Physician's advice on quitting smoking in HIV and TB patients in south India: a randomised clinical trial

Setting: National Institute for Research in Tuberculosis, Madurai, India. Objective: To determine the efficacy of physician's advice on quitting smoking compared with standard counselling in patients with tuberculosis (TB) and patients with human immunodeficiency virus (HIV) infection. Design/Methods: This was a clinical trial conducted in Madurai, south India, among 160 male patients (80 with TB and 80 with HIV), randomised and stratified by nicotine dependence (low/high according to the Fagerström scale), who received physician's advice with standard counselling or standard counselling alone for smoking cessation. Abstinence at 1 month was assessed by self-report and carbon monoxide breath analysis. Results: The patients' mean age was 39.4 years (SD 8.5). Overall, 35% of the patients had high nicotine dependence. Most patients (41%) smoked both cigarettes and bidis. In a combined analysis including both the HIV and the TB groups, quit rates were 41% of the 68 patients in the physician group and 35% of the 68 patients in the standard counselling arm. Conclusions: Physician's advice to quit smoking delivered to patients with TB or HIV is feasible and acceptable. Smoking cessation could easily be initiated in TB patients in programme settings. Future studies should assess long-term abstinence rates with a larger sample size to demonstrate the efficacy of physician's advice.

High Frequency of First-Line Anti-Tuberculosis Drug Resistance among Persons with Chronic Pulmonary Tuberculosis at a Teaching Hospital Chest Clinic

INTRODUCTION

The burden of MDR-TB is unknown in areas that do not have drug susceptibility testing (DST), but its frequency is expected to be higher in previously treated cases. Where DST is not available the WHO recommended standardized retreatment (Category II) regimen is given to previously treated TB patients

OBJECTIVE

To evaluate the frequency and pattern of drug resistance of Mycobacterium tuberculosis isolated from patients with chronic smear positive pulmonary tuberculosis.

METHOD

We conducted a retrospective review of mycobacterial cultures and drug susceptibility testing (DST) performed on sputum samples collected, between January 2005 and September 2006, from 40 patients with pulmonary TB who had failed at least one standard retreatment regimen. Clinical data was extracted from patients' case notes.

RESULTS

M. tuberculosis was recovered from 28 (70%) of the 40 patients. Of the 28 culture positive cases, 10 (36%) had resistance to at least rifampicin and isoniazid (multi-drug resistant TB), 22 (79%) isolates had resistance to streptomycin and 13 (46%) to ethambutol. Of the patients with a positive culture, only one (3.6%) had a fully susceptible organism. Of the 10 patients with MDR TB, 7 had received two or more retreatment courses.

CONCLUSION

The frequency of drug resistant TB was high among patients who failed at least one course of category II therapy. Effective combination regimens based on DST is necessary in patients who remain smear positive on the standardized retreatment regimen.

Gender-based differences in treatment and outcome among HIV patients in South India

OBJECTIVE

To describe gender-based differences in disease progression, treatment, and outcome among patients receiving highly active antiretroviral therapy (HAART) in South India.

METHODS

Therapy-naïve patients initiating HAART between February 1996 and June 2006 at a tertiary HIV referral center in Chennai, South India, were analyzed using the YRG CARE HIV Observational Database. Patients with 1 year of follow-up after initiating HAART were examined to investigate immunological and clinical outcomes, including the development of adverse events to therapy and opportunistic infections.

RESULTS

All previously therapy-naïve patients who initiated HAART with at least 1 year of follow-up (n = 1972) were analyzed. At enrollment into care, women had higher CD4 counts, lower hemoglobin, and higher body mass index (BMI) than their male counterparts (p < 0.05). At the time of initiating therapy, women had higher CD4 counts and lower hemoglobin (p < 0.05); women continued to have higher CD4 counts at 12 months (p < 0.05). After 1 year following HAART initiation, significantly more men developed tuberculosis and Pneumocystis jiroveci pneumonia (p < 0.05), more women experienced lactic acidosis and nausea, and more men developed immune reconstitution syndrome (p < 0.05).

CONCLUSIONS

Significant physiological, immunological, and clinical differences exist between men and women initiating HAART in a resource-limited setting in South India. Future studies should examine whether clinical management strategies should be different for men and women in resource-limited settings.

