Arthur E. Pitchenik

Tuberculosis atypical mycobacteriosis and the acquired immunodeficiency syndrome among Haitian and non-Haitian patients in South Florida.

To study the association between mycobacterial disease and the acquired immunodeficiency syndrome, we reviewed the records of all cases of tuberculosis and all cases of the syndrome reported in Dade County, Florida, from January 1980 through June 1983. Tuberculosis was diagnosed in 27 of 45 Haitians with the syndrome, but in only 1 of 37 non-Haitians with the syndrome (p less than 0.001). Among the 27 Haitians with the syndrome and tuberculosis, 19 had extrapulmonary tuberculosis, whereas among 286 Haitian patients with tuberculosis without the syndrome, only 56 had extrapulmonary tuberculosis (p less than 0.001). Tuberculosis preceded the syndrome by 1 to 17 months (mean, 6) in 22 patients. In 10 patients with the syndrome and positive sputum cultures who were treated with conventional antituberculosis drugs, the cultures became negative within 1 to 4 months and tuberculosis did not recur. The frequency of disseminated atypical mycobacteriosis or positive sputum cultures for atypical mycobacteria was not significantly different between Haitian (11.3%) and non-Haitian (8.3%) patients with the syndrome.

Opportunistic Infections and Kaposi's Sarcoma Among Haitians: Evidence of a New Acquired Immunodeficiency State

Twenty Haitian patients, hospitalized from 1 April 1980 to 20 June 1982, had Pneumocystis carinii pneumonia, central nervous system toxoplasmosis, esophageal candidiasis, cryptococcosis, disseminated cytomegalovirus, progressive herpes simplex virus, chronic enteric coccidiosis, or invasive Kaposis sarcoma. Ten patients died. Opportunistic infections were frequently multiple and were recurrent in three patients. In seven patients disseminated tuberculosis preceded the other infections by 2 to 15 months. There was no evidence of an underlying immunosuppressive disease, and no history of homosexuality or intravenous drug abuse. At least three patients probably acquired the syndrome in Haiti. Lymphadenopathy was common. Seventeen patients tested had anergy, and 18 had lymphopenia. Monoclonal antibody analysis of peripheral-blood T-cell subsets done on 11 patients showed a marked decrease in T-helper cells and an inversion of the normal ratio of T-helper cells to T-suppressor cells. This syndrome among heterosexual Haitians is strikingly similar to the syndrome of immunodeficiency described recently among American homosexuals.

An Index Predicting Relapse and Need for Hospitalization in Patients with Acute Bronchial Asthma

In an attempt to define guidelines for the assessment of acute asthma, we evaluated 205 patients who presented to the emergency room for treatment of asthma. Of the 205, 120 were successfully treated and discharged from the emergency room, 45 were hospitalized, and 40 were treated and discharged from the emergency room but had relapses within 10 days. A predictive index using a combination of presenting factors was developed: pulse rate greater than or equal to 120 per minute, respiratory rate greater than or equal to 30 per minute, pulsus paradoxus greater than or equal to 18 mm Hg, peak expiratory flow rate less than or equal to 120 liters per minute, moderate to severe dyspnea, accessory-muscle use, and wheezing. The index ranged from 0 to 7, increasing with the severity of symptoms. The index scores of the relapse group (4.9 +/- 1.0) and the admitted group (5.1 +/- 1.0) were both significantly different (p less than 0.001) from that of the successfully treated group (1.6 +/- 1.2). An index of 4 or higher was 95 per cent accurate in predicting the risk of relapse and 96 per cent accurate in predicting the need for hospitalization.

The emergence of HIV/AIDS in the Americas and beyond

HIV-1 group M subtype B was the first HIV discovered and is the predominant variant of AIDS virus in most countries outside of sub-Saharan Africa. However, the circumstances of its origin and emergence remain unresolved. Here we propose a geographic sequence and time line for the origin of subtype B and the emergence of pandemic HIV/AIDS out of Africa. Using HIV-1 gene sequences recovered from archival samples from some of the earliest known Haitian AIDS patients, we find that subtype B likely moved from Africa to Haiti in or around 1966 (1962–1970) and then spread there for some years before successfully dispersing elsewhere. A “pandemic” clade, encompassing the vast majority of non-Haitian subtype B infections in the United States and elsewhere around the world, subsequently emerged after a single migration of the virus out of Haiti in or around 1969 (1966–1972). Haiti appears to have the oldest HIV/AIDS epidemic outside sub-Saharan Africa and the most genetically diverse subtype B epidemic, which might present challenges for HIV-1 vaccine design and testing. The emergence of the pandemic variant of subtype B was an important turning point in the history of AIDS, but its spread was likely driven by ecological rather than evolutionary factors. Our results suggest that HIV-1 circulated cryptically in the United States for ≈12 years before the recognition of AIDS in 1981.

