Marisela Silva

Nutrient intake and body weight in a large HIV cohort that includes women and minorities

OBJECTIVEnEvaluate the baseline nutrient intake of an HIV positive population that includes significant representation from women and minorities, and determine the relationship between state of disease and nutritional intake.nnnDESIGNnBaseline data from a prospective study (Nutrition for Healthy Living).nnnSUBJECTSnIndividuals with HIV in the Boston and Rhode Island area (n = 516); 25% were women and 30% were minorities.nnnMETHODSnNutrient intakes from 3-day food records, which included vitamin/mineral supplements, were estimated by gender and nonwhite vs white categories, after grouping by CD4 lymphocyte counts.nnnSTATISTICAL ANALYSESnSpearman correlation coefficients, Wilcoxon signed rank test, Wilcoxon rank sum test, chi2 test, and restricted cubic spline model were used for data analyses as indicated.nnnRESULTSnMacronutrient but not micronutrient intake was statistically and inversely associated with decreasing CD4 cell counts. The median intake of micronutrients was higher in the study sample compared with the same age and gender group in NHANES III data; however, 25% to 35% of the women in our study sample had dietary intakes of less than 75% of the DRIs for vitamins A, C, E and B-6, and iron and zinc. White men had statistically higher values of all micronutrients compared with nonwhite men. Body mass index for men and women ranged from 23 to 25.nnnCONCLUSIONS/APPLICATIONSnMedian values for micronutrient intake from food plus vitamin/mineral supplements were adequate in the overall population studied, but a large percent of women and minorities had inadequate nutrient intakes and would benefit from dietary assessment and counseling.

