Association of immune cell subsets with incident heart failure in two population-based cohorts.

AIMS: Circulating inflammatory markers are associated with incident heart failure (HF), but prospective data on associations of immune cell subsets with incident HF are lacking. We determined the associations of immune cell subsets with incident HF as well as HF subtypes [with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF)]. METHODS AND RESULTS: Peripheral blood immune cell subsets were measured in adults from the Multi-Ethnic Study of Atherosclerosis (MESA) and Cardiovascular Health Study (CHS). Cox proportional hazard models adjusted for demographics, HF risk factors, and cytomegalovirus serostatus were used to evaluate the association of the immune cell subsets with incident HF. The average age of the MESA cohort at the time of immune cell measurements was 63.0 ± 10.4 years with 51% women, and in the CHS cohort, it was 79.6 ± 4.4 years with 62% women. In the meta-analysis of CHS and MESA, a higher proportion of CD4+ T helper (Th) 1 cells (per one standard deviation) was associated with a lower risk of incident HF [hazard ratio (HR) 0.91, (95% CI 0.83-0.99), P = 0.03]. Specifically, higher proportion of CD4+ Th1 cells was significantly associated with a lower risk of HFrEF [HR 0.73, (95% CI 0.62-0.85), <0.001] after correction for multiple testing. No association was observed with HFpEF. No other cell subsets were associated with incident HF. CONCLUSIONS: We observed that higher proportions of CD4+ Th1 cells were associated with a lower risk of incident HFrEF in two distinct population-based cohorts, with similar effect sizes in both cohorts demonstrating replicability. Although unexpected, the consistency of this finding across cohorts merits further investigation.

Miller Fisher variant of Guillain-Barré syndrome associated with lactic acidosis and stavudine therapy.

We describe the first case of Miller Fisher syndrome (opthalmoplegia, ataxia, and areflexia) associated with lactic acidosis as an adverse effect of receipt of an antiretroviral regimen containing stavudine. We review this syndrome in the context of recent descriptions of neuromuscular toxicities attributed to nucleoside analogue reverse-transcriptase inhibitor-induced mitochondrial toxicity.

Comorbid conditions, treatment, and health maintenance in older persons with human immunodeficiency virus infection in New York City.

We retrospectively examined comorbid conditions and health maintenance in 198 patients aged > or =55 years who attended 3 New York City human immunodeficiency virus (HIV) clinics between 1 January 1990 and 30 June 1998. Annual influenza and pneumococcal vaccinations within 5 years were given in 82% and 86% of patients, respectively. Among 57 women, 79% had a Papanicolaou smear within 1 year, and 53% had a mammogram within 2 years. Of 165 patients who received care after 1 July 1996, 147 (89%) had comorbid conditions (mean number of conditions, 2.4), and 133 (81%) received HIV-unrelated medications (mean number of medications, 2.7). Receipt of highly active antiretroviral therapy, its discontinuation because of toxicity, and having an undetectable HIV load were not related to comorbid conditions or use of concurrent medications. Comorbid conditions and use of concurrent HIV-unrelated medications need not adversely affect treatment of HIV-infected older individuals, but increased attention to health maintenance may be necessary.

Risk behavior for transmission of human immunodeficiency virus (HIV) among HIV-seropositive individuals in an urban setting.

We conducted interviews with 256 human immunodeficiency virus (HIV)-infected patients who attended an HIV clinic in New York City to assess ongoing risk behaviors for HIV transmission. After learning that the result of an HIV test was positive, 106 subjects (41%) had unprotected sex, 63 (25%) had a new sexually transmitted disease diagnosis, and 38 (15%) used injection drugs. Unprotected sex was reported by 50% of women, 29% of heterosexual men (P=.006, compared with women), and 42% of men who have sex with men, and it was reported more often by persons with a history of trading sex for money or drugs (P<.001). In multivariate analysis, unprotected sex was associated with a history of trading sex for money or drugs (adjusted odds ratio [AOR], 4.0; 95% confidence interval [CI], 2.2-7.0) and use of highly active antiretroviral therapy (AOR, 1.8; 95% CI, 1.1-3.1). Ongoing risk-reduction counseling and substance abuse treatment for HIV-infected persons are needed to reduce behaviors associated with HIV transmission.

Rickettsial, ehrlichial and Bartonella infections of the myocardium and pericardium.

