Pulmonary arterial hypertension related to human immunodeficiency virus infection:A case series

AIM: To present 18 new cases of human immunodeficiency virus(HIV)-related pulmonary arterial hypertension(PAH) with presenting features,treatment options and follow-up data.METHODS: This is a single-centre,retrospective,observational study that used prospectively collected data,conducted during a 14-year period on HIV-related PAH patients who were referred to a pulmonary hy-pertension unit. All patients infected with HIV were consecutively admitted for an initial evaluation of PAH during the study period and included in our study. Right heart catheterisation was used for the diagnosis of PAH. Specific PAH treatment was started according to the physician's judgment and the recommendations for idiopathic PAH. The data collected included demographic characteristics,parameters related to both HIV infection and PAH and disease follow-up.RESULTS: Eighteen patients were included. Intravenous drug use was the major risk factor for HIV infection. Risk factors for PAH,other than HIV infection,were present in 55.5% patients. The elapsed time between HIV infection and PAH diagnoses was 12.2 ± 6.9 years. At PAH diagnosis,94.1% patients had a CD4 cell count > 200 cells/μL. Highly active antiretroviral therapy(present in 47.1% patients) was associated with an accelerated onset of PAH. Survival rates were 93.8%,92.9% and 85.7% at one,two and three years,respectively. Concerning specific therapy,33.3% of the patients were started on a prostacyclin analogue,and the rest were on oral drugs,mainly phosphodiesterase-5 inhibitors. During the follow-up period,specific therapy was de-escalated to oral drugs in all of the living patients.CONCLUSION: The survival rates of HIV-related PAH patients were higher,most likely due to new aggressive specific therapy. The majority of patients were on oral specific therapy and clinically stable. Moreover,sildenafil appears to be a safe therapy for less severe HIVrelated PAH.

Pancreatic tuberculosis in a human immunodeficiency virus positive patient:A case report

Despite the increased incidence of tuberculosis related to human immunodeficiency virus (HIV) in recent decades, pancreatic tuberculosis has rarely been described. We report a case of pancreatic tuberculosis in a 39-year- old African man who presented with progressive dysphagia, vomiting, weight loss and productive cough, accompanied by localized epigastric pain and one episode of melena. HIV-1 testing was positive and lymphocyte subset profile showed CD4 count of 9/mm3. Abdominal computed tomography (CT) scan with contrast revealed a cystic mass in the body of the pancreas, significant portal and retroperitoneal cystic adenopathy, and multiple cystic lesions in the spleen and liver. CT guided cyst aspiration and node biopsy detected Mycobacterium tuberculosis. The patient responded well on antituberculosis and antiretroviral therapy. Tuberculosis rarely involves the pancreas, probably due to the presence of pancreatic enzymes which interfere with the seeding of Mycobacterium tuberculosis. Pancreatic tuberculosis is considered to be the result of dissemination of the infection from nearby lymphatic nodes. Endoscopic ultrasound or CT guided fine needle aspiration for cytology is the recommended diagnostic technique. Although the prognosis is good with anti-tuberculosis treatment, it could be fatal without correct diagnosis and treatment. The clinician’s high index of suspicion of pancreatic tuberculosis and application of FNAB to obtain pathological evidence are extremely important to a correct diagnosis, especially in young HIV positive patients.

Diagnostic value of antigenemia assay for cytomegalovirus gastrointestinal disease in immunocompromised patients

