Manifestaciones clínico radiológicas en pacientes con coinfección tuberculosis pulmonar y VIH/sida / Clinical-radiologic manifestations inpatients with pulmonary tuberculosis and HIV/AIDS coinfection

Introducción: la infección por Mycobacterium tuberculosis es considerada la coinfección más común en personas VIH positivas. Objetivo: describir las principales características según variables sociodemográficas y clínicas seleccionadas de los pacientes VIH/sida con Tb pulmonar e identificar los hallazgos radiológicos más frecuentes para contribuir a un diagnóstico más temprano y disminuir la mortalidad por esta coinfección. Métodos: se realizó un estudio de casos clínicos. Se incluyeron 120 pacientes con VIH/sida y cultivo de esputo positivo de Mycobacterium tuberculosis, atendidos en el Hospital del Instituto de Medicina Tropical Pedro Kourí, en el periodo comprendido entre enero de 2004 y diciembre del 2010. Resultados: de los casos estudiados el 92,5 por ciento eran masculinos; 48,3 por ciento con color de piel blanca, la media de edad fue 35,6 años. La tuberculosis fue definitoria de sida en el 25,8 por ciento de los casos. La media del conteo de linfocitos T CD4+ fue 193,91 cel/µL. Las manifestaciones clínicas más frecuentes fueron fiebre, tos y pérdida de peso. Predominó el patrón radiológico primario, con infiltrados en lóbulos inferiores, infiltrados con derrame pleural e infiltrados extensos. El 25 por ciento tenían Rx de tórax normales. Conclusiones: la coinfección se presentó independientemente de los niveles de linfocitos T CD4. Las radiografías de tórax sin alteraciones no excluyeron el diagnóstico de tuberculosis en pacientes VIH/sida(AU)

Introduction: Mycobacterium tuberculosis infection is considered the most common coinfection in HIV-positive people. Objective: To describe the main characteristics according to the sociodemographic and clinical variables chosen from HIV/AIDS patients with pulmonary tuberculosis and to identify the most frequent radiological findings, in order to contribute to an earlier diagnosis and to reduce the mortality due to this coinfection. Methods: A clinical case study was carried out. A total of 120 patients with HIV/AIDS and sputum culture positive for Mycobacterium tuberculosis, treated at the Hospital of Pedro Kourí Institute of Tropical Medicine (IPK), and who were admitted between January 2004 and December 2010. Results: Out of the cases studied, 92.5 percent were male, 48.3 percent had white skin, and their mean age was 35.6 years. Tuberculosis was a defining condition for AIDS in 25.8 percent of the cases. The mean CD4+ T-lymphocyte count was 193.91 cells/?L. The most frequent clinical manifestations were fever, cough and weight loss. There was a predominance of the primary radiological pattern, with infiltrates in the lower lobes, infiltrates with pleural effusion, and extensive infiltrates. 25 percent percent had normal chest X-rays. Conclusions: Coinfection occurred independently of CD4+ T-lymphocyte levels. Unchanged chest radiographs did not exclude the diagnosis of tuberculosis in HIV/AIDS patients(AU)

Hemoptisis amenazante secundaria a aneurisma de Rasmussen en paciente VIH / Life-threatening hemoptysis secondary to Rasmussen's aneurysm in an HIV patient

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Photonic approach to the selective inactivation of viruses with a near-infrared subpicosecond fiber laser.

We report a photonic approach for selective inactivation of viruses with a near-infrared subpicosecond laser. We demonstrate that this method can selectively inactivate viral particles ranging from nonpathogenic viruses such as the M13 bacteriophage and the tobacco mosaic virus to pathogenic viruses such as the human papillomavirus and the human immunodeficiency virus (HIV). At the same time, sensitive materials such as human Jurkat T cells, human red blood cells, and mouse dendritic cells remain unharmed. The laser technology targets the global mechanical properties of the viral protein shell, making it relatively insensitive to the local genetic mutation in the target viruses. As a result, the approach can inactivate both the wild and mutated strains of viruses. This intriguing advantage is particularly important in the treatment of diseases involving rapidly mutating viral species such as HIV. Our photonic approach could be used for the disinfection of viral pathogens in blood products and for the treatment of blood-borne viral diseases in the clinic.

