Incidence rate and causes of infection in Thai systemic sclerosis patients.

BACKGROUND: Infection is a common cause of death in systemic sclerosis (SSc) but despite immunosuppressant therapy, there are few reports of opportunistic infection. OBJECTIVES: To estimate the incidence of infection, to determine the etiologic organism, and to assess the risk factors for infection among Thai SSc patients. METHODS: A historical cohort analysis was conducted on patients over 15 years of age, diagnosed with SSc, who attended the Scleroderma Clinic at Srinagarind Hospital, Khon Kaen, Thailand, between January 1, 2005 and December 31, 2006. RESULTS: The medical records of 117 SSc patients were reviewed. The female-to-male ratio was 1.5 : 1.0. Of the total 310 person-years under observation, 63 events of infection occurred. The incidence rate of infection was 20.3 per 100 person-years (95% CI 15.6-26.0) and the incidence rate of major infection was 11.0 per 100 person-years (95% CI 8.4-16.5). The mean age and mean duration of SSc at the time of infection was 50.1 ± 11.1 years (range, 25.2-76.6) and 12.9 ± 10.4 months (range, 0.5-34.6), respectively. Urinary tract infection was the most common infection (23.8%). Opportunistic infection was found in one case (esophageal candidiasis). Esophageal dysmotility was significantly related to major infection (odds ratio [OR] 3.22). There was a clinical association between aspiration pneumonia and esophageal dysmotility (OR 1.23), as well as non-strongyloidiasis diarrhea and gastrointestinal involvement (OR 2.28). One person died due to severe bacterial aspiration pneumonia. CONCLUSIONS: Infection is not uncommon among SSc patients; however, opportunistic infection is rare, despite immunosuppressant therapy. Esophageal dysmotility increases the risk of major infection, particularly of aspiration pneumonia.

Estimates of the impact of diabetes on the incidence of pulmonary tuberculosis in different ethnic groups in England.

BACKGROUND: There is good evidence that diabetes is a risk factor for pulmonary tuberculosis. In England, the rates of both diabetes and tuberculosis vary markedly by ethnic group. OBJECTIVE: To estimate the proportion of incident cases of pulmonary tuberculosis attributable to diabetes (population attributable fraction, PAF) for Asian, black and white men and women aged > or = 15 years in England. METHODS: An epidemiological model was constructed using data on the incidence of tuberculosis, the prevalence of diabetes, the population structure for 2005 and the age-specific relative risk of tuberculosis associated with diabetes from a large cohort study. RESULTS: The estimated PAF of diabetes for pulmonary tuberculosis is highest for Asian men (19.6%, 95% CI 10.9% to 33.1%) and women (14.2%, 95% CI 7.1% to 26.5%). The PAF for all ages is similar in white and black men (6.9%, 95% CI 3.1% to 12.4% and 7.4%, 95% CI 4.6% to 12.9%, respectively) and women (8.2%, 95% CI 3.0% to 15.6% and 8.9%, 95% CI 5.3% to 15.6%, respectively). The similarity of these overall figures, despite a higher prevalence of diabetes in the black population, reflects a much younger mean age of pulmonary tuberculosis in the black population. Overall, of 3461 new cases of pulmonary tuberculosis in England in 2005, 384 (202-780) were estimated to be attributable to diabetes. CONCLUSION: Given the nature of the data available, considerable uncertainty surrounds these estimates. Nonetheless, they highlight the potential importance of diabetes as a risk factor for pulmonary tuberculosis, particularly in groups at high risk of both diseases. Further research to examine the implications of these findings for tuberculosis control is urgently needed.

Influence of race/ethnicity on response to lupus nephritis treatment: the ALMS study.

