Treatment of visceral leishmaniasis in HIV-infected patients: a randomized trial comparing meglumine antimoniate with amphotericin B. Spanish HIV-Leishmania Study Group.

BACKGROUND: Visceral leishmaniasis is common in patients with HIV infection living in endemic areas, but the most effective and safe treatment remains unknown. OBJECTIVE: To compare the efficacy and safety of meglumine antimoniate versus amphotericin B in HIV-infected patients with first episodes of visceral leishmaniasis (VL). DESIGN: An open, multicentre, prospective and randomized trial. SETTING: Twelve tertiary hospitals. PATIENTS: Eighty-nine consecutive HIV-infected patients diagnosed with VL. Patients were randomly assigned to treatment with either meglumine antimoniate (20 mg pentavalent antimony per kilogram of body weight per day) or amphotericin B (0.7 mg/kg per day) both for 28 days. Treatment was considered successful if a bone marrow aspirate performed 1 month after the end of therapy did not detect parasites. Relapse was defined as the reappearance of parasites after an initial cure. RESULTS: An initial cure was attained in 29 of 44 patients (65.9%) randomly assigned to treatment with meglumine antimoniate and 28 of 45 (62.2%) randomly assigned to treatment with amphotericin B. The incidence of moderate to severe adverse events was similar in both groups. The patients treated with meglumine antimoniate had higher incidences of cardiotoxicity (14 versus 0%, P = 0.02) and chemical pancreatitis (30 versus 0%, P < 0.01). However, in the amphotericin B group, nephrotoxicity was more frequent (36 versus 5%, P < 0.01). There was no difference in survival or relapse-free interval according to the allocated group of therapy. CONCLUSION: Treatment of VL with meglumine antimoniate or amphotericin B was shown to have similar efficacy and toxicity rates in Spanish HIV-infected patients. The differences in the toxicity patterns could be useful in choosing one of these agents as first-line treatment.

[Fever of unknown origin in HIV positive patients]. / Fiebre de origen desconocido en pacientes VIH positivos.

OBJECTIVES: To describe the clinical presentation of FUO in patients infected with HIV and to asses the diagnostic usefulness in this population of several test usually recommended in the study of FUO. PATIENTS AND METHODS: We studied the clinical charts of all patients with HIV that required admission to our Hospital during a 23-month period. FUO was defined according to Petersdorf's modified criteria. Fifty-four patients fulfilled study criteria during the entry period. RESULTS: A cause of fever was identified for 48 patients (89%). Tuberculosis, disseminated atypical mycobacteriosis and Leishmaniasis can explain 68% of them. Examination of bone marrow aspirates, lymph node aspirates and biopsy, and culture of clinical specimens for mycobacteria were the procedures with the highest diagnostic yield. CONCLUSIONS: Mycobacterial infection should be considered as a first-line diagnosis in HIV-patients with FUO. It is possible to predict the diagnosis of tuberculosis infection with a high level of confidence (90.5%) through a logistic regression model based on easily obtainable parameters.

[Changes in the profile of HIV-positive patients. What has happened in the last 5 years?]. / Cambios en el perfil de los pacientes VIH positivos. Qué ha pasado en los últimos cinco años?

OBJECTIVE: To evaluate possible changes in the social, cultural and economical profile of our HIV infected patients appearing during the last five years and their potential impact on incidence, prevention, and follow-up of HIV infection. METHODS: We conduce a retrospective analysis of demographic, sociocultural, clinical and therapeutic characteristics of two groups of HIV infected patients reaching for the first time a level of 300 CD4 or less either in 1992 or in 1997. RESULTS: 55 patients with a mean age of 33 years (68% male 32% female) were studied. No differences were found in sexual behavior, HIV status of sexual partner, cultural level, risk practice, VHB or YHC seroprevalence. Attempts al drug quitting in 1992 were made individually and through institutional programs in 1997. Significant differences were found in the number of visits to the outpatient clinic the previous 36 months, and in de number of drugs (1.5 versus 3.5 P < 0.0001). Antirretroviral drugs were use in 62% of our 1992 patients and in 86% of the 1997 group (p < -0.02). CONCLUSIONS: The sociocultural and demographic profile has not changed in our environment in the last five years. However patients were identified later and followed less regularly at our clinic five years ago. Institutional methadone programs are the method or choice in our current patients for stopping illicit drug use. Finally treatment intensity has dramatically increased in our patients parallel to the growing therapeutical arsenal in this field.

