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.     

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.     

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.     

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.     

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.     

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.     

Obese people who seek treatment have different characteristics than those who do not seek treatment.

A group of obese people who had not sought treatment; an obese group who had sought treatment in a professional, hospital-based program; and normal-weight controls (N?=?547) were compared in regard to level of psychopathology, binge eating, and negative emotional eating. Because the groups differed significantly on several demographic variables, 3 demographically matched groups were created and compared (n?=?177, 59 per group). In the matched subgroups, obese people who had sought treatment reported greater psychopathology and more binge eating than did normal-weight controls or those who had not sought treatment. Both obese groups (including those who had not sought treatment) endorsed more symptoms of distress, negative emotional eating, overeating, difficulty resisting temptation, and less exercise than did normal-weight controls. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Can the age limit for endoscopy be increased in dyspepsia patients who do not have alarm symptoms?

We studied the interictal EEG of 50 epileptic patients (28 males, 22 females) who had parenchymal neurocysticercosis, diagnosed by CAT/MRI of the brain, positive immunological reaction for cysticercosis in cerebral spinal fluid or both. Age ranged from 5 to 61 years old; the mean age of onset was 24.2 +/- 12.2 years. Thirty-six patients had generalized seizures, 13 partial seizures with secondarily generalized seizures, and 1 had complex partial seizures. Twenty-two patients had parenchymal calcifications (inactive form); 21 had parenchymal cysts (active form) and 7 had both. EEG was abnormal in 14 patients (28%): 8 had focal slowing, 3 had focal sharp or spike activity, and 3 had both. The EEG was normal in patients with inactive forms of neurocysticercosis. The EEG was abnormal in 50% of patients with active and mixed forms of neurocystercosis and in 48% of patients with active form only. We conclude that the active forms of neurocysticercosis should be suspected when the EEG is found to be abnormal. In additional, EEG abnormality does not depend on the number of lesions, but rather on location and viability of the cysts, and on host response.     

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.     

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.     

Disseminated strongyloidiasis in a patient with acquired immunodeficiency syndrome

Seven patients developed recurrent hemarthroses following total knee arthroplasty. The average interval between arthroplasty and the first bleed was more than 20 months (range, 1-30 months). All seven required open synovectomy an average of 21 months (6-31 months) after arthroplasty. Follow-up evaluation averaged 44 months (19-60 months) and all had an excellent result without further bleeds. A prolific synovitis was seen in all cases, with histologic features revealing a chronic synovitis with fibrosis and hemosiderin staining. Entrapment of the proliferative synovial tissue between the components is postulated to be the etiology for these recurrent bleeds which averaged four per patient prior to synovectomy.     

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.     

Rehabilitation of patients who have suffered a stroke with an aphasic syndrome

A total of 70 patients with aphasic syndromes following a cerebral stroke were treated in a neurological department, a polyclinic and at home. The main diseases which led to the brain stroke were hypertensive disease and general atherosclerosis. The aphasic disturbances were due to hemorrhagic strokes in 19 patients and ischemic-in 51 patients. Training of speech rehabilitation began from the end of the first and the beginning of the second week after the stroke. The inclusion of logopedic lessons into the general complex of restorative therapy, a continuity in conditions of a hospital and a polyclinic, a possibility of a dynamical observation of the patients, dispensarization-all these measures according to the authors' opinion are important and necessary for rehabilitation of the patients who had strokes with the aphasic syndrome.     

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.