Negative Antibody Test Research Articles

Polyarteritis Nodosa Associated With Hepatitis C Virus Infection: A Case Report

Polyarteritis nodosa (PAN) is a systemic necrotizing vasculitis that predominantly affects mediumsized arteries, and is often the consequence of viral infections, mainly HBV. We describe a case of Hepatitis C associated PAN in a patient who had eluded diagnosis for several years. A 55 year old Egyptian female with a history of migraine, B cell lymphoma (in remission), and depression was admitted with diffuse abdominal pain. She denied nausea, vomiting, hematochezia or fever. She had been seen in the GI clinic over many years with post prandial epigastric pain and nausea with negative imaging and endoscopic testing and had been diagnosed with functional dyspepsia. Physical examination revealed the patient looked pale and was in distress with mild tenderness to deep palpation in the left upper abdominal quadrant, with no guarding or rebound. Rectal exam was negative for masses and blood. Lab work was pertinent for a drop in Hgb from 12 g/dl to 9 g/dl. Other routine lab work was normal. After 2 visits to the ED she received a CT abdomen/pelvis, which revealed intra abdominal hemorrhage in the left upper quadrant around the body and tail of the pancreas, between stomach and spleen with extension to the pararenal space (figure 1). Subsequent angiogram disclosed splenic pseudoaneurysm treated by embolization and background changes to vasculature with ectatic and stenosed vessels consistent with PAN (figure 2). Hepatitis B serology was negative but she tested positive for hepatitis C, genotype 4 with viral load of 56,000. A serum cryoglobulin test was negative but perinuclear antineutrophilic cytoplasmic antibody test was positive. Serum complement levels were reduced. She was diagnosed as having classic PAN associated with hepatitis C. She was treated with pegylated interferon, and ribavirin but was a non responder at 4 weeks. She was then treated with sofosbuvir, pegylated interferon and ribavirin for 12 weeks with successful eradication of HCV with remarkable improvement in symptoms. HCV associated PAN is rare but accounts for 20 % of all HCV related vasculitis. It tends to occur more often in older females and up to 20 years from infection. Sustained remission is closely related to successful HCV clearance. It is also likely that the patients past history of B cell lymphoma was linked to HCV as well, with epidemiological studies revealing 2-3 times increased risk of B-cell lymphoma in HCV patients. Indolent disease will often respond to anti viral therapy, but aggressive disease requires traditional chemotherapy. Unfortunately our patient had never been tested for HCV prior to this presentation. In conclusion, we describe the first case of a patient with a prior history of B cell lymphoma, presenting with splenic artery pseudoaneurysm rupture from PAN from HCV successfully treated with new generation anti-viral therapy.Figure 1Figure 2

LB1.2 Pilot study of immediate antiretrovirals and behavioural intervention for persons with acute hiv infection: opportunity for interrupting transmission

Introduction Persons with acute HIV infection (AHI) contribute disproportionately to transmission. In a pilot study, we evaluated a short-term, behavioural and biomedical intervention among persons with AHI in Malawi. Methods We enrolled persons with AHI. AHI was defined as negative or discordant antibody test (s) with detectable virus. Persons were randomised 1:2:2 to standard counselling (SC), a four-session behavioural intervention (BI), or behavioural intervention plus 12 weeks of antiretrovirals (BIA), and followed 26–52 weeks. ARV resistance was assessed at baseline and after therapy. Participants were asked to refer partners for testing. Follow-up was completed in August 2014; phylogenetic analyses were completed in May 2015. Results We identified 59 persons with AHI and enrolled 46 (9 [SC], 18 [BI], 19 [BIA]). Average age was 25; 61% were male. Median viral load (VL) was 5.9 log copies/ml (6.7 [SC]; 5.1 [BI]; 6.1 [BIA]). At week four, 64% (11/17) of BIA participants were suppressed ( Conclusion ARV quickly reduced viremia below transmissible levels and did not induce resistance; however, patients experienced rapid virological rebound after discontinuation. Sexual risk decreased rapidly in all arms. Most referred partners with available sequences were linked transmissions with the AHI index. Early diagnosis with standard AHI counselling and early ARV referral may be sufficient to reduce transmission risk. Disclosure of interest statement This study was supported by the National Institutes of Health, USA; ARVs donated by Merck and Gilead.

