Candidal meningitis in HIV-infected patients: treatment with fluconazole

Although mucocutaneous candidiasis is a common occurrence in HIV-infected patients, candidal meningitis is uncommon. We report 3 cases of candidal meningitis in HIV-positive patients, all intravenous drug abusers, and we discuss the clinical course and outcome, the treatment with fluconazole and possible prophylaxis.     

Acute bacterial meningitis in adults: a clinical and developmental analysis of 100 cases

BACKGROUND: Characterize clinical findings and outcome of acute bacterial meningitis (ABM) in adults, with special emphasis on nosocomial meningitis and meningitis in the elderly. METHODS: We reviewed the charts of all persons 14 years of age or older in whom ABM was diagnosed in our hospital during a 12 and a half-year period. RESULTS: Ninety-seven patients were treated for 100 episodes of ABM, of which 23 percent were nosocomial and 27 percent occurred in elderly persons. Predisposing factors were present in 59 percent of the episodes. Fifty-four percent had the classic triad of fever, nuchal rigidity, and change in mental status. Cerebrospinal fluid pleocytosis with a neutrophilic predominance, hypoglycorrhachia, and elevated protein levels were present in 62 percent of the episodes. A pathogen was identified in 62 percent of the cases, in a higher frequency in elderly persons (p < 0.05) and in patients who had not received antibiotics before the lumbar puncture (p < 0.05). Causal agents more frequently identified were: Streptococcus pneumoniae (27 percent) in community-acquired meningitis, coagulase-negative Staphylococci (35 percent) in nosocomial meningitis, and Strep. pneumoniae (33 percent) in elderly persons. Central nervous system (CNS) complications occurred in 18 percent of episodes, and 15 percent developed systemic complications. The overall mortality rate was 9 percent, higher among patients in whom CNS complications began within 24 hours of admission (p < 0.05). CONCLUSIONS: A high proportion of cases of ABM in adults are nosocomial, or affect elderly persons. The fatality rate is high, particularly among those who develop CNS complications at the onset of the disease.     

Anterior uveitis in HIV-infected patients. 3 cases in patients treated with an antiprotease

OBJECTIVES: Uveitis is an ocular manifestation rarely observed in HIV-infected patients. We observed three cases of anterior uveitis without progressive retinitis in HIV patients receiving antiprotease treatment. CASE REPORT: The first patient developed a first episode of uveitis during ritonavir therapy. Two other episodes occurred with indinavir. The second patient developed uveitis when treated with indinavir. In the third patient, the first episode developed with indinavir and a second with a ritonavir-saquinavir combination. Uveitis was unilateral in 4 episodes. Clinical manifestations were red irritable eyes and, in 2 episodes, reduced visual acuity. The antiprotease was interrupted in 4 of the 6 episodes and clinical course was rapidly favorable. DISCUSSION: Pure anterior uveitis should suggest drug induction in HIV infected patients; rifabutin is often the cause. Infectious causes predominate in case of total uveitis associating choroid and retinal involvement. Cytomegalovirus, herpes zoster, syphilis, and toxoplasmosis have been incriminated. Antiproteases would appear to be a new cause of anterior uveitis in HIV-infected patients.     

Klebsiella pneumoniae meningitis: analysis on clinical features of thirty-two adult patients

BACKGROUND: To assess the clinical features and therapeutic outcomes of adult Klebsiella pneumoniae (KP) meningitis. METHODS: Thirty-two adult patients with KP meningitis were included in this study. Their clinical features, the outcomes with the third generation cephalosporin (moxalactam, cefotaxime, ceftazidime) treatment and prognostic factors were analyzed. RESULTS: These patients' diseases were predominantly community-acquired. Males outnumbered females (3:1). Diabetes mellitus (DM) was the most common underlying disease, followed by other debilitating diseases such as liver cirrhosis, neoplasm and end-stage renal disease (ESRD). Patients with spontaneous meningitis had a more fulminant course with a higher prevalence of bacteremia, shock and death (66%). Metastatic septic abscess was frequent (19%). Among the 21 patients who received initial appropriate antimicrobial therapy (IAAT), 2 took cefotaxime and 1 died; 13 took moxalactam of whom 5 died; and 6 took ceftazidime of whom 3 died. All of the other 11 patients who did not receive IAAT died. CONCLUSIONS: The clinical features of KP meningitis are various and indistinguishable from other form of bacteria meningitis. Most of the patients with KP meningitis are associated with underlying medical problems, such as diabetes mellitus and liver cirrhosis. Many factors, including septic shock, bacteremia, high cerebrospinal fluid lactate concentration, and IAAT, might influence the prognosis. In spite of a high mortality rate, however, IAAT is mandatory to improve the overall survival rate.     

