Perinatal exposure of rats to the HIV drug efavirenz affects medial prefrontal cortex cytoarchitecture.

Efavirenz (EFV) is used for antiretroviral treatment of HIV infection, and successfully inhibits viral replication and mother-to-child transmission of HIV during pregnancy and childbirth. Unfortunately, the drug induces neuropsychiatric symptoms such as anxiety and depressed mood and potentially affects cognitive performance. EFV acts on, among others, the serotonin transporter and serotonin receptors that are expressed in the developing brain. Yet, how perinatal EFV exposure affects brain cytoarchitecture remains unclear. Here, we exposed pregnant and lactating rats to EFV, and examined in the medial prefrontal cortex (mPFC) of their adult offspring the effects of the maternal EFV exposure on cortical architecture. We observed a significant decrease in the number of cells, mainly mature neurons, in the infra/prelimbic and cingulate cortices of adult offspring. Next, we found an altered cortical cytoarchitecture characterized by a significant reduction in deep- and superficial-layer cells. This was accompanied by a sharp increase in programmed cell death, as we identified a significantly higher number of cleaved Caspase-3-positive cells. Finally, the serotonergic and dopaminergic innervation of the mPFC subdomains was increased. Thus, the perinatal exposure to EFV provoked in the mPFC of adult offspring cell death, significant changes in cytoarchitecture, and disturbances in serotonergic and dopaminergic innervation. Our results are important in the light of EFV treatment of HIV-positive pregnant women, and its effect on brain development and cognitive behavior.

New parameters available on Sysmex XE-5000 hematology analyzers contribute to differentiating dengue from leptospirosis and enteric fever.

INTRODUCTION: Distinguishing dengue virus infection from other febrile thrombocytopenic illnesses such as leptospirosis or enteric fever is important but difficult, due to the unavailability of reliable diagnostic tests. Sysmex XE-5000 hematology analyzers use fluorescence flow cytometry to quantitate new parameters including cells in the atypical lymphocyte area (AL), high-fluorescent lymphocyte counts (HFLC), immature granulocytes (IG), and immature platelets (IPF). This study aimed to investigate whether these parameters can help to discriminate between the diseases. MATERIAL AND METHODS: We compared hematocytometry performed by a Sysmex XE-5000 analyzer in Indonesian adults with dengue (n = 93), leptospirosis (n = 11), and enteric fever (n = 6) infection, and in healthy controls (n = 28). RESULTS: Receiver operating characteristic curves comparing dengue and leptospirosis showed that dengue was characterized by increased %AL (AUC 0.87; 95% CI 0.70-1.03), %HFLC (AUC 0.89; 95% CI 0.78-0.99), and %IPF (AUC 0.81; 95% CI 0.65-0.97), while patients with leptospirosis had increased %IG (AUC 0.86; 95% CI 0.71-1.02). Low %AL, %HFLC, and %IG supported a diagnosis of enteric fever. CONCLUSIONS: The detection of AL, HFLC, IG, and IPF by Sysmex XE-5000 hematology analyzers can help to differentiate between common causes of febrile illnesses with thrombocytopenia in dengue endemic areas. We recommend further investigating the discriminatory value of these parameters in clinical practice.

Platelet function alterations in dengue are associated with plasma leakage.

Severe dengue is characterised by thrombocytopenia, plasma leakage and bleeding. Platelets are important for preservation of endothelial integrity. We hypothesised that platelet activation with secondary platelet dysfunction contribute to plasma leakage. In adult Indonesian patients with acute dengue, we measured platelet activation status and the response to the platelet agonist TRAP using flow cytometer-based assays. Patients were monitored daily for plasma leakage by ultrasonography. Acute dengue was associated with platelet activation with an increased expression of the activated fibrinogen receptor (αIIbß3), the lysosomal marker CD63 and the alpha-granule marker CD62P (P-selectin). Upon maximal platelet activation by TRAP, platelet function defects were observed with a significantly reduced maximal activated αIIbß3 and CD63 expression and reduced platelet-monocyte and platelet-neutrophil complexes. Patients in the lowest tertile of activated αIIbß3 and CD63 expression had an odds ratio for plasma leakage of 5.2 (95% confidence interval [CI] 1.3-22.7) and 3.9 (95% CI 1.1-13.7), respectively, compared to the highest tertile. Platelet-derived serotonin has previously been related to plasma leakage and we found increased intra-platelet serotonin concentrations in our patients. In conclusion, platelet activation with platelet function alterations can be found in patients with acute dengue and this may contribute to dengue-associated plasma leakage.

