A Case Report of a Rapidly Progressive Epstein-Barr Virus Encephalitis Infection in an Adult With HIV on Highly Active Antiretroviral Therapy.

Epstein-Barr virus (EBV) encephalitis is a rare complication of EBV infection, with most cases described in children. Although some cases of EBV encephalitis have been reported in adults, they have occurred in the presence of other central nervous system infections, superimposed on an underlying neurocognitive disorder, or in immunocompromised states. We present herein a rare case of rapidly progressive EBV encephalitis in an adult male with HIV infection on highly active antiretroviral therapy (HAART) with no pre-existing neurocognitive symptoms. A 52-year-old African American man with HIV infection on HAART presented with acute altered mental status and weakness. On admission, he had normal muscle tone and reflexes, with no signs of meningism. Head CT without contrast showed no acute intracranial pathology. Blood and urine cultures were negative. CSF analysis was suggestive of a viral infection. Viral studies were positive only for EBV DNA by PCR in CSF. The patient received IV acyclovir for two weeks, followed by four weeks of oral valacyclovir with full recovery. Clinicians should consider a diagnosis of EBV encephalitis in HIV-positive patients on HAART who present with acute altered mental status. Treatment with antiviral therapy should be considered in patients with EBV encephalitis.

Hepatocellular-Cholestatic Pattern of Liver Injury in a Patient With Infectious Mononucleosis.

Hepatic dysfunction in the setting of infectious mononucleosis has been documented in the literature. However, clinically significant jaundice and direct hyperbilirubinemia are rarely associated with this infection. In the instance of undetermined underlying diagnosis and hepatic enzyme derangement, this may pose a diagnostic challenge. Furthermore, several diagnostic tests may be indicated, which could potentially increase resource consumption in any hospital setting. This case report aims to remind physicians that infectious mononucleosis may be a cause of hyperbilirubinemia, which does not usually require further complex testing other than monitoring and supportive therapy.

Early administration of the first antimicrobials should be considered a marker of optimal care of patients with community-acquired pneumonia rather than a predictor of outcomes.

BACKGROUND: The effect of time of the first antimicrobial dose (TFAD) on the outcomes of community-acquired pneumonia (CAP) remains a controversy. METHODS: This was an observational, retrospective study of consecutive adult patients hospitalized with CAP. TFAD was defined as the time in hours from arrival at the emergency department to the intravenous infusion of antimicrobial. All patients received appropriate antibiotic therapy according to available Infectious Diseases Society of America/American Thoracic Society guidelines during the time of our study. Multivariable analysis and a propensity score adjusted methodology were used to measure the association of TFAD with mortality, time to clinical stability (TCS), and length of stay in the hospital (LOS). RESULTS: Data of 372 patients with CAP were studied. A total 29 (8.4%) patients died within 30 days of hospitalization. Our propensity-adjusted logistic regression model did not show a significant association between TFAD and mortality (p=0.148). Patients who died received antimicrobials significantly earlier than survivors: 5.7h vs. 7.5h, respectively (p=0.04). The LOS and TCS were not significantly affected by the TFAD; the LOS hazard ratio was 0.996 (95% confidence interval 0.97-1.02; p=0.774) and the TCS hazard ratio was 1.01 (95% confidence interval 0.98-1.03; p=0.604). CONCLUSIONS: TFAD does not seem to be associated with the clinical outcome of patients with CAP. Early TFAD should be considered as an important marker of optimal care of patients with CAP rather than as a factor predicting outcomes.

Graves' Disease as a Manifestation of Immune Reconstitution in HIV-Infected Individuals after Initiation of Highly Active Antiretroviral Therapy.

Graves' disease after the initiation of highly active antiretroviral therapy (HAART) in certain HIV-1-infected individuals has been described as an immune reconstitution inflammatory syndrome (IRIS). This phenomenon should be suspected in individuals who present with clinical deterioration and a presentation suggestive of hyperthyroidism despite good virological and immunological response to HAART. Signs and symptoms of hyperthyroidism may be discrete or overt and typically develop 8-33 months after initiating therapy. One to two percent of HIV-infected patients can present with overt thyroid disease. Relatively few cases of Graves' IRIS have been reported in the literature to date. We describe four cases of Graves' IRIS in HIV-infected patients who were started on HAART therapy.

The association of serum ferritin and transferrin receptor concentrations with mortality in women with human immunodeficiency virus infection.

