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This study sought to correlate deep bacterial infection with HIV infection and evaluate the influence of HIV on clinical practice and outcome in patients with meningitis, pneumonia, or pyomyositis. At University Hospital, Dar es Salaam, Tanzania, 165 patients were admitted to the hospital with purulent meningitis, pneumonia, or pyomyositis and were evaluated in a prospective, cross-sectional study along with 165 age- and sex-matched controls from orthopedic/trauma wards to determine HIV seroprevalence. Of the 78 patients with purulent meningitis, 19 (24%) were HIV-seropositive, as compared with 13 (17%) in the control group (p=0.345). Of 36 patients with meningitis seen before a meningococcal epidemic affected Dar es Salaam, there was a statistically significant association with HIV infection (p=0.013). 10 of 19 (53%) HIV-seropositives died, compared with 9 of 59 (15%) seronegatives (p=0.028). Of patients with pneumococcal meningitis, 5 of 6 (83%) seropositives died, compared with 2 of 12 (17%) seronegatives (p=0.013). 15 of 45 (33%) patients with pneumonia were HIV-seropositive compared with 4 (9%) in the control group (p=0.001). There was no difference in mortality between seropositive and seronegative patients with pneumonia. HIV seroprevalence was 62% among 42 patients with pyomyositis and 12% among 42 controls (p0.0001). 18 of 25 (72%) seropositive patients with pyomyositis fulfilled the WHO clinical case definition of AIDS. Response to recommended antibiotic treatment was satisfactory among patients with pneumonia and pyomyositis. These results show a strong association between pyomyositis, pneumonia, and HIV infection. They also indicate an increased mortality associated with HIV infection in those patients with pyogenic meningitis, especially pneumococcal meningitis. Pyomyositis should be considered an indicator of stage III HIV disease in the proposed WHO clinical staging system.
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PMID:High HIV seroprevalence and increased HIV-associated mortality among hospitalized patients with deep bacterial infections in Dar es Salaam, Tanzania. 138 10

Rhodococcus equi, an unusual gram positive aerobic actinomycete, was first described as a respiratory pathogen of livestock in 1923. Reports of human clinical illness have emphasized R. equi as a cause of invasive pulmonary infection in severely immunocompromised patients and, recently, have implicated it as a cause of pneumonia, bacteremia and disseminated infection in HIV-infected patients. To determine the distribution of R. equi we evaluated 107 isolates referred to the Centers for Disease Control (CDC) during the period January 1973 through December 1990. The sites of these 107 isolates (101 patient and 6 animal isolates) were: blood (32 isolates), sputum (30), lung tissue (13) and other site (32). Before 1983, when the first R. equi isolate from an HIV-infected patient was received, CDC received a total of 52 patient isolates. In addition, during this 10 year period, R. equi isolates were received from more than one site from only one patient. However, during the two year period 1989-1990, we identified 8 patients with underlying HIV infection and R. equi pneumonia who accounted for 29 of 35 (83%) R. equi patient isolates; 6 of these patients also had bacteremia and three died with disseminated R. equi infection. No isolates were resistant to amoxicillin-clavulanate, ampicillin-sulbactam, gentamicin or imipenem, and few (less than 5%) isolates were resistant to erythromycin, rifampin, tetracycline, and trimethoprim-sulfamethoxazole. These results suggest that HIV-infected patients, in particular, are predisposed to develop invasive pulmonary, fatal disseminated R. equi infection (or both), and appropriate antimicrobial susceptibility testing of clinical isolates may improve the effectiveness of therapy of R. equi-infected patients.
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PMID:Distribution and antimicrobial susceptibility of Rhodococcus equi from clinical specimens. 139 8

Toxoplasmosis is one of the major opportunistic infections observed in France in 15 to 37 percent of HIV-infected patients. Its main manifestation is encephalitis. Other, less frequent manifestations are chorioretinitis, pneumonia or disseminated toxoplasmosis. The conventional treatment is a combination of pyrimethamine 50-75 mg/day and sulfadiazine 6-8 g/day. Acute therapy should be pursued for at least 3 weeks or until optimal response is achieved, i.e. 6 to 8 weeks in most cases. The pyrimethamine-clindamycin combination in doses of at least 2.4 g/day is a possible alternative. Other drugs are being studied, but there is still a need for new drugs active against the parasite, that could be used in humans. In HIV-infected patients treatment should be maintained lifelong to prevent relapses. Maintenance regimens use the same drugs as acute therapy but in lower doses. The main field of research is primary prophylaxis of toxoplasmosis in HIV-infected patients.
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PMID:[Toxoplasmosis in AIDS]. 140 66

