Occurrence of Cryptosporidium andersoni in Brazilian cattle

Feces were collected from 68 dairy cattle, 1 to 12 mo of age, on 12 farms in the municipality of Campos dos Goytacazes, Rio de Janeiro, Brazil, and examined for the presence of Cryptosporidium sp. All samples were subjected to molecular analysis by polymerase chain reaction (nested PCR) of the 18S rRNA. Four positive samples (4.54%) were sequenced and identified as Cryptosporidium andersoni. This species represents a risk for Brazilian cattle because infection can affect cattle productivity. Moreover, C. andersoni is considered a zoonotic species.

Cryptosporidium pig genotype II diagnosed in pigs from the state of Rio De Janeiro, Brazil

Pigs may represent a source of Cryptosporidium sp. infection to humans. The objective of this study was to identify the Cryptosporidium species present in pigs from the State of Rio de Janeiro, Brazil, and verify what risks pigs represent in the transmission of human cryptosporidiosis, because there is no such information to date in Brazil. Ninety-one samples of pig feces were collected from 10 piggeries in 2 municipalities located in the north and northwest regions of the State of Rio de Janeiro, Brazil. A nested polymerase chain reaction (PCR) protocol to amplify an 830-bp fragment of the small subunit rDNA (SSU rRNA) gene was followed by sequencing of all positive PCR samples. Two samples (2.2%) were Cryptosporidium sp. positive and were identified as pig genotype type II (PGII). This genotype has been observed in an immunocompetent person, in cattle without pigs nearby, and from a potential human source. Its potential for zoonotic transmission is little known and should be rigorously studied.

Detection and comparison of Giardia virus (GLV) from different assemblages of Giardia duodenalis

Five assemblages of Giardia duodenalis were identified from cysts in cattle, dog, cat, sheep, and reindeer feces using ribosomal DNA (rDNA) sequencing. Assemblage A was present in cattle and reindeer feces, Assemblages C and D were present in dog feces, Assemblage E was present in cattle and sheep feces, and Assemblage F was present in cat feces. Giardia virus, originally referred to as Giardia lamblia virus (GLV), is a double-stranded RNA virus. Primers designed for the GLV capsid protein gene identified GLV sequences in G. lamblia from a reindeer (Assemblage A) and from a dog (Assemblage C). Two distinct GLV sequences were identified in the dog specimen and 1 sequence was identified in the reindeer specimen. None of these GLV sequences was identical with previously published GLV sequences. It appears that GLVs are genetically diverse and that more than 1 virion can be present in a single sample. Because many of the specimens that contained cysts were found to be negative for GLV, it appears that this test for capsid protein is of limited value for the purposes of detecting G. lamblia.

Examination of naturally exposed bottlenose dolphins (Tursiops truncatus) for Microsporidia, Cryptosporidium, and Giardia

Bottlenose dolphins (Tursiops truncatus) captured in the estuarine waters off the coasts of South Carolina and Florida were examined for the presence of Microsporidia, Cryptosporidium sp., and Giardia sp. DNA extracted from feces or rectal swabs was amplified by polymerase chain reaction using parasite-specific small subunit ribosomal RNA gene primers. All positive specimens were subjected to gene sequence analysis. Of 83 dolphins, 17 were positive for Microsporidia. None was positive for Cryptosporidium or Giardia. Gene sequence data for each of the positive specimens were compared with data in GenBank. Fourteen specimens were found similar to, but not identical to, the microsporidian species Kabatana takedai, Tetramicra brevifilum, and Microgemma tinca, reported from fish, and possibly represent parasites of fish eaten by dolphins. Gene sequence data from 3 other specimens had approximately 87% similarity to Enterocytozoon bieneusi, a species known primarily to infect humans and a variety of terrestrial mammals, including livestock, companion animals, and wildlife. It is not clear if these specimens represent a species from a terrestrial source or a closely related species unique to dolphins. There were neither clinical signs nor age- or gender-related patterns apparent with the presence of these organisms.

