Bilateral renal aspergillosis in a patient with AIDS: a case report and review of reported cases.

Renal aspergillosis is an extremely uncommon complication in HIV-infected patients. In general, prognosis is poor and the need for nephrectomy is emphasized. We report the case of a 37-year-old patient with AIDS since April 2003 (CD4 count 10 cells/mm(3), a high viral load, Candida esophagitis, bilateral pneumonia, HIV encephalopathy). Treatment with zidovudine, lamivudine, nevirapine, and lopinavir/ritonavir was started. Adherence to this medication proved to be a problem, but after 18 weeks of HAART the CD4 count was 110 cells/mm(3) and viral load was undetectable. One year later, he presented with hematuria and flank pain. Computed tomography (CT) scan revealed multiple lesions in both kidneys. Cultures of the abscess aspirates yielded Aspergillus fumigatus. Our review of 18 reported cases shows that prognosis of renal aspergillosis is poor if nephrectomy is not performed. However, in the present case a conservative approach was chosen to avoid life-long dialysis. The patient was treated successfully with a combination of voriconazole, percutaneous drainage, and highly active antiretroviral therapy (HAART). Renal function was completely preserved. Reported cases from the literature of renal aspergillosis in HIV-infected patients are summarized in this paper.

Role of abdominal sonography in excluding abdominal malignancy in the initial workup of patients with abdominal complaints.

OBJECTIVE: The objective of this study was to evaluate the diagnostic performance and role of abdominal sonography in excluding abdominal malignancy in the initial workup of patients with abdominal complaints. MATERIALS AND METHODS: The sonographic report and follow-up data of 494 patients who had undergone a primary sonographic examination were retrospectively reviewed. Sensitivity and specificity of sonography for the diagnosis of an abdominal malignancy-that is, a primary tumor or metastasis-were determined. Multivariate logistic regression analysis was performed to determine the incremental value of sonography, and a prediction rule was derived. RESULTS: An abnormality on sonography--that is, a mass, ascites, pleural effusion, hydronephrosis, or focal intraparenchymal heterogeneity suggestive of a mass--had a sensitivity for abdominal malignancy of 86% and a specificity of 94%. In the multivariate analysis, the sonographic findings were found to have significant incremental value (odds ratio = 74) after adjustment for the clinical determinants. In patients younger than 38 years with no previous malignancy, no palpable mass, normal liver function test results, and negative findings on sonographic examination, the risk of an abdominal malignancy was less than 1 in 500. CONCLUSION: Our results suggest that sonography may be useful in excluding an abdominal malignancy when used in a primary care setting in patients with abdominal complaints who are at low risk for a malignancy.

Arteriolar constriction in mild-to-moderate essential hypertension: an old concept requiring reconsideration?

OBJECTIVE: To investigate differences between in-vivo properties of a vascular bed in hypertensive patients and normotensive controls. DESIGN: Despite the controversy about the origin of essential hypertension and its accompanying vascular changes, it is generally assumed that the characteristic increase in peripheral resistance when hypertension progresses is caused by arteriolar constriction. Yet, there is little experimental evidence that this assumption generally holds in vivo. METHODS: A non-invasive technique was used for studying properties of the complete vascular bed of an upper arm segment under an occluding cuff in 23 previously untreated hypertensive patients and their matched normotensive controls. The method used the segment's electrical impedance to assess the volumes of extravascular fluid and of arterial and venous blood under varying arterial transmural pressures. RESULTS: Compared with that of matched normotensive controls, the compliance of the large arteries of the vascular bed was on average 50.9% lower (P < 0.001) in the hypertensive patients. The compliance of the complete arterial bed at the operating blood pressure level was also lower (40.0%, P < 0.01), but appeared to be significantly higher (45.9%, P < 0.05) at the normotensive blood pressure level. On the venous side, the patients had a higher blood volume (60.0%, P < 0.01) and an increased myogenic response (68.5%, P < 0.05). CONCLUSIONS: The increase in vascular resistance in the hypertensive patients is due primarily to changes in the large and small vessels of the arterial bed. We found no evidence for a generally increased arteriolar constriction.

Comparative effects of diltiazem and lisinopril on left ventricular structure and filling in mild-to-moderate hypertension.

