Life-threatening bacterial pneumonia in male homosexuals with laboratory features of the acquired immunodeficiency syndrome

Two male homosexuals with laboratory features of the acquired immunodeficiency syndrome developed fulminating pneumonia requiring mechanical ventilatory support despite antibiotic therapy. Pathology consistent with bacterial pneumonia without other opportunistic pathogens were found at open lung biopsy. Cultures from the open biopsy grew Hemophilus influenzae in one, and Streptococcus pneumoniae was seen on Gram stain and sputum culture prior to antimicrobial treatment in the other. Each recovered on continued single antibiotic therapy. Life-threatening bacterial pneumonia may be a feature of the acquired immunodeficiency syndrome, possibly due to B cell abnormalities.     

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.     

Dapsone-trimethoprim for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome

All patients with the acquired immunodeficiency syndrome and a first episode of Pneumocystis carinii pneumonia seen at the San Francisco General Hospital between November 1984 and April 1985 were evaluated for oral treatment with dapsone (100 mg/d) plus trimethoprim (20 mg/kg body weight X d). All 15 patients who met the entry criteria improved clinically and radiographically within 3 to 10 days after starting treatment. Repeat pulmonary function tests and gallium lung scans after 3 weeks of therapy also showed improvement. Although side effects occurred in 14 patients, in only 2 were they severe enough to require stopping therapy. Both of these patients had worsening skin rash, and dapsone-trimethoprim therapy was stopped after 10 days. When compared with trimethoprim-sulfamethoxazole or pentamidine used to treat P. carinii pneumonia in similar patients, oral dapsone-trimethoprim is at least as effective, seems to be better tolerated, and may have a lower frequency of serious side effects.     

The treatment of Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome

Forty-four episodes of Pneumocystis carinii pneumonia (PCP) occurred in 36 of 70 patients with the acquired immunodeficiency syndrome. Thirty-four patients with 40 episodes of PCP were treated with trimethoprim-sulfamethoxazole. Therapy was successful in 18 episodes (45%), but was unsuccessful in 15 episodes (37.5%). In the latter cases, two patients died within 72 hours; 13, of whom nine died, had therapy changed to pentamidine. In seven additional episodes (17.5%), trimethoprim-sulfamethoxazole was changed to pentamidine due to adverse reactions; all patients survived. Seven patients (26% of survivors) developed recurrent PCP. Twenty-two patients (65%) developed adverse reactions to trimethoprim-sulfamethoxazole, including leukopenia (20), hepatotoxicity (12), fever (eight), rash (six), and immediate reactions (two). Reactions were most common during the second week of therapy. Patients with the acquired immunodeficiency syndrome who have PCP have a high trimethoprim-sulfamethoxazole failure rate, due either to adverse reactions or unresponsive infection. Late recurrence is common.     

Organizing pneumonia in a patient with newly diagnosed acquired immunodeficiency syndrome

Organizing pneumonia (OP) may be secondary to many clinical settings, including various infections, drugs, radiation therapy, malignant diseases, and connective tissue diseases. The concomitant occurrence of OP with human immunodeficiency virus infection has rarely been described. Recently, we encountered a case of OP confirmed by surgical lung biopsy in a patient with newly diagnosed AIDS. This case is the first in Korea and the second worldwide in which the diagnoses of OP and AIDS were made simultaneously. In this case, other possibilities that lead to OP, such as drug toxicity, were ruled out carefully.     

Pneumococcal bacteremia with pneumonia. Mortality in acquired immunodeficiency syndrome.

