Hepatitis C in the HIV-infected patient

Hepatitis C virus (HCV) coinfection in the presence of HIV raises several challenging issues for the treating clinician. Some evidence indicates that concomitant HIV infection alters HCV virology in ways that are relevant for treatment. Pegylated interferon plus ribavirin is the recommended therapy for HCV in HIV-infected patients. Proportionately fewer HIV/HCV-coinfected patients achieve a sustained virologic response (SVR) compared with those infected with HCV alone. Possible reasons for this include higher levels of HCV viremia and inadequate ribavirin exposure. Strategies under study for optimizing therapeutic response include weight-based ribavirin dosing, use of growth factors to avoid dose reduction, and longer duration of therapy. Aggressive management of adverse effects to avoid dose reduction or treatment discontinuation is also crucial. An integrated multidisciplinary team, including a psychiatrist and addictions specialist, can increase the proportion of HIV/HCV-coinfected patients eligible for treatment. Investigational options exist for patients who relapse after treatment is discontinued and for those with a partial virologic response. Promising therapies that are under development include protease and polymerase inhibitors.     

Vaccination considerations in the asplenic patient

Overwhelming postsplenectomy sepsis is a rare but devastating and often lethal disease. Although vaccines are available, their proper use may be questioned. Standardization of protocols for the immunization of asplenic patients should be universal, thus, likely improving on their use. This article reviews the vaccines to be administered to the asplenic patient.     

Stevens-Johnson syndrome in an HIV-infected patient

Stevens-Johnson syndrome (SJS) is a severe and sometimes lethal form of erythema multiforme most often associated with a drug hypersensitivity reaction. HIV-infected patients suffer a higher incidence of SJS than the general population. This article details a case of nevirapine-induced SJS in an HIV-seropositive man and reviews the clinical features of erythema multiforme, SJS, and their association with drugs commonly used in the treatment of HIV infection.     

Special considerations in pregnant systemic sclerosis patients

Introduction: Evaluating the fertility and pregnancy outcomes in systemic sclerosis (SSc) women is challenging. Studies are still limited or subject to potential methodological biases.

Areas covered: This work is a comprehensive review of the literature. We discuss the potential impact of SSc on women’s pregnancy outcomes and the effects of pregnancy on SSc. We summarize the physiological changes during pregnancy and describe our experience.

Expert commentary: Although the miscarriage rate does not appear increased in SSc, women are exposed to a higher risk of premature birth and intrauterine growth restriction compared with the general population. Early diffuse cutaneous SSc and use of corticosteroids are risk factors, whereas folic acid use prevents against premature birth. All SSc women wishing to conceive should be counselled during a preconception visit. Physiological changes arising during pregnancy may be the source of clinical problems in SSc women with organs with limited capacities.     

Coccidioides thyroiditis in an HIV-infected patient

We report a case of Coccidioides thyroiditis in an HIV-infected patient with a history of recent Coccidioides pneumonia but with negative Coccidioides serology determined by enzyme immunoassay at presentation. Diagnosis of Coccidioides thyroiditis was made based on histopathologic examination and culture of thyroid abscess material obtained by fine-needle aspiration biopsy.     

Management of chronic hepatitis B in the HIV-infected patient

Coinfection with HIV and hepatitis B virus (HBV) is common because of their shared modes of transmission. HIV infection alters the natural history of HBV infection, leading to more severe liver disease, decreased hepatitis B e antigen seroconversion, and higher HBV DNA levels. Furthermore, end-stage liver disease has emerged as a common cause of morbidity and mortality in HIV-infected persons receiving HAART. For these reasons, it is important to vaccinate susceptible persons against HBV infection and to diagnose and treat chronic hepatitis B in HIV-infected persons. The treatment plan for chronic hepatitis B needs to be individualized based on the stage of both viral infections and the available options. It is anticipated that we are entering a period of combination therapy for chronic hepatitis B, but the ideal combination needs to be elucidated.     

Venom immunotherapy in the Hymenoptera-allergic pregnant patient

Natural or iatrogenic causes of anaphylaxis are significant risk factors in pregnancy. A 3% to 5% risk of sting anaphylaxis in any pregnant woman with insect-sting allergy untreated with venom immunotherapy (VIT) can be calculated. Insect-sting anaphylaxis has allegedly caused severe fetal abnormalities and is a potential cause of fetal loss and severe maternal morbidity and/or mortality. Hymenoptera anaphylaxis is a highly preventable cause of anaphylaxis, but VIT may itself carry a risk potential, with an appropriate 5% reaction during buildup and 1% reaction risk during maintenance VIT. To assess the safety of VIT in pregnancy, we have gathered data from 26 women with 43 pregnancies. All the women were receiving VIT. One woman was stung early in pregnancy with anaphylaxis resulting. Outcome of pregnancy was normal. Thirty-six of the pregnancies ended normally. There were two mild adverse reactions to VIT, neither of which required treatment. One child was born with multiple congenital abnormalities of unknown cause. Since congenital malformations may occur as frequently as one in 40 live births, these data do not suggest a significant increased risk from VIT during pregnancy.     

