COVID-associated non-vasculitic thrombotic retiform purpura of the face and extremities: A case report.

SARS-CoV-2 infection can manifest many rashes. However, thrombotic retiform purpura rarely occurs during COVID-19 illness. Aggressive anti-COVID-19 therapy with a high-dose steroid regimen led to rapid recovery. This immunothrombotic phenomenon likely represents a poor type 1 interferon response and complement activation on the endothelial surface in response to acute infection.

Changes in HIV-related hospitalizations during the HAART era in an inner-city hospital.

We evaluated admissions of HIV-positive persons to an inner-city hospital from 2000 to 2005. There was a decline in the number of substance abusers, homeless persons, injection drug abusers, and African Americans, and there was an increase in patients older than 50 years. There were no significant changes in CD4 counts or in utilization of highly active antiretroviral therapy,m but there were more admissions of persons with HIV RNA levels less than 1000 copies/mL, internal medicine problems, cancers, and skin infections. Changes in the demographics of this patient population may reflect external factors (eg, gentrification of low-income housing areas, opening of a new hospital). Lower viral loads suggest better response in those on a highly active antiretroviral regimen, and changes in diagnoses leading to hospitalization may reflect the aging of the HIV population.

The role of rapid vs conventional human immunodeficiency virus testing for inpatients: effects on quality of care.

BACKGROUND: Rapid testing for human immunodeficiency virus (HIV) has improved HIV screening in the outpatient and perinatal settings, but few data report how it may be used to improve the quality of inpatient care. We compared quality of care for inpatients diagnosed in the emergency department via rapid testing vs patients whose conditions were diagnosed via conventional testing during their hospital admission. METHODS: We reviewed medical records to identify patients with first-time positive HIV tests and concurrent hospital admission who were tested via either rapid testing in the emergency department or conventional testing during their hospital admission. We compared quality-of-care end points for these patients. RESULTS: We identified 103 HIV-infected inpatients with no previous HIV diagnosis; the conditions of 48 patients (47%) were diagnosed by rapid testing and 55 (53%) by conventional testing. Mean length of stay was 6 days for the rapid test group vs 13 days for the conventional test group (P<.001); multivariate regression analysis showed that testing modality had an independent, statistically significant effect on length of stay. Nine (16%) of the patients in the conventional test group vs none in the rapid test group were discharged without receiving their HIV test results (P = .002). Patients in the rapid test group attended the outpatient HIV clinic in a mean of 22 days vs 50 days for the conventional test group patients (P = .05). CONCLUSIONS: Rapid HIV testing in the emergency department preceding admission may shorten hospital stay, increase the number of newly diagnosed patients with HIV who are discharged from the hospital aware of their HIV status, and improve entry into outpatient care for patients admitted at the time of their initial HIV diagnosis.

Inpatient care of the HIV infected patient in the highly active antiretroviral therapy (HAART) era.

The inpatient presentation of the HIV infected patient has changed over the years. From the early years when patients presented with accumulating opportunistic infections that led to an early demise to the HAART era with reports of dramatic decreases in opportunistic infections and improvements in life expectancy, the evolution of inpatient HIV care has been a challenge to the clinician. In the HAART era the presentation of the HIV inpatient has diversified and in many ways is more challenging than the management of the HIV inpatient in the pre-HAART era. We will discuss the changing dynamics of HIV inpatient care from socioeconomic changes to changes in the presentation and reasons for hospitalization.

Q fever endocarditis in HIV-infected patient.

We describe a case of Q fever endocarditis in an HIV-infected patient. The case was treated successfully with valvular replacement and a combination of doxycycline and hydroxychloroquine. We review the current literature on Q fever endocarditis, with an emphasis on the co-infection of HIV and Coxiella burnetii.

Pneumocystis carinii pneumonia in HIV-infected patients in the HAART era.

Since the advent of highly active antiretroviral therapy (HAART), the incidence of opportunistic infections (OI) in patients with HIV has markedly decreased. Despite this, there are still large numbers of Pneumocystis carinii pneumonia (PCP) cases at Cook County Hospital (CCH). To better understand this patient group, we performed a retrospective chart review of 120 pathologically proven cases of PCP from January 1998 to June 2001. One hundred four patients were included in the study. Sixty-nine percent of our patients were active substance abusers and 50% had previous knowledge of HIV disease. Of our patients, fewer than 5% were on HAART or PCP prophylaxis on study admission. The overall mortality rate was 14%. Of discharged patients, 65% were placed on HAART therapy and 59% of these achieved a viral load of less than 1000 copies per milliliter in the year postdischarge. Patients who failed to achieve a viral load less than 1000 copies per milliliter were more likely active substance abusers or had a viral load greater than 100,000 copies per milliliter prior to study admission. Our study shows that patients are still being admitted with PCP in the HAART era. Active substance abuse and failure to recognize HIV status contributed heavily to this late presentation of HIV disease. An aggressive approach toward HIV identification and substance abuse treatment may decrease admissions to the hospital for PCP and improve response to HAART therapy.

