Anorectal Lymphogranuloma Venereum in Madrid: A Persistent Emerging Problem in Men Who Have Sex With Men.

BACKGROUND: Since 2003, outbreaks of lymphogranuloma venereum (LGV) with anorectal syndrome have been increasingly recognized in many Western countries. All of them have been classified as LGV serovar L2b, mainly occurring in human immunodeficiency virus (HIV)-infected men who have had sex with men (MSM). We describe a series of 26 diagnosed cases of LGV proctitis in downtown Madrid, Spain, in 2014, after implementing routine diagnostic procedures for this disease in symptomatic MSM. METHODS: We conducted an observational study of patients with symptomatic proctitis attending an outpatient infectious diseases clinic in Madrid, Spain during calendar year 2014. Clinical, epidemiological, laboratory, and therapeutic data were gathered and analyzed. RESULTS: Twenty-six patients were included in the analysis. All were MSM, and 24 of them were HIV-positive. All patients reported having acute proctitis symptoms including tenesmus (85%), pain (88%), constipation (62%), or anal discharge (96%). Proctoscopy showed mucopurulent exudate (25 patients [96%]), and rectal bleeding, with mucosal erythema and/or oedema in all cases. Rectal swabs were obtained from all patients, and LGV serovar L2 was confirmed in all of them. The cure rate was 100% after standard treatments with doxycycline 100 mg twice per day for 3 weeks. Simultaneous rectal infections with other sexually transmitted pathogens (gonorrhoea, herpes simplex virus, Mycoplasma genitalium) and systemic sexually transmitted diseases (STDs) (syphilis, acute HIV, and hepatitis C infections) were also documented in 12 patients (46%), but these co-infections did not appear to influence the clinical manifestations of LGV. CONCLUSIONS: Anorectal LGV is a common cause of acute proctitis and proctocolitis among HIV-infected MSM who practice unprotected anal sex, and it is frequently associated with other rectal STDs. The implementation of routine screening and prompt diagnosis of these rectal infections should be mandatory in all clinical settings attended by HIV and STD patients.

[Practices and perception of risk in human immunodeficiency virus infected males who have sex with other males]. / Prácticas y percepción del riesgo en hombres con infección por el virus de la inmunodeficiencia humana que tienen sexo con otros hombres.

INTRODUCTION: The incidence of human immunodeficiency virus (HIV) and other sexually transmitted diseases increases in males who have sex with males (MSM), despite the knowledge on how to prevent them. To determine the mechanisms that are driving this lack of prevention is important to reverse the trend. PATIENTS AND METHODS: An anonymous, voluntary and self-reporting questionnaire was completed by HIV+ MSM patients who were seen in a hospital clinic, with the aim of finding out the sexual risk practices and behaviour, as well as their perceptions and assessment as regards this risk. The questionnaire included 58questions, divided into 10sections, to explore the knowledge, attitudes, and behaviour as regards HIV. The questionnaires were also given to the physicians, with the aim of exploring their perceptions, attitudes and opinions as regards the situation of the epidemic, prevention, perception of the diseases and the patient, and values in clinical practice. RESULTS: A total of 495 questionnaires from the patients were analysed. Most of them (87%) said they knew how HIV was acquired, and 97% knew how to prevent it, but 69% knew they were in a risk situation, and 43% had little concern of contracting HIV. Almost two-thirds (65%) had sex with ≥2persons on the same day, 47% met on the Internet and 26% had group sex. The same percentage of those surveyed considered that they acted impulsively. They highlighted a lack of information (33%), bad luck (32%), assumed excessive risk (36%), and lake of concern (25%), as the main reasons for acquiring the infection. When confronted with diagnosis 41% of patients answered «I never thought that it would happen to me¼, and 32% said «I had bad luck¼. Of the 121 physicians who completed the questionnaire, 24% considered that infection due to HIV/AIDS was out of control in Spain, and 65% responded that there was an image that HIV/AIDS was a controlled disease and of little concern. A large majority (71%) of those surveyed, considered that the increase in new infections showed that there was no suitable preventive plan. CONCLUSIONS: The management of the risk of acquiring HIV maintains a low level of concern, due to the optimism produced by the advances in the fight against the disease and the current toning down of the discussion. The trivialisation of the risk, on distorting the idea of risky behaviour, is a determining factor of attitudes that makes it impossible to adopt effective preventive behaviour and to take sensible and anticipated decisions.

