Sífilis e infección por el virus de la inmunodeficiencia humana / Syphilis and human immunodeficiency virus infection

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Una propuesta de manejo práctico del paciente coinfectado en el medio penitenciario / A proposal for the practical management of coinfected patients in prison

En España la prevalencia de coinfección VIH-VHC es una de las más elevadas ya que tanto el VIH como el VHC se encuentran fuertemente asociadas a la ADVP, oscila entre el 61 y 69% de los pacientes y si la transmisión ha sido por UDVP del 95%. En la población reclusa la prevalencia de ambos virus se incrementa incluso hasta 15-18 veces. Todos los pacientes con infección por el VIH y el VHC, deben ser evaluados para saber si son subsidiarios para recibir tratamiento de la HCC. Los mejores candidatos para recibir el tratamiento son aquellos que tienen los linfocitos CD4 mayores de 350, no consumo de tóxicosy libres de trastornos neuropsiquiátricos. Los efectos secundarios, que en ocasiones obligan a la interrupción del tratamiento, son una de las principales causas de la menor eficacia del tratamiento en el paciente coinfectado, por lo que es fundamental que el paciente tenga accesibilidad al equipo sanitario para el buen control de los acontecimientos adversos que puedansurgir

In Spain the prevalence of HIV-HCV coinfection is very high. This is due to the fact that HIV and HCV are closely linked to intravenous drug abuse, a causative factor in between 61 to 69% of patients receiving treatment. In 95% of the cases IDU has been established as the cause of transmission. In the prison population the prevalence of both viral infections is some15-18 times higher. Each HIV and HCV infected patient requires evaluation to establish if he/she fulfils the necessary requirements for chronic hepatitis C treatment. The most suitable candidates are those whose CD4 lymphocyte count is higher than 350, do not consume substances and who do not suffer from neuropsychiatric disorders. Interruption of treatment is sometimes necessary because of side effects, which are one of the main causes of reduced therapeutic efficacy in the coinfected patient. Consequently it is important for the patient to have access to the health care team for efficient control of any negative consequences arising from therapy

[Clinical course of cytomegalovirus retinitis with the different antiretroviral therapies in our hospital]. / Evolución de la retinitis por citomegalovirus con las diferentes terapias antirretrovirales en nuestro hospital.

PURPOSE: A study of protease inhibitors on CMV retinitis in HIV infected hospital patients. METHOD: A retrospective study was performed in 485 diagnosed of AIDS, between January, 1990 and December 1998. Among those, 81 patients who were diagnosed of CMV retinitis, the following was studied: anti-retroviral treatment, anti CMV treatment, survival time and CD4 lymphocyte count. RESULTS: Treatment with protease inhibitors in HIV patients showed an increase in life expectancy, reduced the incidence of CMV retinitis and a reduction in CMV retinitis prevention treatment was observed. CONCLUSIONS: Treatment with protease inhibitors has reduced the rate of CMV retinitis in HIV patients.

Evolución de la retinitis por citomegalovirus con las diferentes terapias antirretrovirales en nuestro Hospital / Evolution of cmv retinitis with the different antiretroviral therapies in our Hospital

Objetivo: Estudiar el cambio de incidencia de la retinitis por citomegalovirus desde la introducción de los inhibidores de las proteasas en el tratamiento de los pacientes infectados por VIH en nuestro Hospital. Material y método: Se realiza un estudio retrospectivo de 485 casos diagnosticados de SIDA en nuestro Hospital desde enero de 1990 hasta diciembre de 1998.Se diagnostican un total de 81 retinitis por CMV, en las que se estudia el tratamiento antiretroviral, antiCMV, tiempo de supervivencia, profilaxis frente al CMV y el contaje de linfocitos CD4. Resultados: La introducción de los inhibidores de las proteasas en el tratamiento antirretroviral ha supuesto un aumento de la esperanza de vida de los pacientes, una reducción de la incidencia de retinitis por CMV y la eliminación en la mitad de los casos de la profilaxis frente al CMV. Conclusión: Los inhibidores de las proteasas han supuesto una reducción de la incidencia de retinitis CMV en los pacientes infectados por VIH (AU)

[Human immunodeficiency virus (HIV) infection. The effectiveness of different diagnostic sequences in suspected pulmonary infection]. / Infección por el virus de la inmunodeficiencia humana (VIH). Rentabilidad de diferentes secuencias diagnósticas ante sospecha de infección pulmonar.

