RESUMO
Patients with haematological malignancy are at increased risk of developing central nervous system (CNS) infections, which are associated with significant morbidity and mortality. Neuroimaging plays a pivotal role in the diagnostic pathway of these patients; however, layers of complexity are added to image interpretation by the heterogeneity in imaging manifestations of haematological malignancies in the CNS, overlapping imaging features of CNS infection, treatment-related parenchymal changes and the presence of intracranial comorbidity. In this article, we review important intracranial findings of CNS infection cases accrued in 1,855 studies over more than a decade at a specialist tertiary centre. We offer schema to identify common and important neuroimaging features, discuss key differential diagnoses and frequent diagnostic pitfalls.
Assuntos
Infecções do Sistema Nervoso Central/complicações , Infecções do Sistema Nervoso Central/diagnóstico por imagem , Erros de Diagnóstico/prevenção & controle , Diagnóstico por Imagem/métodos , Neoplasias Hematológicas/complicações , Neuroimagem/métodos , Encéfalo/diagnóstico por imagem , Diagnóstico Diferencial , HumanosRESUMO
OBJECTIVES: Since 2013, the London HIV Mortality Review Group has conducted annual reviews of deaths among people with HIV to reduce avoidable mortality. METHODS: All London HIV care Trusts reported data on 2016 patient deaths in 2017. Deaths were submitted using a modified Causes of Death in HIV reporting form and categorized by a specialist HIV pathologist and two HIV clinicians. RESULTS: There were 206 deaths reported; 77% were among men. Median age at death was 56 years. Cause was established for 82% of deaths, with non-AIDS-related malignancies and AIDS-defining illnesses being the most common causes reported. Risk factors in the year before death included: tobacco smoking (37%), excessive alcohol consumption (19%), non-injecting drug use (10%), injecting drug use (7%) and opioid substitution therapy (6%). Thirty-nine per cent of patients had a history of depression, 33% chronic hypertension, 27% dyslipidaemia, 17% coinfection with hepatitis B virus and/or hepatitis C virus and 14% diabetes mellitus. At the time of death, 81% of patients were on antiretroviral therapy (ART), 61% had a CD4 count < 350 cells/µL, and 24% had a viral load ≥ 200 HIV-1 RNA copies/mL. Thirty-six per cent of deaths were unexpected; 61% of expected deaths were in hospital. Two-thirds of expected deaths had a prior end-of-life care discussion documented. CONCLUSIONS: In 2016, most deaths were attributable to non-AIDS-related conditions and the majority of patients were on ART and virally suppressed. However, several potentially preventable deaths were identified and underlying risk factors were common. As London HIV patients are not representative of people with HIV in the UK, a national mortality review is warranted.
Assuntos
Terapia Antirretroviral de Alta Atividade/estatística & dados numéricos , Causas de Morte , Coinfecção/mortalidade , Infecções por HIV/mortalidade , Síndrome da Imunodeficiência Adquirida , Adulto , Contagem de Linfócito CD4 , Doenças Cardiovasculares/mortalidade , Diabetes Mellitus/mortalidade , Feminino , Inquéritos Epidemiológicos , Hepatite Viral Humana/mortalidade , Humanos , Londres/epidemiologia , Masculino , Pessoa de Meia-Idade , Neoplasias/mortalidade , Fatores de Risco , Transtornos Relacionados ao Uso de Substâncias/mortalidade , Carga ViralRESUMO
To understand the epidemiological significance of Pneumocystis detection in a lung tissue sample of non-immunosuppressed individuals, we examined sampling procedures, laboratory methodology, and patient characteristics of autopsy series reported in the literature. Number of tissue specimens, DNA-extraction procedures, age and underlying diagnosis highly influence yield and are critical to understand yield differences of Pneumocystis among reports of pulmonary colonization in immunocompetent individuals.
