Edmund Ong

Auditing HIV Testing Rates across Europe: Results from the HIDES 2 Study.

European guidelines recommend the routine offer of an HIV test in patients with a number of AIDS-defining and non-AIDS conditions believed to share an association with HIV; so called indicator conditions (IC). Adherence with this guidance across Europe is not known. We audited HIV testing behaviour in patients accessing care for a number of ICs. Participating centres reviewed the case notes of either 100 patients or of all consecutive patients in one year, presenting for each of the following ICs: tuberculosis, non-Hodgkins lymphoma, anal and cervical cancer, hepatitis B and C and oesophageal candidiasis. Observed HIV-positive rates were applied by region and IC to estimate the number of HIV diagnoses potentially missed. Outcomes examined were: HIV test rate (% of total patients with IC), HIV test accepted (% of tests performed/% of tests offered) and new HIV diagnosis rate (%). There were 49 audits from 23 centres, representing 7037 patients. The median test rate across audits was 72% (IQR 32–97), lowest in Northern Europe (median 44%, IQR 22–68%) and highest in Eastern Europe (median 99%, IQR 86–100). Uptake of testing was close to 100% in all regions. The median HIV+ rate was 0.9% (IQR 0.0–4.9), with 29 audits (60.4%) having an HIV+ rate >0.1%. After adjustment, there were no differences between regions of Europe in the proportion with >0.1% testing positive (global p = 0.14). A total of 113 patients tested HIV+. Applying the observed rates of testing HIV+ within individual ICs and regions to all persons presenting with an IC suggested that 105 diagnoses were potentially missed. Testing rates in well-established HIV ICs remained low across Europe, despite high prevalence rates, reflecting missed opportunities for earlier HIV diagnosis and care. Significant numbers may have had an opportunity for HIV diagnosis if all persons included in IC audits had been tested.

Optic neuropathy as the presenting feature of HIV infection: recovery of vision with highly active antiretroviral therapy

Editor,—We describe a rare case of bilateral optic neuropathy caused by HIV which responded to highly active antiretroviral therapy (HAART). ### CASE REPORT In March 1996, a 52 year old man presented with a 6 month history of slowly deteriorating vision in both eyes. By the time he sought medical help he had difficulty reading the newspaper and watching television. He was otherwise well except for a chronic productive cough. He had worked for many years as a teacher in Botswana. He was heterosexual. His only risk factor for HIV transmission was a single encounter with an African woman in the mid 1980s. In 1988 he had dengue fever and malaria. The latter was treated in the UK with quinine and fansidar. In 1995 he was treated in Botswana for a pneumonic illness. He was known to be hypertensive and was taking nifedipine, bendrofluazide, and atenolol. There was nothing else of relevance in his history. On examination he was clubbed and had bilateral coarse crepitations. General examination was otherwise normal. Higher mental function was normal. Visual acuities were 6/18 on the right and 6/9 on the left. He had marked colour desaturation being able to read 2/17 Ishihara plates with the right eye and 3/17 with the left. Both visual fields showed a marked concentric constriction (Fig 1A). Funduscopy revealed bilateral optic disc pallor (Fig 2). Intraocular pressures were normal. Eye movements were normal. His visual evoked response was virtually extinguished on the right and was delayed and of small amplitude on the left. No …

Clinical presentation, treatment, and outcomes in presumed intraocular tuberculosis: experience from Newcastle upon Tyne, UK

PurposeTo report the clinical manifestations and treatment outcomes of patients with presumed intraocular tuberculosis (TB) seen at the Newcastle Uveitis Service, Royal Victoria Infirmary, Newcastle upon Tyne, UK over a 10-year period.MethodsRetrospective review of case notes.ResultsA total of 21 patients were identified. Occlusive retinal vasculitis was the commonest ophthalmological presentation (12 patients). Eight patients (38%) were found to have underlying active systemic TB (four with mediastinal lymphadenopathy, three with pulmonary TB, one with cutaneous TB). Constitutional or respiratory symptoms, elevated inflammatory markers, and an abnormal chest radiograph were poor indicators of active TB. Two patients had inactive intrathoracic TB. Eleven patients had latent TB. Eighteen patients received anti-tuberculous treatment. Final visual acuity was better than or equal to initial visual acuity in 14 out of 16 patients who completed at least 6 months of standard anti-tuberculous treatment.ConclusionsMost patients with presumed intraocular TB have latent TB, but a significant minority has hitherto undetected active TB. Our series suggests that either proven or presumed intraocular TB occurs frequently in the absence of constitutional or respiratory symptoms, elevated inflammatory markers, or an abnormal chest radiograph. A minimum of 6 months standard anti-tuberculous treatment provides good visual outcomes in the majority of patients.

