A randomized controlled trial investigating the efficacy and safety of switching from a protease inhibitor to nevirapine in patients with undetectable viral load.

OBJECTIVE: To assess the antiviral efficacy and safety of switching from a protease inhibitor (PI) to nevirapine in patients with long-term HIV-1 RNA suppression on PI-containing regimens, and to assess its influence in the adherence to treatment. METHODS: In an open-label multicentre study, 160 HIV-infected patients with undetectable viral load for at least 6 months on a PI-containing regimen were randomized to either continue with their PI regimen (n=79) or replace PI with nevirapine (n=81). Clinical assessment included plasma HIV-1 RNA, blood chemistry, haematology, lymphocyte counts and adverse events reports. Adherence to treatment and lipodystrophy syndrome were assessed by patient self-reporting. RESULTS: Treatment efficacy was equivalent in the two arms, for patients with viral loads either above or below 100 000 HIV-1 RNA copies/mL. The increase in CD4 cell count was significant in both arms (P<0.00001) but the average CD4 cell count at 48 weeks was slightly higher in the nevirapine arm (596 vs. 569; P=0.1588). The number of patients with severe hypertriglyceridaemia (>400 mg/dL) after 48 weeks of treatment decreased in the nevirapine arm (from 11 to six), but increased in the PI arm (from four to 11) and led to treatment discontinuation in two patients. Lipodystrophy changes increased in 15% of patients in the PI arm but decreased in 4% of patients in the nevirapine arm. Finally, although adherence was similar in the two arms, patients reported that it required significantly less effort to stay on treatment in the nevirapine arm. Conclusions The results indicate that switching from PI to nevirapine is as effective as continuing with PI for maintaining viral control, even in patients with baseline viral load above 100,000 copies/mL. In addition, reductions in hypertriglyceridaemia and lipodystrophy and in the effort required to stay on treatment were observed.

Penicillin--intermediate-resistant pneumococcal spondylodiscitis.

Pneumococcal osteomyelitis probably was more common in the pre-antibiotic era, but currently is rare. Sickle-cell disease and possibly, bone trauma and advanced age are predisposing factors for pneumococcal osteomyelitis. Bone infection usually occurs as a result of hematogenous spread from an infective focus, which often cannot be identified. In patients without evidence of other focci of infection, pneumococcal spondylodiscitis probably is caused by "primary" pneumococcal bacteriemia, originating in the oropharynx, especially if the patient has alterations that disrupt the oropharyngeal mucose. Whereas early in the antibiotic era, all Streptococcus pneumoniae strains were susceptible to penicillin, resistance to this antibiotic is on the rise, and in many parts of the world, it has emerged as a major problem. We report the case of a young patient with penicillin-resistant pneumococcal vertebral and intervertebral disk disease who had no evidence of pneumococcal infection elsewhere, and we discuss the possible mechanism of infection. We also review briefly the resistance to penicillin of S. pneumoniae and the treatment of choice.

[Mounier-Kuhn syndrome. 2 representative cases of its clinical spectrum]. / Síndrome de Mounier-Kuhn. Dos casos representativos de su espectro clínico.

Tracheobronchomegaly is characterized by tracheal and main bronchial dilatation usually associated with pulmonary parenchymatous disease. It is a rare condition and less than a hundred cases have been reported so far. Two cases of tracheobronchomegaly are here reported, one of them in an asymptomatic patients who came to medical attention because of pneumothorax (a previously non reported association); the other case was in a female patient with advanced age and history of recurrent pneumonic episodes and with marked parenchymatous involvement. In both cases the diagnostic confirmation was made by CT.

Candida albicans osteomyelitis of the zygomatic bone. A distinctive case with a possible peculiar mechanism of infection and therapeutic failure with fluconazole.

This report describes a distinctive case of zygomatic candidiasic osteomyelitis in a diabetic patient with oral candidiasis and malar ulceration secondary to topic 5-fluoroacil toxicity that eventually exposed part of the underlying bone. The mechanism of infection may have been self-inoculation of spores from muguet plaques on the oral mucosa to the exposed bone tissue by hand contact. Such a mechanism of bone infection probably should be considered in patients who frequently have oral candidiasis (diabetes, malignancies, and HIV infection) and open lesions of the skin and soft tissues. Treatment with fluconazole was ineffective, but amphotericin B was curative.

Severe renal hypouricemia secondary to hyperbilirubinemia.

A 64-year-old man with alcoholic liver cirrhosis had a progressive decrease in the serum uric acid (UA) until it became undetectable, an increase renal UA clearance, mild glycosuria with normal serum glucose and a decrease in the tubular reabsorption of phosphate in association with cholestasis secondary to a gallbladder carcinoma. All these abnormalities returned to normal when the serum bilirubin levels decreased following surgical treatment. This clinical observation suggests that the reversible renal tubular transport defect was secondary to high levels of serum bilirubin.