SALMONELLA PYOMYOSITIS IN PATIENTS WITH THE HUMAN IMMUNODEFICIENCY VIRUS

Pyomyositis is a common disease in the tropics, mostly due toStaphylococcus aureus. We report two patients infected withthe human immunodeficiency virus (HIV) who presented with feverand unilateral limb swelling and in whom pyomyositis was diagnosedin quadriceps and gluteus major, respectively. Salmonella enteritidiswas isolated in both, with recurrent episodes of muscle involvementand secondary osteomyelitis in one case. Non-typhi Salmonellapyomyositis may occur in HIV + patients with a relapsing andaggressive clinical course in some cases. KEY WORDS: Human immunodeficiency virus infection, Pyomyositis, Salmonellosis     

Bacterial pyomyositis in the United States

The incidence of reported bacterial pyomyositis is increasing in the United States, especially among immunocompromised persons. This review summarizes all reported cases of pyomyositis among human immunodeficiency virus (HIV)-infected persons worldwide and HIV-negative persons in the United States since 1981. During the era of combination antiretroviral therapy, bacterial pyomyositis among HIV-infected persons typically occurred in those with end-stage acquired immunodeficiency syndrome. Among non-HIV-infected patients, about half have a serious underlying medical problem, most commonly diabetes mellitus, malignancy, or a rheumatologic condition. These patients are more likely to have a gram-negative infection, a normal white blood cell count, multifocal involvement, or higher mortality than those without an underlying medical condition. The characteristics of cases in temperate areas are similar to tropical cases, except that the former occurs more often in immunocompromised persons; this may change with the HIV epidemic in tropical regions.     

Internal obturator muscle abscess caused by Klebsiella pneumoniae

Obturator internus muscle abscess is an infrequent form of pyomyositis. To date, this disease has been described almost exclusively in children and young adults, and in most cases the causative agents are Gram-positive bacteria. We present the first report of obturator internus muscle abscess caused by a highly antibiotic resistant Klebsiella pneumoniae, in an elderly diabetic patient. Once considered very rare, Gram-negative pyomyositis is increasingly reported, and is an important concern in diabetic patients. Since pyomyositis can easily be missed if not considered, physicians should become familiar with this condition, and consider it in the differential diagnosis of septic diabetic patients.     

Cardiovascular complications in patients with HIV infection

As advances in early diagnosis and aggressive therapy, as well as better supportive care, become available to a larger number of patients with HIV infection, survival is being prolonged, and more patients are experiencing cardiac abnormalities. The most common cardiac manifestations of HIV disease are dilated cardiomyopathy, myocarditis, pericardial effusion, endocarditis, pulmonary hypertension, HIV-associated malignant neoplasms, and drug-related cardiotoxicity. The introduction of highly active antiretroviral therapy (HAART) regimens has substantially modified the course of HIV disease by lengthening survival and improving quality of life of HIV-infected patients. However, early data have raised concerns about HAART being associated with an increase in peripheral and coronary arterial disease. This review discusses the principal HIV-associated cardiovascular manifestations and emphasizes new knowledge about their prevalence, pathogenesis, and treatment.     

Staphylococcal pyomyositis in patients infected by the human immunodeficiency virus.

PURPOSE: We describe the manifestations of spontaneous staphylococcal pyomyositis in patients infected by the human immunodeficiency virus (HIV). PATIENTS AND METHODS: We present the courses of five previously unreported patients infected by HIV who presented to our medical centers with spontaneous staphylococcal pyomyositis. Additionally, we review all previously reported cases of this entity in HIV-infected patients and discuss its possible pathogenesis and importance in the context of HIV infection. RESULTS: All patients presented with gradually developing fever and localized pain and swelling without accompanying leukocytosis. Often only scant evidence of local inflammation was found. None of our patients used intravenous drugs, had a history of trauma, had HIV- or zidovudine-related myositis, or had other conditions known to be associated with serious staphylococcal infections. Two patients studied had normal serum levels of all IgG subclasses. Elevated serum IgE, eosinophilic inflammatory infiltrates, or marked peripheral eosinophilia was observed in two patients. CONCLUSIONS: Staphylococcal pyomyositis in HIV-infected patients presents in an indolent fashion, which may delay appropriate diagnosis and treatment. Since staphylococcal pyomyositis is infrequently reported in the United States, the development of 14 such cases (five in this series and nine previously reported) among the first 140,000 cases of acquired immunodeficiency syndrome in this country implies that this patient population is predisposed to this infectious complication. The pathogenesis of this entity is uncertain, but it is notable that HIV-infected patients are commonly colonized by Staphylococcus aureus and that neutrophils from HIV-infected patients frequently manifest phagocytic, chemotactic, and oxidative defects, diminished expression of Fc tau RIII (CD16) and CR1, and impaired bactericidal activity against S. aureus.     

