Acute human immunodeficiency virus infection in a breast-fed infant in New York City

Acute human immunodeficiency virus (HIV) infection in a breast-fed infant is a rare diagnosis in developed countries. We present a six-month old girl with postnatally acquired HIV infection complicated by Pneumocystis jéroveci pneumonia, cytomegalovirus pneumonitis and encephalopathy. Her mother had tested negative for HIV during pregnancy. Children infected by mothers during an acute seroconversion may have more rapid disease progression.

Palatial erosion caused by Mycobacterium Avium complex in a human immunodeficiency virus infected child

Oral manifestations of Mycobacterium Avium complex (MAC) are rare and have only been described in adults. Here we report a 10-year-old female with advanced human immunodeficiency virus infection, who presented with disseminated MAC and an erosive left palate defect.

Changing trends in bacterial infections: Staphylococcus aureus, bacterial pneumonia, Clostridium difficile

Changing bacterial diseases in the general population of which HIV practitioners should be aware include: new staphylococcal syndromes caused by community-acquired methicillin-resistant Staphylococcus aureus USA300 strains (eg, necrotizing skin infections, pneumonia, fasciitis); continued high rates of community-acquired pneumonia in the potent antiretroviral therapy era; increase rates and severity of Clostridium difficile-associated disease due to the fluoroquinolone-resistant NAP1 strain, and the new scare from extensively drug-resistant tuberculosis, primarily as a potential threat to health care in Africa. This article summarizes a presentation on important bacterial infections made by John G. Bartlett, MD, at the International AIDS Society-USA course in New York in March 2007.

Clinical use of polymerase chain reaction performed on peripheral blood and bone marrow samples for the diagnosis and monitoring of visceral leishmaniasis in HIV-infected and HIV-uninfected patients: a single-center, 8-year experience in Italy and review of the literature

BACKGROUND

To overcome some of the limitations of conventional microbiologic techniques, polymerase chain reaction (PCR)-based assays are proposed as useful tools for the diagnosis of visceral leishmaniasis.

PATIENTS AND METHODS

A comparative study using conventional microbiologic techniques (i.e., serologic testing, microscopic examination, and culture) and a Leishmania species-specific PCR assay, using peripheral blood and bone marrow aspirate samples as templates, was conducted during an 8-year period. The study cohort consisted of 594 Italian immunocompetent (adult and pediatric) and immunocompromised (adult) patients experiencing febrile syndromes associated with hematologic alterations and/or hepatosplenomegaly. Identification of the infecting protozoa at the species level was directly obtained by PCR of peripheral blood samples, followed by restriction fragment-length polymorphism analysis of the amplified products, and the results were compared with those of isoenzyme typing of Leishmania species strains from patients, which were isolated in vitro.

RESULTS

Sixty-eight patients (11.4%) had a confirmed diagnosis of visceral leishmaniasis. Eleven cases were observed in human immunodeficiency virus (HIV)-uninfected adults, 20 cases were observed in HIV-infected adults, and the remaining 37 cases were diagnosed in HIV-uninfected children. In the diagnosis of primary visceral leishmaniasis, the sensitivities of the Leishmania species-specific PCR were 95.7% for bone marrow aspirate samples and 98.5% for peripheral blood samples versus sensitivities of 76.2%, 85.5%, and 90.2% for bone marrow aspirate isolation, serologic testing, and microscopic examination of bone marrow biopsy specimens, respectively. None of 229 healthy blood donors or 25 patients with imported malaria who were used as negative control subjects had PCR results positive for Leishmania species in peripheral blood samples (i.e., specificity of Leishmania species-specific PCR, 100%). PCR and restriction fragment-length polymorphism analysis for Leishmania species identification revealed 100% concordance with isoenzyme typing in the 19 patients for whom the latter data were available.

CONCLUSIONS

PCR assay is a highly sensitive and specific tool for the diagnosis of visceral leishmaniasis in both immunocompetent and immunocompromised patients and can be reliably used for rapid parasite identification at the species level.

