Impaired erythropoiesis in the acquired immunodeficiency syndrome with disseminated Mycobacterium avium complex

Magnitude of opportunistic infections and associated factors among HIV-infected individuals attending care and treatment clinics in Dar es Salaam, Tanzania: a hospital-based cross-sectional study

OBJECTIVES

This study aims to assess the magnitude of opportunistic infection (OI) and to identify factors associated with OIs among people living with HIV (PLHIV) on antiretroviral treatment (ART), attending HIV care and treatment clinics.

DESIGN

A hospital-based cross-sectional study.

SETTING

The study was conducted at Muhimbili National Hospital, Mwananyamala and Temeke Regional Referral Hospitals, in Dar es Salaam, Tanzania.

PARTICIPANTS

We enrolled 382 PLHIV on ART who were attending HIV care and treatment clinics in Dar es Salaam. Structured questionnaires were used to collect socio-demographic information, and a checklist was used to extract clinical characteristics from the client's HIV care and treatment clinic cards. Information was subjected to descriptive and regression analysis using Stata V.13. All factors were considered significant at p<0.05.

PRIMARY OUTCOME

Magnitude, spectrum of OI and associated factors among PLHIV using ART.

RESULTS

A total of 382 PLHIV on ART were randomly selected and recruited in the study. The overall prevalence of OIs was 25.13%; the leading OI was tuberculosis affecting 58 patients (15.2%). CD4+ T cell counts≤200 cells/µL (aOR=13.61; 95% CI: 6.09 to 30.38) p<0.001, isoniazid preventive treatment (IPT) (aOR=4.10; 95% CI: 1.97 to 8.53) p<0.001, WHO clinical stage 4 (aOR=6.37; 95% CI: 1.47 to 27.61) p=0.013, divorced individuals (aOR=3.57; 95% CI: 1.43 to 8.90) p=0.006, male (aOR=3.04; 95% CI: 1.50 to 6.17) p=0.007, haemoglobin level<11.0 g/dL (aOR=2.25; 95% CI: 1.14 to 4.47) p=0.020 and level of education of primary and below (aOR=4.31; 95% CI: 1.8 to 10.32) p=0.001 showed significant association with OIs.

CONCLUSION

There was still a high prevalence of OI observed in this study which needs to be addressed. CD4+ T cell counts of ≤200 cells/µL, advanced WHO clinical stages, no use of IPT prophylaxis, anaemia and low education level were predictors of OIs. Promptly implementing the test-and-treat protocol while an individual's immunity is still strong and timely screening for OI are critical.

Anemia and opportunistic infections in hospitalized people living with HIV: a retrospective study

BACKGROUND

There is a high prevalence of anemia among people living with HIV in Guangxi, China. Therefore, we investigated anemia and opportunistic infections in hospitalized people living with HIV and explored the risk factors related to anemia in people living with HIV to actively prevent anemia in people living with HIV.

METHODS

We retrospectively studied people living with HIV admitted to Guangxi Chest Hospital from June 2016 to October 2021. Detailed information on the sociodemographic and clinical features of the participants was collected. The X² test was used to compare the prevalence between the anemic and non-anemic groups. The logistic regression analysis was applied to exclude confounding factors and identify factors related to anemia.

RESULTS

Among 5645 patients with HIV, 1525 (27.02%) had anemia. The overall prevalence of mild, moderate, and severe anemia was 4.66%, 14.08%, and 8.27%, respectively. The factors significantly related to increased risk of anemia were CD4 count < 50 cells/µl (aOR = 2.221, 95% CI = [1.775, 2.779]), CD4 count 50-199 cells/µl (aOR = 1.659, 95% CI = [1.327, 2. 073]), female (aOR = 1.644, 95% CI = [1.436, 1.881]) co-infected with HCV (aOR = 1.465, 95% CI = [1.071, 2.002]), PM (aOR = 2.356, 95% CI = [1.950, 2.849]), or TB (aOR = 1.198, 95% CI = [1.053, 1.365]).

CONCLUSIONS

Within Guangxi of China, 27.02% of hospitalized people living with HIV presented with anemia. Most patients with anemia were in the mild to moderate stage. The low CD4 count, female gender, and concomitant infection with Penicillium marneffei, Hepatitis C virus, or Tuberculosis were independent correlates of anemia. Thus, these findings would be helpful to clinicians in preventing and intervening in anemia in people living with HIV.

