Metabolic profile and cardiovascular risk factors among Latin American HIV-infected patients receiving HAART.

OBJECTIVE: Determine the prevalence of metabolic abnormalities (MA) and estimate the 10-year risk for cardiovascular disease (CVD) among Latin American HIV-infected patients receiving highly active anti-retroviral therapy (HAART). METHODS: A cohort study to evaluate MA and treatment practices to reduce CVD has been conducted in seven Latin American countries. Adult HIV-infected patients with at least one month of HAART were enrolled. Baseline data are presented in this analysis. RESULTS: A total of 4,010 patients were enrolled. Mean age (SD) was 41.9 (10) years; median duration of HAART was 35 (IQR: 10-51) months, 44% received protease inhibitors. The prevalence of dyslipidemia and metabolic syndrome was 80.2% and 20.2%, respectively. The overall 10-year risk of CVD, as measured by the Framingham risk score (FRF), was 10.4 (24.7). Longer exposure to HAART was documented in patients with dyslipidemia, metabolic syndrome and type 2 diabetes mellitus. The FRF score increased with duration of HAART. Male patients had more dyslipidemia, high blood pressure, smoking habit and higher 10-year CVD than females. CONCLUSIONS: Traditional risk factors for CVD are prevalent in this setting leading to intermediate 10-year risk of CVD. Modification of these risk factors through education and intervention programs are needed to reduce CVD.

Metabolic profile and cardiovascular risk factors among Latin American HIV-infected patients receiving HAART

OBJECTIVE: Determine the prevalence of metabolic abnormalities (MA) and estimate the 10-year risk for cardiovascular disease (CVD) among Latin American HIV-infected patients receiving highly active anti-retroviral therapy (HAART). METHODS: A cohort study to evaluate MA and treatment practices to reduce CVD has been conducted in seven Latin American countries. Adult HIV-infected patients with at least one month of HAART were enrolled. Baseline data are presented in this analysis. RESULTS: A total of 4,010 patients were enrolled. Mean age (SD) was 41.9 (10) years; median duration of HAART was 35 (IQR: 10-51) months, 44 percent received protease inhibitors. The prevalence of dyslipidemia and metabolic syndrome was 80.2 percent and 20.2 percent, respectively. The overall 10-year risk of CVD, as measured by the Framingham risk score (FRF), was 10.4 (24.7). Longer exposure to HAART was documented in patients with dyslipidemia, metabolic syndrome and type 2 diabetes mellitus. The FRF score increased with duration of HAART. Male patients had more dyslipidemia, high blood pressure, smoking habit and higher 10-year CVD than females. CONCLUSIONS: Traditional risk factors for CVD are prevalent in this setting leading to intermediate 10-year risk of CVD. Modification of these risk factors through education and intervention programs are needed to reduce CVD.

Analysis of HIV type 1 protease and reverse transcriptase sequences from Venezuela for drug resistance-associated mutations and subtype classification: a UNAIDS study.

We report the first study on prevalence of antiretroviral drug-associated resistance mutations in Venezuela. Protease and reverse transcriptase (RT) coding regions were analyzed in DNA samples obtained from 100 HIV-1-infected individuals. Primary resistance mutations to RT inhibitors were identified in 26% of patients treated with these drugs. Transmission of HIV-1-resistant strains was detected in a drug-naive patient (3%). Primary resistance mutations to protease inhibitors (PIs) were present in 9% of the 44 PI-treated patients and in 1 PI-naive individual. Phylogenetic analysis of these samples has resulted in the most extensive survey, to date, of HIV-1 genetic forms circulating in Venezuela. Ninety-nine samples clustered with subtype B, and 1 individual harbored the first B/F recombinant virus reported in Venezuela, with protease clustering with subtype F and RT with subtype B. In addition, this isolate had a new insertion (Glu-34 duplication) in the protease gene.

In vitro susceptibility of 137 Candida sp. isolates from HIV positive patients to several antifungal drugs.

Oropharyngeal candidiasis caused by various species of Candida is one of the most common infections in HIV seropositive or AIDS patients. Drug resistance among these yeasts is an increasing problem. We studied the frequency of resistance profile to fluconazole, itraconazole, ketoconazole, amphotericin B and terbinafine of 137 isolates of Candida sp. From HIV positive or AIDS patients with oropharyngeal candidiasis at Instituto de Inmunología, U.C.V. and the Hospital "Jose Ignacio Baldó", Caracas Venezuela, using the well diffusion susceptibility test (Magaldi et al.). We found that nearly 10% of C. albicans isolates were primarily fluconazole resistant, 45% of C. albicans isolates from patients with previous treatment were resistant to fluconazole, of which 93% showed cross-resistance to itraconazole, and even about 30% of C. tropicalis (n = 13) were resistant to fluconazole and/or itraconazole. To this respect, several recent reports have been described antifungal cross-resistance among azoles. Therefore, we consider that C. tropicalis should be added to the growing list of yeast in which antifungal drug resistance is common. This report could be useful for therapeutic aspect in AIDS patients with oral candidiasis.

