Enteropathic AIDS in Uganda. An endoscopic, histological and microbiological study

Twenty-three Ugandan patients with enteropathic acquired immunodeficiency syndrome (AIDS, 'slim' disease) were studied. Upper gastrointestinal (GI) endoscopy, colonoscopy, biopsy, stool parasitology and culture were performed. Endoscopy revealed oral and/or oesophageal candidiasis in 22 patients. Stool examination and histology of the upper GI tract showed that 11 patients had cryptosporidiosis and three had isosporiasis (total of 61% of patients with coccidian enteritis). One case of possible Mycobacterium avium mycobacteriosis was also identified. Enteropathic AIDS in Uganda presents with a spectrum of infections similar to that found in developed countries, but the incidence of cryptosporidiosis and isosporiasis is higher.     

Faecal mycobacteria and their relationship to HIV-related enteritis in Lusaka, Zambia

The prevalence of infection with mycobacteria, both typical and atypical, is increasing along with prevalence of infection with HIV. Patients with pulmonary tuberculosis (PTB) and patients with chronic diarrhoea are forming a growing proportion of the patient population in hospitals in central Africa. To investigate the possibility that mycobacteria may be responsible for some of the HIV-related enteropathy seen in Lusaka, we studied 89 patients in four different diagnostic groups, clinically, by Mantoux test and by microscopy and culture of stool specimens for mycobacteria. In the HIV-positive group with chronic diarrhoea (n = 31), two patients were found to have mycobacteria on faecal smear and three were culture positive while of the 15 HIV-negative controls, three were smear positive and three were culture positive. Of the 15 patients with proven PTB, three had positive faecal smears but none were culture positive. In the fourth group of 24 patients with suspected PTB, seven were smear positive and five, culture positive. Only in this last group was there some correlation between smear results and culture results. Although this last finding is difficult to explain, it appears that there is no correlation between the symptom of chronic diarrhoea and the presence of mycobacteria in the stool. We conclude that mycobacteria do not play a significant role in the pathogenesis of HIV-related enteropathy in Lusaka.     

Quantitative histological study of enteropathy associated with HIV infection.

A quantitative histological study was performed on small intestinal biopsies from eight ambulatory patients with HIV infection (AIDS/AIDS-related complex, ARC) and compared with those from 16 normal subjects. Enteropathy was assessed by measurement of villus area, crypt length and mitotic count, as well as duodenal counts of intraepithelial lymphocytes, mucosal mast cells and goblet cells. Enteropathy in subjects with AIDS/ARC was shown by reduced mean villus area of 0.363 (SD 0.081) compared with 0.500 (SD 0.064) mm2 in control subjects (p less than 0.0001), while intestinal crypts were of similar length with 239 (SD 36) compared with 225 (SD 28 microns, but mitotic count was increased to 3.8 (SD 1.2) compared with 2.4 (SD 0.8) (p = 0.01) in the same control subjects. These results indicate villous atrophy with impaired crypt hyperplasia. Duodenal cell counts showed similar numbers of mucosal mast cells, intraepithelial lymphocytes and goblet cells in AIDS/ARC patients and fifteen control subjects.     

Demographic,clinical and microbiological characteristics of maternity patients: A Canadian clinical cohort study

OBJECTIVE:

To determine the demographic, clinical and microbiological characteristics of a representative Canadian obstetrical population.

DESIGN:

A one-year cohort study of all maternity patients who were followed to delivery, using detailed patient questionnaires containing more than 60 demographic and clinical variables, and three microbiological evaluations during gestation - first trimester, 26 to 30 weeks, and labour and delivery. Outcome measurements included birth weight and gestational age.

SETTING:

Labour and delivery suites of all office obstetrical practices affiliated with a single hospital.

POPULATION STUDIED:

A consecutive sample of pregnant women in the study practices during one year were eligible for enrolment; 2237 consecutive patients were approached for consent, 2047 enrolled and 1811 completed the study through delivery.

