Response to Penicillin for Presumed Neurosyphilis in a Patient with Human Immunodeficiency Virus (HIV), a Normal CD4 Count, and an Undetectable Viral Load: A Case Report

Patient: Female, 69-year-old

Final Diagnosis: Neurosyphilis

Symptoms: Altered mental status • unresponsiveness

Medication: —

Clinical Procedure: —

Specialty: Critical Care Medicine • Infectious Diseases • General and Internal Medicine • Neurology

1035. Patient-Reported Outcomes on Long-Acting Cabotegravir + Rilpivirine as Maintenance Therapy: FLAIR 96-Week Results

Background

In the phase 3 FLAIR study, switching to monthly injectable long-acting (LA) cabotegravir (CAB) + rilpivirine (RPV) was noninferior to continued daily oral dolutegravir/abacavir/lamivudine (DTG/ABC/3TC) for the maintenance of virologic suppression over 96 weeks in adults with HIV-1. Key patient-reported outcomes (PROs) through Week 96 are presented.

Methods

In FLAIR, ART-naive adult participants received induction therapy with oral DTG/ABC/3TC for 20 weeks. Those with HIV-1 RNA < 50 c/mL at 16 weeks were randomized (1:1) to continue DTG/ABC/3TC or receive monthly CAB + RPV LA injections after a 4-week lead-in with daily oral CAB + RPV through Week 96. Treatment satisfaction (HIV Treatment Satisfaction Questionnaire status version [HIVTSQs]) and acceptability of injections (Perception of Injection [PIN] Questionnaire) up to Week 96 were secondary endpoints.

Results

A total of 566 participants were randomized (median age, 34 years; 22% female); baseline characteristics were similar between treatment groups. At Week 96, significantly greater improvement from baseline in total treatment satisfaction score was observed in the CAB + RPV LA vs DTG/ABC/3TC treatment group (adjusted mean difference, 2.3 [95% CI, 1.1-3.5]; P< 0.001), further increasing from Weeks 24 (2.1 [0.9-3.3]) and 44 (0.7 [−0.4, 1.9]). Key drivers for the difference in HIVTSQs between treatment groups were items assessing convenience, flexibility, and satisfaction to continue with LA therapy. In participants receiving CAB + RPV LA, mean score for the “Acceptability of ISRs” dimension of PIN (scale, 1-5) significantly decreased (improved) from Week 5 to Weeks 41, 48, and 96 (2.08 to 1.71, 1.66, and 1.71, respectively; P< 0.001 for all). In addition, 82% and 85% of LA participants, respectively, rated pain and local reactions due to injections as “totally” or “very acceptable” at Week 96.

Conclusion

At Week 96, FLAIR participants receiving LA therapy reported greater improvement in treatment satisfaction compared with participants continuing on daily oral medication as well as overall good acceptability of injections with improvement over time. Overall, these results support monthly CAB + RPV LA as an alternative to daily oral regimens for adults with HIV-1.

Disclosures

Vasiliki Chounta, MSc, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) Sharon Walmsley, FRCPC, MD, MSC, GSK (Grant/Research Support)ViiV Healthcare (Grant/Research Support) David Dorey, MMATH, GlaxoSmithKline Inc. (Employee, Shareholder) William Spreen, PharmD, ViiV Healthcare (Employee, Shareholder) Sandy Griffith, PharmD, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee) David Margolis, MD, MPH, GlaxoSmithKline (Shareholder)ViiV Healthcare (Employee)

Experiences of HIV-related discrimination and consequences for internalised stigma, depression and alcohol use