AIM:To investigate the utility of the cytomegalovirus(CMV)antigenemia assay for the diagnosis of CMV gastrointestinal disease(GID). METHODS:One hundred and thirty immunocompromised patients were enrolled in this study.Patients with a history of anti-CMV treatment and who had not undergone examination using the antigenemia assay were excluded.CMV-GID was defined as the detection of large cells with intranuclear inclusions alone or associated with granular cytoplasmic inclusions by biopsy.Biopsy sections were stained with hematoxylin and eosin and immunohistochemically stained with anti-CMV.We evaluated the association between CMV-GID and patient characteristics(symptoms,underlying disease,medication,leukocyte counts,and antigenemia assay).All patients were checked with an human immunodeficiency virus(HIV)antibody test before endoscopic examination.White blood cell(WBC)counts were obtained from medical records within 1 wk of endoscopy.Leukopenia was defined as a total WBC count<5000 cells/mm 3 . For HIV patients,we also checked CD4+counts from medical records. RESULTS:A total of 99 patients were retrospectively selected for analysis.Of the immunocompromised patients,19 had malignant disease,18 had autoimmune disease,19 had disorders of biochemical homeostasis, three had undergone transplantation,and 45 had HIV infection.A total of 50 patients had received immunosuppressive therapy.No patients had inflammatory bowel disease.Fifty-five patients were diagnosed as having CMV-GID.Univariate analysis indicated an association between HIV infection,leukopenia,and positive antigenemia and CMV-GID(P<0.05).Multivariate analysis using logistic regression revealed that HIV infection and positive antigenemia were the only independent factors related to CMV-GID(P<0.01).The sensitivity,specificity,positive predictive value,and negative predictive value of antigenemia for CMV-GID were 65.4%,93.6%, 91.9%,and 71.0%,respectively.In a subgroup analy-sis,patients with leukopenia displayed low sensitivity and high specificity.Minimal differences in accuracy were seen among patients with or without leukopenia. HIV-infected patients displayed low sensitivity and high specificity.Accuracy barely differed between HIV-positive and-negative patients.In HIV-infected patients, CD4 count<50 cells/μL resulted in low sensitivity and high specificity.Differences in accuracy among patients were minor,regardless of CD4 count.In patients who had undergone both quantitative real-time polymerase chain reaction(PCR)and antigenemia assay,real-time PCR was slightly more accurate in terms of sensitivity than the antigenemia assay;however,this difference was not statistically significant(P=0.312). CONCLUSION:If the antigenemia test is positive,endoscopic lesions are acceptable for the diagnosis of CMVGID without biopsy.The accuracy is not affected by HIV infection and leukopenia.Either PCR or the antigenemia assay are valid.

Monitoring hepatitis C virus treatment rates in an Opioid Treatment Program:A longitudinal study

BACKGROUND Direct-acting antivirals(DAAs)are recommended for the treatment of hepatitis C virus(HCV)infection in patients treated with methadone or buprenorphine.AIM To assess HCV treatment rates in an Opioid Treatment Program(OTP).METHODS This longitudinal study included 501 patients(81.4%men,median age:45 years;interquartile range:39-50 years)enrolled in an OTP between October 2015 and September 2017.Patients were followed until September 2019.Data on sociodemographics,substance use,HCV infection,human immunodeficiency virus(HIV)infection and laboratory parameters were collected at entry.We analyzed medical records to evaluate HCV treatment.Kaplan-Meier methods and Cox regression models were used to analyze the DAA treatment uptake and to identify treatment predictors.RESULTS Prevalence of HCV and HIV infection was 70%and 34%,respectively.Among anti-HCV-positive(n=336)patients,47.2%,41.3%,and 31.9%used alcohol,cannabis,and cocaine,respectively.HCV-RNA tests were positive in 233(69.3%)patients.Twentyeight patients(8.3%)cleared the infection,and 59/308(19.1%)had received interferon-based treatment regimens before 2015.Among 249 patients eligible,111(44.6%)received DAAs.Treatment rates significantly increased over time from 7.8/100 person-years(p-y)(95%CI:5.0-12.3)in 2015 to 18.9/100 p-y(95%CI:11.7-30.3)in 2019.In a multivariate analysis,patients with HIV co-infection were twice as likely to receive DAAs(HR=1.94,95%CI:1.21-3.12)than patients with HCV mono-infection.Current drug use was an independent risk factor for not receiving treatment against infection(HR=0.48,95%CI:0.29-0.80).CONCLUSION HCV treatment is evolving in patients with HCV-HIV co-infection.Ongoing drug use while in an OTP might negatively impact the readiness to treat infection.

Is There an Association between Bacterial Vaginosis Infection and HIV-1 Infection Acquisition among Women Aged 18 - 35 Years in Soweto?

