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Oliveira NM, Ferreira FAY, Yonamine RY, Chehter EZ. Antiretroviral drugs and acute pancreatitis in HIV/AIDS patients: is there any association? A literature review. EINSTEIN-SAO PAULO 2014; 12:112-9. [PMID: 24728257 PMCID: PMC4898250 DOI: 10.1590/s1679-45082014rw2561] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2012] [Accepted: 01/06/2014] [Indexed: 02/07/2023] Open
Abstract
In HIV-seropositive individuals, the incidence of acute pancreatitis may achieve 40% per year, higher than the 2% found in the general population. Since 1996, when combined antiretroviral therapy, known as HAART (highly active antiretroviral therapy), was introduced, a broad spectrum of harmful factors to the pancreas, such as opportunistic infections and drugs used for chemoprophylaxis, dropped considerably. Nucleotide analogues and metabolic abnormalities, hepatic steatosis and lactic acidosis have emerged as new conditions that can affect the pancreas. To evaluate the role of antiretroviral drugs to treat HIV/AIDS in a scenario of high incidence of acute pancreatitis in this population, a systematic review was performed, including original articles, case reports and case series studies, whose targets were HIV-seropositive patients that developed acute pancreatitis after exposure to any antiretroviral drugs. This association was confirmed after exclusion of other possible etiologies and/or a recurrent episode of acute pancreatitis after re-exposure to the suspected drug. Zidovudine, efavirenz, and protease inhibitors are thought to lead to acute pancreatitis secondary to hyperlipidemia. Nucleotide reverse transcriptase inhibitors, despite being powerful inhibitors of viral replication, induce a wide spectrum of side effects, including myelotoxicity and acute pancreatitis. Didanosine, zalcitabine and stavudine have been reported as causes of acute and chronic pancreatitis. They pose a high risk with cumulative doses. Didanosine with hydroxyurea, alcohol or pentamidine are additional risk factors, leading to lethal pancreatitis, which is not a frequent event. In addition, other drugs used for prophylaxis of AIDS-related opportunistic diseases, such as sulfamethoxazole-trimethoprim and pentamidine, can produce necrotizing pancreatitis. Despite comorbidities that can lead to pancreatic involvement in the HIV/AIDS population, antiretroviral drug-induced pancreatitis should always be considered in the diagnosis of patients with abdominal pain and elevated pancreatic enzymes.
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Raza S, Chaudhry NA, Brown JD, Aghaie S, Rezai D, Khan A, Tan PDL, Berger BJ. To Study the Clinical, Biochemical and Radiological Features of Acute Pancreatitis in HIV and AIDS. J Clin Med Res 2013; 5:12-7. [PMID: 23390470 PMCID: PMC3564562 DOI: 10.4021/jocmr1040w] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2012] [Indexed: 12/02/2022] Open
Abstract
Background Pancreatitis complicating HIV infection, even in the Highly Active Antiretroviral Therapy (HAART) era, remains a management challenge. We felt there is a need to discern patterns in the biochemical markers, radiological studies, co-infections, length of stay (LOS) in patients with HIV or AIDS AND pancreatitis. Methods This is a retrospective study conducted from June, 2008 to August, 2010 on patients admitted with acute pancreatitis to our hospital. We extracted and compared the following parameters: biochemical markers, HBV markers (surface antigen, core antibody and surface antibody), HCV antibody, radiological studies, and length of stay (LOS). The Balthazar Grade score was used to assess radiological severity of disease. We stratified the cohort into comparison subsets according to CD4 count. Results Ninety-four admissions met the criteria for HIV or AIDS AND pancreatitis; 67 unique patients comprised the cohort. Median age was 48 years (range, 23 to 60 years). Thirty seven (55%) were male, 30 (45%), female. Two third (n = 51) (76%) were African American. Known risk factors included a history of pancreatitis, 17 (25%); cholecystitis, 13 (19%); alcohol abuse, 25 (37%); Intravenous drug abuse, 18 (27%). Only 36 (38%) admissions were on HAART regimen. Biochemical features on admission were: WBC, 6,100/mm3 (900 - 25,700); amylase, 152 U/L (30 - 1,344); lipase, 702.5 U/L (30 - 5,766), triglyceride, 65 mg/dL (57 - 400); glucose, 94 mg/dL (60 - 1,670); lactate, 2.3 mmol/L (1.09 - 5.49); AST, 61.5 U/L (9 - 1,950); LDH, 762 U/L (394 - 5,500); bicarbonate 19.5 mEq/L (3.3 - 82.7). Interestingly, 62% patients had normal pancreas on CT scan on admission. Of 67 individuals, hepatitis profile was available in 43, 21 (49%) were positive for HCV, 11 (26%) had markers for HBV. Four of 11 patients (36) with CD4 < 50 had evidence of persistent HBV (+core, -surface ab). Patients with CD4 < 200 have a median time for hospital course of 8 days (range 4 - 61 days) compare to 3 days in patients with CD4 > 200. P = 0.03 via t-test comparison. One patient with CD4 < 50 died due to acute pancreatitis. Conclusion Pancreatitis remains a major cause of morbidity in HIV-infected individuals. This study has provided detailed features in the HAART therapy era about the clinical, biochemical and radiological features of pancreatitis. Half of our patients were positive for HCV; additionally, 36% with CD4 < 50 had persistent HBV. As opposed to earlier studies, we did not find a female predominance. Patients with CD4 < 200 had a 2.67-fold increase length of stay. Future studies are needed for a closer look on viral cofactors which might precipitate episodes of acute pancreatitis.
