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Background: In patients with moderate to severe histoplasmosis associated with AIDS, the preferred treatment has been the deoxycholate formulation of amphotericin B. However, serious side effects are associated with use of amphotericin B. Objective: To compare amphotericin B with liposomal amphotericin B for induction therapy of moderate to severe disseminated histoplasmosis in patients with AIDS. Design: Randomized, double-blind, multicenter clinical trial. Setting: 21 sites of the U.S. National Institute of Allergy and Infectious Diseases Mycoses Study Group. Patients: 81 patients with AIDS and moderate to severe disseminated histoplasmosis. Measurements: Clinical success, conversion of baseline blood cultures to negative, and acute toxicities that necessitated discontinuation of treatment. Results: Clinical success was achieved in 14 of 22 patients (64%) treated with amphotericin B compared with 45 of 51 patients (88%) receiving liposomal amphotericin B (difference, 24 percentage points [95% CI, 1 to 52 percentage points]). Culture conversion rates were similar. Three patients treated with amphotericin B and one treated with liposomal amphotericin B died during induction (P=0.04). Infusion-related side effects were greater with amphotericin B (63%) than with liposomal amphotericin B (25%)(P=0.002). Nephrotoxicity occurred in 37% of patients treated with amphotericin B and 9% of patients treated with liposomal ampotericin B (P=0.003). Conclusion: Liposomal amphotericin B seems to be a less toxic alternative to amphotericin B and is associated with improved survival.

Background: In AIDS, nodular skin disease can result from various causes. Objective: To report a new manifestation of microsporidial infection presenting as nodular skin disease with underlying osteomyelitis. Design: Case report. Setting: Tertiary-care military medical center in Washington, D.C. Patient: A 36-year-old woman with late-stage AIDS who presented with disseminated, nodular cutaneous lesions and underlying osteomyelitis. Measurements: Disseminated microsporidial infection with an Encephalitozoon-like species was diagnosed by electron microscopic examination of material obtained from the skin lesions. Intervention: The patient received long-term oral clindamycin therapy, which cured her disseminated infection. Conclusions: Microsporidia can cause disseminated cutaneous infections in AIDS patients. The response of this patient to long-term clindamycin therapy merits further evaluation., AIDS patients may be susceptible to microsporidial infection of the skin. Microsporidia are protozoa more often seen in veterinary medicine. A 36-year-old women with late-stage AIDS developed recurrent painful, nodular skin lesions and infection of the underlying bone. Short courses of drug therapy did not permanently resolve the infection. Electron microscopy of a biopsy specimen revealed microspores. High-dose oral clindamycin therapy successfully eradicated the infection, and one year of continuous treatment prevented recurrence.

Background: Cytomegalovirus (CMV) retinitis is the most common intraocular infection in patients with the acquired immunodeficiency syndrome (AIDS). If left untreated, it may lead to progressive destruction of retinal tissue and blindness. Cidofovir is a nucleotide analogue of cytosine that has potent, prolonged in vitro and in vivo activity against herpesviruses, including many CMV isolates that are resistant to ganciclovir and foscarnet. Objective: To determine whether intravenous cidofovir delays progression of previously untreated CMV retinitis. Design: Randomized, controlled trial comparing immediate with deferred cidofovir treatment. Patients in the deferred treatment group were eligible to receive cidofovir after progression of CMV retinitis was documented by retinal photography. Setting: Eight academic medical centers and an independent center that read retinal photographs. Patients: 48 patients with AIDS and previously untreated peripheral CMV retinitis who were randomly assigned to immediate (n = 25) or deferred treatment (n = 23). Intervention: Intravenous cidofovir, 5 mg/kg of body weight, once weekly for 2 weeks and then once every other week. To minimize nephrotoxicity, oral probenecid and intravenous hydration with normal saline were administered with each cidofovir infusion. Measurements: Progression of CMV retinitis was assessed by bilateral, full-field retinal photographs that were read by an ophthalmologist who was masked to treatment assignment. Incidence of side effects, changes in visual acuity, effect on CMV shedding in urine and blood, and mortality were also assessed. Results: The median time to progression of CMV retinitis was 22 days (95% Cl, 10 to 27 days) in the deferred treatment group and 120 days (Cl, 40 to 134 days) in the immediate treatment group (P [is less than] 0.001). Neutropenia (15%) and proteinuria (12%), both asymptomatic, were the most common serious adverse events considered to be possibly related to cidafovir. Cidofovir treatment was discontinued in 10 of 41 patients (24%) because of protocol-defined treatment-limiting nephrotoxicity. Transient reactions to probenecid, including mild to moderate constitutional symptoms or nausea, occurred in 23 of 41 patients (56%) and were dose limiting in 3 (7%). Conclusions: Cidofovir was efficacious in delaying progression of previously untreated CMV retinitis. Treatment was associated with manageable side effects; strict adherence to monitoring of renal function before cidofovir was administered and concomitant administration of probenecid and saline hydration appeared to minimize drug-related nephrotoxicity., Cidofovir appears to be effective in delaying eye complications seen in patients with AIDS and untreated cytomegalovirus (CMV) associated retinitis. Forty-eight patients with CMV-associated retinitis were treated with cidofovir either immediately or after the disease had progressed. Immediate treatment with cidofovir delayed the progression of retinitis from 22 days to 120 days. Side effects included low white blood cell count and increased protein levels in the urine.