HIV recombination: what is the impact on antiretroviral therapy?

Retroviral recombination is a potential mechanism for the development of multiply drug resistant viral strains but the impact on the clinical outcomes of antiretroviral therapy in HIV-infected patients is unclear. Recombination can favour resistance by combining single-point mutations into a multiply resistant genome but can also hinder resistance by breaking up associations between mutations. Previous analyses, based on population genetic models, have suggested that whether recombination is favoured or hindered depends on the fitness interactions between loci, or epistasis. In this paper, a mathematical model is developed that includes viral dynamics during therapy and shows that population dynamics interact non-trivially with population genetics. The outcome of therapy depends critically on the changes to the frequency of cell co-infection and I review the evidence available. Where recombination does have an effect on therapy, it is always to slow or even halt the emergence of multiply resistant strains. I also find that for patients newly infected with multiply resistant strains, recombination can act to prevent reversion to wild-type virus. The analysis suggests that treatment targeted at multiple parts of the viral life-cycle may be less prone to drug resistance due to the genetic barrier caused by recombination but that, once selected, mutants resistant to such regimens may be better able to persist in the population.

Photochemical inactivation of selected viruses and bacteria in platelet concentrates using riboflavin and light.

BACKGROUND: A medical device is being developed for the reduction of pathogens in PLT concentrates (PCs). The device uses broadband UV light and the compound riboflavin (vitamin B(2)). STUDY DESIGN AND METHODS: Pathogens were added to single-donor PLTs. After treatment, the infectivity of each pathogen was measured using established biologic assays. In vitro PLT performance was evaluated after treatment and after 5 days of storage using a panel of 10 in-vitro cell quality assays. RESULTS: In studies with viral pathogens, the Pathogen Reduction Technology (PRT) system provided average log reduction factors of 4.46 +/- 0.39 for intracellular HIV, 5.93 +/- 0.20 for cells associated HIV, and 5.19 +/- 0.50 for West Nile virus. For the nonenveloped porcine parvovirus, a reduction factor greater than 5.0 log was observed. Staphylococcus epidermidis and Escherichia coli bacteria were also tested with observed reduction factors to the limits of detection of 4.0 log or greater. PLT cell quality was adequately maintained after treatment and during storage. Although P-selectin expression, glucose consumption, and lactate production increased relative to controls, this was not beyond accepted levels. The pH of treated PCs also decreased slightly relative to control PLTs on Days 1 and 5. CONCLUSION: The data indicate that the device successfully reduced the number of selected pathogens in PCs. Despite the fact that significant differences exist between treated and control in-vitro variables, it is speculated that the clinical effectiveness of both products will not be significantly different, based on comparison to historical data for products in routine clinical use today.

Comparison of the effects of different antiviral treatments on the antioxidant systems of stroma-free hemoglobin.

The effect of virus inactivation by 1,9-dimethylmethylene blue (DMMB) phototreatment, methylene blue (MB) phototreatment or heat on the activities of antioxidant systems of stroma-free hemoglobin (SFH) was studied. DMMB photoinactivated human immunodeficiency virus by > 3.69 log10 under conditions that inactivated 3.33 log10 of vesicular stomatitis virus (VSV). Under conditions which inactivated VSV by 6.10 log10 (1.37 J/cm2 irradiation and 2 microM DMMB), there was little change in the methemoglobin (Met-Hb) formation, concentration of reduced glutathione (GSH), or superoxide dismutase (SOD), catalase (CAT) or glutathione peroxidase (GPX) activities. However, the activity of glutathione reductase (GR) was decreased by 77%. Under conditions that inactivated VSV by 5.69 log10 (1.37 J/cm2 irradiation and 24 microM MB) there was little effect of MB phototreatment on SOD, CAT, GPX and GSH activities. However, GR activity was decreased by 74% and Met-Hb content reached 3.98%. Under conditions that inactivated VSV by more than 6.20 log10 (60 degrees C for 2 min), virucidal heat treatment resulted in 27% Met-Hb formation and decreased GPX activity by 43%. No significant decline in SOD, CAT or GR activities or GSH concentration was observed. These results suggest that, compared with heat treatment and MB phototreatment, virucidal DMMB treatment preserves not only the oxidative state of hemoglobin but also the antioxidant systems against superoxide and hydrogen peroxide, although the reduced GR activity may limit the quenching capacity of antioxidants in DMMB-treated SFH.

