European Journal of Medical Research - Deutsche AIDS ...

76 EUROPEAN JOURNAL OF MEDICAL RESEARCH
June 27, 2007
leishmaniasis and after courses of liposomal amphotericin B
and short term miltefosine for up to 4 weeks a long-term therapy
with miltefosine was started. Based on chronic damage of
the kidneys, which might have been impaired by previous indinavir
administration, terminal renal insufficiency developed
as a typical side effect of therapy with the polyene amphotericin
B. Independent of the renal function and miltefosine
ART was continued with a combination of LPV-ritonavir
(RTV) (dosage 2 cps bid, than 1 tbl. bid) and a 2-NRTI backbone
including abacavir and lamivudin. After 8 months of follow
up a continuous complete suppression of viral replication
(viral load < 50 copies/l) could be documented and CD4 cell
count remained stable (165 - 232 copies/l). 20 trough levels
before haemodialysis have been determined, revealing sufficient
antiviral activity with a mean of 5979 ng/ml (standard
deviation (SD) 2339 ng/ml). A mean peak concentration after
medication and haemodialysis in 12 samples has been 12177
ng/ml, SD 2470 ng/ml.
Conclusions: Here we could demonstrate a successful ART
with reduced dosage of LPV-RTV in a HIV patient despite
chronic haemodialysis and concomitant medication of miltefosine.
In cases like this drug monitoring is appropriate and
dose adjustment may be helpful to avoid side effects.
C.16 (Poster)
Successful treatment of visceral leishmaniasis (VL)
with long-term miltefosine in a HIV-patient with
terminal renal insufficiency
Heinz W. 1 , Guhl C. 1 , Winzer R. 1 , Langmann P. 2 ,
Klinker H. 1
1 Medizinische Klinik und Poliklinik II der Universität
Würzburg, Schwerpunkt Infekiologie, Würzburg, Germany,
2 Praxis für Gastroenterologie und Infektiologie, Karlstadt,
Germany
Objective: Immunosuppression due to HIV-infection can
support a broad spectrum of infectious diseases. Beside the
common opportunistic infections other acute and chronic infectious
diseases can have a more severe and complicated
course. In addition treatment of HIV and the secondary infection
might directly interact or have cumulative toxic effects.
VL as a chronic disease caused by the parasite Leishmania
donovani is rare in Western-Europe and usually treated with
liposomal amphotericin B (L-AmB) or sodium-stiboglucanate.
New data support good efficacy of miltefosine, a
membrane-active alkyl phospholipid.
Here we describe the case of a HIV patient with severe reduction
of CD4 cells and VL refractory to prolonged therapy
of L-AmB.
Case: In a 40 year old patient HIV was diagnosed 1989. Despite
effective antiretroviral therapy since 1999, with a viral
load below 400 copies/l, he showed persistent immunosuppression
with CD4-count below 100 cells/l in 2003. In August
2003 fatigue, pancytopenia and a polyclonal gammopathy
developed and a VL with involvement of the intestine and
the bone marrow was diagnosed. After first treatment with
miltefosine for 28 days the patient showed incomplete remission
and in April 2004 therapy with L-AmB was started for 20
days with good clinical response and clearance of the germs
in bone marrow. This was followed by a secondary prophylaxis
with L-AmB in a 4-week interval. For a further relapse
with skin infiltrates he received a second course of L-AmB
for 3 weeks followed by miltefosine for one month. Secondary
prophylaxis with L-AmB was continued. Hereunder,
he developed a terminal renal insufficiency on the bases of
chronic kidney damage, needing haemodialysis. In addition, a
relapse with ocular manifestation and predominantly a general
disfiguring skin involvement appeared. Therefore continuous
therapy with miltefosine was started in June 2006. Seven
months later he still shows clinical remission of all manifestations.
Conclusions: Here we report of a case of VL with multiple
manifestations, relapsing after L-AmB therapy and secondary
prophylaxis, which could be successfully treated with continuous
miltefosine administration, despite persisting HIV related
immunosuppression.
C.17 (Poster)
Comparison of Ribavirin plasma concentrations in
HCV-monoinfected and HCV/HIV coinfected
patients with or without concomitant HAART
Guhl C. 1 , Rasche S. 1 , Kubisch A. 1 , Schirmer D. 1 ,
Heinz W. 1 , Winzer R. 1 , Langmann P. 2 , Klinker H. 1
1 Medizinische Klinik und Poliklinik II der Universität
Würzburg, Schwerpunkt Infekiologie, Würzburg, Germany,
2 Praxis für Gastroenterologie und Infektiologie, Karlstadt,
Germany
Objective: Patients coinfected with Human Immunodeficiency
Virus (HIV) and Hepatitis C Virus (HCV) taking HAART
are on higher risk to die of liver-related problems than of
HIV-related illnesses. Therefore, treatment of HCV in HIVpatients
is important but difficult, especially due to a higher
risk of toxicities and pharmacological interactions with
HAART. Ribavirin (RBV) drug levels might play a crucial
role not only in deteriorating drug addicted side effects like
hemolytic anemia but also in effectiveness of treatment and
early virological response. Orally taken, RBV is quickly resorbed.
Maximal plasma concentration (PC) can be reached
after 1.5 hours and a steady state is reached after 4 weeks of
treatment. Measuring PC of RBV can help optimizing the
HCV-treatment. Here we investigated the RBV PC in
HIV/HCV-coinfected patients regarding a comedication with
HAART.
Methods: A high performance liquid chromatography
(HPLC) was established to determine PC of RBV after solid
phase extraction. Plasma samples from patients treated for
HCV have been collected and PC have been determined. The
results were analyzed in correlation to possible HIV-coinfection
and comedication of HAART.
Results: A total of 178 samples of 78 patients has been collected
and PC have been measured during steady-state, i.e. after
4 weeks of treatment and 8 to 16 hours after having taken
the pills. 67 patients (n=136 samples) had HCV only (group
1) and 11 patients (n=42 samples) have been coinfected with
HIV and HCV. 7 of the HCV/HIV-coinfected patients were
treated only against HCV (group 2, 20 samples) and 4 received
concomitant HAART, respectively (group 3, 22 samples).
The plasma trough level for RBV in all samples was
1702 ± 582,5 ng/nl. In group 1 (HCV) the trough level was
1724 ± 590 ng/ml, in group 2 (HCV/HIV without HAART)
1721 ± 623 ng/ml and in group 3 (concomitant d HAART)
1302 ± 225 ng/ml. Due to the small number of patients in
group 2 and 3 significances testing has not been performed.
Conclusions: In this retrospective analysis we could show a
trend that HAART reduces PC of RBV whereas the HIV-in-