Spectrum of opportunistic infections and malignancies in patients with human immunodeficiency virus infection in South Korea

The spectrum of opportunistic infections and malignancies among women on antiretroviral therapy in Ethiopia

ABBREVIATIONS

AIDS: acquired immune deficiency syndrome; CI: confidence interval; EPHI: Ethiopian Public Health Institute; HAART: highly active antiretroviral therapy; HIV: human immunodeficiency virus; HR: hazard ratio; Mg/dl: milligram per deciliter; TB: tuberculosis; PCP: pneumocystis carinii pneumonia; ZJU: Zhejiang University.

Spatiotemporal Clusters and Trends of Pneumocystis Pneumonia in Korea

This study determined the recent status and trend of <i>Pneumocystis jirovecii</i> pneumonia (PcP) in the non-human immunodeficiency virus (HIV) (non-HIV-PcP) and HIV (HIV-PcP) infected populations using data from the Health Insurance Review & Assessment Service (HIRA) and the Korea Disease Control and Prevention Agency (KDCA). SaTScan and Joinpoint were used for statistical analyses. Non-HIV-PcP cases showed an upward trend during the study period from 2010 to 2021, with the largest number in 2021 (551 cases). The upward trend was similar until 2020 after adjusting for the population. Seoul had the highest number of cases (1,597) in the non-HIV-PcP group, which was the same after adjusting for the population (162 cases/1,000,000). It was followed by Jeju-do (89 cases/1,000,000). The most likely cluster (MLC) for the non-HIV-PCP group was Seoul (Relative Risk (RR)=4.59, Log Likelihood Ratio (LLR)=825.531), followed by Jeju-do (RR=1.59, LLR=5.431). An upward trend was observed among the non-HIV-PcP group in the Jeju-do/Jeollanam-do/Jeollabuk-do/Gyeongsangnam-do/Busan/Daejeon/Daegu/Ulsan joint cluster (29.02%, LLR=11.638, <i>P</i><0.001) located in the southern part of Korea. Both women and men in the non-HIV groups showed an overall upward trend of PcP during the study period. Men in the 60-69 age group had the highest annual percentage change (APC 41.8) during 2014-2019. In contrast, the HIV groups showed a falling trend of PcP recently. Men in the 60-69 age group had the most decrease (APC -17.6) during 2018-2021. This study provides an analytic basis for health measures and a nationwide epidemiological surveillance system for the management of PcP.

Prevalence of Multidrug-Resistant Tuberculosis in HIV/Tuberculosis Co-Infected Patients

Tuberculosis (TB) is a common opportunistic infection in human immunodeficiency virus (HIV)-infected patients. Patients with multidrug-resistant (MDR)-TB have poor outcomes. This study aimed to determine the prevalence of MDR-TB in HIV/TB co-infected patients in the Korea. We reviewed the medical records of HIV/TB co-infected patients at two university hospitals between January 1998 and December 2020. During the study period, a total of 87 HIV/TB co-infected patients were identified, and drug susceptibility test results were available for 44 of them. The prevalence of MDR-TB in the study population was 15.9% (7/44, 95% confidence interval, 5.1 - 26.7).

History of Acquired Immune Deficiency Syndrome in Korea

The first human immunodeficiency virus (HIV) infection was reported in Korea in 1985. The number of HIV-infected persons domestically increased in the 1990s showing epidemic indigenousization. Since then, the number of new infections gradually increased every year, and recently more than 1,000 newly infected cases were reported per year. A total of 12,522 infected individuals have been reported up to 2015, of which 2,020 died. The male to female ratio was 15.4:1, and 34.2% of them were under 30 years old. The infection route was homosexual and bisexual contact in 60.1% of cases and heterosexual contact in 34.6% of cases. Candidiasis, Pneumocystis pneumonia, tuberculosis were common as a AIDS (acquired immune deficiency syndrome)-defining illness. But with the introduction of antiretroviral therapy in the late 1990s, non-AIDS defining illnesses such as metabolic complications, cardiovascular diseases, bone diseases, and neuropsychiatric disorders such as neurocognitive dysfunction, depression, and anxiety are emerging as new health problems. The management policy switched its focus from regulating and monitoring of HIV-infected persons to ensuring access to treatment and promotion of voluntary HIV testing in high-risk groups. Also as the age of the infected persons increases, a need for various supports such as social rehabilitation, life counseling, and welfare has emerged.

Changing Spectrum of Opportunistic Illnesses among HIV-Infected Taiwanese Patients in Response to a 10-Year National Anti-TB Programme

The current trends and spectrum of acquired immunodeficiency syndrome (AIDS)-related opportunistic illnesses (AOIs) among newly diagnosed human immunodeficiency virus (HIV)-infected patients after the implementation of the 2006–2015 national anti-tuberculosis (TB) programmes in Taiwan remain unknown. We retrospectively reviewed 1757 patients at two centres in southern Taiwan between 2001 and 2015. Based on the anti-TB programme, patients were classified into periods 1 (2001–2005), 2 (2006–2010), and 3 (2011–2015). We further analysed factors associated with Mycobacterium tuberculosis (MTB) at presentation and during follow-up. The overall AOI incidence rate (23.6%) remained unchanged across the periods, with 81.4% of AOIs occurring at presentation. Pneumocystis jirovecii pneumonia was the leading AOI across the periods. MTB declined significantly from period 1 to period 3 (39.3% vs. 9.3%). Age and CD4+ cell count <200 cells/µL (vs. ≥501) were the risk factors associated with MTB at presentation, whereas period 2/3 (vs. period 1) was the protective factor. Intravenous drug use (vs. homosexual contact) was the risk factor associated with MTB during follow-up, and period 3 (vs. period 1) was the protective factor. AOI statistics in Taiwan must be closely monitored for fluctuations. Although MTB decreased substantially after implementation of the anti-TB programmes, additional efforts to reduce MTB are required.