Screening for sexually transmitted diseases and hepatitis in 18-29-year-old men recently released from prison: feasibility and acceptability

Men entering prisons have high rates of sexually transmitted disease (STD), hepatitis, and HIV. This study sought to determine the acceptability and feasibility of screening for STD and hepatitis in young men released from prison. Participants were interviewed six months after release and offered free screening. Of 42 (56%) eligible men who participated in the qualitative interview, 33 (79%) provided at least a blood or urine specimen. Eight of 33 (24%) men tested had chlamydia, trichomoniasis, hepatitis B or C virus (HBV or HCV). Three of 32 (9%) had chlamydia, three of 32 (9%) had trichomoniasis, two of 28 (7%) had prior syphilis, and two of 28 (7%) had HCV. Of 28 tested for HBV, six (21%) were immune, two (7%) had chronic infection, and 20 (71%) were susceptible. Barriers to screening included lack of forewarning, inconvenience, and insufficient incentive. In conclusion, screening for STD and hepatitis among former inmates can be acceptable and feasible. Forewarning, reducing the time burden, and providing monetary incentives may increase screening rates.

Heroin use in adolescents and young adults admitted for drug detoxification

PURPOSE

To examine heroin use and associated morbidity in young adults undergoing drug detoxification.

METHODS

A retrospective chart review of all persons (ages 18-25) admitted to either of the two state-funded detoxification facilities in Rhode Island was conducted between June 1998 and June 1999. Only those reporting heroin as a primary drug were included in this study (N=201).

RESULTS

Clients were largely male (64%), and white (79%), with a mean age of 22. Of those that reported heroin as their primary drug, 62% used primarily by injection. Mean age of initiation for heroin use was 18.3 years. Twenty-two percent reported a psychiatric diagnosis, and 80% reported a substance-abusing family member. Injection, previous overdose, and a mother with a history of substance use were associated with early initiation of heroin use.

CONCLUSIONS

The majority of young adults with heroin addiction undergoing detoxification began using heroin during late adolescence. Concurrence of psychiatric and medical diagnoses with heroin addiction was common, and may contribute to the severity of drug use. Efforts to identify risk factors for heroin and other injection drug use in adolescents and young adults will be critical for the design of effective interventions to prevent injection drug use and its associated morbidities.

HIV testing in the setting of inpatient acute substance abuse treatment

We examined patients' attitudes toward HIV testing in the setting of acute substance abuse treatment and determined the prevalence of offering routine on-site testing for human immunodeficiency virus (HIV) in inpatient state-funded detoxification centers in New England. Voluntary questionnaires were administered to patients (N = 66 respondents) at the only two state-funded inpatient drug detoxification treatment centers in Rhode Island, and a telephone survey of all state-funded inpatient detoxification facilities across the New England area was conducted. In New England, 17/38 (44.7%) of all state-funded inpatient detoxification facilities didnot routinely offer on-site HIV testing to clients. Of participants, 97% responded positively to the question, "Do you think HIV testing should be available to patients in drug detoxification facilities such as this one?" There were 89% who reported that they would cope "about the same" or "better" with receiving a positive HIV test result while in detoxification treatment versus elsewhere. The greatest number of participants ranked the Orasure HIV test, an assay for HIV-1 transmucosal antibody, as the test they would most prefer while in drug treatment. However, 59% of patients responded that the type of test offered would not make a difference in whether they chose testing. Most patients indicated that they would want to see a physician within a few days of a positive diagnosis of HIV infection. Despite the controversy surrounding the provision of HIV testing to patients in inpatient acute substance abuse treatment, HIV testing is desired among these patients provided that HIV clinical care is readily available.

Successful linkage of medical care and community services for HIV-positive offenders being released from prison

Human immunodeficiency virus (HIV) infection is more prevalent among the incarcerated than the general population. For many offenders, incarceration is the only time that they may access primary care. Project Bridge is a federally funded demonstration project that provides intensive case management for HIV-positive ex-offenders being released from the Rhode Island state prison to the community. The program is based on collaboration between colocated medical and social work staff. The primary goal of the program is to increase continuity of medical care through social stabilization; it follows a harm reduction philosophy in addressing substance use. Program participants are provided with assistance in accessing a variety of medical and social services. The treatment plan may include the following: mental illness triage and referral, substance abuse assessment and treatment, appointments for HIV and other medical conditions, and referral for assistance to community programs that address basic survival needs. In the first 3 years of this program, 97 offenders were enrolled. Injection drug use was reported by 80% of those enrolled. There were 90% followed for 18 months, 7% moved out of state or died, and 3% were lost to follow-up. Reincarceration happened to 48% at least once. Of those expressing a need, 75% were linked with specialty medical care in the community, and 100% received HIV-related medical services. Of those expressing a need for substance abuse treatment, 67% were successful in keeping appointments for substance abuse treatment within the community. Project Bridge has demonstrated that it is possible to maintain HIV-positive ex-offenders in medical care through the provision of ongoing case management services following prison release. Ex-offenders will access HIV-related health care after release when given adequate support.