Pharmacokinetics of the combination raltegravir/atazanavir in HIV-1-infected patients.

OBJECTIVES: To evaluate the use of raltegravir with unboosted atazanavir in combination with one nucleoside reverse transcriptase inhibitor (NRTI) (lamivudine or emtricitabine) as a potentially well-tolerated once-daily (qd) maintenance regimen. METHODS: We compared the pharmacokinetics of raltegravir 400 mg twice daily (bid) with raltegravir 800 mg qd in HIV-infected patients (n=17) on unboosted atazanavir (600 mg qd) in combination with lamivudine or emtricitabine. RESULTS: The area under the plasma concentration vs. time curve for a dose interval t (AUC0 -t ) of 800 mg qd divided by 2 was not significantly different from the AUC0 -t of 400 mg bid (P=0.664) but the minimum concentration (C min ) was 72% lower with the qd regimen (P=0.002). The regimen was well tolerated and the viral load remained undetectable in all patients during the 6 weeks of the study follow-up. CONCLUSIONS: A qd regimen of raltegravir 800 mg, atazanavir 600 mg and lamivudine or emtricitabine resulted in favourable pharmacokinetic profiles and good short-term safety and efficacy data. Larger phase IIb studies are needed to explore this novel regimen.

Regulation of cytokine responses by seasonality of vitamin D status in healthy individuals.

The immune modulating capacity of vitamin D(3) is well-recognized. Ultra-violet (UV) exposure determines production of vitamin D(3) in vivo and varies through the course of the year, especially in temperate regions. However, it is not known whether the human innate immune response differs due to seasonality. To validate the seasonal effects of vitamin D(3) , the effect of 1,25(OH)(2) D(3) on peripheral blood mononuclear cells (PBMC) cytokine response was first determined in vitro. 1,25(OH)(2) D(3) decreased interleukin (IL)-6 and tumour necrosis factor (TNF)-α release by PBMC stimulated with tripalmitoyl-S-glycerylcysteine (Pam3Cys) or lipopolysaccharide (LPS). Subsequently, ex-vivo stimulation studies were performed in 15 healthy volunteers through the course of the four seasons of the year. PBMC were isolated and stimulated with Toll-like receptor (TLR)-2 and TLR-4 ligands Pam3Cys and LPS, respectively. Circulating concentrations of 25(OH)D(3) and 1,25(OH)(2) D(3) were higher during summer (P<0·05) and a down-regulation of TLR-4-mediated IL-1ß, IL-6, TNF-α, interferon (IFN)-γ and IL-10 production in summer was observed compared to winter (P<0·05). The variation in cytokine response upon TLR-2 (Pam3Cys) stimulation was moderate throughout the four seasons. The repressed cytokine production during the summer months could be explained partly by the reduced cell-membrane expression of TLRs. Physiological variation in vitamin D(3) status through the four seasons of the year can lead to alteration in the innate immune responses. Elevated vitamin D(3) level in vivo is associated with down-regulation of cytokine response through diminished surface expression of pattern recognition receptors.

Serum 25-hydroxy-vitamin D3 concentrations increase during tuberculosis treatment in Tanzania.

