Biomedical subjects
Publications and source records attributed to C Perronne.
We report a Bartonella henselae infection in a 40-y-old patient who presented with fever, weight loss, night sweats, elevated lactate dehydrogenase and multinodular splenomegaly with multiple abdominal lymphadenopathies. Splenic cat-scratch disease is an exceptional diagnosis in adults and can easily be mistaken for a splenic lymphoma, thereby leading to an unnecessary splenectomy.
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BACKGROUND: We report a case of CMV retinitis cured in an AIDS patient after two months of regular HAART therapy without CMV medications. CASE REPORT: A 37-year-old patient (baseline CD4 count 47/ml) receiving HAART (2 NRTI and 1 IP) showed poor compliance and had increased his CD4 count for two months reaching 263/ml although HIV viral load remained high (71,840 copies/ml). His fundus was normal. He was evaluated 8 months after a period of loss to follow-up: his CD4 count was 65/ml, HIV viral load was 123,000 copies/ml, CMV serology for IgV and viruria were positive, viremia was negative, his fundus revealed a healed CMV retinitis. Six months later and without any CMV therapy, no relapse has been observed while regularly taking HAART medications. CONCLUSION: Few cases have been reported in which HAART therapy with good immune response and reduced HIV viral load lead to complete regression of CMV retinitis without specific CMV medication. This case suggests that, even with an uncontrolled HIV viral load, HAART via transient immune restoration may contribute to resolving CMV retinitis.
BACKGROUND: A syndrome of lipodystrophy, associated with hypertriglyceridaemia, hypercholesterolaemia, hyperinsulinaemia and peripheral insulin resistance has been reported in protease inhibitor (PI)-treated HIV-infected patients. Because lipid metabolism, fat mass distribution and insulin resistance are partly regulated by steroid hormones, we questioned whether lipodystrophy is related to hormonal perturbations. OBJECTIVE: To evaluate serum lipid and steroid hormone concentrations in HIV-positive men on highly active antiretroviral therapy (HAART) in order to determine whether dyslipidaemia, peripheral loss of fatty tissue and central fat accumulation are related to steroid hormone modifications. DESIGN: A cross-sectional study. METHODS: Thirty-seven HIV-1-positive men on HAART, 23 of whom had symptoms of lipodystrophy, according to a subjective clinical score of lipodystrophy (SCSL), were tested. Serum concentrations of cholesterol, triglycerides and their subclasses, apolipoproteins and steroid hormones, including cortisol, dehydroepiandrosterone (DHEA), DHEA sulphate, androstenedione, testosterone and dihydrotestosterone were measured. RESULTS: Serum cholesterol, very low density lipoprotein (VLDL) cholesterol, triglycerides, VLDL triglycerides, high density lipoprotein (HDL) and low density lipoprotein (LDL) triglycerides, apolipoprotein B (ApoB) and atherogenic ratios of cholesterol:HDL cholesterol, LDL cholesterol:HDL cholesterol and ApoB:apolipoprotein A1 (ApoA1) were significantly increased in lipodystrophy-positive compared with lipodystrophy-negative men. The serum cortisol level was similar in lipodystrophy-positive versus lipodystrophy-negative men, but was elevated compared with controls. Serum DHEA was significantly lower in lipodystrophy-positive versus lipodystrophy-negative men and, consequently, the cortisol:DHEA ratio was increased in lipodystrophy-positive patients. A positive correlation was found between the cortisol:DHEA ratio and increased levels of atherogenic lipids. In addition, the SCSL was positively correlated with dyslipidaemia and the cortisol:DHEA ratio. CONCLUSION: This study demonstrates an association between the cortisol:DHEA ratio, lipid alterations and lipodystrophy. This syndrome might result from an imbalance between peripheral lipolysis and lipogenesis, both regulated by cortisol and DHEA.
PURPOSE: Hepatitis C (HCV) has a high prevalence (10-30%) among human immunodeficiency virus (HIV)-infected patients. However, little information is available regarding the impact of hepatitis C on survival. The objective of our study was to determine the incidence of hepatitis C-related deaths in HIV-HCV co-infected patients. METHODS: The study was a retrospective (1-year), multicenter cohort survey conducted in 63 departments of either internal medicine or infectious diseases in France. It included 26,497 HIV-infected patients, of whom 4,465 (16.8%) presented coinfection due to the hepatitis C virus. The following parameters were studied for the year 1997: total number of deaths, number of deaths related to either AIDS, cirrhosis, hepatocellular carcinoma, or other causes. RESULTS: Among the 26,497 patients, 543 deaths (incidence: 2%) were observed in 1997; 543 deaths were due to AIDS (incidence: 1.7%), 36 to cirrhosis and/or hepatocellular carcinoma (incidence: 0.13%), and 48 (incidence: 0.18%) to another cause. In the subgroup including 4,465 HIV-HCV-coinfected patients, 29 deaths (incidence: 0.64%) were due to either HCV-related cirrhosis or hepatocellular carcinoma. These results were compared with those of a previous similar survey conducted in 1995, before the era of highly active antiretroviral therapy. The only significant difference is the dramatic regression of deaths due to AIDS. CONCLUSION: The impact of hepatitis C virus on the mortality among HIV-infected patients whose follow-up took place in departments of either internal medicine or infectious diseases in France was very low in 1997. The expected increase in the life span in these patients could modify these results in the future, due to recent improvements in the HIV infection treatment.
