AIDS-defining Opportunistic Infection Research Articles

Health Care Needs Assessment and Predictors of HIV Therapy Use Among HIV-Infected Residents of Single-Room Occupancy Hotels in the South Bronx

PURPOSE: continues to devastate urban communities, particularly among marginally-housed, ethnic minority, and drug-using populations. This study (1) describes access to comprehensive medical care, quality of HIV-related care, and attitudes regarding health among HIV-infected residents of single-room occupancy (SRO) hotels and (2) explores predictors of the use of pneumocystis carinii pneumonia (PCP) prophylaxis and highly-active antiretroviral therapy (HAART). METHODS: We conducted a cross-sectional, community-based study of 69 Bronx SRO hotel residents during May 1998. Utilizing door-to-door recruitment, we administered a 41-item, anonymous questionnaire to assess participants' demographic characteristics, level of illness and health care utilization, use of HIV-related therapies, and perceptions of their own health and medical care. RESULTS: Of respondents, 65% identified as African-American or Black, 22% as Puerto Rican, and 13% as White or Other. The median age was 42; 68% were male, and 38% were high school graduates. Most individuals were marginally-housed (median stay = 9 months). Almost all participants (96%) paid for medical services via Medicaid. Of the 93% with HIV infection, 44% had been hospitalized at least once in the past year, 72% reported a history of AIDS-defining opportunistic infections, and the median CD4 count was 214. Over two-thirds were actively using drugs and/or alcohol. Among HIV-infected residents, 81% had seen a doctor in the last three months. However, only 67% felt they had a physician, and 48% felt their access to medical care was average to very poor. Among eligible HIV-infected persons, only 39% had taken HAART and 73% had taken PCP prophylaxis in the last week. Predictors for the use of HAART included absence of active cocaine and/or crack use (RR = 3.91; 95% CI 1.03–14.8; p < .03), use of PCP prophylaxis (RR = 5.69; 95% CI .85–38.1; p < .03) and the belief that HAART can help people with AIDS (RR = 1.75; 95% CI 1.28–2.44; p < .03). HAART use did not correlate with site or frequency of medical care or active alcohol or heroin use. Individuals with regular doctors were less likely to have visited an emergency room in the past 3 months (RR = .41; 95% CI .22–.76; p < .02) and more likely to be taking PCP prophylaxis (RR = 2.68; 95% CI 1.19–6.02; p < .008). CONCLUSION: Despite relatively advanced disease in this population of marginally-housed HIV-infected persons, significant proportions do not have a regular primary care provider, are not taking HAART, and report sub-optimal quality of and access to medical care. Active cocaine and/or crack use correlate with a lesser use of HAART.

The emerging role of CD40 ligand in HIV infection

CD40 ligand (also called CD40L, CD154, or TNFSF5) is a membrane protein expressed mainly by activated CD4+ T cells, which interacts with its receptor, CD40, on a variety of cells. The crucial importance of the CD40L-CD40 system for many immune responses has been extensively described. This review focuses on the multiple roles that this system may play in HIV infection. In early HIV infection, CD40L expression contributes to the immunological control of viral replication by inducing HIV-suppressive chemokines and supporting the production of anti-HIV antibodies and cytotoxic T cells. However, by activating antigen-presenting cells, such as dendritic cells and macrophages, CD40L can also lead to increased CD4+ T cell activation, which promotes the replication of HIV in these lymphocytes. Later, with the development of AIDS, CD40L-expressing CD4+ T cells become selectively depleted, perhaps as a result of a gp120-induced signal through CD4 that down-regulates CD40L expression. This acquired CD40L deficiency may explain the similarity between the types of opportunistic infections that occur in AIDS and in congenital CD40L deficiency. Vaccines or other strategies that promote the growth of CD4+ T cells capable of expressing CD40L may help to sustain host immunity against HIV and prevent AIDS-defining opportunistic infections.

Human immunodeficiency virus-infected adolescents: a descriptive study of older children in New York City, Los Angeles County, Massachusetts and Washington, DC.