SETTING: Vitamin D deficiency is associated with susceptibility to active tuberculosis (TB) in many settings. In vitro studies and studies on human volunteers showed that two of the first-line anti-tuberculosis drugs, isoniazid and rifampicin, reduce 25-hydroxy vitamin D (25[OH]D) concentrations. OBJECTIVE: To study changes in vitamin D status during treatment of Tanzanian hospitalised patients with pulmonary TB (PTB). DESIGN: We compared serum 25[OH]D concentrations in 81 Tanzanian PTB patients before and after 2 months of treatment. RESULTS: Median serum 25[OH]D concentrations increased from 91 nmol/l at baseline to 101 nmol/l after 2 months of TB treatment (median increase 6.0 nmol/l, IQR -0.7-25.0, P = 0.001). Median serum parathyroid hormone concentrations increased from 1.6 to 2.0 pmol/l (median increase 0.46, IQR -0.2-1.1, P < 0.001). CONCLUSION: 25[OH]D serum concentrations increased during the first 2 months of TB treatment in 81 PTB patients in northern Tanzania. Improved dietary intake and increased sunlight exposure may have contributed to the increased 25[OH]D concentrations.

Chlamydia pneumoniae infection enhances microglial activation in atherosclerotic mice.

The presence of Chlamydia pneumoniae in murine brain tissue was studied in atherosclerotic and non-atherosclerotic mice, after peritoneal injection. Furthermore, we investigated whether increased permeability of the blood-brain barrier was implicated in cerebral C. pneumoniae infection and whether intra-cerebral C. pneumoniae infection leads to microglial activation. Using a polymerase chain reaction, C. pneumoniae DNA was found in the brain tissue of 33% of the mice, 3, 7 and 21 days after infection. Atherosclerosis and age does not influence the extend of the cerebral infection. Semiquantitative analyses showed that intra-cerebral C. pneumoniae infection was not accompanied by an altered function of the blood-brain barrier. Microglial activation was assessed with immunohistochemistry, quantified in the hippocampus of each infected mouse and compared with mock infected. Enhanced microglial activation was found in the atherosclerotic mice. Since microglial activation is a key factor in a number of neuroinflammatory diseases, C. pneumoniae infection might play a role in these diseases.

Skin disorders in HIV-infected patients from West Java.

AIM: to describe the spectrum of HIV-related skin disorders as well as their prevalence and relation to CD4-cell counts among HIV-seropositive patients from West Java, Indonesia. METHODS: all HIV-positive patients presenting in 2008 at the HIV-clinic, Hasan Sadikin Hospital, were included in a cross-sectional study. Patients who had a skin complaint were examined by a dermatologist. Skin diseases were classified based on ICD 10. RESULTS: among 843 patients, 121 (14.4%) had a skin complaint, consisting of skin manifestations (73.3%), drug eruptions (30.5%), and sexually transmitted infections (15.7%), some of them had more than one diseases. The most common skin manifestations were drug eruptions, pruritic papular eruptions, seborrhoeic dermatitis, herpes zoster, dermatophytosis, and bacterial skin infections. Among patients who started nevirapine, 6.4% (95%CI: 3.9% - 8.9%) developed any kind of drug eruption, and 1.4% (95%CI 0.2%-2.6%) developed a severe drug eruption. No cases of Kaposi sarcoma, penicilliosis, eosinophilic folliculitis were seen, however one case of histoplasmosis was diagnosed. CONCLUSION: this is the first report describing the prevalence and characteristic of skin manifestation in HIV-positive in Indonesia. Indonesian physicians should be alert about HIV when patient presents with certain skin manifestations. The rate of severe drug eruptions following treatment with nevirapine is a cause of concern that needs further study.

Prevention and treatment of HIV addicted patients: a biopsychosocial approach.

Injecting drug use is the main route of HIV transmission in many parts of Indonesia. Efforts to prevent HIV-transmission through injecting drug use mostly focus on subjects who actively inject. In scientific publications, the term 'injecting drug users' tends to be used without a clear definition and without specifying the pattern of drug use as current or former drug use, frequency, duration, type of injected drug(s) or context (e.g. imprisonment). Actually, injecting drug users (IDUs) have different drug use patterns, risk behavior, somatic co-morbidity, psychiatric co-morbidity, and psychosocial problems. In fact, these patients are suffering from addiction as a chronic brain disease in co-occurrence with somatic and psychiatric disorder and many social problems. Failing in addressing the problems comprehensively will lead to the failure of drug treatment. This is why addiction can be best studied and treated from a biopsychosocial perspective. Accordingly, treatment goals can be differentiated in crisis intervention, cure or recovery (detoxification, relapse prevention), and care or partial remission (stabilization and harm reduction). In summary, injecting drug use in Indonesia is not a single entity and patient oriented prevention and care for IDUs, especially focusing on their addiction, should be addressed to prevent the transmission of HIV/AIDS.

