Pharmacokinetics of rifabutin during atazanavir/ritonavir co-administration in HIV-infected TB patients.

BACKGROUND & OBJECTIVE: Rifabutin (RBT) is the rifamycin that is recommended to treat tuberculosis (TB) in HIV-infected individuals during combination antiretroviral therapy (ART) containing HIV protease inhibitors (PIs). We studied the pharmacokinetics of rifabutin at doses of 300 mg thrice weekly and 150 mg daily during concomitant atazanavir/ritonavir (ATZ/r) administration in adult HIV-infected TB patients treated in the Revised National TB Control Programme (RNTCP) in India. METHODS: This was a multi-centric study conducted in 45 adult HIV-infected TB patients, who were being treated for TB with a RBT-containing regimen and an antiretroviral treatment regimen with ATZ/r, at doses of 300 mg thrice-weekly (n = 36) or 150 mg daily (n = 9). Serial blood draws at pre-dosing and at 1, 2, 4, 6, 8, 12 and 24 hours after drug administration were done. Plasma RBT was estimated by high pressure liquid chromatography (HPLC). RESULTS: The peak concentration (Cmax) of both doses were within the therapeutic range (0.45-0.90 µg/ml) of RBT. Proportion of patients having Cmax above or below the therapeutic range and trough concentration (Cmin) below the minimum inhibitory concentration of RBT did not significantly differ between the two doses. TB treatment outcomes were also similar at both doses. CONCLUSIONS: This is the first and only study from India reporting on the pharmacokinetics of RBT at 300 mg thrice weekly and 150 mg daily doses. Both doses yielded similar plasma RBT concentrations, outcomes and were well tolerated. RBT can be administered at either doses during ATZ/r co-administration in HIV-infected patients with TB.

Type 1 and type 3 Gaucher disease in two siblings in a family: 2 unusual case reports.

Gaucher disease (GD) is an autosomal recessive disorder, characterized by lack of acid ß-glucosidase (glucocerebrosidase) enzyme resulting in accumulation of glucosylceramide in different organs. It is common in Ashkenazi Jews but rare in India. Around five hundred cases are identified and diagnosed in India. We are reporting two interesting cases of type 1 non-neuropathic and type 3 juvenile subacute neuropathic variant of adult Gaucher disease in two of three siblings in a family.

Factors responsible for delayed enrollment for anti-retroviral treatment.

BACKGROUND: Late presentation followed by delayed diagnosis and further delayed initiation of anti-retroviral therapy (ART) increases the risk of opportunistic infections and neoplasms among the HIV infected patients. Furthermore, this leads to not only poor response to therapy but also early death among them. METHODS: An institution based cross-sectional study was undertaken to identify the factor(s) responsible for delayed registration for initiation of therapy among the HIV infected patients with absolute CD4 count <250 cells/µL based on self reports. ART naïve adult HIV patients (age ≥18 years) with baseline CD4 count of <250 cells/µL were included in this study. RESULTS: Most patients 95 (95%) were unaware of the available 'Integrated Counseling and Testing Centres'. Although 13 (13%) respondents had multiple reasons for delayed enrollment, majority 47 (47%) of the delays were due to the physician's failure to suspect and refer them for HIV testing at the earliest opportunity. Other causes include health seeking behavior 13 (13%), fear of stigma 5 (5%), depression 3 (3%), and lack of family support 6 (6%). CONCLUSIONS: Even though delays in pre-ART enrollment have been realized since long, prevention efforts are poor, mostly due to the lack of understanding of the nature of the problem in its social context. Lack of clinical suspicion for HIV infection at the primary and secondary levels of health care still remains the most important reason for the delay. In order to prevent these delays in enrollments, intervention efforts need to be focused on not only the people infected with HIV but the primary health care providers as well, especially the practicing physicians.

Castlemans disease in HIV infected patient from eastern India.

Castlemans disease is a rare lymphoproliferative disorder. We report a patient of Castlemans disease with advanced HIV infection who responded well to conventional HAART. This case is interesting because of the rarity of the disease in the eastern part of India and its good out come with antiretroviral therapy.

Studies on the membrane integrity of human sperm treated with a new injectable male contraceptive.

