Mycobacteremia in patients with the acquired immunodeficiency syndrome

BACKGROUND: Bacillemia is a key event in the pathogenesis of tuberculosis. Although current evidence indicates that Mycobacterium tuberculosis bacteremia is rare in patients seronegative for the human immunodeficiency virus, it has been increasingly reported in patients with the acquired immunodeficiency syndrome (AIDS). OBJECTIVE: To determine clinical and laboratory characteristics of patients with AIDS and tuberculosis with and without bacillemia. METHODS: Fifty patients with AIDS with clinical suspicion of disseminated mycobacterial disease were prospectively selected. Three consecutive blood samples were collected for culture using a standardized protocol. RESULTS: Mycobacterium was isolated from any body site in 42 patients (84%). Bacillemia was detected in 30 (71.4%) of these 42 patients: 11 (28.2%) caused by Mycobacterium avium-intracellulare complex and 19 (71.8%) caused by M tuberculosis. Blood culture was the only method used to confirm the diagnosis in 5 (15%) of the 33 tuberculosis cases. Tuberculosis in patients with AIDS developed with nonspecific insidious symptoms, a remarkable elevated alkaline phosphatase level, and without the classic miliary radiological pattern. We could demonstrate 2 previously unrevealed clinical characteristics of bacteremic tuberculosis in patients with AIDS: a shift to the left in the white blood cell count and abdominal lymph node enlargement. In patients with tuberculosis, the in-hospital mortality rate was higher among patients with bacillemia, although the posttreatment survival rate was comparable. CONCLUSIONS: Blood culture is a valuable tool to confirm the clinical diagnosis of disseminated tuberculosis in patients with AIDS and can distinguish patients with characteristic clinical findings and outcome. Abdominal ultrasonography may be an additional helpful tool to identify these patients.     

Septic shock in patients with the acquired immunodeficiency syndrome

OBJECTIVE: To evaluate the prognosis of patients with septic shock admitted to an intensive care unit (ICU), according to their HIV serostatus. DESIGN: Retrospective study. SETTING: Medical ICU of a university hospital. PATIENTS: 76 patients with septic shock admitted to the same ICU, of whom 28 were HIV positive and 48 were HIV negative. MEASUREMENTS AND RESULTS: Severity scores, number and type of organ failures, and survival rates were assessed in the two groups of patients. Glasgow Coma Scale and general severity scores [Acute Physiology and Chronic Health Evaluation II and Simplified Acute Physiology Score (SAPS)] were significantly worse in HIV-infected patients. The total number of organ failures was also higher in the HIV-positive group: 3.7 +/- 0.2 vs 3.1 +/- 0.2 in the HIV-negative group (p < 0.001). On day 28, 21 (46%) HIV-negative patients were dead compared to 26 (93%) patients in the HIV-positive group (p < 0.001). In the multivariate analysis, HIV infection was an independent risk factor for mortality, as were the SAPS score, use of mechanical ventilation, and the McCabe score. CONCLUSIONS: This study reports a considerable excess mortality in HIV-infected patients with septic shock. Although severity of illness was clearly much more pronounced in HIV-positive patients, retroviral infection was independently associated with death. Improving survival in HIV-positive patients with septic shock may require earlier diagnosis and treatment of the causative infection.     

Pulmonary cryptosporidiosis in patients with acquired immunodeficiency syndrome

Several reports have showed Cryptosporidium species as a cause of intractable diarrhea and malabsorption in patients with acquired immunodeficiency syndrome (HIV). A case of chronic diarrhea in a drug addict woman associated with a symptomatic interstitial pulmonary infection due to Cryptosporidium parvum is described. This unusual C. parvum spread into the bronchial tree is underlined and a survey of the literature is made.     

Utility of scintigraphic methods in patients with fever of unknown origin

BACKGROUND: We assessed the utility of scintigraphy with indium 111-labeled polyclonal human IgG scintigraphy in patients with fever of unknown origin that fulfilled the criteria of temperature of 38.3 degrees C or more for at least 3 weeks and no diagnosis during 1 week of hospital admission. We compared the utility of this technique with results of scintigraphic techniques reported in the literature. METHODS: Data for all patients seen at our university hospital in whom 111In-IgG scanning was performed were analyzed and checked for the criteria for fever of unknown origin. The literature on the utility of scintigraphic techniques in patients with fever of unknown origin was reviewed. RESULTS: We studied 24 patients with fever of unknown origin. In 13 patients, focal 111In-IgG accumulation was observed. In nine (38%) of those, the positive 111In-IgG scintigram led to the final diagnosis; in the other four patients (17%), the scintigraphic findings were not helpful. In the 11 patients with negative 111In-IgG scans, extensive diagnostic workup produced no infection as the final diagnosis in nine patients (38%), one had an abscess in a renal cyst that was detected several months later, and in the other the cause of fever was an infected intravenous line. The overall sensitivity and specificity of 111In-IgG scintigraphy were 81% and 69%, respectively. The positive predictive value was 69% and the negative predictive value was 82%. CONCLUSIONS: Our results show that 111In-IgG scintigraphy significantly contributed to the diagnostic process in patients with fever of unknown origin. A positive scan increased the likelihood of finding the cause of the fever, and a negative scan ruled out an inflammatory component with a high degree of certainty. These data compare favorably with data in the literature concerning other radiopharmaceuticals; a larger prospective evaluation of this technique is indicated.     