HIV infection in families of HIV-positive and 'at-risk' HIV-negative women

Research of HIV infection within the family has focused upon sexual partners and vertical transmission. The scope of the problem of multiple infections and clustering of HIV among family members has, thus far, been less extensively explored. The objectives of this study are to investigate HIV infection in family members of HIV-seropositive and HIV-seronegative high-risk women and to consider the impact of multiple HIV infections within the family. Baseline data were evaluated from a prospective observational cohort of 871 HIV-seropositive and 439 seronegative at-risk women who are participants in a longitudinal study of HIV in women at four sites in the USA (Montefiore, Bronx, NY; Johns Hopkins University, Baltimore, MD; Brown University, Providence, RI; Wayne State University, Detroit, MI). Women were asked if anyone close to them had HIV/AIDS or had died from HIV/AIDS. Responses which included HIV-positive family members were analyzed. In the seropositive cohort, 35% (307/871) of the women had a family member with HIV infection. Of these 307 women, 38% reported having a sibling, 24% a husband and 27% had more than one family member with HIV/AIDS. Forty-nine per cent of Latina women, 34% of black women, and 21% of white women reported having a family member with HIV/AIDS. Using logistic regression analysis, we found that Latina and black women were significantly more likely than white women to have a sibling, extended family member or more than one family member with HIV/AIDS. Compared to seropositive women, seronegative high-risk women enrolled in this study appear equally likely to have an HIV-infected family member. In this study of HIV-positive women and high-risk seronegative women, a third reported having multiple family members with HIV infection, most often in a sibling. The high prevalence of HIV within families, particularly in the families of Latina and black women, mandates attention in planning both prevention and care.

High-risk behaviors and the prevalence of sexually transmitted diseases among women prisoners at the women state penitentiary in Metro Manila

Women prisoners in the Philippines are particularly vulnerable to HIV infection. The economic and social disadvantages that women endure in mainstream society are magnified once they are committed to penitentiaries where control over one's own life is even more restricted and limited. Outside prison, impoverished and uninformed about the ways of protecting their health, women have engaged in unprotected sex with their male partners, many of whom have had casual sex or extra-marital affairs. Within prison, it is therefore not surprising that over 25% of women were already infected with sexually transmitted diseases (STDs). None were infected with HIV. The presence of STDs among female inmates highlights the importance of addressing health needs while at the correctional facility. It also raises the need for educational and prevention programs and health services that will help reduce women's vulnerability to HIV, AIDS and STDs.

Human immunodeficiency virus infection, AIDS, and smoking cessation: the time is now

Treatments for persons who are infected with human immunodeficiency virus (HIV) or who have developed AIDS have advanced to the point where death is no longer the inevitable outcome of diagnosis. Combination antiretroviral therapy has made HIV infection less of a terminal condition and more of a medically manageable chronic disease. Thus, efforts to improve the health status and quality of life of HIV-infected persons have become one of the highest treatment priorities for the next decade. Cigarette smoking is highly prevalent among HIV-infected persons, and quitting smoking would greatly improve the health status of these individuals. However, to date, no studies have evaluated the efficacy of a smoking-cessation intervention specifically tailored to this population. This article reviews the evidence and rationale for advancing smoking-cessation treatments specifically tailored to the needs of HIV-infected persons and provides recommendations for future treatment studies.

Serotonin-2A receptor mRNA expression in rat retinal pigment epithelial cells

Previous studies have shown that rat retinal pigment epithelial (RPE) cells in culture express 5-HT2-type serotonin receptors coupled to phospholipase C activity. The presented data confirm this observation where it is shown that serotonin induced increases in radioactive inositol phosphates accumulation in RPE cells pretreated with tritiated inositol. This increase was significantly (p < 0.01) attenuated by 1 microM spiperone, ketanserin, mesulergine and metergoline while the same concentration of spiroxatrine or yohimbine had no effect, suggesting the involvement of 5-HT2A receptors. Using reverse transcriptase-polymerase chain reaction the presence of 5-HT2A receptor mRNA was demonstrated in total RNA isolated from rat RPE cell cultures. Amplification of a 5-HT2A receptor mRNA-derived product was additionally confirmed by Southern blot analysis. The combined data demonstrates the existence of functional 5-HT2A receptors in rat RPE cells.