Tuberculosis of the spine presenting with a cold abscess through the lumbar triangle of Petit

The increasing incidence of human immunodeficiency virus (HIV) has resulted in an increase in the number of Mycobacterium tuberculosis (TB) infections worldwide. Musculoskeletal tuberculosis often involves the spine. Due to HIV, patients may present atypically and, as a result, a high clinical suspicion is necessary to avoid the catastrophic consequences of untreated Pott's disease of the spine. A cold abscess as a result of tuberculosis can emerge in a number of anatomical regions, and perhaps most notably as a psoas abscess. We report a less common anatomical location of a cold abscess, presenting as a mass in the inferior lumbar region through the lumbar triangle of Jean-Louis Petit. We consider the route that the pus had followed and highlight the need for vigilance when dealing with an abscess in this region, particularly in communities with a high incidence of HIV infection.

Clinical care of the HIV-infected drug user

HIV/AIDS and chemical dependency, the latter often intertwined with mental illness, are complex, overlapping spheres that adversely influence each other and the overall clinical outcomes of the affected individual. Each disorder individually impact tens of millions of people adversely, with explosive epidemics described worldwide. This article addresses the adverse consequences of HIV/AIDS, drug injection, the secondary comorbidities of both, and the impact of immunosuppression on presentation of disease as well as approaches to managing the HIV-infected drug user.

[Neuropathology of progressive multifocal leukoencephalopathy]

Progressive multifocal leukoencephalopathy (PML) is caused by opportunistic infection of JC virus which belongs to Papovavirus, and presents with progressive demyelinating lesion in the central nervous system. PML was originally reported as a rare complication of hematologic disorders, but later greatly increased in number in association with acquired immunodeficeincy syndrome (AIDS). Original neuropathological features of PML consist of demyelination lacking inflammatory reaction or necrosis, accompanying oligodendroglial nuclear inclusions in the periphery of demyelination. The lesion is preferentially localized to gray-white junction of the cerebral hemisphere and manifests as characteristic demyelinating lesion, called scallopping. Detection of JC virus is essential for the final diagnosis of PML and is achieved via immunohistochemical detection of JC virus with antibodies raised against their components, ultrastructural demonstration of virions characteristic of JC virus, or detection with in-situ hybridization of the genome of JC virus. JC virus can replicate only in oligodendroglial cells, but astrocytes are frequently infected by the virus. The resume of immunological function through therapeutic intervention develops new pathology in PML, exhibiting severe inflammatory reaction with edema and necrosis. This new pathological feature is called immune reconstruction syndrome and clinically presents with severe progression in symptoms of the central nervous system. Nevertheless, treatment of PML is directed for the elimination of the viruses by host immune system. The modification of the above immune reconstruction syndrome is essential for successful outcome of such therapeutic trial.

[Neuropathology of progressive multifocal leukoencephalopathy]

Progressive multifocal leukoencephalopathy (PML) is caused by opportunistic infection of JC virus which belongs to Papovavirus, and presents with progressive demyelinating lesion in the central nervous system. PML was originally reported as a rare complication of hematologic disorders, but later greatly increased in number in association with acquired immunodeficeincy syndrome (AIDS). Original neuropathological features of PML consist of demyelination lacking inflammatory reaction or necrosis, accompanying oligodendroglial nuclear inclusions in the periphery of demyelination. The lesion is preferentially localized to gray-white junction of the cerebral hemisphere and manifests as characteristic demyelinating lesion, called scallopping. Detection of JC virus is essential for the final diagnosis of PML and is achieved via immunohistochemical detection of JC virus with antibodies raised against their components, ultrastructural demonstration of virions characteristic of JC virus, or detection with in-situ hybridization of the genome of JC virus. JC virus can replicate only in oligodendroglial cells, but astrocytes are frequently infected by the virus. The resume of immunological function through therapeutic intervention develops new pathology in PML, exhibiting severe inflammatory reaction with edema and necrosis. This new pathological feature is called immune reconstruction syndrome and clinically presents with severe progression in symptoms of the central nervous system. Nevertheless, treatment of PML is directed for the elimination of the viruses by host immune system. The modification of the above immune reconstruction syndrome is essential for successful outcome of such therapeutic trial.

