Risk of Progressive Multifocal Leukoencephalopathy in the Combination Antiretroviral Therapy Era in the French Hospital Database on Human Immunodeficiency Virus (ANRS-C4).

Background: Risk factors for progressive multifocal leukoencephalopathy (PML) in individuals with human immunodeficiency virus (HIV) infection are poorly documented in the era of combination antiretroviral therapy (cART). Methods: We studied HIV-1-infected individuals aged ≥15 years who had no history of PML and were prospectively followed up between 1997 and 2011 in the French Hospital Database on HIV (FHDH-ANRS CO4) cohort. Cox models were used to calculate adjusted hazard ratios (HRs), focusing on sub-Saharan origin, suggested to be protective, and recent cART initiation, potentially associated with an increased risk of PML. Results: PML developed in 555 individuals, in 57 during the first 6 months of cART. From 1997-2000 to 2009-2011, the incidence fell from 1.15 (95% confidence interval [CI], .98-1.31) to 0.49 (.37-.61) per 1000 person-years. Sub-Saharan African origin had no clear influence (HR, 0.80; 95% CI, .58-1.11). Compared with men who have sex with men, injection drug users (IDUs) were at higher risk (HR, 1.80 [95% CI, 1.32-2.45] for male and 1.68 [1.13-2.48] for female IDUs). When IDUs were excluded, hepatitis C virus seropositivity was associated with an increased risk (HR, 1.40; 95% CI, 1.02-1.93). Compared with no cART initiation, initiation <6 months previously was associated with PML onset (HR, 4.91; 95% CI, 2.42-9.95). Conclusions: Recent cART initiation is associated with an increased risk of PML, as are injection drug use and hepatitis C virus seropositivity. Sub-Saharan African origin had no protective effect.

Primary HIV Infection: Clinical Presentation, Testing, and Treatment.

PURPOSE OF REVIEW: The purpose of this review was to provide current data on clinical presentation, diagnosis, and treatment of primary HIV infection (PHI). RECENT FINDINGS: In 65 to 95% of cases, PHI causes acute retroviral syndrome presenting with unspecific flu-like symptoms. Symptomatic PHI was associated with a faster clinical and immunological progression of HIV infection. Point-of-care tests remain less sensitive than fourth-generation immunoassays (IA) in PHI, especially after tenofovir-based prophylaxis use. Early antiretroviral treatment (ART) started during PHI prevents HIV transmission and decreases viral and immunological reservoir constitution. Recommended ART regimens in PHI are combinations of tenofovir and emtricitabine with either darunavir/ritonavir, or dolutegravir. Starting ART the earliest is highly recommended for clinical, virological, immunological, and public health benefits. Reducing HIV reservoir constitution in PHI may optimize potential opportunities for future functional cure.

Successful improvement of Buschke-Löwenstein tumour in an HIV-infected patient with antiretroviral therapy alone.

Buschke-Löwenstein tumour (BLT), also defined as giant condyloma acuminatum, is a rare exophytic tumour affecting the anogenital and perianal regions associated with human papillomavirus (HPV) infections, with a potential of malignant transformation and which is at a greater risk in T-cell mediated immunodeficient patients. Different therapeutic options, alone or in combination, have been reported for the treatment of BLT including local therapy but wide surgical local excision is however recommended as the most important therapeutic intervention. We report a case of a HIV-infected man who developed a voluminous pelvic BLT which disappeared progressively under antiretroviral therapy with no additional treatment, contemporary to an improvement of his immunity, highlighting the possible spontaneous reversibility of HPV-induced tumours in treated HIV infection.

Marine envenomations in returning French travellers seen in a tropical diseases unit, 2008-13.

BACKGROUND: Travel and aquatic activities are increasing in tropical regions. The risk and the spectrum of marine envenomation are unknown in travellers. This work aims to evaluate the prevalence and the characteristics of marine envenomations in returning travellers. METHODS: We retrospectively studied the medical charts of all returning travellers presenting with a health problem in a French tropical disease unit between 2008 and 2013, with focus on travellers complaining of marine envenomation. Characteristics of each type of envenomation are described. RESULTS: Of the 3315 travellers seen during the study period, 43 consulted for a presumed marine envenomation. Six patients were excluded, leaving 37 cases of confirmed marine envenomation. It corresponds to a prevalence of 1.1%. Sex ratio was balanced with 18 men and 19 women. Median age was 42 years (range 25-68 years). Median travel duration was 14 days (range: 6-62 days). The main travel destination was Southeast Asia in 10 cases, followed by islands of East Africa in seven cases. Median elapsed time between envenomation and consultation was 14 days (range: 2-130 days). The purpose of travel was tourism in all cases. The main clinical aspects were oedema, sting marks, cellulitis and flagellations. Eleven cases were presumably caused by corals, 10 by stonefish, 8 by jellyfish, 2 by weever fish, 2 by starfish, 2 by stingray, 1 by lionfish and 1 by sea anemone. CONCLUSION: Prevalence of marine envenomation is low in returning travellers. They are mostly caused by corals, stonefish and jellyfish.

Sézary syndrome without erythroderma.

BACKGROUND: Sézary syndrome is a cutaneous T-cell lymphoma characterized by erythroderma and leukemic involvement. OBJECTIVE: We sought to define the clinical, biologic, and histopathologic features of Sézary syndrome without erythroderma. METHODS: Features of patients with Sézary syndrome and normal-appearing skin or stage-T1 patches, fulfilling Sézary syndrome hematologic criteria and with histologically documented disease in normal-appearing skin were collected. Expression of Sézary syndrome molecular biomarkers in peripheral blood and skin lymphocytes were studied. RESULTS: Five women and 1 man (median age: 71 years) were all referred for generalized pruritus. Four had no specific lesions; 2 had T1-stage patches. Histologic examination of normal-appearing skin from all patients showed lesions compatible with Sézary syndrome. Peripheral blood lymphocytes from 3 of 4 patients tested strongly expressed PLS3, Twist-1, and KIR3DL2. All normal-appearing skin biopsy specimens expressed programmed death-1. Median follow-up was 9 years. Although no patient developed erythroderma, tumors, or abnormal lymph nodes, specific skin lesions appeared in all patients during follow-up. Only 1 death, unrelated to Sézary syndrome, occurred. LIMITATIONS: Retrospective design and small sample size are limitations. CONCLUSION: Sézary syndrome without erythroderma is a rare entity that may have a better prognosis than classic Sézary syndrome.

Disseminated cryptococcosis, invasive aspergillosis, and mucormycosis in a patient treated with alemtuzumab for chronic lymphocytic leukaemia.

We report the case of a 42-y-old man treated with alemtuzumab for chronic lymphocytic leukaemia, who developed 3 successive deep fungal infections. Despite being treated with liposomal amphotericin B and 5-flucytosine for disseminated cryptococcosis, he developed pulmonary invasive aspergillosis, followed by pulmonary mucormycosis. Several deep fungal infections may occur in association in an immunocompromised host after treatment with alemtuzumab.