Judith Berger

Highly Active Antiretroviral Therapy and Viral Response in HIV Type 2 Infection

Human immunodeficiency virus type 2 (HIV-2), the second human retrovirus known to cause AIDS, is endemic to West Africa but is infrequently found outside this region. We present a case series of 10 HIV-2--infected individuals treated in the United States. Physicians applied the principles of highly active antiretroviral therapy (HAART), normally used in treating HIV type 1, with modifications considered appropriate for treating HIV-2. CD4+ cell count, HIV-2 virus load, and clinical status were found to correlate well, providing evidence that HIV-2 virus load is useful in managing treatment of patients with HIV-2 who are receiving therapy. However, HAART regimens with predicted efficacy for treatment of HIV type 1 infection are not as efficacious for treatment of HIV-2. Controlled clinical trials of HIV-2-infected patients receiving various HAART regimens are needed to provide therapeutic guidance to the medical community.

Mycobacterium Fortuitum and Anaerobic Breast Abscess Following Nipple Piercing: Case Presentation and Review of the Literature

PURPOSE Body piercing has become increasingly prevalent. We describe a case of breast infection with combined mycobacteria and anaerobe following nipple piercing, and review the literature. CASE A 17-year-old female developed a breast abscess 4 months after nipple piercing. Cultures grew Prevotalla melangenica and Mycobacterium fortuitum. She required drainage and antibiotic treatment. Three months into her treatment she stopped her medications, relapsed, and required drainage. Two months later, on antimycobacteria therapy, her wound is healing. DISCUSSION Review of the infectious complications of nipple piercing yielded 12 cases, 5 of which had a foreign body. The pathogens isolated (coagulase negative staphylococcus, mycobacteria, streptococcus, anaerobe, and gordonia) are not the usual organisms to be isolated from a breast abscess. This could result from reporting bias or the presence of a foreign body, the nipple ring. The three cases of mycobacteria, in addition to ours, are reviewed. The average age is 22 years. Three to 9 months elapsed between piercing and infection. All cases required drainage. Antimycobacteria therapy was used in three of the four cases for 10 days to 6 months. CONCLUSION With the increasing prevalence of body piercing, it is important to document and report infections. We describe a breast abscess following nipple piercing with combined anaerobic and a mycobacterial pathogens. This underscores the need for obtaining cultures including anaerobes and mycobacteria.

Feasibility of using audio computer-assisted self-interview (ACASI) screening in routine HIV care

Abstract We evaluated the feasibility of implementing audio computer-assisted self-interviews (ACASI) as part of routine clinical care at two community hospital-based HIV clinics in New York City. Between June 2003 and August 2006, 215 patients completed 1001 ACASI sessions in English or Spanish prior to their scheduled clinical appointments. Topics covered included antiretroviral therapy adherence, depression symptoms, alcohol and drug use, and condom use. Patients and providers received feedback reports immediately after each session. Feasibility was evaluated by quantitative analysis of ACASI responses, medical chart reviews, a brief patient questionnaire administered at the conclusion of each computer session, patient focus groups, and semi-structured provider interviews. ACASI interviews frequently identified inadequate medication adherence and depression symptoms: at baseline, 31% of patients reported ≤95% adherence over the past three days and 52% had symptoms of depression (CES-D score ≥16). Substance abuse problems were identified less frequently. Patients were comfortable with the ACASI and appreciated it as an additional communication route with their providers; however, expectations about the level of communication achieved were sometimes higher than actual practice. Providers felt the summary feedback information was useful when received in a timely fashion and when they were familiar with the clinical indicators reported. Repeated ACASI sessions did not have a favorable impact on adherence, depression, or substance use outcomes. No improvements in HIV RNA suppression were observed in comparison to patients who did not participate in the study. We conclude that it is feasible to integrate an ACASI screening tool into routine HIV clinical care to identify patients with inadequate medication adherence and depression symptoms. Repeated screening was not associated with improved clinical outcomes. ACASI screening should be considered in HIV clinical care settings to assist providers in identifying patients with the greatest need for targeted psychosocial services including adherence support and depression care.

Clostridium difficile at a community hospital in the Bronx, New York: Incidence prevalence and risk factors from 2006 to 2008

BACKGROUND The rate of Clostridium difficile has increased over the last decade. This study was undertaken to determine the incidence, prevalence, and risk factors for infection at a 460-bed community hospital in the Bronx, New York. METHOD Retrospective study reviewing all patients with a positive stool test for C difficile toxin A/B from 2006 to 2008. RESULTS Three hundred fifty-two stools were positive for toxin. Average age was 58 years; 4% of patients with stools positive for C difficile were asymptomatic; 7% had community-acquired infection; 57% of C difficile acquisition occurred in the hospital; and 36% were in patients who acquired C difficile from a health care facility prior to admission. The incidence of C difficile was 7.8 cases/10,000 days in 2006, 10.3 in 2007, and 9.7 in 2008. The prevalence was 6.2 cases per 1,000 admissions in 2006, 7.6 in 2007, and 7.0 in 2008. The increased prevalence was not uniform throughout the hospital. CONCLUSION At a community hospital in the Bronx, the incidence of C difficile increased but at a lower rate than previously reported. Prior health facility contact accounted for one third of these cases. Rooms with clusters of patients with C difficile suggest environmental propagation of infection.

Mycobacterium avium intracellulare complex (MAC) presenting with marked jaundice and duodenal ulcerations

Mycobacterium avium intracellulare complex (MAC) presenting with marked jaundice and duodenal ulcerations