Clinical and microbiological survey of Serratia marcescens infection during HIV disease

Clinical charts of 2,398 consecutive HIV-infected patients hospitalized over an 8-year period were reviewed retrospectively to identify all cases of Serratia infection and to evaluate the occurrence and outcome of these cases according to several epidemiological. clinical, and laboratory parameters. Seventeen of 2,398 (0.71%) patients developed Serratia marcescens infections: nine had septicaemia, six had pneumonia, one had a lymph node abscess, and one had cellulitis. All patients were severely immunocompromised, as evidenced by a mean CD4+ lymphocyte count of < 70 cells/microl and a frequent diagnosis of AIDS (13 patients). When compared with other disease localizations, septicaemia was related to a significantly lower CD4+ cell count and a more frequent occurrence of neutropaenia. Antibiotic, corticosteroid, or cotrimoxazole treatment was frequently carried out during the month preceding disease onset. Hospital-acquired Serratia spp. infection was more frequent than community-acquired infection and was significantly related to AIDS, neutropaenia, and sepsis. Antimicrobial sensitivity testing showed complete resistance to ampicillin and cephalothin but elevated susceptibility to ureidopenicillins, second- and third-generation cephalosporins, aminoglycosides, quinolones, and cotrimoxazole. An appropriate antimicrobial treatment attained clinical and microbiological cure in all cases, in absence of related mortality or relapses. Since only 13 episodes of HIV-associated Serratia spp. infection have been described until now in nine different reports (7 patients with pneumonia, 3 with sepsis, 1 with endophthalmitis, 1 with perifolliculitis, and 1 with cholecystitis), our series represents the largest one dealing with Serratia marcescens infection during HIV disease. Serratia marcescens may be responsible for appreciable morbidity among patients with HIV disease, especially when a low CD4 + cell count, neutropaenia, and hospitalization are present. The clinician and the microbiologist facing a severely immunocompromised HIV-infected patient with a suspected bacterial disease should consider the Serratia spp. organisms. In fact, a rapid diagnosis and an adequate and timely treatment can avoid disease relapses and mortality.

Pseudomonas spp. complications in patients with HIV disease: an eight-year clinical and microbiological survey

Two hundred and twenty-four episodes of Pseudomonas spp. complications that occurred in 179 consecutive patients with HIV infection were retrospectively reviewed. Pseudomonas spp. organisms were responsible for 11.6% of 1933 episodes of non-mycobacterial bacterial diseases (5.4% of 1072 episodes of sepsis), observed over an 8-year period; 20.7% of patients experienced disease relapses (45 episodes). These complications mostly involved lower airways (66 cases), urinary tract (53 episodes), and blood (34 cases), with Pseudomonas aeruginosa isolated in 161 episodes, and other Pseudomonas spp. in the remaining 63 cases. An advanced HIV disease was frequently present (as expressed by a prior diagnosis of AIDS, a low CD4+ lymphocyte count, and leukopenia-neutropenia). Indwelling intravascular and urinary catheters were often associated with bacteremia and urinary tract involvement, respectively. More than 60% of patients were given antibiotics and/or cotrimoxazole in the month preceding the onset of Pseudomonas spp. disease. Bacterial strains isolated from our HIV-infected patients showed a favorable sensitivity to piperacillin, ceftazidime, imipenem, amikacin, tobramycin, and ciprofloxacin. An adequate antimicrobial treatment led to clinical and microbiological cure in 73.2% of patients at the first episode, and in 22.3% more subjects after one or more relapses. A lethal outcome occurred in only eight patients of 179 (4.5%), suffering from a far advanced HIV disease; P. aeruginosa infection directly contributed to death in four cases (sepsis, and/or pneumonia). Nosocomial disease occurred in 46.4% of the 224 episodes, and was significantly related to a previous diagnosis of AIDS, concurrent neutropenia, the occurrence of sepsis or urinary tract infection, disease relapses, the involvement of non-aeruginosa Pseudomonas spp., and a lethal outcome, compared with community-acquired infection. Our experience (the largest reported to date) confirms that Pseudomonas spp. (including non-aeruginosa Pseudomonas spp. organisms) is responsible for remarkable morbidity and mortality among patients with HIV infection, and may pose relevant problems to clinicians and microbiologists involved in the care of HIV-infected patients.

The effects of alternative treatments for HIV disease on recommended pharmacological regimens

The use of alternative treatments for HIV disease was assessed before and after the introduction of highly active antiretroviral therapy (HAART) by the use of a standardised questionnaire. These data were related to epidemiological, clinical and laboratory parameters and compliance levels to recommended antiretroviral and anti-Pneumocystis carinii regimens. Compared with the 476 evaluable patients interviewed during the first 9 months of 1996, the 549 evaluable subjects screened in January-September 1998 showed less frequent recourse to alternative treatments (22.8 vs. 35.7% of patients; P < 0.001). A significant correlation between use of alternatives, poor compliance to antiretroviral drugs and anti-P. carinii chemoprophylaxis and clinical and immunological progression of HIV disease was shown in 1996, but was not maintained in 1998. No relevant differences were found in the selection of most non-conventional treatments and in the number of strategies followed and their duration of use. Unorthodox treatments were used by most patients concurrently rather than instead of official therapeutic regimens. No correlation was found between the use of alternative treatment and the patients' age, gender, type of risk for HIV disease and duration of HIV seropositivity. The correlations between alternative and official treatments for HIV disease before and during the HAART era shows that a considerable percentage of patients still resort to alternatives in 1998 compared with 1996 but that this does not interfere with compliance with recommended pharmacological regimens or the progression of the disease.