Neurocognitive and psychological contributions to quality of life in HIV-1-infected women

OBJECTIVES

The purpose of this study was to examine the impact of neurocognitive and emotional distress and immune system dysfunction on quality of life in women with HIV.

METHODS

Thirty-six HIV-seropositive women were administered measures of mood status (Profile of Mood States), quality of life (Multidimensional Quality of Life Questionnaire for Persons with HIV) and cognitive function. CD4 cell counts were obtained as an indicator of immune system status.

RESULTS

Regression analyses revealed that independent of severity of emotional distress, neurocognitive deficits on measures of executive control and speed of information processing were associated with reduced quality of life. Emotional status also was associated with quality of life and together with neurocognitive performance accounted for most of the variance associated with quality of life. Reduced CD4 cell count was significantly associated with neurocognitive deficits, but not severity of emotional distress or quality of life.

CONCLUSIONS

Quality of life among women who are infected with HIV is strongly influenced by both neurocognitive and emotional status, as women with the greatest neurocognitive impairment and emotional distress report the poorest quality of life.

A prospective study of positive tuberculin reactions in women with or at risk for HIV-1 infection. HER Study Group. HIV Epidemiology Research

We prospectively studied 1310 women with or at risk for HIV-1 infection to assess subsequent tuberculin reactions in those with > or = 10 mm induration. Forty-seven HIV-positive and 57 negative women had tuberculin reactions > or = 10 mm induration; reversions to reactions < 10 mm occurred in 44% and 46% of those retested, respectively (P = NS). Among seropositives, reversions were associated with lower CD4+ lymphocyte count (P = 0.02). Of a total of 45 subsequent tuberculin tests in seropositive women, only two (4%) resulted in 5-9 mm induration, both at CD4+ counts < 500/mm3. Three (30%) of an additional 10 seropositive women with maximal reactions of 5-9 mm induration reported prior tuberculosis exposure, a significantly lower proportion than the 36/47 (77%) with reactions > or = 10 mm induration (P < 0.01), but not different than women with maximal reaction sizes < 5 mm (219/814, 27%). This study suggests that reversions of > or = 10 mm tuberculin reactions to 5-9 mm are rare. In HIV-positive persons, especially those with CD4+ lymphocyte counts > or = 500/mm3, reaction sizes of 5-9 mm often may not indicate Mycobacterium tuberculosis infection.

Stages of change for adherence with medication regimens for chronic disease: development and validation of a measure

BACKGROUND

The stages-of-change (SOC) model has been used to explain and predict how behavior change occurs, but it is new as an approach to understanding why patients fail to take their medications as prescribed.

OBJECTIVE

This study validated a 2-item measure of SOC for adherence with medication regimens in 2 groups of patients prescribed pharmacologic therapy for chronic conditions.

METHODS

Two cross-sectional studies of attitudes toward medication adherence included the same measure of SOC for medication adherence. One was a sample of 161 HIV-positive patients in the United States, and the other was an international sample of 731 patients with hypertension. The validity of the measure of SOC for medication adherence was examined in both convenience samples using previously validated self-reported measures of adherence (the Medication Adherence Scale and a measure of adherence from the Medical Outcomes Study), and in the HIV sample using electronic monitoring of adherence behavior in 85 patients.

RESULTS

Construct validity was demonstrated in both samples by associations between SOC and the previously validated measures of adherence (P < 0.001), and predictive validity was supported by significant associations between SOC for medication adherence and electronically monitored medication-taking behavior during the next 30 days (P < 0.03).

CONCLUSIONS

Behavior-change theory suggests that stage-tailored communication strategies are more effective than uniform health-promotion messages. Our results provide a foundation for the development of interventions for medication adherence that are tailored to patients' readiness for change. Our validated 2-item measure of SOC for medication adherence can be used to match communication strategies to individual motivation and readiness for adherence with chronic disease medication regimens.

Marriage, monogamy and HIV: a profile of HIV-infected women in south India

A retrospective study was conducted on 134 HIV-infected females evaluated at an HIV/AIDS centre in south India to characterize their sociodemographics, HIV risk factors and initial clinical presentations. The mean age was 29 years; 81% were housewives; 95% were currently or previously married; 89% reported heterosexual sex as their only HIV risk factor; and 88% reported a history of monogamy. The majority were of reproductive age, thus the potential for vertical transmission of HIV and devastating impacts on families is alarming. Nearly half of these women initially presented asymptomatically implying that partner recruitment can enable early HIV detection. Single partner heterosexual sex with their husband was the only HIV risk factor for the majority of women. HIV prevention and intervention strategies need to focus on married, monogamous Indian women whose self-perception of HIV risk may be low, but whose risk is inextricably linked to the behaviour of their husbands.

