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Query: UMLS:C0019693 (HIV)
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The approach to the HIV-infected patient with pulmonary disease is summarized by the algorithms in Figures 3 and 4. These are not intended to be followed in a rigid step-wise fashion. Rather, the practitioner's knowledge of the patient with his or her accompanying medical risks influences the path taken, including the depth and the speed of the evaluation. For example, the patient with cough who is afebrile and breathing at 18 breaths a minute, with a normal chest radiograph and a CD4 count of 350 cells/mm3, is reasonably treated with a macrolide or cephalosporin for bacterial bronchitis and clinical follow-up while awaiting cultures (see Fig. 4). A febrile patient with a cough productive of thin mucus, but known to have a CD4 count of 60 cells/mm3 should be started on anti-PCP therapy while being evaluated for PCP with an induced sputum and if nondiagnostic, a bronchoscope despite a normal chest radiograph. Screening can be as simple as placing an oximeter on the patient's finger in the clinic. If the oxygen saturation of a patient with a normal chest radiograph is low, then the patient should be hospitalized and begun on treatment for PCP while diagnostic evaluation is initiated. If the oxygen saturation is normal, the patient can be exercised to elicit desaturation. If there is no desaturation, PCP is unlikely. If the results are equivocal (i.e., a decrease in saturation, but less than 3%), rest and exercise arterial blood gases can be performed, along with a Dlco-Gallium scanning can be done in patients known to have abnormal Dlco or those who cannot exercise. Patients with focal infiltrates who have acute onset of symptoms (see Fig. 4) commonly have bacterial infections, but the possibility of PCP or TB should not be dismissed. Induced sputum should be examined if TB or PCP is suspected. Patients who are severely ill might go quickly to bronchoscopy without awaiting improvement on empiric therapy. The patient with diffuse infiltrates (see Fig. 4) needs no screening because the presence of disease is apparent from the radiograph. The diagnostic part quickly leads to bronchoscopy for these patients and the initiation of therapy for PCP when suspected. In patients with known pulmonary KS, gallium scanning can be helpful to rule out acute infection, but bronchoscopy is warranted if the patient is severely ill, or at high risk for PCP. This approach should avoid unnecessary procedures in patients with simple bacterial infections, without missing opportunistic infections and tumors.
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PMID:Approach to the patient with pulmonary disease. 901 78

We examined the effects of travel on the health of a group of HIV-infected adults (n = 89) cared for in a public hospital HIV clinic. In a period of 2 years, 45% travelled to a median of 3 US destinations for at least one week and 20% travelled to at least one international destination for a mean duration of 20 days. At the time of completion of the survey, the majority of these patients were severely immunosuppressed (median CD4+ count, 120/mm3). A physician was consulted concerning travel before 53% of the trips, but only one person consulted a travel medicine expert. All but one patient (98%) who was receiving medical therapy carried sufficient supplies of medication; 95% estimated their compliance with medication at 75% or better. None of the travellers to developing countries received gamma globulin, but one received yellow fever vaccine. Fifteen travellers (43%) became ill either during their trip or immediately thereafter; 3 required hospitalization. While most illnesses were not severe, 4 patients developed potentially life-threatening infections including coccidioidomycosis, cryptococcosis, PCP, and bacterial pneumonia. This survey provides information by which the clinician can anticipate the health care needs of HIV-infected patients who travel. HIV-infected patients should be more aware of the necessity for medical counsel prior to travel.
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PMID:Travels with HIV: the compliance and health of HIV-infected adults who travel. 904 81

The study evaluated the overall survival after AIDS diagnosis of 1,014 patients reported to the Italian AIDS Registry as resident in Tuscany, stratified by age, gender, year of diagnosis, HIV transmission category, initial AIDS-defining disease and CD4+ cells count. The study was a population-based survival analysis, carried out through Kaplan-Meier method (mean survival times-MST-, 1, 2 and 3-year observed survival) and Cox models (crude and adjusted relative risk-RR). The MST was 12.4 months for all cases, increasing from 4-7 months in 1985-1987 to 14 months in 1991-1992. The observed survival was 51.4% at the first year of follow-up, 28.4% at the second year and 14.5% at the third year. The multivariate analysis showed an independent prognostic effect of age, year of diagnosis, initial AIDS-defining disease and CD4+ cells count. The prognosis was worse in cases aged over 44 (reference: 25-29), diagnosed before 1988 (reference: 1991) and with wasting syndrome, toxoplasmosis, HIV encephalopathy or multiple diseases (reference: PCP alone); and better in cases with more than 100 CD4+ cells/mm3 (reference: < or = 50 cells/mm3). The differences in gender and among HIV transmission categories disappeared after age-adjustment. The study confirmed, in an European population-based series, the poor long-term AIDS prognosis and, once AIDS has became clinically manifest, the prognostic value of some clinical and demographic variables.
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PMID:Survival after AIDS diagnosis in Tuscany (Italy), 1985-1992. 908 93

