Aggressive multifocal Buruli ulcer with associated osteomyelitis in an HIV-positive patient.

Mycobacterium ulcerans infection causes a skin disease known as Buruli ulcer (BU), a disorder manifested usually as a solitary and painless nodule or papule that progresses to massive necrotizing destruction and cutaneous ulceration. When healing occurs, it often results in disabling deformities. Buruli ulcer is considered the third most common mycobacterial disease in immunocompetent people, after tuberculosis and leprosy. Although the emergence of Buruli ulcer in Western African countries over the past decade has been dramatic, it has been scarcely reported in industrialized countries. We report a patient from Equatorial Guinea who was human immunodeficiency virus-positive, presenting aggressive and multifocal BU associated with an underlying destructive osteomyelitis, in which only an aggressive surgical approach yielded to a resolution of the disease. In a global world, with increasing migratory population fluxes, an increased awareness of dermatologists regarding the clinical, histopathological and microbiological features of BU is important in order to avoid significant delays in diagnosis and treatment.

Virologic outcome and predictors of virologic failure of highly active antiretroviral therapy containing protease inhibitors.

In this observational single-center cohort study outside the clinical trial setting, outcome and predictors of virologic failure of highly active antiretroviral therapy (HAART) containing a protease inhibitor were evaluated in human immunodeficiency (HIV)-infected persons. The study population consisted of 807 protease inhibitor-naive HIV-seropositive patients who initiated antiretroviral therapy with reverse transcriptase inhibitors and protease inhibitors (indinavir, nelfinavir, ritonavir) between January 1997 and January 1999. Demographic variable, plasma HIV-1 RNA levels, CD4+ T-cell count, adverse drug reactions, and adherence to HAART were assessed. Virologic treatment response was defined as a decrease in plasma HIV-1 RNA load from baseline to below 500 copies per milliliter after 12 months of therapy. Levels of HIV-1 RNA were undetectable in 43% of patients at 12 months. Factors associated with failure to suppress viral load included age 40 years or younger, baseline CD4+ T cell count less than 200 x 10(6) per liter baseline viral load greater than 4.3 log(10) per milliliter, and non-adherence to HAART. After adjustment by logistic regression, non-adherence was the only statistically significant variable associated with virologic failure (odds ratio 0.38, 95% confidence interval 0.21 to 0.67). Unselected patients in whom protease inhibitor is started in a usual clinical setting achieve viral suppression less frequently than do patients in controlled clinical trials. Failure to adherence to HAART was the strongest predictor of virologic failure.

Análisis del estado actual de la rehabilitación y medicina física en la Comunidad Autónoma Valenciana / Analysis of the present status of rehabilitation and physical medicine in the valencian regional community

Introducción: Muchas veces tenemos dificultad para satisfacer las necesidades terapéuticas de nuestros pacientes. Con objeto de identificar las causas del problema, analizamos la adecuación entre objetivos y medios, evaluando los recursos humanos disponibles.Material y método: Analizamos tres aspectos de nuestra especialidad: la situación ideal, la situación real y la imagen proyectada o percibida. De la definición de Rehabilitación deducimos la situación ideal y la relación óptima objetivos/medios. Del análisis de algunas fuentes de información institucionales, determinamos la situación real. En base a nuestra experiencia personal, algunas noticias de prensa y otras publicaciones analizamos la imagen percibida sobre nuestra especialidad.Resultados y discusión: Lo 'ideal' sería disponer de un equipo multiprofesional/interdisciplinar. La realidad es que contamos con un equipo profesional demasiado básico, capaz de atender los problemas subsidiarios de 'Medicina Física', pero con carencias para tratar discapacidades múltiples o complejas. La causa del problema es estructural (carencia de recursos) y funcional (inadecuada utilización); al no haber reconocimiento oficial la gravedad es mayor. La imagen que otros profesionales perciben de nuestra especialidad no es adecuada; esto produce confusiones y podría ser motivo de problemas futuros.Conclusiones: Al carecer del equipo multiprofesional/interdisciplinar, tenemos una Rehabilitación 'bajo mínimos'.Esto genera una imagen confusa y distorsionada de nuestra especialidad y podría desencadenar diversos conflictos. Detectamos que la sociedad necesita y demanda las genuinas soluciones de la Rehabilitación, sin carencias de ningún tipo.Sería conveniente abrir un debate en el seno de nuestras sociedades científicas, para buscar soluciones a estos problemas (AU)