Incidence of disseminated Mycobacterium avium-complex infection in HIV patients receiving antiretroviral therapy with use of Mycobacterium avium-complex prophylaxis

The incidence of disseminated Mycobacterium avium complex (MAC) infection in HIV patients has fallen markedly since the introduction of effective antiretroviral therapy (ART). However, current guidelines still recommend primary prophylaxis. We conducted a retrospective cohort study in a university-affiliated hospital from January 1998 to January 2014. During that period, HIV patients who had at least one CD4 cell count below 50 cells/mm³ and had been treated with ART were enrolled. We compared incidence of disseminated MAC infection in the 12 months after the first CD4 cell count below 50 cells/mm³ between prophylaxis and nonprophylaxis groups. A total of 157 patients were enrolled and the total observation period was 144 patient-years (PY). Thirty-three patients (21%) received primary MAC prophylaxis. The initial CD4 cell count of the prophylaxis group was lower than that of the nonprophylaxis group ( P = 0.024), but the proportion of patients who reached a CD4 cell count >100 cells/mm³ ( P = 0.234) and were virologically suppressed ( P = 0.513) 12 months after ART commencement was not different in the prophylaxis and nonprophylaxis groups. The incidence of MAC did not differ significantly between the groups (3.4/100 PY versus 0.8/100 PY, P = 0.368). Routine MAC prophylaxis may be not required in the era of effective ART.

Looking back to move forward: a twenty-year audit of herpes zoster in Asia-Pacific

Background

Herpes zoster (HZ) is a prevalent viral disease that inflicts substantial morbidity and associated healthcare and socioeconomic burdens. Current treatments are not fully effective, especially among the most vulnerable patients. Although widely recommended, vaccination against HZ is not routine; barriers in Asia-Pacific include long-standing neglect of adult immunisation and sparse local data. To address knowledge gaps, raise awareness, and disseminate best practice, we reviewed recent data and guidelines on HZ from the Asia-Pacific region.

Methods

We searched PubMed, Scopus, and World Health Organization databases for articles about HZ published from 1994 to 2014 by authors from Australia, China, Hong Kong, India, Indonesia, Japan, Korea, Malaysia, New Zealand, the Philippines, Singapore, Taiwan, Thailand, and Vietnam. We selected articles about epidemiology, burden, complications, comorbidities, management, prevention, and recommendations/guidelines. Internet searches retrieved additional HZ immunisation guidelines.

Results

From 4007 retrieved articles, we screened-out 1501 duplicates and excluded 1264 extraneous articles, leaving 1242 unique articles. We found guidelines on adult immunisation from Australia, India, Indonesia, Malaysia, New Zealand, the Philippines, South Korea, and Thailand.

HZ epidemiology in Asia-Pacific is similar to elsewhere; incidence rises with age and peaks at around 70 years – lifetime risk is approximately one-third. Average incidence of 3–10/1000 person-years is rising at around 5% per year. The principal risk factors are immunosenescence and immunosuppression. HZ almost always causes pain, and post-herpetic neuralgia is its most common complication. Half or more of hospitalised HZ patients have post-herpetic neuralgia, secondary infections, or inflammatory sequelae that are occasionally fatal. These disease burdens severely diminish patients’ quality of life and incur heavy healthcare utilisation.

Conclusions

Several countries have abundant data on HZ, but others, especially in South-East Asia, very few. However, Asia-Pacific countries generally lack data on HZ vaccine safety, efficacy and cost-effectiveness. Physicians treating HZ and its complications in Asia-Pacific face familiar challenges but, with a vast aged population, Asia bears a unique and growing burden of disease. Given the strong rationale for prevention, most adult immunisation guidelines include HZ vaccine, yet it remains underused. We urge all stakeholders to give higher priority to adult immunisation in general and HZ in particular.

Electronic supplementary material

The online version of this article (doi:10.1186/s12879-017-2198-y) contains supplementary material, which is available to authorized users.

Opportunistic diseases among HIV-infected patients: a multicenter-nationwide Korean HIV/AIDS cohort study, 2006 to 2013

BACKGROUND/AIMS

The frequencies of opportunistic diseases (ODs) vary across countries based on genetic, environmental, and social differences. The Korean HIV/AIDS cohort study was initiated in 2006 to promote research on human immunodeficiency virus (HIV) infection in Korea, and to provide a logistical network to support multicenter projects on epidemiological, clinical, and laboratory aspects of HIV infection. This study evaluated the prevalence of ODs among HIV-infected patients in the era of highly active antiretroviral therapy, and the risk factors associated with ODs.

METHODS

The study enrolled 1,086 HIV-infected patients from 19 hospitals. This study examined the baseline data of the HIV/AIDS Korean cohort study at the time of enrollment from December 2006 to July 2013.

