Attitudes of medical residents regarding intensive care for patients with the acquired immunodeficiency syndrome

We recently surveyed the medical house staff at the University of California, San Francisco, and found that residents had a good understanding of the poor prognosis of patients with the acquired immunodeficiency syndrome (AIDS) and Pneumocystis carinii pneumonia who require intensive care for respiratory failure, and tended to favor early discussions with patients regarding resuscitation and intensive care. We used the same questionnaire to survey the house staffs of four other programs varying in geography and exposure to patients with AIDS. We found a striking correlation between the number of patients with AIDS cared for by the residents, the assessment of the prognosis of patients with AIDS with P carinii pneumonia, and house-staff attitudes toward discussions about resuscitation and intensive care. The results of this study suggest that the intensity of exposure to patients with AIDS determines the assessment of prognosis, and that one or both of these factors strongly influences attitudes toward intensive care. Regardless of these attitudes, early discussion of resuscitation and intensive care between physicians and patients with AIDS and P carinii pneumonia seems warranted.     

Reassessing intensive care for patients with the acquired immunodeficiency syndrome

The number of patients with the acquired immunodeficiency syndrome (AIDS) admitted to hospitals is increasing dramatically. Treatments such as zidovudine, aerosolized pentamidine, and nutritional support are being administered to subacutely ill patients with increasing effectiveness. The number of patients with AIDS treated in intensive care units, on the other hand, has been decreasing progressively, perhaps as a result of a mortality rate close to 90%. However, because recent data demonstrate (1) a lower mortality rate in patients with AIDS who receive mechanical ventilation and (2) the ability to reverse the wasting syndrome in selected groups, we propose a reassessment of the criteria for intensive care unit admission of patients with AIDS.     

Blastomycosis in patients with the acquired immunodeficiency syndrome.

OBJECTIVE: To describe the clinical, demographic, radiographic, diagnostic, and therapeutic aspects of blastomycosis in patients with the acquired immunodeficiency syndrome (AIDS). DESIGN: A retrospective survey. SETTING: Ten university medical centers and community hospitals, six in geographic areas endemic for Blastomyces dermatitidis, and four outside the endemic area. PATIENTS: We identified 15 patients with blastomycosis and positive serologic test results for human immunodeficiency virus (HIV). MEASUREMENTS: A diagnosis of blastomycosis was based on a positive culture (14 patients) or typical histopathologic features (one patient) for B. dermatitidis in clinical specimens. RESULTS: Twelve of 15 patients had a previous or concomitant AIDS-defining illness at the time of diagnosis of blastomycosis, and only one patient had a CD4 lymphocyte count of greater than 200 cells/mm3. Two patterns of disease emerged: localized pulmonary involvement (seven patients), and disseminated or extrapulmonary blastomycosis (eight patients). Central nervous system involvement was common (40%). Six patients died within 21 days of presentation with blastomycosis, including four patients with disseminated and two with fulminant pulmonary disease. Among the nine patients who survived longer than 1 month, all received amphotericin B as initial antifungal therapy, and most received subsequent therapy with ketoconazole. Only two of these nine patients died with evidence of progressive blastomycosis. CONCLUSIONS: Blastomycosis is a late and frequently fatal infectious complication in a few patients with AIDS. In these patients, overwhelming disseminated disease including involvement of the central nervous system is common, and it is associated with a high early mortality. Initial therapy with amphotericin B is appropriate in patients with AIDS and presumptive blastomycosis.     

Toxoplasma encephalitis in patients with the acquired immunodeficiency syndrome.