HIV-infected inpatients in the HAART era: how do hepatitis C virus coinfected patients differ?

We compared the demographics and clinical characteristics of HIV-infected patients with and without hepatitis C virus (HCV) coinfection hospitalized at Cook County Hospital, Chicago, Illinois, from October 1999 through September 2000. Two hundred three (40%) of the 510 patients were coinfected with HCV. HCV coinfected patients were less likely to be on highly active antiretroviral therapy (HAART) and were frequently hospitalized with higher CD4 counts for non-HIV-related medical problems including complications of liver disease.

Hospitalized HIV-infected patients in the HAART era: a view from the inner city.

To evaluate hospitalizations of HIV-infected patients in the highly active antiretroviral therapy (HAART) era, we analyzed 2736 admissions of 1562 HIV-infected patients to Cook County Hospital from September 20, 1999 to July 10, 2002. Patients were predominantly African American (81%), male (72%), and active substance abusers (74%). Only 48% of patients with a prior HIV diagnosis were taking HAART and 37% of them had a viral load less than 1000 copies per milliliter. Patients on protease inhibitor (PI)-sparing regimens more frequently achieved a viral load less than 1000 copies per milliliter than those on a PI-containing regimens (41% vs. 34% p = 0.036). For patients with CD4 cell counts less than 200 cells per milliliter, those not taking HAART were more likely African American (83% vs. 76%, p < 0.031), homeless (13% vs. 5%, p < 0.001), active substance abusers (79% vs. 65%, p < 0.001), female (28% vs. 22%, p = 0.001), new to the hospital system (19% vs. 6%, p < 0.001), or not recently seen in the outpatient clinic (42% vs. 17%, p < 0.001). In our population, active substance abuse was prevalent and only a minority of patients was taking HAART. Women were receiving HAART less often, independent of race and substance abuse. Aggressive programs are needed in high-risk populations to address substance abuse issues and to improve patient use of HAART.

Difference in the incidence of Clostridium difficile among patients infected with human immunodeficiency virus admitted to a public hospital and a private hospital.

OBJECTIVE: To compare the occurrence of Clostridium difficile among inpatients infected with human immunodeficiency virus (HIV) in two different hospitals. DESIGN: Prospective, observational study. SETTING: Specialized HIV inpatient units. PATIENTS: HIV-infected inpatients at Cook County Hospital (CCH) and Rush Presbyterian St. Luke's Medical Center (RPSLMC). INTERVENTIONS: A clinical and epidemiologic assessment of patient risk factors for C. difficile was performed. C. difficile isolates found on stool, rectal, and environmental cultures were typed by pulsed-field gel electrophoresis. RESULTS: Twenty-seven percent of patients admitted to CCH versus 4% of patients admitted to RPSLMC had positive cultures for C. difficile (P = .001). At CCH, 14.7% of environmental cultures were positive versus 2.9% at RPSLMC (P = .002). Risk factors for C. difficile acquisition included hospitalization at CCH, more severe HIV, use of acyclovir and H2-blockers, and longer hospital stay. Patients admitted to CCH were taking more antibiotics, had longer hospital stays, and more frequently had a history of C. difficile infection. During the study, two strains (CD1A and CD4) extensively contaminated the CCH environment. However, only CD1A caused an outbreak. CONCLUSIONS: The C. difficile acquisition rate at CCH was sevenfold higher than that at RPSLMC, and CCH had a more contaminated environment. Differences in patient acquisition rates likely reflect a greater prevalence of traditional C. difficile risk factors and a concurrent outbreak at CCH. Although two strains heavily contaminated the environment at CCH, only one caused an outbreak, suggesting that factors other than the environment are important in initiating C. difficile outbreaks.

Predominance of a single restriction endonuclease analysis group with intrahospital subgroup diversity among Clostridium difficile isolates at two Chicago hospitals.

OBJECTIVE: To determine the epidemiology and relatedness of Clostridium difficile isolates in two geographically separated hospitals in a large metropolitan area, each with unique patients and personneL DESIGN: Observational descriptive molecular epidemiology of clinical C. difficile isolates. SETTING: Two tertiary-care hospitals in Chicago. METHODS: Consecutive C. difficile isolates from the clinical laboratory of a Veterans Affairs hospital during a 13-month period were typed by restriction endonuclease analysis (REA). During an overlapping 3-month period, stool specimens that tested positive for C. difficile toxin from patients at a nearby county hospital were cultured and the recovered isolates typed by the same method. RESULTS: Nineteen (68%) of 28 nosocomial isolates at the smaller, Veterans Affairs hospital belonged to REA group K. Within this group of closely related strains, 9 distinct REA types were recognized. Twenty-one (72%) of 29 nosocomial isolates at the larger, county hospital also belonged to group K. However, the predominant REA types within group K differed markedly at each institution. CONCLUSIONS: These findings demonstrate a high degree of similarity among nosocomial C. difficile strains from different hospitals in the same city and suggest the possibility of an extended outbreak of a prototype group K strain with subsequent genetic drift at the two different institutions.