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Septic arthritis due to Mycobacterium kansasii is rare; only 40 cases have been published. A French national inquiry revealed the occurrence of 10 new cases between 1992 and 1997 (8 men and 2 women: mean age, 37 years; range, 25-54 years). Seven had an underlying condition: AIDS (n=4), chronic skin psoriasis and AIDS (n=2), or a renal transplant (n=1). Trauma to the joint, use of intra-articular corticosteroid(s) 1 month to 2 years after the event, and chronic skin psoriasis were risk factors. The mean interval between appearance of the first symptoms of arthritis and the diagnosis was 5 months. Monarthritis was localized to the knee (n=4), wrist (n=3), finger (n=1), elbow (n=1), or ankle (n=1). The main diagnostic procedure was culture of a synovial biopsy specimen. In all cases, debridement was associated with antimycobacterial treatment. Three patients died of AIDS during treatment, and another is still undergoing treatment; the other 6 patients were cured. M. kansasii infection should be considered in all cases of indolent arthritis with any of the following risk factors: local trauma, local or systemic corticosteroid therapy, chronic skin psoriasis, and immunodepression, especially that due to human immunodeficiency virus infection.
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Recently, in daily newspapers and on television, attention of the audience has been focused on the overuse of antibiotics and on the role it plays in the emergence and dissemination of resistance mechanisms in the human environment. The role of food from animal origin in relation to the use of antibiotic resistance, infectious diseases, medical practice and ENT infections have accepted to answer a series of questions concerning risks versus usefulness of antibiotic usage. From the answers, we may note convergent views and discrepancies: (i) there was agreement concerning the unnecessary prescription of antibiotics in rhinopharyngitis and few other common viral infections; (ii) the risk of misuse of antibiotics in patients with poor compliance and further risk of erroneous self prescription of the remaining tablets has been cited; (iii) in the problem of resistance resulting from growth promoting antibiotics in animals, it has been experimentally shown that from 2 bacteria of the same species introduced in the animal gut, one susceptible, the other resistant, the latter will be eliminated by means of the "barrier effect"; similarly in case of transfer of resistance from an exogenous bacteria to a "resident" organism of the gut, the latter will be eliminated by the homologous susceptible ones; only an antibiotic therapy may confer importance to the resistant bacteria. In this respect, care should be taken for resistance spread such as that concerning penicillin-resistant pneumococci and surveillance and control of resistance mechanisms has become necessary. However we should look with reluctance at the diffusion of inevitably simplified and truncated information from Media, showing the negative aspects of antibiotics only. Moreover, as underlined by the expert from the Institut Pasteur, there are new perspectives in the development of effective new agents based on the modern "genomic" research.
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The upsurge in Mycobacterium tuberculosis infection in the last 10 years has included 5 to 10% of bone and joint localizations. The AIDS epidemic has contributed considerably, but other factors appear to play a more important role. The concentration of the population and the disorganization of anti-tuberculosis campaigns have allowed the disease to flourish. Poor compliance to treatment has allowed recurrence rates to rise with the consequent risk created by the presence of chronic carriers. As demonstrated by Pertuiset et al., in this issue of La Presse Médicale the incidence of bone and joint tuberculosis is clearly higher in developing countries than in Europe. Bone and joint localizations usually result from secondary reactivation of a septic metastasis after often asymptomatic primary lung disease. Damaged articulations, particularly weight carrying joints, are preferential targets. Chronic, insidious onset in a single joint is a characteristic feature, revealed by joint pain with fever and nocturnal sweating. Acute forms are observed in transplant recipients. If treatment is initiated early enough, ad integrum cure can be achieved, but functional prognosis may be compromised if therapy is given late. In more advanced forms, surgery with drainage and debridement is required.