Neurological form of cryptococcosis. Apropos of 2 atypical cases in non HIV-infected patients

Cryptococcal infection is the most common fungal infection of the central nervous system. More than 50% of the cases of cryptococcal infection are superimposed on an immunosuppressive or other general debilitating condition. Cerebral cryptococcosis usually presents as meningitis or meningoencephalitis, although cerebral granuloma has also been reported. Hydrocephalus is the most common neurosurgical complication of cerebral cryptococcosis. The majority of patients require only medical treatment with antifungal drugs. However, when complications ensue, surgical intervention is mandatory. We suggest that chronic meningitis be ruled out in all patients prior to the placement of shunts. In the two cases reported here treatment of cryptococcal meningitis was a combination of amphotericin B and flucytosine for six weeks. Fluconazole is a new alternative and at least as effective as amphotericin B.     

Anorectal disease in HIV-infected patients

Alpha-1-antiproteinase E, the fourth isoform of rabbit alpha-1-antiproteinase (alpha-1-antitrypsin) having a glutamic acid at the reactive center, has been purified from the plasma by sequential chromatography on hydroxyapatite and anion-exchange columns. The E form of alpha-1-antiproteinase formed a complex with trypsin, chymotrypsin, elastase, plasmin and pancreatic kallikrein as judged by SDS-PAGE. The E form inhibited elastase in a stoichiometric manner and chymotrypsin moderately, but the inhibition of trypsin was gradual. The F form inhibited trypsin most effectively followed by chymotrypsin and elastase. N-chlorosuccinimide reduced the elastase inhibitory activity of the E form, while the F form was more effectively inactivated by the oxidant.     

Evaluation of diarrhea in HIV-infected patients

Diarrhea is a major problem for patients infected with HIV: initial studies indicated that 50% of HIV-seropositive patients developed diarrhea, but this may be an underestimate. Diarrhea has an appreciable adverse affect on the quality of life of these patients; also, they use more health care facilities and health care dollars than HIV-positive patients without diarrhea. Individuals who have homosexuality or bisexuality as their HIV risk factor are more likely to have diarrhea and to have an enteric pathogen identified as the cause of diarrhea than are patients who have heterosexuality or intravenous drug use as their risk factor.     

Fungal infections in HIV-infected patients

Opportunistic fungal infections are commonly encountered in the acquired immunodeficiency syndrome (AIDS) patient population. Fungal infections in the patient infected with the human immunodeficiency virus (HIV) are a major cause of morbidity and mortality. The yeasts Candida and Cryptococcus neoformans, the dimorphic fungi Histoplasma capsulatum and Sporothrix schenckii, and the dermatophyte fungi are the most common pathogenic fungi in patients infected with HIV. The characteristics of these and other relevant mycotic pathogens, and their clinical presentation are discussed. Mycoses in the patient infected with HIV are often atypical, and can be masked by other infections. Cutaneous manifestations may provide valuable diagnostic clues. The clinician must maintain a high index of suspicion to establish an early diagnosis and rapidly institute therapy. Treatment may suppress rather than cure the mycosis, because host immunity in conjunction with antifungal agents is necessary to eliminate infection.     

Staphylococcus aureus pericarditis in HIV-infected patients

Serious infections caused by Staphylococcus aureus in HIV-infected patients have been reported. Contributing factors in the development of invasive S aureus infections include a high rate of skin and nasal colonization, frequent dermatologic disease, and the use of intravenous catheters. The authors report three cases of S aureus pericarditis in HIV-infected patients. While cases of viral, mycobacterial, and malignant pericardial effusions in HIV-infected patients have been reported, a review of the literature disclosed only three cases of bacterial pericarditis. Despite appropriate antibiotic therapy and drainage, a patient's condition may abruptly deteriorate and progress to tamponade. Early recognition of bacteremia and pericarditis and monitoring for cardiac tamponade, along with aggressive treatment, can result in a favorable outcome, but mortality remains high, particularly when S aureus is the causative agent.     

Hypouricemia in patients with meningitis

Serum urate and sodium concentrations were measured in 23 patients with acute viral and bacterial meningitis. Serum urate level was 3.0 +/- 0.2 mg/dl (mean +/- S.D.) (3.6 +/- 1.2 mg/dl in male and 2.5 +/- 0.9 mg /dl in female) on admission, but gradually elevated with improvements of meningitis. It turned to 4.8 +/- 0.2 mg/dl after recovery, and the value on admission was significantly lower than that after recovery (p < 0.0001). Serum sodium level was 137.6 +/- 2.9 mEq/l on admission and 139.7 +/- 2.7 mEq/l after recovery; also lower in the former (p < 0.01). These results show that patients develop transient hypouricemia, which may be explained by SIADH (syndrome of inappropriate secretion of ADH), although SIADH is subclinical in most cases of meningitis.     

