The influence of intravenous drug use and HIV infection in the transmission of tuberculosis.

OBJECTIVE: To investigate whether smear-positive pulmonary tuberculosis (TB) patients present a different risk of TB transmission according to their HIV status, in an area where the majority of HIV-infected patients studied were intravenous drug users (IVDU). METHODS: A case-control study was performed on smear-positive pulmonary TB patients diagnosed between 1990 and 1993 for whom a contact study had been performed. Patients with and without HIV infection were matched by age (+/- 3 years), sex and hospital of diagnosis. A micro-epidemic was defined if two or more secondary cases were detected from the same index case. Data were analysed comparing the percentage of contacts with TB in both groups. RESULTS: Thirty-six secondary cases were detected in 436 contacts of 124 HIV-infected TB patients, whereas only 24 were identified in 624 contacts of 124 HIV-seronegative TB patients [odds ratio (OR), 2.14; 95% confidence interval (CI), 1.22-3.77; P = 0.004]. Comparing the contacts of HIV-infected patients, 34 secondary cases of TB were detected in 371 contacts of 97 IVDU, whereas only two cases were detected in 85 contacts of 27 non-IVDU (OR, 4.19; 95% CI, 1.09-15.95). HIV-seropositive index cases were observed to cause more micro-epidemics than seronegative cases (eight versus four), indicating that micro-epidemic cases were more frequent in the contacts of HIV-infected subjects (27 out of 36 versus 10 out of 24; OR, 1.41; 95% CI, 1.41-12.49; P = 0.009). All index cases in eight micro-epidemics were HIV-seropositive IVDU, whereas only four micro-epidemics were generated by HIV-seronegative subjects, none of whom were IVDU. CONCLUSIONS: Smear-positive pulmonary TB patients were more likely to transmit TB if they were HIV-infected, as evidenced by the role of IVDU in generating micro-epidemics.

[Invasive aspergillosis: treatment]. / Tratamiento de la aspergilosis invasiva.

Invasive aspergillosis is a severe disease, affecting essentially congenital or acquired immunodepressed patients, as well as neutropenic or transplanted ones, and those undergoing prolonged chemotherapy or treatment with corticoids. At present, the physician only disposes of the following treatment: amphotericin B desoxycolate, lipidic amphotericins and itraconazole p.o. or intravenously. Very soon, other drugs like voriconazole, posaconazole, liposomal nystatin and echinocandins probably will have a role in the treatment. It is most important to know thoroughly the patients's base disease and its specific treatment and the role of the drugs at present available, their relevant dosage, biodisponibility and pharmacokinetics, as well as adverse effects and evidence-based criterions of application. It is very important indeed to maintain a high suspicion of the disease and a rapid start of treatment. It is equally important to assess the role of coadjuvant treatments. We insist in the importance of surgery in solving of the disease in some cases (progressive pulmonar aspergillosis, sinusitis) combined with appropriate antifungal treatment.

[Candidemia in AIDS. A retrospective study of nine cases]. / La candidemia en el síndrome de inmunodeficiencia adquirida. Estudio retrospectivo de nueve casos.

Prevalence of candidemia has increased during the last decade, numerous predisposing factors are invoked, like parenteral drug abuse in the case of brown heroin syndrome, neutropenia, prolonged antibiotic therapeutics and immunosupression. Only a few articles are published about candidemia. Candidemia in AIDS patients seems very low; its incidence is estimated approximately one candidemia per 120 patients.

Virologic outcome and predictors of virologic failure of highly active antiretroviral therapy containing protease inhibitors.

In this observational single-center cohort study outside the clinical trial setting, outcome and predictors of virologic failure of highly active antiretroviral therapy (HAART) containing a protease inhibitor were evaluated in human immunodeficiency (HIV)-infected persons. The study population consisted of 807 protease inhibitor-naive HIV-seropositive patients who initiated antiretroviral therapy with reverse transcriptase inhibitors and protease inhibitors (indinavir, nelfinavir, ritonavir) between January 1997 and January 1999. Demographic variable, plasma HIV-1 RNA levels, CD4+ T-cell count, adverse drug reactions, and adherence to HAART were assessed. Virologic treatment response was defined as a decrease in plasma HIV-1 RNA load from baseline to below 500 copies per milliliter after 12 months of therapy. Levels of HIV-1 RNA were undetectable in 43% of patients at 12 months. Factors associated with failure to suppress viral load included age 40 years or younger, baseline CD4+ T cell count less than 200 x 10(6) per liter baseline viral load greater than 4.3 log(10) per milliliter, and non-adherence to HAART. After adjustment by logistic regression, non-adherence was the only statistically significant variable associated with virologic failure (odds ratio 0.38, 95% confidence interval 0.21 to 0.67). Unselected patients in whom protease inhibitor is started in a usual clinical setting achieve viral suppression less frequently than do patients in controlled clinical trials. Failure to adherence to HAART was the strongest predictor of virologic failure.

[Acquired immunodeficiency syndrome: a descriptive study and analysis of survival in 73 cases]. / Síndrome de inmunodeficiencia adquirida: estudio descriptivo y análisis de la supervivencia en 73 casos.

The clinical features and prognostic factors influencing survival in 73 patients diagnosed of acquired immunodeficiency syndrome (AIDS) from June 1984 to November 1988 were evaluated. Mean age was 32 years. The predominant risk group were drug abusers (67%). The most common opportunistic infections were extrapulmonary tuberculosis and esophageal candidiasis. After 6 months, with 42 patients followed up, the probability of survival was 69% +/- 11 (95% confidence interval); after 12 months, with 28 patients, it was 65% +/- 12 (95% confidence interval); and after 18 months, with 11 patients, it was 54% +/- 15 (95% confidence interval). Patients younger than 30 years and those with extrapulmonary tuberculosis had a longer survival than the rest (p = 0.046 and p = 0.014, respectively). The remaining evaluated variables did not have any influence on survival.