Children infected with HIV are entering adolescence with challenging and changing medical and social needs. Through chart review we describe certain medical and social characteristics of adolescents who acquired HIV as children. HIV-infected children 12 years of age and older in 1995 were monitored through the Pediatric Spectrum of HIV Disease study from four US sites. In addition to standard 6-month medical chart reviews, a special chart abstraction in 1997 collected available psychosocial and sexual history information. A total of 131 adolescents HIV-infected as children were studied: 52 infected perinatally; 44 infected through a contaminated blood transfusion; 30 through receipt of contaminated blood products for hemophilia; and 5 with unknown transmission mode. Mean age at last medical contact was 15.5 years, 67% were Hispanic or African-American, 12% were employed, 66% attended regular school, 66% knew their HIV status and 48% (8% for the perinatally infected) lived with their biologic mother. Information on sexual activity showed that 18% had sexual relations, 28% did not and for 53% sexual activity was not recorded in the medical chart. Four percent used illicit drugs, which along with sexual activity showed a positive association with age. Forty-two percent had an AIDS-defining opportunistic infection, and 56% had a recent CD4+ lymphocyte count <200 cells/microl. Adolescents in this study represent a heterogeneous group of surviving HIV-infected children some of whom are sexually active and potential sources of HIV transmission. Clinicians who treat HIV-infected and high risk adolescents face the challenges of providing care and prevention services appropriate to adolescent development.

Epidemiology of human immunodeficiency virus-associated opportunistic infections in the United States in the era of highly active antiretroviral therapy.

The incidence of nearly all AIDS-defining opportunistic infections (OIs) decreased significantly in the United States during 1992-1998; decreases in the most common OIs (Pneumocystis carinii pneumonia ¿PCP, esophageal candidiasis, and disseminated Mycobacterium avium complex ¿MAC disease) were more pronounced in 1996-1998, during which time highly active antiretroviral therapy (HAART) was introduced into medical care. Those OIs that continue to occur do so at low CD4+ T lymphocyte counts, and persons whose CD4+ counts have increased in response to HAART are at low risk for OIs, a circumstance that suggests a high degree of immune reconstitution associated with HAART. PCP, the most common serious OI, continues to occur primarily in persons not previously receiving medical care. The most profound effect on survival of patients with AIDS is conferred by HAART, but specific OI prevention measures (prophylaxis against PCP and MAC and vaccination against Streptococcus pneumoniae) are associated with a survival benefit, even when they coincide with the administration of HAART. Continued monitoring of incidence trends and detection of new syndromes associated with HAART are important priorities in the HAART era.

The influence of nutritional and metabolic status on progression from asymptomatic HIV infection to AIDS-defining diagnosis.

Changes in body weight and lean tissue increase morbidity and mortality during AIDS; however there are few data on the effect of alterations in nutrition and metabolism on disease progression at earlier stages of HIV infection. To assess whether change in weight, lean tissue or skeletal muscle affects progression to AIDS; to assess prospectively the effects of recognized alterations in nutrition and metabolism in asymptomatic HIV-seropositive men on disease progression; and to examine prospectively changes in nutrition and metabolism at AIDS-defining diagnosis. A group of 104 asymptomatic HIV-seropositive men were recruited and prospectively examined at 3-monthly intervals between April 1993 and September 1995. Nutritional status and metabolism were examined using indirect calorimetry, dual energy X-ray absorptiometry and urine excretion of simple sugars. Time-fixed and time-dependent Cox's proportional hazard models were fitted to calculate risks of developing a first AIDS diagnosis, weight loss or death. During the study period, 31 subjects had a first AIDS diagnosis of whom 26 were fully assessed. Changes in nutrition and metabolism do not affect disease progression in asymptomatic HIV infection. However, subjects with a reduction in body weight and basal metabolic index tend to have a higher risk of progression to AIDS-defining diagnosis, independent of CD4 count. There is a significant decrease in all body tissue compartments, a decrease in excretion of urinary sugars and significant increase in resting energy expenditure and fat oxidation associated with a first AIDS diagnosis. Change in metabolic and nutritional status at the asymptomatic stage of HIV infection does not influence disease progression significantly, although there is a trend suggesting weight loss has an independent effect on outcome. There is a cachectic response to AIDS-defining opportunistic infection or tumour.

A prospective study of tuberculosis and HIV disease progression.