BACKGROUND AND OBJECTIVES: Whether degree of iron stores influences progression of human immunodeficiency virus (HIV) disease is controversial. We studied the relationship of indirect measures of iron stores with mortality in highly active antiretroviral therapy (HAART)-naive participants from the Women's Interagency HIV Study. DESIGN AND METHODS: One hundred and fifty-eight HIV-infected women who died before July 1996 were individually matched by CD4+ cell count (within +/- 50 cells/mL) and HIV RNA level (within +/- 0.50 log10 copies/mL) to 154 controls. Serum ferritin and transferrin receptor concentrations were measured in 151 pairs of women. Results. Using multivariable conditional logistic regression models that were adjusted for self-reported antiretroviral therapy use, age, smoking status, ethnicity, hemoglobin concentration, C-reactive protein and aspartate amino transferase, a log10 increase in baseline serum ferritin concentration was associated with a 1.67-fold increase in the odds of death (95% CI: 0.98, 2.86) and a one-unit decrease in transferrin receptor to log10 ferritin ratio was associated with a 1.12-fold (95% CI: 1.01, 1.23) increase in the odds of death. INTERPRETATIONS AND CONCLUSIONS: In this study, higher indirect measures of iron status were associated with reduced survival among HAART-naive HIV-infected women. Additional prospective studies with data on direct measures of iron status along with randomized trials are needed to elucidate the current equipoise over whether iron supplementation is beneficial by preventing anemia or harmful by increasing iron stores in HIV-infected women.

Avascular necrosis and protease inhibitors.

Avascular necrosis (AVN) indicates ischemic death of the bone due to insufficient arterial blood supply. The incidence rate of AVN is higher in HIV-infected patients than in the general population. Although the exact etiology of AVN remains unclear, the literature has shown a relationship between AVN and exposure to highly active antiretroviral therapy (HAART). It should be noted, however, that AVN has been reported before the era of HAART, thus suggesting the involvement of other causative factors as well. Three case reports based on patients attending the infectious disease clinic are presented. No cases of AVN are reported in our clinic population prior to this report. Affected sites of AVN included the hip and shoulders. The incidence of AVN within our patient population was higher than the general population. Although the introduction of HAART has improved patient longevity, it has also led to longer exposure to antiretroviral (ARV) therapy. Thus, it is likely that treatment-related complications may become more apparent in the HIV-infected population. This may be the case with AVN. Therefore, clinicians need to be alert to the potential complication of AVN in HIV-infected patients treated with HAART.

The association of race, sociodemographic, and behavioral characteristics with response to highly active antiretroviral therapy in women.

OBJECTIVE: To determine the association of race with clinical and laboratory outcomes after initiation of highly active antiretroviral therapy (HAART) in HIV-1-infected women in the United States. STUDY DESIGN: Prospective cohort study. PARTICIPANTS: A total of 961 HIV-1-infected women participating in the Women's Interagency HIV Study initiating HAART between July 1, 1995 and September 30, 2003. RESULTS: Over a median of 5.1 years of follow-up, in univariate Cox regression analyses, white women were more likely than African American women to attain a virologic response (relative hazard [RH]=1.34, P=0.005), less likely to experience viral rebound (RH=0.76, P=0.051), and less likely to die (RH=0.63, P=0.040). There were no significant differences, however, among racial groups in outcomes after adjustment for pre-HAART CD4, HIV-1 RNA, history of AIDS-defining illness, age, antiretroviral therapy use, baseline HIV-1 exposure category, and post-HAART behavioral and clinical variables associated with poorer response (discontinuation of HAART, lower income, smoking, current drug use, and depression). Continuous HAART use and lack of depression differed by race and were the strongest predictors of favorable outcomes. CONCLUSION: No significant differences by race were found in virologic, immunologic, or clinical outcomes after adjustment for continued HAART use and depression. These findings suggest that strategies to enhance HAART continuation, including assessing pharmacogenetic influences that may result in greater toxicity and discontinuation rates, and treating depression can improve individual and population-based effects of treatment and potentially mitigate racial disparities in AIDS-related outcomes.

Effect of discontinuing antiretroviral therapy on survival of women initiated on highly active antiretroviral therapy.

OBJECTIVE: To estimate the effect of discontinuing antiretroviral therapy (ART) on survival, among women who initiated highly active antiretroviral therapy (HAART). DESIGN: A multicenter cohort study. METHODS: A total of 951 HAART-initiated women were followed for total mortality between 1995 and 2002. The relative hazard (RH) of death attributable to discontinuing all ART was estimated using an inverse probability of treatment-weighted marginal structural Cox proportional hazards model, as well as standard Cox models. RESULTS: Three hundred and forty-three out of 951 women discontinued all ART during the 3187 person-years of follow-up, and 116 died. The RH of death attributable to discontinuation was 1.97 [95% confidence interval (CI) 1.17, 3.31] from the marginal structural Cox model. A RH of 1.49 (95% CI 0.94, 2.35) was observed using the same set of covariates in a standard Cox model. CONCLUSION: An increased risk of mortality for those HAART initiators who discontinued ART was observed using a marginal structural Cox model. This increased risk was independent of measured treatment failure, and was greatly attenuated in a standard Cox model with time-varying covariates.