RESULTS:

The average patient was white, married and 29 years of age. Slightly more than half of the patients had postsecondary education, but 10% fell below the national poverty line for income. Frequency of factors linked to adverse pregnancy outcomes included cigarette smoking (19%), alcohol ingestion (18%), previously having had a premature infant (7%), and maternal diabetes (2%). Overall prevalence of genital microbes variously implicated in prematurity was 37% for ureaplasma, 11% for group B streptococcus and 4% for Mycoplasma hominis. Prevalence of bacterial vaginosis was 14%. The median gestational age for the cohort was 39 weeks, with 7% of infants born less than 37 weeks'' gestation. Mean birth weight was 3415 g.

CONCLUSIONS:

The present clinical cohort represents demographic and medical characteristics of the Canadian obstetrical population. The birth outcomes are consistent with national data. This database provides valuable information about a general obstetrical population that is managed by a universal health care system.Key Words: Genital tract infections, Prematurity, Risk factorsPremature birth (PB), defined as occurring at less than 37 weeks'' gestation, is the leading cause of perinatal mortality and morbidity in the industrialized world (1,2). Despite this recognition and advances in perinatal care, the prevalence of PB in the developed world has increased in recent years (3-6). The medical and economic impact of PB is appreciated specifically in the perinatal and/or neonatal periods, but also continues throughout life. Many factors, including socioeconomic, reproductive and medical conditions have been implicated in the etiology of PB (5,7). Infections have been increasingly recognized as important risk factors for PB (8-11). In some cases, such as with bacterial vaginosis, the stage of gestation during which infection occurs appears to be important in pregnancy outcome (12,13). However, results from several studies have been inconsistent and confounding risk factors have often not been assessed (10,14,15). Antibiotic treatment trials designed to eradicate infections to decrease the incidence of PB have yielded inconsistent results (14,16-21). The majority of studies on PB, carefully conducted and sometimes including large numbers of patients, have involved high risk obstetrical populations, and the results may not necessarily be extrapolated to general populations (1). The purpose of the present study was to evaluate a general obstetrical cohort population and to ultimately assess genital infections at various stages of pregnancy, including labour, in conjunction with other potential risk factors related to PB or low birth weight (less than 2500 g).     

Susceptibility of Streptococcus pneumoniae to penicillin: a prospective microbiological and clinical study.

We performed a prospective study of all infections with Streptococcus pneumoniae documented during a 22-month period at our hospital. A total of 163 clinically significant strains of S. pneumoniae were isolated from 139 patients whose ages ranged from 8 days to 91 years (mean +/- SD, 42.6 years +/- 26.8 years). Twenty percent of the patients had cancer, and 18% were infected with the human immunodeficiency virus. Pneumococcal infection was nosocomially acquired in one-fourth of cases. One-third of patients had nonpneumonic disease. A wide range of serotypes were isolated, and 42.5% of all strains were nonsusceptible--i.e., showed either intermediate or high-level resistance--to penicillin. The rates of resistance to chloramphenicol, erythromycin, and tetracycline were 23%, 10.8%, and 48.2%, respectively. Twenty-two percent of the infected patients died, with a 15.8% mortality directly attributable to pneumococcal infection. Factors associated with infection by strains of S. pneumoniae not susceptible to penicillin included an age of less than or equal to 10 years, immunosuppression, the presence of a rapidly fatal underlying disease, previous antimicrobial therapy, and infection by serotypes 14 and 23. All clinically significant isolates of S. pneumoniae should be submitted for antimicrobial susceptibility studies, and, whenever a high prevalence of resistance to penicillin and macrolides is detected, the use of these well-established empirical therapeutic regimens should be reconsidered.     

Cancer surveillance of patients with longstanding ulcerative colitis: a clinical, endoscopical, and histological study.

