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Chirehwa MT, Resendiz-Galvan JE, Court R, De Kock M, Wiesner L, de Vries N, Harding J, Gumbo T, Warren R, Maartens G, Denti P, McIlleron H. Optimizing Moxifloxacin Dose in MDR-TB Participants with or without Efavirenz Coadministration Using Population Pharmacokinetic Modeling. Antimicrob Agents Chemother 2023; 67:e0142622. [PMID: 36744891 PMCID: PMC10019313 DOI: 10.1128/aac.01426-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Moxifloxacin is included in some treatment regimens for drug-sensitive tuberculosis (TB) and multidrug-resistant TB (MDR-TB). Aiming to optimize dosing, we described moxifloxacin pharmacokinetic and MIC distribution in participants with MDR-TB. Participants enrolled at two TB hospitals in South Africa underwent intensive pharmacokinetic sampling approximately 1 to 6 weeks after treatment initiation. Plasma drug concentrations and clinical data were analyzed using nonlinear mixed-effects modeling with simulations to evaluate doses for different scenarios. We enrolled 131 participants (54 females), with median age of 35.7 (interquartile range, 28.5 to 43.5) years, median weight of 47 (42.0 to 54.0) kg, and median fat-free mass of 40.1 (32.3 to 44.7) kg; 79 were HIV positive, 29 of whom were on efavirenz-based antiretroviral therapy. Moxifloxacin pharmacokinetics were described with a 2-compartment model, transit absorption, and elimination via a liver compartment. We included allometry based on fat-free mass to estimate disposition parameters. We estimated an oral clearance for a typical patient to be 17.6 L/h. Participants treated with efavirenz had increased clearance, resulting in a 44% reduction in moxifloxacin exposure. Simulations predicted that, even at a median MIC of 0.25 (0.06 to 16) mg/L, the standard daily dose of 400 mg has a low probability of attaining the ratio of the area under the unbound concentration-time curve from 0 to 24 h to the MIC (fAUC0-24)/MIC target of >53, particularly in heavier participants. The high-dose WHO regimen (600 to 800 mg) yielded higher, more balanced exposures across the weight ranges, with better target attainment. When coadministered with efavirenz, moxifloxacin doses of up to 1,000 mg are needed to match these exposures. The safety of higher moxifloxacin doses in clinical settings should be confirmed.
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Affiliation(s)
- M. T. Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - J. E. Resendiz-Galvan
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - R. Court
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - M. De Kock
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, SAMRC Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - L. Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - N. de Vries
- Brooklyn Chest Hospital, Cape Town, South Africa
| | - J. Harding
- DP Marais Hospital, Cape Town, South Africa
| | - T. Gumbo
- Quantitative Preclinical and Clinical Sciences Department, Praedicare Inc., Dallas, Texas, USA
| | - R. Warren
- DST/NRF Centre of Excellence for Biomedical Tuberculosis Research, SAMRC Centre for Tuberculosis Research, Stellenbosch University, Cape Town, South Africa
| | - G. Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - P. Denti
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
| | - H. McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
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Court R, Wiesner L, Stewart A, de Vries N, Harding J, Maartens G, Gumbo T, McIlleron H. Steady state pharmacokinetics of cycloserine in patients on terizidone for multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2019; 22:30-33. [PMID: 29297422 DOI: 10.5588/ijtld.17.0475] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING Terizidone/cycloserine (TRD/CS) is included in standard treatment regimens for multidrug-resistant tuberculosis (MDR-TB) in many countries. The steady state pharmacokinetics (PKs) of CS after TRD administration are not known. OBJECTIVES AND DESIGN We recruited in-patients treated with 250-750 mg oral TRD daily as part of standard treatment regimens for pulmonary MDR-TB in Cape Town, South Africa. Plasma CS assays were performed in samples taken pre-dose and at 2, 4, 6, 8 and 10 h post-dose. CS concentrations were measured using a validated liquid chromatography-tandem mass spectrometry method. Non-compartmental PK analyses were performed. RESULTS Of 35 participants enrolled, 22 were males, and 20 (57%) were infected with the human immunodeficiency virus; the median age was 37 years. The median duration on TRD at the time of sampling was 33 days (interquartile range [IQR] 28-39). The area under the concentration-time curve at 0-10 h (AUC0-10) was 319 μg.h/ml (IQR 267.5-378.7), and peak concentration was 38.1 μg/ml (IQR 32.6-47.2). On multiple regression, dose (mg/kg) was the only factor independently associated with AUC0-10. CONCLUSION Steady state concentrations of CS in patients treated with TRD for MDR-TB were higher than those reported with CS formulations. Our findings support once-daily dosing.
