Infective Endocarditis in Patients with Human Immunodeficiency Virus Infection

OBJECTIVES: To determine the clinical features, sites of involvement, bacteriological findings, and outcome of infective endocarditis (IE) in patients with HIV infection. PATIENTS AND METHODS: All patients with diagnosis of IE admitted to 54 infectious disease centres in Italy over a 15-year period (1984-1999) were reviewed, and 895 cases fulfilled the Duke criteria for definite diagnosis of IE. Data were collected with regard to the clinical, laboratory, and demographic characteristics of patients, as well as results of blood cultures and data on clinical outcome. RESULTS: There were 108 episodes of IE in 105 HIV-infected patients. The mean age of patients was 30.1 years, and the commonest predisposing condition was intravenous drug use (94.3%). Staphylococci were the predominant organisms (60.2%), and the tricuspid valve was the most frequently involved site of infection (51.9%). Left-sided heart involvement (45.4%) and multivalvular involvement (17.6%) were also frequently observed. The greater frequency of S. aureus affecting the tricuspid valve vs. other valves was statistically significant (P<0.001). Six patients (5.9%) underwent surgery, and one (16.7%) of them died. Ninety-five (94.1%) patients were treated medically, and 17 (17.9%) of them died. Overall mortality rate was 17.8%. Any left-sided heart involvement was predictive of an increased risk of death if compared with any right-sided heart involvement (P< 0.004). The mortality rate among HIV-infected patients was higher in those with CD4 cell counts below 200/mm(3). CONCLUSIONS: IE in HIV-infected patients, for the most part intravenous drug users, is more commonly localized to the right side of the heart; however, mixed or left-side valvular infections are frequent. Severe immunosuppression and left-side valvular involvement are associated with a greater risk for mortality.     

Idiopathic Anorectal Ulceration in Patients with Human Immunodeficiency Virus Infection

Opportunistic infections and neoplasms of the anorectum have heen reported in patients with human immunodeficiency virus (HIV) infection. More recently, idiopathic alcerative lesions of the colon and rectum have been described. At our center over a 3-yr period, four patients were identified with ulcerative lesions of the rectum and/or anus that remained idiopathic despite an extensive clinical, serologic, and histopathologic evaluation. Three patients had the acquired immunodeficiency syndrome, and in one anorectal disease was the index manifestation of HIV infection. Only one of the patients had recently engaged in receptive anal intercourse. The presenting complaints were gastrointestinal hieeding in two, which was severe in one, and/or anorectal pain. Multiple colonoscopic evaluations with hiopsy of the distal colorectum documented a solitary ulcer of the rectum in one, solitary ulcer involving the anorectum in two, and multiple ulcers of the rectum and anorectnm in one. In three patients, colonoscopy to the cecum demonstrated no additional lesions. In patients with HIV infection, ulcerative lesions of the anorectum may remain unexplained despite an exhaustive evaluation. The etiology of these lesions, as well as appropriate therapy, remains to be determined.     

The Influence of Mining and Human Immunodeficiency Virus Infection among Patients Admitted for Retreatment of Tuberculosis in Northern Tanzania