OBJECTIVE: To compare mortality due to bacteremic pneumococcal pneumonia in patients with acquired immunodeficiency syndrome (AIDS) vs (control) patients without human immunodeficiency virus (HIV) infection. Non-AIDS patients with HIV infection were incidentally tabulated as a separate group. DESIGN: A two-year retrospective study. SETTING: Inpatients of St. Clare's Hospital, a community hospital in New York City. PATIENTS: Forty-nine patients had 50 separate episodes with at least one positive blood culture for Streptococcus pneumoniae (all were penicillin-sensitive) and pneumonia on chest roentgenogram. Twenty-four patients had no HIV infection, 14 patients had AIDS, and 11 patients with 12 bacteremic episodes were HIV-positive without AIDS. INTERVENTIONS: Treatment for pneumonia was determined by the patient's individual physician. MEASUREMENTS AND MAIN RESULTS: AIDS patients with pneumonia had a mortality of 57.1 percent (8/14), which was significantly higher than the 25 percent (6/24) seen in patients without HIV infection (p less than 0.025, two-sample test for independent proportions). Septic shock, usually occurring within the first five days of hospitalization, was the primary cause of death, occurring in six of eight AIDS patients and six of six patients without HIV infection. If the mortality in the first five days of hospitalization was excluded, the mortality would drop to 33.3 percent in the AIDS population and 5.3 percent in patients without HIV infection. Eleven HIV-infected patients without AIDS survived 12 episodes of bacteremic pneumococcal pneumonia. CONCLUSIONS: Bacteremic pneumococcal pneumonia in the setting of AIDS has a survival rate of less than 50 percent with septic shock as the usual mode of death. This is the highest pneumococcal pneumonia mortality rate ever reported in a large subgroup of patients in the antibiotic era. On the other hand, HIV-infected patients without progression to AIDS have an excellent chance for survival. This may be related in part to young age, absence of many underlying diseases, and a better humoral immune system.     

Aerosolised pentamidine for Pneumocystis carinii pneumonia in patients with acquired immunodeficiency syndrome

The goal of this study was to evaluate inhaled pentamidine for the treatment of patients with mild and moderate Pneumocystis carinii pneumonitis. Eight adults with AIDS and pneumocystis pneumonia (4 with a first episode and 4 with a repeat pneumocystosis) received daily inhalations of aerosol pentamidine isethionate for 21 days. Six patients were treated with doses of 300 mg of pentamidine and the remaining 2 received 600 mg every day. In the 300 mg treatment group, 2 individuals showed discrete and transient neutropenia. However, both subjects that received 600 mg of aerosol pentamidine daily developed leukopenia. One of them had major toxicity (overall severe intolerance of 12.5%) that required drug discontinuation and did not allow any analysis of the treatment efficacy. Of the 7 evaluable patients, 6 (88%) completed the treatment successfully. One subject of the 300 mg regimen experienced an early recurrence. In conclusion, inhaled pentamidine is an effective treatment for mild and moderate cases of P. carinii pneumonia. It is less toxic than standard anti-pneumocystis therapy and is suitable for outpatient use.     

Sputum examination for the diagnosis of Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome

The diagnostic utility of sputum examination in patients with Pneumocystis carinii pneumonia secondary to the acquired immunodeficiency syndrome (AIDS) has so far not been determined. Sputum was induced in 43 patients with AIDS or suspected AIDS just prior to fiberoptic bronchoscopy, scheduled because of an unexplained pulmonary infiltrate on a chest radiograph. Pneumocystis carinii pneumonia was diagnosed by sputum examination and/or by a bronchoscopic procedure in 20 patients. Of these, sputum samples were positive for Pneumocystis organisms in 11 (55%) of 20 patients tested, bronchial washings were positive in 11 (79%) of 14 patients tested, brush biopsies were positive in 9 (53%) of 17 patients tested, and transbronchial lung biopsies were positive in 18 (90%) of 20 patients tested. The presence of P. carinii cysts in sputum did not correlate with the presence of alveolar macrophages in sputum nor with the volume of sputum. Sputum examination for P. carinii organisms, employed as a first diagnostic step in patients with AIDS with pulmonary infiltrates, may frequently obviate the need for bronchoscopy.     

