Visceral leishmaniasis in patients infected with human immunodeficiency virus (HIV)

In an 8-month period nine patients with human immunodeficiency virus (HIV) infection were diagnosed as having visceral leishmaniasis; all diagnoses were based on cultures (eight from bone marrow and one from the skin). Visceral leishmaniasis developed before full-blown acquired immunodeficiency syndrome (AIDS) in seven patients and at the same time as or after AIDS in the other two patients. Three patients had a history of leishmaniasis. Clinical manifestations and laboratory findings were atypical. Leishmania species were cultured from samples taken from all patients; however, six patients had an insignificant antileishmanial antibody titer and Leishmania amastigotes were not seen in their bone marrow smears. Four isolates were identified by isoenzyme analysis as Leishmania donovani infantum. Five patients died, including two patients who had completed at least one 3-week course of therapy with N-methylglucamine antimoniate. Screening should be done for visceral leishmaniasis in patients with HIV infection who live or travel in areas where the disease is endemic. The diagnosis of visceral leishmaniasis may frequently be missed if cultures are not done.     

Non-cryptosporidial diarrhoea in human immunodeficiency virus (HIV) infected patients.

Thirty of 81 consecutive HIV antibody positive patients referred with non-cryptosporidial diarrhoea had no potential infectious cause; most had AIDS related complex rather than the full blown syndrome. Opportunistic infections with cytomegalovirus (CMV), mycobacterium avium-intracellulare (MAI), and herpes simplex virus (HSV), which allowed a diagnosis of AIDS to be made, were found in 19 patients and were the presenting features of AIDS in five. Other potential pathogenic species included entamoeba, giardia, campylobacter, and salmonella (without septicaemia). Cytomegalovirus infection was often accompanied by abdominal pain. Severe weight loss (greater than 10 kg) at presentation was found in patients with CMV infection and MAI. Bloody diarrhoea was confined to the group with HSV procitis. Malignant causes of diarrhoea were rare. Two patients developed a squamous carcinoma of the anorectal margin and one a non-Hodgkin's lymphoma. In only two of 12 patients who had Kaposi's sarcoma was this considered as a cause of diarrhoea. Rigid sigmoidoscopy showed macroscopic abnormalities in over a third (32) of the 81 patients with non-cryptosporidial diarrhoea. Most commonly this was severe inflammation (17) or discrete ulceration (four) [three of whom had CMV colitis]. Kaposi's sarcoma was identified in 11 patients. Non-specific inflammation was seen histologically in 40 of the 60 patients with no sigmoidoscopic inflammatory changes. Barium enema only revealed an abnormality in a minority of the patients and a colonoscopy only revealed information additional to rigid sigmoidoscopy in two patients--one with CMV ulcers in the transverse colon and the other with evidence of Kaposi's sarcoma not seen in the rectum. Ten patients had a rectal biopsy examined by electron microscopy as no infective cause of diarrhoea was uncovered. In four of these microtubular structures which are commonly seen in viral infections were found and two had prelymphomatous changes and in one of these frank lymphoma has developed. We recommend multiple stool analysis, sigmoidoscopy and rectal biopsy as the initial investigations in these patients reserving tests of malabsorption, colonoscopy, and barium enema for the small number of more difficult cases.     

Pneumocystis carinii infection among human immunodeficiency virus (HIV) infected Myanmar patients

A total of 60 HIV infected patients complaining of dry cough for at least two weeks and attending the Out-patient Department of the Specialist Hospital, Waibargi, were screened for Pneumocystis carinii. Induced sputum samples were examined with Giemsa and Gomori silver methenamine stains. P. carinii were detected in 18 patients (30%) with silver stain and 13 patients (21.7%) with Giemsa stain. The sensitivity and specificity of the Giemsa stain were 72.2% and 95.2%, respectively. The range of CD4 counts in P. carinii-positive patients was found to be 0-562/microl, and the mean CD4 count was 132.3/microl. Out of 18 P. carinii-positive cases, CD4 counts of 15 cases (83.3%) were <200/microl and those of 3 cases were >200/microl. Clinically, P. carinii-positive cases were associated with fever in 55.5%, with tightness of the chest in 38.9%, and with cyanosis and tightness of the chest in 11.1%. Co-infection with tuberculosis was found in 16.7%. Anti-pneumocystic prophylaxis is recommended for those patients with a CD4 count <200/microl. Giemsa staining could be used as an alternative diagnostic method for detecting P. carinii. This study documented the existing prevalence of P. carinii among HIV-infected Myanmar patients.     

Treatment of chronic hepatitis C virus infection in human immunodeficiency virus (HIV) infected patients

Treatment of chronic hepatitis C Virus (HCV) infection in human immunodeficiency virus (HIV) infected patients has become a topic of great importance, since the complications of chronic hepatitis are the first one cause of mortality among HIV patients. The aim of this study is to review the biological and epidemiological data in HIV-HCV coinfection, to establish treatment guidelines taking in consideration drugs' adverse effects and interactions, and to report the results of the main studies carried out. The treatment currently accepted includes pegylate interferon andribavirin, which have improved prior treatments, but the response rate depends on HCV genotype.     