Corynebacterium striatum: an emerging nosocomial drug-resistant endocardial pathogen.

Endocarditis due to Corynebacterium striatum has been rarely reported. A 78-year-old patient developed pacemaker endocarditis caused by multidrug-resistant C. striatum, complicated by vertebral osteomyelitis and epidural abscess. Daptomycin therapy successfully eradicated the bacteremia and metastatic infection. A review of the English literature on this emerging nosocomial, multidrug-resistant pathogen is included.

Pulmonary infectious diseases in patients with primary immunodeficiency and those treated with biologic immunomodulating agents.

PURPOSE OF REVIEW: Lung infectious disease is an important cause of morbidity and mortality in patients with primary immunodeficiencies and other conditions that alter immunologic mechanisms against microbial invasion. Lung infectious diseases occurring in patients with congenital immunodeficiency and patients on treatment with biologic anti-inflammatory compounds are discussed. Understanding of the complex relationships between the immune system and microbes is of paramount importance for timely diagnosis and successful treatment of lung infectious diseases in this group of immunocompromised hosts. RECENT FINDINGS: In the past, only a minority of children with severe primary immunodeficiency survived beyond childhood and these disorders were within the scope of the pediatrician. As modern prophylaxis and treatment strategies have been implemented, these patients will now survive into adulthood. Nowadays, therapy with new biologic compounds--tumor necrosis factor (TNF) blockers and anti-CD20 drugs--that disrupt antimicrobial surveillance and the control of intracellular microorganisms such as mycobacteria, fungi and viruses has been associated with the emergence of a new population at risk for the development of severe pulmonary and disseminated infectious diseases. SUMMARY: A wide array of bacteria, viruses, fungi and protozoa may cause severe pulmonary infectious diseases in patients with primary immunodeficiency and patients on treatment with anti-TNF and anti-CD20 drugs. Knowledge of the association of certain microbial agents with specific immune disturbances is of great clinical interest.

Enterococcal endocarditis on native and prosthetic valves: a review of clinical and prognostic factors with emphasis on hospital-acquired infections as a major determinant of outcome.

Enterococci are the third leading cause of infectious endocarditis, and despite advances in diagnosis and treatment, the mortality of enterococcal endocarditis has not changed in recent decades. Although variables such as advanced age, cardiac failure, and brain emboli have been recognized as risk factors for mortality, cooperative multi-institutional studies have not assessed the role of other variables, such as nosocomial acquisition of infection, the presence of comorbidities, or the changing antimicrobial susceptibility of enterococci, as factors determining prognosis.We conducted the current study to determine the risk factors for mortality in patients with enterococcal endocarditis in a single institution. We reviewed 47 consecutive episodes of enterococcal endocarditis in 44 patients diagnosed according to the modified Duke criteria from a retrospective cohort study of cases of infectious endocarditis. The main outcome measure was inhospital mortality. We applied stepwise logistic regression analysis to identify risk factors for mortality.Predisposing heart conditions were observed in 86.3% of patients, and 17 had prosthetic valve endocarditis. A portal of entry was suspected or determined in 38.2%; the genitourinary tract was the most common source of the infection (29.7%). Comorbidities were present in 52.2% of cases. Twelve episodes (25.5%) were acquired during hospitalization. Only 3 isolates of Enterococcus faecalis were highly resistant to gentamicin. Eighteen patients (40.9%) needed valve replacement due to cardiac failure or relapse. Comparing cases of native valve and prosthetic valve endocarditis, we found no differences regarding complications, the need for surgical treatment, or mortality. Eight of 44 (18%) episodes were fatal. Age over 70 years (p = 0.05), heart failure (odds ratio [OR], 1.61; 95% confidence interval [CI], 1.15-2.25; p = 0.001), presence of 1 or more comorbidities (OR, 3.2; 95% CI, 1.11-9.39; p = 0.02), and nosocomial acquisition (OR, 8.05; 95% CI, 1.50-43.2; p = 0.01) were associated with mortality. In the multivariate analysis, only nosocomial acquisition increased the risk of mortality. In patients with enterococcal endocarditis, nosocomial acquisition of infection is an important factor determining outcome. As the incidence of bacteremia and the population of elderly people at risk continue to grow, the hazard of acquiring nosocomial enterococcal endocarditis may increase; hence, major emphasis must be put on prevention.