A 34-year-old HIV-infected man was successfully treated with antimicrobial therapy alone for Rhodococcus equi pneumonia and has survived longer than six months. In the current literature, only two of seven HIV-infected patients so treated have survived as long as six months. Based on our experience and the available literature, it seems reasonable to treat HIV-infected patients with R equi pneumonia who do not require surgical intervention with prolonged intravenous therapy followed by long-term oral therapy with at least two effective antibiotics. The optimal choice and duration of antibiotic therapy need to be determined.
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PMID:Successful medical therapy of Rhodococcus equi pneumonia in a patient with HIV infection. 142 10

The range of clinical presentations of HIV-related disease in Africa has not been adequately described, despite the fact that many hospitals have to rely heavily on clinical diagnosis. Six hundred adult medical patients seen in the Casualty Department of the main Government hospital in Nairobi were enrolled in a study of the presentation and outcome of HIV-related disease: 506 of these patients were admitted, of whom 19 per cent (95) were HIV seropositive. The remaining 94 were dealt with as outpatients: 11 percent (10) of these were seropositive. A history of prior treatment for sexually transmitted disease and, if male, being uncircumcised, were associated with being seropositive. Three presentations were strongly associated with HIV infection: acute fever with no focus except the gastrointestinal tract (enteric fever-like illness), acute cough with fever (community-acquired pneumonia) and chronic diarrhoea with wasting. The WHO clinical case definition (CCD) for AIDS missed a substantial amount of HIV-related morbidity (sensitivity 39 per cent) and misidentified many seronegative patients (positive predictive value 59 per cent). In comparison with the Centers for Disease Control surveillance definition for AIDS, the CCD was specific (91 per cent) and sensitive (79 per cent) but only had a positive predictive values of 30 per cent: the CCD may therefore be a poor surveillance tool for AIDS. Seropositive patients were much more likely to die than were seronegative patients (39 per cent vs. 15 per cent mortality). Enteric fever-like illness was the presentation which most commonly proved fatal. A wider spectrum of disease is associated with underlying HIV immunosuppression than has previously been described in Africa.
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PMID:The presentation and outcome of HIV-related disease in Nairobi. 143 66

4 cases of Pneumocystis carinii pneumonia in HIV-infected patients studied at the University of Zambia Medical School, Lusaka, were verified by bronchoalveolar lavage. Pneumocystis is common in North American AIDS patients, but has been considered rare in Africa. One reason may be that facilities for diagnosis, bronchoscopy with bronchoalveolar lavage, are not usually available. 44 consecutive HIV seropositive patients who were unresponsive to a 10-day course of antibiotics, and whose sputum was negative for acid fast bacteria, underwent bronchoalveolar lavage from February 1990 to December 1990. HIV status was assayed with Welcozyme ELISA kits, and P. carinii was detected with toluidine blue O stain. The 1st case of confirmed P. carinii pneumonia was a 35-year old man who had a productive cough for 4 weeks, fever, and dyspnea. He was treated with co-trimoxazole and was symptom-free in 3 weeks, but developed severe Stevens-Johnson reaction. His cultures were positive for M. tuberculosis at week 8. He was lost to follow-up. The 2nd case was a 26-year old man with a 6-month history of cough and white sputum, treated without effect with antituberculous medication. He improved over 3 weeks with co-trimoxazole, but died of respiratory failure 2 months later. The 3rd case was a 30-year old woman being treated for pulmonary tuberculosis, who became progressively dyspneic 7 months later. She developed a generalized maculo-papular rash after taking co-trimoxazole, so was given dapsone 100 mg/day, prednisone 1 mg/kg/day, and trimethoprim 15 mg/kg for 1 week. She improve in 3 weeks. The 4th case was a 30-year old man with a 4-week history of dry cough and dyspnea and recent high fever. He was given co-trimoxazole, but developed generalized purpura after 5 days. His treatment was changed to Dapsone 100 mg/day, prednisone 1 mg/kg/day, and antituberculous medication. He improved after 3 weeks, and is being maintained on Fansidar 1 tablet/week. These cases are remarkable because 2 of them also had pulmonary tuberculosis, which is often the presumed diagnosis of pneumonia in African AIDS patients. Furthermore, 3 developed serious drug reactions to co-trimoxazole, also considered an uncommon occurrence.
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PMID:Pneumocystis carinii as a cause of pneumonia in HIV-infected patients in Lusaka, Zambia. 144 Aug 16

Extrapulmonary infection with Pneumocystis carinii in AIDS patients on aerosolized pentamidine is occurring more frequently. We report five patients diagnosed with gastrointestinal pneumocystosis while on aerosolized pentamidine prophylaxis and have identified infections involving the peritoneum, liver, and transverse colon, as well as stomach and duodenum. Physicians should have a high index of suspicion for extrapulmonary pneumocystosis, especially involving the gastrointestinal system, in HIV-infected patients, and early diagnosis must be pursued aggressively. The use of aerosolized pentamidine as prophylaxis for P. carinii pneumonia is not protective against gastrointestinal pneumocystosis because of inadequate systemic distribution of the drug. To our knowledge, this is the first report in a clinical journal documenting and photographing P. carinii organisms in ascitic fluid.
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PMID:Gastrointestinal pneumocystosis in HIV-infected patients on aerosolized pentamidine: report of five cases and literature review. 831 27

