Prevalence of abnormal adrenocortical function in human immunodeficiency virus infection by low-dose cosyntropin test.

Recent evidence suggests that 10 microg cosyntropin test has higher sensitivity for detecting hypothalamus-hypophysis-adrenal axis (HHA-A) dysfunction. Our objective was to determine prevalence of glucocorticoid insufficiency with the 10 microg cosyntropin test and the level of the HHA-A defect. One hundred and four HIV-infected patients underwent the 10 microg cosyntropin test. In abnormal and borderline respondents, insulin-induced hypoglycaemia test and human corticotropin releasing hormone test were used to confirm and localize the level of the HHA-A defect. Thirty-two patients with HIV infection and 72 with AIDS were identified. Prevalence of glucocorticoid insufficiency by the 10 microg cosyntropin test was 21.2%. By clinical categories, the frequency in AIDS and HIV infection patients was 26.4% and 9.4%, respectively. Confirmed glucocorticoid insufficiency by insulin-induced hypoglycaemia test was found in 16 out of 19 cases. Twelve cases had primary glucocorticoid insufficiency, 7 had secondary glucocorticoid insufficiency and 3 were false positive. In conclusion, adrenocortical dysfunction occurs in approximately 20% of the cases with HIV disease. Clinical findings commonly occurring in HIV disease as well as adrenocortical insufficiency are not reliable indicators for performing adrenocortical laboratory assessment. Our results suggest screening all AIDS patients with the 10 microg cosyntropin test.

[Occupational accidents and incidence of HIV infection and hepatitis B and C at a Mexican institution]. / Accidentes laborales e incidencia de infección por VIH y hepatitis B y C en una institución mexicana.

INTRODUCTION: The risk of developing parenterally transmitted infections in health-care personnel has become a challenge because of high costs, laboral incapacity and mortality, and social stigmatization. OBJECTIVES: To inform the incidence of occupational exposure in our institution, to determine the type of personnel affected and the circumstances of the injuries, and to assess the serologic follow-up of these employees. METHODS: The occupational injuries spontaneously reported to our infection control program from June 1987 to December 1993, were reviewed. Personnel categories, type of accident, instrument and circumstances of the injury, as well as serologic follow-up for hepatitis B virus (HBV), hepatitis C virus (HCV) or human immunodeficiency virus (HIV) infections, baseline and every three months during the first year were evaluated. RESULTS: In 6.5 years 260 injuries were registered in 240 workers. Two cases were registered in the second semester of 1987, 23 in 1988, 25 in 1989, 23 in 1990, 36 in 1991, 90 in 1992, and 61 in 1993. Housekeeping and maintenance staff were mainly affected (32%), nursing staff in second place (27%), followed by senior medical students (20%). Eighty-eight percent were sharp injuries (20% considered deep injuries). Most of the injuries occurred after instrumental utilization: sharp devices disposed without the use of adequate containers (18%), inappropriate handling of sharp containers (14%) and recapping needles (11%); 36% of the injuries occurred during specific procedures. One HBV seroconversion occurred in 10 surface antigen exposures, one in nine exposures with an HCV contaminated source, and none in 54 accidents with HIV contamination. CONCLUSIONS: The increase in the annual incidence of occupational exposures is due most probably to more awareness to report the injuries. Eighty-eight percent were sharp injuries and at least 43% could have been prevented. Our main educational and preventive efforts should be directed to housekeeping staff, nursing staff, and medical students of our institution.

Evaluation of the sensitivity of RT-23 purified protein derivative for determining tuberculin reactivity in a group of health care workers.

Since 1958 the World Health Organization (WHO) has recommended the use of RT-23 (2 tuberculin unit [TU] purified protein derivative [PPD]) instead of the standard 5 TU PPD to establish the prevalence of tuberculosis (TB) around the world. Before starting a hospital program to control the transmission of TB among health care workers at the National Institute of Nutrition (Mexico City), we compared the tuberculin product commonly used in Mexico (RT-23) with that used in the United States (5 TU PPD). In this trial the Mantoux test was performed on 80 health care workers from various areas of the hospital: 5 TU PPD and RT-23 were simultaneously inoculated in the left forearm and in the right forearm, respectively. The test results for both tuberculin products were read 72 hours later. When a 10-mm induration was used as the cutoff for reactivity, the specificity with use of RT-23 was 100%, but the sensitivity was only 57%. However, when a 5-mm induration was used as the cutoff, the sensitivity with use of RT-23 was 90%. Because of these findings, we advise that every country using RT-23 either consider changing the cutoff for reactivity or consider using 5 TU PPD for reassessment of the data on the incidence and prevalence of TB that were obtained with use of RT-23 (the product recommended by WHO).

[The changing spectrum of fever of unknown origin: trends and comparison with previous series at the Salvador Zubirán National Institute of Nutrition]. / El espectro cambiante de la fiebre de origen oculto: tendencias y comparación con series previas del Instituto Nacional de la Nutrición Salvador Zubirán.

We reviewed 400 medical records of patients admitted because of fever at the National Institute of Nutrition Salvador Zubirán between January 1, 1988 to December 31, 1992. Patient characteristics, diagnostic methods, final diagnosis and patient progress were analyzed, comparing these data with the previous series of the institute. We found 77 cases of fever of unknown origin (FUO), 47 males and 30 females, between 14 to 87 years of age. The final diagnosis encountered were: infections (40%), neoplasias (23%), collagen diseases (13%), and other diagnosis (8%). Sixteen percent of the cases remained without a final diagnosis. The most frequent infections were HIV infection (19%), tuberculosis (19%) and endocarditis (13%). The most common neoplasia was lymphoma (55.6%), with 90% of Hodgkin's disease. SLE was the most common autoimmune disease found. The methods to establish a final diagnosis were: biopsies (52%), serology (17%), cultures (12%), image (11%), and clinical (8%). Final diagnosis by serology tests increased from 2 to 17% in comparison with previous reports. Eight laparotomies were done, which is a less frequent practice than previously (10 vs 35%). We saw only one case of amebic hepatic abscess and had no cases of malaria and salmonellosis as final diagnosis of FUO; HIV infection was found to be a new major cause of FUO.

[Nosocomial urinary tract infections at a second-level hospital]. / Infecciones nosocomiales de vías urinarias en un hospital de segundo nivel.

In order to investigate the incidence, etiologic agents and number of episodes of nosocomial urinary tract infections, a prospective study was carried on at the General Hospital in Durango, Mexico. All the patients admitted to the hospital during the period of March to June, 1991, and whose hospital stay was longer than 48 hours, were included. The infection rate in 962 patients was 12.9 episodes per hundred. The service of Internal Medicine had the highest rate and Pediatrics the lowest. The infection rate was higher among older patients and there was no significant difference between genders. 73% of the patients had only one episode of infection and the presence of a permanent urinary-catheter was the main clinical condition associated with infection. Escherichia coli and Klebsiella sp. were the most frequently isolated microorganisms. Nosocomial urinary tract infections have a very high incidence in a general hospital, therefore there is a pressing need to implement effective control programs.