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Affiliation(s)
- Shahzad Raza
- Department of Internal Medcine, Brookdale University Hospital and Medical Center, New York, NY, USA
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Cryptic parasite revealed improved prospects for treatment and control of human cryptosporidiosis through advanced technologies. ADVANCES IN PARASITOLOGY 2012; 77:141-73. [PMID: 22137584 DOI: 10.1016/b978-0-12-391429-3.00007-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Cryptosporidium is an important genus of parasitic protozoa of humans and other vertebrates and is a major cause of intestinal disease globally. Unlike many common causes of infectious enteritis, there are no widely available, effective vaccine or drug-based intervention strategies for Cryptosporidium, and control is focused mainly on prevention. This approach is particularly deficient for infections of severely immunocompromised and/or suppressed, the elderly or malnourished people. However, cryptosporidiosis also presents a significant burden on immunocompetent individuals, and can, for example have lasting effects on the physical and mental development of children infected at an early age. In the last few decades, our understanding of Cryptosporidium has expanded significantly in numerous areas, including the parasite life-cycle, the processes of excystation, cellular invasion and reproduction, and the interplay between parasite and host. Nonetheless, despite extensive research, many aspects of the biology of Cryptosporidium remain unknown, and treatment and control are challenging. Here, we review the current state of knowledge of Cryptosporidium, with a focus on major advances arising from the recently completed genome sequences of the two species of greatest relevance in humans, namely Cryptosporidium hominis and Cryptosporidium parvum. In addition, we discuss the potential of next-generation sequencing technologies, new advances in in silico analyses and progress in in vitro culturing systems to bridge these gaps and to lead toward effective treatment and control of cryptosporidiosis.
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Shamamian P, Kingman P, Mallen-St. Clair J, Bar-Sagi D. Pathophysiology of Acute Pancreatitis. IMAGING OF THE PANCREAS 2009. [DOI: 10.1007/978-3-540-68251-6_1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Tomonari A, Takahashi S, Takasugi K, Ooi J, Tsukada N, Konuma T, Iseki T, Tojo A, Asano S. Pancreatic hyperamylasemia and hyperlipasemia in association with cytomegalovirus infection following unrelated cord blood transplantation for acute myelogenous leukemia. Int J Hematol 2007; 84:438-40. [PMID: 17189226 DOI: 10.1532/ijh97.06119] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cytomegalovirus (CMV)-associated pancreatitis is rare after allogeneic hematopoietic stem cell transplantation (SCT). We describe a patient who developed pancreatic hyperamylasemia and hyperlipasemia in association with CMV infection after cord blood transplantation (CBT). A 31-year-old man with acute myelogenous leukemia underwent CBT. A neutrophil count consistently greater than 500/microL was achieved on day +21. Positive results for CMV antigenemia on days +35 and +67 prompted 2 courses of preemptive therapy with ganciclovir or foscarnet. The CMV antigenemia value again became positive on day +134. On day +141, serum amylase and lipase activities markedly increased to 1221 IU/L and 894 IU/L, respectively. The patient had no abdominal symptoms. Ultrasonography and computed tomography results showed no abnormalities of the pancreas. A diagnosis of possible pancreatitis was made. After the initiation of foscarnet therapy, the CMV antigenemia results soon became negative, and serum amylase and lipase activities returned to normal. Therefore, CMV infection was considered to play a major role in the development of pancreatic hyperamylasemia and hyperlipasemia in our patient. The present report indicates that CMV infection should be included in the differential diagnosis for patients with pancreatic hyperamylasemia after SCT.
