[Infectious sinusitis in HIV infection. Clinical and therapeutic data on 20 patients]

To assess the clinical presentation and outcome of infectious sinusitis in HIV-infected patients, we analyzed in a retrospective study, the records of HIV-infected patients hospitalized from June 1986 to November 1989. Twenty-eight episodes of infectious sinusitis, defined by radiological signs, were recorded in 20 HIV-infected patients. Clinical presentation suggestive of acute sinusitis was inconstant and in 6 episodes a persistent fever was the only symptom. Concomitant pneumonia was detected in 8 episodes. Bacteria were isolated in 8 episodes, and in 4 of them, Haemophilus influenzae was identified. Clinical relapses occurred in 8/20 patients, requiring a surgical drainage in 3 cases. The frequency of relapses and the possibility of chronicity justify a more prolonged and aggressive therapy in infectious sinusitis occurring in HIV-infected patients.

Sparfloxacin, ethambutol, and cortisol receptor inhibitor RU-40 555 treatment for disseminated Mycobacterium avium complex infection of normal C57BL/6 mice

Sparfloxacin (50 mg/kg of body weight given subcutaneously each day), alone or in combination with ethambutol (50 mg/kg given subcutaneously each day), was examined for its therapeutic efficacy against experimental infection induced with the Mycobacterium avium complex in normal C57BL/6 mice. In addition, the potential anti-infective role of RU-40 555 (100 mg/kg given intraperitoneally each day), a drug that inhibits the cortisol receptors, was examined in the same model. Treatments were started 24 h after intravenous bacterial challenge and were continued for 21 days. Compared with controls, sparfloxacin or ethambutol decreased the CFU counts in spleens and lungs (P < 0.001). The sparfloxacin plus ethambutol combination was more effective than sparfloxacin alone in spleens (P < 0.001) but not in lungs. The sparfloxacin plus ethambutol plus RU-40 555 combination was more effective than the sparfloxacin plus ethambutol combination in spleens and lungs (P < 0.001). Thus, in this model, RU-40 555 enhanced the antibacterial activities of the antibiotics tested. Results of the study showed that normal C57BL/6 mice infected with the M. avium complex can be used for the evaluation of antimicrobial agents.

[Non-typhic Salmonella bacteremias in HIV infections. Clinical and therapeutic data, and course in 68 patients]

Between 1982 and 1989, a retrospective study on non typhi Salmonella bacteremias was performed among patients infected with human immunodeficiency virus hospitalized in 4 departments of Infectious and Tropical Diseases in Paris. The population included 59 men and 9 women; 26.4 percent had been contamined with HIV by heterosexual contact; 17.6 percent originated from Africa or Haiti. Clinical symptoms were fever (100 percent of the cases), present since less than 5 days (65 percent of the cases), and gastrointestinal symptoms, present in 53 percent of the patients. Blood cultures were positive in all cases; Salmonella was less frequently found in other sites: stools (n = 13, 19 percent), urine (n = 5), lymph nodes (n = 1), sputum (n = 1). Mean CD4 cell count was 118 +/- 145/mm3. The serotypes were mainly S. typhimurium (n = 26), S. enteritidis (n = 23), and S. dublin (n = 15). Under antibiotic therapy, the course of the disease was initially favorable in 98.5 percent of the cases. One patient died of septic shock. At least one relapse occurred in 17 percent of the patients, 2.1 +/- 1.6 months after the end of the initial therapy. No relapse was observed in patients taking zidovudine or antibioprophylaxis, but 53 percent of the patients without antibioprophylaxis relapsed (P less than 0.001). The overall survival of the cohort was 25 percent after 18 months. These results show the poor prognosis of a first episode of Salmonella bacteremia in HIV infected patients, making the diagnosis of AIDS highly probable if cellular immunity is markedly impaired.

Unexplained fever and chronic fatigue: abnormal circadian temperature pattern

OBJECTIVES

Standard clinical and biological investigations can be used to determine the origin of persistent and moderate fever in a large number of otherwise asymptomatic patients. However, in a small proportion of cases, isolated fever and fatigue persist despite the absence of detectable organic malfunction. This study was conducted to investigate the circadian thermic pattern in patients with apparently unexplainable fever and chronic fatigue and in those with fever of recognized origin.

