RESUMO
The continual improvement in outcome with highly active antiretroviral therapy (HAART) for human immunodeficiency virus (HIV) infection and visceral transplantation for gut failure stimulated our interest in lifting HIV infection as a contraindication for intestinal and multivisceral transplantation. This report is the first to describe visceral transplantation in a patient with HIV infection. A HAART regimen was introduced in the setting of short-gut syndrome with successful suppression of HIV viral load. The indication for en bloc multivisceral and kidney transplantation was end-stage liver failure with portomesenteric venous thrombosis and chronic renal insufficiency. The underlying hepatic pathology was alcoholic and home parenteral nutrition-associated cirrhosis. Surgery was complicated due to technical difficulties with excessive blood loss and long operative time. The complex posttransplant course included multiple exploratory laparotomies due to serious intra-abdominal and systemic infections. Heavy immunosuppression was required to treat recurrent episodes of severe allograft rejection. Posttransplant oral HAART successfully sustained undetectable viral load. Unfortunately, the patient succumbed to sepsis 3 months posttransplant. With new insights into the biology of gut immunity, mechanisms of allograft tolerance, and HIV-associated immune dysregulation, successful outcome is anticipated, particularly in patients who are in need of isolated intestinal and less-organ-contained visceral allografts.
Assuntos
Rejeição de Enxerto/diagnóstico , Infecções por HIV/complicações , Falência Renal Crônica/cirurgia , Transplante de Rim/efeitos adversos , Falência Hepática/cirurgia , Complicações Pós-Operatórias , Vísceras/transplante , Adulto , Feminino , Rejeição de Enxerto/etiologia , Sobrevivência de Enxerto , HIV/patogenicidade , Infecções por HIV/virologia , Humanos , Imunossupressores/uso terapêutico , Falência Renal Crônica/etiologia , Falência Hepática/etiologia , Masculino , Pessoa de Meia-Idade , Transplante de Órgãos , Prognóstico , Adulto JovemRESUMO
We report a novel anaerobe causing abscess in four patients at three hospitals. In the clinical specimen, bacilli were branching, Gram positive, and acid fast. The organism grew slowly and was not identified by 16S rRNA sequencing. Our findings support the description of a new genus and species of the suborder Corynebacterineae.
Assuntos
Abscesso/microbiologia , Infecções por Actinomycetales/microbiologia , Actinomycetales/classificação , Actinomycetales/isolamento & purificação , Bactérias Anaeróbias/classificação , Bactérias Anaeróbias/isolamento & purificação , Actinomycetales/genética , Adulto , Idoso , Idoso de 80 Anos ou mais , Bactérias Anaeróbias/genética , DNA Bacteriano/química , DNA Bacteriano/genética , DNA Ribossômico/química , DNA Ribossômico/genética , Feminino , Humanos , Masculino , Dados de Sequência Molecular , RNA Ribossômico 16S/genética , Análise de Sequência de DNA , Adulto JovemRESUMO
A novel method for the collection and transportation of dried-blood-plasma samples, SampleTanker (ST), was developed and compared to standard shipping protocols for frozen-plasma specimens containing human immunodeficiency virus type 1 (HIV-1) and/or hepatitis C virus (HCV). Matched frozen and dried 1-ml EDTA-containing plasma samples were collected and analyzed by several molecular-based virologic assays. After addition of 1.175 ml of reconstitution buffer, 1.035 ml of dried plasma was recovered. Mean intra-assay variances were 0.05, 0.05, and 0.06 log(10) copies/ml for the Versant, Amplicor, and NucliSens QT HIV-1 load assays, respectively (P, not significant). However, mean HIV-1 viral load was consistently reduced in dried samples by 0.32 to 0.51 log(10) copies/ml, depending on assay type (P < 0.05). Infectious HIV-1 was not recovered from dried ST plasma. There was no significant difference in HIV-1 viral load results obtained using ST after 8 weeks of storage at ambient temperature. Compared to frozen plasma, HIV-1 genotypic results were >99% concordant at the nucleotide and amino acid levels, as well as for resistance-associated mutations. We further demonstrated successful detection of multiple analytes, including HIV-1 viral load, HIV-1 antiretroviral resistance genotype, and HCV genotype, from a single ST unit. Dried plasma collected with ST yielded comparable results to frozen samples for multiple-analyte clinical testing. As such, ST could be a useful alternative for virologic tests and clinical trials worldwide by significantly diminishing transportation cost and the sample volume restrictions associated with dried-blood-spot technology.
