Tuberculous meningitis with acellular cerebrospinal fluid in AIDS patients.

OBJECTIVE: To describe the clinical manifestations of tuberculous meningitis in HIV-positive patients with acellular cerebrospinal fluid (CSF). DESIGN: Retrospective analysis of case reports. METHODS: Four HIV-positive patients with acellular CSF and tuberculous meningitis are reported. RESULTS: Clinical presentation did not indicate meningeal infection in three of the four cases, and CSF tests were unusual in all cases. Two patients were diagnosed only after death. CONCLUSIONS: Acellular CSF may obstruct the diagnosis of tuberculous meningitis in AIDS patients.

Assessment of allopurinol plus meglumine antimoniate in the treatment of visceral leishmaniasis in patients infected with HIV.

We report on 11 patients with HIV infection and visceral leishmaniasis and who were treated with meglumine antimoniate plus allopurinol for 3 weeks (six patients) or 4 weeks (five patients). Clinical and parasitological cures were achieved in four of the five patients treated for 4 weeks and in one of the six patients treated for 3 weeks. Only one patient developed a severe maculopapular rash. Allopurinol plus meglumine antimoniate was found to be a safe combination of drugs for the treatment of visceral leishmaniasis in patients infected with HIV. The optimal length of this treatment is unknown but a course of at least 4 weeks' duration would appear to be necessary for obtaining parasitological cure in most cases.

AIDS and tuberculosis in Spain. A report of 140 cases.

From January 1984 to October 1990, 140 of 392 (35.7%) patients with the acquired immunodeficiency syndrome (AIDS) were found to have had tuberculosis. One hundred and sixteen were intravenous drug abusers and 16 were homosexual men. Fever, cough, weight loss and generalised lymphadenopathy were common features of their illness. Tuberculin skin tests were negative in 74% and 55% had intraabdominal lymphadenopathy. The chest radiographs showed hilar lymphadenopathy and lower lobe interstitial or alveolar infiltrates, but rarely cavitation. Forty-one of our patients had pulmonary tuberculosis, 38 had extra pulmonary and in 61 it was disseminated. In 80 cases tuberculosis was the presenting feature of AIDS. Tuberculosis usually responded well to chemotherapy.

[Gastrointestinal disease due to cytomegalovirus in patients infected with the human immunodeficiency virus]. / Enfermedad gastrointestinal por citomegalovirus en pacientes infectados por el virus de la inmunodeficiencia humana.

OBJECTIVE: To describe all the clinical settings, endoscopic findings and response to therapy in a series of HIV-positive patients with biopsy proven gastrointestinal CMV disease. PATIENTS: We retrospectively reviewed the medical records of all HIV-infected patients who underwent digestive endoscopies at our Hospital from June 1990 to October 1993. RESULTS: Twelve (7.5%) of 158 HIV-positive patients had gastrointestinal CMV disease. Sites of prove infection included the esophagus (n = 6, 50%), stomach (n = 2, 17%), duodenum (n = 4, 33.3%), ileum (n = 1, 8.5%) and colon (n = 2, 17%). The most common endoscopic findings were focal or diffuse mucosal ulcers. Three patients had pseudotumoral mucosal lesions. Cytomegalic cells were observed in 11 patients (91.6%) and immunohistochemical staining was positive in 9 (81.8%) of 11 patients tested. Eight patients completed a course of treatment with ganciclovir or foscarnet and all of them showed clinical improvement. The median survival time of our AIDS patients with CMV gastrointestinal disease was 7 weeks (range 1-39 weeks). CONCLUSIONS: Gastrointestinal CMV disease may damage any site of the digestive tract in AIDS patients. Routine histopathologic examination was better than immunohistochemical staining for the diagnosis. Treatment improves the clinical situation in most of them. The mean survival is low and it is related to the degree of immunosuppression.

[Which are the vaccines that human immunodeficiency virus infected patients must receive?]. / Qué vacunas deben recibir los pacientes con infección por el virus de la inmunodeficiencia humana?

