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Biomedical subjects

C M Wilcox

Publications and source records attributed to C M Wilcox.

At least 109 records · Page 6Linked to original sources
PubMed1994

Comparison of two corticosteroid regimens for the treatment of HIV-associated idiopathic esophageal ulcer.

OBJECTIVE: Although corticosteroids appear to be efficacious in the treatment of HIV-associated idiopathic esophageal ulcer, the optimal regimen remains undefined. METHODS: Over a 41-month period, all patients with idiopathic esophageal ulcer defined by clinical, endoscopic, and pathological criteria were treated with a defined corticosteroid regimen. The initial 12 patients were treated with prednisone, 40 mg daily tapering to 10 mg/wk, for a 4-wk course of therapy, and 24 subsequent patients were treated with 40 mg daily for 2 wk. All patients were followed clinically, with most patients undergoing endoscopy at the completion of therapy and for recurrent esophageal symptoms. RESULTS: A symptomatic response was seen in 11 patients (92%) in the 4-wk regimen and 23 patients (96%) in the 2-wk regimen. A complete symptomatic response was seen in 10 patients (83%) in the 4-wk regimen, compared with 18 patients (75%) in the 2-wk regimen. A partial response was seen in the 2-wk regimen more often (five patients) than in the 4-wk regimen. Long-term follow-up in responders revealed relapse in two of nine patients (22%) in the 4-wk regimen compared with 12 of 23 (52%) in the 2-wk regimen (p = 0.10). Relapse occurred within 9 wk in all but one patient and was heralded by recurrent odynophagia. The prednisone regimen was well-tolerated, although opportunistic infections occurred in seven patients during or within 1 month of therapy. CONCLUSIONS: Prednisone therapy is highly efficacious for the treatment of idiopathic esophageal ulcer resulting in a rapid clinical response and endoscopic healing. A 2-wk course of therapy may be associated with a higher relapse rate than a 4-wk regimen. Relapse frequently occurs, usually within 2 months of therapy. The side effects profile appears acceptable.

Adult↗
PubMed1994

Esophageal infections: etiology, diagnosis, and management.

With the advent of transplantation and the acquired immunodeficiency syndrome (AIDS), esophageal infections are now a common medical problem. The most common infections involving immunocompromised nonhuman immunodeficiency virus (HIV)-infected patients include viral disease (herpes simplex virus and cytomegalovirus) and Candida. In HIV-infected patients, Candida esophagitis is by far the most common infection; viral disease is seen less frequently. In contrast to other immunocompromised patients, these patients may have esophageal disease from a variety of other fungi and viruses. Immunocompromised patients in whom esophageal symptoms develop after transplantation usually undergo endoscopy for diagnosis because of the possibility that alterations in immunosuppressive agents will be required if an opportunistic infection is causative. In contrast, HIV-infected patients with new-onset esophageal symptoms are usually treated empirically with oral systemic antifungal therapy given the prevalence of Candida esophagitis. Barium esophagography may, however, be worthwhile, depending on the clinical setting, such as the possibility of a reflux-induced stricture. In HIV-infected patients, radiography is less often utilized in the setting of a low CD4 lymphocyte count given the likelihood of an opportunistic infection that requires endoscopic biopsy for a definitive diagnosis. Oral systemic antifungal therapy with either ketoconazole or fluconazole is very effective for the treatment of Candida esophagitis, and these agents have also shown efficacy in the prophylaxis of fungal infections following transplantation, as well as in patients with AIDS following oropharyngeal and esophageal candidiasis. Antiviral therapy with acyclovir for herpes simplex virus and ganciclovir and foscarnet for cytomegalovirus are effective. The efficacy rate for these antiviral agents appears similar in all immunocompromised patients. These agents have also been utilized prophylactically following transplantation. In summary, a variety of infections may involve the esophagus in immunocompromised patients. The diagnostic strategies utilized in these patients are similar; endoscopy and biopsy are the most cost-effective strategy given the need for mucosal biopsy for a definitive diagnosis. Importantly, efficacious therapy is available to treat these disorders. Nevertheless, in patients with AIDS, identification of an opportunistic esophageal disease portends a poor prognosis.

AIDS-Related Opportunistic Infections↗
PubMed1994

Gastric syphilis. Report of seven cases and review of the literature.