Safety and efficacy of an induction dose of pegylated interferon alpha-2a on early hepatitis C virus kinetics in HIV/HCV co-infected patients: the CORAL-1 multicentre pilot study

To evaluate the safety and efficacy of an induction dose of pegylated interferon alpha 2a (IFN-alpha2a) on the 12-week hepatitis C virus (HCV) kinetics in human immunodeficiency virus (HIV) patients co-infected with HCV. One hundred sixteen HIV/HCV co-infected patients from nine hospitals in Spain were randomized to receive 270 microg/week of pegylated IFN-alpha2a for 4 weeks followed by 180 microg/week for 8 weeks or 180 microg/week for 12 weeks. Ribavirin was given at a daily dose of 1000 or 1200 mg. The main outcome measure was the percentage of patients achieving an HCV-RNA below 50 IU/mL or a decrease of 2 or more log(10) at week 12 (early virologic response, EVR). HCV-RNA was measured at baseline, weekly, for the first 4 weeks and monthly thereafter. We observed no difference in the percentage of patients achieving an EVR between arms (on-treatment, 74% in both arms; intention-to-treat, 70% in the induction arm and 67% in the control arm), nor were there differences in the percentage achieving an undetectable HCV qualitative polymerase chain reaction at any time points or in the decrease in HCV-RNA from baseline. No differences were found between arms in the percentage of dropouts (8% in the whole study population). Our study failed to find a benefit of an induction dose of 270 microg/week of pegylated IFN-alpha2a for 4 weeks on the EVR in co-infected patients who are treatment naive. Despite the lack of benefit with this regimen, induction therapy with this schedule was safe and well tolerated in co-infected patients.

Enterocytozoon bieneusi in mature dairy cattle on farms in the eastern United States

Fecal specimens were obtained from mature milking cows on farms in Vermont, New York, Pennsylvania, Maryland, Virginia, North Carolina, and Florida. Polymerase chain reaction (PCR)-positive specimens for Enterocytozoon bieneusi were found in 24 of 541 cows examined (4.4%) and on 12 of 14 farms. The prevalence of E. bieneusi varied considerably from farm to farm, with the lowest prevalence (2.3%) on FL-2 and the highest prevalence (12.5%) on VT-2. None of the cows exhibited signs of diarrhea. All PCR-positive specimens were sequenced to determine the genotype of E. bieneusi. Five genotypes were identified. Three were identified as cattle-specific genotypes previously reported as BEB1, BEB2, and BEB4, and two new genotypes, BEB 6 and BEB7, were found. None have been reported to infect humans.

Clinical features and outcome of spontaneous bacterial peritonitis in HIV-infected cirrhotic patients: a case-control study

The aim of this study was to evaluate the clinical characteristics and outcome of spontaneous bacterial peritonitis, a serious complication in patients with cirrhosis and ascites, in an HIV-infected cirrhotic population. Thirty-five HIV-infected cirrhotic patients who developed spontaneous bacterial peritonitis during a 12-year period were compared with 70 non-HIV-infected cirrhotic subjects. Patients were matched according to the date of the first episode of spontaneous bacterial peritonitis. A bacteriological diagnosis was made in 37 of 47 (79%) and in 50 of 97 (52%) episodes in the HIV group and in the non-HIV group, respectively (p=0.003), and Streptococcus pneumoniae was isolated more frequently in the HIV group (22 vs. 8%, p=0.02). Median survival after the initial diagnosis of spontaneous bacterial peritonitis was 2.9 and 14.0 months in the HIV group and non-HIV group, respectively. Age (hazard ratio [HR] 1.04; 95%CI 1.01-1.07), male sex (HR 2.55; 95%CI 1.34-4.83), Child-Pugh score at first spontaneous bacterial peritonitis episode (HR 1.29; 95%CI 1.10-1.54), renal impairment at first spontaneous bacterial peritonitis episode (HR 2.61; 95%CI 1.49-4.62), and HIV infection (HR 9.81; 95%CI 4.03-23.84) were independently associated with higher long-term mortality after the first diagnosis of spontaneous bacterial peritonitis. In conclusion, HIV-infected cirrhotic patients with spontaneous bacterial peritonitis have a higher rate of bacteriological diagnosis and a more frequent pneumococcal etiology than non-HIV-infected subjects. Life expectancy in these patients, once spontaneous bacterial peritonitis has developed, is poor. These data are particularly relevant for determining the optimal time for liver transplantation in this population.

