Unusual skin ulceration in an HIV-positive patient who had cutaneous syphilis and neurosyphilis

We present a case of a patient coinfected with syphilis and the human immunodeficiency virus (HIV) who had unusual and severe cutaneous ulceration. The profound immune defects associated with HIV may lead to an altered clinical presentation and a more aggressive course in patients infected with Treponema pallidum. Despite non-confirmatory histological findings, we feel our patient's cutaneous ulcers probably represent superficial gummata, which have failed to resolve completely following currently accepted high-dose antisyphilis chemotherapy.     

Human immunodeficiency virus seropositivity in adolescents with syphilis

OBJECTIVE: The purpose of this study was to assess the relationship between syphilis and human immunodeficiency virus (HIV) infection among inner-city, minority group adolescents. METHODS: From August 1989 through June 1990, serum from all positive serologic tests for syphilis, obtained from patients attending a comprehensive adolescent health center in an acquired immunodeficiency syndrome epicenter and its two school-based clinics, were frozen without patient identifiers and were subsequently screened for HIV by enzyme-linked immunosorbent assay with confirmatory Western blot for positives. In addition, a retrospective chart review was performed for all patients with a positive serologic test for syphilis during the study period. RESULTS: Of the 59 specimens with a positive syphilis serologic test, 9 (15.3%) were HIV seropositive. Of the patients with syphilis, 57.4% were black and 42.6% were Hispanic; 16.4% were male (mean age 18.1) and 83.6% were female (mean age 17.8). Only 1 subject (female) was an injection drug user; 4 of the male subjects self-identified as having had sex with other males. Of the subjects, 27.8% had primary, 19.7% had secondary, and 52.5% had latent syphilis at the time of diagnosis. A prior or concurrent sexually transmitted disease was present in 90% of the males and 80% of the females; gonorrhea was the most prevalent sexually transmitted disease in the males (89%) and chlamydia was most prevalent in the females (35%). A history of chancroid and/or herpes was present in 16.4% of the subjects. CONCLUSIONS: It is concluded that the diagnosis of syphilis in an adolescent is a risk factor for HIV infection. All sexually active adolescents should be routinely screened for syphilis, regardless of sexual practices. Those with syphilis should be specifically counseled about their increased risk for HIV infection and the importance of consistent condom use, and they should be referred for formal HIV pretest counseling.     

Chronic non granulomatous ulcerative jejunitis

BACKGROUND: Early human immunodeficiency virus (HIV) defection is essential for initiating treatment and partner-notification activities. Sexually transmitted disease (STD) clinic attendees are at high risk for infection and should be made aware of their HIV status. GOAL: To determine the characteristics associated with not receiving an HIV test result in an STD clinic setting. STUDY DESIGN: Confidential HIV testing was offered to 6,705 persons attending four public STD clinics in Los Angeles who submitted blood for syphilis serology and were tested for HIV antibody in an unlinked HIV serosurvey. Human immunodeficiency virus test results and return status were anonymously linked to other risk information. RESULTS: Only one-third of attendees were tested and given their results. Those testing HIV positive in the anonymous survey and those requesting HIV testing were most likely to receive a test result (i.e., 41% and 49%, respectively). Those solely requesting an STD examination, repeat testers, and African-Americans were least likely to receive a result (i.e., 32%, 30%, and 26%, respectively). CONCLUSIONS: Most STD clinic patients fail to receive an HIV test result. Other strategies, such as rapid HIV testing, are needed to increase participation and receipt of HIV test results in this high-risk population.     

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.     