[Adherence to very active antiretroviral treatment: impact of individualized assessment]. / Adherencia al tratamiento antirretroviral de gran actividad: impacto de una intervención de asesoramiento individualizado.

BACKGROUND: To determine if the intervention of individual advice improves adherence and effectiveness to highly active antiretroviral therapy. METHODS: Randomized open trial. Patients treated with zidovudine + lamivudine + indinavir were assigned (2/1) to conventional care or individual advise. Individual advise consists in adaptation to treatment to patient style of live and detailed information of therapy. Adherence were estimated with structured interview and pillo counts and were considered correct when more than 90% of prescribed drugs were taken. RESULTS: Patients 170, conventional care: 110 and IA: 60. FOLLOW-UP: 24 weeks. Baseline characteristics were similar in both groups. Correct adherence were estimated in 52.7% of conventional care and in 76.7% of individual advise (p = 0.002, relative risk: 1.45; CI 95%: 1.16-1.82). Undetectable viral load (NASBA < 50 copies/ml) in 54.5% of conventional care and in 65% of individual advise (p = 0.18, relative risk: 1.19; CI 95%: 0.93-1.53). Reduction of viral load in the conventional care group 1.02 +/- 0.5 log10/ml, and in the individual advise group 1.98 +/- 0.7 log10/ml. CONCLUSION: The individual advice improve adherence with a tendency to improve effectiveness of highly active antiretroviral therapy.

[Fever of unknown origin in patients with human immunodeficiency virus infection. Study of 100 cases]. / Fiebre de origen desconocido en pacientes con infección por el virus de la inmunodeficiencia humana. Estudio de 100 casos.

BACKGROUND: Fever of unknown origin (FUO) has been insufficiently studied in patients infected with HIV. The aim of this study was to determine the incidence, mean hospital stay, etiology, diagnostic methods and clinical course in patients infected with HIV and FUO. METHODS: Descriptive prospective study of patients infected with HIV and with FUO for a period of 24 months (February 1993-February 1995). Out of a total of 1,202 admissions, 100 were prompted by FUO in 95 patients (61 males, 34 women). Sixty-six per cent were parenteral drug abusers or had been so and the mean T CD4+ lymphocyte count was 0.061 x 10(9)/1 +/- 0.075 x 10(9)/1. RESULTS: The incidence of FUO was 8.3 every 100 patients/year. The mean hospital stay was 31.3 +/- 17.8 days, compared with an overall mean stay for HIV-positive patients of 14.6 +/- 8 days (p < 0.001). An etiologic diagnosis was achieved in 90% of cases. Pulmonary or extrapulmonary tuberculosis accounted for approximately 50% of cases, whereas non tuberculous mycobacteria (MAI and M. kansasii) for 20%. The other etiologies (CMV, visceral leishmaniasis, PCP, toxoplasmosis, cryptococcosis, lymphoma) accounted each for less than 5% of diagnoses. In 14 occasions there were two concomitant diagnoses. Mortality rate was 22%, which was higher when two simultaneous diagnosis were present [RR: 3.17 (1.5-6.6)]. In 45% of fatal cases one of the diagnoses went undiagnosed premortem. The highest diagnostic yield was obtained with sputum culture (34.2% of diagnosis) and blood culture (21.5%). CONCLUSIONS: FUO in common in patients infected with HIV, with important health resources consumption associated. The obtention of diagnosis was possible in a high percentage of patients. It is associated with a high hospital mortality rate. The most common diagnoses were tuberculosis and infections by other mycobacteria. It is possible to obtain the diagnosis with non-invasive procedures in 75% of cases.