Total lymphocyte count, hemoglobin, and delayed-type hypersensitivity as predictors of death and AIDS illness in HIV-1-infected women receiving highly active antiretroviral therapy.

BACKGROUND: Total lymphocyte count (TLC) and hemoglobin level have been suggested as useful and inexpensive parameters to indicate need for HAART in settings in which CD4 cell counts are unavailable. If delayed-type hypersensitivity (DTH) response predicts clinical response in persons using highly active antiretroviral therapy (HAART), it may also prove useful in resource-poor settings. OBJECTIVE: To examine whether TLC, hemoglobin, and DTH response observed prior to initiation of HAART predict post-HAART clinical response. DESIGN: Prospective cohort study. PARTICIPANTS: 873 women in the Women's Interagency HIV Study. MEASUREMENTS: TLC, hemoglobin, CD4 cell counts, and DTH testing using mumps, candida, and tetanus toxoid antigens, performed within 1 year prior to HAART initiation; death; self-report of initiation of HAART use and AIDS-defining illness (ADI). RESULTS: Three different multivariate analyses were performed: 2 models that excluded CD4 cell count and assessed TLC at either < 850 or < 1250 cells/microL, and 1 model that excluded TLC and included CD4 < 200 cells/microL. TLC < 850, TLC < 1250, CD4 < 200 cells/microL, anergy to DTH testing, hemoglobin < 10.6 g/dL, and a pre-HAART report of ADI were each consistently independently associated both with death and with incident ADI. Log likelihood chi2 values suggested similar power among the 3 models in predicting both death and incident ADI. CONCLUSIONS: Pre-HAART TLC, hemoglobin level, anergy to DTH testing, and clinical disease each independently predicted morbidity and death after HAART initiation. These findings support the use of TLC to guide decision-making for HAART initiation and suggest that further study of TLC, hemoglobin level, and DTH responses as an indication to provide HAART may be useful in resource-limited settings.

Initiation of regular marijuana use among a cohort of women infected with or at risk for HIV in the Women's Interagency HIV Study (WIHS).

Our study sought to determine the incidence of weekly marijuana use among HIV-infected and uninfected women, to identify correlates of weekly marijuana use, and to test its association with stage of HIV disease and type of HIV treatment received. A total of 2059 HIV-positive and 569 HIV-negative women from 6 sites were recruited between 1994 and 1995 and followed through 2000. After excluding women who reported weekly marijuana use at baseline, 2050 women were included in the analysis. The incidence rate for initiating marijuana was calculated and survival analysis was performed to determine the correlates of initiating weekly marijuana use. Three hundred and three women initiated weekly marijuana use within 5.5 years of the baseline visit, yielding a cumulative incidence (CI) of 14.8%. There was no significant difference in weekly marijuana use initiation between HIV-infected (CI = 14.5%) and HIV-uninfected women (CI = 16.0%). Younger age and having more sex partners was associated with incident weekly marijuana use among both infected and uninfected women. While undetectable viral load was associated with lower incidence rate (p < 0.001, RH = 0.44) and wasting syndrome with higher incidence (p < 0.01, relative hazard [RH] = 3.1), CD4 count was not. Compared to receiving no AIDS treatment at all, women who received basic combination antiretroviral therapy had significantly higher incidence of weekly marijuana use (p < 0.001, RH = 1.93), while highly active antiretroviral therapy (HAART) receivers had significantly lower incidence (p < 0.001, RH = 0.24). In summary, among HIV-infected women, the incidence of weekly marijuana use was associated with only one marker of HIV disease stage and HAART was associated with lower initiation rate of weekly marijuana use.

Comparison of sequential three-drug regimens as initial therapy for HIV-1 infection.