Enterocytozoon bieneusi genotypes in dairy cattle in the eastern United States

Fecal specimens were obtained from 12-24-month-old dairy heifers on farms in Vermont, New York, Pennsylvania, Maryland, Virginia, North Carolina, and Florida. PCR positive specimens for Enterocytozoon bieneusi were found in 131 of 571 heifers examined (23%) and on all the farms visited. The prevalence of E. bieneusi varied considerably across farms, with the lowest prevalence (4.7%) on MD-2 and the highest prevalence (37.8%) on NY-2. All PCR positive specimens that amplified the ITS region as well as a portion of the flanking large and small subunit ribosomal RNA genes were sequenced to determine the genotype(s) of the E. bieneusi present and six genotypes were identified. Most were identified as cattle-specific genotypes, previously reported from cattle as BEB1, BEB2, BEB3, and BEB4. Two isolates were genetically identical or similar to E. bienesusi reported as the human pathogens Peru 6 and Peru 9 (or D) genotypes. Although our data demonstrate the presence of zoonotic genotypes in cattle, most genotypes found in cattle were host specific.

Consensus conference on chronic viral hepatitis and HIV infection: updated Spanish recommendations

Chronic hepatitis B and C represent a leading cause of morbidity and mortality among human immunodeficiency virus (HIV)-infected patients worldwide. New treatment options against both hepatitis B (HBV) and C (HCV) viruses have prompted us to update previous recommendations for the management of coinfected individuals. Fifteen topics (nine related to HCV, five to HBV and one to both viruses) were selected for this purpose. A panel of Spanish experts in the field was invited to review these areas and propose specific recommendations, which were scored according to the Infectious Disease Society of America (IDSA) grading system. These guidelines represent a comprehensive and updated overview on the management of hepatitis B and C in HIV-infected patients.

First detection of microsporidia in dairy calves in North America

Fecal specimens were obtained from a total of 413 dairy calves from farms in Vermont, New York, Pennsylvania, Maryland, Virginia, North Carolina, and Florida. After removal of fecal debris by sieving and density gradient centrifugation, specimens were examined by fluorescence microscopy, polymerase chain reaction (PCR), and DNA sequencing analysis for the presence of microsporidia. Microscopic examination revealed no spores. PCR using generic primers for microsporidia revealed 70 positive calves. PCR was then conducted using specific primers for Enterocytozoon bieneusi, the most frequently found microsporidian in human infections. These primers revealed 13 positive calves from six farms in five states. DNA sequencing analysis of the 13 E. bieneusi-positive specimens confirmed the PCR results and indicated 96.8-99.8% similarity with E. bieneusi sequences in GenBank. This is the first report of E. bieneusi in cattle in North America.

Correlation between in vitro and in vivo infectivity of Leishmania infantum clones

Eleven clones of a single strain of Leishmania infantum (MCAN/ES/88/ISS441, Doba) were analyzed for biological behavior in vivo and in vitro. Different clones showed differences in growth dependent upon the two culture media employed. All clones displayed only slight differences in H2O2 and NaNO2 sensitivity compared to the original strain, whereas in vitro infectivity for mouse peritoneal macrophages differed significantly among the clones. In vivo infections in hamsters correlated strongly with in vitro infectivity. The phenotypic differences found suggest a polyclonal structure for the Leishmania infantum strain studied.

A Randomized Clinical Trial Comparing Nelfinavir Or Nevirapine Associated to Zidovudine/Lamivudine in HIV-Infected Naive Patients (The Combine Study)

Background

Non-nucleoside reverse transcriptase inhibitor-containing regimens may be a valid alternative to protease inhibitor-containing regimens for initial antiretroviral therapy, but to date few studies comparing these two strategies have been performed.

