Infections in parenteral drug abusers. Further immunologic studies

Enteric neuroimmune interactions coordinate intestinal responses in health and disease

The enteric nervous system (ENS) of the gastrointestinal (GI) tract interacts with the local immune system bidirectionally. Recent publications have demonstrated that such interactions can maintain normal GI functions during homeostasis and contribute to pathological symptoms during infection and inflammation. Infection can also induce long-term changes of the ENS resulting in the development of post-infectious GI disturbances. In this review, we discuss how the ENS can regulate and be regulated by immune responses and how such interactions control whole tissue physiology. We also address the requirements for the proper regeneration of the ENS and restoration of GI function following the resolution of infection.

Medical consequences of substance abuse

Given the preceding review, differentiating the complications of parenteral drug use, HIV disease, and the toxicity of the drugs such as alcohol or cocaine may be a difficult matter for clinicians. The risk for coexisting morbidities is high. Thus, obtaining accurate and complete medical histories is of paramount importance. Drug-abuse treatment and follow-up medical care after an acute complication often involves multiple health care providers. The integration of primary prevention plans with the reinforcement of drug abstinence requires time, commitment, and the coordination of services. This integration should be a priority for individual patients as well as for public health planning.

Opiates and infection

This review on the effects of opiate use on infectious diseases discusses the complete spectrum of infections in the opiate user, including those of the lung, the GI tract, the skin, the skeletal system, and the CNS. There is both increased prevalence and increased severity of bacterial and viral infections in injection drug users with the outcome of increased morbidity and mortality. The experimental administration of opiates has lead to a greater understanding of the effects on susceptibility to and progression of infectious diseases. Animal models of opiate dependence and infection are reviewed with specific attention to cases in which the opiate-mediated effects are harmful and in which cases they are beneficial.

Enrollment of drug abusers in HIV clinical trials: a public health imperative for communities of color

There is an increasing appreciation of the impact of drug abuse on AIDS in the United States because of the pivotal role of injecting drug use in the prevalence of total AIDS cases and case reporting among ethnic/racial minorities, women, and children. While the participation of injecting drug users (IDUs) in HIV clinical trails has increased steadily, the IDU accrual rate lags unacceptably behind the IDU proportion of AIDS cases. The stigma of drug abuse, issues related to poverty, and the underrepresentation of communities of color are the major obstacles to IDU participation in HIV clinical research. It is critical to overcome these obstacles as the spectrum of HIV disease in IDUs requires the development of an IDU-relevant scientific agenda for HIV clinical trials. This, in turn, is crucial to the development of effective therapies for the treatment of HIV disease in IDUs. To the extent that these endeavors are successful, more relevant therapies to communities of color will be developed, as injecting drug use is disproportionately more prevalent in these communities.

Superficial thrombophlebitis. II. Secondary hypercoagulable states

Secondary hypercoagulable states are complex clinical conditions associated with an increased risk of thrombosis in which the exact pathophysiology is poorly understood. Secondary causes of superficial thrombophlebitis include malignancy, pregnancy, use of oral contraceptives, infusion of prothrombin complex concentrates, Behçet's disease, Buerger's disease, Mondor's disease, infectious agents, conditions that promote venous stasis, intravenous catheters and intravenous drug use. Conditions that may stimulate superficial thrombophlebitis include dermatophyte cellulitis at saphenous phlebectomy sites, sarcoidal granulomas, cutaneous polyarteritis nodosa, and hyperalgesic pseudothrombophlebitis in patients who test positive for human immunodeficiency virus. The distinguishing features, clinical evaluation, treatment, and histologic characteristics of the various disorders are reviewed.

A protocol for the treatment of severe infections of the hand

A protocol for the treatment of hand infections was used for 69 patients in a university teaching hospital. The protocol prescribes incision and drainage under optimal conditions (in the operating room) when the patient is first seen and intravenous antibacterial therapy effective against anaerobic and aerobic bacteria initiated immediately after obtaining aerobic and anaerobic cultures. Results of bacteria studies confirmed the significant frequency (nearly 30%) of mixed aerobic and anaerobic infection. Use of the protocol resulted in a shorter hospital stay, faster healing, and fewer complications (recrudescence of infection, reoperation, stiffness, arthritis, and osteomyelitis) when compared with 107 patients who were treated before institution of the protocol.