Brain Abscess Due to Arcanobacterium haemolyticum after Dental Extraction

To the Editor—It has been suggested that 5%–20% of brain abscesses are presumably associated with oral infections or dental procedures [1–4], in which organisms belonging to the oropharyngeal flora, such as Arcanobacterium haemolyticum, are involved [5, 6]. This organism has been documented in cases of pharyngitis and wound infections [7], but rarely in systemic infections [7–9] and even less in brain abscesses [10]. We describe the case of a patient who developed a brain abscess due to A. haemolyticum infection after undergoing dental extraction procedure. An 18-year-old man without a remarkable medical history, except for repeated periodontal manipulations, was admitted to the hospital with headache, vomiting, aphasia, weakness in his left extremities, behavior and mood alterations, and fever. Three months before admission, he had been treated for periodontitis and dental caries in a primary dental clinic. He underwent extraction of multiple teeth. He had been well until 15 days before hospital admission, when intense headache and vomiting developed. Seven days before hospitalization, weakness in his left extremities became worse, and he was unable to stand or walk. A brain CT scan revealed a left-sided hypodense fronto-parietal lesion with cystic, contrast ring enhancement and perilesional edema exerting a significant mass effect (a 1.8-cm displacement of the middle line). He was referred to our hospital and was admitted to a neurosurgical ward. On admission to the neurosurgical ward, he was afebrile. His blood pressure was 140/80 mmHg, his respiratory rate was 14 breaths per min, his heart rate was 82 beats per min, and his temperature was 36.6 C. He was conscious and alert. Neurologic examination revealed no evidence of neck stiffness or of Kernig’s or Brudzinski’s signs. Muscle strength was 3/5 in his left leg muscle and in his left forearm muscle. Laboratory data included a peripheral WBC count of cells/L with 88% neutro9 19.02 10 phils, a hemoglobin level of 13.3 g/dL, a platelet count of platelets/L, 9 304 10 and an erythrocyte sedimentation rate of 10 mm/h. His aspartate aminotransferase, alanine aminotransferase, anaplastic lymphoma kinase, creatinine, blood glucose, plasma sodium, and plasma potassium levels were normal. Subaracnoid hemorrhage was suspected as the likely diagnosis. He was treated with supportive care, but continued to complain of symptoms he had at admission. On his second day in the hospital, he complained of severe headache, and his mental state abruptly became worse, with the onset of confusion and anisocoric pupils. His Glasgow coma score was 10/15. An emergency left-sided craniotomy was performed, with aspiration of an encapsulated mass containing white-yellowish pus (150 mL). The pathological diagnosis was a brain abscess. Immediately after surgery, the patient was treated with ceftriaxone (2 g every 24 h intravenously) and metronidazole (500 mg every 8 h intravenously). The day after surgery, the patient’s mental status returned to nearly normal (Glasgow coma score of 13/15), and he no longer complained of headache. The weakness in his left extremities improved significantly. Microscopic observation of the Gram stained smear of the abscess sample showed pleomorphic gram-positive coryneform bacteria. After 48 h at 37 C, aerobic culture grew minute, translucent, nonpigmented colonies with a small zone of clear hemolysis on 5% sheep blood agar. On the basis of the hemolytic pattern, a negative catalase reaction, and other biochemical test criteria, the isolate was identified as A. haemolyticum [11]. The isolate was found to be susceptible to penicillin, ceftriaxone, gentamicin, clindamicin, doxicicline, and vancomicin, but resistant to trimethoprim-sulfamethoxazole and ciprofloxacin by disk diffusion method. From the seventh day post-surgery, the patient received penicillin G (24 mU intravenously, daily for 21 days). Four weeks later, the patient was successfully discharged from the hospital with no subsequent complications. A. haemolyticum is a catalase-negative, gram-positive, or gram-variable rod whose morphology is dependent on the growth media and conditions [11]. This species (formerly Corynebacterium haemolyticum) is an infrequent cause of pharyngitis in children and young adults. It is occasionally isolated from wound infections and abscesses and is found in patients with meningitis, pneumonia, pyothorax, and septicemia [7–13]. To our knowledge, after a review of the indexed literature, we consider this to be the second reported case in which A. haemolyticum is documented as the etiological agent of a brain abscess (previously, 1 case in a child was reported) [10] and the first in an adult patient. Although A. haemolyticum is susceptible (thus far, universally) to penicillin by in vitro MIC testing, treatment failure despite adequate doses of phenoxymethylpenicillin has been documented [11, 13–15]. Most studies have found that A. haemolyticum is susceptible to all antimicrobials tested, except trimethoprim-sulfamethoxazole [11, 13–16]. In the current case, the isolate was also resistant to ciprofloxacin. This case illustrates the aggressive and serious nature of systemic odontogenic infections in which resistant strains could be producing severe neurological complications. The careful identification of Arcanobacterium species and its corresponding antimicrobial susceptibility test is important, so a complete understanding of the role of these organisms in disease and proper management can be realized [17]. As was seen in our case, A. haemolyticum can be resistant to additional drugs other than trimethoprim-sulfamethoxazole (ciprofloxacin, in this report) and can cause severe life-threatening diseases.

Difficulty Swallowing and Lack of Receipt of Highly Active Antiretroviral Therapy Predict Acute Weight Loss in Human Immunodeficiency Virus Disease

In human immunodeficiency virus (HIV) disease, symptoms of underlying illness may promote weight loss through decreased caloric intake, increased metabolic needs, or nutrient malabsorption. We evaluated disease symptoms as predictors of acute weight loss (i.e., loss of > or =5% of weight). HIV-infected men and women (n=415) were telephoned every 5 weeks to obtain information about weight and recent symptoms. Weight change between each pair of consecutive calls (telephone intervals, 2814) was calculated. Acute weight loss occurred across 4.5% of intervals and among 24% of individuals. Patients reported > or =1 symptom before 58% of telephone intervals. The most common symptoms or symptom complexes before intervals were diarrhea (21% of patients), anorexia (17%), upper respiratory symptoms (16%), skin symptoms (12%), and abdominal pain (12%). Trouble swallowing (6%) and oral symptoms (7%) were less common. Risk of acute weight loss was significantly increased when oral symptoms or trouble swallowing were present, and it was decreased when highly active antiretroviral therapy (HAART) was used or when diarrhea was not present. Even when HAART is being administered, clinicians should remain vigilant regarding weight loss, oral symptoms, and trouble swallowing.