Objective: HIV stigma undermines health and well-being of people living with HIV (PLWH). Conceptual work on stigma mechanisms suggests that experiences of stigma or discrimination increase internalised stigma. However, not all PLWH may internalise the HIV discrimination they experience. We aimed to investigate the role of stress associated with events of HIV-related discrimination on internalised HIV stigma, as well as the downstream effects on depressive symptoms and alcohol use severity. Design: 199 participants were recruited from an HIV clinic in the southeastern United States. Main study measures: HIV-related discrimination was assessed using items adapted from measures of enacted HIV stigma and discrimination. Participants rated perceived stress associated with each discrimination item. Internalised HIV stigma was assessed using the internalised stigma subscale of the HIV Stigma Mechanisms Scale. Depressive symptoms were assessed with the Centre for Epidemiological Studies-Depression Index. Alcohol use severity was assessed with the Alcohol Use Disorders Identification Test. Results: In serial mediation models, HIV-related discrimination was indirectly associated with both depressive symptoms and alcohol use severity through its associations with stress and internalised HIV stigma. Conclusions: Understanding the mechanisms through which PLWH internalise HIV stigma and lead to poor health outcomes can yield clinical foci for intervention.

Psychosocial complications of HIV/AIDS-metabolic disorder comorbidities among patients in a rural area of southeastern United States

As people living with HIV experience longer life-expectancies resulting from antiretroviral therapy, comorbid conditions are increasing, particularly metabolic disorders. There is potential for psychosocial factors such as stigma experiences, depression, and alcohol use to complicate both HIV infection and metabolic disorders, including diabetes mellitus and hyperlipidemia. While the impact of these psychosocial factors on HIV infection alone are widely studied, their role in potentially complicating HIV co-morbid metabolic conditions has received little attention. This study examined the association between HIV-related stigma and depression, and the potential role of alcohol use as a mediating factor in a clinical sample of patients with comorbid HIV infection and metabolic conditions. Results demonstrated that HIV stigma is associated with depression and this relationship is in part accounted for by alcohol use. Our results indicate that interventions aiming to improve the health of people living with HIV and co-morbid metabolic disorders should prioritize addressing alcohol use as it is related to sources of stress, such as stigma, and depression.

Cytomegalovirus Vasculitis and Mucormycosis Coinfection in Late-Stage HIV/AIDS

Case reports have previously been published describing various complications of cytomegalovirus (CMV) and mucormycosis in patients with HIV/AIDS. We describe the first case of CMV vasculitis and mucormycosis coinfection resulting in necrotizing myofascial cellulitis in an extremity in late stage HIV/AIDS. In AIDS patients, CMV reactivates when the CD4 count falls to less than 50 cells/microL (normal, 720-1440 cells/microL). Transient episodes of neutropenia in patients with HIV/AIDS who have low CD 4 cell counts are a predisposing factor for mucormycosis. These predisposing conditions were both present in our patient. Our case raises the question of CMV vasculitis leading to tissue ischemia as a possible contributing factor to the mucormycosis superinfection.

Pancreatic Abscess Secondary to Alcaligenes faecalis

We report a patient with pancreatic abscesses and necrosis secondary to Alcaligenes faecalis infection. He initially presented with alcohol-induced acute pancreatitis. Twenty days after the initial presentation, he re-presented with increasing pain and was found to have pancreatic necrosis and abscesses. Treatment was initiated with meropenem. Because of persistent fevers, computed tomography-guided drainage was performed. The fluid grew A faecalis resistant to meropenem and the patient continued to be febrile. He recovered only after adequate surgical intervention and appropriate antibiotic coverage. Although this is the first case of A faecalis reported to cause pancreatic abscess, we believe selection of this organism occurred because surgical drainage was delayed while the patient was on the recommended treatment with meropenem. This case emphasizes the need for early surgical drainage of pancreatic abscesses to avoid the selection of such resistant pathogens.

A presumptive case of toxocariasis associated with eosinophilic pleural effusion: case report and literature review

Human toxocariasis is a helminthozoonosis caused by Toxocara sp. Larval migration of the organism through the tissues can result in eosinophila associated with a broad spectrum of clinical manifestations. We report a case of eosinophilic pleural effusion and CD8 cell deficiency associated with Toxocara sp. The symptoms of this patient responded promptly to a nonsteroidal anti-inflammatory medication (naproxen). This is only the fourth reported case of a pleural effusion associated with Toxocara.

