HAART Therapy Research Articles

Organotherapic Medicine Improves Blood Glucose Levels in AIDS Patients

Aims: To evaluate the effect of an organotherapic drug, produced from the pancreas of a young pig, on glycemic alterations in AIDS patients. Methodology: Current study was carried out in a double-blind, placebo controlled and randomized design. AIDS patients who had high fasting glucose (>110 mg/dL) were selected so that the effect of the organotherapic drug could be evaluated. The patients were divided into two groups: Group I comprised patients who received the organotherapic drug diluted in 1x10 12 alcohol/ water 8%, once a day, with a sublingual-administered fasting dose of 10 drops, during four months. Group II consisted of patients receiving placebo once a day at the same dosage. Glucose oxidase method and ELISA, following the manufacturer’s instructions, respectively determined levels of glucose and insulin before treatment and monthly until four months after the start of treatment. Results: Results registered hyperglycemia in 30% of the patients (60/200), higher than in the population at large (7-15%). This fact could be related to the time of infection (10.0±4.78 years) and treatment (9.3±3.76 years) of the patients. On the other hand, patients who underwent treatment with organotherapic medicine showed a significant reduction (p<0,001) in blood glucose Short Research Article Pupulin et al.; BJMMR, 6(3): 335-341, 2015; Article no.BJMMR.2015.209 336 levels (from 204.5±86.63 to 86.63±16) and lower insulin levels after four months of treatment (organotherapic group with 8.02±3.598 versus placebo with 23.83±3.670 p<0,001) within normality, regardless of age, time of infection and time of treatment. This fact suggests that the organotherapic drug was effective to stabilize blood glucose levels in patients. Conclusion: Current study evidences that the organotherapic drug obtained from the pancreas of a young pig, diluted 1x10 12 in alcohol/ water 8% improves blood glucose levels in patients with hyperglycemia keeping within the normal range after four months of treatment. Considering the HAART therapy that significantly increases the life expectancy of AIDS patients but with significant metabolic alterations this study shows the possibility of utilization of complementary and alternative therapies. Although results indicate a significant effect of the organotherapic drug, additional studies are needed to evaluate the long-term effects.

Cryopreservation of Adipose Tissue for Cosmetic Treatment of HIV Related Facial Lipoatrophy is Underused

Few infectious diseases have the social stigma or the emotional power that is often associated with HIV. The psychological impact of any disease can be its own difficult, and occasionally insurmountable, hurdle that has very little to do with science or medicine. However, HIV infection seems to have taken on the mantle of a disease with the greatest overall social impact. Over more than three decades of research vast new understanding of the infection and disease progression has taken place. Current states of knowledge have allowed the development of drug cocktails (HAART therapy) that keep a large fraction of morbidity and mortality at bay. But as HIV+ patients live longer and better lives, they must still contend with prejudice and stigma that sometimes associates with disease status. This is often due to the simple fact that HIV+ people look like HIV+ people. As the disease progresses, elements of HIV associated lipodystrophy can change the individuals appearance. Banking of adipose tissue early after diagnosis for subsequent autologous use years later can offer patients a safe and affordable surgical option for reversing the changes in facial appearance and social stigma that associate with HIV status.

Prognostic Factors and Outcomes in Primary Effusion Lymphoma in HIV-Infected Patients: A Single Center Experience

Primary effusion lymphoma (PEL) is a human herpesvirus 8-associated non-Hodgkin lymphoma (NHL) that predominantly develops in serous body cavities leading to recurrent lymphomatous effusions. It is poorly understood and very uncommon, accounting for only 3% of all HIV-related NHL. While outcomes have improved in patients with HIV-associated NHL since the widespread use of HAART, the prognosis of PEL remains very poor and median survival is less than 6 months. This study reports our institution’s experience with PEL over the past decade.Between 2004 and 2014, we treated 8 patients with HIV-associated PEL. All patients were male. The median age was 46.5 years old (range 35-63), three were Caucasian, four were Hispanic, and one was African-American. The primary site of involvement was pericardial in 3 patients, pleural in 3 patients, and extra-cavitary in 2 patients. All patients were Ann Arbor stage IV at the time of diagnosis. The mean LDH and CD4 count at time of diagnosis was 625 U/L and 161 cells/mm3, respectively.Of the eight patients identified with PEL, four have achieved complete remission (CR). Prognostic factors associated with achieving CR include compliance with HAART therapy prior to PEL diagnosis as well as lower serum lactate dehydrogenase (LDH) levels (202±30 versus 1049±290, p=.03). Patients achieving CR also had a higher average CD4 count (228±93 versus 95±35, p=.22) at time of diagnosis. Median survival is nearly 6 years for those in CR whereas it was 32 days in patients that died (one from an acute stroke, one from septic shock, and two from progressive disease). All patients who achieved CR had previously diagnosed HIV whereas two of the four who died were previously undiagnosed with HIV. Interestingly, pericardial sites of involvement were associated with significantly better outcomes as compared to pleural sites in our case series, as well. There was no association between outcome and HIV viral load, duration of HIV infection prior to PEL diagnosis, or presence of AIDS-defining illnesses. The patients achieving CR were treated with HAART in addition to Hyper-CVAD (1a-3b) or 6 cycles of CHOP or EPOCH. In addition, two patients received bortezomib as initial therapy. Given its rarity, our knowledge of PEL relies heavily on case reports and small case series. Here we report our institution’s experience with PEL, identify LDH and CD4 as possible prognostic factors in PEL, and suggest bortezomib-based chemotherapy as an effective treatment option in HIV-associated PEL. DisclosuresNo relevant conflicts of interest to declare.