Pyomyositis in North America: case reports and review.

We report two cases and review the characteristics of pyomyositis. The courses of patients who presented with pyomyositis at the Maricopa Medical Center (Phoenix) are detailed. Ninety-eight reported cases over the last 20 years in North America, found through a MEDLINE search, are summarized. Infection with the human immunodeficiency virus (HIV) may predispose the patient to pyomyositis. The onset is usually insidious with progression to large purulent collections and significant morbidity. The diagnosis is frequently suggested by findings of imaging studies. Staphylococcus aureus is responsible for most cases in tropical areas but is less frequently associated with cases in North America. Since infection with HIV predisposes patients to bacterial infections, pyomyositis will occur more frequently in this patient population. Increased awareness of the disease will improve management. Following aspiration or surgical drainage, therapy with broad-spectrum empirical antibiotics may be considered initially in the treatment of pyomyositis.     

Vanishing bile duct syndrome in human immunodeficiency virus infected adults:A report of two cases

Vanishing bile duct syndrome(VBDS) is a group of rare disorders characterized by ductopenia,the progressive destruction and disappearance of intrahepatic bile ducts leading to cholestasis.Described in association with medications,autoimmune disorders,cancer,transplantation,and infections,the specific mechanisms of disease are not known.To date,only 4 cases of VBDS have been reported in human immunodeficiency virus(HIV) infected patients.We report 2 additional cases of HIV-associated VBDS and review the features common to the HIV-associated cases.Presentation includes hyperbilirubinemia,normal liver imaging,and negative viral and autoimmune hepatitis studies.In HIV-infected subjects,VBDS occurred at a range of CD4+ T-cell counts,in some cases following initiation or change in antiretroviral therapy.Lymphoma was associated with two cases;nevirapine,antibiotics,and viral co-infection were suggested as etiologies in the other cases.In HIV-positive patients with progressive cholestasis,early identification of VBDS and referral for transplantation may improve outcomes.     

Immunopathogenesis of HIV-related heart muscle disease: current perspectives

As more effective antiretroviral therapies improve survival times, growing numbers of HIV-positive patients are at risk of developing end-organ damage or neoplasia. Heart muscle disease is the most important cardiovascular manifestation of HIV infection and seems set to become increasingly prevalent. This may take the form of either a dilated cardiomyopathy or isolated left or right ventricular dysfunction, is associated with a poor prognosis, and results in symptomatic heart failure in up to 5% of HIV patients. The precise cause of HIV-associated cardiomyopathy remains unclear but is undoubtedly complex, and most probably multifactorial. This report examines our current understanding of the immunopathogenesis of HIV-associated cardiomyopathy.     

HIV-associated early gastric adenocarcinoma successfully cured with surgery, and followed over eight years

An extremely rare case report of HIV-associated gastric adenocarcinoma surgically treated in the year 1998 in a 37-year-old male patient already HIV positive for 10 years, with a complete post-surgery disease-free follow-up of eight years, is described. An international literature search allowed us to report the available details of the only nine cases of HIV-associated gastric cancer yet published. Seven occurred prior to the introduction of highly active antiretroviral therapy (HAART) and were burdened by a rapid disease evolution, while only two patients were reported after the introduction of HAART (like ours) and obtained surgical cure. Detailed data regarding complications, sequelae and overall survival are not given. Notably, even four of the nine published reports came from Japan, and an early disease development was usual (37-50 years of age at diagnosis). Due to its relevant differential diagnosis implications with many other HIV-related gastrointestinal disturbances caused by functional and organic diseases (drug-related disturbances, HIV infection itself, opportunistic infections, and Kaposi's sarcoma and malignant lymphomas being the most frequent disorders) and the possibility of maintaining an adequate life-expectancy when diagnosis and aggressive treatment are not delayed, gastric cancer should be considered carefully by all clinicians dealing with HIV disease.     