RESULTS

Candidiasis was the most prevalent opportunistic infection (n = 176, 16.2%), followed by Mycobacterium tuberculosis infection (n = 120, 10.9%), Pneumocystis jirovecii pneumonia (n = 121, 11.0%), cytomegalovirus infection (n = 52, 4.7%), and herpes zoster (n = 44, 4.0%). The prevalence rates of Kaposi's sarcoma (n = 8, 0.7%) and toxoplasmosis (n = 4, 0.4%) were very low compared with other countries. The risk factors for ODs were a low CD4 T cell count at the time of HIV diagnosis (odds ratio [OR], 1.01; p < 0.01), current smoking (OR, 2.27; p = 0.01), current alcohol use (OR, 2.57; p = 0.04), and a history of tuberculosis (OR, 5.23; p < 0.01).

CONCLUSIONS

Using recent Korean nationwide data, this study demonstrated that an important predictor of ODs was a low CD4 T cell count at the time of HIV diagnosis. Tuberculosis remains one of the most important ODs in HIV-infected patients in Korea.

Discriminative expression of whole blood genes in HIV patients with latent and active TB in Ethiopia

BACKGROUND

Transcriptomic host biomarkers could assist in developing effective diagnostics, vaccines and therapeutics for tuberculosis (TB). However, different biomarkers may be discriminatory in different populations depending on the host and bacillary genetics and HIV infection, and need to be addressed.

METHODS

The expression levels of 45 genes that are known to be involved in or affected by TB pathogenesis were analyzed using dual color Reverse Transcriptase Multiplex Ligation-dependent Probe Amplification (dcRT-MLPA) assay in whole blood of 106 HIV positive individuals including active TB patients (TB(+)HIV(+), n = 29), and non TB patients that are tuberculin skin test positive (TST+) (TST(+)HIV(+), n = 26), or TST negative (TST(-)HIV(+), n = 51).

RESULTS

Between the two clinical groups (TB(+)HIV(+) vs. TST(-)HIV(+)) 8 genes were differently expressed (CCL19, CD14, CD8A, FPR1, IL7R, CCL22, TNFRSF1A, and FCGR1A); between TB(+)HIV(+) vs. TST(+)HIV(+), 6 genes (CD14, IL7R, TIMP2, CCL22, TNFRSF1A, and FCGR1A) were differently expressed. Since no difference in gene expression was revealed between TST(+)HIV(+) vs. TST(-)HIV(+), we clustered both the TST(+)HIV(+) and TST(-)HIV(+) individuals as one group (TST(+/-)HIV(+)) and compared gene expression with TB(+)HIV(+) patients. Thus, the results revealed that the levels of five genes (CD8A, TIMP2, CCL22, FCGR1A and TNFRSF1A) were the most accurate single gene markers for differentiation between TB(+)HIV(+) and TST(+/-)HIV(+), with AUCs of 0.71, 0.71, 0.79, 0.83 and 0.73, respectively. However, the combination of two genes (CCL22 + FCGR1A) and FCGR1A alone were the most accurate marker for differentiation between the two groups (TB(+)HIV(+) and TST(+/-)HIV(+)) with AUC of 0.85 and 0.83, respectively.

CONCLUSIONS

We showed that five genes (CD8A, TIMP2, CCL22, FCGR1A and TNFRSF1A), specifically FCGR1A and CCL22 have the potential to discriminate active TB from non-active TB in HIV patients in Ethiopia and could be used to improve diagnostic tools for active TB in HIV patients, and to understand the pathogenesis of TB/HIV coinfection.

Spectrum of Opportunistic Infections and Risk Factors for In-Hospital Mortality of Admitted AIDS Patients in Shanghai

To investigate the frequency and the spectrum of major opportunistic infections (OIs), evaluate the major clinical factors associated with each specific OI, and identify the risk factors for in-hospital death among HIV patients in East China.A retrospective cohort study was made including all the HIV-infected patients who were admitted for the first time to the Shanghai Public Health Clinical Center during June 1, 2013 to June 1, 2015. The demographic and clinical data were collected. Comparison of continuous variables was analyzed by one-way ANOVA and rank sum test. Person χ test and Fisher exact test were applied to analyze the categorical variables. A Cox proportional hazards regression model was used to determine the risk for the occurrence of in-hospital death.In total, 920 patients were enrolled with age of 41.59 ± 13.36 years and 91% male. Median CD4 was 34 (IQR, 13-94) cells/μL. Among these patients, 94.7% acquired OIs while the rest developed malignancies. Pneumocystis pneumonia and bacterial coinfection (42.1%) was found to be the most common OIs, followed by tuberculosis (31.4%), CMV (20.9%), Cryptococcosis (9.0%), and MAC infection (5.2%). Of the above 5 major OIs, CMV-infected patients had the lowest median CD4 cell count 22.50 (IQR, 7.50-82.00) while the patients with tuberculosis infection had the highest count 61.00 (IQR, 27.00-176.00). In-hospital death rate was 4.2 per 100 person-years among these patients. Of note, admitted patients with 2 types of OIs (2.20, 95% CI 1.39-3.48) and those patients who were 40-year old or older (1.75, 95% CI 1.10-2.78) had a higher risk of such death.Pneumocystis pneumonia and tuberculosis were still the leading causes for the admission of HIV-infected patients in East China, and these patients tended to have very low CD4 cell counts. It is believed that expanding the HIV screening test and pushing the infected ones get ART earlier is required for generating a more successful HIV management strategy.