Activation of HIV in human skin by ultraviolet B radiation and its inhibition by NFkappaB blocking agents.

To determine whether ultraviolet B (UVB) irradiation leads to activation of HIV in human skin, we conducted prospective and controlled studies in two academic medical centers in Texas from July 1995 to April 1999. HIV-positive patients with UV-treatable skin diseases were enrolled at each center, 18 subjects at one and 16 at the other. In one center, specimens from lesional and nonlesional skin biopsies were taken before and after sham- or UVB-irradiation administered in vivo or in vitro. In the other center, UVB phototherapy was administered three times weekly and specimens from skin biopsies were taken before and after 2 weeks (six treatments). Cutaneous HIV load was assessed using reverse transcriptase-polymerase chain reaction and reverse transcriptase-polymerase chain reaction in situ hybridization. UVB irradiation led to a 6-10-fold increase in the number of HIV in skin. To ascertain a role for nuclear factor kappa B (NFkappaB) in UVB-inducible HIV activation, two types of blockers, NFkappaB oligonucleotide decoy and sodium salicylate, were tested; each inhibited UVB-inducible HIV activation in skin partially. We conclude that UVB irradiation leads to increased numbers of HIV in human skin via processes that include release of cytoplasmic NFkappaB.

Photochemical inactivation of bacteria and HIV in buffy-coat-derived platelet concentrates under conditions that preserve in vitro platelet function.

BACKGROUND AND OBJECTIVES: A photochemical process has been tested for the inactivation of viruses and bacteria in buffy-coat derived platelet concentrates (BC PCs). MATERIALS AND METHODS: BC PCs in 35% CPD plasma and 65% platelet-additive solution (PAS III) were exposed to photochemical treatment (PCT) with 150 microM of the psoralen S-59 and a 3 J/cm(2) treatment with long-wavelength ultraviolet light (UVA, 320-400 nm). Platelet function was evaluated following PCT using a panel of in vitro assays. RESULTS: This PCT process was highly effective at inactivating gram-positive bacteria (Staphylococcus epidermidis, Staphylococcus aureus, Enterococcus faecalis) and gram-negative bacteria (Enterobacter aerogenes, Pseudomonas aeruginosa, Serratia marcescens). No viable bacteria were detected following PCT and 7 days of platelet storage while bacterial growth was detected in paired untreated control BC PCs. Complete inactivation of the gram-positive Bacillus cereus was achieved only in one of two replicate experiments with BC PCs. PCT was also highly effective for inactivation of human immunodeficiency virus HIV-1 in BC PCs inoculated with approximately 10(6) tissue culture infectious doses per milliliter (TCID(50)/ml) of cell-associated HIV-1. Rapid inactivation was observed with increasing UVA doses: with 150 microM S-59 and a 1 J/cm(2) treatment of UVA, a reduction of 5.6+/-0.5 log TCID(50)/ml was achieved, and a reduction of >6.4 log TCID(50)/ml was achieved with 150 microM S-59 and a 3 J/cm(2) treatment of UVA. No physiologically relevant differences in platelet functions were found between the test and the control BC PCs during 7 days of storage. CONCLUSION: PCT with 150 microM S-59 and a 3 J/cm(2) UVA treatment does not adversely affect in vitro properties of BC PCs stored at 22 degrees C for 7 days. The PCT process inactivated bacteria and HIV-1 inoculated into the BC PCs. These results extend the earlier reported efficacy of PCT apheresis PCs to BC PCs.

Role of the p38 and MEK-1/2/p42/44 MAP kinase pathways in the differential activation of human immunodeficiency virus gene expression by ultraviolet and ionizing radiation.

