Risk Factors for Cryptococcal Meningitis Recurrence in Human Immunodeficiency Virus (HIV)-Infected Patients in a Large Chinese Acquired Immune Deficiency Syndrome (AIDS) Treatment Center.

BACKGROUND Cryptococcal meningitis (CM) is one of the most common opportunistic neuroinfections in patients with HIV. Most studies have focused on non-HIV CM and there are only a few studies on HIV CM in China. The purpose of the present study was to evaluate the characteristics and risk factors for CM recurrence in patients infected with HIV in the Chongqing Public Health Treatment Center in China. MATERIAL AND METHODS From January 2014 to December 2017, all patients with CM aged 18 years or older were enrolled and a case-control study was performed to determine the risk factors associated with recurrence of CM. Antimicrobial susceptibility was determined with a fungal drug sensitivity kit and the sequence types (STs) were analyzed with multilocus sequence typing. RESULTS The incidence of CM in the 5185 HIV-infected patients was 3.5% (179). Follow-up data were available for 82 of the patients for whom complete medical records were available and they were included in the present study. There were 7 STs among 82 Cryptococcus neoformans isolates; ST5 and ST31 were the most prevalent genotypes. Testing showed that C. neoformans had high sensitivity to 5 antifungal drugs and no differences in resistance were observed, even when different STs were tested. Risk factors for recurrence were analyzed in 69 patients, excluding those who died. The results of multivariate analysis showed that only hospital stay was associated with recurrence of CM. CONCLUSIONS Our results indicated that combining education about medication with clinical treatment could help prevent recurrence of CM.

Total mouth photodynamic therapy mediated by blue led and curcumin in individuals with AIDS.

OBJECTIVES: To test the effectiveness of an efficient therapeutic protocol for the total mouth antimicrobial photodynamic therapy (aPDT) mediated by 450 nm blue LED associated with curcumin in individuals with AIDS. METHODS: Patients were selected by exclusion criteria and randomly distributed in groups to test the effectiveness of antimicrobial aPDT with curcumin 0.75 mg/mL associated with the blue LED (67 mW/cm2, 20.1 J/cm2). Before and after the treatments, samples were collected from the saliva being processed in duplicate in selective culture media. The colonies were counted and the results obtained in log10 CFU/mL were statistically tested (T-paired statistical test, 5%). RESULTS: The log10 CFU/mL of Streptococcus spp., Staphylococcus spp., and total count of microorganisms showed statistically significant (p = 0.023; p = 0.001 and p = 0.017, respectively) reduction after treatment in patients with aPDT. CONCLUSION: aPDT was effective in reducing Streptococcusspp. in addition to reducing Staphylococcusspp., enterobacteria and the total count of microorganisms when considering the numbers of TCD4 and TCD8 lymphocytes. The aPDT in the studied protocol was able to control clinically important intraoral microorganisms for AIDS patients, both those with TCD4 lymphocytes above or below 25% of normal and those with TCD8 lymphocytes above 25% of normal.

Dose-Dependent Hyperkalemia Among Hospitalized, HIV-Infected Patients Receiving Sulfamethoxazole/Trimethoprim.

Background: Sulfamethoxazole-trimethoprim (SXT) therapy is commonly used in HIV-infected patients and is associated with hyperkalemia and elevated serum creatinine (SCr). Objective: The purpose of this study was to examine the frequency of hyperkalemia and elevated SCr in hospitalized, HIV-infected patients receiving SXT. Methods: This was a retrospective, single-center cohort study. HIV-infected hospitalized patients receiving a minimum of 3 consecutive days of SXT were included. Patients were grouped according to high dose (≥10 mg/kg/d) and low dose (<10 mg/kg/d) trimethoprim. The primary end point was the frequency of hyperkalemia, severe hyperkalemia, and elevated SCr. Secondary end points included an evaluation of concomitant potassium-altering medications and concomitant nephrotoxic drugs. Results: A total of 100 consecutive patients were selected from all possible patients who met inclusion criteria. Overall, 47 patients experienced at least 1 adverse drug event (ADE) of either hyperkalemia or increased SCr, with 20 patients experiencing these ADEs in the low-dose group and 27 patients experiencing these ADEs in the high-dose group (P = 0.229). The ADEs of hyperkalemia or increased SCr occurred after a shorter period (5.5 vs 8.7 days) in the high-dose group (P = 0.049). Overall frequency of elevated SCr was 24% and of elevated serum K was 36%. Hyperkalemia requiring a therapeutic intervention occurred in 12 patients in the high-dose group compared with 2 in the low-dose group (P = 0.009). Conclusion and Relevance: Rates of elevated SCr and hyperkalemia in hospitalized HIV-infected patients receiving SXT are significant. Hyperkalemia requiring intervention is more common in patients receiving high-dose SXT.