BACKGROUND: Assessment of different diagnostic sequences, in patients VIH(+) with a suspected pulmonary infection. METHODS: A cross-sectional descriptive study of 76 HIV(+) patients with suspected respiratory infection. It has been determined the validity and the pretest and post-test probability of the radiology (Rx) of thorax, 67Ga pulmonary scintigraphy and seric LDH levels, in order to design four different diagnostic algorithms. RESULTS: The diagnostic sequence Rx-LDH-scintigraphy with normal results involved an infection probability of 58.0%. Pathological Rx with successively normal LDH and scintigraphy, implied a likelihood of 97.0%. The LDH elevation in sequence with scintigraphy and Rx rose to 96.1% if both were abnormal and diminished to 8.3% if normal. CONCLUSIONS: The LDH elevation associated with the sequence of normal Rx and scintigraphy suggests a low infection likelihood. On the contrary, associated with pathological Rx and scintigraphy in sequence, practically assures the pulmonary infection.

Infección por el virus de la inmunodeficiencia humana (VlH). Rentabilidad de diferentes secuencias diagnósticas ante sospecha de infección pulmonar / VIH (+) patients: assessment of different diagnostic sequences with a suspected pulmonary infection

Fundamento: Valoración de diferentes secuencias diagnósticas, en pacientes con infección por virus de la inmunodeficiencia humana (VlH), y sospecha de infección pulmonar. Métodos: Estudio descriptivo transversal, de un total de 76 pacientes VIH (+) con sospecha de infección pulmonar. Se determina la validez y razones de probabilidad de infección pulmonar pre y postprueba de la radiografía de tórax (Rx), gammagrafía pulmonar con 67Ga y valores séricos de LDH, con objeto de diseñar cuatro algoritmos diagnósticos diferentes. Resultados: La secuencia diagnóstica Rx-LDH-gammagrafía con resultados normales supuso una probabilidad de infección de 58,0 porciento. Rx alterada con LDH y gammagrafía sucesivamente normales, dio una probabilidad de 97,0 porciento. Una elevación de LDH seguida de gammagrafía y Rx alteradas determinó una probabilidad de infección del 96,1 %. Cuando tras LDH elevada, se obtenía gammagrafía y Rx normales, este porcentaje descendió a 8,3 %. Conclusiones: La elevación de LDH asociada a Rx y gammagrafía secuencialmente normales sugiere una baja probabilidad de infección. Por el contrario, junto a Rx y gammagrafía sucesivamente patológicas, prácticamente aseguran la infección pulmonar (AU)

[Characteristics of chronic hepatitis C in patients infected by human immunodeficiency virus]. / Características de la hepatitis crónica C en pacientes infectados por el virus de la inmunodeficiencia humana.