Background: Studies suggest that there is association between Bacterial Vaginosis and Human Immunodeficiency Virus infection but its temporal effect has not been sufficiently investigated. Methods: It is a secondary data analysis following a cohort study. It was carried out to describe Bacterial Vaginosis infection association to Human Immunodeficiency Virus acquisition. The primary cohort study registered 750 study participants. A gram stain slide prepared from a vaginal swab was used to measure Bacterial Vaginosis as the primary exposure. A score of 7 or above was considered positive for Bacterial Vaginosis. The determination of the dependent variable Human Immunodeficiency Virus infection was achieved through dual rapid tests which were confirmed by using a third generation ELISA. Incident Human Immunodeficiency Virus infection rate was calculated. To test significance, Kaplan Meier survival time analysis and log rank test were carried out. The association of Bacterial Vaginosis with Human Immunodeficiency Virus infection was investigated using Cox regression. Results: The baseline prevalence of Bacterial Vaginosis was 52%, 95% CI;45 - 59. There were 21 Human Immunodeficiency Virus seroconversions in total of which 7 had no Bacterial Vaginosis results and were left out in the analysis. The analysis only involved 14 seroconversions and these were followed for a mean time of 0.40 of a year and total time at risk of 286 person years. This shows incident rate of Human Immunodeficiency Virus infection of 4.9 per 100 person years of follow up, 95 % CI: 2.9 - 8.27. Kaplan Meier curves revealed a higher risk of incident infection among women who were Bacterial Vaginosis positive than the women who were Bacterial Vaginosis negative. A log rank test showed that the probability of incident infection differed among the women depending on Bacterial Vaginosis status, X2 value 3.8, p value 0.05. Adjusting for the other variables, incident Human Immunodeficiency Virus infection was high among Bacterial Vaginosis positive women, adjusted hazard ratio 3.21;95% CI;0.85 - 12.12, p value 0.08, though significance was not attained. Conclusion: The study showed an association between Bacterial Vaginosis and Human Immunodeficiency Virus seroconversion risk though statistical significance was not achieved. Education on vaginal cleansing, screening and treating women with Bacterial Vaginosis could maintain normal vaginal flora and reduce their vulnerability to Human Immunodeficiency Virus.

Early Outcomes of Primary Total Hip Arthroplasty for Osteonecrosis of the Femoral Head in Patients with Human Immunodeficiency Virus in China

Background：Studies have reported that patients with human immunodeficiency virus （HIV） have a high incidence of osteonecrosis of the femoral head （ONFH）.Total hip arthroplasty （THA） is an effective management of ONFH.However,little data exist regarding the use of THA for the HIV patients with ONFH in China.This study reviewed the outcomes of HIV-positive patients who underwent THA for ONFH,compared with HIV-negative individuals.Methods：The patients who underwent THA for ONFH from September 2012 to September 2014 in Beijing Ditan Hospital,Capital Medical University were retrospectively studied.Twenty-eight HIV-positive patients and 35 HIV-negative patients underwent 48 THAs and 45 THAs with cementless components,respectively.Medical records and follow-up data were reviewed.Harris Hip Score （HHS） was applied to evaluate the pain and function of the hips before and after THA.Complications such as wound healing,surgical site infection,deep venous thrombosis,pulmonary embolism,sepsis,mortality,and complications from the prosthesis were reviewed.The operation time,blood loss,and hospital stay were compared between the two groups.Results：The mean follow-up period was 19.5 ± 5.8 months （ranging from 6 to 30 months）.The mean age of the HIV-positive patients with osteonecrosis at the time of surgery was 35 years old,which was significantly lower than that of the HIV-negative group （42 years old） （P 〈 0.05）.The HIV-positive patients underwent surgery a mean of 2.5 years after their original symptoms,which was significantly shorter than the HIV-negatives＇ （mean 4 years） （P 〈 0.05）.Among HIV-positive patients,the prevalence of being male and rate of bilateral procedures were significantly higher than those in the HIV-negative group （P 〈 0.05）.The operation time in HIV-positive patients was significantly longer than that in HIV-negative patients （P 〈 0.05）.There were no significant differences in blood loss or hospital stay between the two groups （P 〉 0.05）.The HHSs of two groups significantly improved after THAs （P 〈 0.05）,without significant difference between two groups.No wound complication,sepsis,mortality,prosthesis complication,and occupational exposure occurred,except for two cases of heterotopic ossification and one case of humeral head necrosis.Conclusions：ONFH is more likely to occur bilaterally in younger HIV-positive males.The development of osteonecrosis seems faster in HIV-positive patients than in HIV-negative patients.This should be cautionary for asymptomatic HIV-positive patients with low viral RNA level and in the primary HIV stage.Despite longer operation times in the HIV-positive patients than in the HIV-negative patients,THA is still a safe and efficient approach to treat ONFH in HIV-positive patients.The incidence of complications is much lower than previously reported.However,the long-term follow-up is needed.