Factors associated with isoniazid resistant tuberculosis among human immunodeficiency virus positive patients in Swaziland: a case-control study.

BACKGROUND: Isoniazid resistant tuberculosis is the most prevalent type of resistance in Swaziland and over two-thirds of the isoniazid resistant tuberculosis patients are tuberculosis and human immunodeficiency virus co-infected. The study aimed to determine risk factors associated with isoniazid resistant tuberculosis among human immunodeficiency virus positive patients in Swaziland. METHODS: This was a case-control study conducted in nine healthcare facilities across Swaziland. Cases were patients with isoniazid resistant tuberculosis (including 78 patients with isoniazid mono-resistant tuberculosis, 42 with polydrug-resistant tuberculosis, and 77 with multidrug-resistant tuberculosis). Controls were presumed drug-susceptible tuberculosis patients (n = 203). Multinomial logistic regression was used to determine related factors. RESULTS: The median time lag from diagnosis to tuberculosis treatment initiation was 50 days for isoniazid mono or poly drug-resistant tuberculosis, 17 days for multidrug-resistant tuberculosis compared to 1 day for drug-susceptible tuberculosis patients. History of previous tuberculosis treatment was positively associated with either isoniazid mono or poly drug-resistant tuberculosis (OR = 7.91, 95% CI: 4.14-15.11) and multidrug-resistant tuberculosis (OR = 12.20, 95% CI: 6.07-24.54). Isoniazid mono or poly resistant tuberculosis patients were more likely to be from rural areas (OR = 2.05, 95% CI: 1.23-3.32) and current heavy alcohol drinkers compared to the drug-susceptible tuberculosis group. Multi drug-resistant tuberculosis patients were more likely to be non-adherent to tuberculosis treatment compared to drug-susceptible tuberculosis group (OR = 3.01, 95% CI: 1.56-5.82). CONCLUSION: To prevent and control isoniazid resistant tuberculosis among HIV-positive patients in Swaziland, the tuberculosis program should strengthen the use of rapid diagnostic tests, detect resistance early, promptly initiate supervised tuberculosis treatment and decentralize quality tuberculosis services to the rural areas. Adherence to tuberculosis treatment should be improved.

[Antimycotic therapy impact on oral mucosa Candida species composition in HIV-infected patients]. / Vliianie antimikoticheskoi terapii na vidovoi i shtammovyi sostav gribov roda Candida polosti rta bol'nykh VICh-infektsiei.

RESEARCH OBJECTIVES: the analysis of a specific and strains drift of Candida in HIV/AIDS patients with oropharyngeal candidiasis and the analysis of Candida sensitivity dynamics to reference antimycotic drugs. The study comprised 49 HIV-infected patients aged 20-69 years. The study revealed candidiasis treatment provides specific and strains drift of Candida. Eradication of fluconazole sensitive C. albicans leads to growth of more resistant strains (C. glabratae, krusei, tropicalis) thus lowering antimycotic therapy efficacy. The efficacy improvement requires selective approach to candidiasis treatment with azol agents.

Experimental Models of Short Courses of Liposomal Amphotericin B for Induction Therapy for Cryptococcal Meningitis.

