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Clinical manifestations of primary human immunodeficiency virus (HIV) infection (acute retroviral syndrome) and virologic characteristics of HIV-1 have rarely been described in Taiwan. Medical records of patients followed at the National Taiwan University Hospital between June 1994 and September 2003 were retrospectively reviewed to identify HIV-infected patients who were diagnosed with primary HIV infection. Blood specimens obtained at the diagnosis of primary HIV infection were submitted for viral subtyping and genotypic resistance assay. Twenty out of 940 patients were diagnosed with acute retroviral syndrome during the study period. All of the patients were males, with a median age of 31 years (range, 23 to 42 years); all were men who had sex with men. The most common clinical manifestations were fever (95%), generalized lymphadenopathy (75%), pharyngitis (70%), skin rashes (70%), and gastrointestinal symptoms (60%) including nausea, vomiting, and diarrhea. Thrombocytopenia (35%), leukopenia (35%), and elevated liver function test (50%) were seen in the laboratory tests. The median CD4 lymphocyte count was 312 cells/microL (range, 112-520 cells/microL), and the plasma HIV RNA load by reverse transcriptase-polymerase chain reaction was 230,500 copies/mL (range, 602 --> 750,000 copies/mL). No major resistance mutations on protease or reverse transcriptase were identified in the 11 available viral isolates. We conclude that primary HIV infection was rarely diagnosed in the designated hospital for HIV care in Taiwan. More education of health care providers and counseling of persons at risk to increase awareness of HIV infection are urgently needed in Taiwan in order to facilitate earlier diagnosis of primary HIV infection and prevent further transmission.
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PMID:Clinical presentations and virologic characteristics of primary human immunodeficiency virus type-1 infection in a university hospital in Taiwan. 1549 7

Although the incidence of most AIDS-defining opportunistic infections, including HIV wasting syndrome, has dramatically decreased since the introduction of highly active antiretroviral therapy (HAART), previous studies have shown that weight loss and wasting are still common in HIV-infected persons. We examined the 6-month risk and determinants of > or =5% weight loss during the period when the use of combination antiretroviral therapy and HAART was commonplace among 713 participants enrolled in the Nutrition for Healthy Living cohort in Boston, Massachusetts between 1995 and 2003. There was a significant 50% increase in the 6-month risk of > or =5% weight loss in the later HAART years (1998-2003) compared with the early HAART years (1995-1997) among most of the participants who reported they were not trying to lose weight (P = 0.002). In addition to calendar time, several other variables were significantly independently associated with risk of > or =5% weight loss, including use of injection drugs; living below the federal poverty level; higher body mass index (BMI; > or =25 kg/m(2)); lower CD4 cell count; higher HIV viral load; and presence of diarrhea, nausea, or fever. The characteristics of weight loss in the later HAART years did not differ from the early HAART years with respect to initial body composition (eg, weight, BMI, triceps skinfold thickness) or changes in body composition during the periods of weight loss. In summary, we have found that the risk of > or =5% unintentional weight loss over 6-month intervals is on the rise in our cohort of HIV-infected participants, despite better control of HIV infection in recent years. Although we still do not know the exact cause of this increase, the fact that it exists indicates the need for clinicians who take care of HIV-infected patients to continue to pay attention to weight loss among particular segments of their patient population. This is particularly important because recent studies have shown that even a 5% weight loss in 6 months markedly increases the risk of death.
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PMID:Increasing risk of 5% or greater unintentional weight loss in a cohort of HIV-infected patients, 1995 to 2003. 1612 85

A 51-year-old man with Crohn's disease for 22 years presented with a dry cough, dyspnoea, fever and diarrhoea. He had steroid-resistant Crohn's disease. Because of nausea complaints, azathioprine was switched to methotrexate with concomitant infliximab induction therapy. During infliximab therapy, symptoms occurred for which the patient was hospitalised and Pneumocystis pneumonia (PCP) was diagnosed by examination of bronchoalveolar lavage fluid; it was successfully treated with co-trimoxazole and prednisolone. The exacerbation of the Crohn's colitis diminished. This is the first Dutch case history of PCP during combination therapy with prednisolone, methotrexate and infliximab. Infliximab treatment has been associated with an increased risk for infectious complications. For patients with Crohn's disease, one should consider giving PCP prophylaxis for the duration of lymphocytopenia on an individual basis, weighing the adverse effects ofco-trimoxazole against the risk of PCP. A CD4-cell count < 0.2 x 10(9)/l or a lymphocyte count < 0.6 x 10(9)/l may be used as a guide.
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PMID:[Pneumocystis pneumonia during infliximab treatment for active Crohn's colitis]. 1644 Jun 27