Patients with aids are at increased risk of opportunistic and non opportunistic infections. It is now known that the incidence can be reduced by prophylactic measures and/or the use of vaccines. HIV infection produces an elevated frequency of severe pneumococcal disease with a rate of bacteriemia caused by Streptococcus pneumoniae 150-300 fold greater than rates reported in non-HIV infected people. For this reason, pneumococcal vaccine should be administered as early as possible in the course of the infection. Besides, the antibody response may be significantly higher for asymptomatic persons. Acute hepatitis caused by hepatitis B virus is milder than in non HIV infected patients but chronic disease is more frequent. The prognosis is worse and there is higher risk for infecting another persons. Hepatitis B vaccine is indicated for all the patients with HIV and negative serology for hepatitis B virus. Influenza vaccine is of limited effectiveness due to the high variability of the virus. Besides, influenza incidence is low among approximately young adults, HIV related immunodeficiency increased influenza risk only minimally, the vaccine is administered yearly and HIV-replication can increase in temporal association with vaccination. For all these reasons, fewer hospitalizations and deaths are prevented making it a far less cost-effective prevention strategy than pneumococcal vaccination. The risk of Haemophilus influenzae infections is elevated, but the vaccine is not routinely recommended because the more frequent serotype in HIV infected patients is b. For these subjects, passive immunization with immunoglobulin may also be necessary to provide protection. In conclusion, pneumococcal and hepatitis B vaccination is a reasonable prevention strategy for HIV infected patients at all stages of immunodeficiency. Influenza and H. influenzae vaccination are not recommended and alternative prevention strategies may be done.

[Meningitis from Listeria monocytogenes in the adult]. / Meningitis por Listeria monocytogenes en el adulto.

We describe the characteristics of 6 adult patients with meningitis by Listeria monocytogenes. Five of them had previous disease and only one of these was being treated with immunosuppressors. All of them presented meningeal syndrome with cephalorhachidean fluid's pleocytosis and five of them, polymorphonuclear predominance. The empirical treatment was correct only in two cases. The mortality rate reached 50%.

[Evidence of infection by HIV-2 in Madrid (1991)]. / Evidencia de infección por el VIH-2 en Madrid (1991).

The presence of antibodies against HIV-2 was analyzed in serum samples from high-risk individuals for retrovirus infection, who were seropositives for HIV-1. Out of a total of 842 samples, 344 presented positive absorbency and 16, threshold ranges, in an enzymatic immunoassay (EIA) designed to detect simultaneously antibodies against HIV-1 and HIV-2. The Western Blot (WB) analysis confirmed the presence of antibodies against HIV-1 in 324 samples with positive or threshold EIA, while it was indetermined in 15 samples. WB was negative in 11 samples. In the 15 samples with indetermined WB and in the 16 samples with threshold EIA, the presence of antibodies against HIV-2 was investigated with an specific WB and a test designed with synthetic peptides (Pepti-lav). Three samples met the isolated seropositivity criteria for HIV-2. Those samples were from 3 african immigrants living in Madrid, which, until now, were asymptomatic, although one of them presented biological signs of immunodeficiency. None of them referred high-risk infectious practices, such a homosexuality or drug-addiction, although all of them referred heterosexual contacts in their native countries. Samples from native subjects meeting serum positivity criteria for HIV-2 were not identified.

[Listeriosis: an infrequent infection in patients with HIV]. / Listeriosis: una infección poco frecuente en pacientes con VIH.

Although resistance to Listeria monocytogenes infection requires intact T-cell mediated immunity, listeriosis is an infrequent problem in patients with HIV infection and only about 50 patients have been reported to date. Only two patients with HIV and L. monocytogenes have been attended in our hospital since the beginning of aids epidemic in 1981. Case 1: a man with HIV and 364 CD4+ cells/mm3 presented fever and occipital headache. The cerebral scan was normal and L. monocytogenes grew in licuor culture. He was outcome after treatment with ampicillin and tobramycin. Case 2: a 47 years old man with HIV, 44 CD4+ cells/mm3 and hepatic virus C cirrhosis was admitted to the hospital because fever and abdominal distension. He was on menstrual pentamidine prophylaxis for Pneumocystis carinii pneumonia (PCP). Bacterial peritonitis was diagnosed and the patient begun treatment with ceftriaxone. The patient dead 72 hours later with hepatic encepholopathy. Postmortem L. monocytogenes grew. Listeriosis is an infrequent disease in patients with HIV that causes difficult diagnostic problems, principally in patients without prophylaxis with cotrimoxazole for PCP.

[Visceral leishmaniasis: a study of 15 cases]. / Leishmaniasis visceral: estudio de 15 casos.

