Histoplasma capsulatum Pacemaker-related Endocarditis Presenting as Endogenous Endophthalmitis.

PURPOSE: To report a unique case of pacemaker-related infective endocarditis manifesting as endogenous endophthalmitis with chorioretinitis secondary to Histoplasma capsulatum. METHOD: Case Report. RESULTS: A 75-year-old man was diagnosed with blood culture-negative infective endocarditis and was admitted with deteriorating vision and ocular inflammation. Examination of the eye indicated significant vitreous inflammation and retinitis. Vitreous cultures were negative, but universal fungal PCR of the vitreous fluid was positive for Histoplasma capsulatum. Histopathology of the fibrous cuff around the extracted right atrial lead demonstrated hyphal and yeast forms and PCR of this material identified Histoplasma capsulatum. Despite aggressive antifungal and surgical treatment, the eye became phthisical. CONCLUSION: We highlight the importance of considering Histoplasma capsulatum in the differential diagnosis of endogenous endophthalmitis, particularly among patients from endemic areas who present with possible endovascular infection.

Coronavirus disease 2019 in an orthotopic liver transplant recipient living with human immunodeficiency virus.

Coronavirus disease 2019 (COVID-19), mediated by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), can manifest with flu-like illness and severe pneumonia with acute respiratory distress syndrome (ARDS). Immunocompromised patients merit particular attention as altered host immunity may influence both disease severity and duration of viral shedding as is described with several other ribonucleic acid respiratory viruses. Yet immunocompromised status alone, in the absence of other comorbidities, may not necessarily predict severe illness presentations and poorer clinical outcomes as indicated by recent reports of COVID-19-infected solid organ transplant recipients and people living with human immunodeficiency virus (HIV). Such patients may even be spared the robust inflammatory response that precipitates ARDS associated with COVID-19, complicating the management of iatrogenic immunosuppression in this setting. We present a case of an orthotopic liver transplant recipient with well-controlled HIV who successfully recovered from a mild, flu-like illness attributed to SARS-CoV-2.

Appropriate laboratory testing in Lyme disease.

Testing for Lyme disease is challenging and if done incorrectly can lead to unnecessary treatment. To interpret serologic test results, first assess the patient's pretest probability of infection based on the probability of exposure and clinical findings. Two-tiered testing remains the gold standard in diagnosing Lyme disease, although new guidelines may be published soon.

Human Immunodeficiency Virus Organ Transplantation.

Human immunodeficiency virus (HIV) has become a chronic disease with a near normal life span resulting in increased risk of organ failure. HIV organ transplantation is a proven and accepted intervention in appropriately selected cases. HIV-positive organ transplantation into HIV-positive recipients is in its nascent stages. Hepatitis C virus, high rates of organ rejection, and immune dysregulation are significant remaining barriers to overcome. This article provides an overview of the transplantation needs in the HIV population focusing on kidney and liver transplants.

Unsatisfactory exfoliative anal cytology samples, 15-year experience with histologic, cytologic, and molecular follow-up.

BACKGROUND: The incidence of anal carcinoma has risen in recent decades. Exfoliative cytology screening of selected high risk patients is performed in many centers. Unsatisfactory cytology results are frustrating to patients, clinicians, and laboratorians. The aim of this study is to ascertain outcomes of patients with non-diagnostic anal cytology. METHODS: A retrospective review of anal cytology testing performed at the Cleveland Clinic between 01/01/2001 and 12/31/2015 was performed. All cases were received as liquid-based samples and processed as ThinPreps (Hologic, Marlborough, MA). Co-testing for HR-HPV DNA was performed using Hybrid Capture 2® (Qiagen, Germantown, MD) in the majority of patients. RESULTS: Of 1,276 ThinPrep anal cytology samples, 130 (10%) were deemed unsatisfactory. 77% of patients were HIV positive. 85% were males. Of the unsatisfactory cases, 116 (89%) were co-tested for HR-HPV DNA. Of those, 40 patients (34%) had a simultaneous positive HR-HPV DNA. Adequate follow up cytology within a one year and a two year period revealed that 18/130 (14%) and 26/130 (20%) of patients had ASC or SIL respectively. Histologic follow-up within one and two years showed 3 patients (2%) and 8 patients (6%) with HSIL or worse. CONCLUSIONS: High risk patients with unsatisfactory anal cytology are not "negative". At least one-third proved to be concomitantly HR-HPV DNA positive with one-fifth showing subsequent cytologic squamous abnormalities and with more than 5% being diagnosed with a high grade intraepithelial lesion within two years. Prompt repeat cytology and/or HR-HPV DNA is recommended for high risk patients with non-diagnostic cytology.