Generalized, pruritic skin eruption in an immunocompromised patient.

A 50-year-old African-American female with a past medical history significant for human immunodeficiency virus (HIV) and non-adherence to HAART therapy, was admitted for failure to thrive and a generalized, pruritic skin eruption. The patient first noticed the eruption on her feet a few months prior to admission. Within days, it had spread to her torso, upper extremities, and scalp. On physical examination, she had well-demarcated, erythematous and scaly, confluent plaques involving the torso, upper and lower extremities (Figure 1). In addition, she had thick, hyperkeratotic plaques on the palms and soles as well as dystrophic fingernails (Figure 2). Skin scrapings were performed and histopathology evaluation was obtained (Figure 3). What is your diagnosis? Generalized, pruritic skin eruption in an immunocompromised patient

Chronic Hepatitis C Prevalence and its Correlation with CD4 Cells and Liver Enzymes Among HIV Positive Patients: A Malaysian Scenario.

PIN5 ChroNIC hePatItIs C PrevaleNCe aNd Its CorrelatIoN wIth Cd4 Cells aNd lIver eNzymes amoNg hIv PosItIve PatIeNts: a malaysIaN sCeNarIo Khan A.H.1, Sulaiman S.A.2, Soo C.T.3, Akhtar A.1, Hamzah D.A.B.A.4, Khan K1 1Universiti Sains Malaysia, Minden, Malaysia, 2Universiti Sains Malaysia, Penang, Malaysia, 3medical department Penang hospital, penang, Minden, Malaysia, 4Urology Unit, Department of Surgery, Health Campus, Universiti Sains Malaysia, Kubang Kerian, 16150, Kelantan, Malaysia, Kelantan Malaysia, Malaysia Objectives: To evaluate the occurrence and clinical outcomes of Hepatitis C (HCV) patients co-infected with Human Immunodeficiency Syndrome (HIV) in a tertiary care hospital. MethOds: A retrospective study of the patients with clinical histories of HIV co-infection with HCV following HAART therapy in Infectious disease Unit at Hospital Palau Pinang (HPP), Malaysia from the year 2007 to 2012. The clinical and demographic data was collected from patient’s records. In present study we analyzed the collected data by using SPSS software (Version 20) to determine the correlation of variables and measure their infection rates in a particular population. Results: The study involves a total of 708 HIV infected patients with the mean age of 40 ± 10.17 years together with 541(76.4%) males and 167(23.6%) females. There were 130(18.4%) patients co-infected with HCV. The assigned population involve in current study was Chinese 427(60.3%) followed by Indians 96(13.6%), Malay 151(21.3%) and minorities 34 (4.8%). There were three main modes of transmission including male heterosexual contact 506(71.5%), homosexual contact 47(6.6%) and intravenous drug users (IVDU) 114(16.1%). The mean CD4 count, ALT and AST levels in HBV-HIV co-infected patients were 374 ± 150.65, 64 ± 76.15, 129 ± 61.06 respectively. The calculated result shows the significant association of several factors like sex (p = < 0.001), IVDU (p = < 0.001) with co-infection of HIV-HCV. The co-morbidities observed in the current study were Pulmonary Tuberculosis (23.6%), Pneumocystis pneumonia (14.4%), Hyperlipidemia (4.4%), Dyslipidemia (3.2%), Anemia (4.5%), Ischemic Heart Disease (2.5%), Diabetes Mellitus (8.2%), Hypertension (6.5%), Asthma (1.4%), Oral Candiasis (5.2%), Syphillus (3.1%), Liver Cirrohsis (1.1%), Cerebral Toxoplasmosis (2.3%), Virological Failure (1.1%). cOnclusiOns: The incidence rate of HCV among HIV individuals were about 18.4% including 76.4% males and 23.6% females. There was a significant correlation between HCV among HIV-positive patients depending on various variables like gender, age, exposure to risk factors. (p< 0.001).

