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The evaluation of new cases of HIV infection is relatively common in Spain, where several thousands of patients with new infections are diagnosed each year. Eighty per cent of them have a chronic HIV infection at the first clinical evaluation, which is symptomatic (late presenters) in up to 30% of patients. The initial evaluation of HIV infection is not only directed at determining the clinical, virological (plasma HIV RNA viral load, resistance test and viral tropism) and immunological (CD4+ T-cell cell count) situation of the patients, but must also address the study of their co-infections (hepatitis, tuberculosis) and comorbidities (cardiovascular, hepatic, renal and bone) and the risk of HIV transmission. This is needed in order to decide, whether or not to start antiretroviral treatment, and with which combined antiretroviral treatment to start with, the prophylaxis of opportunistic infections, and the treatment of coinfections and comorbidities. The past and current medical history, the physical examination and laboratory tests will help us decide if the patient is to receive therapeutic intervention. The level of CD4+ T-cell lymphocytes is the best marker to suggest when to start combined antiretroviral treatment, indicating whether or not to start prophylaxis against opportunistic infections (if patients have a CD4+ T-cell count below 200 cells/mm(3)), and in advanced patients should make us suspect the presence of active opportunistic diseases in symptomatic cases. The management of patients with HIV infection must also include appropriate health education on the modes of transmission and prevention of HIV infection, and also to explain its natural history and how it can be modified with proper antiretroviral treatment, as well as to promote a healthy life. No less important is the psychological support, as these patients must learn to live with a chronic infection, which managed properly can ensure a very good long-term prognosis and quality of life., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

Cryptococcosis is a mycoses that increased considerably with the AIDS epidemic. However, with the introduction in the late 90's of the highly active antiretroviral therapy (HAART), this incidence has significantly decreased, especially in developed countries, in contrast with that of developing countries. The introduction of HAART not only has affected the incidence rate, but also the clinical presentation as a consequence of the immune recovery of the host, leading to the description of the so called immune reconstitution inflammatory syndrome. In addition, some rare clinical manifestations of cyptococcosis are currently shown, such as lymphadenitis and cutaneous involvement. Besides clinical presentation, diagnostic tests have also changed, with a high percentage of cases with negative cerebrospinal fluid (CSF) and blood cultures, negative direct CSF microscopy, and delayed antigen positive results. Antifungal susceptibility patterns have also changed towards a recuperation of susceptibility, which is related to the decrease in both the incidence of cryptococcosis and less use of antifungal agents., (2010 Elsevier España S.L. All rights reserved.)

The number of HIV infected immigrants has increased sharply in Spain. These patients are prone to contracting several different types of opportunistic infections, including bacterial, mycobacterial, fungal and parasitic infections. The present article provides an in-depth review of bacterial and fungal infections, with particular emphasis on those not endemic in our country.

Objective: Evaluation of the usefulness of a quantitative real-time polymerase chain reaction-based (RT-PCR) technique for clinical diagnosis of histoplasmosis., Methods: Primers and probes were designed on the basis of sequences from the ITS regions of ribosomal DNA of 20 clinical strains of Histoplasma capsulatum. LightCycler procedures (Roche Applied Science) were used with probes marked by fluorescence resonance energy transfer (FRET). Reproducibility, sensitivity, and specificity were analyzed. In addition, an internal control was designed to identify false negative results by PCR inhibition. The RT-PCR assay was tested in 22 clinical samples from 14 patients with proven histoplasmosis. In addition, 30 samples from patients with febrile neutropenia or mycoses other than histoplasmosis, and from healthy volunteers were analyzed as controls., Results: The limit of detection of the assay was 1 fg of genomic DNA per microl of sample. The PCR-based technique was reproducible and highly specific. Positive results were obtained in 11/14 (78.6%) patients and in 17/22 (77.3%) clinical samples. RT-PCR was positive in 100% of respiratory secretions and bone marrow samples, but only 70% of sera (p < 0.01). Mean fungal DNA value was 23.1 fg/microl in serum and 4.85 x 10(3) fg/microl in respiratory and bone marrow samples. RT-PCR results were positive in serum from three HIV patients for which antibody detection by immunodiffusion was negative. Specificity was 100%, since PCR results were negative for all the control samples., Conclusion: Thes RT-PCR technique is a sensitive, specific method for early diagnosis of histoplasmosis, particularly when respiratory secretions or bone marrow samples are analyzed. The reliability is lower in serum, but it can be used as an additional, complementary technique to culture and serology in HIV patients.

Objective: The aim of this study is to assess a real-time PCR technique on the LightCycler 2.0 with SYBR-Green I detection as compared to another real-time PCR method based on detection with FRET (fluorescence resonance energy transfer) probes for the quantification of CMV DNA., Methods: The two real-time PCR methods were used to test plasma samples from immunocompromised patients with clinically suspected CMV disease, patients under follow-up without symptoms, and healthy adults. A standard curve for quantitative analysis by the SYBR-Green I method was performed with 10-fold diluted solutions of DNA from the CMV Towne strain (ATCC VR-977) cultured in MRC-5 monolayer. In addition, frozen samples from patients positive for CMV pp65 antigenemia were also analyzed and results compared using the two real time PCR methods., Results: The real-time PCR technique using SYBR-Green I on the LightCycler 2.0 was a highly specific, fast, simple and reliable test to quantify CMV; moreover, it was cost-effective., Conclusion: Quantification of CMV DNA in plasma using this sensitive, fast, low-cost method was advantageous for the diagnosis and follow up of patients with opportunistic CMV infection, which are increasingly more frequent in our daily hospital clinical practice.