To determine whether active tuberculosis alters the rate of progression of HIV infection in dually infected patients. HIV-seropositive patients at two Bronx, New York hospitals with tuberculosis confirmed by culture from July 1992 to February 1995, who survived the initial hospitalization for tuberculosis, were matched on gender, age, CD4+ percentage, and calendar time with HIV-seropositive patients without tuberculosis participating in a study of the natural history of HIV infection. Patients received follow-up observation prospectively until May 23, 1995 to determine survival rates and development of AIDS-defining opportunistic infections (OIs). 70 patients had tuberculosis; 120 did not. Mean CD4+ percentages were 12.4% and 12.5%, respectively. At study entry, 27% of those with tuberculosis had prior AIDS-defining OIs other than tuberculosis, compared with 10% of those without tuberculosis (p = .004). In multivariate survival analysis, controlling for CD4+ level, tuberculosis was not an independent predictor of increased other causes of AIDS-related mortality. However, in a logistic regression model, independent predictors of subsequent OIs included tuberculosis (hazard ratio, 4.1; 95% confidence intervals [CI], 1.9, 8.7), CD4+ count <100/mm3 (hazard ratio, 2.4; 95% CI, 1.1, 5.0) and prior OIs (hazard ration, 3.3; 95% CI, 1.3, 8.3). Tuberculosis was not an independent predictor of increased non-tuberculosis-related mortality in HIV-seropositive patients but was associated with increased risk of development of OIs.

Trends in AIDS-related opportunistic infections among men who have sex with men and among injecting drug users, 1991-1996.

Incidence trends for the 13 most frequent AIDS-defining opportunistic infections (OIs) among men who have sex with men (MSM, n = 15,588) and injecting drug users (IDUs, n = 4475) were examined using data abstracted from medical records in >90 hospitals and clinics in nine US cities during 1991-1996. Among MSM, the most frequent OIs were Mycobacterium avium complex (MAC) disease, Pneumocystis carinii pneumonia (PCP), and cytomegalovirus (CMV) retinitis; decreasing (P < or = .05) trends occurred for 11 OIs (MAC disease, PCP, CMV retinitis, Kaposi's sarcoma, esophageal candidiasis, CMV disease, extrapulmonary cryptococcosis, toxoplasmic encephalitis, tuberculosis, chronic herpes simplex, and disseminated histoplasmosis). Among IDUs, the most frequent OIs were PCP, MAC disease, and esophageal candidiasis; decreasing trends occurred for 5 OIs (PCP, esophageal candidiasis, tuberculosis, chronic herpes simplex, and chronic cryptosporidiosis) and an increase occurred in recurrent pneumonia. The differences in trends for MSM and IDUs may be due to differences in medical care and adherence to preventive medications.

Regression of Acquired Immunodeficiency Syndrome-Related Pulmonary Kaposi's Sarcoma After Highly Active Antiretroviral Therapy

Kaposi's sarcoma (KS) is the most common neoplasm affecting people with the human immunodeficiency virus (HIV) infection. The skin is the most common site of disease; however, KS can also involve visceral organs such as the lungs, leading to severe morbidity and contributing to death in almost 30% of patients with the acquired immunodeficiency syndrome (AIDS). New antiretroviral strategies incorporating combination nucleoside analogues with a protease inhibitor lead to increased circulating CD4+ lymphocyte counts, decreased plasma levels of HIV, and decreased mortality from AIDS-defining opportunistic infections. The effects of highly active antiretroviral therapy (HAART) on AIDS-associated KS remain largely unknown. Herein the case of an antiretroviral-naive man with advanced AIDS (CD4+ helper T-lymphocyte count, 35/mm3; HIV viral RNA quantification, more than 800,000 copies/mL), and symptomatic pulmonary KS is described. After HAART was initiated, his CD4+ cell count increased fourfold, his HIV-viral load decreased to nondetectable levels, and the pulmonary KS regressed dramatically. To my knowledge, this report represents the first documented case of pulmonary KS regression after the initiation of HAART. Although this finding is preliminary, if confirmed by other clinicians, the effect of potent antiretrovirals on KS growth and development will have important implications on the manner in which KS is staged and treated.