BACKGROUND: The aim of this study was to evaluate the integrity of sperm surface characteristics in the presence of a new male contraceptive, RISUG [1 mg styrene maleic anhydride (SMA)/100 microl dimethylsulphoxide (DMSO) in 1 ml sperm solution]. METHODS: Progressively motile human sperm were treated in vitro with RISUG. The cells were analysed for the release of 5'-nucleotidase (5'-NT) (a plasma membrane marker) using 3 mmol/l 5'-AMP and 3 mmol/l beta-glycerophosphate as substrates. Hyaluronidase (an acrosomal membrane marker) was analysed using hyaluronic acid as a substrate. The contents of free and total acrosin, and % proacrosin (all acrosome markers) were assayed using 0.5 mmol/l alpha-N-benzoyl-L-arginine ethylester (BAEE). RESULTS: RISUG caused almost complete disintegration of the plasma membrane leading to significant (P < 0.0001) release of 5'-NT into the surrounding media. Complete dissolution of the acrosome with concomitant vesiculation of the membrane system, as judged from the loss of hyaluronidase, was observed. Total acrosin content in the sperm was also reduced to almost 10%, and proacrosin dropped to 13.2% in the presence of RISUG in comparison to 90.2% in control (P < 0.0001), indicating dispersion of acrosomal contents. CONCLUSION: Under in vitro conditions, RISUG, at a concentration of 1 mg SMA dissolved in 100 microl of DMSO, caused significant damage to the acrosome and its contents, indicating loss of functional ability of sperm.

Mucocutaneous manifestations of HIV infection.

BACKGROUND AND AIMS: Human immunodeficiency virus (HIV) is associated with various mucocutaneous features, which may be the first pointer towards the existence of HIV infection. This study was done to note the different mucocutaneous lesions present in the HIV population in eastern India. METHODS: Four hundred and ten HIV seropositive patients attending the outpatient and inpatient departments were included in the study. RESULTS: Out of 410 HIV positives, 40% had mucocutaneous involvement at presentation. The mean age of the study population was 29 years and male to female ratio was 2.5:1. The common mucocutaneous morbidities included oral candidiasis (36%), dermatophytosis and gingivitis (13% each), herpes zoster (6%), herpes simplex and scabies (5% each). A striking feature, noted in 36% males, was straightening of hairs. Genital herpes was the commonest genital ulcer disease. Lesions associated with declining immunity included oral candidiasis, oral hairy leukoplakia and herpes zoster with median CD4 counts of 98, 62 and 198/ L respectively. CONCLUSION: Early recognition of mucocutaneous manifestations and associated STDs help in better management of HIV/AIDS.

People living with HIV infection / AIDS - a study on lymph node FNAC and CD4 count.

Between July 1997 and December 2000, 1616 HIV seropositive persons were identified by Western Blot test at the School of Tropical Medicine, Kolkata. Four hundred seventy two (29.2%) of them had generalized lymphadenopathy. CD4 count could be done in only 54 of these 472 subjects (11.4%). These 54 patients, consisting of 40 males (74%) and 14 females (26%) were the subjects of the study. Their mean age was 29.5 years. In all these subjects, FNAC was done from the enlarged lymph nodes (non-inguinal). Reactive hyperplasia was seen in 30 cases (55.5%) whose absolute CD4 count varied between 411-945 cells/microL (median value 670 cells/microL). Evidence of tuberculous lymphadenitis was detected in 22 (41%) with CD4 counts varying between 113 and 422 cells/microL (median value 212 cells/microL). Non-Hodgkin lymphoma was diagnosed in 2 cases (3.7%) with CD4 count 79-113 cells/microL. All patients had evidence of HIV-1 infection, excepting one case of dual infection (HIV-1 and 2).

A proton NMR study of the effect of a new intravasal injectable male contraceptive RISUG on seminal plasma metabolites.

Nuclear magnetic resonance (NMR) spectroscopy was used to quantify citrate, glucose, lactate, glycerophosphorylcholine and choline in seminal plasma from subjects injected with a new male contraceptive RISUG, a copolymer of styrene maleic anhydride dissolved in dimethyl sulphoxide, and in seminal plasma from normal ejaculates. No significant difference in the concentration of citrate was observed between the groups, indicating that the prostate is not affected by the contraceptive. The concentrations of glucose, lactate, glycerophosphorylcholine and choline were significantly lower (P < 0.01) in subjects injected with RISUG compared with controls. In addition, metabolite ratios such as choline:citrate, citrate:lactate, choline:lactate and glycerophosphorylcholine:choline were calculated. Citrate:lactate and glycerophosphorylcholine:choline ratios were significantly lower in RISUG-injected subjects than in controls (P < 0.01), thereby indicating the occurrence of partial obstructive azoospermia. The most important finding of the present study was that the intervention of RISUG in the vas deferens even for a period as long as 8 years is absolutely safe and does not lead to prostatic diseases.

Differential decline in Leishmania membrane antigen-specific immunoglobulin G (IgG), IgM, IgE, and IgG subclass antibodies in Indian kala-azar patients after chemotherapy.

