Missed opportunities to diagnose syphilis prior to the development of sight-losing uveitis.

The incidence of syphilis in the UK is rapidly rising. Uveitis (intraocular inflammation) usually occurs in the secondary or later stages of syphilis infection and is sight-threatening. Methods A retrospective analysis of the demographics, presentation, diagnosis, treatment and outcomes of patients with syphilitic uveitis managed in Newcastle from 2005-2016 was carried out. Results Ten males (19 eyes) with syphilitic uveitis had a generally good visual and serological response to penicillin treatment. In eight of the patients there had been a failure to test for syphilis during assessments by various medical practitioners for unexplained symptoms that were attributable to syphilis prior to the eye involvement. Conclusion Uveitis associated with syphilis can be sight-threatening but responds well to treatment. In our case series there were multiple missed opportunities to diagnose syphilis prior to presentation with eye disease, with a general failure of healthcare professionals to take an adequate sexual history.

Auditing HIV Testing Rates across Europe: Results from the HIDES 2 Study.

European guidelines recommend the routine offer of an HIV test in patients with a number of AIDS-defining and non-AIDS conditions believed to share an association with HIV; so called indicator conditions (IC). Adherence with this guidance across Europe is not known. We audited HIV testing behaviour in patients accessing care for a number of ICs. Participating centres reviewed the case notes of either 100 patients or of all consecutive patients in one year, presenting for each of the following ICs: tuberculosis, non-Hodgkins lymphoma, anal and cervical cancer, hepatitis B and C and oesophageal candidiasis. Observed HIV-positive rates were applied by region and IC to estimate the number of HIV diagnoses potentially missed. Outcomes examined were: HIV test rate (% of total patients with IC), HIV test accepted (% of tests performed/% of tests offered) and new HIV diagnosis rate (%). There were 49 audits from 23 centres, representing 7037 patients. The median test rate across audits was 72% (IQR 32-97), lowest in Northern Europe (median 44%, IQR 22-68%) and highest in Eastern Europe (median 99%, IQR 86-100). Uptake of testing was close to 100% in all regions. The median HIV+ rate was 0.9% (IQR 0.0-4.9), with 29 audits (60.4%) having an HIV+ rate >0.1%. After adjustment, there were no differences between regions of Europe in the proportion with >0.1% testing positive (global p = 0.14). A total of 113 patients tested HIV+. Applying the observed rates of testing HIV+ within individual ICs and regions to all persons presenting with an IC suggested that 105 diagnoses were potentially missed. Testing rates in well-established HIV ICs remained low across Europe, despite high prevalence rates, reflecting missed opportunities for earlier HIV diagnosis and care. Significant numbers may have had an opportunity for HIV diagnosis if all persons included in IC audits had been tested.

Interferon-γ release assays in the diagnosis of active tuberculosis disease in a low-incident setting: a 5-year review of data.

The role of interferon-γ release assays in the diagnosis of active tuberculosis disease is uncertain, and recent guidelines do not support their routine use. We reviewed the clinical records of 415 patients who had a QuantiFERON-TB Gold In-Tube assay between 29 June 2005 and 28 October 2010 to determine its performance in the diagnosis of active tuberculosis disease in a low prevalence setting, specifically in human immunodeficiency virus (HIV) -positive and HIV-negative patients, those of UK and non-UK origin, and those with pulmonary and extrapulmonary disease. For the diagnosis of active tuberculosis disease the overall sensitivity of QuantiFERON-TB Gold In-Tube assay was 71.4% (95% CI 59.3-81.1), specificity was 81.0% (95% CI 75.5-85.6) and negative predictive value was 92.6% (95% CI 88.2-95.5). No significant difference in sensitivity was seen in culture-positive and culture-negative tuberculosis, in pulmonary and extrapulmonary disease, or with HIV infection. Specificity and negative predictive value were significantly higher in patients of UK origin compared with those of non-UK origin (89.3% (95% CI 83.3-93.3) and 97.1% (95% CI 92.7-98.9) versus 66.3% (95% CI 55.6-75.5) and 83.3% (95% CI 72.6-90.4)). Our study suggests that there may be a role for interferon-γ release assays in excluding active tuberculosis disease, particularly extrapulmonary disease, in patients originating from areas of low tuberculosis incidence, with a negative test highly predictive of a lack of active tuberculosis disease in this group. We cannot support the use of these assays in the diagnosis of active tuberculosis infection in patients from areas of higher incidence.

HIV-associated fatigue in the era of highly active antiretroviral therapy: novel biological mechanisms?

