Care of Critically Ill Patients with Human Immunodeficiency Virus.

Care of patients with human immunodeficiency virus (HIV) infection in the intensive care unit (ICU) has changed dramatically since the infection was first recognized in the United States in 1981. The purpose of this review is to describe the current important aspects of care of patients with HIV infection in the ICU, with a primary focus on the United States and developed countries. The epidemiology and initial approach to diagnosis and treatment of HIV (including the newest antiretroviral guidelines), common syndromes and their management in the ICU, and typical comorbidities and opportunistic infections of patients with HIV infection are discussed.

Behavioral and Cardiovascular Effects of a Behavioral Weight Loss Program for People Living with HIV.

We recently reported that a 12-week internet weight loss program produced greater weight losses than education control in overweight/obese people living with HIV (PLWH) (4.4 kg vs 1.0 kg; p < 0.05). This manuscript presents the changes in diet, physical activity, behavioral strategies, and cardio-metabolic parameters. Participants (N = 40; 21 males, 19 females) were randomly assigned to an internet behavioral weight loss (WT LOSS) program or internet education control (CONTROL) and assessed before and after the 12-week program. Compared to CONTROL, the WT LOSS arm reported greater use of behavioral strategies, decreases in intake (- 681 kcal/day; p = 0.002), modest, non-significant, increases in daily steps (+ 1079 steps/day) and improvements on the Healthy Eating Index. There were no significant effects on cardio-metabolic parameters. The study suggests that a behavioral weight loss program increases the use of behavioral strategies and modestly improves dietary intake and physical activity in PLWH. Further studies with larger sample sizes and longer follow-up are needed.Clinical Trials Registration: NCT02421406.

Behavioral Weight Loss: A Promising Treatment for Obesity in Adults with HIV.

Obesity and chronic disease are growing problems among people living with HIV (PLWH) across the globe. While a variety of treatments have been developed to address cardiovascular and metabolic disease among PLWH, few treatments have focused on helping PLWH and obesity lose weight. In the general population, behavioral weight loss interventions (i.e., diet, physical activity, and behavior therapy) are the first-line treatment for adults for whom weight loss is recommended. However, little research has tested whether the benefits of these programs translate to PLWH. This paper highlights the key components of behavioral weight loss programs, their outcomes in the general population and in the few studies of PLWH, and suggestions for tailoring these programs for PLWH. Behavioral weight loss programs are a strong potential treatment for reducing the burden of obesity among PLWH and merit future research attention.

Posterior reversible encephalopathy syndrome in a patient with HIV/AIDS and immune reconstitution syndrome: a case study and literature review.

The etiology of posterior reversible encephalopathy (PRES) is typically multifactorial. Patients with HIV are at risk for the development of this syndrome. We review 17 published cases of HIV and PRES and describe the second reported case of PRES in the setting of HIV and immune reconstitution syndrome (IRIS). IRIS has not yet been described as a risk factor for PRES.

A Randomized Controlled Trial of a Behavioral Weight Loss Program for Human Immunodeficiency Virus-Infected Patients.

Obesity compounds the negative health effects of human immunodeficiency virus (HIV) infection. We conducted the first randomized trial of behavioral weight loss for HIV-infected patients (n = 40). Participants randomized to an Internet behavioral weight loss program had greater 12-week weight loss (mean, 4.4 ± 5.4 kg vs 1.0 ± 3.3 kg; P = .02) and improvements in quality of life than controls. Clinical Trials Registration NCT02421406.

HIV and aging.