Cryptococcal meningoencephalitis is a rapidly lethal infection in immunocompromised patients. Induction regimens are usually administered for 2 weeks. The shortest effective period of induction therapy with liposomal amphotericin B (LAMB) is unknown. The pharmacodynamics of LAMB were studied in murine and rabbit models of cryptococcal meningoencephalitis. The concentrations of LAMB in the plasma and brains of mice were measured using high-performance liquid chromatography (HPLC). Histopathological changes were determined. The penetration of LAMB into the brain was determined by immunohistochemistry using an antibody directed to amphotericin B. A dose-dependent decline in fungal burden was observed in the brains of mice, with near-maximal efficacy achieved with LAMB at 10 to 20 mg/kg/day. The terminal elimination half-life in the brain was 133 h. The pharmacodynamics of a single dose of 20 mg/kg was the same as that of 20 mg/kg/day administered for 2 weeks. Changes in quantitative counts were reflected by histopathological changes in the brain. Three doses of LAMB at 5 mg/kg/day in rabbits were required to achieve fungicidal activity in cerebrospinal fluid (cumulative area under the concentration-time curve, 2,500 mg · h/liter). Amphotericin B was visible in the intra- and perivascular spaces, the leptomeninges, and the choroid plexus. The prolonged mean residence time of amphotericin B in the brain suggests that abbreviated induction regimens of LAMB are possible for cryptococcal meningoencephalitis.

Fungicidal efficacy of various honeys against fluconazole-resistant Candida species isolated from HIV+ patients with candidiasis.

OBJECTIVE: Honey is well known to possess a broad spectrum of activity against medically important organisms. The purpose of this study was to assess the antifungal activity of different honeys against 40 fluconazole (FLU) resistant Candida species, including Candida albicans (C. albicans), Candida glabrata, Candida krusei and Candida tropicalis. MATERIALS AND METHODS: Three honey samples were collected from northern (Mazandaran, A), southern (Hormozgan, B) and central (Lorestan, C) regions of Iran. A microdilution technique based on the CLSI, M27-A2 protocol was employed to compare the susceptibility of honeys "A", "B" and "C" against different pathogenic Candida isolates. RESULTS: The results showed that different Candida isolates were resistant to FLU, ranging from 64µg/mL to 512µg/mL. All of the honeys tested had antifungal activities against FLU-resistant Candida species, ranging from 20% to 56.25% (v/v) and 25% to 56.25% (v/v) for minimum inhibitory concentrations (MICs) and minimum fungicidal concentrations (MFCs), respectively. Honey "A" (MIC: 31.59%, v/v) showed higher anti-Candida activity than honey "B" (MIC: 35.99%, v/v) and honey "C" (MIC: 39.2%, v/v). No statistically significant differences were observed among the mean MIC values of the honey samples (P>0.05). The order of overall susceptibility of Candida species to honey samples were; C. krusei>C. glabrata>C. tropicalis>C. albicans (P>0.05). In addition, the mean MICs of Candida strains isolated from the nail, vagina and oral cavity were 33.68%, 36.44% and 39.89%, respectively, and were not significantly different (P>0.05). CONCLUSION: Overall, varying susceptibilities to the anti-Candida properties of different honeys were observed with four FLU-resistant species of Candida. Further research is needed to assess the efficacy of honey as an inhibitor of candidal growth in clinical trials.

Recent advances in AIDS-related cryptococcal meningitis treatment with an emphasis on resource limited settings.

INTRODUCTION: Recent advances in the treatment and prevention of cryptococcal meningitis have the potential to decrease AIDS-related deaths. Areas covered: Targeted screening for asymptomatic cryptococcal antigenemia in persons with AIDS is a cost effective method for reducing early mortality in patients on antiretroviral therapy. For persons with symptomatic cryptococcal meningitis, optimal initial management with amphotericin and flucytosine improves survival compared to alternative therapies; however, amphotsericin is difficult to administer and flucytosine has not been available in middle or low income countries, where cryptococcal meningitis is most prevalent. Expert commentary: Improved care for cryptococcal meningitis patients in resource-limited settings is possible, and new treatment possibilities are emerging.

Integrated therapy for HIV and cryptococcosis.

