Late initiation of HAART among HIV-infected patients in Spain is frequent and related to a higher rate of virological failure but not to immigrant status.

PURPOSE: To determine whether immigrant status is associated with late initiation of highly active antiretroviral treatment (HAART) and/or poor response to antiretrovirals. METHODS: GESIDA 5808 is a multicenter, retrospective cohort study (inclusion period January 2005 through December 2006) of treatment-naïve patients initiating HAART that compares HIV-infected patients who are immigrants with Spanish-born patients. A late starter (LS) was defined as any patient starting HAART with a CD4+ lymphocyte count <200 cells/µL and/or diagnosis of an AIDS-defining illness before or at the start of therapy. The primary endpoint was time to treatment failure (TTF), defined as virological failure (VF), death, opportunistic infection, treatment discontinuation/switch (D/S), or missing patient. Secondary endpoints were time to treatment failure as observed data (TTO; censoring missing patients) and time to virological failure (TVF; censoring missing patients and D/S not due to VF). RESULTS: LS accounted for 56% of the patients. Lower educational and socioeconomic level and intravenous drug use (IVDU) were associated with categorization as LS, but immigrant status was not. Cox regression analysis (hazard ratio [HR]; 95% CI) between LS and non-LS patients showed no differences in TTF (0.97; 0.78-1.20) or TTO (1.18; 0.88-1.58), although it did reveal a difference in TVF (1.97; 1.18-3.29). CD4+ lymphocyte recovery was equivalent for both LS and non-LS patients (159 vs 173). CONCLUSIONS: In our cohort, immigrant status was not shown to be related to late initiation of HAART. Although LS patients did not have a longer TTF for any reason, TVF was significantly shorter. Despite universal free access to HAART in Spain, measures to ensure early diagnosis and treatment of HIV infection are necessary.

Prophylaxis of visceral leishmaniasis in human immunodeficiency virus-infected patients.

OBJECTIVE: To assess the effectiveness of two regimens with allopurinol or pentavalent antimony as secondary prophylaxis for visceral leishmaniasis (VL) in human immunodeficiency virus (HIV)-infected patients. DESIGN: Retrospective, nonrandomized, open trial. SETTING: A 1,000-bed academic tertiary institutional hospital in Barcelona. PATIENTS: Forty-six individuals over 14 years old with HIV infection, who recovered from an episode of VL between January 1988 and February 1995. INTERVENTIONS: Twenty patients did not receive any prophylaxis, nine received 300 mg/8 h of allopurinol, and 17 received 850 mg once-a-month of pentavalent antimony. Patients were followed-up every 3 months, and the endpoint of study was relapse of VL. RESULTS: Twenty-one patients had recurrent VL: 13 of 20 in the control group (65%), 5 of 9 in the allopurinol group (56%), and 3 of 17 in the antimonial group (18%). Kaplan-Meier estimates of the probability of remaining relapse-free at 12 months were 9% without prophylaxis (95% CI, 0-22%), 21% with allopurinol (95% CI, 0-51%), and 93% with antimonials (95% CI, 82-100%) (P < 0.001). Multivariate analysis showed that the only significant variables related to relapsing course of VL were assignment to the antimonial group, and the fact that the patient had experienced a previous episode of VL. CONCLUSIONS: Pentavalent antimony given once a month is effective in the prevention of VL relapses in HIV-infected individuals. It is a low-cost treatment that proved to be well tolerated. Therefore, pentavalent antimony should be considered a suitable agent for secondary prophylaxis against VL.

[Infection and coronary atherosclerosis: the role Chlamydia pneumonia]. / Infección y aterosclerosis coronaria: papel de Chlamydia pneumoniae.