The effect of immunodeficiency on cutaneous delayed-type hypersensitivity testing in HIV-infected women without anergy: implications for tuberculin testing. HER Study Group. HIV Epidemiology Research

SETTING

A collaborative study in four urban medical centers in the United States.

OBJECTIVE

To determine the effect of human immunodeficiency virus (HIV) infection and immunodeficiency on delayed type hypersensitivity (DTH) responses and the implications for interpretation of tuberculin reactions in non-anergic women with or at risk for HIV infection.

DESIGN

Demographic and behavioral information, HIV antibody testing, CD4+ lymphocyte counts, and cutaneous responses to DTH testing with mumps, Candida, tetanus toxoid, and tuberculin (purified protein derivative-PPD) antigens were obtained in 1184 women.

RESULTS

Reactions to one or more of the four antigens occurred in 436 HIV-seropositive and 356 high-risk seronegative women. Among non-anergic women, HIV-seropositives were less likely (P < or = 0.05) to react to mumps (62% vs 81%), tetanus (72% vs 84%), and PPD (13% vs 19%). Induration in HIV-seropositive reactors was associated with CD4+ cell level for mumps (P = 0.004) and tetanus (P < 0.001), but not for Candida or PPD. HIV-seropositive reactors with CD4+ cell counts >500/mm3 did not have significantly smaller reactions than HIV-seronegatives for any antigen tested. PPD sizes were similar among HIV-seropositive reactors with CD4+ cell counts >500/mm3 (12.4 +/- 7.4 mm) and HIV-seronegative reactors (12.0 +/- 8.3 mm); induration > or =10 mm was seen in 16/173 (9.2%) seropositive women with CD4+ cell counts >500/mm3 and 41/356 (11.5%) seronegative women, respectively (P = 0.5).

CONCLUSION

Among HIV-infected women able to react to a DTH antigen, induration in response to that antigen was relatively intact at CD4+ counts >500/mm3. This suggests that degree of immunodeficiency should be considered when interpreting PPD reactions in HIV-infected persons.

Stability of cutaneous anergy in women with or at risk for HIV infection. HIV Epidemiology Research Study Group

OBJECTIVE

To study the stability of cutaneous anergy in women with or at risk for HIV infection.

DESIGN

Prospective multicenter cohort study

METHODS

Interviews, CD4+ lymphocyte counts, and intradermal skin testing with mumps, Candida, and tetanus toxoid antigens were performed on two occasions at a median interval of 74 weeks in 436 HIV-seropositive and 252 seronegative at-risk women; only 10 (2%) HIV-seropositive women were taking highly active antiretroviral therapy at the time of delayed-type hypersensitivity (DTH) testing. Anergy was defined as induration <2 mm to all three antigens.

RESULTS

Skin test reactivity at repeat testing was seen in 202 of 233 (87%) HIV-seronegative women who were not anergic at baseline, compared with 10 (53%) of 19 seronegative women who were anergic at baseline (relative risk [RR], 1.7; 95% confidence interval [CI], 1.07-2.5). Anergy at retesting was seen in 108 of 169 (64%) HIV-seropositive women who were previously anergic, compared with 77 of 267 (29%) who were not previously anergic (RR, 2.2; 95% CI, 1.8-2.8). Among initially anergic seropositive women, CD4+ lymphocyte counts were lower at both initial and follow-up testing in those who remained anergic than in those who reacted at follow-up (p < .001). The relative risks for anergy at retesting of initially anergic seropositive women, compared with initially reactive seropositive women, were related to CD4+ level; 2.5 (95% CI, 1.4-4.3) for CD4+ counts < 200 cells/mm3, 2.0 (95% CI, 1.5-1.7) for CD4+ counts 200-500 cells/mm3, and 1.6 (95% CI, 0.9-2.8) for CD4+ counts >500 cells/mm3.

CONCLUSIONS

Although anergic HIV-seropositive women may become reactive, cutaneous anergy predicts a higher likelihood of anergy at retesting as well as lower CD4+ counts. Stability of anergy is greatest in HIV-seropositive women with low CD4+ counts.

