HIV-associated respiratory diseases

Methicillin-Resistant Coagulase-Negative Staphylococci Carriage is a Protective Factor of Methicillin-Resistant Staphylococcus Aureus Nasal Colonization in HIV-Infected Patients: A Cross-Sectional Study

Background

Methicillin-resistant coagulase-negative Staphylococci (MRCoNS) is regarded as the repository of mecA gene for methicillin-resistant Staphylococcus aureus (MRSA) and may develop methicillin-susceptible Staphylococcus aureus (MSSA) to MRSA. Therefore, we aimed to explore whether MRCoNS carriage is a risk factor of MRSA colonization. Phenotypic characteristics were performed to further assess the associations between MRSA and MRCoNS.

Methods

This cross-sectional study was conducted in Guangzhou, China. Participants completed a questionnaire and provided a nasal swab for further analysis. The risk factors of MRSA colonization were analyzed using nonconditional logistic regression models. The phenotypic characteristics between MRSA and MRCoNS were compared by Chi-square test.

Results

Among the 1001 HIV-infected patients, a total of 119 (11.89%) participants were positive for MRSA, and 34.45% (41/119) of all MRSA carriers were positive for MRCoNS. We found MRCoNS carriage was a protective factor of MRSA colonization (adjusted odds ratio = 0.59, 95% confidence interval: 0.38–0.91). A significant difference in the proportions of antibiotic resistance between MRSA and MRCoNS isolates was found except for penicillin, clindamycin, tetracycline, and teicoplanin. The main STs and CC types of MRSA isolates in this population were ST188 (15.1%) and CC59 (17.6%), respectively.

Conclusions

HIV-infected patients remain a highly vulnerable population for MRSA colonization. Though who carried MRCoNS is less likely to have MRSA colonization, similarity of some antibiotic resistance between MRSA and MRCoNS was found in this study. Regular surveillance on the colonization and antibiotic patterns of MRSA and MRCoNS is still necessary.

Atypical bacterial pneumonia in the HIV-infected population

Human immunodeficiency virus (HIV)-infected individuals are more susceptible to respiratory tract infections by other infectious agents (viruses, bacteria, parasites, and fungi) as their disease progresses to acquired immunodeficiency syndrome. Despite effective antiretroviral therapy, bacterial pneumonia (the most frequently occurring HIV-associated pulmonary illness) remains a common cause of morbidity and mortality in the HIV-infected population. Over the last few decades, studies have looked at the role of atypical bacterial pneumonia (i.e. pneumonia that causes an atypical clinical presentation or responds differently to typical therapeutics) in association with HIV infection. Due to the lack of available diagnostic strategies, the lack of consideration, and the declining immunity of the patient, HIV co-infections with atypical bacteria are currently believed to be underreported. Thus, following an extensive database search, this review aimed to highlight the current knowledge and gaps regarding atypical bacterial pneumonia in HIV. The authors discuss the prevalence of Chlamydophila pneumoniae, Mycoplasma pneumoniae, Coxiella burnetii, Legionella species and others in the HIV-infected population as well as their clinical presentation, methods of detection, and treatment. Further studies looking at the role of these microbes in association with HIV are required. Increased knowledge of these atypical bacteria will lead to a more rapid diagnosis of these infections, resulting in an improved quality of life for the HIV-infected population.

Changes in the etiology, incidence and prognosis of acute lower respiratory track infections in human immunodeficiency virus patients

AIM

To describe the incidence, the changes in the etiology and the prognosis of lower respiratory tract infection (LRTI) in HIV infected patients, presenting by the first time to the Emergency Department (ED), during years 2000-2010.

STUDY DESIGN

Prospective collection of data.

METHODS

Data were collected on the first visit of HIV-infected patients at our ED due to a LRTI, (defined according to the criteria of the European Respiratory Society), between 1/1/2000 and 31/12/2010. A series of epidemiological and laboratory variables as well as the need for admission to the intensive care unit (ICU). LRTI etiology were also collected. The influence ofthe mentioned variables on 30-day mortality were analyzed.

RESULTS

One hundred thirty one patients were included. LRTI represented 27% of visits to the ED by HIV-infected patients. Mean age was 39±9 years. 72% of patients were males. 18% required admission to the ICU. The most frequent LRTI was pneumonia by P. jiroveci in 35 cases, bacterial penumonia in 27 and pulmonary tuberculosis in 20. LRTI incidence gradually reduced significantly over time from 6.13 × 1000 patients/year in year 2000 to 0.23 × 1000 patients/year in 2010 (p<0.05). Overall mortality was 14%. Logistic regression analysis showed that admission to ICU (p<0.004) and viral load (p<0.029) were independent variables predicting mortality.

CONCLUSION

LRTI is a pathology with a decreasing incidence, probably related to the widespread utilization increased of HAART regimens. lts etiology has also been changing, but with a non negligible mortality, mostly when ICU admission was required.

High prevalence of malignancy in HIV-positive patients with mediastinal lymphadenopathy: a study in the era of antiretroviral therapy

Background and objective

Mediastinal lymphadenopathy (MLN) in human immunodeficiency virus (HIV) infection has a wide spectrum of aetiologies with different prognoses and treatments. The decision to pursue a histopathological diagnosis represents a clinical challenge as patients present with non-specific symptoms. This study aimed to determine the aetiology and predictive factors of MLN in a cohort of HIV-infected patients in the combination antiretroviral therapy (cART) era.

Methods

Single-centre retrospective cohort study of 217 consecutive HIV-infected patients who underwent computed tomography (CT) of the chest between January 2004 and December 2009. Fifty-two patients were identified to have MLN (>10 mm in short axis). CT images were re-reviewed by an independent radiologist blinded to the clinical information. Final diagnoses of MLN were obtained from clinical records. Multivariate analysis was performed to identify predictors of aetiology of MLN.

Results

Seventeen patients (33%) had a diagnosis of malignancy. Consolidation on CT was associated with a reduced likelihood of malignancy odds ratio (OR) 0.03 (95% confidence interval 0.002–0.422), and larger lymph nodes were associated with an increase in the odds of malignancy (OR 2.89; 95% confidence interval 1.24–6.71). CD4 count was found not to be a predictor of aetiology of MLN.