Adverse Drug Reactions of Haart Therapy Among Hiv/Aids Patients Treated at Infectious Disease Clinic.

Adverse Drug Reactions of Haart Therapy Among Hiv/Aids Patients Treated at Infectious Disease Clinic.

Impact of Cigarette and Alcohol Use on Adverse Drug Reactions of Haart Therapy Among HIV/AIDS Patients

Impact of Cigarette and Alcohol Use on Adverse Drug Reactions of Haart Therapy Among HIV/AIDS Patients

P006 : SUCCESSFUL RENAL TRANSPLANTATION OF HIV+ PATIENTS WITH T CELL REACTIVE ANTIBODIES AND POSITIVE T CELL CROSSMATCH

Antibody dysregulation associated with HIV infection poses unique challenges in assessing histocompatibility of HIV+ transplant candidates with organ donors. Interpretation of crossmatch results is often difficult and may lead to unnecessary denial of transplantation. In this study, we analyzed pre-transplant crossmatch results in relation to post-transplant outcome in 7 HIV+ renal allograft recipients. During May 1, 2009 to Aug 1, 2013, 7 out of 373 patients who received renal transplantation at our institution were HIV positive. At the time of transplantation, all 7 patients were on HAART therapy, with undetectable viral load and CD4+ T cell counts higher than 200 cells/μl. Anti-HLA antibody testing was performed using the Single Antigen Bead (SAB) assay. Crossmatch (XM) was performed using flow cytometry (FC) and complement dependent cytotoxicity (CDC). Five out of 7 HIV+ patients were previously sensitized to HLA antigens (cPRA > 10%). Two patients had low strength DSA (MFI N = 5) received either Simulect or Thymoglobulin induction, while patients with DSA ( N = 2) received Thymoglobulin and IVIG. All patients received standard maintenance immunosuppression. At one year post-transplantation, the DSA found before transplant were undetectable. De novo DSA directed to donor DQ antigens developed in two patients. None of the patients experienced allograft rejection during the follow-up interval. Graft and patient survival was 100%. No. patients with pre-tx DSA (MFI 2/7 No. positive donor T cell FCXM 4/7 No. positive auto T cell FCXM 4/7 No. positive donor B cell FCXM 0/7 No. positive auto B cell FCXM 0/7 No. patients with de novo DSA at 1 year (MFI > 3000) 2/7 Median follow-up interval, months 21 Serum creatinine, mg/dl 1.4 Graft survival 7/7 Patient survival 7/7 Conclusion We report here that successful transplantation of HIV+ patients against a positive T cell FCXM caused by T cell reactive autoantibodies can be achieved. Pre-transplant DSA and auto-crossmatch results have to be considered in the interpretation of donor crossmatch results in HIV+ patients.

AIDs-related kaposi's sarcoma: Manifestations and management strategies with haart and adjuvant therapies

AIDS-related Kaposi sarcoma varies widely from a few mucocutaneous lesions to more florid ones with life threatening visceral involvement. Highly active antiretroviral therapy (HAART) has radically improved the outcome of this disease, and is pivotal to any treatment of the tumour. Late disease will require adjuvant chemotherapy for some duration to induce remission. Less expensive chemotherapy regimens may be needed in sub Saharan Africa heavily burdened with the disease and poverty. Various biologic agents are undergoing clinical trials at different stages and may prove useful in controlling the disease when combined with HAART and chemotherapy.

Limited evolution of inferred HIV-1 tropism while viremia is undetectable during standard HAART therapy.