Persistent parvovirus B19 related anemia of seven years' duration in an HIV-infected patient: complete remission associated with highly active antiretroviral therapy

A human immunodeficiency virus (HIV)-infected individual was first diagnosed with red blood cell aplasia due to B19 parvovirus infection in late 1989. Over the subsequent seven-year period, he received a total of 119 units of red blood cells (RBCs) and intravenous immunoglobulin every 2-3 weeks. In 1996 combination antiretroviral treatment with a protease inhibitor was initiated. He received four more units during the following two months and then required no more transfusions for the subsequent 24 months of follow-up. His CD4 count progressively increased and DNA polymerase chain reaction for parvovirus B19 became undetectable. Aggressive antiretroviral treatment may effectively diminish transfusion requirements among HIV-infected individuals with pure RBC aplasia resulting from parvovirus B19 infection.

Criteria for assessing cutaneous anergy in women with or at risk for HIV infection. HIV Epidemiologic Research Study Group

BACKGROUND

Controversy exists about both the clinical utility of anergy testing and the optimal criteria for defining anergy.

OBJECTIVE

We sought to assess various definitions of cutaneous anergy for ability to distinguish HIV status, level of immunodeficiency, and ability to mount a tuberculin reaction among women with or at risk for HIV infection.

METHODS

HIV-seropositive (n = 721) and HIV-seronegative (n = 358) at-risk women at academic medical centers in Baltimore, Detroit, New York, and Providence had cutaneous testing with mumps, Candida, tetanus toxoid, and tuberculin antigens. Associations with HIV status and CD4+ lymphocyte levels were analyzed.

RESULTS

Candida, mumps, and tetanus antigens alone or in combination elicited reactions significantly less often in HIV-seropositive than in HIV-seronegative women and less often in seropositive women with lower CD4+ counts, regardless of induration cutpoint chosen to define a positive reaction. The best antigen combinations for distinguishing groups included tetanus and mumps. Some women nonreactive to the 3 antigens ("anergic") had positive tuberculin reactions among both seropositive subjects (range, 1.1% to 2.9% depending on induration cutpoint for defining anergy) and seronegative subjects (range, 8.9% to 14%).

CONCLUSION

Absence of reactions to Candida, mumps, and tetanus antigens alone or in combination and at any induration cutpoint is associated with HIV status and with CD4+ level. Combinations, including tetanus and mumps antigens with an induration cutpoint of less than 2 mm, may be the best for defining anergy.

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.

Pulmonary invasive aspergillosis in patients infected with the human immunodeficiency virus: report of two cases

Patients infected with the human immunodeficiency virus (HIV) have an increased frequency of invasive aspergillosis. We report two cases of invasive pulmonary aspergillosis in patients infected with HIV. Patients had less than 10 CD4 (helper cell) cells/mm3 (2/2), presented with fever (2/2), dyspnea (1/2), and abnormal chest radiograph (2/2). Diagnosis was established by transbronchial biopsy (1/2) and autopsy (1/2). Patients died in spite of treatment with intravenous deoxycholate amphotericin B. Prognosis of invasive pulmonary aspergillosis among patients infected with HIV remains dismal, even with aggressive antifungal treatment.

Enterohemorrhagic Escherichia coli O157:H7--an emerging pathogen

Enterohemorrhagic Escherichia coli O157:H7 has become an important public health problem in recent years, causing more than 20,000 cases of infection and up to 250 deaths per year in the United States. Transmission of infection is most commonly linked to consumption of undercooked ground beef, contaminated drinking water or unpasteurized milk. Patients with this infection most often present with an acute onset of diarrhea and abdominal cramping that progresses over days to bloody stools. The most serious complications of E. coli O157:H7 infection include hemolytic-uremic syndrome and thrombotic thrombocytopenic purpura. Hemolytic-uremic syndrome occurs most often in children less than five years of age and the elderly, while thrombotic thrombocytopenic purpura occurs only in adults. Detection of E. coli O157:H7 requires specific testing that is not performed in routine stool cultures. All patients with documented infection require close observation for the development of possible complications. Use of antibiotics and antimotility agents may worsen the course of the infection and should be avoided.