Assuntos
Dessecação , Infecções por HIV/diagnóstico , HIV/isolamento & purificação , Hepacivirus/isolamento & purificação , Hepatite C/diagnóstico , Plasma/virologia , Manejo de Espécimes/métodos , Genótipo , Humanos , Testes de Sensibilidade Microbiana , Reprodutibilidade dos Testes , Carga ViralRESUMO
Ganciclovir-resistant cytomegalovirus (CMV) infection is an emerging problem in transplant recipients. Foscarnet resistance and cidofovir resistance have also been described, but no previous reports have suggested treatment regimens for patients with CMV refractory to all three of these drugs. Leflunomide, an immunosuppressive drug used in rheumatoid arthritis and in rejection in solid-organ transplantation, has been reported to have novel anti-CMV activity. However, its clinical utility in CMV treatment has not been described previously. We report an allogeneic bone marrow transplant recipient who developed CMV infection refractory to sequential therapy with ganciclovir, foscarnet, and cidofovir. The patient was ultimately treated with a combination of leflunomide and foscarnet. Both phenotypic and genotypic virologic analysis was performed on sequential CMV isolates. The patient's high CMV-DNA viral load became undetectable on leflunomide and foscarnet, but the patient, who had severe graft-versus-host disease (GVHD) of the liver, expired with progressive liver failure and other complications. We concluded that leflunomide is a new immunosuppressive agent with anti-CMV activity, which may be useful in the treatment of multiresistant CMV. However, the toxicity profile of leflunomide in patients with underlying GVHD remains to be defined.
Assuntos
Transplante de Medula Óssea/efeitos adversos , Infecções por Citomegalovirus/tratamento farmacológico , Isoxazóis/uso terapêutico , Terapia de Salvação/métodos , Farmacorresistência Viral , Quimioterapia Combinada , Evolução Fatal , Feminino , Foscarnet/uso terapêutico , Doença Enxerto-Hospedeiro , Humanos , Imunossupressores/uso terapêutico , Leflunomida , Leucemia Mielogênica Crônica BCR-ABL Positiva/complicações , Leucemia Mielogênica Crônica BCR-ABL Positiva/terapia , Falência Hepática , Pessoa de Meia-Idade , Transplante Homólogo , Carga Viral/métodosRESUMO
BACKGROUND: Ganciclovir-resistant (GCV-R) cytomegalovirus (CMV) is now being reported with increasing frequency in solid organ transplant recipients. OBJECTIVE: To describe the clinical characteristics and outcomes of all solid organ transplant patients with GCV-R CMV seen between 1990 and 2000 at a single center. METHODS: Patients with clinically suspected GCV resistance had viral isolates subjected to phenotypic analysis by plaque reduction assay, and also genotypic analysis. Medical records of the 13 patients with GCV-R CMV were reviewed for demographic, microbiologic, clinical, and pathologic data. RESULTS: Thirteen patients were identified, including 5 kidney, 1 heart, and 7 lung transplant recipients. All but one patient (92%) were CMV donor seropositive, recipient negative (D+/R-), and 11/13 (85%) had tissue-invasive CMV. CMV viremia was recurrent in 9/13 (69%); in 2 others, the first CMV episode was fatal. Overall, 9/13 (69%) of patients have died, all of CMV or its complications. Of the 10 who received foscarnet, only one survived. All patients had received GCV-based prophylactic regimens; 8/13 patients (62%) had received CMV hyperimmune globulin (CMVIG) as part of prophylaxis, 6/13 (46%) had received oral ganciclovir, and 5/13 (38%) had received intermittent (3 x/week) IV ganciclovir for prophylaxis. CONCLUSIONS: GCV-R CMV is associated with CMV D+/R- status, tissue-invasive disease, and high mortality even with foscarnet therapy. Exposure to less than fully therapeutic levels of GCV, in the form of oral or intermittent IV GCV, is common. The use of CMVIG in prophylaxis does not appear to prevent resistance. Further work remains to be done to elucidate the risk factors and optimal mode of prophylaxis and treatment for GCV-R CMV.