The comparative effects on echocardiographically determined left ventricular (LV) mass and pulsed Doppler derived indexes of LV diastolic filling were studied in previously untreated hypertensive patients after 6 months of treatment with diltiazem 300 mg once daily (o.d.) (n = 16), and lisinopril 20 mg o.d. (n = 20). LV mass index decreased in the lisinopril group (from 98 to 96 g/m2; mean difference after 6 months of treatment with diltiazem-lisinopril was 13.7 g/m2 [95% confidence interval (CI) 0.8 to 26.6, p < 0.05]. In both groups diastolic filling parameters improved, but there was no statistically significant difference between the groups. Both treatment regimens showed a similar decrease in office and maximal exercise systolic blood pressure (SPB). Ambulatory daytime BP was lower after lisinopril treatment (from 147/96 to 126/83 mm Hg) than after diltiazem treatment (from 142/93 to 135/87 mm Hg); mean difference between diltiazem and lisinopril after 6 months of treatment was 9.7 (95% CI 3.4 to 16.0, p < 0.05)/9.4 (95% CI 2.5 to 16.3, p < 0.05) mm Hg. Nighttime BP decreased from 129/81 to 113/70 mm Hg in the lisinopril group, but not in the diltiazem group (from 125/79 to 122/77 mm Hg); mean difference between diltiazem and lisinopril after 6 months of treatment was 4.4 (95% CI - 0.2 to 8.9)/6.6 (95% CI 1.1 to 12.0) mm Hg. Changes in diastolic filling parameters were significantly correlated with changes in LV mass index in the lisinopril group, suggesting that the improvements in diastolic filling in the diltazem group may be partly due to an effect on factors other than LV mass.

The influence of chronic treatment with betablockade and angiotensin converting enzyme inhibition on the peripheral blood flow in hypertensive patients with and without concomitant intermittent claudication. A comparative cross-over trial.

In a comparative cross-over trial we examined the influence of the betablocker bisoprolol and the ACE-inhibitor lisinopril on the peripheral blood flow of 2 groups of hypertensive patients with and without concomitant intermittent claudication. In 11 patients with hypertension without peripheral arterial obstructive disease and 11 patients with hypertension and claudication we assessed the blood pressure, leg blood flow, vascular resistance, walking distance, transcutaneous oxygen consumption and Laser-Doppler flow after treatment of one month with 10 mg bisoprolol once daily or 20 mg lisinopril once daily. The walking distance of patients with claudication improved in all patients while participating in an exercise program. For both treatment groups this improvement was significant (p < 0.05) compared to baseline, from 264 m at baseline to 313 m with bisoprolol and to 400 m with lisinopril. The difference was not significant between the both drugs. In patients without peripheral vascular obstructive disease we found a significant (p < 0.05) reduction in blood flow for both drugs. The peripheral blood flow parameters of 38 legs showed no statistical significant effect of bisoprolol nor lisinopril on the local vascular resistance at rest, after occlusion or after exercise.

Characterization of hypertensive subjects who become normotensive during three months of office BP follow-up: comparison with subjects with sustained hypertension and normotensives, and follow-up after two years.

After an observation period of three months, 83% of new hypertensives (n = 84), identified in a population survey, became normotensive. Those with sustained hypertension (n = 14) were compared with 14 initially hypertensives who became normotensive and 14 normotensives, matched for age and sex, using ambulatory and exercise BP and echocardiography (both M-mode and Doppler). The initially hypertensive group (n = 11) was re-examined after two years follow-up. The 24h mean ambulatory and submaximal systolic exercise BP did not differ between sustained (139/92 and 210 mmHg) and initially hypertensives (143/95 and 217 mmHg), being significantly lower in the normotensive group (129/85 and 198 mmHg). Left ventricular mass did not differ between the initially hypertensive and the normotensive groups, being significantly higher in the sustained hypertensives. In both hypertensive groups, as compared with normotensives, the ratio between flow velocity in early and late diastole (E/A ratio) tended to be lower and the early diastolic deceleration time (DT) was significantly shorter. After two years, in the untreated initially hypertensives, office DBP had increased to hypertensive values, without change in ambulatory BP, left ventricular mass or early diastolic deceleration time. The E/A ratio had decreased to a level < 1. We conclude that the subjects who became normotensive after three months office BP follow-up have a BP load and signs of compromised left ventricular diastolic function similar to that of the sustained hypertensives, but without increased left ventricular mass.(ABSTRACT TRUNCATED AT 250 WORDS)