Anorectal Lymphogranuloma Venereum in Madrid: A Persistent Emerging Problem in Men Who Have Sex With Men.

BACKGROUND: Since 2003, outbreaks of lymphogranuloma venereum (LGV) with anorectal syndrome have been increasingly recognized in many Western countries. All of them have been classified as LGV serovar L2b, mainly occurring in human immunodeficiency virus (HIV)-infected men who have had sex with men (MSM). We describe a series of 26 diagnosed cases of LGV proctitis in downtown Madrid, Spain, in 2014, after implementing routine diagnostic procedures for this disease in symptomatic MSM. METHODS: We conducted an observational study of patients with symptomatic proctitis attending an outpatient infectious diseases clinic in Madrid, Spain during calendar year 2014. Clinical, epidemiological, laboratory, and therapeutic data were gathered and analyzed. RESULTS: Twenty-six patients were included in the analysis. All were MSM, and 24 of them were HIV-positive. All patients reported having acute proctitis symptoms including tenesmus (85%), pain (88%), constipation (62%), or anal discharge (96%). Proctoscopy showed mucopurulent exudate (25 patients [96%]), and rectal bleeding, with mucosal erythema and/or oedema in all cases. Rectal swabs were obtained from all patients, and LGV serovar L2 was confirmed in all of them. The cure rate was 100% after standard treatments with doxycycline 100 mg twice per day for 3 weeks. Simultaneous rectal infections with other sexually transmitted pathogens (gonorrhoea, herpes simplex virus, Mycoplasma genitalium) and systemic sexually transmitted diseases (STDs) (syphilis, acute HIV, and hepatitis C infections) were also documented in 12 patients (46%), but these co-infections did not appear to influence the clinical manifestations of LGV. CONCLUSIONS: Anorectal LGV is a common cause of acute proctitis and proctocolitis among HIV-infected MSM who practice unprotected anal sex, and it is frequently associated with other rectal STDs. The implementation of routine screening and prompt diagnosis of these rectal infections should be mandatory in all clinical settings attended by HIV and STD patients.

[Practices and perception of risk in human immunodeficiency virus infected males who have sex with other males]. / Prácticas y percepción del riesgo en hombres con infección por el virus de la inmunodeficiencia humana que tienen sexo con otros hombres.

INTRODUCTION: The incidence of human immunodeficiency virus (HIV) and other sexually transmitted diseases increases in males who have sex with males (MSM), despite the knowledge on how to prevent them. To determine the mechanisms that are driving this lack of prevention is important to reverse the trend. PATIENTS AND METHODS: An anonymous, voluntary and self-reporting questionnaire was completed by HIV+ MSM patients who were seen in a hospital clinic, with the aim of finding out the sexual risk practices and behaviour, as well as their perceptions and assessment as regards this risk. The questionnaire included 58questions, divided into 10sections, to explore the knowledge, attitudes, and behaviour as regards HIV. The questionnaires were also given to the physicians, with the aim of exploring their perceptions, attitudes and opinions as regards the situation of the epidemic, prevention, perception of the diseases and the patient, and values in clinical practice. RESULTS: A total of 495 questionnaires from the patients were analysed. Most of them (87%) said they knew how HIV was acquired, and 97% knew how to prevent it, but 69% knew they were in a risk situation, and 43% had little concern of contracting HIV. Almost two-thirds (65%) had sex with ≥2persons on the same day, 47% met on the Internet and 26% had group sex. The same percentage of those surveyed considered that they acted impulsively. They highlighted a lack of information (33%), bad luck (32%), assumed excessive risk (36%), and lake of concern (25%), as the main reasons for acquiring the infection. When confronted with diagnosis 41% of patients answered «I never thought that it would happen to me¼, and 32% said «I had bad luck¼. Of the 121 physicians who completed the questionnaire, 24% considered that infection due to HIV/AIDS was out of control in Spain, and 65% responded that there was an image that HIV/AIDS was a controlled disease and of little concern. A large majority (71%) of those surveyed, considered that the increase in new infections showed that there was no suitable preventive plan. CONCLUSIONS: The management of the risk of acquiring HIV maintains a low level of concern, due to the optimism produced by the advances in the fight against the disease and the current toning down of the discussion. The trivialisation of the risk, on distorting the idea of risky behaviour, is a determining factor of attitudes that makes it impossible to adopt effective preventive behaviour and to take sensible and anticipated decisions.