[Cryptococcal meningoencephalitis. Epidemiology and mortality risk factors in pre- and post-HAART era]. / Meningoencefalitis criptocócica. Epidemiología y factores de riesgo de mortalidad en la era pre- y pos-TARGA.

INTRODUCTION AND OBJECTIVE: Cryptococcal meningoencephalitis (CM) is an uncommon entity, but remains a major cause of morbidity and mortality in patients with AIDS. MATERIAL AND METHODS: Review of CM cases in a university hospital. The diagnosis was determined by isolation of Cryptococcus neoformans in cerebrospinal fluid. Morbidity and mortality was assessed at 12 weeks (early mortality) and between 3 and 18 months after diagnosis (late mortality). RESULTS: We analyzed 32 patients from 2,269 AIDS cases (1.41%). 10 patients between 1990-1996 and 22 between 1997-2014. Cryptococcal antigen in CSF was positive in all cases, with titers>1,024 in 19 patients (63%); this group had lower CD4+ counts (40 ± 33 vs. 139 ± 78 cel/µL) and greater disseminated involvement. After a first CM episode the relapse rate was 34%. Global mortality rate was 28% (9/32), much higher in the pre-HAART era. CONCLUSIONS: CM morbidity and mortality is related to severe immunodeficiency, disseminated disease, high titers of antigen in CSF and delayed initiation of HAART.

Long-term follow-up of asymptomatic HIV-infected patients who discontinued antiretroviral therapy.

BACKGROUND: Whether asymptomatic human immunodeficiency virus (HIV)-infected patients can interrupt treatment remains unknown. METHODS: We performed a prospective, observational study of 46 patients who started therapy with >300 CD4+ cells/mm3 and/or <70,0000 HIV-1 RNA copies/mL. Patients had been receiving highly active antiretroviral therapy (HAART) for at least 6 months. HAART was discontinued, and plasma HIV-1 RNA loads and CD4+ cell counts were determined at 4-month intervals. RESULTS: At the time of HAART discontinuation, the median CD4+ cell count was 793 cells/mm3, and all patients had undetectable viral loads. A rapid decrease of 173 cells/mm3 in the median CD4+ cell count was observed during the first 4 months after HAART was stopped, followed by a slower decrease of 234 cells/mm3 between months 5 and 20. The decrease in the median CD4+ cell count early after HAART discontinuation was inversely correlated with the increase that occurred during receipt of therapy (r=-0.653) and with the count at the time of HAART discontinuation (r=-0.589). The decrease in the median CD4+ cell count after the fourth month without HAART was correlated with the nadir count before HAART initiation (r=-0.349) and the increase during treatment (r=-0.322). The median follow-up duration was 20 months. After 12, 24, and 36 months of observation, 33 patients (71.7%), 22 patients (47.8%), and 16 patients (34.7%), respectively, remained free of therapy. Adverse clinical events were not seen, and all patients who reinitiated HAART responded rapidly. CONCLUSION: Selected asymptomatic HIV-infected patients can safely discontinue therapy for prolonged periods of time.

The impact of hospital-acquired infections on the microbial etiology and prognosis of late-onset prosthetic valve endocarditis.