Cryptococcosis has been one of the most common opportunistic infections and causes of mortality among HIV-infected patients, especially in resource-limited countries. Cryptococcal meningitis is the most common form of cryptococcosis. Laboratory diagnosis of cryptococcosis includes direct microscopic examination, isolation of Cryptococcus from a clinical specimen, and detection of cryptococcal antigen. Without appropriate treatment, cryptococcosis is fatal. Early diagnosis and treatment is the key to treatment success. Treatment of cryptococcosis consists of three main aspects: antifungal therapy, intracranial pressure management for cryptococcal meningitis, and restoration of immune function with antiretroviral therapy (ART). Optimal integration of these three aspects is crucial to achieving successful treatment and reducing the mortality. Antifungal therapy consists of three phases: induction, consolidation, and maintenance. A combination of two drugs, i.e. amphotericin B plus flucytosine or fluconazole, is preferred in the induction phase. Fluconazole monotherapy is recommended during consolidation and maintenance phases. In cryptococcal meningitis, intracranial pressure rises along with CSF fungal burden and is associated with morbidity and mortality. Aggressive control of intracranial pressure should be done. Management options include therapeutic lumbar puncture, lumbar drain insertion, ventriculostomy, or ventriculoperitoneal shunt. Medical treatment such as corticosteroids, mannitol, and acetazolamide are ineffective and should not be used. ART has proven to have a great impact on survival rates among HIV-infected patients with cryptococcosis. The time to start ART in HIV-infected patients with cryptococcosis has to be deferred until 5 weeks after the start of antifungal therapy. In general, any effective ART regimen is acceptable. Potential drug interactions between antiretroviral agents and amphotericin B, flucytosine, and fluconazole are minimal. Of most potential clinical relevance is the concomitant use of fluconazole and nevirapine. Concomitant use of these two drugs should be cautious, and patients should be monitored closely for nevirapine-associated adverse events, including hepatotoxicity. Overlapping toxicities of antifungal and antiretroviral drugs and immune reconstitution inflammatory syndrome are not uncommon. Early recognition and appropriate management of these consequences can reinforce the successful integrated therapy in HIV-infected patients with cryptococcosis.

Oral mycoses and other opportunistic infections in HIV: therapy and emerging problems - a workshop report.

Oral mycoses and other opportunistic infections are recognized features of HIV infection even after four decades of the epidemic. The therapeutic options, challenges of therapy, and evolving patterns of opportunistic infections were evaluated by the workshop. It was observed that high Candida counts and infection are still more prevalent in HIV-positive individuals even in the era of antiretroviral therapy. Furthermore, one or more non-Candida albicans are present in some HIV-positive individuals. While Candida species are more virulent in HIV infection, similar virulence may be present in other states of immunosuppression. Consequently, the interplay between host factors and virulence ultimately determines the clinical outcomes. Adverse clinical outcomes such as candidemia and other deep fungal infections are on the increase in HIV infection. Disseminated histoplasmosis and penicilliosis have been reported, especially with low CD4 counts. Even with advances in antifungal therapy, mortality and morbidity from deep fungal infections have not changed significantly. In addition, long-term exposure to common antifungal drugs such as fluconazole has led to the development of antifungal resistance in 6% to 36%. Development of new antifungal therapeutic agents and the use of alternative therapies may offer breakthrough. In addition, effective strategies to enhance the host immune status are being explored.

Antifungal effect of Trachyspermum ammi against susceptible and fluconazole-resistant strains of Candida albicans.

OBJECTIVE: Trachyspermum ammi (T. ammi) has been known as having many therapeutic properties and its antimicrobial activity has currently received a renewed interest. This study aimed to verify the effectiveness of T. ammi essential oil to inhibit the growth of Candida albicans (C. albicans) strains isolated from HIV(+) patients with oropharyngeal candidiasis (OPC). MATERIALS AND METHODS: The essential oil was obtained by hydrodistillation in a Clevenger apparatus and analyzed by gas chromatography. Susceptibility tests were expressed as inhibition zone by the disk diffusion method and minimal inhibitory concentration (MIC) and minimal fungicidal concentration (MFC) by the broth microdilution method. RESULTS: Thymol (63.4%), p-cymene (19%) and γ-terpinen (16.9%) were found as the most abundant constituents. The disk diffusion results revealed that 67% of oral C. albicans isolates were susceptible, 9% susceptible-dose dependent and 24% resistant to fluconazole. In the broth microdilution method, 68% of isolates were susceptible, 5% susceptible-dose dependent and 27% resistant to fluconazole. The increase in concentration led to a significant reduction in yeasts that were growing in exponential phase. In addition, with increasing in T. ammi oil concentration, the time of remaining cells in lag phase was significantly increased. CONCLUSION: This study showed that all clinical C. albicans isolates were susceptible to T. ammi essential oil, indicating a significant reduction in the yeast growth in exponential phase.

Effect of highly active antiretroviral therapy on vaginal Candida spp. isolation in HIV-infected compared to HIV-uninfected women.