An eight year endoscopical and histological cancer surveillance programme comprising 71 patients with ulcerative colitis is presented. Forty one patients had total colitis and 30 substantial colitis. Mean duration of the disease was 19.7 years (range 9-46 years). An average of 2.6 colonoscopies per patient in the total colitis group were carried out, and at least two biopsies were taken at 10 locations in the colon. In the total colitis group, seven had either low (four), or high grade dysplasia (two), or Dukes' A cancer (one). In the group with substantial colitis two patients with low grade dysplasia were found. Dysplasia or cancer leading to operation was found above the rectum in four of five operated patients, all having had total colitis for 25 to 44 years. The dysplasia and cancer findings at the colonoscopy preceding surgery corresponded well with the surgical specimens. In three operated patients a sequence of dysplasia development was recorded. With the exception of long duration and dysplasia, nothing in the clinical course distinguished the operated cases. Using this surveillance programme prophylactic colectomy can be limited to patients in a high risk group developing dysplasia. The risk of missing a cancer before it becomes incurable seems to be low.     

A clinical, immunological, and histological study of neuritic leprosy patients

An assessment has been made of 108 neuritic leprosy patients to find out if the number of affected nerves and the clinical presentations of these patients give any indication of the underlying severity (classification) of the disease. Detailed clinical recordings, skin smears, lepromin testing with Dharmendra antigen, and a leukocyte migration inhibition test (LMIT) using sonicated Mycobacterium leprae antigens were done in these patients. Nerve biopsies of available affected nerves were taken in 39 patients. The results show that neuritic leprosy patients also have a spectrum. However, none of the clinical parameters, including the number and distribution of affected nerves, the immune response and the nerve histology, were found to be inter-related. Further, even though all of the patients were skin-smear negative, a significant proportion showed lepromatous histology and nearly two thirds had a moderate-to-heavy bacterial load within the nerves.     

Pneumococcal bacteraemia: clinical and microbiological epidemiology in Dundee,Scotland

OBJECTIVE: To report the incidence of drug resistant Streptococcus pneumoniae isolated from blood culture in Dundee, Scotland. We shall also review the clinical and laboratory findings in these cases.METHODS: A retrospective review was undertaken of all cases of S. pneumoniae bacteraemia identified in our local area during a three year period from August 1st, 1997 to July 31st, 2000 (107 cases.) Data was obtained from patient medical records, blood culture reports and results of Stoke's disk testing. Many organisms were also sent to the Scottish Meningococcus and Pneumococcus Reference Laboratory for serogrouping and determination of the minimum inhibitory concentration of common antibiotics.RESULTS: Annual incidence of bacteraemia was approximately 15.9-17.8 per 100000 population. Mortality was 33% (34 and 30% for those with pneumonia or meningitis, respectively). No relationship was seen between patient age and overall mortality. Factors relating to increased mortality were a high respiratory rate (p=0.01), high blood urea level (p=0.05) and the presence of confusion (p<0.01) on admission to hospital.The incidence of penicillin resistant S. pneumoniae was 7%, all of these isolates having low level resistance. Macrolide resistance was 8%. Neither were found to be increasing over the three year period. The most common serogroups were 23 (18%) and 14 (12%).CONCLUSIONS: The incidence of penicillin resistant S. pneumoniae isolated from blood culture in Dundee, Scotland, is similar to the UK average and did not appear to be rising between 1997 and 2000.     

Viridans streptococcal endocarditis: clinical, microbiological, and echocardiographic correlations

Infections caused by species within the viridans streptococci have been associated with different clinical characteristics. We studied 36 patients with viridans streptococcal endocarditis. Complications were seen in 10 (32%) of 31 patients with native valve endocarditis and four (80%) of five with prosthetic valve endocarditis and included death in two, valve replacement in six, persistent infection in three, emboli in two, and congestive heart failure in nine. Two-dimensional echocardiograms demonstrated vegetations in 26 (72%) of 36, flail mitral valves in seven, disruption of aortic valve prosthesis in one, and perivalvular abscesses in three (two Streptococcus sanguis I and one Streptococcus intermedius I). All twelve patients with native valve endocarditis who suffered complications had vegetations detected by two-dimensional echocardiography, whereas seven patients with native valve endocarditis without vegetations, as detected by two-dimensional echocardiography, had no complications (P = .03). We found no significant correlation between streptococcal species and clinical outcome. To confirm our identifications, we sent 16 identical viridans streptococcal endocarditis isolates to five institutions; only three of 16 were identified as the same species by all five institutions. We conclude that viridans streptococcal endocarditis can be associated with a virulent clinical course and that there is marked variability in species designations of individual strains by different laboratories.     

