Prospective evaluation of fever of unknown origin in patients infected with the human immunodeficiency virus. Grupo Andaluz para el Estudio de las Enfermedades Infecciosas

Predictive model for diagnostic yield of bone marrow examination in patients with HIV infection having fever of unknown origin

OBJECTIVE

Bone marrow examination is valuable for identifying the cause of fever of unknown origin (FUO) in HIV-infected patients. Based on the outcomes of bone marrow examination of patients with FUO, we aimed to develop a predictive model for identifying the factors that can increase the diagnostic yield of bone marrow examination.

DESIGN

For this retrospective cohort study, we enrolled HIV-infected patients, aged more than 15 years and diagnosed with FUO, at Songklanakarind Hospital in Southern Thailand, between January 2009 and December 2019.

METHODS

Evaluations were based on bone marrow aspiration, biopsy, and culture; any missing data were imputed with regression imputation.

RESULTS

Among the final 108 included patients, 44 (40.74%) showed positive bone marrow results. The diagnoses mainly comprised histoplasmosis, penicilliosis, and tuberculosis. Bone marrow examination led to treatment modifications in approximately 33% patients. Platelet count less than 150 000 cells/μl, alkaline phosphatase (ALP) level at least 200 U/l, and no previous antibiotic treatment were significantly associated with higher diagnostic yields. The HIV bone marrow (HIVBM) model, comprising of spleen size, hematocrit (Hct), platelet count before bone marrow examination, ALP level at admission, and previous antibiotic treatment, was generated as a nomogram to predict the diagnostic yield of bone marrow examination in HIV-infected patients with FUO.

CONCLUSION

The results of this study indicate that the HIVBM model can be used to predict the diagnostic yield of bone marrow examination, and therefore assist in clinical decision-making regarding bone marrow procedures, to be performed for identifying the origin of fever in HIV-infected patients.

Prevalence of visceral leishmaniasis among people with HIV: a systematic review and meta-analysis

Leishmaniasis is a parasitic infection expressing different clinical phenotypes. Visceral leishmaniasis (VL) is considered an opportunistic infection among people with human immunodeficiency virus (HIV). The objective of this review was to identify published data on the prevalence of Leishmania spp. infection among PWH and to define particular determinants that affect critically the epidemiological characteristics of VL-HIV coinfection and, potentially, its burden on public health. Two independent reviewers conducted a systematic literature search until June 30, 2022. Meta-analyses were conducted using random-effects models to calculate the summary prevalence and respective 95% confidence intervals (CI) of leishmaniasis among PWH. Meta-regression analysis was performed to investigate the impact of putative effect modifiers, such as the mean CD4 cell count, on the major findings. Thirty-four studies were eligible, yielding a summary prevalence of 6% (95%CI, 4-11%) for leishmaniasis (n = 1583) among PWH (n = 85,076). Higher prevalence rates were noted in Asia (17%, 95%CI, 9-30%) and America (9%, 95%CI, 5-17%) than in Europe (4%, 95%CI, 2-8%). Prevalence rates were significantly mediated by the age, sex, and CD4 cell count of participants. Heterogeneity remained significant in all meta-analyses (p < 0.0001). In the majority of included studies, people were coinfected with HIV and Leishmania species associated with VL, as opposed to those associated with cutaneous leishmaniasis. No sign of publication bias was shown (p = 0.06). Our summary of published studies on leishmaniasis among PWH is important to provide prevalence estimates and define potential underlying factors that could guide researchers to generate and further explore specific etiologic hypotheses.

Clinical presentation, causes and outcome of febrile episodes in a prospective cohort of HIV-infected patients

BACKGROUND

Fever was frequently caused by opportunistic conditions in HIV-patients in the early years of the epidemic. Little is known about diagnostic spectrum and outcome of febrile episodes in patients with good access to antiretroviral therapy.

METHODS

We prospectively studied clinical presentation, diagnosis and outcome of febrile episodes in a contemporary cohort of HIV-patients with good access to antiretroviral therapy. Fever was defined as temperature 38.3 °C or higher, measured by a health care provider.