In tuberculosis (TB)–prevalent settings, patients admitted for retreatment of TB may account for a high burden of poor treatment outcome. We performed a retrospective cohort study to characterize retreatment patients and outcomes at a TB referral hospital in northern Tanzania. From 2009 to 2013, 185 patients began a retreatment regimen, the majority for relapse after prior treatment completion. Men accounted for an unexpected majority (88%), 36 (20%) were human immunodeficiency virus (HIV) infected and for 45 (24%) mining was their primary occupation. A poor outcome (death, default, or persistent smear positivity after 7 months of treatment) was found in 37 (23%). HIV infection was the only significant predictor of poor outcome (adjusted odds ratio [aOR] = 2.50, 95% confidence interval [CI] = 1.07–5.83, P = 0.034). Interventions to minimize need for retreatment or improve retreatment success may be regionally specific. In our setting, community-based diagnosis and management among at-risk subpopulations such as miners and those HIV infected appear of highest yield.In Tanzania, like many tuberculosis (TB) endemic countries, patients categorized as undergoing retreatment for TB account for proportionally the highest rates of death, treatment failure, and default among all TB patients excluding those with known drug resistance.¹ The national estimate for treatment success rate in human immunodeficiency virus (HIV)–negative patients without prior treatment was 90%, but was 80% in patients with a history of TB treatment.¹ Patients undergoing retreatment are often prescribed the World Health Organization (WHO) Category II regimen of extended total duration, which contains the daily intramuscular injection of streptomycin, a medication with considerable cumulative side effects including ototoxicity and vestibular toxicity that may further compromise treatment completion.²Kibong''oto Infectious Diseases Hospital (KIDH) is a regional referral hospital for retreatment TB cases, and the national referral hospital for multidrug-resistant (MDR) TB. The Mererani region includes numerous small-scale mining operations, principally involved in the mining of the precious gemstone tanzanite. The mines are run with low-level mechanization, use roughly 8,000 transient workers, and are situated in a community of approximately 200,000 people with interdependence on the mining industry.³ The mining occupation in other TB-endemic settings has been associated with high rates of HIV coinfection, comorbid lung disease such as silicosis and risk of TB reinfection.⁴ Perception suggests that miners account for a considerable number of patients admitted to KIDH for retreatment and may account for a greater proportion of those with poor retreatment outcome.We therefore sought to perform a retrospective cohort study of all patients admitted to KIDH for a retreatment regimen over the past 5 years to define the local burden of retreatment, clinical characteristics among retreatment patients, and predictors of retreatment outcome.The hospital initiative was designed and undertaken by the KIDH administration and approval for analysis was additionally granted by the institutional review board of the University of Virginia. All charts from patients admitted to KIDH from January 1, 2009 to December 31, 2013 were screened. KIDH practice was to treat all patients with a prior history of TB with a WHO Category II regimen excluding those with known drug-resistant TB. Thus, a case was defined as “retreatment,” if prescribed a Category II regimen after having failed a prior drug susceptible TB treatment course, relapsed within 18 months after having completed treatment, or defaulted treatment but remained sputum smear positive. Patients that were treated with a WHO Category II regimen for another reason were labeled as “other,” including smear-negative patients with TB signs and symptoms that had failed an empiric course of antibacterial treatment. Specifically, the regimen was daily injectable streptomycin, oral rifampin, isoniazid, ethambutol, and pyrazinamide given for 2 months, then all oral drugs given for 1 month, followed by 5 months of rifampin and isoniazid.⁵ Chart review included demographics, comorbidities, HIV status, and among the HIV infected, CD4 cells/mm³ and antiretroviral use at admission. Per hospital protocol, an acid-fast bacilli (AFB) sputum smear was performed on admission for all pulmonary TB patients, again at 2 months after treatment, and monthly thereafter until 7 months after treatment. Similarly, a baseline weight (in kilograms) was recorded and repeated monthly after the second month of treatment. Although MDR-TB treatment began in Tanzania at KIDH in 2009, initially drug susceptibility testing was not routinely performed on retreatment patients given logistical constraints and specimen turnaround at the reference laboratory.⁶ After 2013, molecular testing with either the Xpert MTB/RIF (Cepheid, Sunnyvale, CA) or the MTBDRplus (Hain Lifescience, Nehren, Germany) has been performed onsite.During the study period and excluding those with known MDR-TB, total 2,140 patients were admitted for TB treatment, of which 185 (8.6%) received a retreatment regimen (by year of admission: in 2009, 46 [10% of total from that year]; in 2010, 38 [9%]; in 2011, 37 [9%]; in 2012, 36 [8%]; in 2013, 28 [6%]). The majority were men (87.6%) and 36 (19.5%) were HIV infected (

Acute Human Immunodeficiency Virus Infection

The clinical spectrum of acute human immunodeficiency virus (HIV) infection, a common clinical syndrome, may range from asymptomatic to a severe illness. The purpose of this review is to increase awareness of this syndrome, which is rarely suspected and often missed in clinical care settings, and provide an informative reference for primary care providers. The diagnosis of acute HIV infection is important for both patient care and public health concerns. In this article, the epidemiology, pathophysiology, clinical presentation, diagnosis and treatment of acute HIV infection are reviewed.     

The Hepatobiliary Manifestations of Human Immunodeficiency Virus Infection

Liver abnormalities are common in patients with acquired immune deficiency syndrome. These relate to 1) coincident exposure to hepatotropic viruses, 2) complications, either infectious, neoplastic, or iatrogenic, of the immunosuppressed state, or 3) nonspecific changes associated with chronic debilitating illness. We review the hepatobiliary manifestations of acquired immune deficiency syndrome, and discuss our approach to the clinical evaluation of these problems.     

Disturbed Gastric Motor Activity in Patients with Human Immunodeficiency Virus Infection

Background: Human immunodeficiency virus (HIV) infection is accompanied by a wide spectrum of disorders that affect the central and peripheral nervous system. Damage to the peripheral and central nervous system, including its autnnomic division, may become manifest at any stage of the disease. Methods: Twenty HIV-positive patients with abdominal complaints like dyspepsia, dysphagia, vomiting, and nausea underwent several function tests to determine oesophagcal motility, gastric motor and electric activity, and gastric emptying rate. The CDC (Center for Disease Control) classification was used to determine the stage of the disease, which varied from B2 to C3. Before gastric motility examinations all patients underwent endoscopy of the upper gastrointestinal (GI) tract, and none of them showed any morphologic changes of the stomach or oesophagus. Biopsy specimens taken during upper GI endoscopy did not show any histologic alterations of the gastric or oesophageal mucosa. Results: Manometry of the antrum showed an unchanged postprandial (after 200 ml liquid, caloric meal) motility index (MI) when compared with the fasting period (mean fed MI, 174 ± 43; mean fasting MI, 136 ± 51). The same was seen for frequency, amplitude, and duration of antral contractions. The electrogastrographic recordings showed basal rhythm of 3 cpm, and no significant changes of the electric pattern were observed postprandially. The amplitude of electric oscillations (power content) significantly increased postprandially when compared with the fasting period. The gastric emptying rate of liquids, measured by means of the ¹³C-acetatc breath test, was faster in HIV patients than in healthy controls. On the other hand, in HIV patients the scintigraphically determined emptying rate of solids was significantly delayed compared with the normal values. There were no significant differences in the oesophageal motility pattern with regard to the amplitude, duration, and propagation of peristaltic waves when compared with the values obtained from healthy volunteers. Conclusion: Our results suggest that HIV-associated visceral neuropathy may present already in relatively early stages of infection and may contribute to abdominal symptoms that occur frequently in these patients.     

