Value of necropsy in acquired immunodeficiency syndrome

Cytomegalovirus viremia and risk of disease progression and death in HIV-positive patients starting antiretroviral therapy

OBJECTIVE

The aim of this study was to assess the prevalence of cytomegalovirus (CMV) viremia in HIV-positive patients starting antiretroviral therapy (ART) and to evaluate its impact on clinical outcomes.

DESIGN

A retrospective analysis of four clinical trials (INSIGHT FIRST, SMART, START, and ANRS REFLATE TB).

METHODS

Stored plasma samples from participants were used to measure CMV viremia at baseline prior to initiating ART and at visits through 1 year of follow-up after ART initiation. CMV viremia was measured centrally using a quantitative PCR assay. Within FIRST, associations of CMV viremia at baseline and through 8 months of ART were examined with a composite clinical outcome of AIDS, serious non-AIDS events, or death using Cox proportional hazards regression.

RESULTS

Samples from a total of 3176 participants, 1169 from FIRST, 137 from ANRS REFLATE TB, 54 from SMART, and 1816 from START were available with baseline CMV viremia prevalence of 17, 26, 0, and 1%, respectively. Pooled across trials, baseline CMV viremia was associated with low CD4 + T-cell counts and high HIV RNA levels. In FIRST, CMV viremia was detected in only 5% of participants between baseline and month 8. After adjustment for CD4 + T-cell count and HIV RNA levels, hazard ratios for risk of clinical outcomes was 1.15 (0.86-1.54) and 2.58 (1.68-3.98) in FIRST participants with baseline and follow-up CMV viremia, respectively.

CONCLUSION

Baseline CMV viremia in HIV-positive patients starting ART is associated with advanced infection and only persistent CMV viremia after ART initiation is associated with a higher risk of morbidity and mortality.

Morphological changes in the digestive system of 322 necropsies of patients with acquired immune deficiency syndrome: comparison of findings pre- and post-HAART (Highly Active Antiretroviral Therapy)

Involvement of the digestive system in AIDS pathologies or injuries is frequent. Aiming at comparing the frequency, the importance that these lesions have for death and the survival time in patients using or not using HAART, we studied 322 necropsies classified as follows: Group A - without antiretroviral drugs (185 cases); B - one or two antiretroviral drugs or HAART for less than six months (83 cases); C - HAART for six months or longer (54 cases). In the overall analysis of the digestive system, changes were present in 73.6% of cases. The most frequent was Candida infection (22.7%), followed by cytomegalovirus (19.2%), Histoplasma capsulatum (6.5%), mycobacteria (5.6%), and Toxoplasma gondii (4.3%). T. gondii infection was more frequent in group A compared with group C, and cytomegalovirus (CMV) was more frequent in group A compared with groups B and C (p < 0.05); 2.2% of the deaths were due to gastrointestinal bleeding. Regarding the segments, only in the large intestine, and only cytomegalovirus, were more frequent in group A compared with group C. We conclude that digestive system infections are still frequent, even with the use of HAART. However, the average survival time in group C was more than three times greater than the one in group A and nearly double that of group B, demonstrating the clear benefit of this therapy.

Opportunistic Infections in HIV-Infected Patients Differ Strongly in Frequencies and Spectra between Patients with Low CD4+ Cell Counts Examined Postmortem and Compensated Patients Examined Antemortem Irrespective of the HAART Era

Objective

AIDS-related mortality has changed dramatically with the onset of highly active antiretroviral therapy (HAART), which has even allowed compensated HIV-infected patients to withdraw from secondary therapy directed against opportunistic pathogens. However, in recently autopsied HIV-infected patients, we observed that associations with a broad spectrum of pathogens remain, although detailed analyses are lacking. Therefore, we focused on the possible frequency and spectrum shifts in pathogens associated with autopsied HIV-infected patients.

Design

We hypothesized that the pathogens frequency and spectrum changes found in HIV-infected patients examined postmortem did not recapitulate the changes found previously in HIV-infected patients examined antemortem in both the pre- and post-HAART eras. Because this is the first comprehensive study originating from Central and Eastern Europe, we also compared our data with those obtained in the West and Southwest Europe, USA and Latin America.

Methods

We performed autopsies on 124 HIV-infected patients who died from AIDS or other co-morbidities in the Czech Republic between 1985 and 2014. The pathological findings were retrieved from the full postmortem examinations and autopsy records.

Results

We collected a total of 502 host-pathogen records covering 82 pathogen species, a spectrum that did not change according to patients’ therapy or since the onset of the epidemics, which can probably be explained by the fact that even recently deceased patients were usually decompensated (in 95% of the cases, the last available CD4⁺ cell count was falling below 200 cells*μl^-1) regardless of the treatment they received. The newly identified pathogen taxa in HIV-infected patients included Acinetobacter calcoaceticus, Aerococcus viridans and Escherichia hermannii. We observed a very limited overlap in both the spectra and frequencies of the pathogen species found postmortem in HIV-infected patients in Europe, the USA and Latin America.

Conclusions

The shifts documented previously in compensated HIV-infected patients examined antemortem in the post-HAART era are not recapitulated in mostly decompensated HIV-infected patients examined postmortem.

Cryptococcosis in Acquired Immunodeficiency Syndrome Patients Clinically Confirmed and/or Diagnosed at Necropsy in a Teaching Hospital in Brazil

Cryptococcosis occurs in acquired immunodeficiency syndrome (AIDS) patients with poor compliance to antiretroviral therapy or unaware of their human immunodeficiency virus status who present severe immunosuppression at admission. Consequently, high mortality rates are observed due to disseminated fungal infection. This report presents clinical and postmortem data of AIDS patients with cryptococcosis in a teaching hospital in Brazil. Retrospectively, medical and necropsy records of AIDS patients with cryptococcosis clinically confirmed and/or postmortem verified were reviewed. Clinical data were compared with those of patients presenting a good outcome to evaluate disseminated fungal infection and the agreement between clinical and postmortem diagnosis. At admission, most of the 45 patients with cryptococcal meningitis who died, presented more altered consciousness (P = 0.0047), intracranial increased pressure (P = 0.047), and severe malnutrition (P = 0.0006) than the survivors. Of 29 (64.4%) patients with cryptococcal meningitis, 23 died before week 2 on antifungal therapy, and the other six during the next 3 months. The remaining 16 (35.6%) cases had other diagnoses and died soon after. At necropsy, 31 (68.9%) presented disseminated infection involving two or more organs, whereas 14 (31.1%) cases had meningeal or pulmonary localized infection. The agreement of 64.4% between clinical and postmortem diagnosis was similar to some studies. However, other reports have shown figures ranging from 34% to 95%. Currently, a progressive worldwide decrease of autopsies is worrying because the role of postmortem examination is pivotal to verify or identify the death causes, which contributes to improve the quality of clinical diagnosis and medical training.

Diagnostic utility of quantitative plasma cytomegalovirus DNA PCR for cytomegalovirus end-organ diseases in patients with HIV-1 infection

OBJECTIVE

To investigate the diagnostic value of quantitative plasma cytomegalovirus (CMV)-DNA polymerase chain reaction (PCR) for CMV end-organ diseases (CMV-EOD) in patients with HIV-1 infection.

DESIGN

Single-center cross-sectional study.

METHODS

The study subjects were HIV-1-infected patients with CD4 ≤200 per microliter, who had undergone ophthalmologic examination with plasma CMV-DNA PCR measured within 7 days. CMV retinitis and other CMV-EOD were diagnosed according to the ACTG criteria. PCR value was converted into the WHO international standard.

