Climatic factors and Pneumocystis jiroveci infection in southern Spain.

The modes of infection and transmission of Pneumocystis jiroveci remain unclear. This study explored the relationship between the incidence of infection and climatic factors. In total, 536 cases of P. jiroveci infection were identified in the period 1994-1998, with an inverse correlation between the incidence of Pneumocystis pneumonia and the minimum mean ambient temperature (Spearman correlation coefficient: r - 0.30; p 0.02; ARIMA model: r - 0.250, p 0.07). The highest number of cases occurred in winter (anova test, p < 0.05), and there was a clear season-related incidence of P. jiroveci infection.

Aspergillus fumigatus cranial infection after accidental traumatism.

Described here is a case of Aspergillus fumigatus cranial infection secondary to accidental cranial traumatism that occurred in an immunocompetent patient and the questions that arose concerning treatment. No reports of post-traumatic cranial osteomyelitis caused by Aspergillus spp. and the ideal treatment to be followed have yet been described in the literature. In the present case, surgical debridement of the wound followed by treatment with 1 mg/kg/iv/day of amphotericin B for 21 days and then 200 mg/vo/12 h of itraconazole for 6 months obtained good results.

Pneumocystis carinii pneumonia in heart transplant recipients.

OBJECTIVES: In spite of the high prevalence of Pneumocystis carinii (PC) pneumonia in immunocompromised patients, little is known about the epidemiological characteristics of this infection, and whether the cases of PC pneumonia in immunosuppressed patients are the result of a reactivation of a latent infection or a due to a recent infection is unknown. The aim of this study was to provide information about the epidemiological characteristics of PC pneumonia in a cohort of heart transplant (HT) recipients when compared with the epidemiology of PC infection in a cohort of chronic sputum producers (CSP) representative of the general population of the same geographical area. METHODS: We identified all the cases of PC pneumonia in the cohort of 72 subjects who underwent cardiac transplantation at our institution between January 1991 and December 1996 and compared them with the cases of PC infection identified in a non-selected cohort of 34 CSP. This second group was included to obtain an approximation of the frequency of PC carriers in the general population. Identification of PC was accomplished through customary stain techniques and immunofluorescence with monoclonal antibodies. RESULTS: Of the 72 HT recipients four (5.5%) developed PC pneumonia, but one had two episodes. Only one had received primary chemoprophylaxis, but developed PC pneumonia 2 months after discontinuing prophylactic therapy. PC pneumonia episodes were produced 53, 102, 230, 181 and 772 days after the moment of transplant, respectively. PC was identified in two (5.8%) of the 34 CSP. No significant differences were found when the accumulative incidences of PC pneumonia in HT patients and PC infection in CSP were compared (P=0.7). CONCLUSIONS: The frequency of PC pneumonia among HT patients is the same as the frequency of PC infection in the general population. This observation and the long interval between transplantation and the development of PC pneumonia observed in the study support the hypothesis that the occurrence of PC pneumonia in immunocompromised patients might be from a new infection rather than from the reactivation of latent organisms. Therefore, continuous prophylaxis might be indicated in areas with a high prevalence of PC for patients at highest risk.

Prospective evaluation and follow-up of European patients with visceral leishmaniasis and HIV-1 coinfection in the era of highly active antiretroviral therapy.

A prospective descriptive study was designed to determine the impact of highly active antiretroviral therapy (HAART) in the evolution of visceral leishmaniasis (VL) in HIV-1 infected patients. Thirty-two patients were treated with meglumine antimoniate or amphotericin B in lipid formulations. Patients who had undergone previous HAART at study entry (n=17) continued with therapy while receiving treatment for VL. Patients who had never undergone HAART started it after VL treatment finished (n=15). Ten patients were lost to follow-up. All of the remaining patients (n=20) continued to receive HAART and were followed for an average of 441 days. Relapses were observed in 5 of 20 patients. These results indicate that HAART neither prevents the incidence of VL relapse nor modifies the clinical picture described in the pre-HAART era.

[Meningitis by Cryptococcus neoformans in patients with HIV infection]. / Meningitis por Cryptococcus neoformans en pacientes con infección por el VIH.

