Prevalence of adrenal insufficiency in critically ill patients with AIDS.

BACKGROUND: The most common endocrine disorder in patients with human immunodeficiency virus (HIV) is adrenocortical dysfunction. The prevalence of adrenal insufficiency in patients with AIDS is unclear; partly due to different tests, doses of adrenocorticotrophic hormone (ACTH), and criteria used. In addition, there is controversy regarding the assessment of adrenal insufficiency in patients with and without critical illness. OBJECTIVE: To help clarify the prevalence of adrenal insufficiency in patients with AIDS both in critical and non-critical illness, the authors compared the prevalence based on the high-dose ACTH stimulation test. MATERIAL AND METHOD: There were 26 patients with AIDS (19 males and 7 females) with a mean age of 33.6 years (range: 22-46 years). Twelve and 14 patients were in critical and non-critical illness, respectively. RESULT: Overall, the prevalence of adrenal insufficiency was 19.2% (5 of 26) and 30.8% (8 of 26) when a peak stimulated cortisol level of < 18 microg/dL and < 25 microg/dL was defined, respectively. The prevalence was 8.3% and 28.6% in critically and non-critically ill patients; respectively, when a peak stimulated cortisol level of < 18 microg/dL was defined. Finally, when a peak stimulated cortisol level of < 25 microg/dL was defined, the prevalence was 16.7% and 42.9% in critically and non-critically ill patients, respectively. CONCLUSION: Adrenal insufficiency in patients with AIDS is more prevalent than those without HIV infection, no matter what criteria of cortisol response after ACTH test are defined An adrenal testing should be performed in all hospitalized patients with AIDS, both in critical and non-critical illness.

Rapidly growing mycobacteria in King Chulalongkorn Memorial Hospital and review of the literature in Thailand.

Rapidly growing mycobacteria (RGM) have emerged as important human pathogens that can cause a variety of diseases. Thirty isolates of the pathogenic RGM were recovered from patients who attended King Chulalongkorn Memorial Hospital during 1997 and 2003. There were 16 isolates of Mycobacterium chelonae, ten isolates of M. fortuitum and four isolates of M. abscessus. Clinical data was available in only nine patients (five males and four females) including six M. chelonae, two M. abscessus, and one M. fortuitum. The mean age was 37 years (range: 13-62 years). The associated conditions were present in five patients including two diabetes, one HIV infection, one pregnancy, one SLE and one chronic renal failure. A wide spectrum of clinical features was observed. These included two chronic pulmonary infections, two post-traumatic wound infections, two disseminated infections, one lymphadenitis, one keratitis and respiratory colonization. AFB staining was positive in six patients (66.67%). The MIC of one M. chelonae and one M. abscessus were determined by Epsilon test. For M. chelonae, the MIC of clarithromycin, amikacin, ciprofloxacin, sulfamethoxazole and imipenem were 0.25, 2.0, 1.00, > 64, and 0.54 microg/ml, respectively. For M. abscessus, the MIC of clarithromycin, amikacin, ciprofloxacin, tetracycline and sulfamethoxazole were 0.016, 0.016, 0.038, > 16 and 0.002 microg/ml, respectively. Six of eight patients (75%) were initially treated with four first-line antituberculous drugs (isoniazid, rifampicin, pyrazinamide and ethambutol) before obtaining the culture result. Of these, three patients with pulmonary and disseminated infections improved after a prolonged course of these combinations. The patients improved after switching to specific anti-RGM antibiotics. One patient died after 10 months of therapy of four anti-tuberculous drugs. One patient with post-traumatic wound infection was cured with surgical debridement and dicloxacillin. One patient improved after treatment as acute bronchitis with oral amoxicillin. An extensive review of the literature of RGM infections in Thailand is also presented.