Impact of Insertions in the HIV-1 P6 Ptapp Region on the Virological Response to Amprenavir

We evaluated the impact of genetic changes within p6Gag gene on the virological response (VR, mean decrease in plasma viral load at week 12) to unboosted amprenavir (APV). Gag-protease fragments, including gag p2, p7, p1, p6 regions and whole protease (PR) were sequenced from baseline plasma specimens of 84 highly pre-treated but APV-naive patients included in the NARVAL (ANRS 088) trial. The correlation between baseline p6Gag polymorphism, PR mutations, baseline characteristics and VR to APV was analysed in univariate analysis. Insertions (P459Ins) within p6 protein, leading to partial or complete duplication of the PTAPP motif, were significantly associated with a decreased VR (P459Ins versus wild-type; –0.3 ±0.8 vs –1.1 ±1.2 log copies/ml, P=0.007) and were more frequent when the V82A/F/T/S PR mutation was present ( P=0.020). In multivariate analysis, after adjustment on the predictive factors of the VR in the NARVAL trial and on the PR mutations linked with response, there was a strong trend to an association ( P=0.058) between the presence of P459Ins and an altered VR. In conclusion, these results suggest that insertions in the p6 region of HIV-1 gag gene may affect the VR, in highly pre-treated patients receiving an unboosted APV-containing regimen.

Acute painful diabetic neuropathy: two patients with recent insulin-dependent diabetes mellitus

Two young men developed an acute painful peripheral neuropathy a few weeks after being diagnosed to suffer from an insulin-dependent diabetes mellitus. In both cases, peripheral nerve biopsy exhibited a few features of acute axonal degeneration. Additionally, in the first case there was a lymphocytic infiltrate around an endoneurial capillary, and in the second case there were several mast cells in the endoneurium of every fascicle examined. A few months later, the acute pain had disappeared in both cases. Only a few cases of acute painful diabetic neuropathy have been reported so far. A vascular origin seems unlikely and metabolic disorders are probably due to a contemporary severe weight loss. An auto-immune mechanism is an alternative explanation.

Acquired immunodeficiency syndrome-associated Kaposi's sarcoma and human herpesvirus 8 DNA detection in serial peripheral blood mononuclear cell samples

Human herpesvirus 8 (HHV8) DNA was amplified from peripheral blood mononuclear cells (PBMCs) using PCR in 120 HIV-seropositive in- and outpatients who were enrolled in a cohort study between January 1994 and June 1995. Risk factors for HIV infection were homosexuality/bisexuality alone in 64 cases (30 with Kaposi's sarcoma (KS) and 34 without KS, 4 of whom had KS lesions that appeared during follow-up in the cohort), heterosexual contact alone in 32 cases (among whom 1 woman with KS who was the spouse of a bisexual with KS), and transfusion of blood or blood products alone in 24 cases. Three blood samples at 3-4-month intervals were scheduled for each patient. Twenty-five HIV1-seronegative patients served as controls. A total of 47.1% of homo- or bisexual males with KS and 26.7% of homo- or bisexual males without KS had positive HHV8 DNA detection as compared with 21.9% of patients contaminated by heterosexual contact, 8.3% of blood product recipients and 0% of controls. HHV8 DNA detection was intermittent in all but 3 patients according to sequential sampling. Multivariate analysis showed that AIDS-KS was associated with sexual transmission, mainly homo- or bisexual practices and with HHV8 infection assessed by PCR in PBMCs.

Evaluation of serological response to Bartonella henselae, Bartonella quintana and Afipia felis antigens in 64 patients with suspected cat-scratch disease

The serological response to Bartonella henselae, B. quintana, and Afipia felis was assessed by an indirect fluorescence antibody test (IFAT) in 64 patients with suspected cat-scratch disease (CSD) recruited from the Bordeaux area in France. Blood samples were collected from 57 patients with chronic lymphadenopathy who underwent lymph-node biopsy with suggestive histopathologic features of CSD, and from an additional 7 patients with suspected CSD who underwent surgical incision and drainage because of lymph-node tenderness. Of the patients, 31 were male and 33 female, with a median age of 27 years (range 2-89). 69.8% reported cat and/or dog contact. Of the 26/64 (40.6%) patients, serum samples were positive at a titer of 1:100 or more for immunoglobulin G (IgG) antibodies (17 only to B. henselae, 1 only to B. quintana, 3 only to Afipia felis, and 5 to both B. henselae and B. quintana). IgM or IgA antibodies were also detected in 10 patients with IgG antibodies to B. henselae. 11 (17.2%) of the 64 patient serum samples were positive at a low titer of 1:50. These data suggested that serological response assessed by standard IFAT is not enough to confirm a CSD diagnosis.

