Community-acquired pneumonia due to Panton-Valentine leukocidin-producing Staphylococcus aureus in an HIV-2-infected patient.

Pneumonia caused by Panton-Valentine leukocidin-producing Staphylococcus aureus is associated with a high fatality rate. There have been few reported cases in HIV-1-co-infected patients. Here we report a fatal case of severe community-acquired pneumonia caused by Panton-Valentine leukocidin-producing S. aureus in a 45-year-old woman with HIV-2 infection.

The male sexual pain syndromes.

Pain provoked by sexual intercourse in men is a well-recognized symptom that has received surprisingly little attention in the medical literature and has rarely been the subject of systematic study. Sexual pain disorders have generally been considered in the context of the sexual dysfunctions, and in men have received much less attention than in women. Reports of male sexual pain lack use of a uniform definition for the condition. Sexual pain, especially ejaculatory pain, is a common feature of chronic prostatitis/chronic pelvic pain syndrome (CPPS). However, a range of physical and medical causes for sexual pain in men has been reported, usually in the form of isolated clinical reports. Our understanding of the aetiology and pathogenesis of male sexual pain is very limited, and systematic evaluations of treatment approaches are lacking.

Chronic vulval ulceration--another immune reconstitution inflammatory syndrome?

We describe a patient who developed intractable chronic vulval ulceration that we believe was related to immune reconstitution following treatment of HIV infection with highly active antiretroviral treatment (HAART). Immune reconstitution inflammatory syndrome should be considered in the differential diagnosis of unexplained vulval ulceration that arises after starting HAART.

HIV evolution: CTL escape mutation and reversion after transmission.

Within-patient HIV evolution reflects the strong selection pressure driving viral escape from cytotoxic T-lymphocyte (CTL) recognition. Whether this intrapatient accumulation of escape mutations translates into HIV evolution at the population level has not been evaluated. We studied over 300 patients drawn from the B- and C-clade epidemics, focusing on human leukocyte antigen (HLA) alleles HLA-B57 and HLA-B5801, which are associated with long-term HIV control and are therefore likely to exert strong selection pressure on the virus. The CTL response dominating acute infection in HLA-B57/5801-positive subjects drove positive selection of an escape mutation that reverted to wild-type after transmission to HLA-B57/5801-negative individuals. A second escape mutation within the epitope, by contrast, was maintained after transmission. These data show that the process of accumulation of escape mutations within HIV is not inevitable. Complex epitope- and residue-specific selection forces, including CTL-mediated positive selection pressure and virus-mediated purifying selection, operate in tandem to shape HIV evolution at the population level.

Chronic prostatitis and chronic pelvic pain in men: aetiology, diagnosis and management.

Patients with chronic prostatitis/pelvic pain syndrome typically report genital or pelvic pain (in or around the penis, perineum, scrotum) lasting > 3 months. Whereas true chronic bacterial prostatitis is an uncommon condition characterised by recurrent prostatic and urinary infection, chronic pelvic pain syndrome (CPPS) is a common condition in which no infection is found. Recent surveys suggest a prevalence of 2.5-3% for CPPS. The four-glass test, traditionally used to distinguish inflammatory and inflammatory forms of CPPS, has not been adequately validated; whether the distinction is clinically meaningful is increasingly questioned. The aetiology of CPPS is not known; urodynamic studies imply a neuromuscular origin. More recent work supports a role for proinflammatory cytokines in the pathogenesis. In the management of chronic bacterial prostatitis, trials support the use of quinolone antibiotics as first-line treatment. In contrast, the management of CPPS is generally unsatisfactory, as no reliable treatment has been identified. Treatments commonly tried include antibiotics (notably tetracyclines, quinolones and macrolides), anti-inflammatory agents, and alpha blockers. Newer approaches include trials of finasteride, quercetin and rofecoxib. A recent systematic review demonstrated that none of the current diagnostic and treatment methods for CPPS is supported by a robust evidence base.

Chronic prostatitis/chronic pelvic pain syndrome: national survey of genitourinary medicine clinics.

We sought to determine current practice in the diagnosis and management of chronic prostatitis/chronic pelvic pain syndrome (CPPS) in genitourinary medicine departments in the UK, using a detailed questionnaire survey. Evaluable responses were received from 147 (69%) clinics. Seventy-nine (54%) clinics reported seeing >10 new CPPS patients per year. A broad range of investigations was reported to be used in the diagnosis of CPPS. Whilst 89 (61%) clinics reported using the four-glass test in diagnosis, 46 (32%) reported using the test in >90% of patients with CPPS, and 42 (29%) reported never using the test. In the treatment, doxycycline or ciprofloxacin were reported to be first line treatment by 98% clinics, mostly in 4-6 week courses; however, great variation was recorded in second-line choices and use of non-antibiotic approaches. This survey demonstrates that patients with CPPS are regularly diagnosed and managed in genitourinary clinics in the UK, with wide variations in diagnostic and treatment practices.

Usefulness of handgrip to improve ibutilide efficacy in organizing atrial electrical activity during atrial fibrillation.