RESULTS

CMV retinitis and all CMV-EOD were diagnosed in 23 (5%) and 37 (8%) of the 461 study patients, respectively. CMV-DNA was undetectable (<185 IU/mL) in 2 patients with CMV retinitis and 1 with encephalitis. The area under the receiver operating characteristic curve of CMV-DNA for CMV retinitis and all CMV-EOD were 0.80 [95% confidence interval (CI): 0.71 to 0.89] and 0.82 (0.75 to 0.89), respectively. The sensitivity, specificity, positive predictive value, and negative predictive value for each cutoff value of CMV-DNA were as follows: for CMV retinitis, ≥10,086 IU/mL: 26.1%, 94.1%, 18.8%, 96%; ≥2946 IU/mL; 56.5%, 86.8%, 18.3%, 97.4%; ≥959 IU/mL; 60.9%, 78.1%, 12.7%, 97.4%; detectable CMV-DNA (≥185 IU/mL): 91.3%, 48.2%, 8.5%, 99.1%; for all CMV-EOD: ≥10,086 IU/mL: 32.4%, 95.3%, 37.5%, 94.2%; ≥2946 IU/mL; 54.1%, 88%, 28.2%, 95.6%; ≥959 IU/mL; 62.2%, 79.5%, 20.9%, 96%; detectable CMV-DNA; 91.9%, 49.5%, 13.7%, 98.6%.

CONCLUSIONS

Plasma CMV-DNA PCR has a high diagnostic value for both CMV retinitis and all CMV-EOD in patients with advanced HIV-1 infection. A cutoff value of CMV-DNA ≥10,086 IU/mL and ≥2946 IU/mL yields high specificity, whereas undetectable CMV-DNA load (<185 IU/mL) likely rules out CMV-EOD.

Cytomegalovirus viremia in Thai HIV-infected patients on antiretroviral therapy: prevalence and associated mortality

BACKGROUND

Prevalence and risk factors of cytomegalovirus (CMV) viremia in patients infected with human immunodeficiency virus (HIV) starting antiretroviral therapy (ART) in developing countries are understudied.

METHODS

We measured CMV DNA in stored plasma specimens of 293 Thai HIV patients starting ART at CD4 counts <200 cells/mm(3). We examined Cox proportional hazard ratios (HRs) of 24 months mortality and new AIDS-defining illness (ADI).

RESULTS

Of 293 patients, 159 (54.3%) were male. The median age was 33 years. The median baseline CD4 count was 82 cells/mm(3), and the median HIV-1 RNA was 4.9 log10 copies/mL. In total, 273 (93.2%) patients started potent combination ART, and 20 (6.8%) started dual nucleoside reverse transcriptase inhibitor (NRTI) therapy. CMV DNA was detected in 77 of 293 patients (26.3%) at baseline, and 9 of 199 patients with available specimen (4.5%) after 6 months of ART. The median CMV DNA was 548 copies/mL (interquartile range [IQR], 129-3849) at baseline and 114 copies/mL (IQR, 75-1099) at 6 months. In univariate analysis, death was associated with baseline CDC stage C, hemoglobin <10 g/dL, lower CD4 count, and CMV viremia. In multivariate analysis, only CMV DNA >500 copies/mL was significantly associated with mortality (HR: 7.28; 95% CI, 1.32-40.29, P = .023). CD4 count was the only variable associated with new ADI (HR: 0.70 per 50 CD4 cells increase; 95% CI, .49-.997, P = .048).

CONCLUSIONS

In these Thai patients with advanced HIV disease, CMV viremia was frequent, and CMV DNA >500 copies/mL predicted increased mortality despite ART initiation. This calls for increased attention to screening of active CMV infection in advanced HIV patients in developing countries. Trials assessing preemptive anti-CMV therapy may be warranted.

Morphological changes in the digestive system of 93 human immunodeficiency virus positive patients: an autopsy study

Involvement of the digestive system in patients with acquired immunodeficiency syndrome (AIDS) is frequent and many changes in these patients are diagnosed only at autopsy. There are few studies of autopsy with detailed analysis of this system and only one was conducted in Brazil. We evaluated each segment of the digestive system in 93 consecutive autopsies of patients infected with human immunodeficiency virus (HIV) and the importance of these lesions to death. Of these, 90 (96.8%) patients had AIDS. We reviewed medical records, autopsy reports and histological sections from tongue to rectum stained with hematoxylin-eosin. When necessary, we analyzed special stains and immunohistochemistry to investigate infections. There was damage to the digestive system in 73 (78.5%) cases. The most common infections were candidiasis (42%), cytomegalovirus (29%), histoplasmosis (11.8%), toxoplasmosis (9.7%) and mycobacterial infection (9.7%). Malignancies were rare, present in four (4.3%) cases (two Kaposi's sarcoma, one adenocarcinoma and one metastatic embryonal carcinoma). All segments showed lesions: tongue (48.6%), esophagus (44.8%), stomach (44.7%), colon (43.2%) and small intestine (28.9%). The lesions found were immediate cause of death in five (5.4%) cases. In another 36 (38.7%) cases the basic disease was systemic and also compromised the digestive system.

Neuropathology of AIDS: An Autopsy Review of 284 Cases from Brazil Comparing the Findings Pre- and Post-HAART (Highly Active Antiretroviral Therapy) and Pre- and Postmortem Correlation

A retrospective study of central nervous system (CNS) in 284 autopsy AIDS cases in Brazil (1989–2008) divided into 3 groups: A (without antiretroviral treatment: 163 cases); B (other antiretroviral therapies: 76 cases); C (HAART for 3 months or more: 45 cases). In 165 (58.1%) cases, relevant lesions were found, predominantly infections (54.2%); the most frequent was toxoplasmosis (29.9%) followed by cryptococcosis (15.8%), purulent bacterial infections (3.9%), and HIV encephalitis (2.8%); non-Hodgkin lymphomas occurred in 1.4% and vascular lesions in 1.1%. There was no difference when compared the frequency of lesion among the groups; however, toxoplasmosis was less common while HIV encephalitis was more frequent in group C related to A. CNS lesions remain a frequent cause of death in AIDS; however, the mean survival time was four times greater in group C than in A. In 91 (55.1%) of 165 cases with relevant brain lesions (or 32% of the total 284 cases), there was discordance between pre- and postmortem diagnosis; disagreement type 1 (important disease that if diagnosed in life could change the patient prognosis) occurred in 49 (53.8%) of 91 discordant cases (17.6% of the total 284) indicating the autopsy importance, even with HAART and advanced diagnostics technologies.

The spectrum of clinical and pathological manifestations of AIDS in a consecutive series of 236 autopsied cases in mumbai, India

The HIV epidemic in the Asian subcontinent has a significant impact on India. The AIDS associated pathology has not been well evaluated in a representative study hence very little is known about the spectrum of HIV/AIDS associated diseases in Indian subcontinent. To determine the important postmortem findings in HIV infected individuals in Mumbai, autopsy study was carried out. The patient population included patients with AIDS who died at the tertiary care hospital over a 20 year period from 1988 to 2007. A total of 236 (182; 77% males and 54; 23%) females) patients with AIDS were autopsied. The main risk factor for HIV transmission was heterosexual contact (226 patients; 96%) and 223/236 (94%) patients died of HIV-related diseases. Tuberculosis was the prime cause of death in 149 (63%) patients, followed by bacterial pneumonia 33 (14%), cryptococcosis 18 (8%), toxoplasmosis of brain 15 (6%), pneumocystis jiroveci (PCJ) 1 (0.5%) and Non-Hodgkin's lymphoma 7 (3%) cases. The major underlying pathologies are either preventable or treatable conditions. There is an urgent need for attention towards the diagnosis, issue of therapy, and care of HIV disease in developing countries. Reducing mortality in patients with AIDS from infections must be highest public health policy in India.

