[Plasmablastic lymphoma]. / Linfoma plasmablástico.

Plasmablastic lymphoma (PBL) is a rare and aggressive subtype of non-Hodgkin lymphoma that commonly occurs in human immunodeficiency virus (HIV)-positive individuals, and affects oral sites. Occasionally, it has been described in HIV-negative patients and involving non-oral sites. Pathologically, PBL is a high-grade B-cell lymphoma that displays the immunophenotype of a terminally differentiated B-lymphocyte with loss of B-cell markers (CD20) and expression of plasma-cell antigens. Epstein-Barr virus infection and MYC rearrangements are frequently observed. Treatment of PBL is challenging because of the lack of established treatment and poor outcomes, with median survival times shorter than one year. In this review, we discuss the clinical and epidemiologic spectrum of PBL as well as its distinct pathological features. Finally, we summarize the currently available approaches for the treatment of patients with PBL.

Executive summary of the GESIDA/National AIDS Plan Consensus Document on Antiretroviral Therapy in Adults Infected by the Human Immunodeficiency Virus (Updated January 2016).

In this update, antiretroviral therapy (ART) is recommended for all patients infected by type 1 human immunodeficiency virus (HIV-1). The objective of ART is to achieve an undetectable plasma viral load (PVL). Initial ART should comprise 3 drugs, namely, 2 nucleoside reverse transcriptase inhibitors (NRTI), and 1 drug from another family. Four of the recommended regimens, all of which have an integrase strand transfer inhibitor (INSTI) as the third drug, are considered a preferred regimen; a further 6 regimens, which are based on an INSTI, a non-nucleoside reverse transcriptase inhibitor (NNRTI), or a protease inhibitor boosted with cobicistat or ritonavir (PI/COBI, PI/r), are considered alternatives. The reasons and criteria for switching ART are presented both for patients with an undetectable PVL and for patients who experience virological failure, in which case the rescue regimen should include 3 (or at least 2) drugs that are fully active against HIV. The specific criteria for ART in special situations (acute infection, HIV-2 infection, pregnancy) and comorbid conditions (tuberculosis and other opportunistic infections, kidney disease, liver disease, and cancer) are updated.

High prevalence of asymptomatic carriers of Tropheryma whipplei in different populations from the North of Spain.

INTRODUCTION: Tropheryma whipplei is the causative agent of Whipple disease. T. whipplei has also been detected in asymptomatic carriers with a very different prevalence. To date, in Spain, there are no data regarding the prevalence of T. whipplei in a healthy population or in HIV-positive patients, or in chronic fatigue syndrome (CFS). Therefore, the aim of this work was to assess the prevalence of T. whipplei in stools in those populations. METHODS: Stools from 21 HIV-negative subjects, 65 HIV-infected, and 12 CFS patients were analysed using real time-PCR. HIV-negative and positive subjects were divided into two groups, depending on the presence/absence of metabolic syndrome (MS). Positive samples were sequenced. RESULTS: The prevalence of T. whipplei was 25.51% in 98 stool samples analysed. Prevalence in HIV-positive patients was significantly higher than in HIV-negative (33.8% vs. 9.09%, p=0.008). Prevalence in the control group with no associated diseases was 20%, whereas no positive samples were observed in HIV-negative patients with MS, or in those diagnosed with CFS. The prevalence observed in HIV-positive patients without MS was 30.35%, and with MS it was 55.5%. The number of positive samples varies depending on the primers used, although no statistically significant differences were observed. CONCLUSIONS: There is a high prevalence of asymptomatic carriers of T. whipplei among healthy and in HIV-infected people from Spain. The role of T. whipplei in HIV patients with MS is unclear, but the prevalence is higher than in other populations.