First use of thymus transplantation therapy for FOXN1 deficiency (nude/SCID): a report of 2 cases

FOXN1 deficiency is a primary immunodeficiency characterized by athymia, alopecia totalis, and nail dystrophy. Two infants with FOXN1 deficiency were transplanted with cultured postnatal thymus tissue. Subject 1 presented with disseminated Bacillus Calmette-Guérin infection and oligoclonal T cells with no naive markers. Subject 2 had respiratory failure, human herpes virus 6 infection, cytopenias, and no circulating T cells. The subjects were given thymus transplants at 14 and 9 months of life, respectively. Subject 1 received immunosuppression before and for 10 months after transplantation. With follow up of 4.9 and 2.9 years, subjects 1 and 2 are well without infectious complications. The pretransplantation mycobacterial disease in subject 1 and cytopenias in subject 2 resolved. Subject 2 developed autoimmune thyroid disease 1.6 years after transplantation. Both subjects developed functional immunity. Subjects 1 and 2 have 1053/mm(3) and 1232/mm(3) CD3(+) cells, 647/mm(3) and 868/mm(3) CD4(+) T cells, 213/mm(3) and 425/mm(3) naive CD4(+) T cells, and 10 200 and 5700 T-cell receptor rearrangement excision circles per 100 000 CD3(+) cells, respectively. They have normal CD4 T-cell receptor β variable repertoires. Both subjects developed antigen-specific proliferative responses and have discontinued immunoglobulin replacement. In summary, thymus transplantation led to T-cell reconstitution and function in these FOXN1 deficient infants.

Health importance of arsenic in drinking water and food

Arsenic is a toxic metalloid of global concern. It usually originates geogenically but can be intensified by human activities such as applications of pesticides and wood preservatives, mining and smelting operations, and coal combustion. Arsenic-contaminated food is a widespread problem worldwide. Data derived from population-based studies, clinical case series, and case reports relating to ingestion of inorganic arsenic in drinking water, medications, or contaminated food or beverages show the capacity of arsenate and arsenite to adversely affect multiple organ systems. Chronic arsenic poisoning can cause serious health effects including cancers, melanosis (hyperpigmentation or dark spots, and hypopigmentation or white spots), hyperkeratosis (hardened skin), restrictive lung disease, peripheral vascular disease (blackfoot disease), gangrene, diabetes mellitus, hypertension, and ischemic heart disease.

Incidence and predictors of death, retention, and switch to second-line regimens in antiretroviral- treated patients in sub-Saharan African Sites with comprehensive monitoring availability

BACKGROUND

Antiretroviral treatment programs in sub-Saharan Africa have high rates of early mortality and loss to follow-up. Switching to second-line regimens is often delayed because of limited access to laboratory monitoring.

METHODS

Retrospective analysis was performed of a cohort of adults who initiated a standard first-line antiretroviral treatment at 5 public sector sites in 3 African countries. Monitoring included routine CD4 cell counts, human immunodeficiency virus RNA measures, and records of whether appointments were kept. Incidence and predictors of death, loss to follow-up, and switch to second-line regimens were analyzed by time-to-event approaches.

RESULTS

A total of 3749 patients were analyzed; at baseline, 37.1% were classified as having World Health Organization disease stage 3 or 4, and the median CD4 cell count was 192 cells/mL. First-line regimens were nevirapine based in 96.5% of patients; 17.7% of patients attended <95% of their drug pickup appointments. During 4545 person-years of follow-up, mortality was 8.6 deaths per 100 person-years and was predicted by lower baseline CD4 cell count, lower hemoglobin level, and lower body mass index (calculated as weight in kilograms divided by the square of height in meters); more-advanced clinical stage of infection; male sex; and more missed drug pickup appointments. Dropouts (which accrued at a rate of 2.1 dropouts per 100 person-years) were predicted by a lower body mass index, more missed visits and missed drug pickup appointments, and later calendar year. Incidence of switches to second-line regimens was 4.9 per 100 person-years; increased hazards were observed with lower CD4 cell count and earlier calendar year at baseline. In patients who switched, virological failure was predicted by combined clinical and CD4 criteria with 74% sensitivity and 30% specificity.