OBJECTIVE: The aim of the study was to determine the prevalence and risk factors for HIV-associated fatigue in the era of highly active antiretroviral therapy (HAART). METHODS: A cross-sectional survey of 100 stable HIV-infected out-patients was carried out. Severity of fatigue was measured using the Fatigue Impact Scale (FIS). Symptoms of orthostatic intolerance (dysautonomia) were evaluated using the Orthostatic Grading Scale (OGS). Data for HIV-infected patients were compared with those for 166 uninfected controls and 74 patients with chronic fatigue syndrome (CFS)/myalgic encephalomyelitis (encephalopathy) (ME). RESULTS: Ninety-one per cent of HIV-infected patients were on HAART and 78% had suppressed plasma HIV viral load (≤ 40 HIV-1 RNA copies/mL). Fifty-one per cent of HIV-infected patients reported excessive symptomatic fatigue (FIS ≥ 40), and 28% reported severe fatigue symptoms (FIS ≥ 80). The mean FIS score among HIV-infected patients was 50.8 [standard deviation (SD) 41.9] compared with 13.0 (SD 17.6) in uninfected control subjects, and 92.9 (SD 29.0) in CFS patients (P < 0.001 for comparison of HIV-infected patients and uninfected controls). Among HIV-infected patients, fatigue severity was not significantly associated with current or nadir CD4 lymphocyte count, HIV plasma viral load, or whether on HAART. Prior dideoxynucleoside analogue (d-drug) exposure (P = 0.016) and the presence of clinical lipodystrophy syndrome (P = 0.011) were associated with fatigue. Additionally, fatigue severity correlated strongly with symptomatic orthostatic intolerance (r = 0.65; P < 0.001). CONCLUSIONS: Fatigue is very common and often severe in HIV-infected out-patients, despite viral suppression and good immune function. In a subgroup of patients, prior d-drug exposure may contribute to fatigue, suggesting a metabolic basis. Dysautonomia may also drive fatigue associated with HIV infection, as in other chronic diseases, and CFS/ME, and should be further evaluated with the potential for a shared therapeutic approach.

Heritability of the spatial distribution and peak density of macular pigment: a classical twin study.

PURPOSE: To elucidate the heritability of peak density and spatial width of macular pigment (MP) using a Classical Twin Study. METHODS: Fundus autofluorescence images were obtained at 488 nm from 86 subjects or 43 twin pairs (21 monozygotic (MZ) and 22 dizygotic (DZ)) (27 male, 59 female) aged from 55 to 76 years (mean 62.2 ± 5.3 years). The relative topographic distribution of MP was measured using a grey scale of intensity (0-255 units) in a 7° eccentricity around the fovea. Relative peak MP density (rPMPD) and relative spatial distribution of MP (rSDMP) were used as the main outcome measure in the statistical analysis. RESULTS: A significantly higher correlation was found within MZ pairs as compared with that within DZ pairs for rPMPD, (r=0.99, 95% confidence interval (95% CI) 0.93 to 1.00) and 0.22, 95% CI -0.34 to 0.71), respectively, suggesting strong heritability of this trait. When rSDMP was compared, there was no significant difference between the correlations within MZ pairs (r=0.48, 95% CI -0.02 to 0.83) and DZ pairs (r=0.63, 95% CI 0.32 to 0.83), thus rSDMP is unlikely to have a considerable heritable component. In addition, there was no difference between any MP parameter when normal maculae were compared with early age-related macular degeneration (AMD) (rPMPD 0.36 vs 0.34, t=1.18 P=0.243, rSDMP 1.75 vs 1.75, t=0.028 P=0.977). CONCLUSIONS: rPMPD is a strongly heritable trait whereas rSDMP has minimal genetic influence and a greater influence by environmental factors. The presence of macular changes associated with early AMD did not appear to influence any of these pigment parameters.

Three cases of oral syphilis - an overview.

Syphilis is an infectious disease caused by the organism Treponema pallidum. There has been a dramatic increase in the number of new cases of syphilis in the UK over the past decade. Intra-oral ulceration is often the only presenting feature of the disease, which then enters a latent period. A missed diagnosis can often lead to serious complications and may result in further spread of the disease. Three cases are discussed in this paper with varying clinical presentations of the disease. Such a significant increase of syphilis and its high infectivity require the dental profession to increase their awareness of sexually infectious diseases and the appropriate dental management.

Offering HIV testing in an acute medical admissions unit in Newcastle upon Tyne.

The objective of this study was to offer HIV testing to all patients attending the acute medical admissions unit (AMU) in Newcastle upon Tyne to assess feasibility, acceptability and point prevalence in accordance with the 2008 UK National HIV testing guidelines. A prospective audit was performed offering HIV testing to all patients with the capacity to give verbal consent who attended the AMU. In total, 3,753 eligible patients were admitted during the audit period and 586 (15.6%) were considered for testing. Of those approached, 108 (18.4%) were clinically ineligible to test and 478 were offered a test. In the 396 patients who consented (82.8%), there were two new HIV diagnoses (point prevalence 0.5%). Offering HIV testing in an AMU setting is feasible and acceptable to patients. The high uptake rate but low proportion of admissions tested suggests a lack of confidence of medical staff in offering a test. Misconceptions regarding HIV testing remain and greater education is required for healthcare workers.

Management of vivax malaria with low sensitivity to primaquine.