Trends in the postmortem diagnosis of opportunistic invasive fungal infections in patients with AIDS: a retrospective study of 1,630 autopsies performed between 1984 and 2002

We retrospectively evaluated autopsy-proven invasive fungal infections (IFIs) in patients with AIDS who died between 1984 and 2002. IFIs were identified in 297 (18.2%) of 1,630 autopsies. Their prevalence significantly decreased over time (from 25.0% in 1984-1988 to 15% in 1998-2002; P = .004), mainly owing to a significant decrease in pneumocystosis (P = .017) and cryptococcosis (P = .003), whereas the prevalence of aspergillosis and histoplasmosis remained relatively stable and of candidiasis and zygomycosis tended to increase in the last years (P = .028 and P = .042, respectively). IFIs were suspected or confirmed during life in only 46.8% of the cases; this proportion did not vary significantly over time (P = .320). The infections contributed to the deaths of 103 patients (34.7%), and their global impact on mortality was 6.3%. Of fatal cases, 38 (36.9%) were characterized by missed antemortem diagnoses, 17 (45%) of which met Goldman criteria for class I errors. The epidemiology of IFIs in patients with AIDS is evolving and not completely mirrored by clinical diagnoses or current diagnostic methods. Our results confirm the valuable role of autopsy data, even with highly effective therapies and advanced technologies.

Review: thromboses among HIV-infected patients during the highly active antiretroviral therapy era

Venous thrombotic events (VTEs) may occur at higher rates among patients with HIV; some studies suggest that highly active antiretroviral therapy (HAART) may increase the risk for these potentially life-threatening events. We performed a retrospective study among patients with HIV to evaluate the incidence and risk factors for VTEs during the HAART era. A literature review was performed examining VTEs in the pre- and post-HAART eras. Seventeen (3.7%) of 465 patients with HIV experienced a VTE. The overall incidence rate of deep VTEs among HIV-positive persons was 377 cases per 100,000 person-years, a fourfold higher rate compared to age-matched males in the general population. The median age at VTE was 36 years (range, 27-68). Patients with a thrombosis compared to those without had significantly lower current CD4 (153 versus 520 cells/mm(3), p < 0.001) and nadir (76 versus 276 cells/mm(3), p < 0.001) CD4 counts, higher viral loads (3.6 versus 1.7 log(10) copies per milliliter, p = 0.003), and more likely to have a diagnosis of AIDS (76% versus 32%, p < 0.001); there were no differences in demographics, hyperlipidemia, current use of HAART, the duration of HAART or protease inhibitor (PI) exposure. A review of the literature noted 129 VTE cases; mean age was 40 years, mean CD4 count was 181 cells/mm(3), the majority of patients were not receiving HAART, and the most common risk factor was an ongoing infection. Thrombotic events are occurring among patients with HIV despite their relatively young ages. Advanced HIV disease is a risk factor for development of thromboses, possibly due to an increased inflammatory state or the presence of concurrent comorbidities such as infections. HAART or PI therapy does not appear to play a significant role in the occurrence of VTEs.

Incidence and risk factors for bilateral deep venous thrombosis of the lower limbs

The incidence of bilateral deep venous thrombosis in patients with single limb or bilateral symptoms was determined using duplex scan examination. In a prospective study, 157 inpatients with clinical suspicion of deep venous thrombosis underwent duplex scan evaluation of the lower extremities. Demographic characteristics, physical examination data, and risk factor information were collected. In all, 57 (36.3%) patients evaluated presented echographic evidence of acute deep venous thrombosis. Forty-six individuals presented unilateral thrombosis, and 11 patients presented bilateral disease (19.3% of all thrombosis, 7.0% of all patients). Sensitivity and specificity of clinical examination in identifying bilateral thrombosis was 27.2% and 93.3%, respectively. For the risk factors evaluated, active human immunodeficiency virus disease and iliofemoral thrombosis presented an increased risk for bilateral thrombosis (P = .045 and P = .049, respectively). The high incidence of bilateral deep venous thrombosis justifies bilateral duplex scan examination. Active human immunodeficiency virus disease and proximal thrombosis were risk factors for bilateral disease.

CMV quantitative PCR in the diagnosis of CMV disease in patients with HIV-infection - a retrospective autopsy based study

BACKGROUND

Patients with advanced HIV infection at the time of diagnosis and patients not responding to antiretroviral therapy are at risk of cytomegalovirus (CMV) disease. Earlier studies of patients with HIV infection have demonstrated that the diagnosis is often first made post-mortem. In recent years new molecular biological tests have become available for diagnosis of CMV disease. Although clinical evaluation of tests for diagnosis of CMV disease in HIV-infected individuals is suboptimal without autopsy, no results from such studies have been published. The aim of this study was to explore the diagnostic utility of CMV quantitative polymerase chain reaction (PCR) in plasma from HIV and CMV seropositive patients who died during the period 1991-2002 and in whom autopsy was performed.

METHODS

Autopsy was performed in all cases, as part of routine evaluation of HIV-infected cases followed at Ullevaal University Hospital. Of 125 patients included, 53 had CMV disease, 37 of whom were first diagnosed at autopsy. CMV disease was diagnosed either by ophthalmoscopic findings typical of CMV retinitis, biopsy or autopsy. One or two plasma samples taken prior to the first diagnosis of CMV disease (alive or at autopsy) or death without CMV disease were analysed by CMV quantitative PCR. Sensitivity, specificity, positive and negative predictive values were calculated for different CMV viral load cut-offs and according to detection of viraemia in one versus two samples.

RESULTS

Twenty-seven of 53 patients with CMV disease (51%) and 10 of 72 patients without CMV disease (14%) had detectable viraemia in at least one sample. Sensitivity and negative predictive value (NPV) of the test, maximised with a cut-off at the test's limit of detection of CMV viraemia (400 copies/mL), were 47% and 70%, respectively. With cut-off at 10 000 copies/mL, specificity and positive predictive value (PPV) were 100%. With a requirement for CMV viraemia in two samples, specificity and PPV were 100% in patients with CMV viraemia above the limit of detection.

CONCLUSION

Our results indicate that quantitative CMV PCR is best used to rule in, rather than to rule out CMV disease in HIV-infected individuals at high risk.

Cause of death and presence of respiratory disease at autopsy in an HIV-1 seroconversion cohort of southern African gold miners

OBJECTIVES

To describe causes of death and respiratory infections in HIV-infected miners in the pre-antiretroviral era, by duration of HIV infection.

DESIGN

A retrospective cohort of 1950 gold miners with known dates of HIV seroconversion and 6164 HIV-negative miners was followed from the early 1990s to 2002.

METHODS

Causes of death were available from multiple sources: personnel records, clinical records, death certificates and autopsies of cardiorespiratory organs performed for compensation purposes.

RESULTS

Causes of death were known for 279 of 308 HIV-positive (91%) and 234 of 254 HIV-negative (92%) men who died while employed or within 6 months of leaving employment. The mortality rate from unnatural causes was similar in HIV-positive and HIV-negative miners and by duration of HIV infection. Among deaths from natural causes, 87% in HIV-positive and 41% in HIV-negative individuals were caused by infection (P < 0.001); 47% of HIV-positive and 26% of HIV-negative individuals had tuberculosis. The proportion of deaths from natural causes with any infection, or with specific infections (tuberculosis, cryptococcus, pneumocystis), did not vary with the duration of HIV infection. Autopsies were performed on 29% of men who died from natural causes: 83% of HIV-positive and 37% of HIV-negative men had respiratory infections (P < 0.001), half of which were clinically undiagnosed.

