SFGH morning report pearls: CMV ventriculoencephalitis and HIV updates

CMV neurologic disease in patients with AIDS:

  • 3 syndromes: dementia, encephalitis with ventriculoencephalitis, ascending polyradiculomyelopathy
  • ventriculoencephalitis: acute onset with confusion, focal deficits, cranial nerve abnormalities, ataxia
    • MRI: may demonstrate periventricular enhancement (also can be seen with CNS lymphoma/EBV)
    • detect via CSF PCR or antigen assays; antibodies are not useful (although negative anti-CMV IgG makes CMV infection unlikely

HIV updates – fresh off the press from this week in NEJM:  2 important recent trials and a trial update supporting starting ARVs in patients diagnosed with HIV regardless of the CD4 count worldwide!

  • START trial (strategic timing of ARV treatment): large RCT compared initiation of ARVs at CD4 count >500 and <350.  Results: 72% relative reduction in AIDS related events and 39% reduction in non-AIDS related events in patients starting ARVs at higher CD4 count
  • Temprano trial: 2×2 factorial design in the ivory coast comparing early ART, 6-month isoniazid preventive therapy, or both among HIV patients with high CD4 counts: immediate ART and 6 months of isoniazid preventive therapy independently led to lower rates of severe illness
  • HPTN052 update:  – Showed a sustained 93% reduction in HIV transmission with ART use within HIV discordant couples

Evernote link: http://www.evernote.com/l/AoMfJ1wW1GBOlId528NrMQ_ekcQcVTYD9hw/

The INSIGHT START Study Group. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med. DOI: 10.1056/NEJMoa1506816

The TEMPRANO ANRS 12136 Study Group. A trial of early antiretrovirals and isoniazid preventive therapy in Africa. N Engl J Med. DOI: 10.1056/NEJMoa1507198

M Cohen, et al . Final results of the HPTN 052 randomized controlled trial: antiretroviral therapy prevents HIV transmission. Program number MOAC0106LB, Track C.

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