Management of infectious complications in acquired immunodeficiency syndrome

Human Immunodeficiency Virus Infection: Complications and Outcome of Orthopaedic Surgery

Orthopaedic surgeons practicing in areas with a high prevalence of human immunodeficiency virus (HIV) infection may expect that up to 7% of their patients who undergo emergent procedures and 1% to 3% of those who undergo elective surgery will be HIV-positive. Although basic science studies have demonstrated impairment of defenses to routine orthopaedic pathogens as well as to opportunistic organisms, clinical studies have shown that this impairment has not resulted in an increased incidence of postoperative infections or failure of wound healing in the asymptomatic HIV-positive patient. Even for the symptomatic patient, current medical management appears adequate to reduce the risk of early postoperative infection. The HIV-positive patient with a pros-thetic implant may be at increased risk for late hematogenous implant infection as host defenses diminish. Regular medical attention, prophylactic antibiotic therapy before dental work and invasive procedures, and early evaluation and treatment of possible infections are especially important in this setting. Decisions regarding elective surgery should be made on a risk-benefit basis. Because the risk of surgical complications increases with progression of the dis-ease, guidelines for elective surgery should include an assessment of the HIV-positive patient's immune status, including the CD4 lymphocyte count, history of opportunistic infection, serum albumin level, the presence of skin anergy, and the state of nutrition and general health.

Immunological dysregulation of lymph nodes in AIDS patients

Changes in immune competent tissues of the HIV-1-infected person reflect to a certain extent the kind and intensity of immunological dysregulations. The diagnostic approach, however, must include immunophenotyping of cells, immunovirological studies of virus distribution in diseased tissues, and functional tests in addition to classical morphology. The latter technique alone just serves as a crude screening method since structural lesions in lymphoid tissues do not permit discrimination from other HIV-independent immune deficiency and autoimmune disorders. Although the overall appearance of lymph nodes in HIV infection and in chronic autoimmune disorders, such as collagen vascular diseases (e.g., rheumatoid arthritis and systemic lupus erythematosus), is similar, immunophenotyping shows a progressive loss of CD4 cells in HIV infection yet a quantitative increase in this cell population in autoimmune disorders (Krueger 1985a). In addition, there are other persistent active infections by lymphotropic viruses (e.g., EBV or HHV-6) which can cause structural and cellular changes in lymphoid tissues closely resembling HIV-induced lesions (Krueger et al. 1988b; Krueger 1985b). The pathological diagnosis therefore nedds to be supplemented by serological studies and--in selected cases--by in situ hybridization for the demonstration of viral genome. Southern blotting for viral DNA can only detect high numbers of viral genome copies in tissue extracts, not in which cell population the virus resides (e.g., malignant cells vs associated "normal" cells), while the polymerase chain amplification reaction, the most sensitive of all (Buchbinder et al. 1988), cannot yet differentiate between latent and (disease-related) active infection. Taking into consideration the above-described precautions in the evaluation of lymphatic lesions, there are a number of characteristic changes which reflect well the sequelae of HIV infection itself and of the ensuing immune dysregulation. Progressive loss of CD4 cells in the paracortex of lymph nodes and in the peripheral blood leads to inversion of the CD4/CD8 ratio. Loss of demonstrable CD4 cells is probably the consequence not only of cell lysis by HIV-1 infection (note: discrepancy between HIV-1 genome positive cell numbers and depletion of CD4 cells) but also of decreased CD4 marker synthesis in infected cells (Stevenson et al. 1987). In this context it is interesting that Fouchard et al. (1986) were able to show HIV expression in CD8 cells and theorized that these developed from infected CD4 cells which subsequently lost the CD4 epitope and expressed CD8.(ABSTRACT TRUNCATED AT 400 WORDS)

The value of serum cryptococcal antigen in the diagnosis of cryptococcal infection in patients infected with the human immunodeficiency virus

Serum cryptococcal antigen titres were measured in 828 HIV-infected patients with pyrexia, 69 of whom had meningism. Serum cryptococcal antigen was positive in 17 patients of whom 16 had meningism with cryptococcus isolated from their CSF. The other patient had no meningism, had no evidence of cryptococcal infection on repeated CSF examination and remains well. A positive serum cryptococcal antigen test was therefore valuable in the diagnosis of cryptococcal meningitis, although in all 16 patients meningism was present and a diagnostic lumbar puncture was therefore carried out. In our experience routine screening for serum cryptococcal antigen did not predict patients who subsequently developed cryptococcal meningitis.

A review of pulmonary cytopathology in the acquired immunodeficiency syndrome

Over the past 6 yr, we have observed an increase in cytologic specimens from the respiratory tract in patients suspected or known to have AIDS, from 7 of 81,031 cases in 1982 to 1,231 of 55,333 in 1987. Based on our experience with 1,140 patients, this article reviews the technical and morphologic evaluation of pulmonary cytologic specimens from AIDS patients.

Hand infections in patients with acquired immunodeficiency syndrome

Eight patients are reported with hand infections and a diagnosis of acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC). Seven patients had AIDS and one ARC. Four were homosexually active males, three were intravenous drug abusers, and one was the wife of a presumed drug abuser. The hand infections were not truly opportunistic; three patients had herpes, two had osteomyelitis, one had septic arthritis, and two had bacterial abscesses. The presentation or course of the infection was atypical in the majority of patients. The infections were seen early in the course of the disease and in one half of the patients preceded the diagnosis of AIDS. Unusual hand infections, then, may suggest the development of AIDS in a patient at risk.

Clinical clues to AIDS. Recognizing the dermatologic and nondermatologic manifestations

As more types of human immunodeficiency virus (HIV) are recognized and as the incidence of acquired immunodeficiency syndrome (AIDS) increases, more and more manifestations of HIV infection will be recognized. Dermatologic conditions often provide a means of making the presumptive diagnosis. Months or years of asymptomatic disease may have elapsed before cutaneous symptoms appear. However, care must be taken not to over-diagnose on the basis of a single nonspecific finding. To say that all patients with psoriasis have AIDS, for example, would be absurd. Yet an explosive flare of psoriasis or an atypical new presentation should alert the clinician to the possibility of HIV infection. Certainly, multiple suggestive dermatologic findings in any patient would essentially confirm the diagnosis of AIDS regardless of the status of antibody reactivity. A wide range of nondermatologic physical findings can also signal HIV infection. None are specific for AIDS, but again, findings that are rare, atypical, or severe in a normal host should be viewed with suspicion, and any of the signs in an at-risk patient should prompt the clinician to consider AIDS and to include specific tests in the workup. By becoming familiar with the many faces of HIV infection, the clinician can recognize its varied manifestations that may suggest the diagnosis in the absence of other findings.

Central nervous system histoplasmosis. An unappreciated complication of the acquired immunodeficiency syndrome

Involvement of the central nervous system (CNS) by Histoplasma capsulatum is a rare event. It is usually not included in the differential diagnosis of CNS lesions in patients with acquired immunodeficiency syndrome (AIDS). Herein are described four patients with AIDS and progressive disseminated histoplasmosis who had CNS involvement. Histoplasmosis in the CNS may produce meningitis, single or multiple brain abscesses, and may present with either a clinical picture of obtundation or a deteriorating space-occupying CNS lesion. Three of the four patients were treated with amphotericin B and had initial clinical response, but ultimately, all experienced a relapse and died from their infection.