HIV-related thrombocytopenic purpura: a study of 24 cases

In this paper we review our experience with HIV-related thrombocytopenic purpura (TP) in 24 patients seen from October, 1985 through April, 1988: the median follow-up was 16 months (range 3-32). All patients belonged to risk groups for AIDS and intravenous drug abusers represented 83% of the entire cohort. The male/female ratio was 4, and most of the patients were Walter Reed stage 3. The mean value of platelets at diagnosis was 33 x 10(9)/liter (range 6-120), and half of the patients had severe thrombocytopenia with hemorrhagic symptoms. Anemia and/or neutropenia were concomitant with TP in 21% and 17% of cases; four cases had pancytopenia. Marrow pictures showed megakaryocytic hyperplasia in 68% of cases; myelodysplasia or hypoplasia were observed in 14% and 18% of patients, respectively; lymphoid aggregates were present in two cases. Antiplatelet antibodies and circulating immune complexes were detected in 40% and 50% of cases, and the mean T4/T8 ratio was 0.9 (range 0.4-1.8). Half of the patients did not require specific therapy due to lack of bleeding; however no spontaneous reversions to normal platelet values occurred. The response to steroids and to immunoglobulins (either high-dose or anti-D) was good but temporary, and required maintenance therapy. The 2-year actuarial risk of evolution into overt AIDS was 30%, with a crude rate of 4 cases over 365 person-months at risk. The events which determined AIDS were opportunistic infections in two cases, Kaposi's sarcoma and malignant lymphoma in the other two. A comparison with the features of idiopathic TP is made and hypotheses regarding the pathogenetic mechanisms are discussed.     

HIV-related pulmonary arterial hypertension: clinical presentation and management

Pulmonary arterial hypertension (PAH) is a progressive albeit rare long-term complication of HIV infection, which has gained importance following the improved survival of HIV-infected patients with the use of HAART. The clinical and pathological findings in PAH associated with HIV infection (HIV-PAH) share many features with the idiopathic form of the disease. HIV-PAH is associated with a particularly poor prognosis and decreased survival compared with HIV-infected patients without this complication, and patients with HIV-PAH tend to die from the effects of PAH rather than as a result of their HIV infection. Prompt diagnosis and effective treatment of PAH in HIV-infected patients is therefore essential. There are currently only limited data regarding the efficacy of PAH therapies in HIV-PAH. Treatment with epoprostenol has been reported to provide benefit in some cases, but is associated with a range of problems linked to the need for continuous intravenous infusion. The dual endothelin receptor antagonist bosentan has proved to be effective in HIV-PAH without affecting the control of HIV infection, and has the benefit of oral administration. Other PAH therapies including prostacyclin analogs, phosphodiesterase type 5 inhibitors and selective endothelin receptor antagonists have yet to be trialed in this setting. Taking into account currently available data and clinical experience, a treatment algorithm for HIV-PAH based on that defined in treatment guidelines for other forms of PAH is suggested.     

Cefuroxime prophylaxis in cardiovascular surgery: clinical, microbiological, and ecological impact

To determine the efficacy of cefuroxime as a prophylactic agent against infection, we retrospectively evaluated patients who had undergone cefuroxime therapy for cardiovascular surgery procedures in the years 1987 and 1990. In the 403 evaluable patients (203 in 1987 and 200 in 1990), we noted a postoperative surgical wound infection rate of 3% and a nosocomial infection rate of 3%. These rates have remained constant in 1987 and 1990. Despite more than a 6-fold increase in cefuroxime consumption during this same period, we have not observed a selection for staphylococcal infections in cardiovascular surgery patients, nor have we detected a selection for resistant staphylococci in our institution. Our original criteria that caused us to select cefuroxime for routine prophylaxis-notably its equivalent efficacy and safety as compared with other cephalosporins, and its lack of an adverse impact on the hospital flora-remain valid.     

