[Rhabdomyolysis in a bodybuilder using steroids]. / Rabdomyolyse bij een bodybuilder na gebruik van diverse dopingmiddelen.

A 34-year-old bodybuilder presented at the emergency room with fever, vomiting and muscle cramps that had started during a bodybuilding session. Several days before he started training he had used tablets and intramuscular injections containing the anabolic steroids: dehydro-chloro-methyltestosterone, boldenone and trenbolone. In addition, he had taken clenbuterol tablets, liothyronine tablets and subcutaneous injections of phosphatidylcholine. Laboratory investigations revealed massive rhabdomyolysis. The patient was treated with intravenous fluid replacement and sodium bicarbonate to alkalinize the urine. He recovered quickly and his renal function remained unaffected. 'Doping' among amateur athletes in the Netherlands occurs frequently. Apart from long term side-effects, doping can also cause acute health problems. Therefore it is important to ask about doping use during history taking in amateur athletes.

Change to abacavir-lamivudine-tenofovir combination treatment in patients with HIV-1 who had complete virological suppression.

Patients who have not received previous antiretroviral treatment (ART) have a high failure rate on the combination treatment of abacavir, lamivudine, and tenovir. We assessed the virological failure rate in eight patients with HIV-1 who switched to this combination after having complete virological suppression from their previous long-term ART (median 8.0 months, range 7.5-18.0). Five of the eight patients showed virological failure. Four of these five patients had either the K65R mutation, the M184V/I mutation, or both. This combination of drugs cannot therefore be recommended as alternative treatment in patients with HIV-1 who are fully virologically suppressed.

[A paradox: sarcoidosis in an HIV-positive patient]. / Een paradox: sarcoïdose bij een hiv-positieve patiënt.

BACKGROUND: In view of the diminished number of CD4+ lymphocytes, the co-existence of an HIV infection and sarcoidosis seems paradoxical. Immune reconstitution inflammatory syndrome (IRIS) may be observed in response to anti-retroviral therapy (ART). According to the conventional definition, this is caused by an overwhelming immune response to an already present or to a new agent. CASE DESCRIPTION: We describe the case of a 47-year-old HIV-positive patient, who presented with an exacerbation of his sarcoidosis nine months after initiation of ART. Based on the time course and the dynamics of the CD4+ lymphocyte count, this presentation of disease can be placed in the context of IRIS. CONCLUSION: The presentation or exacerbation of sarcoidosis after initiation of antiretroviral therapy in HIV-positive patients with a low CD4+ count at start of therapy can be placed in the context of IRIS.

An unusual presentation and way to diagnose hepatocellular carcinoma.

A 67-year-old man with a history of chronic obstructive pulmonary disease (COPD) was admitted with acute progression of dyspnoea, productive cough, fever, elevated central venous pressure, oedema and liver enzyme abnormalities. Pneumonia with secondary right-sided congestive heart failure was considered. Additional abdominal ultrasound examination confirmed by a CT scan showed a mass in the inferior vena cava (VCI) extending into the right atrium. The central liver location and impaired haemostasis rendered liver biopsy impossible. An alternative approach was discussed and guided by two-dimensional transoesophageal electrocardiography accessing the right internal jugular vein, biopsies were taken from the atrial mass with histology suggesting the presence of a hepatocellular carcinoma as the cause of acute dyspnoea.

[Drug-related problems in an emergency department in the center of Amsterdam, June-November 2000]. / Drugsgerelateerde problemen op een afdeling Spoedeisende Hulp in het centrum van Amsterdam, juni-november 2000.

OBJECTIVE: To gain insight into the nature and magnitude of drug-related problems in the emergency department (ED) of a hospital (Onze Lieve Vrouwe Gasthuis) in Amsterdam, the Netherlands. DESIGN: Prospective, observational. METHOD: During the period from June through to November 2000, the following data were recorded for all patients visiting the ED with drug-related problems: age, sex, nationality, form of presentation, presenting complaint, drugs used, diagnostics performed, treatment in the ED and clinical course leaving the ED. RESULTS: During the study period, 214 (1%) patients were seen with drug-related problems. The largest group consisted mainly of young, foreign occasional users of soft drugs (117 patients, 55%). Their complaints were aspecific and harmless. The need for additional diagnostics was limited, with no additional diagnostic tests being carried out in 178 patients (83%). Treatment consisted of reassurance (50 patients, 23%), observation (123 patients, 58%) and medication (85 patients, 40%). Nineteen patients (9%) needed additional treatment (suturing, plastering, etc.). Ten patients (5%) were admitted to the hospital. Reasons for admission were psychotic episodes, prolonged unconsciousness or respiratory problems. CONCLUSION: The magnitude of the drug problem in an emergency department in the centre of Amsterdam and the use of medical resources were limited. The nature of the problem consisted mainly of mild symptoms following the use of soft drugs, usually by young, foreign occasional users.