Cutaneous manifestations of human immunodeficiency virus infection in Taiwan

Cutaneous manifestations are common and often the presenting feature of human immunodeficiency virus (HIV) infection, but a comprehensive study of HIV-associated skin lesions is not available in Taiwan. We reviewed all skin lesions in all HIV patients diagnosed in our department between 1990 and 1998 to document the spectrum of skin manifestations, the frequency of each disorder, and their relationship with CD4 counts. A total of 64 HIV patients were studied, including 38 with acquired immunodeficiency syndrome (AIDS) (CD4 < 200 x 10(6) cells/L) and 26 who had not developed AIDS (non-AIDS). There were 142 episodes of skin conditions representing 25 different skin diseases, including oral candidiasis (15% in non-AIDS vs 71% in AIDS patients), drug eruptions, herpes simplex, seborrheic dermatitis, dermatophytosis, herpes zoster, secondary syphilis, condyloma acuminatum, Kaposi's sarcoma (16% among AIDS patients), hairy leukoplakia, and molluscum contagiosum (13% among AIDS patients), in decreasing order. Several unusual cases are briefly described, including verrucous herpes infection, condyloma-like molluscum contagiosum, and AIDS-associated pigmented erythroderma. In our study, 70% of all HIV patients had skin diseases, with an average of 2.2 conditions per patient (3.2 in AIDS patients vs 0.7 in non-AIDS patients; p < 0.001). A broad spectrum of HIV-associated skin diseases was observed in our series. The frequency of HIV-associated skin disease was 92% in AIDS patients and 39% in non-AIDS patients; 78% of skin lesions in AIDS patients were diagnosed when CD4 counts were below 100 x 10(6) cells/L.     

Streptococcus pyomyositis occurring in a patient with dermatomyositis in a country with temperate climate.

We describe a man in whom pyomyositis developed in a temperate climate. Three facts make this case unique. First the pyomyositis developed in someone with underlying dermatomyositis, this being the second reported case to our knowledge. Second, the organism involved was a Streptococcus and not a Staphylococcus as in most cases described, and the course of the disease was acute and not subacute as is usually reported. Finally, contrary to most described cases, surgical drainage was not necessary, probably because of the early diagnosis. Pyomyositis should be considered a possible cause of localized pain in patients with underlying inflammatory muscle disease.     

Pyomyositis in a patient with the acquired immunodeficiency syndrome

Pyomyositis is an acute bacterial infection of skeletal muscle. It is a common disease in the tropics; fewer than 50 cases of pyomyositis have been reported in the continental United States. Most patients are healthy males, although the disease has been reported in diabetics and in the immunocompromised. This article presents the first detailed known reported case of pyomyositis in a patient with the acquired immunodeficiency syndrome; Staphylococcus aureus was the etiologic agent.     

Hematologic aspects of human immunodeficiency virus infection: laboratory and clinical considerations

Hematologic abnormalities are common in patients with HIV infection. This review will focus on HIV-associated cytopenias and coagulation abnormalities. Their occurrence, laboratory evaluation, and clinical significance and the mechanisms underlying their development are discussed. Therapeutic modalities are presented, with an emphasis on treatment strategies for HIV-associated thrombocytopenia.     

Pneumococcal pyomyositis: report of 2 cases and review of the literature

Streptococcus pneumoniae is an uncommon cause of pyomyositis. It is unclear whether the clinical presentation and outcome of pneumococcal pyomyositis differ depending on the host's underlying immune status. We describe 2 patients with pneumococcal pyomyositis, review all published cases, and compare characteristics between apparently healthy hosts and at-risk hosts. A total of 35 cases of pneumococcal pyomyositis were identified, 11 in apparently healthy hosts and 24 in at-risk hosts. Two-thirds of the patients had an antecedent respiratory illness or meningitis. At-risk hosts tended to have a longer interval between the development of symptomatic muscle infection and the diagnosis of pyomyositis and a significantly higher risk of disseminated disease at presentation, as manifested by involvement of multiple noncontiguous muscles or presence of meningitis. Overall, other than 1 death, all patients recovered with antibiotics and surgical drainage, but as might be expected there was a significantly higher rate of complications among at-risk hosts.     

Tropical pyomyositis in a temperate climate in an immunocompetent adult.

Tropical pyomyositis, though common in Africa, South America, and the South Pacific, is relatively rare in North America. Reported is the case of a patient who developed chest wall muscle abscesses after sustaining minor chest wall muscle trauma and presented to the emergency department appearing acutely ill. He was treated surgically with irrigation and debridement of the abscesses as well as with antibiotics and recovered fully over a seven-month course. This case illustrates important aspects of tropical pyomyositis with a discussion of the natural history of this disease as well as diagnostic modalities and treatment options for this virulent infectious process that is usually caused by penicillin-resistant Staphylococcus aureus.     