Conclusions

In the era of combination cART, opportunistic infections and malignancy remain to be the frequent causes of MLN in HIV-positive patients, but the prevalence of non-HIV related malignancy has increased compared with previous studies. Although certain findings are predictors of non-malignant disease, pathological diagnosis of MLN in HIV-positive patients should be pursued whenever possible.

Other HIV-associated pneumonias

The incidence, mortality, and epidemiology of human immunodeficiency virus (HIV)-associated pulmonary infections have changed as a result of effective antiretroviral and prophylaxis antimicrobial therapy. The clinical presentation, radiographic abnormalities, and treatment of pneumonia from various uncommon pathogens in patients with AIDS can be different from those in immunocompetent patients. Advances in invasive and noninvasive testing and molecular biological techniques have improved the diagnosis and prognosis of pulmonary infections in patients infected with HIV. This review focuses on pulmonary infections from nontuberculosis mycobacteria, cytomegalovirus, fungi (aspergillosis, cryptococcosis, endemic fungi), and parasites (toxoplasmosis), and uncommon bacterial pneumonia (nocardiosis, rhodococcosis) in these patients.

[Aetiology of AFB negative pneumonias in hospitalized HIV patients in Dakar]

A prospective study was carried out in two tertiary hospitals in Dakar to determine the main causes of sputum acid-fast bacillus (AFB) smear-negative pneumonia in HIV-infected patients. All clinical and microbiological records were reviewed by experts. Seventy patients were finally enrolled. Most of them were hospitalized at an advanced stage of AIDS. The median CD4 cell count was 62/mm(3) and the median body mass index (BMC) was 18 kg/m(2). Thirty-one patients (44 %) were known as seropositive for HIV infection prior to admission. Radiological opacities were localized in 70 % of patients and diffuse in 21 %. Fiberoptic bronchoscopy was performed in 50 patients (71 %). A definite or probable diagnosis was obtained in 55 patients (79 %). Bacterial pneumonia (usually due to Enterobacteriaceae and Pseudomonas aeruginosa), tuberculosis, Pneumocystis pneumoniae and other causes (Kaposi's sarcoma, atypical mycobacteria) were diagnosed in 67 %, 24 %, 5 %, and 13 % of these patients respectively. In conclusion, pneumonia of bacterial origin and tuberculosis can be incriminated in the majority of cases of AFB negative pneumonia observed in HIV patients in Dakar.

Non-infective pulmonary disease in HIV-positive children

It is estimated that over 90% of children infected with human immunodeficiency virus (HIV) live in the developing world and particularly in sub-Saharan Africa. Pulmonary disease is the most common clinical feature of acquired immunodeficiency syndrome (AIDS) in infants and children causing the most morbidity and mortality, and is the primary cause of death in 50% of cases. Children with lung disease are surviving progressively longer because of earlier diagnosis and antiretroviral treatment and, therefore, thoracic manifestations have continued to change and unexpected complications are being encountered. It has been reported that 33% of HIV-positive children have chronic changes on chest radiographs by the age of 4 years. Lymphocytic interstitial pneumonitis is common in the paediatric HIV population and is responsible for 30-40% of pulmonary disease. HIV-positive children also have a higher incidence of pulmonary malignancies, including lymphoma and pulmonary Kaposi sarcoma. Immune reconstitution inflammatory syndrome is seen after highly active antiretroviral treatment. Complications of pulmonary infections, aspiration and rarely interstitial pneumonitis are also seen. This review focuses on the imaging findings of non-infective chronic pulmonary disease.

[Pneumothorax in human immunodeficiency virus infected patients]

INTRODUCTION

The respiratory system still continues to be a common place which deteriorates in HIV patients. Among the signs and symptoms, is the occurrence of a pneumothorax due to trauma and infections and is a cause of aggravation for these patients. The present study attempts to identify and characterise the behaviour of a group of variables in HIV patients with this complication.

MATERIAL AND METHOD

An observational, descriptive case series study was carried out. The desired variables were obtained from clinical records.

RESULTS

Of the total number, 91.67% were males, and the mean age was 32.17 years. The main causes of pneumothorax were infections, particularly due to Pneumocystis jirovecii and deep venous catheterisation. A persistent statistically significant air leak was present in 33.3% of patients and two cases of pleural sepsis. Four patients died, all with acute respiratory failure and bacterial bronchopneumonia.

CONCLUSIONS

The majority were males in the third decade of life, AIDS patients. The main causes of the pneumothorax were infections and catheterisation of the subclavian vein. Immunodepression played a significant prognostic role in the progression and outcome of the patient. Minimum pleurotomy continues to be the first treatment option in these patients, due to their precarious general state which contraindicates a major procedure. The most frequent complication was the persistent air leak, being a significant indicator of a poor prognosis in the progress of these patients. Causes of death such as acute respiratory failure and bilateral bronchopneumonia prevailed.

Aetiology of cavitary lung lesions in patients with HIV infection

BACKGROUND

Although many studies have been carried out on pulmonary diseases in HIV-infected patients, studies specifically investigating the aetiologies of cavitary lung lesions are rare.

METHODS

HIV-infected patients enrolled in a cohort study who presented with cavitary lung lesions by radiography were identified between June 1994 and March 2008. Medical records and radiological and microbiological data for these patients were retrospectively reviewed using a standardized case collection form.

RESULTS

During the 14-year study period, 73 episodes of cavitary lung lesions were diagnosed in 66 of 1790 (3.7%) HIV-infected patients. At the diagnosis of cavitary lung lesions, the median CD4 count was 25 cells/microL (range 1-575 cells/microL). Eighty-one pathogens were considered causative, with fungi being the most common aetiology (42.0%), followed by bacteria (29.6%) and mycobacteria (25.9%). Of the fungal pneumonias, 19 (55.9%) were caused by Penicillium marneffei, 11 (32.4%) by Cryptococcus neoformans, two (5.9%) by Pneumocystis jirovecii, and two (5.9%) by Aspergillus species. During the study period, 11 of 205 patients (5.4%) who were diagnosed as having tuberculosis presented with cavitary lung lesions, compared with 19 of 36 patients (52.8%) with penicilliosis and 11 of 64 patients (17.2%) with cryptococcosis (P<0.0001). The median CD4 count of patients with cavitary lung lesions resulting from tuberculosis (115 cells/microL) was significantly higher than that of patients with cavitary lung lesions resulting from penicilliosis (4 cells/microL) and cryptococcosis (29.5 cells/microL).

