Rafik Samuel

AIDS related opportunistic infections, going but not gone

It is now more than two decades since the AIDS epidemic began with a cluster ofPneumocystiscarinii pneumonia (PCP) in a community of homosexual men. Since then, many other infections have been characterized as opportunistic infections secondary to HIV infection. These include, but are not limited to, infections withToxoplasma gondii, Cytomegalovirus (CMV),Mycobacterium avium complex (MAC), andCryptococcus neoformans. Over the last two decades, there have been dramatic improvements in diagnosis, prevention and treatment of all these infections. As a result, in North America and Western Europe the rates of opportunistic infections secondary to AIDS have decreased substantially. We will review these common opportunistic infections below.

Antiretroviral therapy 2006: Pharmacology, applications, and special situations

As we approach the completion of the first 25 years of the human immunodeficiency virus (HIV) epidemic, there have been dramatic improvements in the care of patients with HIV infection. These have prolonged life and decreased morbidity. There are twenty currently available antiretrovirals approved in the United States for the treatment of this infection. The medications, including their pharmacokinetic properties, side effects, and dosing are reviewed. In addition, the current approach to the use of these medicines is discussed. We have included a section addressing common comorbid conditions including hepatitis B and C along with tuberculosis.

Bacterial Peritonitis Caused by Kingella kingae

ABSTRACT Kingella kingae is a commensal of the upper respiratory tract that occasionally causes skeletal infections in children and endocarditis in children and adults. We report a case of a 55-year-old man with liver disease and tense ascites who performed a paracentesis on himself and developed K. kingae peritonitis and bacteremia.

Prevalence and Characteristics of Patients with Undiagnosed HIV Infection in an Urban Emergency Department

The Centers for Disease Control and Prevention (CDC) recommends offering HIV testing to persons admitted to emergency departments (EDs). Whether by opt-in or opt-out, many EDs (including our own) have found a seroprevalence of 0.8-1.5% when rapid testing is offered. The true seropositivity rate is unknown. We performed a retrospective chart analysis upon all patients presenting to our ED over a 2-week period in the fall of 2007 who had serum drawn as a part of their emergency care. Demographics and clinical characteristics were linked via de-identified serum, which was sent for HIV testing. Nine hundred fifty nine patients had sera available for rapid HIV testing. One hundred twenty one (13%) samples were reactive via the OraQuick(®) test (OraSure Technologies, Bethlehem, PA), a point of care rapid antibody test. Due to concerns about the appropriateness of sera as substrate for the OraQuick(®) technology, reactive samples were retested via standard enzyme immunoassay (EIA)/Western blot. One hundred twelve analyzable samples were retested-38 were positive and 27 of these were from patients who reported a history of HIV infection. The rate of undiagnosed HIV infection was 1.2% (11/914 potentially analyzable samples). Of all patients with HIV in our ED, 29% of them were presumably unaware of their diagnosis. In conclusion, HIV seroprevalence in our urban ED is high, and a large fraction of the patients appears to be unaware of the infection.

Antiretroviral therapy 2010 update: Current practices and controversies

Over the past four years, significant advances have been made in human immunodeficiency virus (HIV) therapy. In addition to the release of two new classes of antiretrovirals, our understanding of the older antiretrovirals continues to improve. Multiple combination pills have been brought to market, simplifying the regimens for patient ease. New controversies have arisen, notably the role of antiretrovirals in the chronic inflammatory state that HIV infection produces, which may lead to excess cardiac, renal, and hepatic mortality. The optimum time to initiate antiretroviral therapy remains unknown but clinicians are treating HIV infection earlier in its course. In this article, we review these and other new issues relating to the care of the HIV patient.

