Cardiac diastolic dysfunction is prevalent in HIV-infected patients

Combination antiretroviral therapy (ART) has markedly improved survival in HIV-infected patients, but not without significant adverse effects including ART-associated dyslipdemia and insulin resistance, which may in part contribute to an increased risk of cardiovascular events. Other contributing factors to cardiovascular risk may include uncontrolled HIV replication, the effects of HIV and ART on vascular endothelium and inflammatory cytokines. Diastolic dysfunction may be an early sign of cardiovascular disease. Our objective was to determine the prevalence of diastolic dysfunction in HIV-infected patients without cardiovascular symptoms. We enrolled 91 subjects in a cross-sectional study of HIV-infected patients without cardiovascular symptoms between September 2004 and August 2005, to assess whether demographics, HIV-related factors, cardiac risk factors, and ART were associated with diastolic dysfunction. All subjects underwent two-dimensional transthoracic echocardiography with tissue Doppler imaging. Subjects were predominately male with a median age of 38 (interquartile range [IQR]: 33, 42) years and median ART duration 6.15 (IQR: 2.1, 8.4) years. Subjects had low Framingham risk scores. Diastolic dysfunction was observed in 34 patients (37%; 95% confidence interval [CI] 27.4, 48.1). Cardiac risk factors or poor prognostic indicators of AIDS progression were uncommon with no difference between subjects with or without diastolic dysfunction. A nonstatistically significant trend in increased rate of diastolic dysfunction was observed in patients receiving protease inhibitors 1 year or more, 44% versus 28%, respectively (univariate odds ratio 2.02, 95% CI 0.83 to 4.90). This was not observed with prolonged use of either non-nucleoside or nucleoside reverse transcriptase inhibitors. A high prevalence of diastolic dysfunction (37%) in a cohort of HIV-infected patients on ART at low risk for AIDS and cardiovascular disease was demonstrated.

Unusual case of Pneumocystis jiroveci pneumonia during primary HIV infection

Symptomatic primary HIV infection occurs in an estimated 50% to 90% of patients. A constellation of symptoms that most closely resembles those of acute infectious mononucleosis characterizes the syndrome. On rare occasions, opportunistic infections present simultaneously with primary HIV infection. We describe a patient who presented with an episode of severe Pneumocystis jiroveci pneumonia during what appeared to be a prolonged primary HIV infection. Serological testing demonstrated the progressive development of reactive bands on serial Western blot determinations. This case highlights how primary HIV infection can produce profound immunosuppression through CD4 lymphocytopenia predisposing patients to opportunistic infection.

Osteonecrosis in HIV-infected persons: radiographic findings delay clinical diagnosis

Patients with HIV infection demonstrate an unexpectedly high incidence of bone-related disorders, most notably osteonecrosis. We describe 4 HIV-infected patients with osteonecrosis for whom reliance on plain radiographs for establishing the diagnosis was misleading and resulted in a delay in diagnosis. NOne o four patients had significant previously reported risk factors that are associated with osteonecrosis in HIV-infected patients. Osteonecrosis appears to be yet another complication of HIV disease or tis related therapies that has potential for significant morbidity. This disease typically requires surgical intervention for optimal management. Clinicians should maintain a high index of suspicion for osteonecrosis in this patient population in cases of unexplained bone pain or persistent groin pain. Given the high incidence of osteonecrosis in patients with HIV infection, unexplained osteonecrosis should prompt HIV screening, particularly in the absence of identifiable risk factors.

Symptomatic hyperlactataemia precipitated by the addition of tetracycline to combination antiretroviral therapy

Hyperlactataemia in the setting of combination antiretroviral therapy for HIV infection occurs on a spectrum ranging from common, asymptomatic laboratory abnormalities to rare, potentially life-threatening lactic acidosis. Some other medications, including the biguanides, tetracycline, and even linezolid, have rarely been reported to cause lactic acidosis. Recently, cases of lactic acidosis or hyperlactataemia have been reported in patients receiving combination antiretroviral therapy that have been precipitated by the addition of other medications-eg, metformin or ribavirin. We report a case of symptomatic hyperlactataemia in a patient on combination antiretroviral therapy that was likely precipitated by the addition of tetracycline and discuss the broader implications of other medications with the potential to cause hyperlactataemia in the setting of combination antiretroviral therapy.

Plague

In the United States, plague poses a threat to humans from the infected animals in the endemic areas of the Western states. Plague may also be used in the near future as an agent of warfare or terrorism. Although the presentation of bubonic plague may be less of a problem, the septicemic and pneumonic forms present challenges to early diagnosis and prompt treatment. The major threat of plague as an agent of terrorism will probably be through the inhalational route. which could result in many cases of the pneumonic form, requiring early recognition and initiation of appropriate therapy. In a mass-casualty scenario, the clinician should be aware of the potential agents of biowarfare and be familiar with the treatment and prophylaxis recommendations outlined by the CDC. It is also prudent to employ universal precautions and respiratory isolation when treating patients with any unknown exposure. In endemic areas, personal protective measures such as use of insecticides, insect repellants, and prompt prophylaxis in cases of exposure to plague are recommended for reducing the incidence of infection. The author also recommends review of CDC website on bioterrorism (http://www.bt.cdc.gov) to keep informed of plague updates.

Defending against viruses in biowarfare. How to respond to smallpox, encephalitides, hemorrhagic fevers

The threat of bioterrorism with use of viruses is increasing. Smallpox, encephalitis, and hemorrhagic fevers are the most likely diseases to result from viral deployment. It is critical that all healthcare professionals become familiar with the clinical presentation, diagnosis, management, and prevention of these diseases. Awareness and preparedness are instrumental in reducing viral transmission and improving survival of the victims.

Tuberculosis and HIV infection. How to safely treat both disorders concurrently

Progress has been made in screening, early recognition, prevention, and treatment of TB, but its coexistence with HIV infection continues to present a challenge. Healthcare professionals should be familiar with guidelines for treating HIV-infected patients with TB while concurrently administering highly active antiretroviral therapy. Primary care physicians are encouraged to consult specialists who are familiar with treatment of patients with such coexisting disease. Whenever feasible, directly observed therapy should be instituted in all cases of TB to promote compliance and reduce the incidence of drug resistance and treatment failure.