Vulvovaginal candidiasis (VVC) in HIV-infected women contributed to the impairment of their quality of life. The aim of this study was to evaluate the effect of highly active antiretroviral therapy (HAART) use on the vaginal Candida spp. isolation in HIV-infected compared to HIV-uninfected women. This cross-sectional study included 178 HIV-infected (HIV group) and 200 HIV-uninfected women (control) that were studied at the Specialized Assistance Service (SAE) for sexually transmitted diseases (STD)/AIDS of the city of Maringá, Brazil, from April 1 to October 30, 2011. The yeasts were isolated and identified by phenotypic and molecular methods. The in vitro antifungal susceptibility to fluconazole, itraconazole, nystatin and amphotericin B was tested by the reference microdilution method. Higher frequencies of total vaginal Candida spp. isolation were found in the HIV-infected group than in the control group. However, both groups showed a similar frequency of colonization and VVC. Although C. albicans was the most frequent and sensitive to azolics and polyenes in both HIV-infected and uninfected women, the emerging resistance of C. glabrata to amphotericin B in the HIV-infected women was observed. Although higher frequency of vaginal Candida spp. isolation had been observed in the HIV-infected than in HIV-uninfected women, colonization and VVC showed similar frequency in both groups, indicating that HAART appears to protect against vaginal colonization and VVC.

Cryptoccocal meningitis in Yaoundé (Cameroon) HIV infected patients: Diagnosis, frequency and Cryptococcus neoformans isolates susceptibility study to fluconazole.

Cryptococcal meningitis is a mycosis encountered especially in patients with Acquired Immunodeficiency Syndrome and is fatal in the absence of treatment. Information on epidemiology, diagnosis and susceptibility profile to antifungal drugs, are scarce in Cameroon. Authors evaluated the diagnosis possibilities of the cryptococcal meningitis in Cameroon, and studied the antifungal susceptibility of isolated strains to fluconazole, used as first line treatment of the disease in Cameroon. Between December 2009 and July 2011, 146 cerebrospinal fluids obtained from HIV patients with suspicion of meningitis were analysed. The diagnosis procedure involved macroscopic and cyto-chemical analysis, India ink test, culture on Sabouraud chloramphenicol medium and antigen latex agglutination test. Antifungal susceptibility testing of isolated strains to fluconazole was done by the E-test(®) method. The diagnosis of cryptococcal meningitis gave 28.08% positive cases. Among these patients, 80% were at stages III and IV and 20% at stage I of the HIV infection, according to the WHO previous classification. Cyto-chemical analysis showed current findings in the case of cryptococcal meningitis. India ink test and latex agglutination test exhibited very high sensitivity and specificity (>94%). Fluconazole antifungal susceptibility testing gave MICs lower than 32µg/mL to 92.7% of isolated strains and MICs greater than this value to 7.3% of isolates. These results showed that cryptococcal meningitis remains a real problem among HIV infected patients in Yaoundé. The emergence of fluconazole reduced susceptibility strains is worrying. Nevertheless, efficacy of rapid detection tests is interesting because this will help in rapid diagnosis and treatment of patients.

[Bacterial pneumonia in HIV-infected patients (excluding mycobacterial infection)]. / Pneumonies bactériennes chez les personnes infectées par le VIH (hors mycobactéries).

Respiratory infections are the most common complications in HIV patients, regardless of the degree of immunosuppression. Even though antiretroviral therapy has a protective effect on the risk of bacterial pneumonia, this still remains high (including those with CD(4)>500/mm(3)). The most frequently isolated bacteria are Streptococcus pneumoniae and Haemophilus influenzae. The clinical and radiological presentations of lower respiratory tract infections in HIV patients are quite variable. The clinical presentation is more severe and the radiological presentation is more atypical if the immunosuppression is severe. The first-line antibiotic therapy is an injectable third-generation cephalosporin (ceftriaxone or cefotaxime) or co-amoxiclav. Pneumococcal vaccination (as well as influenza vaccine) is recommended. Although rare, Nocardia spp. and Rhodococcus equi seem more common among AIDS patients.

Meningitis due to Cryptococcus neoformans: treatment with posaconazole.