CKD and Infectious Diseases in Asia Pacific: Challenges and Opportunities

The exact number of patients with chronic kidney disease (CKD) in Asia Pacific is uncertain. In numeric terms, the region is home to the largest population of patients with untreated chronic kidney failure. The climatic, geographic, social, cultural, economic, and environmental diversity within this region is higher than in any other part of the world. Large parts of the region face a climate-related burden of infectious diseases. Infections contribute to the development and progression of CKD and complicate the course of patients with pre-existing CKD (especially those on dialysis therapy or who are immunosuppressed), increase the cost of CKD care, and contribute to mortality and morbidity. Kidney involvement is a feature of several infectious diseases prevalent in Asia Pacific. Examples include malaria, leptospirosis, scrub typhus, tuberculosis, hepatitis B and C virus, dengue hemorrhagic fever, and Hantaan virus infections. The contribution of infection-associated acute kidney injury to the overall burden of CKD has not been evaluated systematically. Research is needed to quantify the impact of infections on kidney health by undertaking prospective studies. Nephrologists need to work with infectious disease research groups and government infection surveillance and control programs.

Trends and Characteristics of HIV Infection among Suspected Tuberculosis Cases in Public Health Centers in Korea: 2001-2013

OBJECTIVES

The Republic of Korea reports approximately 35,000 new tuberculosis (TB) patients each year, and the number of HIV-infected individuals is steadily increasing. Public health centers (PHCs) conduct TB diagnosis and treatment for risk groups in communities. This study aimed to identify possible trends and characteristics of HIV infection among suspected TB cases in PHCs.

METHODS

Study subjects were suspected TB cases in PHCs who agreed to be tested for HIV from 2001 to 2013. Trends in HIV seroprevalence were assessed through a series of annual cross-sectional analyses. We analyzed suspected TB cases, and HIV-infected individuals among suspected TB cases, by gender, age, nationality, and region.

RESULTS

The number of suspected tuberculosis cases who took an HIV test in PHCs was approximately 6,000 each year from 2001 to 2013. Among the suspected TB cases who took an HIV test, the number of those aged 20-39 is gradually decreasing, while the number of those aged 50-69 is increasing. During this period, 32 HIV-infected individuals were identified; the majority were men (94%), aged 30-49 (68%), Korean (94%), and residents in a metropolitan area (53%). HIV seroprevalence decreased from 8.2 per 10,000 persons in 2001 to 1.9 per 10,000 persons in 2013.

CONCLUSION

This study has identified trends and characteristics of HIV infection among suspected tuberculosis cases in PHCs. This national data provides a basis for public health policy for HIV and tuberculosis infections.

Pneumocystis jirovecii pneumonia in tropical and low and middle income countries: a systematic review and meta-regression

Objective

Pneumocystis jirovecii pneumonia (PCP), the commonest opportunistic infection in HIV-infected patients in the developed world, is less commonly described in tropical and low and middle income countries (LMIC). We sought to investigate predictors of PCP in these settings.

Design

Systematic review and meta-regression.

Methods

Meta-regression of predictors of PCP diagnosis (33 studies). Qualitative and quantitative assessment of recorded CD4 counts, receipt of prophylaxis and antiretrovirals, sensitivity and specificity of clinical signs and symptoms for PCP, co-infection with other pathogens, and case fatality (117 studies).

Results

The most significant predictor of PCP was per capita Gross Domestic Product, which showed strong linear association with odds of PCP diagnosis (p<0.0001). This was not explained by study design or diagnostic quality. Geographical area, population age, study setting and year of study also contributed to risk of PCP. Co-infection was common (444 episodes/1425 PCP cases), frequently with virulent organisms. The predictive value of symptoms, signs or simple tests in LMIC settings for diagnosis of PCP was poor. Case fatality was >30%; treatment was largely appropriate. Prophylaxis appeared to reduce the risk for development of PCP, however 24% of children with PCP were receiving prophylaxis. CD4 counts at presentation with PCP were usually <200×10^3/ml.

Conclusions

There is a positive relationship between GDP and risk of PCP diagnosis. Although failure to diagnose infection in poorer countries may contribute to this, we also hypothesise that poverty exposes at-risk patients to a wide range of infections and that the relatively non-pathogenic P. jirovecii is therefore under-represented. As LMIC develop economically they eliminate the conditions underlying transmission of virulent infection: P. jirovecii, ubiquitous in all settings, then becomes a greater relative threat.

Clinical features and survival outcomes of patients with diffuse large B-cell lymphoma: analysis of web-based data from the Korean Lymphoma Working Party Registry

BACKGROUND

This study aimed to survey the clinical spectrum of diffuse large B-cell lymphoma (DLBCL) in terms of epidemiology, pathologic subtypes, stage, and prognostic index as well as treatment outcomes.

METHODS

In 2007-2008, 13 university hospitals evenly distributed in the Korean peninsula contributed to the online registry of DLBCL at www.lymphoma.or.kr and filed a total of 1,665 cases of DLBCL recorded since 1990.

