Updates
By Carol A. Kemper, MD, FACP, Clinical Associate Professor of Medicine, Stanford University, Division of Infectious Diseases; Santa Clara Valley Medical Center, Section Editor, Updates; Section Editor, HIV, is Associate Editor for Infectious Disease Alert.
Transmission of STD's: The defense rests
Source: Mohanty K. Transmission of Chlamydia and genital warts during sleepwalking. Int J STD AIDS. 2008;19:129-130.
Sleepwalking is a form of parasomnia, which may be exacerbated by alcohol and drug use, is typically associated with non-rapid eye movements or nREM activity on electrophysiologic studies. Sexual activity during these periods of nREM activity — and during sleepwalking — has been well described, leading to variety of usual and unusual sexual behaviors, including indecent exposure, sexual assault, and rape, which may be associated with total amnesia respective to the events. This variant of parasomnia is not-so-euphemistically referred to as 'sexomania." Sexomania has been successfully used as a criminal defense in rape trials in both Canada and Great Britain.
In this unusual case, a 15-year-old was accused of repeatedly sexual abusing his 13-year-old stepsister over a 4-year period of time, resulting in transmission of two sexually transmitted diseases. The abuse began with digital penetration but had recently progressed to insertive vaginal intercourse. The 15-year-old admitted to alcohol use.
The abuse first came to light when the 13-year-old presented with complaints of vaginal discharge and was found to have chlamydia and genital warts. Further investigation confirmed the likely source was her stepbrother, who was also found to have infection with gonorrhea, chlamydia, and penile warts. However, he denied any knowledge of sexual contact or abuse of his stepsister. Once experts confirmed that he was sleeping during sex with his stepsister, all charges were dropped.
MRSA in Pig Farmers
Source: van Rijen MM, et al. Increase in a Dutch hospital of methicillin-resistant Staphylococcus aureus related to animal farming. Clin Infect Dis 2008;46:261-263.
Just like humans, animals can become colonized or infected with MRSA. About three years ago, the presence of MRSA in horses and trainers at several large horse breeding and training facilities in Northern California contributed to an outbreak of MRSA infection in the equine inpatient unit at UC Davis, leading to the death of one horse from MRSA bacteremia (line sepsis) and another from MRSA osteomyelitis.
An increase in MRSA infection in persons hospitalized in the Netherlands from 2002-2006 is likely related to the emergence of a novel strain of MRSA in farm animals. This new clone of non-typable MRSA, which was first identified in the Netherlands around 2004, has since been found in nearly one-fourth of patients hospitalized with MRSA in the Netherlands. Physicians at the hospital surveyed patients with farm animal contact, and found that 32% of persons reporting exposure to calves or pigs were positive for MRSA. These included farmers, their wives, a farmer's daughter, an agricultural student, as well as an inseminator.
Household or professional animal contact can be a risk factor for persons with MRSA infection, and should be included in the patient history, especially in persons with recurrent infection.
Abacavir and DDI Linked to Heart Disease in HIV
Source: Sabin CA, et al. Use of nucleoside reverse transcriptase inhibitors and risk of myocardial infarction in HIV-infected patients enrolled in the D:A:D study: a multi-cohort collaboration. Lancet. 2008;371:1417-1426.
Thymidine analogues for the treatment of HIV infection have been implicated as long-term risk factors for cardiovascular disease. However, in contrast to the investigators' reported expectations for this study, abacavir and didanosine, and not stavudine (d4T), zidovudine (AZT), and lamivudine (3TC), were found to be independently associated with an increased risk of myocardial infarction in persons with HIV infection. In this long-term analysis of persons enrolled in the D:A:D study, risk factors for cardiovascular disease were extensively examined, including the recent and cumulative use of nucleoside-reverse transcriptase inhibitors (NRTI's).
A total of 517 myocardial infarctions occurred in 33,347 persons during a total of 157,912 person-years. Recent use of abacavir (relative risk 1.90, P = .0001) and didanosine (relative risk 1.49, P = .003) were each independently associated with an increased risk of cardiovascular events, though the cumulative use of either agent, or use > 6 months earlier, was not significant. The cardiovascular risk of protease inhibitor therapy vs non-PI-based therapy was not clear in this study.
Investigators stressed that other factors, such as hypertension, smoking, and hyperlipidemia, are much more significant for myocardial infarction, and should be aggressively addressed. The benefits of effective virologic suppression, especially in persons in need of antiretroviral therapy, even if it involves the use of abacavir or didanosine, outweigh the long-term potential risks of therapy.