Limited role for C. pneumoniae, CMV and HSV-1 in cerebral large and small vessel atherosclerosis.

AIMS: To explore whether Chlamydia pneumoniae, Cytomegalovirus and Herpes Simplex Virus type 1 could be detected in large and small cerebral arteries, as well as in an area of brain parenchyma where white matter lesions (leukoaraiosis) can be found, in patients with clinically unmanifested cerebrovascular atherosclerosis. Methods and results( Arterial specimens from the basilar artery and middle cerebral artery, and brain samples from the basal ganglia and periventricular white matter were obtained. Neuropathological changes were assessed in Haematoxylin-Eosin stained sections. Polymerase chain reaction (PCR) was performed on paraffin embedded sections. Subsequently, we performed immunohistochemical staining on samples, which were found positive in PCR. We failed to detect C. pneumoniae, CMV, or HSV-1, in any of the cerebral large vessels. In the brain tissue, we found only one case positive for CMV, and one for C. pneumoniae. Conclusions (our findings suggest a limited role for C. pneumoniae, CMV and HSV-1 in cerebral large and small vessel atherosclerosis.

The effect of cholecalciferol supplementation on vitamin D levels and insulin sensitivity is dose related in vitamin D-deficient HIV-1-infected patients.

OBJECTIVE: The aim of this study was to explore the effects of cholecalciferol supplementation on vitamin D levels, bone mineral density (BMD), body fat distribution and insulin sensitivity in vitamin D-deficient HIV-1-infected patients. METHODS: Twenty vitamin D-deficient HIV-1-infected patients were prospectively treated with 2000 IU cholecalciferol/day for 14 weeks, whereafter treatment was continued with half this dosage until 48 weeks. BMD, body fat distribution, 1,25-dihydroxy vitamin D(3) (1,25(OH)2D3), fasting glucose, insulin, adiponectin, leptin, interleukin (IL)-6 and tumour necrosis factor (TNF)-alpha were measured at baseline, and at 24 and 48 weeks. Parathyroid hormone (PTH), 25-hydroxy vitamin D(3) [25(OH)D(3)], cholesterol and triglycerides were measured at baseline, and at 12, 24 and 48 weeks. RESULTS: After 24 weeks, cholecalciferol supplementation significantly increased 25(OH)D3 and 1,25(OH)2D3 levels and decreased PTH and insulin sensitivity. After 48 weeks, however, only 25(OH)D3 levels remained significantly different from baseline, while the other parameter levels returned to baseline, suggesting a dose-response effect. Cholecalciferol had no effect on BMD, adipokines and triglycerides. CONCLUSIONS: The effect of cholecalciferol treatment in this cohort appears to be dose dependent. Cholecalciferol dosages of > or =2000 IU are necessary to achieve 1,25(OH)2D3 levels that significantly decrease PTH, but also negatively affect insulin sensitivity. The results of this hypothesis-driven explorative study need to be confirmed in larger clinical trials.

[Less ventilator-associated pneumonia after oral decontamination with chlorhexidine; a randomised trial]. / Minder beademingspneumonieën door orale decontaminatie met chloorhexidine; gerandomiseerde trial.

