HHV-8 DNA in blood and the development of HIV-associated Kaposi's sarcoma in the era of HAART--a prospective evaluation.

OBJECTIVE: To explore the significance of HHV-8 viremia in HIV-positive individuals for the risk of developing Kaposi's sarcoma (KS) in the era of highly active antiretroviral therapy. METHODS: 237 HIV-positive patients were included in this prospective evaluation and followed over an average duration of 34 months. HHV-8 DNA in peripheral blood mononuclear cells (PBMCs) and CD4-lymphocytes were determined. In addition AIDS-defining conditions and antiretroviral therapy were documented of all participating subjects. RESULTS: HHV-8 DNA was detectable in PBMCs of 12.6% out of all individuals. 53.3% of these patients initially complained about KS, although 9.2% of patients without HHV-8 DNA in PBMCs were found on KS as well. Furthermore, four patients in total were observed with newly developed KS during follow up visits. None of these patients were noted with detectable HHV-8 DNA at their initial evaluation. CONCLUSIONS: Prevalence of HHV-8 DNA in PBMCs of subjects in this investigation was quite similar to former investigations. However, new diagnosed KS occurred less frequently than demonstrated in previous studies. All of those observed patients with new KS manifestations were negative for HHV-8 DNA in PBMCs at study entry. This observation differs from earlier studies which have postulated the detection of HHV-8 DNA in PBMCs as a predictive value for development of KS. Due to results as presented, a single HHV-8 DNA test in blood has no predictive value in support of predictability of KS development. With respect toto costs and to a less complicated performance antibody assays should be preferred.

Remission of cutaneous Mycobacterium haemophilum infection as a result of antiretroviral therapy in a Human Immunodeficiency Virus--infected patient.

We describe the first Mycobacterium haemophilum infection that occurred in a patient with human immunodeficiency virus in Germany and report 7 newly diagnosed cases of M. haemophilum infection. In the former case, a local M. haemophilum skin infection resolved as a result of successful antiretroviral therapy only; however, that clinical outcome may not be possible for more invasive forms of the disease.

Remission of a cutaneous Mycosis fungoides after topical 5-ALA sensitisation and photodynamic therapy in a patient with advanced HIV-infection.

BACKGROUND: Treatment of Mycosis fungoides (MF) in HIV-infected patients is controversially discoursed. Photodynamic therapy (PDT) after topical sensitization with 5-aminolevulinic acid (5-ALA) is a new and effective modality for treatment of skin malignancies. OBJECTIVE: In this report we describe, what is, to our knowledge, the first case of a patient with MF through advanced HIV-infection, successfully experiencing topical 5-ALA sensitization and PDT. METHODS: 5-ALA ointment was applied to plaques and held in occlusion for 4 hours. PDT was applied using the PDT 1200 irradiation source (Waldmann Medizintechnik System) with 180 J/cm superset 2. RESULTS: Complete remission of MF was achieved, after two completed cycles of photodynamic therapy. CONCLUSION: MF lesions in the presended case showed a high response to 5-ALA sensitization and PDT. This modality appeared to be very effective in treatment of MF in a HIV-infected patient and could be a valuable treatment option for cutaneous T-cell lymphoma in HIV-infected patients.

POEMS syndrome: cicatricial alopecia as an unusual cutaneous manifestation associated with an underlying plasmacytoma.

POEMS syndrome is a rare condition with cutaneous manifestations commonly including angiomas, hypertrichosis, hyperpigmentation, and thickening of the skin. We describe a male patient with a 2-year history of cervical lymphadenopathy, erythematous thickening of the skin on the neck, and progressive walking difficulties. The patient had an occipital erythema with scarring alopecia and sparse follicular pustules at the edge of the lesion. Further investigation revealed symmetric polyneuropathy, hepatosplenomegaly, monoclonal gammopathy, subclinical thyreopathy, and an osteolytic bone lesion of the skull. Histologically, a plasmacytoma with lambda cell restriction was found. The overlying skin showed marked fibrosis, with loss of hair follicles, and a plasma cell infiltrate of polyclonal origin. The cervical lymph nodes showed histologic characteristics of multicentric Castleman's disease, and the skin of the neck showed thickening and vasoproliferation. There was no evidence of further plamacytomas. After excision of the plasmacytoma and postoperative irradiation, the symptoms gradually resolved within a few months. A cicatricial lesion remained on the occiput without further folliculitis or hair loss on the rest of the scalp. This case illustrates the reactive character of POEMS syndrome as a paraneoplastic syndrome in myeloma patients.