Aspergillosis in the acquired immunodeficiency syndrome

The role of Aspergillus species as a pathogen in acquired immunodeficiency syndrome (AIDS) has not been clearly defined. From 1984 to 1989, more than 2,000 AIDS patients were seen at Beth Israel Medical Center, New York. Aspergillus was isolated in ten patients; seven had invasive disease and three had noninvasive disease. Invasive pulmonary aspergillosis (IPA) was diagnosed in six patients and invasive renal aspergillosis was found in one patient. Five were homosexual men and two were intravenous drug users. At presentation, all ten had fever, seven had cough, eight had dyspnea, and five had pleuritic chest pain. Chest roentgenograms revealed focal infiltrates in six patients, bilateral interstitial infiltrates in two patients, and bilateral pneumothoraces in one patient. Predisposing conditions included corticosteroid therapy in four, granulocytopenia (less than 1,000/cu m) in two, and broad-spectrum antibiotic therapy in five. Three of the four patients receiving corticosteroids received them as adjuvant therapy for Pneumocystis carinii pneumonia (PCP). Aspergillus was identified antemortem in eight patients, in bronchoalveolar lavage (BAL) fluid in six, in transbronchial biopsy specimen in three, in open lung biopsy specimen in one, and postmortem in one patient. Six of seven patients had at least one concomitant pulmonary process. Six underwent necropsy and findings showed IPA in three, disseminated aspergillosis in two, and PCP in one. Invasive aspergillosis, although significant, is uncommon in AIDS. When Aspergillus is isolated in the setting of corticosteroid therapy, antibiotics, or granulocytopenia, one must suspect invasive disease.     

Cryptococcosis in the acquired immunodeficiency syndrome

The clinical course and response to therapy of 27 patients with cryptococcosis and the acquired immunodeficiency syndrome were reviewed. Cryptococcosis was the initial manifestation of the syndrome in 7 patients, and the initial opportunistic infection in an additional 7. Meningitis was the commonest clinical feature (18 patients). Blood cultures and serum cryptococcal antigen were frequently positive. In patients with meningitis, leukocyte count, protein level, and glucose level in cerebrospinal fluid were frequently normal; cerebrospinal fluid India ink test (82%), culture (100%), and cryptococcal antigen (100%) were usually positive. Only 10 of 24 patients had no evidence of clinical activity of cryptococcal infection after completion of therapy; 6 of these 10 had relapses shown by clinical findings or at autopsy. Standard courses of amphotericin B alone or combined with flucytosine were ineffective. Cryptococcosis in patients with the syndrome is a debilitating disease that does not respond to conventional therapy; earlier diagnosis or long-term suppressive therapy may improve the prognosis.     

Early predictors of in-hospital mortality for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome

One hundred forty-five patients were initially seen with Pneumocystis carinii pneumonia (PCP). Of the many features examined, several variables were identified early in the hospitalization for PCP that were associated with poor survival. These included multiple admissions, leukocytoses, elevated serum lactate dehydrogenase levels, decreased arterial oxygen pressure (tension), decreased arterial carbon dioxide pressure (tension), and decreased serum albumin levels. Variables that were associated with increased survival included normal respiratory rates and normal findings on lung examination. Patients with multiple pulmonary infections displayed higher mortality rates than patients who had only PCP. Finally, our data did not suggest that the degree of immunosuppression affected in-hospital mortality for PCP.     

Coccidioidomycosis in the acquired immunodeficiency syndrome

Of 27 patients with the acquired immunodeficiency syndrome (AIDS) in Tucson, Arizona, 7 had concurrent coccidioidomycosis. Early manifestations of infection in 6 patients included diffuse nodular pulmonary infiltrates and Coccidioides immitis in many extrathoracic sites. By comparison, a retrospective review of the cases of 300 patients hospitalized with coccidioidal infection identified only 13 patients without AIDS who had the same extent of infection, and only 3 of these patients had no immunosuppressing conditions. Antibodies for coccidioidal antigens at serum dilutions as high as 1:2048 were detected in 5 of the 7 patients with AIDS. Six had temporary responses to amphotericin B treatment, taken both alone and combined with ketoconazole, but all died within 14 months of their diagnosis of coccidioidomycosis. Because annual rates of coccidioidal infection in the Tucson area are 4% or less, the rate of 27% that we calculated, based on 7 patients having the infection during 26 years of risk for AIDS, suggests frequent reactivation of the infection or enhanced susceptibility to endemic exposure in persons with AIDS.     