Interestingly, from another study recently reviewed in Infectious Disease Alert,1 this argument may be appropriate for younger HIV-infected patients who initiate antiretroviral therapy, regardless of stage of disease or viral load. But the benefits of HIV treatment may be more limited by increasing non-HIV-related mortality as patients age, especially if therapy isstarted "too early" at lower HIV viral loads. In such patients, attempts to reduce the toxicities and risks of treatment may be more important, and have greater impact on the risk-benefits of treatment. Other factors, not expressly examined in the article reviewed here, include other drug-related toxicities and quality-of-life issues, such as drug-related pancreatitis, peripheral neuropathy, and lactic acidosis.
- Braithwaite RS, et al. Influence of alternative thresholds for initiating HIV treatment on quality-adjusted life expectancy: a decision model. Ann Intern Med. 2008;148:178-185.
Marijuana Increases Risk of Steatosis
Source: Hezode C, et al. Daily cannibas use: a novel risk factor of steatosis severity in patients with chronic hepatitis C. Gastroenterology. 2008;134:432-439.
Multiple factors contribute to the development of non-alcoholic steatosis ("fatty liver") in patients with HCV and HIV, which are known risk factors for progression of fibrosis and chronic liver disease. Some of these factors include diabetes, hyperlipidemia, and obesity, often associated with insulin resistance and metabolic syndromes. Interestingly, endocannabinoids, found in marijuana, are stimulants of CB1 and CB2 receptors, the former of which mediate some of the psychoactive properties and appetite stimulus of marijuana upon the central nervous system. However, CB1 receptors also play an important role in energy metabolism (eg, liver, placenta), where stimulation of these receptors can contribute to insulin resistance and an increase in obesity and steatosis. CB1 receptor antagonists have been developed (not available in the United States) which can lead to a reduction in weight and prevent the development of steatosis, regardless of caloric intake. Such agents may be especially useful in patients prone to diabetes and obesity.
These authors examined whether the regular use of marijuana increases the risk of hepatic steatosis in persons with chronic HCV infection. A total of 315 HCV-infected patients, who were undergoing liver biopsy as part of another clinical trial, were assessed for cannabis, alcohol, and tobacco use, as well as HCV genotype and plasma viral load, lipids, and Body Mass Index (BMI). The mean age was 45 years; 71% were male and the average BMI was 24.8 kg/M2. Approximately two-thirds of the patients were HCV genotype 1 and 21% were genotype 3. About 24% were daily cannabis smokers (with an average use of 84 cigarettes per month), 12% were occasional users, and 64% were classified as non-users. Approximately 13% were defined as regular alcohol abusers (> 30 grams of alcohol per day); regular cannabis users were more likely to abuse alcohol than non-cannabis users.
Liver biopsies were evaluated independently by two pathologists and scored according to METAVIR criteria, assessing for inflammatory grade, fibrosis, and steatosis. Marked steatosis was defined as > 30% of hepatocytes containing fat vacuoles. Significant fibrosis and activity grade ≥ 2 were found in 36% and 59% of biopsy specimens, respectively. Steatosis was observed in approximately half of the specimens, which was considered marked in 19%.
In multivariate analyses, risk factors for steatosis included the activity factor identified on liver biopsy, HCV genotype 3, hyperglycemia or diabetes, BMI > 27 kg/M2, and serum HCV viral load, as well as daily cannabis use. Adjusting for alcohol intake and HCV genotype, daily cannabis use was a significant risk factor for marked steatosis compared with those with occasional use (P = .03) and no use (P = .008).
This study implicates daily cannabis use as a significant predictor of steatosis and the severity of progression of liver disease in persons with HCV infection, independent of alcohol consumption and HCV genotype. Daily cannabis use appears to alter energy metabolism in the liver, and other organ systems, via CB1 receptors, thereby increasing the likelihood and severity of steatosis. (This article and the accompanying editorial also suggest that the active ingredient in oral pill form delta-9-tetrahydrocannabinol (THC) may have the same effect.) Although comorbidities are common in this group of patients, limiting marijuana use may be beneficial in patients with steatosis and chronic HCV infection.
Sleepwalking is a form of parasomnia, which may be exacerbated by alcohol and drug use, is typically associated with non-rapid eye movements or nREM activity on electrophysiologic studies.You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
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