Important considerations in pregnant patients with lupus nephritis

Introduction: In the last few decades, identification of predictors of pregnancy outcome and appropriate pregnancy planning have significantly reduced the maternal and fetal risks in pregnant women with lupus nephritis.

Areas covered: Successful pregnancies have been reported even in women with chronic renal disease and renal insufficiency. However, refractory hypertension and severe renal or cardiac chronic dysfunction are still considered contraindications to pregnancy. Pre-term delivery and fetal growth restriction may still occur in SLE patients more frequently than in healthy women, even in pregnancies regularly planned and monitored by a team of nephrologists and gynaecologists.

Expert commentary: Stable disease remission is the most important factor for a successful pregnancy. In case of flare-ups of lupus, timely diagnosis and appropriate management may ensure a successful outcome in the majority of pregnant women. The negative role of anti-phospholipid antibodies and of chronic arterial hypertension may be countered with appropriate anticoagulation and anti-hypertensive therapy. Further studies are needed to better assess the possible impact of pregnancy on the long-term outcome of lupus nephritis.     

Ascaris-induced eosinophilic pneumonitis in an HIV-infected patient

A case of Ascaris-induced eosinophilic pneumonitis in an HIV-infected patient is described. Owing to his HIV status and the absence of peripheral blood eosinophilia on admission, the initial diagnosis was incorrect until the passage of two worms in his stool. The patient developed eosinophilia subsequently, and examination of his sputum also showed increased eosinophils. The patient gradually improved with inhaled bronchodilators, steroid and mebendazole. As peripheral blood eosinophilia may be transient and the larval migration phase occurs before eggs are present in stool, a high index of suspicion is required in making the diagnosis of Ascaris pneumonitis. Examination of sputum for larvae or increased eosinophils should be performed in patients suspected of having pulmonary infiltrates from endemic areas irrespective of peripheral blood eosinophil counts.     

Safety of antiretroviral prophylaxis of perinatal transmission for HIV-infected pregnant women and their infants

Worldwide, more than 1600 infants become infected with HIV each day. Almost all infections are a result of mother-to-child transmission of HIV, with most of these infections occurring in resource-poor countries. In developed countries, antiretroviral prophylaxis has dramatically reduced perinatal transmission to <2%. The potential now exists to extend this success to resource-poor countries using effective but shorter and less expensive antiretroviral regimens.With the potential widespread use of antiretroviral therapy for perinatal HIV prevention in resource-limited settings, there will be exposure of increasing numbers of infants to in utero and postpartum antiretroviral drugs for which long-term toxicity data is unknown. This article focuses on a review of what is known about safety of antiretroviral regimens used to interrupt mother-to-child transmission for women and their children.     

Systematic review of the safety of trimethoprim-sulfamethoxazole for prophylaxis in HIV-infected pregnant women: implications for resource-limited settings

Daily prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMZ) significantly decreases morbidity and mortality among people living with HIV. Some clinicians are reluctant to use TMP-SMZ in pregnant and breastfeeding HIV-infected women because of concerns about the possible teratogenicity when used in the first trimester and about its potential to induce hyperbilirubinemia near term and during early breastfeeding. We systematically reviewed evidence regarding the toxicity of TMP-SMZ prophylaxis in pregnant and breastfeeding women to help guide practice in resource-limited settings. We identified relevant literature by searching PubMed and MEDLINE via OVID, Embase, and Science Citation Index for data on hyperbilirubinemia, kernicterus, and teratogenicity associated with administration of sulfonamides and TMP-SMZ through July 2005. We also reviewed the reference lists of identified articles. Most studies demonstrated that TMP-SMZ was not associated with hyperbilirubinemia when administered to mothers during pregnancy and breastfeeding. No cases of kernicterus were reported in neonates after maternal ingestion of sulfonamides. There is mixed evidence linking ingestion of TMP-SMZ and other sulfonamides in early pregnancy to elevated risks of oral clefts, neural tube defects, and cardiovascular and urinary tract abnormalities, although some sources found that supplementation with folic acid might ameliorate this potential risk. Existing guidelines recommend that HIV-infected pregnant women receive prophylaxis, but they differ with regards to stage of disease at which to initiate treatment, need for CD4+ T-lymphocyte testing, and prophylaxis during the first trimester. Existing data indicate that the risk of serious injury to neonates from maternal use of daily TMP-SMZ prophylaxis during pregnancy and breastfeeding is small. Given the substantial benefits of TMP-SMZ prophylaxis for HIV-infected women living in resource-limited settings, this review indicates that it is safe to abide by the WHO guidelines recommending daily TMP-SMZ prophylaxis for HIV-infected pregnant women.