Mycobacterial and nonbacterial pulmonary complications in hospitalized patients with human immunodeficiency virus infection: a prospective, cohort study

Viral infections in inflammatory bowel disease: Tips and tricks for correct management

Over the past decades, the treatment of inflammatory bowel diseases (IBD) has become more targeted, anticipating the use of immune-modifying therapies at an earlier stage. This top-down approach has been correlated with favorable short and long-term outcomes, but it has also brought with it concerns regarding potential infectious complications. This large IBD population treated with immune-modifying therapies, especially if combined, has an increased risk of severe infections, including opportunistic infections that are sustained by viral, bacterial, parasitic, and fungal agents. Viral infections have emerged as a focal safety concern in patients with IBD, representing a challenge for the clinician: they are often difficult to diagnose and are associated with significant morbidity and mortality. The first step is to improve effective preventive strategies, such as applying vaccination protocols, adopt adequate prophylaxis and educate patients about potential risk factors. Since viral infections in immunosuppressed patients may present atypical signs and symptoms, the challenges for the gastroenterologist are to suspect, recognize and diagnose such complications. Appropriate treatment of common viral infections allows us to minimize their impact on disease outcomes and patients’ lives. This practical review supports this standard of care to improve knowledge in this subject area.

Etiology of Respiratory Complications among Iranian HIV Infected Patients

BACKGROUND

Infection with Human Immune deficiency Virus (HIV) is a growing problem in developing countries. Among HIV infected cases, respiratory complications are common, dissimilar in different setting and their diagnosis is challenging. The aim of this study was to determine the spectrum of infectious and non-infectious pulmonary complications among HIV infected patients.

MATERIALS AND METHODS

The retrospective study was done among 710 HIV infected patients admitted in Masih Daneshvari Hospital, National Research Institute of Tuberculosis and Lung Diseases, Tehran, Iran from January 2003 to March 2017. Demographic, clinical, radiologic and laboratory data of 836 episodes of pulmonary complications were reviewed and final diagnosis were extracted.

RESULTS

Mean of CD₄ cell count was 90±131 ×10⁶ cells/L. Definite etiology was found for 653 episodes (78.1%) of pulmonary complications. Infectious respiratory diseases were clearly more common than non-infectious etiologies, 86.1 and 7.6%, respectively. Pulmonary tuberculosis, as the leading cause, involved 542 cases (64.8%) and Pneumocystis jiroveci (P. jiroveci) was the second infectious agent that was found in 111 cases (13.2%). Among non- infectious causes, bronchiectasis and Chronic Obstructive Pulmonary Disease (COPD) exacerbation were on the top of the list, 21 of 64 (32.8%) and 18 0f 64 (28.1%), respectively. Many patients had more than one etiology. P. jiroveci had the highest tendency for dual infections (43 episodes).

CONCLUSION

Pulmonary complications, especially infections are common among HIV cases in Iran, among them tuberculosis is the most common. Respiratory problems may be the first presentation of HIV infection. Clinicians should be aware about the risk of dual infections. Screening for HIV among all tuberculosis cases and vice versa is recommend.

Mycobacterium avium complex infection in patients with human immunodeficiency virus: A systematic review and meta-analysis

BACKGROUND

Mycobacterium avium-intracellulare complex (MAC) is one of the leading causes of death among people living with human immunodeficiency virus (HIV). The current study was aimed to determine the frequency of MAC infection in patients infected with HIV.

METHODS

Embase, PubMed, and Web of Science were searched for relevant studies. All statistical analyses were performed by STATA version 14.

RESULTS

From 6,627 retrieved articles, 23 were included in the final analysis. A total of 18,463 patients with HIV were included in the analysis. The frequency of MAC infection in patients with HIV was found to be 10.6% (95% confidence interval, 6.9-14.2).

CONCLUSION

The relatively large fractions of HIV-infected patients were coinfected with MAC, which may poses significant public health problems. Continued progress in the development of rapid diagnostic methods and preventive therapy for MAC should lead to further improvements in survival and quality of life in patients with HIV.

Pneumocystis jirovecii immunostain versus Gomori/Grocott methenamine silver stain of bronchoalveolar lavage in cell blocks: an institutional experience

INTRODUCTION

Current approaches to Pneumocystis jirovecii (PCJ) screening on bronchioalveolar lavage samples (BAL) include Gomori/Grocott methenamine silver stain (GMS), toluidine blue O stain, Wright-Giemsa stain, immunofluorescent antibody stain, and polymerase chain reaction. Another method available is PCJ immunohistochemistry stain (PCJ IHC). There are no published series evaluating the efficacy of PCJ IHC in cell block preparation of BAL, we sought to compare GMS versus PCJ IHC at our institution.

MATERIALS AND METHODS

We performed a retrospective analysis at our institution of all BAL with cell blocks where PCJ IHC and GMS were done simultaneously since March 2015.

RESULTS

982 BAL samples were identified from 640 patients (median age: 54 years; range: 1-84 years). For 895 cases, GMS and PCJ IHC were performed simultaneously. PCJ was identified in 14 samples, from 13 patients (2.2% of patients) using PCJ IHC. GMS stains were read as positive in only 6 of these 14 cases (42.8%); in two of those cases, PCJ was easily identified on routine Papanicolaou stains. We repeated GMS staining on those 14 cases following before-schedule maintenance in our Ventana Benchmark Autostainer, identifying 12 cases positive. In addition, a significantly higher number of organisms was seen on repeat GMS (median: 58) than the original GMS (median: 8.7). Nevertheless, a statistically significant higher number of organisms was detected by PCJ IHC (median: 474).