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Affiliation(s)
- R Court
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town
| | - L Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town
| | - A Stewart
- Clinical Research Centre, Health Sciences Faculty, University of Cape Town, Cape Town
| | | | - J Harding
- D P Marais Hospital, Cape Town, South Africa
| | - G Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town
| | - T Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - H McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town
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Court R, Chirehwa MT, Wiesner L, de Vries N, Harding J, Gumbo T, Maartens G, McIlleron H. Effect of tablet crushing on drug exposure in the treatment of multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2019; 23:1068-1074. [PMID: 31627771 PMCID: PMC7402384 DOI: 10.5588/ijtld.18.0775] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
SETTING: Treatment outcomes in multidrug-resistant tuberculosis (MDR-TB) are poor. Due to drug toxicity and a long treatment duration, approximately half of patients are treated successfully. Medication is often crushed for patients who have difficulty swallowing whole tablets. Whether crushing tablets affects drug exposure in MDR-TB treatment is not known.OBJECTIVE AND DESIGN: We performed a sequential pharmacokinetic study in patients aged >18 years on MDR-TB treatment at two hospitals in Cape Town, South Africa. We compared the bioavailability of pyrazinamide, moxifloxacin, isoniazid (INH), ethambutol and terizidone when the tablets were crushed and mixed with water before administration vs. swallowed whole. We sampled blood at six time points over 10 h under each condition separated by 2 weeks. Non-compartmental analysis was used to derive the key pharmacokinetic measurements.RESULTS: Twenty participants completed the study: 15 were men, and the median age was 31.5 years. There was a 42% reduction in the area under the curve AUC0-10 of INH when the tablets were crushed compared with whole tablets (geometric mean ratio 58%; 90%CI 47-73). Crushing tablets of pyrazinamide, moxifloxacin, ethambutol and terizidone did not affect the bioavailability significantly.CONCLUSION: We recommend that crushing of INH tablets in the MDR-TB treatment regimen be avoided. Paediatric INH formulations may be a viable alternative if the crushing of INH tablets is indicated.
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Affiliation(s)
- R Court
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
| | - M T Chirehwa
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
| | - L Wiesner
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
| | | | - J Harding
- DP Marais Hospital, Cape Town, South Africa
| | - T Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, TX, USA
| | - G Maartens
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
| | - H McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town
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Court RG, Wiesner L, Chirehwa MT, Stewart A, de Vries N, Harding J, Gumbo T, McIlleron H, Maartens G. Effect of lidocaine on kanamycin injection-site pain in patients with multidrug-resistant tuberculosis. Int J Tuberc Lung Dis 2018; 22:926-930. [PMID: 29991403 PMCID: PMC6040239 DOI: 10.5588/ijtld.18.0091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Accepted: 03/18/2018] [Indexed: 11/10/2022] Open
Abstract
SETTING Reducing pain from intramuscular injection of kanamycin (KM) could improve the tolerability of multidrug-resistant tuberculosis (MDR-TB) treatment. Lidocaine has been shown to be an effective anaesthetic diluent for some intramuscular injections, but has not been investigated with KM in the treatment of adult patients with MDR-TB. OBJECTIVE AND DESIGN We performed a randomised single-blinded crossover study to determine if lidocaine reduces KM injection-site pain. We recruited patients aged 18 years on MDR-TB treatment at two TB hospitals in Cape Town, South Africa. KM pharmacokinetic parameters and a validated numeric pain scale were used at intervals over 10 h following the injection of KM with and without lidocaine on two separate occasions. RESULTS Twenty participants completed the study: 11 were males, the median age was 36 years, 11 were HIV-infected, and the median body mass index was 17.5 kg/m2. The highest pain scores occurred early, and the median pain score was 0 by 30 min. The use of lidocaine with KM significantly reduced pain at the time of injection and 15 min post-dose. On multiple regression analysis, lidocaine halved pain scores (adjusted OR 0.5, 95%CI 0.3-0.9). The area under the curve at 0-10 h of KM with and without lidocaine was respectively 147.7 and 143.6 μg·h/ml. CONCLUSION Lidocaine significantly reduces early injection-site pain and has no effect on KM pharmacokinetics.
