The AIDS patient with abdominal pain: a new challenge for the emergency physician

Effect of the anti-retroviral drug, rilpivirine, on human subcutaneous adipose cells and its nutritional management using quercetin

Rilpivirine, a recently developed drug of choice for initial treatment of HIV-1 infection, can greatly reduce HIV-related inflammation, but in turn, may be associated with adverse secondary effects, including disturbances in lipid metabolism and ultimately in adipose tissue distribution and function. In recent years, research findings on the benefits of anti-oxidant foods and supplements have been employed in counter-acting both oxidative stress as well as inflammation in order to reduce the adverse side effects of anti-retroviral therapy. One such natural flavonoid which possesses anti-inflammatory and anti-oxidative properties is quercetin. This study investigated the effect of quercetin in overcoming the side effects incurred due to rilpivirine administration. The results show substantial reduction in the accumulation of triglyceride levels in a dose- and time-dependent manner for adipose cells treated with either rilpivirine or quercetin alone and in combination, as evidenced by morphological pictures and quantitative measurement of triglycerides throughout the differentiation process. Levels of inflammatory markers such as resistin and IL-8 were increased as compared to the untreated cells. No significant changes in leptin were observed on treatment of adipose cells with rilpivirine alone and its levels were almost comparable to control. Levels of oxidative markers like superoxide dismutase, catalase, and glutathione were also decreased. Treatment with quercetin showed a decrease in the inflammatory status and an increase in the oxidative status of adipose cells, thereby exhibiting its anti-inflammatory and anti-oxidative properties. However, further assessment of lipid metabolism and adipose tissue function in patients administered with rilpivirine-based regimes is advisable considering that totally neutral effects of rilpivirine on lipid homeostasis cannot be anticipated from the current study in vitro. It is concluded that rilpivirine causes an anti-adipogenic and pro-inflammatory response pattern but only at high concentrations, whereas quercetin has been observed to decrease inflammation and restore the levels of anti-oxidant enzymes.

Histoplasmosis-induced ileal perforation in a patient with acquired immune deficiency syndrome: Case report

Intestinal involvement with disseminated histoplasmosis is common in some populations infected with human immunodeficiency virus (HIV)/acquired immune deficiency syndrome (AIDS), especially in those who come from tropical zones. We report the case of a 29‐year‐old male patient, from a tropical zone, with HIV infection and a CD₄ value less than 50 cells/mm³, with a history of abdominal pain, fever, diarrhea, and weight loss. On presentation, he was pale, sweaty, and had abdominal rebound tenderness. Laboratory findings demonstrated microcitic hipocromic anemia, azoemia, and hypoalbuminemia. Abdominal‐X‐rays revealed pneumoperitoneum and air fluid levels. He underwent surgery, and a 1‐cm perforation proximal to ileocecal valve was found. A resection and an ileostomy were performed. Histopathology identified caseating granulomas with yeast, compatible with histoplasmosis. He was treated with anfotericin B plus itraconazol with clinical improvement.

Colorectal Disorders in Acute Human Immunodeficiency Virus Infection: A Case Series

Background.  The gastrointestinal (GI) tract is important in the pathogenesis of human immunodeficiency virus (HIV) infection. We report a case series of lower GI endoscopic and histopathologic findings of HIV-infected individuals after presentation with acute infection. Methods.  We performed a retrospective case review of individuals infected with HIV who enrolled between August 2010 and April 2013 in a primary infection treatment trial. All participants started the trial during acute infection and underwent colonoscopy with biopsies at baseline and after the start of antiretroviral treatment. Results.  Twenty acutely infected individuals were included in the study (mean age, 33 years; range, 20-54 years). All participants were male who reported having receptive anal sex as an HIV risk factor. Nine individuals (45%) had at least 1 finding by colorectal pathology; 1 person had 2 diagnoses (diverticulosis and focal active proctitis). The histopathological findings revealed anal dysplasia in 3 cases: 2 had high-grade anal intraepithelial neoplasia (AIN) and 1 had low-grade AIN. Two persons had a colorectal polyp, 1 hyperplastic and 1 adenomatous. Three persons were diagnosed with diverticulosis, and 2 persons were diagnosed with proctitis, including 1 with focal active proctitis and 1 with cytomegalovirus proctitis. Conclusions.  To our knowledge, this is the first case series report of lower GI disorders in acute HIV-infected individuals. Although the causal relationship remains uncertain, we describe the endoscopic findings that were observed during acute HIV infection among men who have sex with men. Understanding the prevalence of these pathologies may likely shed light on how acute HIV infection damages the lower GI tract.