The role of inflammatory reactions in the pathogenesis of atherosclerosis is widely accepted. Recently, an increasing body of evidence has linked infections to atherosclerosis. It is hypothesized that infections could interact with other risk factors of vascular disease, enhancing the endothelial damage and the production of atherosclerotic plaques. Several different infectious agents have been related to the atherosclerosis genesis: mainly herpesvirus, Helicobacter pylori and Chlamydia pneumoniae. Several lines of evidence strongly link C. pneumoniae to atherosclerosis. Consequently, several studies evaluating the effectiveness of antibiotic treatment in the reduction of cardiac ischemic events in patients with C. pneumoniae seropositivity have been performed. These studies support a causative role for C. pneumoniae. This article reviews the recent evidence linking infections to atherosclerosis, with emphasis on the role of C. pneumoniae on the atherosclerotic plaque.

[Acute pancreatitis due to antimonials in patients with visceral leishmaniasis and HIV infection]. / Pancreatitis aguda por antimoniales en pacientes con leishmaniasis visceral e infección por VIH.

Acute pancreatitis is an adverse effect of the treatment with antimonial drugs which is infrequently described in patients with HIV infection and visceral leishmaniasis (VL). Twenty-two percent of the patients having this treatment had acute pancreatitis (7 cases) in the authors' center. In all the cases, severe immunosuppression was present with pancreatitis appearing following the administration of 3,400 to 15,300 mg of stibogluconate. The pancreatitis was slight in the 7 cases with no complications of note and with no symptoms observed in three cases. The maximum values of amylasemia ranged from 976 to 2,568 U/l, from 1,055 to 5,860 U/l for lipasemia, and from 1,970 to 25,520 U/l for trypsinemia. These values returned to normal from 15 days to 2 months after suppression of the drug. Stibogluconate was readministered in three patients due to VL recurrence with a further acute pancreatitis being observed. The authors conclude that acute pancreatitis is a relatively infrequent complication of antimonial treatment for VL in patients with HIV infection and believe that a maximum dose of 850 mg/day should not be surpassed.

Pneumococcal sacroiliitis in a 4-year-old boy.

Pyogenic sacroiliitis is an extremely rare manifestation of invasive pneumococcal disease in childhood as only four cases have been described to date. We report and comment on a case of pneumococcal sacroiliitis in a 4-year-old boy. This patient was diagnosed promptly on account of the symptom triad of fever, buttock pain, and limping gait, along with characteristic findings in magnetic resonance imaging (MRI) and bone scans, and recovered fully after 6 weeks of antimicrobial therapy. Pyogenic sacroiliitis is an uncommon disease in which the diagnosis is often delayed because of nonspecific clinical presentation. The key to successful management is early diagnosis in which MRI and bone scan findings play a crucial role. If the diagnosis is established promptly, most patients can be managed successfully following the therapeutic principles used in other osteoarticular infections.

[Neurologic manifestations of varicella herpes zoster infection]. / Manifestaciones neurológicas en la infección por el virus de la varicela herpes zoster.

BACKGROUND: The aim of the present study was to analyze the clinical characteristics and fluid alterations in neurologic infection by varicella herpes zoster virus in hospitalized patients. METHODS: A retrospective study of the cases with neurologic involvement by the varicella herpes zoster virus in patients admitted in the authors' hospital from March 1991 to March 1993 was carried out. RESULTS: Our of the 14 patients studied with neurologic involvement by the varicella herpes zoster virus, 10 were males (71%) with a mean age of 38 years (range: 13-83 years). Only 4 patients (28%) presented a base disease (diabetes mellitus in 2 cases and HIV infection in another 2). In 10 cases (71%) the appearance of cutaneous lesions was prior to neurologic manifestations (between 1 and 30 days before neurologic clinical manifestations). All the patients presented hyperthermia at some time. The most common symptoms were: headache, vomiting, confusion and/or neck stiffness, with meningitis, encephalitis and neurologic foci and mixed pictures. In 4 cases (28%) the cephalorhachidian fluid did not present analytical changes suggestive of viral meningitis. All the patients underwent i.v. acyclovir treatment at a dosis of 10-15 mg/kg/8 h with good evolution, with no deaths being observed. In 3 out of the 6 cases presenting neurologic foci the evolution was slow with sequelae following treatment completion. CONCLUSIONS: Neurologic involvement by the varicella herpes zoster virus does not clinically defer from other neutrotropic virus. Fluid alterations were compatible with benign lymphocytary meningitis although some cases of encephalitis showed normal LCR. Taking into account that none of the patients herein reported died and considering the mortality associated with meningitis or encephalitis by varicella herpes zoster referred in the literature in untreated patients, the authors believe that the use of acyclovir is obligatory in these cases.

