Human immunodeficiency virus infection in tuberculosis patients

Human immunodeficiency virus (HIV) serology was performed in non-Asian-born patients 18-65 years old with newly diagnosed tuberculosis at a county tuberculosis clinic, and demographic and clinical features of HIV-seropositive and HIV-seronegative patients were compared. Sixty of 128 eligible patients agreed to participate, of whom 17 (28%) were seropositive. Risk of HIV was associated with homosexual contact, intravenous drug use, or both; however, 4 (24%) of the 17 seropositives denied risk behaviors. Significantly more blacks (48%) than whites (10%) or Latinos (20%) were HIV-seropositive (P less than .01). Site of disease, tuberculin reactivity, response to therapy, drug toxicity, and relapse did not differ significantly between groups. HIV-seropositive patients had significantly lower median CD4+ cell counts (326/mm3, range 23-742/mm3, vs. 929/mm3, range 145-2962/mm3, P less than .0005) and median CD4+:CD8+ ratios (0.50, range 0.14-1.07 vs. 1.54, range 0.35-4.36, P less than .0001). HIV infection is associated with clinically typical tuberculosis and HIV screening of tuberculosis patients is recommended in areas where HIV is endemic.     

Human immunodeficiency virus infection in patients with leukemia

Eighteen human immunodeficiency virus (HIV)-seropositive patients were found among 211 previously treated adult patients with a variety of leukemias who had been multiply transfused before April 1985. Patients known to be homosexual or intravenous drug users were excluded from this study. The spouse of one HIV-seropositive patient became HIV infected and subsequently developed the acquired immune deficiency syndrome. Patients with leukemia who were multiply transfused before the availability of screening of blood products for HIV antibody should be counseled regarding their individual risks of HIV infection and the risk to sexual contacts.     

Human immunodeficiency virus infection in pregnancy

The incidence and prevalence of human immunodeficiency virus (HIV) infection in women of child-bearing age continue to increase both internationally and in Canada. The care of HIV-infected pregnant women is complex, and multiple issues must be addressed, including the current and future health of the woman, minimization of the risk of maternal-infant HIV transmission, and maintenance of the well-being of the fetus and neonate. Vertical transmission of HIV can occur in utero, intrapartum and postpartum, but current evidence suggests that the majority of transmission occurs toward end of term, or during labour and delivery. Several maternal and obstetrical factors influence transmission rates, which can be reduced by optimal medical and obstetrical care. Zidovudine therapy has been demonstrated to reduce maternal-infant transmission significantly, but several issues, including the short and long term safety of antiretrovirals and the optimal use of combination antiretroviral therapy in pregnancy, remain to be defined. It is essential that health care workers providing care to these women fully understand the natural history of HIV disease in pregnancy, the factors that affect vertical transmission and the management issues during pregnancy. Close collaboration among a multidisciplinary team of knowledgeable health professionals and, most importantly, the woman herself can improve both maternal and infant outcomes.     

Human immunodeficiency virus infection and the thyroid.

Abnormalities of thyroid function are associated with a number of systemic conditions, including patients infected with human immunodeficiency virus (HIV). Most patients with early HIV infection and a stable body weight have normal thyroid function. Subtle abnormalities of a number of thyroid function tests have been reported during the early asymptomatic phase of HIV disease. These include an inappropriately normal triiodothyronine (T(3)) and reduced reverse triiodothyronine (rT(3)), and increased thyroxine-binding globulin (TBG) levels. Opportunistic infections involving the thyroid gland, neoplasms such as lymphoma and Kaposi's sarcoma, and medications can alter the thyroid function in individuals with more advanced HIV infection. If thyroid dysfunction is diagnosed in an HIV-infected patient, it should be treated in the usual manner. However, high index of suspicion and caution in the interpretation of thyroid function tests in patients with HIV disease are needed for optimal diagnosis and treatment.     

The causes of esophageal symptoms in human immunodeficiency virus infection. A prospective study of 110 patients.