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Affiliation(s)
- R G Court
- Division of Clinical Pharmacology, Department of Medicine
| | - L Wiesner
- Division of Clinical Pharmacology, Department of Medicine
| | - M T Chirehwa
- Division of Clinical Pharmacology, Department of Medicine
| | - A Stewart
- Clinical Research Centre, Faculty of Health Sciences, University of Cape Town, Cape Town
| | | | - J Harding
- D P Marais Hospital, Cape Town, South Africa
| | - T Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - H McIlleron
- Division of Clinical Pharmacology, Department of Medicine
| | - G Maartens
- Division of Clinical Pharmacology, Department of Medicine
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Hall RG, Pasipanodya JG, Swancutt MA, Meek C, Leff R, Gumbo T. Supervised Machine-Learning Reveals That Old and Obese People Achieve Low Dapsone Concentrations. CPT Pharmacometrics Syst Pharmacol 2017; 6:552-559. [PMID: 28575552 PMCID: PMC5572360 DOI: 10.1002/psp4.12208] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Revised: 04/24/2017] [Accepted: 05/18/2017] [Indexed: 12/04/2022] Open
Abstract
The human species is becoming increasingly obese. Dapsone, which is extensively used across the globe for dermatological disorders, arachnid bites, and for treatment of several bacterial, fungal, and parasitic diseases, could be affected by obesity. We performed a clinical experiment, using optimal design, in volunteers weighing 44-150 kg, to identify the effect of obesity on dapsone pharmacokinetic parameters based on maximum-likelihood solution via the expectation-maximization algorithm. Artificial intelligence-based multivariate adaptive regression splines were used for covariate selection, and identified weight and/or age as predictors of absorption, systemic clearance, and volume of distribution. These relationships occurred only between certain patient weight and age ranges, delimited by multiple hinges and regions of discontinuity, not identified by standard pharmacometric approaches. Older and obese people have lower drug concentrations after standard dosing, but with complex patterns. Given that efficacy is concentration-dependent, optimal dapsone doses need to be personalized for obese patients.
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Affiliation(s)
- RG Hall
- Dose Optimization and Outcomes Research (DOOR) ProgramSchool of Pharmacy, Texas Tech University Health Sciences CenterDallasTexasUSA
| | - JG Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical CenterDallasTexasUSA
| | - MA Swancutt
- Department of MedicineUniversity of Texas Southwestern Medical CenterDallasTexasUSA
| | - C Meek
- Dose Optimization and Outcomes Research (DOOR) ProgramSchool of Pharmacy, Texas Tech University Health Sciences CenterDallasTexasUSA
| | - R Leff
- Dose Optimization and Outcomes Research (DOOR) ProgramSchool of Pharmacy, Texas Tech University Health Sciences CenterDallasTexasUSA
| | - T Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical CenterDallasTexasUSA
- Department of MedicineUniversity of Cape Town, ObservatoryCape TownSouth Africa
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Hall RG, Pasipanodya JG, Meek C, Leff RD, Swancutt M, Gumbo T. Fractal Geometry-Based Decrease in Trimethoprim-Sulfamethoxazole Concentrations in Overweight and Obese People. CPT Pharmacometrics Syst Pharmacol 2016; 5:674-681. [PMID: 27869362 PMCID: PMC5193002 DOI: 10.1002/psp4.12146] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Accepted: 10/04/2016] [Indexed: 01/11/2023]
Abstract
Trimethoprim-sulfamethoxazole (TMP-SMX) is one of the most widely drugs on earth. The World Health Organization recommends it as an essential basic drug for all healthcare systems. Dosing is inconsistently based on weight, assuming linear relationships. Given that obesity is now a global "pandemic" it is vital that we evaluate the effect of obesity on trimethoprim-sulfamethoxazole concentrations. We conducted a prospective clinical experiment based on optimized design strategies and artificial intelligence algorithms and found that weight and body mass index (BMI) had a profound effect on drug clearance and volume of distribution, and followed nonlinear fractal geometry-based relationships. The findings were confirmed by demonstrating decreased TMP-SMX peak and area under the concentration-time curves in overweight patients based on standard regression statistics. The nonlinear relationships can now be used to identify new TMP-SMX doses in overweight and obese patients for each of the infections caused by the >60 pathogens for which the drug is indicated.
