Incidence and prophylaxis of non-tuberculous mycobacteriosis in HIV-infected patients.
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AIDS-Related Opportunistic Infections↗
Biomedical subjects
M Opravil
Publications and source records attributed to M Opravil.
Levels of dapsone and pyrimethamine in serum during once-weekly dosing for prophylaxis of Pneumocystis carinii pneumonia and toxoplasmic encephalitis.
Concentrations of dapsone, monoacetyldapsone, and pyrimethamine were determined in 36 serum samples from human immunodeficiency virus-infected patients on prophylaxis with once-weekly administration of dapsone-pyrimethamine (200 mg of dapsone-75 mg of pyrimethamine). During day 1 after ingestion, median levels of 1,038 ng of dapsone per ml and 356 ng of pyrimethamine per ml were found. During days 6 to 7, the dapsone level fell to < 20 ng/ml in five of nine serum samples, but the pyrimethamine level remained elevated (125 ng/ml). Concurrent, but separately ingested, didanosine administration did not seem to decrease the drug concentrations.
Adult↗
The role of two-segment bronchoalveolar lavage in the diagnosis of pulmonary infections.
STUDY OBJECTIVE: To determine if performing bronchoalveolar lavage (BAL) from more than one lung segment augments the diagnostic yield in patients with pulmonary infection. PATIENTS AND STUDY DESIGN: Seventy-six patients who underwent bisegmental BAL for the diagnosis or exclusion of pulmonary infection were studied prospectively. MAIN RESULTS: In patients with AIDS, the concentration of Pneumocystis carinii was higher in the upper lobes than in the middle lobes, regardless of whether the patients had been receiving pentamidine prophylaxis. In patients without HIV infection, the number of P carinii clusters was much lower. In 2 of 5 HIV-negative patients, P carinii organisms were detectable but in one of two lavage specimens, whereas in only 1 of 19 AIDS patients, P carinii organisms were not found in both lavaged segments. In bacterial pneumonia, BAL fluid from a segment of the radiologically most involved area had a much higher cell concentration, percentage of neutrophils, and concentration of bacteria than from the segment that was not or less severely involved on chest radiograph. In two of nine patients with AIDS and cytomegalovirus (CMV) pneumonia, cytopathogenic CMV effects were not found in both lavaged segments. In one of eight patients, mycobacteria could be cultured only from one of two radiologically involved segments. CONCLUSION: An increase in the diagnostic sensitivity by performing BAL in two lung segments is limited to cases where P carinii pneumonia is a relevant consideration in immunocompromised patients without HIV infection. In bacterial pneumonia, BAL can be performed in a single radiographically involved lung segment without a loss in diagnostic sensitivity. Since our study population of patients with CMV pneumonitis, mycobacterial infections, and fungal infections was small, no reliable conclusions are possible and BAL of more than one lung segment seems justified until more information is available.
AIDS-Related Opportunistic Infections↗
Shortcomings of chest radiography in detecting Pneumocystis carinii pneumonia.
The radiographic presentation of Pneumocystis carinii pneumonia (PCP) was studied in 93 consecutive patients to determine the frequency of normal findings on chest roentgenograms and possible correlations with clinical or laboratory findings. The roentgenograms were reviewed by two radiologists in an independent, blinded way and judged with a score distinguishing between none, interstitial, and acinar infiltrates. Discordance mainly between absent versus interstitial and interstitial versus acinar infiltrates occurred in 23% of roentgenograms and was settled by consensus. The majority of patients presented with moderate-to-mild symptoms; the combination of dyspnea, cough, and fever was present in 53%. Lactate dehydrogenase (LDH) was elevated in 63%, hypoxemia (PaO2 < 75 mm Hg) was present in 57%. Findings on chest roentgenograms were normal in 39%, whereas 36% showed interstitial and 25% acinar infiltrates. These three radiographic groups represented an increasingly severe PCP, indicated by higher LDH levels and hypoxemia (both p < 0.05). In a multivariate logistic regression, normal roentgenograms were predicted by low LDH and low peripheral blood granulocytes (p < 0.005). Mortality within 3 weeks was only 4% and correlated with the severity of infiltrates (p < 0.05). Normal roentgenograms thus corresponded to an oligosymptomatic, less severe PCP. In immunodeficient HIV-infected patients, a normal chest roentgenogram does not exclude PCP and should not distract from attaining a definite diagnosis by examination of induced sputum or bronchoalveolar lavage.
