Salmonella lung involvement in patients with HIV infection.

STUDY OBJECTIVE: To determine the frequency, clinical features, and outcome of lung involvement in HIV-infected patients having nontyphoid strains of Salmonella bacteremia. DESIGN: A retrospective clinical study. PATIENTS AND SETTING: We studied the records of all HIV-infected patients with Salmonella bacteremia diagnosed at a university tertiary hospital from January 1987 to December 1995. RESULTS: Lung involvement was found in 18 (35.3%) of 51 HIV-infected individuals with Salmonella bacteremia. Six of 18 (33.3%) were diagnosed as having definite Salmonella pulmonary infection by isolation of Salmonella from respiratory specimens, while probable Salmonella lung disease was considered in two patients who developed lung abscesses without the identification of any pathogen. Predisposing factors for focal disease, such as prior lung disease or Salmonella serotype, were equally prevalent regardless of the presence of Salmonella pulmonary involvement. Cavitary infiltrates or abscess formation were seen in five of the eight patients. With the exception of one patient coinfected with Nocardia asteroides who died 1 month later, all patients were cured with antibiotic treatment. Superinfection with other pulmonary pathogens (10 cases, 56%) was more frequent than Salmonella pneumonia; the most frequent alternative diagnosis was Pneumocystis carinii pneumonia (5 cases, 28%), pyogenic bacterial infection (17%), and tuberculosis (11%). CONCLUSIONS: In HIV-infected patients with Salmonella bacteremia, lung involvement is frequent, although there were no significant factors to explain this association. Cavitary disease was the most common radiologic pattern, and focal lung disease due to Salmonella does not seem to be associated with a worse prognosis. Coinfection and superinfection with other respiratory pathogens are more common than isolated Salmonella lung disease, and therefore, additional diagnostic procedures must be considered in the evaluation of these patients.

Acute mediastinitis due to Rhodococcus equi in a patient with human immunodeficiency virus infection.

A patient with human immunodeficiency virus infection developed anterior mediastinitis during antibiotic treatment for empyema due to Rhodococcus equi. This is the first reported case of infection with this organism in this setting. Despite an adequate course of therapy and maintenance treatment with antibiotics to which the isolate of Rhodococcus equi was susceptible in vitro, the patient experienced relapse of the infection into the mediastinum. Clinicians should consider this complication when Rhodococcus equi is present in pleural effusions.

[Tuberculosis presenting as diffuse pulmonary infiltrates in AIDS patients: diagnostic performance of clinical samples]. / Presentación de la tuberculosis como infiltrados pulmonares difusos en pacientes con sida: rendimiento diagnóstico de muestras clínicas.

BACKGROUND: In patients with human immunodeficiency virus (HIV) infection, tuberculosis is frequently presented with diffuse pulmonary infiltrates which are indistinguishable from those caused by other respiratory pathogens. It is therefore useful to know the diagnostic performance of different clinical samples. METHODS: We have retrospectively analyzed the clinical histories of 56 patients seen over a 3-year period. All the patients had HIV infection, Mycobacterium tuberculosis isolated in at least one clinical sample and presented with diffuse bilateral infiltrates in thorax radiography. The results of all the clinical samples submitted to the microbiology laboratory. RESULTS: The highest performance in both stainings and cultures were obtained from the biopsy (or aspirate) of adenopathies (93 and 100%, respectively), sputum (57 and 88%) and urine (31 and 64%). A lower than expected sensitivity was obtained in the fibrobronchoscopy samples (bronchoalveolar lavage and transbronchial biopsy). The staining had low sensitivity for predicting positive cultures in all the samples except in the adenopathies. Visualization of granulomas in transbronchial biopsies and bone marrow was more sensitive for diagnosis than the demonstration of resistant acid-alcohol bacilli in the same samples. Globally, rapid diagnosis was obtained in 43 patients (76%). The remaining 13 (24%) patients were not diagnosed until the culture results had been received despite the adequate use of diagnostic procedures. CONCLUSIONS: These findings support the use of empiric treatment when tuberculosis is suspected despite initial negativity of the microbiologic and pathologic examinations following the discarding of other potential causes.

[Tuberculous meningitis caused by resistant microorganisms. Therapeuticfailure in 2 patients with HIV infection and disseminated tuberculosis]. / Meningitis tuberculosa por microorganismos resistentes. Fracaso terapéutico en 2 pacientes con infección por HIV y tuberculosis diseminada.