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Affiliation(s)
- R G Hall
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, School of Pharmacy, Austin, Texas, USA
| | - J G Pasipanodya
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - C Meek
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, School of Pharmacy, Austin, Texas, USA
| | - R D Leff
- Department of Pharmacy Practice, Texas Tech University Health Sciences Center, School of Pharmacy, Austin, Texas, USA
| | - M Swancutt
- Department of Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - T Gumbo
- Center for Infectious Diseases Research and Experimental Therapeutics, Baylor Research Institute, Baylor University Medical Center, Dallas, Texas, USA.,Department of Medicine, University of Cape Town, Observatory, Cape Town, South Africa
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Gwavava C, Chihota VN, Gangaidzo IT, Gumbo T. Dysentery in patients infected with human immunodeficiency virus in Zimbabwe: an emerging role forSchistosoma mansoniandEscherichia coliO157? Annals of Tropical Medicine & Parasitology 2016. [DOI: 10.1080/00034983.2001.11813663] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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Pasipanodya J, Srivastava S, Gumbo T. Fatal Lure of Look-Back Studies in Explaining Pharmacological Events Such as Acquired Drug Resistance in Patients With Multidrug-Resistant Tuberculosis. J Infect Dis 2015; 212:166-7. [DOI: 10.1093/infdis/jiv068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2014] [Accepted: 01/27/2015] [Indexed: 11/15/2022] Open
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Pasipanodya JP, Hall RG, Gumbo T. In silico
-derived bedside formula for individualized micafungin dosing for obese patients in the age of deterministic chaos. Clin Pharmacol Ther 2014; 97:292-7. [DOI: 10.1002/cpt.38] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2014] [Accepted: 11/16/2014] [Indexed: 12/31/2022]
Affiliation(s)
- JP Pasipanodya
- Office of Global Health, UT Southwestern Medical Center; Dallas Texas USA
- Baylor Research Institute; Dallas Texas USA
| | - RG Hall
- Texas Tech University Health Sciences Center; Dallas Texas USA
| | - T Gumbo
- Office of Global Health, UT Southwestern Medical Center; Dallas Texas USA
- Baylor Research Institute; Dallas Texas USA
- Department of Medicine; University of Cape Town, Observatory; Cape Town South Africa
- Department of Medicine; UT Southwestern Medical Center; Dallas Texas USA
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Pasipanodya JG, Srivastava S, Gumbo T. Comment on: Clinical significance of 2 h plasma concentrations of first-line anti-tuberculosis drugs: a prospective observational study. J Antimicrob Chemother 2014; 70:320-1. [DOI: 10.1093/jac/dku345] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Srivastava S, Gumbo T. Integrating drug concentrations and minimum inhibitory concentrations with Bayesian-dose optimisation for multidrug-resistant tuberculosis. Eur Respir J 2013; 43:312-3. [DOI: 10.1183/09031936.00081313] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Gumbo T, Just-Nübling G, Robertson V, Latif AS, Borok MZ, Hohle R. Clinicopathological features of cutaneous histoplasmosis in human immunodeficiency virus-infected patients in Zimbabwe. Trans R Soc Trop Med Hyg 2001; 95:635-6. [PMID: 11816437 DOI: 10.1016/s0035-9203(01)90103-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022] Open
Abstract
Reports of disseminated Histoplasma infection in African AIDS patients are scanty. In Zimbabwe, 12 patients presented in 1994-2000 with facial nodular/papular cutaneous lesions, which became umbilicated and finally ulcerated. Histology revealed non-granulomatous inflammation and macrophages stuffed with Histoplasma. Recognition of these clinical features may lead to more rapid diagnosis of disseminated histoplasmosis in Africa.