Among 504 cases of AIDS diagnosed between 1983 and 1990, there were 86 patients (17%) with toxoplasma encephalitis (TE). All were symptomatic at the time of diagnosis. General signs such as fever, neck stiffness, or headache were present in 87.2%, and 75.6% had focal signs. The primary means of diagnosis was computerized tomographic scanning, revealing 169 lesions of which 80% were immediately contrast-enhancing. All patients had IgG antibodies against Toxoplasma gondii either before (74 of 75 evaluable patients) or at the time of diagnosis of TE (73 of 75). Elevated antibody titers were present in 44% of evaluable patients, compared to 11% of patients with AIDS and other opportunistic infections. Initial treatment was pyrimethamine plus sulfonamides in 65 patients, and pyrimethamine plus clindamycin in 12 patients, with other combinations or no treatment accounting for the remainder. Life-table analysis of the time to discontinuation of treatment because of suspected side effects suggested that sulfadiazine was significantly more toxic, with 48% of patients experiencing an interruption in treatment after 30 days, than pyrimethamine (12%) or clindamycin (24%). The 30-day mortality rate was 12%, and median survival was 310 days after diagnosis, 530 in patients treated with zidovudine and 190 days in those not so treated. Of 82 evaluable patients, 16 relapsed once and 4 of these more than once. The risk of relapse was 27% 1 year after diagnosis of a first episode of TE.     

Medical care costs of patients with acquired immunodeficiency syndrome in Richmond, Va. A quantitative analysis

This study examines inpatient charges for 52 adult patients with the acquired immunodeficiency syndrome (AIDS) who had 102 admissions to the Medical College of Virginia Hospitals, Richmond, from October 1983 through December 1986. Complete charge data were available for 81 hospitalizations; the mean charge per hospitalization was +13,830 (SD, +13,610), the average length of stay was 14.8 days (SD, 13.1 days), and the mean per diem charge was +1058 (SD, +802). For patients who received all their AIDS-related medical care at the Medical College of Virginia Hospitals, total lifetime hospital charges averaged +27,264, the mean number of hospital stays was 2.29, and the average length of stay was 12 days. The average length of hospital stay, total charges per hospitalization, and average charge per day of hospitalization decreased over the study period. These findings suggest that inpatient costs of treating individual patients with AIDS are less than initially estimated and are decreasing due to the ability to more effectively manage these patients.     

Intensive care of patients with the acquired immunodeficiency syndrome. Outcome and changing patterns of utilization

Eighty-two patients with the acquired immunodeficiency syndrome (AIDS) were admitted to the intensive care units (ICUs) at San Francisco General Hospital (SFGH) between March 1981 and December 1985. Of these patients, 69% died in the hospital, as did 87% of patients who required mechanical ventilation because of Pneumocystis carinii pneumonia and respiratory failure. Although the number of hospital admissions of patients with AIDS has increased steadily since the fourth quarter of 1982 (12 admissions) through the fourth quarter of 1985 (158 admissions), the number of admissions to the ICUs peaked at 17 in the second quarter of 1984 and decreased steadily, averaging 5 per quarter in 1985. This decrease was not explained by a reduction in the number of patients with P. carinii pneumonia or an improvement in their treatment. A survey of physicians at SFGH indicated that physicians are aware of the poor prognosis of patients with AIDS with P. carinii pneumonia and respiratory failure, believe that mechanical ventilation is infrequently indicated for this condition, and have become increasingly likely to discuss issues of resuscitation with their patients with AIDS. Therefore, possible explanations for this trend in ICU utilization include changing physician attitudes, in addition to more effective patient counseling and increased availability of hospital and community-based support services that provide alternatives to terminal intensive care.     

Cardiopulmonary resuscitation in patients with the acquired immunodeficiency syndrome. A prospective study

To study the outcome of cardiopulmonary resuscitation (CPR) in patients with acquired immunodeficiency syndrome (AIDS), data on CPR in hospitalized patients were collected prospectively during a one-year study period. Of 43 consecutive patients with AIDS who underwent CPR, 23% were revived in the initial attempt, whereas of 293 patients with other diseases 42% were revived. One (2.3%) of 43 patients with AIDS survived until hospital discharge, and his arrest was iatrogenic, as opposed to 19 (6.5%) of 293 patients with diseases other than AIDS. A respiratory mechanism for the arrest was significantly more common in patients with AIDS. The duration of the unsuccessful attempt did not vary significantly; a higher number of temporary pacemakers was used in patients with diseases other than AIDS indicating a more invasive approach. Survival until hospital discharge is minimal in our series of patients with AIDS, undergoing CPR. We recommend that informative discussions take place early in the course of the disease to provide patients with a better understanding of the available options in case of cardiorespiratory arrest.     