Ultraviolet (UV) radiation is a potent activator of human immunodeficiency virus (HIV) gene expression in a HeLa cell clone having stably integrated copies of an HIV cat (cat gene under control of the HIV promoter) reporter construct, whereas ionizing radiation is ineffective. UV-activated HIV gene expression is completely blocked by the specific p38 mitogen-activated protein (MAP) kinase inhibitor SB203580 and by expression of a kinase-inactive p38 mutant that interferes with normal p38 function, suggesting that this stress-activated protein kinase plays an important role in UV-mediated transcriptional activation of HIV. In support of these findings, we show here that Western blot analysis demonstrated rapid and significant activation of p38 MAP kinase by UV. On the other hand, gamma-radiation activated p38 MAP kinase very poorly in HeLa cells at both low and high doses at times (5-30 min) when UV radiation was effective. UV radiation also activated HIV gene expression (< or = 9-fold) in 1G5 Jurkat T-cells stably transfected with a luciferase reporter gene under control of the HIV promoter. In these cells, gamma-radiation stimulated HIV gene expression but to a lesser extent (< or = 3-fold) and with different kinetics than after UV radiation, and this response was obliterated by the incubation of cells with the mitogen-activated protein kinase/Erk kinase (MEK)-1/2 inhibitor PD98059. This result suggests that in these cells signaling in response to gamma-radiation is transduced through the MEK-1/2/p42/44 MAP kinase pathway to increase HIV gene expression. All combined, these results suggest that activation of p38 MAP kinase is necessary for efficient HIV gene expression triggered by DNA damaging agents, and, in a cell type-specific manner, activation of the MEK-1/2/p42/44 MAP kinase pathway is important for triggering a response to gamma-radiation. Thus, it appears as if UV signaling leading to HIV gene expression requires the p38 MAP kinase pathway whereas activation by gamma-radiation requires the MEK-1/2/p42/44 MAP kinase pathway.

Activation of NF-kappa B and p38 MAP kinase is not sufficient for triggering efficient HIV gene expression in response to stress.

Recent studies have established an essential role for p38 MAP kinase in UV activation of human immunodeficiency virus (HIV) gene expression. However, p38 MAP kinase is not involved in activation of NF-kappa B, a key transcriptional activator of HIV gene expression, in response to UV, suggesting that NF-kappa B acts independently of p38 MAP kinase. In this study, we have investigated whether activation of HIV gene expression occurs when p38 MAP kinase and NF-kappa B are activated by separate stress-causing treatments, each relatively specific for activating only one of the factors. Treatment of cells with sorbitol (hyperosmotic shock) strongly activates p38 MAP kinase, whereas the cytokine TNF-alpha is a poor activator of p38 MAP kinase. On the other hand, TNF-alpha is a strong activator of NF-kappa B whereas sorbitol is not. Sorbitol, however, activates AP-1 DNA binding activity in a manner similar to that of UV. Most importantly, both sorbitol and TNF-alpha are poor activators of HIV gene expression in HeLa cells stably transfected with an HIVcat reporter gene, whereas UV elicits a strong response. The combined treatment with UV and hyperosmotic shock produces an additive effect on HIV gene expression, suggesting that these agents activate at least in part by different mechanisms. The combined treatment with sorbitol and TNF-alpha activates p38 and NF-kappa B to levels similar to those with UV, yet only results in 25-30% of the CAT levels elicited by UV. Inhibition of NF-kappa B activation by the protease inhibitor N-alpha-tosyl-L-phenylalanine chloromethyl ketone (TPCK) prevents UV activation of HIV gene expression, but does not inhibit p38 MAP kinase activation. We conclude that whereas both p38 MAP kinase and NF-kappa B are important for UV activation of HIV gene expression they act independently from each other and activation of both factors is not sufficient for triggering a full HIV gene expression response. Activation of HIV gene expression by UV must therefore involve additional cellular processes, such as those triggered by DNA damage, for generation of a full gene expression response.

Inactivation of HIV by application of heat and radiation: implication in bone banking with irradiated allograft bone.