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Affiliation(s)
- T Gumbo
- Department of Medicine, University of Zimbabwe Medical School, Harare, Zimbabwe
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Gwavava C, Chihota VN, Gangaidzo IT, Gumbo T. Dysentery in patients infected with human immunodeficiency virus in Zimbabwe: an emerging role for Schistosoma mansoni and Escherichia coli O157? Ann Trop Med Parasitol 2001; 95:509-13. [PMID: 11487372 DOI: 10.1080/00034980120076235] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Information on bloody diarrhoea in HIV-positives is scarce. A prospective study was therefore performed, in Zimbabwe, to determine and compare the pathogens associated with bloody diarrhoea in 25 antiretroviral-naïve HIV-infected patients and 15 non-HIV-infected patients. Stool cultures and colonic biopsies were performed. Shigella was isolated from 18 (45%) of the subjects, Schistosoma mansoni from eight (16%), Escherichia coli H7:O157 from three (8%) and Campylobacter jejunii from two (5%). There was no evidence of Salmonella, Entamoeba histolytica or cytomegalovirus infection. Shigella dysenteriae type-1 occurred more often in the HIV-negatives than the HIV-positives (P = 0.02). Although HIV-associated bloody diarrhoea in Zimbabwe appears to be most frequently caused by Shigella, it may also be commonly the result of infection with Sc. mansoni or shiga-toxin-producing E. coli. A larger study specifically to examine the role of Sc. mansoni and E. coli O157 is warranted.
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Affiliation(s)
- C Gwavava
- Department of Medicine, University of Zimbabwe Medical School, P.O. Box A178, Avondale, Harare, Zimbabwe
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Gumbo T, Hakim JG, Mielke J, Siwji S, Just-Nübling G, Ismail A. Cryptococcus myelitis: atypical presentation of a common infection. Clin Infect Dis 2001; 32:1235-6. [PMID: 11283816 DOI: 10.1086/319749] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2000] [Revised: 08/25/2000] [Indexed: 11/03/2022] Open
Abstract
Cryptococcus neoformans is associated with as much as 45% of meningitis in patients admitted for hospital care in Zimbabwe, and it is an important opportunistic infection in patients infected with the human immunodeficiency virus. Cases of cryptococcosis presenting as a spinal cord syndrome have been reported from Zimbabwe and South Africa, but these were all cases of Cryptococcus vertebral osteomyelitis. We describe 3 unusual patients who presented with a myelitis-like syndrome without vertebral osteomyelitis.
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Affiliation(s)
- T Gumbo
- Department of Medicine, University of Zimbabwe Medical School, Harare, Zimbabwe.
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Abstract
We report the case of a patient with Crohn's disease and recurrent pneumonia for over 3 years before the discovery of an occult ileopulmonary fistula and review five other cases in the literature. Patients often present with chronic cough productive of feculent sputum, pleuritic chest pain, and signs of pulmonary consolidation that fail to respond completely to antibiotic therapy. Mixed enteric flora is cultured from sputum and bronchial washings in most cases. Bronchoscopy findings range from chronic bronchial inflammation to feculent material in the airways. Barium enema is often diagnostic. Surgery and Crohn's-specific therapy are key components of curative therapy.
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Affiliation(s)
- T Gumbo
- Department of Infectious Disease, The Cleveland Clinic Foundation, Cleveland, Ohio, USA
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Gumbo T, Gangaidzo IT. Confirmation of transmission of Enterocytozoon bieneusi in South Africa. S Afr Med J 2000; 90:1162, 1164. [PMID: 11234636] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
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Gumbo T, Gangaidzo IT, Sarbah S, Carville A, Tzipori S, Wiest PM. Enterocytozoon bieneusi infection in patients without evidence of immunosuppression: two cases from Zimbabwe found to have positive stools by PCR. Ann Trop Med Parasitol 2000; 94:699-702. [PMID: 11144811 DOI: 10.1080/00034983.2000.11813593] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Patients infected with human immunodeficiency virus (HIV) often also have intestinal infections with Enterocytozoon bieneusi. Recently, infection with this microsporidian has been described in immunocompetent subjects, mainly from Europe. When the stools of six HIV-negative patients who presented with diarrhoea in Zimbabwe were investigated, using a recently described protocol based on PCR, two patients were found to have E. bieneusi infections. These two individuals presented with a self limited diarrhoea, abdominal cramping and nausea. These data indicate that E. bieneusi may be a more common cause of diarrhoea in Zimbabwe than previously thought. Larger, prospective studies are needed.
