us-map.html ¶ A list of severe manifestations of monkeypox can be found at https://emergency. cdc.gov/han/2022/han00475.asp. ** During the study period and as of October 21, 2022, CDC was notified by state and local jurisdictions of five decedents whose death certificates included monkeypox as a cause of death or contributing factor, six decedents whose cause of death is still under active investigation, and one decedent in whom the death was not monkeypox-related. Additional monkeypox cases involving severe disease or death might not be included in this report if CDC has not yet been notified about the case or if the case occurred outside of the study period.

HIV-associated neurocognitive disorders (HAND) persist despite great advancements in combination antiretroviral therapy (cART). The gold standard for diagnosing cognitive impairment consists of a time-consuming neuropsychological battery of tests given by a trained neuropsychologist, however in the outpatient HIV clinic this is not feasible. The International HIV Dementia Scale (IHDS) was developed to help identify individuals with cognitive impairment in the outpatient setting. The IHDS is moderately sensitive for detecting more symptomatic forms of HAND but sensitivity has been shown to be poor in mild impairment. The IHDS has not been evaluated in developed countries in large cohort populations. We conducted a prospective cross-sectional study of only HIV+ individuals in an urban clinic and evaluated the prevalence of HAND and associated risk factors for cognitive impairment using the IHDS. A total of 507 HIV+ individuals participated in the study of which the majority were male (65%) and African American (68%); and 41% had cognitive impairment. On multivariate analysis, African American race (p=2.21), older age (p=1.03), high school education or less (p=2.03) and depression (p=1.05) were associated with cognitive impairment. The high prevalence of HAND in this group suggests that more severe forms of HAND persist despite cART. Identified risk factors were non-HIV-related and suggest that environmental and sociodemographic factors have a significant impact on cognitive functioning and should be given more attention. The IHDS should be further evaluated in large cohort HIV+ and HIV− populations in the United States, as there remains a significant need to identify an effective brief screening tool for cognitive impairment.

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Background Progression along the HIV care continuum has been a key focus for improving outcomes for people living with HIV (PLWH). Transgender women with HIV (TGWWH) have not made the same progress as their cisgender counterparts. Methods All PLWH identifying as transgender women receiving care at our clinic from 1/1/2015 to 12/31/2019 were identified from the electronic health records (EHR) using ICD codes. Demographics, laboratory data, prescription of gender-affirming hormone therapy (GAHT), and visit history were abstracted from the EHR. Retention in care and viral suppression were defined using CDC definitions. The proportions of TGWWH who were consistently retained in care or virally suppressed over time was calculated using a binary response generalized mixed model including random effects and correlated errors. Results Of the 76 PLWH identified by ICD codes, two were excluded for identifying as cisgender and 15 for insufficient records, leaving 59 TGWWH included for analysis. Patients were on average 35 years old, black (86%), with a median CD4 count of 464 cells/µL. There were 13 patients on GAHT at study entry and 31 receiving GAHT at any point during the study period. 55% were virally suppressed at study entry and 86% at GAHT initiation. The proportion of TGWWH who were consistently virally suppressed over time was greater among those receiving GAHT compared to those who were not (p=0.04). Conclusions Rates of viral suppression were significantly greater among TGWWH receiving GAHT when compared to those who were not. More research to evaluate reasons behind this effect are needed.

HIV-infected women are at increased risk of invasive cervical cancer, however screening rates remain low. The objectives of this study were to analyze a quality improvement intervention to increase cervical cancer screening rates in an urban academic HIV clinic and to identify factors associated with inadequate screening. Barriers to screening were identified by a multi-disciplinary quality improvement committee at the Washington University Infectious Diseases clinic. Several strategies were developed to address these barriers. The years pre- and post-implementation were analyzed to examine the clinical impact of the intervention. A total of 422 women were seen in both the pre-implementation and post-implementation periods. In the pre-implementation period, 222 women (53%) underwent cervical cancer screening in the form of Papanicolaou (Pap) testing. In the post-implementation period, 318 women (75.3%) underwent cervical cancer screening (p<0.01). Factors associated with lack of screening included fewer visits attended (pre: 4.2 ± 1.5; post: 3.4 ± 1.4; p<0.01). A multidisciplinary quality improvement intervention was successful in overcoming barriers and increasing cervical cancer screening rates in an urban academic HIV clinic.