OBJECTIVE: To review a serie of patients with cryptococcal meningitis and immunodeficiency syndrome (AIDS) treated in our hospital in the last two years. PATIENTS AND METHODS: Retrospective study of 25 patients infected with the human immunodeficiency virus (HIV) and affected by Cryptococcus neoformans meningitis. The factors analysed were epidemiological data, clinical manifestations, biochemical and microbiological characteristics of cerebrospinal fluid (CSF), radiological abnormalities, treatment, adverse reactions and outcomes. RESULTS: Eighty-four percent of patients had less than 200 CD4/microliter. Cryptococcal infection was the AIDS defining illness in 24% of cases. Patients typically presented with neurologic symptoms such as: headache (88%), fever (68%) and somnolence (68%); 20% presented seizures and 28% focal deficits. There were no CSF biochemical alterations in 25% of them. CSF culture and indian ink stain were positive in 76%. CSF cryptococcal antigen test was positive in 68% of the cases. TC showed abnormalities in 48%. CSF of all patients treated with amphotericin B (AB) plus flucytosine (5FC) whose CSF culture was monitored became negative in the first two weeks, meanwhile those treated only with AB or fluconazol had negative control culture in 60% and 50% respectively. Six patients died within the initial 10 weeks. Death was due to bacterian sepsis in 3 patients and high intracranial pressure was the cause in 2 cases. One happened before treatment was administered. CONCLUSIONS: It's essential to consider the possibility of cryptococcal meningitis in patients infected with HIV and any compatible symptom regardless of CSF biochemical results and immunodepression level (CD4). Although our study was non randomized and so we can't propose a therapeutical schedule based on it, we can say that patients treated with AB plus 5FC showed an earlier conversion from positive to negative CSF cultures without more adverse reactions.

Prevalence of and factors associated with visceral leishmaniasis in human immunodeficiency virus type 1-infected patients in southern Spain.

The actual prevalence of visceral leishmaniasis among human immunodeficiency type 1 (HIV-1)-infected patients in the Mediterranean basin remains unknown. There is also controversy about the risk factors for Leishmania infantum and HIV-1 coinfection. To appraise the prevalence of visceral leishmaniasis in patients infected with HIV-1 in southern Spain and to identify factors associated with this disease, 291 HIV-1 carriers underwent a bone marrow aspiration, regardless of their symptoms. Giemsa-stained samples were searched for Leishmania amastigotes. Thirty-two (11%) patients showed visceral leishmaniasis. Thirteen (41%) patients had subclinical cases of infection. Centers for Disease Control and Prevention (CDC) clinical category C was the factor most strongly associated with this disease (adjusted odds ratio [OR], 1.88 [95% confidence interval, 1.22 to 2.88]), but patients with subclinical cases of infection were found in all CDC categories. Female sex was negatively associated with visceral leishmaniasis (adjusted OR, 0.42 [95% confidence interval, 0.18 to 0.97]). Intravenous drug users showed a higher prevalence than the remaining patients (13.3 versus 4.9%; P = 0.04), but such an association was not independent. These results show that visceral leishmaniasis is a very prevalent disease among HIV-1-infected patients in southern Spain, with a high proportion of cases being subclinical. Like other opportunistic infections, subclinical visceral leishmaniasis can be found at any stage of HIV-1 infection, but symptomatic cases of infection appear mainly when a deep immunosuppression is present. There is also an association of this disease with male sex and intravenous drug use.

Low sensitivity of peripheral blood smear for diagnosis of subclinical visceral leishmaniasis in human immunodeficiency virus type 1-infected patients.

The peripheral blood smear is an easy method for the diagnosis of symptomatic visceral leishmaniasis (VL) in human immunodeficiency virus type 1 (HIV-1)-infected patients. However, its efficiency in diagnosing subclinical VL remains unknown. In this study, Leishmania amastigotes were seen in blood smears from 1 of 13 HIV-1-positive individuals with subclinical VL. This shows that this procedure is not suitable for subclinical-VL diagnosis.

Presence of glomerular basement membrane (GBM) antibodies in HIV- patients with Pneumocystis carinii pneumonia.