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Affiliation(s)
- T Gumbo
- Department of Medicine, University of Zimbabwe Medical School, Harare, Zimbabwe
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Abstract
Aspergillus native valve endocarditis in patients who have not had cardiac surgery is uncommon. We report 3 cases and review 58 other adult patients reported in the English-language literature. Sixty-seven percent of the patients had underlying immunosuppression. The clinical features were fever (74%), embolic episodes (69%), a new or changing heart murmur (41%), and sudden visual loss (13%). Patients with mural endocarditis were more often immunosuppressed, especially due to solid organ transplants, but had lower frequency of heart murmurs and embolic episodes. Echocardiography revealed a vegetation in 78% of all the cases in which it was performed. Examination and culture of biopsy material often helped to establish a diagnosis of Aspergillus infection. Twenty-five patients had an antemortem diagnosis. These patients received a mean cumulative amphotericin B dose of 27 mg/kg. Twenty percent (3/15) of patients who received combined surgical and medical therapy survived, compared to none of those who received medical therapy alone (p = 0.08). Patients who survived were not immunosuppressed. We conclude that native valve aspergillus infective endocarditis is uniformly fatal without surgical intervention and antifungal therapy.
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Affiliation(s)
- T Gumbo
- Department of Infectious Disease, Cleveland Clinic Foundation, OH 44195, USA
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Affiliation(s)
- T Gumbo
- Department of Infectious Disease, The Cleveland Clinic Foundation, Ohio 44195, USA
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Abstract
Candida species are now the fourth leading cause of nosocomial bloodstream infection in hospitalized patients, and non-Candida albicans species now surpass Candida albicans. The clinical features of the most common non-Candida albicans species, Candida (Torulopsis) glabrata, have not been well studied. We retrospectively reviewed the clinical features of 139 patients with C. glabrata blood-stream infection over a period of 7 years. The mean age of patients was 62 years, and the most common admitting diagnoses were malignancy (28%) and coronary artery disease (18%). The most common identified portals of entry were abdominal (22%) and intravascular catheters (16%). At the time of fungemia, 63% of patients had fever, 45% had change in mental status, and 30% were in septic shock. Three of 50 patients examined by an ophthalmologist had chorioretinitis. The overall hospital mortality was 49%. Factors associated with increased mortality in a regression model were prior abdominal surgery (odds ratio [OR] = 2.8; 95% confidence interval [CI] = 1.2-6.3, p = 0.01), and an elevated creatinine (OR = 2.2; 95% CI = 1.0-4.7, p = 0.05). When early deaths (< or = 72 hours) were censored, amphotericin B treatment and total dose were associated with reduced mortality (OR = 0.2; 95% CI = 0.1-0.4, p < 0.001). Nosocomial C. glabrata fungemia is not just a disease of debilitated and neutropenic patients, but affects a wide variety of patients and is associated with a high mortality.