Gastric syphilis had become an uncommon disease, with only 24 cases reported in the English-language literature over the last two decades. However, it may be becoming more frequent. During the last 4 years, seven patients with gastric syphilis have been diagnosed at our institution. The most common presenting symptoms were abdominal pain, nausea, and vomiting with signs of syphilis present in five patients (71%). After radiographic and/or endoscopic evaluation, the initial diagnosis was considered to be cancer in four patients and nonspecific gastritis in three. The syphilis diagnosis was established by identification of spirochetes on mucosal biopsy in six patients. Although these cases appear typical for gastric syphilis, the diagnosis was usually not considered at first. However, gastric syphilis should be considered in patients at risk for sexually transmitted disease who complain of nausea, vomiting, and abdominal pain and in whom unusual gastric lesions or presumed peptic ulcers resistant to standard therapy are found.

Adult↗
PubMed1994

Idiopathic anorectal ulceration in patients with human immunodeficiency virus infection.

Opportunistic infections and neoplasms of the anorectum have been reported in patients with human immunodeficiency virus (HIV) infection. More recently, idiopathic ulcerative lesions of the colon and rectum have been described. At our center over a 3-yr period, four patients were identified with ulcerative lesions of the rectum and/or anus that remained idiopathic despite an extensive clinical, serologic, and histopathologic evaluation. Three patients had the acquired immunodeficiency syndrome, and in one anorectal disease was the index manifestation of HIV infection. Only one of the patients had recently engaged in receptive anal intercourse. The presenting complaints were gastrointestinal bleeding in two, which was severe in one, and/or anorectal pain. Multiple colonoscopic evaluations with biopsy of the distal colorectum documented a solitary ulcer of the rectum in one, solitary ulcer involving the anorectum in two, and multiple ulcers of the rectum and anorectum in one. In three patients, colonoscopy to the cecum demonstrated no additional lesions. In patients with HIV infection, ulcerative lesions of the anorectum may remain unexplained despite an exhaustive evaluation. The etiology of these lesions, as well as appropriate therapy, remains to be determined.

Acquired Immunodeficiency Syndrome↗
PubMed1993

Prevalence of silent myocardial ischemia and arrhythmias in patients with coronary heart disease undergoing gastrointestinal tract endoscopic procedures.

BACKGROUND: Since the introduction of gastrointestinal tract endoscopic procedures, there has been concern about cardiovascular complications, especially in patients with coronary heart disease. Although, in general, these procedures are safe, previous studies have documented perturbations in blood pressure, heart documented perturbations in blood pressure, heart rate, and oxygen saturation, as well as the occurrence of arrhythmias and nonspecific ST-segment electrocardiographic changes during such procedures. No studies, however, have specifically addressed the prevalence of silent myocardial ischemia and arrhythmias in patients with well-established coronary heart disease. METHODS: During a 15-month period, 25 hospitalized patients with well-defined coronary heart disease underwent continuous ambulatory electrocardiographic recording during endoscopic procedures requiring intravenous sedation, as well as during a prolonged baseline period. All patients were considered clinically stable, although 92% were categorized as being at intermediate or high coronary risk by standard risk stratification criteria. Eleven patients (44%) had had previous myocardial infarction, and 68% reported a history of angina. RESULTS: Although 24% of patients had one or more episodes of electrocardiographic ischemia during the recording periods, no patient had evidence of ischemia exclusively during the endoscopic procedure. Arrhythmias were no more frequent during the endoscopic procedures than during a corresponding baseline period. Symptomatic angina or serious arrhythmias did not occur during the procedures. CONCLUSIONS: Our data suggest that endoscopic procedures in patients with stable but severe coronary heart disease, when performed with standard medications, monitoring, and techniques, rarely result in silent or symptomatic myocardial ischemia or serious arrhythmias. In addition, although asymptomatic minor arrhythmias are common during endoscopic procedures, their occurrence appears less frequent than during daily hospital life.

Adult↗
PubMed1993

Endoscopic characterization of idiopathic esophageal ulceration associated with human immunodeficiency virus infection.

