Archive for November, 2008

Clinical and Radiographic Predictors of the Etiology of Pulmonary Nodules in HIV-Infected Patients*

Chest April 2000 V.117 N.4 p.1023-1030

Robert M. Jasmer, MD; Keith J. Edinburgh, MD, MS Ed; Annemarie Thompson, MD; Michael B. Gotway, MD; Jennifer M. Creasman, MSPH; W. Richard Webb, MD and Laurence Huang, MD, FCCP

From the Division of Pulmonary and Critical Care Medicine, San Francisco General Hospital Medical Center, and the Department of Medicine, University of California, San Francisco (Drs. Jasmer, Thompson, Huang, and Ms. Creasman); and the Department of Radiology, University of California, San Francisco (Drs. Edinburgh, Gotway, and Webb), San Francisco, CA.

Study objectives: To determine the etiology and the clinical and radiographic predictors of the etiology of pulmonary nodules in a group of HIV-infected patients.

Design: Retrospective analysis.

Setting: A large urban hospital in San Francisco, CA.

Patients: HIV-infected patients evaluated at San Francisco General Hospital from June 1, 1993, through December 31, 1997, having one or more pulmonary nodules on chest CT.

Main outcome measures: Three physicians reviewed medical records for clinical data and final diagnoses. Three chest radiologists blinded to clinical data reviewed chest CTs. Univariate and multivariate analyses were performed to determine clinical and radiographic predictors of having an opportunistic infection and the specific diagnoses of bacterial pneumonia and tuberculosis.

Results: Eighty seven of 242 patients (36%) had one or more pulmonary nodules on chest CT. Among these 87 patients, opportunistic infections were the underlying etiology in 57 patients; bacterial pneumonia (30 patients) and tuberculosis (14 patients) were the most common infections identified. Multivariate analysis identified fever, cough, and size of nodules < 1 cm on chest CT as independent predictors of having an opportunistic infection. Furthermore, a history of bacterial pneumonia, symptoms for 1 to 7 days, and size of nodules < 1 cm on CT independently predicted a diagnosis of bacterial pneumonia; a history of homelessness, weight loss, and lymphadenopathy on CT independently predicted a diagnosis of tuberculosis.

Conclusions: In HIV-infected patients having one or more pulmonary nodules on chest CT scan, opportunistic infections are the most common cause. Specific clinical and radiographic features can suggest particular opportunistic infections.

abstract

http://www.chestjournal.org/cgi/content/abstract/117/4/1023

PDF

http://www.chestjournal.org/cgi/reprint/117/4/1023

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November 30, 2008 at 11:58 pm Leave a comment

Bacterial Pneumonia in Hospitalized Patients With HIV Infection*

Chest April 2000  V.117  N.4  p.017-1022

The Pulmonary Complications, ICU Support, and Prognostic Factors of Hospitalized Patients With HIV (PIP) Study

Bekele Afessa, MD, FCCP and Bethany Green, DO

From the Department of Internal Medicine, Division of Pulmonary and Critical Care, University of Florida Health Science Center, Jacksonville, FL.

Study objectives:
To describe the causative organisms and factors associated with bacterial pneumonia and to assess its impact on the outcome of hospitalized patients with HIV.

Design: Prospective, observational.

Setting: A university-affiliated medical center.

Methods: We included 1,225 consecutive hospital admissions, from April 1995 through March 1998, of 599 adults with HIV. We collected data on APACHE II (acute physiology and chronic health evaluation II) score, leukocyte and CD4+ lymphocyte counts, length of hospital stay, ICU admission rate, and case-fatality rate. Chest radiographs and laboratory results were reviewed. The presence of bacterial pneumonia was noted.