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Affiliation(s)
- T Gumbo
- Department of Infectious Disease, Cleveland Clinic Foundation, Ohio 44195, USA
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Gumbo T, Sarbah S, Gangaidzo IT, Ortega Y, Sterling CR, Carville A, Tzipori S, Wiest PM. Intestinal parasites in patients with diarrhea and human immunodeficiency virus infection in Zimbabwe. AIDS 1999; 13:819-21. [PMID: 10357381 DOI: 10.1097/00002030-199905070-00011] [Citation(s) in RCA: 66] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine the prevalence of intestinal parasites and risk factors for infection associated with diarrhea in HIV-infected patients in Harare, Zimbabwe. DESIGN Prospective observational study. METHODS Single stool samples were collected from 88 HIV-infected individuals presenting with diarrhea of greater than 1 week duration. Stools were examined for intestinal parasites using modified acid fast stain, fluorescence- labeled monoclonal antibody for Cryptosporidium parvum, as well as a modified trichrome stain and a PCR-based protocol for Enterocytozoon bieneusi. RESULTS C. parvum was detected in 9% (seven out of 82) of samples evaluated, but no Cyclospora was detected. E. bieneusi was detected in 18% (10 out of 55) of stool by trichrome staining and in 51% (28 out of 55) of stool examined by PCR. Risk factors for E. bieneusi infection were: living in rural areas, consumption of nonpiped water, contact with cow dung and household contact with an individual with diarrhea. CONCLUSION E. bieneusi infection was common in HIV-infected patients with diarrhea in Zimbabwe and may be acquired through person-to-person and fecal-oral transmission.
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Affiliation(s)
- T Gumbo
- Department of Infectious Disease, Cleveland Clinic Foundation, Ohio, USA
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24
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Abstract
BACKGROUND Microsporidia are the most common cause of chronic diarrhea in patients infected with human immunodeficiency virus. Patients who have undergone organ transplantation may also be infected. The precise immune defect and the clinical picture in transplant patients have not been studied. METHODS We report a case of microsporidia infection in a heart transplant patient and review three other cases reported in the literature. RESULTS Infection in three solid organ transplant patients occurred when the patients were receiving immunosuppressive therapy for rejection 1.5-3 years after transplantation. Patients had chronic diarrhea, vomiting, dyspepsia, and weight loss for 1 month to 3 years. CONCLUSIONS Microsporidia may be the cause of chronic unexplained diarrhea and gastrointestinal disturbances in transplant patients. Defects in cell-mediated immunity probably play a role in maintaining the chronicity of this infection. Specific screening requests should be made to the microbiology laboratory when microsporidia infection is suspected.
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Affiliation(s)
- T Gumbo
- Department of Infectious Diseases, Cleveland Clinic Foundation, Ohio 44195, USA
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25
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Carville A, Mansfield K, Widmer G, Lackner A, Kotler D, Wiest P, Gumbo T, Sarbah S, Tzipori S. Development and application of genetic probes for detection of Enterocytozoon bieneusi in formalin-fixed stools and in intestinal biopsy specimens from infected patients. Clin Diagn Lab Immunol 1997; 4:405-8. [PMID: 9220155 PMCID: PMC170541 DOI: 10.1128/cdli.4.4.405-408.1997] [Citation(s) in RCA: 44] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The microsporidium Enterocytozoon bieneusi is closely linked to wasting and diarrhea in a high proportion of individuals with AIDS. However, its relative contribution to disease is uncertain because diagnosis until recently depended on procedures involving endoscopy. A sensitive PCR technique which amplifies a fragment of the small-subunit rRNA gene of E. bieneusi from formalin-fixed stool samples was developed. Of 80 formalin-fixed stool samples collected from 74 Zimbabweans and 6 U.S. patients who were human immunodeficiency virus positive, 50% tested positive for E. bieneusi by PCR, whereas 24% tested positive for E. bieneusi by light microscopy of trichrome-stained fecal smears. In addition, we describe an in situ hybridization technique which detected and identified E. bieneusi as the causative agent in all six intestinal biopsy specimens tested. Both the PCR and in situ hybridization procedures are sensitive diagnostic tools which will complement currently available techniques and enable the differentiation of E. bieneusi from other microsporidia to be made.
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Affiliation(s)
- A Carville
- Division of Infectious Diseases, Tufts University School of Veterinary Medicine, North Grafton, Massachusetts 01536, USA
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Abstract
Cyclospora cayetanensis, an emerging pathogen with worldwide distribution, causes diarrhea in both immunocompetent and HIV-infected patients. We review the epidemiology of Cyclospora infection and how to diagnose and treat it.
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Affiliation(s)
- T Gumbo
- Department of Infectious Disease, Cleveland Clinic Foundation, OH 44195, USA
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