Maria L. Alcaide

Septic thrombophlebitis: diagnosis and management.

Septic thrombophlebitis, as a result of invasion from adjacent nonvascular infections, includes conditions such as Lemierre syndrome (internal jugular vein septic thrombophlebitis), pylephlebitis (portal vein septic thrombophlebitis), and septic thrombophlebitis of the dural sinuses and the pelvic veins. All of these conditions are associated with a very high mortality if untreated. Appropriate antibacterial therapy dramatically improves the outcome of these infections and results in a low mortality rate, with the notable exception of septic thrombophlebitis of the durai sinuses. The endovascular nature of these infections results in secondary metastatic disease, including pneumonia, endocarditis, and arthritis due to septic embolization and/or hematogenous bacterial spread. The appropriate diagnosis and management of these infections depends on a high degree of clinical suspicion, the use of imaging studies, and early initiation of empiric antibacterial therapy. In this article, we review the diagnosis and management of septic thrombophlebitis, focusing on Lemierre syndrome, pylephlebitis, and septic thrombophlebitis of the pelvic veins.

Immune Activation in HIV-Infected Aging Women on Antiretrovirals—Implications for Age-Associated Comorbidities: A Cross-Sectional Pilot Study

Background Persistent immune activation and microbial translocation associated with HIV infection likely place HIV-infected aging women at high risk of developing chronic age-related diseases. We investigated immune activation and microbial translocation in HIV-infected aging women in the post-menopausal ages. Methods Twenty-seven post-menopausal women with HIV infection receiving antiretroviral treatment with documented viral suppression and 15 HIV-negative age-matched controls were enrolled. Levels of immune activation markers (T cell immune phenotype, sCD25, sCD14, sCD163), microbial translocation (LPS) and biomarkers of cardiovascular disease and impaired cognitive function (sVCAM-1, sICAM-1 and CXCL10) were evaluated. Results T cell activation and exhaustion, monocyte/macrophage activation, and microbial translocation were significantly higher in HIV-infected women when compared to uninfected controls. Microbial translocation correlated with T cell and monocyte/macrophage activation. Biomarkers of cardiovascular disease and impaired cognition were elevated in women with HIV infection and correlated with immune activation. Conclusions HIV-infected antiretroviral-treated aging women who achieved viral suppression are in a generalized status of immune activation and therefore are at an increased risk of age-associated end-organ diseases compared to uninfected age-matched controls.

Rectal infections with chlamydia and gonorrhoea in women attending a multiethnic sexually transmitted diseases urban clinic

Sexually transmitted rectal infections with Chlamydia trachomatis (CT) and Neisseria gonorrhoeae (GC) have been well documented in men who have sex with men (MSM). Few studies have described infections in women who engage in anal intercourse. We performed testing for rectal infections in women who reported ano-receptive intercourse at the Miami Dade Health Department Sexually Transmitted Diseases (STD) clinic and report the prevalence and characteristics of women with rectal CT or GC infections. Our results revealed a prevalence of 17.5% for rectal chlamydia and 13.4% for rectal gonorrhoea. Urine-based screening alone would have missed 6% of rectal chlamydia infections and 35% of rectal gonorrhoea infections. Anal symptoms were reported in 12.5% of women with rectal chlamydia infections. The only associated factor identified was an age less than 28 years. We conclude that rectal screening for CT and GC should be included in STD prevention strategies, especially in the younger population.

Impaired Antibody Response to Influenza Vaccine in HIV-Infected and Uninfected Aging Women Is Associated with Immune Activation and Inflammation

Background Aging and HIV infection are independently associated with excessive immune activation and impaired immune responses to vaccines, but their relationships have not been examined. Methods For selecting an aging population we enrolled 28 post-menopausal women including 12 healthy volunteers and 16 HIV-infected women on antiretroviral treatment with <100 HIV RNA copies/ml. Antibody titers to trivalent influenza vaccination given during the 2011-2012 season were determined before and 4 weeks after vaccination. Results Seroprotective influenza antibody titers (≥1:40) were observed in 31% HIV+ and 58% HIV-uninfected women pre-vaccination. Following vaccination, magnitude of antibody responses and frequency of seroprotection were lower in HIV+ (75%) than in HIV– (91%) women. Plasma IL-21, the signature cytokine of T follicular helper cells (Tfh), and CD4 T cell IL-21R were upregulated with seroconversion (≥4 fold increase in antibody titer). Post-vaccine antibody responses were inversely correlated with pre-vaccination plasma TNFα levels and with activated CD4 T cells, including activated peripheral (p)Tfh. Plasma TNFα levels were correlated with activated pTfh cells (r=0.48, p=0.02), and inversely with the post-vaccination levels of plasma IL-21 (r=-0.53, p=0.02). In vitro TNFα blockade improved the ability of CD4 T cells to produce IL-21 and of B cells to secrete immunoglobulins, and addition of exogenous IL-21 to cell cultures enhanced B cell function. Higher frequencies of activated and exhausted CD8 T and B cells were noted in HIV+ women, but these markers did not show a correlation with antibody responses. Conclusions In aging HIV-infected and uninfected women, activated CD4 and pTfh cells may compromise influenza vaccine-induced antibody response, for which a mechanism of TNFα-mediated impairment of pTfh-induced IL-21 secretion is postulated. Interventions aimed at reducing chronic inflammation and immune activation in aging, HIV-infected patients may improve their response to vaccines.

