1. 2008 Guidelines for Prevention and
Treatment of Opportunistic
Infections in HIV-Infected Adults
and Adolescents : Part 4
CDC
NIH
HIVMA/IDSA
1

2. Human Herpesvirus-8 Disease
2

3. HHV-8: Epidemiology
• Seroprevalence
– General population: 1-5%
– MSM: 20%–77%
– sub-Saharan Africa: 30%–80%
• Associated with
– KS (i.e., classic, endemic, transplant related, and
AIDS related)
– Primary effusion lymphoma (PEL)
– Multicentric Castleman disease (MCD)
3

4. HHV-8: Epidemiology
• HHV-8 viremia associated with a nine-fold
increased risk for KS compared with HHV-8
seropositive men without HHV-8 viremia
• HHV-8 viremia almost always accompanies
symptomatic episodes of MCD
• KS and PEL most frequently among HIV-infected
persons with CD4+ counts of <200 cells/μL
– although they can occur at any CD4+ count
• Episodes of MCD may present at any CD4+ count.
4

5. HHV-8: Epidemiology
• Ganciclovir, foscarnet, and cidofovir use
inhibit the replication of HHV-8 in vitro
• Patients receiving ganciclovir or foscarnet (but
not acyclovir) have a reduced rate for
developing KS
• Incidence of KS has declined dramatically after
the introduction of PI drugs and highly active
ART
5

6. KSHV Genome
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7. HHV-8: Clinical Manifestations
• Most with chronic infection are asymptomatic
• Primary infection syndrome consisting of fever, rash,
lymphadenopathy, bone marrow failure, and
occasional rapid progression to KS
• MCD presents with generalized adenopathy and fever
and may progress to multi-organ failure
• KS
– mucocutaneous
– lymph node
– visceral (occasionally without the presence of skin lesions )
•
7

8. HHV-8: Clinical Manifestations
• Asymptomatic HHV-8 infection is often
associated with HHV-8 shedding in the saliva
and occasional shedding in genital secretions
– these may result in HHV-8 transmission to
uninfected partners
8

9. HHV-8: Diagnosis
• Routine screening for HHV-8 by PCR or
serologic testing for HHV-8 antibody is not
indicated
• Quantifying HHV-8 in the peripheral blood by
PCR is helpful in the diagnosis and
management of persons with MCD
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10. KSHV and LANA in MCD
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LANA: latency associated nuclear antigen

11. Multicentric Castleman Disease
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12. Kaposi’s Sarcoma
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13. Kaposi’s Sarcoma
13KS with lymphedema
Extensive Pulmonary KS

14. Pulmonary Kaposi’s Sarcoma
14
Before Chemotherapy After Chemotherapy

15. HHV-8: Preventing Disease
• Despite observational evidence supporting a
role for anti-HHV-8 therapy in preventing the
development of KS, the toxicity of current
anti-HHV-8 therapy outweighs the potential
benefits of administration
15

16. HHV-8: Treating Disease
• KS regression has been documented after
ganciclovir or foscarnet therapy
– although one small study indicated cidofovir was
ineffective
• The use of IV ganciclovir or oral valganciclovir
is, however, recommended in the treatment
of MCD and may be useful adjunctive therapy
in the treatment of PEL
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17. HHV-8: Treating Disease
• Highly active ART that suppresses HIV
replication should be administered to all HIV-
infected persons with KS, PEL, or MCD
• Chemotherapy, in combination with ART,
should be considered for patients with PEL or
visceral/extensive cutaneous KS
• Rituximab also appears to be an effective
alternative to antiviral therapy in the
treatment of MCD
17

18. HHV-8 IRIS
• Fatal IRIS has been reported in persons
initiating ART with pre-existing KS and MCD
• The frequency of HHV-8-associated IRIS is not
known
– but suppression of HIV replication and immune
reconstitution are key components of therapy and
initiation of ART should not be delayed.
18