Umbilical endometriosis.

Cutaneous endometriosis is a well known but rare phenomenon. We present a case of spontaneous umbilical endometriosis. The patient revealed a polypoid, brown-blue nodule within the umbilical depression with the typical history of monthly bleeding from the umbilicus. The differential diagnoses are summarized.

Oesophagitis caused by Candida kefyr.

The unusual case of an oesophagitis caused by Candida kefyr in a patient with squamous cell carcinoma of the oropharynx is reported. The further implementation of C. kefyr in the production of milk products is discussed.

[Acanthosis nigricans maligna. Case report and review of the literature]. / Acanthosis nigricans maligna. Fallbeschreibung und Literaturübersicht.

More than 400 cases of acanthosis nigricans maligna (ANM) and 23 cases of "florid cutaneous papillomatosis" (FCP) were published. ANM is an obligatory paraneoplastic symptom. A 28-year old female patient with an adenocarcinoma of the stomach presented with ANM. We review the number and types of associated cancer with ANM. In most cases and adenocarcinoma of the gastrointestinal tract has been present. We feel that FCP is not an entity of its own but a variant of ANM; the literature supports this view.

Increased risk for opportunistic infections during chemotherapy in HIV-infected patients with Kaposi's sarcoma.

BACKGROUND: Kaposi's sarcoma (KS) is the most frequent neoplasm in patients with AIDS, responsible for death in about 20-30% of the affected patients. OBJECTIVE: To determine the frequency of opportunistic infections (OI) and change of CD4+ cell counts in patients with KS treated with chemotherapy compared to a group of matched-pair patients without chemotherapy. METHODS: In a prospective study, the clinical courses of 35 HIV-infected patients with KS treated with chemotherapy were compared with 35 matched-pair patients without chemotherapy. RESULTS: During the observation period of 6 months, 11 OI occurred in 10 patients of the chemotherapy group and 5 OI in 5 patients of the control group. With respect to the changes of CD4+ cell counts, no significant differences could be observed. CONCLUSION: The risk for OI in HIV-infected patients with KS is increased while receiving chemotherapy. This should be reflected upon when chemotherapy is taken into consideration.

How safe is oral isotretinoin?

Since oral isotretinoin (Roaccutane/Accutane) is the only therapy to address all major acne causes, it remains the most effective antiacne therapy available. Due to this unique efficacy and its potential side effects that are predictable and can be managed easily and effectively, it is widely used also in acne patients suffering from serious systemic diseases. As the primary mechanism of action of oral isotretinoin is suppression of sebaceous gland activity, mucocutaneous side effects such as dry lips, nasal passages and eyes are predictable. Pretreatment counseling and concomitant use of moisturizing agents usually manage these side effects effectively; in unusual cases of particularly poor tolerability, dose adjustments suffice. Severe side effects are rare, the most common being aches and pains requiring no therapy, aspirin or paracetamol. As with other retinoids, reliable contraception is mandatory for women of childbearing potential. Acne patients with serious concomitant systemic disease, such as insulin-dependent diabetes, epilepsy or spina bifida, transplant patients, patients with renal failure, multiple sclerosis motor neuron disease and other can also safe be treated with a standard cumulative dose of 120 mg/kg per treatment course.

[Systemic treatment of acne with isotretinoin: current status]. / Systemische Behandlung der Akne mit Isotretinoin: Aktueller Stand.

Introduced in 1979, isotretinoin remains a major advance in acne therapy. Both hospital- and community-based dermatologists have experience with this valuable drug, which, owing to its causal principle of action, offers a large proportion of patients the prospect of a cure. Isotretinoin is now in use in more than 80 countries and has been prescribed for some six million patients. Based on accumulated clinical findings with the drug, more comprehensive recommendations can now be made with respect to indications, dosing and duration of treatment than was possible when the drug was launched. Experience with the drug also provides a basis for reevaluating its safety profile. Finally, at a time when healthcare resources are limited, it is important to examine the cost-benefit ratio of this acne treatment versus other options. This paper is accordingly intended to provide a critical status report as well as a detailed and balanced set of recommendations for clinical practice.

Geotrichosis of oral mucosa.