Psychosocial counselling of patients infected with human immunodeficiency virus (HIV) in Lusaka, Zambia

We describe a method of psychosocial counselling that we have used with HIV-infected patients in Zambia. The protocol included providing the patient with factual information about HIV infection, understanding the patient's concept of their illness, and teaching the need to change sexual behaviour, reduce alcohol consumption, prevent stress, and adjust to family changes. Our aims have been to enable HIV-infected persons to avoid behaviour that might damage their own health, to minimize further transmission of HIV, and to prolong the period of asymptomatic HIV infection and life expectancy.     

Chronic lung disease in human immunodeficiency virus (HIV) infected children

The development of chronic lung disease is common in HIV-infected children. The spectrum of chronic HIV-associated lung disease includes lymphocytic interstitial pneumonia (LIP), chronic infections, immune reconstitution inflammatory syndrome (IRIS), bronchiectasis, malignancies, and interstitial pneumonitis. Chronic lung disease may result from recurrent or persistent pneumonia due to bacterial, mycobacterial, viral, fungal or mixed infections. In high tuberculosis (TB) prevalence areas, M. tuberculosis is an important cause of chronic respiratory illness. With increasing availability of highly active antiretroviral therapy (HAART) for children in developing countries, a rise in the incidence of IRIS due to mycobacterial or other infections is being reported. Diagnosis of chronic lung disease is based on chronic symptoms and persistent chest X-ray changes but definitive diagnosis can be difficult as clinical and radiological findings may be non-specific. Distinguishing LIP from miliary TB remains a difficult challenge in HIV-infected children living in high TB prevalence areas. Treatment includes therapy for specific infections, pulmonary clearance techniques, corticosteroids for children with LIP who are hypoxic or who have airway compression from tuberculous nodes and HAART. Children who are taking TB therapy and HAART need adjustments in their drug regimes to minimize drug interactions and ensure efficacy. Preventative strategies include immunization, chemoprophylaxis, and micronutrient supplementation. Early use of HAART may prevent the development of chronic lung disease.     

Influenza A pneumonitis in a patient infected with the human immunodeficiency virus (HIV)

Influenza A results in considerable morbidity, mortality and economic costs. Although immunoprophylaxis and chemoprophylaxis are targeted toward high-risk groups, persons with human immunodeficiency virus (HIV) infection have not been widely recognized as being at increased risk of influenza infection. We report a case of influenza A pneumonitis in a patient infected with HIV. The literature on influenza immunization of HIV-infected patients is reviewed and the implications for public health are discussed. Consideration should be given to influenza immunization and chemoprophylaxis in this enlarging population. Further investigation of the pathogenesis and epidemiology of influenza in HIV-infected patients is warranted.     

Problems in the management of opportunistic infections in patients infected with human immunodeficiency virus

Opportunistic infections ultimately occur in most patients infected with human immunodeficiency virus (HIV) and are responsible for 90% of deaths. Over the decade since the acquired immunodeficiency syndrome (AIDS) was first recognized, important advances have been made in reducing the morbidity and mortality of opportunistic infections in patients infected with HIV. These include an improved understanding of the relationship between immunologic parameters and infection, allowing the occurrence of infectious complications to be more predictable; development of prophylactic regimens and chronic suppressive regimens that are effective, well tolerated, and convenient; and emphasis on earlier diagnosis and therapeutic intervention of those infectious processes that are not prevented. These advances have allowed the quality and duration of patient survival to improve during this decade, but they can also be anticipated to alter the spectrum of clinical manifestations that health care providers are going to see during this epidemic's second decade.     

Bronchial cancer in patients infected with human immunodeficiency virus (HIV). Report of 3 cases

We report 3 cases of bronchial carcinoma in patients with human immunodeficiency virus (HIV) infection. Like the other 13 cases found in the literature, these were characterized by their occurrence in young subjects, their often adenocarcinomatous nature and their abnormally severe course. These clinical features raise the problem of the role played by HIV in the development and, above all, the clinical expression of bronchial carcinoma.     

Listeriosis in patients infected with human immunodeficiency virus

Although resistance to Listeria monocytogenes infection requires intact T cell-mediated immunity, only 20 patients with human immunodeficiency virus (HIV) infection and listeriosis (including one patient described herein) have been reported to date. Listeriosis developed before AIDS in five cases. Syndromes included meningitis in nine cases, bacteremia in nine, brain abscess in one, and endocarditis in one. Eighteen patients were treated with ampicillin, penicillin, or amoxicillin with or without aminoglycosides. Clinical and microbiologic responses were obtained in one patient with bacteremia treated with vancomycin and in one patient with meningitis treated with trimethoprim-sulfamethoxazole. Three of the nine patients with meningitis died, as did the patient with brain abscess. All nine patients with bacteremia and the patient with endocarditis survived. No case of relapse was documented. L. monocytogenes, although uncommon, should be considered in the differential diagnosis of febrile illness, meningitis, and brain abscess in patients with HIV infection.     

