Mpox in people with advanced HIV infection: a global case series.

BACKGROUND: People living with HIV have accounted for 38-50% of those affected in the 2022 multicountry mpox outbreak. Most reported cases were in people who had high CD4 cell counts and similar outcomes to those without HIV. Emerging data suggest worse clinical outcomes and higher mortality in people with more advanced HIV. We describe the clinical characteristics and outcomes of mpox in a cohort of people with HIV and low CD4 cell counts (CD4 <350 cells per mm3). METHODS: A network of clinicians from 19 countries provided data of confirmed mpox cases between May 11, 2022, and Jan 18, 2023, in people with HIV infection. Contributing centres completed deidentified structured case report sheets to include variables of interest relevant to people living with HIV and to capture more severe outcomes. We restricted this series to include only adults older than 18 years living with HIV and with a CD4 cell count of less than 350 cells per mm3 or, in settings where a CD4 count was not always routinely available, an HIV infection clinically classified as US Centers for Disease Control and Prevention stage C. We describe their clinical presentation, complications, and causes of death. Analyses were descriptive. FINDINGS: We included data of 382 cases: 367 cisgender men, four cisgender women, and ten transgender women. The median age of individuals included was 35 (IQR 30-43) years. At mpox diagnosis, 349 (91%) individuals were known to be living with HIV; 228 (65%) of 349 adherent to antiretroviral therapy (ART); 32 (8%) of 382 had a concurrent opportunistic illness. The median CD4 cell count was 211 (IQR 117-291) cells per mm3, with 85 (22%) individuals with CD4 cell counts of less than 100 cells per mm3 and 94 (25%) with 100-200 cells per mm3. Overall, 193 (51%) of 382 had undetectable viral load. Severe complications were more common in people with a CD4 cell count of less than 100 cells per mm3 than in those with more than 300 cells per mm3, including necrotising skin lesions (54% vs 7%), lung involvement (29% vs 0%) occasionally with nodules, and secondary infections and sepsis (44% vs 9%). Overall, 107 (28%) of 382 were hospitalised, of whom 27 (25%) died. All deaths occurred in people with CD4 counts of less than 200 cells per mm3. Among people with CD4 counts of less than 200 cells per mm3, more deaths occurred in those with high HIV viral load. An immune reconstitution inflammatory syndrome to mpox was suspected in 21 (25%) of 85 people initiated or re-initiated on ART, of whom 12 (57%) of 21 died. 62 (16%) of 382 received tecovirimat and seven (2%) received cidofovir or brincidofovir. Three individuals had laboratory confirmation of tecovirimat resistance. INTERPRETATION: A severe necrotising form of mpox in the context of advanced immunosuppression appears to behave like an AIDS-defining condition, with a high prevalence of fulminant dermatological and systemic manifestations and death. FUNDING: None.

Influence of Stigma on Engagement in HIV Care and Adherence to Antiretroviral Therapy in Specialized HIV Clinics Targeting Men Who Have Sex with Men and Transgender Women in Lima, Peru.

HIV stigma is a social determinant of health that can influence multiple health outcomes, including adherence to antiretroviral therapy (ART), engagement in HIV care, and viral suppression levels in people with HIV (PWH). In Peru, where the HIV epidemic is concentrated in men who have sex with men (MSM) and transgender women (TGW), stigma may play an important role in healthcare engagement. To understand the relationship between stigma and two outcome variables, ART adherence and engagement in HIV care in 400 MSM and TGW, we assessed factors from the Behavioral Model for Vulnerable Populations at two HIV clinics that tailor services for sexual and gender minorities. While some predisposing, need, and enabling resource factors were associated with optimal (≥ 90%) ART adherence or engagement in HIV care, none of the stigma subscales were correlated, suggesting that when LGBTQ-affirming care is provided to MSM/TGW, stigma may not influence HIV-related outcomes.

