Acute promyelocytic leukemia after whole brain irradiation of primary brain lymphoma in an HIV-infected patient.

The occurrence of acute promyelocytic leukemia (APL) in HIV-infected patients has been reported in only five cases. Due to a very small number of reported HIV/APL patients who have been treated with different therapies with the variable outcome, the prognosis of APL in the setting of the HIV-infection is unclear. Here, we report a case of an HIV-patient who developed APL and upon treatment entered a complete remission. A 25-years old male patient was diagnosed with HIV-infection in 1996, but remained untreated. In 2004, the patient was diagnosed with primary central nervous system lymphoma. We treated the patient with antiretroviral therapy and whole-brain irradiation, resulting in complete remission of the lymphoma. In 2006, prompted by a sudden neutropenia, we carried out a set of diagnostic procedures, revealing APL. Induction therapy consisted of standard treatment with all-trans-retinoic-acid (ATRA) and idarubicin. Subsequent cytological and molecular ana?lysis of bone marrow demonstrated complete hematological and molecular remission. Due to the poor general condition, consolidation treatment with ATRA was given in March and April 2007. The last follow-up 14 months later, showed sustained molecular APL remission. In conclusion, we demonstrated that a complete molecular APL remission in an HIV-patient was achieved by using reduced-intensity treatment.

Meningitis and endocarditis caused by group B streptococcus in a human immunodeficiency virus (HIV) infected patient.

We present a case of meningitis and endocarditis caused by Streptococcus agalactiae (group B streptococcus) in an adult patient with human immunodeficiency virus (HIV) infection. To our knowledge, only four other cases of meningitis, none of which had concomitant endocarditis, have been reported so far. A 45-year-old homosexual patient presented with fever, confusion, and signs of meningeal irritation. Streptococcus agalactiae was cultured from the blood, urine, and cerebrospinal fluid (CSF). Diagnosis of meningitis caused by streptococcus agalactiae was made. On day 35, a heart murmur was noticed, and patient developed cardiac decompensation. Echocardiography revealed vegetations on the mitral and aortic valve. After nine weeks of antibiotic treatment, the patient was discharged from the hospital in good general condition, with improved CSF and echocardiographic findings.

Biological, epidemiological and clinical basis of understanding human immunodeficiency virus infection.

Human immunodeficiency virus (HIV) causes a chronic infection beginning in most individuals with an acute syndrome followed by an asymptomatic stage and progresses in untreated adults over a median of 10 years to the late stage called AIDS. The virus rapidly and enormously replicates from the initiation of infection. The principal immunodeficiency caused by HIV is depletion in the subset of T lymphocytes referred to as helper T cells. New anti-HIV drugs given in potent combination regimens have demonstrated impressive efficacy by both clinical and laboratory measures, and have provided evidence that drugs can suppress HIV replication and disease manifestations. HIV/AIDS is still uncommon in Croatia. In the period from 1986 to 2000, 171 patients with AIDS have been reported of whom 101 (59%) died. The incidence of AIDS in 2000 was about 4 cases per million inhabitants. Recent testing of injection drug users at a needle exchange program (Help, Split) revealed an HIV incidence of about 1%.

Survival of AIDS patients in Croatia prior to the introduction of combined antiretroviral therapy with protease inhibitors.

We report our experience on survival of adults with AIDS, treated at the University Hospital of Infectious Diseases, Zagreb, Croatia from October 1986 to December 1998. The median survival of our 116 patients was 15.8 months. Multivariate analysis showed that factors independently associated with survival were type of presenting AIDS indicator disease and CD4+ cell count.

[Cytomegalovirus retinitis in patients with human immunodeficiency virus infection]. / Citomegalovirusni retinitis u oboljelih od infekcije virusom humane imunodeficijencije.

Cytomegalovirus retinitis (CMVR) is a common opportunistic infection and a major cause of blindness in patients with AIDS. The aim of this study was to determine the frequency, clinical course and outcome of CMVR in patients treated at the University Hospital of Infectious Diseases "Dr. Fran Mihaljevic" in Zagreb in the period from January 1995 to April 1996. CMVR was diagnosed in 8 (27.5%) of 29 patients with AIDS. The median CD4 lymphocyte count in patients with CMVR was 44 per mm3, six patients had less than 50 per mm3. Five patients died during the study period, the mean survival being 5.5 months. CMVR was present in both eyes in 5 (62.5%) patients at the time of diagnosis. Blindness in both eyes developed in 3 (37.5%) patients. In order to recognize and promptly treat CMVR frequent ophthalmologic examinations should be performed in patients with advanced HIV disease.

Pneumococcal meningitis in the elderly.

