Utilidad de la cuantificación de carga viral de VIH en líquido cefalorraquídeo, a propósito de un caso / Clinical utility of HIV viral load assessment in cerebral spinal fluid, a case report

Resumen La detección de virus en el líquido cefalorraquídeo (LCR) en pacientes infectados por VIH con carga viral (CV) indetectable en el plasma se ha denominado escape viral. Estas fugas pueden ser asintomáticas o asociadas con enfermedad neurológica. La discordancia de la carga viral de VIH entre plasma y LCR evidenciaría la presencia de distintos compartimentos del virus, con la posibilidad de identificar quasiespecies con mutaciones específicas que confieran resistencia a la TARV. Presentamos el caso clínico de un paciente con infección por VIH en etapa SIDA y una tuberculosis diseminada que presentó un cuadro neurológico manifestado por cefalea y un síndrome convulsivo, en que se encontró una discordancia entre la CV para VIH en plasma y LCR. El estudio genotípico del virus obtenido del LCR identificó nuevas mutaciones que determinaron un cambio de la TARV, con evolución posterior satisfactoria.

Detection of virus in cerebrospinal fluid (CSF) in HIV-infected patients with HIV viral load (VL) undetectable in plasma has been termed viral escape. These leaks may be asymptomatic from a neurological point of view, similar to plasma blips, or associated with neurological disease, with discordant VL between plasma and CSF, and may be evidence of a compartmentalization of the virus and the possibility of identifying quasispecies with mutations that confer resistance to ART. We present the case of a man with AIDS and disseminated tuberculosis who presented neurological symptomatology evidenced by headache and convulsive syndrome, who presented a discordance between plasma and CSF HIV VL; the genotypic test of the virus, obtained by lumbar puncture, identified new mutations that determined a change in ART with subsequent satisfactory evolution.

CD4 count-based failure criteria combined with viral load monitoring may trigger worse switch decisions than viral load monitoring alone.

OBJECTIVE: CD4 count decline often triggers antiretroviral regimen switches in resource-limited settings, even when viral load testing is available. We therefore compared CD4 failure and CD4 trends in patients with viraemia with or without antiretroviral resistance. METHODS: Retrospective cohort study investigating the association of HIV drug resistance with CD4 failure or CD4 trends in patients on first-line antiretroviral regimens during viraemia. Patients with viraemia (HIV RNA >1000 copies/ml) from two HIV treatment programmes in South Africa (n = 350) were included. We investigated the association of M184V and NNRTI resistance with WHO immunological failure criteria and CD4 count trends, using chi-square tests and linear mixed models. RESULTS: Fewer patients with the M184V mutation reached immunologic failure criteria than those without: 51 of 151(34%) vs. 90 of 199 (45%) (P = 0.03). Similarly, 79 of 220 (36%) patients, who had major NNRTI resistance, had immunological failure, whereas 62 of 130 (48%) without (chi-square P = 0.03) did. The CD4 count decline among patients with the M184V mutation was 2.5 cells/mm(3) /year, whereas in those without M184V it was 14 cells/mm(3) /year (P = 0.1), but the difference in CD4 count decline with and without NNRTI resistance was marginal. CONCLUSION: Our data suggest that CD4 count monitoring may lead to inappropriate delayed therapy switches for patients with HIV drug resistance. Conversely, patients with viraemia but no drug resistance are more likely to have a CD4 count decline and thus may be more likely to be switched to a second-line regimen.

La carga viral y células TCD4+ en pacientes infectados con el virus de inmunodeficiencia humana (VIH) coinfectados con sífilis / The viral load and TCD4+ cells in human immunodeficiency virus (HIV) infected patients coinfected with syphilis

La coinfección con sífilis en el paciente infectado con VIH-1 ha aumentado en los últimos años. La sífilis se ha asociado con activación inmunológica, pero el efecto de la misma sobre los parámetros inmunovirológicos en esta población aún son controversiales. El objetivo es evaluar el efecto de la sífilis en el contaje de células TCD4+ y la carga viral del paciente VIH+. Se realizó un estudio retrospectivo, multicéntrico, de casos y controles, extrayendo de las historias clínicas de los pacientes VIH+ que asistieron a control en los últimos 10 años, los reportes de contaje de células TCD4+ y carga viral, antes, durante y después del diagnóstico de sífilis para compararlos entre sí y con un grupo control. 48 pacientes VIH+ diagnosticados con sífilis conformaron el grupo de estudio y 56 sin sífilis, el grupo control. 14 (29%) pacientes con sífilis secundaria, 33 (69%) latente y 1 (2%) primaria. 38 (80%) recibían TARV en el momento de la sífilis. 24 (70%) elevaron sus valores de TCD4+ durante la enfermedad y 27(59%) posterior a ella, con una media de elevación de 19,41 celulas x mm³ (p=0,43) y 23,74 células x mm³ (p=0,28) respectivamente. Las determinaciones de carga viral se elevaron durante la enfermedad en 8 (38%) pacientes con una media de elevación de 64688 copias ARN-VIH/ml (4,96 log10) (p=0,03), y disminuyeron en 13 (45%) con una media de -1163 copias de ARN/ml (3,06 log10) (p=0,99) posteriormente. La sífilis en el paciente VIH+ estuvo asociada a elevaciones significativas en la carga viral y a cambios no significativos en el contaje de células TCD4+ durante la enfermedad.

Syphilis co-infection in HIV-1 patients has increased in recent years. Syphilis has been linked to immunoactivation, however, its effect on immunovirological parameters in this population is still controversial. Objective evaluate the effect of syphilis on the TCD4+ cell count andviral load of the HIV+ patient. A retrospective, multicenter case-control study was conducted by extracting the TCD4+ cell counts and viral load before, during, and after diagnosis of syphilis, from the clinical records of HIV+ patients who attended check-ups in the past 10 years, in order to compare them among themselves and against a control group. Seroprevalence of HIV/Syphilis co-infection was 18%. 48 HIV+ patients diagnosed with syphilis formed the study group, while 56, without syphilis, the control group. 14 (29%) had secondary, 33 (69%) latent and 1 (2%) primary syphilis. 38 (80%) received ART at the time of their syphilis. Of 24 (70%) the TCD4+ values increased during illness, and of 27 (59%) they increased subsequently, with a mean increase of 19.41 cell/mm³ (p=0.43) and 23.74 cell/mm³ (p=0.28) respectively. Measurements of the viral load increased in 8 (38%) patients during the disease with a mean increase of 64,688 HIV RNA copies/ml (4.96 log10) (p=0.03); and in 13 they decreased subsequently (45%) with a mean of -1,163 RNA copies/ml (3.06 log10) (p=0.99). Syphilis in the HIV+ patient was linked to significant increases in the viral load and to non-significant changes in the TCD4+ cell count during the disease.