Specificity of IgM antiglobulins produced in rheumatoid arthritis and tropical infections

Summary The measurement of rheumatoid factors is of limited value in West Africa due to the low rheumatoid factor seroprevalence among patients with rheumatoid arthritis and the increased seroprevalence among healthy individuals and those with infectious diseases in the region. Using ELISA methods, we have been able to increase the specificity of rheumatoid factor measurement although the sensitivity of this test remains low. Furthermore, among the infectious diseases studied, there was no preferential binding of rheumatoid factors to the Fab gamma protion of immunoglobulin over the Fc gamma portion.     

Opportunistic fungal infections in patients with neoplastic disease

Opportunistic infections with yeast and molds are increasingly common in patients with neoplastic diseases. Candida species, Aspergillus species, Phycomyctes, and Cryptococcus neoformans remain most common, but other organisms are being encountered as pathogens. With the exception of Cryptococcus, most opportunistic fungal infections are difficult to diagnose. New diagnostic tests for these diseases are being evaluated. Amphotericin B remains the antifungal agent of choice. In certain patients, the addition of 5-flurocytosine may improve the outcome. Experience with cryptococcosis in severely immunocompromised cancer patients at Memorial Sloan-Kettering Cancer Center suggests that those who are treated with amphotericin B intravenously and intraventricularly via an Ommaya reservoir along with 5-flurocytosine do better than those treated with amphotericin B alone.     

Entecavir as treatment for reactivation of hepatitis B in immunosuppressed patients

AIM: To study the efficacy and safety of entecavir (ETV) as first-line therapy for hepatitis B virus (HBV) reactivation due to immunosuppression. METHODS: Four patients that were treated with different immunosuppressive regimens for hematological malignancies, who presented with HBV reactivation were treated with ETV. Clinical outcome, biochemical and virological factors, including quantitative hepatitis B surface antigen (HBsAg) were studied. RESULTS: In all patients, ETV induced suppression of HBV, and rapid clinical improvement without side effects. In one patient with an alanine aminotransferase (ALT) flare, tenofovir was added after 3 mo of treatment. Until death from disease progression at 6 mo after treatment initiation, this patient did not clear HBV infection. Retrospectively, it is highly probable that thepatient had been non-adherent. In the other three patients, the virological responses were associated with an expeditious decrease in quantitative HBsAg titers with negativity after 2 mo, and all three had HBsAg seroconversion. In one patient, HBV DNA reached a plateau after 3 mo, before becoming undetectable after 1 year, despite early ALT normalization and undetectable quantitative HBsAg. CONCLUSION: ETV seems to be effective and safe treatment for HBV reactivation. Monitoring of quantitative HBsAg might be an additional useful tool to monitor treatment response.     

Opportunistic infections and malignancies in 231 Danish AIDS patients

We analysed cumulative disease frequencies in the first 231 adult Danish AIDS patients with life tables. There was a certain hierarchical pattern in the occurrence of complicating diseases. Herpes zoster, Kaposi's sarcoma and Pneumocystis carinii pneumonia were early manifestations, whereas diseases caused by cytomegalovirus and atypical mycobacteria tended to occur later in the course of AIDS. Compared with all other AIDS patients, homosexual men were more likely to develop Kaposi's sarcoma, cytomegalovirus chorioretinitis and mucocutaneous herpes simplex virus infection. The proportion of patients who developed particular diseases changed with calendar time. Most striking was a three to fourfold decrease in diseases caused by cytomegalovirus. In conclusion, the study showed that disease frequencies in patients with AIDS may vary with the patients risk behaviour and duration of AIDS, and that the frequencies of particular diseases may change with calendar time.     

Epidemiology of healthcare-associated infections among patients from a hemodialysis unit in southeastern Brazil

Patients submitted to hemodialysis are at a high risk for healthcare-associated infections (HAI). Presently there are scarce data to allow benchmarking of HAI rates in developing countries. Also, most studies focus only on bloodstream infections (BSI) or local access infections (LAI). Our study aimed to provide a wide overview of HAI epidemiology in a hemodialysis unit in southeastern Brazil. We present data from prospective surveillance carried out from March 2010 through May 2012. Rates were compared (mid-p exact test) and temporally analyzed in Shewhart control charts for Poisson distributions. The overall incidence of BSI was 1.12 per 1000 access-days. The rate was higher for patients performing dialysis through central venous catheters (CVC), either temporary (RR = 13.35, 95% CI = 6.68–26.95) or permanent (RR = 2.10, 95% CI = 1.09–4.13), as compared to those with arteriovenous fistula. Control charts identified a BSI outbreak caused by Pseudomonas aeruginosa in April 2010. LAI incidence was 3.80 per 1000 access-days. Incidence rates for other HAI (per 1000 patients-day) were as follows: upper respiratory infections, 1.72; pneumonia, 1.35; urinary tract infections, 1.25; skin/soft tissues infections, 0.93. The data point out to the usefulness of applying methods commonly used in hospital-based surveillance for hemodialysis units.     