Adult↗
Systemic absorption after local intracolonic vancomycin in pseudomembranous colitis.
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Acute Kidney Injury↗
[Disseminated toxoplasmosis in AIDS].
Within one year a 46-year-old HIV-positive man developed Pneumocystis carinii pneumonia, candida oesophagitis and recurrent mucocutaneous herpes simplex infections. He finally developed a constant fever without any infection-localizing features. There was pancytopenia, increased activities of the transaminases, lactate dehydrogenase, amylase and lipase, as well as diffuse ST-segment changes in the ECG and discrete pulmonary infiltrates. The anti-toxoplasmosis titre was 8 IU/ml. Despite extensive diagnostic tests no firm diagnosis could be established. The pulmonary infiltrate and the fever regressed under antibiotic treatment with co-trimoxazole. Two months later his general condition deteriorated again with some disorientation and subfebrile temperature, epididymitis and renewed rise in abnormal laboratory values. For the first time computed tomography showed some punctate contrast-medium concentrations in the subcortical area and the medulla. The patient died on the same day. Histological material obtained at the time of autopsy revealed pseudocysts with Toxoplasma gondii and necrotizing inflammation in the brain, myocardium and lungs, as well as the entire gastrointestinal and urogenital tracts. In addition, cytomegalovirus infection of the lung and adrenals was demonstrated. Anti-toxoplasmosis IgG titre, determined postmortem, again registered a marked rise to 251 IU/ml. This suggests that there was reactivation of the toxoplasmosis as part of the immunosuppression process.
AIDS-Related Opportunistic Infections↗
[The prognostic value of different patterns of change in the CD4 lymphocyte counts in 420 symptom-free HIV-1-infected persons].
The pattern of change over time of CD4-lymphocyte counts was investigated prospectively in 420 patients infected with HIV-1 (106 women, 314 men; mean age 34.9 [21-70] years) to assess its value in prognosticating progression to AIDS. Only those CD4-lymphocyte values were taken into account which had been measured in the asymptomatic stage of the HIV infection and before introduction of antiviral treatment. An average of 4.5 (range 3-10) measurements per person were available. Mean observation time was 2.4 years, the mean annual CD4-lymphocyte decrease was 48 cells/microliters. 121 patients (28.8%) had a fall in CD4-lymphocyte count which in the regression analysis significantly differed from zero. In this group there occurred 19 progressions to AIDS (15.7%), in contrast to only 20 (6.6%) in the 299 patients with a nonsignificant CD4 fall (P < 0.01). Multivariate analysis with the Cox regression indicated that the annual reduction in the CD4 count and the initial CD4 count were the only values of prognostic significance regarding progression to AIDS. There was no evidence that percentage and absolute CD4-lymphocyte counts had a different predictive value. When the initial CD4 count was high (> 900 cells/microliters), there was on average a steeper reduction in CD4-lymphocyte counts than when it was lower. This findings argues against a linear CD4 fall during the total period of observation. The annual CD4 fall, described with linear regression, is a prognostic criterion on its own for early recognition of those patients at a high risk of progression to AIDS while still in the asymptomatic stage of HIV infection.
Acquired Immunodeficiency Syndrome↗
T cell response to staphylococcal superantigens by asymptomatic HIV-infected individuals exhibits selective changes in T cell receptor V beta-chain usage.
