Challenges in achieving a target international normalized ratio for deep vein thrombosis among HIV-infected patients with tuberculosis: a case series.

BACKGROUND: Tuberculosis (TB) and HIV are among the risk factors for deep vein thrombosis (DVT). There are several challenges in the management of DVT patients with TB-HIV co-infection including drug-drug interactions and non-adherence due to pill burden. METHODS: HIV infected patients starting treatment for TB were identified and followed up two weekly. Cases of DVT were diagnosed with Doppler ultrasound and patients were initiated on oral anticoagulation with warfarin and followed up with repeated INR measurements and warfarin dose adjustment. RESULTS: We describe 7 cases of TB and HIV-infected patients in Uganda diagnosed with DVT and started on anticoagulation therapy. Their median age was 30 (IQR: 27-39) years and 86 % were male. All patients had co-medication with cotrimoxazole, tenofovir, lamivudine and efavirenz and some were on fluconazole. The therapeutic range of the International Normalization Ratio (INR) was difficult to attain and unpredictable with some patients being under-anticoagulated and others over-anticoagulated. The mean Time in Therapeutic Range (TTR) for patients who had all scheduled INR measurements in the first 12 weeks was 33.3 %. Only one patient among those with all the scheduled INR measurements had achieved a therapeutic INR by 2 weeks. Four out of seven (57 %) of the patients had at least one INR above the therapeutic range which required treatment interruption. None of the patients had major bleeding. CONCLUSION: We recommend more frequent monitoring and timely dose adjustment of the INR, as well as studies on alternative strategies for the treatment of DVT in TB-HIV co-infected patients.

Proteolytic cleavage of the amino terminus of the U(L)15 gene product of herpes simplex virus type 1 is coupled with maturation of viral DNA into unit-length genomes.

The U(L)15 gene of herpes simplex virus type 1 (HSV-1), like U(L)6, U(L)17, U(L)28, U(L)32, and U(L)33, is required for cleavage of concatameric DNA into genomic lengths and for packaging of cleaved genomes into preformed capsids. A previous study indicated that the U(L)15 gene encodes minor capsid proteins. In the present study, we have shown that the amino-terminal 509 amino acids of the U(L)15-encoded protein are sufficient to confer capsid association inasmuch as a carboxyl-terminally truncated form of the U(L)15-encoded protein with an M(r) of approximately 55,000 readily associated with capsids. This and previous studies have shown that, whereas three U(L)15-encoded proteins with apparent M(r)s of 83,000, 80,000, and 79,000 associated with wild-type B capsids, only the full-length 83,000-M(r) protein associated with B capsids purified from cells infected with viruses lacking functional U(L)6, U(L)17, U(L)28, U(L)32, and U(L)33 genes (B. Salmon and J. D. Baines, J. Virol. 72:3045-3050, 1998). Thus, all viral mutants that fail to cleave viral DNA into genomic-length molecules also fail to produce capsid-associated U(L)15 80,000- and 79,000-M(r) proteins. In contrast, the 80,000- and 79,000-M(r) proteins were readily detected in capsids purified from cells infected with a U(L)25 null virus that cleaves, but does not package, DNA. The conclusion that the amino terminus of the 83,000-M(r) protein is truncated to produce the 80,000- and/or 79,000-M(r) protein was supported by the following observations. (i) Whereas the C termini of the 83,000-, 80, 000-, and 79,000-M(r) proteins are identical, immunoreactivity dependent on the first 35 amino acids of the U(L)15 83,000-M(r) protein was absent from the 80,000- and 79,000-M(r) proteins. (ii) The 79,000- and 80,000-M(r) proteins were detected in capsids from cells infected with HSV-1(U(L)15M36V), an engineered virus encoding valine rather than methionine at codon 36. Thus, initiation at codon 36 is unlikely to account for production of the 80,000- and/or 79, 000-M(r) protein. Taken together, these data strongly suggest that capsid-associated U(L)15-encoded protein is proteolytically cleaved near the N terminus and indicate that this modification is tightly linked to maturation of genomic DNA.

The U(L)15 gene of herpes simplex virus type 1 contains within its second exon a novel open reading frame that is translated in frame with the U(L)15 gene product.

The U(L)15 gene of herpes simplex virus type 1 is composed of two exons. A mutation previously shown to preclude viral DNA cleavage and packaging at the nonpermissive temperature was identified as a change from a highly conserved serine to proline at codon 653. Separate viral mutants that contained stop codons inserted into exon I of U(L)15 (designated S648) or an insertion of the Escherichia coli lacZ gene into a truncated U(L)15 exon II [designated HSV-1(delta U(L)15ExII)] were constructed. Recombinant viruses derived from S648 and HSV-1(delta U(L)15ExII) and containing restored U(L)15 genes were constructed and designated S648R and HSV-1(delta U(L)15ExIIR), respectively. Unlike HSV-1(delta U(L)15ExIIR) and S648R, the viruses containing mutant U(L)15 genes failed to cleave and package viral DNA when propagated on noncomplementing cells. As revealed by electron microscopy, large numbers of enveloped capsids lacking viral DNA accumulated within the cytoplasm of cells infected with either S648 or HSV-1(delta U(L)15ExII) but not in cells infected with HSV-1(delta U(L)15ExIIR) or S648R. Thus, one function of the U(L)15 gene is to effectively prevent immature particles lacking DNA from exiting the nucleus by envelopment at the inner lamella of the nuclear membrane. Cells infected with HSV-1(delta U(L)15ExII) did not express the 75,000- or 35,000-apparent-Mr proteins previously shown to be products of the U(L)15 open reading frame, whereas the 35,000-apparent-Mr protein was readily detectable in cells infected with S648. We conclude that at least the 75,000-Mr protein is required for viral DNA cleavage and packaging and hypothesize that the 35,000-Mr protein is derived from translation of a novel mRNA located partially or completely within the second exon of U(L)15.

The UL 16 gene product of herpes simplex virus 1 is a virion protein that colocalizes with intranuclear capsid proteins.

The UL16 gene of herpes simplex virus maps within the intron of the UL 15 gene. This report shows the following: (i) A polyclonal antiserum directed against a bacterial fusion protein containing glutathione S-transferase fused to the C-terminus of the UL 16 gene reacted with an apparent M(r) 40,000 protein in HSV-1 infected cell lysates. (ii) The protein encoded by UL 16 was dependent on viral DNA synthesis for accumulation to detectable levels. (iii) In immunofluorescence studies, the polyclonal UL 16/GST-specific antiserum was shown to stain the nucleus of infected cells at 18 hr after infection in areas containing high concentrations of HSV capsid proteins. These nuclear compartments have been described previously as viral assemblons (Ward et al., J. Virol. 70, 4623-4631, 1996) and are distinct from compartments containing replicating DNA. Localization within assemblons argues for a role of UL 16 encoded protein in capsid assembly or maturation. (iv) At 22 hr after infection, UL 16-specific immunofluorescence was present in both the nucleus and the cytoplasm. (v) Consistent with the change in localization at late times after infection, the UL 16 protein was found to be a component of purified virions.