Natalizumab-Related PML Is Possible Even With Recent Negative JCV Antibody Testing (P4.030)

Natalizumab-Related PML Is Possible Even With Recent Negative JCV Antibody Testing (P4.030)

Liver Fibrosis Progression in Hepatitis C Virus Infection After Seroconversion

Knowing the rate of liver fibrosis progression in hepatitis C virus (HCV)-infected persons can help inform patients and providers (clinicians, medical institutions or organizations, and third-party payers) in making treatment decisions. To determine the rate and factors associated with liver fibrosis progression and hepatic decompensation in persons after acquiring HCV infection. Secondary data analysis of persons in the Electronically Retrieved Cohort of HCV Infected Veterans (ERCHIVES), a national Veterans Affairs (VA) database, between 2002 and 2012. Among 610 514 persons in ERCHIVES (half were HCV positive), we identified those with an initial negative and subsequent positive test result for HCV antibody and positive HCV RNA test result (HCV+). Controls had 2 negative HCV antibody test results (HCV-) in a comparable time frame and were matched 1:1 on age (in 5-year blocks), race, and sex. We excluded persons with human immunodeficiency virus, hepatitis B, less than 24 months of follow-up, hepatocellular carcinoma, and cirrhosis at baseline. Progression of liver fibrosis as estimated by the Fibrosis-4 (FIB-4) index; development of cirrhosis, defined by a FIB-4 score greater than 3.5; and development of hepatic decompensation. The evaluable data set consisted of 1840 persons who were HCV+ and 1840 HCV- controls. The HCV+ persons were younger and had a lower mean (SD) body mass index (27.39 [5.51] vs 29.49 [6.16]; P < .001), a higher prevalence of alcohol and drug abuse and dependence diagnoses, and higher serum aminotransferase levels, but had a lower prevalence of diabetes and hypertension. Fibrosis progression started early after infection among HCV+ persons and tapered off after 5 years. A total of 452 cirrhosis and 85 hepatic decompensation events were recorded. After 10 years of follow-up, HCV+ persons were more likely to have a diagnosis of cirrhosis compared with HCV- controls (18.4% vs 6.1%). Nine years after diagnosis of cirrhosis, hepatic decompensation events were uncommon but had a higher rate in the HCV+ group (1.79% vs 0.33%). Persons who seroconverted for HCV have a more rapid progression of liver fibrosis and accelerated time to development of cirrhosis after seroconversion compared with HCV- controls. Fibrosis progression occurs early after infection; however, hepatic decompensation is uncommon after diagnosis of cirrhosis.

Failure of daily tenofovir to prevent HIV transmission or the establishment of a significant viral reservoir despite continued antiretroviral therapy.

IntroductionTruvada is licenced for HIV-1 prevention in the USA and is available in the private sector. Tenofovir performed as well as Truvada in the PARTNERS PrEP study and is used as HIV pre-exposure prophylaxis (PreP) in some settings. The clinical efficacy of Tenofovir for PrEP outside a clinical trial is unknown. Antiretroviral therapy (ART) at acute HIV-1 infection (AHI) limits the size of the reservoir, optimizing the chance of maintaining viral control off therapy. As such ART at acute HIV infection is proposed to offer a functional cure in a minority of subjects. We present two cases where Tenofovir PrEP failed to prevent HIV acquisition and failed to limit viral reservoir.Materials and MethodsTwo individuals receiving tenofovir monotherapy for Hepatitis B monoinfection were diagnosed with AHI as defined by a negative HIV antibody test within three months of a positive HIV test following unsafe sex with casual male partners. In-depth histories were taken. Viral genotypes and Tenofovir drug levels were measured from samples taken as close to HIV seroconversion as possible and subsequent samples were analyzed for proviral Total HIV-1 DNA by qPCR.ResultsPatient A had received tenofovir for the preceding six years and always maintained an undetectable Hepatitis B viral load with no concerns about adherence. Two weeks preceding the positive HIV antibody test, he experienced mild symptoms (fever, pharyngitis) of HIV seroconversion. HIV status was confirmed by a repeat fourth generation HIV antibody test and by Western Blot and an HIV viral load was undetectable. Tenofovir trough level at HIV diagnosis was within normal limits. The regimen was intensified to Eviplera and a total HIV-1 DNA was 1381 copies/million CD4 T cells. Patient B received four regimens for hepatitis B treatment before starting tenofovir monotherapy in 2011 and subsequently maintained an undetectable hepatitis B viral load. After three years of tenofovir monotherapy he developed a severe symptomatic seroconversion illness and tested HIV antibody positive. The baseline HIV viral load was 103,306 copies/mL. The regimen was intensified and total HIV-1 DNA was 2746 copies/million CD4 T cells.ConclusionsFurther investigation into the efficacy of tenofovir for PrEP outside a clinical trial is required. ART at AHI does not always lead to a low viral reservoir. To explore the possibility of replication incompetent virus, viral outgrowth assays are underway.