Invasive Aspergillus sinusitis in patients with human immunodeficiency virus infection. Report of 2 cases and review

Aspergillus sinusitis is an uncommon complication of advanced human immunodeficiency virus (HIV) infection. We describe 2 patients with AIDS who developed histologically proven invasive Aspergillus sinusitis. We also review the findings of 14 histologically documented and 5 probable cases of invasive Aspergillus sinusitis. The literature on the prevalence, predisposing factors, diagnosis, treatment, and prognosis of the infection is reviewed. Major risk factors for the disease are advanced AIDS, chronic sinusitis or otitis, neutropenia, use of corticosteroids and prolonged use of broad spectrum antibiotics. The most common presenting symptoms are nonspecific and include fever, local pain, and swelling. Despite the newer diagnostic and therapeutic approaches discussed herein, the infection is usually fatal in HIV-infected patients. Early diagnosis and aggressive treatment remain the only available means to improve the currently dismal prognosis of Aspergillus sinusitis.

Comparative analysis of methods for collection and measurement of immunoglobulins in cervical and vaginal secretions of women

The purpose of this study was to systematically compare 3 collection methods, Sno-strips, wicks and cervical-vaginal lavage, for analysis of immunoglobulin concentrations in female genital secretions. In each of 8 women, absorbent wicks and Sno-strips were applied at 4 locations: the lateral wall of the vagina; the posterior vaginal fornix; the surface of the exocervix; and the endocervical canal. Cervical-vaginal lavage was then performed in 4 women with 5 ml PBS. Immunoglobulin and protein concentrations in lavage samples were generally over 100 times lower than in the secretions captured directly from mucosal surfaces with either Sno-strips or wicks. Capture of undiluted secretions with either wicks or Sno-strips allowed calculation of actual immunoglobulin concentrations at specific mucosal sites: for example, median IgA levels were consistently highest in the endocervix and lowest in the vagina. Such information may be crucial in evaluating the correlates of protective immunity against micro-organisms that infect or invade discrete regions of the genital mucosa.

Cytologic-histologic discrepancy in human immunodeficiency virus-positive women referred to a colposcopy clinic

OBJECTIVE

To evaluate the rate of discrepancy between cytology and histology in a referral-based population of human immunodeficiency virus (HIV)-positive women compared to HIV-negative women and women whose HIV status was unknown.

METHODS

From January 1, 1990 to December 31, 1993, approximately 830 women underwent evaluation at Women and Infants' Hospital colposcopy clinic. Women who had histologic diagnosis and recent cytologic evaluation during this interval (N = 678) were selected for study. Forty-one HIV-positive women were compared to 228 HIV-negative women and 409 women whose HIV status was unknown.

RESULTS

Of the 41 HIV-positive women, seven (17%) were noted to have a discrepancy between cytologic and histologic findings. In HIV-negative and HIV-unknown women, 15% (34 of 228) and 22% (91 of 409) were discrepant, respectively. Using HIV-negative women as the reference group, the relative risk of cytologic-histologic discrepancy was 1.1 (95% confidence interval [CI] 0.51-2.41) for HIV-positive women and 1.5 (95% CI 1.04-2.14) for women whose HIV status was unknown.

CONCLUSION

Human immunodeficiency virus-positive women referred for colposcopic evaluation have no more cytologic-histologic discrepancy than HIV-negative women or women whose HIV status is unknown.

Safety of intracavitary urokinase with percutaneous abscess drainage

OBJECTIVE

Percutaneous drainage of abscesses is an effective treatment, but the success rate is lower for abscesses that have septa and are multilocular. Several clinical and in vitro studies suggest urokinase may be useful in such cases. Our study was designed to determine the safety of urokinase administered into an abscess cavity during the course of percutaneous drainage.

SUBJECTS AND METHODS

Our study included 26 consecutive patients with 31 abscesses treated with percutaneous drainage. Exclusion criteria included age less than 18 or more than 95 years, CNS disorders (e.g., tumor, vascular problems), coagulation impairments, hepatic failure, pregnancy, and abscesses in the spleen, pancreas, or interloop area. Three doses were used: group 1 (nine patients), 1000 IU of urokinase per centimeter of abscess diameter; group 2 (11 patients), 2500 IU of urokinase per centimeter of abscess diameter; and group 3 (nine patients), 5000 IU of urokinase per centimeter of abscess diameter. These doses were administered every 8 hr for 3 days along with percutaneous drainage. Charts were reviewed to determine success and to detect adverse clinical events. Studies included sequential CT scans; serial serum determinations of hematocrit, prothrombin time, partial thromboplastin time, platelet count, fibrinogen levels, and levels of fibrin degradation products; and serial laboratory analysis of purulent material for fibrinogen and fibrin degradation products. Percutaneous drainage was considered successful if no surgical intervention was required.

RESULTS

Our results showed no significant change in hematologic studies and no bleeding complications. Analysis of purulent material indicated that urokinase remained active in the abscess milieu. Drainage was successful in seven of 11 patients in group 1, all nine patients in group 2, and 10 of 11 patients in group 3. All eight abscesses with septa were successfully drained.