Effects of passive immunization in patients with the acquired immunodeficiency syndrome-related complex and acquired immunodeficiency syndrome.

Infection with the human immunodeficiency virus type 1 (HIV-1) is usually followed by a vigorous immune response that temporarily protects against disease progression. After a variable asymptomatic period, acquired immunodeficiency syndrome (AIDS)-related complex (ARC) and AIDS develop in most infected individuals. We have demonstrated that healthy HIV-1-infected individuals have neutralizing antibodies and a high titer of antiviral antibodies. In contrast, AIDS patients have undetectable levels of neutralizing antibodies, low titers of antiviral antibodies, and, frequently, HIV p24 antigenemia. These observations prompted us to attempt passive immunization in ARC and AIDS patients. Ten consistently viral-antigen-positive patients (mean, greater than 6 months) were treated, resulting in sustained clearance of p24 antigen. Patients either maintained or increased their antiviral antibody titers. The raised titers result from increased antibody synthesis by the recipients. Circulating CD4+ cell counts were unchanged after 2 months. By the third month none of these patients remained in hospital. As this treatment was of minimal toxicity, it merits wider evaluation in ARC and AIDS patients.     

Lipid-laden perisinusoidal cells in patients with acquired immunodeficiency syndrome.

Liver biopsies were taken from ten AIDS patients. Liver architecture was normal in all patients. On 1-micron-thick sections stained with toluidine blue, all ten cases showed lipid overload of perisinusoidal cells (1 massive, 5 moderate and 4 mild) compared to 2/8 in control patients, who had mild lipid overload. Other sinusoidal abnormalities such as hypertrophy of Kupffer cells and inclusions in endothelial cells were also noticed. Some hepatocytes presented evidence of cellular damage. Perisinusoidal cell lipid overload was not associated with hypervitaminosis A. We hypothesize that the abnormal accumulation of lipids in perisinusoidal cells (non-induced by hypervitaminosis A) in patients with AIDS could be due to defective transport of vitamin A from perisinusoidal cells to hepatocytes, and/or from hepatocytes to blood. The cause of the defect is unknown. Since lipid overload occurs in many and diverse conditions (diabetes, cholestasis, primary biliary cirrhosis, etc.), it seems reasonable to propose that the defect is non-specific and limited to functional or structural damage of the liver whether induced by drugs, liver or systemic diseases.     

Septic arthritis in patients with acquired immunodeficiency syndrome with human immunodeficiency virus infection.

We have evaluated the presence and characteristics of septic arthritis in intravenous (iv) drug users with human immunodeficiency virus (HIV) infection. Sixteen patients with both HIV infection and septic arthritis were studied and compared with 5 patients with septic arthritis but no HIV infection. Clinical profile, laboratory findings at the time of onset, localization, causative organisms, mean hospitalization time and presence of complications were the same in HIV positive and HIV negative patients. Staphylococcus aureus was the most commonly isolated organism in both groups. We conclude that septic arthritis in HIV infected iv drug users is not uncommon, it is produced by the same organisms and presents similar characteristics to the ones found in iv drug users without HIV infection. Therefore, the presence of HIV infection does not appear to modify the characteristics of septic arthritis.     

Enteric coccidiosis among patients with the acquired immunodeficiency syndrome

Ten patients were identified at Jackson Memorial hospital/University of Miami Hospitals and Clinics with enteric coccidial infection due to Cryptosporidium spp. or Isospora belli. All had the acquired immunodeficiency syndrome as manifested by Kaposi's sarcoma or multiple opportunistic infections, or both. They presented with profuse diarrhea associated with weakness, anorexia, and weight loss. Routine examinations of stools for eggs and parasites as performed by the hospital laboratory were negative in all patients. Sugar flotation and modified acid fast techniques were used in the Tropical Disease Laboratory to identify oocysts of Cryptosporidium spp. in stools of seven patients. Malabsorption, characterized by a low 5-hour D-xylose and positive fecal fat, was observed in 6/6 of these patients. In three other patients Isospora belli oocysts were identified in stool specimens or via a duodenal string test. Spiramycin was the only drug found to be effective in treating patients with cryptosporidiosis. Patients with Isospora belli responded to a prolonged course of trimethoprim-sulfamethoxazole.     