Assuntos
Autopsia/métodos , Pulmão/microbiologia , Técnicas Microbiológicas/métodos , Pneumocystis/isolamento & purificação , Pneumonia por Pneumocystis/diagnóstico , Manejo de Espécimes/métodos , Humanos , Pneumonia por Pneumocystis/microbiologiaRESUMO
OBJECTIVES: The aim of the study was to investigate the organization and delivery of HIV and tuberculosis (TB) health care and to analyse potential differences between treatment centres in Eastern (EE) and Western Europe (WE). METHODS: Thirty-eight European HIV and TB treatment centres participating in the TB:HIV study within EuroCoord completed a survey on health care management for coinfected patients in 2013 (EE: 17 respondents; WE:21; 76% of all TB:HIV centres). Descriptive statistics were obtained for regional comparisons. The reported data on health care strategies were compared with actual clinical practice at patient level via data derived from the TB:HIV study. RESULTS: Respondent centres in EE comprised: Belarus (n = 3), Estonia (1), Georgia (1), Latvia (1), Lithuania (1), Poland (4), Romania (1), the Russian Federation (4) and Ukraine (1); those in WE comprised: Belgium (1), Denmark (1), France (1), Italy (7), Spain (2), Switzerland (1) and UK (8). Compared with WE, treatment of HIV and TB in EE are less often located at the same site (47% in EE versus 100% in WE; P < 0.001) and less often provided by the same doctors (41% versus 90%, respectively; P = 0.002), whereas regular screening of HIV-infected patients for TB (80% versus 40%, respectively; P = 0.037) and directly observed treatment (88% versus 20%, respectively; P < 0.001) were more common in EE. The reported availability of rifabutin and second- and third-line anti-TB drugs was lower, and opioid substitution therapy (OST) was available at fewer centres in EE compared with WE (53% versus 100%, respectively; P < 0.001). CONCLUSIONS: Major differences exist between EE and WE in relation to the organization and delivery of health care for HIV/TB-coinfected patients and the availability of anti-TB drugs and OST. Significant discrepancies between reported and actual clinical practices were found in EE.
Assuntos
Antituberculosos/uso terapêutico , Infecções por HIV/tratamento farmacológico , Tuberculose/diagnóstico , Tuberculose/tratamento farmacológico , Coinfecção/diagnóstico , Coinfecção/tratamento farmacológico , Estudos Transversais , Europa (Continente) , Europa Oriental , Infecções por HIV/microbiologia , Inquéritos Epidemiológicos , Humanos , Tratamento de Substituição de Opiáceos/métodos , Rifabutina/uso terapêuticoRESUMO
BACKGROUND: We have previously described the presentation of epidermodysplasia verruciformis (EV)-like eruptions in almost a quarter of hospitalized adolescents with vertically-acquired human immunodeficiency virus (HIV) infection in Harare, Zimbabwe, a region with a high prevalence of HIV infection. METHODS: We performed a clinical case note review and skin biopsy from affected sites in 4 HIV-infected adolescents with EV-like lesions in Harare. Biopsies were processed for histology and for human papillomavirus (HPV) typing. RESULTS: All patients had long-standing skin lesions that pre-dated the diagnosis of HIV by several years. The histology of skin biopsies from all patients was consistent with EV. In each biopsy, EV-associated ß-HPV type 5 was identified (additionally, type 19 was found in 1 biopsy). Cutaneous wart-associated HPV types 1 and 2 were detected in all biopsies, together with genital lesion-associated HPV types 6, 16, and 52, (as well as ≥3 other genital lesion-associated HPV types). Despite immune reconstitution with combination antiretroviral therapy (cART), there was no improvement in EV-like lesions in any patient. CONCLUSIONS: EV is a disfiguring and potentially stigmatizing condition among this patient group and is difficult to treat; cART appears to have no impact on the progression of skin disease. Among adolescents with longstanding HIV-induced immunosuppression and with high levels of sun exposure, close dermatological surveillance for potential skin malignancy is required.
