Infective endocarditis not related to intravenous drug abuse in HIV-1-infected patients: report of eight cases and review of the literature.

OBJECTIVES: To add to the limited information on infective endocarditis (IE) not related to intravenous drug abuse (IVDA) in HIV-1-infected patients. METHODS: We have reviewed the characteristics of eight cases of IE in non-IVDA HIV-1 infected patients diagnosed in our institution between 1979 and 1999 as well as cases in the literature. RESULTS: All our patients were male, and the mean age was 44 years (range 29-64). HIV-1 risk factors were: homosexuality in five, heterosexuality in two, and the use of blood products in one. HIV stage C was found in six cases, and the median (range) CD4 cell count was 22/microL (4-274 cells/microL). IE was caused by Enterococcus faecalis in three cases, staphylococci in two cases, and Salmonella enteritidis, viridans group streptococci and Coxiella burnetii in one case each. Three patients acquired IE while in the hospital. All IE cases involved a native valve, and underlying valve disease was found in three patients. The aortic valve was the most frequently affected (five cases). Two patients underwent surgery, with a good outcome, and one patient died. Fourteen cases of IE not related to IVDA in HIV-1-infected patients were found in the literature review. The most common causative agents were Salmonella spp. and fungi (four cases each). Two patients had prosthetic valve IE, and the mitral valve was the most frequently affected (10 cases). The remaining clinical characteristics and the outcome were similar to those in the present series. CONCLUSIONS: IE not related to IVDA is rare in HIV-1-infected patients. In more than half of the cases, IE develops in patients with advanced HIV-1 disease. A wide etiologic range is found, reflecting different clinical and environmental conditions. None of the patients who underwent surgery died, and the overall mortality rate was not higher than in non-HIV-1-infected patients with IE.

Las infecciones en los pacientes con trasplante de órganos sólidos

Las infecciones en los pacientes trasplantados son más frecuentes y habitualmente más graves, con mayor tendencia a la diseminación y con patrones en ocasiones diferentes que en la población general. En esta revisión se expone una evaluación pre y postrasplante, desde el punto de vista cronológico, de las infecciones más frecuentes y de las medidas preventivas. Con la generalización de los trasplantes de órgano sólido y la mayor supervivencia de los pacientes, cada vez con más frecuencia los médicos de cabecera deberán asistir al control, prevención y tratamiento de estas infecciones y diferenciar los episodios banales de aquellos que exigen una rápida y más compleja evaluación, y a veces un ingreso hospitalario. El médico de cabecera puede colaborar con el equipo de trasplante al derivar a un paciente para evaluación a través de una historia clínica cuidadosa y la realización de algunos exámenes previos. Algunos pacientes pueden ser complejos por sus antecedentes, factores de riesgo y las posibles interacciones farmacológicas que se pueden ocasionar con nuevos medicamentos, por lo que una fluida comunicación entre el médico de cabecera y el especialista del equipo de trasplantes del hospital es fundamental para asegurar una buena calidad de atención al paciente. Algunas recomendaciones sencillas en cuanto a vacunaciones, comidas y protección contra la exposición pueden ser muy efectivas para evitar infecciones potencialmente serias. La introducción de nuevos fármacos inmunodepresores y nuevas estrategias profilácticas van a cambiar el espectro de infecciones a mediano plazo y probablemente aumentar aún más la supervivencia y calidad de vida de los pacientes portadores de algún órgano trasplantado (AU)

[Intestinal parasitic infections and leishmaniasis in patients with HIV infection]. / Infecciones parasitarias intestinales y leishmaniosis en pacientes con infección por el VIH.

Intestinal parasite infections are very frequent in HIV patients with severe immunodeficiency (CD4 < 100/mm3) causing chronic diarrhea and malabsorption in the majority of cases. The most frequent microorganisms are microsporidia and Cryptosporidium parvum while Cyclospora cayetanensis and Isospora belli are more prevalent in subtropical and tropical areas and rare in industrialized areas. The diagnosis can be obtained by stool examination (differences in size and form of cysts), although microsporidia is frequently demonstrated by intestinal biopsy and/or duodenal aspirate. The treatment with cotrimoxazole for C. cayetanensis and I. belli is very effective and does not present any problems in the acute phase, however, due to a high percentage of relapses the treatment must be maintained while the patient is in a severe immunodeficiency state. E. intestinalis usually responds satisfactorily to albendazole while E. bieneusi is resistant to some drugs except in some cases (albendazole, atovaquone ad fumagillin). C parvum is also resistant to most medicaments but shows an adequate or partial clinical: response to paramomicine (< 50%). When there is no response, it is advised to administer octreotide since in half the cases the response is positive either total or partial. Nowadays with the use of protease inhibitors in the antiretroviral treatment a decrease in the incidence of these infections has been observed (microsporidia and C. parvum) even in the stools samples taken from the patients who had them before. As primary prophylaxis for C. parvum, it is better to avoid been exposed to the microorganism taking into account the 1997 preventive measures recommended by the USPHS/IDSA Prevention of Opportunistic Infections Working Group. The coinfection Leishmania-HIV is frequent in the mediterranean area. The most common specie is L. infantum. The incidence is most frequent in immunosuppressed patients (CD4 < 200 mm3) and in parenteral drug addicts. The symptomatology is similar to the one from immunocompetent patients, although in some cases it appears to be subclinical. A chronic development with relapses is frequent. The most effective diagnostic method for the finding of the parasites is thru bone marrow puncture and the culture in Novy-McNeal-Nicolle (NNN) medium. Serological tests have a low sensibility and the PCR is useful in asymptomatic cases, for therapeutical control and in relapses. The treatment is similar to that of immunocompetent patients, using primarily antimonials or amphotericine B (standard or lipid or liposomal forms). Relapses are very frequent, therefore, it is important to perform a secondary prophylaxis. However, no treatment has been completely effective. Mortality rate is high (approximately 25%) during the first month after diagnosis. This fact may be related to the severe immunodeficiency state and/or to the toxicity of the drugs used. The main priority for the future is to find a first line treatment with higher efficacy, decrease in relapses and a lower toxicity.

