Adverse Effects of Direct Acting Antivirals in HIV/HCV Coinfected Patients: A 4-Year Experience in Miami, Florida

Introduction: The new direct acting antivirals (DAA) have demonstrated low rates of adverse effects in controlled studies. However, real world-studies have disclosed emerging toxicities and drug-drug interactions in special populations. Methods: We conducted a retrospective review of HIV/HCV coinfected patients who were treated with DAA at Jackson Memorial Hospital from 2014 to 2017. Our aim was to determine the adverse effects (AE) and factors that are associated with AE in HIV/HCV individuals who are treated with DAA. Results: There were 78 coinfected patients treated with DAA. AE that were secondary to DAA were reported by 21 (26.9%) patients. The most common AE were fatigue (47.6%), gastrointestinal symptoms (38.1%), anemia (14.3%), and headache (14.3%). In comparison with the rest of the study cohort, the patients who developed AE were more often Caucasian (33.3% vs. 10.5%, p = 0.017) and were more frequently treated with PrOD/Ribavirin (9.5% vs. 0%, p = 0.018). In terms of antiretroviral therapy (ART), there was a trend towards a more frequent use of TDF/FTC + NNRTI (33.3% vs. 14%, p = 0.055). Conclusions: These findings demonstrated good tolerability of DAAs in HIV/HCV coinfected patients. More real-world studies are needed to explore the variables that are associated with AE

Dual infection of the central nervous system caused by Cryptococcus and Toxoplasma in a patient with AIDS: a case report and literature review

Dual infection of the central nervous system secondary to Cryptococcus and Toxoplasma is very uncommon, even in the setting of acquired immunodeficiency syndrome (AIDS). We report the case of a 52-year-old patient who was admitted with multiple cranial nerve deficits. Magnetic resonance imaging showed supratentorial and infratentorial enhancing lesions. He was newly diagnosed with HIV infection with a CD4 count of 59 cells/uL and HIV viral load of 299,619 copies/mL. Diagnosis of Cryptococcus meningitis was made by Cryptococcal antigen in cerebrospinal fluid (CSF). The high clinical suspicion for Toxoplasmosis prompted an early empiric treatment for this condition. The diagnosis of Toxoplasmosis was later confirmed by PCR in CSF. Despite an adequate treatment for these two pathologies, his condition deteriorated and eventually expired. We reviewed the English language literature for cases of Cryptococcus and Toxoplasma co-infection of the central nervous system in patients with AIDS. To our knowledge, our patient is the third case of simultaneous infection described in the literature. Clinicians must be aware that focal brain lesions in patients with cryptococcal meningitis should prompt a full evaluation to search for concomitant pathologies of which Toxoplasmosis is the most important. Our case illustrates the utility of PCR in CSF for an early diagnosis of toxoplasmosis, reserving brain biopsy for cases of anti-toxoplasma therapy failure

Tratamiento farmacológico de COVID-19: Conferencia de la Peruvian American Medical Society (PAMS)

El tratamiento farmacológico de COVID-19 ha cambiado mucho durante la pandemia. Medicamentos como la hidroxicloroquina dejaron de utilizarse ya que se demostró que carecían de eficacia clínica. Ivermectina, un medicamento empleado mucho en Perú, carece de evidencia científica suficiente que permita su recomendación. A la fecha, el tratamiento de pacientes hospitalizados se basa en Remdesivir y corticoides; y el de pacientes ambulatorios es solo sintomático, no recomendándose tampoco el uso empírico de antibióticos. El uso de Tocilizumab es todavía controversial ya que los resultados de los ensayos clínicos son contradictorias. A pesar de la frecuencia más alta de eventos trombóticos en COVID-19, no se recomienda en la actualidad la anticoagulación terapéutica empírica

Cryptococcal Lymphadenitis in an HIV-Infected Patient: A Rare Manifestation of Immune Reconstitution Inflammatory Syndrome

Cryptococcosis is a fungal infection that is typically associated with acquired immunodeficiency syndrome (AIDS). The advent of highly active antiretroviral therapy has decreased the frequency of this infection, but has led to the emergence of atypical cases of immune reconstitution inflammatory syndrome (IRIS). Here, we describe the case of a 40-year-old man who was diagnosed with HIV infection and cryptococcal meningitis. He was successfully treated with antifungals and then started antiretroviral therapy. The patient returned to the hospital 15 months later complaining of fever, pain, and neck swelling. A computed tomography (CT) scan revealed a conglomerate of necrotic lymph nodes in the supraclavicular region. He underwent biopsy and histology showed granulomatous inflammation with fungal elements, consistent with Cryptococcus. He tested positive for serum cryptococcal antigen. The patient was treated with liposomal amphotericin and flucytosine. After induction therapy, he was re-started on fluconazole. The final fungal cultures were negative. We attributed our patient’s clinical presentation to “paradoxical” IRIS, which was associated with his previously treated cryptococcosis. Near resolution of the supraclavicular mass was noted at the 3-month follow-up

