The Emergence of Resistance Under Firstline INSTI Regimens

Abstract

We reported an HIV-naïve patient from a resource-limited area who was detected with multiple resistance sites associated with nucleoside reverse transcriptase inhibitors (NRTIs) and integrase strand transfer inhibitors (INSTIs) after the failure of the initial antiviral regimen dolutegravir/lamivudine (DTG/3TC) and subsequent Bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF). On May 8, 2021, a 53-year-old man was diagnosed with AIDS, Marneffei talaromycosis and fungal esophagitis, and was suspected of having tuberculosis (TB) in Guangxi, China. His baseline HIV RNA was 559,000 copies/mL and the CD4 count was 12 cells/µL, but resistance genotype testing was not performed. The patient remained immunosuppressed (CD4 count 3 cells/µL) after 12 weeks of initial antiviral treatment (ART) with DTG/3TC. After he was switched to BIC/FTC/TAF and started anti-TB treatment, the viral load (HIV RNA 163,200 copies/mL) was not effectively controlled, and there were multiple NRTIs drug-resistant mutations (D67N, K70R, M184V, T215V, K219Q) and INSTIs mutations (E138K, G140A, S147SG, Q148R). This suggested that in resource-limited areas, for HIV-naïve patients in advanced stages with active opportunistic infections, HIV RNA>500,000 copies/mL, and low CD4 count, baseline resistance testing and increased HIV RNA testing frequency should be recommended, DTG/3TC was not recommended as initiation, and opportunistic infections should be treated promptly. In addition, switching to other INSTIs was not recommended in the absence of resistance testing and ineffective use of DTG.

Ascaris lumbricoides, an uncommon cause of appendicitis

“…Appendicitis is the cause most important of acute abdomen and needs emergency surgical treatment. 2 The main cause is lumen obstruction. Multiple entities reported (lymphoid hyperplasia the most common 60%, fecaliths 35%).…”

“…5 Lumen obstruction leads to increase in intraluminal pressure leading to mucosal ischemia, vascular congestion, then, mucosa becomes hypoxic and ulcerates resulting in compromise of the mucous barrier of the appendix. 2 More than one worm can be seen in the lumen even when there are no grossly or microscopically visible features of appendicitis. 4 The role of parasitic infection in the aetiology of appendiceal disease has been known for many years and they were most seen in histologically normal appendices and rarely associated with the histological changes.…”

“…3 Besides, the responsibility remains debated. 2 First case report published was in 1906 by Dr. Anley while he was serving in China. 1…”