Recurrent aseptic meningitis due to different non-steroidal anti-inflammatory drugs including rofecoxib

Aseptic meningitis can be caused by viruses, drugs, and connective tissue disorders. The most common drugs causing it include antibiotics like trimethoprim-sulfamethoxazole, non-steroidal anti-inflammatory drugs (NSAIDs), intravenous immunoglobulins, intrathecal agents, vaccines, and monoclonal antibodies. A patient who had aseptic meningitis from three different NSAIDs including rofecoxib is presented.

Open-label study of a twice-daily indinavir 800-mg/ritonavir 200-mg regimen in HIV-infected adults failing a protease inhibitor regimen

There is no standard treatment of HIV-infected patients who fail protease inhibitor (PI)-containing antiretroviral therapy. This open-label, noncomparative 24-week study with a 24-week extension evaluated the efficacy, safety, and tolerability of twice-daily indinavir/ritonavir 800/200 mg plus 2 nucleoside reverse transcriptase inhibitors (NRTIs) in this population. Presented here are the results of the 24-week study. Patients were HIV-infected adults who had prior viral RNA (vRNA) suppression (<400 copies/mL), subsequent failure (> or =400 and < or =100,000 copies/mL) on antiretroviral therapy, and at least one new NRTI available for treatment. The proportions of patients achieving plasma vRNA <400 and <50 copies/mL were analyzed with data as observed (DAO) and intention-to-treat (ITT) models using generalized estimating equations (GEE) or counting noncompleters as failures (NC = F). Mean changes from baseline in vRNA and CD4 cell count were evaluated using DAO and an ITT mixed-model approach. Sixty-three patients (87% male) with a mean age of 42 years and mean baseline vRNA and CD4 cell counts of 3.8 log(10) copies/mL and 360 cells/mm(3), respectively, were enrolled. The proportion (95% confidence interval) of patients achieving vRNA <400 and <50 copies/mL at week 24 were 76% (61%, 87%) and 50% (35%, 65%) for DAO, 64% (50%, 75%) and 43% (30%, 56%) for GEE, and 56% (43%, 68%) and 37% (25%, 50%) for NC = F, respectively. At Week 24, baseline vRNA decreased by >1.0 log(10) copies/mL and CD4 cell counts increased by approximately 90 cells/mm(3). Three patients (5%) experienced serious drug-related adverse events. Seven patients (11%) discontinued treatment due to clinical or laboratory adverse events. In this study, the enhanced, twice-daily regimen of indinavir/ritonavir 800/200 mg plus 2 NRTIs provided suppression of HIV in many patients who had failed a PI-containing regimen and was generally well tolerated.

Delayed Vaccination Does Not Improve Antibody Responses in Splenectomized Rats Experiencing Hypovolemic Shock

Delayed vaccination after splenectomy has been shown to increase the antibody response in normotensive rats. The purpose of this experiment was to study the effect of timing of vaccination on antibody responses in rats undergoing splenectomy and experiencing hypovolemic shock. Sixty male Sprague-Dawley rats weighing 250 to 400 g underwent either a sham abdominal surgery or splenectomy after a 30-minute period of controlled hypovolemic shock. All rats then received pneumococcal vaccinations one day, 7 days, or 28 days postoperatively. Antibody levels were determined by enzyme-linked immunosorbent assay 3 weeks after vaccination. Results were compared by analysis of variance. Animals vaccinated one day postoperatively had similar or higher antibody responses than did rats receiving delayed vaccinations after 7 or 28 days. These results were similar for immunoglobulins G and M and more importantly were consistent for animals undergoing splenectomy and sham operations. Delayed vaccinations failed to improve antibody responses when hypovolemic shock preceded splenectomy. We propose that this is the result of complex cytokine responses to hypovolemic shock. These responses have been studied extensively in the setting of septic shock but not in the setting of hypovolemic or hemorrhagic shock.