STUDY OBJECTIVES: To study the changing etiology of prosthetic valve endocarditis (PVE) and the impact of nosocomial acquisition of the infection on prognosis in a single hospital. METHODS: Retrospective review of 121 cases of PVE during a period of 34 years. Two different periods (the period from 1970 to 1986 [P1], and the period from 1987 to 2003 [P2]) were analyzed. RESULTS: During P1, 58 patients with PVE were treated (30 early PVE and 28 late PVE); during P2, 63 patients with PVE were treated (13 early PVE and 50 late PVE). The frequency of early-onset PVE decreased from 0.94% in P1 to 0.34% in P2 (p < 0.001), but the incidence rate of late-onset PVE did not change (0.33% and 0.42% per year, respectively). The microbiology of early PVE changed over the years: Gram-negative bacilli decreased from 40% during P1 to 7.7% in P2 (p = 0.033). Staphylococci remained the main causes of early PVE in both periods. The microbial etiology of late PVE also changed over the years with enterococci and Staphylococcus aureus as the leading causes during P2. Streptococcus viridans decreased from a leading position to a fourth position. Methicillin-resistant S aureus endocarditis appeared first in 1992. Eleven cases of late-onset PVE in P2 were hospital acquired (22%). In comparison, only two cases (7.1%) of hospital-acquired, late-onset PVE were seen in P1 (p = 0.11). Mortality of early-onset PVE decreased from 80% in P1 to 46% in P2 (p = 0.026). The overall mortality of late-onset PVE did not change between periods: 39% vs 34%. Mortality associated with nosocomial PVE in P2 was 63.6% (7 of 11 patients). In comparison, the mortality of community-acquired cases was 25.6% (10 of 39 patients; p = 0.03). In the multivariate analysis, the presence of comorbidities and hospital acquisition were associated with an excess of mortality (odds ratio [OR], 13.9; 95% confidence interval [CI], 1.23 to 158 [p = 0.033]; and OR, 10.8; 95% CI, 2.16 to 54.7 [p = 0.0037], respectively). CONCLUSION: Although the mortality associated with early-onset PVE has significantly decreased, in this series the mortality of patients with late-onset PVE remained high due mainly to an increasing number of patients with comorbidities who acquired the infection during admission for other diseases.

Mycobacterium simiae Infection in an Immunocompromised Patient without Acquired Immunodeficiency Syndrome.

We report a case of lung infection due to Mycobacterium simiae in an immunocompromised patient without acquired immunodeficiency syndrome. The patient had multiple pulmonary nodules similar to those seen in cases of lung disease caused by Mycobacterium avium in elderly women. Appropriate therapy for M. simiae disease should be determined because, in some cases, the risk of adverse effects can outweigh the potential benefits of treatment.

Effect of penicillin resistance of Streptococcus pneumoniae on the presentation, prognosis, and treatment of pneumococcal endocarditis in adults.

We performed a clinical study of pneumococcal endocarditis (PE) in adults at 15 major Spanish hospitals during a 21-year period (1978-1998). During this time, 63 patients had PE due to Streptococcus pneumoniae diagnosed. Of the 63 isolates recovered from these patients, 24 (38%) and 6 (10%) showed resistance to penicillin (minimum inhibitory concentration [MIC], 0.1-4 microg/mL) and cefotaxime (MIC, 1 microg/mL), respectively. Twenty-two (35%) of the patients died. Left-side heart failure, but not penicillin resistance, was independently associated with a higher risk of death (odds ratio, 1.33; 95% confidence interval, 1.04-1.71; P=.026). Patients without meningitis who had PE due to penicillin-resistant S. pneumoniae could be treated with high-dose penicillin or a third-generation cephalosporin if the MIC for penicillin was < or =1 microg/mL. For patients with concurrent meningitis, high doses of cefotaxime could be used if the MIC for cefotaxime was < or =1 microg/mL. Early recognition of heart failure and surgery may help to decrease mortality.

The spectrum of cardiovascular infections due to Salmonella enterica: a review of clinical features and factors determining outcome.