Prevalence, incidence, and risks for HIV-1 infection in female sex workers in Miami, Florida

Annual cross-sectional prevalence, incidence of new infection, and risks for human immunodeficiency virus type 1 (HIV-1) infection were studied in 607 women convicted of prostitution between October 1987 and December 1990 and tested for HIV under court order. Cross-sectional prevalence was stable for 4 years (23-24% positivity in 1987-1991, p = 0.6). However, the incidence of new infections (rate of seroconversion) in 264 women tested more than once increased significantly each year from 12 per 100 person-years in 1987-1988 to 19 per 100 person-years in 1991 (p < 0.03). Seroconverters were more likely to be young black women with a prior history of syphilis or gonorrhea. A new episode of syphilis or rectal gonorrhea during the follow-up period predicted HIV seroconversion in a survival analysis model. Female sex workers are at great risk of acquiring HIV infection. Although HIV prevalence in cross-sectional samples was stable, incidence was increasing. Interpretation of prevalence trends from convenience samples, such as screening programs, may be difficult because changes in incidence may not be detected.     

Poor efficacy of antimalarial biguanide-dapsone combinations in the treatment of acute, uncomplicated, falciparum malaria in Thailand

Because the ever-changing course of HIV disease, including AIDS, represents a continuous series of unexpected stressors, repeated crisis intervention is appropriate for people who are HIV infected. HIV disease causes situational, developmental, social, and compound crises. People with HIV may experience episodic trauma over the course of the illness and consequently move in and out of equilibrium. Crisis intervention should be offered at every hazardous juncture. This article examines ways to use crisis intervention techniques to help people living with HIV.     

Plasma levels of clonidine following epidural bolus injection in children

PURPOSE: To describe dense vitritis as the primary manifestation of ocular syphilis in three human immunodeficiency virus (HIV)-positive patients and to determine the response of these patients to the established regimen for neurosyphilis. METHODS: Anti-Toxoplasma gondii IgM and IgG antibody titers, tuberculin skin test, chest radiograph, and serum angiotensin-converting enzyme level were obtained because tuberculosis, sarcoidosis, and toxoplasmosis were in the differential diagnosis. Two of the three patients were not known to have HIV infection at the time of initial examination and consented to HIV testing. Treponemal and nontreponemal tests were performed on serum and cerebrospinal fluid to establish a definitive diagnosis. Treatment for neurosyphilis was initiated, and daily ophthalmic examinations were performed, with careful attention to signs commonly associated with syphilitic eye disease. RESULTS: All three patients exhibited improvement in visual acuity and resolution of vitreous haze. There was no evidence of other signs of posterior uveitis. The one patient for whom there has been a 6-month follow-up showed no sequelae of his eye disease. CONCLUSIONS: Human immunodeficiency virus-positive patients with syphilis may present atypically dense vitritis. In these patients, vitritis may be the first manifestation of syphilis. The regimen for neurosyphilis provides effective therapy. Moreover, in some patients, syphilitic vitritis may be the initial manifestation of HIV disease.     

HIV infection in non-pregnant women: a review of current knowledge

HIV infection has become an important health problem among American women. The natural history of HIV infection and AIDS appears to be similar for women and men, and preliminary studies demonstrate similar survival and clinical events for both sexes. The natural history and presentation of common gynecologic infections and conditions may be altered by HIV. Most is known about cervical dysplasia. The risk of cervical dysplasia appears to be increased in women with HIV infection, progression of cervical dysplasia may be more rapid, severity of disease increased, particularly for women with HIV-related immunocompromise. Recently, the Centers for Disease Control and Prevention added invasive cervical cancer as an AIDS-defining condition. Vulvovaginal candidiasis, sexually transmitted diseases, including syphilis, herpes, and cytomegalovirus, and pelvic inflammatory disease are also common in HIV-infected women. Preliminary data suggest that these conditions may be more severe and more difficult to treat in HIV-infected women than uninfected women. Women who are HIV-infected should have thorough evaluation and follow up of all gynecologic conditions, particularly as they become immunosuppressed.     

