Mycobacteraemia among HIV-1-infected patients in São Paulo, Brazil: 1995 to 1998.

From July 1995 to August 1998, mycobacterial blood cultures were obtained from 1032 HIV-infected patients seen at the Centro de Referência e Treinamento de AIDS (CRTA), Hospital São Paulo (HSP), and Centro de Referência de AIDS de Santos (CRAS). Overall, 179 episodes of mycobacteraemia were detected: 111 (62.0%) at CRTA, 50 (27.9%) at HSP, and 18 (10.1%) at CRAS. The frequency of positive cultures declined sharply from 22.6% in 1995 to 6.9% in 1998, consistent with the decrease in opportunistic infections following the publicly funded distribution of highly active antiretroviral therapy. In 1995, mycobacteraemia was more frequently due to Mycobacterium avium complex (59.2%) than Mycobacterium tuberculosis (28.6%), whereas in 1998 the relative frequencies were reversed (28.6 vs. 64.3% respectively), probably justified by the increased virulence of M. tuberculosis and the greater risk of invasive infection in less-immunocompromised patients, including patients unaware they are infected with HIV.

Comparative studies of two-times-daily versus three-times-daily indinavir in combination with zidovudine and lamivudine.

OBJECTIVES: To compare the efficacy and safety of two-times-daily versus three-times-daily indinavir in combination with zidovudine and lamivudine. DESIGN: Two multicenter, open-label, randomized 24-week studies. METHODS: Adults HIV-1 infection, HIV-1 RNA greater than 10000 copies/ml, and no prior lamivudine or protease inhibitor therapy were eligible. In a pilot study (Study A), patients received indinavir at 800 mg every 8 h, 1000 mg every 12 h, or 1200 mg every 12 h. In a subsequent study (Study B), patients received indinavir at 800 mg every 8 h or 1200 mg every 12 h. All subjects received zidovudine (300 mg) and lamivudine (150 mg) every 12 h. An intent-to-treat analysis was used. RESULTS: In Study A, which enrolled 88 patients, neither HIV-1 RNA nor CD4 cell responses differed significantly between treatment groups at 24 weeks when corrected for multiple comparisons. Study B enrolled 433 patients, but was prematurely discontinued when interim analysis suggested greater efficacy of three-times-daily indinavir. Of the first 87 patients reaching week 24, HIV-1 RNA was less than 400 copies/ml in 91% receiving three-times-daily versus 64% receiving two-times-daily indinavir (P < 0.01). CONCLUSION: Three-times-daily indinavir appears more efficacious than two-times-daily dosing when administered with zidovudine and lamivudine. Two-times-daily indinavir dosing should only be considered in situations characterized by favorable pharmacokinetic drug-drug interactions.

Randomized, double-blind trial comparing indinavir alone, zidovudine alone and indinavir plus zidovudine in antiretroviral therapy-naive HIV-infected individuals with CD4 cell counts between 50 and 250/mm3.

Treatment with indinavir has been shown to result in marked decreases in viral load and increases in CD4 cell counts in HIV-infected individuals. A randomized double-blind study to evaluate the efficacy of indinavir alone (800 mg q8h), zidovidine alone (200 mg q8h) or the combination was performed to evaluate progression to AIDS. 996 antiretroviral therapy-naive patients with CD4 cell counts of 50-250/mm3 were allocated to treatment. During the trial the protocol was amended to add lamivudine to the zidovudine-containing arms. The primary endpoint was time to development of an AIDS-defining illness or death. The study was terminated after a protocol-defined interim analysis demonstrated highly significant reductions in progression to a clinical event in the indinavir-containing arms, compared to the zidovudine arm (p<0. 0001). Over a median follow-up of 52 weeks (up to 99 weeks), percent reductions in hazards for the indinavir plus zidovudine and indinavir groups compared to the zidovudine group were 70% and 61%, respectively. Significant reductions in HIV RNA and increases in CD4 cell counts were also seen in the indinavir-containing groups compared to the zidovudine group. Improvement in both CD4 cell count and HIV RNA were associated with reduced risk of disease progression. All three regimens were generally well tolerated.

Prevalence of intestinal parasitic infections in patients with acquired immunodeficiency syndrome in Brazil.