CONCLUSIONS

In an antiretroviral treatment program employing comprehensive monitoring, the probability of switching to second-line therapy was limited. Regular pickup of medication was a predictor of survival and was also strongly predictive of patient retention.

Hematologic disorders associated with human immunodeficiency virus and AIDS

Nurses encounter patients with human immunodeficiency virus infection at various stages of their infection and in a variety of settings. This article focuses on the most common hematologic disorders associated with human immunodeficiency virus infection and acquired immunodeficiency syndrome, which can precipitate complications and frequently accompany hospitalization. It is important for nurses to have a solid foundation as to the cause of these disorders, their impact on quality of life and outcomes, and management strategies.

Lung Disease Due to the More Common Nontuberculous Mycobacteria

As the prevalence of tuberculosis (TB) declines in the developed world, the proportion of mycobacterial lung disease due to nontuberculous mycobacteria (NTM) is increasing. It is not clear whether there is a real increase in prevalence or whether NTM disease is being recognized more often because of the introduction of more sensitive laboratory techniques, and that more specimens are being submitted for mycobacterial staining and culture as the result of a greater understanding of the role of NTM in conditions such as cystic fibrosis, posttransplantation and other forms of iatrogenic immunosuppression, immune reconstitution inflammatory syndrome, fibronodular bronchiectasis, and hypersensitivity pneumonitis. The introduction of BACTEC liquid culture systems (BD; Franklin Lakes, NJ) and the development of nucleic acid amplification and DNA probes allow more rapid diagnosis of mycobacterial disease and the quicker differentiation of NTM from TB isolates. High-performance liquid chromatography, polymerase chain reaction, and restriction fragment length polymorphism analysis have helped to identify new NTM species. Although treatment regimens that include the newer macrolides are more effective than the earlier regimens, failure rates are still too high and relapse may occur after apparently successful therapy. Moreover, treatment regimens are difficult to adhere to because of their long duration, adverse effects, and interactions with the other medications that these patients require. The purpose of this article is to review the common presentations of NTM lung disease, the conditions associated with NTM lung disease, and the clinical features and treatment of the NTM that most commonly cause lung disease.

Change in T-Lymphocyte Count after Initiation of Highly Active Antiretroviral Therapy in HIV-Infected Patients with History of Mycobacterium Avium Complex Infection

Objective

To compare changes in CD4+, CD8+ and total lymphocyte counts after initiation of highly active anti-retroviral therapy (HAART) between HIV-infected patients with and without a recent history of Mycobacterium avium complex (MAC) infection.

Method

Matched exposed-non-exposed retrospective cohort study.

Results

Fifty-one patients with a recent history of MAC infection (MAC+) started a combination of at least three antiretroviral drugs. They were individually matched to 145 patients without any history of MAC infection (MAC-) according to CD4+ T-cell count (±30 cells/mm3), previous experience of antiretroviral treatment, AIDS clinical stage at the time of HAART initiation (baseline), age (±10 years) and gender. MAC+ and MAC- patients presented comparable median levels of total lymphocytes (488 vs 688/mm3, P=0.09), CD4+ (11 vs 16/mm3, P=0.15), CD8+ count (359 vs 386/mm3, P=0.39) and plasma HIV RNA (5.3 vs 5.1 log10 copies/ml, P=0.22) at baseline. After 6 months on HAART, the median increase of CD4+ T-cell count was 28 cells/mm3 (interquartile range [IQR]: 1–63) in MAC+ and 72 cells/mm3 (IQR: 34–120) in MAC- patients ( P<0.0001), whereas the percentage of CD4+ T cells was not significantly different between the two groups ( P=0.13). Comparable differences were observed for total lymphocytes and CD8+ T cells ( P<0.001). The 6 months decline of plasma HIV RNA was not significantly different according to MAC exposure (-1.6 in MAC+ vs -1.8 log10 copies/ml in MAC- patients, P=0.65). Results were confirmed after adjustment for other characteristics than the matching variables and after taking into account potential informative bias due to unbalanced number of deaths between the two groups.

Conclusion

MAC infection at the time of HAART initiation is an important deleterious factor for immune reconstitution. A better understanding of the underlying mechanism and an evaluation of additional treatment strategies are necessary to help immune restoration in such circumstances.