Pharyngitis and Epiglottitis

Acute pharyngitis is one of the most common illnesses for which patients visit primary care physicians. Most cases are of viral origin, and with few exceptions these illnesses are both benign and self-limited. The most important bacterial cause is the beta-hemolytic group A streptococcus. There are other uncommon or rare types of pharyngitis. For some of these treatment is required or available, and some may be life threatening. Among those discussed in this article are diphtheria, gonorrhea, HIV infection, peritonsillar abscess, and epiglottitis.

Wernicke's encephalopathy in AIDS: a preventable cause of fatal neurological deficit

Wernickes encephalopathy is commonly associated with chronic alcohol abuse, but may also occur in patients with poor nutritional status. We report a case of acute Wernickes encephalopathy in a patient with AIDS without any predisposing risk factors for thiamine deficiency. In developing countries, without vitamin supplementation, this disorder may play a role in the morbidity and mortality associated with AIDS. We believe that thiamine supplementation should be considered in cachetic AIDS patients, especially where access to antiretroviral therapy is limited.

HIV infection worsens Age-Associated Defects in Antibody Responses to Influenza Vaccine

BACKGROUND Antibody responses to seasonal influenza vaccines are defective during older age and human immunodeficiency virus (HIV) infection. The effect of HIV on immune function in aging is relatively unknown. METHODS HIV-infected and HIV-uninfected young women (age, 19-54 years) and older women (age, >55 years) were evaluated for B-cell and T-cell responses before and 4 weeks after influenza vaccination. RESULTS Frequencies of seroprotection pre-vaccination and vaccine responsiveness (≥4-fold increase in antibody titer) were lower in HIV-infected participants than in age-matched HIV-uninfected participants. A subgroup of vaccine nonresponders were compared to responders and found to have reduced frequencies of memory B cells and antigen-specific antibody-secreting cells after vaccination. Frequencies of peripheral T-follicular helper (pTfh) cells correlated with memory B-cell function and influenza A(H1N1) antibody titers. Serologic and immunologic deficits were most frequent in older HIV-infected participants. Underlying CD4(+) T-cell immune activation and inflammation correlated negatively with antibody titers and B-cell function, which was not enhanced by exogenous interleukin 21 supplementation in HIV-infected, older vaccine nonresponders. CONCLUSIONS Immune activation associated with HIV infection and impaired pTfh function heighten deficiencies in antibody responses to influenza vaccine in older individuals. Strategies to reduce immune activation or augment pTfh function may enhance antibody responses in the aging HIV-infected population.

Vaginal Cleansing Practices in HIV Infected Zambian Women

Vaginal practices are a variety of behavioral techniques that women use to manage their sexual life and personal hygiene. Women perceive vaginal practices as a beneficial practice. However, vaginal cleansing has been identified as one of the main risk factors for bacterial vaginosis and is potentially implicated in Human Immune Deficiency Virus (HIV) and sexually transmitted infection transmission. This study examined the prevalence of vaginal practices and the types of practices used among a sample of HIV positive women living in Lusaka, Zambia. Over 90% of all women recruited engaged in vaginal practices. Certain practices, such as use of water or soap, were more frequently used for hygiene reasons. Herbs and traditional medicines were mainly used to please sexual partner. Strategies to decrease VP appear urgently needed in the Zambian community.ResumenLas prácticas vaginales son utilizadas por las mujeres para controlar su sexualidad e higiene personal. La mayoría de las mujeres que utilizan practicas vaginales las consideran beneficiosas. Sin embargo, la excesiva higiene vaginal facilita el desarrollo de vaginosis bacteriana y podría aumenta el riesgo de transmitir el virus de la inmunodeficiencia humana (VIH) y otras enfermedades de transmisión sexual. Este estudio describe la prevalencia de prácticas vaginales y los tipos de prácticas utilizadas por mujeres VIH positivas en Lusaka, Zambia. Más del 90% de las mujeres utiliza algún tipo de prácticas vaginales. El agua y jabón se utilizan principalmente por motivos higiénicos. Las plantas y medicinas tradicionales se utilizan principalmente para aumentar el placer sexual de la pareja. Estrategias para disminuir las prácticas vaginales son necesarias en la comunidad femenina de Zambia.

Herpes zoster infection after liver transplantation in patients receiving induction therapy with alemtuzumab

Abstract: Background:  The incidence of herpes zoster (HZ) infection in liver transplant recipients prior to the use of induction therapy with monoclonal antibodies has been reported as being 1.2–18%. We studied the occurrence of HZ in liver transplant recipients that received induction therapy with alemtuzumab (Campath 1H®).

Fulminant hepatitis from herpes simplex virus type 2 in an immunocompetent adult.

Abstract: Herpes simplex virus (HSV) is regarded as a common viral pathogen that produces a wide variety of diseases. After a primary infection, which usually occurs during childhood and may or may not be clinically evident, the virus establishes a latent infection in the local sensory ganglia and can reactivate throughout the life of the individual. Fulminant hepatic failure (FHF) due to HSV infection is a clinical condition well known in pediatric, immunocompromised, and pregnant patients. It is rare in immunocompetent hosts. We report the case of a 51‐year‐old man with no significant past medical history who developed FHF with disseminated intravascular coagulopathy and septic shock secondary to HSV infection. The initial diagnosis was made through a frozen section of a needle liver biopsy and the presence of HSV was confirmed in the permanent section with immunohistochemistry. HSV was grown in cell culture from liver tissue obtained through an autopsy.