Beata Casanas

Clinico-epidemiological profile of HIV/TB coinfected patients in Vadodara, Gujarat.

INTRODUCTION The HIV epidemic has posed major, almost insurmountable, challenges to tuberculosis control efforts across the world. This study analyzes the prevalence and disease profile of HIV/AIDS coinfection in Vadodara, Gujarat, India. MATERIALS AND METHODS This study was conducted in the HIV Referral Clinic at Vadodara, India. Using convenience sampling method, 246 HIV-positive patients coinfected with tuberculosis were enrolled. A detailed history of every case was taken followed by a thorough physical examination. Baseline and follow up laboratory and radiological investigations were carried out as appropriately warranted. RESULTS Out of 500 HIV positive patients who presented to the clinic during the study period, 246 (49.2%) were coinfected with tuberculosis. Out of 246 coinfected cases, 35(14.2%) presented with demonstrable and documented tuberculosis whereas in 211(85.8%) cases, tuberculosis was extemporaneously detected by actively screening the patients. Sixty nine percent of patients were males, while 10.5% of cases were below fifteen years of age. The majority (68%) of patients had manifestations of extrapulmonary tuberculosis; but pulmonary tuberculosis, which is a more common presentation in HIV-negative cases, was present in only fifty five percent of this segment of the population. Abdominal tuberculosis was the most common site (74%) amongst extrapulmonary tuberculosis involvement, followed by clinically palpable lymph nodes (22%) and pleural effusion (17%). CONCLUSION The prevalence of tuberculosis in HIV-positive patients in this study (49%) was substantially higher than that reported in previous studies. However, this could be attributed to a selection and/or a diagnosis bias. This study used abdominal ultrasound for the diagnosis of tuberculosis which might have obviously increased the prevalence. Moreover, these cases were not confirmed by biopsy or other definitive TB diagnostic methods.

Cost of treatment: The single biggest obstacle to HIV/AIDS treatment adherence in lower-middle class patients in Mumbai, India

BACKGROUND This study analyzes the social, economic and behavioral factors most frequently associated with adherence to Highly Active Antiretroviral Treatment (HAART) in urban India. MATERIALS AND METHODS Data was collected in a metropolitan teaching hospital in Mumbai using a cross-sectional survey design. Face-to-face interviews were conducted with 152 patients. The semistructured survey included both open and closed ended questions on socio-demographic, economic and behavioral factors. Factors affecting treatment adherence were analyzed. RESULTS The median age of patients was 40.5 years, 73% were males and all were heterosexual. Patients had been given ART from six months to five years (median is equal to 3.5). Ninety per cent lived at home and commuted to the clinic by bus or train. Behaviorally, 37% were sexually active, but only 55% used condoms. In assessing adherence, income, education, knowledge of their drugs, transportation, side effects, cost of treatment, distance from clinic and personal clinic satisfaction were analyzed. We found that 75% of patients reported cost of HAART to be the single greatest obstacle to adherence (p less than 0.01). Additionally, those claiming knowledge of their drugs were 2.3 times more likely to be adherent (p less than 0.03), while those who abused drugs or alcohol were 53% less likely to be adherent (p less than 0.03). There was no correlation with other factors. CONCLUSIONS Our study population was representative of the lower middle class of India. It found that an educated, employed group considered the cost of treatment to be a significant obstacle for successful therapy. Additionally, it showed a significant increase in adherence when patients had knowledge of their HAART medications. Therefore, reducing the cost of medication as well as teaching about antiretroviral medications are both likely to improve adherence.

Bartonella Species, an Emerging Cause of Blood-Culture-Negative Endocarditis

SUMMARY Since the reclassification of the genus Bartonella in 1993, the number of species has grown from 1 to 45 currently designated members. Likewise, the association of different Bartonella species with human disease continues to grow, as does the range of clinical presentations associated with these bacteria. Among these, blood-culture-negative endocarditis stands out as a common, often undiagnosed, clinical presentation of infection with several different Bartonella species. The limitations of laboratory tests resulting in this underdiagnosis of Bartonella endocarditis are discussed. The varied clinical picture of Bartonella infection and a review of clinical aspects of endocarditis caused by Bartonella are presented. We also summarize the current knowledge of the molecular basis of Bartonella pathogenesis, focusing on surface adhesins in the two Bartonella species that most commonly cause endocarditis, B. henselae and B. quintana. We discuss evidence that surface adhesins are important factors for autoaggregation and biofilm formation by Bartonella species. Finally, we propose that biofilm formation is a critical step in the formation of vegetative masses during Bartonella-mediated endocarditis and represents a potential reservoir for persistence by these bacteria.