Opportunistic infections in patients with inflammatory bowel disease undergoing immunosuppressive therapy

Immunosuppressive agents (azathioprine, methotrexate) are increasingly being used in the treatment of inflammatory bowel disease. The use of immunosuppressive agents is associated with a greater risk of opportunistic infections, the most frequent of which are those caused by cytomegalovirus and varicella zoster virus. We present four cases of opportunistic infections due to Herpesviruses in patients undergoing immunosuppressive treatment with azathioprine for Crohn's disease. We also review the literature published on this topic. Two patients presented cutaneous varicella complicated by pneumonia and esophagitis respectively, one patient had cutaneous herpes zoster and the other had fatal pneumonia possibly caused by the Herpesvirus. In the first three the clinical course of the infection was favorable after withdrawing immunosuppressant treatment and initiating treatment with aziclovir. In patients Crohn's disease azathioprine treatment increases the risk of opportunistic infection by Herpesvirus. However, in the absence of other factors that increase immunosuppression, these infections usually have a benign course with specific antiviral therapy.     

Opportunistic infections in polymyositis and dermatomyositis

OBJECTIVE: To assess prevalence and characteristics of opportunistic infections in patients with polymyositis/dermatomyositis (PM/DM). To determine the predictive values for opportunistic infections on clinical presentation, biochemical findings, and paraclinical features of PM/DM to detect patients at risk of opportunistic infections. METHODS: The medical records of 156 consecutive PM/DM patients in 3 medical centers were reviewed. RESULTS: Eighteen PM/DM patients (11.5%) developed opportunistic infections. The majority of patients exhibited an opportunistic infection after the onset of PM/DM (89% of cases). Opportunistic infections occurred most frequently during the first year following PM/DM diagnosis (62.5%). The pathogen microorganisms responsible for opportunistic infections were various, i.e., Candida albicans, Pneumocystis carinii, Aspergillus fumigatus, Geotrichum capitatum, Mycobacterium avium-intracellulare complex, M. xenopi, M. marinum, M. tuberculosis, Helicobacter heilmanii, cytomegalovirus, and herpes simplex virus. Mortality rates were as high as 27.7% in these PM/DM patients. Higher mean daily doses of steroids, lymphopenia, and lower serum total protein levels were significantly more frequent in the group of PM/DM patients with opportunistic infections. CONCLUSION: Our study underscores the high frequency of opportunistic infections in PM/DM, resulting in an increased mortality rate. It also indicates that a great variety of microorganisms are responsible for opportunistic infections, although they were more often due to fungi (>50% of cases). Our series highlights a predominance of both lung and digestive opportunistic infections (89% of cases). In addition, our results suggest that PM/DM patients presenting with factors predictive of opportunistic infection may require closer monitoring.     

Opportunistic infections in endogenous Cushing's syndrome

The cases of 6 patients with endogenous Cushing's syndrome and opportunistic infections were studied, and compared with those of 17 similar patients reported in the literature. Cushing's syndrome was caused by ectopic adrenocorticotrophic hormone production or adrenal tumors in most patients, and hypercortisolism was extreme. Four infectious processes were preponderant: Cryptococcosis, aspergillosis, nocardiosis, or Pneumocystis carinii pneumonia occurred in 21 patients. Signs and symptoms of infection were often masked by the hypercortisolism. Morning plasma cortisol levels correlated with the infection type (rank-order Spearman correlation coefficient = 0.78, p less than 0.01): Levels of less than 70 micrograms/dL or greater than 121 micrograms/dL were associated with cryptococcosis or pneumocystis, respectively, by discriminant analysis. Of the 9 patients who survived their infection, 8 had evidence that cortisol production was reduced to near normal. In contrast, all 14 patients died in whom cortisol production went uncontrolled. In patients with hypercortisolism from endogenous Cushing's syndrome (especially of nonpituitary origin), opportunistic infections should be anticipated and prompt control of cortisol overproduction should be initiated.     

An approach to the diagnosis of pulmonary infections in immunosuppressed patients.

The goal of this review is to provide an approach to the diagnosis of pulmonary infections in immunosuppressed patients. First, a framework will be provided to narrow the extensive list of possible infectious and noninfectious pulmonary complications. This can be accomplished by considering the underlying immune defect, the pattern of radiographic presentation, the rapidity of progression of radiographic infiltrates, the typical temporal pattern of infection in specific disease states, and the local epidemiology at one's institution. Next, the yields and potential complications of invasive and noninvasive diagnostic techniques for pulmonary infections are reviewed. Lastly, algorithms, which account for the pattern of radiographic presentation, the primary disease and its underlying immune defect and the anticipated yields and complications of diagnostic procedures, are provided as a suggested plan for the use of diagnostic techniques and the institution of therapy.