Regression of liver fibrosis is progressive after sustained virological response to HCV therapy in patients with hepatitis C and HIV coinfection.

There are few data about the long-term histological outcome of HIV-/HCV-coinfected patients after therapy with interferon and ribavirin. We performed an observational study of 216 patients who received therapy against HCV and who had at least three successive transient elastographies (TE) during the follow-up. The primary endpoint was confirmed fibrosis regression, defined as a reduction of at least 1 point in Metavir fibrosis score, confirmed and without worsening in successive TE. At baseline, 23% had fibrosis stage 4 or cirrhosis. Overall, 82 (38%) achieved sustained virological response (SVR), without differences in baseline fibrosis or time of follow-up. Confirmed fibrosis regression was observed in 55% of patients, higher for SVR (71% vs 44%; P < 0.01), and the likelihood of achieving fibrosis regression at 3, 5 and 7 years was 0.17, 0.51 and 0.67, respectively, for SVR patients, in comparison with 0.02, 0.23 and 0.41 for no SVR patients (P < 0.01, log-rank test at any time point). Progressive regression, defined as continuous improvement in successive TE, was observed in 62% of patients with advanced liver fibrosis or cirrhosis who achieved SVR. In a Cox regression model, only SVR (HR, 4.01; 95% CI, 2.33-7.57; P < 0.01) and a younger age (HR, 1.14; 95% CI, 1.05-1.25; P < 0.01; per year) were associated with fibrosis regression. This study confirms that the rate of liver fibrosis regression increases during the follow-up after SVR to interferon therapy in HIV-/HCV-coinfected patients.

Analysis of a quantitative PCR assay for CMV infection in liver transplant recipients: an intent to find the optimal cut-off value.

BACKGROUND: Preemptive therapy required highly predictive tests for CMV disease. CMV antigenemia assay (pp65 Ag) has been commonly used for rapid diagnosis of CMV infection. Amplification methods for early detection of CMV DNA are under analysis. OBJECTIVES: To compare two diagnostic methods for CMV infection and disease in this population: quantitative PCR (qPCR) performed in two different samples, plasma and leukocytes (PMNs) and using a commercial diagnostic test (COBAS Amplicor Monitor Test) versus pp65 Ag. STUDY DESIGN: Prospective study conducted in liver transplant recipients from February 2000 to February 2001. RESULTS: Analyses were performed on 164 samples collected weekly during early post-transplant period from 33 patients. Agreements higher than 78% were observed between the three assays. Optimal qPCR cut-off values were calculated using ROC curves for two specific antigenemia values. For antigenemia >or=10 positive cells, the optimal cut-off value for qPCR in plasma was 1330 copies/ml, with a sensitivity (S) of 58% and a specificity (E) of 98% and the optimal cut-off value for qPCR-cells was 713 copies/5x10(6) cells (S:91.7% and E:86%). Using a threshold of antigenemia >or=20 positive cells, the optimal cut-off values were 1330 copies/ml for qPCR-plasma (S 87%; E 98%) and 4755 copies/5x10(6) cells for qPCR-cells (S 87.5%; E 98%). Prediction values for the three assays were calculated in patients with CMV disease (9 pts; 27%). Considering the assays in a qualitative way, the most sensitive was CMV PCR in cells (S: 100%, E: 54%, PPV: 40%; NPV: 100%). Using specific cut-off values for disease detection the sensitivity, specificity, PPV and NPV for antigenemia >or=10 positive cells were: 89%; 83%; 67%; 95%, respectively. For qPCR-cells >or=713 copies/5x10(6) cells: 100%; 54%; 33% and 100% and for plasma-qPCR>or=1330 copies/ml: 78%, 77%, 47%, 89% respectively. CONCLUSIONS: Optimal cut-off for viral load performed in plasma and cells can be obtained for the breakpoint antigenemia value recommended for initiating preemptive therapy with high specificities and sensitivities. Diagnostic assays like CMV pp65 Ag and quantitative PCR for CMV have similar efficiency and could be recommended as methods of choice for diagnosis and monitoring of active CMV infection after transplantation.