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Affiliation(s)
- Akira Tomonari
- Department of Hematology/Oncology, The Institute of Medical Science, The University of Tokyo, Tokyo, Japan.
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Shankar S, vanSonnenberg E, Silverman SG, Tuncali K, Banks PA. Imaging and Percutaneous Management of Acute Complicated Pancreatitis. Cardiovasc Intervent Radiol 2004; 27:567-80. [PMID: 15578132 DOI: 10.1007/s00270-004-0037-1] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Acute pancreatitis varies from a mild, self-limited disease to one with significant morbidity and mortality in its most severe forms. While clinical criteria abound, imaging has become indispensable to diagnose the extent of the disease and its complications, as well as to guide and monitor therapy. Percutaneous interventional techniques offer options that can be life-saving, surgery-sparing or important adjuncts to operation. Close cooperation and communication between the surgeon, gastroenterologist and interventional radiologist enhance the likelihood of successful patient care.
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Affiliation(s)
- Sridhar Shankar
- Department of Radiology, Brigham and Women's Hospital, Boston, MA 02115, USA
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Gómez-Domínguez E, Rodríguez Serrano DA, Mendoza J, Iscar T, Sarriá C, García-Buey L. [Bile duct obstruction due to non-Hodkin's lymphoma in patients with HIV infection]. GASTROENTEROLOGIA Y HEPATOLOGIA 2003; 26:639-42. [PMID: 14670238 DOI: 10.1016/s0210-5705(03)70424-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Acquired immune deficiency syndrome increases the risk of developing non-Hodgkin's B-cell lymphoma (NHL) (relative risk over 100). NHL tend to be high-grade and to affect the central nervous system and digestive tract. Biliary tract compression is usually due to external compression from enlarged lymph nodes, but is not usually the first manifestation.We describe 2 cases of bile duct obstruction secondary to NHL in patients diagnosed with HIV infection. Histological diagnosis of the lymphoma can be difficult but is necessary so that these patients do not undergo highly aggressive surgical treatment instead of chemotherapy, which currently produces the best results. Therefore, we emphasize the importance of including lymphomas in the differential diagnosis of bile duct obstruction in patients with HIV infection.
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Affiliation(s)
- E Gómez-Domínguez
- Servicio de Aparato Digestivo. Hospital Universitario de La Princesa. Madrid. Spain.
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Floris-Moore MA, Amodio-Groton MI, Catalano MT. Adverse Reactions to Trimethoprim/Sulfamethoxazole in AIDS. Ann Pharmacother 2003; 37:1810-3. [PMID: 14632594 DOI: 10.1345/aph.1d179] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVE To report the case of a woman with AIDS who developed tremor, acute pancreatitis, and elevated serum creatinine levels while receiving trimethoprim/sulfamethoxazole (TMP/SMX). CASE SUMMARY A 37-year-old Puerto Rican woman with AIDS, HIV nephropathy, and a recent history of disseminated histoplasmosis presented with fever, nonproductive cough, pancytopenia, and elevated transaminase and alkaline phosphatase levels. Serum creatinine was near her baseline level of 2.9 mg/dL. Treatment was started with amphotericin B lipid complex for histoplasmosis and intravenous TMP/SMX for presumed Pneumocystis carinii pneumonia. Two days later, the patient developed a high-frequency tremor and severe abdominal pain, and serum creatinine increased to 5.6 mg/dL. TMP/SMX was discontinued, after which the patient's symptoms resolved within 72 hours and serum creatinine returned to baseline levels. DISCUSSION A high incidence of adverse reactions to TMP/SMX has been reported among HIV-infected persons. Toxic sulfamethoxazole metabolites may elicit hypersensitivity reactions. Trimethoprim can inhibit renal creatinine secretion, leading to high serum creatinine levels. Trimethoprim also inhibits dihydrofolate reductase, causing decreased dopamine production, which may lead to parkinsonian symptoms. Use of the Naranjo probability scale indicated a probable relationship between the adverse effect and TMP/SMX. CONCLUSIONS The high frequency and wide range of potential adverse effects associated with the use of TMP/SMX in HIV-infected persons require that clinicians consider drug toxicity as a cause of new symptoms in patients receiving this medication.
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Affiliation(s)
- Michelle A Floris-Moore
- Division of Infectious Diseases, Department of Medicine and Department of Epidemiology & Population Health, Montefiore Medical Center and Albert Einstein College of Medicine, Bronx, NY, USA.
