Thoracic computed tomography of patients infected with the human immunodeficiency virus: relevance for the course of disease.

To determine the diagnostic accuracy and prognostic implications of thoracic computed tomography (CT) in patients with human immunodeficiency virus infection (HIV), CT scans of 154 HIV-infected patients (mean age, 41 years; range 23-65 years; 18 female) with suspicion of pulmonary disease were retrospectively reviewed for signs of disease by two investigators blinded to clinical data other than positive HIV serology. Abnormal CT features were correlated with CD4-T lymphocyte count, histologic or microbiologic diagnosis, and survival. Computed tomography detected features of pulmonary disease in 133 patients. A recent chest film was available in 96 patients, and it was normal in 16. In 17 of 99 patients (17%) with histologic or microbiologic correlation, pathologic CT features could be demonstrated, though histologic and microbiological studies were unrevealing. Median survival was 649 days. Confluent pulmonary infiltrates and bilateral masses on CT indicated advanced disease with a median survival of 115 days (n = 11, p = 0.0005) and 174 days (n = 15, p < 0.0001), respectively. The authors concluded that thoracic CT detects pulmonary lesions in an appreciable portion of HIV-infected patients in whom chest radiographs, microbiologic methods, or histology failed to establish a diagnosis, and that CT findings allow for an estimation of patient survival in acquired immunodeficiency syndrome.

Oral manifestations of toxic epidermal necrolysis (TEN) in patients with AIDS: report of five cases.

OBJECTIVE: To describe oral findings in HIV-infected individuals with toxic epidermal necrolysis (TEN). PATIENTS: In a retrospective study over a 10 year period the medical histories of 931 hospitalised HIV-infected patients were reviewed for the occurrence of TEN. RESULTS: Five cases of TEN were diagnosed (three men, two women; median age: 41 years; median CD4+ T lymphocyte count: 20/microliter). Four patients had been treated with biweekly pyrimethamine/sulfadoxine for prophylaxis against Pneumocystis carinii pneumonia and toxoplasmosis. In one patient flucloxacillin was administered. Signs of TEN with cutaneous epidermolysis occurred and patients showed oral lesions characterized as oropharyngeal blisters and bullae on the palate, buccal mucosa, tongue and floor of the mouth initially. Antibiotics and corticosteroids were administered; none of the patients died. CONCLUSION: Longacting sulfonamides and antibiotics have been implicated as the cause of severe mucocutaneous reactions. Since rash and oral blisters may be the first signs of TEN in patients receiving these it is mandatory to follow up these patients closely to detect oral or cutaneous changes indicating the development of TEN.

Abdominal CT features and survival in acquired immunodeficiency.

PURPOSE: HIV-infected patients show a high incidence of abdominal disease. This investigation was made to determine whether abdominal CT provided prognostically relevant information in these patients. MATERIAL AND METHODS: Images from 533 abdominal CT examinations in 339 HIV-infected patients were retrospectively reviewed for signs of abdominal disease, and correlated with clinical data and survival rates. The Kaplan-Meier analysis and rank testing of survival, and proportional hazards regression were used to define prognostic clinical and imaging findings. RESULTS: Of the 339 patients, 278 (82%) showed abnormal abdominal findings on CT. Median survival was 29 months. Of the imaging findings, hepatic masses (n = 11), pathologically enlarged lymph nodes (n = 48), and ascites (n = 7) were associated with poor survival, giving a median survival of respectively 13 months, 15 months, and less than 1 month. These three features showed no association with CD4(+)-T-lymphocyte count or CDC category. Main determinants of survival were a low CD4(+)-T-lymphocyte count, and certain abnormal CT findings. Splenomegaly (n = 147), hepatomegaly (n = 144), and lymphadenopathy (n = 111) were the most common abdominal findings on CT but lacked prognostic relevance. CONCLUSION: Abdominal CT offered prognostic implications in HIV-infected patients and might serve in risk stratification in selected patients. CT features such as hepatic masses, grossly enlarged lymph nodes, or ascites indicate advanced immunosuppression.

Selective expansion of gammadelta T cells among liver-derived lymphocytes of AIDS patients with disseminated Mycobacterium avium complex infection.

The aim of this study was to investigate a potential expansion of gammadelta T cells in AIDS patients in response to disseminated infection with Mycobacterium avium complex. Liver-derived lymphocytes and peripheral blood lymphocytes were obtained from 5 AIDS patients with disseminated Mycobacterium avium complex infection and 10 HIV-infected patients without mycobacterial disease. Control patients included 14 HIV-negative patients without bacterial disease and 4 HIV-negative patients with disseminated Mycobacterium tuberculosis infection. The percentage of gammadelta T cells among CD3+ T lymphocytes was determined by flow cytometry. gammadelta T cells were markedly enhanced in liver biopsies but not among peripheral blood lymphocytes of AIDS patients with disseminated M. avium complex infection (median liver gammadelta/CD3: 26%) as compared to HIV-infected control patients without mycobacterial disease (median liver gammadelta/CD3: 2.3%; P < 0,005). Disseminated infection with M. tuberculosis in HIV-negative patients leads to a similar expansion of gammadelta T cells among liver-derived CD3+ lymphocytes (median gammadelta/CD3: 15.5%) as compared to control patients without mycobacterial disease (median gammadelta/CD3: 2.15%; P < 0,001).

