Prevalence of osteoporosis and osteopenia in a cohort of HIV positive women with a history of treated neoplasms

Introduction:

Higher prevalence of osteopenia and osteoporosis in HIV positive patients compared to non-infected population has been recognized. However, cancer patients have a higher risk of bone loss and fractures that is multifactorial. The aim of the study was to describe the prevalence of osteopenia and osteoporosis in HIV positive women with history of treated cancer.

Methods:

Between January 2018 and December 2019, women aged >40 years, HIV+ with a history of cancer diagnosis, who attended the AIDS Cancer Clinic at Instituto Nacional de Cancerología, Mexico City, and who had a dual X-ray absorptiometry performed during the study period were included. Two control groups (CG)—HIV negative women with history of cancer (CG1) and non-HIV, non-cancer women (CG2)—were matched by age 1:1.

Results:

Forty-eight patients in each group were included; the mean age was 51.1 ± 8.1 years. Osteopenia was found in femoral neck in 54.2% (HIV+), 37.5% (CG1), and 27.1% (CG2), p = 0.02; in spine was 35.7%, 47.9%, and 31.2%, respectively, p = 0.442. Osteoporosis in femoral neck was documented in 12.5%, 2.1%, and 0% in HIV+, CG1, and CG2 (p = 0.03), and in the spine was 47.9%, 16.7%, and 14.6%, respectively (p = 0.002).

Conclusion:

HIV patients with a history of treated cancer have a much higher prevalence of osteoporosis when compared with same-aged HIV-uninfected women with and without cancer. It is necessary to monitor Bone Mineral Density periodically, and all patients should be encouraged to make lifestyle changes, such as avoid tobacco and alcohol, and to increase exercising.

Bone Marrow Culture Yield for the Diagnosis of Opportunistic Diseases in Patients with AIDS and Disseminated Kaposi Sarcoma

BACKGROUND

Disseminated Kaposi sarcoma (DKS) is present in patients with advanced HIV infection in whom co-infection with other opportunistic pathogens can occur. Bone marrow (BM) aspirate and biopsy comprise a robust diagnostic tool in patients with fever, cytopenias, and abnormal liver tests. However, the yield in patients with DKS has not been determined.

OBJECTIVE

The aim of this study was to evaluate the utility of BM aspirate and biopsy in patients with DKS.

METHODS

We included 40 male patients with a recent diagnosis of DKS. BM aspirate and biopsy was performed as part of the workup to rule out co-infections.

RESULTS

In four patients, Mycobacterium avium complex (MAC) was recovered from culture. In other four patients, intracellular yeasts were observed in the Grocott stain, diagnosed as Histoplasma. The yield of BM was calculated in 20%. Only 12 patients (30%) had fever and 11 (27.5%) had pancytopenia. Alkaline phosphatase (ALP) above normal values and C-reactive protein (CRP) were higher in patients with positive results for BM than in those with negative results (63% vs. 21.9%, and 3.0 vs. 1.2 mg/L; p = 0.03 in both comparisons). No differences were found when complete blood-count abnormalities were compared.

CONCLUSION

We recommend performing a BM aspirate for stains, culture, and biopsy in all HIV patients with DKS, as this will permit the early diagnosis of co-infections and prevent further complications in those who receive chemotherapy.

Obstructive cholangiopathy patient caused by cytomegalovirus and Kaposi sarcoma in a person living with HIV and hepatitis C

We present the case of a 28-year-old man with recently-diagnosed human immunodeficiency virus and hepatitis C virus infection. He developed obstructive cholangiopathy secondary to cytomegalovirus and Kaposi sarcoma, both diagnosed by endoscopic retrograde cholangiopancreatography and biopsies. He received antiretroviral therapy, chemotherapy and valganciclovir with full recovery.

HIV-associated multicentric Castleman disease: a report of 19 cases at an oncology institution

The aim of this study is to describe the clinical characteristics and outcome of multicentric Castleman disease (MCD) in HIV-infected patients at an oncological referral center in Mexico. Clinical records at the HIV-AIDS clinic of all patients diagnosed with MCD from 1994 to 2018 were reviewed. There were 19 patients, mean age was 31.3 ± 8.4 years, and 17 (89.5%) were males. Fifteen patients (79%) had also Kaposi sarcoma (KS). Main clinical characteristics were multiple lymphadenopathy (95%), systemic symptoms (63%), and hepatosplenomegaly (50%). Computed tomography scan and 2-[18F]-fluoro-2-deoxy-d-glucose positron emission tomography showed multiple lymphadenopathy, inversion of the liver:spleen uptake ratio, with an increase in SUVmax (5.7). The histopathology report described plasma cells in 58%, mixed type in 26%, and hyaline vascular in 16%. Eleven patients (57.9%) received different chemotherapy regimens. Seven patients died (36.8%): four related to MCD progression or chemotherapy complications, median survival was eight months. For those patients who survived, median, follow-up was 28 months (p < 0.001). The incidence of MCD in people living with HIV is probably underestimated. In patients with lymphadenopathy, B symptoms, deranged inflammatory markers, and/or disseminated KS, a biopsy of an enlarged lymph node is warranted, and the histology should be reviewed by an experienced pathologist.