OBJECTIVE: To determine the effect of oral decontamination with either chlorhexidine (CHX, 2%) or the combination chlorhexidine-colistin (CHX-COL, 2%-2%) on the frequency and the time to onset of ventilator-associated pneumonia in Intensive Care patients. DESIGN: Double blind, placebo-controlled, multicentre, randomised trial. METHODS: Consecutive ICU patients needing at least 48 h of mechanical ventilation were enrolled in a randomized trial with 3 arms: CHX, CHX-COL, and placebo (PLAC). The trial medication was administered in the oral cavity every 6 h. Oropharyngeal swabs were obtained daily and analysed quantitatively for Gram-positive and Gram-negative microorganisms. Endotracheal colonisation was monitored twice weekly. Ventilator-associated pneumonia was diagnosed on the basis of a combination of clinical, radiological and microbiological criteria. RESULTS: Of 385 patients included, 130 received PLAC, 127 CHX and 128 CHX-COL. Baseline characteristics in the three groups were comparable. The daily risk of ventilator-associated pneumonia was reduced in both treatment groups compared to PLAC: 65% (HR= 0.352; 95% CI: 0.160-0.791; p = 0.012) for CHX and 55% (HR= 0.454; 95%/ CI: 0.224-0.925; p = 0.030) for CHX-COL. CHX-COL provided a significant reduction in oropharyngeal colonisation with both Gram-negative and Gram-positive microorganisms, whereas CHX significantly affected only colonisation with Gram-positive microorganisms. There were no differences in the duration of mechanical ventilation, ICU-stay or ICU-survival. CONCLUSION: Oral decontamination of the oropharyngeal cavity with chlorhexidine or the combination chlorhexidine-colistin reduced the incidence and the time to onset ofventilator-associated pneumonia.

Aetiology and presentation of HIV/AIDS-associated pulmonary infections in patients presenting for bronchoscopy at a referral hospital in northern Tanzania.

OBJECTIVES: To determine the aetiological agents of pulmonary infections in HIV-infected Tanzanians and to correlate the causative agents with clinical, radiographic features, and mortality. DESIGN: A prospective study. SETTING: Kilimanjaro Christian Medical Centre (KCMC), Tanzania. SUBJECTS: Bronchoalveolar lavage fluid (BAL) were obtained from 120 HIV infected patients with pulmonary infections. BAL for causative agents was analysed and correlated with clinical and radiographic features, and one-month outcome. RESULTS: Causative agents were identified in 71 (59.2%) patients and in 16 of these patients, multiple agents were found. Common bacteria were identified in 35 (29.2%) patients, Mycobacterium tuberculosis in 28 (23.3%), Human Herpes Virus 8 (HHV8) in 12 (10%), Pneumocystis jiroveci in nine (7.5%) and fungi in five (4.2%) patients. Median CD4 T cell count of the patients with identified causes was 47 cells/microl (IQR 14-91) and in the 49 patients with undetermined aetiology was 100 cells/ microl (IQR 36-188; p = 0.01). Micronodular chest radiographic lesions were associated with presence of M. tuberculosis (p = 0.002). The one-month mortality was 20 (16.7%). The highest mortality was associated with HHV8 (41.7%) and M. tuberculosis (32.1%). Mortality in patients with undetermined aetiology was 11.3%. No death occurred in patients with PCP. CONCLUSION: In this population of severely immunosuppressed HIV-infected patients with pulmonary infection a variety of causative agents was identified. Micronodular radiographic lesions were indicative of TB. High mortality was associated with M. tuberculosis or HHV8. No death occurred in patients with P. jiroveci infection.

The Asp299Gly Toll-like receptor 4 polymorphism in advanced aortic atherosclerosis.