Prevalence of toxoplasma myocarditis in patients with the acquired immunodeficiency syndrome.

OBJECTIVE--To evaluate the prevalence of cardiac toxoplasmosis in a series of 182 necropsies performed between 1987 and 1991 on patients infected with the human immunodeficiency virus (HIV), to correlate this prevalence with the ante mortem diagnosis of cardiac involvement, and to assess the role of such cardiac lesions in the immediate cause of death. PATIENTS AND METHODS--Complete necropsies of 182 HIV-infected patients (48 women, 134 men) were performed consecutively between 1987 and 1991. Risk factors, identified in 174 cases, included drug abuse (111/182), homosexuality (51/182), and blood transfusions (12/182). 16 samples were systematically obtained from each heart for histological study. If trophozoites or lymphocytic myocarditis were seen, immunohistochemical investigations were carried out with polyclonal antibodies for Toxoplasma gondii. An ultrastructural study was performed in four patients with toxoplasma myocarditis. Myocardial lesions were defined by the Dallas classification. Clinical data (and information on electrocardiograms and echocardiograms) were obtained from medical records. RESULTS--Cardiac toxoplasmosis was diagnosed at necropsy in 21 (12%) patients. Cardiac lesions were associated with toxoplasmic encephalitis in 18 patients and were solitary in three patients. Acute diffuse myocarditis was present in 6/21, rare foci of myocarditis were seen in 8/21, and intramyocytic toxoplasmic cysts without any inflammatory reaction or necrosis were seen in 4/21. Anti-toxoplasma immunolabelling showed cardiac toxoplasmosis in three patients with lymphocytic myocarditis. Particles with the ultrastructural characteristics of Toxoplasma gondii trophozoites were seen in four cases. Six patients had presented with cardiac symptoms, confirmed by electrocardiographic and echocardiographic abnormalities during their disease course, and their cardiac lesions were directly responsible for the death. CONCLUSION--Cardiac toxoplasmosis was common in this necropsy series of HIV-infected patients. Cardiac toxoplasmosis had been suspected clinically in four patients. Myocardial lesions were generally asymptomatic and were not discovered until necropsy. Solitary cardiac involvement was not uncommon reflecting parasite reactivation at a myocardial site. The incidence of cardiac toxoplasmosis in this group of immunodepressed subjects from an area with a high prevalence of this parasitic disease justifies regular follow up of such patients by electrocardiography and echocardiography as well as immediate administration of anti-toxoplasma treatment should sudden heart failure occur.     

Bacterial pneumonia in patients with the acquired immunodeficiency syndrome

Eighteen episodes of community-acquired bacterial pneumonia were diagnosed in 13 patients among 336 with the acquired immunodeficiency syndrome (AIDS) cared for at Memorial Sloan-Kettering Cancer Center since 1979. Bacterial pathogens isolated in 16 of 18 episodes were Haemophilus influenzae in 8, Streptococcus pneumoniae in 6, group B streptococcus in 1, and Branhamella catarrhalis in 1. Eight episodes were presumed Pneumocystis carinii pneumonia until cultures obtained at bronchoscopy confirmed a bacterial cause. Specific antibacterial therapy was curative in 16 of 18 episodes; 2 patients died. Given an estimated yearly incidence of pneumococcal pneumonia in the general population of 2.6/1000, 1.09 cases were expected in our patients with AIDS; we saw 6 (p = 0.001), for an attack rate of 17.9/1000. Bacteria associated with B-cell defects should be anticipated when formulating empiric antibiotic therapy, pending a definitive diagnosis, for pulmonary infiltrates in patients with AIDS.     