Background: Cytomegalovirus (CMV) retinitis is a common infection and a major cause of visual loss in patients with the acquired immunodeficiency syndrome (AIDS). Objective: To evaluate intravenous cidofovir as a treatment for CMV retinitis. Design: Two-stage, multicenter, phase II/III, randomized, controlled clinical trial. Setting: Ophthalmology and AIDS services at tertiary care medical centers. Patients: 64 patients with AIDS and previously untreated, small, peripheral CMV retinitis lesions (that is, patients at low risk for loss of visual acuity). Intervention: Patients were randomly assigned to one of three groups: the deferral group, in which treatment was deferred until retinitis progressed; the low-dose cidofovir group, which received cidofovir, 5 mg/kg of body weight once weekly for 2 weeks, then maintenance therapy with cidofovir, 3 mg/kg once every 2 weeks; or the high-dose cidofovir group, which received cidofovir, 5 mg/kg once weekly for 2 weeks, then maintenance therapy with cidafovir, 5 mg/kg once every 2 weeks. To minimize nephrotoxicity, cidofovir was administered with hydration and probenecid. Measurements: Progression of retinitis, evaluated in a masked manner by a fundus photograph reading center; the amount of retinal area involved by CMV; the loss of visual acuity; and morbidity. Results: Median time to progression was 64 days in the low-dose cidofovir group and 21 days in the deferral group (P = 0.052, log-rank test). The median time to progression was not reached in the high-dose cidofovir group but was 20 days in the deferral group (P = 0.009, log-rank test). Analysis of the rates of increase in the retinal area affected by CMV confirmed the data on time to progression. The three groups had similar rates of visual loss. Proteinuria of 2+ or more occurred at rates of 2.6 per person-year in the deferral group, 2.8 per person-year in the low-dose cidofovir group (P [is greater than] 0.2), and 6.8 per person-year in the high-dose cidofovir group (P =0.135). No patient developed 4+ proteinuria, but two cidofovir recipients developed persistent elevations of serum creatinine levels at more than 177 [micro] mol/L (2.0 mg/dL). Reactions to probenecid occurred at a rate of 0.70 per person-year. Conclusions: Intravenous cidofovir, high- or low-dose, effectively slowed the progression of CMV retinitis. Concomitant probenecid and hydration therapy, intermittent dosing, and monitoring for proteinuria seemed to minimize but not eliminate the risk for nephrotoxicity., Both high and low concentrations of cidofovir treatment appear to be effective in delaying eye complications seen in patients with AIDS and untreated cytomegalovirus (CMV) associated retinitis. Sixty-four patients with CMV-associated retinitis were treated either immediately with a low or high dose of cidofovir or after retinitis had progressed. Low-dose cidofovir delayed retinitis progression from 21 days as seen in the delayed treatment group to 64 days. Half of the group treated with high-dose cidofovir did not progress to CMV-associated retinitis by the study's end.