Desensitization to co-trimoxazole (trimethoprimsulphamethoxazole) in HIV-infected patients: Is patch testing a useful predictor of reaction?

OBJECTIVE To establish the safety and efficacy of desensitization to co-trimoxazole in hypersensitive HIV-infected subjects. To assess if delayed hypersensitivity (type IV) to co-trimoxazole predicts those unable to be desensitized. METHOD desensitization to co-trimoxazole, comprising trimethoprim (T) 0.4 mg and sulphamethoxazole (S) 2 mg initially with doubling dose daily, full strength co-trimoxazole (T/S 160 mg/800 mg) at 10 days. Patch testing with 4.5% and 9% co-trimoxazole in yellow soft paraffin, CMI Multitest. RESULTS nineteen patients, 18 male and one female, were recruited and completed the desensitization regime. Of these 80%(15) achieved successful desensitization. Three of those who reacted did so within 18 days. All patients were successfully managed in an outpatient setting. There were no major adverse reactions. Of those reacting none gave a positive patch test to co-trimoxazole and all showed absent delayed type hypersensitivity reactions to recall antigens. CONCLUSIONS co-trimoxazole desensitization is a safe and efficacious procedure, with a success rate of 80% using the above regime. Patch testing with co-trimoxazole gives no useful information about those that reacted.

Cryptococcosis: An unusual opportunistic infection complicating B cell lymphoproliferative disorders

We report two cases of cryptococcosis in patients with Waldenstroms macroglobulinaemia and chronic lymphocytic leukaemia that responded to prolonged therapy with systemic amphotericin and flucytosine. Cryptococcosis, although more common in those with impaired cell mediated immunity, should also be considered as a complication in patients with impaired antibody responses.

Efficacy and effects on pulmonary function tests of weekly 600 mg aerosol pentamidine as prophylaxis againstPneumocystis carinii pneumonia