With the wider availability of antiretrovirals, the world's HIV population is aging. More than 10% of the 34.5 million HIV-positive individuals worldwide are over the age of 50 years and the average age continues to increase. In the USA more than 50% of the 1.3 million people with HIV are over 50 years old and by the year 2030 it is estimated that 70% will be over the age of 50 years. Although the life expectancy of HIV-positive people has increased dramatically, it still lags behind that of HIV-negative individuals. There is controversy about whether HIV itself accelerates the aging process. Elevated rates of inflammation seen in people with HIV, even if their viral loads are suppressed and their CD4 counts are preserved, are associated with greater rates of cardiovascular, renal, neurocognitive, oncological, and osteoporotic disease. These conditions increase exponentially in the elderly and will represent a major challenge for HIV patients. In addition, conditions such as geriatric syndromes including frailty are also seen at higher rates. Management of the aging HIV patient includes an emphasis on early diagnosis and treatment, preventative measures for co-morbidities, and avoiding polypharmacy. Finally, the issue of quality of life, prioritization of medical issues, and end of life care become increasingly important as the patient grows older.

Obesity prevalence and related risk of comorbidities among HIV+ patients attending a New England ambulatory centre.

BACKGROUND: Human immunodeficiency virus infection and obesity are pro-inflammatory conditions that, when occurring together, may pose a synergistic risk for diabetes and cardiovascular disease. PURPOSE: The aim of the current study was (i) to document the prevalence of obesity in HIV+ patients treated at the Miriam Hospital Immunology Center (Providence, RI) and (ii) to investigate the relationship between obesity and comorbidities. METHODS: The study population consisted of 1,489 HIV+ adults (70% men; average age 48 ± 11 years) treated between 01/01/2012 and 06/30/2014. Separate logistic regressions tested the associations between overweight and obesity and comorbid diagnoses (diabetes, hypertension and cardiovascular disease), as compared with normal weight. Covariates included age, gender and smoking status. RESULTS: Approximately 37% of patients were overweight (body mass index 25.0-29.9), and an additional 28% were obese (body mass index ≥30.0). Obesity was associated with higher odds of comorbid diabetes (OR = 3.26, CI = 1.98-5.39) and hypertension (OR = 2.11, CI = 1.49-2.98). There was no significant association between obesity and the presence of cardiovascular disease (OR = 1.12, CI = 0.66-1.90). Overweight was associated only with higher odds of comorbid diabetes (OR = 1.72; CI = 1.02-2.88). CONCLUSION: Our findings demonstrate a heightened risk of comorbidities in overweight and obese HIV + patients. Future studies should investigate whether weight loss interventions for this population can reduce cardiovascular and metabolic risk factors as they do in other populations.

Multicentric Castleman disease, Kaposi sarcoma, hemophagocytic syndrome, and a novel HHV8-lymphoproliferative disorder.

The case of a 45-year-old man with HIV disease with bulky lymphadenopathy, fevers, and weight loss is presented. Immune reconstitution inflammatory syndrome was initially believed to be the cause, but the patient was found to suffer from Kaposi sarcoma, multicentric Castleman disease, hemophagocytic syndrome, and a newly described lymphoproliferative disorder. The diagnostic reasoning related to the causes of the fulminant illness is discussed as well as the roles of Epstein-Barr virus, human herpesvirus 8, and hepatitis C virus in the patient's clinical presentation and the therapeutic choices.

It is time to implement routine, not risk-based, HIV testing.

Approximately one-quarter of a million persons in the United States who are infected with human immunodeficiency virus (HIV) do not know it. To decrease the number of such persons, primary care providers should make HIV testing a routine component of health care. HIV testing should also be offered routinely in other settings, such as emergency departments, jails, and substance abuse treatment centers. Currently, the Centers for Disease Control and Prevention and the Infectious Diseases Society of America recommend routine HIV testing only in settings where the prevalence of HIV infection is > or =1%; in settings where the prevalence of HIV infection is <1%, testing should be based on risk assessment. Because of the impracticality of strategies for testing that are based on estimates of prevalence, and because of the inaccuracy of risk assessment, we propose that HIV testing be routinely offered to any person who is sexually active. As an adjunct to the implementation of routine testing programs, counseling practices need to be streamlined, and rapid HIV testing needs to be implemented in the appropriate settings.

A diagnostic dilemma in a patient receiving antiretroviral and antituberculosis therapy.

A southern Indian HIV-infected man with tuberculosis (TB) presented with worsening pulmonary infiltrates and increased mediastinal lymphadenopathy because of immune reconstitution 10 days after initiation of HAART. This case highlights the importance of developing guidelines for management of concurrent HIV infection and TB in the developing world.