Microangiopatía trombótica en una paciente con infección por el virus de la inmunodeficiencia humana / Thrombotic microangiopathy in a patient with human inmunodeficiency virus infection

Notificamos un caso de microangiopatía trombótica, caracterizado por un proceso de agregación plaquetaria amenazante para la vida, que presentó afectación multisistémica y rápida evolución en una paciente con infección por el VIH. En este caso exponemos ampliamente los síntomas, la evolución y, finalmente, la necropsia clínica. Esta enfermedad es ahora infrecuente tras la llegada de los antirretrovirales de gran actividad, no obstante, se presenta con síntomas inespecíficos y evoluciona rápidamente a la afectación multisistémica y muerte. En consecuencia, un diagnóstico precoz con base en criterios clínicos y analíticos es fundamental para instaurar el tratamiento adecuado y mejorar la supervivencia.

We report on a case of thrombotic microangiopathy, defined as an extensive and dangerous intravascular platelet aggregation disorder, which progressed to multisystem involvement in a patient with HIV infection. For this clinical case, we detail the symptoms, evolution and, ultimately, the clinical autopsy. This disease is now uncommon due to the arrival of highactivity antiretroviral drugs; however, it can appear with nonspecific symptoms and rapidly progress to multisystem involvement and death. An accurate diagnosis on the basis of clinical and analytical criteria is essential to starting treatment and improving survival.

Executive summary of the GESIDA/National AIDS Plan Consensus Document on antiretroviral therapy in adults infected by the human immunodeficiency virus (updated January 2015).

In this update, antiretroviral therapy (ART) is recommended for all patients infected by type 1 human immunodeficiency virus (HIV-1). The strength and grade of the recommendation vary depending on the CD4+ T-lymphocyte count, the presence of opportunistic infections or comorbid conditions, age, and the efforts to prevent the transmission of HIV. The objective of ART is to achieve an undetectable plasma viral load (PVL). Initial ART should comprise three drugs, namely, two nucleoside reverse transcriptase inhibitors (NRTI) and one drug from another family. Three of the recommended regimens, all of which have an integrase strand transfer inhibitor (INSTI) as the third drug, are considered a preferred regimen; a further seven regimens, which are based on an INSTI, an non-nucleoside reverse transcriptase inhibitor (NNRTI), or a protease inhibitor boosted with ritonavir (PI/r), are considered alternatives. The reasons and criteria for switching ART are presented both for patients with an undetectable PVL and for patients who experience virological failure, in which case the rescue regimen should include three (or at least two) drugs that are fully active against HIV. The specific criteria for ART in special situations (acute infection, HIV-2 infection, pregnancy) and comorbid conditions (tuberculosis and other opportunistic infections, kidney disease, liver disease, and cancer) are updated.

[Consensus statement on metabolic disorders and cardiovascular risks in patients with human immunodeficiency virus]. / Documento de consenso sobre alteraciones metabólicas y riesgo cardiovascular en pacientes con infección por el virus de la inmunodeficiencia humana.

OBJECTIVE: This consensus document is an update of metabolic disorders and cardiovascular risk (CVR) guidelines for HIV-infected patients. METHODS: This document has been approved by an expert panel of GEAM, SPNS and GESIDA after reviewing the results of efficacy and safety of clinical trials, cohort and pharmacokinetic studies published in biomedical journals (PubMed and Embase) or presented in medical scientific meetings. Recommendation strength and the evidence in which they are supported are based on the GRADE system. RESULTS: A healthy lifestyle is recommended, no smoking and at least 30min of aerobic exercise daily. In diabetic patients the same treatment as non-HIV infected patients is recommended. HIV patients with dyslipidemia should be considered as high CVR, thus its therapeutic objective is an LDL less than 100mg/dL. The antihypertensive of ACE inhibitors and ARAII families are better tolerated and have a lower risk of interactions. In HIV-patients with diabetes or metabolic syndrome and elevated transaminases with no defined etiology, the recommended is to rule out a hepatic steatosis Recommendations for action in hormone alterations are also updated. CONCLUSIONS: These new guidelines update previous recommendations regarding all those metabolic disorders involved in CVR. Hormone changes and their management and the impact of metabolic disorders on the liver are also included.