Corynebacterium striatum: an emerging nosocomial drug-resistant endocardial pathogen.

Endocarditis due to Corynebacterium striatum has been rarely reported. A 78-year-old patient developed pacemaker endocarditis caused by multidrug-resistant C. striatum, complicated by vertebral osteomyelitis and epidural abscess. Daptomycin therapy successfully eradicated the bacteremia and metastatic infection. A review of the English literature on this emerging nosocomial, multidrug-resistant pathogen is included.

[Enteric fever in Madrid. A review of the last 30 years]. / Fiebre entérica en Madrid. Una revisión de los últimos 30 años.

BACKGROUND: Our aim is analyze the epidemiological factors of enteric fever in Madrid (Spain) over the last 30 years. MATERIAL AND METHODS: A retrospective review was conducted on cases of typhoid and paratyphoid fever studied in the Fundación Jiménez Díaz (Madrid) between 1980 and 2010. Two similar periods in time were studied (P1: 1980-1993; P2: 1994-2010). RESULTS: There was a total of 61 confirmed cases of enteric fever: 51 (84%) were typhoid and 10 were paratyphoid: 45 patients were native Spanish (40 belonging to P1) and 16 were immigrants (15 in P2, with 11 of them coming from the Indian sub-continent). CONCLUSION: Enteric fever must be present in the differential diagnosis of persistent fever without clear focus in immigrants, mainly from the Indian subcontinent, and travelers from endemic areas.

Pulmonary infectious diseases in patients with primary immunodeficiency and those treated with biologic immunomodulating agents.

PURPOSE OF REVIEW: Lung infectious disease is an important cause of morbidity and mortality in patients with primary immunodeficiencies and other conditions that alter immunologic mechanisms against microbial invasion. Lung infectious diseases occurring in patients with congenital immunodeficiency and patients on treatment with biologic anti-inflammatory compounds are discussed. Understanding of the complex relationships between the immune system and microbes is of paramount importance for timely diagnosis and successful treatment of lung infectious diseases in this group of immunocompromised hosts. RECENT FINDINGS: In the past, only a minority of children with severe primary immunodeficiency survived beyond childhood and these disorders were within the scope of the pediatrician. As modern prophylaxis and treatment strategies have been implemented, these patients will now survive into adulthood. Nowadays, therapy with new biologic compounds--tumor necrosis factor (TNF) blockers and anti-CD20 drugs--that disrupt antimicrobial surveillance and the control of intracellular microorganisms such as mycobacteria, fungi and viruses has been associated with the emergence of a new population at risk for the development of severe pulmonary and disseminated infectious diseases. SUMMARY: A wide array of bacteria, viruses, fungi and protozoa may cause severe pulmonary infectious diseases in patients with primary immunodeficiency and patients on treatment with anti-TNF and anti-CD20 drugs. Knowledge of the association of certain microbial agents with specific immune disturbances is of great clinical interest.

Q fever endocarditis in Spain. Clinical characteristics and outcome.

OBJECTIVES: To describe the clinical presentation of a large number of Q fever endocarditis (QFE) and its management considering the role of serology. PATIENTS AND METHODS: Eighty-three patients with definite QFE (56 native and 27 prosthetic valve) with a long-term follow-up after stopping treatment (median: 48 months) were included. Final outcome (cure or relapse) was compared according with the serological titre at the end of therapy: less than 1:400 of phase I Ig G antibodies by indirect immunofluorescence (group 1, N=23) or more than 1:400 (group 2, N=30). RESULTS: Eleven patients (13.2%) died from QFE and other 8 died for other reasons not related to endocarditis during follow-up. Surgery was performed in 61 (73.5%) patients and combined antimicrobial treatment was long (median: 23 months, IQR: 12 - 36). Seven relapses were observed, but five of them had received an initial incomplete antibiotic regimen. In patients who completed the programmed treatment (range: 12 - 89 months), serological titres at the end of therapy were not useful for predicting the final outcome: one relapse in each group. CONCLUSIONS: QFE requires a prolonged antimicrobial treatment, but serological titres are not useful for determining its duration.