Assuntos
Infecções por HIV/complicações , Papillomaviridae/classificação , Papillomaviridae/isolamento & purificação , Adolescente , Biópsia , Criança , Impressões Digitais de DNA , Epidermodisplasia Verruciforme , Genótipo , Infecções por HIV/transmissão , Histocitoquímica , Humanos , Transmissão Vertical de Doenças Infecciosas , Masculino , Microscopia , Papillomaviridae/genética , Pele/patologia , Pele/virologia , ZimbábueRESUMO
AIM: To evaluate lung disease on chest radiography (CR), the relative frequency of CR abnormalities, and their clinical correlates in adolescents with vertically-acquired human immunodeficiency virus (HIV) infection. MATERIALS AND METHODS: CRs of 75 patients [59 inpatients (33 males; mean age 13.7±2.3 years) and 16 outpatients (eight males; mean age 14.1±2.1 years)] were retrospectively reviewed by three independent observers. The overall extent of disease (to the nearest 5%), its distribution, and the proportional extents (totalling 100%) of different radiographic patterns (including ring/tramline opacities and consolidation) were quantified. CR features and clinical data were compared. RESULTS: CRs were abnormal in 51/75 (68%) with "extensive" disease in 38/51 (74%). Ring/tramline opacities and consolidation predominated (i.e., proportional extent >50%) in 26 and 21 patients, respectively. Consolidation was significantly more common in patients hospitalized primarily for a respiratory illness than patients hospitalized for a non-respiratory illness or in outpatients (p<0.005, χ(2) for trend); by contrast, ring/tramline opacities did not differ in prevalence across the groups. On stepwise logistic regression, predominant consolidation was associated with progressive dyspnoea [odds ratio (OR) 5.60; 95% confidence intervals (CI): 1.60, 20.1; p<0.01] and was associated with a primary respiratory cause for hospital admission (OR: 22.0; CI: 2.7, 181.1; p<0.005). Ring/tramline opacities were equally prevalent in patients with and without chronic symptoms and in those admitted to hospital with respiratory and non-respiratory illness. CONCLUSION: In HIV-infected adolescents, evaluated in secondary practice, CR abnormalities are prevalent. The presence of ring/tramline opacities, believed to reflect chronic airway disease, is not linked chronic respiratory symptoms.
Assuntos
Infecções por HIV/diagnóstico por imagem , Transmissão Vertical de Doenças Infecciosas , Pneumopatias/diagnóstico por imagem , Adolescente , Terapia Antirretroviral de Alta Atividade , Criança , Feminino , Infecções por HIV/epidemiologia , Infecções por HIV/transmissão , Humanos , Pneumopatias/epidemiologia , Masculino , Prevalência , Radiografia , Estudos Retrospectivos , Zimbábue/epidemiologiaRESUMO
OBJECTIVES: The aim of the study was to describe the prevalence of and examine the factors associated with immunosuppression (CD4 < 200 cells/microL) among HIV-infected patients attending two large inner London treatment centres. METHODS: Patients attending for care who had a CD4 count < 200 cells/microL during a 6-month period (1 January to 30 June 2007) were identified from the UK national CD4 surveillance database. Corresponding case notes were reviewed and factors associated with the most recent immunosuppressive episode examined. Patients either previously had a CD4 count > 200 cells/microL at any time under follow-up which had decreased (group A) or never had a CD4 count > 200 cells/microL (group B; late presenters). RESULTS: Of 4589 patients, 10.2% (467) had at least one CD4 count < 200 cells/microL. In group A (60.1% of patients), 70.4% were not receiving antiretroviral therapy (ART) at the time at which the CD4 count fell to < 200 cells/microL. Reasons included: treatment interruption (TI; 32.6%), patient declined ART (20.2%), infrequent attendance (19.1%), physician delay in offer (23.1%) and transient CD4 cell count decrease (3.9%). Among those receiving ART, one in three had poor adherence. In group B, 92.3% had started ART after presentation: most had recently started and were responding virologically. AIDS-defining diagnoses occurred in the year preceding the decrease in CD4 cell count in 12.6% of patients in group A and 33.3% of those in group B. CONCLUSION: The majority of patients became immunosuppressed while under care. Our findings suggest that, in addition to strategies aimed at earlier diagnosis, there are further opportunities to reduce severe immunosuppression in patients already attending for HIV care.