Incidence and risk factors for developing cytomegalovirus retinitis in HIV-infected patients receiving protease inhibitor therapy. Spanish CMV-AIDS Study Group.

OBJECTIVE: To assess the incidence and risk factors for cytomegalovirus (CMV) retinitis in HIV-infected patients who initiated protease inhibitor-containing antiretroviral therapy. DESIGN AND SETTING: Prospective, multicentre study. PATIENTS: A cohort of 172 HIV-infected patients with a CD4 cell count below 100x10(6) cells/l at the time of protease inhibitor introduction. MAIN OUTCOME MEASURES: Confirmed CMV retinitis and mortality, according to CD4 cell count, HIV load, and CMV viraemia. RESULTS: The cumulative incidence of CMV retinitis was 5% at 1 year and 6% at 2 years. Only a positive CMV polymerase chain reaction (PCR) test at therapy initiation was significantly associated with the development of disease (relative hazard, 4.41; 95% confidence interval, 2.12-8.93; P<0.00001). The 12-month Kaplan-Meier CMV retinitis event rate was 38% in patients who were CMV PCR-positive compared with 2% in those who were CMV PCR-negative (P<0.001). Mean CMV load was significantly higher in those individuals who went on to develop CMV retinitis (3700 versus 384 copies/ml, P = 0.002). Only 2% of patients remained CMV PCR-positive after 3 months of protease inhibitor therapy, and CMV viraemia was not associated with a worse therapy response or shorter survival. Transient CMV positivity without a higher risk of disease was observed in 7% of patients at the first month on therapy. CONCLUSIONS: Protease inhibitor-containing antiretroviral therapy significantly reduces the incidence of CMV viraemia and disease. Although a positive CMV PCR test identifies those patients on therapy at highest risk of CMV retinitis, it is not associated with an increased risk of death or a worse response to protease inhibitor therapy.

Predictors of long-term response to protease inhibitor therapy in a cohort of HIV-infected patients.

OBJECTIVE: To assess the rate of long-term effectiveness and factors associated with response to protease inhibitor therapy in a cohort of HIV-infected patients. DESIGN AND SETTING: Prospective, non-randomized study in a tertiary care centre. PATIENTS: A total of 400 HIV-infected patients who started on protease inhibitor therapy (saquinavir, 28%; ritonavir, 26%; indinavir, 46%) from March 1996 to March 1997. MAIN OUTCOMES MEASURES: Long-term virological and immunological effectiveness were defined as HIV RNA levels below 200 copies/ml and CD4+ cell count increase greater than 100 x 10(6)/l, respectively, after 12 months of therapy. RESULTS: Fifty-seven per cent of patients had a prior AIDS-defining illness, and 91% had received nucleoside analogues for a median time of 28 months. Median CD4+ count was 86 x 10(6) cells/l and HIV RNA level was 4.46 log10 copies/ml. The global rate of virological and immunological effectiveness at 1 year was 45 and 59%, respectively. In a logistic regression analysis, treatment failure was associated with higher baseline HIV load [relative risk (RR), 2.10; P<0.01], prior antiretroviral therapy (RR, 2.07; P<0.01), and use of saquinavir (RR, 1.55; P = 0.03), whereas a reduction of more than 1 log10 in HIV load within the first 3 months on therapy was strongly associated with response (RR, 0.65; P<0.01). There was no strict correlation between virological and immunological effectiveness (r = -0.35; P = 0.01). CONCLUSIONS: Nearly half of the patients maintain undetectable HIV load after 1 year of therapy, although important immunological benefit can be obtained in a greater proportion of patients. These data suggest the use of the most potent antiretroviral therapy in pretreated patients with high HIV load, and the capacity of initial virological decline to predict the long-term outcome.

Phenotypic testing predicts virological response in successive protease inhibitor-based regimens.