CONCLUSIONS

Our findings suggest that invasive infections attributable to endemic fungi were the leading cause of cavitary lung lesions among patients in the late stage of HIV infection, and were more common than infections attributable to bacteria and mycobacteria.

Clinical features and etiology of pneumonia in acid-fast bacillus sputum smear-negative HIV-infected patients hospitalized in Asia and Africa

OBJECTIVES

To determine the main causes of acid-fast bacillus sputum smear-negative pneumonia in Asian and African HIV-infected patients

DESIGN AND SETTING

A prospective multicenter study (ANRS 1260) of consecutive hospitalized patients in tertiary hospitals in Phnom Penh, Ho Chi Minh City, Bangui and Dakar.

INTERVENTION

Use of the same clinical, radiological and biological methods at the four sites; regular quality controls of participating laboratories; final review of medical records by experts. Similar criteria used to establish diagnoses.

RESULTS

In all 462 patients were enrolled, 291 in Asia and 171 in Africa. The median CD4 cell count was 25 cells/microl. Radiological opacities were diffuse in 42% of patients and localized in 45%. Fiberoptic bronchoscopy was performed in 354 patients, at similar rates in the four sites. A definite and/or probable diagnosis was obtained in 375 patients (81%). Pneumocystis jiroveci pneumonia, bacterial pneumonia, AFB sputum smear-negative tuberculosis and other infections (fungi, parasites, atypical mycobacteria) were diagnosed in respectively 47, 30, 17 and 12% of Asian patients and 3, 48, 26 and 5% of African patients.

CONCLUSION

In South-east Asia, acid-fast bacillus smear-negative pneumonia is caused by a wide variety of pathogens. When possible, fiberoptic bronchoscopy must be performed rapidly if clinical data are not highly suggestive of bacterial pneumonia, Pneumocystis jiroveci pneumonia or tuberculosis. In contrast, in Africa, bacterial pneumonia and tuberculosis are responsible for the large majority of cases. Fiberoptic bronchoscopy should be restricted to patients with clinical and/or radiological findings not suggestive of bacterial pneumonia or tuberculosis, antibiotic failure, and three consecutive negative sputum smears.

[Human immunodeficiency virus-infected patients with community-acquired pneumonia: implication of respiratory viruses]

El papel de los virus respiratorios (VR) en el paciente infectado por el virus de la inmunodeficiencia humana (VIH) que presenta una neumonía adquirida en la comunidad (NAC) es poco conocido.

El objetivo de este estudio es determinar la implicación de los VR en la NAC del paciente VIH mediante un estudio prospectivo de 3 años en un hospital terciario.

Se diagnosticaron 67 neumonías, y se detectaron VR en 14, en 8 como únicos microorganismos aislados. Los pacientes con NAC y VR evolucionaron de forma similar a los pacientes con NAC.

La infección por VR en pacientes VIH y NAC no supuso un factor de mal pronóstico evolutivo.

[Infectious pulmonary complications in HIV-infected patients in the high by active antiretroviral therapy era in Spain]

Pulmonary complications in HIV-infected patients are at present a first-rate problem. They are the main cause of hospital admission of these patients in our country. Most HIV-patients have a pulmonary complication during the evolution of the infection. The main etiologic diagnosis is bacterial pneumonia, especially pneumococcal pneumonia; the second most frequent cause is Pneumocystis jiroveci (previously named P. carinii) pneumonia and the third cause is mycobacteriosis, particularly Mycobacterium tuberculosis. From early studies, important changes in the epidemiology of HIV-related pulmonary complications have occurred. General prescription of P. jiroveci primary prophylaxis is probably one of the main causes, and, more recently, the use of highly active antiretroviral therapy may also be an underlying explanation. In this review, epidemiology, diagnosis and outcome of HIV-related pulmonary complications in our country are update.

Preserved painting creativity in an artist with Alzheimer's disease

Creativity in any of its forms, either visual, musical, literary or performing arts, may be conceived as a cognitive capability, and should be actively explored in relation to patients with Alzheimer disease and related dementias, even when other cognitive functions do not allow us to even communicate with them. We are reporting the case of a talented artist with the diagnosis of early onset Alzheimer disease (AD) with progressive cognitive impairment but with preservation of her creativity until very late in the course of the disease.

Neither neutrophils nor reactive oxygen species contribute to tissue damage during Pneumocystis pneumonia in mice

Neutrophils are implicated in the damage of lung tissue in many disease states, including infectious diseases and environmental insults. These effects may be due to oxidative or nonoxidative functions of the neutrophil or both. We examined the role of neutrophils in pulmonary damage during infection with the opportunistic fungal pathogen Pneumocystis sp. in four mouse models of neutrophil dysfunction. These were (i) a knockout of the gp91(phox) component of NADPH oxidase, in which reactive oxygen species (ROS) production is greatly reduced; (ii) a double knockout of gp91(phox) and inducible nitric oxide synthase, in which ROS and nitric oxide production is greatly decreased; (iii) a knockout of the chemokine receptor CXCR2, in which accumulation of intra-alveolar neutrophils is severely diminished; and (iv) antibody depletion of circulating neutrophils in wild-type mice with the monoclonal antibody RB6. Surprisingly, in each case, indicators of pulmonary damage (respiratory rates, arterial oxygen partial pressures, and intra-alveolar albumin concentrations) were the same in knockout mice and comparable wild-type mice. Therefore, whereas neutrophils are a valid correlative marker of lung damage during Pneumocystis infection, neither neutrophils nor ROS appear to be the causative agent of tissue damage. We also show that there is no difference in Pneumocystis burdens between wild-type and knockout mice, which supports the idea that neutrophils do not have a major role in the clearance of this organism.