RESULTS

We found 220 febrile episodes in 146 patients. In 25.9% of episodes the patient had a CD4 less than 200/mm³ and in 78.6% the patient was on antiretroviral therapy. There were multiple episodes in 44 patients. A diagnosis was established in 91.8%. Infection accounted for 82.3%, mainly respiratory tract infections, viral syndromes and abdominal infections. Malignancy, drug reactions and inflammatory conditions accounted together for less than 12% of episodes. Fifteen percent were attributed to opportunistic conditions. Episodes in patients with CD4 less than 200 were less likely to be caused by infection, but more likely to be caused by malignancy, drug reactions and opportunistic conditions. In 6.4% the patient died within six months after the onset of fever. Risk factors for death at six months in multivariable analysis were higher age and lower CD4.

CONCLUSIONS

HIV-patients with access to antiretroviral therapy present with fever mostly due to conditions common in the general population. HIV-patients with low CD4 remain at risk for fever due to opportunistic conditions and death.

Diagnostic Value of Percutaneous Liver Biopsy in Fever of Unkown Origin in Patients with Human Immunodeficiency Virus Infection

Fever of unknown origin (FUO) poses a major diagnostic challenge in patients infected with human immunodeficiency virus (HIV). In this retrospective study, we sought to assess the clinical utility of percutaneous liver biopsy as a diagnostic aid for FUO in HIV-infected patients and identify the factors associated with a greater likelihood of a positive diagnostic yield form this procedure. A total of 101 HIV-infected patients with FUO, who had undergone percutaneous liver biopsy in an HIV care hospital, served as the study population. The results obtained from percutaneous liver biopsy were categorized into three groups: (i) diagnostic, (ii) helpful, and (iii) not helpful. Diagnostic and helpful results were classified as useful. The mean (SD) age of patients was 37.6 (6.9) years, and the median (interquartile range [IQR]) CD4 count was 18 (3-62) cells/mm(3). The median (IQR) duration of fever was 20 (8-30) days. Percutaneous liver biopsy was diagnostic in 51 patients (50.5%), helpful in 12 (11.9%) and not helpful in 38 (37.6%) patients. On multivariate analyses, elevation of serum alkaline phosphatase level (OR 1.27 per one time elevation from the upper normal range; 95% CI, 1.03-1.57; P = 0.023), and fever duration of less than 3 weeks (OR 3.82; 95% CI, 1.03-14.18; P = 0.046) was significantly associated with the likelihood of the biopsy findings being classified as useful. Our study supports the case for percutaneous liver biopsy as a useful diagnostic aid in HIV-infected patients with FUO.

Utility of bone marrow examination for workup of fever of unknown origin in patients with HIV/AIDS

AIMS

The utility of bone marrow aspiration and biopsy (BMAB) as a diagnostic tool in patients with HIV/AIDS and fever of unknown origin (FUO) is a subject of debate. Because highly active antiretroviral therapy has reduced incidence of opportunistic infections, it is important to reassess the efficacy of BMAB for this diagnostic purpose. To our knowledge, no such studies have been performed in Harris County which has the highest incidence of HIV in the state of Texas.

METHODS

We reviewed all BMABs from patients with HIV/AIDS and FUO or persistent cytopenia(s) from 2007 to 2011.

RESULTS

Of 57 evaluable patients, BMAB was positive in 24 samples by acid fast bacilli (AFB) or Gomori methenamine silver (GMS) stains (17.5%), presence of granuloma and/or lymphohistiocytic aggregates (31.6%), culture (21.0%) or a combination. Cultures demonstrated Mycobacterium avium/intracellulare (4), M tuberculosis (2), M gordonae (1), Histoplasma capsulatum (3) and Cryptococcus neoformans (2). There were three cases in which a pathogen was grown in culture but that had a negative of 'direct examination' on tissue sections (negative AFB and GMS special stains, no morphological evidence of granuloma/lymphohistiocytic infiltrates).

CONCLUSIONS

This study supports the use of diagnostic BMAB as a rapid decision-making tool in patients with HIV and FUO in the proper clinical setting. BMAB demonstrated infection-related evidence prior to positive bone marrow culture in 75% of cases. Special stains and blood cultures had similar diagnostic yield, but BMAB offers faster results. Thus, this procedure assists in clinical decision making and the refinement of treatment in a more timely manner.