[The role of biological monitoring in the evaluation of the risk of from chemical compounds]

Over the years, the assessment of the risk to human health from occupational and environmental exposure to chemicals has become increasingly important. Exposure to chemicals, their biochemical effects and individual susceptibility can be estimated by biological monitoring carried out on potentially exposed subjects. Valid markers are needed to be effectively used within the framework of biological monitoring programs. Quality assurance, which includes all those activities necessary to provide adequate confidence that the results of laboratory test are reliable, is of the utmost importance. Among these activities the participation in external quality assessment schemes is strongly recommended. Biological monitoring has a key role also in the field of human reproduction since the level of exposure to many chemicals which are known or suspected to be reproductive toxicants can be assessed by specialized laboratories.

The changing face of AIDS-related opportunism: cryptococcosis in the highly active antiretroviral therapy (HAART) era. Case reports and literature review

Only nine cases of AIDS-related cryptococcosis have been reported until now in patients receiving highly active antiretroviral therapy (HAART), all of them with abnormal clinical features. Two HIV-infected patients who experienced an atypical relapse of cryptococcosis shortly after the start of HAART and despite maintenance antifungal treatment, are described. Six different relapses of cryptococcal meningitis were observed in a 28-month period in a patient who obtained a poor immune recovery after HAART (as shown by a CD4+ lymphocyte count ranging from 78 to 149 cells/microL, opposed to a baseline level of 98 cells/microL). On the other hand, a patient with favorable immunological response to HAART (as expressed by a CD4+ count growing from 7 to 186 cells/microL), experienced isolated multiple indolent cryptococcal abscesses involving head, neck, the anterior thoracic wall, and regional lymph nodes, with repeatedly negative cultures, and diagnosis obtained by both histopathologic study and positive serum antigen assay. Both our case reports are representative of novel correlations between opportunistic pathogens and immune reactivity, descending from the introduction of HAART. The first episode describes an exceedingly elevated number of disease relapses despite HAART and antifungal maintenance treatment, which may descend from an incomplete immune response to antiretroviral therapy, possibly responsible for failure in obtaining eradication of yeasts, but also for lack of disease dissemination (usually leading to a lethal multivisceral involvement in the pre-HAART era). The abnormal disease course and localization of second reported patient well depicts an "immune reconstitution syndrome" probably representing a flare-up of a latent fungal infection, caused by a rapidly effective HAART. In patients treated with HAART, AIDS-related cryptococcosis cannot therefore be ruled out by the absence of neurological involvement, and by persistingly negative cultures.

Emerging gram-negative pathogens in the immunocompromised host: Agrobacterium radiobacter septicemia during HIV disease

Three out of 2,412 consecutive HIV-infected patients hospitalized since 1990, developed Agrobacterium radiobacter septicemia. All patients were severely immunocompromised, showing a prior diagnosis of AIDS, concurrent opportunistic infections, a mean CD4+ lymphocyte count below 100 cells/microL, and neutropenia. Nosocomial A. radiobacter sepsis occurred in two cases of three, and was related to a lower neutrophil and CD4+ cell count. Antibiotic and cotrimoxazole treatment were carried out during the month preceding disease onset by two and three patients, respectively. Antimicrobial susceptibility assays showed resistance to ureidopenicillins and aztreonam, and complete sensitivity to carbapenems, amikacin, and ciprofloxacin. A therapeutic regimen including amikacin plus ceftriaxone or ceftazidime obtained clinical and microbiological cure in all cases, in the absence of related mortality or relapses. Only two episodes of HIV-associated A. radiobacter complications have been described to date: one case of sepsis and one patient with pneumonia. Despite their low frequency, gram-negative non-fermenting bacilli should be considered in HIV-infected patients with a suspected bacterial complication, because of their cumbersome identification procedures, and their unpredictable antibiotic susceptibility, with elevated resistance to many compounds expected to be effective against gram-negative organisms. A. radiobacter may play a pathogenic role in patients with advanced HIV disease, even when some commonly recognized risk factors are lacking (in-dwelling catheters and instrumentation), while a very low CD4+ lymphocyte count, leukopenia-neutropenia, hospitalization, and concurrent AIDS-related infectious complications, may act as predisposing factors.

[Viral hepatitis A with atypical course. Clinical, biochemical, and virologic study of 7 cases]

The aim of our study was to assess the clinical, biochemical and virological profile of patients with atypical viral hepatitis A (protracted, relapsed and cholestatic forms). Five patients with the relapsed form and 2 patients with the cholestatic form were studied among 95 patients hospitalized in our Division of Infectious Diseases for viral hepatitis A during the years 1988 to 1998. A relapse was defined by a decrease in serum alanine transaminase levels > or = 50% followed by a > or = 50% increase in the minimal value. The protracted form was defined by elevated serum alanine transaminase levels for more than 6 months. The cholestatic form was defined by the highest value of bilirubinemia above 15 mg/dL or by a persistent jaundice for more than 8 weeks. All 5 of the protracted-relapsed forms had a biphasic course: the median time between onset and relapse of the disease was 8 weeks, and serum aminotransferase activities returned to the normal range within an average of 45 weeks after relapse. The two cholestatic forms were characterized by a very high level of bilirubinemia (24.58 and 19.03 mg/dL) and by protracted jaundice with itching (3 and 8 months). All patients were tested for hepatitis B and C, Cytomegalovirus and Epstein-Barr virus, with negative results. In short, viral hepatitis A is a benign, self-limiting disease which usually resolves in a few weeks. In a non-negligible percentage of cases (3-21%), however, it can assume atypical forms, which are more serious in patients with chronic liver diseases.

