Guillain-Barré syndrome and Mycoplasma pneumoniae infection

Guillain-Barré syndrome subsequent to Mycoplasma pneumoniae is uncommon and difficult to confirm. We report one case. Clinical presentation and therapy were unremarkable. The interest of antibiotics (preventive or curative) is unresolved. The pathophysiology remains hypothetical but Mycoplasma pneumoniae and some surface gangliosides of peripheral nerves share homologous epitopes leading to the production of antibodies. Induced antibodies to ganglioside may cross-react with neural tissues.     

The relationship of Campylobacter jejuni infection and the development of Guillain-Barré syndrome

Campylobacter jejuni is recognized as the most common infectious agent associated with the development of Guillain-Barré syndrome. Available information on the complete genome sequence of C. jejuni NCTC 11168 has helped researchers to identify polysaccharide capsules as well as genetic mechanisms in the synthesis of ganglioside-like cell surface molecules in this bacteria. Toxins may contribute to the host's inflammatory response seen in Guillain-Barré syndrome.     

Atherosclerosis and HIV in the highly active antiretroviral therapy era: towards an epidemic of cardiovascular disease?

Whether the atherogenic metabolic side effects of highly active antiretroviral therapy (HAART) (lipid disorders and glucose intolerance/diabetes) will translate, in the long term, into an increased incidence of cardiovascular events that would offset the survival benefits of this type of therapy is a matter of intense concern. This concern has been substantiated by a series of case reports of HIV-infected patients who had experienced unexplained cardiovascular disease. However, in the absence of prospective, large cohort studies, the answer to this question at present remains elusive. Indirect evidence, from retrospective cohort analyses and non-invasive imaging of peripheral arteries, indicates that HIV-infected persons are at higher risk for atherosclerosis than HIV-negative individuals. However, this risk does not appear to be attributable to HAART. Pending the availability of further data, a global assessment of the risk for heart disease should be performed in all HAART-treated HIV-infected patients, taking into account age and the presence of major risk factors. There is so far no evidence, from a cardiovascular standpoint, to limit administration of HAART. However, interventions on modifiable risk factors, including smoking cessation, are strongly recommended, particularly in high-risk patients.     

Nevirapine- versus efavirenz-based highly active antiretroviral therapy regimens in antiretroviral-naïve patients with advanced HIV infection

Objective

To compare virological and immunological responses to nevirapine (NVP)‐based and efavirenz (EFV)‐based highly active antiretroviral therapy (HAART) regimens in antiretroviral‐naïve patients with advanced HIV infection.

Methods

A retrospective observational cohort study was conducted on antiretroviral‐naïve HIV‐infected patients whose pretreatment CD4 cell counts were less than 100 cells/μL or whose viral loads were greater than 100 000 HIV‐1 RNA copies/mL.

Results

Baseline characteristics of patients in the NVP (n=24) and EFV (n=29) groups were not different. The proportion of patients with viral loads >100 000 copies/mL was higher in the EFV group. The probability of virological success estimated by the Kaplan‐Meier method showed that 3‐ and 6‐month success rates were 30.8% [95% confidence interval (CI): 16.7–52.2%] and 63.1% (95% CI: 44.7–81.3%) for the NVP group. The corresponding values were 41.2% (95% CI: 25.8–61.0%) and 62.9% (95% CI: 45.7–80.1%) for the EFV‐based group. The median success times of the two groups were about 4 and 3 months (P=0.678), respectively, for NVP and EFV. Cox's proportional hazard was used after adjusting for age, previous opportunistic infections (OIs), and viral load at baseline, and showed that patients who received the NVP‐based regimen had about 25% [hazard ratio (HR)=0.75, 95% CI: 0.37–1.51] less chance of virological success than patients who received the EFV‐based regimen (P=0.415). The median times to CD4≥100 cells/μL were 5.6 and 4.4 months for the NVP‐ and EFV‐based regimens, respectively (log‐rank test, P=0.144).

Conclusions

NVP‐ and EFV‐based HAART regimens as initial regimens in patients with advanced HIV infection are effective and comparable, in term of virological and immunological responses. However, further large‐scale randomized controlled clinical trials in this group of patients with advanced HIV infection are needed.

     

Does immune reconstitution syndrome promote active tuberculosis in patients receiving highly active antiretroviral therapy?

OBJECTIVES: To assess whether highly active anti-retroviral therapy (HAART) contributes to the presentation of active tuberculosis (TB). DESIGN: Retrospective single-centre cohort study. METHODS: A total of 111 HIV-infected individuals with active TB were identified at an urban teaching hospital between February 1997 and April 2004. Those receiving HAART at the time of TB diagnosis were assessed. RESULTS: Nineteen of 111 (17%) were receiving HAART when TB developed. Within this group there appeared to be two distinct populations. Thirteen of 19, 12 from ethnic or social groups with high background rates of TB, developed disease a median of 41 days (range, 7-109) after starting HAART ('early TB' group). In six of 19 ('late TB' group), TB occurred a median of 358 days after HAART initiation (range, 258-598). The 'early TB' group had lower CD4 cell counts when starting HAART in comparison with the 'late TB' group (median; 87 versus 218 x 10 cells/l; P = 0.04); however no difference was observed in the rate of change of CD4 cell count (P = 0.5) or HIV load. Paradoxical reaction rate in the 'early TB' group was significantly greater than in the 'late-TB' group (62 versus 0%, P = 0.02) and greater than in a similar control population who started HAART while taking anti-TB therapy (62 versus 30%, P = 0.05). CONCLUSIONS: These data suggest anti-HIV treatment may amplify the presentation of active TB. This has implications for antiretroviral programmes in countries with high TB rates and warrants prospective investigation of a larger cohort.     