Recognition that the murine mammary tumor C-type retrovirus and the replication-defective murine leukemia virus have "superantigen" properties raises the specter that human immunodeficiency virus might also generate T cell impairment and destruction as a result of inherent superantigen properties. The observation that individuals with AIDS lack the expression of several T cell receptor V beta-chain genes lends support to this hypothesis. Staphylococcal exotoxins represent another class of superantigen with a similar ability to stimulate large numbers of T cells bearing specific T cell receptor V beta-chain types. To examine the hypothesis that T cells from HIV-infected individuals may be exposed to a superantigen during the infection process, we have compared the ability of T cells from asymptomatic HIV-infected donors and healthy donors to respond to stimulation with several known staphylococcal exotoxin superantigens. Following in vitro stimulation with staphylococcal enterotoxin D and staphylococcal enterotoxin E, asymptomatic HIV-infected individuals responded with a significantly different T cell receptor V beta-chain usage to that observed for healthy individuals. This skewed V beta-chain usage is likely to reflect preferential conditioning of T cells bearing specific V beta-chains as a result of HIV infection, supporting the hypothesis of superantigen involvement early in the course of infection.
CD4 Antigens↗
Predictive value of bronchoalveolar lavage in excluding a diagnosis of Pneumocystis carinii pneumonia during prophylaxis with aerosolized pentamidine.
We assessed the negative predictive value of bronchoalveolar lavage (BAL) for Pneumocystis carinii pneumonia (PCP) during prophylaxis with aerosolized pentamidine. On the basis of the assumption that undiagnosed and untreated PCP would progress and become clinically apparent, for 3 months we prospectively followed 34 consecutive cases in which BAL had not detected PCP. All patients were immunodeficient, had a symptomatic human immunodeficiency virus infection, and were evaluated for possible PCP during prophylaxis with aerosolized pentamidine. No transbronchial biopsies were performed. In 32 of 34 cases, a diagnosis of PCP could be excluded because of other definite diagnoses or improvement during the follow-up. Despite negative results of an examination of their BAL fluid, two patients received empirical treatment that was active against PCP; these patients were regarded as possibly having undiagnosed PCP. Thus, the negative predictive value of BAL alone was at least 94% (32 of 34 cases) in excluding a diagnosis of PCP during prophylaxis with aerosolized pentamidine.
AIDS-Related Opportunistic Infections↗
Extrapulmonary and disseminated infections due to Mycobacterium malmoense: case report and review.
Mycobacterium malmoense is a potentially pathogenic species that was first described in 1977. During the past decade M. malmoense has been recognized with increasing frequency as a pulmonary pathogen. More than 180 cases of M. malmoense infection have been reported. Most of these infections affected a previously damaged lung. Other infection sites included the skin, lymph nodes, and bursae. Five cases of disseminated infection have been reported. The antituberculous drugs associated with the most favorable susceptibility patterns are rifampin and ethambutol. Because of the slow growth of M. malmoense on conventional, egg-based bacteriologic media, the incubation time should be > 6 weeks; special solid and liquid media are recommended. We report a case of disseminated pulmonary and gastrointestinal infection due to M. malmoense in a patient with AIDS, who was treated successfully with a combination of rifabutin (ansamycin), clofazimine, and isoniazid. In addition, we review the characteristics of extrapulmonary and disseminated infections due to M. malmoense.
AIDS-Related Opportunistic Infections↗
Pyrimethamine inhibits renal secretion of creatinine.
The mechanism of increased serum creatinine after administration of pyrimethamine and dapsone was evaluated for six healthy volunteers. Serum parameters, urine sediment, and clearances of creatinine, inulin, and para-aminohippurate were assessed prior to and 28 h after the ingestion of a single, combined dose of 100 mg of pyrimethamine and 200 mg of dapsone. In a second series, the same renal function tests were performed for nine human immunodeficiency virus-infected men before and after 1 month of prophylactic treatment with a weekly dose of 75 mg of pyrimethamine and 200 mg of dapsone to evaluate sustained effects on renal function. Serum creatinine increased within 28 h from 81 +/- 14 to 102 +/- 16 mumol/liter (P = 0.002) in the healthy volunteers. Blood urea nitrogen, beta 2-microglobulin, and urine remained normal. Creatinine clearance decreased from 125 +/- 27 to 91 +/- 26 ml/min (P < 0.02) without changes in inulin clearance. The effect was reversible within 21 days and attributable to pyrimethamine, as determined by administration of each drug alone. The sustained effect of four doses of pyrimethamine and dapsone in human immunodeficiency virus-infected patients consisted of an analogous rise in serum creatinine from 69 +/- 17 to 87 +/- 32 mumol/liter (P < 0.05). Both creatinine and inulin clearances, however, were unchanged, representing a new equilibrium between creatinine production and elimination at a higher level in serum. Pyrimethamine, thus, may reversibly inhibit renal tubular secretion of creatinine without affecting the glomerular filtration rate. This physiologic effect in pyrimethamine-treated patients must be differentiated from possible organ-related nephropathies.