BackgroundHIV patients on suppressive antiretroviral therapy have undetectable viremia making it impossible to screen plasma HIV tropism if regimen change is required during suppression. We investigated the prevalence and predictors of tropism switch from CCR5-using (“R5”) to non-CCR5-using (“non-R5”) before and after viral suppression in the initially therapy-naïve HOMER cohort from British Columbia, Canada.MethodsWe compared pre-therapy and post-suppression viral genotypic tropism in patients who initiated on PI/NNRTI-based antiretroviral regimens between 1996-1999 (n = 462). Virologic suppression was defined as having two consecutive viral loads of <500 copies/mL, which was the sensitivity limit of most viral load assays at the time. Viral tropism was inferred by V3-loop-population-sequencing and geno2pheno[coreceptor] with cutoff at 5.75% false positive rate (FPR).ResultsWhen virologic suppression was defined as two-consecutive viral loads <500 copies/mL, 34 (9%) of the 397 patients with pre-therapy R5-virus switched to non-R5 at viral load rebound after a median of 19 months (IQR 8–41 months) of undetectable viremia. Duration of viral load suppression was not a predictor of switch, but lower CD4 count during suppression (median 400 versus 250 cells/mL) and an increased prevalence of pre-therapy non-R5 HIV by “deep” sequencing (median 0.2% versus 3.2%) were independently associated with switch (p = 0.03 and p<0.0001, respectively).ConclusionR5-to-non-R5 tropism switches in plasma virus after undetectable viremia were relatively rare events especially among patients with higher CD4 counts during virologic suppression. Our study supports the use of pre-suppression tropism results if maraviroc is being considered during virologic suppression in this subgroup of patients.

Antiretroviral treatment in adult ethnobotanical intravenous drug users recently infected with HIV

During the last few years in Romania, increased numbers of new HIV infections among ethnobotanicals intravenous drug users (eIVDU) were observed. Although most cases have relatively good immunological status, some patients reclaim antiretroviral (ARV) treatment because of very low CD4 count, severe comorbidities and/or pregnancies despite difficulties related to their adherence. Retrospective analysis of 32 patients, eIVDU, treated with ARV in our hospital between 1st January 2010 and 31st January 2014. From all 32 patients, 27 are males (84.4%). The main reason for starting ARV treatment was represented by severe AIDS-defining illness (71.4%) related to immunodepression with CD4 count below 100 cells/cmm 11 cases (34.3%) and one pregnancy. In our study group the mean CD4 count at baseline was of 110.1 cells/cmm (median CD4 102.5 cells/cmm). 24 patients (75%) received at first triple therapy including NNRTI (10 cases with nevirapine, 14 cases with efavirenz), the other 8 patients (25%) received from the beginning regimens with protease inhibitors. 7 patients from the first group were then switched to protease inhibitors, mostly after completing tuberculostatic treatment, while 2 patients from the second group were switched to integrase inhibitors because of potential drug-drug interactions involving rifampin. All patients in our study were coinfected with HCV, 9 patients (28.9%) had also HBV, and 15 patients (46.8%) had active tuberculosis. Only 15 patients were truly adherent to ARV (43.7%); we registered 5 cases of abandon and one death. From all 5 patients who discontinued treatment 3 were social cases; from all 28 patients who are currently treated 20 have good family support (71.4%) and 6 (21.4%) receive psychological counseling and methadone substitution therapy. Mean value of CD4 count at 1 month of HAART therapy was of 225.8 cells/cmm, probably related to ARV treatment received correctly during admission in our clinic, but this value decreased to 213.3 cells/cmm at 3 months, probably related to poor compliance at home. Despite the fact that they are recently infected with HIV, increasingly more eIVDU patients are in need of ARV treatment, because mainly of rapid immunodepression and comorbidities associated with AIDS. Family support as well as psychological counseling and substitution therapy with methadone are mandatory for achieving clinical success with HAART, while lack of adherence is the principal cause for immunological and virological failure. Tuberculosis with both pulmonary and extrapulmonary involvement is the principal complication associated with AIDS, involving almost half of the eIVDU in our country.

Recruitment of adult thymic progenitors is regulated by lymphotoxin beta receptor (HEM4P.240)

Abstract Continuous homing of hematopoietic progenitors from peripheral blood to thymus is essential for the functional maintenance of thymus, especially upon thymic injury. Here we identified the signaling of lymphotoxin beta receptor (LTβR), is essential for the thymic progenitor settling. Dramatically reduced frequency and number of early T-lineage progenitors (ETP) were found in the steady thymus of LTβR knockout (KO) mice. This is probably not due to impaired development of hematopoietic progenitors, since normal frequencies of T-cell precursor were found in the bone marrow of LTβR KO mice. Further experiment by tracing adoptively transferred bone marrow cells directly confirmed a thymic homing defect in LTβR KO mice. Progenitor thymic settling is mediated by a cascade of adhesion and signal events, which involves P-selectin, CCL25, VCAM-1/ICAM-1, etc. We identified P-selectin is down-regulated in the thymi of LTβR KO mice while the expression levels of CCL25, VCAM-1, VCAM-1 are normal. Data from bone marrow chimeric mice suggest that LTβR on radio-resistant, likely stromal cells, regulates thymic progenitor receptivity. Finally, LTβR KO mice demonstrated severely impaired thymus regeneration upon thymus-targeted injury. Taken together, our data reveal a novel role of LTβR on the regulation of thymic progenitor homing. Manipulation of this signaling pathway may boost thymic regeneration and immune reconstitution during chemotherapy, radiotherapy or AIDS HAART therapy.