CONCLUSIONS

PCJ IHC performed in cell block is more sensitive and specific than GMS and is a reliable marker when a low number of PCJ organisms are present.

Respiratory Complications in Iranian Hospitalized Patients with HIV/AIDS

Background

The respiratory tract has been the most commonly affected site of illness in HIV-infected patients. The current study was done to identify the frequency of respiratory complications in a consecutive case series of HIV-positive patients in Iran.

Materials and Methods

This study was a retrospective analysis at the national academic reference medical center of Imam-Khomeini Hospital, in Tehran, Iran. The study included 199 new admissions for 177 HIV-infected patients between 2000 and 2005. Demographic characteristics, risk factors for HIV infection, respiratory complications, and CD4+ lymphocyte counts were evaluated in these patients.

Results

All patients were males. The mean age was 35 years (age range: 15 to 63 years). Among 34 cases with available CD4+ lymphocyte count results, 70.6% had results <200 cells/mm³. Nearly half the patients (47.7%) had respiratory symptoms. The most common pulmonary complications were cough (86.3%), sputum (71.6%), dyspnea (54.7%), and hemoptysis (10.5%). The most common diagnosis was pulmonary tuberculosis (27.1%), followed by other bacterial pneumonias (16.6%) and pneumocystis carinii pneumonia (4.5%). Intravenous drug users who had history of incarceration had the highest risk factors for Mycobacterium tuberculosis infection (59%), and other bacterial pneumonias (52%).

Conclusion

Our study demonstrates that respiratory complications are highly frequent in HIV patients in Iran and that pulmonary tuberculosis is still a common complication in HIV infected patients, despite the availability of effective treatment. Results suggest the need for more effective preventive and prophylactic measures, wider use of antiretroviral treatment and effective chemotherapy for Iranian patients with HIV/AIDS.

Occurrence of HSV-1-induced pneumonitis in patients under standard immunosuppressive therapy for rheumatic, vasculitic, and connective tissue disease

BACKGROUND

Herpes simplex virus type-1 (HSV-1) has been described to cause respiratory tract infections in critically ill patients or in individuals that are immunocompromised. It is a continuing matter of debate under which circumstances HSV-1 is a relevant pathogen for pneumonitis. While its role during critical illness has been investigated by prospective interventional studies, comparatively little systematic data is available on the role of HSV-1 for pneumonitis in outpatients with autoimmune disease under a maintenance regimen of immunosuppression.

METHODS

We retrospectively reviewed the charts of approximately 1400 patients with rheumatoid arthritis, vasculitis, and systemic lupus erythematosus (SLE) that were followed at the outpatient clinic of a German University hospital during the years 2000-2007. Episodes of admission to a ward resulting in the diagnosis of pneumonia/pneumonitis were identified, and the type of pneumonia and clinical features retrospectively studied.

RESULTS

63 patients with rheumatoid arthritis, vasculitis, or SLE were admitted to a ward and diagnosed to have pneumonia/pneumonitis. Using bronchoscopy a total of 6 cases of pulmonary infection associated with HSV-1 in the lower respiratory tract were identified. Among those, 2 cases suggested a causative role of HSV-1 as the sole agent causing pneumonitis that proved clinically responsive to antiviral treatment. In the remaining 4 cases HSV-1 appeared as a bystander of bacterial infection. Maintenance therapy with leflunomide, which inhibits HSV-1 assembly in vitro, was associated with a milder course of pneumonitis in one patient. Detection of HSV-1 was associated with stronger immunosuppressive regimens and vasculitic disease.

CONCLUSION

The present study analyzed the frequency and hallmarks of cases of HSV-1 associated pneumonitis that occurred in a comparatively large cohort of patients with rheumatologic autoimmune diseases. In an area of controversy, this study provides further evidence that HSV-1 causes isolated pneumonitis in the immunocompromised. The study may provide an estimate on the frequency of relevant HSV-1 infection and bacterial agents in outpatients with autoimmune disease.

Biodiversity of amoebae and amoeba-resisting bacteria in a hospital water network

Free-living amoebae (FLA) are ubiquitous organisms that have been isolated from various domestic water systems, such as cooling towers and hospital water networks. In addition to their own pathogenicity, FLA can also act as Trojan horses and be naturally infected with amoeba-resisting bacteria (ARB) that may be involved in human infections, such as pneumonia. We investigated the biodiversity of bacteria and their amoebal hosts in a hospital water network. Using amoebal enrichment on nonnutrient agar, we isolated 15 protist strains from 200 (7.5%) samples. One thermotolerant Hartmannella vermiformis isolate harbored both Legionella pneumophila and Bradyrhizobium japonicum. By using amoebal coculture with axenic Acanthamoeba castellanii as the cellular background, we recovered at least one ARB from 45.5% of the samples. Four new ARB isolates were recovered by culture, and one of these isolates was widely present in the water network. Alphaproteobacteria (such as Rhodoplanes, Methylobacterium, Bradyrhizobium, Afipia, and Bosea) were recovered from 30.5% of the samples, mycobacteria (Mycobacterium gordonae, Mycobacterium kansasii, and Mycobacterium xenopi) were recovered from 20.5% of the samples, and Gammaproteobacteria (Legionella) were recovered from 5.5% of the samples. No Chlamydia or Chlamydia-like organisms were recovered by amoebal coculture or detected by PCR. The observed strong association between the presence of amoebae and the presence of Legionella (P < 0.001) and mycobacteria (P = 0.009) further suggests that FLA are a reservoir for these ARB and underlines the importance of considering amoebae when water control measures are designed.