METHODS

We recorded central temperature continuously for 24 hours in patients with moderate fever of both unexplained and recognized origin, and in a control group of healthy volunteers. A Fourier series was used for harmonic analysis.

RESULTS

Thermic patterns specific to the three groups were identified by statistical and factorial analysis. The patients with fever of unknown origin and chronic fatigue were clearly characterized in terms of the phase, amplitude of the first (fundamental) harmonic and minimum circadian temperature.

CONCLUSION

The abnormal central temperature pattern in these patients may prove to be an important step in the management of febrile patients.

[Acute articular rheumatism: physiopathology, clinical aspects]

Acute rheumatic fever is characterized by non suppurative inflammatory lesions involving the heart, joints, subcutaneous tissues and central nervous system. It is a complication of group A streptococcal upper respiratory tract infection. The pathogenic mechanisms remain unknown although there is a general agreement as to an immunological hypothesis. Pharyngitis must be treated, even if streptococcal origin is not proved. Penicillin remains the first choice antibiotic. Epidemiological studies of all group A streptococcal serotypes isolated should be performed.

Should pulmonary tuberculosis be an AIDS-defining diagnosis in patients infected with HIV?

Between 1983 and 1989, we cared for 56 patients with tuberculosis and human immunodeficiency virus (HIV) infection. In 37 patients (66%), tuberculosis occurred before any other AIDS-defining disease (group 1); in 10 (18%) it occurred during the same month as another AIDS-defining disease (group 2); and in 9 (16%), after the diagnosis of AIDS (group 3). Tuberculosis was entirely pulmonary in 14 patients (25%), entirely extrapulmonary in 9 (16%), and both pulmonary and extrapulmonary in 33 (59%). The frequency of extrapulmonary involvement was similar in patients from group 1 and from groups 2 and 3 (combined): 76% versus 74%. Needle biopsy of the liver revealed hepatic involvement in 18 patients (32%). The mean CD4 lymphocyte count was 232/mm3 when tuberculosis was entirely pulmonary, and 243/mm3 when extrapulmonary disease was present (difference not significant). In group 1, the onset of both pulmonary and extrapulmonary tuberculosis occurred at the same stage of HIV infection, 12 and 10 months, respectively, before any other AIDS-defining disease. Treatment, planned to last 1 year, was highly effective, despite frequent side-effects. Among the 32 patients who completed treatment, relapse of tuberculosis occurred in 2 (6%) with a mean follow-up of 16 months (0-53 months) after completion. Our results suggest that pulmonary tuberculosis should be included in the criteria for diagnosis of AIDS.

Mechanisms of ceftriaxone prophylaxis against late bacteremic vascular graft infection caused by Staphylococcus aureus in a dog model

Possible mechanisms of the prophylactic effect of ceftriaxone against late bacteremic vascular graft infection in dogs were investigated. Dogs bearing an expanded polytetrafluoroethylene graft implanted as thoracoabdominal aortic bypass for one month were exposed to transient bacteremia produced by intravenous injection of 2.6 +/- 1.8 x 10(8) colony forming units Staphylococcus aureus 209P-R. To assess the effect of the antibiotic on bacteria already adherent onto the grafts, we compared the results from six untreated dogs used as controls and six dogs receiving ceftriaxone (0.5 g, intramuscularly) 90 minutes after the bacteremic challenge. The grafts were removed one week after the bacteremic challenge and cut into 10 to 15 fragments, each submitted to viable bacterial counts. The number of grafts and the number of fragments yielding bacterial growth were the same in the two groups. However, the median density of bacteria was lower (p less than 0.01) in the dogs given ceftriaxone, 64 colony forming units/cm (range: 3-8,700), than in the control dogs, 585 colony forming units/cm (range: 12-64,000), suggesting that ceftriaxone had an effect on the postadherence phase of the development of infection. To assess the effect of ceftriaxone on the adherence phase we compared the results from seven untreated dogs and seven dogs receiving ceftriaxone (0.5 g intramuscularly) 90 minutes before the bacteremic challenge. The grafts were removed two hours after the bacteremic challenge. Though all the seven grafts were colonized in each group, the number of fragments yielding bacterial growth was lower (p less than 0.05) in the dogs given ceftriaxone (59/70) than in the control dogs (90/91).(ABSTRACT TRUNCATED AT 250 WORDS)