Two grams daily of oral acyclovir reduces the incidence of cytomegalovirus disease in CMV-seropositive liver transplant recipients.

Our objective in this study was to determine the efficacy of 2 grams a day of oral acyclovir administered for 16 weeks after transplantation for the prevention of cytomegalovirus (CMV) infection and disease in CMV-seropositive liver transplant recipients. Seventy-three adult liver transplant recipients, seropositive for CMV, were randomized to receive either 2 grams a day of oral acyclovir for 16 weeks after transplantation or no prophylaxis. The incidence of CMV disease was significantly lower in the acyclovir group (5%) than in the control group (27%; P < 0.05). By log-rank analysis, the differences in the probability of presenting CMV disease over the first 16 weeks and over the 1st year were also significant (P < 0.05). We conclude that 2 grams a day of oral acyclovir provides effective prophylaxis against CMV disease in CMV-seropositive liver transplant recipients.

Non-invasive pressure support ventilation versus conventional oxygen therapy in acute cardiogenic pulmonary oedema: a randomised trial.

BACKGROUND: Non-invasive pressure support ventilation (NIPSV) is an effective treatment for acute respiratory failure in patients with chronic obstructive pulmonary disease. We assessed the efficacy of this therapy in acute cardiogenic pulmonary oedema in a randomised comparison with conventional oxygen therapy. METHODS: 40 patients were randomly assigned conventional oxygen therapy or NIPSV supplied by a standard ventilator through a face mask, with adjustment of tidal volume and pressure support in addition to a positive end-expiratory pressure of 5 cm water. Physiological measurements were obtained in the first 2 h and at 3 h, 4 h, and 10 h. The main endpoints were intubation rate and resolution time. Analyses were by intention to treat. FINDINGS: Three patients were withdrawn on the basis of clinical and chest radiography results. Endotracheal intubation was required in one (5%) of 19 patients assigned NIPSV and in six (33%) of 18 assigned conventional oxygen therapy (p=0.037). Resolution time (defined as a clinical improvement with oxygen saturation of 96% or more and respiratory rate less than 30 breaths/min) was significantly shorter in the NIPSV group (median 30 [IQR 15-53] vs 105 [50-230] min, p=0.002). NIPSV led to a rapid improvement in oxygenation in the first 2 h. There were no differences in hospital length of stay or mortality. INTERPRETATION: In this study of acute cardiogenic pulmonary oedema, NIPSV was superior to conventional oxygen therapy. Further studies should compare NIPSV with continuous positive airway pressure.

Cytomegalovirus disease as a risk factor for graft loss and death after orthotopic liver transplantation.

To determine whether cytomegalovirus (CMV) disease is an independent risk factor for graft loss and death after orthotopic liver transplantation, we performed a 3-year follow-up study of 143 consecutive liver transplant recipients and six patients who underwent retransplantation. Thirty-seven patients (25%) had had CMV disease and were alive after treatment. Fifty-two deaths and eight graft losses occurred. The cumulative incidence of graft failure at 1 and 3 years of follow-up were 40% and 63%, respectively, for patients with CMV disease, compared with 22% and 33%, respectively, for those without CMV disease (P < .05, logrank test). Cumulative probabilities of survival for patients with and without CMV disease were 64% and 82%, respectively, at 1 year and 46% and 69%, respectively, after 3 years (P < .05, logrank test). Multivariate analysis with use of a time-dependent Cox model showed that previous CMV disease was an independent risk factor for graft loss at 1 and 3 years of follow-up (P = .04 and P = .007) and for patient survival (P = .04 and P = .01). Our results indicate that CMV disease is a significant independent risk factor for graft loss and patient survival after liver transplantation.