OBJECTIVE: To compare the efficacy and safety of mycophenolate mofetil (MMF) and intravenous cyclophosphamide (IVC) as induction treatment for lupus nephritis (LN), by race, ethnicity and geographical region. METHODS: A total of 370 patients with active Class III-V LN received MMF (target dose 3.0 g/day) or IVC (0.5-1.0 g/m(2)/month), plus tapered prednisone, for 24 weeks. Renal function, global disease activity, immunological complement (C3 and C4) and anti-dsDNA levels are the outcomes that were assessed in this study. RESULTS: MMF was not superior to IVC as induction treatment (primary objective). There were important pre-specified interactions between treatment and race (P = 0.047) and treatment and region (P = 0.069) (primary endpoint). MMF and IVC response rates were similar for Asians (53.2 vs 63.9%; P = 0.24) and Whites (56.0 vs 54.2%; P = 0.83), but differed in the combined Other and Black group (60.4 vs 38.5%; P = 0.03). Fewer patients in the Black (40 vs 53.9%; P = 0.39) and Hispanic (38.8 vs 60.9%; P = 0.011) groups responded to IVC. Latin American patients had lower response to IVC (32 vs 60.7%; P = 0.003). Baseline disease characteristics were not predictive of response. The incidence of adverse events (AEs) was similar across groups. Serious AEs were slightly more prevalent among Asians. CONCLUSIONS: MMF and IVC have similar efficacy overall to short-term induction therapy for LN. However, race, ethnicity and geographical region may affect treatment response; more Black and Hispanic patients responded to MMF than IVC. As these factors are inter-related, it is difficult to draw firm conclusions about their importance.

Clinical profile of sickle cell disease in Yemeni children.

UNLABELLED: The clinical spectrum of sickle cell disease (SCD) in the Arabian Peninsula varies widely. This is the first report in Yemeni children. METHODS: A hospital-based, cross-sectional study was undertaken in Al-Wahada Teaching Hospital in Aden of children under 16 years with homozygous (SS) SCD. RESULTS: Fifty-six (55%) were males. There were clinical manifestations in 20% by the age of 6 months and in 67%, 88% and 92% by 1, 2 and 3 years, respectively. Dactylitis (hand-foot syndrome) was the most common presenting symptom and occurred in 54% of cases, followed by acute respiratory infections and other acute febrile illnesses. The main causes of hospitalisation were painful crisis (36%), anaemic crisis (16%) and acute chest syndrome (11%). Hepatomegaly was detected in 72% and splenomegaly in 40%. Cerebrovascular accident, cholelithiasis, hepatic crisis and leg ulcers each occurred in about 5% of patients. There was first- and second-degree consanguinity in 31% and 16%, respectively, of patients' families. CONCLUSION: SCD is a serious problem, affecting children in Yemen from an early age. Disease course and severity were similar to that in Africans and American blacks and some reports from western Saudi Arabia. A screening programme linked to comprehensive medical care and genetic counselling is required to improve management and quality of life.

Causes and predictors of death in South Africans with systemic lupus erythematosus.

OBJECTIVES: Little is known about the long-term outcome and mortality patterns in systemic lupus erythematosus (SLE) in sub-Saharan Africa. We undertook a retrospective study of SLE in mainly black, unemployed patients, seen at a tertiary institution in Soweto, South Africa, to determine the causes and predictors of death. METHODS: Demographic, clinical and laboratory data and outcome were extracted from the case records of patients attending the Lupus Clinic at Chris Hani Baragwanath Hospital. RESULTS: Of the 270 case records with a diagnosis of SLE, 226 met the American College of Rheumatology classification criteria for SLE. The female to male ratio was 18 : 1. The mean (s.d.) age at presentation was 34 (12.5) yrs. Arthritis, nephritis and neuropsychiatric disease had a cumulative frequency of 70.4, 43.8 and 15.9% of patients, respectively. During the course of a mean follow-up period of 54.9 months, 193 (85.3%) and 89 (39.3%) patients were treated with oral corticosteroids and immunosuppressive agents, respectively. There were 55 (24.5%) known deaths and 64 (28.6%) patients were lost to follow-up. The estimated 5 yr survival rates were between 57 and 72%, depending on whether the group of patients lost to follow-up was classified in the analysis as either alive or dead. Infection (32.7%) was the commonest cause of death followed by renal failure (16.4%). Univariate analysis revealed that nephritis, neuropsychiatric disease and hypocomplementaemia were associated with an increased mortality, but multivariate analysis showed nephritis as the only significant predictor of mortality. CONCLUSION: Our findings suggest that SLE in indigent South Africans not only carries a poorer prognosis but also the main cause of death, infection and renal failure differ from those reported recently in industrialized Western countries. Nephritis is common in our patients and is the only independent predictor of poor outcome.