1,5 Tesla MRI in focal nodular hyperplasia. Review of the literature apropos of 7 cases

There are increasing reports of unusual clinical features and atypical courses of syphilis in patients with acquired immunodeficiency syndrome. Recently, we had the opportunity to study an HIV-positive female patient with strong manifestations of secondary syphilis. The case is discussed together with the implications of secondary syphilis in her concomitant ocular affliction. Moreover, we comment on the clinico-therapeutic controversies brought about by the association of infection with Treponema pallidum and HIV.     

Neurosyphilis. A comparative study of the effects of infection with human immunodeficiency virus

BACKGROUND: The course of neurosyphilis has been reported to be altered by human immunodeficiency virus (HIV) infection. Prior reports of neurosyphilis occurring in association with HIV infection have been largely anecdotal and have failed to compare neurosyphilis in patients with HIV infection with an uninfected control group. This study was performed to determine if the clinical presentation encountered is different in the presence of HIV infection. DESIGN: A retrospective, hospital-based, case series study based on chart review encompassing a 64-month period. SETTING: The study was performed in a large, university-affiliated, public health trust hospital in south Florida. PATIENTS: Forty-six hospitalized patients with neurosyphilis were identified; 13 patients fulfilled Centers for Disease Control and Prevention (Atlanta, Ga) criteria for acquired immunodeficiency syndrome (AIDS), 11 were HIV seropositive only, and 22 were HIV uninfected. Neurosyphilis was determined by a reactive cerebrospinal fluid VDRL slide test. RESULTS: The HIV-infected patients (both AIDS and HIV-seropositive groups) were younger and more frequently had features of secondary syphilis, such as rash, fever, adenopathy, headache, or meningismus. Significant differences were observed in cerebrospinal fluid measurements when the HIV-infected group was compared with the HIV-uninfected group, including a higher mean white blood cell count in patients with AIDS and a higher mean protein level and a lower mean glucose level in the HIV-infected group. Syphilitic meningitis was more common in HIV-seropositive patients, although the HIV-uninfected patients presented with a greater variety of types of neurosyphilis. Ophthalmic syphilis was observed more frequently in the HIV-infected group. CONCLUSIONS: Significant differences exist between neurosyphilis occurring in the presence and absence of HIV infection.     

Primary HIV infection

Up to 70% of individuals with primary HIV infection will develop symptoms of an acute illness. The most common symptoms reported are fever, generalized lymphadenopathy, arthralgia and myalgia, headache, pharyngitis, enanthema, skin rash, diarrhoea, and mucocutaneous ulcerations. More rarely, oesophageal candidiasis, meningoencephalitis, rhabdomyolysis and epiglottitis have been reported. The diagnosis of the acute HIV infection syndrome can be established by demonstrating antibodies to HIV or by demonstration of HIV antigen positivity. Detection of virus through culture or PCR may prove to be more sensitive, but are not yet used as routine methods. The course of the primary infection has prognostic importance for the subsequent course of HIV infection. This probably reflects the importance of both the viral phenotype and of the initial immune response to HIV. Primary HIV infection should be considered in any patient with possible exposure to HIV presenting with fever of unknown cause.     

Risk of human immunodeficiency virus infection among pregnant crack cocaine users in a rural community

OBJECTIVE: To investigate why women who use crack cocaine are at increased risk of human immunodeficiency virus (HIV) infection. METHODS: One thousand one hundred fifty-two (99.7%) of 1155 consecutive prenatal patients attending a rural public health clinic were interviewed about drug use and sexual practices and tested for HIV infection and other sexually transmitted diseases. RESULTS: Fifty-one (4.7%) of 1096 pregnant women reported ever using crack cocaine, but only five (10%) of the crack cocaine users had ever injected drugs. Eighteen (35%) of the crack users were HIV infected compared with 22 (2%) of the 1045 women who reported never using crack (odds ratio 25, 95% confidence interval 12-52; P < .001). Crack users were more likely to have had a known HIV-infected sex partner, exchanged sex for money or drugs, and tested positive for syphilis than were non-crack users (for each comparison, P < .001). Before using crack, 18% of crack users had exchanged sex for money or drugs and 8% had averaged three or more sex partners per month; in contrast, after beginning to use crack, 76% of crack users exchanged sex for money or drugs and 63% averaged three or more sex partners per month (for both comparisons, P < .001). Crack users who were not HIV infected were more likely to have almost always used condoms and/or had fewer than three sex partners per month than were HIV-infected crack users (P < .01). CONCLUSION: Women who reported using crack cocaine were at an increased risk of HIV infection because crack use was associated with a significant increase in unprotected sexual contact.     