"In vitro" antifungal activity of protease inhibitors.

In the last five years, as HAART has become standard therapy in HIV seropositive or AIDS patients, changes have been noted in the numbers and types of opportunistic fungal infections in these cohorts of patients. Particularly, oropharyngeal candidiasis have become rare in HIV infected patients since the introduction of new anti-HIV drugs of the protease inhibitors type. At the Immunology Institute of the Universidad Central de Venezuela the most frequent protease inhibitors (PIs) used for the treatment of these patients have been: Nelfinavir (Viracept, Roche), Indinavir (Crixivan Merck), Ritonavir (Norvir, Abbott), Saquinavir (Fortovase, Roche). Recently, we observed that recurrent candidiasis was less frequent and no Candida could be isolated in our patients. A direct relation to the PIs was suspected. In order to assess the "in vitro" antifungal activity of the afore mentioned protease inhibitors on Candida sp., we used both the well diffusion test and the NCCLS broth microdilution test to assay 100 Candida sp. isolates from HIV seropositive or AIDS patients with syntomatic oropharyngeal Candida infection. In general, the data obtained with the well diffusion test were in agreement with those obtained by the broth microdilution test. All 100 isolates were susceptible to Saquinavir and 32 were susceptible to Indinavir using the NCCLS microdilution test, while 97 were susceptible to Saquinavir and 52 to Indinavir by the well diffusion test. From 17 C. albicans resistant to fluconazole, all were susceptible to Saquinavir by the NCCLS micromethod and 16 by the well diffusion test. Our results showed anticandidal activity "in vitro" of PIs, mainly Saquinavir.

HCV RNA sequences in eosinophils of chronic HCV-infected patients.

In the present study we examined the presence of Hepatitis C virus (HCV) RNA sequences in eosinophils (Eos) isolated from 10 chronically HCV-infected patients. At the time of the study patients showed levels of alanine aminotransferase (ALT) and aspartate aminotranferase (AST) above the normal upper limits (129 IU/L +/- 77 and 56.2 IU/L +/- 40, respectively). Absolute and relative total leukocyte and Eos counts were within the normal range. Highly purified eosinophils (> 98 %) were obtained by Ficoll-Hypaque (d = 1.114 g/mL) and Percoll gradient centrifugation following by immunomagnetic absorbtion to cell specific antibodies. Mononuclear cells (MN) and neutrophils (Neu) were also purified from these patients. PCR analysis of these cell populations revealed the presence HCV RNA sequences in 4/10 Eos, 6/10 MN and 2/10 Neu cell samples. The results suggest that, in addition to MN and Neo cells, Eos might also be susceptible to HCV infection.

Prevalence of enteric viruses in human immunodeficiency virus seropositive patients in Venezuela.

The prevalence of enteric viruses associated with gastroenteritis was determined in 125 stool samples from patients infected with the human immunodeficiency virus (HIV), with or without diarrhea. Diagnostic assays included enzyme immunoassays for the identification of rotavirus, adenovirus, and Norwalk virus; polyacrylamide gel electrophoresis for atypical rotaviruses and picobirnaviruses and polymerase chain reaction for astrovirus. Enteric viruses were detected in 6.4% (8 of 125) of the stools collected: five (4.0%) samples positive for adenoviruses, and three (2.3%) samples positive for picobirnaviruses were detected. No rotavirus, astrovirus, or Norwalk virus were observed. Only one of the viruses identified (adenovirus) was found in a sample from a patient with diarrhea. Viruses were detected in 10% of the patients with AIDS, 14% of the symptomatic patients, and none of the asymptomatic persons. These results do not support a major role for enteric viruses in the diarrhea suffered by HIV-infected patients.

Impairment of natural killer (NK) cytotoxic activity in hepatitis C virus (HCV) infection.

In the present study, we evaluated the NK cell cytotoxic activity in a group of HCV-infected individuals. Although the number of NK cells present in the peripheral blood of the HCV-infected patients was comparable to non-infected individuals, spontaneous NK cytotoxicity was four-fold lower (P < 0.001) than in normal donors. This functional impairment was not overcome by depletion of adherent or B cells, and it was partially restored by short-term (18 h) stimulation with IL-2. However, long-term stimulation (72 h) with this lymphokine induced activated killer cell (LAK) activity comparable to normal controls. The reduction in NK cytotoxic response does not seem to be due to soluble suppressive factors, since incubation of normal peripheral blood mononuclear cells (PBMC) with infectious HCV serums for a 4-h period does not affect NK spontaneous cytotoxic activity. Successful in vitro infection of PBMC with HCV infectious serum also resulted in an impairment of NK cytotoxicity, suggesting that altered NK function is associated with HCV infection and may be responsible, at least in part, for the chronicity of the infection.