HIV-DNA content in pTfh cells is associated with residual viremia in elite controllers.

OBJECTIVE: The source of residual HIV viremia is highly debated and its potential relationship with the HIV reservoir has not been clarified. Herein, we analysed the cell-associated HIV-DNA content in two important cell compartments of the HIV reservoir, resting CD4+ T memory (Trm) and peripheral T follicular helper (pTfh) cells, and the association with the residual HIV viremia in individuals with spontaneous HIV replication control (elite controllers, EC group) and in individuals with antiretroviral therapy (ART)-mediated HIV replication control (cART group). DESIGN: A cross-sectional study. METHODS: Seventeen chronically HIV-infected patients with suppressed HIV replication were included. Cell-associated HIV-DNA was measured by ultrasensitive digital-droplet-PCR in purified Trm and pTfh cells. Residual HIV plasma viremia was quantified using a single-copy assay with a sensitivity of 0.3 HIV-RNA copies/ml. RESULTS: A significant and positive correlation was demonstrated between HIV-DNA levels in pTfh cells and residual plasma viral load (rpVL) (rho = 0.928, P = 0.008) in HIV-positive elite controllers, but not in HIV-positive treated patients, despite the lower levels of cell-associated HIV-DNA found in elite controllers compared with cART patients in pTfh cells [176 (77-882) vs. 608 (361-860) copies/million cells, respectively; P = 0.05]. CONCLUSION: This association suggests that pTfh cells could have an important contribution to persistent viremia in elite controllers. This could be the consequence of a more limited control of HIV replication in elite controllers with higher transcriptional activity of HIV in pTfh cells of elite controllers than that in cART patients.

Superficial thrombophlebitis: A new clinical manifestation of the immune reconstitution inflammatory syndrome in a patient with HIV infection.

Skin manifestations of immune reconstitution inflammatory syndrome in response to highly active antiretroviral therapy may account for up to 50% of the clinical presentations in this syndrome. Viable or dying infective antigens, host antigens, tumoral antigens, and others may target immune reconstitution inflammatory syndrome, resulting in a wide spectrum of clinical manifestations. We describe a 26-year-old HIV-infected man who had started highly active antiretroviral therapy a few months earlier. He developed multiple linear nodules following the superficial veins in both legs. Histopathologic examination demonstrated a mostly septal panniculitis with features of superficial thrombophlebitis. We propose that superficial thrombophlebitis should be added to the list of clinical manifestations of this newly observed immune restoration disease.

Transcriptional signature of resting-memory CD4 T cells differentiates spontaneous from treatment-induced HIV control.

The HIV reservoir is the main barrier to eradicating HIV infection, and resting memory CD4 T (Trm) cells are one of the most relevant cellular component harboring latent proviruses. This is the first study analyzing the transcriptional profile of Trm cells, in two well-characterized groups of HIV patients with distinct mechanisms of viral replication control (spontaneous versus treatment-induced). We use a systems biology approach to unravel subtle but important differences in the molecular mechanisms operating at the cellular level that could be associated with the host's ability to control virus replication and persistence. Despite the absence of significant differences in the transcriptome of Trm cells between Elite Controllers (ECs) and cART-treated (TX) patients at the single gene level, we found 353 gene ontology (GO) categories upregulated in EC compared with TX. Our results suggest the existence of mechanisms at two different levels: first boosting both adaptive and innate immune responses, and second promoting active viral replication and halting HIV latency in the Trm cell compartment of ECs as compared with TX patients. These differences in the transcriptional profile of Trm cells could be involved in the lower HIV reservoir observed in ECs compared with TX individuals, although mechanistic studies are needed to confirm this hypothesis. Combining transcriptome analysis and systems biology methods is likely to provide important findings to help us in the design of therapeutic strategies aimed at purging the HIV reservoir. KEY MESSAGES: HIV-elite controllers have the lowest HIV-DNA content in resting memory CD4 T cells. HIV-ECs show a particular transcriptional profile in resting memory CD4 T cells. Molecular mechanisms of enhanced adaptative and innate immune response in HIV-ECs. High viral replication and low viral latency establishment associate to the EC status.