OBJECTIVES: To know the characteristics of chronic hepatitis C in HIV-infected patients and whether there are differences compared with HIV-negative patients, in order to obtain orientative helpful data for the diagnostic-therapeutic decision making, a usually difficult issue in these patients. PATIENTS AND METHODS: Sixty patients with criteria of chronic hepatitis C virus (HCV) criteria were studied. Thirty-three of these patients were coinfected with HIV. The possible associations between the degree of histologic damage and several variables wee studied: age, estimated time of evolution of HCV infection, transaminases, gammaglobulins, GGT, and alcohol consumption. On the other hand, the possible differences regarding the histologic hepatic aggression were assessed. An attempt was made to know whether HIV could negatively influence the evolution of chronic hepatitis C. RESULTS: A direct relationship was observed between hepatic damage, HAI and levels of GOT, GPT, GGT (p < 0.005), and gammaglobulins (p < 0.01). The degree of hepatic fibrosis was directly correlated with the GGT level (mild fibrosis: 47 +/- 34 U/l; severe fibrosis: 86 +/- 60 U/l) (p < 0.05) and the estimated evolution time of infection (p < 0.05). Alcohol consumption was associated with the fibrosis degree (p < 0.01). The degree of histologic damage was similar in the HIV-positive group (HAI: 8.3 +/- 3.6) and HIV-negative patients (HAI: 7.2 +/- 2.8), although the degree of lobular involvement was higher in HIV-positive patients (p < 0.05). CONCLUSIONS: Patients with chronic hepatitis C and infected with HIV did not have a higher degree of hepatic damage than HIV-negative patients. GOT, GPT, and gamma globulin levels, as well as a longer evolution time of HCV infection were associated with a higher degree of hepatic histologic activity. Alcohol consumption seemed to be associated with a poorer course of the liver disease in these patients.

[Clinical implications of hepatitis C virus genotype in human immunodeficiency virus infected patients with chronic liver disease]. / Implicaciones clínicas del genotipo del virus de la hepatitis C en infectados por el virus de la inmunodeficiencia humana con hepatopatía crónica.

OBJECTIVE: To know the prevalence of viral genotype in patients infected with hepatitis C virus (HCV) and coinfected with HIV and evaluate its clinical implications. PATIENTS AND METHODS: The genotype of the HVC was studied (INNO-LiPA HCV II, Imnogenetics, Belgium) in 40 patients coinfected with HIV; from 28 of these patients histologic data of chronic hepatitis were available. The most prevalent genotype was analyzed in this type of patients and its associations with different issues: risk behavior, histologic activity of liver disease and viremia level (quantitative PCR, Amplicor HCV, Roche Diagnostics). RESULTS: Genotype 1 was the most prevalent (55%), and subtype 1a predominated (36.3%). In most cases genotypes 1a and 3 were found (65%) and in four cases (10%) there was coinfection with two genotypes. The most common risk behavior was parenteral drug use (PDU) (34 cases), which might account for the higher prevalence of genotypes 1 and 3. A mild hepatic histologic activity was most frequently associated with genotype 3 compared with genotype 1 (63.6% versus 46.6%). The Knodell histologic activity index (HAI) was higher in the four patients with coinfection 1 + 3 versus the remaining patients (11.2 +/- 2.8 versus 7.8 +/- 3.6). The percentage of patients with genotype 1 with a viral load > 10(5) was higher than that of patients with genotype 3 (80% versus 7.6% [4]) (p < 0.05); in the two cases with subtype 1b viremia levels exceeded this limit. CONCLUSIONS: The prevalent HCV genotypes in patients coinfected with HIV in our environment seem to be 1a and 3, which is probably associated with the more common high risk behavior of PDU among these patients. Genotype 3 seems to be associated with a milder histologic liver damage and a lower viral load, and these two characteristics might be related. The HCV genotype should be considered in subjects coinfected with HIV to obtain a better clinical and prognostic evaluation of the chronic liver disease it causes.

[Interferon treatment of chronic hepatitis C in human immunodeficiency virus infected patients]. / Tratamiento con interferón de la hepatitis crónica C en infectados por el virus de la inmunodeficiencia humana.