STUDY OBJECTIVES.--To determine the prevalence of infectious agents in patients with human immunodeficiency virus infection and odynophagia or dysphagia; the utility of endoscopic, histologic, cytologic, and virologic testing for the diagnosis of esophagitis; and the yield of blind brushings of the esophagus in this setting. DESIGN.--Prospective clinical case study. SETTING.--Urban county hospital. PATIENTS.--One hundred ten consecutive patients with esophageal symptoms and documented human immunodeficiency virus infection. INTERVENTION.--Blind brushing of the esophagus via orogastric tube followed by endoscopy with esophageal brushing for fungal stain, Papanicolau smear, and viral cultures and esophageal biopsies for histologic examination and viral culture. MAIN RESULTS.--Seventy-two (65%) of the 110 patients had a total of 100 esophageal infections. Thirty-three (30%) had Candida alone, 22 (20%) had Candida and cytomegalovirus, two (1.8%) had Candida with cytomegalovirus and herpes simplex virus, seven (6%) had cytomegalovirus alone, six (5%) had herpes simplex virus alone, and two (1.8%) had both viruses. Fifty of 55 patients with plaques alone had Candida, and two (4%) had only viral infection. Of 19 patients with erosions or ulcers, 11 (58%) had a viral infection, two (11%) had Candida alone, and six (30%) had no etiologic agent identified. The sensitivity of endoscopic brushings (95%) was better than that of histologic examination (70%) in the diagnosis of Candida esophagitis. Likewise, viral cultures of brushings or biopsy specimens were more sensitive (67%) than histologic examination (35%) for viral esophagitis. Blind brushing of the esophagus had a sensitivity and specificity for infectious esophagitis of 84% and 75%, respectively. Oral thrush had a sensitivity of 53% and a positive predictive value of 77% for Candida esophagitis.     

Human immunodeficiency virus and respiratory infection

Pulmonary disease remains a major problem for the 33 million individuals who are thought to be infected with human immunodeficiency virus (HIV) worldwide. Respiratory infections are responsible for a large number of the 2 million deaths that occur each year in association with HIV disease. In countries where the majority of the population can access highly active antiretroviral therapy, morbidity and mortality rates have been cut by up to 80%. This has allowed the withdrawal of specific opportunistic infection prophylaxis when immune restoration is deemed to be adequate. Recommendations have been published concerning Pneumocystis carinii prophylaxis. This year has also seen further reports of drug-resistant isolates of Pneumocystis carinii. The clinical relevance of this is still debated. Tuberculosis remains a global problem. The complexity of the interactions between specific anti-HIV and anti-tuberculous treatment have been highlighted. In the developing world, the importance of immunization and prophylaxis (against bacteria and mycobacteria) have recently been further defined in a number of studies.     

A longitudinal immunologic evaluation of hemophiliac patients

Over an average span of one year, we performed a prospective clinical and immunologic evaluation of 30 patients with hemophilia. No patient developed life-threatening opportunistic infection or malignancy; however, the immunologic abnormalities and lymphadenopathy initially present in nine patients (lymphadenopathy group) persisted. In addition, five patients, representing 24% of the initial group without lymphadenopathy, developed generalized lymphadenopathy (converter group). One episode of idiopathic thrombocytopenia (ITP) and one episode of staphylococcal sepsis occurred in this "converter" group; one episode of ITP also occurred in the lymphadenopathy group. Sixteen patients remained asymptomatic. At the time of the follow-up evaluation, those differences in mononuclear cell (MNC) percentages and numbers noted initially among the three hemophiliac groups were no longer present. Natural killer cell function alone or in the presence of biologic response modifiers was not different among hemophiliac and control groups. Before developing lymphadenopathy, the converter group of patients had significantly better lymphocyte mitogenic function than did the other two groups of patients with hemophilia. However, lymphocyte mitogenic responses of all groups of patients with hemophilia significantly deteriorated over the course of the study. The abnormal mitogenic responses noted in these patients was explained in part by higher levels of spontaneous suppressor cell activity in mononuclear cell preparations from patients with hemophilia. We conclude that long-term immunologic studies of this patient population requires both quantitative and qualitative evaluations. Our data show that patients with hemophilia have progressive dysfunction of cell- mediated immunity.     

A prospective trial of structured treatment interruptions in human immunodeficiency virus infection

