Severe weight loss: the predominant clinical presentation of tuberculosis in patients with HIV infection in India.

BACKGROUND: Tuberculosis is endemic in India and its prevalence is reported to be increasing in patients with human immuno-deficiency virus (HIV) infection. Several factors, including the level of immune deficiency, influence the clinical presentation of HIV-associated tuberculosis. METHODS: Between April 1994 and April 1996, 1820 patients with confirmed HIV infection were studied for their clinical, radiological and laboratory parameters. Severe weight loss was observed as a frequent presenting complaint. Hence, a case-control analysis was performed using severe weight loss as the presenting criterion among HIV-seropositive patients. RESULTS: Of the 1820 patients with HIV infection, 410 (23%) presented with severe weight loss of > 10% of body weight within the preceding month. Of these 410 patients, 176 (43%) had tuberculosis, 94 (23%) had chronic diarrhoea, and 89 (22%) had recurrent fever. Among 176 patients with tuberculosis, the following types of HIV-associated tuberculosis were seen: 115/176 (66%) had pulmonary, 49/176 (28%) had extrapulmonary tuberculosis; of these 49 cases with extrapulmonary tuberculosis 33 (18%) had disseminated tuberculosis, and 12/176 (7%) had both pulmonary and extrapulmonary involvement. In the group as a whole, 45/176 (25%) cases had disseminated tuberculosis. Clinical features of HIV-associated tuberculosis in decreasing order of frequency were chronic fever, chronic cough, lymphadenopathy and hepatosplenomegaly. The Mantoux skin test was significantly anergic among patients with extrapulmonary and disseminated tuberculosis (p = 0.001). CONCLUSIONS: There was a significant correlation between severe weight loss and tuberculosis (RR 17.5), chronic diarrhoea (RR 12.8) and recurrent fever (RR 4.5). The diagnostic value of the Mantoux skin test among HIV-associated tuberculosis is reduced, more so among those with extrapulmonary and disseminated forms.

Pathology of the heart in acquired immunodeficiency syndrome.

The spectrum of cardiac lesions in patients with acquired immunodeficiency syndrome in India is not described. To determine the extent of involvement of the heart with this disease, an autopsy study of 52 subjects having acquired immunodeficiency syndrome was carried out. Multiple sections were obtained from different anatomical parts of each heart. Forty-eight of the 52 hearts showed subtle microscopic changes, the most common being myocardial atrophy (48 cases), lymphocytic pericarditis (38 cases), fibrinous pericarditis (1 case), pericardial fibrosis (1 case), lymphocytic myocarditis (29 cases) and myocardial fibrosis (7 cases). Cryptococcosis of the heart was noticed in two cases, while in one case toxoplasmic myocarditis was identified. In only one case clinical presentation of cardiac involvement (pericardial effusion) was noted, which indicates that in spite of the presence of significant pathology in the heart, overt cardiac manifestations are infrequently seen in patients with acquired immunodeficiency syndrome.

Toxoplasmosis of the central nervous system in the acquired immunodeficiency syndrome.

Acute encephalitis caused by Toxoplasma gondi was diagnosed at autopsy in 10 (20.4%) of the 49 patients. All patients had under lying immunodeficiency due to AIDS and showed selective involvement of central nervous system at autopsy. Sexual promiscuity was the risk factor in nine cases while one case had a history of blood transfusion. Diagnosis of toxoplasmosis was hampered by a lack of suspicion that Toxoplasma could be the agent causing necrotising encephalitis. The large number of cases of CNS toxoplasmosis appearing in AIDs patients emphasize the necessity of including toxoplasmosis in the differential diagnosis of encephalitis of unknown aetiology.

Cryptosporidium, isospora and strongyloides in AIDS.

BACKGROUND: Diarrhoea is a common presentation in patients with AIDS. It occurs due to a number of parasites which are seldom seen in immunocompetent hosts. METHODS: Between January 1993 and July 1994, faecal specimens from 77 patients with AIDS presenting with diarrhoea of more than a month's duration were examined by direct wet mount microscopy of saline and iodine preparations and by the modified Ziehl-Neelsen stain. RESULTS: Cryptosporidium, Isospora and Strongyloides stercoralis alone or in combination were present in 29 of the 77 patients. CONCLUSION: The presence of these parasites highlights their pathogenic potential for immunocompromised patients with AIDS. Diarrhoea due to Isosporais responsive to treatment, hence their identification has therapeutic implications as well.