Late presentation of HIV infection: predictors of delayed diagnosis and survival in Eastern Sicily.

OBJECTIVES: Across Europe, more than one third of patients are diagnosed with HIV infection late. Late presentation for care has been associated with higher risk of clinical progression and mortality. In the present study, we evaluated the prevalence, epidemiological characteristics and survival probability of patients with late and very late presentation, newly diagnosed with HIV infection in Catania, Italy, from 1985 to 2010. PATIENTS AND METHODS: According to the European Consensus definition, Late Presenters (LP) were defined as subjects presenting for care with a CD4+ T-cell count below 350 cells/µl or with an AIDS-defining event, regardless of CD4+ T-cell count; patients with advanced HIV disease (Very Late Presenters) (VLP) were those presenting with a CD4+ T-cell count below 200 cells/µl or with an AIDS-defining event, regardless of CD4+ T-cell count. RESULTS: 620 patients were included in the study. 345 (55.6%) subjects were LP, 35% of them were asymptomatic; 246 (39.7%) were VLP. In univariate analysis, late presentation was related to age (p < 0.001), to heterosexual exposure to HIV infection (70% of heterosexual subjects were LP) (p < 0.005) and to being diagnosed during the calendar period from 1991 to 2000 (p < 0.001). Very late presentation was related to age (p < 0.001), male sex (p < 0.01), heterosexual risk (p < 0.001) and to being diagnosed during the calendar period from 1991 to 2000 (p < 0.001). In multivariate analysis, age (p < 0.0001), being older than 50 years old (p = 0.02), years of diagnosis 1991-1995 (p < 0.005) and 1996-2000 (p < 0.05) in the subgroup of late presenters and age (p < 0.0001), being older than 50 years old (p < 0.005), male sex (p < 0.0001), years of diagnosis 1991-1995 (p < 0.05) and 1996-2000 (p < 0.005) in the subgroup of very late presenters maintained statistical significance. The survival probability within LP and VLP group was statistically lower than no LP/VLP (log rank test p < 0.0005 and p < 0.0001, respectively). For both LP (p < 0.002) and VLP (p < 0.0001), survival probability was significantly lower in the pre-HAART era, in comparison with the period of mono/dual therapy and the HAART era. CONCLUSIONS: More than fifty percent of patients in our setting were diagnosed late with HIV infection and, consequently, treated late. Late and very late presentation were associated with lower survival probability. The implementation of strategies focused on targeted prevention efforts and HIV testing programs appears fundamental to diagnose and treat HIV infection as early as possible.

High prevalence of undiagnosed anxiety symptoms among HIV-positive individuals on cART: a cross-sectional study.

INTRODUCTION: Anxiety disorders are frequent in HIV-infected individuals, can pre-exist or occur during HIV infection. We evaluated with a self-reported questionnaire whether anxiety is related to HIV clinical status and therapeutic success in a cohort of HIV-positive subjects in Sicily. PATIENTS AND METHODS: We enrolled 251 patients on combination antiretroviral therapy (cART) for at least six months; Self Rating Anxiety State SAS 054 was used to diagnose anxiety and a Z score ≥ 45 points was considered diagnostic. RESULTS: 47% of patients were diagnosed with anxiety. Patients showing symptoms related to anxiety had experienced a high number of therapeutic switches (fourth line or more). CONCLUSIONS: These data confirm a high prevalence of anxiety symptoms among subjects with HIV infection in Eastern Sicily. Physicians should be aware of the extent of the problem and should be able to adequately manage anxiety in the setting of HIV infection.

LPS and HIV gp120 modulate monocyte/macrophage CYP27B1 and CYP24A1 expression leading to vitamin D consumption and hypovitaminosis D in HIV-infected individuals.