Alefacept is a selective immunomodulating, antipsoriatic drug that blocks the LFA-3/CD2 interaction necessary for the activation and proliferation of memory effector T cells by binding to CD2 expressed on the T cell surface. Because the CD4+ count is reduced by alefacept, it is recommended that this count be monitored on a regular basis to ensure that it does not drop below 250 cells/mul. Few side effects have been related to the use of alefacept that differ from placebo even when CD4+ counts drop below 250 cells/microl. The side effects that have been reported are minor and include: headache, nasopharyngitis, rhinitis, influenza, upper respiratory tract infections, pruritus, arthralgias, fatigue, nausea, accidental injury and increases in liver enzymes. Serious infections and malignancies do not appear linked to the use of alefacept. The percentage of patients who developed antibodies against alefacept is very low. Alefacept is a very safe biological therapy for moderate-to-severe chronic plaque psoriasis with few side effects reported. The utility of checking CD4 counts while administering alefacept for 12 weeks appears minimal.
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PMID:Alefacept: a safety profile. 1625 57

We describe a case of a male patient, 38 years old, HIV-positive (most recent CD4 count about 259/mm(3)), with abdominal pain, nausea, vomiting, anorexia, weight loss, and vespertine high fever with chills. His hemogram showed normocytic and normochromic anemia, with a high erythrocyte sedimentation rate (ESR) and gross granulations in the neutrophils. Transaminases were normal. Bone marrow biopsy evidenced a chronic disease anemia pattern and a lack of infectious agents. Abdominal ultrasound examination showed a normal-size spleen, which exhibited heterogeneous parenchyma and multiple small hypoechoic images, together with small ascites, peripancreatic and para-aortic lymphadenopathy. These findings were confirmed by abdominal CT. The liver was normal in size, but had a hyperechoic image, which was not visualized on CT. Histopathological analysis of one of the multiple abdominal lymph nodes obtained by laparoscopic biopsy exhibited a chronic granulomatous inflammatory process, with caseous necrosis. Tissue sections were positive for BAAR (acid-alcohol-resistant bacillus), and the cultures were positive for Mycobacterium tuberculosis. Anti-tuberculosis treatment was begun, and the patient evolved with improvement of his general state, fever remission and weight gain. Splenic tuberculosis is a rare disease, occurring predominantly in patients in late stages of AIDS and/or disseminated tuberculosis. It is a difficult diagnosis, since there are no specific findings. Hence, complementary examinations, such as abdominal ultrasound/ CT, or fine needle aspiration, are usually necessary for investigation and differential diagnosis. Often, lesion regression after anti-tuberculosis regimens can be seen, and splenectomy is restricted to complicated or refractory disease.
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PMID:Case report of lymph nodal, hepatic and splenic tuberculosis in an HIV-positive patient. 1687 68

This 34-year-old man with a 10-year history of HIV infection presented with an acute onset of severe headache, fever, nausea, vomiting, and left-sided weakness. Computed tomography (CT) scanning demonstrated diffuse subarachnoid hemorrhage (SAH), and subsequent CT angiography revealed multiple large and giant intracranial aneurysms with diffuse vasculopathy. The patient's CD4-positive cell count was low, although he had been receiving combination antiretroviral therapy and his viral load was undetectable. The preponderance of the literature on HIV-infected patients with intracranial vascular involvement has concerned children in whom there is a high viral load. In such children, appropriate antiretroviral therapy may result in the complete resolution of these vascular abnormalities. In the present study, the authors report on the unique case of an HIV-infected adult patient who presented with SAH, diffuse intracranial vasculopathy, and multiple giant and fusiform aneurysms, despite having received adequate antiretroviral treatment and demonstrating an undetectable viral load. Intracranial vascular involvement in these patients may become increasingly common as the management of HIV infection continues to improve and afflicted patients survive for longer periods.
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PMID:Subarachnoid hemorrhage and diffuse vasculopathy in an adult infected with HIV. Case report. 1736 72

HIV/AIDS is changing the human landscape in sub-Saharan Africa. Relatively few patients receive antiretroviral therapy, and many suffer from debilitating diarrhea that affects their quality of life. Given the track record of probiotics to alleviate diarrhea, conventional yogurt fermented with Lactobacillus delbruekii var bulgaricus and Streptococcus thermophilus was supplemented with probiotic Lactobacillus rhamnosus GR-1 and L. reuteri RC-14. Twenty-four HIV/AIDS adult female patients (18 to 44 y) with clinical signs of moderate diarrhea, CD4 counts over 200, and not receiving antiretrovirals or dietary supplements, consumed either 100 mL supplemented or unsupplemented yogurt per day for 15 days. Hematologic profiles, CD4 cell counts, and quality of life was evaluated at baseline, 15 and 30 days postprobiotic-yogurt feeding. There was no significant alteration in the hematologic parameters of both groups before and after the probiotic-yogurt feeding. The probiotic yogurt group at baseline, 15 and 30 days had a mean WBC count of 5.8+/-0.76 x 10(9)/L, 6.0+/-1.02 x 10(9)/L, and 5.4+/-0.14 x 10(9)/L, respectively. However, the mean CD4 cell count remained the same or increased at 15 and 30 days in 11/12 probiotic-treated subjects compared to 3/12 in the control. Diarrhea, flatulence, and nausea resolved in 12/12 probiotic-treated subjects within 2 days, compared to 2/12 receiving yogurt for 15 days. This is the first study to show the benefits of probiotic yogurt on quality of life of women in Nigeria with HIV/AIDS, and suggests that perhaps a simple fermented food can provide some relief in the management of the AIDS epidemic in Africa.
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PMID:Yogurt containing probiotic Lactobacillus rhamnosus GR-1 and L. reuteri RC-14 helps resolve moderate diarrhea and increases CD4 count in HIV/AIDS patients. 1822 3