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Abstract
Pancreatitis is clearly associated with alcohol abuse, but only a relatively small percentage of people who abuse alcohol develops obvious pancreatitis. These observations have led to the concept that the development of alcoholic pancreatitis requires cofactors. Although diet and smoking have been studied, a clear cofactor has not been identified. The study results presented in this paper were obtained to determine whether viral infection of the pancreas would be a cofactor for alcoholic pancreatitis similar to the role of hepatitis virus infections in the development of alcoholic liver disease. To test this hypothesis, mice were fed ethanol with a liquid diet protocol and infected with coxsackievirus B3 (CVB3). It was found that consumption of alcohol alone did not result in pancreatitis as determined by serum levels of amylase or histologic changes in the pancreas. Two strains of CVB3 that are tropic for the pancreas were used; a virulent and an avirulent strain. Infection of alcohol-fed animals with the virulent CVB3 strain 28 resulted in a more severe pancreatitis than the pancreatitis noted in control animals. Alcohol-fed mice infected with the avirulent strain (GA) showed severe pancreatitis, whereas the infection of control mice did not result in obvious pathologic effects in the pancreas. This model allows mechanistic studies to define the role of viral infection as a cofactor for alcoholic pancreatitis.
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Affiliation(s)
- Thomas R Jerrells
- Department of Pathology and Microbiology, University of Nebraska Medical Center, Omaha, Nebraska 68198-6495, USA
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Jimeno Sainz A, Blázquez Encinar JC, García-Herola A, De Teresa Parreño L. Acute pancreatitis as the first manifestation of pancreatic Burkitt's lymphoma in a patient infected by the human immunodeficiency virus. Am J Med 2001; 110:744. [PMID: 11417569 DOI: 10.1016/s0002-9343(01)00725-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Chehter EZ, Longo MA, Laudanna AA, Duarte MI. Involvement of the pancreas in AIDS: a prospective study of 109 post-mortems. AIDS 2000; 14:1879-86. [PMID: 10997390 DOI: 10.1097/00002030-200009080-00001] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Pancreatic involvement in AIDS is rarely mentioned in medical literature. AIMS To identify the main morphological patterns of the pancreas using optical and electron microscopy in AIDS patients. DESIGN An open, prospective, and sequential study in a tertiary institutional hospital. METHODS Consecutive post-mortems of 109 AIDS patients and 38 controls (1995). Baseline characteristics of AIDS patients and controls were evaluated. Morphological analysis consisted of: (i) semi-quantitative score of acinar and parenchymal elements; (ii) qualitative analysis of ducts, vascular components, nerves, and Langerhans' islets; (iii) specific stains and immunohistochemistry for opportunistic agents; (iv) ultrastructural data. RESULTS The mean age of AIDS patients was 37 years; 80% were male; 60% were white; 21% were alcoholic. All patients with AIDS had normal blood amylase, blood glucose, and pancreatic ultrasound. Histological findings were: acinar atrophy (60%), few zymogen granula in acinar cytoplasm (52%), abnormalities in acinar nucleus (65%), pancreatic steatosis (66%), and focal necrosis (17%). Immunohistochemistry revealed: mycobacteriosis (22%), toxoplasmosis (13%), cytomegalovirus (9%), Pneumocystis carinii (9%), and HIV p24 antigen in macrophage cytoplasm (22%). Ultrastructural examination showed: decreased zymogen granula, enlargement and proliferation of the endoplasmic reticulum and mitochondria, nuclear abnormalities, and increased lipid droplets in acinar cytoplasm. CONCLUSION Pancreatic involvement in AIDS is very frequent (90%) and is usually asymptomatic. Morphological changes showed three patterns of pancreatic alterations: 'nutritional-like', inflammatory and both of these together. The 'nutritional-like' pattern (atrophy, few zymogen granula and steatosis) may be due to many factors such as nutritional characteristics (Kwashiorkor-like) induced by the HIV infection or related to the HIV virus itself.