[Usefulness of folinic acid in cytopenia induced by antiparasitic drugs in AIDS patients]

The scientific basis for using folinic acid in combination with the antiparasitic drugs prescribed to AIDS patients has been reviewed. In vitro and experimental data are unclear. On the basis of folinic acid metabolism and pharmacology and of clinical experience, we suggest that folinic acid should not be systematically added to the curative treatment of pneumocystosis with cotrimoxazole. Folinic acid may be added to prophylactic regimens using high-dose cotrimoxazole (i.e. 800 mg sulfamethoxazole twice a day) and in malnourished patients. It should be administered as soon as cytopenia occurs in the course of treatment. Concerning toxoplasmosis, the addition of folinic acid is recommended in doses of 10 to 20 mg/day in acute therapy and 5 to 10 mg/day in maintenance therapy. Dosage must be adjusted to the results of blood counts.

Long-term follow-up of patients with AIDS on maintenance therapy for toxoplasmosis

To assess potential interactions of multiple drug regimens administered to patients with AIDS for toxicity and efficacy, we reviewed the charts of 35 patients on maintenance therapy for toxoplasmosis. Seven relapses of toxoplasmosis occurred in 6 of 35 (17%) patients, and seven episodes of pneumocystosis occurred in 6 of 35 (17%) patients. Four relapses of toxoplasmosis and 5 relapses of pneumocystosis were seen in 20 patients treated with pyrimethamine/clindamycin; 2 relapses of toxoplasmosis and 2 relapses of pneumocystosis were seen in 11 patients treated with pyrimethamine alone, and 1 relapse of toxoplasmosis was seen in 13 patients treated with pyrimethamine/sulfadiazine. Adverse effects were related to pyrimethamine in 10 patients, to clindamycin in 7 patients, and to sulfadiazine in 8 patients. These results must be compared with those of prospective trials to determine the efficacy and safety of various maintenance regimens.

Treatment of acute toxoplasmosis with intravenous clindamycin. The California Collaborative Treatment Group

The interim results are presented of an ongoing large-scale, prospective, randomized study to determine the potential role of clindamycin in the treatment of toxoplasmic encephalitis. Patients were seropositive for Toxoplasma gondii antibodies and had clinical signs compatible with toxoplasmic encephalitis. Data was available on 33 patients, 15 of whom received pyrimethamine p.o./clindamycin i.v. and then p.o., and 18 of whom received pyrimethamine p.o./sulfadiazine p.o. The interim evaluation did not reveal a remarkable difference between the two regimens in the clinical or radiologic response. Adverse reactions to both regimens were common and frequently multiple, there being more adverse gastrointestinal reactions in patients on pyrimethamine/clindamycin and more adverse hematological reactions in those on pyrimethamine/sulfadiazine.

Resting energy expenditure is increased in stable, malnourished HIV-infected patients

Resting energy expenditure (REE) was measured by reference to body composition in 50 malnourished patients with human immunodeficiency virus (HIV) infection and compared with that of 14 healthy subjects. Among HIV patients, 40 had acquired immune deficiency syndrome (AIDS) and 10 had AIDS-related complex (ARC). All were in stable condition and had a previous history of progressive wasting, ie, a mean body weight loss of 14.2 +/- 8.1 kg over 16.6 mo (range 2-49 ms). The mean REE was 14% higher than estimated basal energy expenditure (EBEE), according to the Harris and Benedict formula. Thirty-four patients (68%) were classified as hypermetabolic (REE greater than 110% EBEE). The best predictable variable for REE was fat-free mass (FFM), as determined by an anthropometric method (r = 0.72; P less than 0.001). The mean REE was 12% higher in HIV patients than in the control group FFM (156 +/- 19 vs 124 +/- 17 kJ.kg FFM-1.d-1). We concluded that in stable and malnourished HIV patients, the progressive wasting may be partly related to an increase in REE. The mechanism of this hypermetabolic state remains to be established.