Imaging of opportunistic fungal infections in immunocompromised patient

Opportunistic fungal infection is a common cause of serious morbidity and mortality in the immunocompromised host. Combination of pattern recognition with knowledge of the clinical setting is the best approach to pulmonary infectious processes. The aim of this article is to assess the chest radiographs and CT imaging features of different opportunistic fungal infections in immunocompromised patients.

Annotation: the savant syndrome

BACKGROUND

Whilst interest has focused on the origin and nature of the savant syndrome for over a century, it is only within the past two decades that empirical group studies have been carried out.

METHODS

The following annotation briefly reviews relevant research and also attempts to address outstanding issues in this research area. Traditionally, savants have been defined as intellectually impaired individuals who nevertheless display exceptional skills within specific domains. However, within the extant literature, cases of savants with developmental and other clinical disorders, but with average intellectual functioning, are increasingly reported.

RESULTS

We thus propose that focus should diverge away from IQ scores to encompass discrepancies between functional impairments and unexpected skills. It has long been observed that savant skills are more prevalent in individuals with autism than in those with other disorders. Therefore, in this annotation we seek to explore the parameters of the savant syndrome by considering these skills within the context of neuropsychological accounts of autism. A striking finding amongst those with savant skills, but without the diagnosis of autism, is the presence of cognitive features and behavioural traits associated with the disorder.

CONCLUSIONS

We thus conclude that autism (or autistic traits) and savant skills are inextricably linked and we should therefore look to autism in our quest to solve the puzzle of the savant syndrome.

Absence of the macrophage mannose receptor in mice does not increase susceptibility to Pneumocystis carinii infection in vivo

Host defense against the opportunistic pathogen Pneumocystis carinii requires functional interactions of many cell types. Alveolar macrophages are presumed to be a vital host cell in the clearance of P. carinii, and the mechanisms of this interaction have come under scrutiny. The macrophage mannose receptor is believed to play an important role as a receptor involved in the binding and phagocytosis of P. carinii. Although there is in vitro evidence for this interaction, the in vivo role of this receptor in P. carinii clearance in unclear. Using a mouse model in which the mannose receptor has been deleted, we found that the absence of this receptor is not sufficient to allow infection by P. carinii in otherwise immunocompetent mice. Furthermore, when mice were rendered susceptible to P. carinii by CD4(+) depletion, mannose receptor knockout mice (MR-KO) had pathogen loads equal to those of wild-type mice. However, the MR-KO mice exhibited a greater influx of phagocytes into the alveoli during infection. This was accompanied by increased pulmonary pathology in the MR-KO mice, as well as greater accumulation of glycoproteins in the alveoli (glycoproteins, including harmful hydrolytic enzymes, are normally cleared by the mannose receptor). We also found that the surface expression of the mannose receptor is not downregulated during P. carinii infection in wild-type mice. Our findings suggest that while the macrophage mannose receptor may be important in the recognition of P. carinii, in vivo, this mechanism may be redundant, and the absence of this receptor may be compensated for.

Treatment modalities and outcome of the renal victims of the Marmara earthquake

BACKGROUND/AIMS

Treatment of renal problems during natural catastrophes is highly complicated both for medical and logistic reasons. The therapeutic interventions applied to and the outcome of 639 victims with acute renal problems during the catastrophic Marmara earthquake have been the subject of this study.

METHODS

Questionnaires regarding information about 63 clinical and laboratory variables were sent to 35 reference hospitals that treated the victims. Information considering therapeutic interventions and outcome obtained through these questionnaires was submitted to analysis.

RESULTS

At least one form of renal replacement therapy was administered to 477 (74.6%) of the 639 victims. Of these, 437, 11, and 4 were treated solely by intermittent hemodialysis, continuous renal replacement therapy, and peritoneal dialysis, respectively; 25 victims needed more than one dialysis modality. In total, 5,137 hemodialysis sessions were performed. Also, 2,981, 2,837 and 2,594 units of blood, fresh frozen plasma, and human albumin were administered, respectively. Transfusion of these products was usually associated with higher rates of dialysis needs and mortality. Ninety-seven patients (15.2%) died. The mortality rate of dialyzed victims was higher as compared to nondialyzed ones (17.2 vs. 9.3%, p = 0.015).

CONCLUSIONS

Massive amounts of dialysis treatment as well as blood and blood product transfusions can be necessary in the treatment of catastrophic earthquake victims with nephrological problems. Despite the potential risk of a high mortality, in the case of appropriate and energetic medical interventions, reasonable final outcomes can be achieved.

Causes of death among HIV-infected patients in the era of highly active antiretroviral therapy, Bordeaux, France, 1998-1999

OBJECTIVES

To describe the causes of death in HIV-infected patients in the era of highly active antiretroviral therapy (HAART).

METHOD

A retrospective survey conducted in Bordeaux, France. Medical records of all deaths that had occurred in 1998 and 1999 amongst patients followed within the Aquitaine cohort were reviewed by the same physician. Immediate and underlying causes of death were described, taking into account the morbidity at the time of death.

RESULTS

Sixty-six deaths occurred in 1998, and 41 in 1999. Sixty-seven per cent of deceased patients were male. Median age at time of death was 43 years (range 25-71), median CD4 was 162 cells/microL (0-957); 28% of patients had a CD4 count > 200 cells/microL and 7% plasma viral load < 500 HIV-RNA copies/mL. Amongst morbidity present at the time of death, there were 23 bacterial infections, 16 non-Hodgkin's lymphomas, 16 cirrhoses, 15 non HIV-related malignancies, 13 central nervous system diseases and 10 myocardiopathies. The main immediate causes of death were: multiple organ failure (21%), coma (18%), septic shock (15%) and acute respiratory failure (14%). Underlying causes of death were AIDS-defining events (48%), non AIDS HIV-related infection (3%), hepatitis B- or C-associated cirrhosis (14%), non HIV-related malignancies (11%), cardiovascular events (10%), suicide and overdose (6%), treatment-related fatalities (4%), injury (2%) and unknown (2%). Patients dying from AIDS-related events were more often female, had a lower CD4 count, a higher level of HIV-RNA, a shorter history of HIV infection and were less often coinfected with hepatitis B and C viruses than those dying from other underlying causes.