Jaccoud arthropathy: a rarity in the spectrum of HIV-associated arthropathy

In studies comparing HIV-infected patients with HIV-negative patients, rheumatic manifestations, including reactive arthritis, psoriatic arthritis, myalgia, tendinitis, fibromyalgia, necrotizing vasculitis, polymyositis, Sjogren syndrome, were shown to occur more frequently in the HIV-positive group. Uncommon clinical features and the demonstration of HIV antigens in the synovial membranes suggest a direct role of HIV in the pathogenesis of HIV-associated rheumatic disease. Jaccoud arthropathy is a nonerosive deforming arthropathy reported to occur in cases of chronic rheumatic fever and systemic lupus erythematosus. Only two cases of HIV-associated Jaccoud arthropathy has been reported in the literature thus far, both in patients with features of reactive arthritis. We report a case of HIV-associated Jaccoud arthropathy in a patient without features of reactive arthropathy.     

Nocardia and Lungs in COPD: Beyond Immuno-deficiencies

Nocardia is an opportunistic pathogen and Pulmonary Nocardiosis (PN) occurred in more than half of the cases in subjects with immuno-suppressed status. COPD is one of the most common comorbidity observed in immuno-competent patients with PN. In this perspective study, we report the clinical patterns, the outcomes and the comorbidities of all cases of PN admitted in our Unit in the years 1999–2012. Among 6545 patients admitted in our Unit during the study time, we identified PN in 4 patients. COPD was coexistent in 3 out of 4 cases. A delayed time for the diagnosis was observed. Clinical-radiological improvement was detected in all cases after one month of specific anti-PN therapy.

According to our experience, PN is a rare disease that should be suspected also in immuno-competent patients. COPD is confirmed to be a risk factor for the development of PN, probably due to reduced respiratory defenses and prolonged steroid therapy.     

Secondary syphilis presenting with acute severe hepatic involvement in a patient with undiagnosed HIV disease

A case report of acute, massive, prolonged hepatitis related to secondary syphilis in a patient with undiagnosed HIV infection is described together with possible pathogenetic mechanisms. This is a rare occurrence in resource-rich countries in the era of antibiotics. The impaired immune response and the dysregulation of the cytokine network may have played a role in mediating this severe expression of HIV-associated secondary syphilis. An apparently unexplained acute hepatitis should deserve accurate screening for sexually transmitted diseases, including syphilis and HIV infection.     

A case of group B streptococcal pyomyositis

The group B streptococcus is an opportunistic pathogen that causes a variety of serious infections including bacteremias, puerperal sepsis, and neonatal meningitis. Group B streptococcal infections of muscle are rare. We report here an unusual case of group B streptococcal pyomyositis. Pyomyositis arises predominantly from infections caused by Staphylococcus aureus and, occasionally, Streptococcus pyogenes. Because of the rarity of pyomyositis in temperate climates, the common lack of localizing signs or symptoms, and the frequently negative blood cultures, considerable delay often precedes the diagnosis of pyomyositis; in fact, the infection has been initially misdiagnosed as muscle hematoma, cellulitis, thrombophlebitis, osteomyelitis, or neoplasm. Diagnosis may be greatly aided by radiologic techniques that can demonstrate the sites of muscle enlargement and the presence of fluid collections. The response to antibiotics is usually rapid, but resolution of the infection may require aspiration of deeply situated muscle abscesses. This report describes a diabetic patient with an unusual presentation of pyomyositis that mimicked an acute abdomen.     

Digestive smooth muscle mitochondrial myopathy in patients with mitochondrial-neuro-gastro-intestinal encephalomyopathy (MNGIE)

We report 3 new cases of Mitochondrial-Neuro-Gastro-Intestinal Encephalomyopathy (MNGIE) (or Pseudo-Obstruction-Leukoencephalopathy-Intestinal-Pseudoobstruction Syndrome [POLIP]), a rare disease that associates chronic intestinal pseudo-obstruction (CIPO) and neurological symptoms. A review of the 72 reported cases together with these 3 cases revealed that this condition was associated with (a) a specific cluster of neurological symptoms including leukoencephalopathy (96%), polyneuropathy (96%), ophthalmoplegia (91%) and hearing loss (55%); (b) a CIPO syndrome with the presence of small bowel diverticulae (53%); and (c) mitochondrial cytopathy in 36 of the 37 tested patients (2 of our 3 cases), and thymidine phosphorylase gene mutations in all the 37 tested patients (2 of our cases). The etiology of POLIP/MNGIE syndrome appears therefore to be due to a mitochondrial cytopathy secondary to thymidine phosphorylase gene mutation(s). In 3 cases, including 2 of our 3 patients, mitochondrial abnormalities were evidenced at the ultrastructural level in digestive smooth muscle demonstrating that the pathogenesis of gastrointestinal involvement was directly related to mitochondrial alterations in digestive smooth muscle cells.