A Compositional Look at the Human Gastrointestinal Microbiome and Immune Activation Parameters in HIV Infected Subjects

HIV progression is characterized by immune activation and microbial translocation. One factor that may be contributing to HIV progression could be a dysbiotic microbiome. We therefore hypothesized that the GI mucosal microbiome is altered in HIV patients and this alteration correlates with immune activation in HIV. 121 specimens were collected from 21 HIV positive and 22 control human subjects during colonoscopy. The composition of the lower gastrointestinal tract mucosal and luminal bacterial microbiome was characterized using 16S rDNA pyrosequencing and was correlated to clinical parameters as well as immune activation and circulating bacterial products in HIV patients on ART. The composition of the HIV microbiome was significantly different than that of controls; it was less diverse in the right colon and terminal ileum, and was characterized by loss of bacterial taxa that are typically considered commensals. In HIV samples, there was a gain of some pathogenic bacterial taxa. This is the first report characterizing the terminal ileal and colonic mucosal microbiome in HIV patients with next generation sequencing. Limitations include use of HIV-infected subjects on HAART therapy.

Http://www.omicsonline.org/open-access/doc-i-just-cant-swallow-pills-hiv-infected-patients-and-pill-phagophobia-2155-6113.1000348.php?aid=32174

Introduction: Kaposi Sarcoma (KS) is a soft tissue malignancy that has been categorized into 4 subtypes, however, in the United States, it has frequently been noted in patients with HIV/AIDS and has thus become known as an AIDS-defining illness. When KS is found in the oral cavity, it is usually seen on the hard palate. Oral KS (OKS) is most commonly seen in patients with HIV/AIDS with CD4 counts below 200, and the disease is rarely reported outside of this patient population. HIV patients may be more likely to have KS with the decline of their immune function. Report of case: We report the case of a 31 year old African American male with a 2 year history of HIV who presented to the Otolaryngology clinic with a painful tongue lesion. His CD4 count never fell below 200, which makes this case an outlier among the epidemiology of KS. This case is unique in two different ways. The dorsum of the tongue is one of the least common manifestations of OKS and secondly OKS is usually associated with CD4 counts <200 per microliter, and this patient’s CD4 count stayed above 200 cells per microliter throughout his evaluation and treatment. The tongue lesion was causing dysphagia and odynophagia that was significant enough to cause him to seek medical care. Discussion: Despite the relatively adequate resources for HAART therapy among the American indigent population, some patients still decline this highly efficacious treatment and succumb to its now rare complications. Physicians must actively investigate suspicious oral lesions in HIV patients, particularly when there is a question about the compliance of HAART therapy or other concerning features. The oral cavity may be the initial manifestation site for HIV associated KS thus any suspicious lesion in sexually active patients should lead to testing for HIV.

A Modified Dose Intensive R- CODOX-M/IVAC For HIV-Associated Burkitt and Atypical Burkitt Lymphoma(BL) Demonstrates High Cure Rates and Low Toxicity: Prospective Multicenter Phase II Trial Of The AIDS Malignancy Consortium (AMC 048)