CONCLUSION

Intracavitary urokinase can be given safely during percutaneous drainage of an abscess, with no associated bleeding complications or changes in coagulation parameters.

Treatment of cryptosporidiosis with paromomycin. A report of five cases

Cryptosporidiosis continues to be one of the most devastating complications of the acquired immunodeficiency syndrome, causing severe, chronic diarrhea that is largely refractory to treatment. More than 60 drugs have been tried in the treatment of cryptosporidiosis, none of which have been consistently successful. We describe the successful treatment of cryptosporidiosis in five patients with acquired immunodeficiency syndrome with oral paromomycin at a dose of 1500 to 2000 mg/d. All five patients had resolution of symptoms and normalization of bowel movements, although one patient later relapsed while receiving paromomycin. Three of five patients cleared Cryptosporidium from the stool. Paromomycin is a promising therapy for cryptosporidiosis in acquired immunodeficiency syndrome and further prospective clinical trials are warranted.

In vitro screening of therapeutic agents against Cryptosporidium: hyperimmune cow colostrum is highly inhibitory

An in vitro model of Cryptosporidium parvum infection was developed utilizing an adherent human intestinal epithelial cell line HT29.74. The efficacy of potential immunologic therapy in the form of Cryptosporidium-specific hyperimmune bovine colostrum was evaluated for the ability to inhibit in vitro infection. Oocysts were purified from stool of chronically infected AIDS patients. Hyperimmune colostrum obtained from cows immunized with Cryptosporidium and nonimmune conventional colostrum were evaluated. oocysts (10(5)-10(6)) were pre-incubated with either hyperimmune colostrum, conventional colostrum, or saline as control, for 15 min at room temperature than applied to a 70% confluent monolayer of HT29.74 cells. Cryptosporidium schizonts were identified and counted per 1,000 HT29.74 cells under oil immersion after 24 h. In the presence of hyperimmune colostrum, parasite infection was inhibited by 82% (p less than 0.001), and the presence of conventional colostrum, infection was inhibited by 67% (p less than 0.001). Treatment with the soluble fraction of hyperimmune colostrum resulted in 69% inhibition (p less than 0.001) compared to the soluble fraction of conventional colostrum which resulted in only 17% inhibition (p = NS). In vitro Cryptosporidium parvum infection of the differentiated human enterocyte cell line HT29.74 is a viable method for screening immunologic therapies. Hyperimmune bovine colostrum was highly inhibitory of Cryptosporidium infection in vitro and its soluble fraction remained significantly inhibitory while the soluble fraction of conventional colostrum did not.

Ultrastructural study of asexual development of Cryptosporidium parvum in a human intestinal cell line

The lack of a well-defined in vitro model of Cryptosporidium infection has severely hampered research on the biology of parasitic invasion of the host cell and on intracellular development of the parasite. In vitro infection of the differentiated human enterocyte cell line HT29.74 was studied by electron microscopy to detect changes in parasite and host cell morphology. Cryptosporidium oocysts obtained from AIDS patients were applied to a monolayer of cloned differentiated HT29.74 cells. Parasites and infected cells were evaluated by transmission electron microscopy at 20 min, 1 h, 6 h, 24 h and 7 days. Sporozoite invagination within the epithelial cell microvilli and subsequent penetration was evident at 1 h. At 6 h, the development of a dense band and feeder layer was visible. Development of the trophozoite into a schizont occurred over 24 h. Micronemes and dense granules were clearly visible within sporozoites and merozoites. Organization of vacuoles within the cytoplasm of the host cell was evident below the dense band. A sexual Cryptosporidium development in vitro was morphologically no different from initial development in vivo. In vitro infection of HT29.74 cells provides an excellent model to study parasite-host cell interaction and asexual parasite development.

Serious infectious complications of corticosteroid therapy for COPD

We report seven elderly patients with COPD who developed serious infectious complications during prolonged treatment with high doses of corticosteroids. Infections included invasive pulmonary aspergillosis, Herpes simplex stomatitis and esophagitis, cytomegalovirus pneumonia, bacterial sepsis, fungemia and meningitis due to Cryptococcus neoformans. Each of the three patients who developed invasive aspergillus pneumonia died. The efficacy of prolonged therapy with high doses of corticosteroids in patients with COPD is not proven. These cases illustrate the potential for serious infections in patients with COPD treated with corticosteroids.