Background: Nocardiosis is a bacterial disease that occurs in immunocompromised patients, including those infected by the human immunodeficiency virus (HIV)., Methods: We retrospectively analyzed the clinical records of 27 HIV-positive patients with nocardiosis seen during the period of 1993 to 2004. Clinical presentations, diagnostic methods, predominant species, antimicrobial therapy and outcome were analyzed., Results: Among the total, 81% were males and the median age was 30 years. There was an elevated percentage of alcoholism (89%), smoking (80%) and intravenous drug use (82%). A previous positive serology for HIV infection was present in 85% of the patients. Plasma CD4+ T cell count at the time of diagnosis in 15 of 17 patients (88%) was below 50 cells/microl (median 15 cells/microl). The most frequent clinical onset was pulmonary in 70%, followed by cutaneous in 11% and disseminated in 11%. The main specimens for diagnostic bacterial isolation were sputum (54%), skin and soft tissues (22%) and bronchoalveolar lavage (19%). The predominant pulmonary radiological pattern was alveolar infiltration (74%), followed by cavitations (32%). The species was identified in 13 patients (48%); Nocardia asteroides was isolated in 84% (n = 11). The main antimicrobial drugs prescribed were cotrimoxazole (78%), amikacin (59%) and ciprofloxacin (33%). Dual therapy was used in 78% of the cases, with cotrimoxazole-amikacin being the most frequent. Overall mortality was 37%., Conclusions: Nocardiosis is an unusual infection among HIV-infected patients. The diagnosis should be considered in patients with CD4+ T cell counts below 50/microL and lung or pericardial involvement.

Background: Studying the changing trends of HIV epidemics is a useful means of evaluating the results of current preventive plans as well as of defining future needs and objectives., Methods: We performed a cross-sectional study of the newly-diagnosed cases of HIV infection included in the Spanish VACH cohort. New HIV cases were defined as those diagnosed between January 2001 and December 2002. Their epidemiologic characteristics were compared with those of patients included in the same cohort who had been diagnosed between January 1998 and December 2000., Results: We studied 603 new cases (27% women). In 146 (24.4%) HIV infection had been acquired by sharing material for intravenous drug use (IVDU), 171 (28,6%) were men who had had sex with other men (MSM) and 247 (41.3%) acknowledged some risk for heterosexual HIV transmission. The median age was 36 years (range: 18-80). Only 1.5% of the patients were younger than 20 years while 32.1% were older than 40 years. This percentage was significantly higher than that corresponding to 1998-2000 (27.5%; p < 0,05). HIV infection was diagnosed simultaneously with an AIDS-defining condition in 13.3% of patients and an AIDS-defining disease was diagnosed in the first month after HIV-diagnosis in another 40 patients (6.6%)., Conclusions: We confirm the trends observed in previous studies: a growing proportion of newly diagnosed cases among women, a decreasing proportion of IVDU, a growth of MSM, and a trend toward diagnosis at a later age.

We describe 16 HIV-infected patients with disseminated histoplasmosis (14 men, mean age 28 +/- 7.84 years), diagnosed at Hospital Eva Perón in Argentina during the period of October 1993 to July 2000. Disseminated histoplasmosis occurred in 5.3% of HIV-infected patients over the study period. The main symptoms included fever, weight loss and hepatosplenomegaly in 93.8%. Other relevant findings were respiratory compromise (56.3%), digestive symptoms (43.8%), mucocutaneous lesions (75%) and multiple lymphadenopathy (69%). Treatment consisted of amphotericin B 1 mg/kg/day up to a total dose of 1 g, followed by 400 mg/day of oral itraconazole. Mortality in the acute phase was 19% and 37.5% of patients relapsed.

Background: The changes that HIV coinfection can induce in clinical symptoms, response to treatment and prognosis of visceral Leishmaniasis (VL) are not well known., Method: We retrospectively describe the characteristics of VL in patients with and without HIV infection, between 1988-1998., Results: Fifty episodes of VL were diagnosed in 40 patients. Nineteen (47.5%) were HIV coinfected, 57.8% of them have had an aids defining illness, and the median of CD4+ lymphocytes was 50/mm3. Clinical and laboratory data were similar to patients non HIV infected, except for lower levels of LDH (437 vs 578 U/ml; p = 0.02) and total lymphocytes (665 vs 1.500/mm3; p = 0.004) and higher levels of hemoglobin (9.8 vs 8.7 gr/dl; p = 0.01) and ESR (85 vs 44 mm; p = 0.01). The first episode of VL was diagnosed in 87.5% patients through bone marrow aspirate, and the other cases were diagnosed by biopsies of gum (2), lymph node (1) or liver (1). One patient was diagnosed clinically: he had a positive serology and a good response to antileishmanial therapy. Treatment failed in nine patients (22.5%), 7 HIV-coinfected. Eight patients died (20%), 6 HIV-coinfected. Five deaths were directly attributed to VL. Six coinfected patients (31.5%) relapsed and only one (4.7%) in the other group., Conclusions: We did not find major differences in clinical manifestations or laboratory data between the two groups. Biopsies of several tissues can be particularly helpful for diagnosis in immunocompromised patients with negative bone marrow aspirates. Failures, mortality and relapses are more common in HIV infected patients. VL coinfection usually affects HIV infected patients when they develop severe immunodepression.