Neurogenic bladder in patients with acquired immunodeficiency syndrome

We have performed a urodynamic study on 3 patients with acquired immunodeficiency syndrome (AIDS), presenting with a neurogenic bladder. The first patient had an ascending myelitis of probable herpetic origin, the second patient had a cerebral abscess caused by Toxoplasma gondii, and the third patient had an AIDS dementia complex. The urodynamic study showed an areflexic detrusor in the first 2 patients, and a hyperreflexic detrusor in the third patient.     

Role of MRI in diagnosis of childhood sarcoidosis with fever of unknown origin

Airway hyperresponsiveness (AHR) is a hallmark of asthma and a heritable polygenic trait in the mouse. In the mouse, candidate gene products of hematopoietic origin implicated in asthma mapped to the regions of the previously defined quantitative trait loci. Since hematopoietic cells have been implicated in the pathogenesis of asthma, we evaluated the role of hematopoietic cells in general and T cells specifically in the genetic modulation of native airway responsiveness in mice. Here, with the use of bone marrow transplantation, anti-T-cell monoclonal antibody treatment and T-cell transfer, we demonstrate that intrinsic non-atopic AHR is mediated by T lymphocytes. Our data support the novel concept that, in the absence of identified environmental influences, T cells enhance genetically determined airway responsiveness.     

Progressive ocular toxoplasmosis in patients with acquired immunodeficiency syndrome

We studied two patients, a 43-year-old Hispanic man with a one-year history of acquired immunodeficiency syndrome (AIDS) and a 34-year-old Hispanic man with newly diagnosed AIDS. Both had necrotizing retinitis that progressed to panophthalmitis and orbital cellulitis. Toxoplasmosis was not diagnosed in the first patient early in the course of the disease. The second patient had a history of toxoplasmic retinochoroiditis. Despite anti-toxoplasmosis therapy, visual acuity deteriorated to no light perception in both patients. Diagnostic biopsy of the eye wall was performed on the first patient and enucleation of the globe on the second. Toxoplasmic panophthalmitis and orbital cellulitis were diagnosed in each patient by light microscopy and confirmed by electron microscopy. When patients with AIDS develop necrotizing retinitis, toxoplasmosis must be considered in the differential diagnosis, along with cytomegalovirus retinitis, progressive outer retinal necrosis, and syphilitic retinitis. Unlike cytomegalovirus retinitis, progressive outer retinal necrosis, and syphilitic retinitis, however, toxoplasmosis can cause a progressive intraocular infection, panophthalmitis, and orbital cellulitis in patients with AIDS.     

Intermittent fever of unknown origin

HISTORY AND CLINICAL FINDINGS: A 58-year-old woman was admitted because of intermittent fever for 4 weeks accompanied by slowly developing anaemia and increase in inflammatory parameters. She was being treated for hypertension with atenolol and chlorthalidone, but until 6 weeks before the onset of the described symptoms she had only taken the beta blocker, at which time the diuretic was added because the hypertension was inadequately controlled. Other than slightly impaired general condition and nocturnal fever up to 39.5 degrees C physical examination was unremarkable. INVESTIGATIONS: She had a normochromic normocytic anaemia and the erythrocyte sedimentation rate and C-reactive protein were clearly elevated. Other biochemical tests and blood cultures as well as serological and immunological tests were negative. Bone marrow biopsy showed nonspecific reactive changes. The chest radiograph, lung scintigraphy and abdominal ultrasound were unremarkable. TREATMENT AND COURSE: There was no further fever after the antihypertensive medication had been discontinued. The patient's general condition rapidly improved and all biochemical tests became normal. The lymphocyte transformation test demonstrated stimulation by chlorthalidone. CONCLUSION: Drug fever, in this case due to a sulphonamide derivative, should always be considered in the differential diagnosis of fever of unknown aetiology. No previous case of hypersensitivity reaction to chlorthalidone has been found on a search of the literature.     

