Several new antiretroviral (ARV) agents for treatment experienced HIV-infected patients have been approved since June 2006, including darunavir (DRV) and raltegravir (RAL). While efficacious in clinical trials, the effectiveness, durability, and tolerability of these new ARVs remains understudied in the context of routine clinical care. The Darunavir Outcomes Study is a prospective cohort study of three-class ARV-experienced patients changing regimens at the 1917 Clinic after 1/7/2006. All treatment decisions were at the discretion of primary providers. Multivariate (MV) logistic regression for 48 week VL <400c/ml and Cox models for regimen durability were completed. Propensity score methods controlled for sociodemographics. Among 108 patients, mean age of 46, 48% were white, 80% male, with prior exposure to a mean 10.5 ARVs. Overall, 64% of patients achieved 48-week VL <400 c/ml. In MV modeling DRV/r (OR ¼5.77;95%CI ¼ 1.62-20.58) and RAL (OR ¼ 3.84;95%CI ¼ 1.23-11.95) use increased odds of 48-week suppression. Use of these agents exhibited a trend towards prolonged regimen durability in Cox models. Among those highly ARV-experienced, regimens containing DRV/r and/or RAL were more likely to achieve 48-week VL <400 c/ml and exhibited a trend towards prolonged durability. New agents have transformed the treatment landscape for ARV-experienced patients, with effectiveness in routine clinical care mirroring efficacy in clinical trials.

We report the case of a human immunodeficiency virus-negative woman who developed native valve endocarditis of the aortic valve due to Bartonell henselae infection. The diagnosis was established using serology and PCR analysis of excised aortic valve tissue. CASE REPORTA 38-year-old woman having a remote history of intravenous drug use was admitted to Lyndon B. Johnson Hospital in May 2000 after she presented to the emergency room. She complained of fever, nausea, vomiting, and nonbloody diarrhea over a 2-week period associated with fatigue and generalized weakness. She lived in Texas and owned a fully grown cat and two kittens. Initial examination of the patient revealed a temperature of 39°C, a grade 3/6 diastolic murmur, and splenomegaly. Laboratory evaluation showed the following values: white blood cell count, 2.4 ϫ 10 9 /liter; hemoglobin level, 11.9 g/dl; platelet count, 62 ϫ 10 9 /liter. In addition, a chest radiograph showed moderate cardiomegaly but no effusions or infiltrates. Because of a high level of suspicion that the patient had infective endocarditis, transthoracic echocardiography was performed on the day of admission, which demonstrated the presence of a large, mobile vegetation on a bicuspid aortic valve.Initially, the patient received empirical treatment for infective endocarditis with a combination of vancomycin and gentamicin. Twenty-four hours later, a transesophageal echo test was performed, revealing a 2-cm vegetation attached to both cusps of the bicuspid aortic valve, moderate aortic regurgitation, dilatation of the ascending aorta without evidence of abscess formation, and concentric left ventricular hypertrophy. Two weeks after that, a total of six sets of blood cultures collected by adult isolator tubes prior to and after initiation of antibiotic treatment yielded no growth. Additionally, serum specimens were collected for infectious serology, including agents of culture-negative endocarditis. Subsequently, the patient's hospital course was complicated by the development of glomerulonephritis secondary to her infective endocarditis and nonoliguric acute renal failure due to aminoglycoside toxicity. The serum creatinine level peaked at 3.5 mg/dl. Bartonella serology using an indirect immunofluorescence assay (IFA; Microbiology Reference Laboratory, Cypress, Calif.) showed the following titers: Bartonella henselae immunoglobulin M (IgM), 1:20 (reference range, negative, Ͻ1:20); B. henselae IgG, 1:512 (reference range, negative, Ͻ1:64); Bartonella quintana IgM, 1:20 (reference range, negative, Ͻ1:20); B. quintana IgG, 1:512 (reference range, negative, Ͻ1:64). When a serology result positive for Bartonella species was reported, the patient's antibiotic regimen was changed to ceftriaxone and azithromycin. Serological tests for Brucella, Chlamydia, and Coxiella species, other common etiological agents of culture-negative endocarditis, were negative.Because of the patient's persistent febrile episodes and the presence of no obvious source other than her infective endocarditis, she underwe...

We describe an HIV-positive female patient who had acute abdominal pain as the initial presentation of Strongyloides stercoralis infection. The diagnosis was established by identifying rhabditiform larvae in stool. She also had intra-abdominal tuberculosis without intestinal perforation. To our knowledge, this is the first reported case of such a presentation.