Erythema elevatum diutinum in human immunodeficiency virus-infected patients--report of a case and review of the literature

Erythema elevatum diutinum (EED) is a rare chronic disease of unknown origin, part of the spectrum of cutaneous leucocytoclastic vasculitis. A case of EED in a 32-year-old HIV-infected male patient, with no previous opportunistic infections and a CD4+ cell count of less than 200/mm3, is reported. Therapy with oral dapsone (100 mg/day for 15 days) resulted in clinical cure with no relapse after 6 months of follow-up. To our knowledge, only six cases of EED in HIV-positive patients have been reported to date. A brief review of these seven cases is described.

[Disseminated Kaposi's sarcoma with hepatosplenic involvement in AIDS]

Kaposi sarcoma (KS) is the most frequent neoplasm found in AIDS patients. The disease is often disseminated and preferentially involves the skin and the lymphatic and digestive systems. Hepatosplenic involvement which is considered as a frequent autopsy finding is rarely diagnosed at life. A 27-year-old male HIV positive patient with severe immunosuppression who developed a rapidly progressive laterocervical cutaneous KS confirmed by pathologic study is presented. Abdominal echography and thoracoabdominal CT scand demonstrated lesions highly suggestive of pulmonary, lymph node, hepatic, splenic and rectal involvement by KS. The administration of 2 chemotherapy cycles produced subjective improvement and remission of the cutaneous lesions. Severe pulmonary superinfection led to death. An autopsy study was not performed. Hepatosplenic involvement by KS, diagnosed while the patient is alive is rare. The imaging techniques are useful to diagnose with high probability visceral involvement of KS. Systemic searching for visceral involvement in KS patients would lead to a marked increase in the cases such as that herein described with evident therapeutic and prognostic implications.

[Primary cutaneous cryptococcosis and bacterial pneumonia caused by Pseudomonas aeruginosa in AIDS: clinical case and review of the literature]

BACKGROUND

Clinically symptomatic infection due to Cryptococcus neoformans is found in 5-10% of patients with AIDS. It usually appears as meningitis with or without associated blood stream infection. In the last years, severe Pseudomonas aeruginosa infections in HIV (+) patients, with a high morbidity and mortality, are increasingly reported.

MATERIALS AND METHODS

A 27 year-old male HIV (+) patient, with previous opportunistic infections, was referred because of a nodular lesion on his left wrist, with an axillar homolateral lymph node of long-term evolution. Cryptococcus neoformans var. neoformans was isolated in pure culture from the lesion. Disseminated infection or affection of other organs was ruled out. Therapy with intravenous amphotericin B was initiated, but the patient developed an early nosocomial bacteremic pneumonia due to P. aeruginosa with a fatal outcome. A review of the literature about both complications in AIDS is carried out.

RESULTS

The fungal clinical picture is compatible with primary cutaneous cryptococcosis that is a rare condition (12 clinical reports until 1993), of which only one case report in an AIDS patient has been described in 1994. Since 1990 severe infections due to P. aeruginosa in HIV(+) patients are increasingly reported, and pneumonias, bacteremias, catheter-related sepsis, urinary tract infections, intraabdominal infections, central nervous system and othorrhinolaryngologic infections have been described in patients with AIDS in the English-language literature.

CONCLUSIONS

Primary cutaneous cryptococcosis is another rare form of infection with C. neoformans in patients with AIDS. The increasingly reported cases of severe infections due to P. aeruginosa could have important implications in the therapy of patients with AIDS.

[Campylobacter jejuni infections in a prison population coinfected with the human immunodeficiency virus]

BACKGROUND

Campylobacter jejuni is a common etiological agent of diarrhea in the general population. In recent years it has also been involved as etiological agent of intestinal and extraintestinal infections in patients infected with the human immunodeficiency virus (HIV). The clinical and microbiological features in a series of HIV+ patients infected with C. jejuni in a correctional facility are here reported.

METHODS

Retrospective analysis of clinical records of patients who had C. jejuni recovered from clinical samples diagnosed at the Hospital General Penitenciario (HGP), Madrid, for 2 years (10-1-1991 to 9-30-1993). C. jejuni strains were identified at the Clinical Microbiology Department at the HGP following standard methods. Antibiotic sensitivity testing was performed by the agar dilution and microdilution methods.

