Neurosyphilis: How Do You Know, and What Do You Do?
HIV/AIDS Clinical Care Antiretroviral Rounds
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About 8 years ago, Hector was diagnosed with and treated for syphilis. Two years later, he presented with fever and a diffuse papulosquamous eruption after an unprotected sexual contact. His RPR rose to 1:128. He was treated for presumed secondary syphilis. His symptoms resolved, but he began to complain of more frequent headaches. Two years ago, he again developed fever, and papulosquamous eruption localized to his left arm; his RPR rose to 1:128. He was treated again for secondary syphilis. During the past year, Hector's RPR has remained quite elevated, and he still has frequent severe headaches.
By Keith Henry, MD, and Joseph I. Harwell, MD
October 1, 2002
Prophylactic Panic
HIV/AIDS Clinical Care Antiretroviral Rounds
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Juan C., a patient of yours with an undetectable viral load on antiretroviral therapy, comes to see you in a panic. The previous night, he had a sexual encounter with his partner, an HIV-negative man, and the condom broke. He is distraught, and he insists that his partner begin postexposure prophylaxis immediately. His partner is less anxious, but is willing to take treatment.
By Bruce Soloway, MD, Roland C. Merchant, MD, Kenneth H. Mayer, MD, and Josiah D. Rich, MD, MPH
June 1, 2002
Is High-Grade Dysplasia on Anal Pap a High-Grade Problem?
HIV/AIDS Clinical Care Antiretroviral Rounds
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Tim is on top of the world until his confidence is shaken badly by a first-time "routine" anal Pap smear that shows high-grade dysplasia. This is the first sign that HIV may be affecting his health. What would you tell Tim about this result and would you recommend any changes in his therapy?
By Joel Palefsky, MD, and Carlos del Rio, MD
May 1, 2002
When Success Is a Pain
HIV/AIDS Clinical Care Antiretroviral Rounds
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After being diagnosed with HIV, Carlos was treated with AZT + 3TC + nelfinavir. He responded adequately to therapy; however, because of persistent abdominal discomfort, nelfinavir was changed to indinavir, and he was treated with H2 blockers and omeprazole, without success. Indinavir was changed to efavirenz, but Carlos did not tolerate the CNS side effects. Finally, efavirenz was changed to abacavir. Carlos's abdominal discomfort never improved. His CD4 count and viral load are 440 less than 80, respectively. Amylase, lipase, lactic acid, and LFTs were all normal. His quality of life is poor. What would you do with his medications?
By John G. Bartlett, MD, and Carlos del Rio, MD
August 1, 2001
Less than Optimal?
HIV/AIDS Clinical Care Antiretroviral Rounds
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Ricky tested HIV positive in 1991, just before he entered prison for 10 years. Around 1995 he was started on AZT + 3TC. His CD4-cell count has been "normal," as far as he can remember, and his viral load has been "good." After his release, he is still taking AZT and 3TC and is asymptomatic. Labs show a CD4 count of 550 and a viral load below 400 copies/ml. Ricky says he takes his medication precisely -- never missing a dose -- but he understands that he is getting less than optimal treatment and wants "all three of the drugs."
By Josiah D. Rich, MD, MPH, and Elizabeth Jenny-Avital, MD
July 1, 2001
Resistant to Everything
HIV/AIDS Clinical Care Antiretroviral Rounds
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Plato, a 65-year-old man who has been HIV positive since 1987, is clinically well but has slightly elevated fasting blood-sugar levels and poorly controlled hypertension. Over the past 10 years, his CD4-cell count has dropped steadily despite combination regimens that have included virtually every antiretroviral. He appears to be adherent. His latest regimen is abacavir + d4T + amprenavir + lopinavir/ritonavir. A new genotype shows resistance to all drugs in his past and present regimens. His viral load is 90,000 copies/ml and his CD4 count is 34 cells/mm3 . How should he be managed now?
By John M. Mazzullo, MD, and Peter J. Piliero, MD
May 1, 2001
To "Pulse" or Not to "Pulse"?
HIV/AIDS Clinical Care Antiretroviral Rounds
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After stopping d4T + 3TC + nelfinavir because of severe diarrhea, Mike agreed to resume treatment with d4T + 3TC + nevirapine. His laboratory markers responded optimally, but he said he felt "jumpy and out of it" on the new combination, and after 9 months, he stopped the medications. Three months later, he is convinced to resume treatment. Again, his viral load promptly falls and his CD4 count begins to rise, but he feels "weird." He decides that he can tolerate antiretrovirals only for delimited periods. He suggests that two months on and two months off is a schedule he can live with and hopes you will concur.
By Michael S. Saag, MD, and Keith Henry, MD
March 1, 2001
All About Adherence
HIV/AIDS Clinical Care Antiretroviral Rounds
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Carmen B. has been on and off HIV medications and has moved in and out of care several times. Her adherence to most of her regimens has been intermittent. In August 2000, she was lost to follow-up again. She reappeared in October 2000, stating that she had a new social worker, new support groups, a new therapist, and was in a much better life-situation; she convincingly argued that she was prepared to restart antiretrovirals. Her viral load was 92,500 copies/ml and her CD4 count was 138 cells/mm3 (17%). She started AZT + 3TC + ritonavir + indinavir. Two weeks after beginning her new regimen, she appeared happy and noted 100% adherence and no side effects. An indinavir level, drawn 2 hours after her last reported dose, returned at less than 0.025 µg/ml, below the limits of detection.
By David L. Butcher, MD, Eve Cohen, RN, Brenda Urbina, MD, and Timothy P. Flanigan, MD
February 1, 2001
Family Planning
HIV/AIDS Clinical Care Antiretroviral Rounds
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A 28-year-old West African Woman tests HIV positive during routine screening at the women's clinic. She has, it turns out, tested positive twice before, but claims to have not known. You place her on efavirenz + Combivir. After discussion, you feel confident that MK understands the need to avoid pregnancy while taking efavirenz. A month later, she tells you that she wants to get pregnant and admits that she has not been practicing safe sex. She and her boyfriend have simply assumed that he is also HIV positive. He has moved to Wyoming, and she intends to join him there. MK wants to know what to do to decrease the likelihood that her baby will become infected with HIV. What should you tell her?
By Sigal Yawetz, MD and Susan Cu-Uvin, MD
January 1, 2001
Reason To Be Worried
HIV/AIDS Clinical Care Antiretroviral Rounds
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Bob C. arrives at clinic for a routine appointment. He feels well and appears to be clinically stable. His CD4 count is 50 cells/mm3 and his viral load is 49,100 copies/ml. He is currently taking nelfinavir + nevirapine + ddI. In the past, he has also received AZT, 3TC, ddC, d4T, and ritonavir.
By Keith Henry, MD, and Charles Hicks, MD
October 1, 2000