OBJECTIVE: To know the efficiency and tolerance of INF therapy for chronic virus C hepatitis (HCV) in HIV infected patients compared with non infected patients. PATIENTS AND METHODS: INF-alpha was administered to 39 patients with chronic hepatitis C virus infection criteria. In 17 cases (43.5%) there was coinfection with HIV. Histologic data were available from 30 patients (75%) and also of viral load during therapy (Amplicor HCV, Roche Diagnostics) from 8 patients. We determined the response at the end of the first two months of therapy (ER), at the end of therapy (FR) and after discontinuation (DR) when the transaminase level was normalized and viral RNA was not detected in cases when it was measured. The response rates to INF were compared between HIV-positive and HIV-negative patients and the secondary effects observed evaluated, as well as tolerance and severity, with a particular emphasis on the CD4 lymphocyte level among HIV-positive patients. RESULTS: An ER was obtained in nine HIV-positive patients (52.9%) and thirteen HIV-negative patients (59%); an FR in eight HIV-positive patients (47%) and eleven HIV-negative patients (50%), and DR in two HIV-positive patients (13.3%) and four HIV-negative patients (28%); although a lower rate of DR was observed among HIV-positive patients, these differences were not significant. The disappearance of HCV ARN at the end of therapy was similar for both groups of patients in whom it was measured: five HIV-positive patients (62.5%) and twelve HIV-negative patients (63.1%). We must consider that HIV-positive patients had a higher number of poor response predictors to INF. Secondary reactions were observed in a higher number of HIV-negative patients (81.8% versus 40.9%) and the level of CD4 lymphocytes was markedly reduced during and after therapy in three patients. CONCLUSION: INF therapy in chronic hepatitis C virus infection in HIV-positive patients initially has a similar efficiency to that observed in HIV-negative patients, although perhaps the maintained response rate is lower. A higher number of secondary reactions among HIV-positive patients was not observed, although possible reductions in CD4 levels must be considered among these patients. The use of INF in these patients --if properly selected--is therefore not contraindicated.

[Characteristics of the carriers of antibodies to hepatitis C virus with normal transaminases levels in HIV infected patients]. / Características de los portadores de anticuerpos frente al virus de la hepatitis C con transaminasas normales en infectados por el VIH.

BACKGROUND: To know the characteristics of the carriers of antibodies to hepatitis C virus (HCV) with persistently normal transaminases levels ("carriers") in coinfected with HIV, the incidence of the real viral activity and the factors that could determine it. PATIENTS AND METHODS: We analyzed 114 patients with criteria for chronic hepatitis C, 41 with detectable antibodies (anti-HCV), but without chemical evidence of a deteriorations of the liver function, all of them infected with HIV. In 6 patients was possible to determine the genotype of the HCV (INNO-LiPA HCV Innogenetics. Belgica) and in 32 the HCV-RNA (Amplicor HCV Roche Diagnostics). We compared the characteristics that could be differential between both groups, investigating the possible factors that could define the group of "carriers" with detectable viral activity. RESULTS: From the 32 "carriers" in which we could determine the HCV-RNA, 15 (46.8%) had a positive result. The incidence of women in the "carriers" group was higher (41.4% vs 22.8%) (p < 0.05). The serum levels of gammaglobulin (gr/dl) was higher in the chronic hepatitis group (2.23 +/- 0.6 vs 1.9 +/- 0.5) (p < 0.01); however, these levels were higher for the 15 patients RNA (-) patients (2.19 +/- 0.7 vs 1.66 +/- 0.41) (p < 0.01). The genotype distribution of HCV found in the "carriers" group with detectable viremia was: genotype 1(5 patients), subtype la (3 patients), subtype lb (2 patients) an genotype 3 (3 patients). There was no significant difference with respect to age, sex, degree of immunosuppression or the length of the infection with HCV. CONCLUSIONS: Approximately half of our "carriers" of anti-HCV without evidence of changes in the liver function, infected with HIV, show detectable viremia and so probably liver biopsy would be indicated. Women are more often "carriers" and the high levels of gammaglobulin could define the existence of a real viral activity.

[Viremia levels of the chronic hepatitis c virus in HIV infected patients, clinical implications]. / Niveles de viremia del virus de la hepatitis crónica C en infectados por el virus de inmunodeficiencia humana. Implicaciones clínicas.