BACKGROUND: Recently, the common Asp299Gly polymorphism of the Toll-like receptor 4 (TLR-4) was found to be associated with a reduced incidence of acute myocardial infarction and carotid atherosclerosis. As TLR-4 signalling is causally involved in atherogenesis, the polymorphism was postulated to impart protection from atherosclerosis. To explore a potential atheroprotective effect, we studied the association between the Asp299Gly polymorphism and atherosclerosis in hypertensive patients undergoing angiography for suspected renovascular disease. METHODS: 140 hypertensive subjects underwent intraarterial digital subtraction angiography, during which the presence of atherosclerotic lesions was assessed at the level of the abdominal aorta and renal arteries. Extensiveness of disease was classified as follows: atherosclerosis confined to the abdominal aorta, unilateral renal artery stenosis or bilateral renal artery stenosis. Subsequently, genotyping for the +896 A>G (Asp299Gly) single nucleotide polymorphism was performed in all patients. In statistical analyses 17 patients were excluded because of incomplete data (n=3) or a diagnosis of fibromuscular disease (n=14). RESULTS: 21 patients were found heterozygous for the 299Gly allele, whereas none of the subjects were 299Gly homozygous (299Gly allele frequency 7.8%). The prevalence of the 299Gly allele in atherosclerotic patients was not different from the prevalence observed in subjects without atherosclerotic lesions (16.9 vs 15.5%, p=0.83). Moreover, 299Gly carriership was not associated with the extensiveness of (advanced) aortic atherosclerosis (p=0.64). CONCLUSION: Our results suggest that the Asp299Gly TLR-4 receptor polymorphism is not associated with the prevalence nor extensiveness of (advanced) aortic atherosclerosis.

Aortitis diagnosed by F-18-fluorodeoxyglucose positron emission tomography in a patient with syphilis and HIV coinfection.

The most common manifestation of cardiovascular syphilis, a rare diagnosis since the introduction of penicillin, is aortitis of the ascending aorta. Since the majority of patients with uncomplicated aortitis are asymptomatic, early diagnosis is difficult. We report the case of an HIV-positive patient with asymptomatic syphilitic aortitis that was incidentally diagnosed with F-18-fluorodeoxyglucose (FDG) positron emission tomography (PET). We conclude that FDG-PET could become a promising new imaging technique for both diagnosis and follow-up of patients with syphilitic aortitis.

C-reactive protein, atherosclerosis and kidney function in hypertensive patients.

Previous studies have shown a relationship between coronary or carotid atherosclerosis and C-reactive protein (CRP) concentrations. In the present investigation, we evaluated the relationship between high-sensitivity CRP (hsCRP) concentrations and the presence of atherosclerotic lesions in the renal arteries and/or abdominal aorta. In 95 hypertensive patients who underwent intra-arterial DSA on suspicion of renovascular disease, blood was sampled during the procedure for measurement of hsCRP. The presence of atherosclerotic lesions was assessed at the level of the renal arteries and the abdominal aorta. Haemodynamically significant renal artery stenosis was diagnosed when 50% or more stenosis was observed. Patients with fibromuscular disease (n = 8) or incomplete data (n = 4) were excluded from analysis. The results revealed that the median hsCRP concentrations were significantly higher among the 57 patients with atherosclerosis of the aorta and/or renal arteries compared to those in the 26 patients without any angiographic lesions (4.6 vs 1.7 mg/l; P < 0.005). Moreover, in patients with renal artery stenosis, levels of hsCRP were higher when the degree of stenosis exceeded 50%. However, the association between hsCRP and the presence of atherosclerosis appeared to be confounded by serum creatinine, creatinine clearance, age and gender. In the whole group a significant inverse relationship was found between creatinine clearance and hsCRP (P < 0.05). In conclusion, hsCRP concentrations are related to atherosclerotic lesions in the renal arteries and the abdominal aorta. While this supports the view that atherosclerotic renal artery stenosis is part of a systemic inflammatory vascular disease, increased concentrations of CRP may also coincide with decreased renal function.

Ocular syphilis acquired through oral sex in two HIV-infected patients.

Two cases of ocular syphilis are described in HIV-infected individuals after unprotected oral sex. The primary syphilitic lesion remained unnoticed and lues was therefore only diagnosed after visual symptoms developed.

Highly active antiretroviral therapy for HIV infection: lessons for the future.

HIV-related morbidity and mortality has been greatly reduced since the introduction of highly active antiretroviral therapy. Issues regarding the patient, the virus, the drugs and the treatment team are discussed. HIV treatment remains complex with a rapidly changing field of possibilities and views, and should therefore be limited to specialised centres.