▪ BackgroundConcerns about the potential toxicity of the dose-intensive regimens typically used as treatment for BL in HIV seronegative patients prompted us to modify the CODOX-M/IVAC regimen with the goal of preserving efficacy while improving tolerability. The primary objective was to improve the 1 year overall survival (OS) from 65% based on historical reports to 85%. The early stopping rule for excessive treatment related mortality was not met. MethodsMajor modifications of the original US NCI regimen include the addition of rituximab, reduction in cyclophosphamide to 800 mg/m2 x 2 days, vincristine 2 mg cap, methotrexate 3000 mg/m2 on day 15, reduction of lumbar punctures using combination chemotherapy and continuous infusion of the IVAC portion for the high risk patients. Antibiotic prophylaxis and growth factor support were required. HAART therapy was continued at the discretion of the local investigator. ResultsThirteen AMC centers entered 34 patients. Baseline characteristics included: Classical BL/unclassifiable between DLBCL and BL/other 71/21/9%; High Risk, 94% with stage III/IV 2 (6%)/25 (74%); Median age (range) 42 (19 – 55); CD4 count 195 (0 – 721), CD4 <100, 5 ( 27%); HIV viral load 1819 (Undetectable – 1,187,968). 12 patients had a viral load <100 and only 1 had undetectable plasma HIV RNA level. Only 14 patients were on HAART at study entry. Three/14 were on their second or greater antiretroviral regimen.Treatment statusGr 4 Thrombocytopenia and gr 3 infection(1)Gr 3 hemiparesis (1)Gr 3 confusion(1) unrelated to treatmentGr 3 encephalopathy and grade 3 pneumonitis (1)Gr 4 neutropenia and gr 3 WBCPatients with gr 3-5 treatment related toxicity: any 27; hematologic 20; infection 14 including febrile neutropenia 8; 6 metabolic including 1 tumor lysis syndrome; 4 neurologic; 2 thrombotic; and 1 each coagulation, GI or pain. Notably, only 2 patients had gr 1/2 stomatitis/mucositis and none had gr 3/4. Deaths: Seven patients died. There were three treatment-related deaths including encephalopathy with hepatic failure, hepatitis B and pneumonia (1); fungal infection (1) and complications of HIV (1). There were 2 deaths due to progressive lymphoma. Despite the 5 early treatment terminations, the 1 year overall survival was 83.1% (95% CI 63.9%, 92.6%) and the one year progression free survival was 74.1% (55.5%, 86.4%). ConclusionsModifications of the CODOX-M/IVAC regimen resulted in a gr 3/4 toxicity rate significantly lower than the 100% seen in the parent regimen, and no grade 3/4 mucositis was observed. Despite a protocol completion rate of only 68%, the 1-year survival rate was 83% which compares favorably with 2 reported studies that excluded HIV + pts. (Magrath et al, 1995; Mead et al, 2008) Correlative studies to improve our understanding of HIV-BL will be presented at the meeting. Disclosures:No relevant conflicts of interest to declare.

HIV-Associated Burkitt Lymphoma: Case Report and Literature Review

IntroductionHIV associated Burkitt lymphoma (BL) is a highly aggressive lymphoma. Compared to other AIDS related non-Hodgkin lymphoma's its clinical presentation is less predictable and characterized by rapid clinical changes. The paradigm shift to treat HIV associated disease with highly effective intensive chemotherapy regimens while managing immunosuppression has made it possible to achieve remission and long-term survival. Southern Louisiana has one the of the highest incidence rates of HIV and cancers in the US. The authors present a challenging case of a 33-year old HIV+ male from southern Louisiana with advanced stage BL. The patient presented with advanced disease and a poor performance status. His initial providers recommended palliation only and significant education was needed to allow aggressive treatment. The patient tolerated induction chemotherapy and remains in remission. This is a case based review of local and nationwide epidemiology and the trial data supporting different treatment options for HIV associated Burkitt lymphoma. CaseOur patient is a 33 year-old male who presented with severe cachexia, poor performance status and clinical symptomatic cord compression. He was diagnosed with advanced stage Burkitt lymphoma including bone marrow involvement. His CD4 count was 277 with an HIV viral load of 571,000 copies/mL. Although he had a poor performance status and his primary team favored palliation only he underwent induction chemotherapy with 4 cycles of infusional dose adjusted R-EPOCH with IT CNS chemoprophylaxis. HAART therapy with efavirenz/emtricitabine/tenofovir was started during his initial admission. He tolerated this regimen well, clinically dramatically improved being independent in his ADL/IADLs, and remains in remission. DiscussionThe pathogenesis of HIV-associated Burkitt lymphoma is linked to oncogenic virus co-infection (40% EBV association) and chronic HIV antigen stimulation that provoke expansion of polyclonal B-cells. This leads to oncogenic chromosomal translocations - most notably t(8;14) causing constitutive expression of oncogene c-Myc. HIV patients have a 60 to 200-fold increased incidence of NHL. Relative risk for BL in HIV patients is 261-fold higher compared to the general population. Unlike the nationwide reported 19 per 100,000 person-years, data from a large HIV clinic in southern Louisiana continues to show an incidence rate of 23 per 100,000 person-years. Louisiana continues to have comparatively high incidence rates in HIV (4th in US) and cancer (11th in US) with the highest rates in southern Louisiana parishes. It is important for community physicians, especially in these areas, to feel more confident when treating these HIV associated malignancies.Historically highly immunosuppressive chemotherapy has been avoided in HIV patients with lymphoma as studies in the 1990's showed increased toxicity. The addition of the monoclonal C20 antibody rituximabin the treatment of AIDS associated NHLs was also controversial, as trial results showed increase infectious death rates. However, these clinical trials confirmed similar death rates from infections in individuals with a CD4 count >50. In addition concomitant use of HAART with chemotherapy has improved overall survival. Although the more dose intense Burkitt regimens have not been studied extensively in HIV-associated BL, CODOX-M/IVAC and DA-EPOCH +/- Rituximab (depending on CD4 count) have shown good efficacy and tolerance and are treatment regimens of choice this disease. A recent trial with 14 patients with HIV associated BL receiving RD-CODOXM/IVAC had 86% progression free survival rate at 1 year; patients receiving concomitant HAART had 100% PFS rate at 1 year. In another trial, 10 HIV associated BL patients receiving DA-EPOCH-R showed a 100% overall survival rate at 57 months. ConclusionHIV associated Burkitt lymphoma should be treated with HAART and high dose chemotherapy. Long-term remission has been shown with regimens including CODOX-M/IVAC and DA-EPOCH +/-Rituximab (R use discouraged in low CD4 counts). This case based report outlines the relatively high prevalence of disease in Southern Louisiana and emphasizes that remission is possible in patients with poor performance status and advanced disease. [Display omitted] Disclosures:No relevant conflicts of interest to declare.

