Switch from protease inhibitor- to efavirenz-based antiretroviral therapy improves quality of life, treatment satisfaction and adherence with low rates of virological failure in virologically suppressed patients.

Regimen selection in antiretroviral therapy can impact treatment adherence, quality of life (QoL) and treatment satisfaction, and may influence clinical outcome. We evaluated the effect of regimen switching on virological, safety and patient-reported outcomes. In this 48-week, open-label, randomized, non-inferiority study, 262 HIV-1-infected adult patients with a viral load <50 copies/mL on protease inhibitor (PI)-based regimens were switched to either once-daily efavirenz, lamivudine and enteric-coated didanosine (efavirenz-A [QD]) or once-daily efavirenz plus continuation of current nucleoside reverse transcriptase inhibitors (efavirenz-B). In the primary outcome of patients who maintained virological suppression at week 48, efavirenz-A (QD) was non-inferior to efavirenz-B (81% versus 79%, respectively). Both regimens were associated with low virological failure rates and significant improvements in treatment satisfaction, adherence and QoL after switching from PI-based therapy, with no differences between regimens. Switching from a PI- to an efavirenz-based regimen was generally safe and well tolerated.

Fulminant hepatitis from herpes simplex virus type 2 in an immunocompetent adult.

Herpes simplex virus (HSV) is regarded as a common viral pathogen that produces a wide variety of diseases. After a primary infection, which usually occurs during childhood and may or may not be clinically evident, the virus establishes a latent infection in the local sensory ganglia and can reactivate throughout the life of the individual. Fulminant hepatic failure (FHF) due to HSV infection is a clinical condition well known in pediatric, immunocompromised, and pregnant patients. It is rare in immunocompetent hosts. We report the case of a 51-year-old man with no significant past medical history who developed FHF with disseminated intravascular coagulopathy and septic shock secondary to HSV infection. The initial diagnosis was made through a frozen section of a needle liver biopsy and the presence of HSV was confirmed in the permanent section with immunohistochemistry. HSV was grown in cell culture from liver tissue obtained through an autopsy.

HIV-related Pneumocystis carinii pneumonia in older patients hospitalized in the early HAART era.

OBJECTIVE: To determine whether older age continues to influence patterns of care and in-hospital mortality for hospitalized persons with HIV-related Pneumocystis carinii pneumonia (PCP), as determined in our prior study from the 1980s. DESIGN: Retrospective chart review. PATIENTS/SETTING: Patients (1,861) with HIV-related PCP at 78 hospitals in 8 cities from 1995 to 1997. MEASUREMENTS: Medical record notation of possible HIV infection; alveolar-arterial oxygen gradient; CD4 lymphocyte count; presence or absence of wasting; timely use of anti-PCP medications; in-hospital mortality. MAIN RESULTS: Compared to younger patients, patients > or =50 years of age were less likely to have HIV mentioned in their progress notes (70% vs 82%, P <.001), have mild or moderately severe PCP cases at admission (89% vs 96%, P <.002), receive anti-PCP medications within the first 2 days of hospitalization (86% vs 93%, P <.002), and survive hospitalization (82% vs 90%, P <.003). However, age was not a significant predictor of mortality after adjustment for severity of PCP and timeliness of therapy. CONCLUSIONS: While inpatient PCP mortality has improved by 50% in the past decade, 2-fold age-related mortality differences persist. As in the 1980s, these differences are associated with lower rates of recognition of HIV, increased severity of illness at admission, and delays in initiation of PCP-specific treatments among older individuals--factors suggestive of delayed recognition of HIV infection, pneumonia, and PCP, respectively. Continued vigilance for the possibility of HIV and HIV-related PCP among persons > or =50 years of age who present with new pulmonary symptoms should be encouraged.

Mycobacterium kansasii disease in patients infected with human immunodeficiency virus.

We evaluated the presenting characteristics, response to therapy, and outcome for 46 patients infected with Mycobacterium kansasii and human immunodeficiency virus (HIV). M. kansasii infection occurred late in HIV disease (mean CD4 lymphocyte count, 52.4/mm3), when most patients had already developed AIDS; 91.3% of the patients had pulmonary involvement, and 21.7% had disseminated disease. Clinical and radiographic findings were consistent with pulmonary disease and had been present for approximately 4 weeks. Fourteen of the treated patients had disease that resolved or abated (mean survival +/- SE, 73.7 weeks +/- 14.6 weeks), and 13 had disease that persisted unchanged or worsened (mean survival +/- SE, 57.3 +/- 15.8 weeks). The outcome was poor for 17 patients who did not receive effective therapy (mean survival +/- SE, 14.1 +/- 5.3 weeks). M. kansasii infection presents late in the course of HIV disease, and the lung is the organ most frequently involved. Survival is clearly influenced by therapy, and even patients who respond poorly to therapy survive longer than those who are not treated.

M proteins of group G streptococci: mechanisms of resistance to phagocytosis.

Group G streptococci that express M protein and resist phagocytosis in human blood (virulent strains) were compared with strains of groups G and A that are readily phagocytosed (avirulent). Virulent group G streptococci were less effective (P < .05) as activators of the alternative complement pathway (ACP) than were avirulent streptococci. In immunofluorescence studies, C3 bound more avidly to avirulent than to virulent group G streptococci. Resistance of virulent group G strains to ACP opsonization and to phagocytosis was markedly diminished by removal with pepsin of the type-specific portion of the M molecule. Preincubation with fibrinogen did not diminish ACP activation or C3 binding by virulent group G and A streptococci but did exert an antiphagocytic effect. Given the similarity of M proteins of groups G and A in structure and function, other microbial constituents are likely responsible for differences in the spectra of illnesses attributable to the two serogroups.

Subcutaneous nodules as a dermatologic manifestation of bacteremia due to Pseudomonas aeruginosa.

Sepsis due to Pseudomonas aeruginosa continues to be an important source of morbidity and mortality in hospitalized patients. Early recognition of this condition is of paramount importance in choosing specific therapy at the earliest possible moment. We present three cases in which P aeruginosa bacteremia was manifested by subcutaneous nodules. Although such lesions have been reported before, we place new emphasis on the uniqueness of this lesion to P aeruginosa, the feasibility of visualizing the organism and culturing it from biopsies of the lesions, and the possibility of choosing appropriate therapy early through recognition.