Is procalcitonin a marker of invasive bacterial infection in acute sickle-cell vaso-occlusive crisis?

Fever is often present during painful vaso-occlusive crisis (VOC) in sickle-cell disease (SCD), but does not always indicate infection. The aim of our study was to test procalcitonin as a marker of invasive bacterial infection in VOC. Consecutive SCD adults hospitalized for VOC were included. Data were collected at admission and within 24 h after the onset of fever. We distinguished patients with clinically defined and microbiologically documented invasive bacterial infection from patients with no evidence of invasive bacterial infection and who fared well without antibiotics. One hundred and twelve patients were enrolled (61% females, median age 23 years, 88% homozygous SCD). All patients with procalcitonin (PCT) level ≥1 µg/L had an invasive bacterial infection, but two patients (33%) with an invasive bacterial infection had a PCT level <1 µg/L. High levels of PCT indicate invasive bacterial infection. However, a single low PCT level without follow-up measurement cannot rule out an invasive bacterial infection and should not withhold the prescription of antibiotics.

[Infectious esophagitis in HIV infection]. / Oesophagites infectieuses au cours de l'infection à VIH.

Infectious oesophagitis is the most frequent of digestive tract diseases occurring in patients with AIDS. It is diagnosed by endoscopy which permits brushing and biopsy of mucosal lesions for cytological, histological and microbiological examinations. In 40 to 50 percent of HIV positive patients, Candida is responsible for oesophagitis which is often asymptomatic and almost regularly associated with oral candidiasis. Brushing is preferable to biopsy to confirm a diagnosis which is frequently obvious at endoscopy. The prevalence of CMV and HSV oesophagitis has perhaps been underestimated. Diagnosis rests on the finding of intranuclear inclusions, usually in endothelial cells of the chorion for CMV and in epithelial cells for HSV. The demonstration of viral antigens by immunoperoxidase staining is useful in difficult cases, as is viral culture. Antiviral agents (gancyclovir against CMV, acyclovir against HSV) are usually effective. Co-infection with both Candida and a virus is not uncommon. The other pathogens, such as bacteria or mycobacteria, are exceptional. The authors suggest a therapeutic strategy taking into account epidemiological and clinical data.

[Prophylactic prescription of low-molecular-weight heparin in the non-surgical setting: impact of recommendations]. / Prescription préventive des héparines de bas poids moléculaire en milieu non chirurgical: l'impact de recommandations.

OBJECTIVE: Low-molecular-weight heparins (LMWH) had official approval for use for venous thromboembolism prophylaxis only for surgery patients when this survey was conducted, but were nevertheless often used in non-surgery patients. We conducted this "before and after" survey from May 1998 to April 1999 to assess the impact of the recommendations implemented in the beginning of 1999. METHODS: Data on the use of LMWH were collected on three different days within a three week interval in all non-surgery departments at the Tenon hospital before distribution of expert recommendations early in 1999. Published in La Presse Médicale in January 2000, these recommendations issued from an external panel of 43 experts who were contacted to establish a consensus opinion using the Delphi method. Data were again collected on three different days after implementation of the recommendations. Implementation was based on a patient-specific prescription order form requested by the hospital pharmacy for delivery to the department. RESULTS: Data were collected for 121 prescriptions prior to the recommendations and for 158 after. Sex-ratio, mean age and percentage of LMWH prescriptions did not differ significantly between the two periods. There was a lower number of non-appropriate prescriptions after implementation of the recommendations from 54.5% to 35.4% (p = 0.01) with better conformity for recommendation A (high-risk patients) (36% versus 43%, NS) and for recommendation B (= 2 risk situations or = 1 risk situation and = 2 aggravating factors) (10% versus 22%, p = 0.01). Better conformity of LMWH prescriptions in oncology and radiotherapy departments partially explained this general improvement, but the difference remained significant when excluding these two departments (p = 0.04). CONCLUSION: This study shows that physician compliance with recognized expert recommendations can improve their implementation. This procedure is now in general use in the Tenon hospital.

Sonography in AIDS-related cholangitis: prevalence and cause of an echogenic nodule in the distal end of the common bile duct.