Cytomegalovirus (CMV) retinitis, a common complication of the acquired immunodeficiency syndrome (AIDS), is increasing in frequency as patients infected with the human immunodeficiency virus (HIV) live longer. In recent years, the lifetime risk for CNXY disease in HIV-infected persons has increased from 24.9% to 44.9%. Cytomegalovirus retinitis is usually diagnosed clinically: Almost all patients are CMV seropositive and have [CD4.sup.+] counts less than 50 cells/[mm.sup.3]. Specific diagnostic tests that use antigen detection or quantitation of circulating nucleic acid to detect CMV are being developed, but they have not been validated for routine clinical use. Such tests would help predict disease, diagnose acute retinitis, and monitor therapy. Therapy with systemic agents, including intravenous ganciclovir, intravenous foscarnet, and intravenous cidofovir, is effective. However, it is cumbersome, costly, and associated with considerable toxicity, thereby encouraging investigation of other therapeutic approaches. intravitreous injections with antiviral agents are effective, but the short half-life of available agents makes these injections inconvenient. Intraocular implants that slowly release ganciclovir have been effective for both acute therapy and long-term maintenance but they need to be directly compared with intravenous and oral regimens to determine which regimen will optimally maximize convenience, preserve vision, and improve survival. Cytomegalovirus retinitis could be prevented by improved antiretroviral therapies or by immune-based therapies that would prolong the time during which patients remain immunocompetent. Once patients become immunologically susceptible to CMV end-organ disease (when their [CD4.sup.+] counts decrease to, Participants at a National Institute of Health conference presented the current thought on identification, patient characteristics, and treatment options for patients with cytomegalovirus (CMV) retinitis in association with AIDS. Most patients with CMV retinitis have low CD4 cell counts and are identified by physical examination. Treatments currently being tested include ganciclovir given intravenously or as an eye implant or therapies injected directly into the eye. All of these options have proven to be effective but are costly, inconvenient, and potentially toxic.

Preventive treatment and better diagnosis and treatment of pneumocystosis in HIV-infected people may be responsible for the decrease in deaths among HIV-infected people. Data on secondary disease trends among people who died from HIV infection from 1987 to 1992 showed that the largest decrease in deaths was associated with pneumocystosis. Decreases in HIV-related deaths complicated by cryptococcosis and candidiasis were also noted. Pneumonia caused by unspecified organisms became the biggest secondary cause of HIV-related deaths due to the decrease in pneumocystosis. About 18% of HIV-related deaths were caused by pneumonia. Earlier detection of HIV and adequate medical care may enable HIV-infected people to receive better treatment for secondary diseases.

* Objective: To evaluate the efficacy of twice-weekly maintenance therapy with sulfadiazine-pyrimethamine to prevent toxoplasmic encephalitis relapse in patients with the acquired immunodeficiency syndrome (AIDS). * Design: Randomized, open, multicenter trial. Patients were randomly assigned to receive sulfadiazine (500 mg) four times per day plus pyrimethamine (25 mg) plus folinic acid (15 mg) either daily (n = 60) or twice weekly (n = 45). * Setting: 8 university teaching hospitals. * Patients: Between February 1990 and June 1993, 105 patients with HIV infection were enrolled after each had had resolution of an acute episode of toxoplasmic encephalitis treated with sulfadiazine (1 g four times per day) plus pyrimethamine (50 mg/d) plus folinic acid (1 5 mg/d) for 4 to 8 weeks. * Measurements. Clinical and biological evaluations done every 30 to 60 days. End points were toxoplasmic encephalitis relapse, death, and interruption of therapy due to adverse reactions. * Results: After a median follow-up period of 11 months (range, 1 to 39 months), patients receiving the twice-weekly regimen had a higher rate of relapse than patients receiving the daily regimen (1 9.5 compared with 4.4 per 100 patient-years; incidence rate ratio, 4.36 [95% CI, 1.05 to 25.5); P = 0.024). The estimated cumulative percentages of relapse at 12 months were 30% and 6%, respectively (P = 0.029), with an adjusted risk ratio (adjusted for age, sex, risk behavior, previous diagnosis of AIDS, Pneumocystis carinii pneumonia prophylaxis before initial episode of toxoplasmosis, CD4 cell count, baseline number of brain lesions, radiologic sequelae, and antiretroviral therapy during follow-up) of 5.6 (CI, 1.2 to 25.6; P = 0.028). Patients receiving the twice-weekly regimen had 1.6 times (CI, 0.9 to 2.9 times; P = 0.11) the adjusted risk for death of patients receiving the daily regimen. No statistical differences were found in the patients who stopped receiving the regimens due to adverse effects. No patient developed P. carinii pneumonia during the study period, even though 17 patients (10 receiving the daily regimen and 7 receiving the twice-weekly regimen) had had an episode of P. carinii pneumonia before study entry. * Conclusions: At the given doses, a combination of sulfadiazine, pyrimethamine, and folinic acid was less effective when administered twice weekly than when administered daily, although the twice-weekly regimen was much more effective than historic controls., Twice-weekly treatment with sulfadiazine, pyrimethamine, and folinic acid may not be as effective as daily treatment for patients with toxoplasmic encephalitis associated with acquired immunodeficiency syndrome (AIDS). Toxoplasmic encephalitis is an inflammation of the brain. Researchers administered either a daily or twice-weekly dose of sulfadiazine, pyrimethamine, and folinic acid to 105 AIDS patients with a previous episode of toxoplasmic encephalitis. Of the 60 AIDS patients receiving the daily dose, only 6% experienced a recurrence of toxoplasmic encephalitis in the first 12 months. Of the 45 AIDS patients receiving the twice-weekly dose, 30% experienced a recurrence of toxoplasmic encephalitis during this time period. Patients given a daily dose survived for an average of 15.2 months. Patients given a twice-weekly dose survived for an average of 11.9 months.