We conducted a randomized, open-label trial in 42 French hospitals to compare the clinical and bacteriologic efficacy of combination therapy with clarithromycin/clofazimine (Clm/Clof) with that of combination therapy with clarithromycin/rifabutin/ethambutol (Clm/Rib/Eth) as treatment for Mycobacterium avium bacteremia. One hundred forty-four human immunodeficiency virus-seropositive patients older than 18 years of age who had CD4 lymphocyte counts of <100/mm3 and a blood culture positive for M. avium were enrolled in the study. The main measures of outcome were blood cultures, abatement of clinical symptoms (fever), and survival. Treatment success (defined as patient living, either no fever or a reduction of > or = 1 degrees C in initial body temperature, and a blood culture negative for M. avium) was similar in both treatment groups at months 2 and 6. However, following initial resolution of infection, relapse of M. avium bacteremia occurred in more patients in the Clm/Clof group than in the Clm/Rib/Eth group (22 vs. six, respectively; P < .001); these relapses were accompanied by emergence of strains resistant to clarithromycin in 21 and two patients, respectively. In conclusion, combination therapy with Clm/Rib/Eth prevented relapse of mycobacterial disease and, compared with combination therapy with Clm/Clof, was associated with a significant decrease in the emergence of resistant M. avium strains in HIV-infected patients treated for at least 28 weeks.
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Mycobacterium avium complex (MAC) infections in AIDS are increasingly common and contribute to the mortality in severe immunocompromised patients. In this paper, we review the published studies on the prevention of the MAC infections. Rifabutin and the new macrolides (clarithromycin, azithromycin) are shown to be effective in the primary prevention. However, they can fail and are difficult to manage with the antiretroviral treatment, specially antiproteases and prevention of the other opportunistic infections. For the prevention of the relapse of the MAC infections, it is necessary to give a prolonged treatment with a bio-therapy associating at least a new macrolide with rifabutin or ethambutol, which is also difficult to manage with the other treatments.
Immunosuppressed patients have an increased risk of developing active tuberculosis, either by reactivation of an old infection, or by horizontal acquisition during a contact with a contagious tuberculous patient. The diagnosis of tuberculosis requires a clinical examination and the realization of a PPD skin test and a pulmonary radiograph. Symptomatic tuberculosis is a contra-indication to chemoprophylaxis and requires a full curative treatment. The decision to undertake chemoprophylaxis should be individual. When indicated, it relies classically on a 6-month regimen of isoniazid. Short term chemoprophylactic regimens, such as rifampicin-isoniazid during 3 months or rifampicin-pyrazinamide during 2 months, have shown some efficacy. The interaction of rifampicin with corticosteroids or ciclosporin often impedes the use of this antibiotic. Apart from HIV infection, no clinical study of chemoprophylaxis is available in immunosuppressed patients.
Infections of the central nervous system by Herpes simplex viruses (Herpes simplex type 1 and Herpes simplex type 2) are uncommon in acquired immune deficiency syndrome and are often clinically and pathologically atypical. We have collected 11 cases of herpes simplex encephalomyelitis in AIDS patients reported in the literature. Only 3 of these cases presented with a typical, necrotizing, limbic encephalitis. Other clinicopathological patterns included ventriculitis, rhombencephalitis and myelitis. Ventriculitis and rhombencephalitis were usually due to infection by HSV-1, whereas myelitis was mostly due to HSV-2 infection. Distinction between the 2 types of virus is often difficult by immunohistochemistry due to frequent cross reactivity and usually requires tissue culture, in situ hybridization, or polymerase chain reaction. Association of HSV encephalomyelitis with productive infection of the central nervous system by the human immunodeficiency virus was only found in one case. In contrast, co-infection with cytomegalovirus was found in 9 of the 11 cases. One case also had had varicella zoster virus vasculitis, and another case also had a cerebral malignant non Hodgkin's lymphoma in which Epstein Barr virus genome was identified. This supports the view that concomitant herpes-virus infections of the central nervous system is a characteristic feature of AIDS.
Though most often asymptomatic, tuberculous infection induces a delayed hypersensitivity reaction in the host by activating cellular immunity thus rendering the host refractory, "a priori", to a new infection; at least provided that the infecting dose is not massive or that the immune system of the host is not compromised. Less that ten per cent of immuno-competent individuals infected by Mycobacterium tuberculosis will develop tuberculous disease during their life. The intradermal reaction (IDR to tuberculin) in revealing delayed hypersensitivity to Mycobacterial antigens is in the absence of obvious signs, the only means of diagnosing a tuberculous infection in an individual. It is performed in France by an intradermal injection of 0.1 mls (10 U) of Merieux tuberculin. The response is read at 72 hours. In those who have not had BCG vaccination, an area of induration with a diameter of greater than or equal to 10 mm gives a positive result and is evidence of a tuberculous infection. The test is negative if the diameter is less than 5 mm and indeterminate between 5 and 9 mm. These indeterminate reactions may be the consequence of previous BCG vaccination or of a contact with atypical Mycobacteria in the environment. An IDR of greater than or equal to 10 mm less than ten years after BCG vaccination would not permit any discrimination between a reaction to the vaccine or an authentic tuberculous infection. On the other hand, an IDR of greater than 10 mm ten years after BCG vaccination is evidence of renewed contact with wild tubercle bacilli in 88 per cent of cases. In individuals whose immune defence is altered in particular in patients infected with HIV the threshold of positivity for IDR is lowered to 5 mm.
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