Liver involvement in HIV-infected patients with early syphilis.

The aim of the paper is to analyse the prevalence of liver involvement and related factors in HIV-infected patients with early syphilis (<2 years). Liver involvement was defined as an elevation above normal ranges of alanine transaminase, aspartate aminotransferase, gamma-glutamyltransferase and/or alkaline phosphatase during early syphilis, or doubling of previous levels in patients with liver enzyme elevation before syphilis. We undertook a multicentre study and of the 147 cases, 86.4% were men who had sex with men, and the diagnoses of syphilis and HIV infection were coincident in 48 (32.7%). Liver involvement was detected in 45 (30.6%) and the only related factor was a rapid plasma reagin (RPR) titre ≥1/64 (odds ratio 3.76; 95% confidence interval 1.3-10.5; P = 0.012). In conclusion, liver involvement occurs in around one-third of HIV-infected patients with early syphilis and is associated with high RPR levels. Syphilis should be included in the differential diagnosis of liver enzyme elevation in HIV-infected patients.

Tuberculosis recurrente en pacientes coinfectados por VIH / Recurrent tuberculosis in patients with coinfection by HIV

Objetivos. Analizar e identificar factores asociados a la recurrencia de la tuberculosis (TB) en pacientes infectados por el virus de la inmunodeficiencia humana (VIH). Pacientes y métodos. Se seleccionaron pacientes infectados por VIH diagnosticados de TB entre 1995-2000 y que completaron el tratamiento correctamente. Se compararon aquellos pacientes que presentaron una recurrencia de enfermedad tuberculosa con los que no lo hicieron. Se realizó análisis multivariante por regresión logística para identificar factores asociados a un nuevo episodio de TB. Resultados. De un total de 223 pacientes infectados por VIH diagnosticados de TB, 159 (71,3 por ciento) completaron adecuadamente el tratamiento y fueron considerados curados. El resto fueron excluidos por fallecer antes de completar el tratamiento (5,8 por ciento), perdidos en el seguimiento (11,7 por ciento), abandono terapéutico (9,4 por ciento) y fracaso terapéutico (1,8 por ciento). De los 159 pacientes evaluables, 14 (8,8 por ciento) presentaron posterior recurrencia. Los pacientes con TB recurrente presentaron un mayor grado de inmunodepresión, más eventos previos diagnósticos de sida y mayor frecuencia de TB extrapulmonar en el episodio inicial. Tras el análisis multivariante, un recuento de linfocitos CD4 inferior a 100/mm3 en el primer episodio de TB se asoció con enfermedad tuberculosa recurrente (odds ratio [OR]: 4,6; intervalo de confianza [IC] 95 por ciento:1,3-18,2). En los episodios recurrentes la mortalidad fue alta (35,7 por ciento).Conclusiones. La recurrencia de TB en pacientes coinfectados por VIH ocurre en individuos con inmunodepresión profunda y se asocia a una alta mortalidad (AU)

[Recurrent tuberculosis in patients with coinfection by HIV]. / Tuberculosis recurrente en pacientes coinfectados por VIH.

OBJECTIVES: Analysis and identification of factors associated with the tuberculosis (TB) recurrence in HIV-infected patients. PATIENTS AND METHODS: The HIV-infected patients diagnosed with TB between 1995-2000 and with correct completion of the treatment were selected. There were compared those patients who presented a tuberculous disease recurrence with those which did not presented it. Multivariate analysis was carried out by logistic regression in order to identify factors associated with a new episode of TB. RESULTS: In the total sample of 223 diagnosed HIV-infected patients with TB, 159 (71.3%) patients completed adequately the treatment and were considered cured. The rest were excluded because of: death before completing the treatment (5.8%), lost in the follow-up (11.7%), therapeutic abandonment (9.4%), and therapeutic failure (1.8%). In the 159 patient final sample, 14 (8.8%) patients presented later recurrence. The patients with recurrent TB presented a greater degree of immunosuppression, more previous complications indicative of AIDS, and greater frequency of extrapulmonary TB in the initial episode. After the multivariate analysis, a count of lymphocytes CD4 lower than 100/mm3 in the first episode of TB was associated with recurrent tuberculous disease (odds ratio [OR]: 4,6; 95% confidence index [CI]: 1,3-18,2). Mortality was high (35.7%) in the patients with recurrent episodes. CONCLUSIONS: The recurrence of TB in patients coinfected by HIV occurs in individuals with profound immunossuppression and is associated to high mortality.