A livid, sharply defined enanthema of the oral mucosa with ulcerations on the soft palate in a patient presenting with de novo acute myeloid leukaemia with prolonged, therapy-induced granulocytopenia (< 0.5 nl-1 for 113 days!) was diagnosed as geotrichosis. Geotrichum capitatum was identified both in vivo and in vitro. Pneumonic infiltrates in the upper lobes of both lungs were treated with amphotericin B infusions. Healing of the aforementioned enanthema was only achieved after addition of 5-fluorocytosine to therapy. Susceptibility determinations with several Geotrichum capitatum isolates led to the conclusion that amphotericin B was unsuitable as a therapeutic agent in this case. 5-Fluorocytosine and itraconazole exhibited superior antifungal and antimycotic activity.

[HIV-associated mycoses]. / HIV-assoziierte Mykosen.

Candidosis, cryptococcosis, and histoplasmosis often occur as HIV-associated mycoses. However, aspergillosis can be observed quite recently. The morphology of the pathogen of HIV-associated mycoses in vivo and in vitro is demonstrated and discussed.

[Bacillary angiomatosis]. / Bazilläre Angiomatose.

Bacillary angiomatosis (BA) is a rare infectious disease usually associated with HIV infection. Recent molecular biologic investigations confirm that both Rochalimaea henselae and Rochalimaea quintana can cause BA. The bacteria can be identified by Warthin-Starry staining and electron microscopy. The typical clinical signs are solitary or multiple dermal or subcutaneous nodules. Bone, liver, spleen and other organs may also be involved. We describe the clinical and histological features of a 39-year-old HIV-infected patient with cutaneous and bony lesions of BA. All manifestations of BA disappeared during therapy with erythromycin.

[Primary and secondary prevention of Pneumocystis carinii pneumonia with pentamidine aerosol. Effectiveness, side effects and incidence of extrapulmonary Pneumocystis carinii manifestations]. / Primäre und sekundäre Prophylaxe der Pneumocystis-carinii-Pneumonie mit Pentamidin-Aerosol. Wirksamkeit, Nebenwirkungen und Häufigkeit der extrapulmonalen Pneumocystis-carinii-Manifestation.

BACKGROUND: We report on a retrospective study in 544 HIV-positive patients, (42 women, 502 men, mean age 35 years) showing CD4 lymphocyte counts below 200 c/mcl or after their cure of Pneumocystis carinii pneumonia, who received 300 mg pentamidine aerosol as prophylaxis against Pneumocystis carinii pneumonia every four week. PATIENTS AND METHODS: 277 patients were asymptomatic, 120 in the AIDS related complex stage (ARC) and 147 in the full stage of AIDS. The mean follow-up was 14.4 months. RESULTS: A total of 25 cases of Pneumocystis carinii pneumonia was observed (3.83/year): in the primary prophylaxis group 18 (3.25%/year), in the secondary prophylaxis group seven (6.8%/year). By introducing the loading dose (one inhalation per day for five consecutive days for patients with CD4 cell counts below 150 c/mcl) we reduced the percentage of early manifestations within the first three months from 61% to 14%. No extrapulmonary Pneumocystis carinii manifestation was observed. CONCLUSION: This study supports the efficacy of pentamidine aerosol prophylaxis of primary and secondary Pneumocystis carinii pneumonia.

Fluconazole therapy of oral candidiasis in HIV-infected patients: results of a multicentre study.

In an open phase-III study 103 HIV-positive patients with oral candidiasis were treated with oral fluconazole 100 mg/day for 7-21 days (mean 12.2 +/- 6.1 days). Ninety per cent of the patients presented with the full clinical picture of AIDS, in 83% CD4-lymphocytes were < 100/mm3. Clinical and mycological (smear and mouth rinsing) examinations were performed at the start of therapy, after weeks 1, 2, and 3, and at the end of therapy. The clinical findings showed fluconazole therapy to have achieved cure in 71% of the patients and improvement in 16%. Therapy failed in 13%. Mycological tests revealed elimination in 57% and reduction in colony counts in 23% of patients. Therapy failure according to mycological criteria was observed in 20% of all subjects. Adverse events were recorded for 26% of all patients. A causal connection with study therapy was considered as "unlikely" in 20 cases, "questionable" in 17 cases, and "likely" in three cases. Premature discontinuation of fluconazole therapy was required in seven patients, in three of them because of adverse events due to fluconazole. Even in patients with advanced HIV infection and consequently severe immunodeficiency, fluconazole is an important improvement of the therapeutic spectrum.