To further characterize the clinical features, response to therapy, and outcome of Pneumocystis carinii choroiditis in patients with AIDS, we retrospectively reviewed the course of choroiditis for eight patients identified from two institutions through April 1991. Seven patients had prior Pneumocystis carinii pneumonia and had received aerosolized pentamidine prophylaxis for a median of 10 months; one patient had no prior history of pneumonia or prophylaxis. The median CD4+ lymphocyte count for six patients was 11 cells/mm3. Choroiditis was a preterminal diagnosis for three patients--two with associated disseminated pneumocystosis. Ocular manifestations improved or resolved with therapy for five of the six treated patients. All five subsequently received prophylaxis with dapsone (n = 2), dapsone/trimethoprim (n = 2), or aerosolized pentamidine (n = 1). Choroiditis recurred at 15 months in the one patient receiving aerosolized pentamidine. The median survival from time of diagnosis was 44 weeks. A literature review including an additional 40 cases support the conclusions that (a) Pneumocystis choroiditis is a rare complication of advanced HIV disease, occurring often in the context of systemic pneumocystosis; (b) ocular signs and symptoms may improve or resolve with specific antipneumocystis therapy; and (c) relapse may occur, particularly in those not receiving systemic prophylaxis.
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PMID:Pneumocystis carinii choroiditis in patients with AIDS: clinical features, response to therapy, and outcome. 145 21

A clinical AIDS case definition is needed for surveillance in countries where the CDC case definition is not practical. To derive such a definition, we compared 110 HIV-seropositive and 135 randomly selected HIV-seronegative adult medical-ward inpatients in Brazil. Multivariate analysis of clinical signs and symptoms and simple diagnoses resulted in a discriminant function with sensitivity of 89% and specificity of 96% in predicting for AIDS. These data were the empirical basis for a clinical definition of AIDS in adults drafted in a Caracas, Venezuela, workshop sponsored by the Pan American Health Organization. The revised "Caracas" definition presented here requires a positive HIV serology, the absence of cancer or other cause of immunosuppression, plus > or = 10 cumulative points, as follows: Kaposi's sarcoma (10 points); extrapulmonary/noncavitary pulmonary tuberculosis (10); oral candidiasis or hairy leukoplakia (5); cavitary pulmonary/unspecified tuberculosis (5); herpes zoster < 60 years of age (5); CNS dysfunction (5); diarrhea > or = 1 month (2); fever > or = 1 month (2); cachexia or > 10% weight loss (2); asthenia > or = 1 month (2); persistent dermatitis (2); anemia, lymphopenia, or thrombocytopenia (2); persistent cough or any pneumonia except TB (2); and lymphadenopathy > or = 1 cm at > or = 2 noninguinal sites for > or = 1 month (2). This definition has a sensitivity of 95% and a specificity of 100% (91% without HIV serology) when applied to the Brazilian patients in this study. The Caracas definition has been adopted by Brazil, Honduras, and Surinam, and is in validation elsewhere. The use of a reasonably sensitive and specific case definition commensurate with available diagnostic resources should facilitate AIDS surveillance in developing countries.
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PMID:A simplified surveillance case definition of AIDS derived from empirical clinical data. The Clinical AIDS Study Group, and the Working Group on AIDS case definition. 145 32

It would require a detailed knowledge of virology, molecular biology, epidemiology, clinical medicine and politics, to appropriately compare and contrast the hypotheses on the causes of AIDS. The purpose of this review was not to do that, but to inform colleagues that alternative etiologies for AIDS have been considered. No doubt, this healthy questioning will continue until it has been demonstrated--via controlled studies of high-risk groups (both HIV positive and negative), matched for all other characteristics--that only those individuals with HIV positivity actually develop AIDS. It cannot be denied that a common theme to the hypotheses is the presence of high-risk activities. This has been used against the risk-AIDS hypothesis. How, for example, could it explain babies born with immunodeficiencies, K. Bergalis contacting AIDS from her dentist, the British nurse who died of AIDS after contracting HIV from her husband, or AIDS in the wives of hemophiliacs? It may be that these people died of specific diseases (leukemia, pneumonia, infections), which 20 years ago would have been diagnosed as such. Now, because these individuals are found to be HIV positive, they are viewed as AIDS patients. Alternatively, they may not have been asked about their nutritional status, use of psychoactive drugs, and immunosuppressive sexual practices. Additionally, it is possible that by the time AIDS was diagnosed they may have already received numerous antibiotic (immunosuppressive) drug treatments. In North America, for whatever reason, AIDS is associated with high-risk groups.(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Does HIV cause AIDS? A review. 832 31


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