Adverse drug reactions to trimethoprim-sulfamethoxazole (TMP/SMX) are common in HIV-positive patients. However, only one case of TMP/SMX-related rhabdomyolysis has been reported, so far. We report a 55-year old-man with asymptomatic rhabdomyolysis after oral high-dose TMP/SMX for suspected PCP. Laboratory changes settled after discontinuation of the drug.
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PMID:Mild rhabdomyolysis after high-dose trimethoprim-sulfamethoxazole in a patient with HIV infection. 915 43

Procalcitonin (ProCT) is a recently described marker of severe sepsis. It was decided to assess the value of proCT as a marker of secondary infection in patients infected with HIV-1. ProCT plasma levels were measured by immunoluminometric assay in a prospective study in 155 HIV-infected individuals: 102 asymptomatic and 53 with lever or suspected secondary infections. The baseline plasma level of ProCT was low (0.5 ng/ml +/- 0.37), even in the latest stages of the disease, and did not differ from the values of healthy subjects (0.54 ng/ml +/- 0.08). EDTA-treated whole blood was collected from patients before starting specific antimicrobial therapy. No elevation of ProCT level was detected in HIV-infected patients with evolving secondary infections including PCP (n = 4), cerebral toxoplasmosis (n = 4), viral infections (n = 9), mycobacterial infections (n = 5), localized bacterial (n = 12) and fungal infections (n = 4), malignancies (n = 3), and in various associated infectious and non-infectious febrile events (n = 13). All these plasma values were lower than 2.1 ng/ml. In contrast, high ProCT plasma levels were detected in one HIV-infected patient with a septicaemic Haemophilus influenzae infection (16.5 ng/ml) and another one with a septicaemic Pseudomonas aeruginosa infection (44.1 ng/ ml), ProCT values decreased rapidly under appropriate therapy. ProCT seems to be a specific marker of bacterial sepsis in HIV-infected patients, as no increase in other secondary infections could be detected in those patients. A rapid determination of ProCT level could be useful to confirm or refute bacterial sepsis for a better management of febrile HIV-infected patients.
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PMID:Procalcitonin as a marker of bacterial sepsis in patients infected with HIV-1. 927 23

In a randomized double blind placebo controlled trial, HIV sero-positive patients with CD4+ cell count less than 200 x 10(6)/l or an AIDS diagnosis were evaluated for drug reactions to trimethoprim-sulphamethoxazole (TMP-SMX) during treatment, including pretreatment, with N-acetylcysteine (NAC) 800 mg daily or placebo. TMP-SMX (one double-strength tablet containing 160 mg of trimethoprim and 800 mg of sulphamethoxazole) was given three times weekly as primary Pneumocystis carinii (PCP) prophylaxis. Thirty percent (n = 15) of the patients experienced adverse reactions 8-20 (mean 12.7) days after starting with TMP-SMX. At entry, low cysteine and glutathione levels in plasma were found in the HIV-positive patients. Age, sex, CD4+ count, plasma cysteine and glutathione levels were not risk factors for adverse reactions to TMP-SMX. However, concomitant therapy with nucleoside analogues was associated with increased risk for TMP-SMX reactions. Oral NAC 800 mg daily was well tolerated, but replenished neither cysteine nor glutathione levels in plasma. NAC 800 mg/day did not significantly decrease the risk of adverse reactions to TMP-SMX in this study, and could thus not be recommended for this purpose. A prolonged pretreatment period and/or higher dose of NAC may be necessary for clinical effect.
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PMID:N-acetylcysteine treatment and the risk of toxic reactions to trimethoprim-sulphamethoxazole in primary Pneumocystis carinii prophylaxis in HIV-infected patients. 935 48