[Salmonella typhimurium as the causal agent of pulmonary cavitations]. / Salmonella typhimurium como agente productor de cavidades pulmonares.

BACKGROUND: Relation between patients with immunosuppression (malignancy, renal transplant) and bacteremia by Salmonella non-typhi, specially by Salmonella typhimurium, is known. This relation has been published for patients who suffer from AIDS, and so Salmonella bacteremia could even begin the clinical disease. But even though the relation between the infection by Salmonella and AIDS is well known, and the pulmonary involvement in them has been told, this etiology as a producing agent of lung cavitation has not much documentation. METHODS: We examined three patients (two women and one man) suffering from fever of one week of duration, cough, expectoration and thoracic pain in two of them. The third patient had fever and cachexia without clinical symptoms. The man and the two women had a blood count with neutrophilia and leucocytosis in two cases and leucopenia in the other one. All of them suffered a very important depression of cell immunity (CD4 of 140, 70 and 4, respectively) and positive blood cultures for Salmonella typhimurium. RESULTS: Chest X-Ray showed, in all the cases, pulmonary cavities. CONCLUSIONS: Salmonella typhimurium must be included among the agents that can produce pulmonary cavities like Staphylococcus aureus, mycobacteria, fungus and other gram-negative bacilli.

[Sepsis caused by Mycobacterium tuberculosis in patients with AIDS]. / Sepsis por Mycobacterium tuberculosis en pacientes con SIDA.

BACKGROUND: Techniques for detecting mycobacteria in blood can be a good alternative for diagnosing tuberculosis in acquired-immunodeficiency syndrome patients (AIDS). PATIENTS AND METHODS: Eleven patients with AIDS and pulmonary tuberculosis, and four controls with AIDS and without tuberculosis were studied. The diagnosis of mycobacteremia was made by the identification of the microorganisms in blood. The method used was a lysis-centrifugation with subsequent stain or culture identification in different media (agar Löwenstein-Jensen, M7H9, M7H11, brain-heart infusion and Sauton broth). RESULTS: In one case, direct staining of sample was positive. The culture results were positive in all 11 patients with tuberculosis and in none of the controls. M7H11 was the media that allows the fastest detection. CONCLUSIONS: This technique can be a good alternative method for tuberculosis diagnosis in AIDS patients. Is easy to perform, relatively fast an with diagnostic performance. It also could be of interest in extra-pulmonary tuberculosis.

Arthritis in Mediterranean spotted fever.

Although arthralgia is a common complaint in Mediterranean spotted fever, frank arthritis is very unusual. We report two cases of this condition during the course of Mediterranean spotted fever. Synovial fluid was inflammatory in both patients and the disease resolved after doxycycline therapy. Immunofluorescence test for Rickettsia conorii in synovial fluid was negative, suggesting a reactive arthritis.

Bacterial infection as a presenting manifestation of visceral leishmaniasis.

Two patients admitted to the hospital because of severe bacterial infection were diagnosed as having visceral leishmaniasis. The types of bacterial infection were perianal abscess and pneumonia; Escherichia coli and Streptococcus pneumoniae were isolated from exudates and blood cultures, respectively. A third patient admitted because of acute necrotizing infection of the pharynx and visceral leishmaniasis is also discussed. Cultures from this patient failed to yield pathogens. Anemia, leukopenia, or thrombocytopenia was present in all patients, and bone marrow aspirate revealed the presence of Leishmania in macrophages. We conclude that in areas where leishmaniasis is endemic, early bone marrow aspirate should, in most instances, be performed in patients with bacterial infection associated with anemia, leukopenia, or thrombocytopenia if hepatomegaly and/or splenomegaly is present.