[Progressive multifocal leukoencephalopathy--epidemiology, clinical pictures, diagnosis and therapy]

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by the reactivation of a ubiquitous polyomavirus JC (JCV). PML was for many years a rare disease occurring only in patients with underlying severe impaired immunity. Over the past three decades, the incidence of PML has significantly increased related to the AIDS (acquired immunodeficiency syndrome) pandemic and, more recently, to the growing use of immunosuppressive drugs. The clinical presentation of PML is variable with neurological symptoms corresponding to affected cerebral areas. Usually, the clinical outcome of patients with PML is poor with an inexorable progression to death within 6 months of symptom onset. Although PML usually requires a brain biopsy or autopsy for confirmation, radiological imaging and a demonstration of JCV-DNA in the CSF (cerebrospinal fluid) provide supportive evidence for the diagnosis. Although there is no proven effective therapy for PML, patients with HIV (human immunodeficeincy virus)-related PML may benefit significantly from HAART (highly active antiretroviral therapy). In this article the author reviews the epidemiology, especially in Japan, current challenges in the diagnosis and the treatment guidelines of patients with PML based on recent advances in the understanding of the JC virus biology.

[Progressive multifocal leukoencephalopathy--epidemiology, clinical pictures, diagnosis and therapy]

Progressive multifocal leukoencephalopathy (PML) is a demyelinating disease of the central nervous system caused by the reactivation of a ubiquitous polyomavirus JC (JCV). PML was for many years a rare disease occurring only in patients with underlying severe impaired immunity. Over the past three decades, the incidence of PML has significantly increased related to the AIDS (acquired immunodeficiency syndrome) pandemic and, more recently, to the growing use of immunosuppressive drugs. The clinical presentation of PML is variable with neurological symptoms corresponding to affected cerebral areas. Usually, the clinical outcome of patients with PML is poor with an inexorable progression to death within 6 months of symptom onset. Although PML usually requires a brain biopsy or autopsy for confirmation, radiological imaging and a demonstration of JCV-DNA in the CSF (cerebrospinal fluid) provide supportive evidence for the diagnosis. Although there is no proven effective therapy for PML, patients with HIV (human immunodeficeincy virus)-related PML may benefit significantly from HAART (highly active antiretroviral therapy). In this article the author reviews the epidemiology, especially in Japan, current challenges in the diagnosis and the treatment guidelines of patients with PML based on recent advances in the understanding of the JC virus biology.

Tuberculosis infection presenting as brain abscess in an immunocompromised host

Despite advances in modern treatment, tuberculosis remains an ever-present problem. With the HIV epidemic, the prevalence of tuberculosis has risen. Contributing to this trend has been the development of multi-resistant tuberculosis strains, as well as rising immigration from nations where tuberculosis is endemic. Although tuberculosis most commonly manifests as a pulmonary process, milary tuberculosis is also on the rise. Neurotuberculosis, a rare but dangerous progression of pulmonary tuberculosis, remains a difficult diagnostic and treatment dilemma to practitioners both in the United States and abroad. We describe an unusual presentation of neurotuberculosis infection in a previously asymptomatic patient. Early recognition and treatment of intracranial tuberculosis is important if mortality is to be prevented.

Bronchoscopic study on aetiology of chronic cough in HIV-infected adults with negative sputum smears for Mycobacterium tuberculosis at Kenyatta National Hospital, Nairobi

OBJECTIVE

To establish the aetiology of chronic cough in HIV-infected patients with negative sputum smears for Acid Fast Bacilli (AFB).

DESIGN

A cross-sectional descriptive study.