Preoperative risk factors influencing the incidence of postoperative sepsis in human immunodeficiency virus-infected patients: a retrospective cohort study

BACKGROUND

Compared to noninfected patients, human immunodeficiency virus (HIV)-infected patients undergoing surgery have an increased postoperative risk of developing sepsis. We aimed to investigate the preoperative risk factors that affect the incidence of sepsis after surgery in HIV-infected patients.

METHODS

Clinical parameters of 215 patients with HIV/acquired immunodeficiency syndrome (AIDS) who had undergone surgery between January 2011 and February 2012 were examined retrospectively for the effect of HIV/AIDS on the incidence of postoperative sepsis.

RESULTS

Logistic regression analysis identified four independent risk factors of postoperative sepsis in HIV-infected patients: CD4 counts [B = -0.007, odds ratio (OR) 0.993]; blood albumin levels (B = -0.077, OR 0.926); surgical infection (B = 1.887, OR 6.598); major surgery (B = 1.013, OR 2.754). The incidence of postoperative sepsis was high with CD4 counts ≤ 100 cells/μl, albumin levels <35 g/L, the presence of surgical infection, the patient had undergone major surgery--81.25%, 39/48; 76.47%, 26/34; 70.73%, 29/41; and 54.76%, 46/84, respectively, compared to that of the total cohort (40.93%, 88/215). When CD4 counts were >350 cells/μl, the incidence of postoperative sepsis was significantly lower (16.36%, 9/55).

CONCLUSIONS

Low CD4 cell counts, hypoalbuminemia, surgical infection, and major surgery are independent risk factors for the development of postoperative sepsis among HIV-infected patients. CD4 cell numbers and albumin levels negatively correlated with the incidence of postoperative sepsis, whereas surgical infections and major surgical procedures positively correlated with the incidence of postoperative sepsis.

Ileal Perforation in a patient with acquired immune deficiency syndrome

Gastrointestinal involvement is common in patients of human immunodeficiency virus infection (HIV) and the acquired immunodeficiency syndrome (AIDS). Specific gastrointestinal disorders often correlate with degree of immunosuppression. In advance cases of HIV infection GI symptoms are usually part of systemic infection. In such scenario multiple infections are common so failure to diagnose a specific cause is not uncommon. We here present a case study of a patient with ileal perforation with tubercular etiology and its management.

Anti-infective treatment in HIV-infected patients during perioperative period

OBJECTIVE

To investigate anti-infective treatments in HIV-infected surgical patients during the perioperative period.

METHODS

A retrospective study of sepsis and surgical site infections (SSIs) was conducted in 266 HIV-infected patients. The patients were divided into 3 groups based on CD4+ T cells counts in the preoperative period: group A (0-199 cell/ul), group B (200-349 cell/ul) and group C ([greater than or equal to] 350 cell/ul). When the CD4 count was below 350 cells/uL, anti-retrovirus therapy was started. For patients whose preoperative CD4 counts were [less than or equal to] 200 cells/uL, preoperative antibiotic medication was started.

RESULTS

Patients in group A were more likely to get sepsis than patients in the other two groups (p0.01). Among 82 patients with clean wounds, only one patient got SSIs. All patients with dirty wounds had acquired SSIs after surgery. There were only 6 patients dead at 30 days after surgery, a death rate of 2.3%. Sepsis appeared in 110 patients (41%).

CONCLUSIONS

Complete evaluation of surgical risk and suitable perioperative anti-infective treatment may lead to better outcome for HIV-infected surgical patients.

