Human monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case series.

BACKGROUND: Between May and November, 2022, global outbreaks of human monkeypox virus infection have been reported in more than 78 000 people worldwide, predominantly in men who have sex with men. We describe the epidemiological and clinical characteristics of monkeypox virus infection in cisgender (cis) and transgender (trans) women and non-binary individuals assigned female sex at birth to improve identification and understanding of risk factors. METHODS: International collaborators in geographical locations with high numbers of diagnoses of monkeypox virus infection were approached and invited to contribute data on women and non-binary individuals with confirmed monkeypox virus infection. Contributing centres completed deidentified structured case-report spreadsheets, adapted and developed by participating clinicians, to include variables of interest relevant to women and non-binary individuals assigned female at birth. We describe the epidemiology and clinical course observed in the reported infections. FINDINGS: Collaborators reported data for a total of 136 individuals with monkeypox virus infection who presented between May 11 and Oct 4, 2022, across 15 countries. Overall median age was 34 years (IQR 28-40; range 19-84). The cohort comprised 62 trans women, 69 cis women, and five non-binary individuals (who were, because of small numbers, grouped with cis women to form a category of people assigned female at birth for the purpose of comparison). 121 (89%) of 136 individuals reported sex with men. 37 (27%) of all individuals were living with HIV, with a higher proportion among trans women (31 [50%] of 62) than among cis women and non-binary individuals (six [8%] of 74). Sexual transmission was suspected in 55 (89%) trans women (with the remainder having an unknown route of transmission) and 45 (61%) cis women and non-binary individuals; non-sexual routes of transmission (including household and occupational exposures) were reported only in cis women and non-binary individuals. 25 (34%) of 74 cis women and non-binary individuals submitted to the case series were initially misdiagnosed. Overall, among individuals with available data, rash was described in 124 (93%) of 134 individuals and described as anogenital in 95 (74%) of 129 and as vesiculopustular in 105 (87%) of 121. Median number of lesions was ten (IQR 5-24; range 1-200). Mucosal lesions involving the vagina, anus, or oropharynx or eye occurred in 65 (55%) of 119 individuals with available data. Vaginal and anal sex were associated with lesions at those sites. Monkeypox virus DNA was detected by PCR from vaginal swab samples in all 14 samples tested. 17 (13%) individuals were hospitalised, predominantly for bacterial superinfection of lesions and pain management. 33 (24%) individuals were treated with tecovirimat and six (4%) received post-exposure vaccinations. No deaths were reported. INTERPRETATION: The clinical features of monkeypox in women and non-binary individuals were similar to those described in men, including the presence of anal and genital lesions with prominent mucosal involvement. Anatomically, anogenital lesions were reflective of sexual practices: vulvovaginal lesions predominated in cis women and non-binary individuals and anorectal features predominated in trans women. The prevalence of HIV co-infection in the cohort was high. FUNDING: None

Damaged Intestinal Epithelial Integrity Linked to Microbial Translocation in Pathogenic Simian Immunodeficiency Virus Infections

The chronic phase of HIV infection is marked by pathological activation of the immune system, the extent of which better predicts disease progression than either plasma viral load or CD4+ T cell count. Recently, translocation of microbial products from the gastrointestinal tract has been proposed as an underlying cause of this immune activation, based on indirect evidence including the detection of microbial products and specific immune responses in the plasma of chronically HIV-infected humans or SIV-infected Asian macaques. We analyzed tissues from SIV-infected rhesus macaques (RMs) to provide direct in situ evidence for translocation of microbial constituents from the lumen of the intestine into the lamina propria and to draining and peripheral lymph nodes and liver, accompanied by local immune responses in affected tissues. In chronically SIV-infected RMs this translocation is associated with breakdown of the integrity of the epithelial barrier of the gastrointestinal (GI) tract and apparent inability of lamina propria macrophages to effectively phagocytose translocated microbial constituents. By contrast, in the chronic phase of SIV infection in sooty mangabeys, we found no evidence of epithelial barrier breakdown, no increased microbial translocation and no pathological immune activation. Because immune activation is characteristic of the chronic phase of progressive HIV/SIV infections, these findings suggest that increased microbial translocation from the GI tract, in excess of capacity to clear the translocated microbial constituents, helps drive pathological immune activation. Novel therapeutic approaches to inhibit microbial translocation and/or attenuate chronic immune activation in HIV-infected individuals may complement treatments aimed at direct suppression of viral replication