OBJECTIVE: To evaluate the importance of the number of active drugs, as determined by phenotypic resistance testing, in achieving virological response in successive salvage regimens. DESIGN: Phenotypic study of 57 plasma samples corresponding to 24 patients who had sequentially received three protease inhibitor-containing regimens. Phenotypic susceptibility to a drug (active drug) was defined as less than a four-fold-increase in the IC50 in comparison with the wild type. MAIN OUTCOME MEASURE: Virological response according to the number of active drugs (three versus two or fewer), HIV load, length of antiretroviral exposure, and line of protease inhibitor-based therapy (first, second and third regimen). RESULTS: Before the first protease inhibitor-based therapy, the median time on antiretroviral treatment was 42 months, and before the second and third protease inhibitor-salvage regimens it was 10 and 8 months, respectively. The number of patients receiving three active drugs simultaneously was 24, 35 and 31% in each line of therapy. At week 12, a close correlation was found between the presence of three active drugs in the antiretroviral regimen and the rate of virological response, in comparison with those patients receiving two or fewer active drugs [76 versus 45%, relative risk (RR), 1.7; 95% confidence interval (CI) 1.1-2.6; P = 0.028]. In a multivariate analysis, the use of two or fewer active drugs was an independent predictor of lack of response, regardless of HIV load, length of previous antiretroviral exposure and line of salvage therapy (RR, 4.5; 95%CI, 1.1-18.3; P = 0.03). Of note, a higher rate of response was observed in patients receiving the first protease inhibitor-containing regimen in comparison with those in subsequent protease inhibitor-based salvage regimens (83 versus 50 versus 28%, P < 0.01), even when only those patients receiving three active drugs were included (100 versus 71 versus 60%). CONCLUSIONS: This data confirm the usefulness of phenotypic testing in guiding antiretroviral therapy in heavily pretreated patients. The number of active drugs and the line of salvage therapy are independent predictors of virological response, regardless of HIV load and the length of antiretroviral exposure.

Patients failing saquinavir therapy require an early change to indinavir before HIV-1 viral load reaches high levels.

Sequential use of antiretroviral therapy with protease inhibitors (PI) is frequently prescribed owing to failure or intolerance of the first selected agent. Controversial data exist about the virological and immunological outcome of patients in whom a change to a second PI regimen is needed. A prospective study of 113 HIV-positive patients (male, 84%; mean age 36 years; previous AIDS-defining event, 35%; previous antiretroviral therapy with nucleoside analogues, 94%) who started a saquinavir-containing regimen between March 1996 and March 1997 and had to change to indinavir (n = 79) owing to intolerance, failure or medical criteria was performed. At the time of the switch, median CD4 cell count was 221 cells/mm3 and the HIV RNA level was 3.98 log10 copies/ml. The rate of viral suppression (HIV RNA levels below 200 copies/ml) was 40% at 3 months and 28% at month 6 after indinavir was instituted. In a logistic regression analysis, only the baseline viral load [relative risk (RR), 2.85; 95% confidence interval (CI), 1.31-6.05; P = 0.007] was statistically associated with the lack of viral suppression on indinavir. Although there are not sufficient data about the best therapeutic option if a change in PI-containing regimens therapy is considered, this study supports the recommendation of an early change of the PI-containing regimens, before the HIV-1 viral load reaches high levels.

Efficacy, tolerance, and pharmacokinetics of the combination of stavudine, nevirapine, nelfinavir, and saquinavir as salvage regimen after ritonavir or indinavir failure.

The high rate of protease inhibitor treatment failure in clinical cohorts makes it necessary to define novel salvage therapies. In a prospective study of 31 HIV-infected patients included in a salvage regimen with stavudine, nevirapine, nelfinavir, and saquinavir, viral load decreased a median of 1.65 log(10) and 1.95 log(10) after 6 and 12 months of treatment, respectively, and 35 and 56% of patients had an HIV RNA level below 50 copies/ml at the same time points. At baseline, the mean number of mutations in the protease gene was 10 (2-19), and the V82A and L90M mutations were present in 54 and 21% of patients. The presence of the V82A mutation did not affect significantly the rate of response (36 vs. 38%), whereas the L90M mutation was associated with treatment failure (0 vs. 43%). Plasma trough levels of nelfinavir (NFV) and saquinavir (SQV), in a twice daily dosing regimen, were above the protein-corrected IC(95) in most patients despite the addition of an enzymatic inducer such as nevirapine, and peak levels were 2- and 5-fold increased with respect to standard doses. However, pharmacokinetics of saquinavir-hard gel capsule (SQV-hgc) did not improve significantly in the three times daily dosing regimen. In conclusion, the combination of stavudine, nevirapine, nelfinavir, and saquinavir increased plasma drug levels and produced an adequate virological response in patients who had failed indinavir or ritonavir therapy. This degree of response is not significantly decreased in the presence of genotypic mutations associated with indinavir/ritonavir (IDV/RTV) resistance.