Assuntos
Infecções por Citomegalovirus/diagnóstico , Infecções por Citomegalovirus/prevenção & controle , Ganciclovir/uso terapêutico , Transplante de Órgãos/efeitos adversos , Citomegalovirus/patogenicidade , Infecções por Citomegalovirus/terapia , Farmacorresistência Viral , Quimioterapia Combinada , Feminino , Foscarnet/farmacologia , Foscarnet/uso terapêutico , Humanos , Masculino , Pessoa de Meia-IdadeRESUMO
PURPOSE: Proven clinical efficacy of protease-sparing regimens (PSR) has been shown. Concerns exist about broad applicability of these regimens in advanced naïve patients. Recent reports have associated a rise in liver enzymes with nevi rapine; however, no data exist with efavirenz. METHOD: 17 consecutive antiretroviral-naïve HIV patients were started on a PSR with efavirenz plus two nucleoside reverse transcriptase inhibitors. Baseline liver enzymes, serum CD38, CD4, and HIV viral load data were collected. Correlation between change in viral load and immune reconstitution on therapy were compared to baseline laboratory values. RESULTS: All patients had a mean viral load decrease of >2 logs, including patients with low initial CD4% or high viral load, and there was no increase of liver enzymes observed at a median follow-up of 42 weeks (range 17-78). There was a perfect correlation between the change in viral load and the initial viral load (p <.0001, r = 1.00) including patients with viral load > or =100,000 copies/mL and CD4 count< or =50 (n = 5). Even patients with low initial CD4 had a significant percentage increase in CD4 count (p <.0002, r = 0.7880). CD38% showed a positive correlation with change in viral load (p =.046, r = 0.522). CONCLUSION: All patients experienced a mean viral load decrease of >2 logs (88% less than 400 copies/mL and 35% less than 20 copies/mL). There were no observed increases in liver enzymes. Patients with low CD4 counts, high initial viral load, or high CD38 expression still experienced a significant change in viral load.
Assuntos
Fármacos Anti-HIV/uso terapêutico , Infecções por HIV/tratamento farmacológico , Oxazinas/uso terapêutico , Inibidores da Transcriptase Reversa/uso terapêutico , Adulto , Alcinos , Benzoxazinas , Contagem de Linfócito CD4 , Ciclopropanos , Quimioterapia Combinada , Feminino , Infecções por HIV/virologia , HIV-1/isolamento & purificação , HIV-1/fisiologia , Humanos , Masculino , Pessoa de Meia-Idade , RNA Viral/sangue , Resultado do Tratamento , Carga ViralRESUMO
Rahnella aquatilis infections are rare. We report the case of a 46-y-old African-American male with relapsed acute lymphoblastic leukemia who had R. aquatilis bacteremia after beginning reinduction chemotherapy. He was treated for 4 weeks with piperacillin-tazobactam and gentamicin. He recovered from the infection and had an allogenic bone marrow transplant a month later.
Assuntos
Bacteriemia/microbiologia , Linfoma de Burkitt/terapia , Infecções por Bactérias Gram-Negativas/microbiologia , Rahnella , Bacteriemia/tratamento farmacológico , Transplante de Medula Óssea , Quimioterapia Combinada/uso terapêutico , Infecções por Bactérias Gram-Negativas/tratamento farmacológico , Humanos , Hospedeiro Imunocomprometido , Imunossupressores/efeitos adversos , Masculino , Pessoa de Meia-Idade , Ácido Penicilânico/análogos & derivados , Ácido Penicilânico/uso terapêutico , Piperacilina/uso terapêutico , Combinação Piperacilina e TazobactamAssuntos
Líquido Cefalorraquidiano/citologia , Meningite Asséptica/diagnóstico , Aciclovir/administração & dosagem , Aciclovir/uso terapêutico , Adulto , Diagnóstico Diferencial , Seguimentos , Humanos , Leucócitos Mononucleares , Leucocitose/diagnóstico , Masculino , Meningite Asséptica/líquido cefalorraquidiano , Recidiva , Punção Espinal , Síndrome , Fatores de TempoRESUMO
Aspergillus native valve endocarditis in patients who have not had cardiac surgery is uncommon. We report 3 cases and review 58 other adult patients reported in the English-language literature. Sixty-seven percent of the patients had underlying immunosuppression. The clinical features were fever (74%), embolic episodes (69%), a new or changing heart murmur (41%), and sudden visual loss (13%). Patients with mural endocarditis were more often immunosuppressed, especially due to solid organ transplants, but had lower frequency of heart murmurs and embolic episodes. Echocardiography revealed a vegetation in 78% of all the cases in which it was performed. Examination and culture of biopsy material often helped to establish a diagnosis of Aspergillus infection. Twenty-five patients had an antemortem diagnosis. These patients received a mean cumulative amphotericin B dose of 27 mg/kg. Twenty percent (3/15) of patients who received combined surgical and medical therapy survived, compared to none of those who received medical therapy alone (p = 0.08). Patients who survived were not immunosuppressed. We conclude that native valve aspergillus infective endocarditis is uniformly fatal without surgical intervention and antifungal therapy.