AIDS and the surgeon

Several issues related to the AIDS virus concern the surgeon. This article discusses the common presentations of AIDS in each body system with special emphasis on conditions that require surgical intervention, alternatives to surgical procedures for diagnosis, and precautions for the handling of tissue and body secretions of individuals suspected of harboring the AIDS virus.

Management of soft-tissue infections of the upper extremity in parenteral drug abusers

Management of extensive soft-tissue infections of the upper extremity in 23 parenteral drug abusers was reviewed. Bacterial cultures most often revealed oral flora, including streptococcal species in 77 percent of patients and anaerobes in 59 percent. Staph. aureus was present in only one patient. Ninety percent of the organisms were sensitive to penicillin and 98 percent to first-generation cephalosporins. Blood culture specimens, obtained at admission, were negative in 15 patients. All patients responded well to operative debridement, excision of involved veins, and local wound care. Surgical debridement is the mainstay of therapy. We believe that intravenous antibiotic therapy with a first-generation cephalosporin should be used in the acute phase for control of surrounding cellulitis and prevention of bacteremia.

Serologic, immunologic, and clinical features of parenteral drug users from contrasting populations

We screened inpatient and outpatient parenteral drug users with no clinical evidence of AIDS for immunodeficiency and antibodies to HTLV-III by ELISA. Among 20 outpatient drug users, 5 (25%) were seropositive. Three of these (and 2 who were seronegative) had low T-cell ratios. Over 6 months, 1 seropositive patient with a low ratio developed oral thrush and weight loss. We also studied 13 parenteral drug users hospitalized for conditions other than AIDS. Eight had low T-cell ratios, and at least 6 of these developed AIDS or ARC within 4 months. Serum from 8 of 13 inpatients was available for HTLV-III testing: 6/8 were seropositive and 3 of these 6 were among those developing AIDS or ARC. Abnormal T-cell ratios among all patients were associated with abnormal HTLV-III serology (p = .02). Of the 7 patients who developed AIDS or ARC, 4 were tested for both antibodies and T-cell ratios: all 4 were seropositive and had low ratios. A low ratio (p = .0004), a positive ELISA (p = .014), and abnormalities of both tests (p = .001) were associated with the development of AIDS or ARC. Of the 26 patients without AIDS or ARC, 3 were lost to follow-up and 23 did not develop AIDS or ARC. Six of these 26 had abnormal ratios. Of the 21 patients who did not develop AIDS or ARC and who were tested for HTLV antibodies, 2 were lost to follow-up. Seven of 21 were seropositive and 2/21 were both seropositive and had a low ratio. One of these 2 seropositive patients with low ratios also had lymphadenopathy, but he was lost to follow-up. The other had no adenopathy and remained well until her death from trauma a year later. This study found two populations with very different risks. Six of 13 hospitalized parenteral drug users and only 1 of 20 healthy outpatients developed AIDS or ARC.

Three-year incidence of AIDS in five cohorts of HTLV-III-infected risk group members

The incidence of the acquired immune deficiency syndrome (AIDS) among persons infected with human T-lymphotropic virus type III (HTLV-III) was evaluated prospectively among 725 persons who were at high risk of AIDS and had enrolled before October 1982 in cohort studies of homosexual men, parenteral drug users, and hemophiliacs. A total of 276 (38.1 percent) of the subjects were either HTLV-III seropositive at enrollment or developed HTLV-III antibodies subsequently. AIDS had developed in 28 (10.1 percent) of the seropositive subjects before August 1985. By actuarial survival calculations, the 3-year incidence of AIDS among all HTLV-III seropositive subjects was 34.2 percent in the cohort of homosexual men in Manhattan, New York, and 14.9 percent (range 8.0 to 17.2 percent) in the four other cohorts. Out of 117 subjects followed for a mean of 31 months after documented seroconversion, five (all hemophiliacs) developed AIDS 28 to 62 months after the estimated date of seroconversion, supporting the hypothesis that there is a long latency between acquisition of viral infection and the development of clinical AIDS. This long latency could account for the significantly higher AIDS incidence in the New York cohort compared with other cohorts if the virus entered the New York homosexual population before it entered the populations from which the other cohorts were drawn. However, risk of AIDS development in different populations may also depend on the presence of as yet unidentified cofactors.