Antibiotic prophylaxis of late bacteremic vascular graft infection in a dog model

This study was undertaken to determine the efficacy of a single-dose antibiotic injection to prevent late bacteremic vascular graft infection. Twelve dogs had thoracoabdominal aortic bypass with expanded polytetrafluoroethylene grafts. One month later, a bacteremic challenge was produced by rapid intravenous injection of 5 x 10(8) Staphylococcus aureus. Dogs were treated by pairs, each dog of a pair being randomly assigned to receive either 0.5 g ceftriaxone (group I, n = 6) or saline (group II, n = 6), intramuscularly, 90 minutes before challenge. Grafts were harvested seven days after bacteremic challenge. They were cut into 10 fragments, each of which were submitted to bacterial counts. Results of bacterial counts were expressed as colony forming units per square centimeter of graft segment. The overall infection rates were zero of six grafts in group I and four of six in group II (p less than 0.05). In group I, none of the 60 graft fragments were found to be culture positive (p greater than 0.01). Bacterial counts from the 24 infected fragments were highly variable, ranging from 12 colony forming units/cm2 to 64 x 10(3) colony forming units/cm2. Serial quantitative blood cultures revealed a similar decrease of bacteremia in both groups with 2.4 +/- 0.9 x 10(2) (group I) and 1.2 +/- 0.9 x 10(2) (group II) colony forming units/ml at three hours. Mean ceftriaxone serum level was 26 +/- 18 mg/L at the time of bacteremic challenge. These data suggest that a single dose of ceftriaxone given before bacteremic challenge is sufficient to prevent late bacteremic vascular graft infection in this model.(ABSTRACT TRUNCATED AT 250 WORDS)

Varicella in patients infected with the human immunodeficiency virus

In a retrospective study of 421 patients infected with human immunodeficiency virus, 15 (3.5%) had varicella. Twelve patients had a typical varicella. Complications were as follows: profuse eruption, 6; hemorrhagic eruption, 1; hepatitis, 5; and pulmonary involvement, 1; 1 patient developed an intravascular disseminated coagulation and died of varicella. Three patients with acquired immunodeficiency syndrome, having a history of varicella, presented with an atypical form of varicella with a small number of disseminated cutaneous poxlike lesions; 1 of these patients experienced three relapses of atypical varicella. Assay of serum antibodies to varicella zoster virus showed that, while typical varicella was the primary varicella zoster virus infection, atypical varicella was a reactivation of varicella zoster virus infection. Acyclovir was given to 11 patients and vidarabine to 1 patient. The one patient who died and the one who suffered a relapse had received acyclovir. Thus, varicella in patients infected with human immunodeficiency virus may be complicated and even lethal. Atypical forms of varicella could be, as is the case with herpes zoster, a reactivation of endogenous varicella zoster virus.

[Zona in 50 patients infected by human immunodeficiency virus. Clinical manifestations and prognostic value]

Between January 1981 and April 1989, 50 patients infected with HIV were examined for herpes zoster. Herpes zoster enabled HIV infection to be detected in 23 patients (46 percent). It had only one localisation (involving contiguous dermatomes) in 37 patients, two localisations in 6 patients, three or four localisations in 1 patient each, and was disseminated in 5 patients. Localisations were mostly thoracic and cervicofacial. Herpes zoster was treated with acyclovir in 29 patients. All patients, treated or untreated, recovered from herpes zoster, but 9 of them (18 percent) had sequelae: pain in 8 and hypoacousia in 1. Herpes zoster recurred once in 8 patients and twice in 2. Among the patients with AIDS related complex 20 percent developed AIDS after herpes zoster at one year and 30 percent at two years. Among all the patients, the proportion of deaths after herpes zoster was 13 percent at one year and 34 percent at two years.

Vancomycin-aminoglycoside combinations in therapy of endocarditis caused by Enterococcus species and Streptococcus bovis

Between 1974 and 1986, five patients with enterococcal endocarditis (three of whom had a prosthetic valve) and three patients with Streptococcus bovis endocarditis were treated with a combination of vancomycin and an aminoglycoside for a mean duration of 40 days. This regimen was prescribed because of allergy to beta-lactam (n = 7) and/or failure of previous treatment (n = 4). Three of the eight patients underwent valve replacement. In the six evaluable patients cure was achieved with the vancomycin-aminoglycoside combination. An increase of the creatinine serum levels was observed in all cases but it was never necessary to discontinue treatment, adjustment of the vancomycin and aminoglycoside dosage according to the serum and/or serum creatinine levels allowing continuation of therapy.