Enfermedad de Crohn o tuberculosis intestinal / Intestinal tuberculosis or Crhon disease

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Diagnostic usefulness of percutaneous liver biopsy in HIV-infected patients with fever of unknown origin.

OBJECTIVES: to determine the value of percutaneous liver biopsy (PLB) in the diagnosis of fever of unknown origin (FUO) in HIV-infected patients and establish a prediction model for its usefulness to enable diagnosis of FUO in these patients to be standardized. METHODS: a total of 58 HIV-infected patients who underwent PLB for the evaluation of FUO were studied at 'Carlos Haya' Hospital in Malaga, Spain. The patients were classified into three groups, according to the results of the PLB: (a) diagnostic PLB (when a definitive diagnosis was obtained); (b) helpful PLB (the tissue sample showed suggestive, but not definitive, findings); and (c) normal or non-specific PLB (no contribution to diagnosis, the findings being normal or irrelevant). Multivariate analysis was made to establish a prediction model for the diagnostic usefulness of PLB, calculating the positive (PPV) and negative (NPV) predictive values. RESULTS: PLB was carried out in 58 HIV-infected patients during diagnosis of FUO. Risk factors for HIV infection included intravenous drug use (72.4%), homosexual or bisexual activities (12.1%), and heterosexual transmission (15.5%). Fifty-two out of 58 patients (89.6%) had previous AIDS-defining illnesses. The mean CD4 lymphocyte count +/-SD was 56.4+/-80.9/mm3. The mean duration of fever was 43 days. Diagnosis could be established in 51 (87.9%) patients, with tuberculosis (50%) and leishmaniasis (20.7%) being the most common. The PLB was diagnostic in 25 cases (43.1%), helpful in 13 (22.4%), and normal or non-specific in the remaining 20 (34.5%). Biopsy-associated complications occurred in two cases. The presence of hepatomegaly or splenomegaly were the most useful factors in predicting the usefulness of the PLB, with a PPV of 86.1% and NPV of 68.2%. In patients with tuberculosis, an increased alkaline phosphatase and hepatomegaly had a PPV of 86.4% and a NPV of 71.4%. CONCLUSIONS: PLB is a useful technique for the diagnosis of FUO in HIV-infected persons. Early PLB should be considered in those patients with hepatosplenomegaly and increased alkaline phosphatase levels.

[The clinical and evolutional characteristics of visceral leishmaniasis in patients with HIV infection]. / Características clínicas y evolutivas de la leishmaniasis visceral en pacientes con infección por VIH.

OBJECTIVE: To analyze the clinical features, yield of the diagnostic techniques, and therapeutic response of HIV-associated visceral leishmaniasis (VL), and compare the initial episodes to the relapses. METHODS: Forty-one episodes of leishmaniasis visceral, diagnosed in 31 HIV-positive patients between 1st February 1992 and 31st January 1996 were reviewed. RESULTS: The prevalence of VL in HIV-positive patients in our center was 4.2%. Fifty-eight percent of the patients had AIDS prior to the diagnosis of VL. Fever was more frequent in the initial episodes than in the relapses (90.3% versus 60%; p < 0.05; OR: 6.2; IC 95%: 0.8-51.5), splenomegaly was more frequent in the relapses (100% versus 71%; p = 0.05). The diagnostic delay was longer in the initial episodes (27.2 +/- 22.7 versus 5 +/- 4.8 days; p < 0.05). The diagnostic yield of bone marrow biopsy was 82.1%, of liver biopsy 72.7% and of splenic fine-needle aspiration 87.5%. The indirect immunofluorescence test for Leishmania antibodies was positive in 5.9% of cases. Therapeutic failure occurred in 47.6% of patients treated with antimonials and 3.3% of patients treated with amphotericin B. Those patients who received secondary prophylaxis had less relapses than those who did not (17.6% versus 66.7%; p < 0.05; OR: 0.11; IC 95%: 0.01-1.28). Of the 31 patients, twenty-six (83.8%) died, and in none of them was the cause of the death directly related to LV. CONCLUSION: HIV-associated VL manifests clinically in a similar fashion to the immunocompetent's disease. It appears in advanced immunosuppression phases, behaving like other AIDS-defining illnesses. In spite of a good therapeutic response the relapse rate is high.