HIV/AIDS患者机会性感染及其临床特点

目的分析人类免疫缺陷病毒(HIV)所致获得性免疫缺陷综合征(AIDS)患者机会性感染的临床特征,为临床诊治提供依据。方法对2009-01/08在成都市传染病医院住院诊治的153例HIV/AIDS合并机会性感染的患者进行分析。结果为一种或多种非特异性临床表现,常见表现为发热(75.2%)、咳嗽咳痰(67.3%)、消瘦(41.2%)、腹痛腹泻(18.3%)、乏力纳差(15.7%)、头痛(5.9%)及意识障碍(3.3%)。常见的机会性感染为呼吸系统感染(82.4%)(病原菌以真菌和结核杆菌为主),其次为中枢神经系统感染(9.2%)、消化系统感染(7.2%)及皮肤病变(7.8%);部分患者存在多部位(51.6%)及多种病原菌(34.6%)感染。137例检测了T淋巴细胞亚群,其中120例(78.4%)CD4+T淋巴细胞计数200 cell/μl。经治疗后,明显好转109例(71.2%),病情改善22例(14.4%),死亡22例(14.4%);疾病转归与CD4+T淋巴细胞计数有一定关系,81.8%的死亡患者CD4+T淋巴细胞计数50 cell/μl。结论 HIV/AIDS患者机会性感染的部位以肺部最多,病原菌以真菌及结核杆菌为主,部分患者存在多部位、多病原菌感染。     

Oral Beclomethasone Dipropionate as an Alternative to Systemic Steroids in Mild to Moderate Ulcerative Colitis Not Responding to Aminosalicylates

Backgroud  

Aminosalicylates (5-ASA) are first-line treatment for mild-moderate ulcerative colitis (UC). Systemic corticosteroids (CS) are considered for patients in whom 5-ASA has been unsuccessful, but their use is limited by adverse effects. Beclomethasone dipropionate (BDP), a topically acting steroid with low systemic bioavailability, has a more favorable safety profile, but its role in clinical practice is not yet well established.     

Impedance Planimetric Characterization of Esophagus in Systemic Sclerosis Patients with Severe Involvement of Esophagus

This study was designed to evaluate thedistensibility and secondary peristalsis of theesophagus in patients suffering from systemic sclerosiswith severe esophageal involvement. Balloon distensionwith impedance planimetric measurement of luminalcross-sectional area was done 7 and 15 cm above thelower esophageal sphincter in 13 patients and ninehealthy controls. The controls were studied both with and without receiving the anticholinergic drugbutylscopolamine. The cross-sectional area-pressurerelations were nonlinear with the largestcross-sectional area in patients at both measuring siteswhen compared to controls (P < 0.001). Theanticholinergic drug butylscopolamine increased thecross-sectional area in controls (P < 0.001). Thecross-sectional area distensibility, defined asCSA₀ ^-1 CSA P^-1 did not differ betweenpatients and controls. Balloon distensions elicitedcontractions proximal to the distension site. Theamplitude and frequency of contractions at the distaldistension site were significantly reduced in the patients whencompared to the controls (P < 0.05). In conclusion,the distal esophagus is most severely affected inpatients with systemic sclerosis with increased cross-sectional area and impairedperistalsis.     

Opportunistic infections in patients with AIDS: clues to the epidemiology of AIDS and the relative virulence of pathogens

The frequency of nine reactivating or opportunistic infections and Kaposi's sarcoma among patients with the acquired immunodeficiency syndrome (AIDS) was reviewed. The diagnoses of 87 patients reported from the Colorado AIDS registry and 359 others from literature reports were abstracted, and data were placed in one of 11 categories on the basis of the risk group of the patient. Pneumocystis carinii infection was significantly commoner among blood or blood-product recipients than among natives of the tropics (P less than .001). Tuberculosis and toxoplasmosis each were significantly commoner among natives of the tropics than natives of developed countries (P less than .001), whereas disseminated Mycobacterium avium-Mycobacterium intracellulare infections were present more often in the latter group. Among natives of the tropics treated in developed countries, cytomegaloviral infection was diagnosed significantly less often (22%) than among persons from developed countries in whom sexual transmission was presumed (47%; P = .0005). These data suggest that the pattern of infections manifested in AIDS could provide clues about transmission and that there may be a hierarchy of reactivation of latent infections in which populations with exposure to multiple agents manifest these preferentially to Pneumocystis carinii.     