Non-AIDS defining cancer (NADC) among HIV-infected patients at an oncology tertiary-care center in Mexico

Background

Non-AIDS defining cancers (NADCs) have been an increasing cause of morbidity and mortality in patients with HIV. There is no data on the spectrum of NADCs in Mexico. We describe the type of neoplasms, clinical characteristics, and outcomes of HIV-infected patients with NADCs.

Methods

We conducted a retrospective study of all patients with confirmed diagnosis of NADC attending the HIV/AIDS clinic at the National Cancer Institute in Mexico City (a tertiary-care center for adult patients with cancer) from January 1990 to December 2016.

Results

From 1126 HIV-positive individuals seen at the institute since 1990, 127 (11.3%) were diagnosed with NADCs; seven patients developed two NADCs during their follow-up. At diagnosis of NADC median age was 43.7 ± 10.9 years; 101 (79.5%) were male; median CD4 was 273 cells/mm³, 70 patients had a CD4 count of > 200 cells/mm³, 73 had undetectable HIV viral load and 82 had taken combined antiretroviral therapy (cART) for more than 1 year. The most frequent NADCs were in men, Hodgkin lymphoma (34.3%) followed by anal cancer (15.7%), whereas in women, were vulvo-vaginal cancers associated to human papilloma virus (HPV) (51.8%), followed by breast cancer (25.9%). The main risk factor associated with death was cancer progression or relapse (OR, 28.2, 2.5–317.1; p = 0.007).

Conclusions

HL- and HPV-related neoplasms are the commonest NADC in a cancer referral hospital from a middle-income country with universal access to cART since year 2005. Screening for early anogenital lesions should be emphasized in patients with HIV. It is essential to establish multidisciplinary groups involving Hemato-oncologists, Oncologists, Gynecologists, and HIV Specialists in the treatment of these patients.

Infectious Complications and Multidrug-Resistant Bacteria in Patients With Hematopoietic Stem Cell Transplantation in the First 12 Months After Transplant

BACKGROUND

Hematopoietic stem cell transplantation (HSCT) has been used as treatment in different hematologic and solid malignancies. The aim of this study was to describe the frequency of infectious complications, microbiology, and outcome in patients undergoing HSCT in Mexico during the pre-engraftment period and the impact on mortality rates at 12 months.

METHODS

We conducted a retrospective study of all hematologic malignancies that received HSCT from January 2009 and December 2014, at an oncology reference center.

RESULTS

We included 210 patients: 144 autologous (69%) and 66 allogeneic HSCT (31%). There were 184 infections documented in 109 patients; incidence rate was 47.2 per 1000 neutropenia/days and 22.4 per 1000 hospitalization/days. The main infections reported were pneumonia (n = 40, 19%), bloodstream infections (n = 36, 17.1%), and central line-associated bloodstream infections (n = 28, 13.3%). There were 110 bacteria isolated, 31 were multidrug-resistant (26 were extended-spectrum beta-lactamase; Escherichia coli). There were 25 disseminated or complicated viral infections and 20 invasive fungal diseases. Fourteen patients died in the first 30 days (all related to the infectious process). In multivariate analysis leukemia, more than 2 chemotherapy regimens before transplant and pneumonia were related to 12-month mortality rates.

CONCLUSIONS

Even though infectious processes are frequent in patients with HSCT, multidrug-resistant bacteria were not as frequent as supposed; however, when these microorganisms are involved, mortality rate is increased. It is important to be alert that patients with pneumonia have a significantly increased mortality risk in the first year.

The impact of hospital-acquired infections with multidrug-resistant bacteria in an oncology intensive care unit

OBJECTIVE

To describe overall site-specific hospital-acquired infection (HAI) rates and to describe the microbiological and antibiotic resistance profiles of infecting pathogens, together with their impact on multidrug-resistant (MDR) bacteria-associated mortality.

METHODS

We conducted a 5-year retrospective descriptive study of HAI in patients in the intensive care unit (ICU) of a cancer center in Mexico from January 2007 to December 2011. The following information was collected: patient characteristics and comorbidities, data related to the neoplasm and its treatment, microbiology, and the resistance pattern of all isolates.

RESULTS

During the study period, 1418 patients were admitted to the ICU; 134 of them developed 159 infections, with an incidence of 11.2/100 hospitalized patients and 32.2/per 1000 patient-days. Two hundred sixty-six microorganisms were isolated. The overall prevalence of MDR-HAI was 39.5%. The most frequent organisms were as follows: 54 (20%) Escherichia coli (94.4% of these were extended-spectrum beta-lactamase producers), 32 (12%) Staphylococcus aureus (90.6% of these were methicillin-resistant), 32 (12%) Enterococcus faecium (18.7% of these were vancomycin-resistant), and 20 (6%) Acinetobacter baumannii (all were MDR). Among patients admitted to the ICU, 252 (17.8%) died. Death was related to the HAI in 58 (23%) of these patients (p<0.001) and 51 (88%) had a MDR organism isolated (p=0.05).

