Vitamin D status in chronic fatigue syndrome/myalgic encephalomyelitis: a cohort study from the North-West of England.

OBJECTIVE: Severe vitamin D deficiency is a recognised cause of skeletal muscle fatigue and myopathy. The aim of this study was to examine whether chronic fatigue syndrome/myalgic encephalomyelitis (CFS/ME) is associated with altered circulating vitamin D metabolites. DESIGN: Cohort study. SETTING: UK university hospital, recruiting from April 2014 to April 2015. PARTICIPANTS: Ninety-two patients with CFS/ME and 94 age-matched healthy controls (HCs). MAIN OUTCOME MEASURES: The presence of a significant association between CFS/ME, fatigue and vitamin D measures. RESULTS: No evidence of a deficiency in serum total 25(OH) vitamin D (25(OH)D2 and 25(OH)D3 metabolites) was evident in individuals with CFS/ME. Liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis revealed that total 25(OH)D was significantly higher (p=0.001) in serum of patients with CFS/ME compared with HCs (60.2 and 47.3 nmol/L, respectively). Analysis of food/supplement diaries with WinDiets revealed that the higher total 25(OH) vitamin D concentrations observed in the CFS/ME group were associated with increased vitamin D intake through use of supplements compared with the control group. Analysis of Chalder Fatigue Questionnaire data revealed no association between perceived fatigue and vitamin D levels. CONCLUSIONS: Low serum concentrations of total 25(OH)D do not appear to be a contributing factor to the level of fatigue of CFS/ME.

In routine UK hospital practice T-SPOT.TB™ is useful in some patients with a modest pre-test probability of active tuberculosis.

OBJECTIVE: to assess the usefulness of the T-SPOT.TB™ interferon-gamma release assay (IGRA), as used in a regional hospital infectious diseases unit in Northwest England, for the diagnosis of active tuberculosis. DESIGN: Retrospective case series. RESULTS: T-SPOT.TB™ test was applied to a group of 64 patients, 20 of whom had tuberculosis (mostly extra-pulmonary tuberculosis). The T-SPOT.TB™ test had a sensitivity of 83.3% and a specificity of 75% for the diagnosis of active tuberculosis, compared with culture. A positive IGRA approximately doubled the pre-test probability of disease from 0.23 to 0.5. This doubling of probability was true regardless of HIV status, though for HIV+ patients the sensitivity was lower (sensitivity 66.7%, post test probability 0.4 for a positive IGRA result). When extrapolated to the local population the test was most useful for exclusion of disease; post test probability 0.006 (or 1 in 167) for a negative IGRA result. CONCLUSION: Although it can add weight to a clinical diagnosis, T-SPOT.TB™ assay is not reliable for the diagnosis of active tuberculosis in a real world setting where the test is often used in patients with smear negative or extra-pulmonary disease. The test is useful for ruling out disease in HIV negative patients.

'Septrin psychosis' among renal transplant patients with Pneumocystis jirovecii pneumonia.

OBJECTIVES: To report on the temporal relationship between administration of trimethoprim/sulfamethoxazole to medically immunosuppressed HIV-negative renal patients with Pneumocystis jirovecii pneumonia (PCP) and the development of an acute psychosis. METHODS: We investigated a retrospective case series of renal transplant and immunosuppressed patients with PCP within an ongoing outbreak in the northwest of England since 2009. Four patients with PCP developed psychosis following treatment with trimethoprim/sulfamethoxazole. RESULTS: Four of twenty patients developed acute psychoses following administration of trimethoprim/sulfamethoxazole, including one accidental re-challenge. Symptoms resolved within 24 h of changing the therapy. The striking temporal relationship between the initiation and discontinuation of the drug and the behavioural changes suggests a causal relationship. CONCLUSIONS: With increasing solid organ transplantation and the use of immunosuppressants, vigilance regarding trimethoprim/sulfamethoxazole dose modification is required and the routine use of therapeutic drug monitoring should be considered.

Managing hepatitis B/HIV co-infected: adding entecavir to truvada (tenofovir disoproxil/emtricitabine) experienced patients.

BACKGROUND: Combination emtricitabine (FTC) or lamivudine (LAM) with tenofovir disoproxil (TDF) is the recommended first-line regime for treatment in chronic hepatitis B virus (HBV)/HIV co-infection. However, in those failing to suppress, few data exist regarding further management. In HBV/HIV co-infection, there are no published data describing outcomes when entecavir (ETV) is then added to TDF-based regimes in patients no longer suppressing their HBV. We report the first series of patients using ETV with truvada-based HAART in HBV/HIV co-infected patients with previous HBV therapy failure, including inadequate suppression. METHODS: A prospective observational study. RESULTS: Thirteen HIV/HBV co-infected patients (all male, hepatitis B e antigen positive and hepatitis B e antibody negative) were commenced on ETV in addition to background truvada. All patients were previously exposed to LAM or FTC and TDF (median 53 months, range 6−123). Seven patients had LAM monotherapy prior to TDF/LAM or FTC combination; the remaining six patients were exposed to FTC or LAM and TDF combination. Median time of follow-up was 74 weeks (range 16−159) and median HBV decline was 2.53 log(10) IU/ml (range 1.28−7.36). Thirty-eight percent of patients achieved undetectable HBV DNA level by the end of the study and eight of 13 (62%) achieved normal alanine aminotransferase (ALT) levels with median reduction −28 U/l (range −152 to 37). TDF was stopped in one patient because of renal toxicity. ETV was well tolerated with no change of estimated glomerular filtration rate during the study. CONCLUSION: Entecavir can be considered in addition to TDF/FTC in HBV/HIV co-infected treatment-experienced patients failing to fully suppress their HBV viral load.

Challenges in HIV post-exposure prophylaxis for occupational injuries in a large teaching hospital in Malawi.

We describe the evaluation of the HIV post-exposure prophylaxis (PEP) programme for occupational injuries in Queen Elizabeth Central Hospital, Blantyre, Malawi. An audit was performed 1 year after introduction, by reviewing files of all clients who sought advice regarding PEP. In addition, the incidence of occupational injuries and awareness of the programme were assessed through interviews with nurses. The logistics of the programme were adequate. Of 29 clients who reported occupational injuries,19 started PEP. Only double antiretroviral drug therapy was available; side-effects were common but generally mild. Attendance of scheduled follow-up visits was poor, and few HIV test results after completion of PEP were obtained. Interviews with nurses revealed a high incidence of occupational injuries, but many did not report for advice about PEP; mostly because of unawareness of the programme and a reluctance to be tested for HIV.