Evaluating New Definitions of Acute and Early HIV Infection from HIV Surveillance Data.

Background : The U.S. HIV staging system is being revised to more comprehensively track early and acute HIV infection (AHI). We evaluated our ability to identify known cases of AHI using King County (KC) HIV surveillance data.Methodology : AHI cases were men who have sex with men (MSM) with negative antibody and positive pooled nucleic acid amplification (NAAT) tests identified through KC testing sites. We used KC surveillance data to calculate inter-test intervals (ITI, time from last negative to first positive test) and the serologic algorithm for recent HIV seroconversion (STARHS). For surveillance data, AHI was defined as an ITI of ≤ 30 days and early infection as an ITI ≤ 180 days or STARHS recent result. Dates of last negative HIV tests were obtained from lab reports in the HIV surveillance system or data collected for HIV Incidence Surveillance.Results : Between 2005 and 2011, 47 MSM with AHI were identified by pooled NAAT. Of the 47 cases, 36% had ITI < 1 day, 60% had an ITI < 30 days, and 70% (95% CI=55-82%) had an ITI ≤ 6 months and would have been identified as early HIV infection. Of the 47, 38% had STARHS testing and 94% were STARHS recent.Conclusion : MSM with known AHI were not identified by proposed definitions of AHI and early infection. These known AHI cases were frequently missed by HIV surveillance because concurrent negative antibody tests were not reported. Successful implementation of the revisions to the HIV staging system will require more comprehensive reporting.

G.P.139: Congenital myasthenic syndrome due to novel choline acetyltransferase (ChAT) gene mutations in Kadazandusun family from Borneo

Pathogenic mutations of the choline acetyltransferase (ChAT) gene alters its function and causes reduced synthesis of acetylcholine and its depletion in synaptic vesicles. This results in a rare presynaptic form of congenital myasthenic syndrome which presents at birth or in infancy characterised by apnoeic attacks. We present Kadazandusun family, an ethnic group native to Sabah, in north Borneo, with ChAT deficiency in which 5 of 6 siblings of non-consanguineous parents were affected. 2 died in their infancy from apnoeic atatacks while another sibling died at the age of 12 years from a severe apnoeic episode after an intercurrent infection. We reviewed 2 brothers, the eldest and the 4th at 24 and 18 years of age respectively, although both had presented in infancy with bilateral ptosis and limb weakness. The elder brother had episodes of apnoea and weakness on exposure to cold well water in their village. A congenital myasthenic syndrome was suspected and both brothers were treated on pyridostigmine after positive Tensilon tests and negative acetylcholine receptor antibody tests. On review, both had muscle weakness after moderate to severe exertion and repetitive nerve stimulation test of the abductor digiti minimi, which was normal at rest, showed sustained decremental response after prolonged 5 min stimulation at 10 Hz. Screening of the ChAT gene showed compound heterozygous mutation in both brothers, c.1069G>C and c.2263_2265delTCT in exons 6 and 15 respectively. Each parent was heterozygous for one of the mutations, which were not seen in any of 50 normal controls obtained from the native population of Sabah. In summary, we present a Kadazandusun family with ChAT deficiency congenital myasthenic syndrome, in which, 3 affected siblings died from apnoeic episodes, while another 2 survived to adulthood. This variable severity could be attributed to treatment with pyridostigmine as well as recognised improvement with age in this condition.