Mechanical Characteristics of Distension-Evoked Peristaltic Contractions in the Esophagus of Systemic Sclerosis Patients

Background  

Systemic sclerosis (SS) patients with severe esophageal affection have impaired peristalsis. However, motor function evaluated in vivo by manometry and fluoroscopy does not provide detailed information about the individual contraction cycles.     

Heightened Sensitivity of the Esophagus to Radiation in a Patient with AIDS

Esophageal stricture is an uncommon complication in HIV-negative patients treated with radiation to the chest for lung cancer. There have been a number of recent reports on the association of cancer and HIV-positive patients, as well as a greater sensitivity to radiation therapy of the mucous membranes in HIV/AIDS patients. This article reflects a review of the literature on the risk of major complications and morbidity of the esophagus in HIV⁺/AIDS patients whose chests are treated with radiation for lung cancer. Included is a report of a previously unpublished case of an early and severe esophageal reaction to radiation therapy in an AIDS patient.     

Spectrum of Opportunistic Infections and Profile of CD4<Superscript>+</Superscript> Counts among AIDS Patients in North India

Abstract. Background: As the number of AIDS cases increases in India, information available among clinicians about the prevalence of opportunistic infections (OIs) is scarce. The aim of the present study was to document the characteristic OIs of HIV-infected North Indian patients along with their CD4⁺ counts. Patients and Methods: The study group consisted of subjects with confirmed serodiagnosis of HIV, attending the medical clinics at a tertiary health care center in North India. The CD4⁺ counts were estimated by FACS Calibur (BD) flow cytometer. Simultaneously, routine microbiology smears, cultures and serology were performed to confirm OI. Results: In this retrospective study of 421 subjects, the predominant OI was tuberculosis (47%, 189 cells/µl), followed by parasitic diarrhea (43.5%, 227 cells/µl) and oral candidiasis (25.2%, 189 cells/µl). Conclusion: Tuberculosis was the most frequent OI in the HIV-infected patients studied, and the major mode of transmission of HIV was by sexual route. The median CD4⁺ counts observed were lower when compared to other studies.     

Salivary Growth Factors and Cytokines Are Not Deficient in Patients with Gastroesophageal Reflux Disease or Barrett's Esophagus

Growth factors, such as epidermal growth factor (EGF), are known to protect upper gut mucosa against irritants and to enhance healing of ulcerative lesions in animal models. A number of salivary growth factors are found in human saliva. The aim of this study was to determine if salivary growth factors and cytokines are deficient in patients with esophagitis or with Barrett's metaplasia. Fifteen healthy subjects, eight patients with esophagitis, and 13 patients with Barrett's metaplasia were included. Salivary concentration of EGF, FGF, IL-1, and IL-6 were measured during esophageal saline and hydrochloric acid perfusion and in the postprandial state. There was no statistically significant difference in the concentration of EGF or cytokines among the three study groups in each experimental condition or among the three experimental conditions in each group. FGF basic could not be detected in saliva. In conclusion, these findings do not support the hypothesis that a deficiency in salivary growth factors or cytokines plays a significant role in the development of mild to moderate reflux esophagitis or Barrett's metaplasia.     

Analysis of the Specific Immune Response against Capsular Polysaccharides of Two Patients with Systemic Enterococcal Infections

Abstract Systemic enterococcal infections often lead to life–threatening disease. By analyzing the immune response of two patients with systemic enterococcal infections against enterococcal polysaccharide antigens, we found that both patients had antibodies against all four of the capsular serotypes identified to date. Antibody concentrations against the causative capsular serotype were in the same range as antibodies against the other three capsular protoserotypes. Interestingly, we noted a difference between the two patients with respect to opsonic activity in the killing assay: one patient showed better killing of all four capsular prototypes than the other. However, killing against the infecting serotype was not increased in comparison to killing of the other serotypes in the two patients. This finding supports previously published data that most healthy humans possess preexisting, naturally acquired, anti–enterococcal antibodies. We conclude, therefore, that systemic infection with enterococci does not lead to higher antibody concentrations or better opsonic killing against the causative capsular serotype. This paper is dedicated to the founders of the Walter Marget Foundation, D. Adam and F. Daschner, in gratitude for their support of the training in infectious diseases.     