CONCLUSIONS

AIDS-related events are no longer the major causes of death of HIV-infected patients in the era of HAART. This evolving mortality pattern justifies an adaptation of both the epidemiological surveillance and the clinical monitoring of HIV-infected patients.

Pulmonary infiltrates in immunosuppressed patients: analysis of a diagnostic protocol

A diagnostic protocol was started to study the etiology of pulmonary infiltrates in immunosuppressed patients. The diagnostic yields of the different techniques were analyzed, with special emphasis on the importance of the sample quality and the role of rapid techniques in the diagnostic strategy. In total, 241 patients with newly developed pulmonary infiltrates within a period of 19 months were included. Noninvasive or invasive evaluation was performed according to the characteristics of the infiltrates. Diagnosis was achieved in 202 patients (84%); 173 patients (72%) had pneumonia, and specific etiologic agents were found in 114 (66%). Bronchoaspirate and bronchoalveolar lavage showed the highest yields, either on global analysis (23 of 35 specimens [66%] and 70 of 134 specimens [52%], respectively) or on analysis of each type of pneumonia. A tendency toward better results with optimal-quality samples was observed, and a statistically significant difference was found in sputum bacterial culture. Rapid diagnostic tests yielded results in 71 of 114 (62.2%) diagnoses of etiological pneumonia.

Pulmonary infiltrates in HIV-infected patients in the highly active antiretroviral therapy era in Spain

OBJECTIVE

To study the incidence, etiology, and outcome of pulmonary infiltrates (PIs) in HIV-infected patients and to evaluate the yield of diagnostic procedures.

DESIGN

Prospective observational study of consecutive hospital admissions.

SETTING

Tertiary hospital.

PATIENTS

HIV-infected patients with new-onset radiologic PIs from April 1998 to March 1999.

METHODS

The study protocol included chest radiography, blood and sputum cultures, serologic testing for "atypical" causes of pneumonia, testing for Legionella urinary antigen, testing for cytomegalovirus antigenemia, and bronchoscopy in case of diffuse or progressive PIs.

RESULTS

One hundred two episodes in 92 patients were recorded. The incidence of PIs was 18 episodes per 100 hospital admission-years (95% confidence interval [CI]: 15-21). An etiologic diagnosis was achieved in 62 cases (61%). Bacterial pneumonia (BP), Pneumocystis carinii pneumonia (PCP), and mycobacteriosis were the main diagnoses. The incidences of BP and mycobacteriosis were not statistically different in highly active antiretroviral therapy (HAART) versus non-HAART patients. The incidence of PCP was lower in those receiving HAART (p =.011), however. Nine patients died (10%). Independent factors associated with higher mortality were mechanical ventilation (odds ratio [OR] = 83; CI: 4.2-1,682), age >50 years (OR = 23; CI: 2-283), and not having an etiologic diagnosis (OR = 22; CI: 1.6-293).

CONCLUSIONS

Pulmonary infiltrates are still a frequent cause of hospital admission in the HAART era, and BP is the main etiology. There was no difference in the rate of BP and mycobacteriosis in HAART and non-HAART patients. Not having an etiologic diagnosis is an independent factor associated with mortality.

Pulmonary infiltrates in HIV-infected patients in the highly active antiretroviral therapy era in Spain

OBJECTIVE

To study the incidence, etiology, and outcome of pulmonary infiltrates (PIs) in HIV-infected patients and to evaluate the yield of diagnostic procedures.

DESIGN

Prospective observational study of consecutive hospital admissions.

SETTING

Tertiary hospital.

PATIENTS

HIV-infected patients with new-onset radiologic PIs from April 1998 to March 1999.

METHODS

The study protocol included chest radiography, blood and sputum cultures, serologic testing for "atypical" causes of pneumonia, testing for Legionella urinary antigen, testing for cytomegalovirus antigenemia, and bronchoscopy in case of diffuse or progressive PIs.

RESULTS

One hundred two episodes in 92 patients were recorded. The incidence of PIs was 18 episodes per 100 hospital admission-years (95% confidence interval [CI]: 15-21). An etiologic diagnosis was achieved in 62 cases (61%). Bacterial pneumonia (BP), Pneumocystis carinii pneumonia (PCP), and mycobacteriosis were the main diagnoses. The incidences of BP and mycobacteriosis were not statistically different in highly active antiretroviral therapy (HAART) versus non-HAART patients. The incidence of PCP was lower in those receiving HAART (p =.011), however. Nine patients died (10%). Independent factors associated with higher mortality were mechanical ventilation (odds ratio [OR] = 83; CI: 4.2-1,682), age >50 years (OR = 23; CI: 2-283), and not having an etiologic diagnosis (OR = 22; CI: 1.6-293).

CONCLUSIONS

Pulmonary infiltrates are still a frequent cause of hospital admission in the HAART era, and BP is the main etiology. There was no difference in the rate of BP and mycobacteriosis in HAART and non-HAART patients. Not having an etiologic diagnosis is an independent factor associated with mortality.

Incidence and determinants of bacterial infections in HIV-positive patients receiving anti-Pneumocystis carinii/Toxoplasma gondii primary prophylaxis within a randomized clinical trial

We assessed the incidence and determinants of bacteremia, pneumonia, and sinusitis/otitis in HIV-positive people receiving cotrimoxazole (CTX) or dapsone-pyrimethamine (DP) for primary prophylaxis of Pneumocystis carinii pneumonia (PCP) and toxoplasmic encephalitis (TE) within a randomized clinical trial. In total, 244 patients were randomized: 122 were assigned to CTX and 122 to DP. In the cohort, 22 bacteremia, 63 pneumonia, and 39 sinusitis/otitis cases were observed. Incidence rates of bacteremia, pneumonia, and sinusitis/otitis as well as the 2-year probability of remaining free from any bacterial infection were not significantly different between the two groups. At multivariate analysis, the risks of developing bacteremia and pneumonia were found to be independently increased by the use of a central venous catheter (hazard ratio [HR], 4.48; p <.05 and HR, 4.13; p <.01, respectively) and by hospitalization (HR, 28.82; p <.05 and HR, 10.15; p <.05, respectively). In conclusion, CTX at the dosage employed for primary PCP/TE prophylaxis does not seem to protect against bacterial infections more than second-line DP.