Idiopathic esophageal ulcerations (IEUs) associated with human immunodeficiency virus (HIV) infection are now recognized as an important cause of esophageal disease in this population. Limited radiographic and endoscopic reports have almost uniformly described these lesions as solitary and giant. Over a 28-month period, we identified 68 IEUs endoscopically in 23 patients. Most patients had long-standing HIV infection and a low CD4(+) lymphocyte count. Multiple ulcers were identified in 57% of endoscopies. Giant ulcers were seen in one-third, with 37% < or = 1 cm in greatest dimension. Most of the lesions were in the mild- to distal esophagus. The ulcers were characterized as either shallow or intermediate in depth in 53%, with a deep ulcer in 7%. A "heaped-up" appearance of the ulcer was identified in 40%. An esophageal mucosal bridge(s) was seen in two patients. In contrast to previous reports, IEUs are variable endoscopically in number, size, and appearance. Given this lack of uniformity in appearance, which may mimic other causes of esophageal ulceration, all HIV-infected patients with an esophageal ulceration should undergo endoscopy with biopsy to obtain a definitive diagnosis.

Adult↗
PubMed1993

Re: In search of CMV.

Explore the source record for details and available documents.

AIDS-Related Opportunistic Infections↗
PubMed1993

Serious gastrointestinal disorders associated with human immunodeficiency virus infection.

Disorders of the gastrointestinal tract are a frequent complication of AIDS. Although the majority of these processes are not life threatening, some diseases will require ICU monitoring. With the increasing longevity of the HIV-infected patient, many more patients may be admitted to the ICU for a variety of other complications where gastrointestinal disorders may be manifested. This article focuses on the differential diagnosis for the more common gastrointestinal complications of HIV infection as well as a rational approach for the ICU setting.

Clinical Protocols↗
PubMed1992

Improved light-microscopical detection of microsporidia spores in stool and duodenal aspirates. The Enteric Opportunistic Infections Working Group.

BACKGROUND: The diagnosis of infection with Enterocytozoon bieneusi, a microsporidian organism that causes chronic diarrhea in patients infected with the human immunodeficiency virus (HIV), has depended on invasive procedures. We have developed a new method to detect microsporidia spores in feces and duodenal aspirates. METHODS: Stool was obtained from four HIV-infected patients with biopsy-confirmed intestinal microsporidiosis. Slides prepared from unconcentrated, formalin-fixed stool specimens were stained with a new chromotrope-based technique and examined by light microscopy. Methods of stool concentration were also compared. The technique was then evaluated by examining 215 specimens from 134 HIV-infected persons with or without diarrhea. In addition, duodenal aspirates from 10 patients with unexplained chronic diarrhea were examined by light microscopy after staining according to the new and the traditional techniques. RESULTS: E. bieneusi spores were found in all unconcentrated stool specimens from the four patients with microsporidiosis. The use of various methods of stool concentration did not improve the detection of microsporidia spores. In the prospective study, microsporidiosis was detected in samples from 6 of 27 patients with chronic diarrhea, but in none of those from 42 patients with acute diarrhea or 65 patients without diarrhea. The presence of microsporidia spores in stool specimens and duodenal aspirates allowed the successful prediction of the presence of microsporidia in small-bowel biopsy specimens from all four patients who subsequently underwent endoscopy. CONCLUSIONS: E. bieneusi is an important cause of chronic diarrhea in HIV-infected persons. This new diagnostic technique serves as a practical, noninvasive means to detect microsporidia spores in stool specimens and is also applicable to the examination of duodenal aspirates.

Animals↗
PubMed1992

Cytomegalovirus peritonitis in a patient with the acquired immunodeficiency syndrome.

Peritonitis has been reported infrequently in patients with the acquired immunodeficiency syndrome (AIDS). Intestinal or colonic perforation resulting from cytomegalovirus (CMV) enteritis is the most common cause of peritonitis in these patients. We report a patient with CMV peritonitis occurring in the absence of perforation (primary peritonitis) to alert physicians to this potentially treatable disorder.

Abdominal Pain↗
PubMed1992

A pilot study of oral corticosteroid therapy for idiopathic esophageal ulcerations associated with human immunodeficiency virus infection.