OBJECTIVES: To evaluate the prevalence of intestinal parasitic infections and to investigate the possible associations of clinical status and laboratory findings with the different parasites found in stool samples. METHODS: Each patient was provided with one standard fecal collection vial containing 10% formalin for detecting ova, larvae, and cysts. To detect Cryptosporidium parvum and Isospora belli, the acid-fast Kinyoun stain and fluorescent auramine-rhodamine stain were used. RESULTS: A total of 200 patients with acquired immunodeficiency syndrome participated in this study; 40% were infected with at least one pathogenic species. The total prevalence of parasites was 16% for Giardia lamblia, 13% for Entamoeba coli, 7% for Cryptosporidium parvum, 3.5% for Endolimax nana, 2.5% for Ascaris lumbricoides, 2.5% for Strongyloides stercoralis, 2% for Isospora belli, and 0.5% for Blastocystis hominis. Results showed that diarrhea was significantly associated with cryptosporidiosis, giardiasis, and isosporiasis. However, no association was observed between the CD4+ cell counts and the manifestation of any particular parasite. CONCLUSIONS: The data support the value of standard fecal examinations in human immunodeficiency virus-infected patients, even in the absence of diarrhea, since these examinations easily can be performed, with low costs, and frequently disclose treatable conditions.

[An evaluation of the relationship between intestinal parasitoses and the risk factors for HIV in AIDS patients]. / Avaliação da relação entre parasitoses intestinais e fatores de risco para o HIV em pacientes com AIDS.

We conducted a cohort survey on 200 AIDS patients in São Paulo, SP, Brazil, to verify if the presence of enteroparasites is associated with the various risk factors for HIV infection. Diarrhea was significantly more frequent in the group of patients presenting enteroparasitosis (p < 0.00001). Giardia lamblia, found in 32 (16%) cases, was the most prevalent parasite. The presence of parasites in the stool samples was not significantly associated with risk factors for HIV infection, mainly when considering Giardia lamblia and Cryptosporidium parvum (p = 0.99 and 0.69, respectively). The controversy found in the literature indicates that additional studies should be done in the different geographical regions of the country.

Enteric parasites and AIDS.

OBJECTIVE: To report on the importance of intestinal parasites in patients with AIDS, showing relevant data in the medical literature, with special emphasis on epidemiology, diagnosis and treatment of enteroparasitosis, especially cryptosporidiosis, isosporiasis, microsporidiasis and strongyloidiasis. DESIGN: Narrative review.

Estímulo do eixo hipófise-adrenocortical com o hormônio liberador de corticotrofina (CRH) na síndrome de imunodeficiência adquirida: evidência de ativaçäo do sistema imune-neuroendócrino / Stimulus of hypophyseal-adrenocortical axis with the corticotropin releasing hormone (CRH) in acquired immunodeficiency syndrome: evidence for activation of the immune-neuroendocrine system

Portadores de AIDS podem apresentar alteraçöes primárias e/ou secundárias do eixo hipotálamo-hipofisário-adrenocortical (EHHA), com manifestaçöes clínicas que väo de crises addisonianas a quadros de hipercortisolismo. Objeto. Avaliar o EHHA de 20 pacientes de AIDS e 17 controles normais, mediante testes de estímulo com ACTH exógeno (cosintropina, 250µg IV em bolo, com dosagem de cortisol basal e 60min após) e, subseqüentemente, teste de estímulo com hormônio liberador de corticotrofina ovino sintético (oCRH, 1µg/kg IV em bolo, com dosagens de ACTH e cortisol basais e a intervalos de 15-30min durante duas horas). Resultados. Diferente dos voluntários normais, pacientes de AIDS apresentaram estado de hipercortisolismo basal e após estímulo, tanto com cosintropina como com o CRH; cortisol (em µg/dL, média + or - cosintropina - basal 22,5 + or - 7,1 x 10,6 + or - 3,6 (p < 0,01) e após estímulo, 36,0 + or - 12,8 x 28,3 + or - 7,6 (p< 0,05); teste de oCRH - basal 19,7 + or - 9,0 x 10,1 + or - 3,4 (p < 0,01) e no pico de resposta, 27,5 + or - 8,9 x 18,3 + or 0 5,1 (p < 0,05). Além disso, a secreçäo de ACTH encontrava-se também significantemente mais elevada nos pacientes de AIDS após o teste de estímulo com o CRH; ACTH (em pg/mL) nos pacientes com AIDS x normais: teste de oCRH - basal 42,2 + or - 33,5 x 28,9 + or - 12,7 (NS) e no pico de resposta, 104,7 + or - 62,2 x 59,3 + or - 17,6 (p < 0,05). Conclusöes. Pela condiçäo de estresse continuado, os pacientes de AIDS apresentam estado de hipercortisolismo e de hipersecreçäo de ACTH, revelando resistência ao mecanismo de feedback negativo. Este fenômeno pode ser explicado pela interaçäo do sistema imunológico com o EHHA, com ativaçäo deste eixo pela liberaçäo de linfocinas circulantes que estimulariam, diretamente, hipotálamo e hipófise a produzir CRH e ACTH, respectivamente

