H. Taelman

Ophthalmic Manifestations of Infections with Cryptococcus neoformans in Patients with the Acquired Immunodeficiency Syndrome

The present study was undertaken to determine the nature and the prevalence of ophthalmic manifestations of infections with Cryptococcus neoformans in human immunodeficiency virus seropositive patients and to analyze whether the presence or absence of ocular signs is associated with improved survival. Eighty human immunodeficiency virus seropositive patients with cryptococcal infection were enrolled. We observed papilledema in 26 of the 80 patients (32.5%). Visual loss and abducens nerve palsy occurred in seven patients (9%). Only two patients (2.5%) had optic atrophy. Visual loss caused by optic nerve involvement was less frequent among the 62 patients treated with oral conazoles exclusively than among the 18 patients who had received amphotericin Bora combination of amphotericin B and conazoles. Actual invasion of the intraocular structures with Cryptococcus neoformans was an uncommon complication in our series. In addition to the ocular manifestations attributable to cryptococcal disease, human immunodeficiency virus-related retinopathy was present in nearly half of the patients. Cytomegalovirus retinitis was diagnosed in four patients (5%). The 26 patients (32.5%) with papilledema had a median survival of 182 days vs 160 days for the patients without papilledema. The median survival for 18 patients (22.5%) with cotton-wool spots was 102 days vs 186 days for those without cotton-wool spots. The differences between these subgroups were not statistically significant.

PLEURAL EFFUSION, TUBERCULOSIS AND HIV-1 INFECTION IN KIGALI, RWANDA

OBJECTIVE AND METHODS An increasing number of diagnoses of pleural effusions (PE) have been made over the last 8 years in the Department of Internal Medicine of the Centre Hospitalier de Kigali, Rwanda. In order to determine the aetiology of PE and to examine its possible association with HIV-1 infection, we performed an aetiological work-up, including thoracocentesis and pleural punch biopsy, of all new patients with PE of undetermined aetiology referred to the Division of Pulmonary Diseases of the Department of Internal Medicine of the Centre Hospitalier de Kigali between 14 September 1988 and 16 October 1989. HIV-1 serological testing was performed for most of the patients. RESULTS A total of 127 patients (81 men, 46 women; mean age, 34 years; range, 16-71 years) with PE of undetermined aetiology were enrolled. Pleural tuberculosis was diagnosed in 110 (86%) and confirmed histologically and/or bacteriologically in 90 (82%). Of 98 pleural tuberculosis patients tested for HIV-1-antibody, 82 (83%) were HIV-1-seropositive. Metastatic cancer was responsible for PE in six (5%) patients, Kaposis sarcoma in three, lymphoma in one (all four HIV-1-seropositive), anaplastic carcinoma in one, and adenocarcinoma in one (both HIV-1-seronegative). Non-tuberculous pneumonia was documented in five (4%) patients and was associated with HIV-1 infection in four. Other causes of PE were congestive heart failure (three patients), decompensated cirrhosis (one), constrictive percarditis (one), or undetermined (one); only one of these patients was HIV-1-seropositive. CONCLUSIONS We conclude that tuberculosis is the predominant cause of PE in our patients and is strongly associated with HIV-1 infection. Although less frequent, non-tuberculous pneumonia, Kaposis sarcoma and lymphoma are other causes of HIV-1-associated PE. In an African area highly endemic for HIV-1 and Mycobacterium tuberculosis co-infection, PE should be considered a good marker of tuberculosis as well as HIV-1 infection.

Antimicrobial susceptibility and serotype distribution of Streptococcus pneumoniae from Rwanda, 1984–1990

A total of 383 clinical isolates of Streptococcus pneumoniae, obtained from an equal number of patients in Kigali, Rwanda, was tested for resistance to penicillin G with a 1 microgram oxacillin disc. Of these isolates, 99 (25.8%) showed reduced zones of inhibition. By means of an agar dilution method, 21% all isolates were confirmed as relatively resistant (MIC > or = 0.12- < or = 1.0 mg/l) strains of Streptococcus pneumoniae (RRSP). A high degree of resistance to penicillin G (MIC > or = 2 mg/l) was not observed. Resistance to chloramphenicol (MIC > or = 8 mg/l) was found in 31% RRSP and in 6% penicillin susceptible strains (PSSP). Doxycycline resistance was common in both RRSP and PSSP strains. All isolates remained fully susceptible to erythromycin. Children more often harboured a strain giving a reduced inhibition zone than did adults (74/230 versus 25/153; P = 0.0005). A total of 32 serotypes or serogroups were identified, seven of them relating to 64.8% all isolates typed. Of all the isolates 84% belonged to a serotype represented in the 23-valent vaccine or to a cross-reacting serotype. Serotype 25, not included in the vaccine, accounted for 10.7% typed isolates from adults but only for 2.0% typed isolates from children. Results of susceptibility testing and clinical experience suggest that penicillin G, ampicillin and chloramphenicol should not be used alone as empirical treatment for pneumococcal meningitis in patients in Rwanda.