Delayed vaccination does not improve antibody responses in splenectomized rats experiencing hypovolemic shock

Delayed vaccination after splenectomy has been shown to increase the antibody response in normotensive rats. The purpose of this experiment was to study the effect of timing of vaccination on antibody responses in rats undergoing splenectomy and experiencing hypovolemic shock. Sixty male Sprague-Dawley rats weighing 250 to 400 g underwent either a sham abdominal surgery or splenectomy after a 30-minute period of controlled hypovolemic shock. All rats then received pneumococcal vaccinations one day, 7 days, or 28 days postoperatively. Antibody levels were determined by enzyme-linked immunosorbent assay 3 weeks after vaccination. Results were compared by analysis of variance. Animals vaccinated one day postoperatively had similar or higher antibody responses than did rats receiving delayed vaccinations after 7 or 28 days. These results were similar for immunoglobulins G and M and more importantly were consistent for animals undergoing splenectomy and sham operations. Delayed vaccinations failed to improve antibody responses when hypovolemic shock preceded splenectomy. We propose that this is the result of complex cytokine responses to hypovolemic shock. These responses have been studied extensively in the setting of septic shock but not in the setting of hypovolemic or hemorrhagic shock.

Cushing's disease: clinical manifestations and diagnostic evaluation

The most common endogenous cause of Cushing's syndrome is Cushing's disease. Frequent clinical findings include weight gain, truncal obesity, striae, hypertension, glucose intolerance and infections. Cranial nerve II may be affected by enlarging pituitary adenomas in Cushing's disease; cranial nerves III, IV and VI may also be affected. The evaluation of patients with suspected Cushing's disease and syndrome requires an understanding of the proper use and limitations of the tests commonly included in the diagnostic work-up. The best screening test for Cushing's syndrome is a 24-hour urine collection with analysis for urinary free cortisol excretion. Low-dose and high-dose dexamethasone suppression tests, corticotropin assays, a corticotropin-releasing hormone stimulation test and inferior petrosal sinus catheterization may be required for a definitive diagnosis. Magnetic resonance imaging is useful in localizing the lesion. Surgical removal of the lesion by a transphenoidal approach is usually successful, but long-term follow-up is required. Some patients require lifetime glucocorticoid replacement therapy.

Students together against negative decisions (STAND): evaluation of a school-based sexual risk reduction intervention in the rural south

Twenty-one 10th graders selected as opinion leaders by their peers in a rural county in a southern state participated in a 36-hour peer-educator training program Students Together Against Negative Decisions (STAND) based on diffusion of innovations theory and the transtheoretical model. Comparison subjects received either a 22-hour leadership training course (n = 20) or no intervention (n = 45). STAND and comparison subjects completed a 154-item written knowledge, attitude, and behavior survey at the beginning of the training (Time 1), at the end of the training (Time 2), and again 8 months later (Time 3). One hundred and sixty-seven other 9th and 10th graders in the intervention county and 74 in the comparison county completed an abbreviated telephone interview at Time 1 and Time 3. At Time 3 STAND-trained peer educators reported significantly greater increases in AIDS Risk Behavior Knowledge (more than 4 times comparison groups), frequency of conversations with peers about birth control/condoms (+180% vs. +12%) and sexually transmitted diseases (STDs; +282% vs. -33%), condom use self efficacy (+16% vs. -1%), and consistent condom use (+28% vs. +15%). STAND teens also reported substantial favorable trends at Time 3, including increased condom use (+213% vs. +31%) and decreased unprotected intercourse (-30% vs. +29%). At Time 3 teens in the intervention county reported significantly greater increases in the number of people who talked with friends in the preceding 3 months about STDs (+39% vs. -19%) or with a parent/adult about sex (+6% vs. -37%). Intervention county teens also reported a substantial but nonsignificant 2.6-fold greater increase in condom use at last intercourse (+64% vs. +25%) but unfavorable changes in other risk behaviors. The STAND peer-educator training program appears to be an effective method for improving selected sexual knowledge, attitudes, and behaviors among participant teenagers in the rural South.

