by Carol A. Kemper, MD, FACP

Management of Lipodystrophy in HIV: A Mini-Update

Source: Abstracts of the Fifth International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV. July 8-11, 2003. Paris.

Recent abstracts from the Fifth International Workshop on Adverse Drug Reactions and Lipodystrophy in HIV highlighted the recent advances in the management of lipoatrophy/lipodystrophy in patients with HIV. A randomized, double-blind, placebo-controlled study of rosiglitazone in HIV-infected patients with lipoatrophy/dystrophy found significant increases in insulin sensitivity, increased body fat, and increased levels of adiponectin in treated patients compared with controls (Hadigan C. Oral Abstract 12). By 3 months of therapy, body fat had increased 15% in the treatment group compared with 5% in the placebo group. In a second smaller study, improved insulin resistance, increases in subcutaneous body fat, and decreases in visceral fat were observed in 4 patients receiving 3 months of rosiglitazone (Visnegarwala F. Poster Abstract 74).

Recombinant growth hormone (rGH) has become increasingly popular on the West Coast for the treatment of lipodystrophy. In one larger study, 555 patients were randomized to receive either rGH 6 mg daily or 6 mg every other day or placebo for 8 weeks (Kottler. Poster Abstract 93). Increased body weight and lean body mass were observed in both treatment groups compared with placebo recipients, although the effects were greatest in patients receiving daily rGH. Trunk fat increased disproportionately to limb fat, thereby increasing the trunk:limb fat ratio.

Two smaller studies found progressive increases in body fat in patients after switching from d4T to another reverse transcriptase inhibitor. Increases in body fat by both DEXA and computed tomographic scanning were observed in one group of patients 48 weeks after switching from d4T to either abacavir or zidovudine (McComsey G. Poster Abstract 90); virologic control was reportedly maintained. Similar effects were observed in patients enrolled in the MITOX study in Sydney: Limb fat increased 36% in patients switched from either a d4T- or zidovudine-containing regimen to an abacavir-containing one. Incremental increases in fat accumulation were observed throughout the 2-year period of observation, suggesting that a long period of time is required to reverse the process.

Yersiniosis Outbreak in Black Infants

Source: Jones TF. Emerg Infect Dis. 2003;9(8):1007-1009.

Yersiniosis is an uncommon cause of food-borne disease and generally accounts for only a small number of sporadic cases of infection in the United States. An outbreak of Yersiniosis limited solely to black infants in Tennessee therefore prompted an investigation as to the cause. During a 3-month period from November 15, 2001, to February 15, 2002, 12 cases of Yersinia infection occurred in infants younger than 1 year of age. All of the patients were black and had presented to local medical centers with severe diarrhea, and all of them had positive stool cultures for Y enterocolitica.

A case-controlled study was conducted to identify a potential cause. Ten infants (who could be located) and their caregivers and 51 controls were interviewed. Of the 10 cases, 8 (80%) had reported fever, 7 (70%) reported blood stools, 7 (70%) reported vomiting, and 4 (40%) required hospitalization. Interestingly, 6 of the cases occurred within days of Thanksgiving, Christmas, or New Year’s. Chitterlings had been prepared in the homes of every one of the case patients compared with only 35% of controls. (Chitterlings are that part of the pig small intestine that is often fried and served with special sauce, especially around the holidays.) At least 4 different brands of chitterlings were purchased at 5 different grocery stores. Ten to 80 pounds of raw intestines (possibly contaminated with feces) were prepared at any one time, with several hours of thawing, cleaning, and cooking in and around the sink and kitchen area. The caregivers variously described washing children’s bottles in the sink, handling children and their bottles and pacifiers while doing food prep, and small children in and around the food prep area.

Nine of the Yersinia isolates from the children were available for analysis. All were identified as serotype 0:3 biotype 4. Pulsed-field gel electrophoresis revealed 7 distinct patterns. Of 13 samples of chitterlings purchased by Jones and associates from various stores in Tennessee, 2 tested positive for Y enterocolitica, and 5 were positive for various species of Salmonella.

These data suggest that no one common source is responsible for these cases; simply exposure to the food prep area was sufficient exposure for these small children. None of the infants actually ate the chitterlings. Jones states that attempts to educate the public about the risk of preparing chitterlings in this traditional fashion around the holidays have been unsuccessful, despite the risk to smaller family members.

Transfusion- Associated WNV

Source: Eurosurveillance Weekly. 2003; 7(34).

The current year has seen the reemergence of West Nile Virus in the United States, with further encroachment into Canada and Mexico, and an extension of the transmission season. In addition to the usual mode of transmission, human infection has been caused by percutaneous exposure to infected tissue or blood products, transplantation of infected organs, and via breast-feeding and the transplacental route. As of March 2003, the CDC had accumulated reports of 61 possible cases of transfusion-associated WNV infection in the United States. Of these, tests confirmed that at least 14 donors had resulted in 21 cases. The problem is that 5 of these 14 donors had no clue they were ill, and several of the remaining donors developed symptoms only after their donation. This suggests that individuals with subclinical infection may have sufficient levels of viremia to cause clinically significant disease in a susceptible host. Obviously, screening based on the presence of self-reported symptoms is not sufficient. Since July 1, 2003, using a newly developed nucleic acid test (NAT), the United States has been screening all potential blood donors for WNV. Thus far, a single positive donor has been detected.

The possibility of transfusion-associated WNV infection has also raised concerns in the United Kingdom and Europe, which presently do not screen blood donors, some of whom may have recently visited endemic areas. Ireland alone estimates that up to 10% of their donors may visit Canada or the United States during the summer months. As a result, the United Kingdom and many European countries have adopted various deferral policies, whereby travelers to high-risk areas are asked to defer donation for ~ 28 days. These policies are putting an additional squeeze on the pool of blood supplies in these countries, already limited by the presence of bovine spongiform encephalopathy in some areas.

Dr. Kemper is Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center Section Editor, Updates Section Editor, HIV.