The Importance of Occult Hepatitis B Infection Screening in Pre-Transplant Evaluation

Implication for health policy/practice/research/medical education: This paper argues the importance of occult hepatitis B infection screening in pre-transplant evaluation. It is applicable for those in the field of organ transplantation. Copyright © 2014, NewPub; Published by Kowsar Corp. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Occult hepatitis B virus infection (OHB) is defined based on the existence of hepatitis B virus (HBV) DNA in liver tissue or serum of the patients, in spite of negative antibody test result for hepatitis B surface antigen (1). Most of these patients have positive hepatitis B core antibody (HBc Ab) test result as the evidence of past HBV infection. Ramezani et al. recommended the evaluation of HBc Ab in hemodialysis patients for detection of OHB (2). There might be low titer of HBc Ab in minority of OHB patients due to immunosuppression. In the other word, all serological Ab panels for HBV might be negative in OHB setting. Searching for HBV DNA in serum is promising for determination of OHB in the immune deficiency state. However, this method could not be recommended in the routine screening due to its high expense. Therefore, defining the best diagnostic strategy for detection of OHB seems to be challenging in particular subgroups of patients. Although the precise clinical manifestations and pathogenesis of OHB are not clear, it is considered as a probable source of HBV infection via blood transfusion, hemodialysis, and organ transplantation. Reactivation of OHB in the post-transplantation phase could be fatal. It is wise to improve the yield of diagnostic tool for OHB screening in the pre-transplant phase to lower the liver-related morbidity and mortality in the transplant candidates. The important issues on OHB are the aggravation of chronic liver damage and concomitant fibrosis (3). Some studies showed that this condition causes progression of cirrhosis and development of hepatocellular carcinoma in chronic liver disease (4) OHB lowers the virologic response in hepatitis C infection (5) Song et al. declared that HBV transmission could occur via transfusion, hemodialysis, and organ transplantation (1). Considering the possibility of HBV reactivation, they suggested the screening of OBI in the post-transplantation phase. Furthermore, they mentioned the need for antiviral therapy in HBsAg-negative transplanted patients who are anti-HBc positive, to prevent the reactivation of HBV infection. HBV recurrence has occurred even two years after discontinuation of the immunosuppression (6). Fontenele et al. issued the role of OHB screening in hemodialysis patients to prevent the transmission of HBV and the consequent liver cell damage (7). Based on the current evidence, it seems reasonable to screen for OHB in the pre-transplantation phase and follow the patient carefully for early detection of OHB relapse. HBc Ab test is a practical screening method for OHB and is a surrogate marker of previous HBV infection in the immune competent patients. HBV DNA assay is an accepted alternative for OHB screening in the immunosuppressed individuals whose HBc Ab is in a low detectable titer.

Jaccoud's Arthropathy with Radial Shaft Deformity in a Patient with a History of Mild Carditis and Sydenham's Chorea