Over the last two decades there have been numerous reports of primaquine failure in the treatment of Plasmodium vivax extending from the Western Pacific to South East Asia, India and Central and South America. In sub-Saharan Africa only five returning travellers have been reported with relapse of vivax malaria after primaquine and the absence of corroborating reports has prompted investigators to interpret their observations in terms of non-compliance. In 1997, 26 US military personnel serving in Somalia experienced attacks of P. vivax after terminal prophylaxis with primaquine. We have observed repeated relapses of P. vivax in two travellers, one to the Philippines and the other to Kenya despite both conventional and prolonged primaquine therapy. Here we report this clinical problem and propose a response to the emerging failure of the standard regimen of primaquine by considering the existing efficacy and toxicity data.

Pancreatic exocrine insufficiency in HIV-positive patients.

OBJECTIVES: We describe the management of a cohort of eight HIV-positive patients on antiretroviral medication with evidence of pancreatic insufficiency consisting of chronic diarrhoea and a low faecal elastase measurement. PATIENTS AND METHODS: Twenty-two patients with chronic diarrhoea for whom a faecal elastase measurement was available were identified retrospectively. We compared baseline demographic characteristics, antiretroviral treatment and symptoms of steatorrhea between patients with evidence of pancreatic insufficiency, i.e. a low faecal elastase measurement of <200 microg/g (cases), and patients with evidence of normal pancreatic function, i.e. a normal faecal elastase measurement of >200 microg/g (controls). We describe the management of the patients with evidence of pancreatic insufficiency. RESULTS: Of the 22 patients, eight had evidence of pancreatic insufficiency, i.e. a low faecal elastase measurement. Comparing cases with controls, cases were more likely to have symptoms of steatorrhea (P=0.03) or to have lost weight (P=0.02). Cases were also significantly more likely to have taken didanosine (ddI) as part of their antiretroviral treatment when their symptoms started. Seven cases were treated with oral pancreatic supplements and all had symptomatic improvement of their diarrhoea. One patient stopped treatment with oral pancreatic supplements because of side effects without a relapse of symptoms; he had also stopped zalcitabine (ddC). CONCLUSIONS: We believe that measurement of faecal elastase to detect pancreatic insufficiency should be part of the standard investigation of HIV-positive patients with chronic diarrhoea alongside assessment for other causes of diarrhoea. Faecal elastase measurements should be requested, in particular, in all patients with diarrhoea and weight loss, or symptoms of steatorrhea, and in those on treatment with an antiretroviral regime containing ddI. If the faecal elastase level is low, a switch of antiretroviral medication to a nonddI/ddC-containing regime should be considered and treatment with oral pancreatic enzyme therapy should be instituted.

Spontaneous clinical improvement in HIV-associated follicular syndrome.

Since 1991 infrequent reports have described a distinctive triad of nodulocystic acne, striking follicular spines and an eruption resembling pityriasis rubra pilaris (PRP) in HIV-positive patients. It has been suggested that this may represent a subtype of PRP, or alternatively that it should be viewed as a unique HIV-associated follicular occlusion triad. Clinical manifestations may be severe, and in several cases have been ultimately fatal, with death occurring due to complications of cutaneous sepsis. We describe a case demonstrating severe conglobate acne, follicular keratotic spines and histologically confirmed PRP in association with HIV infection. Clinical features and treatment modalities of previously reported cases are reviewed. Despite refusing all topical and systemic treatment our patient showed spontaneous remission of skin signs after 2 years.

Subdural block--from a spinal? A case report.

INTRODUCTION: Multicompartmental blocks are commonly described in epidurals but not spinals. We describe a case of subarachnoid block performed in an obese patient which resulted in a clinical presentation resembling that of a subdural block. CLINICAL PICTURE: A 29-year-old woman, scheduled for saucerisation of thigh carbuncle, was administered 2.1 mL of hyperbaric bupivacaine. The spinal resulted in a late onset of sensory block that extended to the neck and upper limbs. There was no sympathetic or motor blockade. TREATMENT/OUTCOME: The block receded spontaneously without causing any cardiovascular or respiratory compromise. CONCLUSIONS: The diagnosis of subdural block must be considered in patients with unusual presentations after a spinal anaesthetic. Factors affecting spread of hyperbaric bupivacaine are also highlighted.

A case of pulmonary haemorrhage following jet ventilation for vocal cord surgery.

INTRODUCTION: This case report highlights haemoptysis occurring after post-extubation laryngospasm. CLINICAL PICTURE: General anaesthesia using Sanders jet ventilation with a Benjamin tube was administered for a patient undergoing vocal cord biopsy. He developed laryngospasm followed by significant pulmonary haemorrhage and widespread crepitations in the lung. TREATMENT: Laryngospasm was aborted with assisted ventilation with oxygen 100% via bag and mask. OUTCOME: Oxygenation was well maintained with nasal prongs only postoperatively and haemoptysis resolved after 2 days. CONCLUSION: It is imperative to prevent laryngospasm from occurring and swift action must be taken to avoid pulmonary haemorrhage.