Dermatomiositis juvenil: un reto diagnóstico / Juvenile dermatomyositis: a challenge diagnoses

La Dermatomiositis Juvenil es una enfermedad inflamatoria y degenerativa del músculo estriado capaz de ocasionar errores diagnósticos y tratamientos inadecuados, debido a que su baja incidencia conduce a una falta de conocimiento entre los médicos. Presentamos un caso, ocurrido en el Hospital Privado Centro Médico de Caracas en Febrero de 1966, en un adolescente de 13 años con un cuadro clínico característico, pero con cifras alarmantes de creatininquinasa. La respuesta terapéutica fue excelente

Lymphocyte subset diversity in idiopathic CD4+ T lymphocytopenia.

The clinical and public health importance of CD4+ T lymphocytopenia without human immunodeficiency virus infection is still unclear. We describe herein two new human immunodeficiency virus-negative patients with low numbers of peripheral CD4+ T cells and opportunistic infections (cerebral toxoplasmosis and tuberculosis plus extrapulmonary histoplasmosis). The low numbers of CD4+ CD29+ memory cells, the high percentage of gamma delta T-cell receptor cells, and the recovery of CD4+ cells after treatment were remarkable.

Decreased T-cell proliferative response to common environmental antigens could be an indicator of early human immunodeficiency virus-mediated lymphocyte lesions.

To evaluate CD4+/CD29+ cells and their responses to different antigens in polar stages of human immunodeficiency virus (HIV) infection, we studied 26 HIV-seropositive carriers (SPCs) and 15 patients with AIDS simultaneously with 20 healthy volunteers (HVs) and 10 seronegative homosexual and bisexual men (SNH). CD3, CD4, CD29, and CD45RA phenotypes were analyzed by two-color flow cytometry. Significant depletion of CD4+ T cells and both memory (CD4+/CD29+) and naive (CD4+/CD45RA+) T-cell subsets was found among SPCs and AIDS patients compared with the numbers of such cells in the HV and SNH groups. Responses to optimal doses of Candida albicans, streptokinase, and tetanus toxoid were explored in peripheral blood mononuclear cells and CD4(+)- and CD4+/CD29(+)-enriched cell populations. In SPCs, the response to C. albicans in peripheral blood mononuclear cells showed a statistically significant diminution compared with the response of HVs (15,308 versus 35,951 cpm). In addition, a significantly reduced response to streptokinase was evident only when cell preparations were CD4+/CD29+ enriched (3,048 versus 10,367 cpm). Furthermore, the SPC group comprised seven responders to at least one antigen and seven nonresponders to any of the selected specific antigens. Absence of a response in these latter patients was independent of the absolute counts of memory and naive T-cell populations. The response to tetanus toxoid, although diminished in SPCs, was not significantly different from that in controls. Our results suggest that defective responses to common environmental antigens, unrelated to the absolute number of CD4+/CD29+ cells, is probably an early indicator of an HIV-induced lymphocyte lesion.

A double-blind, cross-over study using salbutamol, beclomethasone, and a combination of both in bronchial asthma.

A double-blind, cross-over protocol was applied to 22 asthmatic patients who were previously subjected to provocation tests with methacholine. The baseline FEV1 for mild asthma was 89.6 +/- 13.6% while for moderate asthma it was 73 +/- 6%. The initial provocation tests with methacholine revealed that the mild asthma group needed a greater accumulated dose of methacholine than that required by the moderate asthma group to lower the FEV1 by 20%, stressing the enhanced bronchial hyperreactivity present in the latter group. Significant differences in the PD20 values were obtained in both groups of patients using the combination of salbutamol plus beclomethasone. Salbutamol alone was ineffective to change the PD20 values in mild asthma while beclomethasone alone was able to change significantly the PD20 values in these patients, stressing the importance of the inflammatory component in the pathogenesis of stable asthma. Furthermore, the combination of both drugs was also more effective in the moderate asthma group than either medication alone, confirming the pharmacological control of the obstructive and inflammatory changes that are already established in patients with moderate asthma.

[Immunoclinical, molecular and immunopathologic approach to chronic viral hepatitis. Therapeutic considerations]. / Abordaje inmunoclinico, molecular e inmunopatológico de la hepatitis crónica viral. Consideraciones terapeuticas.