Acute Interstitial Nephritis Associated with Linezolid

TO THE EDITOR: Acute interstitial nephritis (AIN) associated with linezolid is rare but has been previously reported.1,2 We report a case of AIN in a young man receiving linezolid for osteomyelitis. Case Report. A 21-year-old man with a history of intravenous drug abuse presented to the emergency department complaining of severe pain and swelling in the left thigh and fever of 1 week’s duration after recent dynamic hip and screw surgery with hardware placement. Initial diagnostic tests included blood urea nitrogen (BUN) 10 mg/dL, serum creatinine (SCr) 1 mg/dL, and white blood cell (WBC) count 20.1 × 103/mm3 with 1.1% eosinophils. These values remained stable and the WBC count normalized by the time of discharge. Vancomycin was initiated after a bone scan showed likely osteomyelitis of the femur. Blood and hip joint cultures were negative. Due to the patient’s improvement on vancomycin, oral linezolid 600 mg every 12 hours for a total of 8 weeks was prescribed. Ten days after discharge, the patient returned to the hospital with a diffuse pruritic maculopapular rash and a fever. Vital signs were temperature 37.9 ̊C, blood pressure 146/70 mm Hg, and heart rate 122 beats/ min. Significant laboratory test results included a WBC count of 8.9 × 103/mm3 with 24.7% eosinophils, BUN 41 mg/dL, and SCr 3.8 mg/dL. Urine studies showed eosinophiluria and microscopic hematuria; a renal ultrasound was normal. The patient reported taking linezolid for 7 days before losing the prescription bottle 4 days prior to this admission. He reported that the pruritus and rash developed shortly after starting linezolid. The patient received antihistamines to control symptoms. There was no evidence of skin desquamation or mucosal involvement. SCr remained elevated at 3.6 mg/dL for the first several days of hospitalization. Shortly after admission, the rash began to improve, but the patient remained febrile, with continued eosinophilia. A clinician from the Nephrology service diagnosed the patient with AIN due to eosinophiluria and linezolid exposure. The patient responded to corticosteroids and SCr began to decline on hospital day 8. Blood and urine cultures were negative and intravenous vancomycin was the planned therapy. However, the patient left the hospital against medical advice and did not return. Discussion. There have been 2 published case reports of AIN related to linezolid.1,2 Our patient had clinical manifestations similar to those in these cases, including maculopapular rash, facial edema, eosinophilia, and elevations in SCr, all of which developed within 1 week of linezolid exposure and responded with supportive care, corticosteroids, and linezolid discontinuation. According to the Naranjo probability scale, the likelihood of linezolid having caused this reaction is probable.3 The majority of AIN cases are induced by drug therapy.4 With the exception of vancomycin, our patient was not receiving any other classes of drugs that would be suspected of inducing AIN. However, he received vancomycin without complications during both hospitalizations. He did not have any documented previous exposure to linezolid, had the clinical hallmarks of AIN, and responded to therapy for AIN. We cannot exclude the use of contaminated intravenous drugs as a possible cause for this reaction. Patients receiving linezolid should be closely and routinely monitored for potential adverse events, including AIN.

Impact of outpatient electronic medical record on antiretroviral errors among hospitalized patients

Inappropriate antiretroviral therapy puts patients infected with human immunodeficiency virus (HIV) at high risk for toxicities and the development of drug-resistant virus. While multiple studies have found high rates of antiretroviral medication errors among hospitalized patients infected with HIV

Antiretroviral therapy 2000

As we enter the new millennium, there have been dramatic improvements in the care of patients with HIV infection. These have prolonged life and decreased morbidity and mortality. There are fourteen currently available antiretrovirals approved in the United States for the treatment of this infection. The medications, including their pharmacokinetic properties, side effects, and dosing are reviewed. In addition, the current approach to the use of these medicines is discussed.

Infections in Heart and Lung Transplant Recipients

Abstract Patients undergoing thoracic organ transplantation procedures involving the heart or lung are at increased risk for developing a wide variety of infections due to their underlying immunosuppression and/or other factors. Lung transplant recipients are at high risk for developing infections caused by bacteria, viruses, and opportunistic fungi, whereas heart transplant recipients are at risk for developing infections caused by these same microorganisms, as well as parasitic infections, including toxoplasmosis and New World trypanosomiasis. This review will highlight the various infections that thoracic organ transplant recipients may develop following their procedures.

Virologic Success in an Urban HIV Clinic: Outcome at 12 Months in Patients Who Were HAART Naïve

Abstract Background: Randomized controlled trials with highly active antiretroviral therapy (HAART) have demonstrated over 70% virologic success rates, although patients in an inner city HIV setting likely have lower virologic success. Method: We studied the outcome of all treatment-naive patients beginning HAART in our urban clinic in Philadelphia, Pennsylvania. The primary outcome was virologic success at 12 months for all patients who were initiated on HAART. Secondary outcomes included virologic success at 12 months for only those who remained in care and the determination of which demographics influenced virologic success. Results: Between 2003 and 2005, 109 patients were initiated on HAART: 39% women, 79% African American, 17% Hispanic, median CD4+ count 120 cells/mm3, and HIV-1 RNA 4.9 log10copies/mL. Twenty-two were lost to follow-up after HAART initiation. Of the 87 who remained in care, 41 maintained a HIV-1 RNA <400 copies/mL through 12 months on their initial HAART regimen. Emerging drug resistance was documented in 7 of 87 patients. NNRTI-based HAART was significantly associated with greater virologic failure due to emerging resistance compared to a PI-based regimen. Conclusion: Our retrospective study demonstrates the difficulties in administering successful HIV care to an urban population, and efforts to help patients overcome barriers to consistent medical care must be a priority.