Myocarditis and pericarditis are uncommon complications of human rickettsial, ehrlichial and Bartonella infections. Myocardial inflammation usually occurs in the setting of acute disseminated infection. Organisms associated with myocarditis include: Rickettsia rickettsii, R. conorii, Orientia tsutsugamushi, Coxiella burnetii, Anaplasma phagocytophila (the causative agent of Human Granulocytic Ehrlichiosis) and Bartonella henselae. Pericarditis has been described in the setting of R. conorii and Coxiella burnetii infections. This article reviews the epidemiology, pathologic characteristics, clinical manifestations, diagnosis and treatment of myocarditis and pericarditis caused by these organisms.

Agreement between Mantoux skin testing and QuantiFERON-TB assay using dual mycobacterial antigens in current and former injection drug users.

BACKGROUND: Individuals infected with non-tuberculous mycobacteria may elicit false-positive reactions on tuberculin skin testing. The QuantiFERON-TB (QFT) assay utilizes tuberculin and M. avium antigens and, therefore, may be more specific for latent tuberculosis infection. The objective of this study was to investigate the agreement between the QFT and single and dual antigen skin testing for detecting latent M. tuberculosis and assess the impact of cross-reactions from latent infection with other mycobacteria in inner-city injection drug users, a population at high risk for tuberculosis. MATERIAL/METHODS: We studied the agreement of results from skin testing using tuberculin and purified protein derivative-Battey (PPD-B) with the QFT test using tuberculin and Mycobacterium avium sensitin (MAS) in 48 HIV-seronegative injection drug users. RESULTS: The agreement between skin testing and the QFT assay for tuberculin was 73% (kappa = 0.45) and for PPD-B/MAS was 63% (kappa = 0.12). Agreement between skin test tuberculin dominance (tuberculin reaction > or =5 mm greater than PPD-B) and QFT tuberculin dominance (proportional difference between MAS and tuberculin reaction of > or =10%) was 75% (kappa = 0.53). All subjects tuberculin dominant by skin test were also QFT positive for tuberculin. Agreement between skin test Battey dominance and QFT avium dominance was 83% (kappa = 0.12). CONCLUSIONS: Results from the QFT assay and skin testing demonstrated moderate concordance in identifying subjects with latent tuberculous infection, and use of dual antigens did not appreciably improve the agreement between the two methods.

Relationship of serum immunoglobulin and IgG subclass levels to race, ethnicity and behavioral characteristics in HIV infection.

BACKGROUND: To determine whether demographic and behavioral factors affect immunoglobulin regulation in HIV infection, we studied injection drug users, women, and minority ethnic and racial groups with and without HIV infection. MATERIAL/METHODS: A prospective cross-sectional study of ambulatory persons with or at risk for HIV infection was conducted. We enrolled 48 injection drug users (IDUs) and 43 non-IDUs seropositive for HIV and 22 seronegative at-risk individuals in the Bronx, New York City. Sixteen HIV-seronegative, non-IDUs controls were also studied. Total serum immunoglobulin levels, IgG subclasses and lymphocyte phenotypes were measured. RESULTS: Serum IgG, IgA, IgG(1) and IgG(3) were increased in all stages of HIV infection controlling for injection drug use, gender, race and age (p0.05). Serum IgM levels were significantly decreased in HIV seropositives compared to HIV seronegatives (p<0.02). Two patterns of serum immunoglobulin level elevation were found in HIV infection: 1) IgG, IgG(1) and IgG(3) levels were elevated in early and advanced HIV infection; 2) IgA, IgG(2) and IgG(4) levels were elevated only in advanced HIV infection. IgG levels were increased in Blacks compared to Caucasians with HIV infection (p=0.01). CONCLUSIONS: Serum IgG, IgG(1) and IgG(3) levels are increased in early HIV infection, while serum IgA, IgG(2), and IgG(3) levels are increased only in advanced HIV infection. In contrast, serum IgM levels are decreased in HIV infection. HIV-seropositive Blacks have higher serum IgG levels than HIV-seropositive Caucasians. Further studies are necessary to determine the mechanism(s) underlying the different patterns of immunoglobulin elevation in HIV infection.

Cryptococcal fungemia in a neutropenic patient with AIDS while receiving caspofungin.

Empiric choice of anti-fungal therapy in febrile neutropenia should be based upon a host's susceptibility to specific fungal pathogens. We present a case of a patient with multiple risk factors for fungemia including HIV infection, Hodgkin's disease, corticosteroid use and chemotherapy-induced neutropenia who developed disseminated cryptococcal infection while receiving caspofungin.