Mesenterial, omental, and peritoneal disorders in antiretroviral-treated HIV/AIDS patients: spectrum of cross-sectional imaging findings

In the era of highly active antiretroviral therapy, radiologists are increasingly confronted with a progressively aging HIV-infected population with improved immune function and survival, in whom a wide spectrum of infectious and neoplastic opportunistic disorders may be encountered. Furthermore, HIV / AIDS patients commonly have unspecific symptoms and physical signs, multicentric or coexisting diseases, so that diagnostic imaging studies are crucial to correctly identify and stage HIV-related abnormalities. Currently, volumetric multidetector CT (MDCT) provides comprehensive assessment and confident post-treatment follow-up of opportunistic abnormalities involving the mesentery, omentum, and peritoneum. In this pictorial essay, the cross-sectional imaging appearances of opportunistic disorders involving the mesentery, peritoneum, or both compartments in HIV / AIDS patients are reviewed, with emphasis on those MDCT findings that may be helpful for differential diagnosis along with knowledge of the degree of immune suppression as measured by the CD4 lymphocyte count. Familiarity with the varied spectrum of HIV-related opportunistic disorders encountered in antiretroviral - treated patients and their imaging appearances should allow radiologists to improve their confidence in the characterization of abnormal findings observed on abdominal cross-sectional imaging studies.

Prevention and treatment of surgical site infection in HIV-infected patients

BACKGROUND

Surgical site infection (SSI) are the third most frequently reported nosocomial infection, and the most common on surgical wards. HIV-infected patients may increase the possibility of developing SSI after surgery. There are few reported date on incidence and the preventive measures of SSI in HIV-infected patients. This study was to determine the incidence and the associated risk factors for SSI in HIV-infected patients. And we also explored the preventive measures.

METHODS

A retrospective study of SSI was conducted in 242 HIV-infected patients including 17 patients who combined with hemophilia from October 2008 to September 2011 in Shanghai Public Health Clinical Center. SSI were classified according to Centers for Disease Control and Prevention (CDC) criteria and identified by bedside surveillance and post-discharge follow-up. Data were analyzed using SPSS 16.0 statistical software (SPSS Inc., Chicago, IL).

RESULTS

The SSI incidence rate was 47.5% (115 of 242); 38.4% incisional SSIs, 5.4% deep incisional SSIs and 3.7% organ/space SSIs. The SSI incidence rate was 37.9% in HIV-infected patients undergoing abdominal operation. Patients undergoing abdominal surgery with lower preoperative CD4 counts were more likely to develop SSIs. The incidence increased from 2.6% in clean wounds to 100% in dirty wounds. In the HIV-infected patients combined with hemophilia, the mean preoperative albumin and postoperative hemoglobin were found significantly lower than those in no-SSIs group (P<0.05).

CONCLUSIONS

SSI is frequent in HIV-infected patients. And suitable perioperative management may decrease the SSIs incidence rate of HIV-infected patients.

Outcomes of Laparoscopic and Open Appendectomy for Acute Appendicitis in Patients with Acquired Immunodeficiency Syndrome

The aims of this study were to compare outcomes of appendectomy between acquired immunodeficiency syndrome (AIDS) and nonAIDS patients and laparoscopic appendectomy (LA) versus open appendectomy (OA) in AIDS patients. Using the Nationwide Inpatient Sample database, from 2006 to 2008, clinical data of patients with AIDS who underwent LA and OA were evaluated. A total of 800 patients with AIDS underwent appendectomy during these years. Patients with AIDS had a significantly higher postoperative complication rate (22.56% vs 10.36%), longer length of stay [(LOS) 4.9 vs 2.9 days], and higher mortality (0.61% vs 0.16%) compared with non-AIDS patients. In nonperforated cases in patients with AIDS, LA was associated with a significantly lower complication rate (11.25% vs 21.61%), lower mortality (0.0% vs 2.78%), and shorter mean LOS (3.22 days vs 4.82 days) compared with OA. In perforated cases in patients with AIDS, LA had a significantly lower complication rate (27.52% vs 57.50%), and shorter mean LOS (5.92 days vs 9.67 days) compared with OA. No mortality was reported in either group. In patients with AIDS, LA has a lower morbidity, lower mortality, and shorter LOS compared with OA. Laparoscopic appendectomy should be considered as a preferred operative option for acute appendicitis in patients with AIDS.