[Changes in clinic-epidemiological characteristics of new cases of HIV-1 infection in Castellón (Spain), and its impact on delayed presentation (1987-2011)]. / Cambios en las características clínico-epidemiológicas de los nuevos casos de infección por el VIH-1 en Castellón (España) y su repercusión en la presentación tardía (1987-2011).

OBJECTIVE: To describe the trend of the clinical and epidemiological characteristics of a cohort of HIV-1 infected patients in Castellón (Spain), and its impact on the delayed presentation. METHODS: Data from HIV-1 infected outpatients presenting for care for the first time between 1987 and 2011 were retrospectively analyzed. RESULTS: There have been significant changes in the characteristics of the 1001 newly presented patients during the period studied. An increase in the mean age was observed (increasing from about 30 years before 1996, to approximately 35 after the 2000-2002 period), as well as an increase in the percentage of immigrants (<2% before 1997, to 50% in the 2009-2011 period), and a decline in the proportion of intravenous drug use as the main transmission route (changing from being 92.3% before 1988 to below 20% after the 2003-2005 period), together with a decrease in the proportion of hepatitis-C coinfection. The rate of late presentation has not significantly changed, being 47.1% in the period studied. Factors associated with this late presentation were: older age, hospital diagnosis, an increased delay between estimated infection time and diagnosis, and between diagnosis and initial presentation. CONCLUSIONS: The epidemiology of HIV-1 infection in our area has dramatically changed since the beginning of the disease. The increasing delay between estimated infection time and diagnosis is an important cause of the lack of variation in the late presentation rate, and highlights the low impact of early diagnosis strategies.

Executive summary of the GeSIDA/National AIDS Plan consensus document on antiretroviral therapy in adults infected by the human immunodeficiency virus (updated January 2014).

In this update, antiretroviral therapy (ART) is recommended for all patients infected by type 1 human immunodeficiency virus (HIV-1). The strength and grade of the recommendation varies with clinical circumstances, number of CD4 cells, comorbid conditions and prevention of transmission of HIV. The objective of ART is to achieve an undetectable plasma viral load. Initial ART should always comprise a combination of 3 drugs, including 2 nucleoside reverse transcriptase inhibitors and a third drug from a different family (non-nucleoside reverse transcriptase inhibitor, protease inhibitor, or integrase inhibitor). This update presents the causes and criteria for switching ART in patients with undetectable plasma viral load and in cases of virological failure. An update is also provided for the specific criteria for ART in special situations (acute infection, HIV-2 infection, and pregnancy) and with comorbid conditions (tuberculosis or other opportunistic infections, kidney disease, liver disease, and cancer).

[GeSIDA/National AIDS Plan: Consensus document on antiretroviral therapy in adults infected by the human immunodeficiency virus (Updated January 2014)]. / Documento de consenso de GeSIDA/Plan Nacional sobre el Sida respecto al tratamiento antirretroviral en adultos infectados por el virus de la inmunodeficiencia humana (Actualización enero 2014).