Background: Jaccoud’s arthropathy was first described in 1869 in a patient with recurrent attacks of acute rheumatic fever and recurrent migratory polyarthritis. The typical features include characteristic joint deviation with metacarpophalangeal subluxation, ulnar deviation, swan neck deformity of the fingers, and Z deformity of both thumbs and hook formation and alignment disorders without noticeable erosions on radiographs. In this report, Jaccoud’s arthropathy presenting with deformity of shaft of the radius is described. Case presentation: A 12-year-old-girl was diagnosed to have chorea at the age of 8 years after she presented with irregular, jerky, rapid and involuntary movements that involved the face, the trunk and the distal extremities. She was treated with haloperidol. The chorea resolved after 3 months of treatment. Echocardiogram showed thickening of the mitral valve leaflets and mild mitral regurgitation. Three years later, the child presented with progressive symmetric deformity of the wrist joints. She reported no pain or limitation of movement. On physical examination, there was no cardiac murmur. There was varus deformity of both wrist joints. There was no tenderness or limitation of movement. Anti-streptolysin O was negative at the first presentation and on this visit. Rheumatoid factor was negative but antinuclear antibody test was positive. Echocardiogram showed complete resolution of the mitral regurgitation. X-ray of the wrists showed marked symmetric curving of the distal radius and varus deformity of the wrists. There was joint deviation with metacarpophalangeal subluxation and ulnar deviation of the hand. There was no Z deformity of the thumbs. Conclusion: The common presentation of Jaccould’s arthropathy is involvement of the wrist, metacarpophalangeal joints and joints of the feet. The metacarpal and metatarsal bones are the ones, which are commonly affected. Our patient has an unusual presentation of deformity of the distal radial bone. This has not been described, at least to our knowledge.

Fisher-Bickerstaff syndrome with negative anti-ganglioside antibody test results associated with mycoplasma pneumoniae infection

Miller-Fisher syndrome and Bickerstaff brainstem encephalitis are two conditions that have probably a common autoimmune etiology. Anti-ganglioside antibodies are present in most of the patients with these clinical conditions. The symptoms of these disorders variably involve peripheral nervous system or central nervous system. There is an unclassified group of patients who have symptoms of both Miller-Fisher syndrome and Bickerstaff brainstem encephalitis and a new eponymic terminology “Fisher-Bickerstaff syndrome” is suggested for these patients. Mycoplasma Pneumonia as a cause of Fisher-Bickerstaff syndrome has not been reported before. Clinical and radiologic features of a nine-year-old boy with “Fisher-Bickerstaff syndrome” associated with Mycoplasma Pneumonia infection are presented. A nine-year-old boy presented with ptosis, diplopia, drowsiness, areflexia. He had a history of recent upper respiratory tract infection and laboratory evidence of Mycoplasma Pneumonia infection. Brain magnetic resonance imaging revealed hyperintense lesions in the brainstem and electromyography revealed absent H reflex and reduced F wave responses in median nerves. Anti-ganglioside antibodies were negative. The patient dramatically responded to intravenous immunoglobuline treatment. Mycoplasma Pneumonia may cause Fisher-Bickerstaff syndrome without a rise in anti-ganglioside antibodies. Intravenous immunoglubuline treatment seems a good therapeutic option for these cases.

4.0 When to start

4.0 When to start

Spasmodic Muscle Cramps and Weakness as Presenting Symptoms in Wilson Disease

Wilson disease (WD) is an autosomal-recessive disorder of hepatic copper metabolism that has tremendous variability in its presentation. Phenotypic diversity of the disease can lead to delayed diagnosis. We describe a case of WD in a 10-year-old boy presenting with 3 months of increasingly intense, spasmodic lower extremity muscle cramps. Physical examination revealed tenderness on calf palpation and dark flat lesions over his ankles, knees, and elbows. Initial testing revealed creatine kinase of 302 IU/L (normal 24-248 IU/L), hemoglobin of 8.9 g/dL (11.5-15.5 g/dL), aspartate aminotransferase of 114 IU/L (16-52 IU/L), alanine aminotransferase of 54 IU/L (2-30 IU/L), and myoglobinuria. Extensive evaluation of his myopathy, including MRI and muscle biopsy, was negative. Additional laboratory tests revealed a prothrombin time of 21.3 seconds (11.8-15.5 seconds), total bilirubin of 1.4 mg/dL (<1 mg/dL), direct bilirubin of 0.5 mg/dL (<0.3 mg/dL), albumin of 2.1 g/dL (3.1-4.6 g/dL), a reticulocyte percentage of 4.5% (0.5%-2.5%), a negative Coombs direct antibody test, ceruloplasmin of 3 mg/dL (21-51 mg/dL), and 24-h urine copper of 393 μg/24 h (15-60 μg/24 h). Liver biopsy showed patchy advanced fibrosis, mild inflammation, positive staining for copper, and a tissue copper concentration of 768 µg/g (10-35 μg/g). Brain MRI revealed symmetric intrinsic T1 shortening within bilateral basal ganglia. Trientene therapy was initiated for WD. Symptoms and laboratory abnormalities resolved and remain normal at 21 months' follow-up. Musculoskeletal involvement in WD is uncommon and typically defined as bone demineralization, arthropathy, or hypokalemic muscle weakness. In patients with unexplained musculoskeletal symptoms and hepatic abnormalities, a diagnosis of WD should be considered and appropriate evaluation initiated.