Transient elastography: A non-invasive tool for assessing liver fibrosis in HIV/HCV patients

AIM: To assess the prevalence of advanced liver fibrosis (ALF) in human immunodeficiency virus (HIV), hepatitis C virus (HCV) and HIV/HCV patients using transient elastography, and to identify factors associated with ALF. METHODS: Between September 2008 and October 2009, 71 HIV mono-infected, 57 HIV/HCV co-infected and 53 HCV mono-infected patients on regular follow-up at our Center were enrolled in this study. Alcohol intake, the main parameters of liver function, presence of HCV-RNA, HIV-RNA, duration of highly active anti-retroviraltherapy (HAART) and CD4 cell count were recorded. ALF was defined as liver stiffness (LS) ≥ 9.5 kPa. To estimate liver fibrosis (LF) a further 2 reliable biochemical scores, aspartate aminotransferase platelet ratio index (APRI) and FIB-4, were also used. RESULTS: LS values of co-infected patients were higher than in either HIV or HCV mono-infected patients (χ 2M H = 4, P < 0.04). In fact, LS ≥ 9.5 was significantly higher in co-infected than in HIV and HCV mono-infected pa-tients (χ 2 = 5, P < 0.03). Also APRI and the FIB-4 index showed more LF in co-infected than in HIV mono-infect-ed patients (P < 0.0001), but not in HCV mono-infected patients. In HIV?HCV co-infected patients, the extent of LS was significantly associated with alcohol intake (P < 0.04) and lower CD4+ cell count (P < 0.02). In HCV pa-tients, LS was correlated with alcohol intake (P < 0.001) and cholesterol levels (P < 0.03). Body mass index, dia-betes, HCV-and HIV-viremia were not significantly cor-related with LS. In addition, 20% of co-infected patients had virologically unsuccessful HAART; in 50% compliance was low, CD4+ levels were < 400 cells/mm 3 and LS was > 9.5 kPa. There was no significant correlation between extent of LF and HAART exposure or duration of HAART exposure, in particular with specific dideoxynucleoside analogues. CONCLUSION: ALF was more frequent in co-infected than mono-infected patients. This result correlated with lower CD4 levels. Protective immunological effects of HAART on LF progression outweigh its hepatotoxic effects.

Critical review of topical management of oral hairy leukoplakia

Oral hairy leukoplakia(OHL) is a disease associated with Epstein-Barr virus and human immunodeficiency virus infections. OHL is usually an asymptomatic lesion, but in some cases treatment is recommended to reestablish the normal characteristics of the tongue, to eliminate pathogenic microorganisms, to improve patient comfort and for cosmetic reasons. Proposed treatments for this condition include surgery, systemic antiviral treatment and topical management. Topical treatment is an inexpensive and safe therapy that is easy to apply, noninvasive, free of systemic adverse effects and effective over a long period of time. The aim of this study was to present a review of the literature for topical therapy for OHL. Gentian violet, retinoids, podophyllin, acyclovir and podophyllin associated with topical antiviral drugs were used to treat OHL. Reports with this focus are limited, and since 2010, no new studies have been published that discuss the efficacy of topical treatments for OHL. Podophyllin with acyclovircream was found to be effective, causing regression of lesions with no recurrences. Additional searches are necessary to provide clinical evidence of topical man agement effectiveness.