OBJECTIVE: This consensus document is an update of combined antiretroviral therapy (cART) guidelines for HIV-1 infected adult patients. METHODS: To formulate these recommendations a panel composed of members of the Grupo de Estudio de Sida and the Plan Nacional sobre el Sida reviewed the efficacy and safety advances in clinical trials, cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. Recommendations strength and the evidence in which they are supported are based on modified criteria of the Infectious Diseases Society of America. RESULTS: In this update, antiretroviral therapy (ART) is recommended for all patients infected by type 1 human immunodeficiency virus (HIV-1). The strength and grade of the recommendation varies with the clinical circumstances: CDC stage B or C disease (A-I), asymptomatic patients (depending on the CD4+ T-lymphocyte count: <350cells/µL, A-I; 350-500 cells/µL, A-II, and >500 cells/µL, B-III), comorbid conditions (HIV nephropathy, chronic hepatitis caused by HBV or HCV, age >55years, high cardiovascular risk, neurocognitive disorders, and cancer, A-II), and prevention of transmission of HIV (mother-to-child or heterosexual, A-I; men who have sex with men, A-III). The objective of ART is to achieve an undetectable plasma viral load. Initial ART should always comprise a combination of 3 drugs, including 2 nucleoside reverse transcriptase inhibitors and a third drug from a different family (non-nucleoside reverse transcriptase inhibitor, protease inhibitor, or integrase inhibitor). Some of the possible initial regimens have been considered alternatives. This update presents the causes and criteria for switching ART in patients with undetectable plasma viral load and in cases of virological failure where rescue ART should comprise 2 or 3 drugs that are fully active against the virus. An update is also provided for the specific criteria for ART in special situations (acute infection, HIV-2 infection, and pregnancy) and with comorbid conditions (tuberculosis or other opportunistic infections, kidney disease, liver disease, and cancer). CONCLUSIONS: These new guidelines updates previous recommendations related to cART (when to begin and what drugs should be used), how to monitor and what to do in case of viral failure or drug adverse reactions. cART specific criteria in comorbid patients and special situations are equally updated.

[Cognitive complaints in people with human immunodeficiency virus in Spain: prevalence and related variables]. / Quejas cognitivas en personas con infección por el virus de la inmunodeficiencia humana en España: prevalencia y variables relacionadas.

BACKGROUND AND OBJECTIVE: Cognitive complaints have been scarcely studied in people with HIV in Spain. The aim of this research was to know the prevalence of cognitive complaints in HIV-infected people, as well as its potential relationships with demographic, clinical and psychological variables, in the era of combination antiretroviral therapies. PATIENTS AND METHOD: Observational multicenter study developed in 4 hospitals and 10 NGOs, in which 791 people with HIV in Spain participated. A self-reported questionnaire was used to evaluate demographic and clinical variables, and an assessment of cognitive complaints, emotional status and quality of life variables was also included. Descriptive and inferential tests were used for statistical analyses. RESULTS: Almost half of the sample (49.8%) referred cognitive complaints, in 72.1% of them an association with interference on daily living activities was found. Memory and attention were the areas most prevalently perceived as affected. The existence of cognitive complaints correlated with a longer HIV infection, lower CD4+ cell count, undetectable viral load and worse quality of life. A discriminant analysis determined that depression, anxiety, older age, living with no partner and low education level allowed to classify optimally HIV-infected people with cognitive complaints. CONCLUSIONS: Self-reported cognitive complaints are frequent in people infected with HIV in the current era of combination antiretroviral therapies. This fact is related to emotional disturbances and poor quality of life, but also to impaired immunological and virological status.

[Consensus Statement by GeSIDA/National AIDS Plan Secretariat on antiretroviral treatment in adults infected by the human immunodeficiency virus (Updated January 2013)]. / Documento de consenso de GeSIDA/Plan Nacional sobre el Sida respecto al tratamiento antirretroviral en adultos infectados por el virus de la inmunodeficiencia humana (actualización enero 2013).