HIV-infected children in resource-limited settings are increasingly gaining greater access to highly active antiretroviral therapy (HAART) but documented longitudinal data remains limited. We aimed to study the clinical and immunological outcomes among 67 South Indian HIV-infected children with >18 months of follow-up on HAART at a tertiary HIV care program. The median CD4 cell count at enrolment was 290 cells microl(-1) and at treatment initiation was 225 cells microl(-1). Patients demonstrated a significant rise in their CD4 cell counts between treatment initiation and after 6 months (701 cells microll(-1); p = 0.007), 12 months (741 cells microl(-1); p = 0.037), and 18 months of therapy (718 cells microl(-1); p = 0.005). The most common adverse events to therapy were nausea (20.9%) and rash (25.4%). Over one-fifth of patients (25.4%) substituted therapy due to toxicities and 19.4% of patients switched to second-line protease inhibitor-containing regimens. In this South Indian pediatric cohort, generic HAART was safe, effective and relatively well tolerated.
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PMID:Safety, tolerability and effectiveness of generic HAART in HIV-infected children in South India. 1882 38

A 58-year-old man admitted for fever, nausea, vomiting, and anuria after the start of HAART, including tenofovir, had a viral load of 1.1 x 10(5) copies/mL, a CD4-positive lymphocyte count of 81/microL, and serum creatinine of 0.8 mg/dL before HAART. He underwent renal biopsy and temporary dialysis. We concluded that the patient had acute tubular necrosis because of potentially impaired renal function and the high amount of medication, and judging from the renal biopsy specimen and clinical course. When implementing HAART, physicians should be aware of and monitor potential patient misunderstanding of instructions on dosage and administration and for possible complications in medicinal combinations and potential side effects. TDF taken together with lopinavir may increase the plasma concentration of TDF or other medications that could worsen renal function. It should also be noted that renal dysfunction is a potential complication in the elderly.
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PMID:[A case of acute renal failure involving high amounts of tenofovir after HAART start]. 1908 22

Advanced immunosuppression from HIV infection can lead to gastrointestinal symptoms such as diarrhea, nausea, vomiting, dysphagia, weight loss, and abdominal pain. There is a complex, combined effect of HIV infection plus antiretroviral treatment on the incidence of gastrointestinal symptoms, and, for some trials, the majority of gastrointestinal adverse events may not be related to antiretroviral treatment. Antiretroviral treatment can lead to improvements in gastrointestinal symptoms for patients with advanced immunosuppression. This was observed in the TORO trials of enfuvirtide and the DUET trials of etravirine, which were conducted in highly treatment experienced patients with low baseline CD4 counts. While antiretroviral treatment can improve immune function, leading to fewer gastrointestinal symptoms, this could be counter-balanced by adverse gastrointestinal toxicity profiles from certain antiretrovirals. Ritonavir-boosted protease inhibitors show a range of gastrointestinal side effects; there are differences in tolerability within this class of antiretrovirals, influenced both by the dose of ritonavir used and the choice of boosted protease inhibitor. Overall, lopinavir/ritonavir and fosamprenavir/ritonavir tend to show the highest rates of drug-related grade 2-4 diarrhea, compared with atazanavir/ritonavir, darunavir/ritonavir, or saquinavir/ritonavir. Of the nucleoside analogs, zidovudine leads to a well-characterized problem of nausea. Issues relating to gastrointestinal complications are often subjective, reliant upon patient reporting and perception, along with clinician interaction and intervention. In trial publications, many different systems are used to present gastrointestinal adverse events. Most are based on the US Division of AIDS Grading Scale, ranging from grade 1 (mild) to grade 4 (life-threatening). Clinical trials most commonly report grade 2-4 gastrointestinal adverse events, which are at least possibly related to study medication. In future, it is important for clinical trials to report gastrointestinal adverse events in a consistent way. The percentage of patients with drug-related grade 2-4 events should be reported. In addition, the percentage with any grade 2-4 gastrointestinal adverse event should be included, since there could be subjectivity in the assessment of drug relatedness in open-label clinical trials. The percentage of patients who use medications to lessen the symptoms of diarrhea and other gastrointestinal adverse events should also be reported.
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PMID:Risk factors for gastrointestinal adverse events in HIV treated and untreated patients. 1929 32


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