We report 15 cases of visceral leishmaniasis in adults, diagnosed by visualization of the parasite in 14 of them and in one case, based on clinic, serology and good response to treatment. Thirteen patients developed an acute clinical state and two patients, a subacute-chronic state. All of them had fever, half of them, a constitutional syndrome and 12, visceromegaly. Fifteen had anemia, 13, leukopenia and 10, thrombopenia. Serology was positive in 75% of cases. All patients were treated with meglumine antimoniate. No adverse effects were observed and in 14 patients, the treatment was successful. There were no recurrences. A patient died due to septic shock by Pneumococcus with DCI.

[Ciguatera: eight imported cases]. / Ciguatera: ocho casos importados.

INTRODUCTION: Ciguatera poisoning is a clinical syndrome associated to consumption of marine fish with toxins as ciguatoxin, maitotoxin, scariotoxin, palytoxin and okadaic acid, produced by dinoflagellates present in seas with coral reefs. It has a wide distribution in tropic ans sub-tropic areas. MATERIAL AND METHODS: We review the clinical records of 8 patients diagnosed of ciguatera from 1993 of 2001. Diagnosis was based on clinical picture and the antecedent of eating fish from endemic area. RESULTS: All patients were travelers, and all showed neurological symptoms, as parestesias and paradoxical dysesthesia. Five patients received treatment with intravenous mannitol, with fast improvement. DISCUSSION: Travelers to danger zones, mainly Caribbean area, Indic Ocean and Pacific Ocean regions, should be noticed about the risk of ciguatera.

[The treatment of AIDS and its associated pathology]. / Tratamiento del SIDA y de su patología asociada.

A distinction has to be made in the treatment of the acquired immune deficiency syndrome (AIDS), on one hand there is the treatment of the associated pathology that these patients suffer when their immune system is unable to cope with diseases such as opportunistic infections and neoplasms; on the other there is the treatment of the human immune deficiency virus (HIV) itself. In this work we review the state-of-the-art of both therapies, paying special attention to the treatment of opportunistic infections, because they hold responsibility for the deaths in 80% to 90% of these patients; the importance of the concept of prophylactic treatment, primary as well as secondary, in these diseases is outlined. The treatment of associated neoplasms has a worse outcome. Finally the antiviral therapies against HIV itself, are discussed, paying special attention to zidovudine (AZT) and didexosinosine, two of the more currently widely used drugs in the treatment of these patients. We end with the review of combined therapy, which probably will become, in the next future, the solution in the treatment of this disease.

Pseudotumoral appearance of cytomegalovirus esophagitis and gastritis in AIDS patients.

Cytomegalovirus (CMV) is frequently isolated from patients with acquired immunodeficiency syndrome (AIDS), and often causes disseminated disease. Gastrointestinal CMV involvement is recognized with increased frequency in AIDS patients. It can involve the entire alimentary tract and usually produces mucosal ulceration. Pseudotumoral lesions develop very infrequently. We report two unusual detailed cases of biopsy-proven CMV esophagitis and gastritis resembling carcinoma, in patients with human immunodeficiency virus infection. In AIDS patients, the gastrointestinal CMV involvement could show pseudotumoral appearance.

Two cases of imported gnathostomiasis in Spanish women.

Reported here are two new cases of imported cutaneous gnathostomiasis that occurred in two Spanish women. The first patient acquired the helminth infection while travelling in Southeast Asia and the second in Mexico. Although the highest prevalence of gnathostomiasis infection is in Southeast Asia, the disease is now an emerging public health problem in some countries of Latin America. The cases reported here demonstrate the increasing frequency with which human gnathostomiasis is being diagnosed in nonendemic countries as a result of more extensive international travel and migration.

Gastrointestinal leishmaniasis in human immunodeficiency virus-infected patients: report of five cases and review.

We describe five cases of gastrointestinal leishmaniasis in patients with human immunodeficiency virus infection and review 10 additional cases reported in the literature. All of the patients had CD4+ cell counts of < 200/mm3, and AIDS had been previously diagnosed for 12 patients. Fever and splenomegaly were present in 46% of cases. Thirteen patients had digestive symptoms; these symptoms included diarrhea (6), dysphagia and/or odynophagia (6), abdominal pain (2), epigastric pain (2), gastrointestinal hemorrhage (1), and rectal discomfort (1). The regions of the digestive tract most frequently affected by Leishmania organisms were the duodenal mucosa (90%) and the gastric mucosa (75%). Endoscopy showed normal-appearing mucosa in 45% of cases. In 10 cases the diagnosis of visceral leishmaniasis was first made by biopsy of the gastrointestinal mucosa. In most cases treatment with antimonial agents was not effective.