Intraoral non-Hodgkin''s lymphoma in seven patients with acquired immunodeficiency syndrome

Transcranial Doppler sonography (TCD) of the middle, anterior and posterior cerebral arteries and of the basilar artery was used to evaluate the mean blood velocity (V mean) and the pulsatility index [PI = (V systolic-V diastolic)/V mean] as a vascular resistance index in 63 patients (male 40, female 23, mean age 43 +/- 19 y) with bacterial meningitis (n = 33, including 2 patients with fungal meningitis) and viral meningitis (n = 30) within 12 h after admission of the patients. The findings were similar for all intracranial arteries. Compared with reference values of 69 healthy volunteers [V mean of middle cerebral artery [MCA] 57 +/- 13 cm/s, MCA-PI 0.83 +/- 0.15], MCA-V mean was increased in patients with Glasgow coma scale (GCS) scores of 14 and 15 (71 +/- 18 cm/s; t-test: p < 0.001), not significantly different in the patients with GCS scores of 10-13 (55 +/- 21 cm/s) and decreased in those with GCS scores of 3-9 (42 +/- 21 cm/s, p < 0.01). The MCA-PI increased from 0.93 +/- 0.22 in the patients with GCS scores of 14-15 to 2.81 +/- 2.06 in those with GCS scores of 3-9 (p < 0.001 vs. controls). By regression analysis, MCA-V mean decreased and MCA-PI increased with decreasing GCS scores (p < 0.001). Only in patients with bacterial meningitis was the Glasgow outcome scale (GOS) score lower the more the MCA-PI was increased (regression analysis p < 0.001). We conclude that in patients with bacterial and viral meningitis, and in a good clinical state, the cerebral blood flow seems increased by hyperemia; with clinical deterioration the cerebral haemodynamics worsen. However, the early assessment of the cerebral blood flow by TCD seems useful for predicting outcome in bacterial meningitis only.     

Bone marrow transplantation in primary immunodeficiency syndrome and in osteopetrosis

The designation primary immunodeficiency embraces a multiplicity of diseases of which only the more severe constitute indications for BMT (bone marrow transplantation)--e.g. severe combined immunodeficiency (SCID), Wiskott-Aldrich syndrome, familial haemophagocytic lymphohistiocytosis and malignant osteopetrosis. In cases of immunodeficiency, the outcome of BMT is strongly dependent on the patient's age, clinical status at transplantation and the type of immunodeficiency. In children with SCID who undergo BMT during the first few months of life, lasting cures can be obtained in almost 100 percent of the cases, whereas there is only a 15 percent probability of success if the child is older, infected, cannot undergo cytostatic preconditioning or cannot be given T-cell depleted bone marrow.     

Chronic varicella-zoster virus epithelial keratitis in patients with acquired immunodeficiency syndrome

OBJECTIVE: To characterize further a chronic epithelial keratitis caused by varicella-zoster virus infection in patients with acquired immunodeficiency syndrome (AIDS). METHODS: Patients with AIDS and chronic epithelial keratitis associated with varicella-zoster virus from 3 institutions were identified. Patient records were reviewed retrospectively for the following data: medical and demographic characteristics, techniques of diagnosis, physical findings, course, response to treatment, and outcome. RESULTS: Sixteen patients were studied. CD4+ T-lymphocyte cell counts were available in 11 patients, with a median of 0.034 x 10(9)/L (range, 0-0.094 x 10(9)/L). Two patients had no history of a zosteriform rash. In the remaining patients, the interval between rash and keratitis ranged from 0 days to 6 years. In all cases, the keratitis was chronic and characterized by gray, elevated, dendriform epithelial lesions that stained variably with fluorescein and rose bengal. The peripheral and midperipheral cornea was most commonly affected, and, in 13 of the 16 patients, the lesions crossed the limbus. Pain was a prominent feature, occurring in 12 of 16 patients. In 9 of 12 patients tested, varicella-zoster virus was identified by culture, direct fluorescent antibody testing, polymerase chain reaction testing, or a combination of these studies, with direct fluorescent antibody testing (6 of 8 positive results) and polymerase chain reaction testing (3 of 3 positive results) appearing to be the most sensitive. Response to antiviral medication was variable. CONCLUSIONS: In patients with AIDS, varicella-zoster virus may cause a chronic infection of the corneal epithelium. The keratitis is characterized by dendriform lesions, prolonged course, and frequently by extreme pain. It can occur without an associated dermatitis.     