Objective

To evaluate the efficacy and safety of nelfinavir or nevirapine associated to zidovudine/lamivudine in HIV-infected naive patients.

Design

Randomized, open-label, multicentre trial.

Setting

Twelve centres in Spain (9) and Argentina (3).

Patients

One hundred and forty-two HIV-infected naive patients without AIDS.

Interventions

Patients received combivir (zidovudine 300 mg/lamivudine 150 mg, twice-daily) plus either nelfinavir (1250 mg) twice-daily (zidovudine/lamivudine/nelfinavir, n=70) or nevirapine (200 mg) twice-daily (zidovudine/lamivudine/nevirapine, n=72), and were followed for 12 months. The primary endpoint was the proportion of patients with a plasma HIV-1 RNA (pVL) of less than 200 copies/ml by PCR at 12 months. pVL of less than 20 copies/ml (PCR), changes in CD4 counts, clinical progression and adverse events were also evaluated. Efficacy was assessed using intent-to-treat (ITT) (missing=failure) and on-treatment analysis.

Results

At 12 months in the ITT analysis the proportion of patients with pVL below 200 copies/ml was 60% (95% CI 48.5–71.5) in the zidovudine/lamivudine/nelfinavir arm and 75% (95% CI 65–85) in the zidovudine/lamivudine/nevirapine arm ( P=0.06), and the proportion below 20 copies/ml was 50% (95% CI 38.3–61.7) and 65% (95% CI 54.2–76.2), respectively ( P=0.06). No differences were found when comparing the subgroup of patients with baseline pVL of more than 100 000 copies/ml. A gain of +173 and +162 CD4 cells/mm3, respectively, was observed. Zidovudine/lamivudine/nelfinavir was discontinued in 21% of patients, and zidovudine/lamivudine/ nevirapine in 25%, due to toxicity ( P>0.2).

Conclusions

Our results suggest that zidovudine/ lamivudine/nevirapine is at least as effective as zidovudine/lamivudine/nelfinavir as first-line therapy for HIV disease.

Pharyngeal bot flies in Cervus elaphus in central Spain: prevalence and population dynamics

The prevalence and intensity of infestations by bot flies Pharyngomyia picta and Cephenemyia auribarbis in red deer (Cervus elaphus) from Quintos de Mora (Toledo, Spain) were determined over a 1-yr period. Bots were present all year. No clear correlations were found between age or sex of the host and parasitization levels (prevalence and intensity). Considerable variation was found in prevalence and intensity, with larger values from December to March. Cephenemyia auribarbis was restricted from November to March, with maximum numbers of L-3 in February. Pharyngomyia picta showed a more complex profile with 2 peaks (March and August), indicating 2 generations per year.

[Health care resources utilization in HIV-infected patients: creation of a data base and cost results]

OBJECTIVES

To make and validate a data base that allows to collect information about clinical characteristics and use of health care services by HIV-infected patients. An additional purpose is to obtain some data about costs of health care services utilization.

METHODS

We have designed an informatic data base that includes: demographic data, clinical data and health care services utilization during the follow up. One hundred and nine patients were selected from 5 different hospitals in Spain and they were followed for 6 months (from January to June 1997). Analytic accounting of one hospital and official tariffs were used to calculate costs of the health care services.

RESULTS

The informatic data base designed is useful and appropriate to collect the information of these patients. The annual average cost is 2.5 millions dollars, ranging from 1 million dollars for asymptomatic patients to 3.8 millions for AIDS patients. The comparison of our results with previous studies shows an increased cost of asymptomatic patients.

CONCLUSIONS

These results give a preliminary information about health care services utilization by HIV-infected patients and confirm the possibility of using the designed instrument in the future. Since HIV-infection presents an uncertain evolution and a variable prognosis, to implant a tracking system is a necessary requirement in order to obtain a fast and accurate information system about the evolution of clinical variables and their economic repercussions.