[Safety regarding invasive procedures in HIV-positive patients]. / Veiligheid rond invasieve ingrepen bij HIV-geïnfecteerde patiënten.

A 46-year-old man and a 58-year-old man, both known for several years with HIV infection, were admitted for operations due to aortic valve insufficiency (aortic valve replacement) and posttraumatic coxarthrosis (total hip replacement) respectively. In accordance with the protocol, preoperative viral infections (HIV, hepatitis B and C) were inventoried, the HIV viral load was lowered medicinally and the operation team informed. During each operation a consultant was present in the operating theatre to provide advice in the case of a needlestick or cut accident. No accidents occurred. Both patients were discharged to home in a good condition.

[Reducing the risk of blood-transmitted infections of HIV, hepatitis B or C virus in a teaching hospital in Amsterdam--evaluation of a protocol for needlestick accidents among hospital staff during the period 1997-2001]. / Risicoreductie van bloedoverdraagbare besmetting met HIV, hepatitis-B- of -C-virus in een opleidingsziekenhuis in Amsterdam--evaluatie van een protocol voor 'prikaccidenten' bij ziekenhuismedewerkers, 1997-2001.

OBJECTIVE: To evaluate a protocol for hospital staff aimed at reducing their risk of exposure to blood-transmitted infections. DESIGN: Prospective. METHOD: In August 1997 a protocol was introduced to the Onze Lieve Vrouwe Gasthuis Hospital in Amsterdam, with procedures to be followed after percutaneous or mucocutaneous blood contact in which there was a chance of transmission of hepatitis B (HBV) or C (HCV), as well as guidelines for the prescription of post-exposure prophylaxis (PEP) after accidents with an HIV risk. In the period 1 August 1997-30 June 2001 data were collected from registration forms that reported accidents and the ensuing events. RESULTS: A total of 403 accidents were reported by 138 (34.2%) physicians, 135 (33.5%) ward nurses, 46 (11.4%) operation assistants, 30 (7.4%) co-assistants, 21 (5.2%) analysts and 33 (8.2%) persons with another position. There was a constant increase in the number of reports over the period. The seroprevalence of the source patients was: 6.9% (25/360) HIV, 8.1% (6/74) HBV and 6.3% (23/363) HCV. PEP was prescribed on 46 occasions: 15 times for an HIV positive source and 31 times for what was initially an unknown HIV source. Following the introduction of a rapid HIV test in September 1999, there was a reduction in the number of unnecessary PEP prescriptions from 4 in 1997, 7 in 1998 and 16 in 1999 to 3 in 2000 and 1 in 2001. All 15 persons who were correctly started on a PEP treatment took the medication for a period of 28 days despite many side effects. No seroconversions were established during the follow-up period of 6 months.

Evaluation of the rapid immunoassay determine HIV 1/2 for detection of antibodies to human immunodeficiency virus types 1 and 2.

We evaluated the reliability of a rapid human immunodeficiency virus type 1 test for quick clinical decision making, such as in needle-stick accidents. The test was evaluated with 1,160 patients. It proved to be a simple and useful test with 99.6% specificity and 99.4% sensitivity. One patient with late-stage AIDS had a false-negative result.

Differential CD4 T-cell response in HIV-1-infected patients using protease inhibitor-based or nevirapine-based highly active antiretroviral therapy.

OBJECTIVES: To study the dynamics of CD4 T-lymphocyte counts (CD4 counts) after the initiation of either protease inhibitor (PI)-based or nevirapine (NVP)-based first-line highly active antiretroviral therapy (HAART). DESIGN AND METHODS: A retrospective cohort study of 1029 HIV-infected antiretroviral therapy-naive patients initiating either PI-based or NVP-based HAART was carried out. Patients were censored as soon as they experienced virological failure, or changed their original antiretroviral regimen for any reason. RESULTS: In total, 920 and 109 patients initiated PI- and NVP-based HAART, respectively. The patients in the PI group more often had AIDS (15 vs. 6% in the NVP group), had a lower median baseline CD4 count (234 vs. 250 cells/microL in the NVP group) and had higher median baseline plasma HIV-1 RNA levels (pVL) (5.0 vs. 4.7 log10 HIV-1 RNA copies/mL in the NVP group). After 96 weeks of follow-up, the mean increase from baseline in CD4 count, adjusted for baseline CD4 count, age, gender and baseline pVL, was 310 cells/microL in the PI group and 212 cells/microL in the NVP group (P=0.003). This difference was mainly attributable to the patients in the NVP group initiating HAART with a baseline CD4 count below 200 cells/microL. There were no differences between the PI and NVP groups with respect to the change in the number of CD4 cells as a proportion of the total number of lymphocytes. CONCLUSION: Patients successfully treated with NVP-based HAART have a smaller increase in absolute CD4 cells compared with those treated with PI-based HAART.