SETTING

Kenyatta National Hospital, a tertiary referral centre in Kenya

SUBJECTS

Sixty five HIV-infected adults presenting with chronic cough and negative sputum smears for AFBs.

RESULTS

Sixty-two patients were included in the final analysis. Aetiology of chronic cough was established in 42 (68%) patients. Pneumocystis jiroveci, bacterial pneumonia and Mycobacterium tuberculosis were diagnosed in 22 (35.5%), 17 (27.4%) and 14 (22.5%) patients respectively. Majority (98%) of patients with a diagnosis had multiple causes established in them. Ciprofloxacin had activity against 91% of the isolated organisms while Penicillin was active against 35% only.

CONCLUSION

This study documents Pneumocystis jiroveci pneumonia as a common cause of morbidity in a subset of HIV infected patients with chronic cough and negative sputum smears for AFB in Kenya.

[The clinical features for tuberculosis in compromised hosts]

We investigated the clinical features and measures for tuberculosis with diabetes mellitus, AIDS, gastrectomy, malignant tumor, or receiving anti-tumor necrosis factor-alpha. In these days, tuberculosis patients with diabetes mellitus are increasing. Their tuberculosis is often found in advanced cases and the periods of symptomatics are short. In short, in tuberculosis with diabetes mellitus, the progress of tuberculosis is fast. Japanese patients of tuberculosis with AIDS are frequent in mid-life and increasing. Extra-pulmonary tuberculosis including disseminated tuberculosis is frequent with patients of AIDS. The prognosis of them is improved with the spread of HAART treatment. The most frequent occasion for gastrectomy is gastric cancer and the prognosis is good. Many of them are thin and malnutrition. The prognosis of tuberculosis with malignant tumor is bad, especially with lung cancer and malignant lymphoma. People receiving infliximab, an antitumor necrosis factor-alpha, are frequent to have onset of tuberculosis. Particularly, extra-pulmonary tuberculosis, including disseminated tuberculosis are often. Tuberculin reaction before receiving infliximab are weak. No one, receiving chemoprophylaxis, has onset of tuberculosis. When the rate of chemoprophylaxis increases, the number of tuberculosis patients decreases. Immunocompromised hosts need to be examined periodical or extraordinary when they had symptoms of tuberculosis to discover the onset of tuberculosis. To prevent the onset of tuberculosis, patients who previously infected tuberculosis should receive active chemoprophylaxis regardless of their age.

A SAS macro for constrained randomization of group-randomized designs

Group-randomized study designs are useful when individually-randomized designs either are not possible, or will not be able to estimate the parameters of interest. Group-randomized trials often have small number of experimental units or groups and strong geographically-induced between-unit correlation, thereby increasing the chance of obtaining a "bad" randomization outcome. It has been suggested to highly constrain the design through restriction to those allocations that meet specified criteria based on certain covariates available at the baseline. We describe a SAS macro that allocates treatment conditions in a two-arm stratified group-randomized design that ensures balance on relevant covariates. The application of the macro is illustrated using two examples of group-randomized designs.

Evaluation of cryptococcus laurentii meningitis in a patient with HIV infection: a case report and review of the literature

Cryptococcus neoformans is the most common cryptococci causing infection in humans. Non-neoformans cryptococci have generally been regarded as saprophytes and rarely reported as human pathogens. We report a probable case of Cryptococcus laurentii meningitis in a HIV-infected patient and reviewed the literature on risk factors and treatment of this infection in humans. This patient was successfully treated with amphotericin B followed by fluconazole. Awareness of the emerging antifungal-resistant C. laurentii strains, as reported in the literature, should be emphasized, especially in immunocompromised patients.