Exfoliative cheilitis (EC) in AIDS: association with Candida infection.

Forty-seven of 165 patients with AIDS (28.5%) showed exfoliative cheilitis (EC), predominantly of the lower lip (n = 37). Histologically, hyphae were revealed in 23 of 47 cases (49%). In 14 of 23 specimens the histological and microbiological findings were in accordance. Smears of the vermilion border revealed Candida albicans in half of the cases (51%); however, combinations with C. krusei, C. tropicalis and C. glabrata were also seen. Twenty of 35 patients given fluconazole either prophylactically or therapeutically showed clinical signs of oral candidiasis. Frequent moistening of the lips may result in infection of the vermilion border with Candida species; consequent desiccation of the lips will lead to scale formation and exfoliation. Smears of the vermilion border of the lower lip of 20 controls with AIDS were positive in four cases. Twenty HIV-negative controls without EC showed negative microbiological results for Candida species. Exfoliative cheilitis may be associated with Candida infection in some cases and may be considered another variant of candidiasis in AIDS patients.

Oral manifestations in 70 German HIV-infected women.

OBJECTIVE: To describe the prevalence of oral lesions in HIV-infected women, and to determine the association of oral lesions with the level of immunosuppression and the route of transmission. PATIENTS: In a retrospective, cross-sectional study, a cohort of 70 HIV-infected women (median age: 32.5 y; median CD4(+)-cell count 262 per microliter) comprising 18% of all HIV-infected individuals (n = 389) was selected in an outpatient clinic. Oral lesions strongly associated with HIV-infection were evaluated. RESULTS: The overall prevalence of oral lesions was 27/70 (39%). Among HIV-infected women with CD4(+)-cell counts < 200 per microliter, the prevalence was 65% (19/29); and with counts > 200 per microliter, the prevalence was 27% (11/41). The prevalence of candidiasis and hairy leukoplakia was similar among those infected heterosexually or by intravenous drug use. CONCLUSIONS: As reported in men, these findings demonstrate that oral lesions are common in HIV-infected women. Candidiasis is more likely to occur at low CD4(+)-cell counts, whereas no difference was seen regarding the level of immunosuppression and hairy leukoplakia. Interestingly, the route of transmission does not play a role regarding the presence of oral lesions among HIV-infected women.

[HIV-associated salivary gland diseases. Review of the literature and 3 case reports]. / HIV-assoziierte Speicheldrüsenerkrankungen. Literaturübersicht und 3 Fallbeschreibungen.

HIV-associated salivary gland disease (HIV-SGD) includes lymphoepithelial lesions and cysts involving the salivary gland tissue and/or intraglandular lymph nodes, and Sjögren-like conditions. Three cases of salivary gland disease occurring in HIV-infected patients are reported. Histopathological examination showed squamous epithelium-lined cysts. In the walls of the cysts lymphoid tissue, epitheloid granulomas and giant cells were found. The clinical and histopathological criteria as well as magnetic resonance imaging and therapy are discussed.

Intestinal disease in acquired immunodeficiency: evaluation by CT.

Intestinal symptoms affect most AIDS patients at some point in their disease. The purpose of this study was to evaluate the use of CT in this setting. A total of 339 abdominal CT exams were reviewed for signs of intestinal disease. Abdominal CT scans of 45 patients with intestinal symptoms were compared with colonoscopy and histologic data. The CT results were correlated with CD4( +) T-lymphocyte counts and patient survival. More than 14 % of all abdominal CT exams displayed signs of enteric disease. Of the 45 patients studied with both CT and colonoscopy, 35 (78 %) had signs of intestinal disease by CT. Of these 35 patients, colonoscopic signs of an intestinal lesion were found in 29 and histologic proof of disease was established in 30 cases. Colonoscopy and histology detected 8 lesions missed by CT. There were 14 cases of unspecific colitis, 15 cases of cytomegalovirus (CMV) colitis, and 4 cases of enteric tuberculosis as per biopsy. Five patients presented with Kaposi's sarcoma and 1 with a non-Hodgkin's lymphoma. Neither colonoscopic nor CT signs of intestinal disease did reliably distinguish between histologic subgroups. Specifically, CMV colitis could not be distinguished from unspecific colitis. CD4( +) T-lymphocyte counts for histologic subgroups were not significantly different, either. No colonoscopic or histologic feature predicted survival, whereas low CD4 counts and ascites on CT indicated a poor prognosis. Whereas CT detects signs of intestinal disease in most AIDS patients, these signs remain largely unspecific. Colonoscopy and biopsies provide no consistently valid standard with which to compare CT because of controversial sensitivity and specificity of these methods. The CT technique detects small bowel as well as extraintestinal disease. Therefore, CT is an important diagnostic modality in abdominal disease of immunocompromised patients.