Treating stage IV pressure ulcers with negative pressure therapy: a case report

Decubitus ulcers remain a significant healthcare concern today, especially in the elderly and immobile population. Following the observation of three Stage IV decubitus ulcers refractory to standard medical and surgical therapy for 10 months, a new vacuum-assisted closure device (V.A.C.) was initiated to speed wound healing. The V.A.C. was initiated in August 1996. The three Stage IV ulcers were located on the patient's right ischium, left ischium, and sacrum. On initiation, they measured 7 1/2 cm x 2 1/2 cm x 2 1/2 cm, 8 cm x 3 1/2 cm x 2 1/2 cm, and 3 1/2 cm x 2 cm x 2 cm respectively. The treatment consisted of insertion of sterile sponge into the wound bed connected to the negative pressure device by suction hose. The device operated at a negative pressure of 125 mm Hg with a 5-minute-on 2-minute-off-cycle. Dressing changes were performed every 48 hours during the treatment period. Successful closure of the sacral ulcer occurred in October 1996. The ischial ulcers were small enough to be taken off V.A.C. therapy in early November 1996. While we are encouraged by the results of this study, further additional clinical studies are warranted.

Emerging and reemerging infectious diseases: a multidisciplinary perspective

Predictions that infectious diseases would be eliminated as a major threat to human health have been shattered by emerging and reemerging infections, among them acquired immunodeficiency syndrome (AIDS), hemorrhagic fevers, marked increases in infections caused by antimicrobial-resistant bacteria, and the resurgence of tuberculosis and malaria. Understanding the dynamics of emerging and reemerging infections is critical to efforts to reduce the morbidity and mortality of such infections, to establish policy related to preparedness for infectious threats, and for decisions on where to use limited resources in the fight against infections. In order to offer a multidisciplinary perspective, 23 infectious disease specialists, epidemiologists, geneticists, microbiologists, and population biologists participated in an open forum at Emory University on emerging and reemerging infectious diseases. As summarized below, the group addressed questions about the definition, the identification, the factors responsible for, and multidisciplinary approaches to emerging and reemerging infections.

Increased prevalence of renal cell carcinoma in patients with HIV infection

Following the observation of the occurrence of renal cell carcinoma (RCC) in a local HIV patient, a retrospective case review was conducted on our local hospital population to determine if the prevalence of RCC in patients with HIV infection was greater than in the non-HIV population. All 66,715 unique adult patient admissions (over 18) to the Medical Center of Central Georgia from 1990 through 1994 were reviewed to determine the total number of HIV admissions, the total number of patients with RCC, and the total number of patients with concomitant RCC and HIV infection. The expected prevalence of HIV-positive adults with RCC in this hospital population was then calculated based on local RCC prevalence data using the Poisson equation. Three hundred eight admissions were HIV infected, two of which had concomitant RCC. Forty-eight additional cases of RCC were documented during this time in non-HIV patients. The probability of an adult coming to this institution with RCC is 0.0007. Using this density in the Poisson equation, the probability of observing two cases of RCC in 308 HIV admissions was 0.01873, p < 0.05. The difference between the two proportions equation yielded a z value of 1.121. Data reveal that the prevalence of RCC in our hospital HIV patients is 8.5 times greater than in our non-HIV population, with an average age of occurrence approximately 15 years younger than national statistics.

Myeloperoxidase deficiency manifesting as pustular candidal dermatitis

Myeloperoxidase deficiency is the most common neutrophilic lysosomal enzyme deficiency. Case studies indicate that individuals with myeloperoxidase deficiency are not susceptible to serious infection in the absence of coexisting conditions such as diabetes mellitus. We present a case of myeloperoxidase deficiency manifesting as disseminated pustular candidal dermatitis in a nondiabetic male. Ceftriaxone therapy was administered to the patient for 8 days after he received a closed head injury and before the development of fever and pustular dermatitis. Candida albicans was isolated from the skin lesion. His neutrophils demonstrated a qualitative lack of myeloperoxidase. Patients who develop rapidly disseminated fungal dermatitis while they are receiving antimicrobial therapy that is relatively limited in coverage should be evaluated for myeloperoxidase deficiency.