RESUMEN: El estigma hacia el VIH es un determinante social de la salud que puede influir en múltiples desenlaces, incluyendo la adherencia a la terapia antirretroviral (TAR), el compromiso con la atención del VIH y los niveles de supresión viral en personas viviendo con VIH (PVV). En el Perú, donde la epidemia del VIH se concentra en hombres que tienen sexo con hombres (HSH) y mujeres transgénero (MT), el estigma puede desempeñar un papel importante en el compromiso con la atención médica. Para comprender la relación entre el estigma y dos variables de resultado, la adherencia al TAR y el compromiso con la atención del VIH en 400 HSH y MT, evaluamos factores del Modelo de Comportamiento para Poblaciones Vulnerables en dos clínicas de VIH que adaptan sus servicios para minorías sexuales y de género. Si bien algunos factores predisponentes, de necesidad y de recursos habilitantes se asociaron con una adherencia óptima (≥ 90%) al TAR o al compromiso con la atención del VIH, ninguna de las sub-escalas de estigma estuvieron correlacionadas, sugiriendo que cuando se brinda atención que afirma a la comunidad LGBTQ a HSH/MT, el estigma puede no influir en los desenlaces relacionados con el VIH.

Unmasked immune reconstitution inflammatory syndrome towards B-cell non-Hodgkin lymphoma during treatment of esophageal actinomycosis in a patient with advanced HIV: a case report.

BACKGROUND: Actinomycosis is an unusual chronic bacterial infection, even rarer in people living with HIV. It is not considered an AIDS-defining disease. However, the role in co-presentation or overlap with other opportunistic conditions of advanced HIV is unknown. CASE PRESENTATION: A 49-year-old Peruvian male presented with a 4-month history of dysphagia, odynophagia, hyporexia and wasting. He underwent an upper digestive endoscopy, in which ulcers with a necrotic center were observed, therefore, the initial diagnostic assumption was esophageal cancer. Subsequent pathology report excluded neoplasms and confirmed the diagnosis of actinomycosis. Serology for human immunodeficiency virus was requested, yielding a positive result. Antimicrobial treatment with amoxicillin and antiretroviral therapy were indicated, with slow clinical improvement. After 4 months, epigastric discomfort presented, for which a new upper digestive endoscopy was performed, revealing a deep gastric ulcer, which was compatible with diffuse large B-cell non-Hodgkin lymphoma. CONCLUSION: Esophageal actinomycosis in people living with HIV is very rare. We suggest HIV-associated immunosuppression is not enough to allow for actinomycosis to develop, and masked underlying entities should be sought. The existence of such entities in people living with HIV should raise awareness of the possibility of unmasked immune reconstitution inflammatory syndrome once treatment has started.

Risk of human leptospirosis in Colombia: spatiotemporal analysis and related hydroclimatic factors.

BACKGROUND: Leptospirosis is an endemic zoonosis in tropical areas that is mainly related to rural activities; nevertheless, human leptospirosis (HL) outbreaks differ among regions. In Colombia, HL notifications are mandatory. Our objective was to determine the spatiotemporal distribution of HL in Colombia during 2007-2018 and its relationship with the main hydroclimatic variables. METHODS: We determined the estimated incidence and lethality of HL according to department and year. The Bayesian spatiotemporal analysis of an autoregressive model (STAR) model included HL cases and hydroclimatic factors (average temperature, rainfall and relative humidity) for quarterly periods. RESULTS: During the study period, 10 586 HL cases were registered (estimated incidence: 1.75 cases x 105) and 243 deaths by HL (lethality 2.3%). The STAR model found association of HL risk with temperature (RR:6.80; 95% CI 3.57 to 12.48) and space. Quindío and three other Amazonian departments (Guainía, Guaviare and Putumayo) had a positive relationship with a significant number of HL cases, adjusted for quarterly precipitation and humidity. CONCLUSION: Spatial analysis showed a high risk of HL in departments of the western Andean Colombian regions. By contrast, in the spatiotemporal model, a higher HL risk was associated with temperature and departments of the North Colombian Amazon regions and Quindío in the Colombian Andean region.

Malignant syphilis as the presenting complaint of advanced HIV.

Malignant syphilis is an infrequent secondary manifestation in patients with human immunodeficiency virus (HIV), with polymorphous and disseminated skin lesions being related to severe immunosuppression. Lesions have intense inflammatory circinate, ulcer-crusted and nodular skin lesions of diffuse distribution throughout the body, that can be confused with vasculitis or cutaneous lymphomas. We report a patient recently diagnosed with HIV infection in the acquired immunodeficiency syndrome stage with malignant syphilis as the debut of HIV.