Detection of Toxoplasma gondii by PCR and tissue culture in cerebrospinal fluid and blood of human immunodeficiency virus-seropositive patients

To investigate whether both tissue culture and PCR on a sequence from the repetitive rDNA could contribute to the diagnosis of toxoplasmosis, blood samples and, if they were available, cerebrospinal fluid (CSF) and aqueous humor samples from 72 human immunodeficiency virus-seropositive patients with suspected toxoplasmosis were prospectively tested. For 10 patients with fever of unknown origin but without confirmed toxoplasmosis, no Toxoplasma gondii was detected. For two patients with confirmed toxoplasmic uveitis, only PCR of aqueous humor samples was positive. Of 60 patients (48 with CSF samples) with neurological signs, 25 (from 13 of whom CSF samples were available) had confirmed cerebral toxoplasmosis and 10 had a positive PCR of CSF and/or blood samples, while for 1 patient culture of the CSF sample was also positive. Unlike tissue culture, PCR of rDNA is of value for the detection of cerebral toxoplasmosis in human immunodeficiency virus-seropositive patients, provided that both CSF and blood samples are available (sensitivity, 76.9%; specificity, 100%).

[Evaluation of antibiotherapy in dental surgery]

OBJECTIVES

Debate on antibiotic prophylaxis in patients with infectious endocarditis has emphasized the need for reliable data on the effectiveness of antibiotic therapy in dentistry patients.

METHODS

We randomly sampled 583 antibiotic prescriptions delivered by dentists working in out-patient clinics in the French department of Gironde in 1992. Two-hundred fifty-seven prescriptions were analyzed in detail after telephone contact with the prescribing practicians in coordination with infectiology experts from university hospitals.

RESULTS

Antibiotic treatment was successful in 85.6% of the cases. The indication was justified in 74.1% and the dose was judged insufficient in 24% as was the administration rhythm in 37.8%. The duration of treatment was not in conformity with generally accepted prescription in 23.1% of the cases, usually being too short. According to the recommendations of the Consensus Conference on prophylaxis against infectious endocarditis held in Paris, March 27, 1992, antibiotic prophylaxy was not justified in 14.4% of the cases. In addition, the drug chosen in these cases was not in conformity with the recommendations in 43.2% and the duration in 100%.

CONCLUSION

These findings emphasize that more adapted university and postgraduate training in antibiotic prescription both for prophylaxis and cure is needed in odontostomatology since a large number of antibiotics prescriptions are delivered by dentists.

Spontaneous splenic rupture: an uncommon complication of cytomegalovirus infection

A previously healthy 25-year-old man developed a spontaneous rupture of the spleen during a cytomegalovirus (CMV) infection. The only other clinical feature was a well tolerated fever of 37.5 degrees C to 39 degrees C during the month before. The diagnosis was confirmed by the presence of IgM antibodies to CMV in the serum and by typical intranuclear inclusions for CMV identified by splenic histopathological findings. The patient recovered completely. Spontaneous splenic rupture is uncommon in primary cytomegalovirus infection.

Scrub typhus: an imported Rickettsial disease

A case of scrub typhus due to Rickettsia tsutsugamushi is reported. This imported rickettsial disease was contracted by a 30-year-old woman while traveling in Thailand, and was transmitted by an infected mite's bite. Diagnosis was confirmed by specific serology and resolution was obtained by tetracycline therapy. Current concepts of the disease are reviewed.