SummaryA prospective study was designed to evaluate the efficacy and effects on pulmonary function tests of weekly 600 mg aerosolised pentamidine as prophylaxis againstPneumocystis carinii pneumonia (PCP) amongst two groups of patients infected with the human immunodeficiency virus. Group 1 (primary prophylaxis) consisted of patients with either diseases indicative of AIDS other than PCP or whose absolute CD4 positive lymphocyte count was below 200/mm3, and Group 2 (secondary prophylaxis) comprised patients with previous proven episodes of PCP. Fifty-five patients (30-Group 1, 25-Group 2) were studied over a period of 36 months, and no patients reached a study end point of either relapse or death due to PCP after a mean duration of treatment of 14.9 months (range 9–36 months). There were no significant differences between the pulmonary function tests (forced expiratory volume in the first second, forced vital capacity and carbon monoxide diffusion capacity) performed at the start and end of the study on both groups of surviving patients. Ten patients (18%) reported coughing and eight patients (15%) were documented to have bronchoconstriction, which was found to be preventable by prior administration of disodiumcromoglycate. The results showed that weekly 600 mg aerosolised pentamidine is effective and well tolerated for primary and secondary prophylaxis against PCP without additional adverse effects. Further prospective randomized trials are needed to determine whether doses higher than the current recommended 300 mg monthly dosage of aerosolised pentamidine provide more efficacy before such an alternative prophylactic treatment is generally adopted for patients who cannot tolerate other systemic agents.ZusammenfassungIn einer prospektiven Studie wurden die klinische Wirksamkeit einer wöchentlichen Applikation von 600 mg Pentamidin als Aerosol zur Prophylaxe gegen diePneumocystis carinii-Pneumonie (PCP) und der Einfluß auf die Lungenfunktionsparameter untersucht. Eingeschlossen in die Studie wurden zwei Gruppen von Patienten mit HIV-Infektion. Die Gruppe 1 (primäre Prophylaxe) bestand aus Patienten, bei denen Krankheiten aus dem AIDS-Symptomenkreis vorlagen oder die eine absolute CD4-Zellzahl unter 200/mm3 hatten, jedoch keine PCP. Gruppe 2 (sekundäre Prophylaxe) setzte sich aus Patienten zusammen, die bereits PCP-Episoden durchgemacht hatten. Über einen Zeitraum von 36 Monaten wurden 55 Patienten (30 Gruppe 1, 25 Gruppe 2) untersucht. Nach einer mittleren Behandlungsdauer von 14,9 Monaten (9 bis 36 Monaten) hatte keiner der Patienten ein Rezidiv erlitten oder war an PCP verstorben. Die Lungenfunktionsparameter (Ein-Sekundenwert, forcierte Vitalkapazität, CO-Diffusionskapazität) zeigten in den beiden Gruppen bei den überlebenden Patienten keine signifikanten Unterschiede in den zu Beginn und am Ende der Studie erhobenen Werten. Zehn Patienten (18%) berichteten über Husten und bei acht (15%) wurde eine Bronchokonstriktion nachgewiesen, die sich durch vorherige Inhalation von Disodiumcromoglykat vermeiden ließ. Die Ergebnisse zeigen, daß Pentamidin in einer Dosis von 600 mg als Aerosol einmal wöchentlich appliziert, eine effektive Prophylaxe der PCP darstellt, gut vertragen wird und keine zusätzlichen Nebenwirkungen verursacht. Es ist erforderlich, weitere randomisierte Studien durchzuführen, um festzustellen, ob höhere Dosen von Pentamidin in Aerosolform bessere Wirksamkeit bieten als die derzeit empfohlene Gabe von 300 mg einmal monatlich, bevor ein solches alternatives Prophylaxeregime generell für Patienten eingesetzt wird, die andere systemische Substanzen nicht tolerieren.A prospective study was designed to evaluate the efficacy and effects on pulmonary function tests of weekly 600 mg aerosolised pentamidine as prophylaxis againstPneumocystis carinii pneumonia (PCP) amongst two groups of patients infected with the human immunodeficiency virus. Group 1 (primary prophylaxis) consisted of patients with either diseases indicative of AIDS other than PCP or whose absolute CD4 positive lymphocyte count was below 200/mm3, and Group 2 (secondary prophylaxis) comprised patients with previous proven episodes of PCP. Fifty-five patients (30-Group 1, 25-Group 2) were studied over a period of 36 months, and no patients reached a study end point of either relapse or death due to PCP after a mean duration of treatment of 14.9 months (range 9–36 months). There were no significant differences between the pulmonary function tests (forced expiratory volume in the first second, forced vital capacity and carbon monoxide diffusion capacity) performed at the start and end of the study on both groups of surviving patients. Ten patients (18%) reported coughing and eight patients (15%) were documented to have bronchoconstriction, which was found to be preventable by prior administration of disodiumcromoglycate. The results showed that weekly 600 mg aerosolised pentamidine is effective and well tolerated for primary and secondary prophylaxis against PCP without additional adverse effects. Further prospective randomized trials are needed to determine whether doses higher than the current recommended 300 mg monthly dosage of aerosolised pentamidine provide more efficacy before such an alternative prophylactic treatment is generally adopted for patients who cannot tolerate other systemic agents. In einer prospektiven Studie wurden die klinische Wirksamkeit einer wöchentlichen Applikation von 600 mg Pentamidin als Aerosol zur Prophylaxe gegen diePneumocystis carinii-Pneumonie (PCP) und der Einfluß auf die Lungenfunktionsparameter untersucht. Eingeschlossen in die Studie wurden zwei Gruppen von Patienten mit HIV-Infektion. Die Gruppe 1 (primäre Prophylaxe) bestand aus Patienten, bei denen Krankheiten aus dem AIDS-Symptomenkreis vorlagen oder die eine absolute CD4-Zellzahl unter 200/mm3 hatten, jedoch keine PCP. Gruppe 2 (sekundäre Prophylaxe) setzte sich aus Patienten zusammen, die bereits PCP-Episoden durchgemacht hatten. Über einen Zeitraum von 36 Monaten wurden 55 Patienten (30 Gruppe 1, 25 Gruppe 2) untersucht. Nach einer mittleren Behandlungsdauer von 14,9 Monaten (9 bis 36 Monaten) hatte keiner der Patienten ein Rezidiv erlitten oder war an PCP verstorben. Die Lungenfunktionsparameter (Ein-Sekundenwert, forcierte Vitalkapazität, CO-Diffusionskapazität) zeigten in den beiden Gruppen bei den überlebenden Patienten keine signifikanten Unterschiede in den zu Beginn und am Ende der Studie erhobenen Werten. Zehn Patienten (18%) berichteten über Husten und bei acht (15%) wurde eine Bronchokonstriktion nachgewiesen, die sich durch vorherige Inhalation von Disodiumcromoglykat vermeiden ließ. Die Ergebnisse zeigen, daß Pentamidin in einer Dosis von 600 mg als Aerosol einmal wöchentlich appliziert, eine effektive Prophylaxe der PCP darstellt, gut vertragen wird und keine zusätzlichen Nebenwirkungen verursacht. Es ist erforderlich, weitere randomisierte Studien durchzuführen, um festzustellen, ob höhere Dosen von Pentamidin in Aerosolform bessere Wirksamkeit bieten als die derzeit empfohlene Gabe von 300 mg einmal monatlich, bevor ein solches alternatives Prophylaxeregime generell für Patienten eingesetzt wird, die andere systemische Substanzen nicht tolerieren.