OBJECTIVE: This consensus document is an update of combined antiretroviral therapy (cART) guidelines for HIV-1 infected adult patients. METHODS: To formulate these recommendations a panel composed of members of the GeSIDA/National AIDS Plan Secretariat (Grupo de Estudio de Sida and the Secretaría del Plan Nacional sobre el Sida) reviewed the efficacy and safety advances in clinical trials, cohort and pharmacokinetic studies published in medical journals (PubMed and Embase) or presented in medical scientific meetings. The strength of the recommendations and the evidence which support them are based on a modification of the criteria of Infectious Diseases Society of America. RESULTS: cART is recommended in patients with symptoms of HIV infection, in pregnant women, in serodiscordant couples with high risk of transmission, in hepatitisB co-infection requiring treatment, and in HIV nephropathy. cART is recommended in asymptomatic patients if CD4 is <500cells/µl. If CD4 are >500cells/µl cART should be considered in the case of chronic hepatitisC, cirrhosis, high cardiovascular risk, plasma viral load >100.000 copies/ml, proportion of CD4 cells <14%, neurocognitive deficits, and in people aged >55years. The objective of cART is to achieve an undetectable viral load. The first cART should include 2 reverse transcriptase inhibitors (RTI) nucleoside analogs and a third drug (a non-analog RTI, a ritonavir boosted protease inhibitor, or an integrase inhibitor). The panel has consensually selected some drug combinations, for the first cART and specific criteria for cART in acute HIV infection, in tuberculosis and other HIV related opportunistic infections, for the women and in pregnancy, in hepatitisB or C co-infection, in HIV-2 infection, and in post-exposure prophylaxis. CONCLUSIONS: These new guidelines update previous recommendations related to first cART (when to begin and what drugs should be used), how to monitor, and what to do in case of viral failure or adverse drug reactions. cART specific criteria in comorbid patients and special situations are similarly updated.

Executive summary of the Consensus Document of GeSIDA and Spanish Secretariat for the National Plan on AIDS on combined antiretroviral treatment in adults infected by the human immunodeficiency virus (January 2013).

In the present update of the guidelines, a starting combination antiretroviral treatment (cART) is recommended in symptomatic patients, in pregnant women, in serodiscordant couples with a high risk of transmission, in patients co-infected with hepatitis B virus requiring treatment, and in patients with HIV-related nephropathy. Guidelines on cART are included in the event of a concurrent diagnosis of HIV infection with an AIDS-defining event. In asymptomatic naïve patients, cART is recommended if the CD4(+) lymphocyte count is <500cells/µL; if the CD4(+) lymphocyte count is >500cells/µL, cART can be delayed, although it may be considered in patients with liver cirrhosis, chronic infection due to hepatitis C virus, high cardiovascular risk, plasma viral load (PVL) >10(5)copies/mL, CD4(+) lymphocyte percentage <14%, cognitive impairment, and age >55 years. cART in naïve patients requires a combination of 3 drugs, and its aim is to achieve undetectable PVL. Treatment adherence plays a key role in sustaining a favorable response. cART can, and should be, changed if virological failure occurs, in order to return to undetectable PVL. Approaches to cART in acute HIV infection, in women, in pregnancy, in tuberculosis, and post-exposure prophylaxis are also examined.

[Pulmonary hypertension in patients infected with human immunodeficiency virus: current situation]. / Hipertensión arterial pulmonar en pacientes con infección por el virus de la inmunodeficiencia humana: situación actual.

The increase in survival that has been achieved with the new treatments in the era of highly active antiretroviral therapy, has enabled clinicians and researchers to analyze issues that emerge in the long term in patients with HIV infection. Although the majority of cardiovascular complications have been widely described, the pathogenesis of pulmonary arterial hypertension is still poorly understood, and is one of the more complex and feared complications as it worsens the prognosis and quality of life of these patients This article reviews newer aspects related to the aetiology, symptoms, diagnosis and treatment of this disease.

Tuberculosis in patients with systemic lupus erythematosus: Spain's situation.

There has recently been an increase in the incidence of patients with systemic lupus erythematosus (SLE) due mainly to earlier diagnosis, and increased survival. Tuberculosis in our country is one of the most prevalent infectious diseases, and one of the underlying causes would be HIV infection and increased immigration from areas with high tuberculosis prevalence; this phenomenon is truly important in patients with autoimmune diseases, as clinical presentation, severity and prognosis of tuberculosis are often different to that of immunocompetent patients. Studies of tuberculosis in patients with SLE are scarce and inconclusive, with many doubts existing about the performance or non-tuberculous prophylaxis in this population and the absence of a protocol due to lack of conclusive studies. New techniques for diagnosis of tuberculosis (IGRAs) may be useful in this population due to higher sensitivity than Mantoux, helping avoid false negatives.