[Other infections (Streptococcus pneumoniae, Haemophilus influenzae, Pseudomonas aeruginosa, Salmonella spp., Campylobacter spp., Nocardia asteroides, Rhodococcus equi and Bartonella spp.)]

People infected with human immunodeficiency virus (HIV) are at increased risk for bacterial infections due to HIV-associated immunologic defects. Bacterial infections were found to be, both a predictor of progression to AIDS and a substantial cause of mortality in pre-AIDS stages. Most bacterial infections are caused by Streptococcus pneumoniae, Haemophilus influenzae, Salmonella spp. and Pseudomonas aeruginosa. Rhodococcus equi, Nocardia spp., Campylobacter spp. and Bartonella spp. are less common. Data derived from two AIDS Clinical Trials Group studies showed that the most common bacterial infections were sinusitis (8.5 per 100 episodes per person years [py]), bacterial pneumonia (5.0 per 100 py), bronchitis (4.1 per 100 py) and soft tissue infections (3.5 per 100 py). In this review clinical characteristics and treatment recommendations according to data available in the literature for these infections are summarized.

[Eradication of measles in Cuba]

The vaccine against measles came into use in Cuba in 1971. During the seventies, a new early strategy for measles control was established, and it was followed by further efforts in the early eighties. Despite improvements to the control program, disease outbreaks continued to occur. In 1986, after examining the experience acquired through the control initiatives that were already in place, a new measles vaccination strategy was adopted. In time, the new vaccination strategy against measles came to have three main components: first, a single vaccination "catching-up" campaign targeting children 1 to 14 years of age. Second, efforts were made to achieve and maintain high vaccine coverage through mandatory vaccination services for 12-month-old children ("maintenance vaccination"). Finally, periodic "follow-up" campaigns were carried out for children 2 to 6 years of age. Steps were taken, for the purpose of monitoring the progress made so far toward eliminating measles, to strengthen disease surveillance systems, including the screening of suspected cases. The "catching-up" and "follow-up" campaigns both achieved greater than 98% coverage within targeted age groups. The routine vaccination program has also maintained high coverage. The high population immunity against measles that has been attained through these vaccination strategies has resulted in a rapid decrease in the incidence of the disease. From 1989 to 1992, less than 20 laboratory-confirmed cases were reported annually. In Cuba, the last case confirmed through serologic screening was reported in July 1993. Cuba's strategy for measles elimination has interrupted disease transmission and kept the causal virus from circulating on the island. Cuba's experience with measles elimination suggests that if an appropriate vaccination strategy is applied, measles can be globally eradicated.

pp65 antigenemia as a marker of future CMV disease and mortality in HIV-infected patients

We retrospectively evaluated the role of pp65 antigenemia (AGM) as a marker of cytomegalovirus (CMV) disease and mortality in 241 HIV-infected patients with fever. Of 225 patients in whom CD4 count was available, 189 (84%) had counts below 100/microL and 209 (92.8%) below 200/microL, 149 patients had negative AGM (AGM-) and 92 had positive AGM (AGM+), AGM+ patients were at a more advanced stage of HIV disease, as evaluated by CD4 count (p < 0.001) and prior AIDS diagnosis (p < 0.001). Overall, 29 patients (12%) presented concomitant CMV disease (18 retinitis): 24 (26%) in the AGM+ group and 5 (3.3%) in the AGM- group (p < 0.001). AGM had a negative predictive value of 96.6% but a positive predictive value of 26% which increased to 65% if a cut-off of > 10 CMV-positive cells/10(5) leukocytes was considered. The cumulative rate of future CMV disease at 3 months was 0% in AGM patients, 3% in patients with AGM 1-10/10(5) and 36% in patients with AGM > 10/10(5). In a multivariate analysis, no antiretroviral therapy, AGM+ and CMV disease were independently associated with mortality. The role of AGM as a marker of present CMV disease is limited. However, quantitative AGM may select patients at a high risk of future CMV disease. In addition, AGM may be a marker of shorter survival in severely immunosuppressed HIV-infected patients.