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Affiliation(s)
- E Z Chehter
- Department of Gastroenterology, Medical School, São Paulo University, Brazil
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Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 19-2000. A 17-year-old boy with obstructive jaundice. N Engl J Med 2000; 342:1893-900. [PMID: 10861326 DOI: 10.1056/nejm200006223422508] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Max B, Sherer R. Management of the adverse effects of antiretroviral therapy and medication adherence. Clin Infect Dis 2000; 30 Suppl 2:S96-116. [PMID: 10860894 DOI: 10.1086/313859] [Citation(s) in RCA: 136] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A commonly cited cause of poor adherence to highly active antiretroviral therapy (HAART) is adverse drug reactions. Short-term adverse effects are potential threats to successful introduction and maintenance of HAART. The long-term toxicities of HAART are still emerging and being defined, as evidenced by the recently described metabolic disorders (i.e., the syndrome of maldistribution, hyperlipemia, glucose intolerance and insulin resistance). With 14 licensed agents in 2000, other agents in common use, and numerous combinations of >/=3 drugs, awareness and recognition of adverse effects are increasingly important for clinicians and patients. The common adverse drug reactions encountered with HAART, including new agents and their impact on patient adherence, are reviewed. Current strategies to anticipate and mitigate adverse effects are summarized.
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Affiliation(s)
- B Max
- CORE Center for Prevention, Care, and Research of Infectious Disease, Division of Infectious Disease, Chicago, IL 60612, USA.
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Carroccio A, Di Prima L, Di Grigoli C, Soresi M, Farinella E, Di Martino D, Guarino A, Notarbartolo A, Montalto G. Exocrine pancreatic function and fat malabsorption in human immunodeficiency virus-infected patients. Scand J Gastroenterol 1999; 34:729-34. [PMID: 10466886 DOI: 10.1080/003655299750025958] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Nutrients malabsorption frequently occurs in human immunodeficiency virus (HIV)-infected patients, but very few studies have investigated exocrine pancreatic digestive capacity in these patients. We therefore evaluated the frequency of exocrine pancreatic impairment and its eventual relation with fat malabsorption in HIV-infected patients. METHODS Thirty-five HIV-infected patients (30 male, 5 female: mean age +/- standard deviation, 33.6 +/- 7.2 years) and 51 sex- and age-matched controls without gastroenterologic diseases were studied. In all subjects fecal elastase 1 (EL-1) was assayed, and fecal fat excretion was evaluated with the steatocrit test. RESULTS Nineteen of 35 (54%) HIV-infected patients showed subnormal EL-1 values, whereas all the controls had normal values; furthermore, EL-1 values were significantly lower in patients than in controls: mean (95% confidence intervals), 207 ( 164-251 ) microg/g versus 312 (291-332) microg/g (P < 0.0001). Increased fecal fat excretion was observed in almost all (25 of 35) HIV-infected patients, and an inverse but not significant correlation was found between fecal EL-1 and steatocrit values. No association was found between reduced fecal EL-1 and the severity of HIV disease or nutritional and immunologic status. Opportunistic infections and drug administration had no influence on EL-1 concentrations in stools. CONCLUSIONS Reduced exopancreatic function is frequent in HIV-infected patients but does not seem to be a major factor contributing to fat malabsorption.
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Affiliation(s)
- A Carroccio
- Dept. of Internal Medicine, University of Palermo, Ospedale Guadagna of Palermo, Italy
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Manocha AP, Sossenheimer M, Martin SP, Sherman KE, Venkatesan T, Whitcomb DC, Ulrich CD. Prevalence and predictors of severe acute pancreatitis in patients with acquired immune deficiency syndrome (AIDS). Am J Gastroenterol 1999; 94:784-9. [PMID: 10086666 DOI: 10.1111/j.1572-0241.1999.00951.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Recent case control data suggested that a severe course of acute pancreatitis in HIV+ patients was 1) common (50% of cases), 2) poorly predicted by Ranson's criteria (sensitivity 41%), and 3) accurately predicted by a diagnosis of AIDS (positive predictive value 67%). However, the definition of severity included length of stay in hospital and excluded commonly accepted markers (local complications, systemic complications, and need for surgery). The aim of this study was to determine 1) the prevalence of severity and 2) the value of these predictors with regard to severity, as defined by commonly accepted standardized criteria in patients with AIDS and acute pancreatitis. METHODS A retrospective review identified 50 patients with AIDS exhibiting clinical, laboratory, and/or radiological features of acute pancreatitis. RESULTS Only five patients followed a severe course as defined by accepted markers. Of these patients, 29 had values available for at least nine of 11 of Ranson's criteria (sensitivity 80%, specificity 54%). Points were awarded most commonly for decreased serum Ca2+ (n = 14) and elevated serum LDH (n = 7). CONCLUSIONS In patients with AIDS and acute pancreatitis at our institutions, 1) the prevalence of severity and 2) the sensitivity of Ranson's criteria with regard to severity is comparable to that reported in large historical case series of immunocompetent patients. Pseudohypocalcemia and/or elevation in LDH are frequent, likely due to the catabolic infectious disease state.