Effects of HAART on the gut mucosal immune system in HIV-infected patients

0 Titelblatt und Inhaltsverzeichnis 1.0 Einleitung 1 1.1 1.2 1.3 1.4 Die besondere Rolle der intestinalen Mukosa bei der HIV-Infektion Zytokine Zytokinexpression in der Mukosa während der HIV-Infektion Zielsetzung 1 3 7 8 2..0 Material 9 2.1 2.2 2.2.1 2.2.2 2.3 2.4 2.5 2.6 2.7 2.8 2.9 2.10 2.11 Charakterisierung von Patienten und Kontrollpersonen HIV-Beladung und CD4+T-Zellzahl> HIV-Beladung im Blut und in der intestinalen Mukosa unter HAART CD4+T-Zellzahlen im Blut und in der intestinalen Mukosa unter HAART Chemikalien und Reagenzien Kits Enzyme mit Puffern Primer und Hybridisierungssonden Zellen. Puffer und Stammlösungen Kulturmedien.. Geräte Verbrauchsmaterialien 9 10 10 11 11 12 14 15 16 17 18 19 19 3.0 Methoden 20 3.1 3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.8.1. 3.8.2. 3.8.3. 3.8.4. 3.8.5. 3.8.6. 3.8.7. 3.9. 3.9.1. 3.9.2. 3.9.3. 3.10. RNA-Extraktion Bestimmung von Konzentration und Reinheit der RNA DNase-Verdauung Reverse Transkription. Primerdesign Amplifikation von cDNA mittels konventioneller PCR Detektion der Amplifikate mittels Gelelektrophorese. Herstellung quantitativer Standardreihen für die Echtzeit-PCR PCR-Produktreinigung. Klonierung, Transformation und Kultivierung. Plasmidextraktion. Restriktionsverdauung. Bestimmung der Konzentration des Plasmids im Eluat. Berechnung der Kopienzahl pro Mikroliter Erstellung der Verdünnungsreihen mit definierter Kopienzahl Echtzeit-PCR mit dem LightCycler Der LightCycler..... SYBR Green....... Spezifische Hybridisierungssonden. Statistische Auswertung... 20 21 22 23 24 25 27 28 28 29 31 32 34 35 35 36 36 39 41 43 4.0 Ergebnisse 44 4.1. 4.2 4.3 4.3.1. 4.3.2. 4.3.3. 4.3.4. 4.3.5. 4.3.6. 4.4 RNA-Isolierung. Wiederfindung PCR-Etablierung. Methodische Nachweisgrenze LightCycler-PCR: SYBR Green oder spezifische Hybridisierungssonden Amplifikation der quantitativen Standardreihen am LightCycler Detektion der PCR-Produkte am LightCycler Mit Antikörpern geblockte Taq- versus herkömmliche Taq-Polymerase Variation der LightCycler-Messungen bei verdünnten Proben von GAPDH Veränderungen der mukosalen Zytokin-mRNA-Expression von HIV-infizierten Patienten unter HAART versus Kontrollpersonen 44 45 46 46 47 48 51 54 56 57 5.0 Diskussion 62 5.1. 5.2 Diskussion der Methoden Mukosale Zytokin-mRNA-Expression ... 62 65 Zusammenfassung 69 Literaturverzeichnis 71Die intestinale Mukosa ist für die Pathogenese der HIV-Infektion von besonderer Bedeutung. Hier findet eine hohe HIV-Replikation und ein schneller CD4+T-Zellverlust statt. Die Ursachen hierfür sind bisher unbekannt. Lokale Zytokine könnnen hierbei eine besondere Rolle spielen. Ziele dieser Arbeit waren daher a) die Bestimmung der Expression mukosaler Zytokine, die für die HIV-Replikation von Bedeutung sind und b) die Erfassung von Veränderungen der Zytokinexpression unter HAART. Hierfür wurde eine Methode entwickelt, die es erlaubt, aus geringen Mengen bioptischen Untersuchungsmaterials Zytokin- Expressionsmuster zu analysieren. Mittels Echtzeit-RT-PCR wurde in Sigmabiopsien von 7 Kontrollpersonen und zehn HIV- infizierten Patienten vor, sowie einen, vier und neun Monate nach Einleitung einer HAART die Zytokin- mRNA-Expression von IL-2, IL-4, IL-6, IL-10, IL-16, IFN-γ, TNF-α, CCL3 und CCL5 basierend auf der LightCycler-Technik mit spezifischen Hybridisierungs- Detektionssonden gemessen und zur mRNA-Expression des Housekeeping-Gens GAPDH in Beziehung gesetzt. Im Vergleich zu Kontrollpersonen zeigten HAART-naive Patienten eine erhöhte mukosale mRNA-Expression für IL-4, IL-6, IL-10, IFN-?, TNF-?, CCL3 und CCL5, keine Unterschiede ergaben sich für IL-2 und IL-16. Diese Befunde zeigen eine erhöhte Aktivierung im mukosalen Immunsystem bei der HIV-Infektion, die allerdings keinem etablierten Th1- bzw. Th2-Muster entspricht. Nach Einleitung einer HAART kam es bei allen untersuchten Patienten zu einem schnellen Anstieg der mukosalen CD4+T-Zellzahl und einem deutlichen Abfall der mukosalen Viruslast unter die Nachweisgrenze, dennoch zeigte sich für HIV-infizierte Patienten im Vergleich zu Kontrollen weiterhin eine erhöhte mukosale mRNA- Expression für IL-4, IL-6, IL-10, IFN-γ, TNF-α, CCL3 und CCL5. Diese trotz effektiver Inhibition der Virusvermehrung gesteigerte Aktivierung des mukosalen Immunsystems spricht gegen eine entscheidende ursächliche Rolle der Virusreplikation oder viraler Antigene für die mukosale Immunaktivierung. Die hohe Virusreplikation in der intestinalen Mukosa bei unbehandelten Patienten ist daher eher Folge der gesteigerten Immunaktivierung, ein Effekt, der gerade für die hoch exprimierten inflammatorischen Zytokine TNF-α, IFN-γ und IL-6 plausibel erscheint. Die hohe Expression von CCL3 und CCL5 in Verbindung mit einer hohen HIV-Produktion bei unbehandelten Patienten deutet darauf hin, dass mögliche HIV- supprimierende Effekte dieser Zytokine durch die Rekrutierung und Aktivierung potentieller Zielzellen in der Mukosa aufgehoben werden. Ihre anhaltend hohe Expression unter HAART könnte weiterhin die schnelle und überschießende Repopulation des Dickdarms mit CD4+T- Zellen verursachen. HIV-infzierte T-Zellen und Makrophagen sezernieren inflammatorische Zytokine, die die epitheliale Barriere schädigen können. Auch nach Elimination des auslösenden Antigens durch HAART könnte eine solche durch HIV induzierte Barrierestörung über vermehrten Einstrom luminaler