HIV, depression and compliance: the mediating role of cytokines. A review of the international literature

HIV-positive individuals are at greater risk of depression, which is known to influence their well-being negatively. In fact, depression may promote unhealthy behaviors (e.g. drug use and intentional unprotected sex); furthermore, depression may also act reducing immune system functioning. However, the relationship between the immune system and depression is bidirectional, since many physchoneuroimmunological research studies have shown that immune system activation, more specifically pro-inflammatory cytokines, increases the risk of depression. Thus, HIV-positive persons with co-infection (e.g. HCV), taking HAART and/or interferon-α, may show cytokine dysregulation. This may explain the greater prevalence of depression among HIV-positive individuals. In fact, pro-inflammatory cytokines and cortisol (also known as stress hormone), both promote tryptophan depletion, which is commonly associated with depressive symptoms. Hence, depression may negatively influence compliance, increasing the risk for incorrect assumption of antiretroviral leading to a significant reduction of immune system functioning. This review examines the relationship between HIV infection, co-infection (e.g., HCV), HAART and/or interferon-α therapy and cytokine dysregulation, with a focus on the influence of pro-inflammatory cytokines in promoting depression, which could ultimately reduce compliance. Evidence-based pharmacological and psycho-social interventions on depression are also discussed.

Disseminated Histoplasmosis and CMV Colitides Coinfection in AIDS

Purpose: The number of immunocompromised patients continues to grow, with improved screening and treatment of HIV, as well as the increasing use of immunosuppressive medications. Such patients are at increased risks for developing GI opportunistic infections. Even though cytomegalovirus (CMV) remains one of the most common opportunistic infection, patients may have coinfections with other rare, opportunistic fungal infections that may be associated with high mortality. We present a rare case of disseminated Histoplasmosis and CMV coinfection in an AIDS patient. A 41-year-old Hispanic male with history of AIDS and recently started on HAART therapy now presents with progressive, persistent diarrhea. He reports between 8-10 non-bloody, watery bowel movements daily, associated with a 20-pounds weight loss, intermittent night sweats, and subjective fevers. On physical exam, the patient had low-grade fever with mild hypotension. He was non-toxic appearing, with evidence of epigastric tenderness with mild voluntary guarding, but no rebound tenderness. On laboratory review, his white count was 3,400, CD4 count of 31, and an alkaline phosphatase of 190, but otherwise normal liver function tests. His blood cultures, stool cultures, ova, parasites, and Clostridium difficile were negative. The patient's abdominal computed tomography showed mild thickening of the small bowel and colon, with moderate mesenteric adenopathy. His upper endoscopy showed severe candidal esophagitis in the entire esophagus, non-erosive gastritis, and duodenitis, with multiple biopsies showing evidence of many yeast organisms present on GMS and PAS stains without evidence of mycobacterium present on AFB stain. His colonoscopy showed severe left-sided colitis with ulcerating, edematous, and erythematous mucosa, with multiple biopsies and viral and fungal cultures positive for histoplasmosis, CMV via PCR, as well as demonstrating aggregates of histiocytes in the lamina propria, granulomas, and chronic active colitis. His serology was consistently positive for histoplasmosis, but negative for giardia, cryptosporidium, cyclospora, and microsporidia. The patient was subsequently treated for combined histoplasmosis, CMV, and esophageal candidiasis with marked symptom and biochemical improvement, and he continues to be on antifungal therapy for one-year for disseminated histoplasmosis. Our case highlights the importance of screening for coinfections in immunocompromised patients involving CMV, but also less frequent opportunistic infections, like histoplasmosis, that can be associated with high mortality.