Comparative Outcomes of Bariatric Surgery in Patients With and Without Human Immunodeficiency Virus.

BACKGROUND: Paradoxically, advances in anti-retroviral therapy that has increased survival for patients with human immunodeficiency virus (HIV) have resulted in greater numbers of HIV+ patients developing other chronic diseases, including obesity. Little comparative literature exists detailing perioperative or metabolic outcomes of bariatric surgery in the HIV+ population compared to HIV negative (HIV-) controls. METHODS: This is a retrospective case-control study with both HIV+ (case) and HIV- control patients. Individuals undergoing sleeve gastrectomy (SG) or Roux-en-Y gastric bypass (RYGB) between January 1, 2006 and December 31, 2015 were included. HIV+ status was defined as any individual with documented history of HIV. RESULTS: Eleven HIV+ patients underwent RYGB or SG during the study period. After matching (1:5 HIV+: HIV-) both cohorts had similar mean age (42 years), gender distribution (63% female), and preoperative BMI (48 kg/m2), as well as comorbidities. There were no differences in postoperative length of stay, or all cause 30-day morbidity. There were 63.7% HIV+ and 76.4% with 1-year follow-up available. Both percent excess weight loss (56% HIV+ vs. 60% HIV-) and BMI (32 HIV+ vs. 34 kg/m2 HIV-) were similar in both groups. There were minimal changes to CD4 count or HIV viral load in the patients during the follow-up period. CONCLUSION: Bariatric surgery is safe and feasible in HIV-infected population well controlled on anti-retroviral medication. The short-term surgical and metabolic outcomes are similar to HIV- controls with minimal effect on the CD4 count and viral load in HIV+ cohort for long-term follow-up.

Preanalytic process linked to spuriously elevated HIV viral loads: improvement on an FDA-approved process.

The processing of specimens often occurs in a central processing area within laboratories. We demonstrated that plasma centrifuged in the central laboratory but allowed to remain within the primary tube following centrifugation was associated with spuriously elevated HIV viral loads compared with recentrifugation of the plasma just prior to testing.

Candidate for a live vaccine?

Immune dysfunction is a well-known phenomenon in end-stage liver disease (ESLD). The pretransplant period offers a unique window for primary care physicians to optimize the transplant's vaccine protection before antirejection medications are initiated. Live vaccinations are selected cautiously but the varicella-zoster virus (VZV) vaccine, Zostavax, is recommended for pretransplant candidates. This case highlights an ESLD patient who developed disseminated cutaneous VZV within 30 days of vaccination.

Common infectious complications of liver transplant.

Major improvements in the care of liver transplant recipients have mitigated but not eliminated the risk of potentially life-threatening infectious complications. This review provides general information about risk factors, prophylactic strategies, diagnostic workup, and therapy for some of the most commonly encountered infections after liver transplant.

Antimicrobial stewardship program to reduce antiretroviral medication errors in hospitalized patients with human immunodeficiency virus infection.

OBJECTIVE: Evaluate antimicrobial stewardship interventions targeted to reduce highly active antiretroviral therapy (HAART)- or opportunistic infection (OI)-related medication errors and increase error resolution. DESIGN: Retrospective before-after study. SETTING: Academic medical center. PATIENTS: Inpatients who were prescribed antiretroviral therapy before the intervention (January 1, 2011, to October 31, 2011) and after the intervention (July 1, 2012, to December 31, 2012). Patients treated with lamivudine or tenofovir monotherapy for hepatitis B were excluded. METHODS: Antimicrobial stewardship interventions included education, modification of electronic medication records, collaboration with the infectious diseases (ID) department, and prospective audit and review of HAART and OI regimens by an ID clinical pharmacist. RESULTS: Data for 162 admissions from the preintervention period and 110 admissions from the postintervention period were included. The number of admissions with a medication error was significantly reduced after the intervention (81 [50%] of 162 admissions vs 37 (34%) of 110 admissions; P < .00)1. A total of 124 errors occurred in the preintervention group (mean no. of errors, 1.5 per admission), and 43 errors occurred in the postintervention group (mean no. of errors, 1.2 per admission). The most common error types were major drug interactions and dosing in the preintervention group and renal adjustment and OI-related errors in the postintervention group. A significantly higher error resolution rate was observed in the postintervention group (36% vs 74%; P < .001). After adjustment for potential confounders with logistic regression, admission in the postintervention group was independently associated with fewer medication errors (odds ratio, 0.4 [95% confidence interval, 0.24-0.77]; P = .005). Overall, presence of an ID consultant demonstrated a higher error resolution rate (32% without a consultation vs 68% with a consultation; P = .002). CONCLUSIONS: Multifaceted, multidisciplinary stewardship efforts reduced the rate and increased the overall resolution of HAART-related medication errors.

