Group A streptococcal bacteremia: outcome and prognostic factors

In the last two decades, an increase in the incidence of invasive group A streptococcus (GAS) infections has been reported. The aim of this study was to determine the clinical and epidemiological characteristics and the natural history of GAS bacteremias at our hospital by performing a retrospective study of all cases of GAS bacteremia diagnosed at our University hospital from 1994 to 2003. We reported 42 cases of GAS bacteremia (27 men, mean age 42.3 +/- 31.6 years). None had more than one episode and four cases were nosocomial. The mean annual incidence rate was 1.01 cases per 100,000 population. An increase in the incidence but not in severity of GAS bacteremia was observed in the last 5-year period (p<0.001). The rates were highest in young children and the elderly and those with underlying medical conditions; 73.8% of patients had some underlying chronic illness, and the most relevant conditions included peripheral vascular disease and diabetes mellitus. Mortality was high and the worst outcome corresponded to elderly patients with streptococcal toxic shock syndrome (STSS). Thirty patients (71.4%) had a disruption in the integrity of the skin barrier, 14 (33.3%) were immunocompromised patients and 6 patients (14.3%) were intravenous drug users. A source of the bacteremia was noted in 38 patients (90.5%), with skin and soft tissue infection being the major portals of entry. Twelve patients (28.6%) fulfilled the STSS criteria. All strains were susceptible to penicillin and vancomycin. Resistance to erythromycin was 21.4% and to ciprofloxacin was 17.5%. The global mortality rate was 28.6%. Only STSS was significantly associated with increased mortality in the multivariate analysis.

[Non-Hodgkin lymphomas with systemic presentation in patients with HIV infection. Clinical and prognostic factors in a series evaluated before the introduction of the highly active antiretroviral therapy (HAART)]

PATIENTS AND METHOD

We studied patients with acquired human immunodeficiency virus (HIV) infection that developed non-Hodgkin's lymphoma (NHL) from January 1985 to October 2001.

RESULTS

44 patients (36 men, 8 women; median age 34 years) were included. Burkitt's lymphoma was diagnosed in 34%, and diffuse large cell B lymphoma in 29.5%. A history of AIDS diagnosis was detected in 20 cases (45%). International prognostic index (IPI) was 0-1 in 19 patients (43%), 2 in 12 (27%) and higher than 3 in 13 (30%). Chemotherapy was used in 64% of the patients, radiation therapy in 2% and both in 11%. Criteria for partial response were reached in 13 patients (29%), for complete remission in 2 (4%) and for stabilization in 1 (2%). Nine (20%) patients are alive (5 without disease), 22 (50%) died because of NHL, 5 (11%) died because of treatment associated toxicity and 8 died because of other causes. Median survival were 3 months, with a 1-year survival estimate of 24% and a 2-year survival estimate of 14%. In the univariate analysis of prognostic factors, IPI = 0-1 in comparison with IPI = 2-5 (p = 0.000), physical status (PS) < or = 2 (p = 0.021) and absence of B symptoms (p = 0.012) were significant. In the multivariate analysis, IPI = 0-1 was also significant (p = 0.000).

CONCLUSIONS

Patients with HIV and NHL has multiple factors of poor prognosis. The survival is limited and chemotherapy toxicity is high. Patients with low IPI are a subgroup with better prognosis.

[Environmental mycobacterial diseases in patients with and without HIV infection: epidemiology and clinical course]

The objective of the present study was to ascertain the clinical features, risk factors, microbiologic spectrum and course of disease after treatment of infections by environmental mycobacteria (EM) in patients with and without HIV infection in our community. Eighty-eight patients with diseases caused by EM diagnosed between 1989 and 1997 were studied; 46 (52.7%) were HIV-positive. Mycobacterium kansasii was the most prevalent pathogen (54%) overall, followed by M. avium complex (40%). However, M. avium complex was most prevalent among HIV-positive patients (61%) and M. kansasii was most prevalent among HIV-negative patients (76%). Localized lung infections were most common among HIV-negative patients, whereas 74% of HIV-positive patients had disseminated disease. Among HIV-negative patients, chronic obstructive pulmonary disease and corticosteroid use were common associations. Pulmonary disease was subacute and non-specific in both patient groups, whereas abdominal pain was the first symptom of most patients with disseminated disease. On the chest films of 76% of the HIV-negative patients, we observed cavitation and infiltrates; 60% of HIV-negative patients had normal x-rays. No differences in antibiotic sensitivity were observed between strains from HIV-positive and HIV-negative patients. The prognosis was good in the HIV-negative group with combined therapy with 2 to 4 first-line antituberculous drugs, whereas response was poor in HIV-positive patients in spite of prolonged treatment with 3 to 5 drugs. Nevertheless, thanks to the highly effective anti-retroviral treatment of recent years, we seem to be observing improved response to therapy with less aggressive forms of EM disease.