Assuntos
Infecções por HIV/imunologia , HIV-1/imunologia , Hospedeiro Imunocomprometido , Recusa do Paciente ao Tratamento/estatística & dados numéricos , Síndrome da Imunodeficiência Adquirida/epidemiologia , Síndrome da Imunodeficiência Adquirida/imunologia , Adulto , Assistência Ambulatorial , Antirretrovirais/uso terapêutico , População Negra , Contagem de Linfócito CD4/estatística & dados numéricos , Diagnóstico Tardio/efeitos adversos , Diagnóstico Tardio/estatística & dados numéricos , Feminino , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Humanos , Londres , Masculino , Pessoa de Meia-Idade , Fatores de Risco , Falha de Tratamento , Recusa do Paciente ao Tratamento/psicologia , Reino Unido/epidemiologia , Carga Viral , População BrancaRESUMO
C-reactive protein (CRP) is a sensitive marker of inflammation and tissue damage. We aimed to describe CRP responses in HIV-infected patients presenting with Pneumocystis pneumonia (PCP), bacterial pneumonia (BP) and pulmonary tuberculosis (TB) and, in patients with PCP, to identify if elevated CRP has prognostic significance. Data obtained by case-note review of consecutive HIV-infected adults with acute respiratory episodes included admission CRP (elevated >5 mg/L), haemoglobin, white blood count, CD4 count and partial pressure of oxygen in the blood (PaO(2)), presence of pulmonary co-pathology/intercurrent infection and outcome (survival). Median (range) CRP in patients with BP = 120 mg/L (<5-620 mg/L), TB = 44 mg/L (<5-256.3 mg/L) and PCP = 35 mg/L (<5-254 mg/L). CRP was elevated in 93/103 (90.3%) patients with PCP; six patients died; and all had an elevated CRP. PaO(2) and CRP values were associated as follows: average CRP levels declined by 10% (95% confidence interval [CI] 0.20%) per kPa increase in PaO(2) = 0.002. Factors associated with death were higher CRP, odds ratio (OR) (95% CI) = 5.30 (1.61 to 17.51) per 100 mg/L increase, P = 0.006 and haemoglobin, OR (95% CI) = 0.52 (0.29 to 0.93) per g/dL, P = 0.033. CRP is elevated in the majority of HIV-infected patients with PCP, BP and TB. Admission CRP measurement lacks specificity, but in PCP elevations of CRP are associated with disease severity (PaO(2)) and poor outcome and might be used prognostically, together with other mortality risk factors; further prospective evaluation is needed.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/imunologia , Proteína C-Reativa/imunologia , Pneumocystis carinii , Pneumonia por Pneumocystis/imunologia , Adulto , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pneumonia Bacteriana/imunologia , Prognóstico , Estudos Retrospectivos , Tuberculose Pulmonar/imunologiaRESUMO
We reviewed our practice in order to determine the optimum neuroimaging strategy for HIV-infected patients with acute neurological presentations between April 2007 and August 2008. Overall magnetic resonance imaging (MRI) detected cranial abnormalities in more than twice as many patients as did computed tomography (CT) (74% and 32%, n = 54 and 38, respectively). Replacement of CT by first-line MRI for all patients would have required an additional 16 MRI scans, although at a saving of 38 CT scans. Our study highlights the importance of first-line MRI brain imaging in HIV patients with neurological symptoms and reinforces the need for early transfer of patients from centres that do not have rapid access to (or expert interpretation of) MRI scanning, to an appropriate HIV specialist centre.