Following the unexpected finding of antibodies to GBM in a patient with Pneumocystis carinii pneumonia in the absence of kidney abnormalities, the presence of anti-GBM antibodies was analysed in 14 patients with pulmonary P. carinii infection who did not have clinical evidence of autoimmune glomerulonephritis. Patients were divided into three groups: HIV- with P. carinii pneumonia (n = 4), HIV+ with P. carinii pneumonia (n = 5) and HIV- carriers of P. carinii without pneumonia (n = 5). As control groups, HIV- patients with community-acquired non-P. carinii pneumonia (n = 6) and healthy individuals (n = 16) were included. Anti-GBM antibodies, studied with a quantitative enzyme immunoassay (EIA) for anti-alpha3 chain of collagen IV antibodies, were detected in three out of the four HIV-patients with P. carinii pneumonia, but not in any individuals of the other categories. These results suggest that P. carinii alveolar injury or the host response to the organism could affect the basal membrane Goodpasture antigen or a similar antigen, and induces anti-GBM antibody production in HIV- patients, and support the hypothesis that, at least in some cases, Goodpasture's syndrome could be triggered by an alveolar lesion induced by a P. carinii pneumonia.

Pneumocystis carinii meningoradiculitis in a patient with AIDS.

Pneumocystis carinii is a common opportunistic pathogen in patients infected with the human immunodeficiency virus (HIV). Pneumocystis carinii pneumonia is common, while extrapulmonary infections with Pneumocystis carinii have been reported sparingly. The clinical features are frequently nonspecific. The detection of Pneumocystis carinii in cerebrospinal fluid (CSF) has not been reported thus far. In this report, an unusual case of Pneumocystis carinii meningoradiculitis in an HIV-infected patient who had previously received primary prophylaxis with trimethoprim-sulfamethoxazole is presented.

[Cryptococcosis of the central nervous system. Clinical and diagnostic characteristics]. / Criptococosis del sistema nervioso central. Características clínicas y diagnóstico.

BACKGROUND: Evaluation of the clinical features and diagnostic methods in the cryptococcosis of central nervous system (CNS), so as to facilitate a rapid recognition which may result in earlier diagnosis in view of the rapid increase in frequency shown in that condition. METHODS: A retrospective study of 13 patients with CNS cryptococcosis seen during the last 4 years. The isolation of C. neoformans in CSF, cerebral biopsy or other appropriate tissue was required for inclusion. The following were evaluated: 1) Age, sex, and underlying disease; 2) Clinical features; 3) Yield of biochemical, microbiological, pathological and imaging diagnostic procedures; 4) Treatment and evolution. RESULTS: Age (X +/- SD): 37 +/- 20 years (range: 15-81). Sex: 77% males. Underlying disease was identified in 10 cases (77%): HIV infection in 7 (54%), diabetes mellitus in 2, alcohol abuse in 2, systemic erythematous lupus on corticoid and immunosuppressant therapy in 1 and chronic liver disease in 1. Clinical features on admission: abnormal behaviour in 10 (77%), headache in 10, low/high grade fever in 9 (69%), abnormal consciousness in 7, respiratory features in 5 (38%); motor deficit, cranial nerve involvement and visual abnormalities in 4 (31%) each; and meningeal signs in 3. Investigation of CSF was carried out in 12 cases. The biochemical studies were normal in 5 (42%). China ink stain was positive in 55% of cases, and latex agglutination in 80%. CSF culture was diagnostic in 92% of cases and the culture for C. neoformans was positive in 2 cerebral and one pulmonary biopsies and in two urine cultures. All patients were treated with amphotericin B and flucytosine was associated in 9. Two patients were subsequently treated with fluconazole. The outcome was good in 8 patients, and 4 had sequelae. One case relapsed. CONCLUSIONS: 1) HIV infection is the most common underlying disease. 2) There is a high rate of CNS cryptococcosis with normal CSF or with mild biochemical abnormalities. 3) The yield of the microbiological studies of CSF is high, with diagnostic confirmation in 92% of cases. 4) Differences in CNS cryptococcosis were not found between cases with HIV infection and those with other underlying diseases.