Sarcoidosis after antiretroviral therapy in a patient with acquired immunodeficiency syndrome.

A 53-year-old man with acquired immunodeficiency syndrome (AIDS) developed clinical and radiological features compatible with sarcoidosis 14 months after starting highly active antiretroviral therapy (HAART). The CD4 lymphocyte count had increased from 5 cells/mm(3) to 235 cells/mm(3) with HAART. Transbronchial lung biopsy showed nonnecrotizing granulomas. All studies for an infectious etiology were negative. His condition improved after treatment with corticosteroids. To our knowledge, this is the fifth case report of sarcoidosis occurring after initiation of antiretroviral therapy for AIDS.     

Ketoconazole-resistant Candida esophagitis in patients with acquired immunodeficiency syndrome

Although ketoconazole has been shown to be effective in treating esophageal candidiasis in other immunodeficiency states, similar studies have not been reported in patients with acquired immunodeficiency syndrome. Six patients with acquired immunodeficiency syndrome and oral and esophageal candidiasis who had been treated with ketoconazole for more than 2 mo were evaluated with barium esophagram and endoscopy with biopsy and brush cytology. All of the patients had persistent Candida esophagitis. In 2 patients, fungal cultures and sensitivity testing indicated Candida albicans resistant to ketoconazole in vitro. In patients with acquired immunodeficiency syndrome, esophageal candidiasis may not resolve with up to 6 mo of ketoconazole therapy and may require more vigorous antifungal therapy than in patients with other immunodeficiency states.     

Initiation of therapy with a subcutaneously administered antiretroviral in treatment-experienced HIV-infected patients: understanding physician and patient perspectives

Enfuvirtide (Fuzeon) is the first self-injectable antiretroviral (ARV) therapy approved for the treatment of HIV. This study was undertaken to explore the perceptions of injectable ARVs among physicians and treatment-experienced HIV-infected patients and identify potential motivators or barriers to the initiation of injectable ARV therapies. This empirical study was conducted based on qualitative field research conducted in multiple centres in five European countries and the US. A purposive sampling strategy was employed and structured interviews carried out with physicians and patients. Discussion guides for these interviews focused on attitudinal responses to a range of key areas. For physicians, these areas included HIV treatment, treatment-experienced patients and their relationships with them and injectable therapy usage, while for patients - some of whom were receiving enfuvirtide therapy - the focus included relationships with their physicians and attitudes towards injectable ARV therapy. Sixty-eight physicians and 43 patients were interviewed. Qualitative analysis of the interview responses revealed a number of recurring themes among physician and patient perceptions of HIV and its treatment. Physicians tended to view injectable ARVs as a last resort, with only limited suitability among treatment-experienced patients and a low level of patient acceptability. In contrast, patients generally perceived the potential value of effective injectable ARV therapy, if recommended to them by their physicians, indicating that its benefits could outweigh the drawbacks associated with its administration. This study identified some potential disconnects between physician and patient perceptions of injectable therapy. Our findings emphasize the need for patients to discuss their treatment goals with their physicians so that they can work together to find the regimen that is most likely to achieve these goals.     

Candida albicans epididymo-orchitis and fungemia in a patient with chronic myelogenous leukemia

The fourth reported case of candidal epididymo-orchitis in the literature and the first reported case successfully cured with only low dose amphotericin B is described. A 75-year-old male with chronic myelogenous leukemia presented with acute testicular and epididymal swelling and pain. Subsequent investigations suggested the diagnosis of epididymo-orchitis due to Candida albicans. This was successfully treated with intravenous amphotericin B (total dose of 500 mg). Based on the three previous case reports and the current case several characteristic features that increased the suspicion of this entity were identified. These features include an immunocompromised state, candiduria, specific epididymal ultrasonographic appearance, as well as typical clinical features of epididymo-orchitis.     

Recurrences of cytomegalovirus retinitis in a human immunodeficiency virus-infected patient, despite potent antiretroviral therapy and apparent immune reconstitution.

We describe a 42-year-old man with human immunodeficiency virus infection who developed multiple recurrences of cytomegalovirus (CMV) retinitis despite receiving highly active antiretroviral therapy and having apparent immune reconstitution as evidenced by CD4(+) T lymphocyte counts of > 200 cells/mm(3). Laboratory investigation during one recurrence of retinitis confirmed that there was active CMV replication in the plasma and vitreous fluid. In addition, lymphoproliferative responses to CMV antigens were absent despite evidence of reactivity to Candida antigen and pokeweed mitogen. The clinical significance of this case and of other recently reported cases is discussed.     

Outcomes in HIV-infected patients on antiretroviral therapy with tuberculosis

HIV-infected patients with active tuberculosis (TB) having CD4 counts < 100/mm3 and who were antiretroviral therapy (ART) na?ve were reviewed retrospectively to determine the outcomes of their tuberculosis infection. All patients received ART at or after receiving anti-TB treatment. Clinical manifestations, treatment regimens and outcomes were analyzed. Of 101 patients, 62 (61.4%) completed TB treatment. Of these, 53.2% were treated with a 6-month standard TB regimen, while the rest were treated with prolonged TB regimens. The median interval between anti-TB treatment and ART was 68 days (range: 0-381). Among the clinically cured patients 66.1% received rifampin concomitantly with nevirapine, and 32.3% received rifampin concomitantly with efavirenz. The treatment success rate was 75.6%, with a mortality rate of 6.1%. The risk factors for death were resistant TB (p = 0.03) and poor compliance (p < 0.05). Seven point nine percent had multi-drug resistant TB. Possible or probable immune reconstitution inflammatory syndrome (IRIS) was seen in 15 cases (14.9%). No life-threatening IRIS was reported, and it did not affect disease outcome (p = 0.5). A shorter time between anti-TB treatment and ART onset was associated with the occurrence of IRIS (31 days vs 90 days; p < 0.05). Regarding adverse drug effects, 44.6% had side effects due either to anti-TB drugs or ART. Sixty-six point one percent of them occurred within the first 2 months of TB treatment, and 43 (76.8%) had to stop or change either anti-TB treatment or ART. The mortality rate with TB and HIV on ART was low and the occurrence of IRIS did not carry any additional mortality.     

Changes in mitochondrial DNA copy number in blood cells from HIV-infected patients undergoing antiretroviral therapy

Mitochondrial DNA (mtDNA) copy number was measured in peripheral blood mononuclear cells (PBMCs) from 69 individuals using a real-time NASBA quantitative assay. Patients with HIV infection harbored significantly lower mtDNA copy number in PBMC than HIV-negative controls. Besides, subjects on stavudine-containing regimens showed significantly lower median mtDNA amounts than HIV-positive patients receiving other antiretroviral drugs, and this was associated with higher lactate levels. Thus, either HIV infection itself or treatment with stavudine-containing regimens might induce mtDNA depletion and related metabolic disturbances as hyperlactatemia.