BACKGROUND: To know the clinical implications of the viremia level and its evolution in time of the hepatitis C virus (HCV) in patients with chronic hepatitis and infected with the Human Immunodeficiency Virus (HIV). PATIENTS AND METHODS: We have studied the viremia level of the HCV in a a 38 patients group with active chronic hepatitis and infected with the HIV, using a quantitative PCR technic (Amplicor HCV, Roche Diagnostics); we had histological data in 33 of these patients. In 20 patients was analyzed the evolution in time of the viremia level with two or three serialized measurements (20 and 10 patients respectively), throughout 7.5 and 14.8 months on the average. We have analyzed some aspects like the risky behaviors associated with transmission, the estimated time from the contagious, the degree of histological damage and the immunitary impairment. RESULTS: We have observed a tendency to present a higher viremia level (logarithmic expression) with longer evolution time from the infection (p = 0.08). The viral load had an inverse relation with the degree of histological fibrosis (Light fibrosis: 4.5 +/- 0.8 log vs Severe fibrosis: 3.7 +/- 0.8 log) (p < 0.01) and a direct relation with the Knodell histological activity index (HAI), only with those patients with a lower fibrosis degree (p < 0.01). There was no relation between the viremia level of the HCV and the degree of immunosuppression measured by the CD4 lymphocyte count, at least in those patients in which it was higher than 200/mm3. We have not observed relations between the viral load and the age or the transaminases level. The evolution in time of the viremia tended to rise from 3.7 +/- 1.3 to 4.5 +/- 0.9 log in 14.8 months on the average, although there were some cases with tendency to decrease. We have not observed relation between its increase/month and the degree of histological damage or the CD4 lymphocyte count. CONCLUSIONS: The viral load of the HCV in HIV-infected patients seems to have an inverse relation with the degree of liver fibrosis and direct relation with the histological activity when the fibrosis light and so it could indirectly inform us about the liver aggression. The degree of immunosuppression measured by the CD4 lymphocyte count, when these are > 200/mm3, doesn't seem to influence the viremia level of the HCV. The evolution of the viral load in time tend to rise although there could be some cases with intermittent or descending evolution, without these tendencies have any clinical implications.

[Epidemic Kaposi's sarcoma. Apropos of 14 cases]. / Sarcoma de Kaposi epidémico. A propósito de 14 casos.

The epidemic Kaposi's sarcoma is the most common AIDS associated cancer. The lesions are located in any part of the organism. The skin affection is the most frequent. The risk group with a highest incidence is the "male homosexuals". Though the diagnosis of Kaposi's sarcoma doesn't determine "per se" the prognosis "quad vitam", there exist some analytic parameters at the time of the diagnosis that are useful for the prognosis of the HIV infection. We present 14 Kaposi's sarcoma and HIV infected cases analyzing some parameters and evaluating their prognosis and surviving hope.

[An epidemiological study of pulmonary tuberculosis in inpatients]. / Estudio epidemiológico de la tuberculosis pulmonar en pacientes ingresados.

OBJECTIVE: To evaluate the profile of the patient admitted to hospital with pulmonary tuberculosis and the clinical-radiological signs and symptoms of the illness. DESIGN: A descriptive, retrospective study. SETTING: The study was carried out in the Miguel Servet Hospital in Zaragoza. PATIENTS AND OTHER PARTICIPANTS: Patients over 14 who were admitted for pulmonary tuberculosis between 1985 and june 1990 and who fulfilled the requisite diagnostic criteria. MEASUREMENTS AND MAIN RESULTS: Out of the 423 patients studied, 75.17% were male. Average age of the whole sample was 45.9. 31% were retired. 55% (232 cases) had factors predisposing to tuberculosis. The 12% were infected by HIV (human immunodeficiency virus). The most common presentation symptoms were coughing and the radiological semeiology of condensation. In 22.7% there was extrapulmonary tubercular infection, most commonly in ganglia. Delay in diagnosis was over three months in 19.8% of the cases. CONCLUSIONS: Tuberculosis is a common illness in our ambit and particularly affects those patients with underlying pathology. Given that there are still important delays in diagnosis, doctors need to be highly aware of the possibility.