PURPOSE: To evaluate the efficacy and safety of oral prednisone therapy for idiopathic esophageal ulcerations (IEU) associated with human immunodeficiency virus (HIV) infection. PATIENTS AND METHODS: Over a 14-month period, all HIV-infected patients with IEU as defined by clinical, endoscopic, and pathologic criteria were prospectively identified. Prednisone was initiated at a dose of 40 mg/d orally, tapering 10 mg/wk, for a total of 1 month of therapy. Patients were closely followed to determine the response to therapy as well as the occurrence of any side effects related to prednisone. All patients were requested to undergo endoscopy within 1 week of the completion of therapy. RESULTS: Of 14 patients identified with IEU, 12 consented to prednisone therapy. The mean duration of esophageal symptoms was 2.9 weeks, and odynophagia was the most common presenting symptom. Ten of 12 patients had the acquired immunodeficiency syndrome. Eleven of the 12 patients (92%) had a complete symptomatic response, usually within the first week of therapy. In some patients, the response was dramatic such that oral intake could be rapidly resumed and discharge from the hospital possible. Two patients completed 2 and 3 weeks of therapy, respectively, prior to death, both with a complete symptomatic response. Endoscopic re-examination in seven patients demonstrated complete ulcer healing in all six symptomatic responders, but a persistent ulceration in the one nonresponder. The oral corticosteroid regimen was well tolerated. Mild asymptomatic Candida esophagitis was identified in three of seven patients undergoing follow-up endoscopy. One patient developed self-limited herpes zoster during therapy. No systemic opportunistic infections were documented during or within 1 month of the completion of therapy. CONCLUSIONS: Oral corticosteroid therapy appears to be a highly efficacious and safe therapy for HIV-associated IEU. Further controlled studies will be necessary to conclusively establish efficacy, as well as determine the optimal dose and duration of therapy.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Esophageal disease in the acquired immunodeficiency syndrome: etiology, diagnosis, and management.

Esophageal disease is a common complication and cause of morbidity in patients with human immunodeficiency virus (HIV) infection. Opportunistic esophageal diseases may occur in patients with long-standing infection or may be the initial manifestation of HIV disease. Although a variety of both opportunistic and nonopportunistic disorders result in esophageal disease in this population, candidal esophagitis is the most common cause of symptomatic disease. Ulcerative esophagitis resulting from cytomegalovirus and idiopathic esophageal ulceration constitute the next most important etiologies. In contrast to other immunocompromised hosts, herpes simplex virus esophagitis appears to be relatively uncommon. Multiple simultaneously discovered esophageal disorders have been documented in up to 50% of patients. Opportunistic neoplasms are an infrequent cause of symptomatic disease. Candidal esophagitis may present with either dysphagia or odynophagia, and oropharyngeal candidiasis is usually present at the time of diagnosis. In contrast, ulcerative esophagitis is usually first manifested by moderate to severe odynophagia. Barium esophagography and upper endoscopy are the most commonly employed diagnostic modalities for the evaluation of the symptomatic patient. Although barium esophagography may identify specific abnormalities, this procedure appears to be relatively insensitive for the detection of mild candidal disease as well as nondiagnostic for ulcerative lesions when compared with endoscopy. In the HIV-infected patient with new-onset esophageal symptoms, an empiric trial of a systemically acting oral antifungal agent should probably be the initial management strategy. If the patient does not respond to standard therapy within 1 to 2 weeks, an endoscopic evaluation appears to be the most cost-effective diagnostic test given the diversity of potential disorders, the possibility of one or more co-pathogens or diseases, the potential for an immediate diagnosis, and the availability of mucosal biopsy to make a definite diagnosis of ulcerative or mass lesions. Given the presently available therapy for these diverse processes, establishing a definitive diagnosis in the symptomatic patient not responsive to empiric antifungal therapy is warranted.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Atypical cytomegalovirus inclusions in gastrointestinal biopsy specimens from patients with the acquired immunodeficiency syndrome: diagnostic role of in situ nucleic acid hybridization.

