Treatment of acute hepatitis C infection in HIV-infected patients: a retrospective analysis of eleven cases.

Studies on hepatitis C virus (HCV) monoinfected patients suggest high sustained treatment response rates of up to 98% when interferon monotherapy is administered during the acute phase of HCV-infection. To clarify whether early treatment of acute hepatitis C is similarly efficient in human immunodeficiency virus (HIV) positive patients, we conducted a retrospective survey of HIV-positive patients with acute HCV infection. Eleven HIV-positive patients who had been treated with interferon or interferon/ribavirin were identified at eight HIV-specialty outpatient clinics. The patients had been treated over a median 25 weeks with standard interferon (two patients), pegylated interferon (four patients) and pegylated interferon in combination with ribavirin (five patients). A post-treatment response (negative serum HCV-RNA at the end of treatment) was seen in 10 of 11 patients and HCV-RNA remained undetectable 24 weeks after the end of treatment in all the 10 responders. Alanine aminotransferase (ALT) normalized in eight patients while two virological responders and one nonresponder showed persistent mild ALT elevations. In conclusion, early treatment of acute hepatitis C seems to achieve high sustained virological treatment response rates also in patients with HIV-infection.

[Management of primary HIV-infection]. / Umstrittenes Management der primären HIV-Infektion. lm Frühstadium antiretroviral behandeln--ja oder nein?

Clinical suspicion of a primary HIV infection is aroused by the patient's exposure history and can only be confirmed by an HIV PCR test. The classic HIV antibody test (ELISA) often is non-reactive during the very early stage of HIV infection. The value of antiviral therapy during primary HIV infection is unclear. In spite of a positive influence on surrogate markers in vitro, studies so far have not been able to demonstrate a clinical benefit. Treatment should be carried out only in specialized infectious disease centers, most preferably within controlled clinical studies.

Mycobacterium microti llama-type infection presenting as pulmonary tuberculosis in a human immunodeficiency virus-positive patient.

A rare case of Mycobacterium microti infection in a human immunodeficiency virus-positive patient is described. Because of unusual morphological and cultural features, the pathogen was analyzed by spoligotyping and identified as the Mycobacterium microti llama type. Although culture of M. microti is difficult, drug susceptibility testing could be performed, which correlated with the clinical outcome.

Delayed low density lipoprotein (LDL) catabolism despite a functional intact LDL-apolipoprotein B particle and LDL-receptor in a subject with clinical homozygous familial hypercholesterolemia.

We identified a 38-yr-old male patient with the clinical expression of homozygous familial hypercholesterolemia presenting as severe coronary artery disease, tendon and skin xanthomas, arcus lipoides, and joint pain. The genetic trait seems to be autosomal recessive. Interestingly, serum concentrations of cholesterol responded well to diet and statins. We had no evidence of an abnormal low density lipoprotein (LDL)-apolipoprotein B (apoB) particle, which was isolated from the patient using the U937 proliferation assay as a functional test of the LDL-binding capacity. The apoB 3500 and apoB 3531 defects were ruled out by PCR. In addition, we found no evidence for a defect within the LDL-receptor by skin fibroblast analysis, linkage analysis, single-strand conformational polymorphism and Southern blot screening across the entire LDL-receptor gene. The in vivo kinetics of radioiodinated LDL-apoB were evaluated in the proband and three normal controls, subsequently. The LDL-apoB isolated from the patient showed a normal catabolism, confirming an intact LDL particle. In contrast the fractional catabolic rate (d-1) of autologous LDL in the subject and the normal controls revealed a remarkable delayed catabolism of the patient's LDL (0.15 vs. 0.33-0.43 d-1). In addition, the elevation of LDL-cholesterol in the patient resulted from an increased production rate with 22.8 mg/kg per day vs. 12.7-15.7 mg/kg per day. These data indicate that there is another catabolic defect beyond the apoB and LDL-receptor gene causing familial hypercholesterolemia.

Analysis of novel apolipoprotein B mutations using a modified U937 cell line LDL binding assay.

The U937 myelomonocyte proliferation assay can be used to detect patients with familial defective apolipoprotein B-100 (FDB). Previous studies have employed electronic cell counting to assess cell proliferation. We simplified the assay using 3H-thymidine incorporation DNA analysis to measure cell growth. We tested the modified method by analyzing the effects of different concentrations of native low density lipoproteins (LDL), methylated LDL, as well as LDLs obtained from patients with FDB on cell growth. Methylation of LDL to various degrees reduced cell proliferation correspondingly, and LDLs obtained from FDB patients decreased cell growth confirming that the modified method was able to detect binding defective species of LDL. We applied this method to analyze three novel apoB polymorphisms recently characterized in this laboratory (apoB His1896-->Arg, apoB Asn1887-->Ser, apoB Ala4454-->Thr), which did not significantly alter U937 cell proliferation. Our results show that this simplified assay can be used for screening for LDL variants with defective binding.

Rapidly progressive seronegative spondylarthropathy with atlantodental subluxation in a patient with moderately advanced HIV infection.

It has been suggested that the immunosuppressed state associated with HIV infection may influence the clinical course of rheumatic diseases. We describe the case of a patient with moderately advanced HIV infection who developed a psoriatic rash and a rapidly progressive spondylarthropathy of the cervical spine with atlantodental subluxation requiring spondylodesis. This case supports the hypothesis that HIV infection may be associated with uncommon manifestations and a rapidly progressive course refractory to medical therapy in patients with spondylarthropathy.