Antigene eine mukosale Entzündung aufrechterhalten. Ob und zu welchem Zeitpunkt sich die beschriebene Immunaktivierung unter effektiver Virussuppression zurückbildet, ist derzeit unklar. Zumindest neun Monate nach effektiver HAART finden sich in der intestinalen Mukosa eine im Vergleich zu Kontrollen sehr hohe Anzahl von CD4+T-Zellen und eine hohe Expression inflammatorischer Zytokine, die unter anderem auch die Expression der HIV-Korezeptoren CCR5 und CXCR4 stimulieren. Es liegen damit zahlreiche Zielzellen unter für die HIV-Infektion und -Replikation optimalen Bedingungen vor, die bei Therapieversagen oder Therapiepausen Ausgangspunkt für einen schnellen und ausgeprägten Rebound des HIV sein können.Background: Diarrhoea and other gastrointestinal disorders are some of the most common manifestations of HIV-infection and AIDS. The mucosa-associated immune system (MALT) pertaining to the gastrointestinal tract probably houses the largest accumulation of immunocompetent cells in the body. Previous research has shown that the loss of CD4+T- cells during HIV-infection is much more pronounced in the mucosa than in the peripheral blood. This may be a consequence of the high level of viral replication seen in the mucosa. The reasons for these findings have been unclear. It has been suggested that the presence of HIV antigen may trigger the production of proinflammatory cytokines, which results in CD4+T-cell activation making these cells prone to HIV infection. In this scenario HIV enhances its own replication by stimulating cytokine production. Objectives: 1.) to quantitate the mRNA expression of selected proinflammatory, regulatory and HIV-inhibitory cytokines in the mucosa of HIV-infected patients and to compare it to healthy controls. 2.) to study the changes in cytokine expression in the course of highly active antiretroviral therapy (HAART). Methods: HIV-infected patients underwent endoscopic biopsy of colonic mucosa before and one, four and nine months after the start of HAART. Healthy volunteers, who underwent a single endoscopic biopsy served as controls. HIV-RNA and CD4+T-cell counts were measured in the blood and in the biopsy specimens. Quantitative real time PCR assays were developed to determine the mRNA expression of TNF-α, IFN-γ, IL-6, IL-2, IL-4, IL-10, IL- 16, CCL3 and CCL5 in the biopsy specimens. Specific hybridisation probes were used for the detection of the amplification products. Cytokine mRNA levels were normalised to mRNA levels of the housekeeping gene GAPDH. Results: The sensitivity of the RT-PCR assay for each cytokine and GAPDH was high with a limit of quantification of ten template copies/capillary. The calibration curve was linear over 5 orders of magnitude with R2 values > 0,998. For each of the cytokine PCRs the mean efficiency as expressed by the slope of the standard calibration curve was < 3,7 showing very little inter-assay variability (C.V. 2% - 14%). The intra-assay precision was satisfactory with C.V. < 10% throughout the whole calibration range. Nine HIV-1 infected males and one female were included in the study. The median (range) age was 42 (27 53). The median (range) plasma HIV RNA and CD4 cell count at baseline was 4,9 log-10 copies/ml (3,2 6,3) and 210 cells/µl (23 1217) respectively. The control group consisted of four males and three females with a median (range) age of 56 (48 70). The expression of the proinflammatory cytokines in the colonic mucosa was significantly higher in the HIV-infected patients as compared to the healthy controls: median (IQR) [copies cytokine mRNA/1000 copies GAPDH mRNA]; TNF-?: 1,67 (0,35 3,21) vs. 0,08 (0,06 0,11) p<0,05; IFN-?: 0,11 (0,09 0,72) vs. 0,02 (0,01 0,02) p<0,05; IL-6: 0,24 (0,14 0,95) vs. 0,01 (0,00 0,01) p<0,05. The expression level of the regulatory cytokines IL-4 and IL-10 was also higher in the HIV- infected study population: IL-4: 0,06 (0,03 0,41) vs. 0,01 (0,01 0,02), p<0,05; IL-10: 0,35 (0,11 0,84) vs. 0,01 (0,01 0,02) p<0,05. Accordingly the chemokines CCL3 and CCL5 were elevated in the HIV-infected study population: CCL3: 1,02 (0,69 3,81) vs. 0,11 (0,10 0,35) p<0,05; CCL5: 25,68 (15,24 132,10) vs. 8,80 (6,40 10,72); p<0,05. Despite a dramatic decline of virus load in both the blood and the mucosa and a rise of CD4+T-cells in the blood and the mucosa the high level of expression of all studied cytokines remained unchanged throughout nine months of HAART. Discussion: With the elimination of the HIV antigen from the mucosa we expected the expression of proinflammatory cytokines to fall. As cytokine production remained high despite fully suppressive antiviral therapy factors other than HIV must be responsible for causing mucosal inflammation. We suggest that the barrier of the colonic mucosa may have been disrupted earlier in the course of the infection leading to a continuous influx of luminal antigen, which maintains the inflammatory response even in the absence of the offending agent. The rapid repopulation of the mucosa with CD4+T-cells shown in this study could be explained by the chemotactic properties of CCL3 and CCL5 whose expression has been shown to be more than ten fold that of controls. Both the presence of a large number of CD4+T-cells and the continued high levels of inflammatory cytokines leading to T-cell activation could be the basis for the explosive virus replication often seen in the case of treatment interruption or failure