[Stimulus of the hypophyseal-adrenocortical axis with corticotropin releasing hormone (CRH) in acquired immunodeficiency syndrome. Evidence for activation of the immune-neuroendocrine system]. / Estímulo do eixo hipófise-adrenocortical com o hormônio liberador de corticotrofina (CRH) na síndrome de imunodeficiência adquirida. Evidência de ativação do sistema imune-neuroendócrino.

Ten-20% of patients with AIDS may present clinical evidence of primary or secondary adrenal insufficiency. PURPOSE--To evaluate the hypothalamic-pituitary-adrenocortical axis (HPAA) with CRH in patients with AIDS. METHODS--We studied 20 patients with AIDS and 17 normal subjects (NS) with exogenous ACTH (cosyntropin, 250 micrograms IV bolus) followed one week later by ovine corticotropin releasing hormone (oCRH 1 microgram/kg BW IV bolus). Basal and 60' cortisol (micrograms/dL) were determined in the former whereas ACTH (pg/mL) and cortisol were measured every 15-30' for 2 hours in the latter. RESULTS--Basal and peak values (mean +/- SD) of ACTH and cortisol for both tests were: cosyntropin test (AIDS x NS): basal cortisol 22.5 +/- 7.1 x 10.6 +/- 3.6 (p < 0.01), peak 36.0 +/- 12.8 x 28.3 +/- 7.6 (p < 0.05); oCRH test: basal ACTH 42.2 +/- 33.5 x 28.9 +/- 12.7 (NS), peak 104.7 +/- 62.2 x 59.3 +/- 17.6 (p < 0.05); basal cortisol 19.7 +/- 9.0 x 10.1 +/- 3.4 (p < 0.01), peak 27.5 +/- 8.9 x 18.3 +/- 5.1 (p < 0.05). CONCLUSION--AIDS patients had elevated basal and CRH stimulated ACTH levels and an intact glucocorticoid pathway with elevated basal and peak cortisol levels to both stimulation tests. This situation is probably due to the stressful disease condition, where lymphokines may play a role activating the hypothalamic-pituitary axis.

Leishmaniose visceral e sindrome da imunodeficiencia adquirida (SIDA): relato de um caso / Visceral leishmaniais and acquired immunodeficiency syndrome (AIDS) : case report

Os autores descrevem um caso de associacao de leishmaniose visceral, SIDA e provavel tuberculose disseminada. Discutem a possibilidade de associacao desta protozoonose e infeccao pelo virus da Imunodeficiencia Adquirida (VIH) principalmente pelo aumento de prevalencia de infeccao pelo VIH em areas endemicas para o calazar. A presenca de imunodepressao pelo VIH possibilita manifestacoes de agentes oportunistas muitas vezes associados e relacionados com as endemias prevalentes nestas regioes de subdesenvolvimento.

[Visceral leishmaniasis and acquired immunodeficiency syndrome (AIDS). Report of a case]. / Leishmaniose visceral e síndrome da imunodeficiência adquirida (SIDA). Relato de um caso.

This is a case report that describe an association of AIDS, visceral leishmaniasis and probable disseminated tuberculosis. Due to the spread of AIDS in developing areas worldwide this association would be more frequently, seen on subjects from endemic areas where this protozoonosis is prevalent. More than one opportunistic infection related with the endemic diseases of the developing regions can be associated with those immunocompromised patients.