Flavobacterium spp. organisms as opportunistic bacterial pathogens during advanced HIV disease

OBJECTIVE

To assess the role of Flavobacterium spp. infection in patients with HIV disease.

METHODS

Clinical charts of 2412 consecutive HIV-infected patients hospitalized in a 8-year period were retrospectively reviewed, to identify all cases of Flavobacterium spp. infections, and to evaluate their occurrence and outcome according to several epidemiological, clinical, and laboratory parameters.

RESULTS

Six patients out of 2412 (0.25%), developed Flavobacterium spp. complications: septicaemia in five cases, and pneumonia in the remaining patient, with F. meningosepticum and F. odoratum isolated in two cases and one case, respectively, and unnamed Flavobacterium spp. organisms in the remaining three cases. Flavobacterium spp. organisms were responsible for six out of 1939 overall episodes of non-mycobacterial bacterial diseases observed in our patient group (0.31%). All patients were severely immunocompromised, showing a prior diagnosis of AIDS, a mean CD4+ lymphocyte count of 64.2 (range 12-187) cells/microl, and a mean neutrophil count of 1.143 (range 700-1600) cells (range 700-1600) cells/microl. Antibiotic, corticosteriod, or cotrimoxazole treatment was carried out during the month preceding disease onset by three, two and five patients, respectively. Community-acquired and nosocomial Flavobacterium spp. disease were equally frequent, but the latter occurred with a significantly lower mean neutrophil and CD4+ cell count. Antimicrobial susceptibility assays showed complete sensitivity to ciprofloxacin, and variable resistance to ureidopenicillins, ceftazidime, imipenem, aztreonam, and aminoglycosides. An appropriate antimicrobial regimen obtained clinical and microbiological cure in all cases, in absence of related mortality or relapses.

CONCLUSIONS

Since only one episode of HIV-associated F. (Sphingobacterium) multivorum complication has been described to date, our series represents the largest one dealing with Flavobacterium spp. infection in the setting of HIV disease. Our experience suggests that Flavobacterium spp. organisms may play a pathogenic role in patients with advanced HIV disease, even when some commonly recognized risk factors are lacking (i.e. indwelling catheters, instrumentation, IV drug abuse), while a very low CD4+ lymphocyte count, leukopaenia-neutropaenia, and concurrent AIDS-related infectious complications may act as important predisposing factors. In view of the infrequent occurrence of these infections, early suspicion is essential for both clinicians and microbiologists facing immunocompromised patients at risk for invasive bacterial complications. Flavobacterium spp. organisms should be taken into consideration as nosocomial- or community-acquired opportunistic pathogens, due to their relationship with advanced immunodeficiency and their elevated resistance to many antimicrobial agents commonly used against Gram-negative bacterial pathogens.

A comparison of immunocomplex-dissociated serum HIV-1 p24 antigenemia and plasma HIV-1 viral load: assessment of 3,129 paired assays

In order to compare HIV-1 p24 antigenemia and plasma HIV-1 RNA levels as markers of viral replication, 3,129 paired determinations of alkaline immunocomplex-dissociated serum HIV-1 p24 antigenemia (performed with an immunoenzymatic assay), and plasma HIV-1 RNA levels (carried out with a branched DNA method, a reverse transcriptase-coupled polymerase chain reaction, and a nucleic acid sequence-based assay) were assessed over a two-year-period. When excluding samples with undetectable plasma HIV-1 RNA levels (which tested negative or borderline positive at serum p24 antigen assay in 97.9% of cases), immunocomplex-dissociated p24 antigenemia proved significantly less sensitive than viral load at all considered HIV-1 RNA reference levels, although the profile of positive serum p24 antigen assays (values above 10 pg/ml) paralleled the trend of plasma HIV-1 viral load, especially at higher levels. However, serum HIV-1 p24 antigenemia (even after immunocomplex dissociation) can be longer suggested as a the sole virological tool in the laboratory management of HIV-1 infection, due to its significantly lower sensitivity levels compared with viral load assessment.

Typhoid fever and HIV infection: a rare disease association in industrialized countries

Typhoid fever is still a global health problem, mainly in tropical and subtropical areas of the world and in developing countries, where relatively elevated morbidity and mortality rates still are present, mostly because of persisting poor hygienic conditions. In the majority of Mediterranean regions, including Italy, the disease is constantly present, though with a low prevalence rate, as a result of an endemic persistence of Salmonella typhi infection.1-4 On the other hand, in industrialized countries, most cases of S. typhi infection are related to foreign travel or prior residence in endemic countries.4-6 In the United States, 2445 cases of typhoid fever have been reported in the decade 1985 to 1994, and the annual number of cases remained relatively stable over time: over 70% of episodes were acquired in endemic countries (mostly Mexico and India).6 The persisting morbidity of S. typhi also may be supported by the increasing resistance rate of this pathogen against a number of commonly used antimicrobial compounds. For instance, 6% of 331 evaluable S. typhi strains were resistant to ampicillin, chloramphenicol, and cotrimoxazole, and 22% of isolates were resistant to at least one of these three agents in a recent survey performed in the United States.6 The spread of antibiotic resistance among S. typhi isolates is emerging in many countries, and multidrug-resistant strains have been isolated, as well as isolates with poor susceptibility to fluoroquinolones,3-5,7-9 so that in vitro susceptibility should be determined for all cultured strains, and antimicrobial treatment should be adjusted accordingly. Nevertheless, fluoroquinolones (e.g., ciprofloxacin and pefloxacin) or third-generation cephalosporins, still represent the best choice for empirical treatment,2,4,6-8,10 and mortality remains rare in Western countries (less than 1% of episodes), although it is expected to be greater in developing areas of the world. The aim of this report is to describe two cases of typhoid fever that occurred in patients with human immunodeficiency virus (HIV) infection, a rarely reported disease association in industrialized countries.