Results: Bacterial pneumonia was diagnosed in 111 hospitalizations (9%): 80 (72%) were community-acquired infections. The CD4+ lymphocyte count was lower (median, 38 vs 66/µL, p = 0.0027), APACHE II score higher (17 vs 13, p < 0.0001), length of hospital stay longer (median, 6 vs 4), and ICU admission (28% vs 9%) and case-fatality rates (21% vs 4%) higher in patients with bacterial pneumonia compared with those without bacterial pneumonia. The most common pathogen was Pseudomonas aeruginosa (32 admissions), followed by Streptococcus pneumoniae (22 admissions), Staphylococcus aureus (16 admissions), and Haemophilus influenzae (11 admissions). Thirty-three (30%) of the pneumonias were bacteremic. Bacteremia was more common in pneumococcal than in pseudomonal pneumonia (95% vs 9%, p < 0.0001). Compared with patients with pneumococcal pneumonia, patients with pseudomonal pneumonia had lower leukocyte and CD4+ lymphocyte counts, longer hospital stay, and similar case-fatality rate.

Conclusions: P aeruginosa is becoming a common cause of both community-acquired and nosocomial bacterial pneumonia in hospitalized patients with HIV, especially in those with low leukocyte and CD4+ lymphocyte counts.

abstract

http://www.chestjournal.org/cgi/content/abstract/117/4/1017

PDF

http://www.chestjournal.org/cgi/reprint/117/4/1017


November 30, 2008 at 11:57 pm Leave a comment

Maternal Neutralizing Antibody and Transmission of Hepatitis C Virus to Infants

Journal of Infectious Diseases 1 December 2008 V.198 N.11 p.1651-1655

BRIEF REPORT

Kimberly A. Dowd,1 Ronald C. Hershow,5 Sigal Yawetz,6 Philip LaRussa,7 Clemente Diaz,9 Sheldon H. Landesman,8 Mary E. Paul,10 Jennifer S. Read,4 Ming Lu,3 David L. Thomas,1,2 Dale M. Netski,1 and Stuart C. Ray1

Departments of 1Medicine and 2Epidemiology, Johns Hopkins Medical Institutions, and 3Clinical Trials and Surveys, Baltimore, and 4Pediatric, Adolescent, and Maternal AIDS Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Department of Health and Human Services, Bethesda, Maryland; 5University of Illinois at Chicago School of Public Health, Chicago; 6Division of Infectious Diseases, Brigham and Women’s Hospital and Harvard Medical School, Boston, Massachusetts; 7College of Physicians and Surgeons, Columbia University, New York, and 8Department of Medicine, Brookdale Hospital, Brooklyn, New York; 9University of Puerto Rico, San Juan; 10Baylor College of Medicine, Houston, Texas

To determine whether lower levels of hepatitis C virus (HCV)–specific neutralizing antibodies (nAb) are associated with an increased risk of mother-to-child transmission (MTCT) of HCV, HCV nAb titers were assessed in 63 mothers coinfected with HCV and human immunodeficiency virus (HIV) type 1. Of the mothers, 16 transmitted HCV to their infant, but no difference was detected between the ability of maternal plasma from transmitters and nontransmitters to neutralize heterologous HCV pseudoparticles (median nAb titer, 1:125 vs. 1:100; ). In the setting of HIV/HCV coinfection, we found no evidence that HCV nAbs are associated with the prevention of MTCT of HCV.

abstract

http://www.journals.uchicago.edu/doi/abs/10.1086/593067

November 29, 2008 at 12:58 pm Leave a comment

Prediction of Infection Due to Antibiotic-Resistant Bacteria by Select Risk Factors for Health Care–Associated Pneumonia

Archives of Internal Medicine November 10, 2008 V.168 N.20 p.2205-2210

Andrew F. Shorr, MD, MPH; Marya D. Zilberberg, MD; Scott T. Micek, PharmD; Marin H. Kollef, MD

Pulmonary and Critical Care Section, Washington Hospital Center, Washington, DC (Dr Shorr); School of Public Health and Health Sciences, University of Massachusetts, Amherst (Dr Zilberberg); and School of Pharmacy, Washington University (Dr Micek), and Pulmonary and Critical Care Section, Barnes-Jewish Hospital (Dr Kollef), St Louis, Missouri.

Background Pathogens such as methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa now cause pneumonia in patients presenting to the hospital. The concept of health care–associated pneumonia (HCAP) attempts to capture this, but its predictive value is unclear.

