Tuberculosis and HIV infection. Evaluation of 132 cases

Perioperative blood glucose and insulin levels were measured in children (1-9 years of age) randomly assigned to two groups according to anesthesia technique, general anesthesia (group GA) or general anesthesia combined with regional anesthesia (group RA). Children in the GA group (n = 10) received halothane and opioids, while children of the RA group received epidural anesthesia with bupivacaine (0.25%) and adrenaline combined with halothane anesthesia (n = 10). Children in both groups received 2.5% dextrose in 0.4 N saline administered by volumetric infusion pumps throughout the study period, the infusion rate being adapted to the child's age. Blood samples for glucose and insulin determinations were obtained: at induction, at the end of surgery, and 30, 60 and 120 min after surgery. In response to an identical glucose load, blood glucose levels increased significantly in both groups (P < 0.001), while no differences between groups were observed. Insulin levels did not change significantly postoperatively in the GA group (P = 0.058), while a significant increase was observed in the RA group (P < 0.001). Insulin/blood glucose ratio increased significantly only in the RA group (P < 0.05). The higher insulin secretion in response to glucose infusion in the RA group compared to the GA group may indicate an increased peripheral insulin resistance after regional anesthesia or, more likely, this secretion may be beneficial in contributing to improve postoperative nitrogen balance.     

Clinical complications of HIV infection

HIV infection results in a profound weakening of the immune system that leaves the patient vulnerable to a bewildering array of clinical complications. Understanding of the pathogenesis of these clinical complications, knowledge of the current stage and treatment of HIV infection, and recognition of certain clinical syndromes can help the clinician sort through these potential complications, prioritize them, and formulate a plan for diagnosis and treatment. This article provides a summary of the clinical presentation, diagnosis, treatment, and prevention of the most common complications of HIV infection.     

Biological and virologic characteristics of primary HIV infection

BACKGROUND: The clinical events surrounding acute HIV-1 infection have been well described, but little is known about whether the virologic course of acute HIV-1 infection influences the subsequent progression of disease. OBJECTIVE: To define the virologic natural history of acute and very early HIV infection. DESIGN: Prospective, longitudinal cohort study. SETTING: University of Washington Research Clinic PARTICIPANTS: 74 adults enrolled soon after acquisition of HIV (mean, 69 days). MEASUREMENTS: Plasma HIV-1 RNA levels; quantitative cell cultures; CD4 cell counts; and detailed clinical assessments done at study entry, biweekly for 1 month, monthly for 2 months, and quarterly thereafter. RESULTS: In the first 30 days after acquisition of HIV, HIV-1 RNA levels varied greatly among participants (range, 27,200 to 1.6 x 10(6) copies per mL of plasma). Levels of HIV-1 RNA decreased by a mean of 6.5% per week for the first 120 days and then increased by a mean of 0.15% per week. CD4 cell counts decreased by a mean of 5.2 cells/mm3 per week for the first 160 days and by a mean of 1.9 cells/mm3 per week thereafter (P < 0.01). Disease progressed faster in participants who sought medical care for their acute seroconversion syndrome (P = 0.01) and those who had high plasma HIV-1 RNA levels 120 to 365 days after acquisition (P < 0.01). Peak levels in the first 120 days were not predictive of disease progression. CONCLUSIONS: The variability in viral RNA levels associated with acute HIV-1 infection is greater than previously appreciated. Within 120 days of acquisition, plasma HIV RNA levels rapidly decrease to an inflection point, after which they gradually increase. Virus-host interactions soon after acquisition seem to have a major influence on the long-term outcome of HIV-1 disease.     

HIV infection and health policy.

The epidemic of human immunodeficiency virus (HIV) infection has given an urgency to health policy dilemmas that have long been brewing. By exacerbating long-standing problems, the epidemic has surpassed what we find tolerable and has pressured politicians and health officials to find solutions. Whether the approaches they take will substantially contribute to solving the underlying problems is unclear. Many persons engaged in health policy believe that in responding to the AIDS crisis we may be defining our society for future historians. Judgment may be passed on how compassionately we care for those who are sick, how effectively we choose our public health measures, and how creatively we apply our scientific knowledge. This paper addresses six challenges that face policymakers: (a) protecting people from discrimination, (b) designing testing and screening programs, (c) developing safe and effective antiviral drugs, (d) planning for future vaccine trials, (e) organizing and delivering health care to sufferers of HIV infection, and (f) financing such health care. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Occult HIV infection: diagnosis and treatment of older patients

The decrease in immune status that accompanies normal aging leaves individuals age 50 and older increasingly susceptible to the two main modes of HIV infection: sexual activity and blood transfusions. Although therapy for older HIV patients is essentially the same as for younger patients, knowledge of appropriate drug dosages and nutritional issues that influence the care of the older HIV patient is essential for physicians treating this population. Physicians need to recognize the clinical features of HIV-related dementia and opportunistic infections that distinguish it from other age-related illnesses such as Alzheimer's and Parkinson's disease. Known risk factors that affect older patients should influence physicians to routinely include HIV in their differential diagnoses.     