Counselling for an HIV test

Doctors may feel uncomfortable with the prospect of discussing a human immunodeficiency virus (HIV) antibody test with their patient. This is in part because they do not enquire about high risk activity as part of a medical history. With increasing medical and public awareness of both the clinical manifestations and social implications of HIV infection, it is important that all doctors receive guidance on how to deal with these issues. Counselling is not the usual term used to describe obtaining informed consent. In the general medical setting, tests for hepatitis B and syphilis are routinely carried out without specific consent even though results of these tests may have profound effects on both the patient and their sexual partners. However society and ethical considerations have made HIV testing different. HIV testing will inevitably become more widespread, and thus become a more routine part of patient investigation and management.     

Does HIV status influence the outcome of patients admitted to a surgical intensive care unit? A prospective double blind study

OBJECTIVES: (a) To assess the impact of HIV status (HIV negative, HIV positive, AIDS) on the outcome of patients admitted to intensive care units for diseases unrelated to HIV; (b) to decide whether a positive test result for HIV should be a criterion for excluding patients from intensive care for diseases unrelated to HIV. DESIGN: A prospective double blind study of all admissions over six months. HIV status was determined in all patients by enzyme linked immunosorbent assay (ELISA), immunofluorescence assay, western blotting, and flow cytometry. The ethics committee considered the clinical implications of the study important enough to waive patients' right to informed consent. Staff and patients were blinded to HIV results. On discharge patients could be advised of their HIV status if they wished. SETTING: A 16 bed surgical intensive care unit. SUBJECTS: All 267 men and 135 women admitted to the unit during the study period. INTERVENTIONS: None. MAIN OUTCOME MEASURES: APACHE II score (acute physiological, age, and chronic health evaluation), organ failure, septic shock, durations of intensive care unit and hospital stay, and intensive care unit and hospital mortality. RESULTS: No patient had AIDS. 52 patients were tested positive for HIV and 350 patients were tested negative. The two groups were similar in sex distribution but differed significantly in age, incidence of organ failure (37 (71%) v 171 (49%) patients), and incidence of septic shock (20 (38%) v 54 (15%)). After adjustment for age there were no differences in intensive care unit or hospital mortality or in the durations of stay in the intensive care unit or hospital. CONCLUSIONS: Morbidity was higher in HIV positive patients but there was no difference in mortality. In this patient population a positive HIV test result should not be a criterion for excluding a patient from intensive care.     

Providing patients with their diagnostic test results. A vignette study in general practice

The communication of results of HIV tests and chest-X-rays because of persistent coughing are of particular interest because potential life-threatening disease may be disclosed. For HIV tests it is recommended that the result is communicated to the patient in the doctor's office face to face. In this questionnaire study based on two simulated case-stories with a 63 year-old man referred to chest-X-rays because of persistent coughing, and a 27 year-old man, who had been living in Africa for some time, now wanting a HIV test performed, we found that only half (53%) of the general practitioners (GP) did communicate HIV test results in the consultation office. X-ray test results were only communicated in the consultation office by 18% of the GPs. Communication of test results which might have serious implications to the patient should preferably not be done by telephone. Patients should be told of potentially serious results in person by their own physician.     