Intermittent trimethoprim-sulfamethoxazole compared with dapsone-pyrimethamine for the simultaneous primary prophylaxis of Pneumocystis pneumonia and toxoplasmosis in patients infected with HIV

OBJECTIVE

To evaluate the efficacy and safety of two oral, intermittent drug regimens for the simultaneous primary prophylaxis of Pneumocystis carinii pneumonia and toxoplasmosis in patients with HIV infection.

DESIGN

Nonblinded randomized study: Patients received either 1) trimethoprim-sulfamethoxazole (160 mg-800 mg orally twice a day on a thrice weekly regimen) or 2) 100 mg of dapsone plus 50 mg of pyrimethamine orally twice weekly.

SETTING

University teaching hospital in Barcelona.

PATIENTS

230 patients infected with HIV who had CD4 cell counts of less than 200 x 10(6)/L and who had not previously had P. carinii pneumonia or toxoplasmosis.

MEASUREMENTS

Clinical and biological evaluations; adverse reactions; and end points of P. carinii pneumonia, toxoplasmosis, and death.

RESULTS

After a median follow-up of 430 days, 6 (6.3%) of 96 evaluable patients receiving dapsone-pyrimethamine and 0 of 104 evaluable patients receiving trimethoprim-sulfamethoxazole developed P. carinii pneumonia (P < 0.0001). The cumulative rates of P. carinii pneumonia at 12 and 24 months were 0% and 0% for patients receiving trimethoprim-sulfamethoxazole and 4% and 11% for patients receiving dapsone-pyrimethamine (Mantel-Cox, P = 0.014). However, only one episode of P. carinii pneumonia developed while patients were taking these drugs. No differences were observed for toxoplasmosis (one episode in the trimethoprim-sulfamethoxazole arm and two in the dapsone-pyrimethamine arm), with cumulative rates at 12 and 24 months of 0% and 4% for the trimethoprim-sulfamethoxazole arm and 2% and 7% for the dapsone-pyrimethamine arm (P = 0.65). Similar mortality rates were observed during follow-up (P = 0.85). Nineteen patients (9.5%) discontinued therapy with the drugs because of adverse effects: Ten were in the trimethoprim-sulfamethoxazole arm and 9 were in the dapsone-pyrimethamine arm (P = 0.95).

CONCLUSIONS

Thrice-weekly trimethoprim-sulfamethoxazole is an effective and well-tolerated regimen for the simultaneous primary prophylaxis of P. carinii pneumonia and toxoplasmosis in patients infected with HIV. Twice-weekly dapsone-pyrimethamine appears to be a safe and effective alternative.

Utility of the gallium-67 citrate scan for the early diagnosis of tuberculosis in patients infected with the human immunodeficiency virus

Diagnosis of tuberculosis in patients infected with the human immunodeficiency virus (HIV) is sometimes difficult because of atypical clinical and radiographic findings. The aim of this retrospective study was to determine the utility of a gallium-67 citrate scan (67Ga scan) of the chest for the early diagnosis of tuberculosis in patients infected with HIV. We selected 174 67Ga scans performed as a part of the clinical evaluation of 145 HIV-infected patients with normal pulmonary parenchyma (seen on chest radiographs) and fever of unknown origin. Scans were evaluated as to whether there was uptake in lymphoid regions (a positive 67Ga scan) or not (a negative scan). Tuberculosis was the most common condition associated with a positive 67Ga scan (48[72.7%] of 66 positive 67Ga scans). Nodal uptake had a 72.7% positive predictive value and a 92.6% negative predictive value for tuberculosis. In our experience, 67Ga scanning is a useful tool for the clinical evaluation of HIV-infected patients with unexplained fever. In areas with a high prevalence of tuberculous infection, a 67Ga scan of an HIV-infected patients that shows nodal uptake allows the clinician to initiate prompt empirical antituberculous therapy while waiting for culture results. Conversely, a 67Ga scan that does not show nodal uptake makes the diagnosis of tuberculosis unlikely.

