Fanconi syndrome in a patient receiving pre-exposure prophylaxis for HIV infection: case report.

BACKGROUND: Tenofovir disoproxil is efficacious in the preventing HIV infection as part of a pre-exposure prophylaxis (PrEP) regimen. Although its use has been associated with impaired renal function, instances of Fanconi syndrome are extremely rare. This may change with increased uptake of PrEP. METHODS: A 55-year-old male patient (he/him/his) was commenced on PrEP with a baseline estimated glomerular filtration rate (eGFR) of approximately 60mL/min/1.73m2 . RESULTS: Within 6months, he developed new and worsening proteinuria, glycosuria and aminoaciduria despite no apparent change in eGFR. PrEP was discontinued and his urinary abnormalities rapidly resolved. The patient remains off PrEP. CONCLUSIONS: Fanconi syndrome is a rare, but known complication of tenofovir disoproxil. This is the first report related to PrEP in Australia. While tenofovir associated nephrotoxicity in patients taking PrEP is uncommon, the patient's age and pre-existing renal impairment placed him at substantially higher risk. At-risk patients need more frequent monitoring of their eGFR and proteinuria. Urinary protein to creatinine ratio is the preferred to dipstick testing for proteinuria and the latter does not readily detect the low molecular wight proteinuria characteristic of tenofovir toxicity. Early recognition of these patients is essential, as prompt cessation of PrEP can often reverse renal abnormalities.

Reactive arthritis associated with proctitis due to Chlamydia trachomatis serovar L2b.

We report the first case of reactive arthritis associated with lymphogranuloma venereum (LGV) proctitis in Australia. Since 2004, LGV proctitis has emerged as an important infection worldwide in men who have sex with men. While reactive arthritis is usually associated with serovars D to K of Chlamydia trachomatis, association with LGV serovars is historically rare. Screening for chlamydial infection should be considered in this group if they present with an acute arthritis otherwise the condition could go undiagnosed. Asymptomatic infections are being increasingly reported in Europe and prolonged treatment is required to ensure a cure.

Iatrogenic Cushing's syndrome with osteoporosis and secondary adrenal failure in human immunodeficiency virus-infected patients receiving inhaled corticosteroids and ritonavir-boosted protease inhibitors: six cases.

Ritonavir, a protease inhibitor (PI), is a potent inhibitor of cytochrome P450 3A4. This pharmacological effect, even at low doses (

Effectiveness of a team intervention in reducing modifiable cardiovascular disease risk in HIV-infected subjects on antiretroviral therapy.

INTRODUCTION: The increasing age, higher modifiable and inherent cardiovascular disease (CVD) risk of HIV-infected patients [1] necessitates improved approaches to reducing co-morbidities. We aimed to assess the effectiveness of a team intervention in reducing modifiable CVD risk. MATERIALS AND METHODS: HIV-infected patients ≥50 years attending a large HIV caseload primary-care practice, who were virologically suppressed on antiretroviral therapy (ART), with moderate or severe 10-year CVD Framingham risk (≥10%) were recruited for this prospective case-control study. Intervention participants were provided a team approach to care, which involved treatment by study doctors for lipid, hypertension and ART management, and monthly review by a team of research nurses and dieticians for smoking cessation, exercise and dietary advice over 12 months. Controls were matched on age and smoking status, and were given standard of care (SOC) by non-study doctors. Outcomes included CVD risk factors, body composition and CVD risk assessment, including Framingham 10-yr risk [2] and D:A:D 5-year estimated risk of coronary heart disease (CHD) [3]. Repeated measures analysis of variance was used to examine pre- and post-intervention differences, with p-values used to assess time and main effects of approach to care (Intervention, SOC). RESULTS: A total of 33 patients completed the intervention, with 33 controls (58.0±6.8 and 59.1±6.9 years, respectively). Smoking cessation occurred in 25% cases versus nil controls. There was a significant change in CVD risk between intervention and control groups, in both Framingham scores (time and group×time interaction) and D:A:D scores (group×time interaction only) (Table 1). There was also a significant difference in change in total cholesterol over the study period (time and group×time interaction). Body composition was only measured in intervention patients, with a significant loss in % body fat observed in pre- and post-intervention. CONCLUSIONS: Team intervention was significantly more effective than standard of care in reducing CVD risk in HIV-infected patients on ART. A team approach to care may be an important component of reducing CVD risk in this population.

Triple-class HIV antiretroviral therapy failure in an Australian primary care setting.

OBJECTIVE: To determine the prevalence, characteristics and virological outcomes of triple-class antiretroviral drug failure (TCF) and triple-class virological failure (TCVF) in HIV-infected patients attending an Australian high caseload primary care clinic. METHODS: Cross-sectional observational study using a retrospective review of electronic medical records from 1007 patients with HIV attending Holdsworth House Medical Practice in Darlinghurst, Australia, between 2007 and 2008. TCF was defined as failure (virological, immunological, clinical, intolerance or other) of at least one drug in each of the three major classes of highly active antiretroviral therapy. RESULTS: A total of 51 patients (5.1%) with TCF were identified. Of these patients, 31.4% had experienced virological failure of each of the three main drug classes. Eighty-eight percent of patients with TCF and 75% of patients with TCVF had achieved virological suppression (HIV RNA <400 copies mL(-1)). Total mean (s.d.) duration on antiretroviral therapy (ART) was 12.2 (3.3) years, with patients receiving an average of 18 antiretroviral drugs during this period. Reasons for treatment change included intolerance (88% of patients), virological failure (84%), immunological failure (24%) and poor adherence (20%). CONCLUSIONS: The prevalence of TCF and TCVF in patients with long-term HIV infection and extensive antiretroviral experience is low in primary care sites. Despite experiencing failure to the three main classes of ART, successful virological outcomes are still achievable in the majority of such patients.

Sexually transmissible infection testing guidelines for men who have sex with men.

Since 2002, biennial production of sexually transmissible infection testing guidelines for men who have sex with men has supported sexually transmitted infection control efforts in inner Sydney, Australia.