Illness In HIV-infected Patients Research Articles

2264. The Burden of Respiratory Viral Illness in HIV-Infected Patients

BackgroundAmong individuals living with human immunodeficiency virus (HIV), pulmonary complications are the most frequent cause of morbidity and mortality. Although bacterial and fungal pathogens are well-described etiologies of lung disease, the role of respiratory viruses remains poorly understood. We sought to describe the burden of respiratory viral illness in HIV-infected inpatients admitted to our tertiary care center.MethodsAll HIV-infected inpatients from August 2015 to March 2018 were approached if they presented with respiratory symptoms, defined as cough, dyspnea, sore throat, rhinorrhea, wheezing, or stridor. Eighty patients were enrolled. After obtaining informed consent, nasopharyngeal swabs and blood were collected. If the subject underwent bronchoscopy per the treating physician, excess bronchoalveolar lavage (BAL) sample was collected. Demographic and clinical data were recorded for each subject. Multiplex PCR testing of all respiratory samples was performed.ResultsOf the 70 HIV-infected patients that have undergone complete analysis, 23 (33%) tested positive for respiratory viruses. Of these, 11 (48%) were positive for rhinovirus, 3 were positive for influenza A (13%), 2 for parainfluenza 3 (9%), 2 for coronavirus (9%), and one each tested positive for adenovirus, parainfluenza 4, respiratory syncytial virus and influenza B. One patient had co-infection with rhinovirus and human metapneumovirus. Patients infected with a respiratory virus had severe illness as nearly half (10/23; 48%) required intensive care, 5 (22%) required mechanical ventilation, 4 (17%) were discharged to a higher level of care, and 3 (13%) died.ConclusionThe role of respiratory viruses on the lung health of HIV-infected patients is poorly defined. In this study, respiratory viruses were identified in over a third of HIV-infected inpatients, representing a substantial disease burden. Moreover, these patients demonstrated significant disease severity. Given these findings, there is a need for future studies of viral infections in HIV-infected individuals to elucidate mechanisms of susceptibility to reduce the burden of pulmonary morbidity in this vulnerable population.Disclosures All authors: No reported disclosures.

Epidemiology and Outcomes in Critically Ill Patients with Human Immunodeficiency Virus Infection in the Era of Combination Antiretroviral Therapy.

Purpose. The impact of critical illness on survival of HIV-infected patients in the era of antiretroviral therapy remains uncertain. We describe the epidemiology of critical illness in this population and identify predictors of mortality. Materials and Methods. Retrospective cohort of HIV-infected patients was admitted to intensive care from 2002 to 2014. Patient sociodemographics, comorbidities, case-mix, illness severity, and 30-day mortality were captured. Multivariable Cox regression analyses were performed to identify predictors of mortality. Results. Of 282 patients, mean age was 44 years (SD 10) and 169 (59%) were male. Median (IQR) CD4 count and plasma viral load (PVL) were 125 cells/mm3 (30–300) and 28,000 copies/mL (110–270,000). Fifty-five (20%) patients died within 30 days. Factors independently associated with mortality included APACHE II score (adjusted hazard ratio [aHR] 1.12; 95% CI 1.08–1.16; p < 0.001), cirrhosis (aHR 2.30; 95% CI 1.12–4.73; p = 0.024), coronary artery disease (aHR 6.98; 95% CI 2.20–22.13; p = 0.001), and duration of HIV infection (aHR 1.07 per year; 95% CI 1.02–1.13; p = 0.01). CD4 count and PVL were not associated with mortality. Conclusions. Mortality from an episode of critical illness in HIV-infected patients remains high but appears to be driven by acute illness severity and HIV-unrelated comorbid disease rather than degree of immune suppression.

Searching for biomarkers of comorbidities in sera of treated HIV-infected patients by isoelectric focusing.