Hypertriglyceridemia in the acquired immunodeficiency syndrome

PURPOSE: A relationship between the induction of hypertriglyceridemia by cytokines and the cachexia seen in chronic infection has been proposed by other investigators. Since patients with the acquired immunodeficiency syndrome (AIDS) often experience progressive tissue wasting, we decided to examine serum lipid levels and body cell mass in patients with AIDS. PATIENTS AND METHODS: Serum lipid levels and body cell mass were measured in 32 patients with the acquired immunodeficiency syndrome (AIDS), eight asymptomatic subjects who were anti-human immunodeficiency virus (HIV) antibody positive, and 17 heterosexual and homosexual control subjects who did not have antibodies to HIV. RESULTS: Mean triglyceride concentrations and the prevalence of hypertriglyceridemia (50 percent) were significantly increased in patients with AIDS compared with control subjects (p less than 0.002 and p less than 0.005, respectively), whereas the mean triglyceride levels of HIV-positive subjects were intermediate. There were no differences in cholesterol levels among the three groups. Using total body potassium adjusted for height and age (KHT) as a measure of body cell mass, 16 of 32 patients with AIDS but none of the HIV-positive or control subjects had significant depletion of body cell mass. There was no direct relationship between triglyceride levels and KHT among AIDS or HIV-positive subjects. In patients with AIDS, mean triglyceride levels and the prevalence of hypertriglyceridemia were similar in the presence and absence of wasting. CONCLUSION: Hypertriglyceridemia is a common finding in AIDS and is independent of the degree of wasting.     

Mycobacterium kansasii and pneumocystis carinii pneumonia in a patient with the acquired immunodeficiency syndrome

Summary The case of a Swiss AIDS patient suffering fromMycobacterium kansasii lung disease is described. The course of the illness was complicated byPneumocystis carinii pneumonia. Therapy with isoniazid, ethambutol, clofazimine, ciprofloxacin and, after the onset ofP. carinii pneumonia, trimethoprim-sulfamethoxazole led to a rapid and sustained clinical recovery of the patient.

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Mycobacterium kansasii und Pneumocystis carinii-Pneumonie bei einem AIDS-Patienten

Zusammenfassung Der Fall eines Schweizer AIDS-Patienten mit einerMycobacterium kansasii-Lungenkrankheit wird beschrieben. Der Verlauf der Krankheit wurde durch einePneumocystis carinii-Pneumonie kompliziert. Therapie mit Isoniazid, Ethambutol, Clofazimin, Ciprofloxacin und, nach Ausbruch derP. carinii-Pneumonie, Trimethoprim-Sulfamethoxazol führte zu einer raschen und andauernden klinischen Wiederherstellung des Patienten.

     

Nonbronchoscopic bronchoalveolar lavage for the diagnosis for Pneumocystis carinii pneumonia in the acquired immunodeficiency syndrome

We compared conventional bronchoscopic transbronchial biopsy (TBB) and bronchoalveolar lavage (BAL) with non-bronchoscopic bronchoalveolar lavage (NB-BAL) in nine patients with acquired immunodeficiency syndrome (AIDS) and bilateral lung infiltrates. NB-BAL was carried out with a control-tipped reusable catheter. In each patient, bronchoscopic procedures were performed in the right lung, followed immediately by NB-BAL in the left lung. The specimens obtained by NB-BAL confirmed the presence of P carinii pneumonia in seven of eight patients in whom the diagnosis was established by TBB or BAL. Viral cultures of NB-BAL specimens yielded cytomegalovirus (CMV) in four of five subjects with evidence of CMV via bronchoscopic technique, including two instances in which CMV was not detected by BAL. Complications were limited to right-sided pneumothorax attributable to TBB. Accuracy of NB-BAL appears to be comparable to that of conventional bronchoscopic approaches in the diagnosis of AIDS-related pulmonary infection with P carinii or CMV. NB-BAL may be a safer and more economical alternative to TBB and BAL in the diagnosis of pulmonary opportunistic infections.