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Affiliation(s)
- A P Manocha
- Department of Medicine, University of Cincinnati Medical Center, Ohio, USA
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Coelho JC, Wiederkehr JC, Parolin MB, Balbi E, Nassif AE. Isolated tuberculosis of the pancreas after orthotopic liver transplantation. LIVER TRANSPLANTATION AND SURGERY : OFFICIAL PUBLICATION OF THE AMERICAN ASSOCIATION FOR THE STUDY OF LIVER DISEASES AND THE INTERNATIONAL LIVER TRANSPLANTATION SOCIETY 1999; 5:153-5. [PMID: 10071356 DOI: 10.1002/lt.500050212] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
A patient presented with intermittent high fever, upper abdominal pain, and loss of appetite 9 months after an orthotopic liver transplantation. Computed tomography showed a large mass in the pancreas that was confirmed at laparotomy. Pathological examination of the pancreatic biopsy specimen showed several chronic granulomatous lesions with caseating necrosis. Two and one half months after beginning antituberculous treatment, there was an important reduction of the pancreatic mass.
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Affiliation(s)
- J C Coelho
- Division of Liver Transplantation, Clinical Hospital of the Federal University of Parana, Brazil
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18
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Gore RM, Miller FH, Yaghmai V. Acquired immunodeficiency syndrome (AIDS) of the abdominal organs: imaging features. Semin Ultrasound CT MR 1998; 19:175-89. [PMID: 9567322 DOI: 10.1016/s0887-2171(98)90059-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The liver, spleen, biliary tract, pancreas, and kidneys are commonly affected by opportunistic infection, malignancy, and inflammatory disorders during the course of human immunodeficiency virus (HIV) infection. Clinical manifestations of solid abdominal visceral involvement are protean and usually nonspecific, but it is important to establish a specific diagnosis promptly in these often critically ill patients. This presentation reviews the cross-sectional imaging spectrum of HIV-associated lesions of these organs.
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Affiliation(s)
- R M Gore
- Department of Radiology, Northwestern University Medical School, Chicago, IL, USA
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Abstract
Pancreatic disease in patients with AIDS often is so mild that the diagnosis may be missed. The pancreas can be affected by systemic illness caused by opportunistic infections, Kaposi's sarcoma, or lymphoma. More commonly, drugs used to treat patients infected with human immunodeficiency virus can cause pancreatitis and result in significant morbidity and, rarely, mortality. We report one such case in a 47-year-old patient with AIDS in whom pancreatitis developed while taking 2',3'-dideoxyinosine (ddI). His condition improved on ddI withdrawal, but he suffered a fatal relapse while receiving 2',3'-dideoxycytidine and trimethoprim-sulfamethoxazole. This case gives me the opportunity to review the literature regarding the incidence, causes, and diagnosis of human immunodeficiency virus-associated pancreatitis.
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Affiliation(s)
- D M Aboulafia
- Section of Hematology/Oncology, Virginia Mason Medical Center, Seattle, Washington 98111, USA
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Lesprit P, de La Blanchardiere A, Guibal A, Gauthier J, Modaï J, Decazes J. Diabète sucré médicamenteux au cours de l'infection par le VIH. A propos de cinq cas. Med Mal Infect 1997. [DOI: 10.1016/s0399-077x(97)80248-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Teare JP, Daly CA, Rodgers C, Padley SP, Coker RJ, Main J, Harris JR, Scullion D, Bray GP, Summerfield JA. Pancreatic abnormalities and AIDS related sclerosing cholangitis. Genitourin Med 1997; 73:271-3. [PMID: 9389948 PMCID: PMC1195856 DOI: 10.1136/sti.73.4.271] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVES Biliary tract abnormalities are well recognised in AIDS, most frequently related to opportunistic infection with Cryptosporidium, Microsporidium, and cytomegalovirus. We noted a high frequency of pancreatic abnormalities associated with biliary tract disease. To define these further we reviewed the clinical and radiological features in these patients. METHODS Notes and radiographs were available from two centres for 83 HIV positive patients who had undergone endoscopic retrograde cholangiopancreatography for the investigation of cholestatic liver function tests or abdominal pain. RESULTS 56 patients had AIDS related sclerosing cholangitis (ARSC); 86% of these patients had epigastric or right upper quadrant pain and 52% had hepatomegaly. Of the patients with ARSC, 10 had papillary stenosis alone, 11 had intra- and extrahepatic sclerosing cholangitis alone, and 35 had a combination of the two. Ampullary biopsies performed in 24 patients confirmed an opportunistic infection in 16. In 15 patients, intraluminal polyps were noted on the cholangiogram. Pancreatograms were available in 34 of the 45 patients with papillary stenosis, in which 29 (81%) had associated pancreatic duct dilatation, often with associated features of chronic pancreatitis. In the remaining 27 patients, final diagnoses included drug induced liver disease, acalculous cholecystitis, gall bladder empyema, chronic B virus hepatitis, and alcoholic liver disease. CONCLUSION Pancreatic abnormalities are commonly seen with ARSC and may be responsible for some of the pain not relieved by biliary sphincterotomy. The most frequent radiographic biliary abnormality is papillary stenosis combined with ductal sclerosis.