Through a pilot study which includes a clinical, molecular and immunopathological approach to the chronic Hepatitis induced by HBV or by HCV, we determined that 66% of HBsAg carriers are in the "non viremic" phase. The positive HBeAg "viremic" carriers showed HBV-DNA quantitation which varies between > 50 pg to > 100 pg. Both types of carries are infected with the "wild" type HBV. Each subgroup of positive surface antigemia carriers demonstrated a differential immunopathological response. So far, 96% of the HCV carriers investigated, showed HCV-RNA associated to repeatedly positive anti-HCV antibodies. Those patients with increased ALT values uniformly expressed liver histopathological signs of inflammation caused by HCV; demonstrating also the presence of peripheral blood mononuclear cells infected with HCV. At the present, the genotypes investigation indicates a predominance of HCV genotype II (1b). Autoimmune phenomenons associated to HCV have been detected only in 3 patients. The therapeutic approach with interferon alpha applied to the HCV infection preliminary showed similar results to those reported worldwide. Currently, a comprehensive approach to the chronic HBV and chronic HCV infections requires the application of Immunochemistry, Molecular Biology and Cellular Immunology combined technologies.

Assessment of delta virus infection in Venezuelan high-risk population for hepatitis B virus.

HDV infectivity particularly related to sexual activity has been difficult to establish. We investigated the prevalence of HDV in a high risk urban male population currently evaluated for HIV infection. Fourth-eight homosexual or bisexual men (96% positive for HIV) being routinely followed in the outpatient clinic, 40 sera obtained randomly from male homosexuals and 24 HBsAg carriers were examined by ELISA and Western Blot. HDV RNA was assessed by slot-blot after hybridization with cDNA probe from a recombinant plasmid (pS-1). [None of the 48 male subjects or from a recombinant plasmid (pS-1).] None of the 48 male subjects or from the randomly selected homosexuals tested positive for anti-HDV. HDV RNA searched in a selected group of sera from either high risk population or from HBsAg carriers proved also to be negative. We suggest that factors other than HBV chronic bearing and/or sexual promiscuity should be associated with HDV spread.

[Absence of delta agent infection in high risk male subjects infected with B virus and human immunodeficiency virus]. / Ausencia de infección por virus delta en sujetos masculinos de alto riesgo infectados por virus B y virus de inmunodeficiencia humana.

Positive contacts to DV were investigated among 50 males, 48 homosexuals and 2 heterosexuals intravenously drug-addicts. None shown presence of anti-VD antibodies, while 98% and 50% from the total group demonstrated confirmed reactivity to HIV and HBV respectively. Further, 19 subjects who notified 5 or more sexual partners per year, shown one or more positive HBV markers, finding only observed in 6 subjects from 31 who notified less than 5 partners per year (p less than 0.001). The absence of DV positive contacts suggest that epidemiologically the DV seems to be loss of non-influenced by the sexual condition of the exposed population.

[Chronic diarrhea as a clinical expression of common variable hypogammaglobulinemia: apropos of 3 cases]. / Diarrea crónica como expresión clínica de la hipogammaglobulinemia común variable. A propósito de 3 casos.

Sixty per cent of the patients with immuno-compromise of the humoral compartment may show chronic diarrhoea, specially seen in the common variable hypogammaglobulinemia (CVH). We presented 3 cases of late-onset CVH who referred chronic diarrhoea as the main symptom. The immunodiagnosis revealed undetectable or subnormal immunoglobulins levels (G, M, A), preserved total haemolytic complement and a negative autoimmune screening. The cell compartment analysis showed increased number of suppressor T lymphocytes (CD8) plus hyporesponsiveness of the total peripheral lymphocytes to polyclonal mitogens such PHA. The clinical approach of the CVH patients should be performed by a multispecialized team including the clinical immunologist and the gastrointestinal and infectious diseases specialists.

Immunopathogenic aspects of infection by the human immunodeficiency virus in Venezuela.

A study of the immunopathogenic characteristics of HIV infection was begun in 1984 at the National Reference Center on Clinical Immunology (CNRIC) in Caracas, Venezuela, on 240 individuals with a variety of clinical manifestations. The most important findings were depletion of the CD4 cells in HIV-infected individuals, including asymptomatic carriers; significant reduction of the CD3-, CD16+ large granular lymphocytes (LGL) in AIDS cases; decrease in LGL cytotoxic activity in infected persons versus controls, along with increased lytic function induced by stimulation with recombinant interleukin-2 in both groups; and reduction of the CD4 population in AIDS patients, independent of the presence or absence of free serum antigen. Such research is helping to clarify the immunopathogenic mechanisms of HIV and possible geographic and demographic variations.