S. Xerinda

Severe imported malaria in an intensive care unit: a review of 59 cases

BackgroundIn view of the close relationship of Portugal with African countries, particularly former Portuguese colonies, the diagnosis of malaria is not a rare thing. When a traveller returns ill from endemic areas, malaria should be the number one suspect. World Health Organization treatment guidelines recommend that adults with severe malaria should be admitted to an intensive care unit (ICU).MethodsSevere cases of malaria in patients admitted to an ICU were reviewed retrospectively (1990-2011) and identification of variables associated with in-ICU mortality performed. Malaria prediction score (MPS), malaria score for adults (MSA), simplified acute physiology score (SAPSII) and a score based on WHOs malaria severe criteria were applied. Statistical analysis was performed using StataV12.ResultsFifty nine patients were included in the study, all but three were adults; 47 (79,6%) were male; parasitaemia on admission, quantified in 48/59 (81.3%) patients, was equal or greater than 2% in 47 of them (97.9%); the most common complications were thrombocytopaenia in 54 (91.5%) patients, associated with disseminated intravascular coagulation (DIC) in seven (11.8%), renal failure in 31 (52.5%) patients, 18 of which (30.5%) oliguric, shock in 29 (49.1%) patients, liver dysfunction in 27 (45.7%) patients, acidaemia in 23 (38.9%) patients, cerebral dysfunction in 22 (37.2%) patients, 11 of whom with unrousable coma, pulmonary oedema/ARDS in 22 (37.2%) patients, hypoglycaemia in 18 (30.5%) patients; 29 (49.1%) patients presented five or more dysfunctions. The case fatality rate was 15.2%. Comparing the four scores, the SAPS II and the WHO score were the most sensitive to death prediction. In the univariate analysis, death was associated with the SAPS II score, cerebral malaria, acute renal and respiratory failure, DIC, spontaneous bleeding, acidosis and hypoglycaemia. Age, partial immunity to malaria, delay in malaria diagnosis and the level of parasitaemia were not associated with death in this cohort.ConclusionSevere malaria cases should be continued monitored in the ICUs. SAPS II and the WHO score are good predictors of mortality in malaria patients, but other specific scores deserve to be studied prospectively.

Impact of Lipodystrophy on the prevalence and components of metabolic syndrome in HIV-infected patients.

BackgroundIn HIV-infected patients, combination antiretroviral therapy (cART) is associated with clinical lipodystrophy (CL) and metabolic abnormalities (MA). This study aimed to evaluate the prevalence of the metabolic syndrome (MS) and its components, and to determine whether patients with or without CL had a different prevalence of MA.MethodsWe evaluated 345 HIV-infected patients on cART using two different MS definitions (NCEP-ATPIII-2005 and IDF-2005) and the Framingham risk score.ResultsCL was present in 58.7% of the patients. The prevalence of the MS was 52.2% (ATPIII) and 43.2% (IDF), and it was not significantly different between patients with (W) or without (WT) CL, regardless of the definition used (ATPIII WCL 52.9% vs WT CL 51.1%; p = 0.738; IDF WCL 41.3% vs WTCL 46.0%; p = 0.379). Moderate concordance was observed between the 2 definitions (kappa = 0.484; p < 0.001) and after gender stratification there was good concordance in women (kappa = 0.759; p < 0.001). Patients with CL had lower waist circumference and HDL-C and higher triglycerides levels. In women, CL was significantly associated with MS, hypertriglyceridemia and low HDL cholesterol independently of age, cART and BMI. Patients with CL had a significantly higher risk of coronary heart disease at 10 years, measured by the Framingham risk score, than patients without CL. Those with CL and with MS had higher frequencies of moderate and high risk categories than those without MS.ConclusionsThe prevalence of the MS was high in these HIV-infected patients with an age average of 40 years and this finding could explain why HIV patients have an increased risk for cardiovascular disease (CVD).

Assessment of body fat composition disturbances by bioimpedance analysis in HIV-infected adults

HIV-lipodystrophy syndrome is characterized by different patterns of body fat distribution (BFD) which are identified by clinical and body composition (BC) assessment, including bioimpedance analysis (BIA). Our aim was to compare BC in HIV-infected patients on combination antiretroviral therapy (cART) according to 4 distinct phenotypes of BFD (G1-no lipodystrophy, G2-isolated central fat accumulation, G3-lipoatrophy, G4-mixed forms of lipodystrophy) and assessed factors associated with them. Anthropometry and BIA were performed in 344 HIV-1 patients. G2 and G4 phenotype patients had significantly higher fat mass (FM) but no differences were observed in fat-free mass (FFM) and total body water among the 4 phenotypes. Significant negative associations were found between the presence of lipoatrophy and female gender, body mass index (BMI), waist (WC), hip (HC) and thigh circumferences, and total body FM estimated by BIA. After adjustment for gender, cART duration and BMI, G3 had significant lower WC [odds ratio (OR)=0.84; 0.78–0.90] and HC (OR=0.88; 0.81–0.96) mean. Independently of gender, cART duration and BMI, G2 remained significantly associated with higher WC (OR=1.11; 1.05–1.18) and HC (OR=1.15; 1.07–1.23) mean, and with FM estimated by BIA [FM as %, OR=1.17 (1.09–1.26); and FM as kg, OR=1.15 (1.06–1.25)]. There was a significant positive association between G4 and female gender (OR=1.66; 1.01–2.75), BMI (OR=1.10; 1.04–1.17) and WC (OR=1.15; 1.09–1.21). The similar FFM along the BFD spectrum describes the actual BC of these patients without sarcopenia. In a clinical setting, BIA is an easy and useful tool to evaluate fat mass and FFM and gives us a picture of BC that was not possible with anthropometry.

