title: Rapid and persistent selection of the K103N mutation as a majority quasispecies in a HIV1-patient exposed to efavirenz for three weeks: a case report and review of the literature.
abstract: BACKGROUND
  Selection of the K103N mutation is associated with moderately reduced in vitro fitness of HIV. Strains bearing K103N in vivo tend to persist, even in the absence of additional drug pressure, as minority quasispecies, often undetectable in genotyping resistance testing assays, performed at standard conditions. Here, we report on the rapid and long lasting selection of a K103N bearing strain as the dominant quasispecies after very short exposure to efavirenz in vivo.
  
  
  METHODS
  A 55-year-old Caucasian man was switched to efavirenz, zidovudine and lamivudine in February 2003, while on viral suppression in his first-line highly active anti-retroviral treatment regimen. One month later, he reported inconsistent adherence and his viremia level was 5700 c/mL. He did not attend further checkups until September 2005, when his viral load was 181,000 c/mL. The patient reported interrupting his medications approximately three weeks after simplification. The genotyping resistance testing assay was performed both on HIV RNA and HIV DNA from plasma, yielding an identical pattern with the isolate presence of the K103N mutation in the prevalent strain.
  
  
  CONCLUSIONS
  Persistence of the K103N mutation as a majority quasispecies may ensue after a very short exposure to efavirenz. Our case would therefore suggest that the presence of the K103N mutation should always be ruled out by genotyping resistance testing assays, even after minimal exposures to efavirenz.
authors.affiliation: Clinical Pathology Unit, Ospedale Civile "Spirito Santo", Via Fonte Romana 8, 65124 Pescara, Italy. e.polilli@libero.it.
authors.forename: Ennio
authors.initials: E
authors.lastname: Polilli
authors.forename: Giustino
authors.initials: G
authors.lastname: Parruti
authors.forename: Luana
authors.initials: L
authors.lastname: Cosentino
authors.forename: Federica
authors.initials: F
authors.lastname: Sozio
authors.forename: Annalisa
authors.initials: A
authors.lastname: Saracino
authors.forename: Augusta
authors.initials: A
authors.lastname: Consorte
authors.forename: Gioacchino
authors.initials: G
authors.lastname: Angarano
authors.forename: Francesco
authors.initials: F
authors.lastname: Di Masi
authors.forename: Elena
authors.initials: E
authors.lastname: Mazzotta
authors.forename: Paolo
authors.initials: P
authors.lastname: Fazii