Detection of phospholipase C in nontuberculous mycobacteria and its possible role in hemolytic activity

Phospholipase C plays a key role in the pathogenesis of several bacterial infections, for example, those caused by Clostridium perfringens and Listeria monocytogenes. Previous studies have reported multiple copies of plc genes homologous to Pseudomonas aeruginosa plcH and plcN genes encoding the hemolytic and nonhemolytic phospholipase C enzymes in the genomes of Mycobacterium tuberculosis, M. marinum, M. bovis, and M. ulcerans. In this study we analyzed the possible relationship between phospholipase C and hemolytic activity in 21 strains of nontuberculous mycobacteria representing nine different species. Detection of phospholipase C enzymatic activity was carried out using thin-layer chromatography to detect diglycerides in the hydrolysates of radiolabeled phosphatidylcholine. DNA sequences of M. kansasii and M. marinum homologous to the genes encoding phospholipase C from M. tuberculosis and M. ulcerans were identified by DNA-DNA hybridization and sequencing. Finally, we developed a direct and simple assay to detect mycobacterial hemolytic activity. This assay is based on a modified blood agar medium that allows the growth and expression of hemolysis of slow-growing mycobacteria. Hemolytic activity was detected in M. avium, M. intracellulare, M. ulcerans, M. marinum, M. tuberculosis, and M. kansasii mycobacteria with phospholipase C activity, but not in M. fortuitum. No hemolytic activity was detected in M. smegmatis, M. gordonae, and M. vaccae. Whether or not phospholipase C enzyme plays a role in the pathogenesis of nontuberculous mycobacterial diseases needs further investigation.

The pathophysiology of disseminated Mycobacterium avium complex disease in AIDS

Mycobacterium avium complex (MAC) organisms cause disseminated disease in patients with AIDS. The organisms penetrate the gastrointestinal mucosa by unknown mechanisms and are phagocytosed by macrophages in the lamina propria. These cells cannot kill the organisms, and MAC spreads through the submucosal tissue. Lymphatic drainage transports mycobacteria to abdominal lymph nodes, from which the organisms enter the bloodstream. Hematogenous spread can occur to many sites, but spleen, bone marrow, and liver are the most common. Tissue destruction is rare, and most signs and symptoms of MAC disease are due to elaboration of cytokines. MAC is rarely the direct cause of death but increases the risk for superinfection; death may result from malnutrition or other infections.

HIV influence on hematopoiesis at the initial stage of infection

Alterations in the parameters responsible for the characteristic anemic condition of AIDS patients who are at the final stage of infection have already been established. However, the development of these alterations at the initial stage of infection, where no opportunistic infections occur, needs further study. The goal of this study was to verify whether laboratory alterations observed on patients at the final stages of the disease could already be seen at the beginning of HIV infection, or were the result of opportunistic infections. To that end, HIV-seropositive patients identified by the ELISA test and confirmed by immunofluorescence were screened by infectologist doctors and classified as per the Walter Reed Army Institute System. Results showed that thrombocytopenia occurred at an early stage during HIV infection. The number of leukocytes and erythrocytes diminished progressively as the disease advanced, and levels of hemoglobin, transferrin and serum iron were also diminished with the progression of the disease. These results indicate that the laboratory alterations observed in HIV-seropositive patients during the initial stages were, probably, due to virus infection, because these patients did not present opportunistic infections.

[Disseminated Mycobacterium avium complex infections in AIDS. Apropos of 100 cases. Groupe d'Epidémiologie clinique du SIDA en Aquitaine]

The improvement of survival of AIDS patients allowed the emergence of disseminated Mycobacterium avium Complex infections (D.MAC). Here we report the experience of the group of "Epidémiologie clinique du sida en Aquitaine (GECSA)" about 100 patients. There were no differences according to sex, age and route of acquisition of HIV. Clinical and biological characteristics of the infections were not specific. The mean TCD4+ lymphocytes count was 18/mm3. The diagnostic was generally established by systematic blood culture on Septi-Chek in patients with TCD4+ lymphocytes count below 75/mm3. The recommendations on therapy for D.MAC are to use regimen containing azithromycin or clarithromycin, ethambutol and one of the following drugs, rifabutin, clofazimine, amikacin, or ciprofloxacin. Rifabutin is recommended for prophylaxis in patients with lymphocytes TCD4+ count below 100/mm3.