Quasi-experimental evaluation of three AIDS prevention activities for maintaining knowledge, improving attitudes, and changing risk behaviors of high school seniors

Twelfth graders in a small southern city participated in one of three interventions: a question and answer (QA) session, a presentation by a person with AIDS (PWA), or a role-play activity (RP). A pre-intervention questionnaire assessed AIDS-related knowledge and attitudes. Immediate post-intervention questionnaires assessed knowledge and the intervention itself, and, five weeks later, a questionnaire reassessed knowledge and attitudes in addition to changes in risk behaviors. Knowledge gains were similar in the three groups; forgetting was greatest among PWA students. The attitudes of the RP group toward persons with AIDS tended to be the most positive, but differences among the groups were not statistically significant. The pro- portion of RP students (65.9% ) who reported changing their sexual activities after the intervention was significantly greater than that proportion of the other groups. These findings suggest that role-play activities can be more effective in achieving HIV/AIDS-related attitudinal and behavioral change than question-and-answer discussions or presentations by PWAs.

Human immunodeficiency virus infection: knowledge of the disease and attitudes toward related issues and policies among health care workers in a low-incidence nonurban hospital

We compared the knowledge and attitudes regarding human immunodeficiency virus (HIV) infection among employees in a tertiary care teaching hospital in a nonurban southeastern city with a relatively low incidence of acquired immunodeficiency syndrome (AIDS). All 260 physicians and a random sample of 240 other employees were asked to complete a 59-item anonymous mail survey. All groups of respondents, including physicians, showed a lack of understanding of critical aspects of AIDS, particularly transmission. Negative attitudes such as victim blaming and not liking to care for persons with HIV infection were common, especially among house staff and respondents who do not give hands-on care. Misinformation, aversion, fear, and lack of compassion were evidenced by a substantial proportion of the respondents, particularly house staff. The attitudes expressed suggest that there is more focus on the rights of the caregiver than on the welfare of patients. These findings show that there is a need for medical education that focuses on both knowledge and affective issues of HIV infection.

HIV and the brain: evidence of early involvement and progressive damage

AIDS is often accompanied by progressive encephalopathy and 'subcortical' dementia, but there is uncertainty regarding how early the brain involvement may begin in the course of HIV infection. This study used a cognitive auditory 'oddball' paradigm to elicit sensory and cognitive event related potential (ERP) components from healthy controls and from patients at different stages of HIV infection. Sensory component latencies did not differ between groups, but cognitive components showed progressive delays corresponding to increasingly severe clinical stages of HIV infection. The earliest changes were found among asymptomatic HIV + patients, suggesting that this test is a sensitive indicator of early subclinical CNS damage. In contrast, neither frequency analysis nor nonlinear dynamical analysis of the EEG showed differences between healthy controls and patients.

AIDS-related lymphoma diagnosed by flow cytometry of a pleural effusion

We have presented a case in which flow cytometry of pleural fluid was applied in the diagnosis of an AIDS-related lymphoma. Flow cytometric evaluation of malignant effusions is a less invasive means of diagnosing these neoplasms than tissue biopsy.

Fusobacterium osteomyelitis associated with intraosseous gas

The diagnosis of acute anaerobic osteomyelitis was made in a 57-year-old hypertensive diabetic woman complaining of groin pain and fever. Roentgenograms and computed tomography demonstrated intraosseous gas in the right femoral head and surrounding soft tissue. Cultures obtained from open biopsy were positive for the anaerobic gram-negative bacillus Fusobacterium necrophorum, a normal inhabitant of the mouth, bowel, and urogenital tract. The patient responded to an antibiotic regimen of metronidazole combined with initial debridement and drainage, followed by resection of the femoral head (Girdle-stone arthroplasty). The hospital course was complicated by fungal and pseudomonal superinfection. The patient was afebrile and ambulatory at discharge two months after admission. A case of Fusobacterium necrophorum osteomyelitis causing intraosseous gas seems not to have been previously reported in the literature.