Campylobacter enteritis and the Guillain-Barré syndrome

Campylobacter jejuni is one of the most common causes of bacterial gastroenteritis in the United States and worldwide with approximately 2.4 million infections per year in the United States. A now clearly recognized sequelae following Campylobacter infection is the Guillain-Barré syndrome, an acute immune-mediated attack on the peripheral nervous system. How Campylobacter induces Guillain-Barré syndrome is the subject of intense investigation, and this article discusses some of the recent advances in our understanding of the clinical, epidemiologic, and pathogenic features of the disease.     

Acute onset of nephrotic syndrome during interferon-α retreatment for chronic active hepatitis C

A 57-year-old woman was scheduled to receive recombinant interferon-α retreatment for chronic active hepatitis C. During the course of therapy, the patient showed rapid onset of oliguria, dizziness, edema, and a pre-shock state. She was subsequently admitted to hospital and was diagnosed as having nephrotic syndrome. After admission, albumin-dominant proteinuria persisted despite the discontinuation of interferon therapy. Light microscopy of a renal needle biopsy specimen showed interstitial lymphoid cell infiltration, but no marked changes of the glomeruli and no staining for immunoglobulin or complement. Electron microscopy showed diffuse effacement of the glomerular epithelial foot processes, leading to a diagnosis of minimal change nephrotic syndrome with interstitial nephritis. Proteinuria resolved after the initiation of oral prednisolone therapy (1 mg/kg per day). The number of patients with chronic hepatitis C requiring interferon retreatment is increasing rapidly. We herein report this rare case of acute onset of nephrotic syndrome during interferon-α retreatment. Received: March 30, 2001 / Accepted: July 6, 2001 Reprint requests to: S. Nishimura     

Secondary hyperparathyroidism in HIV patients: is there any responsibility of highly active antiretroviral therapy?

Secondary hyperparathyroidism may develop in the presence of hypovitaminosis D in order to maintain calcium homeostasis. We conducted a cross-sectional analysis in a cohort of 371 patients, identifying secondary hyperparathyroidism in 65 patients. This high prevalence (17.5%) was in part justified by the high prevalence of hypovitaminosis D (77.4%) in the whole sample, but we also identified an independent association with the use of tenofovir.     

Human immunodeficiency virus infection unresponsive to highly active antiretroviral therapy: denial of poor medication adherence or recalcitrant infection?

Poor clinical and virologic response to combination antiretroviral therapy for human immunodeficiency virus (HIV) infection may stem from a variety of factors including poor medication adherence, development of drug-resistant HIV strains, drug interactions, efflux pumps, and unfavorable pharmacokinetics. Diagnosing nonadherence to medication is particularly challenging. We present a case of lack of response to antiretroviral therapy in a patient who denied problems with medication adherence. The patient underwent a variety of objective examinations, all of which suggested poor medication adherence was responsible for his nonresponse to antiretrovirals. An approach to evaluating patients for causes of poor response to antiretroviral therapy and nonadherence and implications for clinical practice are discussed.     

Directly administered antiretroviral therapy in the treatment of HIV infection: benefit or burden?

While combination antiretroviral treatment has had a profound impact on the morbidity and mortality of human immunodeficiency virus (HIV) infection, the adherence demands of this therapy are high and failure to maintain viral suppression is common. Directly administered antiretroviral therapy (DAART) has garnered attention recently as a strategy to improve medication adherence and clinical outcomes in HIV-infected individuals. This review is intended to provide an update on the use of DAART and the challenges posed by this strategy, explore settings in which DAART may be used, discuss the role of antiretroviral regimens with improved pharmacokinetic features, and propose future directions for DAART strategies. DAART is modeled on directly observed therapy (DOT) for the treatment of tuberculosis. However, differences in curability, medication dosing frequency, duration of treatment, and the biologic dynamics of infection, pose unique challenges to DAART strategies. Numerous settings have been proposed for DAART, including community based outreach programs, prisons, long-term care facilities, substance abuse treatment sites, and resource-poor countries. Experience with DAART to date has been limited to pilot studies or retrospective comparisons. The prospect of simplified, once-daily antiretroviral therapy holds promise for DAART. However, improvements in antiretroviral therapy may also improve outcomes in patients taking therapy on a self-administered basis. Randomized controlled trials of DAART are needed before this strategy can be embraced in any setting. In future studies it will be important to compare DAART with self-administered therapy in terms of initial virologic and immunologic responses, durability of responses, the development of antiretroviral resistance, and cost effectiveness.