RESULTS

Twenty-eight patients were diagnosed as being infected with C. jejuni. The mean age was 32.4 years (95% CI: 30.1-34.7). Twenty-seven patients (96%) were males. Twenty-five patients (90%) were intravenous drug users (IVDU). Sixty-one percent of cases clustered in the september and october months. The main clinical symptoms were diarrhea with no pathological products and fever. Mean lymphocyte CD4+ count was 103/mm3 (95% CI: 45-162). Blood cultures were obtained from 13 patients, and bacteremia was detected in three of them (23%), with no associated mortality. Forty-eight percent of C. jejuni strains were resistant to fluorquinolones, and all of them were susceptible to erythromycin. The latter antibiotic was used as therapy in 82% of patients and clinical and microbiological cure was achieved in all 17 patients who were evaluated at follow-up.

CONCLUSIONS

Campylobacter jejuni is an important enteropathogen in correctional facility population infected with HIV, which in this study involved severely immunosuppressed patients. The main clinical presentation was acute enterocolitis and bacteremia (detected in 23%), a higher percentage than that reported in the literature. An increased quinolone-resistance rate was detected (48%). Erythromycin, and possibly the new macrolides, are currently the antibiotics of choice.

[HTLV-II infection in Spain. Analysis of 113 cases identified until November, 1994. Spanish Group for the Study of HTLV/I/II]

BACKGROUND

HTLV-II is a human retrovirus considered to be responsible for the genesis of some lymphoproliferative and neurologic syndromes. The virus is endemic in some Amerindian and African tribes as well amongst injecting drug addicts (IDA) in North America and Europe.

METHODS

The clinical, epidemiologic and virologic characteristics of the patients with HTLV-II infection identified in Spain up to November 1994 are described.

RESULTS

One hundred thirteen subjects have been identified with HTLV-II infection in Spain with 4 being African immigrants residing in Madrid and the remaining being IDA from other European countries. Most were males (94/113; 83%). All were IDA except six (5 had acquired the infection by sexual contact and one by blood transfusion). Most of the IDA infected with HTLV-II were coinfected with HIV-1 (93/113; 83%). No patient showed clinical manifestations attributable to HTLV-II infection although one drug addict male coinfected with HIV-1 and HTLV-II developed a non-inflammatory proximal myopathy.

CONCLUSIONS

Infection by HTLV-II is present in Spain and affects with preference to injecting drug addicts. It has been shown to be of growing incidence with a current global prevalence of 2% in IDA.

Prevalence of human T-cell lymphotropic virus type 1 (HTLV-1) and HTLV-2 infection among Spanish drug users measured by HTLV-1 assay and HTLV-1 and -2 assay. HTLV-1 and HTLV-2 Spanish Study Group

The prevalence of human T-cell lymphotropic virus type 1 (HTLV-1) and HTLV-2 infection in 1992 and 1993 was determined by testing 2,152 specimens from injection drug users living in 11 geographic areas in Spain. Results obtained by an authentic HTLV-1 and -2 test were compared with those obtained by an HTLV-1 assay. HTLV infection was identified in 7 of 11 regions, with an overall prevalence of 2.5% (range, 0.4 to 11.5%). Fourty-four (81%) of 54 subjects were infected with HTLV-2; the viral strains in the remaining 10 subjects could not be serologically typed. Underestimation of HTLV infection because of the low sensitivities of HTLV-1 enzyme immunoassays for HTLV-2 antibody was relatively low (< 20%). Therefore, previous epidemiologic findings generated with HTLV-1 enzyme immunoassays appear to be reasonably accurate. Our results suggest that the rate of HTLV infection may have been increasing recently among Spanish drug users.

Correlation of in-vitro susceptibility test results with clinical response: a study of azole therapy in AIDS patients

The in-vitro susceptibilities of 40 clinical isolates of Candida albicans to ketoconazole and fluconazole were determined and an attempt was made to correlate these data with the clinical responses of the patients from whom the strains were originally isolated to treatment with these agents. Of 40 patients with the acquired immunodeficiency syndrome (AIDS) with oropharyngeal and/or oesophageal candidosis, 21 received ketoconazole and 19 fluconazole. Susceptibility testing was performed by a microbroth dilution method with RPMI-2% glucose medium according to the recommendations of the National Committee for Clinical Laboratory Standards; growth inhibition was estimated spectrophotometrically and the MIC endpoint was defined in terms of the IC1/2. The MICs of 236 additional strains of C. albicans, which were also isolated from AIDS patients, were used to establish a susceptibility profile for this species. On the basis of the susceptibility test results and the clinical responses of the 40 patients, the following tentative breakpoints for ketoconazole and fluconazole are proposed: patients with infections caused by C. albicans strains with MICs of ketoconazole and fluconazole or < or = 0.001 and < or = 0.25 mg/L respectively would be expected to respond to treatment with these agents and isolates with MICs which meet these criteria are therefore classified as susceptible; patients with infections caused by strains with MICs of ketoconazole and fluconazole of > or = 0.06 and > or = 16.0 mg/L respectively would not be expected to respond to treatment with these agents and isolates with MICs which meet these criteria are therefore classified as resistant; the response of patients with infections caused by strains with MICs of ketoconazole and fluconazole of 0.003-0.03 and 0.5-8.0 mg/L respectively cannot be reliably predicted and isolates with MICs which fall within these ranges are therefore classified as being of indeterminate susceptibility. The present study demonstrates that the results of in-vitro susceptibility testing with RPMI-2% glucose broth correlate with the clinical response to therapy and can be used to facilitate optimal treatment in AIDS patients with oropharyngeal and/or oesophageal candidosis.