Coinfección VIH-hepatitis B y C en la provincia de Cienfuegos / HIV/hepatitis B and C co-infection in Cienfuegos province

Objetivo: identificar la prevalencia de la infección por los virus de la hepatitis B (VHB) y C (VHC) en individuos infectados por VIH en la provincia de Cienfuegos. Métodos: se realizó un estudio de corte transversal hasta el mes del abril de 2005 y se analizaron variables clínicas y el recuento de linfocitos TCD4+ (LTCD4+). Resultados: la prevalencia de la infección por el VHB resultó 14,4 por ciento y por el VHC 20 por ciento. La frecuencia del SIDA fue superior en los pacientes con hepatitis B (77,8 por ciento) respecto a los infectados por el VHC (28,6 por ciento). El porcentaje de casos con menos de 500 LTCD4+ resultó superior en los coinfectados por el VHC (57,4 por ciento); 4 enfermos (14,8 por ciento) tenían realizado estudio histológico hepático. Conclusión: la coinfección de los VHB/VHC y el VIH es un problema frecuente en la provincia, sin embargo, se desconocen aspectos clínicos y epidemiológicos que ameritan nuevos estudios(AU)

Objective: To identify the prevalence of hepatitis B and C virus infections (HVB) and (HVC) in individuals infected by HIV in Cienfuegos province. Methods: A cross-sectional study was performed till April 2005 in which clinical variables and TCD4+ lymphocyte count were analyzed. Results: the prevalence of HVB infection was 14,4 percent and of HVC was 20 percent. AIDS frequency was higher in patients suffering from hepatitis B (77,8 percent) than in those with hepatitis C (28,6 percent). Percentage of cases under 500 TCD4+ count was higher in patients coinfested with HVC (57,4 percent); also 4 patients (14,8 percent) had been performed a hepatic histological study. Conclusion: HVB/HVC co-infection and HIV is a common problem in the province; however, clinical and epidemiological aspects that are yet unknown call for new studies(AU)

Coinfección VIH-hepatitis B y C en la provincia de Cienfuegos / HIV/hepatitis B and C co-infection in Cienfuegos province

Objetivo: identificar la prevalencia de la infección por los virus de la hepatitis B (VHB) y C (VHC) en individuos infectados por VIH en la provincia de Cienfuegos. Métodos: se realizó un estudio de corte transversal hasta el mes del abril de 2005 y se analizaron variables clínicas y el recuento de linfocitos TCD4+ (LTCD4+). Resultados: la prevalencia de la infección por el VHB resultó 14,4 por ciento y por el VHC 20 por ciento. La frecuencia del SIDA fue superior en los pacientes con hepatitis B (77,8 por ciento) respecto a los infectados por el VHC (28,6 por ciento). El porcentaje de casos con menos de 500 LTCD4+ resultó superior en los coinfectados por el VHC (57,4 por ciento); 4 enfermos (14,8 por ciento) tenían realizado estudio histológico hepático. Conclusión: la coinfección de los VHB/VHC y el VIH es un problema frecuente en la provincia, sin embargo, se desconocen aspectos clínicos y epidemiológicos que ameritan nuevos estudios.

Objective: To identify the prevalence of hepatitis B and C virus infections (HVB) and (HVC) in individuals infected by HIV in Cienfuegos province. Methods: A cross-sectional study was performed till April 2005 in which clinical variables and TCD4+ lymphocyte count were analyzed. Results: the prevalence of HVB infection was 14,4 percent and of HVC was 20 percent. AIDS frequency was higher in patients suffering from hepatitis B (77,8 percent) than in those with hepatitis C (28,6 percent). Percentage of cases under 500 TCD4+ count was higher in patients coinfested with HVC (57,4 percent); also 4 patients (14,8 percent) had been performed a hepatic histological study. Conclusion: HVB/HVC co-infection and HIV is a common problem in the province; however, clinical and epidemiological aspects that are yet unknown call for new studies.