Assuntos
Infecções por HIV/complicações , Imageamento por Ressonância Magnética , Doenças do Sistema Nervoso/patologia , Doenças do Sistema Nervoso/virologia , Tomografia Computadorizada por Raios X , Doença Aguda , Adulto , Encéfalo/patologia , Encéfalo/virologia , Humanos , Pessoa de Meia-Idade , Sensibilidade e EspecificidadeRESUMO
BACKGROUND: Using 2004-2007 TB:HIV Study data
Assuntos
Coinfecção , Infecções por HIV , Mycobacterium tuberculosis , Tuberculose , Antituberculosos/uso terapêutico , Coinfecção/tratamento farmacológico , Atenção à Saúde , Europa (Continente)/epidemiologia , Feminino , Infecções por HIV/complicações , Infecções por HIV/tratamento farmacológico , Infecções por HIV/epidemiologia , Humanos , América Latina/epidemiologia , Masculino , Testes de Sensibilidade Microbiana , Modelos de Riscos Proporcionais , Tuberculose/diagnóstico , Tuberculose/tratamento farmacológicoRESUMO
Electrophysiological recording methods were applied to the isolated, retina-eyecup preparation of the rabbit. Perfusion with a chloride-free solution has a selective, reversible effect on the retinal network. This study establishes chloride ions as an important requirement for certain "information channels" within the retina.
Assuntos
Cloretos/fisiologia , Retina/fisiologia , Animais , Eletrorretinografia , Potenciais Evocados , Gânglios/citologia , Técnicas In Vitro , Neurônios/fisiologia , Estimulação Luminosa , Coelhos , Retina/citologiaRESUMO
The hypothesis that a synaptic transmitter is released by photoreceptors in the dark is supported by experiments in which cobalt was used as a synaptic blocking agent, while intracellular recordings of receptors and neurons that are directly postsynaptic to receptors were maintained. In the dark the depolarizing bipolars are hyperpolarized, whereas the hyperpolarizing bipolars are depolarized.
Assuntos
Células Fotorreceptoras/fisiologia , Retina/fisiologia , Animais , Cobalto/farmacologia , Escuridão , Técnicas In Vitro , Luz , Potenciais da Membrana/efeitos dos fármacos , Células Fotorreceptoras/efeitos dos fármacos , Retina/citologia , Sinapses/fisiologia , Transmissão Sináptica/efeitos dos fármacos , UrodelosRESUMO
cis-2,3-Piperidinedicarboxylic acid (PDA), an excitatory amino acid antagonist, reversibly blocked cone input to OFF bipolars and horizontal cells, whereas ON bipolars were relatively unaffected. Kainic acid effects were also blocked, indicating a postsynaptic mechanism of action. The use of PDA helps to characterize one of two classes of excitatory amino acid synaptic receptors that mediate cone influence in the outer retina.
Assuntos
Aminoácidos/fisiologia , Células Fotorreceptoras/fisiologia , Retina/fisiologia , Animais , Ácido Caínico/farmacologia , Necturus , Neurotransmissores/fisiologia , Ácidos Pipecólicos , Retina/citologiaRESUMO
Information processing in the vertebrate retina occurs in two separate channels known as ON and OFF channels. When intracellular electrophysiological recordings were obtained from the perfused retina-eyecup preparation of the mud-puppy (Necturus maculosus), the addition of 2-amino-4-phosphonobutyric acid to the bathing medium blocked all responses in the ON channel but left intact the OFF responses including OFF ganglion cell discharge. 2-Amino-4-phosphonobutyric acid blocks the light response of the ON bipolar cell by mimicking the endogenous photoreceptor transmitter.
Assuntos
Aminobutiratos/farmacologia , Compostos Organofosforados/farmacologia , Retina/efeitos dos fármacos , Potenciais de Ação/efeitos dos fármacos , Animais , Técnicas In Vitro , Luz , Necturus , Receptores de Neurotransmissores/efeitos dos fármacos , Retina/citologia , Retina/fisiologia , Retina/efeitos da radiação , Visão Ocular/efeitos dos fármacosRESUMO
About one-half of on-off ganglion cells have inhibitory postsynaptic potentials (IPSP's) which are blocked by strychnine, while the remainder have IPSP's which are blocked by picrotoxin or bicuculline. These antagonists do not abolish light activity of the presynaptic inhibitory neuron, the amacrine cell. The existence of separate gamma-aminobutyric acid- and glycine-releasing amacrine cells is implied by these results.