A clinical study of the combination of 100 mg ritonavir plus 800 mg indinavir as salvage therapy: influence of increased plasma drug levels in the rate of response.

PURPOSE: The purpose of our study was to evaluate the efficacy of indinavir (IDV) in a twice daily dosing regimen with coadministration of 100 mg ritonavir (RTV) and to explore the influence of plasma drug levels in the rate of virologic response. METHOD: We performed a prospective study of 59 patients who switched to a salvage regimen with two nucleoside analogs plus the combination of 100 mg RTV plus 800 mg IDV twice daily. Pharmacokinetics of IDV and RTV were assessed in 11 patients. RESULTS: Previous antiretroviral exposure was 44 months, and 78% and 39% of patients had previously failed regimens with either IDV or RTV. Median CD4 count was 248 x 10(6)/L and HIV load was 3.9 log(10) copies/mL. The median number of mutations in the protease gene was 9 (3-14), predominantly at residues 82 (53%), 90 (42%), and 46 (32%). After 24 weeks, 61% of patients had a viral load decrease greater than 1 log(10), and 38% had a viral load below 50 copies/mL. Nephrolitiasis, hematuria, or flank pain was observed in 13 patients (22%), leading to withdrawal in six cases (10%). IDV trough levels were well above the IC(95) (median 1.75 mg/L, interquartile range 1.07-2.57), but RTV trough levels were below the IC(95) in 88% of patients. There was a close correlation between higher peak levels of IDV, virological response, and renal toxicity. CONCLUSION: RTV/IDV 100/800 mg in a twice daily dosing regimen is associated with a significant virological response in patients with antiretroviral treatment failure. The correlation between plasma drug levels, toxicity, and response suggests the usefulness of individualized drug monitoring.

[Lyme borreliosis: how is it manifested in Spain?]. / Borreliosis de Lyme: cómo se manifiesta en España?

BACKGROUND: Lyme borreliosis is not usually diagnosed in Spanish patients since before 1987. The aim of this study was to know the clinical spectrum of infection by Borrelia burgdorferi in Spain by a prospective epidemiologic study. METHODS: The period of collection of cases was from 1987 to 1989 and the follow-up period was of 2 years following diagnosis. Detection of serum antibodies was performed by indirect immunofluorescence and ELISA to patients with clinical suspicion of Lyme borreliosis established in 17 Spanish hospitals. The clinical and serologic data and the possibility of other disease which could justify the symptoms were evaluated with the doctor responsible for the patient. RESULTS: Fifty-four patients with clinical manifestations and serologic data indicative of the disease and in whom other diagnosis were excluded were detected. Other diseases which could be the cause of the symptomatology were diagnosed in 26 patients with positive serology. Sixty-three percent of the patients had neurologic symptoms, 46% articular symptoms, 44% cutaneous symptoms and 9% cardiac symptoms. CONCLUSIONS: Lyme borreliosis is not exceptional in Spain. Its clinical spectrum may be situated half way between American and European epidemiologic descriptions. Serology must be interpreted by the clinical manifestations.

[Frequency of the clinical manifestations of Lyme borreliosis in Spain]. / Frecuencia de las manifestaciones clínicas de la borreliosis de Lyme en España.

