To evaluate the occurrence of hepatotoxicity in patients during antiretroviral therapy (ART) that contains protease inhibitors and the role of hepatitis viruses in its development, we performed a retrospective study including 1325 HIV-infected patients treated with ART for at least 6 months. Presence or absence of hepatitis viruses, alanine aminotransferase (ALT), total bilirubin, CD4 cell count, and plasma HIV RNA levels were evaluated. Hepatotoxicity developed in a few study subjects without coinfection, whereas it was significantly higher in coinfected patients. Univariate logistic regression analysis showed that viral hepatitis coinfections are independent risk factors for hepatotoxicity. After 6 months of treatment, ritonavir was associated with higher rates of severe hepatotoxicity in the coinfected group; in fact, ritonavir seems to be the most strongly hepatotoxic agent among coinfected patients. After 12 months of therapy, hepatotoxicity occurred more frequently in patients with hepatitis C virus who did not respond to antiretroviral therapy (ART), whereas patients who did respond to ART showed decreased ALT levels. Hepatotoxicity is not exclusively an effect of drug toxicity, and the presence of hepatitis coinfection is an independent risk factor. Moreover, chronic hepatotoxicity mainly occurs in patients who did not respond to therapy. Conversely, patients who did respond to ART seemed to show improvement of chronic liver infection.

Our results demonstrate a statistically significant correlation of aminotransferase values with the histological parameters, and an even stronger correlation with the AST values. Our study therefore suggests that aminotransferase values, especially AST, may correlate with liver damage.

We report a case of Hymenolepis diminuta infection in an Italian child affected by tuberous sclerosis. Praziquantel is the drug of choice for the treatment of H. diminuta infection. However, considering the patient's neurological disease, we decided to use not praziquantel but niclosamide, which proved equally effective. CASE REPORTA 2-year-old boy living in the urban area of Rome, Italy, was referred to the Department of Tropical and Infectious Diseases of the University of Rome "La Sapienza" owing to the emission of tapeworm proglottids in his stool. In the previous 2 weeks, the patient had episodes of itching and nocturnal restlessness. His medical history was positive for tuberous sclerosis with no overt neurological complications other than seizures that were controlled with diazepam. The results of a physical examination were normal. No abnormalities were revealed by blood and urine analyses. Macroscopic and microscopic tapeworm examinations were suggestive of Hymenolepis diminuta proglottids. The parasitological examination of concentrated stool samples revealed spherical eggs, 70 m in diameter, with a striated outer membrane and a thin inner membrane and containing six central hooklets but no polar filaments (Fig. 1); they were identified as H. diminuta eggs and differentiated from H. nana eggs, which have a similar appearance but are smaller and have two evident polar thickenings, from each of which arise four to eight polar filaments. Owing to the possible convulsant effect of praziquantel, oral niclosamide (1 g for the first day, 500 mg/day for the following 6 days) was prescribed (1, 3). Parasitological stool examinations 7, 9, 15, and 30 days after the end of treatment were negative for H. diminuta eggs.

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