[Choice of initial regimen for antiretroviral-naïve HIV patients: Analysis of motivation]. / Analyse des motivations du choix des antirétroviraux (ARV) prescrits chez des patients infectés par le VIH (PVVIH) naïfs.

OBJECTIVE: Several therapeutic combination antiretroviral therapy regimen are available for initial treatment in naïve HIV infected patients. The choice of a particular regimen remains often subjective. The aim of this study was to determine factors associated with the choice of molecules in initial ARV prescriptions. METHODS: From 01/01 to 30/10/2014, every initial cART prescription was analyzed regarding patients and physicians characteristics. Then, prescriptions were evaluated by an independent committee of ART prescribers. RESULTS: One hundred and thirty two consecutive initial prescriptions by 34 physicians of 11 medical centers were included: 71 M, migrants: 57 %, MSM: 21 %, CD4<200/mm3: 26 %, HIV RNA>100 000 cp/mL (33 %). cART regimen were: NRTI/PI (43 %), NRTI/NNRTI (29.5 %), NRTI/integrase inhibitor (23 %). 75 % of initial cART regimen were consistent with expert guidelines recommendations. The choice of initial cART was not influenced by the type of HIV contamination risk group, patient's geographic origin, CD4 levels. In contrast, working or not (P=0.007), pregnancy wish (P=0.07), pregnancy (P=0.001), HIV RNA levels (P=0.02) and HIV primary infection (P=0.049) influenced the initial choice. Neither physician's age, nor physician's experience influenced this choice. The prescription's non accordance to 2013 French guidelines was mainly related to integrase inhibitor utilisation (P= 0.0001). CONCLUSION: Overall, cART initial choice is mostly consistent with guidelines. Primary HIV infection, procreation features and high viral load are the main factors influencing this choice. New regimen with better tolerability is prescribed even if it is not yet included in the guidelines.

Lactobacillus septic arthritis.

Lactobacillus is a Gram positive bacteria found in the mouth, gastrointestinal and female genital tract. Serious infections due to Lactobacillus are becoming increasingly common. We present a 49-year-old diabetic patient with Lactobacillus septic arthritis. To our knowledge, this is the first reported case. Usually, Lactobacillus is implicated with bacteremia, endocarditis and more rarely pneumonia, meningitis and endovascular infection, and half of the cases are reported in immunocompromised patients. As in our patient, diabetes mellitus is a comorbid condition which has been clearly noted. Our finding suggests that further studies are necessary to establish the significance of Lactobacillus as an etiologic agent of septic arthritis.

[Primary Human Immunodeficiency Virus infection revealed by psychiatric symptoms]. / Primo-infection par le VIH révélée par une symptomatologie psychiatrique.

INTRODUCTION: Any atypical psychiatric disorder, especially if associated with somatic manifestations and when any psychiatric antecedents are missing, should lead to search for an organic pathology, and notably a Human Immunodeficiency Virus (HIV) infection. In the case of Primary Human Immunodeficiency Virus Infection (PHI), which is often symptomatic, the diagnosis is seldom made, probably because of atypical or non specific manifestations. Therefore, it is essential to consider such a diagnosis, because it may have important clinical and public health consequences (stopping the contamination chain). CASE-REPORT: We present the case of a 38 year-old homosexual man from West Indies, in whom the diagnosis of PHI had been made on the basis of psychiatric symptoms evoking a Major Depressive Episode with a doubt on the presence of psychotic symptoms. To our knowledge, this is the first report of psychiatric PHI found in scientific literature. Clinical presentation was atypical: the patient had no psychiatric history (except probably a schizotypical personality, according to his family), symptoms were atypical (sudden onset and fast improvement) associated with somatic symptoms (fever, headache, sound intolerance), the latter possibly due to a meningo-encephalitis, which had been underestimated and attributed to dehydration in a period when France was faced with an important and unexpected heatwave. Blood samples were performed on admission and revealed a thrombopenia and presence of HIV P24 antigen, testifying a contamination by HIV 2 to 4 weeks earlier, this possibility having been confirmed by the patient. Further analyses found a Western-Blot partially positive test and an HIV viral load of 315 711 Eq copies/mL. DISCUSSION: The main question about this report is the primary or secondary nature of psychiatric symptoms towards HIV infection, given that in this patient mood alteration could have possibly occurred, before HIV contamination, due to particularities of his personal and professional life. We can also question whether the neurological manifestations of PHI might be changed by a schizotypical personality. Further reports are required to answer these questions.

Decreases in plasma TNF-alpha level and IFN-gamma mRNA level in peripheral blood mononuclear cells (PBMC) and an increase in IL-2 mRNA level in PBMC are associated with effective highly active antiretroviral therapy in HIV-infected patients.

In this study, we investigated the cytokine profiles of 14 treatment-naive HIV-infected patients on the initiation of highly active antiretroviral therapy (HAART). At baseline, plasma levels of TNF-alpha and its mRNA in peripheral blood mononuclear cells (PBMC) were highest in the most severely immunocompromised patients (<200 CD4+ cells/mm3). After 12 months of HAART, the virus was undetectable in the plasma of all patients (<200 copies/ml), and median CD4 T cell counts had increased (+164 cells/mm3). We also observed a gradual decrease in the number of proviral DNA copies in PBMC and in immune activation, with lower levels of IFN-gamma mRNA in PBMC associated with weaker activation of CD8+ T cells and lower levels of plasma TNF-alpha. IL-2 mRNA levels in PBMC were found to increase in parallel. The decrease in TNF-alpha and IFN-gamma levels and the increase in IL-2 production appear to be correlated with the efficacy of HAART in naive immunocompromised HIV-infected individuals.

[Agranulocytosis in acute hepatitis B in an HIV seropositive patient]. / Agranulocytose au cours d'une hépatite B aiguë chez un patient séropositif pour le VIH.

BACKGROUND: During the course of acute hepatitis B, hematology disorders are common though they are generally mild and occur early. Agranulocytosis is exceptional and occurs late in the disease course. CASE REPORT: We report a case of agranulocytosis which developed 3 weeks after onset of acute hepatitis B in an HIV-positive patient. Peripheral and central hematological disorders led to the diagnosis. Agranulocytosis developed during the cytolytic phase of the primary hepatitis B infection and regressed after administration of hematopoietic growth factors. DISCUSSION: It is sometimes difficult to establish the causal effect of hepatitis B in the development of agranulocytosis in patients with an HIV co-infection who are on a multiple drug regimen and subject to multiple bacterial, viral or parasite infections.