[Chronic enteropathy of unknown etiology in patients with AIDS. An analysis of 40 cases]. / Enteropatía crónica de etiología desconocida en pacientes con SIDA. Análisis de 40 casos.

BACKGROUND: Data about the etiology of chronic enteropathy in AIDS patients are scarce and are very dependent upon the geographical area. The aim of this study was to detect microorganisms potentially associated with chronic enteropathy in AIDS patients with diarrhoea for more than one month, and initial negative routine stool bacterial cultures and examinations for ova and parasites. The degrees of associated intestinal malabsorption and immunodeficiency were also analysed. PATIENTS AND METHODS: Forty consecutive patients were recruited from January 1993 to December 1994. The following studies were performed: Intestinal absorption tests (d-xylose and 14C-triolein), CD4/CD8 cell counts, microbiological studies (standard stool cultures for detection of bacteria and examinations for ova and parasites including the detection of Enterocitozoon bieneusi spores by the Weber's stain), upper gastrointestinal endoscopy or colonoscopy with intestinal biopsies and blood cultures for CMV and mycobacteria. RESULTS: The median duration of diarrhoea was 4 months and the mean weight loss was 8.4 kg. Ninety percent of patients had less than 0.1 x 10(9) CD4+ cells/l, with a mean CD4+ cell count of 0.035 x 10(9)/l. Malabsorption was found in 84% of patients. An etiological diagnosis of chronic enteropathy was reached in 60% of the patients. The yield of pathological examination was 37% and the microbiological test using samples of faeces and blood were positive in 45% and 20% of cases respectively. The most frequently identified microorganisms were CMV (10 cases), E. bieneusi (9), enterobacteria (8), Cryptosporidium parvum (5), Leishmania donovani (2). Patients with enteropathy caused by E. bieneusi had lower count of CD4 cells (p = 0.005) and with higher serum levels of alkaline phosphatase (p = 0.02) than patients with CMV enteropathy. CONCLUSIONS: Stool Weber's stain and CMV and mycobacterial blood cultures should be added to the standard work-up diagnosis in patients with chronic diarrhoea and a CD4+cells count below 0.1 x 10(9) l. Upper and/or lower gastrointestinal endoscopies with intestinal biopsies should be performed only in patients with persistent diarrhea without microbiological diagnosis or a lack of response to treatment.

[The efficiency of organizational measures in improving the management of the prior appointment program]. / Efectividad de medidas organizativas en la mejora de la gestión del Programa de Cita Previa.

OBJECTIVES: To estimate the organisational impact of the volume of appointments processed in the Primary Care (PC) Administration Units (AU) of Area 10, and to evaluate the effectiveness of organisational measures to correct the excess of appointments processed at particular times of day. DESIGN: Before-and-after intervention study. SETTING: AU of 16 PC teams from Madrid's Area 10. PARTICIPANTS: All the appointments made for users by 78 clerks in the 16 AU in the Area during the two weeks of the study. INTERVENTIONS: Strengthening of administrative staff dealing with the appointment system; and an information campaign for users about the system. MEASUREMENTS AND RESULTS: The percentage of appointments processed by AU was broken down for morning and afternoon, by the way the appointment was made (telephone/counter) and by the scheduling of the list. The hourly development was analysed by a graph. A mean number of appointments per clerk per day was found. The above figures were compared for before and after intervention. CONCLUSIONS: The work load caused by the appointment system was redistributed by internal organisational measures, since user habits did not alter.

[Infectious endocarditis in idiopathic hypertrophic subaortic stenosis. Report of a case (author's transl)]. / Endocarditis infecciosa en estenosis subaórtica hipertrófica idiopática. A propósito de una observación.

A case is reported of aortic valve endocarditis in a 53 year-old female patient with idiopathic hypertrophic subaortic stenosis. Emphasis is made on the value of ultrasonography in the diagnosis of both conditions. Ecography has also prognostic interest when big vegetations are found. A comment is made on the need for early surgical replacement of the aortic valve when valvular insufficiency is present.