Q fever in Japan: an update review

As neglected zoonosis for many years, Q fever is now ubiquitous in Japan. Similarly to elsewhere in the world, domestic animals are considered to be important reservoirs of the causal agent, Coxiella burnetii, a resistant intracellular bacterium. Infected animals shed bacteria in milk, feces, urine, vaginal mucous and birth products. Inhalation of bacteria present in the environment is the main route of animal and human infection. Shedding of C. burnetii in milk by domestic ruminants has a very limited impact as raw milk is seldom ingested by the Japanese population. The clinical expression of Q fever in Japan is similar to its clinical expression elsewhere. However clinical cases in children are more frequently reported in this country. Moreover, C. burnetii is specified as one of the causative organisms of atypical pneumonia in the Japanese Respiratory Society Guideline for the management of community-acquired pneumonia. In Japan, C. burnetii isolates are associated with acute illness and are mainly of moderate to low virulence. Cats are considered a significant source of C. burnetii responsible for human outbreaks in association with the presence of infected parturient cats. Since its recognition as a reportable disease in 1999, 7-46 clinical cases of Q fever have been reported by year. The epidemiology of Q fever in Japan remains to be elucidated and the exact modes of transmission are still unproven. Important further research is necessary to improve knowledge of the disease itself, the endogenous hosts and reservoirs, and the epidemiological cycle of coxiellosis in Japan.

The changing etiology of fever of intermediate duration

BACKGROUND

Fever of intermediate duration (FID) is a common condition. Currently, its most frequent causes are not well defined.

METHODS

Prospective study of FID cases attended at a hospital in 2 periods: 1983-1989 and 2004-2005. Blood cultures and serologic studies for Brucella melitensis, Coxiella burnetii, Rickettsia typhi, Rickettsia conorii, cytomegalovirus, and Epstein-Barr virus were performed on all patients. Other microbiological, serological, radiological, or invasive procedures were performed according to clinician-in-charge criteria.

RESULTS

A total of 505 patients were included from 1983 to 1989, and 179 from 2004 to 2005. A diagnosis was reached in 410 (81.1%) and 109 patients (60.9%), respectively. The cause of FID was an infectious disease in 389 patients from the first period (94.8% of those with a final diagnosis) and 92 from the second (84.4%). Most were systemic infections, 328 (80%) in 1983-1989 and 74 (67.8%) in 2004-2005, followed by focal infections, 9.5% and 16.5%, respectively. Q fever was the most frequent etiology in both periods. In 2004-2005, brucellosis decreased and HIV infection emerged as a cause of FID. The origin of FID was non-infectious in 5.1% and 15.5%, respectively.

CONCLUSIONS

Q fever is the most frequent cause of FID in southern Spain. Studies over time are needed to identify changes in the etiologic spectrum of this condition. Important viral etiologies, such as HIV infection, may be detected as causes of FID. Further studies are needed to determine the importance of other agents as causes of FID.

Management of pyrexia of unknown origin in HIV-positive patients

Recently, we managed the case of a young HIV-positive man with a pyrexial illness and severe constitutional symptoms, the cause of which was elusive for several weeks. Here we review the causes of pyrexia of unknown origin in HIV-positive individuals, review appropriate investigations and discuss possible empirical treatment when this is required.

Fever of unknown origin in HIV/AIDS patients

Fever of unknown or uncertain origin (FUO) constitutes a common clinical challenge in patients infected with HIV. It is usually caused by disseminated opportunistic infection, and the relative frequency of each cause of FUO is influenced by multiple factors including CD4 count, geographic setting, and local prevalences of infectious agents, which may provide clues to the diagnosis. Infections presenting as FUO in the HIV population occur most often in the late stages of the disease and high diagnostic suspicion for mycobacterial disease should be maintained when evaluating these patients, particularly in areas of high prevalence. This article discusses the causes, diagnosis, and treatment of FUO in HIV-infected individuals.