Abdominal pain in special populations

Evaluation and management of acute abdominal pain in special populations can be challenging for the emergency physician. This article focuses on two specific populations: patients with altered immunologic function and postprocedural patients. Recognition of life-threatening abdominal diseases may be delayed in immunosuppressed patients because of the atypical presentations of these conditions. In postprocedural patients, evaluation of acute abdominal symptoms requires an understanding of the complications of procedures often performed by others. The unique characteristics of abdominal pain in these two populations and, more specifically, which diseases to consider and how to use appropriate testing to detect life-threatening conditions, are discussed.

Pain management among medical in-patients in Blantyre, Malawi

BACKGROUND

Pain is a leading symptom which influences patients to seek medical attention. The management of pain among patients attending in-patient care in southern African countries has been little described. Information regarding the prevalence of pain and the quality of its management may be useful in guiding clinical decisions, training of health workers and health care quality improvements.

METHODS

A hospital-based audit was conducted to estimate the prevalence of pain and examine the quality of its management among patients admitted to adult medical wards at Queen Elizabeth Central Hospital (QECH), Blantyre, Malawi in 2004. Data were abstracted from ward charts of consecutive patients' who had been either been discharged or had died within a specified period. Characteristics of interest included; socio-demographic data, presence or absence of pain at admission, characterization or description of pain when present, and drug treatment given. Data were analyzed to obtain frequencies and proportions of the characteristics and assess the prevalence of pain and quality of care.

RESULTS

A total of 121 patients' case notes were reviewed and the prevalence of pain was recorded for 91 (75.2%) of the patients. Clinicians had recorded pertinent information regarding pain management with the following frequency: pain severity or intensity 5/91 (5.5%), alleviating factors 5 (5.5%), pain radiation 7 (7.7%), exacerbating factors in 9 (9.9%) and periodicity in 43 (47.3%) of the cases. Males with pain were more than 3 times more likely to receive analgesic as compared to females, p < 0.01. Paracetamol was the commonest analgesic prescribed.

CONCLUSION

Inadequate management of pain among patients attending medical wards at QECH was found. There is need for prospective studies to further characterize pain management and identify pain management gaps in Malawi. Interviews of clinicians and documentation of observations within clinical practice are likely to be of value.

Diverticulitis in immunosuppressed patients

The differential diagnosis of abdominal pain should not rank diverticulitis any differently in immunosuppressed transplant or AIDS patients than in other patients of the same sex and age and with the same clinical presentation. Immunocompromised patients have increased postoperative infectious risks in direct proportion to the degree of their immune deficiency.

National estimation of rates of HIV serology testing in US emergency departments 1993-2005: baseline prior to the 2006 Centers for Disease Control and Prevention recommendations

OBJECTIVE

The 2006 Centers for Disease Control and Prevention recommendations place increased emphasis on emergency departments (EDs) as one of the most important medical care settings for implementing routine HIV testing. No longitudinal estimates exist regarding national rates of HIV testing in EDs. We analyzed a nationally representative ED database to assess HIV testing rates and characterize patients who received HIV testing, prior to the release of the 2006 guidelines.

DESIGN

A cross-sectional analysis of US ED visits (1993-2005) using the National Hospital Ambulatory Medical Care Survey was performed.

METHODS

Patients aged 13-64 years were included for analysis. Diagnoses were grouped with Healthcare Cost and Utilization Project Clinical Classifications Software. Analyses were performed using procedures for multiple-stage survey data.

RESULTS

HIV testing was performed in an estimated 2.8 million ED visits (95% confidence interval, 2.4-3.2) or a rate of 3.2 per 1000 ED visits (95% confidence interval, 2.8-3.7). Patients aged 20-39 years, African-American, and Hispanic had the highest testing rates. Among those tested, leading reasons for visit were abdominal pain (9%), puncture wound/needlestick (8%), rape victim (6%), and fever (5%). The leading medication class prescribed was antimicrobials (32%). The leading ED diagnosis was injury/poisoning (30%) followed by infectious diseases (18%). Of note, 6% of those tested were diagnosed with HIV infection during their ED visits.

CONCLUSION

Prior to the release of the 2006 Centers for Disease Control and Prevention guidelines for routine HIV testing in all healthcare settings, baseline national HIV testing rates in EDs were extremely low and appeared to be driven by clinical presentation.