[The diagnosis of new cases of HIV infection: a reversal of the trend?]

In order to assess the trend of new cases of HIV infection, spontaneous requests of HIV counseling and testing made at our outpatient Center since 1993 were retrospectively evaluated. During the considered 6-year period, 7,492 subjects had voluntary HIV testing, and 225 proved HIV-positive (3.0%). While the overall number of spontaneous requests of HIV serology did not show remarkable variations over time, a tendency towards a significant increase of newly diagnosed HIV disease was observed during the past two years (1997 and 1998). In particular, among the 57 subjects with HIV infection disclosed in 1998, a predominance of young adults and a relatively elevated frequency of females compared with males was demonstrated, while heterosexual (38 cases) and homo-bisexual contacts (18 cases) accounted for the great majority of newly identified retroviral infections, and 66.1% out of the 56 patients who acquired HIV infection by sexual route were stable partners of individuals with known HIV disease. Although epidemiological estimates foresaw a progressive reduction of cases of HIV infection since 1990, a surprising increase of newly diagnosed HIV disease among patients who spontaneously asked for HIV testing was observed in our experience. The apparent temporal coincidence of this phenomenon with the remarkable advances obtained in both diagnostic and therapeutic strategies of HIV disease just since 1996, could not be a fortuitous event. The non-decline of newly diagnosed cases of HIV infection should re-orient strategies of communication and prophylaxis dealing with HIV disease, and involving the general population and people with persisting high-risk behavior.

Should patients with early loss of serum HCV-RNA during alpha interferon therapy for chronic hepatitis C be treated for 6 or 12 months?

BACKGROUND/AIMS

Retrospective studies have suggested that early loss of serum HCV-RNA predicts sustained response to alpha-interferon treatment in chronic hepatitis C, but the optimal duration of therapy after loss of HCV-RNA is not known. The aims of this study were: a) to prospectively evaluate the effectiveness of HCV-RNA testing after 1 month of alpha-interferon treatment in the prediction of sustained response, and b) to compare the efficacy of 6 and 12 months of therapy in patients with a negative serum HCV-RNA test after the first month of treatment.

METHODS

One hundred and thirty patients were administered interferon alpha-2b at doses related to body weight (< or > or = 60 kg) and to HCV genotype: 5 or 8 MU tiw for type 1, and 3 or 5 MU tiw for genotypes non-1. Serum HCV-RNA testing was performed using in-house nested RT-PCR at month 1, at the end of treatment and 6 months afterwards. We considered sustained response to be the maintenance of normal alanine aminotransferase and negativity at serum HCV-RNA testing until the end of follow-up.

RESULTS

Sustained response was observed in 2/72 (2.8%) patients with detectable HCV-RNA after the initial month of therapy, in 8/30 (26.7%) patients with early loss of HCV-RNA treated for 6 months and in 20/28 (71.4%) patients treated for 12 months (p<0.01).

CONCLUSIONS

Serum HCV-RNA detectability after the first month is strongly associated with a very poor chance of sustained response, and these cases should be offered other treatments. Patients with early loss of HCV-RNA should complete a 12-month treatment, which appeared more effective than a 6-month treatment.

[Smectite in AIDS-associated chronic idiopathic diarrhea]

BACKGROUND

A prospective clinical survey was carried out in order to determine the effects of Smectite in patients with AIDS-associated chronic idiopathic diarrhea.

METHODS

A total of 22 patients has been included in this study. All patients received smectite, 3 g orally three times daily far from meals for a period of 10-21 days. The outcome of chronic diarrhea has been evaluated during treatment.

RESULTS

A significant reduction of duration of diarrhea, of frequency of stool number, and of the amount of liquid stools, has been recorded in all patients after the third and the fourth day of treatment. No major adverse effects and drug interactions have been documented in all treated patients.

CONCLUSIONS

Smectite may be considered as adjuvant therapy in patients with AIDS-associated chronic idiopathic diarrhea by virtue of its efficacy and tolerability.

AIDS-related visceral aspergillosis: an underdiagnosed disease during life?

Five out of nine consecutive patients with HIV-related visceral aspergillosis observed by us since 1984 were diagnosed only at necropsy examination. The histopathological features of these five patients [two with isolated pneumonia, one with central nervous system (CNS) involvement, one with brain abscess and respiratory disease and one with pulmonary, pleural and kidney infection] have been evaluated according to epidemiological, clinical and radiological features. On the basis of our experience, life-threatening aspergillosis, which is often misdiagnosed or missed in the setting of HIV infection and AIDS, should be suspected in patients with far-advanced underlying disease and unexplained signs and symptoms, even in the absence of some presumed risk factors (i.e. neutropenia and prior steroid treatment). Plain chest radiography and bronchoscopy with broncholaveolar lavage may fail to reveal respiratory disease, CNS aspergillosis is not necessarily associated with suggestive neuroradiological features and disseminated disease may present with multiorgan failure. The unfavorable outcome of this emerging AIDS complication can be improved only by earlier diagnosis based on invasive techniques and appropriate and timely treatment.