Possible overestimation of penicillin resistant Streptococcus pneumoniae colonization rates due to misidentification of oropharyngeal streptococci.

Standard identification of Streptococcus pneumoniae by optochin and bile solubility testing can lead to ambiguous results for certain isolates. Newer bacteriologic identification techniques (e.g., DNA probes) now exist. In a prospective point prevalence study of oropharyngeal S. pneumoniae carriage rates among outpatients, we compared standard organism identification techniques to DNA probe testing. By standard identification criteria, 35 (4%) of 872 isolates were characterized as presumptive S. pneumoniae. Thirty of 35 presumptive isolates were recoverable for DNA probing; 9 (30%) presumptive isolates were confirmed using a DNA probe. The antimicrobial susceptibility pattern of these DNA probe positive isolates closely paralleled that of clinical blood isolates of S. pneumoniae obtained during the study period. The 21 (70%) DNA probe negative isolates, which may represent phylogenetically related species (such as S. mitis or S. oralis), had significantly reduced antimicrobial susceptibility patterns when compared with the DNA probe positive isolates. In colonization studies, if classic criteria (optochin disc zone and bile solubility) are the sole means of identification, S. pneumoniae penicillin resistance rates may be over-reported.

Epidemiology and outcome of Clostridium difficile infection and diarrhea in HIV infected inpatients.

Clostridium difficile causes diarrhea in HIV infected patients but reports of prevalence, risk factors, and outcome vary. We studied the impact of C. difficile in 161 HIV infected inpatients admitted to Cook County Hospital. Patients with C. difficile had more hospital admissions in the previous 6 months (p =.04), spent more days in the hospital in the previous 3 months (p =.02), more often had previously received H2 blockers or treatment for Pneumocystis carinii (p <.05), and had a more frequent history of herpesvirus (p =.03) or opportunistic infections (p =.04). C. difficile associated diarrhea (CDAD) was the etiology in 32% of all study patients with diarrhea. Patients with CDAD were hospitalized for longer periods (p =.02) and received more antibiotics (p =.002). C. difficile was frequently present in our HIV infected patients, especially those with advanced HIV disease, but appeared to have little impact on morbidity or mortality.

Hospitalization in HIV in Chicago.

BACKGROUND: Reduction in HIV-related morbidity and mortality in the highly active antiretroviral therapy (HAART) era has been unevenly distributed in the United States, and its impact on hospitalizations in urban minority populations in the public sector has been poorly characterized. METHODS: We conducted a retrospective analysis of clinical and administrative data sets of an urban public hospital HIV clinic from 1997 and 1998 to identify the correlates of hospitalization early in the HAART era. RESULTS: 2,647 unduplicated HIV-infected patients were seen in 1997 and 1998 at the CORE Center. There were 31.7 percent women, 71 percent African-Americans and 12 percent Hispanics, and the mean age was 38 years. Men who had sex with men (MSM), injection drug users (IDU), and heterosexuals each made up one third of the population. A majority of the patients had no health insurance, and 27 percent had Medicaid. The median CD4 T cell count was 266 cells/microL, and the median viral load was 1,901 copies/ml. Hospitalizations declined significantly from 1997 (1,579) to 1998 (1,160). Admissions were confined to 25 percent of clinic patients, and 16 patients (range 8-15) had eight or more admissions. African-Americans and Hispanics had significantly more and longer hospitalizations than whites, but there was no difference by gender. IDUs had significantly more admissions than non-IDUs (28 percent vs. 21 percent respectively). On multivariate analysis, lower CD4 T cell count and higher viral load predicted risk of admission in all periods. Unexpectedly, hospitalization rates were high in patients in the highest baseline CD4 T cell stratum, > 500 cells/ml (45 of 353, 13 percent), and lowest viral load stratum, < 500 copies/ml (103 of 675, 15 percent), and rose from 1997 to 1998. HAART (i.e., 1 or 2 drug regimens) predicted fewer hospitalizations compared to 1 or 2 drug regimens. In a subset of patients who filled prescriptions on site, HAART increased from 72 percent to 85 percent and 1-2 drug regimens fell from 28 percent to 15 percent from 1997 to 1998. Regular care was associated with more frequent hospitalization and more hospital days per admission than no regular care. Hospitalized patients had significantly higher mortality than patients not hospitalized (12 percent vs. 2 percent respectively). CONCLUSION: HIV-related hospitalizations were frequent in the HAART era and decreased over time. Older age, lack of HAART, lower CD4 T cell count, higher viral load, and minority race predicted hospitalization, while gender did not. However, patients with extremely favorable CD4 T cell and viral load counts also had higher than expected hospitalization rates. Three quarters of patients had no hospitalizations, and clustering of hospitalizations in a small number of patients may enable targeted programs to reduce recidivism.