Survival prognosis of HIV-infected patients

This study investigated the secretory pattern of unstimulated minor salivary glands in 10 contiguous specified areas of the hard palate in 12 healthy unmedicated adult men and women. Each participant was assessed twice at each of two visits in the same specific palatal areas from the distal portion of the second molar to 30 mm anterior. The 10 areas were isolated, dried, and sampled with a paper strip for 60 seconds. The strips were read with a Periotron device. The rates of flow were significantly influenced by position; higher values were noted posteriorly and medially during testing and retesting at both visits. The rates of flow from the palatal glands were greatest in the area between the maxillary second molars. This method proved to be simple, accurate, and reliable for measuring the secretions of the palatal glands. This method may prove useful for investigating how the relationship between the pattern and the secretory rate of minor salivary glands influences retention of the complete maxillary denture.     

Sturge-Weber syndrome: experience with 14 cases

We report a first documented case in Senegal with simple transposition of the great arteries diagnosed in a 2 months old girl treated by Rashkind atrioseptostomy. Our patient benefited from clinical examination, ECG (15 derivations), chest X ray and standard laboratory tests. Pulsed-Doppler, two dimensional and TM echocardiography have been performed with an ATL MK 600 echocardiograph. Cardiac catheterism, angiocardiography and Rashkind procedure have been realized in our Department. These data are discussed and compared to the literature. At admission this patient presents with major cyanosis and polypnea. At examination, there is a 3/6 murmur at the left sternal border and a subclavicular continuous murmur. Laboratory tests showed metabolic acidosis and severe hypoxemia. Chest x-ray showed a cardio-thoracic ratio at 0.64 with increased pulmonary vascular markings. ECG showed right ventricular hypertrophy. Echocardiography-Doppler revealed ventriculo-arterial discordance with restrictive atrial septal defect and persistent ductus arteriosus. Rashkind procedure was followed by an increased aortic saturation. After 6 weeks there was an improvement of cyanosis and cardiac failure. Diagnosis of transposition of the great arteries is actually easier with development of ultrasonography which is useful when performed by experienced cardiologist. Spontaneous prognosis of this malformation is very poor. Rashkind atrioseptostomy is an important step for the initial treatment of transposition of the great arteries in terms of survival before open heart surgery.     

Neuropsychiatric performance of HIV-infected patients

AIM: Can neuropsychic impairment which is clinically observed in the case of HIV-infected patients be objectivized, and what is the relationship to somatic features caused by the disease? PATIENTS AND METHOD: 65 HIV-infected men with no history of drug-addiction were examined by means of a test battery which monitored the functions memory/concentration and speed of response. The probands were then compared to a healthy control group which was parallelized with respect to age, sex and education. Immune status, HIV and AIDS associated symptoms as well as educational diseases were checked for their connection with neuropsychic impairment. RESULTS: Compared to healthy persons HIV patients presented significant deficits with respect to memory and concentration but showed no reduction of speed of response. Significant correlation could be determined with only one somatic feature: Half of the patients who had lost more than 10% of their body weight during the preceding three months suffered from clinically relevant memory and concentration disorders. CONCLUSIONS: 1. The massive memory and concentration disorders impair and isolate the patients and can have considerable job-related consequences. 2. Measures preventing loss of weight should be initiated as early as possible. 3. Training sessions, e.g. nutritional consultation, must take the patients' deficits with respect to concentration and memory into consideration. 4. Possible connections between loss of weight and changes in brain metabolism should be examined. 5. Future studies should determine whether measures weight increase coincide with an improvement of memory and concentration.     

Cryptococcal meningitis: our experience in 24 black patients

The records of 24 patients with cryptococcal meningitis, admitted to King Edward VIII Hospital in Durban, were reviewed. There were 21 adults and 3 children over periods of 10 and 18 years, respectively. Slightly more males were affected. The age distribution was fairly even. The common clinical presentations were headache, neck stiffness, mental changes, cranial nerve palsies and papilloedema. The diagnosis was proved by the presense of Cryptococcus neoformans in the cerebrospinal fluid (CSF) in 21 of the patients, and in pathological tissue in the remaining 3 patients. A significant percentage of patients presented with an initial polymorphonuclear leucocyte predominance in the CSF. The other CSF findings were elevated protein and low sugar levels. Tuberculosis was the common coexisting disease. We found the mortality rate of 58% to be very high and a significant number of patients died even after adequate treatment with amphotericin B either singly or in combination with 5-fluorocytosine.