BACKGROUND: Central nervous system infections caused by Cryptococcus neoformans remain to be opportunistic infections with high mortality in severely immunocompromised patients such as patients with AIDS. Amphotericin B deoxycholate and fluconazole remain to be the drugs of choice; however, in consideration of the intolerance to amphotericin B deoxycholate and the possible resistance to fluconazole, it is necessary to evaluate other azoles, such as posaconazole, that have demonstrated lower adverse events. The objective of this study was to describe the characteristics and clinical and microbiological response of the use of posaconazole in patients with CNS infections caused by C. neoformans. METHODS: We designed a case study that included eight patients diagnosed with AIDS and cryptococcal meningitis. Seven patients were treated with 800 mg of posaconazole orally for 28 days. RESULTS: During the second week of treatment, a cerebrospinal fluid (CSF) culture was performed and was negative for the development of C. neoformans. The patients showed an improvement in signs and symptoms of impairment of the CNS such as reduction of cephalea, fever, visual disturbances such as double vision, meningism and papilledema, and improved alertness and environmental awareness. CONCLUSIONS: CNS fungal infections usually occur in immunocompromised patients. The use of systemic antifungal agents contributes to the development of fungal resistance. The results of this study suggest that posaconazole is a good alternative in the treatment of fungal CNS infection due to C. neoformans.

Histoplasmosis in HIV-positive patients in Ceará, Brazil: clinical-laboratory aspects and in vitro antifungal susceptibility of Histoplasma capsulatum isolates.

This study contains a descriptive analysis of histoplasmosis in AIDS patients between 2006 and 2010 in the state of Ceará, Brazil. Additionally, the in vitro susceptibility of Histoplasma capsulatum isolates obtained during this period was assessed. We report 208 cases of patients with histoplasmosis and AIDS, describing the epidemiological, clinical, laboratory and therapeutic aspects. The in vitro antifungal susceptibility test was carried out by the microdilution method, according to Clinical and Laboratory Standards Institute, with H. capsulatum in the filamentous and yeast phases, against the antifungals amphotericin B, fluconazole, itraconazole, voriconazole and caspofungin. In 38.9% of the cases, histoplasmosis was the first indicator of AIDS and in 85.8% of the patients the CD4 cell count was lower than 100 cells/mm(3). The lactate dehydrogenase levels were high in all the patients evaluated, with impairment of hepatic and renal function and evolution to death in 42.3% of the cases. The in vitro susceptibility profile demonstrated there was no antifungal resistance among the isolates evaluated. There was a significant increase in the number of histoplasmosis cases in HIV-positive patients during the period surveyed in the state of Ceará, northeastern Brazil, but no antifungal resistance among the recovered isolates of H. capsulatum.

Selenium levels in persons with HIV/tuberculosis in India, Madurai City.

BACKGROUND: Selenium plays a vital role in the immune status of the individual. The prospective observational study was conducted from September 2009 to March 2010. The aim of the present study is to investigate the association between serum selenium levels and pulmonary tuberculosis (PTB) patients with (n = 40) and without HIV (n = 40) in comparison to healthy controls (healthy family members; n = 20) who satisfied rigid selection criteria. METHODS: Standard methods were adopted to collect an early morning fasting blood sample for serum selenium concentrations, determined by atomic absorption spectrometry (AAS), and albumin, determined by the bro mocresol green method. RESULTS: The mean +/- SD for Body Mass Index (BMI), selenium, and albumin among the controls, HIV positive, and HIV negative patients were 19.6 +/- 0.6, 18 +/- 0.4 and 18.5 +/- 0.6 kg/m2; 113.1 +/- 4.1, 27.44 +/- 8, and 65.92 +/- 9, microg/dL; and 4.1 +/- 0.6, 2.9 +/- 0.4 and 3.6 +/- 0.7 g/dL, respectively. BMI, serum selenium, and albumin levels were found to be significantly lower (p < 0.004, p < 0.0321, and p < 0.002, respectively). CONCLUSIONS: Low serum selenium levels are associated with increased risk of pulmonary infection caused by mycobacteria.

Conventional systemic treatments associated with therapeutic sites of local lesions of secondary syphilis in the oral cavity in patients with AIDS.