Chagas' heart disease: Descriptive analysis of 141 patients in a hospital of Madrid, Spain.

BACKGROUND: Spain is the European country with the highest number of Trypanosoma cruzi infected patients. Due to the cardiac complications that these patients can develop, it is of paramount importance to evaluate the value of the different heart diagnostic tools. METHOD: In this observational study, we describe the main characteristics and data from electrocardiogram, chest X-ray, echocardiogram and cardiac magnetic resonance imaging (MRI) of 141 patients with Chagas' disease attended in a tertiary university hospital in Madrid from 2009 to 2018. RESULTS: A total of 50 patients (35.4%) had at least one abnormal cardiac test: 34.2% altered electrocardiogram (40/117), 24.5% altered echocardiogram (27/110) and 9.2% abnormal cardiac MRI (13/41). Of those 13 with a pathological MRI, 53.8% had normal results for any other test. The most frequent alterations observed were hypokinesia with decreased LVEF (left ventricular ejection fraction), dilatation of cavities and cardiac fibrosis. Two thirds of patients with abnormal cardiac test were asymptomatic. Altered echocardiogram was found in 43.8% of patients ≥50 years compared to 16.6% under 50 years (p = 0.003). CONCLUSIONS: A transthoracic echocardiogram and a MRI of the heart added a 23.8% increment in diagnosing cardiac pathological findings.

[Satisfaction, index of body mass and its influence on physical self-concept]. / Satisfacción e índice de masa corporal y su influencia en el autoconcepto físico.

OBJECTIVE: Over the past decade, overweight and childhood obesity has increased markedly, and children are therefore dissatisfied with their body image due to the beauty canons established in today's society. The purpose of this paper was to examine the level of obesity and body satisfaction based on sociodemographic and contextual variables of the educational center as well as the relationship they have with the physical self-concept on a sample of primary school and compulsory secondary school students city of Badajoz. METHODS: The instruments used in the study were the questionnaire of Physical Self-concept (CAF) and questionnaire of Bodily Silhouettes. RESULTS: The study involved 1,093 schoolchildren aged between 11 and 14 years old (M = 11.6) from 19 educational centers. CONCLUSIONS: There is a high percentage of overweight students (20%) and a high percentage of satisfied students with their body image (79%). Regarding the relationship between the level of obesity and body satisfaction with sociodemographic and contextual variables we can see how obesity presents significant differences depending on the nature of the center and the educational offer. On the other hand, the correlation analyzes carried out reveal significant differences between the level of obesity and body dissatisfaction with some scales of physical self-concept. You can also observe significant differences between the level of obesity of the school with body dissatisfaction (more cases than expected of students satisfied with their body image with normal weight and fewer cases than expected of students satisfied with their body image with overweight and obesity).