Infectious pseudotumors are unusual proliferations of histiocytes in response to certain microbial organisms. Occasionally this process may involve large airways, producing a mass lesion that may cause respiratory obstruction. Infectious pseudotumors can be confused with malignancy in their radiologic appearance and clinical presentation. We present a case of an aggressive endotracheal pseudotumor associated with Rhodococcus equi infection in a patient with advanced HIV disease. Microscopically, the lesion was composed of sheets of epithelioid histiocytes with large, strongly eosinophilic intra-cytoplasmic granules and features of malakoplakia. In this report, we review the literature of these unusual lesions and compare them to cases of conventional malakoplakia involving the large airways. We also explore the pathogenetic mechanisms that may contribute to the distinctive histologic appearance of Rhodococcus-associated pseudotumors.

Background Recent studies have identified an increase in nephrotoxicty in patients receiving vancomycin plus piperacillin-tazobactam (PT) when compared with vancomycin monotherapy. To date, studies have evaluated all hospitalized patients or intensive care unit patients only. The purposes of this study were to examine the incidence of acute kidney injury (AKI) in patients who received vancomycin either as monotherapy or with PT in a non–intensive care unit medical-surgical setting and to identify potential risk factors for the development of AKI. Methods A retrospective chart review was performed to identify patients who received vancomycin either as monotherapy or in combination with PT for at least 48 hours. Patients were evaluated for development of AKI, defined as serum creatinine increase of 50% from baseline. Statistical analysis included demographic, univariate, and multivariable analyses. Results One hundred eighty-nine patients met inclusion criteria. More patients in the vancomycin + PT group developed AKI than in the vancomycin monotherapy group (18.4% vs 5.6%, P = 0.008). After multivariable logistic regression of patients receiving vancomycin, PT, African American, and perioperative patients remained statistically associated with AKI. These risk factors gave odds ratios of 3.9, 3.8, and 4.0, respectively. Conclusions Patients receiving PT in addition to vancomycin were more likely to develop AKI compared with those receiving vancomycin monotherapy. African American and perioperative patients may have a higher risk.

CitationThe purpose of this study was to describe the occurrence of the M184V mutation in a single clinic setting over a period of 10 years. We examined the combination Antiretroviral Therapy (cART) being taken at the time of first identification of the M184V mutation as well as Second Line Regimens (SLR) started immediately after the documentation of M184V. SLR were evaluated for frequency and time to Virologic Suppression (VS) as well as frequency and time to subsequent Virologic Failure (VF). Prevalence of the M184V mutation, ART regimen leading to M184V acquisition, and outcomes of SLR in patients with M184V (as measured by time to initial VS and subsequent VF on SLR) were analyzed in a retrospective cohort study of all HIV-infected persons receiving care at a university clinic. Results: Of 2500 screened clinic patients, 220 had an acquired MI184V mutation (8.8%). There were 158(72%) male and 171(78%) African-American patients. The mean time from the start of a regimen to the documented M184V mutation was 575(0-3253) days. Independent of Nucleoside Reverse Transcriptase Inhibitor (NRTI) backbone, the mean time to development of M184V in Non-Nucleoside Reverse Transcriptase Inhibitor (NNRTI) (n=109) and Protease Inhibitor (PI) based (n=84) regimens was 538(+/-556) and 622 (+/-620) days, respectively (p=0.325) approximately, 78% of patients achieved VS on a SLR in a mean of 179 days. Of the 122(57%) of patients whose SLR retained FTC/3TC, VS was achieved in 80% compared to 74% without FTC/3TC (p=0.285) with no significant difference in time to VS (152(+/-187) and 181(+/-257) days respectively, p=0.406). There were no significant differences in achievement of VS in PI (n=158) and NNRTI (n=27) -based SLRs independent of the NRTI backbone, 76% vs. 78%, respectively (p=0.837) with a similar time to VS (180(+/-228) vs. 128(+/-158) days, p=0.313). All patients on PI+Raltegravir (RAL) (n=10) and PI+NNRTI (n=12) -based regimens achieved VS (vs. 76% in PI+2NRTI (p=0.078 and p=0.054, respectively). Regardless of SLR, about 50% of each group experienced VF after VS with a similar time to failure. Conclusions: M184V mutation developed in 9% of patients in a mean of 575 days with no significant differences between ART regimens. Following initiation of an SLR, the majority of patients achieved VS in approximately 179 days irrespective of the regimen. The addition of 3TC/FTC did not significantly affect VS. Although numbers were small, 100% of patients on two fully active non-NRTI-backbone-based regimens attained VS. Approximately half of all patients subsequently failed on SLR, regardless of regimen used, suggesting that the development of M184V is a marker of noncompliance to therapy.