[Prion diseases. The association of bovine spongiform encephalopathy with new variant of Creutzfeldt-Jakob disease]

This review summarizes current knowledge of prion diseases and investigates connections between the bovine spongiform encephalopathy epidemic, observed in Great Britain since 1986, and the new variant of human Creutzfeldt-Jakob disease, reported for the first time in 1996. Information from the international literature and results of the most recent experimental studies on prion diseases and transmissible spongiform encephalopathies are evaluated, and particular attention is focused on the possible transmission of the etiological agents of spongiform encephalopathy, the prions, from animals to humans. Epidemiological, clinical, and histopathological data and experimental results seem to confirm the suspected link between bovine spongiform encephalopathy and the new variant of Creutzfeldt-Jakob disease. In this context, transmission of prions from infected cattle to humans by oral intake seems not only possible but also very probable.

Pulmonary Kaposi's sarcoma in AIDS patients treated with combined chemotherapy and recombinant human granulocyte colony-stimulating factor

Optimal delivery of chemotherapy in AIDS patients with Kaposi's sarcoma (KS) is frequently limited by hematological toxicity, mainly neutropenia. We have conducted an open-label study to investigate the safety and efficacy of recombinant human granulocyte colony-stimulating factor (filgrastim, r-metHuG-CSF) administration in 25 AIDS patients with pulmonary KS treated with Adriamycin, bleomycin, and vincristine (ABV) combination. The patients were assigned to receive r-metHuG-CSF (Neupogen, Dompé, Biotec, 5 mg/kg of body weight per day) injected subcutaneously for 3-5 days before chemotherapy until the absolute neutrophil count was higher than 25 x 10(9); r-metHuG-CSF was then discontinued 5 days before chemotherapy. Patients were eligible to resume r-metHuG-CSF 3 days after completing the anticancer regimen until normalization of the absolute neutrophil count occurred, for a maximum of 10 days. The cytotoxic regimen included vincristine 1.4 mg/m2, bleomycin 10 mg/m2, and doxorubicin 20 mg/m2, every 2 weeks. The overall response rate was 58% with a complete response rate of 18%. Median survival was 11 months and median response duration was 6 months. Adverse effects consisted of transient nausea and vomiting in 48% of patients, and moderate headache in 43%. Hematologic toxicities included anemia in 27%, and mild to moderate neutropenia (grade II-III) in 38%. The mean leukocyte and neutrophil nadirs were 1920 and 850 mm3. The mean duration of neutropenia was 3.2 days. The combination of r-metHuG-CSF and ABV chemotherapy was well tolerated. Administration of r-metHuG-CSF within 5 days before chemotherapy appears to be an acceptable treatment with important clinical implications. We stress that further studies are needed to determine the maximum tolerable doses of combination chemotherapy supported by G-CSF in AIDS-associated KS patients.

Case-control study of amphotericin B in a triglyceride fat emulsion versus conventional amphotericin B in patients with AIDS

We evaluated the efficacy and tolerability of amphotericin B triglyceride emulsion in 16 patients with acquired immunodeficiency syndrome-related candidal esophagitis and cryptococcosis, compared with standard amphotericin B in 24 patients. Compared with the conventional formulation, the fat emulsion was administered in a significantly greater daily dose, and required shorter induction period and infusion time (p<0.001-<0.03). Although the two drugs had similar clinical and microbiologic efficacy, the fat emulsion had a better safety profile with respect to frequency of flu-like symptoms, other local and systemic adverse events, and treatment discontinuation (p<0.02-<0.05). Because it is easily available and inexpensive, it may have a number of advantages over the conventional formulation. Further similar comparisons are warranted, in addition to investigations to assess whether reduced toxicity can be obtained with fat emulsion without impairing (or possibly improving) the efficacy of this key antifungal agent.

[Lymph node dissemination of a serious Pneumocystis carinii respiratory infection in AIDS: histopathological and ultrastructural aspects]

A case report of isolated lymph node extension of atypical respiratory Pneumocystis carinii infection which occurred in an HIV-infected patient undergoing aerosolized pentamidine prophylaxis is presented with its histopathological and ultrastructural features. AIDS-associated extrapulmonary and disseminated pneumocystosis are discussed on the ground of their frequency, localizations, risk factors, clinical presentation, and outcome.

[Lead exposure: risk evaluation for the general Italian population in 1990]

The second Italian campaign for the biological surveillance of the general population against the risk of lead intoxication has been carried out according to the regulations contained in the Presidential Decree DPR 496/82. The investigations of the second campaign--based on the measurement of blood lead levels (PbB)--have been carried out mainly between 1992 and 1996 by various operating centers in some Italian regions. A work group from the Istituto Superiore di Sanità (Italian National Institute of Health) coordinated the activity of the various centers and organised an appropriate quality control program to guarantee the quality of the analytical data collected. A total of 7749 non exposed subjects (4346 females and 3403 males) has been examined, 1170 of which (559 females and 611 males) were under 15 years of age. The median PbB was, for adults, 86 micrograms/l in males and 53.5 micrograms/l in females. As for subjects under the age of 15, PbB levels were 50 micrograms/l and 43 micrograms/l in males and females, respectively. Our investigation confirms the correlation between blood lead levels, wine, and cigarette smoking. The comparison with the results of previous investigations shows a reduction between 40% and 50% of PbB in the general Italian population during the 1985-96 period. It should be pointed out that in certain areas more than 5% of subjects under 15 years of age had PbB exceeding the level (100 micrograms/l) considered safe for avoiding irreversible injury to the central nervous system.