Organ Transplantation and HIV Progress or Success? A Review of Current Status.

Advancements in the scientific understanding of human immunodeficiency virus (HIV) and care of those afflicted have progressed to make HIV a chronic disease and significantly extend the lives of HIV patients. Subsequently, an aging population has emerged, with the conditions inherent with advanced years, including organ failure. Organ transplantation is an accepted modality for organ failure; however, it was felt to be contraindicated in HIV patients because HIV was an ultimately fatal condition that would be hastened by additional immune suppression. Highly active antiretroviral therapy has dramatically altered that mind-set. After limited early experience and a recent large national trial, HIV organ transplantation has gained a degree of acceptance. This article will review the progress and unresolved issues.

Immunologic failure despite suppressive antiretroviral therapy is related to activation and turnover of memory CD4 cells.

BACKGROUND: Failure to normalize CD4(+) T-cell numbers despite effective antiretroviral therapy is an important problem in human immunodeficiency virus (HIV) infection. METHODS: To evaluate potential determinants of immune failure in this setting, we performed a comprehensive immunophenotypic characterization of patients with immune failure despite HIV suppression, persons who experienced CD4(+) T-cell restoration with therapy, and healthy controls. RESULTS: Profound depletion of all CD4(+) T-cell maturation subsets and depletion of naive CD8(+) T cells was found in immune failure, implying failure of T-cell production/expansion. In immune failure, both CD4(+) and CD8(+) cells were activated but only memory CD4(+) cells were cycling at increased frequency. This may be the consequence of inflammation induced by in vivo exposure to microbial products, as soluble levels of the endotoxin receptor CD14(+) and interleukin 6 were elevated in immune failure. In multivariate analyses, naive T-cell depletion, phenotypic activation (CD38(+) and HLA-DR expression), cycling of memory CD4(+) T cells, and levels of soluble CD14 (sCD14) distinguished immune failure from immune success, even when adjusted for CD4(+) T-cell nadir, age at treatment initiation, and other clinical indices. CONCLUSIONS: Immune activation that appears related to exposure to microbial elements distinguishes immune failure from immune success in treated HIV infection.

Seek and treat: HIV update 2011.

Although mortality rates from human immunodeficiency virus (HIV) infection have declined dramatically in the United States, the incidence of new infections has not improved for more than a decade. The case is now strong for routine screening and early treatment of HIV infection to reduce transmission of the infection and to give patients an opportunity to live a reasonably healthy life. Clinicians in all health care settings should routinely and matter-of-factly test their patients for HIV infection, just as they screen for other diseases.

HIV screening for all: the new standard of care.

The US Centers for Disease Control and Prevention has revised its recommendations for screening for human immunodeficiency virus (HIV) (MMWR Recomm Rep 2006; 55(RR14):1-17) and now recommends HIV screening for all patients age 13 to 64 years in all health care settings, including hospital emergency departments, urgent care clinics, inpatient services, sexually transmitted disease clinics, tuberculosis clinics, and primary care offices.

Inflammatory progressive multifocal leukoencephalopathy in human immunodeficiency virus-negative patients.

OBJECTIVE: Inflammatory progressive multifocal leukoencephalopathy (iPML) with enhancing magnetic resonance imaging (MRI) lesions and leukocyte infiltration occurs in human immunodeficiency virus (HIV)-infected individuals after highly active antiretroviral therapy (HAART) treatment. MRI diagnostic criteria for PML suggest that iPML does not occur in HIV-negative individuals. METHODS: We studied pathologically proved PML (12 by biopsy, 9 with MRI, 32 at autopsy). RESULTS: HIV-negative (2/5) and -positive (2/4) PML patients had enhancing MRI lesions, correlated with CD3(+) lymphocyte infiltration. Inflammatory infiltrates occurred in the majority of HIV-negative (7/8) and HIV-positive/HAART (17/20) cases (p > 0.2), but in only 2 of 16 HIV-positive/non-HAART cases (p < 0.001). INTERPRETATION: iPML showed radiographic and pathological similarity in HIV-positive/HAART and HIV-negative patients. HIV-negative iPML necessitates further consideration of MRI criteria for PML.