We analyzed the effect of handgrip on atrial electrical activity during atrial fibrillation (AF) by recording right and left atrial activity in 15 patients with persistent AF under baseline conditions and after saline and ibutilide infusions. The handgrip test for 15 seconds, which was always associated with a significant increase in mean atrial cycle length, was recorded in both atria (right atrium: saline vs saline + handgrip 141 +/- 29 vs 171 +/- 24 ms, p <0.001; ibutilide vs ibutilide + handgrip: 197 +/- 43 vs 221 +/- 39 ms, p <0.005). Handgrip favorably modifies atrial electrophysiologic properties during AF.

Automatic activity of a decremental long atrioventricular accessory pathway: an unusual feature.

The electrophysiological properties of decremental atrioventricular and atriofascicular pathways are not completely understood. We report the case of a patient with fast reentrant tachycardia due to a decremental long atrioventricular pathway, who showed a slow automatic tachycardia arising from the same pathway that was successfully eliminated by radiofrequency catheter ablation.

Lichen sclerosus in adult men: a study of HLA associations and susceptibility to autoimmune disease.

Lichen sclerosus is a skin disorder of unknown prevalence affecting both men and women, and several studies have established HLA associations in women with this disease. Autoimmune disease associations in the form of a personal and/or family history of autoimmune disease have also been shown to be related to lichen sclerosus. In this study, we examined 58 men (mean age 38 years) with lichen sclerosus, 39 of whom had histologically proven disease. HLA tissue typing by phototyping was performed on these patients and contrasted with that of 602 control subjects. There was no difference in antigen frequencies of the HLA class I loci. The patient group was found to have an increased frequency of several HLA antigens of the class II loci: DR11, 13 of 58 (22%) patients vs. 75 of 602 (13%) control subjects (P = 0.05); DR12, five of 58 (9%) patients vs. 16 of 602 (3%) control subjects (P = 0.04); DQ7, 26 of 58 (45%) patients vs. 189 of 602 (31%) control subjects (P = 0.05). There were few autoimmune disease associations: two of 58 (3%) patients had a personal history of a different autoimmune disease, two patients were found to have abnormal thyroid function and six of 58 (10%) had a first-degree relative with an autoimmune disease. There was no difference in the frequency of the autoimmune haplotype HLA A1, B8, DR3/17, DQ2 compared with the control population. HLA DQ7 has now been shown to occur more frequently in both male and female patients with lichen sclerosus, which may reflect the immunopathogenesis of the disease. Autoimmune disease associations, however, are less common in men with lichen sclerosus.

[Radiofrequency transcatheter ablation of a bidirectional decremental accessory atrioventricular pathway in the coronary sinus]. / Ablazione transcatetere mediante radiofrequenza di via accessoria atrioventricolare decrementale bidirezionale in seno coronarico.

We report the case of a 63-year-old patient who underwent radiofrequency catheter ablation of an atrioventricular accessory pathway with bidirectional decremental conduction properties. The successful ablation site was the distal end of a wedge-shaped dilation of the first tract of the coronary sinus. Atrioventricular accessory pathways with anterograde decremental conduction properties was thought to belong to fibers with Mahaim type electrophysiological properties. They rarely show decremental retrograde conduction properties. Most Mahaim type atrioventricular pathways are right-sided with atrial insertion points at various sites along the tricuspid ring. On the other hand, left-sided decrementally conducting accessory pathways are very rare. Mahaim type atrioventricular pathways were never found in the coronary sinus. The bidirectional decremental conduction properties and in particular the anatomic site of the atrioventricular accessory pathway we describe in the present report are both very interesting findings.

Rapid death of adoptively transferred T cells in acquired immunodeficiency syndrome.

Human immunodeficiency virus (HIV)-specific cytotoxic T lymphocytes (CTL) probably play the major role in controlling HIV replication. However, the value of adoptive transfer of HIV-specific CTL expanded in vitro to HIV+ patients has been limited: this contrasts with the success of CTL therapy in treating or preventing Epstein-Barr virus and cytomegalovirus disease after bone marrow transplantation (BMT). We investigated the fate of expanded HIV-specific CTL clones in vivo following adoptive transfer to a patient with acquired immunodeficiency syndrome (AIDS). Two autologous CTL clones specific for HIV Gag and Pol were expanded to large numbers (>10(9)) in vitro and infused into an HIV-infected patient whose viral load was rising despite antiretroviral therapy. The fate of one clone was monitored by staining peripheral blood mononuclear cells (PBMCs) with T-cell receptor-specific tetrameric major histocompatibility complex (MHC)-peptide complexes. Although the CTL transfer was well tolerated, there were no significant changes in CD4 and CD8 lymphocyte counts and virus load. By tracking an infused clone using soluble MHC-peptide complexes, we show that cells bearing the Gag-specific T-cell receptors were rapidly eliminated within hours of infusion through apoptosis. Thus, the failure of adoptively transferred HIV-specific CTL to reduce virus load in AIDS may be due to rapid apoptosis of the infused cells, triggered by a number of potential mechanisms. Further trials of adoptive transfer of CTL should take into account the susceptibility of infused cells to in vivo apoptosis.