Radiographic findings in HIV-positive patients with sensitive and resistant tuberculosis.

To facilitate early recognition of multi-drug resistant (MDR) Mycobacterium tuberculosis (MTB) disease in HIV-positive patients we evaluated the chest x-ray films of 72 patients in a tertiary care center in New York City. Thirty-three patients had sensitive MTB, 3 had single-drug resistant (SDR) MTB, and 36 patients had multi-drug resistant (MDR) MTB. All chest x-ray films were reviewed and correlated with drug sensitivities, additional diagnostic results, and clinical courses. There were no significant radiographic differences among the 3 groups on initial presentation (p > 0.05). Cavities were found in 12 patients, upper lobe disease in 23, lower lobe disease in 15, possible intrathoracic lymphadenopathy in 30, diffuse infiltrates in 12, pleural effusion in 13, and a miliary pattern in 3 patients. Normal chest x-ray films were found in ten patients. After 2 weeks of therapy, 20 out of 35 MDR-MTB patients developed new effusions, possible intrathoracic lymphadenopathy, or worsening infiltrates. With deterioration, the probability of MDR MTB was 95 percent in our case control study. Thus, it would be reasonable to adjust antituberculosis therapy in HIV-positive patients with deteriorating conditions shown on chest x-ray films after 2 weeks of therapy.

Hafnia alvei. Respiratory tract isolates in a community hospital over a three-year period and a literature review.

In a retrospective review, a group of seven patients were found to have a sputum culture positive for Hafnia alvei. Hafnia alvei is a Gram-negative enteric and oropharyngeal bacillus and usually is nonpathogenic. All our patients had a chronic underlying illness and one of the patients was endotracheally intubated at the time of the isolation of this organism. Six of seven patients had other organisms isolated along with H alvei, and only one patient had a pure growth of H alvei confirmed by a culture obtained from a bronchoscopic protected brush specimen. All isolates displayed resistance to conventional antibiotics including cephalosporins and penicillins. Although rare, H alvei may be a potential pathogen in a patient with a chronic underlying illness.

Mycobacterium gordonae: a treatable disease in HIV-positive patients.

PURPOSE: To evaluate the pathogenicity of Mycobacterium gordonae in patients with and without human immunodeficiency virus (HIV) infection. PATIENTS AND METHODS: Twenty-one HIV-positive and 15 HIV-negative patients in a tertiary care center. A descriptive, case-control, and cohort study with a review of the literature with a computer-based data research. RESULTS: The 15 HIV-negative patients had colonization only. Seven HIV-positive patients had colonization, 12 had possible disease, and 2 had dissemination. The two patients with definitive dissemination improved objectively with treatment. CONCLUSION: Mycobacterium gordonae in HIV-negative patients is rarely a pathogen. In HIV-positive patients with a low CD4+ cell count, it can cause significant disease and treatment is beneficial.

Disseminated Strongyloides stercoralis in human immunodeficiency virus-infected patients. Treatment failure and a review of the literature.

We describe a North American human immunodeficiency virus (HIV)-positive patient with Strongyloides stercoralis infection of the gastrointestinal tract, who required repeated "standard" courses of thiabendazole. Pulmonary infection with numerous roundworms developed, as suspected by bronchoalveolar lavage, and while he was receiving therapy, dissemination occurred. On autopsy, S stercoralis was recovered in the gastrointestinal tract, liver, lung, and heart. After a literature review, we conclude that HIV-positive patients have a higher risk of dissemination and "standard" treatment failure. This may occur without elevation of IgE or eosinophilia. Those patients may require prolonged courses of thiabendazole or alternatively ivermectin therapy.

Multidrug resistant Mycobacterium tuberculosis in patients with human immunodeficiency virus infection.

Multidrug resistant Mycobacterium tuberculosis (MDR-MTB) infection has not been recognized as a serious problem in patients with human immunodeficiency virus (HIV) infection. Multidrug resistance (MDR) has appeared in our medical center in 24 out of 72 patients between January 1990 and May 1991 compared to 8 out of 132 patients within the period from 1982 to 1987 (relative risk 5.50 with 95 percent confidence interval 2.61 to 11.61). We describe 19 patients with MDR in MTB (isoniazid and at least one additional first line drug), who had serologic evidence of HIV infection, 13 of whom were diagnosed with acquired immunodeficiency syndrome (AIDS). The MTB cultures from 10 out of 19 patients with MDR were resistant to three or more drugs. Fifteen patients died although 9 out of these 15 had received at least a four-drug regimen for a mean time of seven weeks (range 2 to 12). This increase in MDR was seen in ten homosexuals and nine intravenous drug users. This rapid appearance of MDR-MTB strains is worrisome. New strategies for empiric therapy of such patients while awaiting sensitivity data are needed.

[Pleurodesis using an acrylate glue in the treatment of therapy-resistant symptomatic pneumothorax]. / Pleurodese mittels eines Acrylatklebers in der Behandlung therapieresistenter symptomatischer Pneumothoraces.

In 7 patients with therapy-resistant pneumothorax and a contraindication of surgery in obstructive large-bullae pulmonary emphysema, pulmonary fibrosis in the terminal stage (in one case bilateral), extensive pulmonary cysts, cystic pulmonary fibrosis, and large-cavernous pulmonary tuberculosis, an acrylate tissue adhesive was applied on 8 occasions through a pleural catheter. Following the rapid withdrawal of the catheter, the lungs remained fully expanded in five cases. In two cases, the tissue adhesive had to be applied interpleurally a second time, and in one case on three occasions at one-day intervals. In none of these cases did any major complications occur.