A prospective study on the outcome of human immunodeficiency virus-infected patients requiring mechanical ventilation in a high-burden setting.

BACKGROUND: There is a paucity of data on the mortality of patients admitted to the intensive care unit (ICU), despite the fact that human immunodeficiency virus (HIV)-related diseases represent a significant burden to health care resources particularly in sub-Saharan Africa. AIM: To describe the outcome and prognostic factors of HIV-infected patients requiring mechanical ventilation in an ICU. DESIGN: Prospective observational study. METHODS: All 54 patients (34.8 ± 10.4 years, 38 females) admitted with confirmed HIV from October 2012 until May 2013 were enrolled. Disease severity was graded according to APACHEII score. Admission diagnoses, clinical features and laboratory investigations, complications and outcomes were recorded. RESULTS: The mean length of ICU stay was 11.0 days (range: 1-49 days), and 33 patients survived (ICU mortality: 38.9%). The in-hospital mortality at 30 days was 48.1%. ICU mortality was associated with an AIDS-defining diagnosis (OR = 7.97, P = 0.003). Non-survivors had higher APACHEII scores (25.8 vs. 18.6, P = 0.001) and lower mean admission CD4 counts (102.5 vs. 225.2, P = 0.014). Multiple logistical regression analysis confirmed the independent predictive value of WHO stage 4 disease (P = 0.008), lower mean CD4 count on admission (P = 0.057) and higher APACHEII score (P = 0.010) on ICU mortality, and WHO stage 4 (P = 0.007) and higher APACHE II score (P = 0.003) on 30-day mortality. CONCLUSIONS: The ICU mortality of mechanically ventilated HIV-positive patients was high. WHO stage 4 disease and a higher APACHEII score were predictive of both ICU and 30-day mortality, whereas a low CD4 count on admission was associated with ICU mortality.

Tuberculosis in the intensive care unit: a prospective observational study.

SETTING: Data on the determinants of tuberculosis (TB) mortality in the intensive care unit (ICU) are scarce. OBJECTIVE: To describe factors influencing outcomes of patients admitted with TB requiring mechanical ventilation. DESIGN: All TB patients admitted to the ICU of an academic hospital in South Africa from January 2012 to May 2013 were enrolled. Disease severity was graded according to the Acute Physiology And Chronic Health Evaluation (APACHE II) score. Comorbid diagnoses, clinical features, radiological and laboratory investigations and outcomes were recorded. RESULTS: Of 83 patients (mean age 36.5 ± 12.9 years; 45 females; 44 human immunodeficiency virus [HIV] positive) admitted with pulmonary (n = 69) and/or extra-pulmonary (n = 37) TB, 39 died in the ICU (mortality 44.2%), and a further 10 died during hospitalisation (in-hospital mortality 59.0%). Few clinical parameters, special investigations or other ancillary tests predicted outcome. Only CD4 count <200 cells/mm(3) in HIV-co-infected patients (P = 0.043) and absence of lobar consolidation (P = 0.018) were associated with ICU mortality, whereas a high APACHE II score (22.6 vs. 18.1, P = 0.016) and development of renal failure (P = 0.016) were associated with hospital mortality. CONCLUSION: The mortality of TB patients admitted to the ICU was extremely high. Very few parameters were associated with poor outcome, and no single parameter predicted both ICU and in-patient mortality.

Usefulness of FDG-PET to diagnose intravascular lymphoma with encephalopathy and renal involvement.

Intravascular lymphoma (IVL) is a rare subtype of extranodal diffuse large B-cell lymphoma. It is characterized by proliferation of neoplastic Lymphoid cells almost exclusively within the lumina of small blood vessels. It can affect virtually every organ system. Due to its rarity and its diverse and heterogeneous clinical presentation, diagnosis is difficult and often made post-mortem. When diagnosed early, it is, however, potentially treatable. We present a young woman with longstanding constitutional symptoms, positive antinuclear antibody, elevated LDH levels and rapidly progressive encephalopathy. FDG-PET scan showed intense uptake in the renal cortex, which prompted us to perform a kidney biopsy which was compatible with IVL. The value of PET in establishing the diagnosis of this rare disease will be discussed.