Cytomegalovirus (CMV) infection of the gastrointestinal tract is a common cause of morbidity and mortality in the acquired immunodeficiency syndrome. The proper recognition of CMV-infected cells in gastrointestinal mucosal biopsies is critical so that effective therapy is not delayed, preventing further viral dissemination. Although the pathology criteria for classic CMV inclusions have been well described, the occurrence of morphologically atypical inclusions has been reported but the inclusions are not well characterized. This study prospectively examined the relative frequency of classic and atypical CMV inclusions in gastrointestinal mucosal biopsy specimens from 13 human immunodeficiency virus-positive symptomatic patients. The results demonstrated that classic inclusions were rarely found, including four esophageal, one gastric, and one colonic biopsy specimens in which none were seen. However, atypical CMV inclusions were identified from all biopsy specimens examined; these inclusions were much more numerous than classic inclusions and could be categorized into three morphologic types. The atypical inclusions were difficult to precisely identify as CMV-infected cells, but in situ DNA hybridization for CMV was valuable in establishing their viral origin, thus permitting the correct etiologic diagnosis.

Acquired Immunodeficiency Syndrome↗
PubMed1992

Symptomatic CMV duodenitis. An important clinical problem in AIDS.

Duodenal disease resulting from cytomegalovirus (CMV) infection is unusual in the absence of other gastrointestinal disease. We report two cases of CMV infection symptomatically isolated to the duodenum. One patient presented with ulcer-type dyspepsia, and the other with severe gastrointestinal bleeding. Ganciclovir therapy resulted in both a clinical and endoscopic remission. The importance of endoscopic evaluation is discussed given the necessity of mucosal biopsy for diagnosis and the availability of specific and effective therapy.

Abdominal Pain↗
PubMed1992

Prospective evaluation of a peritoneal dialysis catheter system for large volume paracentesis.

Large volume paracentesis is becoming a popular form of therapy for patients with massive ascites and cirrhosis. Although the physiologic effects of the removal of large amounts of ascitic fluid have been well described, the techniques utilized to perform the procedure are either not well documented or not currently available. Over a 13-month period, 52 patients with moderate to severe ascites have undergone 73 large volume paracenteses with a peritoneal dialysis catheter system. The mean volume of ascitic fluid removed was 7.6 L, with a mean time of removal of 129 min. Total paracentesis was accomplished within 1 h in 38% of procedures. The most common site for paracentesis was the left lower quadrant. Complications related to the procedure were few, the most common being a self-limited ascitic fluid leak at the sight of paracentesis. No patient experienced intestinal perforation, peritonitis, or a significant change in serum creatinine after the procedure. The widely available peritoneal dialysis catheter system represents a safe and rapid technique for the removal of large quantities of ascitic fluid.

Ascites↗
PubMed1991

Effect of octreotide on refractory AIDS-associated diarrhea. A prospective, multicenter clinical trial.

OBJECTIVE: To determine the efficacy and safety of octreotide for treatment of refractory, profuse diarrhea in patients with the acquired immunodeficiency syndrome (AIDS). DESIGN: A prospective, open-label study. SETTING: Inpatient metabolic units of four university medical centers. PATIENTS: Fifty-one patients infected with human immunodeficiency virus (HIV) who had uncontrolled diarrhea (greater than or equal to 500-mL liquid stool per day) despite treatment with maximally tolerable doses of antidiarrheal medications. INTERVENTION: After initial baseline studies, patients received octreotide, 50 micrograms every 8 hours for 48 hours. If stool volume was not reduced to less than 250 mL/d, the dose of octreotide was increased stepwise to 100, 250, and 500 micrograms. MAIN RESULTS: Fifty men and one woman (mean age, 36.3 +/- 1.1 years) entered and completed the 28-day protocol (14 days of inpatient therapy and 14 days of outpatient therapy). Stool frequency and volume decreased significantly (6.5 +/- 0.5 stools per day on day 0 compared with 3.8 +/- 0.3 stools per day on day 21 [P less than 0.001] and 1604 +/- 180 mL/d on day 0 compared with 1084 +/- 162 mL/d on day 14 [P less than 0.001], respectively). Twenty-one patients (41.2%) were considered to be partial or complete responders (reduction in daily stool volume by greater than or equal to 50% of initial collections or reduction to less than or equal to 250 mL/d). Of the 21 responders, 14 (67%) had no identifiable pathogens at initial screening compared with 9 of 30 (30%) nonresponders (P less than 0.01). CONCLUSION: Patients with AIDS-associated refractory watery diarrhea, especially those without identifiable pathogens, may respond favorably to subcutaneously administered octreotide. This drug deserves further study in a randomized, placebo-controlled trial.

Acquired Immunodeficiency Syndrome↗