Adult↗
[Etiology and therapy of pneumothorax in AIDS patients].
Pneumothoraces in patients with AIDS are a rare, acute and severe complication. Between January 1989 and December 1991 3 patients with spontaneous pneumothorax were operated after a 2-week treatment with chest tube drainage only had failed. The average follow-up time after the operation was 7 months. There was no recurrence. Within the same 3 years 3 patients were treated in the Clinic for Internal Medicine by means of tube drainage only. Thus, only one case was successful. The average survival after receiving the tube was 3 weeks. Their death was not related on their pneumothorax. The mean age of the 6 patients was 34 years (23-49). In 5 patients the pneumothorax was associated with Pneumocystis carinii-pneumonia and in 3 of them also with prophylactic pentamidine aerosol therapy. A minimal invasive operation of operable AIDS-patients with pneumothorax shows good results, shortens the time of therapy and is possible despite the bad prognosis of the disease.
AIDS-Related Opportunistic Infections↗
[Diagnosis and course of patients with HIV infections and exclusion of Pneumocystis carinii pneumonia].
30 patients infected with HIV (20 men, 10 women; mean age 34 [26-54] years), suspected of having Pneumocystis carinii (Pc) pneumonia, had undergone bronchoalveolar lavage which proved negative for Pc. They were then kept under observation for 5 months. No transbronchial biopsy was performed. 27 patients were in stage IV of the HIV infection, and 14 had been on pentamidine prophylaxis. The most frequent diagnosis with the bronchial lavage was bacterial infection (19 patients), next most frequent was mycobacterial infection (6, atypical in 5). A neoplasia (Kaposi sarcoma; non-Hodgkin lymphoma) was found in two, with pulmonary involvement. The diagnosis remained unclear in only three patients who were treated as for Pc pneumonia. The remaining 27 patients did not receive any treatment against Pc. Nonetheless, there were no cases of Pc pneumonia in the 5 months of observation so that bronchoalveolar lavage has a negative predictive value of 90% (27 of 30), high enough to make additional bronchial biopsy unnecessary.
Adult↗
[Primary pulmonary hypertension and mesangioproliferative glomerulonephritis in HIV infection].
Four years after an HIV infection and without any preceding illness characteristic of AIDS, a 24-year-old woman developed dyspnoea on exertion and peripheral oedema. She had for several years been an intravenous drug addict and contracted hepatitis A and B. There were no symptoms of the HIV infection. Clinical, radiological and echocardiographic examination demonstrated right ventricular failure caused by pulmonary hypertension not due to pulmonary embolism or another known aetiology. The patient died suddenly 9 months after the diagnosis from heart failure. Autopsy established primary pulmonary hypertension with pathognomonic plexogenic pulmonary arterial disease which had led to cor pulmonale with overload myocarditis. Although there had been no clinical signs of renal failure, there was histological evidence of mesangioproliferative glomerulonephritis and non-destructive interstitial nephritis. This case demonstrates that, in addition to the typical AIDS-associated diseases, other rarer syndromes may, in uncertain ways but connected with the HIV infection, decide the prognosis of such patients.
Adult↗
[HIV-associated malignant lymphomas].