[Cerebral toxoplasmosis]

Toxoplasmic encephalitis is associated with high mortality and morbidity and still presents a notable incidence in our setting. Neither the clinical symptoms nor radiological features are diagnostic of this disease; however, because of its frequency and clinical importance, specific treatment is begun whenever toxoplasmosis is suspected. In patients with negative serology, or who are receiving adequate prophylaxis, or who do not respond to 2 weeks of treatment, or who present radiological lesions suggestive of another illness, diagnosis should not be delayed, and brain biopsy should be considered as soon as possible. In these cases, SPECT with 201TI (sensitivity and specificity over 90-95% for lymphoma) and/or the PCR technique to detect T. gondii (sensitivity 50-65% and specificity 95-100%) or Epstein-Barr virus (sensitivity 70-80% and specificity 95% for lymphoma) can be very useful. The treatment of choice is pyrimethamine (100 mg the first day followed by 50 mg/day) and sulphadiazine (1-1.5 g/6 h) during 6-8 weeks. If the patient is allergic to sulfadiazine and cannot be desensitized the regimen of choice is pyrimethamine and clindamycin (600 mg/6 h), with similar efficacy. Clinical experience with other therapeutic alternatives is limited. Pyrimethamine can be associated with clarithromycin (0.5-1 g/12 h), azithromycin (1-1.5 g/day) atovaquone (750 mg/6 h), dapsone (100 mg/day) or doxycyclin (200 mg/12 h). Cotrimoxazole or clindamycin can be administered intravenously to patients who cannot receive enteral treatment. The toxicity of these therapeutic regimens is significant and treatment has to be suspended in 10-40% of cases. The interactions that can be produced with other drugs used to treat HIV-infected patients are generally of little clinical relevance.

Clinical presentation of HIV infection in patients aged 50 years or older

OBJECTIVES

To describe the clinical presentation of HIV disease in older patients.

METHODS

In the period 1989-1996 we reviewed the medical records of 100 patients with human immunodeficiency virus (HIV) infection aged 50 years or older and, 197 controls among HIV-infected patients aged 15-40 years, who attended six institutions in the autonomous community of Valencia (Spain).

RESULTS

Older patients were mostly males (86%), men who have sex with men (42%) or unknown (20%) as exposure categories. Older patients had lower CD4 cell counts/mm3 (163+/-136 vs. 450+/-373, P= 0.008), and had AIDS at first evaluation (49% vs. 29%, P = 0.0006) compared with younger patients. For patients presenting with AIDS at HIV infection diagnosis, type and frequency of AIDS indicator diseases did not differ between older and younger patients.

CONCLUSION

Studies on clues for early detection of HIV infection in patients aged 50 years or older are urgently needed to improve the health care in this population.

[Pseudomonas aeruginosa bacteremia in patients with HIV infection: clinicoepidemiologic study of 17 episodes]

BACKGROUND

Bacteremic infection with Pseudomonas aeruginosa is an uncommon and late phenomenon in the natural history of infection with human immunodeficiency virus (HIV). Our objective was to study the clinico-epidemiological characteristics of P. aeruginosa bacteremia (PAB) in patients infected with HIV.

PATIENTS AND METHODS

A retrospective study of 17 episodes of PAB in 16 patients infected with HIV in three tertiary hospitals in the Valencia Community. Data were collected by means of a protocol designed to obtain clinical and epidemiological information.

RESULTS

Fourteen out of 16 HIV-positive patients with PAB were males and in nine patients the risk factor for the acquisition of HIV was parenteral drug abuse. Eighty-one percent (13 patients) met diagnostic criteria for AIDS. Fourteen patients had less than 100 CD4 lymphocytes/mm3 at diagnosis of bacteremia (mean value 25.8). PAB was acquired in the community in 13 episodes (76.4%). Nine patients (56.2%) had received some type of antimicrobial therapy during the last month, 12 (75%) were taking anti-retroviral therapy, and 6 (37.5%) were receiving prophylaxis against P. carinii. The most frequent source for PAB was pneumonia with 7 episodes (41.2%), followed by the intravascular catheter infection with 2 (12%). In six episodes (35.3%) no source was identified. Only one episode was evaluated as recurrence. Only two of the seven patients with pneumonia had pulmonary cavitation in the chest X-ray. Fifteen episodes resolved (94%) and in only one case was dead directly related to PAB.

CONCLUSIONS

In our experience, PAB in patients infected with HIV emerges in the advanced stages of disease. The most common source was the lower respiratory tract and in most cases PAB was acquired in the community. The mortality rate resulting from PAB was lower than that previously reported in the literature.

[Severe self-limiting hypersensitivity reaction after immunotherapy with intravesical BCG]

We present the case of a 67-years-old patient diagnosed of superficial vesical transitional carcinoma which, under immunotherapy with intravesical BCG, developed a severe hypersensitivity reaction with spontaneous resolution. We describe several adverse reactions after the administration of intravesical BCG, as well as its diagnostic and therapeutic problems, especially in the cases of hypersensitivity.

[Porphyria cutanea tarda and human immunodeficiency virus infection]

Recently, cases of porphyria cutanea tarda (PCT) have been reported associated with infection due to human immunodeficiency virus (HIV). We presented the cases of three males, former ethanol users, and which have had previously a contact with the Hepatitis B virus. In one of the patients symptomatology appeared after treatment with zidovudine was begun. We suggest that HIV infection associated with other toxic or viral factors could contribute to the early development of a PCT latent until that moment.

Jejunal malignant lymphoma in a patient with adult-onset hypo-gamma-globulinemia and nodular lymphoid hyperplasia of the small bowel

A malignant lymphoma of the small bowel developed in a 55-yr-old woman who had intestinal malabsorption for 20 yr, late-onset hypo-gamma-globulinemia, and nodular lymphoid hyperplasia. The tumor arose in the first jejunal loop and appeared to be of B-immunoblastic type (diffuse large noncleaved cells). This case indicates that nodular lymphoid hyperplasia in the context of immunodeficiency may be a condition leading to lymphoid malignancy.