Cloning and analysis of the envelope protein clone of HIV-1, CHNHLJ03009c34 from an infected individual in Heilongjiang province

To analyze the variability and phenotype of envelope glycoprotein （Env） of human immunodeficiency virus type 1 （HIV-1） prevalent in Heilongjiang province, cloning of the full-length env gene from the peripheral blood mononuclear cells （PBMCs） of an HIV-1 positive individual in Heilongjiang province in China was performed by using conserved region primers. The amplified PCR products were cloned into a plasmid vector and sequenced. Phylogenetic analysis was done upon the full-length Env amino acid sequence. Subsequently, an HIV-1 pseudotyped virus bearing the envelope protein was constructed and the infectivity was examined using U87 cell lines expressing CD4 with either CCR5 or CXCR4. As the result, two functional env clones named as CHNHLJ03009c34 （GenBank Accession No： AY905493 ） and CHNHLJ03009c33 were obtained. It was found that the homology between CHNHLJ03009c34 and an HIV-1 subtype B＇ strain, RIA-2, isolated from Yunnan province, was 91.52% through comparing and analyzing full-length Env amino acid sequence of HIV-1 isolated from either China or abroad. Phylogenetic analysis indicated that CHNHLJ03009c34 has the closest molecular relation with strain RIA2 based on analyzing the full-length of the Env, while it became an independent branch upon analyzing the sequences of C2-V3 region of the Env. The secondary structure analysis of the envelope protein showed that the antigenicity and hydrophobicity of the strain demonstrated have no definite difference from that of RL42. Examination of infectivity showed that pseudovirus CHNHLI03009c34 could only infect U87. CD4. CCR5 cells, indicating that it was a RS-tropic HIV-1. In the conclusion, two HIV-1 env clones from an infected individual in Heilongjiang province have been identified as subtype B＇ and RS-tropic HIV-1. This is the first report on the analysis of primary isolates in Heilongjiang province.

Malignant Syphilis as an Initial Presentation of HIV Infection: A Case Report

Introduction:Malignant syphilis(MS)is a rare and severe variant of secondary syphilis that is frequently associated with HIV infection.The clinical impact of HIV and syphilis co-infection is bidirectional,and the presence of MS is associated with acute HIV infection.Clinically,MS is characterized by nodular and ulcerative lesions affecting the trunk and extremities,which are covered with thick crusts.The treatment of choice for MS remains benzathine penicillin G.Herein,we report a case in which MS was the initial presentation of HIV infection.Case presentation:A 35-year-old male patient came with the chief complaint of extensive erythematous nodular rash for the past one month,with notable ulceration on some lesions with annular configuration along with fever and malaise.Based on the abovementioned clinical,laboratory,and histopathologic findings,the patient was diagnosed with MS and HIV.The diagnosis was established based on histopathological examination and syphilis serological testing.Discussion:Cutaneous disorders are a frequent presenting feature of HIV infection.The clinical manifestations of syphilis in immunosuppressed patients are often severe and/or atypical.The patient was then treated with weekly intramuscular administration of 2.4 million units of benzathine penicillin G for 3 weeks and achieved rapid and significant clinical improvement,with no Jarisch-Herxheimer reaction.Conclusion:Co-infection with syphilis and HIV alters the course of both diseases,and most HIV-infected patients with syphilis have typical disease manifestations associated with decreased CD4+T-cell counts.

Effects of Glyke in Treating 60 HIV-Infected Patients

Using Giyke, a Chinese Materia Medica, in treating 60 human immunodeticiency virus in-fected patients. the total effective rate was 35%. the rates of immunological improvement and stabilitywere 68. 3% - 90% , while those of symptoms amelioration were 35% - 64% respectively. Polymerasechain reaction was used to check one of two patients and revealed positive. Experimental study showedGlyke could inhibit simian immunodeficiency virus as well as enhance the patient's immune function.