Central⁄Peripheral Fat Mass Ratio Is Associated With Increased Risk of Hypertension in HIV-Infected Patients

J Clin Hypertens (Greenwich). 2012; 14:593–600.

Severe Tuberculosis Requiring Intensive Care: A Descriptive Analysis

Background. This study aims to describe the characteristics of tuberculosis (TB) patients requiring intensive care and to determine the in-hospital mortality and the associated predictive factors. Methods. Retrospective cohort study of all TB patients admitted to the ICU of the Infectious Diseases Department of Centro Hospitalar de São João (Porto, Portugal) between January 2007 and July 2014. Comorbid diagnoses, clinical features, radiological and laboratory investigations, and outcomes were reviewed. Univariate analysis was performed to identify risk factors for death. Results. We included 39 patients: median age was 52.0 years and 74.4% were male. Twenty-one patients (53.8%) died during hospital stay (15 in the ICU). The diagnosis of isolated pulmonary TB, a positive smear for acid-fast-bacilli and a positive PCR for Mycobacterium tuberculosis in patients of pulmonary disease, severe sepsis/septic shock, acute renal failure and Multiple Organ Dysfunction Syndrome on admission, the need for mechanical ventilation or vasopressor support, hospital acquired infection, use of adjunctive corticotherapy, smoking, and alcohol abuse were significantly associated with mortality (p < 0.05). Conclusion. This cohort of TB patients requiring intensive care presented a high mortality rate. Most risk factors for mortality were related to organ failure, but others could be attributed to delay in the diagnostic and therapeutic approach, important targets for intervention.

CO044. UM EM CADA 5 DOENTES COM INFECÇÃO VIH TÊM HIPOGONADISMO

e o tecido adiposo visceral (VAT) abdominal, que individualmente podem ter contributos diferentes para as alteracoes metabolicas. Os doentes com infeccao VIH sob terapeutica anti-retrovirica (TAR) podem ter alteracoes da composicao corporal, que se podem reflectir em diferente distribuicao do TA. Objetivo: Avaliar a SAT, VAT e razao VAT/SAT avaliada por TC a nivel abdominal: 1) em doentes infectados pelo VIH-1 sob TAR vs controlos nao infectados; 2) em doentes com e sem lipodistrofia definida pela clinica vs controlos; 3) em doentes com lipodistro-fia definida pela “razao massa gorda tronco/membros” (RMGTM) definida por DEXA vs controlos. Metodos: Avaliamos em 173 controlos e 211 doentes com infeccao VIH-1 sob TAR, parâmetros antropometricos e a massa gorda a nivel abdominal determinada por TC SAT, VAT e VAT/SAT, apos ajuste para a idade e IMC. Resultados: Independentemente do genero, a massa gorda total (MGT) e SAT era maior nos controlos do que nas doentes VIH e a razao VAT/SAT era maior nas doentes. Quando considerada a lipodistrofia clinica, nas mulheres, a SAT era maior nos controlos e naquelas sem lipodistrofia, sendo a razao VAT/SAT maior nas com infeccao (com ou sem LC). Nos homens, a MGT e SAT era maior nos controlos e naqueles sem LC; a razao VAT/SAT era maior nos que tinham infeccao (com ou sem LC). Se lipodistrofia definida por RMGTM, observou-se que nas mulheres, a SAT era maior nos controlos e nas sem lipodistrofia e a razao VAT/SAT era maior nas com infeccao (com ou sem lipodistrof ia). Nos homens, a MGT e SAT era maior nos controlos e naqueles sem lipodistrofia; a razao VAT/SAT era maior nos com infeccao (quer com ou sem lipodistrofia). Em ambos os generos observou-se maior VAT nos com lipodistrofia. Conclusao: Observou-se maior VAT/SAT nos doentes infectados, independentemente do genero e da definicao de lipodistrofia utilizada.

Effectiveness and safety of a single-tablet regimen of emtricitabine/efavirenz/tenofovir in HIV-1-infected patients in infectious diseases department

Evaluate the effectiveness and safety of simplification of tenofovir/emtricitabine/efavirenz (TDF/FTC/EFV) in selected treatment‐experienced HIV‐1‐infected patients who have been virologically suppressed for>3 months on their current regimen.

Factors associated with immune status in the diagnosis of HIV infection

Current guidelines recommend the start of antiretroviral therapy before advanced immunosuppression, which is not always possible. The purpose of this study is to evaluate factors associated with the degree of immunosuppression at the diagnosis of HIV infection.

Hospital admissions and associated diagnosis of HIV patients in the HAART era

of results 318 patients (approximately 20% of the patients followed at the clinic) were admitted, accounting for 521 admissions; 47.6% of them HIV-related. 227 (43.6%) admissions were due to AIDS opportunistic infections, 33 (6.4%) to AIDS-defining or non-AIDS-defining cancers, and 220 (42.2%) were due to non-opportunistic infections. 35 (6.7%) of the admissions were new HIV diagnoses (two acute HIV infections) and 25 (71.4%) of these were AIDS-defining conditions. Hepatic disase accounted for 33 (6.4%) of the total causes of admissions. Eight (1.5%) admissions were HAART-related (toxicity/tolerability). 221 (69.5%) of the admitted patients had been lost to follow-up at the outpatient clinic for >6 months and 239 (75.1%) had no/poor adherence to their HAART regimens. 85.1% of the patients who were under HAART >6 months (n = 47), were virologically suppressed. Mean CD4 cell count of admitted patients was 156 ± 178 cells/ mm3.