Based on their characteristics, we hypothesized that the following parameters, namely collagen IV, glutathione S-transferase, secretory component (SC), and AMP-activated protein kinase α1α2 may be useful serum markers in the detection of comorbidities in treated HIV-infected patients. These parameters were determined in 204 HIV-infected patients and 35 controls by using IEF and densitometry. Collagen IV was undetectable in controls and the majority of HIV-infected patients. Twenty-two HIV-infected patients presented significantly elevated levels of collagen IV, most of them were coinfected with hepatitis C virus and/or hepatitis B virus. SC was undetectable in controls. SC was significantly increased in 81 HIV-infected patients and significantly correlated with aspartate aminotransferase (r = 0.267, p = 0.0049), alkaline phosphatase (r = 0.309, p = 0.0011), and γ-glutamyl-transferase (r = 0.264, p = 0.0054). Glutathione S-transferase levels of HIV-infected patients were significantly higher than the controls (3779 ± 5860 vs. 785 ± 71 DU, p = 0.0007) and significantly correlated with serum urea (r = 0.204, p = 0.0038), triglycerides (r = 0.209, p = 0.0033), and lipase (r = 0.219, p = 0.0025). AMP-activated protein kinase α1α2 levels of HIV-infected patients were significantly higher than the controls (5676 ± 6248 vs. 1189 ± 6248 DU, p = 0.0009). Further studies are needed to demonstrate the relevance of these results to diagnose non-AIDS-related illnesses in HIV-infected patients.

Non-AIDS-defining illnesses and causes of death in HIV-infected patients in St. Petersburg and Leningrad Region

With the aim of an evaluation of the prevalence of non-AIDS-defining illnesses and causes of death in HIVinfected patients 111 medical records of subjects admitted to the specialized hospitals in St. Petersburg in 2001–2008,were analyzed retrospectively. The most frequent non-AIDSdefining illnesses in HIV-infected patients in the era of the absence of the systematical antiretroviral therapy are gastrointestinal diseases. HIV-infected patients mostly die from generalized tuberculosis and chronic viral hepatitis at the End-Stage liver cirrhosis. To properly evaluate the preavalnce of Non-HIV-related diseases and causes of death in HIV-infected people in St. Petersburg and Leningrad region we need to conduct prospective cohort study in comparison with general population.

Clinical implications and management of drug-drug interactions between antiretroviral agents and psychotropic medications

Medications used in the treatment of human immunodeficiency virus (HIV) often have drug-drug interactions which complicate treatment of psychiatric illnesses in HIV-infected patients. Protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) are the two classes of HIV medications most likely to be involved with interactions, with the majority occurring via the cytochrome P450 (CYP450) system. These interactions can result in either increased or decreased exposure to psychotropic and antiretroviral medications, often requiring dosage adjustments and increased monitoring. This article reviews some of the major drug interactions with antiretroviral agents.

Clinical review: Respiratory failure in HIV-infected patients - a changing picture

Respiratory failure in HIV-infected patients is a relatively common presentation to ICU. The debate on ICU treatment of HIV-infected patients goes on despite an overall decline in mortality amongst these patients since the AIDS epidemic. Many intensive care physicians feel that ICU treatment of critically ill HIV patients is likely to be futile. This is mainly due to the unfavourable outcome of HIV patients with Pneumocystis jirovecii pneumonia who need mechanical ventilation. However, the changing spectrum of respiratory illness in HIV-infected patients and improved outcome from critical illness remain under-recognised. Also, the awareness of certain factors that can affect their outcome remains low. As there are important ethical and practical implications for intensive care clinicians while making decisions to provide ICU support to HIV-infected patients, a review of literature was undertaken. It is notable that the respiratory illnesses that are not directly related to underlying HIV disease are now commonly encountered in the highly active antiretroviral therapy (HAART) era. The overall incidence of P. jirovecii as a cause of respiratory failure has declined since the AIDS epidemic and sepsis including bacterial pneumonia has emerged as a frequent cause of hospital and ICU admission amongst HIV patients. The improved overall outcome of HIV patients needing ICU admission is related to advancement in general ICU care, including adoption of improved ventilation strategies. An awareness of respiratory illnesses in HIV-infected patients along with an appropriate diagnostic and treatment strategy may obviate the need for invasive ventilation and improve outcome further. HIV-infected patients presenting with respiratory failure will benefit from early admission to critical care for treatment and support. There is evidence to suggest that continuing or starting HAART in critically ill HIV patients is beneficial and hence should be considered after multidisciplinary discussion. As a very high percentage (up to 40%) of HIV patients are not known to be HIV infected at the time of ICU admission, the clinicians should keep a low threshold for requesting HIV testing for patients with recurrent pneumonia.