Decreased incidence of infection after renal transplantation with the use of cyclosporine

The incidence of infection within six months of cadaveric kidney transplantation was reviewed in 183 consecutive patients. Prior to June, 1985, 91 patients received azathioprine 2 mg/kg/day and prednisone 0.5 mg/kg/day; 63 patients (group A1) also received antilymphocyte globulin 15 mg/kg/day for the first ten days, whereas for the 28 other patients (group A2) antilymphocyte globulin had to be withdrawn before 72 hours because of general intolerance. The next 92 patients received cyclosporine 5-8 mg/kg/day and prednisone 0.25 mg/kg/day (group B). The three groups were similar for all studied parameters except for the number of patients with anti-HLA antibodies. At six months the mortality rate was not significantly different between the three groups. After six months the number of infections per patient was 1.47, 1.03 and 0.84 (p less than 0.01) in groups A1, A2 and B respectively; the percentage of patients developing one or more infections was 81, 58 and 57% (p less than 0.01); bacterial infections: 57, 50 and 34% (p less than 0.01); viral infections: 40, 14 and 10% (p less than 0.01); cytomegalovirus infections: 27, 11 and 4% (p less than 0.001). After adjustment with logistic regression upon factors which might facilitate infections, the results showed a significantly lower incidence of infection for the cyclosporine-treated group, especially for cytomegalovirus, as compared with the antilymphocyte globulin-treated group.

[Cardiac lesions in AIDS]

The frequency of cardiac lesions in AIDS patients is diversely evaluated. At post-mortem examination macroscopic lesions are said to have been found in 20 percent of the patients, and microscopic lesions in 50 percent. In some clinical studies, up to 55 percent of the patients had echocardiographic abnormalities. All three cardiac wall layers may be involved. Cases of myopericardial Kaposi's sarcoma or non-Hodgkin's lymphoma have been described, together with infectious myocarditis or pericarditis, non-obstructive cardiomyopathy, aseptic fibrinous pericarditis, marantic endocarditis and other, less frequent lesions.

[Malaria and retinal hemorrhages]

A 24-year-old woman presented with retinal hemorrhages, back from a travel in Cameroon. She took a chloroquine chemoprophylaxis. We diagnosed a malaria due to Plasmodium falciparum with anemia, splenomegaly and low parasitemia. A speedy clinical and ophthalmological recovery was obtained with mefloquine therapy. We discuss physiopathology of such uncommon retinal damage during malaria.

[Epidemiology, clinical aspects and treatment of nosocomial septicemias]

One hundred one nosocomial septicemias (NS) were studied among 461 cases of septicemias (22%) collected by French Septicemia Expert System Group during 1985. The mean-age of the patients was 58 +/- 23 years while it was 56 +/- 23 years in the 360 community acquired septicemias (CAS). The source of septicemia was found more frequently in NS than in CAS (79/101 versus 223/360; p less than 0.002): mainly urinary tract and intravenous therapy in NS, urinary tract, gastrointestinal and biliary origin in CAS. Invasive procedures (except surgical procedures) were more frequent in NS than in CAS (13/101 vs 14/360; p less than 0.0001). Underlying diseases were more often associated with NS than with CAS (96/101 vs 276/360; p less than 0.0001). Many pathogens were involved in these NS but the frequency of S. aureus meti-S and meti-R, S. epidermidis, Enterobacter, Klebsiella, Serratia, Proteus indol + and Pseudomonas carbeni-R was significantly greater in NS than in CAS. There was no significant difference between NS and CAS for septic localizations, respiratory distress syndrome and septic shock. Two antibiotics (and possibly 3 antibiotics for polymicrobial septicemias) were more often used in NS than in CAS (61/101 vs 135/360; p = 0.002). If the duration of hospitalization was not significantly greater in NS than in CAS (26 +/- 29 days vs 23 +/- 33 days), the overall mortality was significantly more important (25.6% vs 14.9%; p less than 0.05).