Opportunistic infections of the oesophagus in AIDS patients: clinical and therapeutic problems

Abstract. The gastrointestinal tract is frequently involved in the acquired immunodeficiency syndrome. One of the most common digestive manifestations is dysphagia/odynophagia which constitutes the presenting feature of the syndrome in a number of patients and occurs in many others during the subsequent phases of the illness. In the majority of cases it is due to an oesophageal infection by opportunistic pathogens (fungi or viruses or both) and may be successfully treated, at least temporarily, by specific antimicrobials. The present article examines the most recent acquisitions in terms of diagnosis and treatment of such common clinical problem.     

My Goals Are Not Their Goals: Barriers and Facilitators to Delivery of Patient-Centered Care for Patients with Multimorbidity

BackgroundPatient-centered care reflecting patient preferences and needs is integral to high-quality care. Individualized care is important for psychosocially complex or high-risk patients with multiple chronic conditions (i.e., multimorbidity), given greater potential risks of interventions and reduced benefits. These patients are increasingly prevalent in primary care. Few studies have examined provision of patient-centered care from the clinician perspective, particularly from primary care physicians serving in integrated, patient-centered medical home settings within the US Veterans Health Administration.ObjectiveWe sought to clarify facilitators and barriers perceived by primary care physicians in the Veterans Health Administration to delivering patient-centered care for high-risk or complex patients with multimorbidity.DesignWe conducted semi-structured telephone interviews from April to July 2020 among physicians across 20 clinical sites. Findings were analyzed with deductive content analysis based on conceptual models of patient-centeredness and hierarchical factors affecting care delivery.ParticipantsOf 23 physicians interviewed, most were female (n = 14/23, 61%), serving in hospital-affiliated outpatient clinics (n = 14/23, 61%). Participants had a mean of 21 (SD = 11.3) years of experience.Key ResultsFacilitators included the following: effective physician-patient communication to individualize care, prioritize among multiple needs, and elicit goals to improve patient engagement; access to care, enabled by interdisciplinary teams, and dictating personalized care planning; effortful but worthwhile care coordination and continuity; meeting complex needs through effective teamwork; and integrating medical and non-medical care aspects in recognition of patients’ psychosocial contexts. Barriers included the following: intra- and interpersonal (e.g., perceived patient reluctance to engage in care); organizational (e.g., limited encounter time); and community or policy impediments (e.g., state decisional capacity laws) to patient-centered care.ConclusionsPhysicians perceived individual physician-patient interactions were the greatest facilitators or barriers to patient-centered care. Efforts to increase primary care patient-centeredness for complex or high-risk patients with multimorbidity could focus on targeting physician-patient communication and reducing interpersonal conflict.KEYWORDS: multimorbidity, qualitative research, patient-centered care, clinical decision-making, health priorities     

Successful Elimination of Reflux Symptoms Does Not Insure Adequate Control of Acid Reflux in Patients with Barrett's Esophagus

Objective: Patients with Barrett's metaplasia of the esophagus often lack the appropriate amount of heartburn for their severity of gastroesophageal reflux. Therefore, we studied patients with Barrett's metaplasia by prolonged ambulatory pH monitoring after completely suppressing their heartburn symptoms to determine whether acid reflux was underestimated in symptom assessment. Methods: Five patients with Barrett's esophagus, all of whom presented with heartburn, were treated with omeprazole (20–60 mg/day) until they were asymptomatic. Twenty-four-bour pH ambulatory monitoring was performed while they were on omeprazole. Results: Four of five patients showed persistent abnormal gastroesophageal reflux after treatment with omeprazole. Two patients showed abnormally increased supine reflux and two patients had an abnormal increase in both supine and uprigbt reflux. Only one patient had complete inbibition of tbe acid reflux by the omeprazole (20 mg b.i.d.). Conclusions: Treating the patient with Barrett's esophagus to the endpoint of eradication of heartburn does not insure adequate control of acid reflux. Prolonged ambulatory pH monitoring of the esophagus should be conducted to demonstrate that an adequate dose of omeprazole has been given, despite symptomatic improvement.     