Oligosymptomatic diphtheria infection in adults: two contacts of the Peruvian index case after 20 years without disease report.

In Peru, diphtheria infection was eradicated in the last two decades. However, recently, diphtheria pharyngeal infection was confirmed and reported in a 5-year-old boy (index case). We report two more cases of this outbreak (in the index case parents) with confirmed diphtheria infection and tox gene identified by molecular assay, who were in close contact with the index case and never presented any symptoms. Both parents had a congestive pharynx with erythematous plaques at the back of it. In adults, diphtheria infection can be oligosymptomatic or mimic viral pharyngitis, which could lead to misdiagnosis and, furthermore, an increased risk of transmission in regions with lower immunization rates.

[Disseminated histoplasmosis and haemophagocytic syndrome in HIV patients: A case series in a Peruvian hospital]. / Histoplasmosis diseminada y síndrome hemofagocítico en pacientes VIH: serie de casos en un hospital peruano.

BACKGROUND: Disseminated histoplasmosis (DH) is an opportunistic fungal infection in severely immunocompromised patients with HIV infection. Haemophagocytic syndrome (HFS), which can occur in these co-infected patients when the immune response is significantly altered, is often associated with high mortality. AIMS: To describe the epidemiological, clinical, analytical and microbiological characteristics, along with studying the presence of HFS, in patients with DH-HIV. METHODS: A retrospective study was conducted on a case series using data from the clinical records of patients diagnosed with DH and HIV infection during the years 2014 and 2015. RESULTS: DH was diagnosed in 8 (1.3%) of 597 HIV patients. All patients were in stage C3, and 75% (6/8) were not receiving combined antiretroviral therapy (CART). The remaining two patients had recently begun CART (possible immune reconstitution syndrome). Five (62.5%) of the 8 patients met criteria for HFS. The most frequent clinical symptoms were lymphoproliferative and consumptive syndrome, respiratory compromise, and cytopenia. Histoplasma was isolated in lymph nodes of 75% (6/8) of the patients, in blood samples in 25% (2/8), and also in intestinal tissue in one patient. The antifungal therapy was amphotericin B deoxycholate, without adjuvants. The overall mortality was 50%. CONCLUSIONS: In this case series, DH-HIV co-infection frequently progressed to HFS with high mortality. The clinical picture may resemble that of other systemic opportunistic infections, such as tuberculosis, or can take place simultaneously with other infections. Clinical suspicion is important in patients with severe cytopenia and lymphoproliferative and consumptive syndrome in order to establish an early diagnosis and prescribing a timely specific therapy.

Hospital-acquired SARS-CoV-2 pneumonia in a person living with HIV.

We report the case of a 38 year-old man living with well-controlled HIV on antiretroviral therapy who developed cerebellar symptoms and was admitted to hospital for management of an intraventricular cryptococcoma. During his hospital stay he contracted SARS CoV-2 infection within the hospital setting with a fatal outcome.

Lateral amyotrophic sclerosis-like onset after combined antiretroviral treatment initiation.

Motor neuron disease (MND) have an incidence of 2 in 100 000 persons, resulting in the death of 1 in every 500 people affected. The most common disease in MND spectrum is amyotrophic lateral sclerosis (ALS). We describe the case of an ALS-like syndrome in a HIV patient. This case report presents a 38 years old male from Peru with HIV who after 2 months of combined antiretroviral treatment (cART) initiation was admitted to the hospital for spastic paraplegia. On his first admission, rapid plasma reagent (RPR) was positive and he was treated for neurosyphilis and discharged. Nevertheless, one month after, he was admitted for the second time because paraplegia persisted. Laboratory tests, electromyography and imaging were performed, and ALS was diagnosed. Normally, HIV treated patient with ALS tend to have a better prognosis, however this was not the case. In this case report, we discuss possible association between ALS and immune reconstitution inflammatory syndrome in HIV patients.

[Malaria in HIV-Infected patients: a series of cases in a peruvian hospital]. / Malaria en pacientes con infección por VIH: serie de casos en un hospital peruano.