19. HHV-8: Pregnancy
• Routine screening for HHV-8 by PCR or serology is not
indicated for pregnant women
• Perinatal transmission of HHV-8 may infrequently
occur
– cases of KS developing in the infant shortly after birth
– higher risk of transmission with higher maternal HHV-8
antibody titer
– substantially higher rate of HHV-8 seropositivity among
children born to HHV-8 antibody-positive compared with
HHV-8 antibody-negative women
– increased mortality through 24 months among HIV-
infected infants born to HHV-8-seropositive compared
with HHV-8-seronegative mothers
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20. Progressive Multifocal
Leukoencephalopathy (JC Virus)
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21. PML: Epidemiology
• Caused by the polyoma virus JC virus (JCV) and
characterized by focal demyelination
• 85% of adults are seropositive for JCV
• Primary JCV infection usually occurs in childhood
– asymptomatic
• Chronic asymptomatic carrier
– frequent virus detection in urine (30%) and tonsils
(40%) of immunologically normal adults
• PML associated with immunosuppression
– natalizumab , rituximab
– HIV
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22. PML: Epidemiology
• Incidence of PML has decreased substantially
in HAART era
• PML may still appear in with CD4 > 200 as well
as in those on ART
• PML may develop in the setting of initiating
ART and immune reconstitution
• The overall probability of survival at 6 months
was 61.5% in HAART era 1
22
Giancola et al. AIDS Res Hum Retroviruses. 2008 Feb;24(2):155-62

23. PML: Clinical Manifestations
• Focal neurological deficits, usually with
insidious onset and steady progression
• Any region of the CNS may be involved but
more favored are
– the occipital lobes (with hemianopia)
– frontal and parietal lobes (hemiparesis and
hemisensory deficits)
– cerebellar peduncles and deep white matter
(dysmetria and ataxia)
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24. PML: Clinical Manifestations
• The time course of this evolving demyelination,
with clinical progression over several weeks,
often provides a clue to diagnosis
– cerebral toxoplasmosis and primary CNS lymphoma
characteristically progress more rapidly over hours or
just a few days
– cerebral infarcts begin even more abruptly
• Headache and fever are not part of the disease
• Seizures in 20%
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25. PML: Prognostic Factors
• CD4 at presentation
– OR (death) 2.71 if CD4<100 (reference:>=100)
• Contrast enhancement at presentation
(favorable)
• Radiological improvement at 6 months on
ART1
– OR 14.0 (2.2-87.2), p = 0.003
25
1. Giancola et al. AIDS Res Hum Retroviruses. 2008 Feb;24(2):155-62

26. Survival with PML
26
Falco et al. J Acquir Immune Defic Syndr. 2008 Sep 1;49(1):26-31

27. PML: Diagnosis
• Combination of clinical and neuroimaging
findings
– steady progression of focal neurological deficits
– MRI almost always confirms distinct white matter
lesions
• hyperintense (white) on T2-weighted and FLAIR sequences
• hypointense (dark) on T1-weighted sequences
• usually no mass effect or displacement of normal structures
• Contrast enhancement unusual unless IRIS
– PCR to identify JCV DNA in CSF (+ in 70-90%)
– Brain biopsy (rarely necessary)
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28. PML
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29. Inflammatory PML: IRIS
• Reported to present within the first weeks to
months after initiating ART
• Atypical features that include mass effect of
the PML lesions with surrounding edema and
sometimes striking contrast enhancement on
MRI
• Likelihood of detecting JCV in CSF may be
reduced in these patients compared to
“classical” PML
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30. Inflammatory PML: IRIS
• The cellular immune response against JCV,
mediated by CD8+ T-lymphocytes, is key in the
containment of PML progression and has been
associated with a favorable clinical outcome
• However, an “excessive” response related to
IRIS may be lethal as a consequence of the
inflammatory reaction or, rarely, brain
swelling and herniation
30

31. Martinez, J. V. et al. Neurology 2006;67:1692-1694
PML: Before (A,B) and After HAART (1 month: C-E; 3 months: F-G)

32. Martinez, J. V. et al. Neurology 2006;67:1692-1694
Inflammatory PML

33. PML: Treatment
• ART should be started immediately
• ART should be changed to an effective
regimen if already on ART
• Effectiveness of an ART-intensification
strategy in patients with undetectable plasma
HIV requires further study
• More than half of patients with PML
experience a remission after initiating
effective ART
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34. PML: Treatment
• Not recommended
– cytarabine
– cidofovir
– interferon-alpha
– topotecan
• Serotonergic 5HT2a receptor antagonists (e.g.
mirtazapine) not justified for routine use
– 5HT2a receptor can serve as the cellular receptor
for JCV in a glial cell culture system
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35. IRIS PML: Treatment
• No evidence supporting the routine use of
corticosteroids in HIV-related PML without an
inflammatory response on neuroimaging
• In those with progressing clinical deficits and
neuoroimaging features suggesting inflammatory
disease (edema, swelling, and contrast enhancement),
corticosteroid treatment is justified
• Although some have suggested stopping ART in the
face of PML-IRIS, this is likely counterproductive in the
longer run and is not recommended
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36. PML: Treatment Failure
• Working definition
– continued clinical worsening and continued
detection of CSF JCV at 3 months
• Optimize ART
• Experimental options
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