RESULTS

Our analysis showed a higher prevalence of DLBCL in male than in female individuals (M:F=958:707), and extranodal disease was more common than primary nodular disease (53% vs. 47%). Among the 1,544 patients who had been treated with CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) or rituximab-CHOP (R-CHOP) therapy with or without radiation, 993 (63.9%) were alive, with 80% free of disease, 417 were dead (26.8%), with 13% free of disease, and 144 (9.3%) were lost to follow-up, with 23% free of disease. Age below 60 years, stage at diagnosis, international prognostic index (IPI) score regardless of age, and addition of rituximab to CHOP therapy in low- and low-intermediate-risk groups according to IPI scores significantly increased survival duration.

CONCLUSION

The epidemiology, clinical spectrum, and biological behavior of DLBCL in Korea are similar to those observed in Western countries, and the advent of rituximab improved survival.

Incidence and risk factors of tuberculosis in patients with human immunodeficiency virus infection

Korea is a low prevalence country for human immunodeficiency virus (HIV) infection and has an intermediate tuberculosis (TB) burden. We previously reported that the incidence of TB in HIV-infected patients was 9.6 cases per 100 person-years (P-Y) between 1988 and 1997. The aims of the present study were to measure any change in incidence from the previous study, and to identify risk factors for TB in HIV-infected patients. We reviewed all medical records of HIV-infected patients who were followed-up in one tertiary hospital between 1998 and 2010. Over the total observation period of 5858.33 P-Y, TB developed in 70 patients (1.19 cases per 100 P-Y; 95% confidence interval [CI], 0.91-1.47 cases per 100 P-Y). Based on Poisson regression, one risk factor associated with TB was an initial CD4+ cell count below 200 cells/µL (relative risk, 2.34; 95% CI, 1.47-3.73). Mean CD4+ cell counts of pulmonary, extrapulmonary, and both pulmonary and extrapulmonary TB were 179.8 cells/µL, 138.3 cells/µL, and 114.2 cells/µL, respectively (P = 0.55). In conclusion, the incidence of TB in HIV-infected patients has decreased since the previous study. An initial CD4+ cell count below 200 cells/µL is an independent risk factor for development of TB in HIV-infected patients.

Late presentation of HIV disease and its associated factors among newly diagnosed patients before and after abolition of a government policy of mass mandatory screening

OBJECTIVE

To investigate the risk factors for late presentation in the Republic of Korea, where massive mandatory screening for HIV infection was conducted by the government until the late 1990s.

METHODS

Data over the period 1987-2008 were analyzed from HIV patients for whom records of CD4 cell counts within 3 months of HIV diagnosis were available. Using multivariate logistic regression analysis including demographic and clinical variables, we examined factors associated with late presentation, defined as having a CD4 cell count of less than 200 cells/mm(3) at the time of diagnosis.

RESULTS

Of a total of 994 patients with a new diagnosis of HIV infection, 405 (41%) were late presenters. As the proportion of patients diagnosed by mandatory screening decreased over time (31% in 1987-1998 versus 8% in 1999-2008, P < 0.001), the proportion of late presenters increased (31% in 1987-1998 versus 43% in 1999-2008, P = 0.007). The independent risk factors for late presentation were older age (adjusted odds ratio [aOR], per increase of 10 years, 1.31; 95% confidence interval [CI], 1.15-1.49; P < 0.001), male sex (aOR, 1.74; 95% CI, 1.03-2.95; P = 0.040), negativity for VDRL (aOR, 1.58; 95% CI, 1.16-2.14; P = 0.003), and diagnosis after 1999 (aOR, 1.64; 95% CI, 1.05-2.56; P = 0.031).

CONCLUSIONS

Older age, male sex, negativity for VDRL, and diagnosis after 1999, were associated with late presentation, and the proportion of late presenters increased after the mandatory testing policy was abolished.

Spectrum of intracranial parenchymal lesions in patients with human immunodeficiency virus infection in the Republic of Korea

The incidence of specific intracranial parenchymal lesions of HIV-infected patients varies considerably between countries. In the Republic of Korea, the number of HIV-infected patients is increasing, but little is known regarding the spectrum of intracranial parenchymal lesions in these patients. The aim of the present study was to obtain this information. To identify HIV patients with intracranial parenchymal lesions, the electronic database of radiological reports for 1,167 HIV-infected patients, seen from 1999 to 2008 at the Seoul National University Hospital, were reviewed. Neuroradiologic studies were performed on 165 of these patients, and intracranial parenchymal lesions were detected in 40 (3.4%) of them. Thirty-seven were male, and median age was 41 yr (range, 26-61). At the time of the diagnosis of intracranial parenchymal lesions, median CD4(+) lymphocyte count was 40 cells/microL (range 5-560) and in 33 (82.5%) patients, it was less than 200 cells/microL. Progressive multifocal leukoencephalopathy (12 patients) is the most frequent intracranial parenchymal lesions, followed by intracranial tuberculoma (7 patients), primary central nervous system lymphoma (7 patients), intracranial cryptococcoma (4 patients), Toxoplasma encephalitis (4 patients), and disseminated non-tuberculous mycobacterial infection (3 patients).