[Splenic abscesses caused by Mycobacterium tuberculosis in AIDS]

BACKGROUND

Up to 70% of the patients with tuberculosis and HIV infection develop extrapulmonary disease. Abdominal participation is generally of the lymph node type with splenic tuberculosis being rare.

METHODS

Two cases of splenic tuberculosis from a series of 557 patients diagnosed with AIDS in a general hospital from March 1984 to March 1993 are described.

RESULTS

Splenic tuberculosis was the first manifestation of AIDS in these 2 patients. On pulmonary gammagraphy with gallium-67 both cases presented peripheral polyadenopathies and enhancement of hiliary and paratracheal lymph nodes. Abdominal ultrasound scan and computerized tomography revealed multiple hypoechogenic and hypodense splenic lesions, respectively, in the 2 cases. Diagnosis was made following isolation of Mycobacterium tuberculosis in blood cultures. Rapid response to tuberculostatic drugs was shown in one patient while the second responded favorably on the addition of glucocorticoids.

CONCLUSIONS

The homogenicity of the clinical-radiological picture of the 2 cases herein presented and those previously described in the literature allows the initiation of empiric anti-tuberculous treatment. A treatment schedule with glucocorticoids may be effective in patients presenting slow response to tuberculostatic treatment, thus avoiding therapeutic splenectomy.

[Diagnosis and treatment of esophageal ulcers in patients seropositive for the human immunodeficiency virus (HIV-positive)]

Esophageal ulcers are often found in patients with human immunodeficiency virus infection. We have retrospectively reviewed the upper endoscopies performed in these patients during the last four years. 149 examinations were realized in 73 patients. Fourteen patients with esophageal ulcers were diagnosed. A severe immunological impairment was present in all patients (CD4 24.4 +/- 31.1 cells/ul). Symptoms were non-specific, with prevailing dysphagia and odynophagia. The etiological diagnosis was reached by histological studies and cultures in 5 cases (36%), three due to Herpes virus type I, one due to Cytomegalovirus and another one to Mycobacterium tuberculosis. Patients with multiple ulcers or small ones were successfully treated with antiviral drugs, even when the etiological studies were negative. Corticosteroids were useful in single and large ulcers in which diagnostic tests were negative.

Thrice-weekly cotrimoxazole is better than weekly dapsone-pyrimethamine for the primary prevention of Pneumocystis carinii pneumonia in HIV-infected patients

OBJECTIVE

To compare the efficacy and safety of two intermittent regimens for the simultaneous primary prevention of Pneumocystis carinii pneumonia (PCP) and toxoplasmosis in HIV-infected patients.

DESIGN

Prospective randomized open trial.

SETTING

HIV outpatient clinic of an Infectious Disease Service and a 1000-bed university teaching hospital.

PATIENTS

A total of 166 HIV-infected patients with a CD4 cell count < 200 x 10(6)/l or a CD4 percentage < 20%, without previous PCP or toxoplasmosis.

INTERVENTION

Patients were randomized to oral (1) cotrimoxazole [160 mg trimethoprim (TMP) and 800 mg sulphamethoxazole (SMX)] twice a day on Mondays, Wednesdays and Fridays (n = 81), or (2) dapsone (100 mg) plus pyrimethamine (25 mg) (DP) once a week (n = 85).

MAIN OUTCOME MEASURES

Clinical and biological evaluation was performed every 30-60 days. End-points were PCP, toxoplasmosis and death. Adverse reactions were considered as defined in the protocol.

RESULTS

After a mean follow-up of 380 days, intention-to-treat analysis revealed that DP patients had a higher rate of PCP [13 out of 85 (15.2%) versus three out of 81 (3.7%); P = 0.01]. The cumulative rates of PCP at 12 and 24 months were 5 and 42% for DP patients and 3 and 10% for TMP-SMX patients, respectively (Mantel-Cox, P = 0.0007). Of the 29 patients who died during follow-up, 14 were in the TMP-SMX group and 15 in the DP group (not significant). Two patients in the TMP-SMX group and three in the DP group developed toxoplasmosis (not significant). Adverse reactions were common (66.7% of TMP-SMX patients and 42.4% of DP patients; P = 0.001). However, only 12.3% of TMP-SMX patients and 2.3% of DP patients (P = 0.01) had to discontinue therapy because of toxicity.