[Fungal infections in HIV-infected patients]

Recent situation of HIV-related mycosis was discussed in this paper, with the analysis of 1) annual report of HIV trends in Japan by the AIDS epidemiology committee, 2) report of HIV-related opportunistic infections (OIs) collected by the AIDS-OIs research group funded by the Ministry of Health, Labour and Welfare, and 3) 17 cases of HIV-related aspergillosis collected by the author. Annual AIDS cases were increasing, and their major diseases were included with the following mycosis: pneumosystis pneumonia 35.7%, candidiasis 19.1%, and cryptococcosis 2.4%. There were two foreigner's cases of histoplasmosis and no coccidioidosis. Candidiasis was likely to be shown in Japanese patients and cryptococcosis was in foreigners. Outcome of cryptococcosis was very poor as 32.7% of patients died. There were 17 HIV-related aspergillosis, which consisted of 13 cases of lung diseases, 2 of brain lesions, and one each of sinus and stomach disease. Remarkable risk factor of HIV-related aspergillosis was decrease of CD4 cell count less than 10/microl, in addition to the usual risk factors of aspergillosis. Outcome of aspergillosis was very poor, as all treated cases died except one recent case treated with voriconazole.

Determinants of Survival Without Antiretroviral Therapy After Infancy in HIV-1-Infected Zambian Children in the CHAP Trial

BACKGROUND

There are few data on predictors of HIV progression in untreated children in resource-limited settings.

METHODS

Children with HIV Antibiotic Prophylaxis (CHAP) was a randomized trial comparing cotrimoxazole prophylaxis with placebo in HIV-infected Zambian children. The prognostic value of baseline characteristics was investigated using Cox models.

RESULTS

Five hundred fourteen children aged 1 to 14 (median 5.5) years contributed 607 years follow-up (maximum 2.6 years). Half were boys, and in 67%, the mother was the primary carer; at baseline, median CD4 percentage was 11% and weight was less than third percentile in 67%. One hundred sixty-five children died (27.2 per 100 years at risk; 95% confidence interval 23.3-31.6). Low weight-for-age, CD4 percentage, hemoglobin, mother as primary carer, current malnutrition, and previous hospital admissions for respiratory tract infections or recurrent severe bacterial infections were independent predictors of poorer survival, whereas oral candidiasis predicted poorer survival only when baseline CD4 percentage was not considered. Mortality rates per 100 child years of 44.5 (37.2-53.2), 14.7 (10.9-19.8), and 2.3 (0.3-16.7) were associated with new World Health Organization stages 4, 3, and 1/2, respectively, applied retrospectively; very low weight-for-age was the only staging feature for 42% of stage 4 children.

CONCLUSIONS

Malnutrition and hospitalizations for respiratory/bacterial infections predict mortality independent of immunosuppression, suggesting that they capture HIV- and non-HIV-related mortality, whereas oral candidiasis is a proxy for immunosuppression.

Immune reconstitution inflammatory syndrome in the CNS of HIV-infected patients

OBJECTIVE

To describe challenges in diagnosis and management of patients with clinical syndromes of immune reconstitution inflammatory syndrome (IRIS) involving the CNS.

METHODS

The authors describe three patients with clinically distinct neurologic manifestations of IRIS with HIV infection who presented as diagnostic and therapeutic challenges.

RESULTS

One patient with cryptococcal meningitis developed acute cerebellitis with mass effect and brainstem compression. Corticosteroid therapy was associated with complete resolution of the cerebellar lesion but the patient developed VZV encephalitis. Another patient with progressive multifocal leukoencephalopathy developed subacute progression of focal neurologic deficits associated with contrast enhancing lesions on brain MRI. This patient had spontaneous resolution of the lesion but was left with residual deficits. One patient developed a progressive dementing syndrome and deterioration over several months resulting in coma during combination antiretroviral therapy. A brain biopsy in this latter patient showed massive infiltration of T lymphocytes predominantly of the CD8 subtype. This patient had a significant improvement with corticosteroids and change in antiretroviral regimen although she was left with residual cognitive impairment.

CONCLUSIONS

Immune reconstitution inflammatory syndrome should be suspected in patients who show clinical or radiologic deterioration following initiation of antiretroviral therapy accompanied with improvement in CD4 cell count and viral load. Some patients may respond to a brief course of treatment with corticosteroids.