Methods We examined patients admitted with pneumonia; infection with a resistant pathogen served as the study end point. Health care–associated pneumonia was present if a patient met one of the following criteria: recent hospitalization, nursing home residence, long-term hemodialysis, or immunosuppression. We compared rates of resistant infection among patients meeting any criteria for HCAP with those who did not have HCAP and explored the individual components of the definition.

Results Among the cohort (n = 639), resistant pathogens were recovered in 289 (45.2%). Although each component of HCAP occurred more frequently in persons with resistant infections, the broad definition had a specificity of only 48.6% and misclassified one-third of the subjects. Logistic regression showed 4 variables associated with resistant pneumonia: recent hospitalization, nursing home residence, hemodialysis, and intensive care unit admission. A scoring system assigning 4, 3, 2, and 1 points, respectively, for each variable had moderate predictive power for segregating those with and without resistant bacteria. Among patients with fewer than 3 points, the prevalence of resistant pathogens was less than 20% compared with 55% and more than 75% in persons with scores ranging from 3 to 5 and more than 5 points, respectively (P < .001).

Conclusions Although resistance is common in HCAP, not all component criteria for HCAP convey similar risk. Simple scoring tools may facilitate more accurate identification of persons with pneumonia caused by resistant pathogens.

abstract

http://archinte.ama-assn.org/cgi/content/abstract/168/20/2205

November 29, 2008 at 12:55 pm Leave a comment

Combined Mutations in Pre-S/Surface and Core Promoter/Precore Regions of Hepatitis B Virus Increase the Risk of Hepatocellular Carcinoma: A Case-Control Study

Journal of Infectious Diseases  1 December 2008  V.198  N.11  p.1634-1642

Chien-Hung Chen,1,2 Chi-Sin Changchien,1 Chuan-Mo Lee,1 Chao-Hung Hung,1 Tsung-Hui Hu,1
Jing-Houng Wang,1 Jyh-Chwan Wang,1 and Sheng-Nan Lu1

1Division of Hepatogastroenterology, Department of Internal Medicine, and 2Graduate Institute of Clinical Medical Sciences, Chang Gung Memorial Hospital-Kaohsiung Medical Center, Chang Gung University College of Medicine, Kaohsiung, Taiwan

Background. We sought to investigate the role of sequence variations in pre-S/surface and basal core promoter (BCP)/precore regions of the hepatitis B virus (HBV) in hepatocellular carcinoma (HCC).

Methods. The direct sequencing in pre-S/surface and BCP/precore regions of HBV was determined for 80 patients with HCC and 160 control patients with HBV infection.

Results. Compared with control patients, patients with HCC had higher frequencies of pre-S deletions and amino acid substitutions at codon 4, 7, and 81 in pre-S1 genes; at the start codon in pre-S2 genes; and at codon 68 in surface genes. Patients also had a lower frequency of amino acid substitution at codon 2 in pre-S2 genes, compared with control patients. In BCP/precore regions, patients with HCC had higher frequencies of C or G1753, A1762/T1764, T1846, and A1899. Multivariate analysis showed that pre-S deletions, I68T surface gene, T1762/A1764, and A1899 were independent factors associated with the development of HCC. The HBV strain with a complex mutation pattern rather than a single mutation was associated with HCC, and the HCC risks increased for patients having these factors in combination.

Conclusions. Pre-S deletions, I68T in surface gene, T1762/A1764, and A1899 were independent risk factors for HCC. Combination of these viral mutations appeared to increase the risk of HCC.

abstract

http://www.journals.uchicago.edu/doi/abs/10.1086/592990

November 29, 2008 at 12:51 pm Leave a comment

Extensively Drug-Resistant Tuberculosis in the United States, 1993-2007

JAMA  November 12, 2008  V.300  N.18  p.2153-2160

N. Sarita Shah, MD, MPH; Robert Pratt, BS; Lori Armstrong, PhD; Valerie Robison, DDS, MPH, PhD;
Kenneth G. Castro, MD; J. Peter Cegielski, MD, MPH

Division of Tuberculosis Elimination, Centers for Disease Control and Prevention, Atlanta, Georgia. Dr
Shah is now with the Department of Medicine, Albert Einstein College of Medicine, Bronx, New York.