Cutaneous Manifestation of Tuberculosis

AbstractCutaneous tuberculosis (CTB) is an uncommon form of extrapulmonary tuberculosis (TB). It is characterized as an invasion of the skin by Mycobacterium tuberculosis and, less commonly, Mycobacterium bovis and the bacilli Calmette-Guerin vaccine. Cutaneous TB is rare despite the high prevalence of TB worldwide. The highest incidence of CTB is in underdeveloped, resource-poor countries. With some exceptions, lupus vulgaris (LV) is the most common form. Cutaneous TB manifests a wide spectrum of clinical presentations, and current classification systems are based on the route of transmission and the immunologic state of the host. The exogenous (or primary) form of CTB occurs via traumatic direct inoculation of M. tuberculosis into the skin or mucous membranes leading to primary cutaneous TB, TB verrucosa cutis, and rarely LV. The endogenous (or secondary) form of CTB occurs through lymphatic, hematogenous, or contiguous spread of M. tuberculosis to the skin from an internal focus leading to the development of LV, scrofuloderma, TB cutis orificialis, miliary TB, and metastatic TB abscesses. Tuberculids are another form of CTB resulting from a hypersensitivity reaction to an internal source of M. tuberculosis antigens. Diagnosis can be made based on history, morphologic features, and histopathologic characteristics but can be complicated and substantially delayed because of the resemblance to other dermatologic conditions. Furthermore, skin biopsy and/or acid-fast bacilli staining and culture may fail to reveal the presence of M. tuberculosis. As with TB of other organs, treatment of CTB requires a 4-drug chemotherapeutic regimen that usually consists of rifampin, isoniazid, pyrazinamide, and ethambutol for 2 months followed by a 2-drug regimen for 4 months. Depending on the type of CTB, several years of chemotherapy and/or surgical excision may be needed.

Pasteurella multocida infections in cancer patients.

Abstract Background: Pasteurella multocida is a small, gram-negative coccobacillus, which most commonly causes soft tissue infections due to animal bites or scratches, mainly from cats and dogs. Immunocompromised hosts, such as cancer patients, are more likely to develop systemic complications as a result of P. multocida infections. Objective: Retrospectively analyze the medical records of four afflicted patients being managed at Moffitt Cancer Center, Tampa, USA between 1999 and 2009, and careful study for additional 32 cases of P. multocida infection among cancer patients with variegated histology found in the current medical literature. Methods: Of 36 subjects, 67% of the patients had been diagnosed with a solid organ cancer, whereas 33% had a hematologic malignancy. Clinical scenarios described fever as the most frequent initial presentation and bacteremia as the most prevalent mode of infection. Results: Forty-seven percent of the patients had experienced some sort of animal contact and 41% showed evidence of skin or soft tissue infection. The status of the white blood cell count, was available in 22 patients (of 36 patients), and 27% demonstrated neutropenia. The survival percentage of the patients with known clinical outcome was 77%. Conclusion: Medical management mostly involved antibiosis with beta-lactams. Atypical scenario of Pasteurella multocida infection may involve bites or scratches (specifically from cats or dogs) in a cancer patient presenting with sepsis and accompanied by skin or soft tissue or respiratory tract infection. A high level of suspicion for P. multocida as a possible pathogen in cancer patients would facilitate an amelioration in morbidity ameliorating, and timely initiation of specific antibiotics.