We developed methods for inactivating the human immunodeficiency virus by heat and ionizing radiation and tested the effects of these treatments on the mechanical strength of bone. Simultaneous use of heat and radiation caused a considerably greater inactivation of HIV than the additive effects of the two separate treatments, but also caused a significant reduction in the maximum load sustained by the bone specimens tested with an Instrom machine. Application of the same doses but given in the sequential fashion of radiation followed by heat also caused marked inactivation of HIV and had less effect on the mechanical strength of the bone.

Genetic evidence that stress-activated p38 MAP kinase is necessary but not sufficient for UV activation of HIV gene expression.

We have examined the role of stress-activated p38 MAP kinase in regulating human immunodeficiency virus (HIV) gene expression in response to ultraviolet light (UV). We found that UV activated p38 in HeLa cells harboring stably integrated copies of an HIVcat plasmid to levels similar to those obtained by hyperosmotic shock. However, hyperosmotic shock resulted in one order of magnitude smaller increase in CAT activity than treatment with UV. The specific p38 inhibitor SB203580 significantly decreased (>80%) UV activation of HIV gene expression whereas PD98059, a specific MEK-1 inhibitor did not, suggesting that p38 is specifically involved in the HIV UV response and little to no contribution is provided by MEK-1 and the p42/p44 MAP kinase pathway. Whereas increased binding of NF-kappaB to an oligonucleotide spanning the HIV enhancer was observed after UV, as expected, this binding was not affected by SB203580. Furthermore, UV activation of HIV gene expression in cells having the cat reporter gene under control of an HIV promoter deleted of the enhancer (-69/+80) produced results indistinguishable from those using HIVcat/HeLa cells with an intact HIV promoter (-485/+80), suggesting that SB203580 acts through the basal transcription machinery. Northern blot analysis of steady-state RNA from HIVcat/HeLa cells revealed an almost complete inhibition of UV activation with SB203580 at the RNA level. Similarly, the UV response was almost completely obliterated at the CAT and RNA levels in HIVcat/HeLa cells stably transfected with a plasmid expressing a kinase-inactive mutant of p38 (isoform alpha), without affecting NF-kappaB activation, providing strong genetic evidence that p38, at least the alpha isoform, is necessary for UV activation of HIV gene expression and that NF-kappaB activation alone is insufficient. These results firmly establish p38 MAP kinase as a key modulator of HIV gene expression in response to UV that acts independently of NF-kappaB.

Sterilization of HIV with irradiation: relevance to infected bone allografts.

BACKGROUND: Bone allograft banks commonly sterilize frozen bone by irradiation. The dose-response relationship for HIV is calculated and the dose required to inactivate the bioburden of virus that may be present in allograft bone is determined. METHODS: A virus titre experiment is performed using irradiated frozen HIV. The virus is maintained on dry ice (approximately -70 degrees C) and is exposed to a cobalt 60 source with 0-40 kGy irradiation at 5 kGy intervals. Lymphocyte cell cultures are exposed to serial dilutions of the irradiated virus. The virus titre is quantified by cytological changes of HIV infection and p24 immunofluorescence. RESULTS: There is a linear relationship between the virus titre and the radiation dose delivered. The inactivation rate of irradiated virus was 0.1134 log10 tissue culture infective doses 50/mL per kGy (95% confidence intervals, 0.1248-0.1020). The irradiation dose required to inactivate the HIV bioburden in allograft bone is 35 kGy. The irradiation dose required to achieve a sterility assurance level of 10(-6) is 89 kGy. This dose exceeds current recommendations for sterilizing medical products and the current practice of many bone banks. CONCLUSIONS: It is concluded that gamma irradiation should be disregarded as a significant virus inactivation method for bone allografts.

HIV expression is induced in dying cells.