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Affiliation(s)
- J P Teare
- Department of Gastroenterology, St Mary's Hospital, Paddington, London
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Barthet M, Chauveau E, Bonnet E, Petit N, Bernard JP, Gastaut JA, Sahel J. Pancreatic ductal changes in HIV-infected patients. Gastrointest Endosc 1997; 45:59-63. [PMID: 9013171 DOI: 10.1016/s0016-5107(97)70303-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND AIDS-related sclerosing cholangitis occurs in patients with advanced immunodeficiency, but ductal pancreatic alterations have not been evaluated in large series. METHODS Twenty-nine consecutive patients with a mean age of 33 years underwent ERCP for biliary work-up. Complete pancreatography was obtained in 28 patients. Serum levels of amylase were increased in 17 patients prior to ERCP. The mean duration of HIV infection was 6.1 years (range 3 to 10 years). RESULTS Fifteen patients (53.6%) had pancreatographic changes classified according to the Cambridge classification (stage 1, 4 cases; stage 2, 7 cases; stage 3, 4 cases). Dilatations, irregularities, short stenoses of the main pancreatic duct, and irregularities of side branches were the most frequent abnormalities. Fourteen of these 15 patients (93.3%) had cholangitis and a CD4 cell count of less than 60 per cubic millimeter. Risk factors for pancreatic damage were similar in patients with and without pancreatographic changes. Opportunistic infection occurred in 14 of 15 patients with pancreatographic changes (candida, cytomegalovirus, cryptosporidia, microsporidia, and mycobacteria). CONCLUSION Abnormal pancreatographies were found in about half of the HIV-infected patients who underwent ERCP. The pancreatographic features were suggestive of chronic pancreatitis and were closely related to the presence of AIDS-related sclerosing cholangitis.
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Affiliation(s)
- M Barthet
- Department of Gastroenterology and Hepatology, Hopital Sainte-Marguerite, Marseille, France
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Abstract
Endocrine abnormalities occur frequently in HIV-infected patients. Although the majority of endocrine disorders reflect chronic infection, stress, and malnutrition, some disorders are characteristic of HIV infection or AIDS and deserve particular clinical attention. Identification of HIV patients at risk of frank endocrine disorders, rapid and correct diagnosis, and appropriate management are essential steps to minimize morbidity and mortality. Finally, increasing evidence from in vitro studies suggests that various hormones may influence HIV replication as well as the course of HIV disease and associated disorders. Future studies on the molecular mechanisms of hormones on HIV action and clinical studies on the effects of hormones as adjunctives to established forms of therapy may stimulate development of novel therapeutic strategies that will benefit HIV-infected patients.
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Affiliation(s)
- L C Hofbauer
- Medizinische Klinik, Klinikum Innenstadt, Ludwig-Maximilians-Universität, Munich, Germany
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Vidotto V, Aoki S, Campanini G. A vitamin-free minimal synthetic medium for Cryptococcus neoformans. Mycopathologia 1996; 133:139-42. [PMID: 8927118 DOI: 10.1007/bf02373020] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
The use of a simple synthetic medium is essential for study on the growth and physiology of Cryptococcus neoformans. In the present study, a minimal synthetic liquid medium (MSM) was tested for the growth of 23 C. neoformans strains. This medium contained a low concentration of glucose, ammonium sulphate and inorganic salts with a pH value of 4.5, but no amino acids or vitamins. The strains were starved for 4 days to eliminate nutrients which might have been carried over from their pre-culture medium. Then, they were inoculated in the MSM as an initial OD of 0.020 at 550 nm and incubated at 37 degrees C for 20 days. Cell growth was generally monitored daily by measuring the absorbance at 550 nm. The medium supported the growth of the strains tested and gave an average final OD of 0.500. The results obtained indicate that C. neoformans may be autotrophic with respect to vitamins and in particular to thiamine. The MSM medium is easy to prepare and store. It is highly reproducible and useful for studies on the growth and physiology of C. neoformans.