Oral manifestations in a patient with idiopathic CD4+ lymphocytopenia.

A 56-year-old patient with idiopathic CD4+ lymphocytopenia (ICL) is described. In addition to a complex medical history and clinical course, he presented with oral manifestations including episodic erythematous candidiasis, persistent angular cheilitis, lingua exfoliativa areata, and teleangiectasia of facial skin and buccal mucosa. Light microscopy and transmission electron microscopy (TEM) revealed vascular structures similar to findings in clinically uninvolved oral mucosa of patients with HIV infection. Further observations of patients with ICL are warranted to clarify the significance of oral findings made in the present case.

[Diagnostic results of abdominal computerized tomography in HIV-infected patients]. / Diagnostische Ergebnisse der abdominellen Computertomographie bei HIV-infizierten Patienten.

The exact frequency of pathologic findings in abdominal computed tomograms of HIV-infected patients is not yet known. To analyse such findings, CT scans of 339 HIV-infected patients were reviewed. While over four fifths of patients displayed abnormal findings; hepatosplenomegaly, lymphadenopathy, pathologically enlarged lymph nodes, and bowel wall thickening were the most common signs of disease. Only for enlarged lymph nodes could a dependency on clinical stage of the infection be demonstrated. As a conclusion, abdominal computed tomography reveals pathologic findings in the vast majority of HIV-infected patients, almost independent of clinical stage. Specifically, CT provides well documented lymph node staging. There are practically no age-or sex-dependent disease patterns in abdominal CT scans.

Human immunodeficiency virus-associated squamous cell carcinomas of the head and neck presenting as oral and primary intraosseous squamous cell carcinomas.

Six cases of squamous cell carcinoma arising in the head and neck of patients infected with the human immunodeficiency virus are described. This article reports the first two cases of primary intraosseous squamous cell carcinoma associated with infection with human immunodeficiency virus. Clinical presentation, results of imaging studies, histologic characteristics, therapies applied, and the clinical follow-up are described in detail for each of the six cases. These data are evaluated through a review of the current literature.

Isolation of atypical mycobacteria from tap water in hospitals and homes: is this a possible source of disseminated MAC infection in AIDS patients?

Infections caused by mycobacteria other than tuberculosis (MOTT), especially Mycobacterium avium complex (MAC), are common in AIDS patients, but rare in immunocompetent persons. The route of transmission is unknown, but tap water could provide a possible source of infection: MAC was isolated from tap water in the U.S.A. but this has not been reported in Germany. We therefore investigated tap water in Berlin for the presence of mycobacteria and compared radiometric (Bactec) and standard plate culture methods processing large volumes of water samples. The Bactec method yielded equal results compared to standard methods but had the advantage of easy handling. Mycobacteria were isolated from 50/118 (42.4%) samples and from 21/30 (70%) sites. The most frequently isolated species was Mycobacterium gordonae (from 28% samples and from 53.3% sites); MAC was isolated from two samples only (1.7%).

Oral cryptococcosis in a patient with AIDS. A case report.

A 59-year-old Caucasian male patient with AIDS is described who presented with an oral lesion of cryptococcosis. The gingival ulceration was the only detectable lesion of cryptococcosis. Diagnosis was established by histopathologic findings from biopsy and detection of serum cryptococcal antigen. The patient was treated with amphotericin B and flucytosine. After four weeks of therapy cryptococcal antigen turned negative. The oral ulceration diminished in size, but an inflammatory tissue reaction persisted.

Intensive treatment of AIDS-related non-Hodgkin's lymphomas with the MACOP-B protocol.

The usefulness of intensive chemotherapy with the MACOP-B protocol was evaluated in 8 patients with AIDS-related non-Hodgkin's lymphoma (NHL). Four patients had a prior AIDS diagnosis. The median CD4+ lymphocyte count was 0.079 cells x 10(9)/l (range 0.016-0.330). All patients responded to treatment. Four patients finished chemotherapy, all with complete remission, while another 3 patients deteriorated prior to finishing treatment and died. The median survival was 4 months (range 1 to 86 months). Major causes of the poor outcome were AIDS-related opportunistic infections and meningeal CNS involvement by NHL developing during or after chemotherapy. Patients with AIDS-related NHL usually do not appear to benefit from treatment with MACOP-B protocol. Advanced immunodeficiency is associated with poor tolerance to treatment and inability to finish this chemotherapy protocol. MACOP-B chemotherapy does not prevent meningeal spread of lymphoma in spite of using repeatedly systemic methotrexate crossing the blood-brain barrier. CNS prophylaxis with repeated application of intrathecal methotrexate may lower the risk of meningeal spread of lymphoma, which developed in 1 of 5 patients given CNS prophylaxis as compared to 2 of 3 patients without CNS prophylaxis.