[The quantification of human immunodeficiency virus viremia in patients with rapid and slow progression of the disease]

BACKGROUND

The natural course of the human immunodeficiency virus type 1 (HIV-1) infection is very variable. The factors which appear to determine the speed of immunodeficiency progression are multiple, although the virulence of the predominant viral strain seems to be one the main factors. The plasmatic viremia in individuals with rapid and slow HIV-1 progression was analyzed in an attempt to establish the degree of correlation between HIV-1 replication and the natural course of the disease.

METHODS

Forty-two samples from 34 seropositive patients, 11 with rapid progression criteria (< 5 years from acute infection and CD4+ lymphocytes < 0.2 x 10(9)/l) and 23 with slow progression (> 7 years from demonstrated infection and > 0.5 x 10(9) CD4+ lymphocytes/l) were studied. The plasmatic viremia was quantified by a new method of plasma DNA genetic amplification, denominated the branched DNA (bDNA) technique. As a reference circulating p24 was determined and the presence of several proviral regions were studied in peripheral blood lymphocytes by polymerase chain reaction (PCR).

RESULTS

The presence of RNA molecules was detected in plasma of 7 (58.3%) out of 12 samples of rapid progression (RP) patients by bDNA. To the contrary, this was negative in 30 samples from slow progression (SP) patients. Four of the 5 negative RP samples corresponded to patients who had taken antiretroviral drugs at the time of the study. The p24 antigenemia was positive in 5 (41.6%) from the RP patients and in none of the SP patients. The presence of gag, pol and env sequences was positive by PCR in all RP patients and in most of the SP patients. However, repeatedly negative results by PCR were observed in 5 SP samples for all or some of the genomic regions studied.

CONCLUSIONS

Patients with rapid progression of HIV-1 have higher plasmatic viremia than subjects with slow disease progression.

[Intestinal parasitoses in the prison population in the Madrid area (1991-1993)]

BACKGROUND

Intestinal parasitoses are frequent in populations in tropical and subtropical areas, HIV infection has favoured an increase in the prevalence of some of these parasitoses . Both conditions concur in innate populations. The aim of this study was to determine the prevalence and clinical characteristics of the intestinal parasitosis in a penitentiary population from the Madrid area.

METHODS

On the basis of the data from the Laboratory of Clinical Microbiology in the Hospital General Penitenciario, patients with the diagnosis of intestinal parasitosis were retrospectively reviewed. The study period covered 29 months (from 1/8/91 to 31/12/93). Samples were taken from patients admitted to, and attended, in the outpatient area of this hospital in addition to those held in dependents prisons. Processing was done by direct macroscopic and microscopic visualization (400x) of the sediment obtained by the formol-ether concentration method (Ritchie). Modified Ziehl staining was carried out. Demographic, clinical-evolutive and microbiologic data of the patients were analyzed.

RESULTS

One thousand two hundred eighty-one samples corresponding to 1,033 patients were studied 131 (10.2%) positives corresponding to 96 (9.3%) patients were observed. 88.5% (n = 85) were males. The mean age was 31.2 years (CI 95%: 29.3-32.9). The patients were from Europe in 39.7% of the cases (Spain: 94%), Africa 28.9% and Latin America 28.9%. Twenty-five patients were HIV+ (46%) with a mean CD4 count of 160/mm3 (CI 95%: 65-255) and 29 were HIV-. Globally, the most frequently found parasites were uncinaria (22%), Giardia lamblia (21%) and Cryptosporidium parvum (20%). One case of intestinal capillariasis was diagnosed. Fifteen mixed parasitoses (15.6%) were observed and the most frequent association was Trichuris trichiura and uncinaria in 8 patients (5 HIV+ and 3 unknown HIV). Clinical manifestations were present in 63.7% (42/66) of the patients with diarrhea being the most frequent (25 cases). In patients in whom the clinical evolution could be evaluated, it was favorable in most of the cases except in those with Cryptosporidium parasitosis.