Context Worldwide emergence of extensively drug-resistant tuberculosis (XDR-TB) has raised global
public health concern, given the limited therapy options and high mortality.

Objectives To describe the epidemiology of XDR-TB in the United States and to identify unique
characteristics of XDR-TB cases compared with multidrug-resistant TB (MDR-TB) and drug-susceptible
TB cases.

Design, Setting, and Patients Descriptive analysis of US TB cases reported from 1993 to 2007.
Extensively drug-resistant TB was defined as resistance to isoniazid, a rifamycin, a fluoroquinolone, and at least 1 of amikacin, kanamycin, or capreomycin based on drug susceptibility test results from initial and
follow-up specimens.

Main Outcome Measures Extensively drug-resistant TB case counts and trends, risk factors for XDR-TB, and overall survival.

Results A total of 83 cases of XDR-TB were reported in the United States from 1993 to 2007. The
number of XDR-TB cases declined from 18 (0.07% of 25 107 TB cases) in 1993 to 2 (0.02% of 13 293
TB cases) in 2007, reported to date. Among those with known human immunodeficiency virus (HIV) test
results, 31 (53%) were HIV-positive. Compared with MDR-TB cases, XDR-TB cases were more likely
to have disseminated TB disease (prevalence ratio [PR], 2.06; 95% confidence interval [CI], 1.19-3.58),
less likely to convert to a negative sputum culture (PR, 0.55; 95% CI, 0.33-0.94), and had a prolonged
infectious period (median time to culture conversion, 183 days vs 93 days for MDR-TB; P < .001).
Twenty-six XDR-TB cases (35%) died during treatment, of whom 21 (81%) were known to be
HIV-infected. Mortality was higher among XDR-TB cases than among MDR-TB cases (PR, 1.82; 95%
CI, 1.10-3.02) and drug-susceptible TB cases (PR, 6.10; 95% CI, 3.65-10.20).

Conclusion Although the number of US XDR-TB cases has declined since 1993, coinciding with improved TB and HIV/AIDS control, cases continue to be reported each year.

abstract

http://jama.ama-assn.org/cgi/content/abstract/300/18/2153

November 27, 2008 at 4:05 pm Leave a comment

Symptomatic Hepatitis B Virus (HBV) Reactivation despite Reduced Viral Fitness Is Associated with HBV Test and Immune Escape Mutations in an HIV-Coinfected Patient

Journal of Infectious Diseases  1 December 2008  V.198  N.11  p.1620-1624

BRIEF REPORT

Cornelia Henke-Gendo,1 Samad Amini-Bavil-Olyaee,2 Deepthi Challapalli,1 Christian Trautwein,2 Heidi Deppe,1 Thomas F. Schulz,1 Albert Heim,1a and Frank Tacke2a

1Institute of Virology, Medical School Hannover, 2Medical Clinic III, Rheinisch-Westfälische Technische Hochschule–University Hospital Aachen, Aachen, Germany

Two sequential hepatitis B virus (HBV) strains obtained before and during an icteric flare-up of an occult HBV infection in a patient coinfected with human immunodeficiency virus revealed HBV surface antigen (HBsAg) test escape mutations, although the patient had never received hepatitis B–specific immunoglobulin. In contrast to the high HBV DNA loads, recurrence of HBsAg, and resulting icteric hepatitis, phenotypic analysis of the mutated HBV strains revealed significantly reduced replication efficacies in vitro, compared with wild-type HBV. Therefore, immune escape in the transiently anti-HBs–positive patient appeared to be crucial for persistence and reactivation. Immune escape mutants evolved even without exogenous selective pressure, hampered detection in HBsAg screening, and might be transmitted during reactivation with high HBV loads.

abstract

http://www.journals.uchicago.edu/doi/abs/10.1086/592987

November 27, 2008 at 4:00 pm Leave a comment

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