Biomarkers and Heart Disease: What is Translational Success?

Biomarkers and Heart Disease: What is Translational Success?

Changing characteristics and risk factors of patients with and without incident HCV infection among HIV-infected individuals

Chronic hepatitis C virus (HCV) infection has become a leading cause of non-acquired immunodeficiency syndrome (AIDS)-related morbidity and mortality for human immunodeficiency virus (HIV)-infected persons in the highly active antiretroviral therapy (HAART) era. Despite injection drug use (IDU) remaining the main route of HCV infection, recent reports indicate outbreaks of acute HCV infection among HIV-infected men who have sex with men (MSM) and sexually transmitted infections in the absence of IDU. We conducted a retrospective observational study of behavioural and demographic factors of patients with and without incident HCV infection among HIV-infected individuals followed at the AIDS Clinic of the Infectious Disease Department of the University of Ancona from 1989 to 2011. Overall, 440 patients were considered; a total of 145 patients had initial positive HCV antibody test results (HCV+); a total of 295 patients had initial negative HCV antibody test results (HCV-). In the latter population, 14 seroconverted to HCV antibody (neoHCV), with an overall incidence of 0.59 per 100 person-years. While IDU was the principal risk factor of HCV+, the main route of transmission of incident HCV infection was sexual transmission. The HCV- group was significantly older than the other two groups and showed a significantly lower CD4 count at HIV diagnosis than neoHCV. Being Italian and having a low level of education were significantly more represented in HCV+. Younger age at HIV infection, IDU and additional risk factors other than sexual transmission significantly affected the probability of being HCV+. The cumulative probability of developing HCV infection in the HCV- group was calculated to be 6% at 15 years. The epidemiology of the newly acquired HCV in HIV+ persons is changing. Therefore, a frequent and constant counselling about HCV infection is desirable and a periodical screening test is mandatory.

Samples with high virus load cause a trend toward lower signal in feline coronavirus antibody tests.

Measurement of feline coronavirus (FCoV) antibody titres is utilised mainly for diagnosing feline infectious peritonitis (FIP) and for quarantine purposes. However, occasional samples show a falsely low or negative FCoV antibody test. We tested the hypothesis that such results are due to virus in the sample binding antibody and rendering it unavailable to antigen in the test. Thirteen effusions, one plasma and three undefined samples from cats with FIP, which gave unexpectedly low FCoV antibody titres, were examined by real-time reverse transcriptase polymerase chain reaction (RT-PCR). Increasing amounts of virus correlated with lower signals in indirect immunoflourescent, enzyme-linked immunosorbent asssay and rapid immunomigration antibody tests. However, five samples were negative by RT-PCR, so the presence of virus alone may not explain all cases of false-negative FCoV antibody tests, although it is a possible explanation in 71% of discordant samples. We conclude that falsely low or negative FCoV antibody tests can occur in samples rich in virus.