Critical Illness in HIV-Infected Patients in the Era of Combination Antiretroviral Therapy

As HIV-infected persons on combination antiretroviral therapy (ART) are living longer and rates of opportunistic infections have declined, serious non-AIDS-related diseases account for an increasing proportion of deaths. Consistent with these changes, non-AIDS-related illnesses account for the majority of ICU admissions in more recent studies, in contrast to earlier eras of the AIDS epidemic. Although mortality after ICU admission has improved significantly since the earliest HIV era, it remains substantial. In this article, we discuss the current state of knowledge regarding the impact of ART on incidence, etiology, and outcomes of critical illness among HIV-infected patients. In addition, we consider issues related to administration of ART in the ICU and identify important areas of future research.

Management of common psychiatric conditions in the HIV-positive population

Presentation and management of psychiatric illness in HIV-infected patients can pose a challenge for clinicians. Psychiatric illness can exist premorbidly or result from the progression and treatment of HIV infection, influencing the course of the illness both through behavior and putative biological factors. Mood disorders, anxiety, psychosis, delirium, dementia, and substance abuse disorders all factor heavily into the care of HIV-infected patients. Management, however, continues to draw on small and skewed datasets, and remains largely an extrapolation from seronegative patient experience. The following is a discussion of treatment considerations derived from recent literature, as well as a consideration of judgments that clinicians may make in the absence of available data. The use of antidepressants, stimulants, mood stabilizers, and antipsychotics is discussed, as are precautions that must be taken with the HIV population when using these medications, not only because of side effect vulnerability, but because of significant drug-drug interactions.

Diarrhea and AIDS in the era of highly active antiretroviral therapy.

severe malnutrition, low-grade fever with night sweats, and, finally, a wasting away followed by death. Although multiple illness in HIV-infected patients. parasites, pathogenic bacteria, and, occasionally, viruses have been isolated from the stool of up to two-thirds of patients with AIDS, pathogen-specific therapy has generally been only Causes of Diarrhea in HIV-Infected Patients minimally effective and diarrhea generally considered a mani- Bacteria festation of the underlying immunodeficiency. Diarrhea has been described previously in association with Pathogen-specific therapy is often successful in cases where various other immunodeficiency syndromes; up to 60% of pa- pathogenic bacteria are identified. Such cases include infections tients with common variable hypogammaglobulinemia have due to Shigella, Salmonella, and Campylobacter species for diarrhea, with 40% developing malnutrition [1, 2]. In the case which treatment with the fluoroquinolones usually resolves the of severe combined immunodeficiency, patients are extremely diarrhea and fever. However, relapses after discontinuation of prone to infections and they commonly succumb to chronic therapy have been observed more frequently among HIV-indiarrhea and malabsorption. In selective IgA deficiency — the fected individuals than in the general population. A curious most common immunodeficiency state in humans that affects syndrome of nontyphoidal salmonella bacteremia that repeat1 of 500 ‐ 3,000 people in the general population — recurrent edly relapses when effective therapy is discontinued has been bronchosinusopulmonary infections are often associated with reported, a phenomenon observed in other opportunistic infeca high incidence of gastrointestinal disease, including diarrhea, tions such as cryptococcal meningitis and disseminated histosteatorrhea, and celiac sprue. plasmosis [3]. Campylobacter upsaliensis has recently been In the Western world, diarrhea has also dominated the clini- identified as a cause of chronic diarrhea in Australia [4]. cal picture of patients with advanced HIV and, in fact, has Diarrhea associated with Clostridium difficile can be a particbeen a clinical indicator of progression of immunodeficiency ularly difficult diagnostic dilemma in patients with AIDS, given along with thrush, weight loss, fevers, and night sweats. In that they are often taking various types of antibiotics and bemany cases pathogenic organisms could be isolated, and vari- cause diarrhea is so common among these patients. A C. diffious algorithms were developed to standardize the work-up of cile ‐ toxin assay should always be part of a work-up for newthis condition. However, not all cases of chronic diarrhea in onset watery diarrhea, with or without fecal leukocytes, espeadvanced AIDS can be attributed to an infectious etiology, cially if the diarrhea is associated with fever, leukocytosis, and thus the therapeutic approach is limited. Drug side effects, cramps. Treatment with metronidazole, 250 mg po t.i.d. for 7 gastrointestinal malignancies (Kaposi’s sarcoma, lymphoma), to 10 days, is usually curative. However, as in the general and HIV enteropathy are often listed as likely causes. population, up to 20% of patients will have a relapse, and these relapses should be retreated with metronidazole at the same dosage. The annual incidence of C. difficile ‐ associated diarPublication of this State-of-the-Art Clinical Article has been made possible rhea in HIV-positive individuals who were hospitalized ranged