Cryptococcal Lymphadenitis in an HIV-Infected Patient: A Rare Manifestation of Immune Reconstitution Inflammatory Syndrome

Cryptococcosis is a fungal infection that is typically associated with acquired immunodeficiency syndrome (AIDS). The advent of highly active antiretroviral therapy has decreased the frequency of this infection, but has led to the emergence of atypical cases of immune reconstitution inflammatory syndrome (IRIS). Here, we describe the case of a 40-year-old man who was diagnosed with HIV infection and cryptococcal meningitis. He was successfully treated with antifungals and then started antiretroviral therapy. The patient returned to the hospital 15 months later complaining of fever, pain, and neck swelling. A computed tomography (CT) scan revealed a conglomerate of necrotic lymph nodes in the supraclavicular region. He underwent biopsy and histology showed granulomatous inflammation with fungal elements, consistent with Cryptococcus . He tested positive for serum cryptococcal antigen. The patient was treated with liposomal amphotericin and flucytosine. After induction therapy, he was re-started on fluconazole. The final fungal cultures were negative. We attributed our patient’s clinical presentation to “paradoxical” IRIS, which was associated with his previously treated cryptococcosis. Near resolution of the supraclavicular mass was noted at the 3-month follow-up

Bacteremia caused by cellulosimicrobium in a bone marrow transplant patient: A case report and literature review

Background: Cellulosimicrobium sp. is a ubiquitous gram-positive bacillus that was formerly known as Oerskovia. This bacterium is found in soil and decaying plant material and is rarely associated with infections in humans. Case report: We report the case of a 44 year-old woman with history of bone marrow transplant that developed Cellulosimicrobium sp. bacteremia secondary to a central line infection. She was admitted with presumed sepsis. Blood cultures from central line and periphery revealed the growth of gram-positive rods that were further identified as Cellulosimicrobium sp. by MALDI-TOF. She was treated with vancomycin and line removal. Microbiologic cure was achieved; however, she developed hospital-acquired pneumonia, which led to a fatal outcome. Conclusion: To our knowledge, there are only 15 documented cases of Cellulosimicrobium sp. bacteremia. Our case illustrates the potential pathogenicity of this bacterium and the importance of appropriate antimicrobial therapy and removal of infected central catheters. It is essential to know that gram-positive bacilli should not be disregarded as contaminants when recovered from multiple blood cultures. In this situation, a full microbiologic identification must be attempted

Evolution of Pretreatment Assessment and Direct Acting Antiviral Regimens in Accordance with Upgrading Guidelines: A Retrospective Study in HIV/HCV Coinfected Patients

Since the advent of new direct acting antivirals (DAA), substantial changes in hepatitis C (HCV) treatment guidelines have occurred. However, little is known about how these recommendations have been adopted into clinical practice. We conducted a retrospective review of human immunodeficiency virus (HIV)/HCV coinfected patients treated with DAAs at the Ryan White Clinic of the Jackson Health System in Miami, FL, USA. Our aim was to determine changes in HCV evaluation and treatment patterns in the use of DAAs over a four-year period from January 2014 to December 2017. Data were divided into two periods: period 1 (2014–2015) and period 2 (2016–2017). In comparison with the rest of the cohort, patients in period 2 had a lower frequency of advanced liver disease (24.4% vs. 48.6%, p = 0.026) and underwent more elastography (34.1% vs. 2.7%, p < 0.001) and less ultrasound (78.0% vs. 97.3%, p = 0.011). They were more often treated with ledipasvir/sofosbuvir (85.4% vs. 56.8%, p = 0.005) and less often with simeprevir/sofosbuvir (0% vs. 32.4%, p < 0.001). Gastrointestinal side effects were reported less frequently (2.4% vs. 18.9%, p = 0.017) in this period. In accordance with the updated guidelines, our study demonstrated a growing preference for non-invasive methods to assess fibrosis in recent years. Regarding treatment, there was a clear preference for second generation DAAs in 2016–2017, along with initiation of treatment in the early stages of liver disease

Fatal Curvularia brain abscess in a heart and kidney transplant recipient

A 42-year-old woman with history of heart failure status post orthotopic heart transplant and end stage renal disease presented to the hospital with decompensated heart failure that progressed to cardiogenic shock. She underwent a new orthotopic heart transplant and cadaveric donor kidney transplant. Three weeks later, she experienced right facial droop and right upper extremity weakness. Computed tomography showed a left frontal cortical lesion with vasogenic edema and a central hemorrhagic component. Given the concern for an angioinvasive mold infection, she was started on voriconazole and amphotericin B. Brain biopsy was performed and histopathology revealed septated hyphae with acute angle branching. Mycology culture isolated Curvularia sp. Unfortunately, her mental status deteriorated with subsequent development of multiorgan failure that led to death. Keywords: Curvularia, Brain abscess, Transplan