HIV-Related Non-Hodgkin's Lymphoma: CHOP Induction Therapy and Interferon-α-2b/Zidovudine Maintenance Therapy

In a prospective multicenter study 68 out of 158 patients with HIV infection and malignant lymphoma were assigned to a risk-adapted induction therapy using the following algorithm: High-risk patients fulfilled 2 of 3 criteria: T4 lymphocytes < 50/μ:L; WHO activity index 3 or 4; pre-existing AIDS-defining opportunistic infection. Normal-risk patients received 4 to 6 cycles of CHOP chemotherapy; those that achieved complete remission (CR) received zidovudine (500 mg/d) and interferon-α maintenance therapy (5 million units three times a week) for one year. High-risk patients received low-dose CHOP or vincristine/prednisone chemotherapy. Supportive care was performed with pentamidine inhalation and G-CSF. Intrathecal (it) methotrexate was given for CNS prophylaxis.The median survival was 634 days for 38 patients of the normal-risk group and 129 days for 30 patients of the high-risk group. 18 high-risk patients treated with low-dose CHOP had better survival (156 days) than 12 patients treated with vincristine/prednisone (72 days p = 0.044). 68% of the patients in the normal-risk group achieved complete remission. 5 out of 18 high-risk patients treated with low-dose CHOP achieved complete remission. Three normal-risk patients developed fatal opportunistic infections during chemotherapy. Immune parameters deteriorated after CHOP induction and partially recovered with maintenance treatment.We conclude that the normal-risk patients survived longer than reported in most published studies. Toxicity was low. Low-dose CHOP seems to be superior to vincristine/prednisone therapy in high-risk patients.

Low doses of zidovudine plus didanosine are less effective than higher doses of didanosine monotherapy: a randomized trial in patients pretreated with zidovudine.

OBJECTIVE: To compare the clinical efficacy and tolerance of didanosine (ddl) monotherapy with low-dose zidovudine/didanosine (AZT/ddl) therapy among HIV-infected patients previously treated with AZT. METHODS: A randomized controlled trial was carried out of ddl 400 mg daily versus AZT/ddl 300/200 mg daily among patients with CD4 cell counts </=350 mm3 and prior AZT treatment for at least 16 weeks. Fifty eight patients received ddl monotherapy and 66 combined treatment. RESULTS: Patients were similar with respect to demographic, clinical and laboratory characteristics, and prior AZT treatment. Median duration of follow-up was 17.3 months. In the ddl group, 20 patients (34%) discontinued treatment because of toxicity, compared to 19 (29%) in the AZT/ddl group (p=0.38). There was no statistically significant difference in CD4 change between the two groups. In the ddl group, 16 patients (28%) developed a clinical endpoint (death or AIDS-defining opportunistic infection), compared to 33 (50%) in the combined therapy group (relative risk 1.8; 95% confidence interval 1.1-2.9; p=0.01). CONCLUSIONS: For fairly advanced AZT-pretreated patients, monotherapy with ddl was clinically and statistically superior to the low-dose AZT/ddl combination in preventing AIDS-defining illness and death. When access to drugs is limited, e.g. in under-resourced countries, combining available drugs and reducing dosage may be less effective than a single drug at the conventional dosage.

Changing incidence of AIDS-defining illnesses in the era of antiretroviral combination therapy

To determine the incidence of AIDS-defining opportunistic infections and malignancies over a 5-year period from 1992 to 1996. Subcohort of 1003 homosexual men with HIV infection and CD4 count less than 200 x 10(6) cells/l from the Frankfurt AIDS Cohort Study. Data including the earliest date that a CD4 T-lymphocyte count < 200 x 10(6)/l was reached and the dates of AIDS-defining events were compiled from medical records. Incidence analyses for AIDS-defining events and death during the subsequent 5 years (1992-1996) were performed using rates per 100 person-years of exposure. During the observation period, the number of patients per year with CD4 T-lymphocyte counts < 200 x 10(6)/l varied between 402 and 511. In 1992, 56.7% of patients experienced at least one AIDS-defining illness, and 20.7% in 1996. The annual number of AIDS-defining events per 100 patient-years of observation declined from 143.5 in 1992 to 38.3 in 1996, and the number of AIDS-related deaths fell from 25.7 to 12.9. Analysis of the number of events confirmed this trend for malignancies and single opportunistic infections, with the exception of mycobacterial diseases. The incidence of AIDS-defining events in patients with advanced HIV infection at Frankfurt University Hospital has declined by more than 70% from 1992 to 1996.