The clinical signs of malaria in HIV patients may vary depending on the immunological status of the patient. Nationally, evidence regarding co-infection is scarce. This research describes four cases from a hospital in Iquitos, Peru, of patients diagnosed with HIV infection and a positive blood test for malaria. Two of these patients had Plasmodium falciparum infection, and two had Plasmodium vivax infection. One of the patients was in the AIDS stage with poor adherence to combination antiretroviral therapy (cART), and the other three were in the early stages and not receiving cART.

Las manifestaciones clínicas de la malaria en pacientes con VIH pueden ser variables dependiendo del estado inmunológico del paciente. La evidencia en relación a la coinfección es escasa a nivel nacional. Se describen cuatro casos procedentes de un hospital de Iquitos-Perú con diagnóstico de infección por VIH y examen de sangre positivo para malaria. De estos pacientes, dos tenían infección por Plasmodium falciparum y dos por Plasmodium vivax. Un paciente se encontraba en estadio sida con mala adherencia a la terapia antirretroviral combinada (TARVc) y el resto se encontraba en estadios tempranos sin recibir TARVc.

[Klebsiella pneumoniae NEW DELHI METALO-LACTAMASE IN A PERUVIAN NATIONAL HOSPITAL]. / Klebsiella pneumoniae Nueva Delhi metalo-betalactamasa en el Hospital Nacional Dos de Mayo. Lima, Perú.

The emergence of Enterobacteria producing carbapenemases of type New Delhi Metalo beta-lactamases (NDM), >represent, today, a real problem of world public health. The presence of this resistance mechanism limits or nullifies the therapeutic options to combat these bacteria. In Latin America, the figures are getting higher, as they are reported in Guatemala, Colombia, Chile, Argentina, among others. Peru has not, to date, described the presence of this resistance pattern; however for several years it has been presumed to exist. Nine cases of Klebsiella pneumoniae NDM are described, as infectious or colonizing agents, in critically ill patients, mostly with neurosurgical pathology, of Hospital Nacional Dos de Mayo in Lima - Peru. The patients in the series described below represent the first reports of Klebsiella pneumoniae NDM in Peru.

La emergencia de enterobacterias productoras de carbapenemasas de tipo Nueva Delhi Metalo beta-lactamasas (NDM), representan, hoy en día, un verdadero problema de salud pública mundial. La presencia de este mecanismo de resistencia limita o anula las opciones terapéuticas para combatir a estas bacterias. En Latinoamérica, las cifras son cada vez más elevadas, pues se reportan en Guatemala, Colombia, Chile, Argentina, entre otros. Perú no ha descrito, hasta la fecha, la presencia de este patrón de resistencia; sin embargo, desde hace varios años se presume de su existencia. Se describen nueve casos de Klebsiella pneumoniae NDM, como agentes infecciosos o colonizantes, en pacientes críticamente enfermos, en su mayoría con patología neuroquirúrgica, del Hospital Nacional Dos de Mayo, en Lima - Perú. Los pacientes de la serie descrita a continuación, representan los primeros reportes de Klebsiella pneumoniae NDM en el Perú.

Profile and professional expectations of medical students from 11 Latin American countries: the Red-LIRHUS project.

BACKGROUND: Latin America is undergoing a human resource crisis in health care in terms of labor shortage, misdistribution and poor orientation to primary care. Workforce data are needed to inform the planning of long-term strategies to address this problem. This study aimed to evaluate the academic and motivational profile, as well as the professional expectations, of Latin American medical students. RESULTS: We conducted an observational, cross-sectional, multi-country study evaluating medical students from 11 Spanish-speaking countries in 2011-2012. Motivations to study medicine, migration intentions, intent to enter postgraduate programs, and perceptions regarding primary care were evaluated via a self-administered questionnaire. Outcomes were measured with pilot-tested questions and previously validated scales. A total of 11,072 valid surveys from 63 medical schools were gathered and analyzed. CONCLUSIONS: This study describes the profile and expectations of the future workforce being trained in Latin America. The obtained information will be useful for governments and universities in planning strategies to improve their current state of affairs regarding human resources for health care professions.