Pathogenesis in kala-azar is associated with depressed cellular immunity and significant elevation of antileishmanial antibodies. Since these antibodies are present even after cure, analysis of the parasite-specific isotypes and immunoglobulin G (IgG) subclasses in kala-azar patients may shed new light on the immune responses during progression and resolution of infection. Using leishmanial membrane antigenic extracts, we investigated the relative levels of specific IgG, IgM, IgA, IgE, and IgG subclasses in Indian kala-azar patient sera during disease, drug resistance, and cure. Acute-phase sera showed strong stimulation of IgG, followed by IgE and IgM and lastly by IgA antibodies. IgG subclass analysis revealed expression of all of the subclasses, with a predominance of IgG1 during disease. Following sodium stibogluconate (SAG) resistance, the levels of IgG, IgM, IgE, and IgG4 remained constant, while there was a decrease in the titers of IgG2 and IgG3. In contrast, a significant (2.2-fold) increase in IgG1 was observed in these individuals. Cure, in both SAG-responsive and unresponsive patients, correlated with a decline in the levels of IgG, IgM, IgE, and all of the IgG subclasses. The stimulation of IgG1 and the persistence, most importantly, of IgE and IgG4 following drug resistance, along with a decline in IgE, IgG4, and IgG1 with cure, demonstrate the potential of these isotypes as possible markers for monitoring effective treatment in kala-azar.

Multiple-pulse-mediated electrofusion of intact erythrocyte onto human term placental amnion.

The creation of surface modified human term placental amnion by electrofusing human cells onto its surface has been thought of. A multiple-pulse electrofusion protocol with 10 square pulses of 10-micros pulse length, and electric field of 0.2 kV cm(-1), can make erythrocyte-amnion tissue electrofusion possible. The protocol devised merge the cell-tissue-adherence steps with fusogenic pulse. The finding opens up a new avenue of cell electrofusion onto human tissue with minimal procedural complexities.

Theoretical aspects of single pulse induced modulation of cell-cell interactions favoring iso-electrofusion.

A single pulse-mediated electrofusion of freely suspending widely separated cells could reduce steps in the protocol. Prediction of such electrofusion is still unsolved. In pre-pulse condition, quantitative estimation with three-layered model cell surface reveals electrostatic repulsion (due to negative surface charge) is the major hindrance to membrane-to-membrane contact. On theoretical grounds we predict that designed single high voltage pulsing on widely separated model cell surface can counteract the non-specific repulsive interaction and favor approach of two apposed membranes. But hydrodynamic modulation of pulse exposed cell surface interaction can hamper approach of membranes contact when cells are held at a gap of more than approximately 450 A.

Membrane microextension: a possible mechanism for establishing molecular contact in electrofusion.

True cell membrane contact is an essential condition for electro-pulsed cell fusion, but initial morphological perturbation leading to true contact is still not clear. Dielectrophoresis mediated compression and fusogenic pulse induced compaction of cells led to rapid merger of tight membranes, and deprived direct microscopic view of surface membrane perturbation. Freely suspending cells with large and different cell-cell gaps may proceed to electrofusion with perturbed membrane and initiates fusion events at different time. These pulsed exposed cells can be used for capturing changes in the membrane surface and early electrofusion events. Early stage of fusion of freely suspended intact human erythrocytes exposed to single exponential decay pulse was studied by scanning electron microscopy (SEM). Field pulse induces small membrane bumps. Interaction of bumps on adjacent membranes lead to true membrane contact and form bridges between the membranes as microextension, combining both membranes into a topologically single structure. Some fusion products showed expanded fusion zones, which suggest indication of open lumen at contact area.

Immunoglobulin subclass distribution and diagnostic value of Leishmania donovani antigen-specific immunoglobulin G3 in Indian kala-azar patients.

Visceral leishmaniasis, or kala-azar, a fatal tropical disease, remains problematic, as early diagnosis is difficult and treatment often results in drug resistance and relapse. We have developed a sensitive enzyme-linked immunosorbent assay (ELISA), using leishmanial membrane antigenic extracts (LAg) to detect specific antibody responses in 25 untreated Indian visceral leishmaniasis patients. To investigate the pathogenetic significance of isotype markers in kala-azar, relative levels of specific immunoglobulin G (IgG), IgM, IgA, IgE, and IgG subclasses were analyzed under clinically established diseased conditions. Since LAg showed higher sensitivity for specific IgG than lysate, the immunoglobulin isotype responses were evaluated, with LAg as antigen. Compared to 60 controls, which included patients with malaria, tuberculosis, leprosy, and typhoid and healthy subjects, visceral leishmaniasis patients showed significantly higher IgG (100% sensitivity, 85% specificity), IgM (48% sensitivity, 100% specificity), and IgE (44% sensitivity, 98.3% specificity) responses. Low levels of IgA in visceral leishmaniasis patients contrasted with a 13-fold-higher reactivity in sera from patients with leprosy. Among IgG subclasses, IgG1, -3, and -4 responses were significantly higher in visceral leishmaniasis patients than in the controls. IgG2 response, however, was significantly higher (twofold) in leprosy than even visceral leishmaniasis patients. The rank orders for sensitivity (IgG = IgG1 = IgG3 = IgG4 > IgG2 > IgM > IgE > IgA) and specificity (IgM = IgG3 > IgE > IgG4 > IgG2 > IgG > IgG1 > IgA) for LAg-specific antibody responses suggest the potentiality of IgG3 as a diagnostic marker for visceral leishmaniasis.