[Clinical studies of the incidence of pulmonary and extrapulmonary tuberculosis]. / Klinische Untersuchungen über die Häufigkeit der pulmonalen und extrapulmonalen Tuberkulose.

On the whole 797 patients (mean age 49.5 +/- 18.6 years) with tuberculosis who were hospitalized during 1987 and the first half of the year 1994 were investigated. 148 (18.6%) of these patients were foreigners. Regarding the age, the patients of German origin were mostly above 40 years (70.5%). Within the group of foreigners, 61.5% were below 40 years. 83.3% of the patients suffered from pulmonary and 11.4% from extrapulmonary and 11.4% from extrapulmonary tuberculosis. 5.3% of these patients had both manifestations. The tuberculin tine test was positive in 95.7% and negative in 4.3%. In 63.9% of all patients the tuberculosis was localized in the upper lobe of the lung. The tuberculosis was established bacteriologically in 56.0% and histologically in 16.5%. Both methods were applied in 13.6%. The tuberculosis was deteriorated by chronic alcoholism. Malignant diseases were recorded in 17 (2.1%) of the patients. 22 (2.8%) died during their stay at the hospital.

Racial and ethnic differences in outcome in zidovudine-treated patients with advanced HIV disease. Zidovudine Epidemiology Study Group.

UNLABELLED: OBJECTIVES--To determine if racial-ethnic differences exist in survival, disease progression, and development of myelosuppression in zidovudine-treated patients with advanced human immunodeficiency virus (HIV) disease. DESIGN--Prospective observational study. SETTING: -Hospital and private clinics in 12 metropolitan centers. PATIENTS: -The study included 754 non-Hispanic white, 165 black, and 106 Hispanic patients with the acquired immunodeficiency syndrome (AIDS) or advanced AIDS-related complex (ARC) who received up to 2 years of zidovudine therapy. OUTCOME MEASURES--Survival, development of Pneumocystis carinii pneumonia (PCP), other opportunistic infections, and myelosuppression. RESULTS--At initiation of zidovudine therapy, Hispanic and particularly black patients had more advanced HIV disease than white patients, as indicated by lower baseline CD4+ counts, hematocrits, and AIDS-defining diagnoses. Black patients with AIDS also had a worse prognosis compared with white and Hispanic patients with AIDS. The product-limit survival rates at 2 years for white, black, and Hispanic patients with AIDS were 40%, 27%, and 39%, respectively (black vs white, P = .01; Hispanic vs white, P = .32, by the log-rank test). The respective proportions of patients who developed PCP at 2 years were 46%, 66%, and 44% (black vs white, P = .0001; Hispanic vs white, P = .86) and for other opportunistic infections the proportions were 56%, 63%, and 63%, respectively (black vs white, P = .03; Hispanic vs white, P = .09). There were no significant racial-ethnic differences in survival or in the development of opportunistic infections for patients with ARC, and there were no differences in the incidence of myelosuppression or dose reduction or suspension for patients with either ARC or AIDS. After adjusting for more advanced HIV disease (mainly low CD4+ counts and hematocrits), black race was no longer a significant independent predictor of survival. Adjustment for racial differences in the use of PCP prophylaxis accounted for most of the excess risk for the development of PCP in black patients compared with white patients with AIDS. CONCLUSIONS--Racial differences in survival and the development of opportunistic infections are mainly due to the more advanced HIV disease in black patients when zidovudine therapy is started and to their less frequent use of PCP prophylaxis. Innovative approaches are needed to ensure more widespread use of and earlier access to zidovudine therapy and PCP prophylaxis.