Kaposi's sarcoma of the head and neck in patients with acquired immunodeficiency syndrome

Kaposi's sarcoma is the most common neoplastic process in patients infected with the human immunodeficiency virus. Moreover, the occurrence of Kaposi's sarcoma in human immunodeficiency virus-infected patients advances their classification to having the acquired immunodeficiency syndrome. We reviewed the medical records of 48 patients with human immunodeficiency virus infection who had Kaposi's sarcoma documented on their initial visit to the hospital. The onset of Kaposi's sarcoma occurred independent of the Centers for Disease Control and Prevention classification of human immunodeficiency virus infection (modified to exclude Kaposi's sarcoma). This neoplasm developed more frequently in patients who acquired human immunodeficiency virus infection by sexual contact (75% of cases), but manifestations were not significantly different in any of the risk populations for human immunodeficiency virus infection. Kaposi's sarcoma lesions were unpredictable and either showed progression, remained static, or occasionally, regressed spontaneously. Moreover, the lesions were usually multifocal at presentation, with the head and neck (62.5% of cases) as the primary site of involvement. In this region cutaneous lesions predominated (66.7%), followed by mucosal (56.7%) and deep structure (13.3%) involvement. The majority of patients with acquired immunodeficiency syndrome Kaposi's sarcoma involving head and neck structures were asymptomatic (80% of cases). Mucosal lesions were associated with symptoms in 29.3% of cases, whereas cutaneous lesions had symptoms in 5% of cases.     

Neuroleptic malignant syndrome in the acquired immunodeficiency syndrome

Patients infected by the human immunodeficiency virus are predisposed to many infectious and noninfectious complications and often receive a variety of drugs. Furthermore, they seem to have a particular susceptibility to idiosyncratic adverse drug reactions. It is therefore surprising that only a few cases of the neuroleptic malignant syndrome have been described in patients with the acquired immunodeficiency syndrome. A high index of suspicion is required to diagnose the neuroleptic malignant syndrome in these patients, as its usual manifestations, including fever and altered consciousness, are frequently attributed to an underlying infection.     

Resource utilization patterns in patients with acquired immunodeficiency syndrome (AIDS)

A survey in 1991 of resource use patterns and factors affecting the cost of care for the acquired immunodeficiency syndrome (AIDS) in Mulago Hospital, Kampala, Uganda, revealed that drugs constitute 97% of the mean cost of care of affected individuals in the outpatient and 37% in hospitalized patients. The cost of drugs per treatment episode was Ug.Sh.5785.00 in the outpatient and Ug.Sh.8309.00 for inpatients. (The exchange rate for 1991 was US$ = Ug.Sh.910.00). Analysis of an attempt to provide essential drugs for the growing number of AIDS subjects shows that drugs alone could consume the entire health budget of the Ministry of Health in Uganda. There is therefore need to critically consider options to control the high cost for drugs in AIDS care.     

Treatment of infections in the patient with acquired immunodeficiency syndrome

Modern technology has led to a contemporary medical practice that must be able to manage a variety of opportunistic infections in the immunocompromised host. The most common causes of immune suppression are immunosuppressive therapy after organ transplantation, granulocytopenia secondary to cancer chemotherapy, and the human immunodeficiency virus (HIV). All of these forms of immunosuppression predispose patients to a wide variety of opportunistic infections caused by reduction in T- and B-cell lymphocyte function as well as depression of neutrophils. However, the acquired immunodeficiency syndrome (AIDS) has presented the clinician with the greatest challenge in this area. Therefore, it is imperative that physicians and other health care professionals have a comprehensive understanding of the recommended therapy as well as the epidemiology, pathogenesis, and diagnosis of the various infections in these patients.     

Human microsporidiosis in the acquired immunodeficiency syndrome

BACKGROUND AND OBJECTIVE: Photodynamic therapy (PDT) using 5-aminolevulinic acid (ALA)-induced protoporphyrin IX (PpIX) for sensitization is a promising treatment for carcinoma in situ and diffuse premalignant changes of the bladder. We studied the biodistribution of PpIX in a range of tissues with oral and intravesical routes of administration of ALA and compared the photodynamic effects on bladder and skin. STUDY DESIGN/MATERIALS AND METHODS: Normal Wistar rats were given oral or intravesical ALA and PpIX levels in the liver, kidney, skin, and bladder measured by fluorescence microscopy on tissue sections. At the time of maximum PpIX levels, the bladder and skin on the back were illuminated with light at 630 nm and the PDT effects compared. RESULTS: PpIX fluorescence in the urothelium after 200 mg/kg given intravesically was comparable to that found after 100 mg/kg orally. The ratio of PpIX levels between the urothelium and the underlying muscle was the same for both routes of administration, although there appeared to be more selectivity of urothelial PDT necrosis after intravesical administration. Skin photosensitization was greater after oral ALA, the epidermal PpIX level being three times higher than after intravesical administration for comparable urothelial levels and the PDT effect being more marked. CONCLUSIONS: Intravesical instillation is preferable to oral administration of ALA for PDT ablation of the urothelium of the rat bladder without damage to the underlying tissue layers and for minimizing skin photosensitivity. The technique is now ready for clinical trials.