Nonspecific interstitial pneumonitis without evidence of Pneumocystis carinii in asymptomatic patients infected with human immunodeficiency virus (HIV)

STUDY OBJECTIVE: To assess how often Pneumocystis carinii organisms, P. carinii pneumonia, or other pulmonary pathologic processes were present in persons infected with human immunodeficiency virus (HIV) without pulmonary symptoms or previous history of P. carinii, and with a normal chest roentgenogram. DESIGN: Serial, prospective assessment of eligible HIV-seropositive patients over 21 months. PATIENTS: Twenty-four HIV-seropositive patients with either a nonpulmonary manifestation of the acquired immunodeficiency syndrome (AIDS) (n = 12) or an absolute CD4 lymphocyte count of 0.200 X 10(9) cells/L or less (n = 12), no pulmonary symptoms, a normal chest roentgenogram, no history of P. carinii pneumonia, and no history of treatment with antipneumocystis prophylaxis. INTERVENTIONS: Pulmonary assessment with arterial blood gases, pulmonary function tests, gallium-67 citrate scans, and bronchoscopy with bronchoalveolar lavage and transbronchial biopsies. MEASUREMENTS AND MAIN RESULTS: Mean alveolar-arterial gradient was 11.1 mm Hg +/- 8.5 and mean diffusion capacity was 73.0% +/- 20.0% of predicted. None of the 24 patients showed P. carinii or other pathogens on stains of bronchoalveolar lavage fluid. No patient had histologic evidence of P. carinii pneumonia. Transbronchial biopsy specimens showed chronic, nonspecific interstitial pneumonitis (11 of 23) and no pathologic abnormality (12 of 23). Six patients have developed P. carinii pneumonia during 2 to 18 months of follow-up. CONCLUSIONS: HIV-infected patients without pulmonary symptoms did not have detectable Pneumocystis organisms in bronchoalveolar lavage fluid or transbronchial biopsy specimens; but 11 of 23 had evidence of chronic, nonspecific interstitial pneumonitis. Pneumocystis organisms in a pulmonary specimen from a symptomatic patient probably indicate the cause of the pulmonary dysfunction even if only a few are detected.     

Prophylaxis against opportunistic infections in persons infected with human immunodeficiency virus

This article outlines the current official recommendations for the prevention of opportunistic disease in adults and adolescents infected with human immunodeficiency virus, including specific guidelines for discontinuing primary and secondary prophylaxis when immune reconstitution has occurred as a result of highly active antiretroviral therapies. The recommendations, developed by the U. S. Public Health Service and the Infectious Diseases Society of America for clinicians and healthcare providers, were originally published in 1995 and revised in 1997, 1999, and 2002. The 2002 recommendations are summarized in this article.     

Impact of human immunodeficiency virus (HIV) infection on the progression of liver fibrosis in hepatitis C virus infected patients

OBJECTIVES: To compare the rate of hepatic fibrosis progression in hepatitis C virus (HCV) infected and human immunodeficiency virus (HIV)-HCV coinfected patients, and to identify factors that may influence fibrosis progression. PATIENTS AND METHODS: A total of 153 HCV infected and 55 HCV-HIV coinfected patients were identified from two London hospitals. Eligible patients had known dates of HCV acquisition, were HCV-RNA positive, and had undergone a liver biopsy, which was graded using the Ishak score. Univariate and multivariate logistic regression analyses were used to identify factors associated with fibrosis progression rate and the development of advanced fibrosis (stages 3 and 4). RESULTS: The estimated median fibrosis progression rate was 0.17 units/year (interquartile range (IQR) 0.10-0.25) in HIV-HCV coinfected and 0.13 (IQR 0.07-0.17) in HCV monoinfected patients (p=0.01), equating to an estimated time from HCV infection to cirrhosis of 23 and 32 years, respectively. Older age at infection (p<0.001), HIV positivity (p=0.019), higher alanine aminotransferase (ALT) level (p=0.039), and higher inflammatory activity (p<0.001) on first biopsy were all independently associated with more rapid fibrosis progression. ALT was correlated with histological index (r=0.35, p<0.001). A CD4 cell count < or =250 x 10(6)/l was independently associated with advanced liver fibrosis (odds ratio 5.36 (95% confidence interval 1.26-22.79)) and was also correlated with a higher histological index (r=-0.42, p=0.002). CONCLUSION: HIV infection modifies the natural history of HCV by accelerating the rate of fibrosis progression by 1.4 fold, and the development of advanced fibrosis threefold. A low CD4 cell count was independently associated with advanced disease and correlated with higher histological index, which suggests that early antiretroviral therapy may be of benefit in slowing HCV progression in coinfected patients.