Cardiovascular infections due to Salmonella enterica are infrequently reported, so their clinical features, prognosis, and optimal treatment are not completely known. Mortality associated with aortitis and endocarditis caused by nontyphoidal Salmonella remains exceedingly high. In this review of cases of cardiovascular infections due to Salmonella enterica studied in 2 hospitals in Madrid, we tried to assess the clinical manifestations and the procedures leading to diagnosis in addition to treatment and outcome. To complete the spectrum of infections related to cardiovascular surgery, cases of postoperative mediastinitis, pericarditis, and infections associated with cardiac devices were also included.Twenty-three patients were reviewed: 11 had mycotic aneurysms; 7 had endocarditis; 2 had device-related infections; and 3 had pericarditis, mediastinitis, and infection of an arteriovenous fistula, respectively. The risk of endovascular infection in patients older than 60 years with bacteremia due to nontyphoidal Salmonella was 23%. Most patients with aortitis had risk factors for atherosclerosis, and 6 had preexisting atherosclerotic aortic aneurysms. All except 1 patient with endocarditis had underlying cardiac disorders. Acquired immunodeficiency disease (AIDS) was a major risk factor for salmonella bacteremia in 1 patient with aortitis and 1 with endocarditis. Fever, unremitting sepsis, "breakthrough" and relapsing bacteremia were the most common clinical findings. In addition, abdominal or thoracic pain and cardiac failure and pericarditis were common features in patients with aortitis and endocarditis respectively. Computed tomography (CT) scan, arteriography, and echocardiography were the main diagnostic tools. Mortality associated with mycotic aneurysms and endocarditis due to S. enterica was 45% and 28%, respectively. Thoracic aneurysms, rupture, and shock at the time of diagnosis were associated with increased mortality in patients with aortitis. In situ bypass grafting was successfully performed in most cases. After surgery, antimicrobial therapy was continued for 4-9 weeks. No relapses were observed after a mean follow-up of 64 months. Antimicrobial therapy alone or combined with valve replacement or excision of a ventricular aneurysm was successful treatment for most patients with salmonella endocarditis. Combined medical and surgical treatment was required for patients with mediastinitis and pericarditis, and patients with device-related infections needed removal of the complete device. Diagnosis of aortitis due to nontyphoidal Salmonella should be established as early as possible to reduce mortality. Patients older than 60 years who have positive blood cultures for Salmonella along with fever and back, abdominal, or chest pain should have an extensive workup for infective aortitis. Immediate bactericidal antimicrobial therapy should be started and a CT scan should be performed on an emergency basis. If a mycotic aneurysm is found, surgical resection should follow as soon as possible. Resection of the aneurysm with in situ bypass grafting is the procedure of choice. Postoperative antimicrobial therapy for 6-8 weeks seems enough to avoid relapses. Optimal treatment of patients with endocarditis occurring on ventricular aneurysms must include resection of the aneurysmal sac. Salmonella endocarditis can be successfully treated with antimicrobials alone. Valve replacement should be reserved for patients with cardiac failure or persisting sepsis, and for those who relapse after discontinuation of antimicrobial therapy.

Visceral leishmaniasis in immunocompromised patients with and without AIDS: a comparison of clinical features and prognosis.

Visceral leishmaniasis is basically a disease of healthy infants and adults. However, in the last decade an increasing number of cases of kala azar in immunocompromised patients have been reported with emphasis on atypical manifestations of the disease. During a period of 11 years, 20 immunocompromised patients with AIDS (12 patient), haematological neoplasia (3 patients), corticosteroid therapy (3 patients) or renal transplantation (2 patients) were studied by one or more of the authors. We did not find differences in the presentation of leishmaniasis between patient with or without AIDS and most patients had fever, enlargement of the liver and spleen, blood cytopenias and biochemical abnormalities. Serology was more frequently positive in HIV-negative than in HIV-positive patients (100% versus 63.6%; P=0.13). Bone marrow biopsy was diagnostic in 66% and 87% of patients with and without AIDS, respectively. Failure of anti-leishmanial therapy occurred in 6 of 19 patients treated (31.5%), and 3 patients with AIDS and another 3 without AIDS died during the first episode of leishmaniasis. Of 12 survivors, relapses occurred in five (41.6%). Only patients in whom immunosuppression was ameliorated by means of antiretroviral therapy or by reduction of corticosteroid and other immunosuppressive drugs did not relapse. Treatment of kala azar in immunocompromised host is in satisfactory and new drugs or strategies are urgently needed.

Prosthetic valve endocarditis due to Listeria monocytogenes. Report of two cases and reviews.