Review of zoonotic parasites in medical and veterinary fields in the Republic of Korea

Zoonotic parasites are animal parasites that can infect humans. The major zoonotic protozoa in the Republic of Korea are Babesia bovis, Chilomastix mesnili, Cryptosporidium parvum, Endolimax nana, Entamoeba coli, Entamoeba hitolytica, Giardia lamblia, Iodamoeba bütschlii, Pneumocystis carinii, Sarcocystis cruzi, and Toxoplasma gondii. The major zoonotic helminths in Korea include trematodes, cestodes, and nematodes. Trematodes are Clonorchis sinensis, Echinostoma hortense, Echinostoma spp., Fasciola hepatica, Heterophyes nocens, Metagonimus yokogawai, and Paragonimus westermani. Cestodes are Diphyllobothrium latum, Dipylidium caninum, Echinococcus granulosus, Hymenolepis nana, Raillietina tetragona, sparganum (Spirometra spp.), Taenia saginata, T. solium, and T. asiatica. Nematodes are Ancylostoma caninum, Brugia malayi, Capillaria hepatica, Dirofilaria immitis, Gnathostoma dololesi, Gnathostoma spinigerum, Loa loa, Onchocerca gibsoni, Strongyloides stercoralis, Thelazia callipaeda, Trichinella spiralis, Trichostrongylus orientalis, Trichuris trichiura, and Trichuris vulpis. The one arthropod is Sarcoptes scabiei. Many of these parasites have disappeared or were in decline after the 1990's. Since the late 1990's, the important zoonotic protozoa have been C. parvum, E. nana, E. coli, E. hitolytica, G. lamblia, I. buetschlii, P. carinii and T. gondii. The important zoonotic helminths have been C. sinensis, H. nocens, M. yokogawai, P. westermani, D. latum, T. asiatica, sparganum, B. malayi, T. orientalis, T. callipaeda and T. spiralis. However, outbreaks of these parasites are only in a few endemic areas. The outbreaks of Enterobius vermicularis and head lice, human parasites, have recently increased in the kindergartens and primary schools in the Republic of Korea.

Characteristics of HIV seroprevalence of visitors to public health centers under the national HIV surveillance system in Korea: cross sectional study

Background

In Korea, the cumulative number of HIV-infected individuals was smaller than those of other countries. Mandatory HIV tests, dominating method until 1990's, have been gradually changed to voluntary HIV tests. We investigated HIV seroprevalence status and its characteristics of visitors to Public Health Centers (PHCs), which conducted both mandatory test and voluntary test under the national HIV/STI surveillance program.

Methods

We used HIV-testing data from 246 PHCs in 2005 through the Health Care Information System. The number of test taker was calculated using the code distinguished by the residential identification number. The subjects were classified into four groups by reason for testing; General group, HIV infection suspected group (HIV ISG), HIV test recommended group (HIV TRG), and sexually transmitted infection (STI) risk group.

Results

People living with HIV/AIDS were 149 (124 male and 25 female) among 280,456 individuals tested at PHCs. HIV seroprevalence was 5.3 per 10,000 individuals. Overall, the male revealed significantly higher seroprevalence than the female (adjusted Odds Ratio (adj. OR): 6.2; CI 3.8–10.2). Individuals aged 30–39 years (adj. OR: 2.6; CI 1.7–4.0), and 40–49 years (adj. OR: 3.8; CI 2.4–6.0) had higher seroprevalence than 20–29 years. Seroprevalence of HIV ISG (voluntary test takers and cases referred by doctors) was significantly higher than those of others. Foreigners showed higher seroprevalence than native Koreans (adj. OR: 3.8; CI 2.2–6.4). HIV ISG (adj. OR: 4.9; CI 3.2–7.5), and HIV TRG (adj. OR: 2.6; CI 1.3–5.4) had higher seroprevalence than General group.

Conclusion

A question on the efficiency of current mandatory test is raised because the seroprevalence of mandatory test takers was low. However, HIV ISG included voluntary test takers was high in our result. Therefore, we suggest that Korea needs to develop a method encouraging more people to take voluntary tests at PHCs, also to expand the anonymous testing centers and Voluntary Counselling and Testing Program (VCT) for general population to easily access to HIV testing.

Estimation of the current global burden of cryptococcal meningitis among persons living with HIV/AIDS

OBJECTIVE

Cryptococcal meningitis is one of the most important HIV-related opportunistic infections, especially in the developing world. In order to help develop global strategies and priorities for prevention and treatment, it is important to estimate the burden of cryptococcal meningitis.

DESIGN

Global burden of disease estimation using published studies.

METHODS

We used the median incidence rate of available studies in a geographic region to estimate the region-specific cryptococcal meningitis incidence; this was multiplied by the 2007 United Nations Programme on HIV/AIDS HIV population estimate for each region to estimate cryptococcal meningitis cases. To estimate deaths, we assumed a 9% 3-month case-fatality rate among high-income regions, a 55% rate among low-income and middle-income regions, and a 70% rate in sub-Saharan Africa, based on studies published in these areas and expert opinion.

RESULTS

Published incidence ranged from 0.04 to 12% per year among persons with HIV. Sub-Saharan Africa had the highest yearly burden estimate (median incidence 3.2%, 720 000 cases; range, 144 000-1.3 million). Median incidence was lowest in Western and Central Europe and Oceania (</=0.1% each). Globally, approximately 957 900 cases (range, 371 700-1 544 000) of cryptococcal meningitis occur each year, resulting in 624 700 deaths (range, 125 000-1 124 900) by 3 months after infection.