Non-invasive reversal of intraluminal vas deferens polymer injection-induced azoospermia--technology.

AIM: The rationale and technique underlying a novel concept of non-invasive removal of an intravasal vas deferens polymeric contraceptive drug to reverse drug injection-induced azoospermia are explained. Thus the conventional methods of surgical exploration to remove vas deferens plugs and intravasal injection of solvents to flush out contraceptive drugs are to be replaced by steps which will be readily accepted by subjects. METHODS: The approach is based upon the non-invasive application of specific forces to various segments of the vas deferens so that non-sclerosing and non-tissue-adherent compounds, in particular styrene maleic anhydride (SMA) can be expelled. Forces are generated by palpation; percutaneous electrical stimulation; vibration application; and percussion. The forces help to propel the intravasal polymer towards the ejaculatory duct for expulsion during ejaculation. All aspects of the total technique are clinically acceptable, simple, atraumatic, unlikely to cause pain and discomfort even without tranquilizers, local or general anaesthetics. The procedure may be repeated several times in different sittings spaced apart by about one week to achieve adequate plug expulsion. RESULTS: Model experiments demonstrated the feasibility of the concept. The polymer was nonadherent and could be moved within the vas deferens by the application of specific forces. Sufficient removal was possible to enable spermatic fluid to be transported along a region previously occupied by the polymer. A corroborating subhuman primate study by an independent investigator has shown that the semen profile becomes normal following the reversal. CONCLUSION: Adoption of the new technique may provide a means of non surgical restoration of normal semen profile after a period of fertility control obtained by intravasal drug injection.

Histoplasmosis in eastern India: the tip of the iceberg?

Systemic histoplasmosis has various clinical presentations and is of especially concern in immunocompromised patients. A high index of suspicion is required for its diagnosis. A total of 38 cases had been reported from India up to 1996. The most frequent occurrence of cases was around Calcutta in eastern India where the previous case was detected 20 years earlier. However, we have diagnosed 5 cases in the past 2 years from eastern India which are reported here. These cases may indicate under-diagnosis and under-reporting of histoplasmosis in India. All 5 patients had disseminated disease with multisystem involvement including 2 with bilateral adrenal enlargement. Two were diabetic and only 1 patient was infected with HIV.

Reversibility with sodium bicarbonate of styrene maleic anhydride, an intravasal injectable contraceptive, in male rats.

A copolymer of styrene and maleic anhydride (SMA) was dissolved in dimethyl sulphoxide (DMSO) and injected into the lumen of the vas deferens of rats. The polymer was retained in the lumen for a period of more than 90 days. Sodium bicarbonate (10%), pH 8.9, was used to flush the polymeric material from the vas deferens lumen. The reversibility and patency of the vas deferens was thus obtained. Sodium bicarbonate proved to be an effective alternative to dimethyl sulphoxide for reversal.

Distribution of IgG subclasses in antimonial unresponsive Indian kala-azar patients.

Sodium antimony gluconate (SAG) is the mainstay of treatment for visceral leishmaniasis (VL) or kala-azar. In view of the increasing incidence of refractoriness to SAG in India, we compared the levels of parasite-specific IgG and IgG subclasses in 20 longitudinally followed up kala-azar patients. In both SAG-responsive (n = 10) and unresponsive patients (n = 10), the levels of total IgG, IgG1, IgG2, IgG3 and IgG4 were increased, the rank order being IgG1 > IgG2 > IgG3 = IgG4. Following treatment, a significant decrease in total IgG and the four subclasses occurred in the SAG-responsive group, whereas in the SAG-unresponsive group these levels were unchanged or slightly increased. Therefore, monitoring of IgG1 and IgG2 levels in Indian kala-azar patients is a good serologic alternative to monitoring the disease status.

Interplay of matrices in cartilage synovial fluid combine under moderate & high loadings.

Interplay of the constituents of the articular cartilage synovial fluid combine and its role was examined through the biochemical and rheological studies on bovine joints. The results showed an inverse relationship between the changes in the hyaluronic acid of synovial fluid and the proteoglycans content in articular cartilage together with alterations in the rheological properties of synovial fluid. The study indicated that the inter-movement of fluid solutes across the cartilage and synovial fluid may have an important role in the pathophysiology of osteoarthritis.