CONCLUSIONS

Intestinal parasites are of relevance within a prison population, presenting some differences to the intestinal parasites observed in a general population. The most frequently observed parasite was uncinaria in HIV- patients and Cryptosporidium parvum in HIV+ patients. Mixed parasitosis was not infrequent (15.6%). 25% of the intestinal parasitosis are asymptomatic. When symptomatology does exist, diarrhea is the most common clinical manifestation. The clinical evolution is usually favourable with the exception of some cases of diarrhea by Cryptosporidium in severely immunosuppressed HIV+ patients.

[Resistant tuberculosis in a prison population during 1991-1993]

BACKGROUND

To know the prevalence of resistant tuberculosis and the characteristics of the same in the penitentiary medium in the Madrid area (Spain).

METHODS

From March 1, 1991 to August 31, 1993 a prospective study was carried out in patients with isolations of Mycobacterium tuberculosis resistant to some of the common antituberculous drugs within the context of tuberculosis in a penitentiary population attended in the Hospital General Penitenciario (Madrid). Demographic, clinical, analytical, and microbiological data were collected as was that on the antituberculous treatment used. The study of sensitivities was performed by the proportions method.

RESULTS

Tuberculosis was diagnosed in 275 patients according to strict microbiological criteria (positive Löwenstein culture). The antibiogram was performed in 218 isolations. Twenty strains resistant to some first line antituberculous drug (9%) (confidence interval [CI] p < 0.05:6-14), 9 of which were found to be multiresistant, were detected in 20 patients. Out of the patients in whom the sensitivity of the isolate was known, 173 had not previously undergone antituberculous treatment. Six of these patients were found to be resistant to isoniazide (3.5%) (CI p < 0.05:1.4-7.7) and 2 patients were resistant to rifampicin (1.2%) (CI p < 0.5:0.2-4.5). The other 45 patients had previously undergone antituberculous drugs with 8 isolates presenting resistance to isoniazide and 11 to rifampicin. Eighty-four percent of the patients with resistant tuberculosis and 90% of the sensitive cases were coinfected with HIV infection with the differences not being statistically significant. The HIV positive patients with resistant tuberculosis showed a mean CD4 positive lymphocytes of 0.76 x 10(9)/l (CI p < 0.5:0.028-0.213) and those with sensitive tuberculosis had 0.165 x 10(9)/l (CI p < 0.05:0.133-0.196) (p < 0.01).

CONCLUSIONS

Tuberculosis resistant to common antituberculous drugs was detected in a Spanish penitentiary population. The level of the resistance of the isolations of Mycobacterium tuberculosis should be monitored both inside and outside of the penitentiary medium in an attempt to avoid the progression of resistant tuberculosis within the Community.

[Tricuspid endocarditis caused by penicillin-resistant Staphylococcus aureus: 2 cases in parenteral drug addicts]

BACKGROUND

Staphylococcus aureus is the main causal agent of infectious endocarditis (IE) in intravenous drug addicts (IVDA) with most of the strains, isolated in Spain being resistant to penicillin and sensitive to methycillin, although the latter condition varied in recent years. Two cases of IE caused by S. aureus strains sensitive to penicillin in IVDA are presented.

METHODS

All bacteremia episodes diagnosed in the Hospital General Penitenciario (Madrid) over a 33-month period (March 1991 to December 1993) were prospectively studied. Special attention was given to patients diagnosed of IE. Blood cultures were processed according to the usual technique by a non radiometric system.

RESULTS

One hundred and four bacteremias were detected with 14 being produced by S. aureus. Ten episodes of the total number of bacteremias fulfilled criteria for IE with 2 being produced by strains of S. aureus sensitive to penicillin (CMI < 0.06 mu/ml). Both patients had coinfection by HIV. The clinical evolution prior to diagnosis was prolonged although clinical and microbiologic cure were achieved with intravenous beta-lactam antibiotics treatment, without complications.

CONCLUSIONS

Despite the low incidence of the isolation of Staphylococcus aureus sensitive to penicillin (< 3%) recently observed in Spain, strains producing severe infections, showing patterns of sensitivity such as those found during the preantibiotic era, may still be isolated.

