferred initial therapy is a non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimen. CD4' T-cell count and viral load should be monitored for at least twice and once a year, respectively. Proper management of antiretroviral-related toxicity and enhancement of adherence are crucial for the long-term success of ART.

HIV-associated primary pulmonary hypertension: a first case report in Thailand and literature review.

A 32-year-old woman had asymptomatic HIV infection diagnosed with primary pulmonary hypertension simultaneously. She presented after a three-month rapid progression of symptoms and hemodynamic change. Physical examination and laboratory findings were compatible with pulmonary hypertension. No sensible cause could be found for the pulmonary hypertension except the HIV seropositivity; therefore, HIV-associated primary pulmonary hypertension was diagnosed. She was treated with diltiazem and oral anti-coagulation. After four months, her functional status improved from a NYHA functional class of II to I and improved in right venticular function. Since HIV is epidemic, the authors recommend HIV testing in cases of primary pulmonary hypertension.

Detection of opportunistic and non-opportunistic intestinal parasites and liver flukes in HIV-positive and HIV-negative subjects.

We assessed the frequency and distribution of infection with opportunistic and non-opportunistic intestinal parasites and the liver fluke, Opisthorchis viverrini, in HIV-seropositive and HIV-seronegative subjects. Age- and sex-matched HIV-seropositive (n = 78) and HIV-seronegative patients (n = 78) from two hospitals in Khon Kaen Province, Thailand, participated in this study from November 1998 to August 2000. These subjects were divided according to the presence of diarrhea and CD4 counts. A single stool sample was obtained and analyzed by using specific techniques. Opisthorchis viverrini, was the most common parasite (19.2%) in each group. The prevalence rates of Cryptosporidium spp (11.5%) and Strongyloides stercoralis (17.9%) in the HIV-seropositive group were significantly (p < 0.05) higher than those in the HIV-seronegative group (1.0% for Cryptosporidium spp and 7.7% for S. stercoralis infections). The prevalences of these two parasites were 28% for Cryptosporidium spp and 20% for S. stercoralis in HIV-seropositives with diarrhea and CD4 counts lower than 100 cells/mm3, and were higher compared with patients without diarrhea or with high CD4 counts. These results suggest that infection with these parasites increases during HIV infection. The epidemiological distribution of Cryptosporidium and S. stercoralis may have implications for AIDS-related diseases.

Acute lupus hemophagocytic syndrome: report of a case and review of the literature.

The authors reported a case of systemic lupus erythematosus (SLE) with an unusual presentation. The patient presented with acute febrile illness along with progressive pancytopenia related to increasing hemophagocytic activity of histiocytes in the bone marrow. Concomitant polyarthritis, myositis, nephritis, high titer of antinuclear factor (1:2,560) and positive test for anti-DNA antibody made him fit the diagnostic criteria of SLE. No definite evidence of associated infections was confirmed by bacteriologic, serologic and viral studies. He did not respond to empiric antibiotic therapy but dramatically responded to corticosteroid treatment. Therefore, diagnosis of acute lupus hemophagocytic syndrome was made. The clinical presentation, laboratory diagnosis, and management of the patient are discussed and the literature was reviewed and presented.

Exertional rhabdomyolysis following excessive exercise of university freshman cheer-training.

Exertional rhabdomyolysis is a life threatening condition resulting from lysis of muscle cells after vigorous exercise. It can cause many complications such as renal failure. It occurs most commonly in military personnel but also in civilians who have excessive excercise after work. Two cases of freshmen who had exertional rhabdomyolysis were reported to illustrate the potential risk of cheer-training. Appropriate measures should be arranged to prevent this condition. Diagnosis and treatment should be given promptly to prevent serious complications.

Tuberculous pyomyositis.

Tuberculosis, caused by Mycobacterium tuberculosis is a common infection both in immunocompromised and normal hosts. Its clinical manifestation can by divided as pulmonary and extrapulmonary form. Pyomyositis caused by M. tuberculosis is extremely rare. The authors report 2 patients, one with underlying dermatomyositis, and the other with polymyositis. The diagnosis was delayed according to nonspecific symptoms and masking effect of steroid therapy, which led to complications. Microscopy and culture of the pus confirmed the diagnosis. Surgical drainage was done and antituberculous therapy was given. The patient with dermatomyositis was complicated by drug induced hepatitis and died but the other was cured. Tuberculous pyomyositis should be considered in patients who are immunocompromised hosts.

Splenic abscess: clinical features, microbiologic finding, treatment and outcome.

Splenic abscess is a rare clinical entity but may be underreported. A retrospective study at Srinagarind Hospital revealed 60 cases of splenic abscess between 1992 and 2001. The causative organisms were identified in 41 cases (68.3%). Gram negative bacilli were commonly isolated and Burkholderia pseudomallei was the most predominant. Diabetes mellitus and leukemia were common underlying diseases found in 46.3 per cent and 9.7 per cent of culture confirmed cases, respectively. The patients usually presented with fever, left upper quadrant pain, tenderness and splenomegaly. Multiple abscesses were more commonly found in the melioidosis than in the non-melioidosis group (p = 0.032), but a single abscess was more commonly found in the non-melioidosis than in the melioidosis group (p = 0.032). Concurrent liver abscesses, often multiple, were not different in both groups. Antimicrobials alone were given in 66.7 per cent of cases with melioidosis and 64.7 per cent of non-melioidosis group. Splenectomy and percutaneous aspiration were performed only in 29.3 per cent and 4.9 per cent of cases with splenic abscess. The overall mortality rate of splenic abscess was only 4.9 per cent in the present series. In conclusion, splenic abscess is not uncommon. Burkholderia pseudomalleli is the most common causative agent found in the present series. Therefore, it should be targeted in the initial empirical antibiotic therapy before the culture results are available especially when multiple lesions in the spleen and concurrent multiple liver abscesses are seen. Prolonged treatment with appropriate antimicrobials alone is usually effective. Splenectomy and/or aspiration may be useful in selected patients.