[Chronic bone infections after surgery. Treatment with the new quinolones]

A prospective open study carried out over 5 years and including 20 patients suffering from chronic bone suppuration following orthopaedic surgery has confirmed the value of the new quinolones (NQ) in these indications. The patients received pefloxacin or ciprofloxacin most often combined with rifampicin or fusidic acid for a mean period of 7 months. Single or multiple organism infections were documented in 14 patients, the majority being Staph. aureus (n = 13) and Pseudomonas (n = 14). Samples were sterile in 6 cases. Fourteen therapeutic successes and 5 failures were observed. In one patient, improvement was noted but the post-treatment follow-up insufficient to pronounce a cure. Success was obtained in 14 out of 16 patients who had sensitive organisms or sterile samples. The mean post-treatment follow-up (16 months) was satisfactory but insufficient to speak of cure. However, in these patients for whom further surgery, however desirable, is often refused, NQ constitute an improvement which raises hopes of cure or allows further surgery.

[Tuberculosis in patients infected with the human immunodeficiency virus. 30 cases]

Between May, 1983 and September, 1987, 8 per cent of the patients hospitalised for an HIV infection (i.e. 30 patients, 20 with an ARC and 10 with AIDS) had tuberculosis. The percentage of patients originating from Central Africa or Haiti was important (23 per cent). Tuberculosis was thoracic (76 per cent) and/or extrathoracic (63 per cent). The main organs involved were the lungs (n = 21), the mediastinal lymph nodes (n = 9), the superficial lymph nodes (n = 9), and the liver (n = 8). The pulmonary infection was often multilobar (n = 14), but without caverns. The tuberculin PPD (purified protein derived) test was positive in 63 per cent of ARC patients and in 30 per cent of AIDS patients. The diagnosis of tuberculosis was confirmed in 27/30 patients by culture of Mycobacterium tuberculosis (n = 23) and/or histology (n = 13), and in the remaining patients by response to a specific treatment. In 3 patients with normal X-ray film of the chest, M. tuberculosis could be recovered by culture of the gastric fluid. Antituberculous treatment was effective, but its optimum duration is to be determined since relapse may occur, even after one year of treatment. The side-effects of the treatment were unusually frequent (54 per cent). The occurrence of tuberculosis seemed to aggravate the prognosis of the HIV disease, since 57 per cent of the ARC patients reached the stage of AIDS within 6 months on average. These results are in agreement with the new recommendations of the Centers for disease control which include extrapulmonary tuberculosis in the AIDS criteria. However, in our study, pulmonary tuberculosis had the same detrimental effect and should therefore be included in the AIDS criteria.

Experimental colonization of a polyester vascular graft with Staphylococcus aureus: a quantitative and morphologic study

Colonization of a polyester (Dacron) vascular graft by Staphylococcus aureus 209P-R was studied. Twenty-five dogs had thoracoabdominal aortic bypass. After intervals of 2 hours (three dogs), 8 days (five dogs), 1 month (six dogs), 2 months (six dogs), or 6 months (five dogs), a bacteremic challenge was produced by intravenous injection of 6 x 10(8) colony-forming units of S. aureus. Two hours later grafts were removed and cut into 10 fragments, each submitted to bacterial counts and scanning electron microscopic studies. Results of bacterial counts were expressed in colony-forming units (CFU) per square centimeter of graft segment (median [lower to upper quartiles]). Normal canine aortas (n = 2) used as controls trapped no bacteria. Colonization of Dacron grafts varied according to the duration of graft function (p less than 0.01): after 2 hours, 4416.5 CFU (1158 to 9073 CFU); after 8 days, 1515 CFU (963 to 2893 CFU); after 1 month, 199 CFU (86 to 538 CFU); after 2 months, 615 CFU (243 to 1407 CFU); and after 6 months, 1 CFU (1 to 5 CFU). Heavily colonized fragments were observed for duration of graft function of 2 months or less, whereas at 6 months all the fragments trapped fewer than 50 CFU/cm2 of graft segment. Scanning electron microscopy showed that colonization was closely associated with healing. Staphylococcal entrapment was related to the amount of fibrin deposits, which were especially abundant where the thrombotic matrix was unorganized and on bare polyester filaments. Graft colonization is especially to be feared in the first weeks after graft implantation, an observation which may help to define guidelines for preventing hematogenous vascular graft infection.