Infectious sinusitis in HIV infection. Clinical and therapeutic data on 20 patients

To assess the clinical presentation and outcome of infectious sinusitis in HIV-infected patients, we analyzed in a retrospective study, the records of HIV-infected patients hospitalized from June 1986 to November 1989. Twenty-eight episodes of infectious sinusitis, defined by radiological signs, were recorded in 20 HIV-infected patients. Clinical presentation suggestive of acute sinusitis was inconstant and in 6 episodes a persistent fever was the only symptom. Concomitant pneumonia was detected in 8 episodes. Bacteria were isolated in 8 episodes, and in 4 of them, Haemophilus influenzae was identified. Clinical relapses occurred in 8/20 patients, requiring a surgical drainage in 3 cases. The frequency of relapses and the possibility of chronicity justify a more prolonged and aggressive therapy in infectious sinusitis occurring in HIV-infected patients.     

Caregivers and HIV infection. Services and issues

Because of the complexity of their illness, patients infected with HIV may require many services to facilitate the management of the disease. The primary care provider must understand and facilitate the services that are needed and needs to be familiar with the individuals responsible for the care of each patient. There are many stresses that have been identified in HIV caregiving, for informal caregivers and health care workers. These stresses are described, and suggestions for appropriate interventions are outlined.     

Clinical significance of HIV DNA in polymorphonuclear neutrophils from patients with HIV infection

The elucidation of the enzymatic processing mechanism associated with the formation of antigenic peptide fragments that combine with MHC class II molecules is fundamental to our understanding of the immune system. We have investigated a structurally well defined protein, recombinant human growth hormone (rhGH), as an antigen, and present data supporting the hypothesis that the enzyme cathepsin B can produce peptide fragments bearing T cell epitopes associated with lymphocyte proliferative response to hGH in Balb/c (H-2dhaplotype) mice. Minimal T cell epitopes are not generated; rather the cathepsin cleavage sites flank the three antigenic peptide regions, amino acid residues 31-41, 81-100, and 166-181.     

Morphological diagnosis of intrauterine chlamydia infection and its clinico-anatomical characteristics

Clinicomorphological characteristics of intrauterine chlamydiasis (IUC) are given. The authors describe a cottonwool-like meningochorioiditis the observation of which at necropsy allows IUC suspection. Chlamydial etiology of this condition is confirmed by means of electron microscopy and immunofluorescence. Fibroblast proliferation of the pia mater followed by intensive fibrillogenesis plays a most important role in morphogenesis of cottonwool-like nodules. The occurrence of IUC at the necropsies varies depending on the age of foetuses and newborns from 6.2 to 38.7%.     

Clinical features of tuberculosis associated with HIV infection in Taiwan

To understand the clinical characteristics and outcome of tuberculosis (TB) in patients with acquired immunodeficiency syndrome (AIDS) in Taiwan, we reviewed the medical records of 118 adult AIDS patients who were hospitalized at National Taiwan University Hospital between January 1988 and September 1995. Among them, 29 (24.6%) had TB. The mean age of the AIDS patients with TB was 37 years (range, 25-66 yr). Most patients were in the advanced stages of AIDS when human immunodeficiency virus (HIV) infection and/or TB were first diagnosed. The mean CD4+ lymphocyte count was 0.037 x 10(9)/L (range, 0-0.152 x 10(9)/L) at the time TB was diagnosed. There was no statistically significant difference in the mean CD4+ lymphocyte count between patients with isolated pulmonary TB and those with extrapulmonary involvement. Twenty-two patients (75.8%) had extrapulmonary TB with the most common site being the lymph nodes (72.7%). Clinical symptoms were nonspecific, and the chest physical examination was not helpful in the diagnosis. Acid-fast bacilli were detected in sputum smears from eight patients (36.4%). A primary tuberculosis pattern (hilar adenopathy, pleural effusion, middle or lower lobe infiltrates) in the chest radiographs was the most common radiologic finding (36.4%) in patients with pulmonary TB. The reactivation pattern (predominant upper-lobe infiltrates with or without cavitation) could only be found in cases of pulmonary TB without extrapulmonary involvement. Atypical patterns (diffuse interstitial infiltrates mimicking Pneumocystis carinii pneumonia or other patterns) and normal chest radiographs were noted in nearly one-third of the patients with pulmonary TB. A good response to antituberculosis drugs and a favorable outcome were demonstrated in the patients, except for two with drug-resistant Mycobacterium tuberculosis infection. Early identification of TB in HIV-infected patients requires clinical awareness of the unusual clinical presentations, especially among patients in the advanced stages of AIDS.