[Environmental lead exposure in the Venetian population from 1976-1992]

Blood lead levels observed in the general population of Venice and the surrounding area are reported for the period between 1976 and 1992. A time dependent decrease of blood lead levels is evident and parallels the step wise decrease of lead levels in gasoline which took place between 1981 and 1991. The observed lowering time trend of blood lead levels could possibly be ascribed, perhaps not negligibly, to technological improvements, the development of new analytical procedures and the continuous practice of quality control.

[Evaluation of environmental lead exposure in Latium: 2d DPR 496/82 campaign]

In the Latium region, according to the regulations contained in the presidential decree DPR 496/82, the investigations of the second campaign--based on the measurement of blood lead levels (PbB)--have been carried out between 1992 and 1994. Three samples of subjects were examined: adult subjects (33 males and 628 females) living in Priverno, a small town in the South of the Latium region; adults subjects living in the Rome area (81 males and 168 females; subjects under the age of 15 (65 males and 54 females) living in the Rome area. Concerning Priverno, the median PbB was 70 micrograms/l in males and 40 micrograms/l in females; in Rome 66 micrograms/l and 42 micrograms/ l in males and females, respectively. In subjects under the age of 15, PbB levels were 40.5 micrograms/l and 35.5 micrograms/l in males and females, respectively. As for adults PbB levels were significantly higher in female than in male subjects and in subjects aged 41 years and over in comparison with subjects aged 15-40 years. PbB levels were significantly higher in wine drinkers in comparison with non-drinkers. The difference between smokers and non smokers was significant only in female subjects living in Rome. In multiple regression analysis the association of PbB with age, sex, alcohol consumption and smoking habit were confirmed, and a positive relation between PbB and the condition of being living in Rome. As for Rome, the comparison with the results of previous investigations shows a reduction between 50% and 60% of PbB during the 1985-1992 period.

[Quality control of data produced in biological population surveillance studies on the risk of environmental lead poisoning]

The biological surveys of the general population against the risk of lead intoxication carried out in Italy--in accomplishment both of the EEC directive EEC 77/312 and the Presidential Decree 496/1982--have been always conceived as multicentric activities. Therefore, starting from the first campaign carried out in 1979, strict quality control procedures have been adopted. In brief, each participant laboratory used internal quality control samples and took part in external quality assessment exercises. In addition, ten percent of the blood samples collected during the campaign were analyzed as blind duplicate by both participating laboratories and a reference laboratory. In this paper the quality control procedures adopted will be presented and discussed in detail together with the quality of results obtained in each campaign.

AZT plus methotrexate in HIV-related non-Hodgkin's lymphomas

AZT is a thymidine analogue useful in the treatment of AIDS. It has been demonstrated that this compound can possess a significant antineoplastic activity when combined with de novo thymidylate synthesis inhibitors, such as 5-fluorouracil (5FU) and methotrexate (MTX). Here we report a review of our data concerning the efficacy and tolerance of the combination AZT + MTX in HIV-related non Hodgkin's lymphomas (NHL). Twenty-nine patients were treated, at weekly intervals, with three (patient 1 to 10) or six (patient 11 to 29) consecutive courses of MTX 1g/m2 and increasing doses of oral AZT (2, 4 and 6g/m2) with leucovorin rescue. Of 26 evaluable patients, a total (complete + partial) response rate of 77% was obtained. The median complete response duration was 16.8 months. There was one therapy-related death due to septic shock. Grade III-IV neutropenia was observed after 19% of the courses, but was prevented by G-CSF administration in 82/119 courses. Grade III-IV anemia was observed after 9% of the courses. In conclusion, the combination AZT + MTX was effective and well tolerated in our series of HIV-related NHL patients.

Randomized trial of trimethoprim-sulfamethoxazole versus pyrimethamine-sulfadiazine for therapy of toxoplasmic encephalitis in patients with AIDS. Italian Collaborative Study Group

The aim of the present pilot study was to compare the efficacy and safety of trimethoprim (TMP) and sulfamethoxazole (SMX) with those of the standard therapy pyrimethamine (P)-sulfadiazine (S) for the treatment of toxoplasmic encephalitis in patients with AIDS. This was a pilot, multicenter, randomized, and prospective study. Patients were randomly assigned to receive TMP (10 mg/kg of body weight/day) and SMX (50 mg/kg/day) or P (50 mg daily) and S (60 mg/kg/day) as acute therapy (for 4 weeks) and then as maintenance therapy for 3 months at half of the original dosage. Seventy-seven patients were enrolled and randomized to the study: 40 patients were treated with TMP-SMX and 37 were treated with P-S. There was no statistically significant difference in clinical efficacy during acute therapy. In contrast, patients randomized to TMP-SMX appeared more likely to achieve a complete radiologic response after acute therapy. Adverse reactions were significantly more frequent in patients treated with P-S, and skin rash was the most common adverse event noted in these patients. In conclusion, the results of the study suggest that TMP-SMX appears to be a valuable alternative to P-S, in particular in patients with opportunistic bacterial infections.