BACKGROUND: Tuberculosis in HIV infected patients does not carry a worse therapeutic response rate. Treatment failure is usually due to incomplete schedule, with development of acquired resistance. Two patients with HIV infection and disseminated tuberculosis who developed fatal meningitis are presented. METHODS: In vitro studies of sensitivity to anti-tuberculous drugs were carried out, using the proportions method. RESULTS: Following a good initial evolution, both patients were readmitted with tuberculous meningitis resistant to isoniazide in both and to rifampicin in one of the patients. In one patient, the original strain (which was sensitive) was available. In this patient, changes in the treatment were performed in the initial phase. CONCLUSIONS: The importance of anti-tuberculous multiple therapy, particularly in the initial phases, for HIV positive patients is crucial. The lengthen of admission when good patient's compliance is in question, but also to avoid, whenever possible, changes in treatment are important measures in this stage. Meningitis may occur as a form of therapeutic failure and its cure may be difficult if the strains are resistant.

[Community-acquired pneumonia: prospective study of 101 adult, immunocompetent patients for 1 year]. / Neumonías extrahospitalarias: estudio prospectivo de 101 pacientes adultos e inmunocompetentes durante un año.

BACKGROUND: A one year prospective study was carried out to assess the etiology of community-acquired pneumonia (CAP), and also to know the incidence, characteristics and evolution of infection by Chlamydia pneumoniae; and the effectiveness of DNA probes in CAP due to Mycoplasma pneumoniae and Legionella. METHODS: One hundred and ten patients with a diagnosis of CAP in the emergency department were studied. Serologic studies were performed, and also tests commonly used for the diagnosis of respiratory tract pathogens in respiratory samples, including serology and culture of Chlamydia pneumoniae and DNA probes for Mycoplasma pneumoniae and Legionella. RESULTS: In 72 cases (71.3%) some pathogen was found and in 5 cases more than one microorganism was involved. The etiology was bacterial in 31% of the cases, with S. pneumoniae being the most frequent (19 cases). Forty percent of the cases were "atypical" pneumonias with 33 cases of M. pneumoniae and 5 by Chlamydia pneumoniae. Diagnostic data of viral pneumonia were found in 2 cases. DNA probes were not useful for the diagnosis of pneumonia by Legionella pneumophila and had low effectiveness (31.8%) in Mycoplasma pneumoniae CAP. CONCLUSIONS: a) M. pneumoniae was the most frequent pathogen (33%). b) DNA probes for M. pneumoniae had low sensitivity in sputum (31.8%) and none in pharyngeal exudate. c) Acute infection by C. pneumoniae was diagnosed in 5 cases. Previous data of infection were recorded in 60.4% of the patients. d) Bacterial pneumonia (31%) was underestimated due to a low rate of bacteremic cases (7.9%) and the low number of positive cultures with definitive diagnostic value. e) The evolution was good except in two cases (death due to staphylococcal pneumonia with alcohol withdrawal syndrome and multiorganic failure by disseminated chicken-pox).

[Roxithromycin in the treatment of community-acquired pneumonia]. / Roxitromicina en el tratamiento de las neumonías extrahospitalarias.

BACKGROUND: The aim of the present study was to prospectively evaluate the efficacy and tolerance of roxithromycin in the empiric treatment of extra-hospitalary pneumonias in immunocompetent adult patients. METHODS: Over a 12 month period 101 patients with extra-hospitalary pneumonia who attended the Emergency Department were studied. Of these, 53 were treated as out patients (5 with amoxicillin-clavulanic, 25 with erythromycin and 23 with roxithromycin at daily doses of 300 mg for 10 days). The treatment was randomly chosen, with no patient selection, thus making heterogeneous groups and, therefore, the study could not be comparative. RESULTS: In patients receiving roxithromycin, an etiologic diagnosis was achieved in 15 cases (65.3%), with Mycoplasma pneumoniae, being the most frequent pathogen (10 cases), followed by Streptococcus pneumoniae (3), Chlamydia pneumoniae (1) and Haemophilus influenzae (1). The mean duration of fever was 1.9 days, 6.7 days for respiratory manifestations and resolution of the radiographic infiltrate 11.6 days. The evolution was good in all the patients with no secondary effects or relapse occurring in any patient. CONCLUSION: Roxithromycin is an effective, safe and comfortable antibiotic in the treatment of infections of the lower respiratory tract acquired in the community.

Pneumocystis carinii pneumonia in HIV-infected patients: diagnostic yield of induced sputum and immunofluorescent stain with monoclonal antibodies.