Disseminated tuberculosis in the acquired immunodeficiency syndrome era.

To assess the influence of human immunodeficiency virus type 1 (HIV)-induced immunodeficiency on the clinical, radiographic, and pathologic features of disseminated tuberculosis (TB), we studied 79 patients presenting in 1984 through 1987 with miliary or focal disseminated disease due to Mycobacterium tuberculosis, as well as 4 additional non-HIV patients diagnosed after 1987. Clinically defined acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC) was present in 51 (Group 1). A total of 20 had TB unrelated to HIV disease (Group 2). The remaining 12 were excluded because the role of HIV could not be determined. Clinical features were similar between groups aside from younger age; lower hemoglobin, total leukocyte, lymphocyte, and platelet counts; and more frequent tuberculin anergy (90 versus 40%) in AIDS/ARC patients (p less than or equal to 0.03). Chest radiographs showed a miliary pattern in about half of each group. Pleural effusion occurred only in AIDS/ARC patients (24%, p = 0.02), but intrathoracic lymphadenopathy was present in about a third of each group. Tissue biopsies (n = 70) usually revealed necrotizing granulomatous inflammation in each group, with a tendency to greater necrosis and more numerous acid-fast bacilli in Group 1. Granulomas were usually poorly formed in AIDS/ARC patients (59 versus 18%, p = 0.01). Autopsy of 9 AIDS/ARC patients with overwhelming miliary TB revealed a "nonreactive" histologic pattern with poorly organized or absent granulomas, extensive necrosis, and numerous bacilli. HIV-related disseminated TB causes a major constitutional illness with a high short-term mortality (25%).(ABSTRACT TRUNCATED AT 250 WORDS)

Role of flexible bronchoscopy and bronchoalveolar lavage in the diagnosis of pediatric acquired immunodeficiency syndrome-related pulmonary disease.

Flexible fiberoptic bronchoscopy with bronchoalveolar lavage was performed in 16 pediatric patients with the acquired immunodeficiency syndrome (AIDS) and deterioration in pulmonary function suggestive of opportunistic infection. In 62% of the patients Pneumocystis carinii was identified. Culture results showed a pure growth of Pseudomonas aeruginosa for one patient in addition to the Pneumocystis carinii. Bronchoscopy with lavage was well tolerated, with few complications even among patients with significant tachypnea and hypoxia. Because of its relative safety and effectiveness, this procedure should be considered the first invasive measurement used for evaluation of parenchymal lung disease in this population of patients.

[AIDS in children based on autopsy data from the Kalmyk ASSR]. / SPID u detei po sektsionnym materialam Kalmytskoi ASSR.

6 cases of HIV infection were revealed by enzyme immunoassay and immunoblotting among 144 children who had died in Elista. Another 5 children might have had HIV-infection but laboratory analyses either were lacking or gave doubtful results. Laboratory results were negative in 133 children. Similar severe changes of the lymphoid system typical for immunodeficiency were found in all children. These changes in HIV infection were characterized by lymphogenic generalized RNA infection. Complications (secondary diseases) in the form of DNA-virus infections (cytomegalia and herpes simplex), pneumocystosis and other viral and bacterial processes were observed in children of all groups. The disease was found mainly in Kalmyks. Blood examination of healthy Kalmyks revealed some differences in the form of significant decrease of the lysosomal cationic proteins content and the peroxydase activity of neutrophil leucocytes as compared to the same indexes obtained in Leningrad. There was also a tendency to the decrease of T-lymphocyte content. The children dying from immunodeficiencies lived mainly along the litoral of an ancient sea.