CONCLUSION

Tuberculosis was the leading cause of death in HIV-positive and negative men who died from natural causes. Although the mortality rate from natural causes increased greatly with the duration of HIV infection, the pattern of disease hardly changed, suggesting that slow and fast progressors succumb to the same range of diseases.

Postmortem findings and opportunistic infections in HIV-positive patients from a public hospital in Peru

There is a paucity of HIV autopsy data from South America and none that document the postmortem findings in patients with HIV/AIDS in Peru. The purpose of this autopsy study was to determine the spectrum of opportunistic infections and the causes of mortality in HIV-positive patients at a public hospital in Lima. Clinico-epidemiological information regarding HIV infection in Peru is also reviewed. Sixteen HIV-related hospital postmortems, performed between 1999 and 2004, were included in this retrospective analysis. The primary cause of death was established in 12 patients: one died of neoplasia and 11 of infectious diseases, including 3 from pulmonary infection, 7 from disseminated infection, and 2 from central nervous system infection (one case had dual pathology). Opportunistic infections were identified in 14 cases, comprising cytomegalovirus, histoplasmosis, cryptococcosis, toxoplasmosis, Pneumocystis pneumonia, aspergillosis, tuberculosis, varicella zoster virus, and cryptosporidiosis. Fourteen patients had at least one AIDS-related disease that had been neither clinically suspected nor diagnosed premortem. Moreover, 82% of the diagnoses considered to be of important clinical significance had not been suspected antemortem. The spectrum and frequency of certain opportunistic infections differed from other South American autopsy studies, highlighting the importance of performing HIV/AIDS postmortems in resource-limited countries where locally specific disease patterns may be observed.

Portal vein thrombosis in a patient with HIV treated with a protease inhibitor-containing regimen

We report a case of an HIV seropositive female patient treated with a protease inhibitor-containing regimen who developed recurrent severe life-threathening episodes of haematemesis over time, caused by ruptured oesophageal varices as a consequence of a portal vein thrombosis. Coagulation tests revealed a protein S deficiency, an elevated homocysteinemia and a constitutional elevated plasma factor VIII coagulant activity. These coagulopathies and the HIV infection are independent risk factors for developing venous thromboembolic events. The protease inhibitor treatment may have played a role in increasing the thromboembolic risk. The recurrent bleedings only stopped after invasive surgery. The invasive splenorenal shunt operation was in this case a life-saving procedure.

Thrombotic complications in patients infected with HIV in the era of highly active antiretroviral therapy: a case series

BACKGROUND

Recent reports suggest that patients infected with human immunodeficiency virus (HIV) may have an increased risk of developing thrombosis, but the etiology, risk factors, and clinical course remain largely undefined, with few descriptive case series.

METHODS

We identified 30 patients from an HIV outpatient clinic (treatment population, 650 persons) who had had a total of 43 venous or arterial thromboses during 1996-2002. Data pertaining to demographic characteristics, medical history, thrombosis presentation, and clinical outcomes were abstracted from patient medical records.

RESULTS

The median patient age at the time of thrombosis was 43 years. Although the presence of persistent antibody to phospholipids was the most common abnormal finding in the laboratory, evaluation of thrombophilia, cases of low levels of proteins C and S and antithrombin III, and elevated levels of factor VIII and homocysteine were also identified. Seventy-seven percent of the patients smoked cigarettes, 57% had dyslipidemia, and 43% had a malignancy (most commonly Kaposi sarcoma). Although the Centers for Disease Control and Prevention (CDC) classification for 16 patients (53%) was C3, most showed evidence of immune reconstitution (median CD4 cell count, 290 cells/ mu L) and control of the virus (median HIV load, 2290 copies/mL). Lower extremity, deep vein thrombosis and pulmonary emboli accounted for 66% of all thrombotic events. The median time to diagnosis of thrombosis was 1 day (range, 3 h to 3 weeks).

CONCLUSIONS

Patients in this series were characterized by a relatively young age at the time of thrombosis, a predominance of elevated levels of lipids, a history of malignancy, and an advanced CDC HIV classification but not by a low CD4 cell count or an elevated HIV load.

Importance of cytomegalovirus viraemia in risk of disease progression and death in HIV-infected patients receiving highly active antiretroviral therapy

BACKGROUND

Before highly active antiretroviral therapy (HAART) became available, cytomegalovirus was a major cause of opportunistic infection in HIV-infected patients and was associated with accelerated progression to AIDS and death. We have investigated whether cytomegalovirus viraemia remains a significant risk factor for progression of HIV disease and death in the era of HAART.

METHODS

374 patients whose CD4-cell count had ever been below 100 per microL were enrolled in a prospective study. Serial blood samples were tested for cytomegalovirus by PCR. Rates of new cytomegalovirus disease, new AIDS-defining disorders, and death were calculated over a median follow-up of 37 months after stratification according to baseline and most recent cytomegalovirus PCR status at any point during follow-up.

FINDINGS

Of 2969 PCR assays, 375 (12.6%) were positive for cytomegalovirus DNA. 259 (69.3%) patients were persistently negative for cytomegalovirus by PCR; 15 were persistently positive; and 100 were intermittently positive and negative. In multivariate models, cytomegalovirus PCR-positive status as a time-updated covariate was significantly associated with increased relative rates of progression to a new AIDS-defining disorder (2.22 [95% CI 1.27-3.88] p=0.005) and death (4.14 [1.97-8.70] p=0.0002).

INTERPRETATION

Detection of cytomegalovirus in blood by PCR continues to identify patients with a poor prognosis, even in the era of HAART. Randomised controlled clinical trials of drugs active against cytomegalovirus are needed to investigate whether this virus is a marker or a determinant of HIV disease progression.

Bloodstream infections in late-stage acquired immunodeficiency syndrome patients evaluated by a lysis centrifugation system

Opportunistic infections, which affect acquired immunodeficiency syndrome (Aids) patients, are frequently disseminated and may cause bloodstream infections (BSI). The aim of this study was to evaluate the main causes of BSI in Aids patients with advanced stage of the disease, with special emphasis on the identification of fungemia. During a 21 months period, all patients with Aids (CD4 < 200) and febrile syndrome admitted to 3 university hospitals were systematically evaluated. For each patient presenting fever, a pair of blood cultures was collected and processed by using a commercial lysis-centrifugation system. One hundred and eleven patients (75 males) with a mean age of 36 years (median 33 years) and mean CD4 count of 64 cells/ml were included. Among the 111 patients evaluated we documented 54 episodes of BSI, including 46 patients with truly systemic infections and 8 episodes considered as contaminants. BSI were caused by gram-positive bacteria (43%), fungi (20%), gram-negative bacteria (15%), mycobacteria (15%), and mixed flora (7%). The crude mortality rate of our patients was 39%, being 50% for patients with BSI and 31% for the others. In conclusion, BSI are a common related to systemic infections on Aids patients with advanced stage of disease and is associated with a high rate of mortality.