Influence of selective management on the prognosis and the risk of rupture of abdominal aortic aneurysms.

A total of 199 patients with abdominal aortic aneurysms were followed up to investigate the influence of selective management on the prognosis and the risk rupture of abdominal aortic aneurysms. Decisions to operate or to continue watchful waiting with treatment of risk factors for expansion were based on aneurysm size, expansion rate, aneurysm-related symptoms, and individual operative risk. Rupture occurred in eight cases. All aneurysms were larger than 5 cm, and six were larger than 6 cm in diameter at the last measurement before rupture. The resulting overall 5-year cumulative rate of rupture was 7.3% (Kaplan Meier). The 134 patients who underwent more than one ultrasound examination were observed for an average of 4.0 years (536 patient-years). The expansion rate was significantly correlated with the initial diameter and the diastolic blood pressure (best subset multiple regression analysis: r = 0.403; P < 0.001). A correlation with the systolic blood pressure was found only in univariate analysis (r = 0.236; P = 0.011). Amplitude of blood pressure, serum cholesterol level, low-density and high-density lipoproteins, ratio of low- to high-density lipoproteins age, and the extent of smoking habits were not correlated with the expansion rate. Our conclusion is that larger diameter and higher diastolic blood pressure are important risk factors for expansion of abdominal aortic aneurysms. Selective management of abdominal aortic aneurysms based on aneurysmal size, expansion rate, and patient characteristics may result in a low rate of rupture.

Identification of defective binding of low density lipoprotein by the U937 proliferation assay in German patients with familial defective apolipoprotein B-100.

Familial defective apolipoprotein B-100 (FDB) is a dominantly inherited disorder characterized by decreased binding of low density lipoprotein (LDL) to the LDL receptor due to a substitution of glutamine for arginine in residue 3500 of apolipoprotein B-100. We present the results of the U937 cell proliferation assay for the detection of familial defective apo B100 in 13 German FDB patients. Due to a defect in the pathway of cholesterol synthesis the human myelomonocytic tumour cell line U937 lacks the ability to synthesize cholesterol which makes proliferation of these cells dependent on the presence of exogenous LDL-cholesterol. U937 cells were incubated with LDL from 13 FDB-patients, 10 healthy normocholesterolaemic individuals (NC) and 26 patients with familial hypercholesterolaemia due to a defective LDL-receptor (FH). At LDL-cholesterol concentrations below 1 microgram ml-1 no proliferation occurred. In the presence of LDL from FDB patients at concentrations between 2.5 micrograms ml-1 and 15.0 micrograms ml-1, the proliferation was significantly reduced compared to LDL from FH-patients and normocholesterolaemic controls. At 5 micrograms ml-1 the reduction was 31-80% regardless of age, sex, apo E genotype, Lp(a)- and lipid levels. At concentrations above 25.0 micrograms ml-1 no further differences were observed. The present results indicate that the U937 proliferation assay is a reliable test for the detection of defective LDL-binding due to the 3500 mutation in FDB patients. It may be useful for the detection of defective binding of LDL due to other mutations in the apo B-100 gene.

Independent mutation of arginine(3500)-->glutamine associated with familial defective apolipoprotein B-100.

Familial defective apolipoprotein B-100 (FDB) is characterized by a decreased affinity of low density lipoprotein (LDL) to the LDL receptor resulting in a dominantly inherited increase of plasma LDL. It is postulated that FDB is caused by a G to A mutation at nucleotide 10,708 in exon 26 of the apoB gene creating a substitution of glutamine for arginine in amino acid 3500. The arginine(3500)-->glutamine mutation has been identified on the same haplotype of the apoB gene in several populations from North America and Europe, suggesting that it occurred on a single ancestral gene. Independent mutations were not observed. The purpose of this paper is to report on a family where individuals show a dominantly inherited increase of plasma LDL associated with an independent arginine(3500)-->glutamine mutation as determined by haplotype analysis using polymorphic markers of the apoB gene. The identification of these individuals is strong evidence that the arginine(3500)-->glutamine mutation is causative for the defective binding of apoB-100.

The spontaneous course of small abdominal aortic aneurysms. Aneurysmal growth rates and life expectancy.

Since abdominal ultrasonography has become a routine diagnostic procedure, increasing numbers of small asymptomatic abdominal aortic aneurysms are detected incidentally. Of 128 patients (108 male, 20 female) with abdominal aortic aneurysms, 96 patients were observed clinically and by repeated ultrasound studies for an average of 3.47 years, adding up to a total observation period of 333 patient-years. Among these 96 patients, 72 had small aneurysms (averaged diameters less than 5 cm). Three of them were lost to follow up. None of the remaining 69 patients died from rupture, 20 died from other causes and 8 patients were successfully operated. Of the patients with a large aneurysm one was lost to follow up. Five patients of the remaining 23 died as a result of rupture, 7 were successfully operated. The average growth rate of small aneurysms was 0.18 cm/year, whereas the larger aneurysms showed a growth rate of 0.28 cm/year (diameter). The survival rate of patients with small aneurysms was 94% after one year, 80% after 3 years, and 73% after 5 years, indicating that life expectancy is reduced in patients with an aneurysm of the abdominal aorta, but not because of complications of the aneurysm.