Opportunistic infections in patients with AIDS admitted to an university hospital of the Southeast of Brazil

Opportunistic diseases in HIV-infected patients have changed since the introduction of highly active anti-retroviral therapy (HAART). This study aims at evaluating the frequency of associated diseases in patients with AIDS admitted to an university hospital of Brazil, before and after HAART. The medical records of 342 HIV-infected patients were reviewed and divided into two groups: group 1 comprised 247 patients before HAART and, group 2, 95 patients after HAART. The male-to-female rate dropped from 5:1 to 2:1for HIV infection. There was an increase in the prevalence of tuberculosis and toxoplasmosis, with a decrease in Kaposi's sarcoma, histoplasmosis and cryptococcosis. A reduction of in-hospital mortality (42.0% vs. 16.9%; p = 0.00002) has also occurred. An agreement between the main clinical diagnoses and autopsy findings was observed in 10 out of 20 cases (50%). Two patients with disseminated schistosomiasis and 2 with paracoccidioidomycosis are reported. Overall, except for cerebral toxoplasmosis, it has been noticed a smaller proportion of opportunistic conditions related to severe immunosuppression in the post HAART group. There was also a significant reduction in the in-hospital mortality, possibly reflecting improvement in the treatment of the HIV infection.     

Frequency of Positive Tests for Cytomegalovirus in AIDS Patients: Endoscopic Lesions Compared with Normal Mucosa

Ten patients with the acquired immunodeficiency syndrome and an endoscopic erosive/ulcerative lesion in esophagus (4), stomach (3), or colon (3) were prospectively studied with multiple biopsies (244 biopsies from 33 sites) to determine: 1) the frequency of positive tests for cytomegalovirus (CMV) in the lesions versus normal mucosa, 2) the influence of number of biopsies on the rate of positivity. As seen on histology, five out of 10 lesions bad cytomegalic cells, but only six of 45(13%) of the biopsies taken from lesions that were positive showed the diagnostic changes. Immunoperoxidase was positive in two of the lesions with cytomegalic cells, but the positive staining occurred in only three of 35(9%) biopsies from the histologically positive lesions. Culture was positive in one of 10 lesions, and the rate of positivity did not depend on number of cultures sent or number of biopsies per culture. Polymerase cabin reaction was positive in six of 10 lesions, including all lesions positive by either histology (5), immunoperoxidase stain (2), or culture (1). The frequency of a biopsy being positive for CMV in normal mucosa was found to be 4%, 0%, 17%, and 28% by histology, immunoperoxidase stain, culture, and polymerase cabin reaction, respectively. In AIDS patients at high risk for CMV, bistologic evidence of CMV infection is uncommon in normal mucosa but is frequent in suspicious lesions. However, the frequency of diagnostic histology is highly dependent on the number of biopsies taken and the diligence of the pathologist. Polymerase chain reaction has the potential to become a rapid test to rule out CMV infection in gastrointestinal tissue.     

Foscarnet in the Treatment of Cytomegalovirus Infection of the Esophagus and Colon in Patients with the Acquired Immune Deficiency Syndrome

Foscarnet, administered via a central line, was used for the treatment of 18 episodes of cytomegalovirus (CMV) esophageal ulceration in 15 patients, and in the treatment of 27 episodes of CMV colitis in 22 patients. In 15 of the 18 episodes of the esophageal disease, there was complete loss of symptoms within 2 wk. Only three of the 15 patients responding to foscarnet therapy had a relapse of their esophageal disease. Two of these patients were successfully retreated with foscarnet. Of the 22 patients receiving foscarnet for CMV colitis, four died during foscarnet therapy. Of the 18 patients completing the course of treatment with foscarnet for first-episode CMV colitis, 11 remitted completely and six had a partial remission. All patients with partial remission had a second pathogen responsible for the continuation of their diarrhea. Only one patient completing a course of foscarnet failed to respond microscopically to treatment. Three patients experienced relapse of their CMV colitis, two of whom responded to further courses of foscarnet. Foscarnet is an effective therapy for CMV disease of the gastrointestinal tract, with rapid resolution of clinical symptoms, long-term remission of esophageal disease, and shorter disease-free periods for CMV colitis.     