Brief Report: HIV-1 Seroconversion Is Not Associated With Prolonged Rectal Mucosal Inflammation

OBJECTIVE: Determine the impact of HIV-1 seroconversion on inflammatory cytokines in the rectal mucosa. SETTING: Secondary analysis of data from men who have sex with men (MSM) and transgender women who participated in a HIV prevention trial Lima, Peru METHODS: From July to December 2017, 605 MSM and transgender women were screened for rectal gonorrhea/chlamydia (GC/CT). 50 GC/CT positive cases were randomly selected and matched with 52 GC/CT negative controls by age and number of receptive anal intercourse (RAI) partners in last month. All participants were HIV-negative at baseline and those with GC/CT at baseline and/or follow-up received appropriate antibiotic therapy. Participants underwent sponge collection of rectal secretions for measurement of inflammatory cytokines (IL-1β, IL-6, IL-8, and TNF-α) and were screened for rectal GC/CT and HIV at baseline, 3-months, and 6-months. Wilcoxon Rank-Sum tests compared inflammatory cytokine levels between participants diagnosed with HIV during follow-up compared to persons who remained HIV-negative. RESULTS: Eight participants were diagnosed with HIV at the 3-month (n=6) or 6-month (n=2) visit. Median number of RAI partners in the month prior to HIV diagnosis was the same for those who acquired HIV and those who did not. There were no significant differences in inflammatory cytokine levels in rectal mucosa between participants who did and did not experience HIV seroconversion at any time point. CONCLUSIONS: Despite a surge in viral replication during acute infection, findings from this study suggest that there is no prolonged effect of HIV-1 seroconversion on inflammatory cytokine levels in the rectal mucosa