Influence of HIV infection on presentation of Kaposi's sarcoma

We report a retrospective review of 57 patients with endemic Kaposi's sarcoma (EKS) seen between 1981 and 1990 and 40 prospectively diagnosed patients with and without human immunodeficiency virus (HIV) infection seen between 1991 and 1995. In the retrospective study 52 patients were males and five were females. Their ages ranged between 15 and 62 years with a mean of 39 years.Thirty-five (61%) patients had symptoms for more than 1 year. Nodular KS was seen in 75% of the patients. In the prospective study 26 patients had EKS while 14 had AIDS associated KS (AAKS). Among the patients with EKS 24 were males and two were females. The mean duration of symptoms was 20 months. The CD4 count done on nine patients ranged between 900 and 1300 cells/mm3 and there was no mortality within 1 year of presentation. Eleven of the patients with AAKS were males and three were females. Their ages ranged between 22 months and 41 years with a mean of 26. Nine patients had symptoms for less than 6 months. Ten patients had peripheral lymphadenopathy. CD4 counts done on 11 patients ranged between 200 and 800 cells/mm3. Five patients (35%) died within 6 months of presentation. Between 1991 and 1995, 486 patients were seen with HIV infection. Patients with AAKS present with fulminant disease which seemed quickly fatal.

Pulmonary infections in immunocompromised hosts: the importance of correlating the conventional radiologic appearance with the clinical setting

The lung is one of the most frequently involved organs in a variety of complications in the immunocompromised host. Among the pulmonary complications that occur in this kind of patient, infection is the most common and is associated with high morbidity and mortality. Although chest radiography and computed tomography (CT) are essential diagnostic tools, radiologists often have difficulty in establishing the correct diagnosis on the basis of radiologic findings alone. The reasons are that the immunocompromised host is potentially susceptible to infection from many different microorganisms and that radiologic findings are seldom specific for the detection of a particular pathogen. Experience has shown that a particular clinical setting predisposes patients to infection by particular pathogens. The setting comprises (a) the specific epidemiologic or environmental exposure, (b) the type of underlying immune defect, (c) the duration and severity of immune compromise, and (d) the progression rate and pattern of the radiologic abnormality. Correlating the radiologic appearance with the clinical setting can expedite diagnosis and appropriate therapy. In this review, the authors describe the clinical settings that are helpful in choosing the radiologic approach to treatment of the immunocompromised host who presents with suspected pulmonary infection.

Talc granulomatosis. A differential diagnosis of interstitial lung disease in HIV patients

Consumers of adulterated drugs may present with talc-induced interstitial lung disease. A transbronchial biopsy specimen showing granulomas with intracellular talc crystals is necessary to confirm this diagnosis. In patients infected with HIV, such a condition can be indistinguishable at first glance from opportunistic infections or other pulmonary diseases. A case is presented of a seropositive patient whose chest radiographs showed a diffuse interstitial pattern.

Pleural effusions in patients with AIDS

OBJECTIVE

To describe the range of pathology causing pleural effusions in HIV infected patients with acute respiratory episodes and to attempt to identify whether any associated radiological abnormalities enabled aetiological discrimination.

METHODS

Prospective study of chest radiographs of 58 consecutive HIV infected patients with pleural effusion and their microbiological, cytological, and histopathological diagnoses.

RESULTS

A specific diagnosis was made in all cases. Diagnoses were Kaposi's sarcoma, 19 patients; para-pneumonic effusion, 16 patients; tuberculosis, eight patients; Pneumocystis carinii pneumonia, six patients; lymphoma, four patients; pulmonary embolus, two patients; and heart failure, aspergillus/leishmaniasis, and Cryptococcus neoformans, one case each. Most effusions (50/58) were small. Bilateral effusions were commoner in Kaposi's sarcoma (12/19) and lymphoma (3/4) than in para-pneumonic effusion (3/16). Concomitant interstitial parenchymal shadowing did not aid discrimination. A combination of bilateral effusions, focal air space consolidation, intrapulmonary nodules, and/or hilar lymphadenopathy suggests Kaposi's sarcoma. Unilateral effusion with focal air space consolidation suggests para-pneumonic effusion if intrapulmonary nodules are absent: if miliary nodules and/or mediastinal lymphadenopathy are detected, this suggests tuberculosis.

CONCLUSIONS

A wide variety of infectious and malignant conditions cause pleural effusions in HIV infected patients, the most common cause in this group was Kaposi's sarcoma. The presence of additional radiological abnormalities such as focal air space consolidation, intrapulmonary nodules, and mediastinal lymphadenopathy aids aetiological discrimination.

The implications of HIV for the anaesthetist and the intensivist

The acquired immune deficiency syndrome has reached pandemic proportions. Anaesthetists should be aware of the implications of dealing with increasing numbers of both diagnosed and undiagnosed, symptomatic and asymptomatic, human immunodeficiency virus-infected patients in the fields of intensive therapy, operating theatre anaesthesia, obstetrics and pain management. With recent advances, important insights have been gained into the pathogenesis of human immunodeficiency virus. Molecular techniques allow quantification of viral burden, and together with CD4 T-lymphocyte count, prognosis and response to therapy can be evaluated. New drugs and therapeutic regimens have improved prognosis for those who are infected with the virus and vertical transmission of infection from mother to infant can be minimised. Should accidental occupational exposure to the virus occur, a prophylactic regimen of antiretroviral drugs can be administered in an attempt to prevent subsequent human immunodeficiency virus infection.