Patients with HIV infection may develop common diseases with atypical clinical features. HIV infection can change the classic clinical course of syphilis and increase the incidence of malignant syphilis. Malignant syphilis is a rare subtype of secondary syphilis that presents special clinical and histological features and has been associated with several processes characterized by variable degrees of immunosuppression. It is necessary to consider the possibility of this entity in the differential diagnoses in HIV-infected patients with cutaneous lesions. The dental surgeon (or oral surgeon) is vital to the medical team for promoting the health and improving the quality of life of syphilis patients. A patient with HIV infection was referred to us for complaints of a white patch on the tongue, stinging and burning sensation on the tongue, loss of taste, and dryness of the mouth. On clinical examination, the patient was found to have a tabetic gait (the Prussian soldier gait) associated with Charcot arthropathy. We also identified bilateral lesions with ulceration and exposure of the tissue that were tender, characterized by discrete necrosis. The treatment that was initiated at that time involved cleaning the area with gauze to remove all the white patches, followed by rinsing with bicarbonate in water (one teaspoon of baking soda dissolved in half a glass of water) four times a day. Additionally, fluconazole (100 mg/day for 7 days) was prescribed. We diagnosed secondary malignant syphilis of approximately 5 days duration. As an adjunctive therapy, we performed low-intensity laser treatment using a GaAsAl (gallium-aluminum arsenide) laser at 790 nm. With this treatment there was progressive resolution of the lesions.

Correlation of susceptibility of Cryptococcus neoformans to amphotericin B with clinical outcome.

Testing of Cryptococcus neoformans for susceptibility to antifungal drugs by standard microtiter methods has not been shown to correlate with clinical outcomes. This report describes a modified quantitative broth macrodilution susceptibility method showing a correlation with both the patient's quantitative biological response in the cerebrospinal fluid (CSF) and the survival of 85 patients treated with amphotericin B (AMB). The Spearman rank correlation between the quantitative in vitro measure of susceptibility and the quantitative measure of the number of organisms in the patient's CSF was 0.37 (P < 0.01; 95% confidence interval [95% CI], 0.20, 0.60) for the first susceptibility test replicate and 0.46 (P < 0.001; 95% CI, 0.21, 0.62) for the second susceptibility test replicate. The median in vitro estimated response (defined as the fungal burden after AMB treatment) at 1.5 mg/liter AMB for patients alive at day 14 was 5 CFU (95% CI, 3, 8), compared to 57 CFU (95% CI, 4, 832) for those who died before day 14. These exploratory results suggest that patients whose isolates show a quantitative in vitro susceptibility response below 10 CFU/ml were more likely to survive beyond day 14.

Oral Candida isolates among HIV-infected subjects in Nigeria.

BACKGROUND: Nigeria is a West African country of more than 150 million persons with the second highest case of HIV/AIDS infected patients in the world. The species spectrum of oral yeast colonization and the susceptibility to a wide range of antifungal agents is poorly understood in Nigeria especially in the south east, south south, and the northern axis. This study evaluates the species spectrum of oral colonization by Candida species in HIV-infected patients in Nigeria and the in vitro susceptibility pattern of the Candida isolates to a broad range of antifungal agents. METHODS: Two hundred oropharyngeal swabs from HIV-infected patients and 100 age-matched healthy controls were screened for yeast isolates using standard procedures and confirmed by the analytical profile index 20C along with other biochemical tests. In vitro susceptibility testing of the yeast isolates to antifungals were performed using the broth microdilution method protocol recommended by the Clinical Laboratory Scientific Institute. RESULTS: Of 200 patients screened, 120 (60%) were colonized by yeasts. C albicans was the dominating species in both groups with 54 (45%) isolated from HIV subjects. The non-albicans Candida species accounted for 55% with C tropicalis 22 (18.3%) showing the highest frequency. We observed that 11.7% of all yeasts isolates were resistant to fluconazole, 8.3% to flucytosine, 7.5% to itraconazole, and 1.7% to voriconazole. All isolates were susceptible to amphotericin B and most of them demonstrated very low voriconazole minimal inhibitory concentrations. Apart from C albicans, C tropicalis and C parapsilosis isolates were also recovered from apparently healthy control subjects. CONCLUSION: Although C albicans continues to be the dominant Candida species in oral Candida carriage of HIV-infected patients in Nigeria, the nonalbicans Candida species are increasing. Furthermore, the finding of resistant isolates in our study emphasizes the need for antifungal susceptibility testing whenever antifungal treatment is desired especially in HIV-infected subjects.