OBJETIVO: En la última década el sobrepeso y la obesidad infantil ha aumentado notablemente, y por consiguiente, los niños/as no se encuentran satisfechos con su imagen corporal debido a los cánones de belleza instaurados en la sociedad actual. El propósito de este trabajo fue examinar el nivel de obesidad y la satisfacción corporal en función de variables sociodemográficas (sexo y edad) y contextuales del centro educativo (curso, carácter del centro y oferta educativa), así como la relación que éstas tienen con el autoconcepto físico, sobre una muestra de escolares de Educación Primaria y Educación Secundaria obligatoria de la ciudad de Badajoz. METODOS: Los instrumentos utilizados en el estudio fueron el cuestionario de Autoconcepto Físico (CAF) y el cuestionario de siluetas corporales. RESULTADOS: En el estudio participaron 1.093 escolares con edades comprendidas entre los 11 y 14 años (M=11,6) de 19 centros educativos. Se observa un elevado porcentaje de alumnos con sobrepeso (20%) y un porcentaje elevado de alumnos satisfechos con su imagen corporal (79%). En cuanto a la relación entre el nivel de obesidad y la satisfacción corporal con las variables sociodemográficas y contextuales, podemos ver cómo la obesidad presenta diferencias significativas en función del carácter del centro y de la oferta educativa. CONCLUSIONES: Los análisis de correlación efectuados ponen de manifiesto diferencias significativas entre el nivel de obesidad y la insatisfacción corporal con algunas escalas de autoconcepto físico. También se pueden observar diferencias significativas entre el nivel de obesidad del escolar y su insatisfacción corporal (más casos de los esperados de alumnos con normopeso satisfechos con su imagen corporal y menos casos de los esperados de alumnos con sobrepeso y obesidad satisfechos con su imagen corporal).

CD32 Expression is not Associated to HIV-DNA content in CD4 cell subsets of individuals with Different Levels of HIV Control.

A recent study has pointed out to CD32a as a potential biomarker of HIV-persistent CD4 cells. We have characterized the level and phenotype of CD32+ cells contained in different subsets of CD4 T-cells and its potential correlation with level of total HIV-DNA in thirty HIV patients (10 typical progressors naïve for cART, 10 cART-suppressed patients, and 10 elite controllers). Total HIV-DNA was quantified in different subsets of CD4 T-cells: Trm and pTfh cells. Level and immunephenotype of CD32+ cells were analyzed in these same subsets by flow cytometry. CD32 expression in Trm and pTfh subsets was similar in the different groups, and there was no significant correlation between the level of total HIV-DNA and the level of CD32 expression in these subsets. However, total HIV-DNA level was correlated with expression of CD127 (rho = -0.46, p = 0.043) and of CCR6 (rho = -0.418, p = 0.027) on CD32+ cells. Our results do not support CD32 as a biomarker of total HIV-DNA content. However, analyzing the expression of certain markers by CD32+ cells could improve the utility of this marker in the clinical setting, prompting the necessity of further studies to both validate our results and to explore the potential utility of certain markers expressed by CD32+ cells.

Do CD8(+)CD25(+) cells predict immune reconstitution syndrome in HIV-positive patients who begin HAART?

Although undesirable, immune reconstitution syndrome (IRS) indicates a favourable effect of HAART and it should be differentiated from an opportunistic infection because of their distinct implications and management. Our group analysed different immunological parameters with the aim of identifying IRS predictors in patients who begin HAART. We found that CD8(+)CD25(+) cell pretreatment values in patients who developed IRS were four times higher than in those patients who did not develop IRS.

Enterococcal endocarditis on native and prosthetic valves: a review of clinical and prognostic factors with emphasis on hospital-acquired infections as a major determinant of outcome.