Blue and breathless

A25-year-old HIV-antibody positive female had been admitted to hospital on 12 occasions with respiratory infections over a 3-year period. Pneumocystis carinii pneumonia (PCP) had been suspected twice but never proven and sputum culture for tuberculosis was repeatedly negative. Her CD4 count was 6/mm3. Treatment had been problematic. Antiretroviral therapy was not tolerated, she reported a rash with cotrimoxazole and nebulized pentamidine provoked severe bronchospasm. During her twelfth hospital admission PCP was suspected despite negative induced sputa. She completed treatment with intravenous pentamidine and corticosteroids followed by oral clindamycin with primaquine. Following discharge dapsone 100 mg thrice weekly was started as secondary prophylaxis. Twelve days later she was readmitted with worsening dyspnoea, fever and vomiting. Inadvertently she had taken 300 mg dapsone daily for 4 days. Physical examination revealed a deeply cyanosed patient. Respiratory rate was 50/minute, heart rate 130/minute, temperature 37.6°C and blood pressure 120/70 mmHg. Chest radiograph showed a diffuse bilateral pneumonia and arterial blood gases breathing air revealed a PaO2 of 8.37 kPa, PCO2 of 3.92 kPa and a calculated oxygen saturation of 93.3%. Haemoglobin concentration was 9.7 g/dl, blood film demonstrated 6% reticulocytes with Heinz body inclusions and the methaemoglobin level was 30%.

Activated charcoal, high flow oxygen and 2 mg/kg intravenous methylene blue was commenced. Piperacillin-tazobactam and gentamicin were added for presumptive severe hospitalacquired pneumonia and she was transfused one unit of blood. PaO2 improved to 31.8 kPa on 100% oxygen but she remained deeply cyanosed. The methaemoglobin level 12 hours later was 34% so a further bolus of methylene blue followed by an infusion (0.1 mg/kg/hour) was administered. During the administration of methylene blue pulse oximetry showed a dramatic fall in oxygen ‘saturation’. Twenty-four hours later methaemoglobin level was 1.7% and by day three <1% with an oxygen saturation of 88% measured by pulse oximetry. Following discontinuation of methylene blue on day five an arterial blood sample showed PaO2 was 11 kPa on air with a calculated oxygen saturation of 96%. Repeat chest X-ray showed a right middle-lobe bulla with partial clearing of the infiltrates. She was discharged on day 12 at her own request but died 3 weeks later in hospital following admission with a pneumothorax and severe pneumonia. Autopsy was refused.

The lung in the immunocompromised patient. Infectious complications part 2

Pulmonary infections decisively contribute to morbidity and mortality in immunocompromised patients. Bacterial, mycobacterial and infections with Pneumocystis carinii have been reviewed in an article in the last issue of Respiration. In this review, viral and fungal pulmonary infections are discussed in HIV-positive patients and in patients treated with high-dose chemotherapy, stem cell or solid-organ transplantation.

Clinical aspects of Pneumocystis carinii pneumonia in HIV-infected patients: 1997

In 1997 in Europe P. carinii pneumonia is largely a disease of individuals who are either unaware of their HIV serostatus or who decline prophylaxis despite knowing they are HIV positive. Although fibre optic bronchoscopy and bronchoalveolar lavage is the diagnostic 'gold standard' polymerase chain reaction (PCR) amplification applied to oropharyngeal washings appears to have a moderate to high diagnostic yield. With further development this may provide a truly non-invasive diagnostic test. There is a clear need for an inherently more effective regimen for prophylaxis both for those with adverse reactions (ADR) to co-trimoxazole and also for those with low CD4 lymphocyte counts. Ideally, new drug regimens should afford cross-prophylaxis against bacterial, mycobacterial and other fungal infections. Given the high frequency of ADR to co-trimoxazole when used as treatment for P. carinii pneumonia, there is also a need for effective, non-toxic alternative therapies.

Persistent and chronic lung disease in HIV-1 infected and uninfected African children

OBJECTIVE

The causes of persistent lung disease (PLD) and chronic lung disease (CLD) are unknown in HIV-infected children in developing countries. We describe the causes and course of PLD and CLD in HIV-infected and uninfected children.

METHOD

Of 194 children with lung disease persisting for at least 1 month who were seen at the paediatric respiratory clinic over a 2-year period, 42 underwent invasive investigations after failed initial management over 3 months. PLD was defined as the presence of clinical and radiological features of lung disease for more than 1 month, and CLD as these features for more than 3 months.

RESULTS

One hundred and thirty-eight (71%) of the 194 children with PLD were HIV-infected, 52 (27%) were not infected and four (2%) were of undetermined HIV status. Forty-eight per cent of the HIV-infected children and 52% of the HIV-uninfected children responded to initial treatment over 3 months; the presumptive diagnoses in these were tuberculosis, interstitial pneumonitis, bronchiectasis and post-ventilation lung syndrome. Of the 28 HIV-infected children with CLD who underwent invasive investigations 16 (57%) had lymphoid interstitial pneumonitis, eight (29%) had tuberculosis and four (14%) had non-specific interstitial pneumonitis. Of the 14 HIV-uninfected children with CLD who had invasive testing there were four cases (29%) each of tuberculosis and interstitial pneumonitis, three (22%) cases of bronchiectasis and one case of each of extrinsic allergic alveolitis, crytogenic fibrosing alveolitis and non-Hodgkin's lymphoma.

CONCLUSION

This is the first set of data on the causes of CLD in HIV-infected children in a developing country. Every effort should be made to identify the infectious agent, whether M. tuberculosis or a secondary bacterial infection in LIP, in order to treat most appropriately these children with lung disease.

Pulmonary aspergillosis and invasive disease in AIDS: review of 342 cases

Aspergillosis is an infrequent but commonly fatal infection among HIV-infected individuals. We review 342 cases of pulmonary Aspergillus infection that have been reported among HIV-infected patients, with a focus on invasive disease. Invasive pulmonary aspergillosis usually occurs among patients with <50 CD4 cells/mm3. Major predisposing conditions include neutropenia and steroid treatment. Fever, cough, and dyspnea are each present in >60% of the cases. BAL is often suggestive, but biopsy specimens are necessary for definite diagnosis. Amphotericin B is the mainstay of treatment and mortality is > 80%. Avoiding neutropenia and judicious use of steroids may be helpful in prevention. Aggressive diagnostic approach, early initiation of treatment, adequate dosing of antifungals, and close follow-up may improve the currently dismal prognosis.