Autopsy-proven determinants of death in HIV-infected patients treated for pulmonary tuberculosis in Sao Paulo, Brazil

The aim of this work is to describe and compare pulmonary pathology and proven causes of death in HIV-infected and non-HIV patients treated for tuberculosis, to identify the presence and extension of the lesions, and to suggest appropriate interventions based on the results. Of 246 adult patients (aged > 15) autopsied with tuberculosis and tested for HIV infection at Hospital das Clinicas, School of Medicine, São Paulo University, from January 1994 to December 1996, 100 HIV-infected patients were matched with 44 non-HIV-infected patients. Demographic determinants influencing patients' death were as follows: 1. Age and sex were not found to be important for the histological outcome, but do seem to correlate with HIV infection. Older patients with tuberculosis are less likely to be HIV-infected; 2. Previous tuberculosis and its treatment had no influence on the course of secondary or reinfection tuberculosis; 3. The efficiency of the diagnostic criteria used at the time of death was very low (59.2%); 4. Tuberculosis was more frequently investigated in HIV-infected than in non-HIV-infected patients; 5. Only 79 (56%) of the patients received first line agents for treatment; 6. Patients presented with advanced disease; 7. Their mortality is high, and death occurs early. Morphological determinants with influence on patient's death were related to differences in the spectrum of tuberculosis presentation and time of treatment. Noncaseating generalized multibacillary tuberculosis was likely to be the primary cause of death in HIV-infected patients who died during therapy, whereas deaths of patients occurring after the second course of treatment because of recurrence or incomplete treatment were increased for other manifestations of HIV disease (pyogenic pneumonia, Pneumocystis carinii pneumonia, cerebral toxoplasmosis, wasting syndrome). In these patients, dimorphic tuberculosis, an intermediate reactive spectrum form of presentation, was the predominant histological finding. In the opposite spectrum, paucibacillary tuberculosis, a reactive form of tuberculosis presentation, was equally regarded in non-HIV-infected patients as the primary cause of death after four months of therapy. In the same spectrum, non-HIV-infected patients with tuberculosis, who completed all or most of their treatment, died of associated diseases after therapy (alcoholism, cancer, diabetes mellitus). Autopsy-proven determinants of death were associated with HIV status, the spectrum of tuberculosis presentation, and time of treatment. Early treatment for tuberculosis and associated diseases can improve survival and the quality of life even of highly immunosuppressed patients.

Ocular pathology in acquired immunodeficiency syndrome

Gross and microscopic ocular findings were prospectively studied in 38 human immunodeficiency virus (HIV)-seropositive subjects undergoing postmortem examination. Pathologic lesions were detected in 27 patients (71%), with 67% of the abnormal findings detected only microscopically.

HIV infection is a risk factor for venous thromboembolism

The reported incidence of venous thromboembolism (VTE) in patients with human immunodeficiency virus (HIV) infection has ranged from 0.25 to 0.96% in clinical studies, but up to 17% at autopsy. A preliminary analysis at our hospital suggested that the frequency of VTE among HIV-positive individuals might be higher than previously reported. To further evaluate this issue, we performed a retrospective study of patients with a diagnosis of VTE and/or HIV infection discharged from our hospital between July 1, 1998 and June 30, 1999. A total of 13,496 patients were discharged during the year of the study. There were 244 patients with VTE and 362 who were HIV-positive. Ten of the 244 patients with VTE were HIV-positive (4.1%). The frequency of VTE among HIV-positive individuals was 10/362 (2.8%) compared to 234/13134 (1.8%) in the non-HIV-positive group, but the difference is not statistically significant. However, in patients under age 50, the frequencies were significantly different: 10/302 (3.31%) versus 35/6594 (0.53%), respectively (p < 0.0001). The frequency of VTE in HIV-positive patients less than 50 years old (3.31%) was greater than in HIV-positive patients over 50 years of age (0/60), but the difference did not reach statistical significance. In contrast, in the non-HIV-positive group, VTE was significantly more frequent in those 50 and older compared to younger patients (3.04% versus 0.53%, p = 0.0001). Statistical analysis indicated that the direction of association between age and diagnosis of VTE differed for HIV-positive patients versus non-HIV-positive patients. Our results suggest that HIV-positive patients under age 50 are at increased risk for VTE compared with non-HIV-positive individuals.

Autopsy findings in a human immunodeficiency virus-infected population over 2 decades: influences of gender, ethnicity, risk factors, and time

OBJECTIVES

To examine autopsy pathology in an urban population infected with the human immunodeficiency virus (HIV) and to determine if age at death and disease frequencies are associated with gender, HIV risk factors, ethnicity, and therapeutic era.

DESIGN AND METHODS

Retrospective analysis of autopsy data from 394 HIV-infected adults. The population was divided into 3 therapeutic eras for analysis: group A, 1979-1986; group B, 1987-1995; and group C, 1996-2000.

RESULTS

Women died at significantly younger ages than men (mean +/- SEM age, 38.9 +/- 1.0 years vs 42.5 +/- 0.64 years), even after adjustment for risk factors, ethnicity, and therapeutic era. This age discrepancy occurred despite a lower prevalence of arteriosclerosis, cachexia, and hepatitis B in women and no significant differences in the frequencies of other infectious diseases. Whites had a longer survival than patients of other ethnicities (mean age at death, 44.7 +/- 1.2 years for whites, 39.9 +/- 0.80 years for blacks, and 41.3 +/- 0.87 years for Hispanic individuals). Renal, cardiac, and splenic pathologies, Mycobacterium avium-intracellulare (MAI) infection, and cachexia were more common in blacks than in whites and/or Hispanic individuals, and cytomegalovirus and systemic lymphoma were more common in whites and Hispanic individuals than in blacks. Diseases associated with intravenous drug use were hepatitis C, cirrhosis, and tuberculosis; those with all sexual risk factors, cytomegalovirus infection, herpes simplex virus infection, and Pneumocystis carinii pneumonia; and those with homosexual risk, Kaposi sarcoma and MAI infection. The prevalence of many disease entities changed over time: compared with the other groups, group C had lower prevalences of many viral and fungal illnesses, MAI infection, systemic lymphoma, cachexia, and Kaposi sarcoma and higher prevalences of hepatitis, cirrhosis, arteriosclerosis, staphylococcal and streptococcal infections, and traumatic lesions. When the data were adjusted for changing demographic and risk composition, the only significant changes in disease frequency for period C were decreased prevalences of PCP and Kaposi sarcoma and increased prevalences of cirrhosis and arteriosclerosis.

CONCLUSIONS

Significant gender- and ethnicity-related differences in age of death occurred in this HIV-infected population, and these differences were not explained by the frequencies of diseases. The lower prevalences of PCP and Kaposi sarcoma in group C are likely a reflection of the impact of potent therapies on causes of mortality. The higher prevalences of cirrhosis and arteriosclerosis suggest that entities not targeted by antiretroviral reconstitution of immunity will play an increasingly important role in HIV-related mortality in the future.

Concomitant progressive multifocal leucoencephalopathy and primary central nervous system lymphoma expressing JC virus oncogenic protein, large T antigen

This report describes the concomitant occurrence of the JC virus (JCV) induced demyelinating disease progressive multifocal leucoencephalopathy (PML) and a primary central nervous system lymphoma (PCNS-L) in a patient with AIDS. Postmortem neuropathological examination revealed characteristic features of PML including multiple lesions of demyelination, enlarged oligodendrocytes with hyperchromatic nuclei (many containing eosinophilic intranuclear inclusions), and enlarged astrocytes with bizarre hyperchromatic nuclei. Immunohistochemical analysis demonstrated the expression of the JCV capsid protein VP-1 in the nuclei of infected oligodendrocytes and astrocytes. The PCNS-L lesion located in the basal ganglia was highly cellular, distributed perivascularly, and consisted of large atypical plasmacytoid lymphocytes. Immunohistochemical examination of this neoplasm identified it to be of B cell origin. Moreover, expression of the JCV oncogenic protein, T antigen, was detected in the nuclei of the neoplastic lymphocytes. This study provides the first evidence for a possible association between JCV and PCNS-L.

Pulmonary pathology in patients with AIDS: an autopsy study from Mumbai

OBJECTIVE

Although India has a high prevalence of HIV/AIDS, the associated pathologies responsible for morbidity have not been evaluated previously in a representative study. Hence, an autopsy study was carried out to analyse the spectrum of pulmonary lesions in patients with HIV/AIDS.