Enterococci are the third leading cause of infectious endocarditis, and despite advances in diagnosis and treatment, the mortality of enterococcal endocarditis has not changed in recent decades. Although variables such as advanced age, cardiac failure, and brain emboli have been recognized as risk factors for mortality, cooperative multi-institutional studies have not assessed the role of other variables, such as nosocomial acquisition of infection, the presence of comorbidities, or the changing antimicrobial susceptibility of enterococci, as factors determining prognosis.We conducted the current study to determine the risk factors for mortality in patients with enterococcal endocarditis in a single institution. We reviewed 47 consecutive episodes of enterococcal endocarditis in 44 patients diagnosed according to the modified Duke criteria from a retrospective cohort study of cases of infectious endocarditis. The main outcome measure was inhospital mortality. We applied stepwise logistic regression analysis to identify risk factors for mortality.Predisposing heart conditions were observed in 86.3% of patients, and 17 had prosthetic valve endocarditis. A portal of entry was suspected or determined in 38.2%; the genitourinary tract was the most common source of the infection (29.7%). Comorbidities were present in 52.2% of cases. Twelve episodes (25.5%) were acquired during hospitalization. Only 3 isolates of Enterococcus faecalis were highly resistant to gentamicin. Eighteen patients (40.9%) needed valve replacement due to cardiac failure or relapse. Comparing cases of native valve and prosthetic valve endocarditis, we found no differences regarding complications, the need for surgical treatment, or mortality. Eight of 44 (18%) episodes were fatal. Age over 70 years (p = 0.05), heart failure (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.15-2.25; p = 0.001), presence of 1 or more comorbidities (OR, 3.2; 95% CI, 1.11-9.39; p = 0.02), and nosocomial acquisition (OR, 8.05; 95% CI, 1.50-43.2; p = 0.01) were associated with mortality. In the multivariate analysis, only nosocomial acquisition increased the risk of mortality. In patients with enterococcal endocarditis, nosocomial acquisition of infection is an important factor determining outcome. As the incidence of bacteremia and the population of elderly people at risk continue to grow, the hazard of acquiring nosocomial enterococcal endocarditis may increase; hence, major emphasis must be put on prevention.

Peripheral T follicular helper Cells Make a Difference in HIV Reservoir Size between Elite Controllers and Patients on Successful cART.

HIV latency is the main barrier to HIV eradication. Peripheral T follicular helper (pTfh) cells have a prominent role in HIV persistence. Herein, we analyzed the HIV reservoir size within memory CD4+ T-cell subsets in patients with HIV replication control. Twenty HIV-infected patients with suppressed HIV replication were included, with 10 elite controllers (EC) and 10 treated (TX) individuals. The HIV reservoir size was analyzed in resting memory CD4+ T-cells (Trm), pTfh, and non-pTfh cells using an ultrasensitive digital-droplet-PCR assay. Inter-group and intra-group differences were tested using non-parametric tests. Compared with the TX patients, the EC patients had smaller HIV reservoir not only in Trm but also in pTfh and non-pTfh subsets of memory CD4+ T-cells. The largest differences were observed in pTfh cells (p = 0.025). The pTfh and non-pTfh cells harbored similar levels of HIV-DNA in the EC (p = 0.60) and TX patients (p = 0.17); however, the contribution to HIV-DNA levels in memory CD4+ T-cells varied among the pTfh and non-pTfh subsets in both groups of patients. The EC patients showed smaller HIV reservoir in memory CD4+ cells, especially in the pTfh subset, a population of cells with a pivotal role in the antiviral immune response, suggesting a potential link between low levels of infection in pTfh cells and the ability of the EC patients to spontaneously control HIV replication.

[Cryptococcal meningoencephalitis. Epidemiology and mortality risk factors in pre- and post-HAART era]. / Meningoencefalitis criptocócica. Epidemiología y factores de riesgo de mortalidad en la era pre- y pos-TARGA.

INTRODUCTION AND OBJECTIVE: Cryptococcal meningoencephalitis (CM) is an uncommon entity, but remains a major cause of morbidity and mortality in patients with AIDS. MATERIAL AND METHODS: Review of CM cases in a university hospital. The diagnosis was determined by isolation of Cryptococcus neoformans in cerebrospinal fluid. Morbidity and mortality was assessed at 12 weeks (early mortality) and between 3 and 18 months after diagnosis (late mortality). RESULTS: We analyzed 32 patients from 2,269 AIDS cases (1.41%). 10 patients between 1990-1996 and 22 between 1997-2014. Cryptococcal antigen in CSF was positive in all cases, with titers>1,024 in 19 patients (63%); this group had lower CD4+ counts (40 ± 33 vs. 139 ± 78 cel/µL) and greater disseminated involvement. After a first CM episode the relapse rate was 34%. Global mortality rate was 28% (9/32), much higher in the pre-HAART era. CONCLUSIONS: CM morbidity and mortality is related to severe immunodeficiency, disseminated disease, high titers of antigen in CSF and delayed initiation of HAART.