INTRODUCTION: There are differences in the clinical manifestations of Lyme borreliosis (LB) in different parts of the world. The aim of this work was to analyze its clinical manifestations in Spain. METHODS: We evaluated by ELISA and IFI the sera of 1,500 patients with clinical suspicion of LB between January 1987 to February 1993. Spanish criteria of LB (amplified CDC criteria of LB for epidemiological purpuse) were used. Clinical and serological data were evaluated with the patients' physicians and other etiologies were reasonably excluded in accepted cases of LB. RESULTS: Sixty-four patients of 138 with a positive serology (46%) met the LB criteria. Neurological manifestations were presented by 40 patients (62.5%) (in control group 23%, p < 0.05) cutaneous lesions by 20 patients (31%), articular manifestations by 18 patients (28%) (in control groups 56%; p < 0.05) and cardiac manifestations in two. Cutaneous manifestations included 17 erythema migrans, 2 acrodermatitis chronica atrophicans and 1 lymphocytoma). Artritis was present in 18 cases. Neurological manifestations included 16 cases of meningitis (2 with encephalitis), 11 of craneal neuropathy and 25 of peripheral neuropathy (13 of polyneuropathy). Cardiac manifestations acepted was 2 atrioventricular blockade. We detected 21% of false positive serology and in 33% of the positive cases, the LB criteria was not met. CONCLUSIONS: The low percentage of cutaneous manifestations is probably due to the fact that this series consist predominantly of hospital patients. In Spain, as in the rest Europe the predominant manifestations are neurological, however artritis are not infrequent manifestations.

Diagnostic value of polymerase chain reaction in blood and aqueous humor in immunocompetent patients with ocular toxoplasmosis.

PURPOSE: To evaluate the diagnostic value of polymerase chain reaction (PCR) in blood and aqueous humor samples from immunocompetent patients with reactivated ocular toxoplasmosis. METHODS: Group 1 was composed of seven patients with a clinical diagnosis of reactivated ocular toxoplasmosis. Group 2 consisted of 33 controls. In each subject, blood and aqueous humor samples were obtained for detection of Toxoplasma gondii DNA by means of simple PCR, seminested PCR, and Southern blot hybridization. RESULTS: Group 1: Simple PCR was positive in 3 of 7 blood samples (42%) and in 2 of 7 (28%) aqueous humor samples. Seminested PCR was positive in 4 of 7 (57%) blood samples and in 3 of 7 (42%) aqueous humor samples. Group 2: Simple and seminested PCR were positive in both samples in 2 of 33 (6%) and 4 of 33 (12%), respectively. Sensitivity 57% (18.41-90.10), specificity 87% (71.80-96.60); positive and negative likelihood ratio 4.38 and 0.49, respectively. CONCLUSIONS: Polymerase chain reaction can be useful for confirming the diagnosis of ocular toxoplasmosis, especially in those eyes where fundus examination does not yield conclusive results. The detection of T. gondii DNA in blood suggests that reactivation of ocular toxoplasmosis cannot be considered a local event.

[Serologic diagnosis of Lyme disease. A pending problem]. / Diagnóstico serológico de la enfermedad de Lyme. Un problema pendiente.

We analyze the experience in serologic diagnosis of Lyme's borreliosis. From a total of 551 patients studied from 1987 to 1989, we further evaluate 80 cases with erythema chronicum migrans or a clinical diagnosis of Lyme's disease and positive serological tests. The techniques used were IFI, ELISA1 (Whittaker Bioproducts) and ELISA2 (MarDx Diagnostics). Serological tests results were evaluated in relation to clinical data. Five cases were excluded because of no-specific symptoms. There were 20 false-positive results, mainly due to other infections (HIV infection, tuberculosis, Mediterranean spotted fever and syphilis). Fifty-five patients were considered clinically of having Lyme's disease. IFI test was positive in 81.8% of all the 55 cases, ELISA2 in 58.4% of 53 cases tested and ELISA1 in 23% of 43 cases tested. Correlation between IFI and ELISA2 positive test was seen in 45% of cases. Specificity of all tests was higher than 97%. The study shows that sensitivity for all three techniques used was not optimal, and also there are some differences in their results. However, specificity was adequate.

[Neurological manifestations in patients with sera positive for Borrelia burgdorferi]. / Manifestaciones neurológicas en pacientes con serología positiva frente a Borrelia burgdorferi.