Spontaneous suppressor cell activity in patients with the acquired immune deficiency syndrome and associated conditions

Patients with the acquired immune deficiency syndrome (AIDS) have depressed cell-mediated immunity partially explained by a depletion of helper-inducer T-lymphocytes. We questioned if the remaining elements of the mononuclear cell (MNC) population also played a part in the immunologic abnormalities noted. We therefore evaluated the ability of MNC populations from homosexuals with AIDS and AIDS-associated conditions to suppress the mitogenic responses of control MNCs in an assay of "spontaneous suppressor" cell activity (SSCA). Asymptomatic homosexuals and homosexuals with chronic lymphadenopathy, Kaposi's sarcoma, or opportunistic infections (OIs) had levels of SSCA equal to or greater than that of control subjects. Levels were significantly higher in patients with lymphadenopathy (p less than or equal to 0.1) and in patients with OI (p less than or equal to 0.05). Although percentages of Ia+ cells were increased in all homosexual groups and highest in patients with OIs (p less than or equal to 0.05), percentages of either monocytes or suppressor/cytotoxic T-lymphocytes, potential mediators of SSCA function, did not correlate with levels of SSCA observed. Therefore, patients with AIDS and AIDS-associated conditions have MNC populations that appear to interact in producing normal or augmented down regulation of residual T-lymphocyte function, even in the face of helper/inducer T-lymphocyte depletion.

Kaposi's sarcoma with a non-Hodgkin's lymphoma. Its association in a male homosexual with human T-cell lymphotropic virus type III infection

Combined tumor syndromes, specifically reticuloendothelial malignancies and Kaposi's sarcoma, have long been recognized. With the recognition of the acquired immunodeficiency syndrome (AIDS), several patients with concurrent non-Hodgkin's lymphoma and Kaposi's sarcoma have been reported at high risk for developing AIDS. The present Centers for Disease Control definition of AIDS excludes these patients on the assumption that one tumor is affecting the cellular immunity, allowing for the development of the second malignancy. In evaluating such a patient who had serologic evidence of human T-cell lymphotropic virus type III infection, the probable cause of AIDS, we have reviewed reports of patients with similar concurrent malignancies before and since the onset of the AIDS epidemic. We conclude that patients in high-risk groups for AIDS who develop similar combined tumor syndromes should be classified as having AIDS.

Pleural effusion and anicteric hepatitis associated with cat-scratch disease. Documentation by cat-scratch bacillus

Prior to the discovery of the coccobacillus in the lymph nodes of patients with cat-scratch disease by Wear and associates, the diagnosis was based on clinical findings and a nonstandardized skin test. Atypical cases either remained an enigma or were questioned as to accuracy of diagnosis. We present here a case of cat-scratch disease associated with pleural effusion, anicteric hepatitis, and other systemic manifestations confirmed by identification of the coccobacillus. It is the first association with a pleural effusion. With the Warthin-Starry stain, we anticipate a redefinition of this disease. The confirmation of atypical cases will help broaden the clinical spectrum, as well as guide us to consider this diagnosis where its classic manifestations may be absent.

Overview of bacterial infections of the skin and soft tissue and clinical experience with ticarcillin plus clavulanate potassium in their treatment

The etiology, diagnosis, and treatment of skin and soft tissue infections are discussed, and the results of clinical experience with ticarcillin plus clavulanate potassium in these diseases at one clinic are reported. In a randomized and controlled clinical trial, the safety and effectiveness of ticarcillin plus clavulanate potassium and cefazolin were compared in the treatment of soft tissue infections in 20 patients. The 12 patients in the group treated with ticarcillin plus clavulanate potassium included 10 men and two women, with a mean age of 61 years; the eight patients in the group treated with cefazolin were five men and three women, with a mean age of 63.8 years. Ticarcillin plus clavulanate potassium was administered for four to 26 days (mean 12.5 days), and cefazolin for four to 20 days (mean 12 days). There were 29 evaluable pathogens in the group receiving ticarcillin plus clavulanate potassium and 22 in the group receiving cefazolin. Of the 29 pathogens in the former group, 22 were eradicated; three reinfections or superinfections occurred but were ultimately eradicated, and four pathogens persisted. Eighteen of the 22 pathogens in the cefazolin-treated group were eliminated and the other four persisted. Clinically, six of the 12 patients in the ticarcillin plus clavulanate potassium-treated group had cures, four showed improvement, and two failed to show a response. In the cefazolin-treated group, five of the eight patients had cures, one showed improvement, and two failed to show a response.