In a case-control study, prophylaxis with cotrimoxazole for toxoplasmic encephalitis (TE) in HIV-infected patients was evaluated. Cotrimoxazole had been given as PCP prophylaxis. 20 patients with TE were identified and 72 matching control cases were found. All patients had IgG-antibodies to Toxoplasma gondii and CD4+ T-cell counts < or = 100/microliter. The use and duration of cotrimoxazole prophylaxis were recorded. It was found that among the patients with TE, none had used cotrimoxazole for > 70% of the observation time, and that the 1-y incidence was 0% in the control group vs. 41% in those patients without sufficient cotrimoxazole use. The conclusion is that cotrimoxazole is effective as primary prophylaxis for TE, even in a dose of 480 mg daily.
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PMID:Cotrimoxazole is effective as primary prophylaxis for toxoplasmic encephalitis in HIV-infected patients: a case control study. 943 40

Oropharyngeal washings (Ophs) from 27 HIV infected patients (18 with P. carinii pneumonia, PCP, and 9 without PCP) were examined for P. carinii using morphological staining and DNA amplification with PCR-SHELA and nested PCR methods. The comparison of these techniques shows that 1. the amplification of P. carinii DNA is more sensitive than (and as specific as) morphological staining; 2. PCR-SHELA is less sensitive than (and as specific as) nested PCR.
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PMID:Detection of Pneumocystis carinii in oropharyngeal washings by PCR-SHELA and nested PCR. 950 33

The first case of AIDS in India was reported in 1986. Subsequently, a surveillance system was developed in 1987. The data from this surveillance activity suggest that the HIV infection has now spread to the general population and to all parts of the country, except Arunachal Pradesh in North-eastern India. With the changing scenario of the AIDS epidemic, a host of opportunistic infections add to the present endemic state of some already existing infections like tuberculosis. This report analyses the AIDS cases in India, reported to the National AIDS Control Organization over the years between 1986 to 1997. A total of 3,551 AIDS cases had been reported till 31st May 1997. Tuberculosis (pulmonary and extrapulmonary) is the major opportunistic infection affecting 62% of the cases followed by candidiasis seen in 57% of the patients. In 1997, of the 390 AIDS cases analysed, tuberculosis (pulmonary and extrapulmonary) accounted for 56.5% of the total cases whereas candidiasis was seen in 61% of the cases. An increasing trend was observed with tuberculosis from 58% in 1986-1992 to 68.5% in 1995. No trend could be established in the case of candidiasis, though, a high prevalence of 66% was seen in the cases between 1986 and 1992. An increase was also observed in cases of PCP, cerebral toxoplasmosis and Kaposi sarcoma. In the AIDS cases, chronic diarrhea (76%), weight loss (87%) and fever (85%) appeared to be the major presenting symptoms. But, of the 390 AIDS cases reported in 1997, only 47% of them were suffering from chronic diarrhea. With increase in the number of AIDS cases, India is burdened with a dual epidemic of HIV/AIDS and tuberculosis. The National AIDS Control Organization in India, is involved in training clinicians and laboratory personnel in the diagnosis and management of the AIDS cases. With better diagnosis of the opportunistic infections, especially diarrhea, in AIDS patients, a better picture will emerge regarding the opportunistic infections which would help clinicians and health planners to tackle the AIDS epidemic in a more effective manner.
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PMID:AIDS in India: recent trends in opportunistic infections. 988 31

The objective of this study was to assess the value of quantitative HIV-1 RNA as a predictor for the short-term risk of developing AIDS-defining events in comparison with CD4 cell counts. A total of 1,028 samples from 324 patients were analysed. Median initial CD4 cell counts and HIV-1 RNA were 249 x 10(6)/l (range 0-1400 x 10(6)/l) and 4.5 log copies/ml (range: 2.3-6.4 log copies/ml). CD4 cell counts and viral load (VL) values obtained the year before a single AIDS-indicator disease were selected to define the risk of developing that event. Cox regression models with CD4 cell counts and VL values treated as time-dependent covariates were performed to analyse the risk for developing certain events. Receiver operating characteristic (ROC) curves were used to compare CD4 cell counts and VL values as predictive markers for progression. During a median follow-up of 870 d (range 30-1381 d), 132 patients developed AIDS. Median log VL values during the year before the event were 3.6 for non-progressors and 5.2 for those who developed AIDS (p < 0.0001). Minimum log VL threshold values for developing diseases were 2.3 for tuberculosis, 3.8 for Candida esophagitis, 4.4 for wasting syndrome, 4.5 for CMV disease and 4.7 for PCP. VL values were not, however, a better predictive marker for developing specific events than were CD4 cell counts. Although we have identified VL thresholds for the risk of developing certain AIDS-indicator diseases, the indication for starting prophylactic regimens may still be based on CD4 cell counts.
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PMID:Short-term risk for AIDS-indicator diseases predicted by plasma HIV-1 RNA and CD4+ lymphocytes. 1038 Dec 16


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