Cryptococcus Pneumonia Complicating Churg-Strauss Syndrome

Crytpococcus neoformans usually infects individuals who are HIV-infected or immunosuppressed for other reasons and clinically presents as meningoencephalitis, pneumonia or disseminated disease. We describe a 57-year-old man with history of asthma, allergic rhinosinusitis, nasal polyps and chronic receipt of low dose steroids who presented to the emergency department with fever, dry cough, respiratory distress and hematuria. His laboratory studies showed leukocytosis and eosinophilia with a negative HIV antibody test. CT scan of the chest showed right lower lobe patchy opacities. The patient deteriorated during hospitalization, developed hemoptysis and hypoxia, and was electively intubated. Repeat CT scan of the chest showed diffuse alveolar and interstitial opacities with mediastinal lymphadenopathy. The cytoplasmic anti-neutrophil cytoplasmic antibody (C-ANCA) was markedly elevated and the patient was diagnosed with Churg-Strauss Syndrome (CSS). Culture of bronchoalveolar lavage fluid yielded growth of Cryptococcus neoformans . The patient responded well to treatment with cyclophosphamide, corticosteroids, plasmapharesis and fluconazole. This case highlights the possibility that Cryptococcus neoformans can either infect or colonize patients who are immunosuppressed, including those with CSS. doi: http://dx.doi.org/10.4021/jmc755w

Sexually transmitted infection with an immune‐escape mutant hepatitis B virus (HBV) in an HBV‐vaccinated individual with acute HIV‐HCV infection

Immune pressure exerted on HBV by anti‐HBV antibodies and long‐term therapy with drugs that mutagenize the viral polymerase gene can select for mutations in its surface gene, leading to vaccine escape and evasion from serological detection. In general, these mutations are considered to be poorly transmissible. However, cases of HBV infection with vaccine‐escape mutant viruses have been reported in vaccinated individuals, mainly from high‐prevalence regions of the world. The possibility of an infection with HBV despite an effective vaccination may pose a major health issue, requiring a change in routine diagnostic and screening programmes. Here, we report a case of a HBV vaccine escape mutant infection in an effectively vaccinated individual. The patient was a 27‐year old man who has sex with men (MSM) who presented in September 2011 for the first time in a Berlin outpatient HIV clinic due to a newly diagnosed HIV infection. He was aware of several sexual high‐risk contacts within the past, but had a negative HIV and HCV antibody test (ELISA) in April 2011. He complained about slight fever, swollen cervical and axillary lymph nodes and general muscle pain. The Western blot confirmed an HIV infection. The HIV viral load was 24,000 copies/mL, the CD4 count was 550/mm3. His ALT levels were elevated to 10×the upper limit of normal (ULN) and he was additionally found to have acute HCV infection: The HCV viral load was 2 million IU/mL, the HCV genotype was 2c. Furthermore, he was anti‐HBc negative, HBsAG negative, and his anti‐HBs level was 121 IU/L. He reported to have been vaccinated for HBV in the past. Three months later, the patient was routinely retested. At this time point, his HBsAg turned out to be positive and anti‐HBs antibodies had vanished. His HBV viral load was 600 million IU/mL, and ALT had decreased to 2×ULN. Population sequencing revealed a genotype F and a S143L mutation in the surface gene consistent with a vaccine escape mutant HBV. A retrospective analysis of the initial blood sample showed a HBV DNA of 90 IU/mL.ConclusionTo our knowledge, this is the first report of a sexually transmitted HBV virus with vaccine‐escape mutation in a vaccinated individual. Despite a fairly high CD4 count, the transmission may have been promoted by a loss of immunity through an acute HIV infection. Clinicians need to be aware of the possibility of HBV infections with mutant viruses.

Classic polyarteritis nodosa associated with hepatitis C virus infection: a case report

IntroductionHepatitis C virus has been under-recognized as an etiologic factor for polyarteritis nodosa and the presence of hepatitis C antigenemia in patients with polyarteritis nodosa has been reported as insignificant. In the literature hepatitis C virus-associated polyarteritis nodosa is a rare and controversial entity.Case presentationA 34-year-old Sri Lankan Tamil man presented to our facility with a two-week history of slow-resolving pneumonia of the right mid and lower zones. On physical examination he had panniculitic type tender skin nodules with background livedo reticularis. A skin biopsy was suggestive of a small and medium vessel vasculitis compatible with polyarteritis nodosa. He was tested positive for hepatitis C antibodies. A serum cryoglobulin test was negative but perinuclear antineutrophilic cytoplasmic antibody test was positive. Serum complement levels were reduced. He was diagnosed as having classic polyarteritis nodosa associated with hepatitis C infection. He later developed left-sided radiculopathy involving both upper and lower limbs and an ischemic cardiac event. His hepatitis C infection was managed with polyethylene glycol-interferon 2α combined with oral ribavirin. Simultaneously, his classic polyarteritis nodosa was treated with prednisolone and cyclophosphamide. He made a good recovery.ConclusionsHepatitis C virus infection is capable of inducing a fulminant form of vasculitis in the form of polyarteritis nodosa. It may be easily confused early in its course with mixed cryoglobulinemia, which is commonly known to be associated with hepatitis C virus. Awareness of hepatitis C virus-related polyarteritis nodosa helps in diagnosing the condition early so combined immunosuppressive and antiviral treatment can be started as soon as possible.