The efficacy of fluconazole 600 mg/day versus itraconazole 600 mg/day as consolidation therapy of cryptococcal meningitis in AIDS patients.

Cryptococcal meningitis is one of the major complications affecting the central nervous system of patients suffering from AIDS. The results of treatment, when following current recommendation are still unsatisfactory. OBJECTIVE: This study aimed to evaluate the efficacy of a higher than recommended dose of oral fluconazole and itraconazole as consolidation therapy for cryptococcal meningitis in AIDS patients. DESIGN AND METHOD: HIV infected patients with primary cryptococcal meningitis, who had been treated initially with amphotericin B for 2 weeks were included in this study. They were randomized into two groups, to receive either fluconazole 600 mg daily or itraconazole 600 mg daily for 10 weeks. The response towards the two different treatments was clinically defined to be successful, if after 10 weeks of treatment no clinical symptoms and signs of meningitis remained and the cerebrospinal fluid (CSF) fungal culture was negative. RESULTS: The trial was performed from April 1999 to April 2000 at Srinagarind Hospital, Khon Kaen, Thailand. At the beginning of the trial 44 cases were selected, but only 35 patients proved to be suitable for the final evaluation of the study. Out of those, 19 cases were assigned to the fluconazole and 16 cases to the itraconazole group. Ten weeks after treatment, all patients clinically recovered completely. The CSF sterilization rate for the fluconazole group and for the itraconazole group were 100 and 94 per cent respectively. The Fisher's exact test showed no significant difference in the CSF sterilization rate between both groups (p = 0.26). CONCLUSION: The result of this study indicates that treatment with either 600 mg per day of fluconazole or itraconazole as consolidation treatment have the same efficacy for AIDS patients suffering from cryptococcal meningitis. The results of this study also suggest, comparing the result of this trial with the results of similar trials published somewhere else, that treatment with the higher doses may be superior to treatment regimens using lower doses, as can be judged from the clinical outcome and the results of the mycological cultures.

Kikuchi-Fujimoto's disease, histiocytic necrotizing lymphadenitis, mimicking systemic lupus erythematosus.

Kikuchi-Fujimoto's disease (KFD) or histiocytic necrotizing lymphadenitis is a self-limiting condition characterized by fever, neutropenia and lymphadenopathy. It is rarely associated with systemic lupus erythematosus (SLE). The authors reported a case of Kikuchi's necrotizing lymphadenitis who presented with fever, generalized lymphadenopathy, moderate leukopenia, polyarthritis, vasculitis-like lesions and oral ulcers compatible with SLE but serologic tests for autoimmune disease were all negative. The clinical symptoms resolved spontaneously within 3 months without any treatment. Because there is an association between KFD and SLE, great care should be taken with a patient who presents with either KFD or SLE.

Quinolones and Salmonella septic arthritis.

Salmonella septic arthritis is an infrequent infectious disease but can cause progressive joint destruction resulting in disability. The authors retrospectively reviewed cases with culture proved Salmonella septic arthritis in Srinagarind Hospital, Khon Kaen from 1994 to 2000. There were 23 episodes in 16 cases; all had underlying diseases and a history of steroid abuse or steroid and immunosuppressive therapy. Systemic lupus erythematosus was the most commonly found underlying disease (56%). Salmonella group D and group B were isolated in 13 and 3 cases. Most first episodes had acute onset of monoarthritis. The antibiotics used as initial treatment of the first episodes were beta lactam, cotrimoxazole or quinolones. There were 8 cases with disabled sequelae and 7 cases with relapse. For 13 evaluable first episodes, relapse occurred in 3 cases in the cephalosporin/penicillin and 4 cases in the cotrimoxazole treated group but none in the quinolones. Six relapse cases were treated successfully with quinolones as well as one with cotrimoxazole. Although 5 relapse cases treated with quinolones had previous progressive joint destruction or avascular necrosis, there was no further joint damage after re-treatment with quinolones. In conclusion, quinolones were more effective than beta-lactams and cotrimoxazole for the treatment of Salmonella septic arthritis to prevent relapse and progressive joint destruction.

A randomized, open-label, comparative trial of BID and TID dosing of saquinavir enhanced oral formulation as part of a triple therapy for advanced AIDS patients.

OBJECTIVE: To compare the efficacy and safety of 1,400 mg BID and 1,200 mg TID of saquinavir soft gel given with zidovudine and lamivudine in antiretroviral-naïve, advanced AIDS patients. METHOD: A randomized, open-label study conducted at a university hospital. RESULTS: Forty cases were enrolled in the study, 20 cases in each group. The mean CD4 cell count was 29 cells/mm3. The mean log10 HIV-1 RNA was 5.27 copies/mL. Using an on-treatment analysis, the reduction in plasma log10HIV-1 RNA of BID and TID groups was not statistically significant at -2.44 vs -2.60 copies/mL (-0.16, 95% CI -0.63 to 0.30; p= 0.48). The mean increase in CD4 cell counts was not statistically significant at +144 and +159 cells/mm3 (11, 95% CI -75 to 97; p=0.79). CONCLUSION: The preliminary data suggests that in antiretroviral-naïve, advanced AIDS patients, 1,400 mg BID of saquinavir soft gel given with two nucleoside analogues might be as effective as the standard 1,200 mg TID.