INTRODUCTION: Endocarditis due to Listeria monocytogenes is a rare but serious disease often leading to valve dysfunction and heart failure. Two cases of listerial prosthetic valve endocarditis are reviewed along with 66 cases previously reported. RESULTS: The mean age of patients with listerial endocarditis increased from 47.1 years in the decades from 1955-1984 to 65.5 years from 1985-2000. Chronic debilitating diseases, solid tumours and immunosuppression associated with organ transplantation, hematologic neoplasia or AIDS were found in 41.1% of cases. Listerial endocarditis was a vegetative and destructive process, with dehiscense of the prosthesis and occasionally, abscess formation, fistulization and pericarditis. Treatment with penicillin or ampicillin alone or combined with gentamicin was adequate therapy in most cases. Vancomycin together with gentamicin may be a reasonable alternative therapy. CONCLUSIONS: Despite problems associated with microbial persistence and relapses in other forms of human listeriosis, antimicrobial therapy alone may be a successful treatment for listerial endocarditis, including cases occurring on prosthetic valves. Valve replacement may be reserved for complicated cases with valve dehiscense, cardiac failure or myocardial abscess. Overall mortality was 35.3%, although most patients who died did so before 1985 and since then mortality has been significantly reduced to 12%.

Bacteremic pneumococcal infections in immunocompromised patients without AIDS: the impact of beta-lactam resistance on mortality.

BACKGROUND: Streptococcus pneumoniae is the leading cause of community-acquired pneumonia in the elderly, and in recent years it has arisen as an important pathogen in HIV-infected patients. However, there is a scarcity of information on clinical and therapeutic problems associated with pneumococcal infections in other immuno-compromised patients. The objective of this study was to assess the most relevant epidemiologic aspects, clinical features and prognostic factors of pneumococcal bacteremia in immunocompromised hosts without AIDS. METHODS: This was a retrospective analysis of patients with pneumococcemia, carried out in a 600-bed, university-affiliated hospital in Madrid, Spain. Two-hundred and sixty patients were evaluated retrospectively; 69 (26.5%) immunocompromised patients based on strict case definitions were compared with a group composed of 191 non-immunocompromised hosts with a variety of chronic conditions. Conventional management of pneumococcal bacteremia according to clinical standards was assessed. The MICs of penicillin and other beta-lactam antibiotics, and related mortality and hospital mortality at 30 days, were measured. RESULTS: A comparison of clinical manifestations of pneumococcemia between immunocompromised patients and non-immunocompromised patients did not show differences in the presence of fever, obtundation, type of lung involvement, frequency of primary bacteremia, or meningitis. Hospital-acquired pneumococcemia was significantly more frequent in immunocompromised patients (34.7% versus 6.8%, P<0.0001), and resistance to penicillin was also more common in pneumococcal strains isolated from these patients (37.5% versus 20%, P=0.0009). Septic shock occurred more frequently in immunocompromised patients, although the overall and related mortality were not significantly different from those found in non-immunocompromised patients (33.3% versus 22.5%, P=0.07, and 28.9% versus 20.9%, P=0.7 respectively). In the multivariate analysis, multilobar pneumonia (odds ratio (OR) 15.7; 95% CI 6.00-41.30; P<0.001), inadequate treatment (OR 12.20; 95% CI 4.10-37.20; P<0.001), obtundation (OR 5.80; 95% CI 2.20-15.00; P<0.001) and hospital-acquired bacteremia (OR 4.80; 95% CI 1.00-14.60; P<0.006) were associated with an increased risk of mortality in patients with pneumococcemia. Only multilobar pneumonia (OR 7.90; 95% CI 4.10-15.35; P<0.001) was significantly associated with an increased risk of mortality in immunocompromised patients. Patients with acute leukemia and lymphoma had a greater mortality rate than non-immunocompromised patients (53.8% related mortality, P=0.05). Analysis of these patients showed frequent inadequate empirical therapy with ceftazidime plus amikacin in the presence of beta-lactam resistance. CONCLUSIONS: Much of the burden of pneumococcal bacteremia was attributable to immunosuppressive diseases. In immunocompromised patients, pneumococcemia was frequently acquired within the hospital during the treatment of the underlying condition, and resistance to penicillin was common. Patients with acute leukemia and lymphoma who develop fever and pneumonia should be treated with drugs active against beta-lactam-resistant pneumococci, irrespective of the setting in which the infection develops.

Cutaneous and medullar gnathostomiasis in travelers to Mexico and Thailand.

Gnathostomiasis is a rare nematode disease acquired by travelers to endemic areas. The most common clinical presentations are cutaneous forms; however, neurologic involvement can also occur. We present two cases of gnathostomiasis, one of them with severe neurologic complications, in Spanish travelers to Thailand and Mexico, who consumed local food and became infected.