Streptococcus pneumoniae acute suppurative parotitis in a patient with Sjögren's syndrome.

A case of suppurative parotitis due to Streptococcus pneumoniae is reported in a patient with Sjögren's syndrome. The rarity of this condition is noted by a review of the literature.

High prevalence of tuberculosis in AIDS patients in Spain.

A total of 67 cases of tuberculosis was diagnosed in the first 100 cases of AIDS, diagnosed according to the former CDC criteria, at a hospital in Madrid, Spain. This is the highest known prevalence of tuberculosis in AIDS patients both within and outside Spain. The clinical manifestations of tuberculosis were very variable and atypical. The rate of isolation of Mycobacterium tuberculosis from blood was particularly high: of 25 patients in whom blood cultures were performed, 16 were positive. In a third of the patients with proven mycobacteremia, blood was the first or the only positive specimen. In general, therapy resulted in rapid clinical improvement, but in some cases mycobacteria were isolated from clinical or necroscopy specimens months after what was considered adequate therapy.

[Arachnoiditis and intraspinal lesion. Complications of tuberculous meningitis in 2 patients with human immunodeficiency virus infection]. / Aracnoiditis y lesión intramedular. Complicaciones de la meningitis tuberculosa en dos pacientes con infección por el virus de la inmunodeficiencia humana.

Radiculomyelitis (arachnoiditis) (RMA) is a severe complication of tuberculous meningitis (TM). Two patients with HIV infection and TM are here reported. These patients developed RMA. In Spain only four cases of RMA have previously been reported (only one of them was HIV-positive). Clinical manifestations (subacute paraplegia, radicular pain, sensitive level and neurogenic bladder) are reported. Cerebrospinal fluid had inflammatory features, wit predominance of mononuclear cells and remarkable increase in protein content. Magnetic resonance imaging (MRI) is the most suitable diagnostic method. The therapeutic possibilities of this complication are discussed.

[Retrospective study of early readmissions at an internal medicine service]. / Estudio retrospectivo de los reingresos precoces de un servicio de medicina interna.

OBJECTIVE: To determine the frequency of hospital re-admissions to an Internal Medicine Department at a Community General Hospital as well as variables associated with them. METHODS: Analysis of hospital discharges during 1997. Data were provided by the Coding and Filing Service, and included sociodemographic data and aspects related to medical care to each patient, as well as discharge DRF according to the HCFA version. A logistic regression model was developed to identify variables independently associated with early re-admission risk (less than 30 days after discharge). RESULTS: The rate of early re-admission was 7.4%. The variables associated with a higher risk of admission included age, a hospital stay longer than the mean at first admission, and AIDS-associated conditions and heart diseases as main discharge diagnoses. CONCLUSIONS: Based on our data, we cannot consider the readmission rates as a reliable index in itself to be assessed negatively, as some re-admissions come unexpectedly and/or are unavoidable.

Infectious endocarditis due to non-typhi Salmonella in patients infected with human immunodeficiency virus: report of two cases and review.

Endocarditis is not usually considered a complication of AIDS. Because salmonellal bacteremia is common in HIV-infected patients and because salmonellae have a propensity to adhere to endothelial cells, these patients are at risk of endocarditis and endarteritis. We report two cases of endocarditis due to Salmonella enteritidis and review three previously reported cases. All five patients had underlying heart valve disease and developed fever, breakthrough or relapsing bacteremia, heart murmurs, and cardiac failure; four of five patients were older than 45 years. One patient died, but the other four were successfully treated with beta-lactam agents alone or in combination with aminoglycosides or with ofloxacin (valve replacement was not required). As AIDS patients get older, the number of cases of endocarditis or endarteritis due to Salmonella species may increase, particularly in geographic areas where Salmonella species are prevalent.