Impact of tobacco use on the development of opportunistic respiratory infections in HIV seropositive patients on antiretroviral therapy

The increased risk of developing lung diseases in cigarette smokers has been well recognized. The association between smoking and the risk of developing pulmonary infections in HIV‐1‐infected patients, however, which has not been established, was evaluated in the present study. Twenty‐seven cases with lower respiratory infections (15 Pneumocystis carinii pneumonia (PCP), 12 TB cases) were compared with 27 age, gender, socio‐economic and HIV status‐matched patients, without history of respiratory diseases. Medical history and physical examinations were obtained every 6 months. Blood was drawn for CD4 and viral load measurements. A substantial number of HIV+ smokers who developed PCP (one‐third) had been on highly active retroviral therapy (HAART) for more than 6 months and prophylaxis had been discontinued. Multivariate analyses indicated that in HIV‐infected people, after controlling for HIV status and antiretrovirals, cigarette smoking doubled the risk for developing PCP (p =0.01). Multivariate analyses demonstrated that long‐term smoking also increased the risk (2×) of developing tuberculosis (p =0.04). Moreover, daily tobacco use seemed to attenuate by 40% the immune and virological response to antiretroviral therapies. These findings indicate that tobacco use significantly increases the risk of pulmonary diseases in HIV infected subjects and has a potential deleterious impact on antiretroviral treatment.

The Prevalence of Tuberculosis and Drug Resistance among Haitians

TUBERCULOSIS is a major health problem among Haitians who have recently entered southern Florida. Among those medically screened on arrival, we found that the prevalence of tuberculosis was 650 cas...

ICU survival of patients with the acquired immunodeficiency syndrome

The ICU records of 31 patients with the acquired immunodeficiency syndrome were reviewed. Of 23 (74%) patients admitted for respiratory failure requiring intubation and mechanical ventilation, 20 (87%) patients had Pneumocystis carinii and/or cytomegalovirus pneumonia. Of the eight patients admitted without respiratory failure, five (63%) were monitored after brain biopsy. Respiratory failure patients remained in the ICU for 10 ± 1 days, compared to 5 ± 1 days for those without respiratory failure (p < .05). Overall mortality was 24 patients (77%); 21 (91%) of 23 respiratory failure patients died, compared to three (38%) of the eight without respiratory failure (p < .01). All seven ICU survivors lived to hospital discharge.

Use of Rifabutin with Protease Inhibitors for Human Immunodeficiency Virus-Infected Patients with Tuberculosis

Drug interactions between rifamycins and highly active antiretroviral therapy (HAART) have raised concerns in the treatment of human immunodeficiency virus (HIV)-infected patients with tuberculosis. We conducted a study of this interaction by measuring serum drug levels of all HIV-infected patients with tuberculosis who were admitted to A. G. Holley State Tuberculosis Hospital (Florida) from October 1997 through December 1998, who were concomitantly treated with rifabutin and HAART. All 25 patients studied became culture-negative within 2 months of initiation of therapy for tuberculosis and remained negative for a median of 13 months follow-up after completion of therapy. HIV viral loads (mean+/-SEM) decreased significantly from 4.95+/-0.21 log10 copies/mL before initiation of HAART to 2.77+/-0.07 log10 copies/mL before discharge (P<.001); 20 of 25 patients achieved viral loads of <500copies/mL. In summary, the concomitant use of rifabutin and HAART can lead to successful treatment of HIV-infected patients with tuberculosis without increased side effects.

The acquired immunodeficiency syndrome in the wife of a hemophiliac.

A 71-year-old previously healthy woman developed unexplained thrush, onychomycosis, Pneumocystis carinii pneumonia, and a T-cell defect consistent with the acquired immunodeficiency syndrome. Her only apparent risk factor was infrequent, monogamous sexual contact with her husband, a 74-year-old hemophiliac who had received factor VIII concentrate and subsequently died due to P. carinii pneumonia. She first developed probable signs of the syndrome (recurrent thrush and onychomycosis) 1 year before her husband became ill. These findings suggest that the syndrome can be transmitted heterosexually by an asymptomatic person, and that the female sexual partners of hemophiliacs treated with factor VIII concentrate may be at risk of acquiring the syndrome; frequent sexual contact or several sexual partners are not necessary for transmission to occur; and the syndrome can occur in elderly people if exposed to risk factors. This case further supports the theory that the syndrome in hemophiliacs is due to an infectious agent that can be transmitted heterosexually as well as parenterally.

Tuberculosis Control and the AIDS Epidemic in Developing Countries

Excerpt The acquired immunodeficiency syndrome (AIDS) epidemic poses profound problems for the control of tuberculosis in developing countries. Even though tuberculous infection and tuberculosis ar...