Role of fluconazole in the management of AIDS-related cryptococcosis, according to daily dosing

No unanimous consent has been reached about treatment guidelines of cryptococcosis in the setting of AIDS, as well as about optimal fluconazole dosing in both initial and suppressive therapy. In order to evaluate the relationship between fluconazole dosing and clinical and microbiological outcome of AIDS-related cryptococcosis, a retrospective study was carried out on 30 consecutive patients. Among the 12 subjects treated with fluconazole doses < 400 mg/day, an unfavorable course was significantly more frequent (early mortality, poor clinical and microbiological response, appearance of early relapses) compared with the 18 patients who received daily doses > or = 400 mg, while no differences were observed between the two treatment groups according to known risk factors for a poor prognosis. When assessing maintenance treatment (22 evaluable cases), the 15 patients receiving oral fluconazole at doses < 200 mg/day showed earlier disease relapse and mortality as opposed to the 7 individuals treated with high-dose fluconazole (> or = 200 mg/day), in the absence of significantly different risk factors for disease recurrence. Our experience pointed out a significant difference in clinical activity of fluconazole in AIDS-related cryptococcosis according to its daily dosing, and suggested 400 and 200 mg as the threshold daily dose for an effective initial and suppressive therapy, respectively, since the probability of treatment failure seemed greater with low-dose drug administration, after controlling data for prognostic markers of disease severity. Controlled studies are warranted, comparing high-dose fluconazole with standard regimens containing amphotericin B in the treatment of AIDS-associated cryptococcosis, and identifying the best fluconazole dosing for both acute-phase and maintenance treatment.

Fluconazole susceptibility and strain variation of Candida albicans isolates from HIV-infected patients with oropharyngeal candidosis

Over a 16 month period we conducted a prospective study in a cohort of 45 HIV-positive patients to detect the development of resistance to fluconazole and to analyse the epidemiology of oropharyngeal candidosis (OPC). Each episode was treated with fluconazole 100 mg/day po for 10 days. All yeast isolates were tested for their in-vitro susceptibility to fluconazole. Multiple strains of Candida albicans simultaneously isolated from a given patient were typed by electrophoretic karyotyping. Overall, 106 episodes of OPC were diagnosed among the 45 patients: 18/45 patients (40%) had only one episode, 11/45 (24%) had two episodes, and the remaining 16/45 (36%) had three or more episodes (range 3-7). Cure (complete resolution of signs and symptoms and negative post-treatment cultures) and improvement (complete resolution of signs and symptoms but positive post-treatment cultures) were observed in 30/106 (28%) and 69/106 (65%) episodes of OPC, respectively. Failure (absence of improvement or exacerbation of signs and symptoms) was observed in seven episodes (7%) from four patients. In two of these four patients a significant and progressive increase in fluconazole MICs was observed: from 0.25 to 16 mg/L in one patient, and from < or = 0.125 to 32 mg/L in the second one. Tests on multiple colonies from individual isolation plates showed that it was not unusual to obtain different fluconazole MICs, indicating that, in order to avoid misleading results, one should perform in-vitro susceptibility testing by using a multiple colony inoculum rather than an inoculum made from a single colony. A total of 213 strains of C. albicans isolated from seven patients who suffered from four or more episodes of OPC through the course of the study were typed by electrophoretic karyotyping. Five individuals (71%) were infected with yeasts with only one DNA type, while the other two patients showed the presence of two or three different DNA types. The simultaneous presence of multiple types was found only in one of the seven subjects. Our data confirm the efficacy of fluconazole 100 mg/day for the treatment of OPC in HIV patients. Isolation of fluconazole-resistant strains of C. albicans with this regimen is rare. The vast majority of HIV patients are infected with a unique strain of C. albicans throughout each episode of infection. A minority of patients, however, can harbour strains of C. albicans with variable patterns of fluconazole susceptibility simultaneously.

Xanthomonas maltophilia: an emerging pathogen in patients with HIV disease

Fifty-four episodes of Xanthomonas maltophilia infection were observed in 52 HIV-infected patients out of 2062 assessed (2.52%) over a 6-year period: sepsis/bacteraemia in 44 cases, lower airways infection in 5 cases, urinary tract infection and pharyngitis in 2 cases each, and lymph node involvement in one patient. X. maltophilia represented the fourth most common non-mycobacterial bacterial pathogen responsible for bacteraemia in HIV-infected patients: 44 cases out of 721 diagnosed (6.1%). When compared with non-typhoid Salmonella spp. bacteraemia, an increased risk to develop X. maltophilia disseminated infection was seen according to the progression of HIV-related immunodeficiency, the occurrence of leukopenia-neutropenia, central venous catheterization, previous antibiotic and/or corticosteroid treatment, and hospitalization. In 3 patients suffering from concurrent AIDS-related disorders, X. maltophilia infection contributed to death, while a recurrence occurred in 2 cases only. Due to the poor antimicrobial susceptibility of this pathogen (also confirmed in our series), X. maltophilia bacteraemia associated with advanced HIV infection and concurrent risk factors, may represent a potentially severe disease.

Imported tropical diseases in subjects with HIV infection

The authors report a case of Plasmodium falciparum malaria and a case of lymphatic filariasis caused by Brugia malayi, imported by HIV-infected patients during trips in endemic countries. The clinical and laboratory picture, as well as treatment response of imported malaria and filariasis did not differ significantly in patients with HIV infection compared with immunocompetent subjects. The exposition to tropical diseases during exotic travels has to be taken into account, in the differential diagnosis of infectious disorders complicating the course of HIV disease.

[AIDS-related cryptococcosis: diagnostic aspects, prognostic and therapeutic implications]

Diagnostic techniques of AIDS-related cryptococcosis were assessed in a series of 43 HIV-infected patients, and microbiological features were correlated to the clinical course and outcome of disease. Polysaccharide antigen detection was the most sensitive method for central nervous system infection, followed by direct microscopy and culture: in 4 patients this visceral mycosis was initially diagnosed by the detection of isolated cerebrospinal fluid antigen. Thirty-one patients out of 43 suffered from disseminated infection (with positive blood cultures and/or antigenemia). The occurrence of clinical relapses, a lethal outcome, and time to relapses or to death, did not differ significantly between patients with isolated central nervous system and those with disseminated cryptococcosis.

