The perils of relying on anti-hepatitis B total core antibody in screening individuals infected with HIV.

Co-infection with HIV and hepatitis B virus (HBV) has serious long-term consequences. We describe a case of an HIV-infected heterosexual black African man with a delayed diagnosis of HBV infection. Baseline HBV screening was performed using a sequential testing algorithm starting with a total core antibody (anti-HBc) test, which was negative. He had no evidence of immunity against HBV and subsequently received three unsuccessful courses of HBV vaccination. He had mild but persistent elevation of liver enzymes over a five-year period despite maintaining full suppression of HIV replication on efavirenz, lamivudine and zidovudine; the latter was changed to abacavir due to lipoatrophy. Further testing revealed e-antibody positive chronic HBV infection with undetectable anti-HBc reactivity. High-grade HBV viraemia associated with L180M and M240V drug-resistance mutations was confirmed. He was subsequently switched to a tenofovir-based regimen, which achieved HBV suppression. Adopting effective HBV screening strategies in HIV-infected patients is recommended.

Chronic norovirus infection in pediatric hematopoietic stem cell transplant recipients: a cause of prolonged intestinal failure requiring intensive nutritional support.

Norovirus infection is a major cause of nonbacterial gastroenteritis. In immunocompetent individuals the illness caused by norovirus is mostly self limiting. Excretion of norovirus has been reported to be prolonged in the immunocompromised including adult HSCT recipients. We report a case series of 13 children who received HSCT and required prolonged parenteral and enteral nutrition due to severe gut dysfunction accompanying protracted norovirus excretion that was monitored by RT-PCR. The median duration of viral excretion was 150 days (range 60-380) and the eventual clearance of norovirus from feces was closely associated with donor T cell recovery in the peripheral blood. There was no disease manifestation beyond the gut but the severity and length of norovirus associated illness suggests that HSCT should be delayed where possible in patients excreting the virus prior to conditioning therapy.