The risk of AIDS-defining events is decreasing over time in the German HIV-1 Seroconverter Cohort

BackgroundWith ageing of the HIV-infected population, long-term exposure to treatment, varying adherence, emerging resistance and complications to therapies, effectiveness of Highly Active Antiretroviral Therapy (HAART) needs to be monitored continuously at the population level. The German HIV-1 Seroconverter Cohort is a multi-centre, open, long-term observational cohort including patients with a known or reliably estimated date of HIV-infection i.e. last negative and first positive HIV antibody test within a maximum three-year interval or laboratory evidence of seroconversion. Our study aims to investigate survival improvements and changes in AIDS risk over calendar periods in the German HIV-1 Seroconverter Cohort.MethodsRetrospective (for the pre-1997 period) and prospective (since 1997) data from the German HIV-1 Seroconverter Cohort were used. Time from seroconversion to first AIDS-defining event over calendar periods was analysed by using Cox models adjusting for age at seroconversion, sex, transmission groups and short HIV test interval. Kaplan-Meier methods were used to determine expected survival (remaining AIDS-free) by calendar period.Results2162 seroconverters with 8976 person-years of observation were included in our analysis (up to 31.12.2010). A total of 196 first AIDSdefining events were reported. Two periods i.e. 19972000 and 2007-2010 were statistically associated with a reduction in the risk of AIDS, accounting for an overall reduction of 80%. Compared to1997-2000, hazard ratios were 2.6 (95%CI, 1.6-4.8; p=0.000) in pre-1997 and 0.5 (95%CI, 0.3-0.8; p=0.007) in 20072010. Independent risk factor for AIDS progression was age at seroconversion (HR, 1.3 per 10year-increase; p=0.001).ConclusionHAART effectiveness has improved in the German HIV-1-Seroconverter Cohort. The risk to develop AIDS decreased significantly in 19972000 and in 20072010. However, elderly may require particular monitoring in view of their faster progression to AIDS.

Acute Hepatitis and Esophageal Candidiasis During Primary Human Immunodeficiency Virus Infection

Primary human immunodeficiency virus infection (PHI) may take place without symptoms or may be associated with mononucleosislike illness. Sometimes, the clinical presentation includes aseptic meningitis, mucocutaneous ulcers, oropharyngeal candidiasis and elevated aminotransferases. We describe the case of a 25-year-old male, who had sex with other men, and presented to the emergency department with elevated aminotransferases levels and esophageal candidiasis. Acute hepatitis markers (hepatitis A, B, C, Epstein-Barr virus and cytomegalovirus) were performed and all were negative. Repeated testes revealed 3 consecutive negative HIV antibody tests with a strongly high HIV-1 RNA plasma concentration (g 500,000 copies /mL) and a loss of CD4+ T cells (347 cells/µL), characterizing an acute hepatitis occurring during a course of an acute retroviral syndrome. Antiretroviral therapy was started while waiting a genotyping test performed to assess the presence of potential drug resistance mutations, and the patient recovered uneventfully, with normalization of aminotransferases, CD4 restoration and viral load become undetectable. Genotyping test indicated primary antiretroviral mutations, and appropriate changes in antiretroviral therapy were performed. Our case like other reports suggested that a diagnosis of PHI needs to be considered in patients who presented with acute hepatitis. J Med Cases. 2012;3(2):116-118 doi: https://doi.org/10.4021/jmc489w