Differences on Primary Care Labor Perceptions in Medical Students from 11 Latin American Countries.

BACKGROUND: The shortage in Latin-American Primary Care (PC) workforce may be due to negative perceptions about it. These perceptions might be probably influenced by particular features of health systems and academic environments, thus varying between countries. METHODS: Observational, analytic and cross-sectional multicountry study that evaluated 9,561 first and fifth-year medical students from 63 medical schools of 11 Latin American countries through a survey. Perceptions on PC work was evaluated through a previously validated scale. Tertiles of the scores were created in order to compare the different countries. Crude and adjusted prevalence ratios were calculated using simple and multiple Poisson regression with robust variance. RESULTS: Approximately 53% of subjects were female; mean age was 20.4±2.9 years; 35.5% were fifth-year students. Statistically significant differences were found between the study subjects' country, using Peru as reference. Students from Chile, Colombia, Mexico and Paraguay perceived PC work more positively, while those from Ecuador showed a less favorable position. No differences were found among perceptions of Bolivian, Salvadoran, Honduran and Venezuelan students when compared to their Peruvian peers. CONCLUSIONS: Perceptions of PC among medical students from Latin America vary according to country. Considering such differences can be of major importance for potential local specific interventions.

Gender Associated with the Intention to Choose a Medical Specialty in Medical Students: A Cross-Sectional Study in 11 Countries in Latin America.

INTRODUCTION: The selection of a medical specialty has been associated with multiple factors, such as personal preferences, academic exposure, motivational factors and sociodemographic factors, such as gender. The number of women in the medical field has increased in recent years. In Latin America, we have not found any studies that explore this relationship. OBJECTIVE: To determine whether there is an association between gender and the intention to choose a medical specialty in medical students from 11 countries in Latin America. METHODS: Secondary analysis of the Collaborative Working Group for the Research of Human Resources for Health (Red-LIRHUS) data; a multi-country project of students in their first year and fifth year of study, from 63 medical schools in 11 Latin American countries. All students who referred intention to choose a certain medical specialty were considered as participants. RESULTS: Of the 11073 surveyed students, 9235 indicated the name of a specific specialty. The specialties chosen most often in the fifth year were General Surgery (13.0%), Pediatrics (11.0%), Internal Medicine (10.3%) and Obstetrics/Gynecology (9.0%). For women, the top choices were Pediatrics (15.8%), Obstetrics/Gynecology (11.0%), Cardiology (8.7%), General Surgery (8.6%), and Oncology (6.4%). In the adjusted analysis, the female gender was associated with the choice of Obstetrics/Gynecology (RP: 2.75; IC95%: 2.24-3.39); Pediatric Surgery (RP: 2.19; IC95%: 1.19-4.00), Dermatology (RP: 1.91; IC95%:1.24-2.93), Pediatrics (RP: 1.83; IC95%: 1.56-2.17), and Oncology (RP: 1.37; IC95%: 1.10-1.71). CONCLUSIONS: There is an association between the female gender and the intention to choose Obstetrics/Gynecology, Pediatrics, Pediatric Surgery, Dermatology, and Oncology. We recommend conducting studies that consider other factors that can influence the choice of a medical specialty.

[Letters to the editor published in Peruvian biomedical journals indexed in SciELO-Peru 2006-2013]. / Cartas al editor publicadas en revistas biomédicas peruanas indizadas en SciELO-Perú 2006-2013.

This bibliometric study describes the characteristics of letters to the editor published between 2006-2013 in biomedical journals indexed in SciELO-Peru.253 letters (10.3% of total publications) were collected. Most letters (139) were in the Peruvian Journal of Experimental Medicine and Public Health, with marked increase throughout those years. 25% of letters submitted included medical student participation. 14% of authors presented with international affiliations and 27% with endogenous affiliation - common in university journals (Anales de la Facultad de Medicina, Revista Médica Herediana).The usual criteria justifying the publication of letters were: opinion of medical fact or public domain (35.6%) and discussion of results, methodological flaws or interpretation (22.9%). In biomedical journals indexed in SciELO Peru the letters to the editor comprise a percentage of publications that has increased in recent years, with low publication of letters of findings or primary data, compared with opinion or criticism.