Cytokine Expression in the Colonic Mucosa of Human Immunodeficiency Virus-Infected Individuals before and during 9 Months of Antiretroviral Therapy▿

High-level human immunodeficiency virus (HIV) replication and the rapid breakdown of the mucosal immune system are the hallmarks of HIV infection in the gut. Cytokine dysregulation may be related to both phenomena. Using real-time PCR we quantified the colonic mucosal mRNA expression of selected proinflammatory and regulatory (gamma interferon [IFN-gamma], tumor necrosis factor alpha [TNF-α], and interleukin-2 [IL-2], IL-4, IL-6, and IL-10) and HIV-inhibitory (IL-16, CCL3, and CCL5) cytokines for 10 HIV-infected patients before and during 9 months of highly active antiretroviral therapy (HAART). HIV RNA and T-cell dynamics were measured in the colonic mucosa and the blood. Seven HIV-negative individuals served as controls. The mucosal mRNA expression of TNF-α, IFN-gamma, IL-4, IL-6, and IL-10 was significantly higher in HIV-infected patients than in control patients and remained elevated during 9 months of HAART despite the decline in blood and mucosal HIV RNA levels and an increase in the level of CD4+ T lymphocytes. The mRNA levels of CCL3 and CCL5, both of which were elevated before treatment, returned to nearly normal during therapy. Despite reductions in levels of mucosal HIV RNA and the restoration of mucosal CD4+ T lymphocytes, antiretroviral therapy failed to restore the normal colonic immunologic environment

Human monkeypox virus infection in women and non-binary individuals during the 2022 outbreaks: a global case series

International audienceBackground: Between May and November, 2022, global outbreaks of human monkeypox virus infection have been reported in more than 78 000 people worldwide, predominantly in men who have sex with men. We describe the epidemiological and clinical characteristics of monkeypox virus infection in cisgender (cis) and transgender (trans) women and non-binary individuals assigned female sex at birth to improve identification and understanding of risk factors.Methods: International collaborators in geographical locations with high numbers of diagnoses of monkeypox virus infection were approached and invited to contribute data on women and non-binary individuals with confirmed monkeypox virus infection. Contributing centres completed deidentified structured case-report spreadsheets, adapted and developed by participating clinicians, to include variables of interest relevant to women and non-binary individuals assigned female at birth. We describe the epidemiology and clinical course observed in the reported infections.Findings: Collaborators reported data for a total of 136 individuals with monkeypox virus infection who presented between May 11 and Oct 4, 2022, across 15 countries. Overall median age was 34 years (IQR 28-40; range 19-84). The cohort comprised 62 trans women, 69 cis women, and five non-binary individuals (who were, because of small numbers, grouped with cis women to form a category of people assigned female at birth for the purpose of comparison). 121 (89%) of 136 individuals reported sex with men. 37 (27%) of all individuals were living with HIV, with a higher proportion among trans women (31 [50%] of 62) than among cis women and non-binary individuals (six [8%] of 74). Sexual transmission was suspected in 55 (89%) trans women (with the remainder having an unknown route of transmission) and 45 (61%) cis women and non-binary individuals; non-sexual routes of transmission (including household and occupational exposures) were reported only in cis women and non-binary individuals. 25 (34%) of 74 cis women and non-binary individuals submitted to the case series were initially misdiagnosed. Overall, among individuals with available data, rash was described in 124 (93%) of 134 individuals and described as anogenital in 95 (74%) of 129 and as vesiculopustular in 105 (87%) of 121. Median number of lesions was ten (IQR 5-24; range 1-200). Mucosal lesions involving the vagina, anus, or oropharynx or eye occurred in 65 (55%) of 119 individuals with available data. Vaginal and anal sex were associated with lesions at those sites. Monkeypox virus DNA was detected by PCR from vaginal swab samples in all 14 samples tested. 17 (13%) individuals were hospitalised, predominantly for bacterial superinfection of lesions and pain management. 33 (24%) individuals were treated with tecovirimat and six (4%) received post-exposure vaccinations. No deaths were reported.Interpretation: The clinical features of monkeypox in women and non-binary individuals were similar to those described in men, including the presence of anal and genital lesions with prominent mucosal involvement. Anatomically, anogenital lesions were reflective of sexual practices: vulvovaginal lesions predominated in cis women and non-binary individuals and anorectal features predominated in trans women. The prevalence of HIV co-infection in the cohort was high