Bacteremia and respiratory involvement by Alcaligenes xylosoxidans in patients infected with the human immunodeficiency virus

Seven cases of Alcaligenes xylosoxidans bacteremia and/or respiratory disease in patients infected with the human immunodeficiency virus (HIV) are described. Reported only thrice previously in this setting, these bacterial complications occurred during different phases of HIV infection and were associated with leukopenia-neutropenia in four patients and a central vascular catheter in two. Although the majority of cases were diagnosed after day 3 of hospitalization, a distinct source of infection was never identified. In four patients with advanced underlying disease, a polymicrobial infection was present. In vitro resistance to aminoglycosides, first-generation cephalosporins, and aztreonam was identified, but treatment with fluoroquinolones, piperacillin, or an aminoglycoside in combination with either ceftazidime or pefloxacin was successful in all cases. The relevance of Alcaligenes xylosoxidans and related species of gram-negative non-glucose fermenting bacilli as opportunistic pathogens in the immunocompromised host and in the setting of HIV infection is briefly reviewed.

C-reactive protein elevation and early outcome in patients with unstable angina pectoris

C-reactive protein, a reactant of the acute phase of inflammation, has been shown to be increased in patients with unstable angina. Moreover, it has recently been found that increased C-reactive protein is associated with a poor outcome during hospitalization in selected patients with severe unstable angina. The aim of this study was to investigate the prognostic value of C-reactive protein elevation in a large population with unstable angina. We measured serum levels of this marker in 140 patients hospitalized with unstable angina (class IIIB of the Braunwald classification, mean time from last anginal episode 5 +/- 5 hours). Thirty-nine of them (28%) had increased serum levels on hospital admission and 33 (24%) experienced an adverse outcome (myocardial infarction or refractory angina) during hospitalization. Kaplan-Meier analysis showed that the probability of developing cardiac events during hospitalization was not different between patients with and without abnormal C-reactive protein levels. Furthermore, the incidence of ischemia at Holter monitoring during the first 72 hours after hospitalization was not different between patients with and without abnormal C-reactive protein. In a representative population of patients with unstable angina, a sizable proportion had increased serum C-reactive protein levels; however, abnormal concentrations of C-reactive protein do not predict an adverse outcome in the early phase after the acute episode.

In vivo effects of recombinant human granulocyte-macrophage colony-stimulating factor (rHuGM-CSF), alone and associated with zidovudine, on HIV-1 replication

The effects of the administration of recombinant human granulocyte-macrophage colony-stimulating factor (rHuGM-CSF) on HIV-1 replication were evaluated in 15 patients with advanced HIV-1 disease and severe leukopenia, by monitoring immunocomplex dissociated p24 antigenemia, during 21 overall courses of therapy with rHuGM-CSF (lasting 2 to 27 weeks), alone or associated with zidovudine. During most treatment courses with rHuGM-CSF (17 out of 21), no significant modifications of HIV-1 antigenemia were recognized. A remarkable increase in viral replication occurred in only two courses out of 13 performed with rHuGM-CSF alone, while a significant reduction of antigenemia was observed in two courses of rHuGM-CSF out of 8 administered with zidovudine, after 10 weeks of combined treatment. Our experience is discussed on the grounds of both experimental and clinical investigations dealing with interactions between rHuGM-CSF and zidovudine during HIV-1 disease, focusing on risks of increased viral burden during treatment with rHuGM-CSF alone, and the synergistic activity of the combination with zidovudine against HIV-1 replication.

Tuberculous pericarditis and AIDS: case reports and review

Pericarditis is one of the most common cardiac complications in the course of HIV disease. Opportunistic infections and neoplastic processes represent the most common etiology of pericardial disease. Pericardial tuberculosis is an uncommon condition, especially in developed countries. Two cases of tuberculous pericarditis in adult patients with AIDS occurred over a 12-month period at our clinic, which prompted a literature review of the published cases of tuberculous pericarditis in AIDS. Of note is that in the first patient pericardial effusion represented the AIDS-defining illness and was an expression of a disseminated tuberculous disease. The second patient developed a fatal pericarditis due to a multiple-drug resistant Mycobacterium tuberculosis infection.

Quantitative cytomegalovirus (CMV) antigenaemia during antiviral treatment of AIDS-related CMV disease

In order to assess the value of quantitative measurement of cytomegalovirus (CMV) antigenaemia as a marker for the guidance of antiviral chemotherapy in the AIDS setting, 33 patients with CMV complications and showing at least 20 pp65-positive polymorphonuclear leucocytes per 2 x 10(5) cells, received either ganciclovir or foscarnet as induction and maintenance therapy. Antigenaemia was assessed every 1-4 weeks. During acute-phase antiviral therapy, a significant decrease of CMV antigenaemia (>50% of pretreatment levels) paralleled clinical improvement in 2-7 weeks in 32 of 33 subjects. In ten of 24 evaluable patients followed up during a further 4-12 months, disease relapses occurred concurrently with an increase of CMV antigenaemia in seven cases, while three cases of relapsing retinitis did not show a significant increase in antigenaemia. All patients with recurrent disease had a favourable response to further treatment, including halted clinical progression and significant decrease in antigenaemia. In HIV-related CMV disease, periodic monitoring of quantitative CMV antigenaemia proves useful in evaluating response to antivirals, in guiding therapeutic management and in predicting disease relapses.