Salmonella bacteremia in African patients with human immunodeficiency virus infection

During a two-year period, 26 Central African patients with AIDS or AIDS-related complex were seen in two Belgian hospitals and five of these patients presented with non-typhoidSalmonella bacteremia. Three additional patients were observed in a Rwandese hospital. These eight African patients were compared with 16 non-AIDS patients with non-typhoidSalmonella bacteremias. The patients with AIDS or AIDS-related complex did not have gastroenteritis, but they did have a high recurrence rate and high prevalence ofSalmonella typhimurium. Long-term antibiotic prophylaxis seems warranted for such patients despite the high frequency of side effects from antibiotics.

Cluster of HTLV-III/LAV infection in an African family

Acquired immunodeficiency syndrome (AIDS) has been reported in infants and children, as has mother-to-infant transmission, suggesting in-utero or perinatal infection. We report a familial cluster of three Rwandese brothers and their parents with T-cell deficiency and carriage of antibodies to human T-cell lymphotropic virus type III (HTLV-III)/lymphadenopathy-associated virus (LAV) with features suggesting other routes of transmission.

LAV/HTLV-III infection in children of African origin: Experience in Belgium

From December 1982 to June 1985, we diagnosed LAV/HTLV-III infection in 16 children of African origin living in Belgium or referred to one of the hospitals participating in this study. Diagnosis was proven in seven of them by isolation of virus of the LAV/HTLV-III group. In the nine others, LAV/HTLV-III infection was highly probable because of the presence of antibodies against the virus (seven subjects) or clinical and immunological evidence of immune deficiency associated with a parental history of LAV/HTLV-III infection (two subjects). Five of these children had a severe illness starting in the first months of life (range 20 days-4 months) and died within 4 months (range 19 days-10 months). Eight children presented later in life (mean age 35 months, range 2–66 months) with a milder and more chronic disease characterized by the presence of generalized lymphadenopathy (6/8), hepatomegaly (5/8), splenomegaly (5/8), interstitial pulmonary infiltration (4/8), parotid swelling (3/8), CSF lymphocytosis (3/5), diarrhoea without pathogen isolated (1/8) and fever (1/8).At least one of the parents of each child was of African origin. At the time of birth of their child two mothers and one father had an AIDS-related complex. After a mean period of 34 months (range 3–87 months) five fathers and six mothers had a symptomatic LAV/HTLV-III infection (AIDS or AIDS-related complex).

Ophthalmic Manifestations of Infections With Cryptococcus neoformans in Patients With the Acquired Immunodeficiency Syndrome

The present study was undertaken to determine the nature and the prevalence of ophthalmic manifestations of infections with Cryptococcus neoformans in human immunodeficiency virus seropositive patients and to analyze whether the presence or absence of ocular signs is associated with improved survival. Eighty human immunodeficiency virus seropositive patients with cryptococcal infection were enrolled. We observed papilledema in 26 of the 80 patients (32.5%). Visual loss and abducens nerve palsy occurred in seven patients (9%). Only two patients (2.5%) had optic atrophy. Visual loss caused by optic nerve involvement was less frequent among the 62 patients treated with oral conazoles exclusively than among the 18 patients who had received amphotericin B or a combination of amphotericin B and conazoles. Actual invasion of the intraocular structures with Cryptococcus neoformans was an uncommon complication in our series. In addition to the ocular manifestations attributable to cryptococcal disease, human immunodeficiency virus-related retinopathy was present in nearly half of the patients. Cytomegalovirus retinitis was diagnosed in four patients (5%). The 26 patients (32.5%) with papilledema had a median survival of 182 days vs 160 days for the patients without papilledema. The median survival for 18 patients (22.5%) with cotton-wool spots was 102 days vs 186 days for those without cotton-wool spots. The differences between these subgroups were not statistically significant.

T-CELL DEFICIENCY IN AN AFRICAN FAMILY

We report the case of a 19-month old African boy born from parents with clinical and immunological features suggesting prodromal acquired immunodeficiency syndrome (AIDS). He showed early failure to thrive, generalized lymphadenopathy, bilateral parotitis. Later he developped persistent interstitial pneumonia, persistent oral thrush and mild hepatosplenomegaly. Immunological studies showed hyper IgG level (3.2 g/dl), reversed T-helper/T-suppressor (T4/T8) ratio (19/68) and T-cell defect (cutaneous anergy for different antigens, depressed in vitro response for concanavalin, phytohaemagglutinin and Pokeweed mitogens). Open lung biopsy showed interstitial nodular lymphocytic infiltrates on optic microscopy and cytoplasmic particles on electron microscopy which are of uncertain origin. Recently the two older brothers were investigated. The oldest (6 years) showed chronic parotitis, hyper IgG level (4.7 g/dl), reversed T4/T8 ratio (18/49) and depressed in vitro response to mitogens. The second (5 years) showed slight parotitis, reversed T4/T8 ratio (29/32) and depressed in vitro response to mitogens. Both had normal chest X-rays The clinical and immunological presentation of the three children resemble that of infants with AIDS-like syndrome described by others in the USA. We suggest specific modes of transmission could be involved in familial acquiring of AIDS (transplacental-route, breast feeding, or other routine close-contact).