METHODS

A retrospective and prospective autopsy study was carried out during 1988-2000 at Mumbai, India. Lungs from 143 adults, with at least 10 sections from each case, were examined using routine and special stains.

RESULTS

The risk factors for 97 men (68%) and 38 women (27%) included: heterosexual sex with multiple partners (135 cases, 95%); blood transfusions (three cases; 2%); sex between men (two cases; 1%); and unknown risk factors (three cases, 2%). Pulmonary pathology was observed in 126 (88%) cases. The lesions identified were tuberculosis (85 cases, 59%), bacterial pneumonia (26 cases, 18%), cytomegalovirus (CMV) infection (10 cases, 7%), cryptococcosis (eight cases, 6%), Pneumocystis carinii pneumonia (seven cases, 5%), aspergillosis (four cases, 3%), toxoplasmosis (two cases, 1%), Kaposi's sarcoma (one case, 1%), squamous cell carcinoma (one case, 1%). Two or more infections were observed in 18 (13%) cases.

CONCLUSIONS

Pulmonary diseases and risk factors among patients with AIDS in India differ from those reported in industrialized countries. Tuberculosis was the most frequently observed pulmonary infection, followed by bacterial pneumonia and CMV pneumonitis. In contrast with industrialized countries, PCP remains less common in our patients. The information on opportunistic infections obtained in this study will be useful for managing HIV/AIDS cases at district level hospitals where diagnosing specific HIV-associated diseases is not always possible.

Value of limited necropsy in HIV-positive patients

We performed limited autopsy with histological examination of tissue cores obtained percutaneously using the Tru-Cut needle and the Jamshidi trocar in 150 adult HIV-positive patients. Data were compared retrospectively with the antemortem clinical diagnosis. Eighty-one percent of the patients were male, and 78% were intravenous drug users. Specimens were obtained from the brain, liver, lung, bone marrow, and kidney of most patients. The main findings included liver cirrhosis in 22 cases (associated with HCV infection in 81%), Pneumocystis carinii pneumonia in 21, Cytomegalovirus (CMV) infection in 19, Mycobacterium avium-intracellulaire (MAI) infection in 17, bacterial pneumonia in 14, tuberculosis in 12, and lymphoma in 13 cases. Forty-six (30.6%) patients had at least one clinical diagnosis that was confirmed by autopsy, i.e., there was 40.6% agreement between pre- and postmortem findings. Forty-six (30.6%) patients had at least one clinical diagnosis that was not confirmed at autopsy, whereas 41 (27.3%) had at least one AIDS-related or unrelated disease that was not suspected clinically. The results obtained by limited autopsy are principally comparable to those achieved by full necropsy, with the advantages of decreasing the contagious risk, saving cost and time, including a rapid final diagnosis, and easily obtaining the consent for postmortem examination so that necropsy studies may be performed on a larger number of patients, thus contributing to a better understanding of the spectrum of HIV infection in our environment.

Central nervous system aspergillosis in patients with human immunodeficiency virus infection. Report of 6 cases and review

Central nervous system (CNS) aspergillosis is a relatively uncommon complication of human immunodeficiency virus (HIV) infection. We describe 6 patients with the acquired immunodeficiency syndrome (AIDS) who developed CNS aspergillosis, and we review a total of 33 cases of CNS aspergillosis among HIV-infected individuals that were diagnosed by histology and/or culture. All patients were diagnosed with advanced HIV infection. Major risk factors for the disease included neutropenia and corticosteroid use. The most common presenting symptoms were nonspecific neurologic manifestations including headache, cranial or somatic nerve weakness or paresthesia, altered mental status, and seizures. The most common sites of additional Aspergillus involvement were the lungs, sinuses, ears, and orbits, while in one-fourth of the cases CNS was the only site of Aspergillus infection. The final diagnosis of CNS aspergillosis was made on autopsy in more than half the cases, and medical treatment of CNS aspergillosis was unsuccessful in all cases. CNS aspergillosis should be included in the differential diagnosis of HIV-infected patients who present with nonspecific neurologic symptoms and signs. If we take into account the much higher prevalence of invasive aspergillosis of the lungs, the findings in the present report suggest that CNS aspergillosis in HIV-infected individuals occurs more often as a result of direct extension from the sinuses, orbits, and ears than through hematogenous spread from the lungs. Physicians should be aware that the CNS might be the only site of Aspergillus involvement and include CNS aspergillosis in the differential diagnosis of HIV-infected patients presenting with focal neurologic signs and symptoms, especially when the head CT reveals hypodense lesions.

Induction and maintenance therapy of cytomegalovirus central nervous system infection in HIV-infected patients

OBJECTIVE

To evaluate the efficacy and safety of the foscarnet-ganciclovir combination in induction therapy (IT) and maintenance therapy (MT) for cytomegalovirus (CMV) central neurological disorders in HIV-infected patients.

DESIGN

An open pilot non-comparative multicentre study.

METHODS

Thirty-one patients with acute CMV encephalitis (CMVe) (n = 17) or CMV myelitis (CMVm) (n = 14) during the era before highly active antiretroviral therapy (HAART) received intravenous IT with foscarnet 90 mg/kg plus ganciclovir 5 mg/kg twice a day followed by MT. The primary endpoint was clinical efficacy, assessed at the end of the induction phase.

RESULTS

The foscarnet-ganciclovir combination in IT resulted in a 74% (23 out of 31 patients) clinical improvement or stabilization. Eight patients did not respond clinically. Side-effects leading to drug discontinuation occurred in 10 patients during IT. Among the 23 patients who qualified for the maintenance phase, CMV disease progressed in 10, with a median time to the first relapse of 126 days (range 64-264 days). Overall, the median survival time was 3 months [95% confidence interval (CI), 2-4 months].

CONCLUSION

The combination of foscarnet and ganciclovir can safely be used for CMV central nervous system (CNS) infection, with an improvement or stabilization in 74% of patients. Life-long MT with this combination is recommended as long as the immune system is profoundly impaired.

B-cell stimulation and prolonged immune deficiency are risk factors for non-Hodgkin's lymphoma in people with AIDS

OBJECTIVES

To identify risk factors for non-Hodgkin's lymphoma (NHL) in people with HIV infection.

DESIGN AND SETTING

Case-control study in Sydney, Australia.

PARTICIPANTS AND METHODS

Two hundred and nineteen patients with AIDS-related NHL were compared with 219 HIV-infected controls without NHL, matched for CD4 positive cell count and date of specimen collection. Data on demographic, infectious, treatment-related and immunological factors were abstracted by medical record review. The association between demographic factors, sexually transmissible diseases, HIV-related opportunistic infections, anti-viral therapy, duration of immune deficiency and indices of immune stimulation and risk of NHL were derived for these groups.

RESULTS

In a multivariate model, there were two independent groups of predictors of NHL risk. The first was duration of immunodeficiency, as measured by longer time since seroconversion (P for trend 0.008), and lower CD4 positive cell count 1 year prior to the time of NHL diagnosis (P for trend 0.009). The second predictor was B-cell stimulation, as indicated by higher serum globulin (a surrogate marker for serum immunoglobulin, P for trend 0.044) and HIV p24 antigenaemia [odds ratio (OR) for p24 positivity, 1.82; 95% confidence interval (CI), 1.15-2.88]. Indices of B-cell stimulation preceded the diagnosis of NHL by several years. Factors not related to NHL risk included clinical indices of Epstein-Barr virus infection and receipt of individual nucleoside analogue antiretroviral agents. Combination therapy with these agents was associated with a non-significant reduction in NHL risk (OR, 0.68; 95% CI, 0.39-1.18).