BACKGROUND: According to the "autovaccination hypothesis," reexposure to human immunodeficiency virus (HIV) during treatment interruptions may stimulate the HIV-specific immune response and lead to low viremia after withdrawal of highly active antiretroviral treatment (HAART). Many patients who started HAART earlier in their disease course than is currently recommended would like to discontinue, but it is unknown whether it is safe to do so. OBJECTIVES: To determine whether repeated treatment interruptions of HAART (1) stimulated the cytotoxic HIV-specific immune response and whether such stimulation correlated with low viremia off treatment, and (2) were safe with respect to clinical complications, development of viral resistance, and decline in CD4 cell counts. DESIGN: Interventional study with before-after comparison. SETTING: Outpatient clinics of university hospitals in Switzerland and Spain. PATIENTS: A total of 133 patients receiving HAART, with a median CD4 cell count of 740/ microL, and whose viral load had been undetectable for a median of 21 months. INTERVENTIONS: HAART was interrupted for 2 weeks, restarted, and continued for 8 weeks. After 4 such cycles, treatment was indefinitely suspended 40 weeks after study entry. MAIN OUTCOME MEASURES: HIV-specific cytotoxic T-cell responses were evaluated by interferon gamma enzyme-linked immunospot analysis. The proportion of "responders" (viral load <5000 copies/mL) was measured at weeks 52 and 96. HIV-related diseases and CD4 cell counts were recorded. RESULTS: Seventeen percent of patients (95% confidence interval, 11%-25%) were responders at week 52, and 8% at week 96. Low pre-HAART viral load and lack of rebound during weeks 0 to 40 predicted response. HIV-specific CD8+ T cells increased between week 0 (median, 343 spot-forming cells per million peripheral blood lymphocytes [SFC/106 PBL]) and week 52 (median, 1930 SFC/106 PBL), but there was an inverse correlation between response and the number of spot-forming cells. Eighty-five (64%) of 133 patients stopped therapy for at least 12 weeks, and 55 (41%) for at least 56 weeks. The median CD4 cell count decreased from 792/ microL to 615/ microL during the first 12 weeks without treatment, but stabilized thereafter. One patient (0.75%) developed drug resistance necessitating salvage treatment. There were no AIDS-related clinical complications. CONCLUSIONS: Results of this study do not favor the autovaccination hypothesis. Treatment interruptions did not provoke clinical complications, and there was little drug resistance. Comparative trials will have to show what benefit, if any, is associated with intermittent, as opposed to continuous treatment.     

Circulating anticoagulants in immunodeficiency virus infection. Results of a prospective study of 157 seropositive patients

One hundred and fifty-seven HIV seropositive patients were included in a prospective study of coagulation parameters. Activated partial thromboplastin time, prothrombin time, thrombin time and specific factor assays of the intrinsic pathway were performed using standard techniques. The tissue thromboplastin inhibition test and antiphospholipid antibodies were used to establish the presence of circulating lupus anticoagulant. Among the 46 patients with a prolonged activated partial thromboplastin time, an anti-prothrombinase was present in 33. Of the 111 patients with a normal activated partial thromboplastin time, anti-prothrombinase was present in 51. Circulating lupus anticoagulant seems to be common in HIV seropositive patients, since it was found in 84 patients (53.5%). Our findings confirm that the presence of circulating anticoagulants is not particularly associated with opportunistic infections or the development of the disease. It is possible that these inhibitors could be mediated by anti-phospholipid antibodies. In HIV seropositive patients, defective T cell regulation of B cells leads to polyclonal hypergammaglobulinemia. These antibodies may be directed against endogenous or exogenous phospholipids.     

Human immunodeficiency virus infection and the liver

Liver disease in human immunodeficiency virus(HIV)-infected individuals encompasses the spectrum from abnormal liver function tests,liver decompensation,with and without evidence of cirrhosis on biopsy,to non-alcoholic liver disease and its more severe form,non-alcoholic steatohepatitis and hepatocellular cancer.HIV can infect multiple cells in the liver,leading to enhanced intrahepatic apoptosis,activation and fibrosis.HIV can also alter gastro-intestinal tract permeability,leading to increased levels of circulating lipopolysaccharide that may have an impact on liver function.This review focuses on recent changes in the epidemiology,pathogenesis and clinical presentation of liver disease in HIV-infected patients,in the absence of co-infection with hepatitis B virus or hepatitis C virus,with a specific focus on issues relevant to low and middle income countries.     

Human immunodeficiency virus infection and renal failure

Renal manifestations are an important component of HIV disease. Renal disease significantly contributes to morbidity and mortality in patients with HIV. Great progress has been made in identifying specific glomerular lesions and its pathogenesis. Newer antiretroviral agents offer great promise in preventing renal disease and also in patients with established HIVAN. Survival of patients with HIV and ESRD (irrespective of cause) who are receiving RRT continues to improve over the years. Acute reversible renal failure, a preventable complication, is also declining in hospitalized HIV patients. More and more physicians, who in the past were reluctant to care for patients with HIV and renal failure because of grim prognosis, are now becoming familiar with the renal sequelae and are encouraged by recent favorable results. As knowledge about viruses is expanding, the proper use of newer highly effective antiretroviral and other agents in complicated patients should further improve both the survival and quality of life in patients with HIV infection and renal disease.     

Human immunodeficiency virus infection in systemic lupus erythematosus

This report describes a female patient with systemic lupus erythematosus (SLE) who was infected with the human immunodeficiency virus (HIV). Using stored serum, the precise timing of HIV seroconversion was determined and the early effects of HIV infection on SLE examined. This infection resulted in clinical improvement and the disappearance of autoantibody production. A literature review of the association between HIV and SLE is provided.