Splenic tuberculosis in patients with AIDS.

Splenic tuberculosis is an uncommonly considered diagnosis in clinical practice. We report splenic tuberculosis in three patients with AIDS who were admitted to the hospital because of fever and constitutional syndrome. In all of the patients, abdominal sonography and abdominal computed tomography revealed multiple hypoechoic and hypodense lesions, respectively. In two patients needle aspiration of the spleen with sonographic control was the diagnostic procedure. In the third patient the diagnosis was confirmed after splenectomy. In AIDS patients tuberculosis must be included in the differential diagnosis of hypoechoic and hypodense lesions by means of sonography and computed tomography, respectively, especially in those patients with active tuberculosis.

Simultaneous human immunodeficiency virus and Hepatitis C infection following a needlestick injury.

Needlestick injuries to health professionals at the Hospital del Mar, Barcelona since 1987 have been prospectively studied; a total of 296 such accidents in 286 subjects have been registered. We report the first case to our knowledge of simultaneous human immunodeficiency virus (HIV) and hepatitis C (HCV) infection in a nurse who suffered a needlestick injury after a blood sampling. Forty-four days after the accident she had symptoms and laboratory findings of acute hepatitis. Subsequent laboratory tests showed elevation in the aminotransferases and antibodies against HIV. The seroconversion to HCV was not detected until 109 days after the injury. The precise sequence of clinical and biological events of this case of simultaneous HIV and HCV infection is reported.

[Fever of unknown origin in patients with human immunodeficiency virus infection. Study of 100 cases]. / Fiebre de origen desconocido en pacientes con infección por el virus de la inmunodeficiencia humana. Estudio de 100 casos.

BACKGROUND: Fever of unknown origin (FUO) has been insufficiently studied in patients infected with HIV. The aim of this study was to determine the incidence, mean hospital stay, etiology, diagnostic methods and clinical course in patients infected with HIV and FUO. METHODS: Descriptive prospective study of patients infected with HIV and with FUO for a period of 24 months (February 1993-February 1995). Out of a total of 1,202 admissions, 100 were prompted by FUO in 95 patients (61 males, 34 women). Sixty-six per cent were parenteral drug abusers or had been so and the mean T CD4+ lymphocyte count was 0.061 x 10(9)/1 +/- 0.075 x 10(9)/1. RESULTS: The incidence of FUO was 8.3 every 100 patients/year. The mean hospital stay was 31.3 +/- 17.8 days, compared with an overall mean stay for HIV-positive patients of 14.6 +/- 8 days (p < 0.001). An etiologic diagnosis was achieved in 90% of cases. Pulmonary or extrapulmonary tuberculosis accounted for approximately 50% of cases, whereas non tuberculous mycobacteria (MAI and M. kansasii) for 20%. The other etiologies (CMV, visceral leishmaniasis, PCP, toxoplasmosis, cryptococcosis, lymphoma) accounted each for less than 5% of diagnoses. In 14 occasions there were two concomitant diagnoses. Mortality rate was 22%, which was higher when two simultaneous diagnosis were present [RR: 3.17 (1.5-6.6)]. In 45% of fatal cases one of the diagnoses went undiagnosed premortem. The highest diagnostic yield was obtained with sputum culture (34.2% of diagnosis) and blood culture (21.5%). CONCLUSIONS: FUO in common in patients infected with HIV, with important health resources consumption associated. The obtention of diagnosis was possible in a high percentage of patients. It is associated with a high hospital mortality rate. The most common diagnoses were tuberculosis and infections by other mycobacteria. It is possible to obtain the diagnosis with non-invasive procedures in 75% of cases.

[Animal bites. Study of 606 cases]. / Mordedura por animales. Estudio de 606 casos.

BACKGROUND: There is scarce information on animal bites in Spain. The objective of this study was to know the incidence, characteristics of the bitten persons, characteristics of biting animals, location of wounds and therapeutic behavior in our environment. PATIENTS AND METHODS: Descriptive study of patients who visited a rabies service after having been bitten by animals. STUDY PERIOD: from March, 1st, 1995, to February, 29th, 1996. During the study period 606 patients were visited and 2,400 telephone consultations answered. RESULTS: The incidence was 100 animal bites per 100,000 inhabitants/year. The male/female distribution of attended patients was 347/251 (47.3 vs 42.7%, respectively), a mean age of 32.5 +/- 21 years; 25% of cases were aged less than 15 years. The offending animals were: dogs 450 (74.3%), cats 97 (16%), rats 32 (5.3%), hamsters 16 (2.6%) and other animals 11 (1.8%). In 52.8% of cases the offending animals were owned by the bitten persons or domestic; in children 64.2% of cases were animals with these characteristics (p < 0.007); in this group of patients the rabies vaccination was correct in 61% of dogs and 40% of cats. The hand was the most frequent location of the wound, although face and neck locations were not uncommon in children (13.2%) compared with adults (4.4%) (p < 0.0002). The therapeutic behavior includes antitetanic prophylaxis in virtually all cases; antibiotic therapy was inappropriate in 44.4 of cases; a correct diversion towards the rabies service occurred in 42.4% of cases. The post-exposition rabies vaccine was administered in 218 patients, with a rate of 7.3/100,000 inhabitants/year. CONCLUSIONS: In the Barcelona province area animal bites are relatively common; in general populations preventive measures and health education are required, particularly among domestic animal owners, as well as health care personnel on the proper behavior when faced with animal bites.