Early scurvy complicating anorexia nervosa.

Scurvy is an extremely rare complication of anorexia nervosa. Despite the poor intake of nutrients, anorexia nervosa is not commonly associated with vitamin deficiencies. We report a case of early scurvy complicating long-standing anorexia nervosa. Anorexia nervosa appears to be increasing in incidence. Although scurvy is unusual, this case shows the importance of its recognition as a nutritional consequence of anorexia nervosa.

Neutrophil-Kupffer cell interaction: a critical component of host defenses to systemic bacterial infections.

Most bacteria that enter the bloodstream are taken up and eliminated within the liver. The specific mechanisms that underlie the role of the liver in the resolution of systemic bacterial infections remain to be determined. The vast majority of studies undertaken to date have focused on the function of resident tissue macrophages (Kupffer cells) that line the liver sinusoids. Indeed, it is often reported that Kupffer cells ingest and kill the bulk of organisms taken up by the liver. Recent studies indicate, however, that phagocytosis by Kupffer cells is not the principal mechanism by which organisms are eliminated. Rather, elimination depends on the complex interaction of Kupffer cells and bactericidal neutrophils that immigrate rapidly to the liver in response to infection. We discuss the critical role of neutrophil-Kupffer cell interaction in innate host defenses and, conceivably, the development and expression of adaptive immunity in the liver.

Listeria monocytogenes: clinical and experimental update.

Listeria monocytogenes, a small gram-positive bacillus, causes sepsis and meningitis in immunocompromised patients and a devastating maternal/fetal infection in pregnant women. Recent outbreaks demonstrated that L. monocytogenes can cause gastroenteritis in otherwise healthy individuals and more severe invasive disease in immunocompromised patients. Centralized processing in the food industry may be the cause of these large-scale listeriosis outbreaks. The mouse model of listeriosis, which was developed in the 1960s, has been extraordinarily useful for studying T cell-mediated immunity. Contrary to the original concept that macrophages are the principal effector cells in listeriosis, we found that immigrating neutrophils play the predominant role in early liver defenses. At later time points, CD8(+) T cells lyse infected hepatocytes by both perforin- and Fas-L/Fas--dependent mechanisms. Of interest, nonclassical major histocompatibility complex (MHC) class Ib--restricted cytolytic activity is expressed early during primary infection, whereas MHC class Ia--restricted activity is predominant through late primary and secondary infections.

Complementary adhesion molecules promote neutrophil-Kupffer cell interaction and the elimination of bacteria taken up by the liver.

Most bacteria that enter the bloodstream are taken up by the liver. Previously, we reported that such organisms are initially bound extracellularly and subsequently killed by immigrating neutrophils, not Kupffer cells as widely presumed in the literature. Rather, the principal functions of Kupffer cells demonstrated herein are to clear bacteria from the peripheral blood and to promote accumulation of bactericidal neutrophils at the principal site of microbial deposition in the liver, i.e., the Kupffer cell surface. In a mouse model of listeriosis, uptake of bacteria by the liver at 10 min postinfection i.v. was reduced from approximately 60% of the inoculum in normal mice to approximately 15% in mice rendered Kupffer cell deficient. Immunocytochemical analysis of liver sections derived from normal animals at 2 h postinfection revealed the massive immigration of neutrophils and their colocalization with Kupffer cells. Photomicrographs of the purified nonparenchymal liver cell population derived from these infected mice demonstrated listeriae inside neutrophils and neutrophils within Kupffer cells. Complementary adhesion molecules promoted the interaction between these two cell populations. Pretreatment of mice with mAbs specific for CD11b/CD18 (type 3 complement receptor) or its counter-receptor, CD54, inhibited the accumulation of neutrophils in the liver and the elimination of listeriae. Complement was not a factor; complement depletion affected neither the clearance of listeriae by Kupffer cells nor the antimicrobial activity expressed by infiltrating neutrophils.