BACKGROUND: The optimal sequencing of antiretroviral regimens for the treatment of infection with human immunodeficiency virus type 1 (HIV-1) is unknown. We compared several different antiretroviral treatment strategies. METHODS: This multicenter, randomized, partially double-blind trial used a factorial design to compare pairs of sequential three-drug regimens, starting with a regimen including zidovudine and lamivudine or a regimen including didanosine and stavudine in combination with either nelfinavir or efavirenz. The primary end point was the length of time to the failure of the second three-drug regimen. RESULTS: A total of 620 subjects who had not previously received antiretroviral therapy were followed for a median of 2.3 years. Starting with a three-drug regimen containing efavirenz combined with zidovudine and lamivudine (but not efavirenz combined with didanosine and stavudine) appeared to delay the failure of the second regimen, as compared with starting with a regimen containing nelfinavir (hazard ratio for failure of the second regimen, 0.71; 95 percent confidence interval, 0.48 to 1.06), as well as to delay the second virologic failure (hazard ratio, 0.56; 95 percent confidence interval, 0.29 to 1.09), and significantly delayed the failure of the first regimen (hazard ratio, 0.39) and the first virologic failure (hazard ratio, 0.34). Starting with zidovudine and lamivudine combined with efavirenz (but not zidovudine and lamivudine combined with nelfinavir) appeared to delay the failure of the second regimen, as compared with starting with didanosine and stavudine (hazard ratio, 0.68), and significantly delayed both the first and the second virologic failures (hazard ratio for the first virologic failure, 0.39; hazard ratio for the second virologic failure, 0.47), as well as the failure of the first regimen (hazard ratio, 0.35). The initial use of zidovudine, lamivudine, and efavirenz resulted in a shorter time to viral suppression. CONCLUSIONS: The efficacy of antiretroviral drugs depends on how they are combined. The combination of zidovudine, lamivudine, and efavirenz is superior to the other antiretroviral regimens used as initial therapy in this study.

Seroprevalence of HTLV-I and HTLV-II among a cohort of HIV-infected women and women at risk for HIV infection. Women's Interagency HIV Study

OBJECTIVES: To determine the seroprevalence of, and risk factors for, HTLV-I and HTLV-II infection among HIV-infected women and women at high risk for HIV infection. DESIGN: Cross-sectional analysis of baseline data for women enrolled in the prospective Women's Interagency HIV Study (WIHS). METHODS: From October 1994 through November 1995, 2657 women from five metropolitan areas in the United States (Chicago, Los Angeles, New York City [two sites], Northern California, and Washington DC) were enrolled in WIHS. An interview-based survey collected data on demographics, behavior, and medical history. HTLV-I and HTLV-II determinations were made using a combined HTLV-I/HTLV-II indirect immunofluorescent antibody (IFA) screening test, an IFA titration specificity test, and individual HTLV-I and HTLV-II confirmatory Western blots. Fisher's exact tests and logistic regression were used to determine univariate and multi variate independent predictors for HTLV-II infection. RESULTS: Of 2625 women enrolled in WIHS with confirmed HIV results, 2487 (95 percent) were tested for HTLV-I and HTLV-II. Of these, 241 (10 percent) HTLV-II-seropositive and 13 (0.5 percent) were HTLV-I-seropositive. On multivariate analysis, independent predictors of HTLV-II infection included injection drug use (OR = 5.2; p < .001), black race (OR = 3.6; p < 0.001), age > 35 years (OR = 3.3; p < .001) and a history of sex with a male injecting drug user (OR = 1.9; p < .001). Among women injected with HIV, the seroprevalence of HTLV-II was 11 percent compared infected with HIV, the seroprevalence of HTLV-II was 11 percent compared with 6 percent for women at risk for HIV but not infected (p < .001). However, HIV was not an independent predictor of HTLV-II infection in multivariate analysis. CONCLUSIONS: This cross sectional analysis confirms that HTLV-II is found commonly in HIV-infected women at risk for HIV in major urban areas throughout the United States and that HTLV-II is far more common than HTLV-I in these populations. Although injecting drug use is most strongly associated with HTLV-II infection, sexual transmission likely contributes to the high HTLV-II seroprevalence in this cohort.(AU)

Peritonitis in acute peritoneal dialysis at the University Hospital of the West Indies: a five-year review

The records of patients receiving acute peritoneal dialysis during the 1983 - 1987 were retrospectively evaluated. Of a total of 59 patients receiving dialysis, 10 developed peritonitis. Staphylococcus aureus was the single most frequently isolated organism. However, gram-negative bacilli as a group were more common. We recommend the use of cloxacillin orally and gentamicin intra-peritoneally as empiric antibiotic coverage until results of culture reports are available (AU)

Malaria revisited: "Jamaican perspective" - abstract

A retrospective study of all reported smear-positive cases of malaria in Jamaica between 1966 and 1989 was undertaken. There were 76 cases of imported malaria. Fourteen (14) of these cases were seen and treated at the University Hospital of the West Indies or at the University Health Centre. The results and their implications are discussed (AU)

The bioavailability of potassium in bananas

Bananas are known to have a high K+ content. The bioavailability of the K+ in bananas was compared with that in Slow-K tablets in 5 normal subjects. 24-hr urinary K+ excretion was assumed to be an index of K+ absorbed from the gatro-intestinal tract. The results indicate that the K+ in bananasis available, since 24-hr K+ excretion rose significantly during the period of banana consumption. The rise in K+ excretion while taking Slow-K was however, greater, the difference between the two being highly significant (p<0.01). The possible reasons for this difference are discussed. It is suggested that bananas may be a useful and safer alternative to Slow-K for K+ supplementation in patients in whom the extra calories are not contraindicated (AU)