Ridzon et al. (March 27 issue) (1) report a case of the transmission of human immunodeficiency virus (HIV) and hepatitis C virus (HCV) from a single source, followed by unusually long times to seroconversion for both viruses. We report a similar case, but one in which transmission was followed by seroconversion times similar to those previously described for HIV (2) and for HCV. (3)
In a suicide attempt, a 27-year-old man injected himself in the brachial vein with 0.1 ml of blood that he had obtained, using the same insulin syringe, from a drug addict seropositive for HIV and HCV. Thirteen days after the injection, the man had a temperature of 40 degrees C, sweating, and erythematous pharyngitis. These symptoms lasted 10 days. On day 17 the concentration of p24 antigen was 250 ng per liter, the HIV Western blot assay had no positive band, and an enzyme immunoassay for antibodies to HIV was negative. The test for HIV antibodies first became positive on day 31, when the HIV Western blot assay revealed only weak bands for gp160, p55, p24, and p18. The full HIV-positive Western blot pattern was obtained on day 73. The assay for antibodies to HCV became positive on day 123. Zidovudine treatment began on day 51 and was continued for seven months. Four years later, with only the seven months of zidovudine treatment, the patient was free of symptoms.
This patient differed from the one described by Ridzon et al. (1) in that concomitant transmission of HIV and HCV was followed by normal seroconversion times for both viruses. (2,3) Four years after the dual contamination, the patient remained symptom-free. Thus, simultaneous acquisition of the two viruses is not always followed by a rapid progression of HIV or HCV disease. We do not know whether the zidovudine treatment slowed the progression of HIV disease, as has been suggested. (4,5) We also do not know whether that treatment interfered with the progression of HCV disease by reducing the HIV-related immunodeficiency.
The use of combination therapy against HIV has been proposed after exposure to that virus. Interferon alfa can be given to prevent HCV infection, but nothing is known about its efficacy as prophylaxis. (3) These two cases of simultaneous exposure to HIV and HCV raise the question of whether interferon alfa therapy should be administered with combination therapy for HIV after such exposures or only after HCV infection has been documented.
Francois Biron, M.D.
Hopital de la Croix-Rousse
69317 Lyons CEDEX 4, France
Bernard Verrier, Ph.D.
Centre National de la Recherche pour la Sante BioMerieux
69364 Lyons CEDEX 7, France
Dominique Peyramond, M.D.
Hopital de la Croix-Rousse
69317 Lyons CEDEX 4, France
References
1. Ridzon R, Gallagher K, Ciesielski C, et al. Simultaneous transmission of human immunodeficiency
virus and hepatitis C virus from a needle-stick injury. N Engl J Med
1997;336:919-22.
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2. Tindall B, Cooper DA. Primary HIV infection: host responses and
intervention strategies. AIDS 1991;5:1-14.
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3. Iwarson S, Norkrans G, Wejstal R. Hepatitis C: natural history of a
unique injection. Clin Infect Dis 1995;20:1361-70.
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4. van Der Poel CL, Cuypers HTM, Reesink HW, et al. Confirmation
of hepatitis C virus infection by new four-antigen recombinant immunoblot assay. Lancet 1991;337:317-9.
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5. Kinloch-de Loes S, Hirschel BJ, Hoen B, et al. A controlled trial of zidovudine in primary human
immunodeficiency virus infection. N Engl J Med 1995;333:408-13.
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To the Editor:
Biron et al. describe another case of simultaneous transmission of HIV and HCV. There are two notable differences between that case and the one we described. In their patient, the times to seroconversion were shorter, and the course of the illness was much less aggressive. The reasons for these differences are unclear. Because the groups at risk for these two blood-borne pathogens overlap, it is likely that more such dual infections will occur. Additional studies will be needed to determine the range of seroconversion times, the continuum of immune responses, and the clinical outcome in such cases.
The care of patients with percutaneous or mucosal exposure to blood from an HCV-infected person is problematic, because prophylaxis with immune globulin after the exposure does not appear to be effective, (1) and no data are available for use in assessing the postexposure efficacy of interferon or other antiviral agents. Given the rate of transmission of HCV as a result of exposure to blood, clinical trials to assess the efficacy of postexposure prophylaxis against HCV infection will be difficult because of the large sample needed for the study to have sufficient power. As has been done in the case of exposure to HIV through blood, surveillance data on exposures to HCV-infected blood may be helpful and provide additional information about the potential efficacy of various types of postexposure prophylaxis. Although the mechanisms of the effect of interferon in patients with hepatitis C are poorly understood, the antiviral mechanisms of the drug may require the presence of an established infection. (2) Interferon must be administered parenterally, and its side effects can be severe. On the basis of these considerations, postexposure prophylaxis against HCV infection is not currently recommended. (3)
Renee Ridzon, M.D.
Eric E. Mast, M.D.
Centers for Disease Control and Prevention
Atlanta, GA 30333
Kathleen Gallagher, M.P.H.
Massachusetts Department of Public Health
Boston, MA 02130
References
1. Krawczynski K, Alter MJ, Tankersley DL, et al. Effect of immune
globulin on the prevention of experimental hepatitis C virus infection. J Infect Dis 1996;173:822-8.
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2. Peters M, Davis GL, Dooley JS, Hoofnagle JH. The interferon
system in acute and chronic viral hepatitis. Prog Liver Dis 1986;8:453-67.
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3. What is the risk of acquiring hepatitis C for health care workers
and what are the recommendations for prophylaxis and follow-up after occupational exposure to
hepatitis C virus? Hepatitis surveillance report no. 56. Atlanta: Centers for Disease Control and
Prevention, 1995.
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