Using HeLa cells stably transfected with an HIV-LTR-CAT construct, we demonstrated a peak in CAT induction that occurs in viable (but not necessarily cell-division-competent) cells 24 h following exposure to some cell-killing agents. gamma rays were the only cell-killing agent which did not induce HIV transcription; this can be attributed to the fact that gamma-ray-induced apoptotic death requires functional p53, which is not present in HeLa cells. For all other agents, HIV-LTR induction was dose-dependent and correlated with the amount of cell killing that occurred in the culture. Doses which caused over 99% cell killing induced HIV-LTR transcription maximally, demonstrating that cells that will go on to die by 14 days are the cells expressing HIV-LTR-CAT.

Effect of low-dose gamma radiation of HIV replication in human peripheral blood mononuclear cells.

Recent studies have demonstrated that UV light and x-irradiation enhance human immunodeficiency virus (HIV) gene expression. There are few published data on related effects of gamma-radiation. This may be of clinical relevance, as radiotherapy has been used extensively for the treatment of acquired immunodeficiency syndrome associated conditions. With this in mind, we have studied the effects of gamma-radiation on HIV replication in mononuclear cells (MC). These cells were obtained from five seronegative healthy donors, exposed to 0-200 cGy gamma-radiation, stimulated with phytohemagglutinin-P (PHA-P) for 24 h, infected with a laboratory strain of HIV (HTLV-IIIB, multiplicity of infection = 0.001), then carried in culture for 14 days. Overall, when considering p24 antigen levels on days 7 and 11 in cultures established from cells exposed to 50 cGy, the maximal levels were significantly higher than those measured in the parallel control cultures taken as a whole (P < 0.05), with viral replication enhanced as much as 1000-fold in one case. No significant cytotoxicity was observed following exposure to doses up to 50 cGy. The mechanism of the observed effect remains unknown but may relate to direct gene activation and/or free radical generation, leading to such activation. To date, there is no evidence that viral stimulation occurs following therapeutic radiation in a clinical setting.

Medical UV exposures and HIV activation.

This paper presents the first attempt to evaluate the potential of clinical UV exposures to induce the human immunodeficiency (HIV) promoter and, thus, to upregulate HIV growth in those skin cells that are directly affected by the exposure. Using the data for HIV promoter activation in vitro, we computed UVB and psoralen plus UVA (PUVA) doses that produce 50% of the maximal promoter activation (AD50). Then, using (a) literature data for UV transmittance in the human skin, (b) a composite action spectrum for HIV promoter and pyrimidine dimer induction by UVB and (c) an action spectrum for DNA synthesis inhibition by PUVA, we estimated the distribution of medical UVB and PUVA doses in the skin. This allowed us to estimate how deep into the skin the HIV-activating doses might penetrate in an initial and an advanced stage of UVB or PUVA therapy. Such analysis was done for normal type II skin and for single exposures. The results allow us to predict where in the skin the HIV promoter may be induced by selected small and large therapeutic UVB or PUVA doses. To accommodate changes in skin topography due to disease and UV therapy, our considerations would require further refinements. For UVB we found that, when the incident dose on the surface of the skin is 500 J/m2 (290-320 nm) (initial stage of the therapy), the dose producing 50% of the maximal HIV promoter activation (ADUVB50) is limited to the stratum corneum. However, with an incident dose of 5000 J/m2 (an advanced stage of the therapy), ADUVB50) may be delivered as far as the living cells of the epidermis and even to some parts of the upper dermis. For PUVA we found that, when the incident UVA doses are 25 or 100 kJ/m2 (320-400 nm) (an initial and an advanced stage of therapy, respectively), and the 8-methoxypsoralen concentration in the blood is 0.1 microgram/mL (the desired level), the combined doses to the mid epidermis (and some areas of the upper dermis) are well below the 50% HIV promoter-activating PUVA dose (ADPUVA50). Only under the worst scenario conditions, i.e. an exceptionally high drug concentration in the patient's tissues and localization of HIV in the nearest proximity to the skin surface, would the combined PUVA dose expected during photochemotherapy exceed ADPUVA50. These results suggest that the probability of HIV activation in the epidermis by direct mechanisms is higher for UVB than for PUVA treatment. However, complexities of the UV-inducible HIV activation and immunomodulatory phenomena are such that our results by themselves should not be taken as an indication that UVB therapy carries a higher risk than PUVA therapy when administered to HIV-infected patients.