CONCLUSION

This study, the first attempt to estimate the global burden of cryptococcal meningitis, finds the number of cases and deaths to be very high, with most occurring in sub-Saharan Africa. Further work is needed to better define the scope of the problem and track the epidemiology of this infection, in order to prioritize prevention, diagnosis, and treatment strategies.

Clinical and microbiological characteristics of community-acquired pneumonia among human immunodeficiency virus-infected patients in northern Thailand

Human immunodeficiency virus (HIV) infections are prevalent in Thailand. However, the clinical and microbiological characteristics of community-acquired pneumonia (CAP) in such patients are not completely clear at present. In the present study, we analyzed the characteristics of CAP in 191 HIV-infected patients (192 episodes, 130 males and 61 females, mean age 32.9 years, range: 20-62) who had been admitted to Nakornping Hospital in northern Thailand between December 1996 and January 2002. The mean peripheral blood CD4 lymphocyte count was 68.5/mm3 (range: 0-791). The most common organisms detected in the blood of the subjects were as follows: Penicillium marneffei, 13, Salmonella spp., 5, Cryptococcus neoformans, 4, Staphylococcus aureus, 3, and Rhodococcus equi, 3, and the most common organisms detected in sputum included Haemophilus influenzae, 38, P. marneffei, 10, Streptococcus pneumoniae, 10, R. equi, 9, and S. aureus, 9. Life-threatening meningitis in 5 (cryptococcal in 3 and tuberculous in 2), pneumothorax in 2, and tuberculous lymphadenitis in 1 were also noted, resulting in 21 fatalities (10.9%). The mean peripheral blood CD4 lymphocyte count for cases in which the subject died was 74.8/mm3 (range: 0-340). Logistic regression analysis demonstrated that high age (odds ratio of over 40 years: 15.62) and R. equi infection (odds ratio: 8.14) are related to death of HIV-infected patients with CAP. The above findings indicate that various types of organisms, including mixed organisms, cause CAP in HIV-infected patients in northern Thailand, and high age and R. equi infection seem to be risk factors for death.

Immune reconstitution inflammatory syndrome in the first year after HAART: influence on long-term clinical outcome

Little is known about the effect of immune reconstitution inflammatory syndrome (IRIS) on the long-term clinical outcome. Of 52 opportunistic infections (OI) occurring within one year after the start of HAART in 387 HIV patients, 33 (63%) were classified as having IRIS. The patients with IRIS showed no significant difference in the AIDS event-free survival curve compared with the matched control group without OI and in contrast to non-IRIS OI.

High proportion of T-cell systemic non-Hodgkin lymphoma in HIV-infected patients in Lima, Peru

OBJECTIVE

Few reports have described the clinical and pathologic characteristics of HIV-related systemic non-Hodgkin lymphoma (sNHL) in developing countries. We aimed to determine these characteristics from a national HIV reference center in Peru and to evaluate factors associated with survival.

METHODS

A retrospective/prospective study of patients with HIV-related sNHL from the Guillermo Almenara General Hospital in Lima, Peru between 1993 and 2004. Clinical characteristics at diagnosis included age, gender, risk behavior, previous AIDS diagnosis, opportunistic diseases, previous highly active antiretroviral therapy, Karnofsky score, origin, clinical stage and B-cell symptoms of sNHL, and CD4 cell count. Cases of sNHL were classified according to the criteria of the World Health Organization.

RESULTS

Thirty-three cases were identified (26 male, age range: 38 +/- 10 years). Ten patients (30%) had a prior history of AIDS, 14 (42%) had a Karnofsky score of <or=70, and 18 (56%) had clinical stage IV sNHL. The CD4 cell count median value was 111 cells/microL (n = 25). Twenty-four cases (73%) were B-cell sNHL, and 9 cases (27%) were T-cell sNHL, both from peripheral cells. Nineteen cases of sNHL were extranodal: 15 of B-cell origin and 4 of T-cell origin. Eighteen cases of B-cell sNHL had diffuse large cell histologic findings, and all cases of T-cell sNHL were unspecified. Although there were no significant differences in clinical characteristics between phenotypes, patients with T-cell sNHL had less aggressive disease and a better survival rate.

CONCLUSIONS

A high proportion of T-cell sNHL cases was found at an HIV reference center in Peru. Clinical characteristics were similar between B-cell and T-cell lymphoma patients. T-cell lymphoma was less aggressive, and patients with T-cell lymphoma had a better survival rate than those with B-cell lymphoma.

Parasitic infections in HIV-infected patients who visited Seoul National University Hospital during the period 1995-2003

The prevalence of parasitic infections was investigated in human immunodeficiency virus (HIV)-infected patients (n = 105) who visited Seoul National University Hospital, Seoul, Korea, during the period from 1995 to 2003. Fecal samples were collected from 67 patients for intestinal parasite examinations, and sputum or bronchoalveolar lavage samples from 60 patients for examination of Pneumocystis carinii. Both samples were obtained from 22 patients. Thirty-three (31.4%) of the 105 were found to have parasitic infections; Cryptosporidium parvum (10.5%; 7/67), Isospora belli (7.5%; 5/67), Clonorchis sinensis (3.0%; 2/67), Giardia lamblia (1.5%; 1/67), Gymnophalloides seoi (1.5%; 1/67), and Pneumocystis carinii (28.3%; 17/60). The hospital records of the 11 intestinal parasite-infected patients showed that all suffered from diarrhea. This study shows that parasitic infections are important clinical complications in HIV-infected patients in the Republic of Korea.