OBJECTIVE: The purpose of this study was to determine the prevalence and cause of an echogenic nodule in the distal end of the common bile duct seen on sonograms in patients who have AIDS-related cholangitis. SUBJECTS AND METHODS: Sonograms of the liver and bile ducts were obtained in 15 patients who had AIDS-related cholangitis. Both 3.75- and 5-MHz transducers were used in all patients. The appearance of an echogenic nodule in the distal end of the common bile duct was compared with the results of endoscopic retrograde cholangiograms in 12 patients and with biopsies of the papilla of Vater in the first five cases. RESULTS: Sonograms showed a hyperechoic nodule in the distal end of the common bile duct in 10 of the 15 cases. Visualization was improved after oral administration of water. The finding correlated with edema of the papilla of Vater noted on retrograde cholangiograms in eight cases. Biopsy of the papilla of Vater in five cases showed an inflammatory infiltrate. The nodule became smaller in one patient when cholestasis improved after treatment for cryptosporidiosis. CONCLUSION: An echogenic nodule was detected in the distal end of the common bile duct on sonograms in two thirds of patients who had AIDS-related cholangitis. Our findings suggest the abnormality is caused by edema of the papilla of Vater.

[Treatment with doxycycline and nifuroxazide of Isospora belli infection in AIDS]. / Traitement par doxycycline et nifuroxazide de l'infection à Isospora belli au cours du SIDA.

Isospora belli infection is the most frequent coccidiosis after cryptosporidiosis in AIDS patients. Chronic watery diarrhea is observed. Trimethoprim-sulfamethoxazole is the recommended treatment. Four AIDS patients were intolerant to this drug and were treated with doxycycline and nifuroxazide. Three patients were cured. Two patients died of other infections. The two last patients relapsed and were treated again with long term doxycycline. No relapse occurred during the following twelve months.

Long-term outcome and treatment modifications in a prospective cohort of human immunodeficiency virus type 1-infected patients on triple-drug antiretroviral regimens. Triest Cohort Investigators.

We designed a cohort in order to assess the long-term effects of triple-drug antiretroviral combinations in 608 patients infected with human immunodeficiency virus type 1 (HIV-1). We recruited patients who had been previously treated with nucleoside analogues as well as treatment-naive patients who were starting triple-drug antiretroviral combinations consisting of nucleoside analogues, either alone or in combination with a protease inhibitor. After a median follow-up time of 22 months, the incidence rates of acquired immune deficiency syndrome-defining events and death were, respectively, 6.9 (95% confidence interval [CI], 5.3-8.8) and 2.9 (95% CI, 1.9-4.2) per 100 person-years. Advanced clinical stage of disease (P=.004), a low CD4(+) cell count (P=.002), and a low quality-of-life score (P=.001) at baseline were independent predictors of clinical progression. The initial triple-drug combination was modified a total of 647 times in 321 patients. The only independent predictor of treatment modification was previous exposure to a nucleoside analogue in patients who did not receive a new nucleoside analogue at inclusion (P=.001). Plasma HIV RNA values below 500 copies/mL were obtained in 88% of the treatment-naive patients and in 57% of the previously treated patients (P<.001). Compared with previously treated patients who received > or = 1 new nucleoside analogue at enrollment, previously treated patients who did not receive a new nucleoside analogue at enrollment were twice as likely to have plasma HIV RNA values >500 copies/mL at the last visit (adjusted odds ratio [OR], 1.8; 95% confidence interval [CI], 1.2-2.8), and the antiretroviral-naive patients were significantly less likely to have plasma HIV RNA values >500 copies/mL at the last visit (adjusted OR, 0.2; 95% CI, 0.1-0.4).

AIDS-related Pneumocystis carinii pneumonia in the era of adjunctive steroids: implication of BAL neutrophilia.

Factors predictive of mortality in patients with AIDS and Pneumocystis carinii pneumonia (PCP) were identified before the introduction of adjunctive steroids, but they have not been reevaluated since. Because PCP still occurs in AIDS, remaining fatal in some cases, we conducted a multivariate analysis of factors predicting mortality in patients with HIV-positive PCP managed from 1990 to 1995, i.e., after the consensus conference on the use of adjunctive steroids. The predictive value of clinical, laboratory, and bronchoalveolar lavage (BAL) data at admission and during the course of PCP was studied retrospectively using multivariate methods, in 144 patients with AIDS. Overall mortality was 21.5%. The univariate analysis identified seven factors predictive of 90-d mortality: Pa(O(2)) on room air < 60 mm Hg, lactate dehydrogenase > 1,000 IU, albuminemia < 30 g/L, BAL neutrophilia > 10%, nosocomial infection, pneumothorax, and a need for mechanical ventilation. Four of these factors were independently associated with 90-d mortality in the multivariate analysis; among them, two were evaluable at admission, namely, Pa(O(2)) < 60 mm Hg on room air and BAL neutrophilia > 10%, and two during hospitalization, namely, the development of pneumothorax and a need for mechanical ventilation. Moreover, BAL neutrophilia was correlated to occurrence of pneumothorax and a need for mechanical ventilation. In the era of adjunctive steroid use, AIDS-related PCP remains fairly common. Two independent factors evaluable at admission, Pa(O(2)) on room air and BAL neutrophilia, are predictive of death.