Penicillium marneffei presenting as an immune reconstitution inflammatory syndrome (IRIS) in a patient with advanced HIV.

A 62-year-old British man with advanced HIV was established on antiretroviral therapy and treatment for disseminated Mycobacterium avium complex and Cytomegalovirus infections. One month later he re-presented with epigastric pain, an epigastric mass and skin lesions. Abdominal imaging revealed large volume lymphadenopathy, which was not present on previous imaging. Blood cultures yielded Penicillium marneffei, a dimorphic fungus endemic to South-east Asia. The patient had spent several years travelling in Thailand prior to the diagnosis of HIV. Penicilliosis is a common AIDS-defining illness in endemic areas, but remains rare in Europe. In this case, it presented in the context of a rapidly decreasing viral load as an immune reconstitution inflammatory syndrome. The challenges of management in the context of multiple comorbidities and polypharmacy are discussed.

Isoniazid-resistant intracranial tuberculoma treated with a combination of moxifloxacin and first-line anti-tuberculosis medication.

We report a case of a previously healthy 23-year-old Somalian care assistant. She presented with a 4 month history of persistent occipital headaches associated with intermittent nausea and vomiting. Computed tomography and magnetic resonance imaging of the brain showed a large enhancing lesion in the right cerebellar hemisphere with surrounding ring lesions, suggestive of an intracranial neoplasm with metastases. However, tuberculoma of the brain was confirmed based on histology of the excision biopsy and cerebrospinal fluid (CSF) culture results: Mycobacterium tuberculosis resistant to isoniazid (INH) with sensitivity to other standard drugs, including fluoroquinolones, was cultured from CSF. No primary focus to suggest spread from elsewhere was found. The patient was treated successfully with moxifloxacin, rifampicin, pyrazinamide and ethambutol. Isolated INH-resistant intracranial tuberculoma is rare in adults. It can mimic other intracranial masses and should be kept in mind, especially in populations with a high risk of tuberculosis. Clinical use of moxifloxacin in INH-resistant tuberculomas is limited in humans and this case demonstrates that moxifloxacin may be an effective alternative treatment.

Severe myositis on commencement of efavirenz, abacavir and lamivudine, in the absence of lactic acidosis or classical abacavir hypersensitivity.

Myositis in HIV may be due to HIV itself, or to opportunistic infection, malignancy or drug treatment. Severe myositis or rhabdomyolysis have never been reported with the commonly used nucleoside reverse transcriptase inhibitor abacavir, although creatine phosphokinase may rise modestly, particularly if abacavir hypersensitivity occurs. We report an unusual case of abacavir use associated with a thousand-fold rise in creatine phosphokinase in the absence of features of hypersensitivity. The case was also notable firstly in that there was an absence of the HLA-B5701 allele, the most common human leucocyte antigen (HLA) allele associated with hypersensitivity, and, secondly, as the case occurred in an African patient, African people not being prone to abacavir hypersensitivity.

Healthcare associated discitis in the era of antimicrobial resistance.

Discitis is a recognized and serious complication of healthcare. We describe the cases of 4 patients, who presented to our unit over a 1 year period. All had exposure to healthcare before the onset of discitis and developed complex infections. There were no additional risk factors for discitis in any of the cases. The risk factors for discitis were peripheral intravenous cannulation in 1 case, intraabdominal surgery in 2 cases and multiple risks including intensive care admission and urethral catheterization in another case. The described cases demonstrate the importance of ascertaining a definitive microbiological diagnosis in healthcare associated discitis and the complex and expensive antibiotic regimens that may be required for the management of such cases. Clinicians should be aware when seeing patients with back pain and recent health care exposure that discitis can be present and complicated and that resistant organisms can be the cause.

Low prevalence of transmitted antiretroviral drug resistance in a large UK HIV-1 cohort.

OBJECTIVES: To describe current practice in testing for transmitted antiretroviral drug resistance (TDR) and the prevalence of TDR in a large UK HIV-1 cohort. METHODS: The study includes a retrospective analysis of newly diagnosed HIV-1-infected patients presenting to eight HIV clinics in the north of England between March 2005 and March 2007. Resistance mutations were defined by IAS-USA. Predicted phenotypes were calculated by the Stanford University database. RESULTS: Five hundred and fifty-eight patients were studied, of whom 394 (70.6%) had heterosexually acquired HIV and 377 (67.6%) were infected outside the UK. TDR testing was performed in 406 patients (72.8%). Thirteen of 392 viral resistance profiles (3.3%) showed genotypic TDR. There was no significant association between TDR and any demographic or risk factor or baseline CD4 count. In particular, rates of TDR were similar in white British (6/147, 4.1%) and black African (7/224, 3.1%) patients. The numbers of patients with TDR to individual drug classes were: nucleoside reverse transcriptase inhibitors, 2 (0.5%); non-nucleoside reverse transcriptase inhibitors, 7 (1.8%); and protease inhibitors, 4 (1.0%). No patients had multi-class resistance detected. Eleven patients (2.8%) were predicted to have significant phenotypic resistance to at least one drug. CONCLUSIONS: In a large unselected UK cohort, with high coverage of TDR testing, the prevalence of TDR was low and is in accordance with recent data, showing a decrease in the prevalence of TDR in the UK. Differences in population mix did not appear to explain this low rate.