[Clinical evaluation of ceftriaxone in severe infections in adults]

Thirty patients (17 male, 13 female; age 17 to 84 years; normal renal function in 23 cases) with severe bacterial infections were treated with ceftriaxone. The infections was septicemia in 20 cases, a septicemia-like condition in 2 and a focal infection in 8 (2 abscesses of the lung, 2 pyelonephritis, 1 abscess of the liver, 1 subphrenic abscess, 1 meningitis developed from an abscess of the brain and 1 acute intestinal infection). 25 infections were bacteriologically documented, with recovery of the following pathogens: 20 Gram negative rods (including 10 E. coli) that were all susceptible to ceftriaxone (MIC = 0.02 to 0.5 mg/l) except 2 (1 Pseudomonas and 1 E. cloacae), 5 susceptible Gram positive cocci (3 Pneumococcus, 1 Streptococcus and 1 Staphylococcus epidermidis) and 3 susceptible anaerobes (2 B. fragilis and 1 B. melaninogenicus). Ceftriaxone was given alone in 15 cases and in association with another antibiotic in 15 cases (aminoglycoside in 10 cases, nitroimidazole in 4 and fosfomycin in 1). The dose of ceftriaxone was 1 to 2 g per day in 28 cases, 3 g per day in 1 case (meningitis with abscess of the brain) and 1 g every other day in 1 case (chronic renal failure under hemodialysis). Duration of treatment ranged from 10 to 62 days (average 17 days). The usual routes of administration were IV and IM; the SC route was used on 4 occasions. Pharmacokinetic studies of serum levels were carried out in several patients including two who had ceftriaxone subcutaneously; results were consistent with those previously reported in the literature.(ABSTRACT TRUNCATED AT 250 WORDS)

[Hepatic manifestations of psittacosis]

A moderate increase in transaminases and alkaline phosphatase serum concentrations was observed in 14 of 32 patients with psittacosis (antibodies anti-Chlamydia psittaci greater than or equal to 1/40 with the complement fixation test). Clinical manifestations were present in 4 patients (hepatomegaly in 4 cases; jaundice in one case). In one patient, histological examination of a liver specimen showed granuloma. In 13 patients treated with tetracycline or macrolides, the outcome was favorable. One patient recovered spontaneously. In comparison with the group of 18 patients without hepatic involvement, there was no difference pertaining to epidemiological, clinical, or serological findings. Equally, there was no difference in the course of the disease.

[Clinical evaluation of a ticarcillin-clavulanic acid combination in severe infections in adults]

Timentin (ticarcillin (TCR) + clavulanic acid (AC)) was given for severe bacterial infections to sixteen hospitalized patients (10 male and 6 female; 16 to 75 years of age; normal renal function in 12). Infections included 8 septicemias (of which 4 were secondary to pyelonephritis), 6 pyelonephritis (in addition to the four above-mentioned cases), and 3 suppurated cellulitis of the lower limbs (with septicemia in one case). The following bacteria were recovered: 10 Escherichia coli, 1 Pseudomonas aeruginosa, 1 Enterobacter cloacae, 1 Providencia stuartii, 1 Salmonella typhi, 1 Klebsiella pneumoniae, and 1 Staphylococcus aureus. The sixteen strains were all susceptible to timentin (MICs determined by agar dilution: TCR + AC 4 mg/l: 0.5-16 mg/l; TCR + AC 8 mg/l: 0.2-16 mg/l). Thirteen strains were susceptible to TCR (MIC less than or equal to 16 mg/l), and three (1 E. coli, 1 K. pneumoniae, and 1 S. aureus) were resistant to TCR (MIC greater than or equal to 256 mg/l). 14 patients received timentin alone, while two were also given dibekacin. Timentin was given in one-hour IV infusions in a dosage of 9.6 g/24 h (3.2 g X 3) in 10 patients and 6.4 g/24 h (3.2 g X 2) in 6. Duration of therapy was 14 to 16 days in half of cases (range 5 to 21 days). At termination of the infusion, serum concentrations of ticarcillin and clavulanic acid (determined in ten patients) were greater than 50 mg/l and 3-7.4 mg/l respectively, and serum bactericidal activity (evaluated in ten cases) was consistently less than 1/2.(ABSTRACT TRUNCATED AT 250 WORDS)

[Evaluation of perioperative cefoxitin in the prevention of infectious complications of surgery in cancer of the upper respiratory-digestive tracts]