A Rare Case of Severe Proctocolitis Secondary to Penicillium marneffei in a Patient with AIDS

Purpose: We report a rare case of Penicillium marneffei proctitis in a 45-year-old HIV+ Caucasian male with chronic hepatitis C presenting with fever, weight loss and bloody diarrhea. Six months prior, he had returned from an 18-month stay in China. He was not taking antiretroviral medications. On physical examination, he was thin, anxious and ill-appearing, with mild tachycardia. He exhibited painless bilateral inguinal lymphadenopathy. Laboratory examination was significant for mild anemia, and slight elevation in liver enzymes. CD4 count was 40, and the HIV viral load 57,700. During investigation for the cause of diarrhea, all stool studies were normal. Colonoscopy revealed severe proctocolitis with erythematous and nodular friable mucosa. Rectal biopsy showed fungal organisms identified as Penicillium marneffei by visualizing characteristic intracytoplasmic transverse septa. This same organism was found in blood cultures and on inguinal lymph node biopsy. Hospital course was complicated by continued hematochezia, eventually requiring blood transfusion. The patient was treated successfully with two weeks of IV amphotericin B followed by 10 weeks of oral itraconazole. HAART therapy consisting of darunavir, ritonavir and raltegravir was initiated 10 days after hospital discharge. Discussion:P. marneffei is a thermically dimorphic fungus that causes systemic mycoses in healthy and immunocompromised individuals and has varied presentations in HIV+ patients, including lung, skin and visceral lymph node involvement. It is endemic to parts of Southeastern Asia, Thailand and Northern India. It is also one of the top three opportunistic infections in southeast Asia (second only to extrapulmonary tuberculosis and Cryptococcus). Common presenting features are fever, weight loss, anemia and dermatologic manifestations. Diarrhea has been reported in as many as 30% of patients with AIDS and disseminated P. marneffei infection. Reviewing English medical literature, most reports of penicilliosis come from Southeast Asia, and are typically opportunistic pulmonary infections. There are reports of chronic diarrhea as a presenting complaint, but gastrointestinal involvement by histopathologic diagnosis has not been well-described. Only 4 cases of P. marneffei infections have been diagnosed in the United States, none of which had intestinal involvement. With diarrhea being a common complaint of AIDS patients worldwide, special attention must be made to elicit adequate travel/exposure history during work-up of the cause of diarrhea. The mortality rate of untreated penicilliosis is extremely high, demonstrating the need for prompt endoscopic diagnosis with biopsy and initiation of treatment.

A Classic Case of Diarrhea in a Severely Immune-compromised Patient

Purpose: A classic presentation of an exceedingly rare entity. Case Report: A 28-year-old African-American female with HIV/AIDS most recent CD4 1, VL 600,000 copies/mL who is non-compliant with HAART therapy presented to the emergency department with complaints of profuse watery non-bloody diarrhea for three weeks associated with abdominal cramping and night sweats. She also had 10-pound unintentional weight loss over the three weeks. She denied nausea and vomiting. She denied sick contacts and recent travel. Her past medical history also includes: oral/esophageal candidiasis, pneumocystis jirovecii pneumonia and molluscum contagiosum. On examination, she was found to have a fever of 103.8F, hypotension and tachycardia. She appeared severely cachectic and listless. Her abdomen was scaphoid with hyperactive but normo-pitched bowel sounds, soft and non-tender. The stool was liquid, brown mixed with mucous; there was no bright red blood or melena. Labs were significant for profound iron deficiency anemia, thrombocytosis and electrolytes disturbance. The liver function tests were within normal limits. Stool studies and culture were negative. Rectal swab viral culture was also negative. CAT scan of the abdomen and pelvis revealed hepatomegaly, splenomegaly with multiple hypoattenuated lesions in the spleen and multiple mesenteric lymph nodes. Flexible- sigmoidoscopy was normal and the pathology on random biopsies showed chronic non-specific inflammation. Esophagogastroduodenoscopy revealed thickening pale nodular duodenal folds interdigitated with atrophic friable mucosa (Figure 1). Pathology was significant for numerous histiocytes within the lamina propria with PAS and AFB stain positive revealing numerous intracellular organisms morphologically consistent with Mycobacterium avium-intracellulare complex. Subsequently, blood cultures returned positive for Mycobacterium avium-intracellular complex as well. She was started on ethambutol, clarithromycin, and rifabutin, and her symptoms resolved.Figure