Syphilitic aortitis and "accelerated" atherosclerosis

The authors present the case of a 42 year old patient admitted for surgery of massive aortic regurgitation. Investigation of this patient who had no significant cardiovascular risk factors, showed diffuse and accelerated atherosclerosis (severe stenosis at the origin of both subclavian arteries at both superficial femoral arteries). Tertiary syphilis with neurological involvement and aortitis was confirmed by histological examination (peroperative biopsy of the aortic wall). This case is unusual due to the association of early atherosclerosis with tertiary syphilis and raises the question of the causality of syphilis in the generation of these atherosclerotic lesions.     

Concentric rings simulating tinea imbricata in secondary syphilis. A case report

A female patient with secondary syphilis presented with concentric rings of papules simulating tinea imbricata. To avoid the occurrence of "ping-pong" syphilis, it is stressed that both sexual partners should be treated simultaneously.     

Gutenberg recycled

The Tuskegee Study, an observational study of over 400 sharecroppers with untreated syphilis, was conducted by the U.S. Public Health Service to document the course of the disease in blacks, and racial differences in the clinical manifestations of syphilis. The men were not told they had syphilis, not given counseling on avoiding spread of the disease, and not given treatment throughout the course of the study. The study became the longest (1932-1972) nontherapeutic experiment on humans in the history of medicine, and has come to represent not only the exploitation of blacks in medical history, but the potential for exploitation of any population that may be vulnerable because of race, ethnicity, gender, disability, age or social class. It is important for physicians who will be caring for an increasingly diverse nation to understand the lasting implications of this study for their patients, but the effects of the Tuskegee Syphilis Study are demonstrated most strikingly by unsuccessful attempts at improving representation of minority patients in clinical trials.     

Long-term effects of HIV counseling and testing for women: Behavioral and psychological consequences are limited at 18 months posttest.

Behavioral and psychological consequences of HIV counseling and testing (HIV C&T) for women were examined in a longitudinal, prospective study. Women who received HIV C&T at community health clinics (n?=?106) and a comparison group of never-tested women (n?=?54) were interviewed five times over 18 months. There was no change in risk behaviors as a consequence of testing: tested and untested women engaged in high-risk sexual behavior at baseline and 18 months later. Tested women reported more anxiety, depression, and intrusive thoughts about AIDS than did untested women. Although tested women were more concerned about AIDS, their potential risk factors over the study period generally were equivalent to those for untested women. HIV counseling and testing should be considered one aspect of a broader program of HIV prevention. Identification of alternative interventions must be a public health priority. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Seropositive rheumatoid arthritis with interstitial lung disease in giant cell arteritis

Unusually high mortality rates have been recorded among HIV-infected tuberculosis patients in urban Africa 6 and 12 months after initiation of tuberculosis treatment--a trend that impedes efforts to achieve the 85% cure rate target set by the World Health Organization. This study investigated tuberculosis treatment outcomes in relation to HIV serostatus in a rural district of Malawi (Ntcheu). All 205 smear-positive pulmonary tuberculosis patients newly diagnosed in the district in 1995 received 2 months of daily supervised streptomycin, rifampicin, isoniazid, and pyrazinamide in the hospital followed by 6 months of isoniazid and thiacetazone at home. HIV testing, offered to all tuberculosis patients, was accepted by 110 (54%), 73 (66%) of whom were HIV-positive. By the end of treatment, 126 patients (61%) had been cured and 56 (27%) had died. Significantly fewer HIV-positive patients or patients who declined HIV testing were cured (59% and 55%, respectively) than those who agreed to testing and were HIV-negative (84%). The mortality rate was 29% among patients who tested HIV-positive, 8% among those with a negative test result, and 34% among patients who declined HIV testing. Acceptance of HIV testing improved over the course of the study period in response to changes in counseling techniques, especially clarification that blood taken for HIV testing would not be used for transfusions. Overall, these findings suggest that, in areas where HIV infection is prevalent, an 85% tuberculosis cure rate may be unrealistic.