* Objectives: To compare the effects of oral suspensions of megestrol acetate, 800 mg/d, and placebo on body weight in patients with acquired immunodeficiency syndrome (AIDS)-related weight loss. * Design: Randomized, double-blind, placebo-controlled trial. * Setting: Outpatient community and university patient care setting. * Patients: Consecutive patients with AIDS who had substantial weight loss and anorexia were enrolled. Of 271 patients, 270 and 195 were evaluable for safety and efficacy, respectively. * Interventions: Patients were randomly assigned to receive placebo or megestrol acetate (1 00 mg, 400 mg, or 800 mg) daily for 12 weeks. * Main Outcome Measures: The primary efficacy criterion was weight gain. Patients were evaluated at 4-week intervals for changes in weight and body composition, caloric intake, sense of well-being, toxic effects, and appetite. * Results: For evaluable patients receiving 800 mg of megestrol acetate per day, 64.2% gained 2.27 kg (5 pounds) or more compared with 21.4% of patients receiving placebo (P < 0.001). An intent-to-treat analysis showed significant differences (P = 0.002) between those receiving placebo and those receiving 800 mg of megestrol acetate for the number of patients who gained 2.27 kg (5 pounds) or more (8 of 32 [25%] compared with 38 of 61 [62.3%], respectively). Compared with patients receiving placebo at the time of maximum weight change, evaluable patients receiving megestrol acetate, 800 mg/d, reported improvement in overall well-being and had an increase in mean weight gain (-0.725 compared with 3.54 kg [-1.6 compared with +7.8 pounds]; P < 0.001), lean body mass (-0.772 compared with (1.14 kg [-1.7 compared with +2.5 pounds]; P< 0.001), appetite grade (P < 0.001), and caloric intake (-107 compared with +645.6 calories/d; P = 0.001). * Conclusions. In patients with AIDS-related weight loss, megestrol acetate can stimulate appetite, food intake, and statistically significant weight gain that is associated with a patient-reported improvement in an overall sense of well-being., Megestrol acetate may be an effective treatment for cachexia in AIDS patients. Cachexia is a state of ill health and malnutrition that can result from weakness and loss of appetite and can lead to wasting. Megestrol acetate is a synthetic hormone that stimulates appetite. A total of 270 AIDS patients with significant weight loss were randomly assigned to take megestrol acetate at a dose of 100 milligrams (mg), 400 mg or 800 mg per day, or to take a placebo. In the first 12 weeks of the study, 64.2% of patients taking 800 mg of megestrol acetate gained at least five pounds, compared with 56.6% in the 400-mg group, 44.3% in the 100-mg group and 21.4% in the placebo group. More patients in the 800-mg group reported increased appetite than in the other groups, and their daily caloric intake also increased. Patients taking 800 mg of megestrol acetate also reported an improvement in well-being. Side effects were mostly minor and included cough, fever, fatigue, labored breathing, diarrhea and weakness.