Leishmaniasis as an opportunistic infection in HIV-infected patients: determinants of relapse and mortality in a collaborative study of 228 episodes in a Mediterreanean region

The clinical presentation of visceral leishmaniasis shares similarities with other geographically specific infectious diseases associated with AIDS in terms of relapsing course and atypical presentation. However, visceral leishmaniasis has not, until now, been included in the AIDS case definition. The aim of this study was to describe the clinical features and determinants for relapse and case-fatality of visceral leishmaniasis in HIV-infected patients from a Spanish Mediterranean area. A chart review was conducted in 16 hospitals in the autonomous communities of Valencia and Murcia (Spain). From 1988 to 2001, a total of 228 episodes of visceral leishmaniasis were diagnosed in 155 HIV-infected patients by the detection of amastigotes in bone marrow aspirates or in other tissue samples. Most patients had advanced HIV disease, with a median CD4(+) lymphocyte cell count of 55 cells x 10(9) l, and 56% of them had a previous AIDS-indicator disease. The median duration of follow-up was 8.4 months. HIV-infected patients with visceral leishmaniasis presented with fever (76%), hepatomegaly (77%), splenomegaly (78%), and varying degrees of cytopenias. Leishmania was detected in atypical sites in 22 (14%) patients. A total of 37 (24%) patients had a relapse of visceral leishmaniasis. Female gender was a risk factor for relapse, whereas administration of secondary prophylaxis for visceral leishmaniasis and a completed therapy for visceral leishmaniasis were protective factors against relapse. A total of 86 (54%) patients died. Independent determinants for survival were CD4(+) lymphocyte cell count, completed therapy for leishmania, and secondary prophylaxis for visceral leishmaniasis. The findings show that, in HIV-infected patients, visceral leishmaniasis occurs in late stages of HIV disease and often has a relapsing course. Secondary prophylaxis reduces the risk of relapse. Visceral leishmaniasis in the HIV-infected population should be included in the CDC clinical category C for the definition of AIDS in the same way that other geographically specific opportunistic infections are included.

Diagnostic usefulness of percutaneous liver biopsy in HIV-infected patients with fever of unknown origin

OBJECTIVES

to determine the value of percutaneous liver biopsy (PLB) in the diagnosis of fever of unknown origin (FUO) in HIV-infected patients and establish a prediction model for its usefulness to enable diagnosis of FUO in these patients to be standardized.

METHODS

a total of 58 HIV-infected patients who underwent PLB for the evaluation of FUO were studied at 'Carlos Haya' Hospital in Malaga, Spain. The patients were classified into three groups, according to the results of the PLB: (a) diagnostic PLB (when a definitive diagnosis was obtained); (b) helpful PLB (the tissue sample showed suggestive, but not definitive, findings); and (c) normal or non-specific PLB (no contribution to diagnosis, the findings being normal or irrelevant). Multivariate analysis was made to establish a prediction model for the diagnostic usefulness of PLB, calculating the positive (PPV) and negative (NPV) predictive values.

RESULTS

PLB was carried out in 58 HIV-infected patients during diagnosis of FUO. Risk factors for HIV infection included intravenous drug use (72.4%), homosexual or bisexual activities (12.1%), and heterosexual transmission (15.5%). Fifty-two out of 58 patients (89.6%) had previous AIDS-defining illnesses. The mean CD4 lymphocyte count +/-SD was 56.4+/-80.9/mm3. The mean duration of fever was 43 days. Diagnosis could be established in 51 (87.9%) patients, with tuberculosis (50%) and leishmaniasis (20.7%) being the most common. The PLB was diagnostic in 25 cases (43.1%), helpful in 13 (22.4%), and normal or non-specific in the remaining 20 (34.5%). Biopsy-associated complications occurred in two cases. The presence of hepatomegaly or splenomegaly were the most useful factors in predicting the usefulness of the PLB, with a PPV of 86.1% and NPV of 68.2%. In patients with tuberculosis, an increased alkaline phosphatase and hepatomegaly had a PPV of 86.4% and a NPV of 71.4%.

CONCLUSIONS

PLB is a useful technique for the diagnosis of FUO in HIV-infected persons. Early PLB should be considered in those patients with hepatosplenomegaly and increased alkaline phosphatase levels.