Twenty-three patients (22 male and 1 female) aged 41 to 70 years (mean age 56.4 years) with cancer of the upper respiratory and digestive tracts were entered into the study prior to a major surgical procedure involving incision of cervical mucous membranes. Participants were randomly assigned either to a control group (10 patients) which received no routine intra or postoperative antibiotics, or to a treatment group (13 patients) given cefoxitin perioperatively. Treated patients were given 30 mg/kg cefoxitin intravenously over 30 mn, one hour before surgery was begun, and 30 mg/kg over one hour, 3 hours and 6 hours after the initial infusion was started. Rate of local infection was 80% (8/10) and 15% (2/10) in the control group and treated group respectively (p less than 0.001). In addition, a significant difference in rates of local complications was found: 7 disjunctions and/or fistulae or pharyngostomes in the control group against one suppuration with disjunction in the treated group. In the treated group, a mean 24.6 day reduction in time lapse to cicatrization was observed. Fever greater than or equal to 39 degrees C occurring or persisting beyond the 48th postoperative hour was also significantly more frequent in the control group (7/10 versus 3/13). In contrast, no significant difference was found between rates of other infectious localizations. Local bacterial flora recovered in both groups before and/or after surgery was unremarkable and prophylactic cefoxitin selected no particular pathogens.

[Studies on liver abscesses (author's transl)]

The authors report 25 observations of liver abscesses in the same service over a 5 years period. Diagnostic difficulties are pointed out and the value of echography, a simple and well tolerated examination, are emphasized immunologic studies allow the differentiation of the two types off liver abscesses i.e., pyogenic and amoebic, thus orientating their different treatments. The treatment of pyogenic abscesses (12 cases) is chiefly surgical, supported with suitable antibiotic therapy. Amoebic abscesses require medical treatment in collected abscesses of little or mean volume. In our series the number of patients requiring surgery is important (13 cases). This is due to persisting residual pouches or to the absence of well defined cliical improvement with medical treatment and the occurence of pre-burst or burst symptoms.

[Treatment of bacterial endocarditis with oral amoxicillin and intra-muscular gentamicin]

Fourteen patients suffering from bacterial endocarditis due to a streptococcus or staphylococcus were treated using a combination of amoxicillin per os in a dose of 1 gram every 2 or 3 hours and gentamicin in a dose of 60 mg intramuscularly every 6 or 8 hours. Two patients failed to tolerate amoxicillin, which had to be replaced by penicillin G. Two others, after a period of improvement, relapsed and were cured by the substitution of penicillin G given intravenously, in place of amoxicillin. The ten remaining patients were cured after a normal period of time had elapsed. Two of them were even treated at home. Bactericidal powers of serum obtained by the combination were satisfactory at between 1/16 to 1/4096 one hour after the administration of the antibiotics. This therapeutic protocol is thus effective, and has the advantage of improving the patient's comfort. It should nevertheless be reserved for use against sensitive organisms in patients without digestive problems, the bactericidal power of the serum being verified.

Pharmacokinetics of amoxycillin according to administration schedule

Thirty subjects, free of any heart, kidney or liver disease, were given the same dosage of amoxycillin--100 mg/kg/24 hr. The first ten were given the drug in three equal doses at 8-hourly intervals, a further ten in four doses at 6-hourly intervals, and the last ten in eight doses at 3-hourly intervals. The final administration schedule resulted in much higher and more regular serum levels of amoxycillin than the other two, suitable for the treatment of severe infectious conditions, and has the advantage of avoiding prolonged antibiotic infusions which are a source of venous complications in the patient. The first results obtained clinically, which will be published in a further paper, seem favourable.

[Infectious complications of malignant lymphomas. Evaluation of 411 infections observed in 629 patients]

The main clinical and paraclinical characteristics of 411 infections which occured in 629 patients with malignant lymphoma, treated between 1960 and 1973, are reported here. The theoretical interest of such cases is emphasized, they permit one to contrast Hodgkin's disease with other forms of lymphoma in view of the very marked paraneoplastic immune deficiency in the first group. The practical, diagnostic and therpeutic problems raised are exceptionally difficult and may become even more simple with more efficacious anticancer therapy which, curing more regularly patients from their blood disease, avoids the factors which favour these infections.