Progression of human immunodeficiency virus infection in patients with tuberculosis disease. A cohort study in Bordeaux, France, 1988-1994. The Groupe d'Epidémiologie Clinique du Sida en Aquitaine (GECSA).

To assess the role of Mycobacterium tuberculosis disease in human immunodeficiency virus (HIV) infection, the authors compared survival of tuberculosis patients and controls matched on year of HIV diagnosis and CD4+ lymphocyte count. Patients were selected in the Aquitaine Cohort, which follows, since 1985, all patients infected with HIV, aged more than 13 years, in five hospitals. Time of inclusion of controls was the date of diagnosis of tuberculosis for the corresponding tuberculosis patient. Patients who had received primary prophylaxis against mycobacteria other than tuberculosis were excluded. As of June 30, 1994, 104 tuberculosis patients and 620 controls were selected; they were similar, except for history of intravenous drug use (tuberculosis patients, 51%, vs. controls, 31%) and AIDS-defining opportunistic infection (40 vs. 29%). Survival was shorter in tuberculosis patients than in controls (risk ratio 1.5, 95% confidence interval 1.2-2.1) even after controlling for differences at entry. The risk of AIDS-defining opportunistic infection or a decrease to fewer than 50 CD4+ cells/mm3 was slightly but not statistically greater in tuberculosis patients than in controls. Tuberculosis disease affected survival but not occurrence of subsequent opportunistic infections or rate of CD4+ count decline. Tuberculosis may be a marker of advanced HIV and may accelerate its course of infection.

The metabolic response to opportunistic infections in AIDS.

The metabolic response to AIDS-defining opportunistic infections was examined to provide a logical basis for the management of associated weight loss. A prospective study of metabolism in AIDS. HIV outpatients' department and wards at the Chelsea and Westminster Hospital, London. Ten asymptomatic Centers for Disease Control and Prevention stage II HIV-seropositive control subjects and 36 HIV-seropositive patients with a single newly diagnosed and untreated opportunistic infection [10 with microsporidial or cryptosporidial diarrhoea, 10 with Pneumocystis carinii pneumonia, nine with cytomegalovirus enteritis and seven with systemic Mycobacterium avium-intracellulare]. Subjects had measurements of resting energy expenditure using indirect calorimetry and of body composition using dual energy X-ray absorptiometry. Subjects with protozoal diarrhoea had a decreased resting energy expenditure (P < 0.05) and decreased body fat (P < 0.01). Subjects with P. carinii pneumonia had an elevated resting energy expenditure (P < 0.05). Subjects with systemic M. avium-intracellulare had an elevated resting energy expenditure (P < 0.05) and decreased skeletal muscle mass (P < 0.05). Subjects with cytomegalovirus enteritis had a non-significant elevation of resting energy expenditure with a non-significant loss of both fat and lean tissue. Subjects with protozoal diarrhoea show a starvation response to infection and subjects with systemic M. avium-intracellulare show a cachectic response. Since there is a variation in the metabolic response to opportunistic infection in AIDS patients, nutritional management should be directed according to the specific cause.

Seasonal variation of disseminated Penicillium marneffei infections in northern Thailand: a clue to the reservoir?

Disseminated Penicillium marneffei infections are common AIDS-defining opportunistic infections among persons with human immunodeficiency virus (HIV) infection in northern Thailand. Penicilliosis due to P. marneffei is the third most frequent AIDS-defining infection in this population, after tuberculosis and cryptococcosis. Very little is known about the epidemiology and natural reservoir of P. marneffei. The seasonal distribution of two common AIDS-defining fungal infections was compared among patients diagnosed between 1991 and 1994 at Chiang Mai University Hospital. There were 550 cases (492 male, 58 female patients) of P. marneffei and 793 cases (685 male, 108 female patients) of Cryptococcus neoformans infection diagnosed. In each year, P. marneffei but not C. neoformans infections were more frequent in the rainy than the dry season. Seasonal variation of P. marneffei infections in AIDS patients in northern Thailand may provide valuable information in determining the important reservoirs and exposures to this organism that lead to disseminated disease in these patients.