Salmonella infections in patients with the acquired immunodeficiency syndrome

Defects in T-cell function have been seen in patients with the acquired immunodeficiency syndrome. Although the cellular immune system plays a key role in host defense against Salmonella, there have been no detailed reports of salmonellosis in patients with this syndrome. We report our experience with salmonella infections in six patients. Salmonellosis in these patients was unusually severe, characterized by widespread infection, bacteremia, and relapse, despite standard antibiotic treatment. Because of the difficulty in eradicating salmonella infection in patients with the acquired immunodeficiency syndrome, long-term suppressive treatment with antibiotics seems warranted.     

Critical care nurses' attitudes toward, concerns about, and knowledge of the acquired immunodeficiency syndrome

Two samples of critical care nurses (from a secular teaching hospital and a religious-affiliated community hospital, respectively) were compared on their attitudes, concerns, and knowledge regarding the acquired immunodeficiency syndrome (AIDS). Nurses from the teaching hospital had significantly (p = 0.003) more favorable attitudes toward patients with AIDS than did the community hospital nurses. Modal response in each group for perceived risk of acquiring AIDS from patients was 1 chance in 10,000. If given a choice, a sizable percentage in both the teaching (45%) and the community hospital (65%) groups would refuse to care for patients with AIDS. Those indicating preference for refusing showed significantly higher levels of concern and significantly less favorable attitudes than the others. Knowledge about AIDS was high, with means in each group exceeding 14 out of 16 possible points. Implications for nursing practice are discussed.     

High-protein ascites in patients with the acquired immunodeficiency syndrome

Diseases of the liver or peritoneum resulting in ascites have been infrequently reported in patients with the acquired immunodeficiency syndrome. Since 1985, eight noncirrhotic patients with the acquired immunodeficiency syndrome presenting with new onset high-protein ascites have been evaluated. All but one patient had nondiagnostic paracentesis studies. Laparoscopy with biopsy of identified abnormalities or percutaneous omental biopsy were diagnostic in four patients. Non-Hodgkin's lymphoma was the cause in three patients, and disseminated cryptococcosis occurred in one patient. In the four other patients, chronic nonspecific peritonitis was found at laparoscopy; follow-up of these latter patients, including exploratory laparotomy in one patient and autopsy in two patients, disclosed no specific cause. Patients with the acquired immunodeficiency syndrome and high-protein ascites of uncertain etiology should undergo directed peritoneal evaluation as a potentially treatable disorder may be found. However, despite extensive evaluation, a subset of patients in whom no specific cause can be identified still remains.     

Intestinal infections in patients with acquired immunodeficiency syndrome

We studied prospectively 132 patients with acquired immunodeficiency syndrome to define the spectrum of enteric pathogens during this disease, with special reference to the correlation between the lesions, the infections, and the symptoms. Forty-four percent of the patients harbored at least one enteric pathogen: the most frequently recovered were Cryptosporidium (28), cytomegalovirus (16), Entamoeba histolytica (13), Giardia lamblia (9), and Mycobacterium avium intracellulare (7). Patients harboring pathogens were more likely to be diarrheics (69%) than patients without a pathogen (38%; P=0.01) and more likely to have endoscopic lesions (29%) than patients without a pathogen (4%; P<0.001). The most common pathogen associated with diarrhea was Cryptosporidium. Cytomegalovirus, Entamoeba histolytica, and Salmonella typhimurium were each significantly associated with endoscopic lesions. Patients with cytomegalovirus infection tended to have a greater incidence of ulcer than patients without cytomegalovirus infection. Stool analysis diagnosed 61% of the infections, while endoscopy diagnosed 44%. Seven percent were recognized by stool analysis and endoscopy. When considering the 24 patients in whom accurate diagnosis warranted endoscopic biopsies, stool examination alone would have given an incomplete diagnosis in 14 patients (due to the presence of polyinfection). The frequency of inaccurate diagnosis of infection by stool determination alone, plus the development of new antiviral agents that suppress cytomegalovirus, may favor the earlier application of endoscopic evaluation in these patients.Computerized treatment of data has been allowed by the Commission Nationale Informatique et Liberté (registration NB. 104713).This work was supported in part by Institut National de la Santé et de la Recherche Médicale, (grant UR/010/237) and by Fondation Médicale pour la Recherche, and by Paris VII Faculté.Portions of this study were presented at the American Gastroenterological Association in May 1987.