Specific diagnosis of progressive multifocal leukoencephalopathy by polymerase chain reaction.

Using polymerase chain reaction (PCR), 34 cerebrospinal fluid (CSF) samples from 28 patients with progressive multifocal leukoencephalopathy (PML) were analyzed. As controls, 116 samples were evaluated from 82 human immunodeficiency virus type 1 (HIV-1)-infected patients and 1 HIV-1-negative patient. Of the HIV-1-positive patients, 23 had cerebral toxoplasmosis, 10 had HIV leukoencephalopathy, and 49 had other neurologic complications. Detection of JC virus (JCV) DNA in CSF was increased 10-fold by the addition of carrier DNA before phenol-chloroform-isoamyl alcohol extraction. The primer pair JC 26/29, from the VP1/large T region, had a limit of detection of 10(5) JCV DNA molecules/100 microL. The primer pair JC 36/39, located in the large T gene region, had a 100-fold lower limit of detection. With JC 26/29, the sensitivity was 43% (12/28) and specificity was 100%. Using JC 36/39, sensitivity increased to 82% (23/28), and false-positive results were not observed. Diagnosis of PML is greatly aided by PCR analysis of CSF.

Malaria prophylaxis: identifying risk groups for non-compliance.

To investigate behaviour in the use of drug prophylaxis against malaria and the risk factors for non-compliance, 507 European or North American travelers returning from endemic areas were studied retrospectively at Berlin in a 11-year period from 1980 to 1990. Compliance was significantly correlated with shorter travel duration: the group with good compliance stayed 37.2 +/- 38.5 days (mean +/- SD) in contrast to 69.8 +/- 93.5 days in the group of patients with no compliance (p = 0.00001). Older patients were significantly more compliant than patients aged < 55 years (20/27 compliant at > 54 years vs. 175/476 at < 55 years; p = 0.0001). Compliance was significantly affected by travel destination (Southern and East African regions; p = 0.0054), age (< or = 15 and > or = 55 years, respectively; p = 0.0001), and reason of travel (package tours; p = 0.0001). CART analysis confirmed logistic regression analysis with respect to age and travel type, and revealed that patients using only one information source were significantly more compliant than those using two or more information sources. Travel agencies were nearly as well informed as Institutes of Tropical Medicine, but family doctors had a significant incidence of giving wrong advice. This study should enable medical personnel dealing with prophylactic advice against malaria to identify patients at high risk for non-compliance, and to educate them more carefully than other travellers regarding antimalarial drug prophylaxis.

Safety of alternating ganciclovir and foscarnet maintenance therapy in human immunodeficiency virus (HIV)-related cytomegalovirus infections. An open-labeled pilot study.

In the treatment of cytomegalovirus (CMV) disease in patients with AIDS, a life-long suppression therapy following an induction therapy consisting of ganciclovir or foscarnet is essential. Due to drug-related toxicities, anti-CMV therapy frequently has to be discontinued. To determine whether toxicities and side effects may be reduced with an alternating combination therapy consisting of ganciclovir and foscarnet (ganciclovir: 5 mg/kg every other day; foscarnet: 120 mg/kg every other day), 10 AIDS patients with CMV disease received this maintenance therapy for a median time of 18.5 weeks (5-51 weeks). Side effects were reported from 5 patients (nausea 5, malaise/fatigue 2, penile ulcers 1). Hematological or renal toxicities were mild, 1-week discontinuation of therapy due to neutropenia was necessary in 1 patient. Progression of CMV disease was observed in 3 patients at 2, 6, and 30 weeks of maintenance therapy. Median relapse-free interval for all patients was 105 days. We conclude that combination therapy with ganciclovir and foscarnet can be used safely for induction and maintenance therapy. Therefore, this regimen should be assessed in further trials to evaluate safety, efficacy, and the development of resistance in comparison to ganciclovir or foscarnet monotherapy.

Epidemic oro-facial Kaposi's sarcoma (eKS)--report on 124 cases.

Oro-facial epidemic Kaposi's sarcoma (eKS) was observed in 124 patients (123 homo-/bisexual men, average age 37.9 years, and one 35-year-old transsexual patient). Average survival time was 1 year 9 months (range: 3 months 4 years 6 months). 57.3% of the patients had died. The hard and/or soft palate, gingiva and tongue were most frequently affected, with falling frequency within these locations. Oral manifestations of eKS appear to be common; treatment modalities must be optimised.