CONCLUSIONS

The emergence of MDR bacteria poses a difficult task for physicians, who have limited therapeutic options. Critically ill cancer patients admitted to the ICU are at major risk of a bacterial MDR-HAI that will impact adversely on mortality.

Cystic echinococcosis: a disease mimicking cancer in a non-endemic country report of two cases

Echinococcosis is a parasitic disease that involves dogs as definitive host and sheep as intermediate host. Humans become infected incidentally through fecal-oral contact, particularly in the course of playful and close contact with an infected dog. Mexico is considered a region that is virtually free of cystic echinoccocosis. This manuscript describes two cases that were referred to a tertiary-care oncology hospital with a diagnosis of cancer. In one case, the presumptive diagnosis was liver cancer because abdominal ultrasonography revealed a low-density mass in the right hepatic lobe. Drainage was performed and cytologic examination of the fluid showed multiple Echinococcus cyst as well as prostoscolex. The case was resolved with percutaneous drainage and administration of albendazole for two months. In the second case, the patient was referred with a diagnosis of disseminated cervical cancer A cyst was identified in the upper right lung lobe; a diagnostic puncture was performed showing an Echinococcus cyst. This resolved solely with two months of albendazole administration.

Intralesional vinblastine vs. 3% sodium tetradecyl sulfate for the treatment of oral Kaposi's sarcoma. A double blind, randomized clinical trial

In this double-blind, randomized trial, we compared the clinical efficacy of intralesional vinblastine (VNB) and 3% sodium tetradecyl sulfate (STS) in the treatment of oral Kaposi's sarcoma (OKS). Subjects with OKS were randomly assigned to receive a single intralesional injection of either VNB or STS, at a standard dose (0.2 mg/cm(2)). Differences were evaluated by the Mann-Whitney U and Fisher's exact tests. Sixteen HIV-infected patients were included, eight received VNB and eight received STS; clinical response was evaluated at days 7, 14, and 28 following treatment. Tumor size reduction was 0.68 and 0.61 cm in the VNB and STS groups, respectively (P=0.80). Two VNB patients had complete or partial response whereas four STS subjects had partial responses (P=0.61). Patients in both groups experienced minimal toxicity. We conclude that intralesional vinblastine or STS are adequate for the management of OKS. The benefits of STS are its low cost and ease of use.

Chemotherapy-associated oral mucosal lesions in patients with leukaemia or lymphoma

In order to determine the incidence rate of oral lesions associated with chemotherapy, as well as well as its association with clinical and laboratory parameters and potential risk factors, 50 in-patients with non-Hodgkin's lymphoma or leukaemia under chemotherapy were followed from January 1993 to May 1994. Basal and weekly oral examinations were performed. Clinical and laboratory data were registered. Wilcoxon's rank sum test, chi square test, univariate and multivariate logistic regression analyses were used, 36 individuals with leukaemia and 14 with non-Hodgkin's lymphoma were followed for 158 weeks; mean age was 33 years (range 15-85). Oral lesion incidence rate was 45/100 patients-week. Exfoliative cheilitis and infections (herpes and candidosis) were the most common oral complications, followed by haemorrhagic lesions and mucositis. Haemorrhagic lesions correlated with thrombocytopenia (RR = 30.5). Etoposide administration (RR = 8.6), alkylating agents (RR = 15.6), a prior course of chemotherapy (RR = 23.2) and neutropenia (RR = 4.16) were predictors of mucositis. Oral lesions were a common complication in this study, and a possible association of mucositis with several factors is suggested.

[An epidemic of primary bacteremia due to an endemic strain of Serratia marcescens in an intensive care unit]

An outbreak of Serratia marcescens bacteremia detected in the intensive care unit (ICU) of a tertiary care center on the last days of October, 1985, is described. The rate of primary S. marcescens nosocomial bacteremia during the pre-epidemic period (January-September 1985) was 6.25 per cent; and for the post-epidemic period compared with the epidemic were significantly different (p < 0.0001). The outbreak strains belonged to the biotype A8b, which has been endemic in our hospital. The responsible organism exhibited an unusual antimicrobial resistance pattern associated to the presence of a specific plasmid (greater than 50 kilobases), which showed similar fragments after restriction endonuclease digestion. No specific risk factors were identified in the case-control study. The outbreak was probably related to a greater influx of infected patients, resulting in less careful infection control measures, due to the emergency situation which suffered the hospital after the earthquakes in 1985. The unusual high rate of blood isolation of S. marcescens at the ICU was the first sign of the outbreak. The prompt reinforcement of infection control policies facilitated its resolution.

[Repercussions of blood transmission in the epidemiology of AIDS-HIV infection in Mexican children]

The first case of AIDS associated with contaminated blood products occurred in a child; with this 2 very important situations were recognized, firstly, the possibility of transmitting the disease through blood products, and secondly, that children are not exempt from acquiring the disease. Intimately related to transfusions of contaminated blood products are perinatal AIDS cases. With the measures set forth by the Mexican Government in order to prevent the transmission of HIV-1 through contaminated blood product, a decrease in cases of AIDS acquired through transfusions in expected in the near future. Not so for cases of perinatal AIDS, where educational campaigns directed towards women and high risk groups will have to be established.