Successful use of subcutaneous ivermectin for the treatment of Strongyloides stercoralis hyperinfection in the setting of small bowel obstruction and paralytic ileus in the immunocompromised population

Severe Strongyloides stercoralis, such as hyperinfection syndrome, carries a high mortality risk. Even with appropriate treatment, patients may experience infectious complications and failure of therapy. Currently, there are no Food and Drug Administration–approved parenteral therapies available for treatment in patients who develop gastrointestinal complications from hyperinfection, including small bowel obstruction. A veterinary form of ivermectin is available as a subcutaneous injection, although current literature in humans is limited. We report on the successful treatment of two surviving immunocompromised patients with S. stercoralis hyperinfection syndrome after prompt recognition and initiation of veterinary subcutaneous ivermectin therapy.

Nongastrointestinal Aeromonas hydrophila Infections in Patients With Cancer

AbstractAeromonas hydrophila is an aquatic bacterium that causes sporadic, opportunistic warm-weather soft tissue infections and bacteremias, classically among men with predisposing liver disorders or leukemias. Although the portal of entry often remains elusive, the end result in these immunodeficient populations can be devastating.At our institution, we exhaustively reviewed patient charts and records and identified A. hydrophila from fluid specimens in 24 symptomatic patients with cancer over a period of 23 years. Seven of our patients were male and the other 17 patients were female, and the median age was 64 years.Predisposing conditions were identified as follows: Six of them had solid organ malignancies, and two had a diagnosis of hematologic malignancies; four patients had altered hepatic function, whereas 3 patients had neutropenia. Only one patient was found to have the classical risk factor of liver cirrhosis, in this case, secondary to chemotherapy.The 2 patients exhibiting soft tissue manifestations of Aeromonas acquired the bacterium in the community and presented with local abscess and fever. Only one of the 2 patients gave a history of fresh water exposure. We successfully managed these 2 patients with nonsurgical intervention.

Neurosyphilis and HIV Infection

Syphilis and HIV are both diseases of major public health importance globally, affecting tens of millions of people and leading to millions of deaths every year. There is a complex demographic, epidemiologic, and biologic interaction between the HIV virus and Treponema pallidum, the causative agent of syphilis. These interactions lead not only to higher rates of coinfection but also are believed to affect pathogenic mechanisms that result in early central nervous system syphilis among HIV-coinfected patients. Acute syphilitic meningitis and neuro-ophthalmologic syphilitic involvement are also believed to occur at a higher rate and early in the course of syphilis among HIV-coinfected individuals. There needs to be a higher index of suspicion for syphilitic involvement of the CNS among HIV patients especially those with ophthalmological and/or ontological complaints. While there may need to be subtle differences, current recommendations for diagnostic workup for neurosyphilis in HIV-coinfected patients are similar to that of non-HIV patients. Intravenous penicillin remains the treatment of choice for neurosyphilis.

Orthopoxviruses and Human Disease

Orthopoxvirus is a genus belonging to the family of Poxviridae. There are four species, within this genus, which are most known to cause human disease: variola virus (smallpox) and zoonotic species that include monkeypox virus, cowpox virus, and vaccinia virus. The clinical manifestations of orthopoxvirus-related disease fall within a spectrum from localized to systemic disease. Orthopoxviruses are most prominent due to smallpox and the burden of illness it has placed on human beings throughout history. The declaration of the eradication of smallpox in 1980 is considered one of the greatest triumphs in public health history. With smallpox now eradicated, the lesser-known orthopoxviruses are being given more attention with well-publicized outbreaks including human monkeypox and bovine vaccinia (vaccinia virus-related disease). The advent of nucleic acid amplification tests has improved our ability to differentiate among species and has helped identify novel pathogenic orthopoxviruses in recent years. The persistent pathogenicity of the lesser-known orthopoxviruses and the advent of novel species demonstrate that orthopoxviruses will likely continue to play a future role in human disease.

Central Nervous System Tuberculosis

Human immunodeficiency virus (HIV) and tuberculosis (TB) are, respectively, the number one and number two causes of infectious deaths worldwide. The relationship between these two microorganisms is unique, due to the synergistic ability of each disease to reactivate and accelerate the progression of the other. Through discussion of their general pathophysiology and the specific role of the human cellular immune response, four mechanisms will be delineated to further elaborate this challenging phenomenon.