The role of the Th-1 to Th-2 shift of the cytokine profiles of CD4 helper cells in the pathogenesis of autoimmune and hypercatabolic diseases

The task of the immune system is the continuous elimination of endogenous cellular debris and the elimination, when necessary, of exogenous structures. It therefore seems useful and practical to add to the paradigms 'self' and 'not self' the term 'altered self'. The concept of stress, introduced by W. B. Cannon and H. Selye in the 1930s, covers the wide range of aggressive environmental influences which for their part result in a uniform shift of the metabolism in the direction of catabolism. This results from the activation of the neuroendocrine stress axis, hypothalamus-pituitary-adrenals, and causes an increased release of catecholamines and glucocorticoids. These latter substances limit life-threatening acute-phase reactions by endogenous inflammation mediators. The purpose of the shift of the cytokine profiles of the CD4 lymphocytes from Th-1 to Th-2 is, with the return of a raised cortisol level to normal values, to temporarily take over the anti-inflammatory functions of the cortisol. A sustained Th-2 shift is an expression of a persistent hypercortisolism in autoimmune states. The suppression of the anti-inflammatory effects of cortisol as a result of states of excessive stress leads to hypercatabolic diseases such as AIDS, sepsis and toxic shock syndrome and protein calorie malnutrition (NAIDS). In the prevention and treatment of AIDS and NAIDS, besides the elimination of the causes of stress, the prophylactic and therapeutic efforts are based mainly on the activation of the mesenchymal production of anabolic matrix components, mainly glycosaminoglycans, and the neutralization of O2 and NO radicals and inflammation mediators from macrophages by polyanions and polyphenols. In our opinion, in sepsis and toxic shock syndromes, lasting reduction of the mortality rates for these diseases is best achieved through the early administration of high intravenous doses of gammaglobulins.

Pre-AIDS mortality in HIV-infected individuals in England, Wales and Northern Ireland, 1982-1996

OBJECTIVE

To assess pre-AIDS mortality in HIV-infected patients in England, Wales and Northern Ireland during the period 1982-1996.

DESIGN

Surveillance data on pre-AIDS and AIDS deaths reported to the PHLS-AIDS Centre were analysed.

METHODS

Pre-AIDS mortality was estimated as the proportion of pre-AIDS deaths among all deaths in HIV-infected people. Trends over time in the number of pre-AIDS and AIDS deaths were compared using Poisson regression with logarithmic link. Causes of pre-AIDS deaths were recorded. Comparisons were made between the pre-AIDS and the AIDS death groups by logistic regression for: age, location of residence at death, year of death and risk exposure.

RESULTS

Four-hundred and sixty-eight pre-AIDS deaths and 8574 AIDS deaths were identified. Pre-AIDS mortality accounted for 5.0% of HIV-related deaths. Trends over time in the number of pre-AIDS and AIDS deaths were not significantly different (P=0.11). Reported causes of pre-AIDS death included pneumonia (92), liver disease (62), septicaemia (51), malignancies (49), suicide (45), cardiopulmonary causes (46), haemorrhage (42), overdose (24) and accidental causes (24). Factors positively associated with pre-AIDS death were injecting drug use, haemophilia and blood transfusion, residence outside the Thames regions, and death at an older age.

CONCLUSIONS

Pre-AIDS mortality represents a substantial proportion of HIV mortality, particularly where injecting drug use is a frequent route of HIV transmission.

Pain as a complication of HIV disease

Pain as a symptom is common to many pathologic conditions. At its most elementary level, it is a signal from peripheral nerves with specialized receptors that there is a change in the local environment, such as pressure, pH, temperature, or some other noxious stimulus, that can be detrimental to function. Pain is particularly prevalent in patients with HIV infection. The assessment, evaluation, and treatment of pain should be an integral part of comprehensive patient care.

Diagnosis of pulmonary Kaposi's sarcoma by detection of human herpes virus 8 in bronchoalveolar lavage

Human herpes virus 8 (HHV8) DNA has recently been detected in sarcoma tissue of patients with Kaposi's sarcoma. HHV8 DNA could also be found in bronchoalveolar lavage (BAL) fluid of patients with tracheobronchial Kaposi's sarcoma. To determine the specificity, sensitivity and predictive values of HHV8 DNA detection in the BAL for the diagnosis of pulmonary Kaposi's sarcoma, 100 consecutive BAL were prospectively analyzed for the presence of HHV8 DNA using a nested PCR assay. In addition, 19 BAL samples of 14 AIDS patients with cutaneous or visceral Kaposi's sarcoma were retrospectively investigated. The prospective group consisted of 79 BAL performed in immunocompromised and of 21 BAL in nonimmunocompromised patients. Four patients of the prospectively analyzed group undergoing six BAL showed tracheobronchial Kaposi's sarcoma at five bronchoscopies. All of the five BAL samples performed in these patients with endoscopically visible Kaposi's sarcoma were positive for HHV8 DNA. Following chemotherapy and antiretroviral treatment tracheobronchial Kaposi's sarcoma was no longer detectable at a subsequent bronchoscopy and HHV8 DNA in BAL became negative in one patient. One BAL sample of a HIV-positive patient with no evidence of Kaposi's sarcoma was HHV8 DNA-positive. The sensitivity, specificity, positive and negative predictive values of HHV8 detection for the diagnosis of tracheobronchial Kaposi's sarcoma were 100%, 98.9%, 83.3%, and 100%, respectively. Twelve of 19 BAL samples of the retrospective group were HHV8 DNA-positive. In this group, 10 patients undergoing a total of 14 BAL suffered from pulmonary Kaposi's sarcoma. HHV8 DNA was documented in 10 of these 14 BAL samples. In three BAL of this group HHV8 DNA was positive, but pulmonary Kaposi's sarcoma was diagnosed at a later stage. In conclusion, the detection of HHV8 DNA in BAL is restricted to patients with Kaposi's sarcoma and is highly sensitive and specific for pulmonary involvement of Kaposi's sarcoma.