Cytokine responses induced by Mycobacterium tuberculosis in patients with HIV-1 infection and tuberculosis

OBJECTIVE

Tuberculosis (TB) is an important opportunistic infection in HIV patients. Immune responses to Mycobacterium tuberculosis in HIV/TB patients were evaluated.

METHODS

Fifteen patients with HIV/TB, ten with HIV, four with TB, and five controls were enrolled. Peripheral blood mononuclear cells were isolated and stimulated with mycobacterial antigen (PPD). Interferon (IFN)-gamma and TNF-alpha in culture supernatants were measured by ELISA.

RESULTS

IFN-gamma and TNF-alpha production after PPD stimulation was markedly decreased in HIV patients, but not in HIV/TB patients. In HIV patients with a CD4 cell count of less than 200/mm3, IFN-gamma and TNF-alpha production after PPD stimulation was higher in HIV/TB patients than in HIV patients. Cytokine responses to M. tuberculosis reconstituted after highly active antiretroviral therapy (HAART) and were prominent in HIV/TB patients.

CONCLUSIONS

Cytokine responses to M. tuberculosis were retained in HIV-infected patients with tuberculosis, even in patients with a CD4 cell count of less than 200/mm3, and reconstituted after HAART.

Pneumocystis carinii pneumonia in patients in the developing world who have acquired immunodeficiency syndrome

We review Pneumocystis carinii pneumonia (PCP) in patients in the developing world (i.e., Africa, Asia, the Philippines, and Central and South America) who have acquired immunodeficiency disease (AIDS). During the first decade of the AIDS pandemic, PCP rarely occurred in African adults. More recent reports have noted that PCP comprises a significantly greater percentage of cases of pneumonia than it did in the past. This trend dramatically contrasts with that observed in industrialized nations, where a reduction in the number of cases of PCP has occurred as a result of the widespread use of primary P. carinii prophylaxis and highly active antiretroviral therapy. Throughout the developing world, the rate of coinfection with Mycobacterium tuberculosis and PCP is high, ranging from 25% to 80%. Initiation of treatment when PCP is in an advanced stage may account for the high mortality rates (20%-80%) associated with pediatric PCP in the developing world.

Prophylaxis with trimethoprim-sulfamethoxazole for human immunodeficiency virus-infected patients: impact on risk for infectious diseases

Trimethoprim-sulfamethoxazole (TMP-SMZ) is widely prescribed as prophylaxis for Pneumocystis carinii pneumonia (PCP) in human immunodeficiency virus (HIV)-infected persons. Its efficacy against other infections has not been thoroughly evaluated. To compare the risk for infectious diseases for persons who were prescribed TMP-SMZ with that for patients who were not prescribed TMP-SMZ, we examined data collected from the medical records of HIV-infected patients (January 1990 through September 1999) who were enrolled in the Adult and Adolescent Spectrum of HIV Disease Project. During intervals when patients had CD4(+) T lymphocyte counts of <200 cells/microL (19,081 persons; 22,801 person-years), prescription of TMP-SMZ was associated with significant protection from toxoplasmosis, salmonellosis, infection with Haemophilus species, invasive or any staphylococcal infection, and PCP, but not from Shigella, pneumococcal or nonpneumococcal Streptococcus, Klebsiella, or Pseudomonas species. We demonstrate that prescription of TMP-SMZ for PCP prophylaxis in persons with HIV infection is associated with significantly decreased risk for several infectious diseases. These findings may be of interest to HIV prevention programs in resource-poor countries.

HIV neuropathy: insights in the pathology of HIV peripheral nerve disease

HIV-associated neuropathies (HIV-N) have become the most frequent neurological disorder associated with HIV infection. The most common forms of HIV-N are the distal sensory polyneuropathy (DSP) and antiretroviral toxic neuropathies (ATN), disorders characterized mostly by sensory symptoms that include spontaneous or evoked pain that follow a subacute or chronic course. The main pathological features that characterize DSP and ATN include "dying back" axonal degeneration of long axons in distal regions, loss of unmyelinated fibers, and variable degree of macrophage infiltration in peripheral nerves and dorsal root ganglia. Marked activation of macrophages as well as the effect of pro-inflammatory cytokines appear to be the main immunopathogenic factors in DSP. Interference with DNA synthesis and mitochondrial abnormalities produced by nucleoside antiretrovirals have been hypothesized as pathogenic factors involved in ATN. The use of skin biopsy has become a useful tool in the evaluation of HIV-N. Reduction in fiber density, increased frequency of fiber varicosities and fiber fragmentation are prominent features of skin biopsies from patients with HIV-N. Other forms of HIV-N include acute or chronic inflammatory polyneuropathies, uncommon disorders that may ocur during seroconversion or early stages of HIV infection. Opportunisitic infections, mostly associated with cytomegalovirus or herpes zoster virus infection occur in late stages of AIDS and produce characteristic clinical features such as mononeuritis multiple or radiculopathies.