Bacillary angiomatosis and bacillary peliosis in patients infected with human immunodeficiency virus: clinical characteristics in a case-control study.

Clinical characteristics associated with bacillary angiomatosis and bacillary peliosis (BAP) in patients with human immunodeficiency virus (HIV) infection were evaluated in a case-control study; 42 case-patients and 84 controls were matched by clinical care institution. Case-patients presented with fever (temperature, > 37.8 degrees C; 93%), a median CD4 lymphocyte count of 21/mm3, cutaneous or subcutaneous vascular lesions (55%), lymphadenopathy (21%), and/or abdominal symptoms (24%). Many case-patients experienced long delays between medical evaluation and diagnosis of BAP (median, 4 weeks; range, 1 day to 24 months). Case-patients were more likely than controls to have fever, lymphadenopathy, hepatomegaly, splenomegaly, a low CD4 lymphocyte count, anemia, or an elevated serum level of alkaline phosphatase (AP) (P < .001). In multivariate analysis, a CD4 lymphocyte count of < 200/mm3 (matched odds ratio [OR], 9.9; P < .09), anemia reflected by a hematocrit value of < 0.36 (OR, 19.7; P < .04), and an elevated AP level of > or = 2.6 mukat/L (OR, 23.9; P < .05) remained associated with disease after therapy with zidovudine was controlled for. BAP should be considered an AIDS-defining opportunistic infection and should be included in the differential diagnosis for febrile, HIV-infected patients with cutaneous or osteolytic lesions, lymphadenopathy, abdominal symptoms, anemia, or an elevated serum level of AP.

CD4 lymphocyte count in HIV positive persons exposed to cryptococcus neo formans

A report is presented on four HIV-positive homosexual men examined after several months of exposure during cleaning of a flat from masses of pigeon droppings heavily colonized by Cryptococcus neoformans. Only one out of the four persons, with a CD4 lymphocyte count of 50/microL, fell sick from systemic cryptococcosis, but not the others, with CD4 lymphocyte counts of 180, 250, and 630/microL, respectively; they remained clinically and mycologically inconspicuous and free from C. neoformans. Open questions in view of the epidemiology of opportunistic pathogens in AIDS are discussed with regard to the CD4 cell count as a parameter indicating a predisposition for cryptococcosis as an airborne AIDS-defining opportunistic infection. This has been confirmed by specific cultural diagnosis of the agent in both the environment and the patient. Already in 1987/88, the probable source of infection had been the subject of epidemiological studies on C. neoformans in Berlin.

Preventing disseminated Mycobacterium avium complex disease in patients infected with human immunodeficiency virus.

Disseminated Mycobacterium avium complex (MAC) infection is an important late-stage complication of infection with the human immunodeficiency virus. Since MAC is widely dispersed in the environment, the source of infection for patients with disseminated MAC generally cannot be determined. Therefore, specific recommendations for avoiding exposure are not supported at this time. Routine screening of stools and sputum to detect MAC colonization as a means of targeting prophylaxis for disseminated disease is also not recommended at present. Two randomized, placebo-controlled trials have demonstrated that prophylactic use of rifabutin in persons with low CD4 lymphocyte counts results in a 50% decrease in MAC bacteremia as well as a reduction in some signs, symptoms, and laboratory abnormalities associated with MAC disease. Thus a prophylactic daily dose of rifabutin (300 mg) should be considered for adults who have had a previous AIDS-defining opportunistic illness and who have a CD4 lymphocyte count of < 75/microL. Many experts would consider prophylaxis appropriate only when the CD4 lymphocyte count is < 50/microL, particularly when there has not been a previous AIDS-defining opportunistic infection. Clinicians should be aware of drug interactions and potential adverse effects associated with the use of rifabutin. Preliminary reports of randomized, placebo-controlled trials suggest that chemoprophylaxis with clarithromycin is also effective in the prevention of disseminated MAC disease, and evaluation of other agents is under way. Prophylaxis for disseminated MAC infection in children has not been evaluated but is presumed to be as effective as that in adults. Decisions regarding initiation of MAC chemoprophylaxis should be individualized.

Suspected Pneumocystis carinii pneumonia with a negative induced sputum examination. Is early bronchoscopy useful?