Cytomegalovirus cholecystitis and colitis associated with the acquired immunodeficiency syndrome

Cytomegalovirus (CMV) is an important cause of acalculous gangrenous cholecystitis in immunocompromised persons. We report a case of acalculous acute cholecystitis and active colitis associated with CMV in a patient suffering from the acquired immune deficiency syndrome. The condition was treated successfully with surgery and 9-(1,3,-dihydroxy-2-propoxymethyl)guanine intravenously.

Bronchial responsiveness in AIDS patients with Pneumocystis carinii pneumonia.

ObjectiveTo study bronchial responsiveness to inhaled histamine among HIV-infected patients. DesignA prospective study in a regional infectious diseases unit. MethodsThree groups of patients were studied. Group A consisted of AIDS patients (n = 7) who had had Pneumocystis carinii pneumonia (PCP), group B of AIDS patients (n = 7) not known to have had PCP, and group C of asymptomatic HIV-positive patients (n = 7). Inhalational histamine challenge in cumulative doses (0.03–3.91 μmol) was administered by a nebulizer. It was stopped when the forced expiratory volume in 1 sec (FEV1) had fallen by more than 20% of the baseline value or when the cumulative dose administered exceeded 3.91 μmol. Response was measured as percentage change in FEV1 from the baseline value, and plotted on a linear scale against log dose histamine to enable the dose of histamine causing a 20% fall in FEV1 (PD20-FEV1) to be determined. Statistical analysis was performed by analysis of variance. ResultsAIDS patients previously infected with PCP (group A) had a significantly lower PD20-FEV1 [(mean, 0.31 μmol; range, 0.07–0.95; s.d., 0.31; s.e., 0.12; 95% confidence interval (CI), 0.03–0.60)] than AIDS patients without PCP (group B; mean, 1.01 μmol; range, 0.20–2.00; s.d., 0.67; s.e., 0.25; 95% CI, 0.39–1.64) or asymptomatic HIV-positive patients (group C; mean, 1.28 μmol; range, 0.49–1.80; s.d., 0.51; s.e., 0.19; 95% CI, 0.81–1.76) (P<0.05). There was no significant difference between groups B and C. All patients recorded PD20-FEV1within the asthmatic range of bronchial hyper-responsiveness. ConclusionsThese results suggest that development of PCP in a small group of HIV-infected patients induces a significantly greater degree of bronchial hyper-responsiveness.

Three cases of oral syphilis – an overview

Syphilis is an infectious disease caused by the organism Treponema pallidum. There has been a dramatic increase in the number of new cases of syphilis in the UK over the past decade. Intra-oral ulceration is often the only presenting feature of the disease, which then enters a latent period. A missed diagnosis can often lead to serious complications and may result in further spread of the disease. Three cases are discussed in this paper with varying clinical presentations of the disease. Such a significant increase of syphilis and its high infectivity require the dental profession to increase their awareness of sexually infectious diseases and the appropriate dental management.

Miliary Pneumocystis carinii pneumonia in acquired immunodeficiency syndrome.

Pneumocystis carinii pneumonia (PCP) is the most common opportunistic pulmonary infection in patients with the acquired immunodeficiency syndrome (AIDS)l. The most frequent radiographic appearance is a pattern of bilateral interstitial or alveolar infiltrates-, Radiographic appearances of initial or relapses of PCP can be atypical and include lobar distribution, pleural effusion, hilar adenopathy, sparing of previously irradiated areas of lung, abscess or cyst formation, honeycomb appearance, spontaneous pneumothorax and occasionally discrete nodular densities-A We describe a case of PCP presenting as a diffuse bilateral, miliary pattern in a patient with AIDS.