CONCLUSIONS

Markers of long-standing immune deficiency and B-cell stimulation were associated with an increased risk of developing NHL. Unless the strongest risk factor for NHL, immune deficiency, can be reversed, NHL is likely to become proportionately more important as a cause of morbidity and mortality in people with HIV infection.

Autopsy findings in the acquired immunodeficiency syndrome (AIDS). A report of 395 cases from the south of France

Necropsy findings in 395 adult patients with the acquired immunodeficiency syndrome (AIDS) who died in Nice, France, between March 1983 and May 1996 were compared retrospectively with antemortem diagnoses, risk factors and number of positive T CD4 lymphocytes at the time of death. Special emphasis on bacterial infections was made in this study. Lesions observed from 1983 through 1989 and from 1990 through 1996 were compared. We assessed the role of organ lesions in the immediate cause of death. The organ system distribution of major opportunistic infections and neoplasms was similar throughout the years of the study. The most common diagnostic disease entities in all organ sites were cytomegalovirus infection, toxoplasmosis and candidiasis. Toxoplasmosis was more common in the intravenous drug abuser group. Bacterial infections were frequent and contributed to the mortality and morbidity of all risk factor groups. Kaposi' sarcoma continued to occur more frequently in the homosexual population. Cytomegalovirus infection remained one of the most common causes of death from 1983 to 1996. Mortality from fungal and bacterial infections, and mycobacteriosis increased in frequency during the course of this study whereas deaths from pneumocystosis declined. The death rate from malignant lymphoma and carcinoma increased after 1989. The clinical cause of death concurred with the pathological cause in 55% of the cases. Lung was the most frequent organ involved followed by the central nervous system the gastrointestinal tract and the heart.

Acute pulmonary embolism in patients with HIV disease

OBJECTIVES

To determine the incidence, mode of presentation, and outcome of pulmonary embolism (PE) in patients with HIV infection.

METHODS

Retrospective review of clinical case records, imaging department database, and necropsy reports of patients admitted to the specialist HIV/AIDS unit at UCL hospitals from April 1993 to August 1997 in order to identify those with a diagnosis of PE.

RESULTS

During the study period there were 3792 admissions of whom 10 (0.26%) had PE. All patients with PE presented with fever, seven were dyspnoeic, and seven had cough: all were thought initially to have respiratory infection. Only five patients had pleural pain. All 10 patients had abnormal baseline chest radiographs. The diagnosis in six was made by computed tomograph (CT) pulmonary angiography, in two was made by ventilation perfusion (V/Q) scanning, in one by both techniques, and in one at necropsy. CT angiography in addition to identifying thrombus also showed concomitant lung parenchymal abnormalities in all but one patient. Nine patients with PE had one or more risk factors for venous thromboembolism as did 34/40 case matched controls (odds ratio = 1.67; 95% confidence interval = 0.18-15.5). All patients diagnosed in life were anticoagulated and five survived.

CONCLUSIONS

PE was uncommon in this HIV infected population. The diagnosis should be considered in patients with respiratory infection which does not respond to antibiotics. Identifiable risk factors for venous thromboembolism appear to be unhelpful in increasing clinical index of suspicion for PE. As baseline chest radiographs are frequently abnormal, the diagnostic utility of V/Q scanning may be reduced and CT pulmonary angiography is the imaging modality of first choice.

AIDS-related visceral aspergillosis: an underdiagnosed disease during life?

Five out of nine consecutive patients with HIV-related visceral aspergillosis observed by us since 1984 were diagnosed only at necropsy examination. The histopathological features of these five patients [two with isolated pneumonia, one with central nervous system (CNS) involvement, one with brain abscess and respiratory disease and one with pulmonary, pleural and kidney infection] have been evaluated according to epidemiological, clinical and radiological features. On the basis of our experience, life-threatening aspergillosis, which is often misdiagnosed or missed in the setting of HIV infection and AIDS, should be suspected in patients with far-advanced underlying disease and unexplained signs and symptoms, even in the absence of some presumed risk factors (i.e. neutropenia and prior steroid treatment). Plain chest radiography and bronchoscopy with broncholaveolar lavage may fail to reveal respiratory disease, CNS aspergillosis is not necessarily associated with suggestive neuroradiological features and disseminated disease may present with multiorgan failure. The unfavorable outcome of this emerging AIDS complication can be improved only by earlier diagnosis based on invasive techniques and appropriate and timely treatment.

Pulmonary aspergillosis and invasive disease in AIDS: review of 342 cases

Aspergillosis is an infrequent but commonly fatal infection among HIV-infected individuals. We review 342 cases of pulmonary Aspergillus infection that have been reported among HIV-infected patients, with a focus on invasive disease. Invasive pulmonary aspergillosis usually occurs among patients with <50 CD4 cells/mm3. Major predisposing conditions include neutropenia and steroid treatment. Fever, cough, and dyspnea are each present in >60% of the cases. BAL is often suggestive, but biopsy specimens are necessary for definite diagnosis. Amphotericin B is the mainstay of treatment and mortality is > 80%. Avoiding neutropenia and judicious use of steroids may be helpful in prevention. Aggressive diagnostic approach, early initiation of treatment, adequate dosing of antifungals, and close follow-up may improve the currently dismal prognosis.

The epidemiology and prevention of invasive aspergillosis

Over the past two decades, the incidence of invasive aspergillosis (IA) has risen inexorably. This is almost certainly the consequence of the more widespread use of aggressive cancer chemotherapy regimens, the expansion of organ transplant programmes and the advent of the acquired immunodeficiency syndrome (AIDS) epidemic. Despite the development of new approaches to therapy, IA still remains a life-threatening infection in immunocompromised patients and is the most important cause of fungal death in cancer patients. It is clear that the prevention of severe fungal infection by the use of effective infection control measure should be the priority of the teams involved in managing at-risk patients. The evidence from clinical and molecular epidemiological studies is reviewed and current thinking on sources and routes of transmission of the organism are discussed. Our increasing understanding of these has led to the development of a variety of environmental and general strategies for the prevention of IA. It is anticipated that these, coupled with the use of prophylactic antifungal agents active against Aspergillus spp., will have a significant impact upon the morbidity and mortality associated with this infection.

Ganciclovir and foscarnet efficacy in AIDS-related CMV polyradiculopathy

Cytomegalovirus (CMV) polyradiculopathy is a rare complication of AIDS in which ascending motor weakness, sensory loss and urinary retention are associated with polymorphonuclear pleocytosis and positive CMV polymerase chain reaction in the cerebrospinal fluid (CSF). We describe three patients with this syndrome. One patient's paresis improved after ganciclovir therapy. Another patient deteriorated despite foscarnet treatment, but improved after ganciclovir was added. The third patient died from ascending paralysis despite ganciclovir-foscarnet combination. Reviewing the literature, we conclude that antiviral treatment reduced mortality from 100 to 22%. In patients with ascending paralysis treatment, failure may be caused by viral drug resistance, at least in some patients. Risk factors for treatment failure are preceding monotherapy for other CMV diseases or persistent CSF pleocytosis on serial CSF analysis. We suggest that these patients should therefore be treated with the alternative drug or a ganciclovir-foscarnet combination therapy.

