Mycobacterium kansasii in HIV patients: clarithromycin and antiretroviral effects.

SETTING: Charity Hospital New Orleans, Louisiana, USA. OBJECTIVE: To define the differences between the pre-HAART (highly active anti-retroviral treatment) and HAART eras in patients co-infected with Mycobacterium kansasii and the human immunodeficiency virus (HIV). DESIGN: A retrospective chart review revealed 82 patients with HIV and M. kansasii during the 6-year period from 1 July 1991 to 30 June 1997 (pre-HAART era), while the 6-year period from 1 July 1997 to 30 June 2003 (HAART era) revealed 55 cases. RESULTS: Among all patients with M. kansasii and HIV, 47 (34%) had an additional, concurrent mycobacterial infection and two had triple mycobacterial species isolation. More patients (17/82, 21%) had disseminated mycobacterial disease in the pre-HAART era than in the HAART era (3/55, 5%; P = 0.045). Pre-HAART patients treated without clarithromycin (CLM) survived a median of 2 months vs. 10 months for pre-HAART patients treated with CLM (P = 0.05). Those treated without CLM had a median survival of 2 months in the pre-HAART era (n = 19) vs. 10.5 months in the HAART era (n = 12, P < 0.02). CONCLUSION: CLM use in treatment of M. kansasii in HIV-co-infected patients is associated with significantly longer survival.

Rapid, low-technology MIC determination with clinical Mycobacterium tuberculosis isolates by using the microplate Alamar Blue assay.

A colorimetric, microplate-based Alamar Blue assay (MABA) method was used to determine the MICs of isoniazid (INH), rifampin, streptomycin (SM), and ethambutol (EMB) for 34 Peruvian Mycobacterium tuberculosis isolates (including both pansensitive and multidrug-resistant strains) and the H37Rv strain by using bacterial suspensions prepared directly from solid media. Results for all isolates were available within 8 days. Discordant results were observed on initial tests for 3 of 16 INH-susceptible isolates, 5 of 31 EMB-susceptible isolates, and 2 of 4 SM-resistant isolates (by the BACTEC 460 system). The overall agreements between the MICs obtained by MABA and the results obtained with the BACTEC 460 system were 87.9% for initial results and 93.6% after retesting 12 of 17 samples with discrepant results. Interpretation of MABA endpoints improved with technical experience. The MABA is a simple, rapid, low-cost, appropriate technology which does not require expensive instrumentation and which makes use of a nontoxic, temperature-stable reagent.

Aspergillus flavus mycetoma and epidural abscess successfully treated with itraconazole.

Aspergillus spp. rarely cause mycetomata. We report a patient with diabetes and nephrotic syndrome with Aspergillus flavus mycetoma of the back, with the development of an epidural abscess, diskitis and vertebral osteomyelitis. The patient was successfully treated with decompressive laminectomy and a 14-month itraconazole regimen. Serial serum itraconazole levels and quantitative Aspergillus antigen levels were performed. This is the second reported and first extrapedal case of mycetoma caused by A. flavus.

Clinical manifestations and implications of coinfection with Mycobacterium kansasii and human immunodeficiency virus type 1.

We conducted a retrospective study to further elucidate the clinical presentations and prognosis of disease due to Mycobacterium kansasii in patients infected with human immunodeficiency virus (HIV). Forty-nine HIV-infected patients first had M. kansasii isolated at a mean CD4 cell count of 62/mm3 and at a mean interval of 17 months after the diagnosis of AIDS. Seventeen of the 49 patients had disseminated disease caused by M. kansasii. Twenty-nine patients had a positive acid-fast smear of sputum, and 35 were known to be cigarette smokers. At the time of initial isolation of M. kansasii, 13 patients had other concurrent pulmonary isolates and 15 had another mycobacterial species concurrently isolated (the Mycobacterium avium complex in 13 instances). Patients who received antimycobacterial treatment survived longer than those who did not. Only one of the 49 patients was definitively determined to be colonized with M. kansasii without disease; therefore, it appears that pulmonary isolates of M. kansasii in HIV-infected patients are almost always associated with disease. The increase in rates of M. kansasii disease among HIV-infected patients has paralleled the rise of AIDS in Louisiana. So far, this state has recorded more coinfections with M. kansasii and HIV than any other.

Blastomycosis and human immunodeficiency virus: three new cases and review.

Reports of blastomycosis in individuals infected with the human immunodeficiency virus (HIV) are increasing. We report on 3 patients co-infected with blastomycosis and HIV (to add to the previously reported 21), and review important clinical aspects and outcomes in all cases. The percentage of patients co-infected with blastomycosis and HIV who had disseminated blastomycosis (63%) was similar to the blastomycosis patients in the general population (67%); however, as a group the patients with HIV were severely immunosuppressed and fared poorly. Severe immunodeficiency was indicated by CD4 counts < 200/mm3 in 85% of co-infected patients. Central nervous system (CNS) involvement occurred in 46% of this group, approximately 5 to 10 times more frequently than in individuals not infected with HIV previously reported at 5% to 10%. The mortality rate from blastomycosis for patients with both HIV infection and blastomycosis is 54%, about 5 times the mortality rate of blastomycosis patients in the general population, previously reported at < 10%. Disseminated blastomycosis in individuals with HIV may appear as deep cutaneous ulcers, as was the case in two of our patients. Although blastomycosis is not an AIDS-defining infection, it may be reasonable to consider HIV testing and measurement of CD4 counts in patients with blastomycosis. Such testing could help identify individuals who are HIV positive but asymptomatic who have blastomycosis, as well as provide useful information regarding a possible association between CD4 cell deficiency and various clinical manifestations of blastomycosis. Patients with HIV and blastomycosis should be examined carefully for any evidence of CNS involvement. Lifetime therapy with ketoconazole or itraconazole is likely to be of benefit to patients with HIV who have been treated successfully for blastomycosis.

Susceptibility of Mycobacterium kansasii to ofloxacin, sparfloxacin, clarithromycin, azithromycin, and fusidic acid.

The MICs of ofloxacin, sparfloxacin, clarithromycin, azithromycin, and fusidic acid for clinical isolates of Mycobacterium kansasii were determined by the radiometric (BACTEC) method. All drugs except azithromycin elicited MICs for 90% of the strains tested that were lower than previously reported achievable maximum concentrations in serum. Ofloxacin, sparfloxacin, and clarithromycin had the largest maximum concentration in serum/MIC for 90% of strains ratio of the drugs tested.