In U.S. patients with the acquired immunodeficiency syndrome (AIDS), Pneumocystis carinii pneumonia is the most frequent AIDS-defining opportunistic infection. Sputum induction and bronchoscopy are effective techniques for obtaining specimens used to identify P. carinii although debate continues over their optimal use, specifically whether to perform bronchoscopy after a negative induced sputum examination for P. carinii. To evaluate the usefulness of bronchoscopy in this situation, we reviewed all cases of suspected P. carinii pneumonia in which sputum induction for P. carinii was performed at San Francisco General Hospital during a 4-yr period. Bronchoscopy, performed after a negative induced sputum examination, yielded a diagnosis in 50.5% of evaluations. The most frequent diagnoses were P. carinii pneumonia (192), tracheobronchial Kaposi's sarcoma (93), tuberculosis (28), and Cryptococcus neoformans pneumonia (9). Bronchoscopy provided either the only or an earlier diagnosis in 64.3% of tuberculosis cases. Bronchoscopy with BAL was free of complications, and, importantly, a negative BAL examination for P. carinii allowed physicians to discontinue empiric P. carinii pneumonia treatment in 95%. In patients with suspected P. carinii pneumonia with a negative induced sputum examination for P. carinii, early bronchoscopy with BAL should be performed.

Acute Uveitis in Patients With Acquired Immunodeficiency Syndrome Receiving Prophylactic Rifabutin

Hypopyon uveitis secondary to rifabutin therapy in seven patients with acquired immunodeficiency syndrome (AIDS), reported by Saran et al 1 in the September 1994 issue of theArchives, was diagnosed during treatment for systemic Mycobacterium avium complex (MAC) infection. We found three cases of acute uveitis without hypopyon in patients with AIDS who were taking a prophylactic dosage of 300 to 450 mg/d of rifabutin. Report of Cases. Case 1. A 51-year-old white homosexual man with a CD4 count of 0.02X 109/L (20/μL) but with no history of AIDS-defining opportunistic infections developed acute uveitis 14 weeks after beginning prophylaxis for MAC infection (rifabutin, 450 mg/d). Other medications included fluconazole, 200 mg/d; a steroid inhaler (beclomethasone) as needed; oxybutynin chloride, 5 mg twice a day; paroxetine hydrochloride, 20 mg/d; and acyclovir, 3200 mg/d. The patient presented with sudden onset of photophobia and pain in the left eye. Examination of the left

The Changing Epidemiology of Human Immunodeficiency Virus Infection in Older Persons

To describe the epidemiology of human immunodeficiency virus (HIV) infection diagnosed in persons aged 60 years and older at a large urban county hospital. Retrospective chart review of patients, aged 60 years and older, diagnosed with HIV infection, among 6,493 patients identified with positive EIA-HIV tests performed at Grady Memorial Hospital between January 1, 1985 and July 1, 1992. A total of 32 HIV-infected elderly patients, including 27 men and five women, with a mean age of 64.8 years (range, 60-83 years) were identified. Among the 27 men, HIV risk factors included: homosexual/bisexual (10 patients); injection drug users (IDU) (5); transfusion-associated (2); heterosexual (2); eight patients had no HIV risk factor identified. Among the five women, only one had an identified risk factor (blood transfusion). HIV testing of 47% (15/32) elderly patients was performed after a diagnosis of an AIDS-defining opportunistic infection. Among 24 elderly patients who presented to a physician with signs or symptoms of HIV infection, testing for HIV was often delayed (median 3.1 months, range: 1-10 months). Eleven patients underwent work-ups to rule out a malignancy, and three patients were initially diagnosed with organic brain syndrome. Ten of the 32 patients (31%) had a history of syphilis, and 90% (19/21) of patients tested were found to be immune to hepatitis B. The majority of HIV-infected patients 60 years or older acquired their infection through sexual intercourse or IDU. The diagnosis of HIV infection in the elderly was usually not considered by clinicians until late in the course of infection, despite a high prevalence of prior sexually transmitted diseases (STDs). Our data indicate that clinicians who take care of elderly patients should do a complete sexual history and offer sexual education. HIV testing and counseling should be considered for all individuals with a history of recent STDs or reporting behaviors putting them at risk for HIV infection.