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Summary Background Pre-exposure prophylaxis (PrEP) with emtricitabine and tenofovir disoproxil fumarate is highly effective against acquisition of HIV infection, and only two cases of infection with a multidrug-resistant virus have been reported under adequate long-term adherence, as evidenced by tenofovir diphosphate concentrations in dried blood spots. We report a case of wild-type HIV-1 infection despite consistent use of emtricitabine and tenofovir disoproxil fumarate. Methods The patient participated in the Amsterdam PrEP project, a demonstration project of daily and event-driven PrEP. We did extensive testing for HIV, including plasma HIV RNA and nested PCR on bulk peripheral blood mononuclear cells (PBMCs) and sigmoid biopsies after seroconversion. Findings A 50-year-old man who has sex with men and had been on daily emtricitabine and tenofovir disoproxil fumarate for 8 months presented with fever, urinary tract infection caused by Escherichia coli , anal lymphogranuloma venereum infection, and a positive fourth-generation HIV test. We found an atypical seroconversion pattern, with initially only gp160 antibodies detected in the western blot. HIV RNA could not be detected in plasma, and nested PCR for HIV RNA and DNA on bulk PBMCs and sigmoid biopsies were negative. PrEP was discontinued; 3 weeks later HIV RNA was detected in plasma. No drug-resistant mutations were detected. Tenofovir diphosphate concentrations in dried blood spots were stable and high. Interpretation To our knowledge, this is the first detailed case report suggesting wild-type HIV-1 infection despite good adherence, evidenced by repeatedly high concentrations of tenofovir diphosphate in dried blood spots. PrEP providers need to be aware that infection can occur despite good adherence. Regular HIV testing and awareness of atypical patterns of seroconversion is highly recommended. Funding ZonMw, National Institute for Public Health and the Environment, Internal GGD research funds, Aidsfonds, Stichting AmsterdamDiner Foundation, Gilead Sciences, Janssen Pharmaceutica, M A C AIDS Fund, and ViiV Healthcare.

Inleiding Uit de door het Landelijk Overleg CoAssistenten (LOCA) uitgevoerde enquetes blijkt dat zowel coassistenten, onderwijskundigen als artsen (opleiders) vinden dat er tijdens de coschappen te weinig aandacht is voor feedback.

A patient with Graves’ disease was admitted with a thyroid storm. She had severe hypercalcaemia caused by thyrotoxicosis. Treatment was complicated by vomiting and diarrhoea. With intravenous ondansetron, hydration and bisphosphonates, GI symptoms improved and oral thyreostatics could be started. This, combined with bisphosphonate administration, resulted in a mild hungry bone syndrome.

Introduction: Foreign body aspiration (FBA) is rare in adults and its clinical presentation can be very diverse. Acute symptoms as dyspnea and choking are often immediately linked to FBA. However, mild or even asymptomatic chronic pulmonary symptoms can be presented as a result of FBA. Physical examination is usually nonspecific. Chest X-ray is often normal or shows nonspecific findings. Treatment and definite diagnosis can be accomplished using rigid or flexible bronchoscopy. Case Series: We present two cases of foreign body aspiration. The first case was the aspiration of a broken tracheostomy tube leading to acute respiratory failure and the second case was the aspiration of a medication blister which initially presented as atypical chronic pulmonary symptoms but evolved to a medical emergency of acute respiratory failure. Conclusion: These two cases show the broad range of symptoms and findings associated with FBA. When patients present with nonspecific pulmonary findings, FBA should be included in the differential diagnosis. (This page in not part of the published article.) International Journal of Case Reports and Images, Vol. 7 No. 7, July 2016. ISSN – [0976-3198] Int J Case Rep Images 2016;7(7):422–426. www.ijcasereportsandimages.com Woittiez et al. 422 CASE REPORT OPEN ACCESS Respiratory failure in adults due to foreign body aspiration: A case series Lycke R. Woittiez, Elsbeth J. Wesselink, Marcel A. de Leeuw, Cornelis Slagt