The purpose of this study was to evaluate the diagnostic yield of induced sputum (IS), assessing the reliability of indirect immunofluorescent stain with monoclonal antibodies (IFMoAb) and methenamine silver (Met-Ag) and analysing factors likely to influence the sensitivity of these techniques. An analysis was prospectively carried out on IS specimens collected from 61 human immunodeficiency virus (HIV)-infected patients during 69 episodes of suspected Pneumocystis carinii pneumonia. Ultrasonic nebulizers with hypertonic 2% saline were used. IFMoAb to P. carinii and Met-Ag were performed after cytocentrifugation of the specimen. Results were compared with those of bronchoalveolar lavage (BAL) with/without transbronchial biopsy (TBB), performed not more than seven days after induction of sputum. P. carinii pneumonia was confirmed in 32 episodes, of which IS was diagnostic in 23. The sensitivity of the staining procedures was 69% for IFMoAb, and 28% for Met-Ag. The three episodes of P. carinii pneumonia in patients on oral chemoprophylaxis yielded negative IS results; in contrast, IS was negative in only 6 of the 29 cases not receiving chemoprophylaxis. IS is a non-aggressive procedure that diagnosed P. carinii pneumonia in 72% of our cases. The yield increased significantly when IFMoAb was used in patients not receiving oral chemoprophylaxis.

[Nosocomial varicella: study of an epidemic outbreak among immunosuppressed patients]. / Varicela nosocomial: estudio de un brote epidémico entre pacientes inmunodeprimidos.

We describe the guidelines used and the clinical and epidemiological data of a varicella outbreak seen in our service. The index case was a male drug addict, seropositive for HIV, with disseminated varicella. A total of 40 health care workers were in contact with the patient. Of them, 37 were considered not to be susceptible of having the disease. The remaining three health care workers developed varicella, and one had been also in contact with other hospitalized patients during the exposure period. Serological test for varicella (FAMA) of all 20 exposed patients (all HIV positive) showed that only four were susceptible. Those were put on isolation and immunoglobulin against zoster-varicella (VZIG) was used. Only one developed varicella. We recommend: a) the index case has to bep put under strict isolation precautions or discharged; b) acyclovir should be given to all immunosuppressed patients; c) immunoglobulin (VZIG) should be used in immunosuppressed patients susceptible to varicella and exposed to index case, and d) live, attenuated vaccine should be used in non immunosuppressed susceptible patients.

[Pneumocystis carinii pneumonia in patients with HIV infection at a Spanish hospital]. / Neumonía por Pneumocystis carinii en pacientes con infección por VIH en un hospital español.

Thirty cases of a first episode of Pneumocystis carinii pneumonia in patients with HIV infection were collected in a 32 month period. Most patients had long standing fever, cough and dyspnea. Laboratory findings were nonspecific. Remarkably, LDH activity was high in 88% of patients and the T4 lymphocyte count was lower than 200/mm3 in all patients in whom it was measured. Chest radiogram showed bilateral alveolar-interstitial pattern in 90% of cases. Bronchoalveolar lavage with ultracentrifugation was found to be the most effective diagnostic study, with 95% sensitivity. The frequency of secondary effects to cotrimoxazole which required to change to pentamidine was 13.3%. During hospital admission, 16.6% of the patients died, and the survivors had mortality rates of 4% and 85% after 3 and 20 months, respectively.

[Neutropenia secondary to cefotaxime use]. / Neutropenia secundaria a cefotaxima.

Agranulocytosis is an uncommon complication of beta-lactam antibiotic therapy. Two patients who developed absolute neutropenia and anemia after having received 168 g of cefotaxime are reported. There was fever and rash, and hematologic recovery too place 10 and 6 days after withdrawal of the drug. The bone marrow culture showed that the incubation of cells with cefotaxime (10 micrograms/ml) induced a 26 +/- 1% inhibition of the formation of granulocytic colonies (CFU-GM) in controls and a 47% and 48% inhibition, respectively, in the two patients with neutropenia. When serum was added to the culture, the control serum improved the in vitro granulopoietic response, while the serum from the first patient inhibited in 77 +/- 1.5% the formation of CFU-CM in the control marrow. The need for the monitoring of peripheral blood cells in patients receiving long term treatment with beta-lactam antibiotics emphasized, as we have shown the suppressor effect of cefotaxime on the hematopoietic precursors and the effect of an autoimmune mechanism in some cases.