Co-Morbid Infections in Hansen's Disease Patients in the United States: Considerations for Treatment

120 patients attending a Hansen''s disease public health satellite clinic were evaluated for selected latent co-morbidities, consisting of strongyloidiasis, Chagas disease, hepatitis B, HIV, and tuberculosis, and potential exacerbation by immunosuppressive therapy. Implications for treatment of Hansen''s disease are discussed.Leprosy (Hansen''s disease) is rare in the United States; there are approximately 6,500 reported current patients, roughly half of whom require active medical management. On average, 150 new cases are diagnosed annually. Approximately 90% of these cases are diagnosed in immigrants from developing countries where other chronic infections are endemic. In the United States, Hansen''s disease is most frequently diagnosed by dermatologists, who may be unaware of, or uncomfortable with treating these diseases. The current guidelines used by practitioners for public health satellite Hansen''s disease clinics do not include routine screening for infections other than latent tuberculosis.An under-appreciated challenge in Hansen''s disease treatment involves reactivation of, or interaction with, asymptomatic infections caused by therapy given for Hansen''s disease. These infections include chronic hepatitis B, chronic strongyloidiasis, latent tuberculosis, Chagas disease, and human immunodeficiency virus (HIV) infection. High-dose, moderate-term steroid therapy is frequently used to treat acute neuritis and type 1 or type 2 reactions in leprosy,^1,2 which are immunologically mediated inflammatory phenomena that may be seen before, during, or after multidrug therapy. Less commonly, tissue necrosis factor inhibitors, methotrexate, and cyclosporine may also be used to treat these inflammatory complications.² Type 2 reactions may also produce iritis, arthritis, neuritis, orchitis, and lymphadenitis, and often have protracted courses with episodes occurring over weeks, months, or years.Seroprevalences of chronic hepatitis B, chronic strongyloidiasis, HIV infection, and Chagas disease were retrospectively evaluated in our study population during January 1, 2007–December 31, 2012. Screening serologic analyses were ordered routinely at the first visit to the Hansen''s Clinic and not only when steroids were considered. However, Chagas antibody testing was added in April 2011, when it became readily available, for patients already in treatment at that time. Some of these patients may have been receiving steroid therapy when tested. HIV testing was limited to patients who gave informed consent. Hepatitis B surface antigen was screened by the AxSYM microparticle enzyme immunoassay (Abbott Laboratories, North Chicago, IL) for samples received before March 2010, and by the Advia Centaur chemiluminometric sandwich immunoassay (Siemens Healthcare Diagnostics, Tarrytown, NY) for samples received thereafter. Samples that were positive were referred to ARUP Laboratories (Salt Lake City, UT) for confirmation by antibody neutralization.The HIV serologic analysis for HIV-1 and HIV-2 was performed using an AxSYM immunoassay analyzer (Abbott Laboratories) for samples received before December 2009, and using the Advia Centaur immunoassay until December 2011, after which HIV serologic analysis was performed using an Architect i1000 immunoassay (Abbott Laboratories). Confirmatory testing was not required because no samples failed HIV screening. Strongyloides and Chagas disease samples were assayed at the Centers for Disease Control (Atlanta, GA) using an enzyme immunoassay and indirect fluorescent antibody testing. We also screened for latent tuberculosis by using a 5 TU tuberculin skin test (purified protein derivative) and Centers for Disease Control and Prevention criteria for positivity.One hundred twenty actively followed patients, consisting primarily of immigrants from Brazil, Southeast Asia, and Africa (

Motility Studies in Fifty Patients with Achalasia of the Esophagus

Esophageal motility tests with constantly perfused polyethylene catheters were done in 50 patients with achalasia of the esophagus using 30 asymptomatic adults as control. The mean gastroesophageal sphincter pressure was 19.0 ± 1.3 mm. Hg. (mean ± SE) which was significantly higher than the control group (P < 0.001). The intraesophageal resting pressure was significantly higher than the mean fundic pressure and no correlation among resting gastroesophageal sphincter pressure and resting intraesophageal pressure was found. An incomplete relaxation of the sphincter after swallowing was found in 45 patients with achalasia as opposed to complete sphincter relaxation in normals.