Effective treatment of experimental cytomegalovirus-induced encephalo-meningitis in immunocompromised rats with HPMPC

Cytomegalovirus (CMV)-induced encephalomeningitis is a dramatic complication in patients with the acquired immunodeficiency syndrome (AIDS) and treatment of this infection remains a major clinical problem. In order to study the pathogenesis and treatment of CMV-induced encephalomeningitis, we experimentally induced intracranial rat CMV (RCMV) infection in rats that were immunosuppressed by total body X-irradiation. CMV infection was monitored by viral plaque assay for estimation of the viral load. CMV-induced pathology, the presence of CMV-infected cells, as well as the presence of T-lymphocytes and monocytes/macrophages were studied by histopathologic and immunohistochemical staining techniques. The meninges showed CMV infection in mononuclear infiltrative cells and in endothelium of small blood vessels 8 days after intracerebral inoculation. This was accompagnied by multiple haemorraghes and inflammatory cell infiltration. The infection and inflammatory response persisted for at least 21 days p.i. Animals were treated with (S)-1-(3-hydroxy-2-phosphonylmethoxypropyl)cytosine (HPMPC), 9-(1,3-dihydroxy-2-propoxymethyl)guanine (DHPG), hyperimmune serum (HIS) and both DHPG and HIS combined. Treatment with one dosage of HPMPC at 20 mg/kg effectively reduced virus titers. However, all other treatment modalities were not effective. In conclusion, the pathology of RCMV-induced encephalomeningitis in immunocompromised rats closely resembles that of AIDS patients. The infection is effectively treated by HPMPC.

Agreement between premortem and postmortem diagnoses in patients with acquired immunodeficiency syndrome observed at a Brazilian teaching hospital

Acquired immunodeficiency syndrome (AIDS) is one of the main causes of death in adults worldwide. More commonly than in the general population, in patients with AIDS there is substantial disagreement between causes of death which are clinically suspected and those established by postmortem examination. The findings of 52 postmortem examinations were compared to the premortem (clinical) diagnoses, and there was 46% agreement between them. Fifty two percent of the patients had more than one postmortem diagnosis, and 48% had at least one AIDS-related disease not suspected clinically. Cytomegalovirus infection was the commonest (30.7%) autopsy finding, but not a single case had been suspected premortem. Bacterial infection, tuberculosis, and histoplasmosis were also common, sometimes not previously suspected, postmortem findings. This study shows that multiple infections occur simultaneously in AIDS patients, and that many among them are never suspected before the postmortem examination. These findings suggest that an aggressive investigation of infections and cancers should be done in patients with AIDS, particularly in those who do not respond to therapy of an already recognized condition.

The African polio vaccine-acquired immune deficiency syndrome connection

Seroepidemiological, clinical and molecular findings suggest that the acquired immune deficiency syndrome virus human immunodeficiency virus-1 was introduced into the human species at the time (late 1950s) and in the geographic area (Zaire) in which millions of Africans were vaccinated with attenuated poliomyelitis virus strains that were produced in kidney tissue obtained from monkeys. Since monkeys not only harbor viruses that are remarkably similar to and genetically related to human immunodeficiency virus-1, but also served as tissue donors for the African polio vaccine, it is reasonable to suspect that a then non-detectable monkey virus with human-1-like properties was unknowingly co-cultured with the attenuated poliovirus virus and subsequently administered to the vaccinees. The possibility of such a polio vaccine-acquired immune deficiency syndrome connection is a reminder of the unpredictable danger of artifically crossing natural species-barriers in biomedical laboratories.

Autopsy patterns of disease among subgroups of an inner-city Bronx AIDS population

The Bronx, New York, has a large, inner-city, AIDS population which contains a greater proportion of women and intravenous drug users and a lower percentage of homosexuals than the U.S. AIDS population overall. Because this population is reflective of the evolving trends in the national AIDS population, our objective was to gain an understanding of patterns of infections, malignancies, and cause of death among these individuals. All autopsies (252) performed on patients with AIDS at two hospitals affiliated with a major academic center in the Bronx between 1982 and 1995 were reviewed. Cytomegalovirus (CMV) as an infection or as a cause of death (COD) occurred more commonly among patients who had been infected with HIV through sexual relations (p = 0.0002 and p = 0.0011, respectively). Bacterial pneumonia was the most common source of pulmonary infection, although Pneumocystis carinii pneumonia was more often a cause of death. A higher frequency of aspergillus infection in female subjects was also noted (p = 0.010). These and other observations may have ramifications for treatment and prevention in analogous AIDS inner-city populations.

Neuropathology of human immunodeficiency virus infection at different disease stages

The authors studied the brains of 471 adults infected with human immunodeficiency virus type 1 (HIV-1): 123 asymptomatic carriers, 127 in an early stage of acquired immunodeficiency syndrome (AIDS) with pulmonary tuberculosis or bacterial infections, and 221 in fully developed AIDS with opportunistic infections or neoplasms. Lymphocyte infiltration of the leptomeninges and of perivascular spaces occurred at all stages, but the frequency was significantly higher in asymptomatic carriers. Microglial nodules appeared at all stages of disease; they were not an early indicator of HIV encephalitis (HIVE). The incidence of HIVE was unrelated to the stage of AIDS, suggesting that HIVE occurs before opportunistic infections and neoplasms. Drug abuse, such as cocaine and opiates, may enhance HIV replication and increase the incidence of HIVE in the early stage of AIDS. Opportunistic infections or lymphoma involved only the brain in 31.2% of persons with fully developed AIDS. Conversely, opportunistic infections or neoplasms involved only organs other than the brain in 55.7% of persons with fully developed AIDS. In 13.1% of persons with fully developed AIDS, opportunistic infections or neoplasms involved the brain and other organs. Multiple intracranial opportunistic infections and lymphoma coexisted in 4.1% of persons with fully developed AIDS. The authors identified cerebrovascular disease in 10.6% of asymptomatic carriers, 7.1% of early AIDS, and 5.0% of fully developed AIDS. The observed sequence of abnormalities may be useful in understanding the progression of HIV disease in the brain.

Clinical diagnosis of mycobacterial diseases versus autopsy findings in 350 patients with AIDS

Three-hundred fifty consecutively autopsied AIDS patients in Milan, Italy, were studied to determine the frequencies of clinical and postmortem diagnoses of mycobacterial diseases, to evaluate the clinical histories of those patients with mycobacterial diseases, and to investigate the reasons for nondiagnosis of mycobacterial diseases during life. Seventy-eight patients (22.3%) had mycobacterial diseases. In 64 cases (18.3%) the diagnosis was made antemortem and in 50 (14.2%) at autopsy; there were 36 cases of concordant clinical and postmortem diagnoses. Nontuberculous mycobacterioses (NTM) were diagnosed in 41 patients (20 clinical/postmortem diagnoses, 11 clinical diagnoses, and 10 postmortem diagnoses), extrapulmonary tuberculosis (TB) in 19 patients (7 clinical/postmorten, 8 clinical, 4 postmortem), and pulmonary TB in 18 patients (9 clinical/postmorten, 9 clinical). Patients with a clinical diagnosis of mycobacteriosis but with no pathological evidence of disease at autopsy were considered to have recovered on the basis of negative culture findings and prolonged antimycobacterial treatment. In Italian patients with AIDS, NTM occurs less frequently and TB more frequently than in American AIDS patients. At least some of the patients reported in this study seemed to have recovered from mycobacterial disease after prolonged treatment. The lack of diagnosis during life can be attributed to aspecific symptoms, a rapidly terminal course, and the presence of concomitant opportunistic diseases.

Gastrointestinal translocation as a possible source of candidemia in an AIDS patient

Apart from cryptococcosis and histoplasmosis, which are mycoses contained by T cell-mediated mechanisms of host defense, fungemia is rarely found in AIDS patients. The frequency of fungemia due to Candida spp. has been reported to be as low as 1%. We report a non-neutropenic AIDS patient who presented a candidemia which probably arose from her gastrointestinal tract.