The authors reviewed 70 cases of Streptococcus pneumoniae meningitis occurring over a 5-years period (1985-1989). Clinical features, outcome and laboratory findings in elderly patients (> 60 years of age, 21 patients) were compared with those in younger patients (< 59 years of age, 49 patients). Mortality rate was 57% in elderly group vs. 20% in younger. Admission to the hospital was delayed in the elderly. Only 67.6% of them were admitted on the first two days of the illness vs. 81.6% of younger patients. Nearly 62% of them were deeply soporous or comatose on admission (Mathew-Lawson grade 3 and 4), while in the control group only 31% of patients had such severely altered mental status. Although glucose cerebrospinal fluid (CSF)/blood ratio tended to be lower in the elderly (0.09 vs 0.17) the difference did not reach statistical significance. Thrombocytes in the peripheral blood were lower in the elderly (113 x 10(9)/L vs. 148 x 10(9)/L, p < 0.05). When we compared laboratory findings in survivors and nonsurvivors from both groups, nonsurvivors had significantly lower glucose CSF/blood ratio (0.054 vs. 0.174, p = 0.008), and higher bilirubin levels in serum (27.9 vs 14.7, p = 0.003), but differences were more obvious in younger group of patients. Our results suggest that there is increased risk of death among elderly patients. It can be at least partially attributed to their later admittance to the hospital and because of that delayed start of the appropriate therapy and more severe conscious disturbances. All these factors contribute to the greater case-fatality ratio observed in elderly patients with pneumococcal meningitis.

The clinical picture of rabies in a child.

An eight-year-old boy developed rabies 31 days after having been scratched by a dog and died 9 day later. Intensive supportive medical treatment was complicated by apnea, cardiac arrest, hypotension, increased secretion of antidiuretic hormone and severe hypoproteinemia. The treatment with intramuscular human antirabies immunoglobulin (HRIG) 2400 I.U. and intrathecal 1200 I.U. in combination with intramuscular interferon alpha 4 million I.U. was given every second day. The diagnosis of rabies was confirmed before death, on the third day of the disease, by direct fluorescent antibody staining of the saliva and cerebrospinal fluid for viral antigen. At the autopsy, the brain tissue specimens were tested for the presence of the virus by inoculation into the suckling mice brain and for the viral antigen by direct fluorescent antibody method. The brain tissue specimens collected at autopsy were also tested for virus by direct fluorescent antibody method.

Entry of ciprofloxacin into cerebrospinal fluid during bacterial, viral and tuberculous meningitis.

We studied the entry of ciprofloxacin into the cerebrospinal fluid (CSF) in 37 patients with various types of meningitis (bacterial meningitis 10 patients, viral 12 patients, tuberculous 7 patients). Eight patients were in the control group with normal CSF finding. Mean ciprofloxacin concentrations in the CSF 50-60 minutes after 200 mg of ciprofloxacin was given in infusion were 0.20 +/- 0.12 mg/L in patients with bacterial meningitis, which was significantly higher than in other tested groups (p = 0.0325). Ciprofloxacin achieved concentrations in the CSF 6.5-39% of serum (mean value 15% +/- 9%) in the bacterial meningitis group, while in the groups with viral and tuberculous meningitis the levels were significantly lower (approximately 9% of serum) but still higher than in the control group (approximately 5% of serum). Our data suggest that ciprofloxacin should be very cautiously used in selected patients with bacterial meningitis caused by multiple resistant strains of gram negative bacteria.

Ciprofloxacin in the treatment of gram-negative bacillary meningitis.

Gram-negative bacillary meningitis (typically caused by E. coli, K. pneumoniae, P. aeruginosa, A. calcoaceticus, and others) has been associated with head trauma, neurosurgical operations, pathologic anastomosis with nasal cavity, and CSF rhinorrhea, as well as with impaired host defenses. Intravenous ciprofloxacin was given to 20 patients with gram-negative bacillary meningitis. The dose of ciprofloxacin was 200 mg by intravenous infusion, over 30 minutes, every 12 hours for 10 days. Two patients also received intravenous cefotaxime and penicillin G. All patients were monitored daily. Of 20 patients, 18 had cure and therapy failed in two. Because relatively low concentrations of ciprofloxacin are achieved in the CSF, the drug should be used in the treatment of gram-negative bacillary meningitis only if the MICs of the causative pathogen and the ciprofloxacin concentration in CSF can be followed. A randomized, controlled study is needed to compare the efficacy of intravenous ciprofloxacin with standard antibiotic therapy in the treatment of this disease.

Plasma cholinesterase activity in patients during therapy with dexamethasone or prednisone.

We have studied the effects of i.v. dexamethasone and oral prednisone on plasma cholinesterase (ChE) activity in 13 male and 10 female patients during long-term treatment with dexamethasone or prednisone. A decrease in ChE activity--probably due to inhibition of ChE synthesis in the liver--was seen in all the patients. In individual patients there was a drop in enzyme activity of 14-57% (dexamethasone) and 23-69% (prednisone) respectively, compared with individual control values. After withdrawal of dexamethasone, ChE activity in most cases increased to above control values and the period necessary for complete restoration of ChE activity was variable (between 25-70 days). Our results suggest that the decrease in ChE activity in patients treated with dexamethasone or prednisone depends on the initial dose of the drug as well as on the duration of treatment.

[Subacute encephalitis caused by herpes simplex virus]. / Subakutni tok encefalitisa uzrokovanog virusom herpes simpleks.

The authors present a case of herpes-simplex encephalitis in a 58-year-old woman. The disease had a biphasic course and lasted 87 days. The clinical picture, laboratory data and the pathologic-anatomical changes of the disease are discussed. The authors also emphasize the importance of the encephalitic process in the brain stem, which can make the clinical picture even more complicated because of the appearance of respiratory disturbances.