We evaluated the impact of cytomegalovirus (CMV)-induced immune responses, autoimmune-induced immune responses, and microbial translocation on immune activation in 191 human immunodeficiency virus type 1-infected patients from the ANRS CO3 Aquitaine Cohort. All enrolled subjects had achieved long-term virological suppression during receipt of combination antiretroviral therapy (cART). HLA-DR(+)/CD38(+) expression was 16.8% among CD8(+) T cells. Independent of age, CD4(+) T-cell count, 16S ribosomal DNA load, and regulatory T-cell count, positive results of Quantiferon CMV analysis (P = .02), positive results of CMV-pp65 enzyme-linked immunosorbent spot analysis (P = .01), positive results of CMV-pp65-specific CD8(+) T-cell analysis (P = .05), and CMV seropositivity (P = .01) were associated with a higher percentage of CD8+ T cells that expressed HLA-DR+/CD38+. Autoimmune response and microbial translocation were not associated with immune activation. Therefore, the CMV-induced immune response seems to be associated with chronic immune activation in cART recipients with sustained virological suppression.

ObjectivesTo describe the causes of death in HIV-infected patients in the era of highly active antiretroviral therapy (HAART). MethodA retrospective survey conducted in Bordeaux, France. Medical records of all deaths that had occurred in 1998 and 1999 amongst patients followed within the Aquitaine cohort were reviewed by the same physician. Immediate and underlying causes of death were described, taking into account the morbidity at the time of death. ResultsSixty-six deaths occurred in 1998, and 41 in 1999. Sixty-seven per cent of deceased patients were male. Median age at time of death was 43 years (range 25±71), median CD4 was 162 cells/mL (0±957); 28% of patients had a CD4 count > 200 cells/mL and 7% plasma viral load < 500 HIV-RNA copies/mL. Amongst morbidity present at the time of death, there were 23 bacterial infections, 16 non-Hodgkin's lymphomas, 16 cirrhoses, 15 non HIV-related malignancies, 13 central nervous system diseases and 10 myocardiopathies. The main immediate causes of death were: multiple organ failure (21%), coma (18%), septic shock (15%) and acute respiratory failure (14%). Underlying causes of death were AIDS-de®ning events (48%), non AIDS HIV-related infection (3%), hepatitis B-or C-associated cirrhosis (14%), non HIV-related malignancies (11%), cardiovascular events (10%), suicide and overdose (6%), treatment-related fatalities (4%), injury (2%) and unknown (2%). Patients dying from AIDS-related events were more often female, had a lower CD4 count, a higher level of HIV-RNA, a shorter history of HIV infection and were less often coinfected with hepatitis B and C viruses than those dying from other underlying causes.Conclusions AIDS-related events are no longer the major causes of death of HIV-infected patients in the era of HAART. This evolving mortality pattern justi®es an adaptation of both the epidemiological surveillance and the clinical monitoring of HIV-infected patients.

Eight cases of psittacosis due to Chlamydia psittaci were identified in May 2013 among 15 individuals involved in chicken gutting activities on a mixed poultry farm in France. All cases were women between 42 and 67 years-old. Cases were diagnosed by serology and PCR of respiratory samples. Appropriate treatment was immediately administered to the eight hospitalised individuals after exposure to birds had been discovered. In the chicken flocks, mainly C. gallinacea was detected, a new member of the family Chlamydiaceae, whereas the ducks were found to harbour predominantly C. psittaci, the classical agent of psittacosis. In addition, C. psittaci was found in the same flock as the chickens that the patients had slaughtered. Both human and C. psittaci-positive avian samples carried the same ompA genotype E/B of C. psittaci, which is widespread among French duck flocks. Repeated grassland rotations between duck and chicken flocks on the farm may explain the presence of C. psittaci in the chickens. Inspection by the veterinary service led to temporary closure of the farm. All birds had to be euthanised on site as no slaughterhouses accepted processing them. Farm buildings and grasslands were cleaned and/or disinfected before the introduction of new poultry birds.

Our results show that internationally recommended MDR-TB treatment regimens were infrequently used and that ART use and viral suppression was well below the target of 90%, reflecting the challenging patient population and the environment in which health care is provided. Urgent improvement of management of patients with TB/HIV in EE, in particular for those with MDR-TB, is needed and includes widespread access to rapid TB diagnostics, better access to and use of second-line TB drugs, timely ART initiation with viral load monitoring, and integration of TB/HIV care.

To the Editor: Rituximab, a chimeric murine-human monoclonal anti CD20 antibody, is approved for the treatment of relapsed or refractory, CD20(+) B-cell, low-grade or follicular non-Hodgkin's lymphoma (NHL). This antibody is also being used and evaluated against other CD20-expressing hematological malignancies and autoimmune disorders [1]. Recently, D'Arcy and Mannick [2] reported the first case of serum sickness occurring 10 days after the patient started a protocol of 4 weekly infusions of rituximab for refractory autoimmune polyneuropathy. The patient presented with fever, polyarthritis, and transient decrease of C3 and C4 levels. IgG antibodies directed to the murine FabЈ fragments of the rituximab were found [2]. We observed a similar clinical presentation in a 48-year-old woman with refractory immune thrombocytopenia (anti-nuclear factor negative). Six days after the second course of rituximab on a weekly protocol, the patient was admitted because of fever (38.5°C), malaise, symmetric polyarthritis of large and small joints, and a morbilliform skin eruption. At the same time, her platelet count dropped to 2,000, and she was treated with methylprednisolone 500 mg (i.v.) for 2 days. The patient responded favorably to the treatment, and less than 48 h after the treatment was started the symptoms and the signs of serum sickness resolved.Although rituximab is a chimeric murine-human antibody, only 3 patients out of more than 300 patients who were treated with rituximab and were tested for human anti-chimeric antibodies showed detectable antibodies levels [3]. None of them was reported to develop serum sickness. This is the second case reported of rituximab-induced serum sickness; both cases occurred a few days after the second course of rituximab for an autoimmune disorder, and both of them responded favorably to glucosteroid treatment. We believe that with increasing clinical experience with rituximab more cases of serum sickness will occur; therefore, the clinicians should be aware of this adverse effect. YAIR HERISHANU Effective Treatment With Recombinant Factor VIIa of Severe Bleeding Due to Acquired Factor VIII Inhibitor and Acquired ThrombocytopathyTo the Editor: Acquired hemophilia is a rare, severe hemorrhagic diathesis in nonhemophiliac patients [1]. Moreover, the appearance of a coagulation factor VIII inhibitor and alteration in the platelet function are exceptional. Activated recombinant factor VII (rVIIa) has been used recently in the antihemorrhagic treatment of patients with factor VIII inhibitors and thrombopathies [2]. We present, to the best of our knowledge, the first case of a nonhemophiliac patient, with acquired hemophilia and thrombopathy secondary to a malignant hemopathy, who was treated satisfactorily with rVIIa.A 65-year-old nonhemophiliac man presented a large hematoma of his right arm following extraction for arterial gasometry test. The activated partial thromboplastin time was 118 sec (control 25-40 sec), which was not corrected by normal fresh plasma; factor VIII:C 3%; factor V...

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