Extrapulmonary Tuberculosis in Patients with Human Immunodeficiency Virus Infection

The annual number of cases of culture-proven extrapulmonary tuberculosis (TB) at our hospital increased from 47 cases in 1983 to 113 cases in 1988. At least 43% (199) of 464 consecutive patients with extrapulmonary TB during this 6-year period were infected with the human immunodeficiency virus (HIV); since HIV serologic testing was not performed routinely the true HIV prevalence is likely to be higher. Of the HIV-infected patients, 59% were intravenous drug users, 31% were Haitian, 3% were homosexual males, 1% were perinatally-infected infants, and 6% did not have a known risk factor for HIV infection. Ninety-eight percent of the HIV-infected patients were black (84%) or hispanic (14%). The HIV-infected patients were more likely than the control patients to have either disseminated, genitourinary, intra-abdominal, mediastinal, or concurrent pulmonary TB. Fever was nearly universal among the HIV-infected patients, but was absent in about one-third of the control patients. Among untreated HIV-infected patients, disease progression was rapid and nearly always fatal. Among HIV-infected patients who received treatment, the response to therapy, as judged by hospital survival and time to defervescence, was similar to that of the control patients. Despite the extensive tuberculous dissemination among the HIV-infected patients, the diagnosis of TB was difficult and often delayed. In addition to the decrease in tuberculin reactivity and the atypical chest radiograph patterns, there was a need to consider other HIV-related infections in the differential diagnosis. Although sputum specimens grew M. tuberculosis in greater than 90% of the HIV-infected patients in whom they were obtained, sputum AFB stains were positive in less than 50%. Blood and urine specimen cultures were positive in 56% and 77% of the HIV-infected patients in whom these specimens were obtained, but did not provide a means of early diagnosis. Cerebrospinal fluid and pleural fluid were abnormal in nearly all patients with involvement of these sites but were rarely AFB-positive and were, therefore, only suggestive of TB. Procedures such as biopsies and aspirates of peripheral lymph nodes, visceral lymph nodes, liver, and bone marrow provided the highest immediate diagnostic yields with rates between 50% and 90%. These procedures must be considered early in the course of illness in HIV-infected patients with suspected extrapulmonary TB due to the rapidly progressive nature of this often fatal but usually treatable infection.

Diagnosis and management of HIV-infected patients with diarrhoea.

Diarrhoea and weight loss are found in more than 50% of patients with AIDS and in some patients can be so severe that death may occur even in the absence of opportunistic infections. Systematic evaluation of diarrhoeal illness in HIV-infected patients will often identify a treatable aetiology. Despite the tendency for recurrences, the majority of patients will respond to anti-infective therapy. A practical approach to the diagnosis and management of HIV-infected patients with diarrhoea is presented in this article.