Assuntos
Aminobutiratos/fisiologia , Glicina/fisiologia , Neurônios/fisiologia , Retina/fisiologia , Urodelos/fisiologia , Ácido gama-Aminobutírico/fisiologia , Animais , Bicuculina/farmacologia , Potenciais Evocados/efeitos dos fármacos , Gânglios/fisiologia , Glicina/metabolismo , Técnicas In Vitro , Inibição Neural , Neurônios/metabolismo , Estimulação Luminosa , Picrotoxina/farmacologia , Estricnina/farmacologia , Ácido gama-Aminobutírico/metabolismoRESUMO
An HIV-infected man presented with acute onset of right iliac fossa pain. Initial assessment of clinical and computed tomography findings suggested a diagnosis of appendicitis. A macroscopically normal appendix was removed. Further imaging performed postoperatively because of persistent symptoms showed a right iliac fossa mass; culture of pus aspirated from the mass grew group A beta-haemolytic Streptococcus confirming a diagnosis of suppurative iliac lymphadenitis.
Assuntos
Apendicite/diagnóstico , Diagnóstico Diferencial , Infecções por HIV/complicações , Ílio , Linfadenite/diagnóstico , Infecções Estreptocócicas/diagnóstico , Adulto , Apendicectomia , Apêndice/cirurgia , Erros de Diagnóstico , Humanos , Ílio/cirurgia , Laparoscopia , Linfadenite/complicações , Linfadenite/microbiologia , Masculino , Dor Pélvica , Infecções Estreptocócicas/complicações , Infecções Estreptocócicas/microbiologia , Streptococcus pyogenes/isolamento & purificação , Adulto JovemRESUMO
Two HIV-infected patients had recurrent cryptococcal meningitis (CM) despite treatment with fluconazole and immune reconstitution with combination antiretroviral therapy (CART). Following treatment of CM with fluconazole, lumbar puncture should be performed either after completion of induction treatment for CM or before starting CART, in order to confirm cerebrospinal fluid sterility.
Assuntos
Infecções Oportunistas Relacionadas com a AIDS/diagnóstico , Soropositividade para HIV/tratamento farmacológico , HIV-1 , Meningite Criptocócica/diagnóstico , Infecções Oportunistas Relacionadas com a AIDS/tratamento farmacológico , Infecções Oportunistas Relacionadas com a AIDS/imunologia , Adolescente , Adulto , Anfotericina B/uso terapêutico , Fármacos Anti-HIV/uso terapêutico , Antifúngicos/uso terapêutico , Terapia Antirretroviral de Alta Atividade , Contagem de Linfócito CD4 , Evolução Fatal , Fluconazol/uso terapêutico , Soropositividade para HIV/complicações , Humanos , Masculino , Meningite Criptocócica/tratamento farmacológico , Meningite Criptocócica/imunologia , RecidivaRESUMO
A retrospective case-notes audit of 359 HIV-1-infected adult patients with first-episode laboratory-confirmed Pneumocystis jirovecii pneumonia treated with co-trimoxazole (from 1987 adjuvant steroids were used if PaO(2) <9.3 kPa) showed that only 230/359 (64%) patients completed treatment; 104 (29%) patients had treatment-limiting toxicity; rash occurred in 4/60 (6.7%) patients in 1985-1988 and in 15/47 (31.9%) in 2005-2008. Twenty-five patients (7%) failed co-trimoxazole treatment. Overall mortality was 13.6% (49/359); mortality among patients who failed co-trimoxazole treatment was 48% (12/25) and by contrast mortality was 4.8% (5/104) among patients with treatment-limiting toxicity.