人免疫缺陷病毒感染与血栓形成性疾病

人免疫缺陷病毒(HIV)感染者血液中可出现抗磷脂抗体、狼疮抗凝物,von Willebrand因子、D-二聚体水平升高,蛋白S、蛋白C、抗血栓素和肝素辅因子减少,从而导致血液高凝状态.此外,HIV感染本身及继发性机会性感染也可使血管内皮受损.血液高凝状态和血管内皮损伤均可促使血栓形成性疾病的发生.     

Tropical Diseases Screening in Immigrant Patients with Human Immunodeficiency Virus Infection in Spain

Latent parasitic infections can reactivate because of immunosuppression. We conducted a prospective observational study of all human immunodeficiency virus (HIV)–infected immigrants who visited the Infectious Diseases Department of the Hospital Universitari Vall d''Hebron, Barcelona, Spain, during June 2010–May 2011. Screening of the most prevalent tropical diseases (intestinal parasitosis, Chagas disease, leishmaniasis, malaria, schistosomiasis, and strongyloidiasis) was performed according to geographic origin. A total of 190 patients were included: 141 (74.2%) from Latin America, 41 (21.6%) from sub-Saharan Africa, and 8 (4.2%) from northern Africa. Overall, 36.8% (70 of 190) of the patients had at least one positive result for any parasitic disease: 5 patients with positive Trypanosoma cruzi serology, 11 patients with positive Schistosoma mansoni serology, 35 patients with positive Strongyloides stercoralis serology, 7 patients with positive Leishmania infantum serology, intestinal parasitosis were detected in 37 patients, malaria was diagnosed in one symptomatic patient. We propose a screening and management strategy of latent parasitic infections in immigrant patients infected with HIV.     

Delayed Gastric Emptying in Human Immunodeficiency Virus Infection

Gastric emptying may be delayed in HIV infection. We aimed to characterize the pattern of gastric emptying in HIV seropositive subjects and correlate the findings with symptoms, as well as to identify possible etiological factors. Solid gastric emptying was measured using scintigraphy in 54 HIV seropositive subjects and 12 HIV seronegative controls. Gastrointestinal symptoms were evaluated using a standardized numerical score, and autonomic function was assessed using spectral analysis of heart rate variability. Fasting and postprandial duodenojejunal activity was recorded using strain gauge manometry catheters. Gastric emptying rate, but not lag phase, was significantly delayed in HIV-infected subjects, particularly those with enteric infections and more advanced disease. Delayed gastric emptying did not correlate with symptoms, autonomic dysfunction, or small intestinal motility. In conclusion, abnormalities found in autonomic function and gastric emptying in HIV infection are multifactorial in nature. The contribution of upper gastrointestinal motor dysfunction to gastric symptoms in such individuals is unclear.     

Disseminated Histoplasmosis in Early Human Immunodeficiency Virus Infection

Early human immunodeficiency virus (HIV) infection leads to transient immunosuppression followed by a quasi-homeostatic state with slow progression towards AIDS. Histoplasmosis has never been reported in early HIV. We present a case of disseminated histoplasmosis with documented recent seroconversion and review the literature regarding other opportunistic infections in early HIV.     

Current Therapy for Human Immunodeficiency Virus Infection and Acquired Immunodeficiency Syndrome

Antiretroviral treatments with highly active antiretroviral therapy (HAART) have shown remarkable progress in the past decade and resulted in impressive improvements in life expectancy and quality of life for patients infected with human immunodeficiency virus 1 (HIV-1). Despite the clinical benefits, the management of HIV infection faces many problems. Although HAART is able to suppress the viral load in the plasma, it is unable to eradicate it, and once HAART is initiated, treatment needs to be continued over a lifetime. The side effects of long-term HAART, such as lipodystrophy, lactic acidosis, insulin resistance, and hyperlipidemia, are negative impacts for patients who receive HAART. In addition, patients need to demonstrate high adherence to the therapy to achieve viral suppression and prevent the development of a drug-resistant virus. This review discusses currently recommended antiretroviral treatment strategies, the difficulties with antiretroviral treatments, and current issues regarding HIV management.