CONCLUSIONS

At the given doses, DP was inferior to TMP-SMX in preventing first episodes of PCP. Although more patients and a longer follow-up are required, the regimens appeared to prevent toxoplasmosis equally well.

[Pulmonary cryptococcosis in AIDS]

We present here three AIDS patients with disseminated cryptococcal infection and lung involvement. Two patients presented with respiratory symptoms and in the third one, pulmonary disease was only a radiologic finding. Chest X-ray films showed an interstitial pattern in two cases and pulmonary cavitation in one case. One patient has also simultaneous infection by P. carinii. Diagnosis was established by culture from bronchoalveolar lavage in all cases and also by non-induced sputum exam in two cases. All patients were treated with amphotericin B, with good clinical outcome, and without relapses under maintenance therapy with fluconazole. Cryptococcosis must be included in differential diagnosis of AIDS patients with diffuse interstitial lung infiltrates. The presence of C. neoformans in respiratory samples does not rule out the existence of other opportunistic infections, and therefore bronchoalveolar lavage is advisable.

[Uveitis: an etiological study of 200 cases following a protocol]

BACKGROUND

To evaluate the usefulness of a systematic study of patients with uveitis and to assess the associated systemic diseases.

METHODS

200 patients seen in an outpatient clinic for the evaluation of uveitis between 1981 and 1988 were included in the study. Patients with eye disease associated with drug abuse or human immunodeficiency virus were excluded. The study protocol included an initial clinical and ophthalmological evaluation followed by selected specific investigations.

RESULTS

Anatomical localization: anterior uveitis 122 (61%), posterior 41 (20.5%), panuveitis 30 (15%) and intermediate 7 (3.5%).

ETIOLOGY

74 cases (37%) were secondary, 101 (50.5%) were idiopathic, and 25 (12.5%) were specific syndromes of uveitis of unknown cause. Toxoplasmosis was the most common cause of infective uveitis, and ankylosing spondylitis was the most common noninfective cause. Diagnostic process: group 1, diagnosed by the ophthalmological investigation (25 cases); group 2, diagnosed on the basis of the accompanying clinical features and/or specific investigations (66 cases); and group 3, diagnosed by wider detection methods (8 cases).

CONCLUSIONS

There was a remarkably high rate uveitis without etiological diagnosis. The evaluation of patients with uveitis requires a careful evaluation of ocular and systemic features, followed by selected specific investigation. The indiscriminate use of diagnostic tests is not warranted.

[Ocular toxoplasmosis in patients with acquired immunodeficiency syndrome]

Ocular toxoplasmosis is an uncommonly reported complication in patients with acquired immunodeficiency syndrome. Three patients with human immunodeficiency virus (HIV) infection and ocular toxoplasmosis are reported. In two of them, cerebral toxoplasmosis was associated. Ocular involvement presented as exudative chorioretinitis, bilateral in 2 cases and unilateral in 1. The diagnosis was made on the basis of ocular disease associated with lesions consistent with toxoplasmosis of central nervous system (CNS) and response to antitoxoplasma treatment in one case, and ocular disease with rising antitoxoplasma serologic titers in the remaining two. Initial therapy included pyrimethamine plus sulfadiazine in 2 cases and pyrimethamine plus clindamycin in 1. The 2 patients treated with sulfadiazine showed hypersensitivity features, and clindamycin had to be substituted. The response to therapy was favorable, although one patient died few days after the development of CNS lesions. When chorioretinitis develops in a patient with HIV infection, ocular toxoplasmosis should be considered. As CNS involvement is commonly associated and relapse after the withdrawal of therapy is likely, these patients should be treated as those with isolated toxoplasma encephalitis.