Febrile neutropenia in children with cancer: a retrospective Norwegian multicentre study of clinical and microbiological outcome

Our objective was to describe clinical and laboratory characteristics, treatment and outcome among Norwegian children with cancer suffering from chemotherapy-induced febrile neutropenia (FN). We retrospectively reviewed data on paediatric FN episodes in 7 Norwegian hospitals during a 2.5-y period. A total of 236 episodes of FN occurred in 95 children. Acute lymphoblastic leukaemia was the most common diagnosis (49 patients). Blood cultures yielded growth in 39 episodes (17%). Primary empirical antibiotic regimens could be assigned to 2 main groups: 1) benzylpenicillin or ampicillin and an aminoglycoside (58%) or 2) a regimen based on third-generation cephalosporins (42%). There were no statistically significant differences in outcome between the 2 regimens in terms of need to change initial antibiotic treatment, d of fever or maximum C-reactive protein values. One infection-related death (fungal septicaemia) occurred during the study period. We conclude that incidence of septicaemia and clinical outcome is similar to recent international trials on paediatric FN, but antibiotic treatment in Norway differs from international guidelines. However, patients in our study were successfully and safely treated, irrespective of the primary empirical antibiotic regimen.     

Post-radiotherapeutic left main coronary ostial stenosis: clinical and histological study

Pericardial abnormalities remain the most common manifestationof radiation-induced cardiac disease, but coronary artery lesionsare not rare. In this report we describe a left coronary ostialstenosis which appeared five years after mediastinal irradiationfor breast carcinoma in a 50-year-old woman. The patient underwentcoronary angiography. A pressure drop was observed as the leftcatheter tip engaged the left coronary ostium; so, only nonselectivecoronary opacifications were performed showing an isolated,marked narrowing of the left coronary ostia. During surgery,a circumferential aortotomy allowed the examination of the leftcoronary ostium which appeared severely stenosed. The coronarytree was otherwise normal. A termino-terminal saphenous veingraft was anastomosed on the left stem and its proximal partwas implanted on the ascending aorta. The coronary ostium andthe proximal part of the left main stem were excised and themacroscopic examination of the proximal part of the left coronaryartery confirmed the diagnosis of severe ostial stenosis. Microscopicexamination of the coronary ostium showed a severe intimal thickeningwithout any evident lesion of the media. This intimal thickeningconsisted of fibrous tissue without extracellular lipid deposit.Microscopic examination of the aorta near the coronary ostiumalso demonstrated an intimal thickening without any lesion ofthe media. Coronary ostial stenosis appears to be a rare lesion;its incidence has varied between 0·13 and 2·7%in angiographic studies and there is co-existing disease inmultiple coronary vessels in the majority of cases. This coronarylesion in a middle-aged woman after a mediastinal irradiation,its histologic aspect (pure intimal fibrous thickening), andthe secondary appearance of complete atrio-ventricular block,fits the pattern previously ascribed to radiotherapy. Only twoother cases of coronary ostial lesion almost certainly secondaryto mediastinal irradiation have been reported.     

The spleen in Felty's syndrome: a histological, morphometrical, and immunohistochemical study

A histological study employing morphometrical and immunohistochemical methods was performed in 3 spleens removed because of Felty's syndrome (FS). A comparison was made with control spleens and with spleens removed from patients with idiopathic thrombocytopenic purpura (ITP) or autoimmune hemolytic anemia (AIHA). In FS, the spleen is enlarged, mainly due to expansion of the red pulp. The sinuses are enlarged, too, and contain many macrophages. 2 of our specimens showed many hyperplastic germinal centers; the 3rd contained no germinal centers. Only in the former cases did splenectomy lead to an increase in the number of circulating granulocytes. Immunohistologically, FS spleens differed from the control, the ITP, and the AIHA spleens. The results have provided further evidence indicating that the pathogenesis of granulocytopenia in FS differs from that of autoimmune hematocytopenias, and have given rise to the hypothesis that, in FS, the spleen is the site of interaction between immune complexes and granulocytes.