Hypopyon uveitis in patients with acquired immunodeficiency syndrome treated for systemic Mycobacterium avium complex infection with rifabutin.

OBJECTIVE: Iridocyclitis has been identified as a dosage-dependent side effect in patients with the acquired immunodeficiency syndrome (AIDS) who are treated for Mycobacterium avium complex (MAC) infection with systemic rifabutin. We reviewed cases of acute hypopyon uveitis occurring in patients with AIDS to establish whether there was an association. DESIGN: Retrospective case series. SETTING: Outpatient clinic and inpatient hospital-based ophthalmology referral practice and infectious disease specialty service. PATIENTS: Seven patients with AIDS, aged 10 to 40 years, presenting with acute unilateral hypopyon mimicking infectious endophthalmitis. MAIN OUTCOME MEASURES: Findings from complete ophthalmological evaluation and ancillary laboratory testing. RESULTS: At the time of presentation, all seven patients were receiving treatment for MAC infection with rifabutin (dosage range, 300 to 600 mg/d) and clarithromycin. Results of microbiological investigations in five patients were negative. Iridocyclitis became bilateral in all seven patients, and hypopyon developed in the contralateral eye in five of seven patients. Hypopyon resolved rapidly with intensive topical corticosteroid therapy. Residual inflammation responded to topical corticosteroids with or without reduction of the rifabutin dosage. CONCLUSIONS: Concomitant use of rifabutin, clarithromycin, and fluconazole may precipitate hypopyon uveitis in patients with AIDS being treated for MAC infection.

Anergy in tuberculosis.

Anergy in tuberculosis is of considerable clinical and immunological interest. Although negative skin reactions may be secondary to improper tuberculin testing or to certain diseases, drugs, vaccinations and constitutional factors known to affect cell-mediated immunity, often no underlying explanation is apparent. Unexplained negative reactions occur with a highly variable frequency in a wide variety of tuberculous infections. Anergy in tuberculosis is usually generalized, is often accompanied by other immunologic abnormalities, and frequently disappears as the disease is treated. Most anergic patients do not differ substantially from reactive patients in clinical features or prognosis. The mechanism of anergy in tuberculosis is unknown, but leading hypotheses suggest that immunologic compartmentalization, suppressor cells, or serum inhibitors (perhaps of mycobacterial origin) may be involved.

Human immunodeficiency virus type 1 in the semen of men receiving highly active antiretroviral therapy.

BACKGROUND: Highly active antiretroviral therapy can effectively decrease the levels of human immunodeficiency virus type 1 (HIV-1) virions in peripheral plasma and seminal fluid of infected men. Whether the genital tract of HIV-1-infected men who are receiving highly active antiretroviral therapy and who have no detectable virus in the peripheral plasma harbors replication-competent virus is not known. METHODS: We collected peripheral-blood and semen samples from seven men with HIV-1 infections who were receiving highly active antiretroviral therapy and who had no detectable viral RNA (fewer than 50 copies per milliliter) in plasma and analyzed the samples for cell-associated proviral DNA using a quantitative polymerase-chain-reaction assay. Replication-competent viruses were evaluated by cell-coculture assays. Proviral DNA and replication-competent virus obtained from peripheral-blood and seminal cells were also analyzed by sequencing relevant viral genes. RESULTS: Despite the long-term suppression of HIV-1 RNA in the plasma of the seven men, proviral DNA was detected in seminal cells in four. Replication-competent viruses were recovered from peripheral-blood cells in three men and from the seminal cells in two of these three men. The viruses recovered from the seminal cells had no genotypic mutations suggestive of resistance to antiretroviral drugs and were macrophage-tropic, a feature that is characteristic of HIV-1 strains that are capable of being sexually transmitted. CONCLUSIONS: In HIV-1-infected men who are receiving highly active antiretroviral therapy and who have no detectable levels of viral RNA in plasma the virus may be present in seminal cells and therefore may be capable of being transmitted sexually.

Transient ischemic attacks and minor stroke during sleep. Relationship to obstructive sleep apnea syndrome.

BACKGROUND: It is reported that 13% to 44% of all cerebrovascular accidents (CVAs) occur during sleep. In addition to other well-known risk factors, snoring, sleep apnea, obesity, and daytime sleepiness have been shown to significantly increase the risk of stroke. We describe two cases that support the statistical relationship between snoring, sleep apnea, and CVA during sleep. CASE DESCRIPTIONS: In the first case, motor aphasia was noted in a 64-year-old, 5-ft, 1-in, 218-lb woman when she awakened from sleep at approximately 4 AM. This completely resolved within 3 hours. During her subsequent hospitalization she was found to have severe obstructive sleep apnea that responded well to treatment with nasal continuous positive airway pressure. There has been no recurrence of symptoms in this patient. The second patient was a 59-year-old, 5-ft, 6-in, 260-lb woman who presented to the Sleep Disorders Center with signs and symptoms of severe sleep apnea. In addition, she had awakened from sleep approximately 6 months earlier with numbness and weakness on her right side. Although these symptoms had greatly improved, she continued to complain about residual weakness that was worse on awakening from sleep. Sleep studies confirmed severe obstructive sleep apnea that responded very well to treatment with nasal continuous positive airway pressure. CONCLUSIONS: Snoring and obstructive sleep apnea not only increase the statistical risk of CVA but could be the proximal trigger that precipitates these events during sleep. These two cases provide clinical support for this relationship. Successful diagnosis and treatment of obstructive sleep apnea in the patient with transient ischemic attacks and minor stroke may be an important tool for preventing recurrence.

Pneumococcal soft-tissue infections: possible association with connective tissue diseases.

Streptococcus pneumoniae is not a well-recognized cause of soft-tissue infections. In less than 4 years, 12 cases of pneumococcal soft-tissue infection were identified through discussions with infections disease subspecialists in the Philadelphia area. Principal sites of involvement included skin and fascia, tongue, epiglottis, thyroid, brain, and breast. Pneumococcal bacteremia was documented in six cases (50%); in three of these, pneumococci were also cultured from the involved soft tissues. In the cases in which bacteremia was not demonstrated, pneumococci were isolated from the infected sites. Six patients had connective tissue diseases, of which five were diagnosed as systemic lupus erythematosus. Four of these patients were receiving corticosteroids when their infections developed. Two additional patients were HIV-seropositive intravenous drug users. S. pneumoniae may be a more important cause of soft-tissue infections than previously appreciated, especially in patients with connective tissue diseases.