Assuntos
Aspergilose/fisiopatologia , Endocardite Bacteriana/fisiopatologia , Valvas Cardíacas/patologia , Idoso , Anfotericina B/uso terapêutico , Antifúngicos/uso terapêutico , Aspergilose/diagnóstico , Aspergilose/tratamento farmacológico , Diagnóstico Diferencial , Endocardite Bacteriana/diagnóstico , Endocardite Bacteriana/tratamento farmacológico , Feminino , Valvas Cardíacas/microbiologia , Humanos , Hospedeiro Imunocomprometido , Masculino , Pessoa de Meia-Idade , PrognósticoAssuntos
Antígenos de Superfície/administração & dosagem , Proteínas da Membrana Bacteriana Externa/administração & dosagem , Vacinas Bacterianas/administração & dosagem , Lipoproteínas , Doença de Lyme/prevenção & controle , Guias como Assunto , Humanos , Doença de Lyme/epidemiologia , Estados Unidos/epidemiologiaRESUMO
Tick-borne diseases can be severe or even fatal, but when identified early, most can be easily treated. Tick-borne diseases often present with nonspecific symptoms. Therefore it is important for the primary care physician to be familiar with the epidemiology of these diseases and their presentations. Although Lyme disease is the most common and well-known of the many tick-borne diseases, Rocky Mountain spotted fever, ehrlichiosis, and babesiosis are also threats throughout the United States.
Assuntos
Lipoproteínas , Doenças Transmitidas por Carrapatos , Carrapatos , Animais , Antígenos de Superfície/uso terapêutico , Proteínas da Membrana Bacteriana Externa/uso terapêutico , Vacinas Bacterianas/uso terapêutico , Diagnóstico Diferencial , Humanos , Doenças Transmitidas por Carrapatos/diagnóstico , Doenças Transmitidas por Carrapatos/tratamento farmacológico , Doenças Transmitidas por Carrapatos/epidemiologia , Doenças Transmitidas por Carrapatos/prevenção & controle , Estados Unidos/epidemiologiaRESUMO
Infection with toxin-producing strains of Clostridium difficile is common and potentially life-threatening. It occurs mostly in patients in the hospital or nursing home who are taking or have recently taken antibiotics. Two toxins, A and B, damage the colonic mucosa, resulting in symptoms ranging from mild diarrhea to bloody diarrhea with fever and abdominal pain, colitis, or even pseudomembranous colitis. Severe cases may involve dehydration, toxic megacolon, or colonic perforation. This article reviews the microbiology, epidemiology, clinical manifestations, diagnosis, treatment, and prevention of this disease.
Assuntos
Clostridioides difficile , Diarreia/etiologia , Enterocolite Pseudomembranosa , Adulto , Enterocolite Pseudomembranosa/diagnóstico , Enterocolite Pseudomembranosa/fisiopatologia , Enterocolite Pseudomembranosa/terapia , Humanos , MasculinoRESUMO
Listeria monocytogenes has become a major pathogen in foodborne illness. It most often affects patients who are pregnant, at the extremes of life, or immunocompromised in some way. A variety of clinical manifestations are possible, but bacteremia and meningitis are most common. This article reviews the epidemiology, microbiology, populations at risk, clinical manifestations, treatment, and prevention of listeriosis.
Assuntos
Doenças Transmitidas por Alimentos/microbiologia , Listeriose/diagnóstico , Listeriose/terapia , Adolescente , Adulto , Distribuição por Idade , Idoso , Ampicilina/uso terapêutico , Bacteriemia/etiologia , Criança , Pré-Escolar , Endocardite/etiologia , Eritromicina/uso terapêutico , Feminino , Doenças Transmitidas por Alimentos/diagnóstico , Gastroenterite/etiologia , Humanos , Incidência , Lactente , Recém-Nascido , Listeria monocytogenes/isolamento & purificação , Listeria monocytogenes/patogenicidade , Listeriose/complicações , Listeriose/epidemiologia , Masculino , Meningite/etiologia , Pessoa de Meia-Idade , Gravidez , Complicações Infecciosas na Gravidez , Taxa de Sobrevida , Combinação Trimetoprima e Sulfametoxazol/uso terapêutico , VancomicinaRESUMO
The spectacle values of young healthy students were determined morning and afternoon by means of phoropter and autorefractometer. In addition, keratometry was performed. When the morning and afternoon refraction values were compared the latter were found to be about 0.25 diopters lower. This effect cannot be attributed exclusively to changes in the radius of the cornea.