AIM: Vitamin D deficiency is very common among HIV-infected subjects. We cross-sectionally evaluated the prevalence and risk factors for hypovitaminosis D in 91 HIV-infected Italian patients. PATIENTS AND METHODS: We studied in a cohort of 91 HIV-infected Italian patients the metabolism of Vitamin D by evaluating the in vitro expression of CYP27B1, CYP24A1 and vitamin D receptor (VDR) by monocytes and macrophages stimulated with the viral envelope protein gp120 or lipopolysaccharide (LPS). RESULTS: The prevalence of vitamin D deficiency (25OHD < 10 ng/ml) and vitamin D insufficiency (25OHD 10-30 ng/ml) was 31% and 57%, respectively. In univariate analysis, female sex (p = 0.01), increasing age (p = 0.05), higher highly sensitive-C reactive protein (p = 0.025), higher parathyroid hormone (PTH) (p = 0.043) and lower BMI (p = 0.04) were associated with vitamin D deficiency. In multivariate analysis, the association was still significant only for PTH (p = 0.03) and female sex (p = 0.03). Monocyte stimulation with LPS (100 ng/ml) or gp120 (1 µg/ml) significantly upregulated CYP27B1 mRNA expression. Moreover, gp120 significantly increased VDR mRNA levels. On the contrary, neither LPS nor gp120 modified CYP24A1 levels. Macrophage stimulation with LPS (100 ng/ml) significantly upregulated CYP27B1 and CYP24A1 mRNA expression. When monocytes were cultured in the presence of 25OHD (40 ng/ml) and stimulated with LPS we detected significantly lower levels of 25OHD in the supernatant. CONCLUSIONS: Vitamin D deficiency was very common in our cohort of HIV-infected patients. Chronic inflammation, including residual viral replication, may contribute to hypovitaminosis D, by modulating vitamin D metabolism and catabolism. Systematic screening may help identifying subjects requiring supplementation.

Cryptococcal meningitis in an HIV-1-infected person: relapses or IRIS? Case report and review of the literature.

After starting highly active antiretroviral therapy (HAART), HIV-infected patients may experience what is termed immune reconstitution inflammatory syndrome (IRIS). IRIS is characterized by a paradoxical inflammatory response to either previously or recently treated infections or unmasked subclinical infections, when the patient regains the ability to mount a suitable immune response against specific antigens or pathogens. Cryptococcal IRIS (C-IRIS) is thought to be mediated by recovery of Cryptococcus-specific immune responses, resulting in exaggerated host inflammatory responses. In HIV-positive subjects, two distinct modes of presentation of C-IRIS are recognized, "paradoxical" and "unmasking" C-IRIS. "Paradoxical" C-IRIS presents as worsening or recurrence of treated cryptococcal disease following HAART initiation, despite microbiological treatment success. In the "unmasking" form, patients with no prior diagnosis may develop acute symptoms of cryptococcosis, such as meningitis or necrotizing lymphadenopathy, after starting HAART. Here, we present the case of an HIV-positive man, who developed cryptococcal meningitis two months after having started HAART and experienced several meningeal relapses and a "paradoxical" C-IRIS during the following year.

Description of a rare case of splenic abscess due to spontaneous E. cohi bacteremia in a cirrhotic patient.

We report on a rare case of splenic abscess due to spontaneous Escherichia coli bacteremia in a 49-year old cirrhotic. No other source potentially responsible for bacteremia was found through careful diagnostic research. Splenic abscess appeared from ultrasonography and computerized tomography as a 6-7 cm lesion located at the lower splenic pole. Blood cultures allowed to isolate E. coli which, on the basis of antibiotic susceptibility, was treated by a 21-day intravenous cetazidime course at a dose of 6 g/day. The isolated E. coli strain resulted as quinolone-resistant. Disappearance either of high fever or of abscessual splenic lesion was achieved without surgery after the antibiotic round. Spontaneous bacteremia may occur in cirrhotic patients due to intestinal bacteria traslocation from gut lumen to blood. Nevertheless, isolated splenic localization is a very rare event.

Incidence of breast cancer in Piedmont: 1979-1981.

A population-based survey of histologically diagnosed breast cancer was carried out among residents in Piedmont. A total of 5267 incident cases occurring in 1979-1981 was collected, corresponding to an age-standardized (on the world population) incidence rate of 49.5/100,000 per year. Rates (standardized on the population of Piedmont in 1981) were highest in the city of Torino (112.4/100,000 per year) and lowest in the province of Cuneo (67.5), whereas in the other provinces they ranged between 85.3 and 90.0. Estimation of rates in the 54 Local Health Authorities of Piedmont detected up to 2-fold differences between adjacent areas. A correlation was found between rates and size of the population of town of residence. Comparison with age-specific incidence rates from the Cancer Registry of the nearby province of Varese suggested a loss of nonhistologically confirmed cases selectively in older age groups. The distribution of cases diagnosed in 1979 by histologic type is presented. The proportion of diagnoses reported in terms which were consistent with the 1978 WHO Histological Typing of Breast Tumours was 61.3%. It was highest among cases identified in Pathology Services located in University Hospitals and/or diagnosing more than 50 breast cancers per year.