Human intestinal capillariasis in an area of nonendemicity: case report and review

We report a rare case of human intestinal capillariasis in a young Colombian man who presented with abdominal pain and mild, self-limited diarrhea. Capillaria eggs were visualized in the feces, and treatment with mebendazole (200 mg/d for 3 weeks) resulted in clinical and parasitological cure. To our knowledge, this is the first case in a South American person and the second case reported in Europe. This case highlights the acquisition of endemic intestinal parasitosis far away from classically considered areas of endemicity. We review the English-language literature on human intestinal capillariasis and compare findings from other cases with those from the current case.

[Tuberculosis in a prison population: a study of 138 cases]

BACKGROUND

Tuberculosis continues to be a disease of great importance in Spain with few data known on prison populations. In the present study an analysis of the incidence and characteristics of tuberculosis in the prison population people is done.

METHODS

The General Penitentiary Hospital attends a prison population from the penitentiary centers of Madrid and its surrounding areas. From 1 March 1991-31 August 1992 a retrospective study of the patients with tuberculosis diagnosed by culture isolation of Mycobacterium tuberculosis was performed. Demographic, clinical, analytical, microbiologic analysis as well as data concerning to associated infections, antituberculous treatment and its possible toxicity as well as the evolution of the patients were collected.

RESULTS

During the period studied 138 patients--120 corresponding to the area of Madrid and 18 to patients referred from other penitentiary areas--were diagnosed. The rate of incidence of tuberculosis in the penitentiary population in the area of Madrid was of 1170.5 cases per 100,000 prisoners per year (confidence interval [CI] 95%; 961-1380). The mean age was 30 years (CI 95%; 29-31) and 97% were males. Eighty-four percent were positive for the human immunodeficiency virus (HIV) and 84% were intravenous drug addicts. The clinical form of presentation of the tuberculosis in the HIV positive patients was: pulmonary in 57% of the cases, disseminated in 29% and extrapulmonary in 14% and was pulmonary in all the cases of HIV negative patients. The mean CD4 lymphocytes count was 0.216 x 10(9)/l in HIV positive patients with pulmonary tuberculosis, and in disseminated tuberculosis was 0.062 x 10(9)/l (p < 0.001). The positivity of acid-alcohol resistant staining in the sputum samples and/or induced sputum was 67.4% in the patients with pulmonary tuberculosis and 77.4% in disseminated tuberculosis. Ten percent of the patients were found to abandon antituberculous treatment in the first trimester.

CONCLUSIONS

The incidence of tuberculosis in the prison population in much higher than that for the general population in Spain, largely due to the high prevalence of HIV infection in this population.

[Bacteremia due to Mycobacterium tuberculosis in patients coinfected with the human immunodeficiency virus]

BACKGROUND

Since the appearance of AIDS, bacteremia by Mycobacterium tuberculosis is an event described with ever greater frequency. The isolation of M. tuberculosis in blood cultures in patients coinfected by the human immunodeficiency virus and M. tuberculosis may vary the initial clinical diagnosis and confirm the picture as disseminated tuberculosis.

METHODS

The clinical records of patients admitted to the General Penitentiary Hospital of Madrid with significant bacteremia during the study period (March 1, 1991-September 1992) were retrospectively and prospectively reviewed. Special attention was given to the bacteremias by M. tuberculosis with the most significant clinical evolutive data being collected. The blood cultures were performed according to the routine technique using a non radiometric system with 10-day incubation and posterior processing of the sample for visualization and culture for mycobacteria.

RESULTS

In an 18 moth period and out of a total of 284 positive blood cultures (154 significant isolations) 14 episodes of bacteremia by M. tuberculosis were studied in 12 prison patients coinfected by the human immunodeficiency virus with associated severe immunosuppression (mean of CD4 = 0.068 x 10(9)/l). All the patients were intravenous drug addicts. Likewise, 37 other significant bacteremias were reviewed. The positivity of the blood culture as the sole sample or associated to respiratory isolations, changed the initial diagnosis and classified the picture as disseminated tuberculosis on 6 occasions (43%). All the patients presented pictures of disseminated tuberculosis although only four had been previously diagnosed of AIDS.

CONCLUSIONS

Bacteremia by M. tuberculosis is frequent in patients infected by the human immunodeficiency virus. M. tuberculosis (27.4%) was the most frequently isolated microorganism in blood cultures in this study. The processing of blood cultures for mycobacteria may be useful in patients positive for the human immunodeficiency virus with tuberculosis in order to confirm the diagnosis of disseminated tuberculosis. The isolation of M. tuberculosis in the blood may vary the initial diagnosis and could modify the prevalence of AIDS cases in Spain.