In a retrospective analysis of data from 35 cases with malignant lymphoma from a cohort of 2017 HIV-infected patients, the stage of HIV-disease, the CD4 counts at the time of diagnosis, and the use of antineoplastic agents or radiotherapy were correlated with outcome. 6 patients had Hodgkin's lymphoma (HL) and 29 non-Hodgkin-lymphoma (NHL). 11 of these lymphomas were classified according to the international working formulation (IWF) as high grade (H, I and J, respectively) and 8 as intermediate grade (G). 10 could not be classified. 22 patients with NHL had stage IV disease according to the Ann Arbor classification, all of whom had manifestations at extranodular sites. 23 patients with NHL were treated with multiagent chemotherapy (18 with m-BACOD or CHOP, 5 patients with various other regimens) and four of them had additional radiotherapy. One patient received radiotherapy only. Two of 24 treated patients showed complete and five a partial response. Median survival of patients without treatment (all of them in poor general condition at the time of diagnosis) was 1.8 months and treated patients survived a median of 5 months. The pretreatment CD4 count was the most important predictor of survival. Patients with prior Aids-diagnosis showed a tendency towards shorter survival. The observed remission rate indicates that HL in HIV-infected patients is better treatable than HIV-associated NHL. However, the overall outcome of HL in our patients was clearly less favorable compared to the course of HL usually seen in patients without HIV infection. The proportion of patients with HL among all patients with malignant lymphoma and HIV disease was unexpectedly larger in our cohort compared to others. Therefore, a possible association of HL and HIV infection, as addressed by several other authors, needs further clarification.
Adult↗
Intestinal Enterocytozoon bieneusi microsporidiosis in an HIV-infected patient: diagnosis by ileo-colonoscopic biopsies and long-term follow up.
A 39-year-old patient with acquired immunodeficiency syndrome was diagnosed as having intestinal Enterocytozoon bieneusi microsporidiosis after persistent watery diarrhea for 30 months and a 16-kg weight loss. Microsporidian parasites were found by light and electron microscopy in tissue specimens of the duodenum, jejunum, and terminal ileum, and by light microscopic examination of stool specimens. When duodenal tissue sections obtained 16 months previously were reviewed retrospectively, E. bieneusi was also found. Until now, diagnosis of intestinal microsporidiosis has been based on examination of bioptic specimens of the upper small intestine because the sensitivity of new coprodiagnostic techniques has not been determined. Our findings of ileal microsporidiosis show that examination of the terminal ileum and ileal biopsy collection in tandem with colonoscopy is indicated for patients infected with human immunodeficiency virus and suffering from unexplained chronic diarrhea. The long-term course of our patient demonstrates that E. bieneusi, although not necessarily life threatening, can cause protracted debilitating diarrhea and wasting in severely immunodeficient patients.
AIDS-Related Opportunistic Infections↗
Disseminated coinfection with Mycobacterium avium complex and Mycobacterium kansasii in a patient with AIDS and liver abscess.
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Acquired Immunodeficiency Syndrome↗
Prospective evaluation of a prognostic score for Pneumocystis carinii pneumonia in HIV-infected patients.
Serum lactate dehydrogenase levels, alveolar-arterial oxygen gradient, and percentage of neutrophils in bronchoalveolar lavage correlate most strongly with early mortality in Pneumocystis carinii pneumonia (PCP) in HIV-infected patients. However, the individual outcome can not be predicted by these parameters due to a considerable overlap between survivors and nonsurvivors. We prospectively investigated a PCP severity score, which has been developed earlier based on a retrospective analysis. Seven of 94 consecutively examined HIV-infected patients died within 14 days after diagnosis of PCP. A PCP severity score greater than 7 had a positive predictive value for early fatal outcome of 66.7 percent (6/9) and a negative predictive value of 98.8 percent (84/85). The overall diagnostic accuracy was 95.7 percent (90/94). The positive predictive value for early fatal outcome of a P(A-a)O2 > 35 mm Hg was 24 percent (6/25); the negative predictive value was 98.6 percent (68/69). However, the overall diagnostic accuracy was only 78.7 percent (74/94). The PCP severity score is a valuable tool for clinical decision making, for the early identification of patients with a prognostic unfavorable course, and for the comparison of patient populations in future studies of HIV-associated PCP.
AIDS-Related Opportunistic Infections↗