Eight years of case histories of patients with positive serum tests for Borrelia burgdorferi (Bb) are reviewed with the aims of analyzing the neurological manifestations involved and of assessing the value of serology in the diagnosis of neuroborreliosis (NB) in our clinical setting. Of the 105 cases with neurological manifestations that could be examined, 25 patients (24%) with other infections, neoplasms or other diseases had false positive serologies. Forty-one patients (39%) met the criteria for NB diagnosis: 26 had lymphocytic meningitis, 13 had polyradiculitis and 20 had cranial neuropathy. Spinal fluid cultures were positive in 43% of the patients on whom the test was performed, and all patients in this group who were treated with antibiotics improved. The other 39 patients (37%) had only neurological manifestations, which were not typical of NB (peripheral neuropathy, stroke, demyelinating disease, dementia or myelopathy), but for which no other etiology could be demonstrated. Spinal fluid serology was positive in 16% of those cases studied and none of those treated only with antibiotics improved. Among patients with both neurological manifestations and Bb positive serology, there were many false positives and cases with signs that were of dubious relation to infection by Bb; therefore, the prevalence of cases consistent with NB is low [corrected].

Value of PCR for detection of Toxoplasma gondii in aqueous humor and blood samples from immunocompetent patients with ocular toxoplasmosis.

Toxoplasma gondii infection is an important cause of chorioretinitis in the United States and Europe. Most cases of Toxoplasma chorioretinitis result from congenital infection. Patients are often asymptomatic during life, with a peak incidence of symptomatic illness in the second and third decades of life. Diagnosis is mainly supported by ophthalmological examination and a good response to installed therapy. However, establishment of a diagnosis by ophthalmological examination alone can be difficult in some cases. To determine the diagnostic value of PCR for the detection of T. gondii, 56 blood and 56 aqueous humor samples from 56 immunocompetent patients were examined. Fifteen patients with a diagnosis of ocular toxoplasmosis had increased serum anti-T. gondii immunoglobulin G levels but were negative for anti-T. gondii immunoglobulin M (group 1), and 41 patients were used as controls (group 2). Samples were taken before antiparasitic therapy was initiated, and only one blood sample and one aqueous humor sample were obtained for each patient. Single nested PCRs and Southern blot hybridization were performed with DNA extracted from these samples. The results obtained showed sensitivity and specificity values of 53. 3 and 83%, respectively. Interestingly, among all patients with ocular toxoplasmosis, a positive PCR result with the aqueous humor sample was accompanied by a positive PCR result with the blood sample. This result suggests that ocular toxoplasmosis should not be considered a local event, as PCR testing of blood samples from patients with ocular toxoplasmosis yielded the same result as PCR testing of aqueous humor samples. PCR testing may be useful for discriminating between ocular toxoplasmosis and other ocular diseases, and also can avoid the problems associated with ocular puncture.

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.

Improved outcome of cytomegalovirus retinitis in AIDS patients after introduction of protease inhibitors.

The objective of this study was to evaluate the influence of protease inhibitor therapy on the rate of progression and survival of 17 AIDS patients with stable Cytomegalovirus retinitis, who were receiving anti-CMV therapy. CD4+ count, HIV load, and CMV antigenemia assay were determined at baseline, at the first month, and every 3 months thereafter. Median CD4+ count increased from 11 to 87 cells/mm3, and median HIV RNA level decreased from 4.96 to 3.28 log10 copies/ml, after 6 months on therapy. Although 9 patients (53%) relapsed in a median time of 97 days (range, 15-152 days), no further episodes were observed during a median follow-up of 17 months (range, 5-18 months). Thus, the probability of remaining free of relapse was twofold higher than that observed in matched patients who did not receive protease inhibitors. Median CD4+ count at the 3rd month was higher in those individuals who went on to progress (p = .03), and a positive result to a CMV antigenemia test was associated with progression of retinitis (relative hazard, 4.45; p = .04). Survival rate was 94% at 17 months (89% increase). Therefore, protease inhibitor therapy reduces retinitis progression and improves survival. However, the immunologic response may not provide initial sufficient protection to avoid, or even may play a role on, early CMV progression.

[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.