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Affiliation(s)
- V Vidotto
- Istituto Malattie Infettive, Università di Torino, Italy
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Coronado O, Mastroianni A, Scarani P, Manfredi R, Chiodo F. Toxoplasmic pancreatitis in a patient with AIDS. Med Mal Infect 1995. [DOI: 10.1016/s0399-077x(05)80319-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Pelucio MT, Rothenhaus T, Smith M, Ward DJ. Fatal pancreatitis as a complication of therapy for HIV infection. J Emerg Med 1995; 13:633-7. [PMID: 8530781 DOI: 10.1016/0736-4679(95)00068-l] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Acute pancreatitis in HIV-infected patients with or without AIDS has been reported with increasing frequency over the past several years. Drugs used to treat HIV-infected patients are often the cause. We report a case of a 46-year-old HIV-infected man who presented to the emergency department with abdominal pain and was diagnosed with acute pancreatitis. The patient had recently begun taking 2',3'-dideoxyinosine (ddI). He died shortly after admission to the hospital; CT scan and autopsy confirmed the cause of death as hemorrhagic pancreatitis. We briefly review the literature on the incidence and severity of pancreatitis in association with ddI and pentamidine therapy.
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Affiliation(s)
- M T Pelucio
- Department of Emergency Medicine, Ronald Reagan Institute of Emergency Medicine, George Washington University Medical Center, Washington, District of Columbia, USA
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Abstract
PURPOSE To analyze whether pancreatitis presents differently in HIV-seropositive patients compared to the general population, and to evaluate the accuracy of classic predictors of pancreatitis severity in patients with HIV infection. METHODS A multiyear, multicenter, retrospective study of 44 consecutive patients with acute pancreatitis and HIV and 44 consecutive control patients with acute pancreatitis without HIV. RESULTS Of 939 hospitalized patients with HIV, 44 (4.7%) had acute pancreatitis, 27 of whom had AIDS. Pancreatitis presented with similar clinical findings in HIV patients and controls except that HIV patients had greater anemia, hypoalbuminemia, and leukopenia (Student's t-test P < 0.0001, < 0.0002, < 0.0001, respectively), and a higher incidence of fever, diarrhea, and hepatomegaly. These differences probably stem from HIV-related immunosuppression and malnourishment rather than pancreatitis. Patients with HIV had a higher frequency of medication-associated pancreatitis due to pancreatoxic medications used in HIV patients (18 versus 2 cases; odds ratio [OR] 14.54; Student's t-test P < 0.0001). They had a lower frequency of gallstone pancreatitis (2 versus 22 cases; OR 0.05; P < 0.0001). Patients with HIV had a higher frequency of a severe hospital course, defined as prolonged hospitalization or death in hospital (22 versus 12 cases; chi-square P < 0.05). The presence of AIDS or leukopenia in patients with HIV was strongly associated with a severe hospital course. The Ranson and modified Glasgow scales were poor predictors of disease severity in HIV patients (eg, Ranson scale sensitivity 41%; positive predictive value 53%; negative predictive value 52%). These scales' lack of markers of immunosuppression impeded their performance. The APACHE II scale, which contains markers of immunosuppression, was a moderately robust predictor of disease severity in HIV patients (sensitivity 73%; specificity 68%; positive predictive value 70%; negative predictive value 71%). All three scales predicted the disease severity in control patients well. CONCLUSIONS Pancreatitis presents similarly in HIV patients as in the general population with the following significant differences: a high frequency of medication-associated pancreatitis, a low frequency of gallstone pancreatitis, a high frequency of HIV-related causes (most commonly from HIV-related drugs), additional symptoms and signs due to underlying immunosuppression, and a more severe hospital course. The APACHE II system can be used to predict whether a patient with HIV and pancreatitis is at risk for prolonged hospitalization or death in hospital.
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Affiliation(s)
- M S Cappell
- Department of Medicine, University of Medicine and Dentistry, New Jersey-Robert Wood Johnson Medical School, New Brunswick 08903-0019
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AIDS aware. ACTA ACUST UNITED AC 1994; 8:174-9. [PMID: 11362151 DOI: 10.1089/apc.1994.8.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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