* Objective: To study the effects of a megestrol acetate liquid formulation (800 mg/d) on body weight, body composition, caloric intake, and mental outlook in patients with the acquired immunodeficiency syndrome (AIDS) who had cachexia. * Design: Twelve-week, multicenter, randomized, double-blind, placebo-controlled trial. * Setting: Multiple clinical centers. * Patients: 100 patients with AIDS who had weight loss of 10% or more of ideal body weight were randomly assigned to placebo (n = 48) or megestrol acetate (n = 52). * Measurements: Caloric intake, body weight, body composition, and sense of well-being. * Results: Most patients receiving megestrol acetate had increased caloric intake resulting in body weight gain (mainly fat mass). From baseline to week 8, the megestrol acetate group increased their daily caloric intake by 608 calories, whereas the placebo group increased intake by 134 calories (difference, 474 calories; 95% CI, -68 to 880 calories). Body weight in the megestrol acetate group increased by 3.86 kg from baseline to week 8, although it decreased by 0.46 kg in the placebo group (difference, 4.32 kg; CI, 2.42 to 6.22 kg). At week 8 in the megestrol acetate group, patients gained 3.68 kg in fat mass and those in the placebo group lost 0.28 kg (difference, 3.96 kg; CI, 2.49 to 5.43 kg). Body water, lean mass, and patient survival were not statistically different between treatment groups. Patients treated with megestrol acetate had an increased sense of well-being when compared with patients who received placebo. * Conclusions: This megestrol acetate liquid formulation is well tolerated, increases food intake, results in body weight gain, and improves the sense of well-being in cachectic patients with AIDS., Megestrol acetate may be an effective treatment for cachexia in AIDS patients. Cachexia is a state of ill health and malnutrition that can result from weakness and loss of appetite and can lead to wasting. Megestrol acetate is a synthetic hormone that stimulates appetite. Among 42 AIDS patients with cachexia who completed a 12-week study, 22 received 800 milligrams of megestrol acetate daily and 20 took a placebo. By the end of the study, patients taking megestrol acetate had increased daily caloric intake by 447 calories, compared to patients in the placebo group whose intake had decreased by 241 calories relative to the beginning of the study. Body weight increased among the megestrol acetate group and decreased among the placebo group. More patients who took megestrol acetate reported an improvement in well-being than patients who took placebo. Side effects of megestrol acetate included diarrhea, flatulence, weakness, impotence and general pain.

* Secondary infections remain the leading cause of death in patients with the acquired immunodeficiency syndrome (AIDS). Dealing with the rapidly evolving spectrum of infectious problems seen in patients with AIDS requires knowledge of current therapeutic and prophylactic strategies. Through an extensive preclinical trials network supported by both industry and government, an increasing number of new agents are being identified and rapidly moved into clinical trials. Several agents are now available to treat diseases caused by Pneumocystis carinii, and corticosteroids have become a useful adjunct to antimicrobial agents in the treatment of P. carinii pneumonia. Although the treatment of toxoplasmosis remains a challenge, alternatives to sulfadiazine and pyrimethamine are now available. Mycobacterial infections, particularly with Mycobacterium tuberculosis, have become an increasing problem for patients with AIDS, and both old and new combination drug regimens are being used. Cytomegalovirus disease, until recently an untreatable problem, can now at least be partially managed with antiviral agents. The use of more complete prophylactic regimens may decrease the morbidity and mortality from opportunistic infections., Many advances have been made in the treatment of the opportunistic infections that occur in AIDS patients. Methods are available to prevent and treat Pneumocystis carinii pneumonia, toxoplasmosis, Mycobacterium tuberculosis, Mycobacterium avium-intracellulare complex infection, and cytomegalovirus (CMV) infection. Serious opportunistic infections are not a problem until the CD4 T-cell count drops below 200 cells per microliter, and some rarely occur until levels have fallen below 100 cells per microliter. Problems with medication include cost, patient compliance, toxicity, reactions among drugs in patients on multiple drug regimens, the development of resistant strains of organisms, and as AIDS patients live longer, new types of infection.

* Objective: To describe 13 infections caused by Mycobacterium haemophilum. * Design: Identification of patients by microbiologic record review, followed by medical record review and a case-control study. * Setting: Seven metropolitan hospitals in New York. * Patients: All patients with M. haemophilum infections diagnosed between January 1989 and September 1991 and followed through September 1992. Surviving patients were enrolled in the case-control study. * Results: infection with M. haemophilum causes dissominated cutaneous lesions, bacteremia, and diseases of the bones, joints, lymphatics, and the lungs. Improper culture techniques may delay laboratory diagnosis, and isolates may be identified incorrectly as other mycobacterial species. Persons with profound deficits in cell-mediated immunity have an increased risk for infection. These include persons with human immunodeficiency virus infection or lymphoma and those receiving medication to treat immunosuppression after organ transplant. Various antimycobacterial regimens have been used with apparent success to treat M. hasmophilum infection. However, standards for defining antimicrobial susceptibility to the organism do not exist. * Conclusions: Clinicians should consider this pathogen when evaluating an immunocompromised patient with cutaneous ulcerating lesions, joint effusions, or osteomyelitis. Microbiologists must be familiar with the fastidious growth requirements of this organism and screen appropriate specimens for mycobacteria using an acid-fast stain. If acid-fast bacilli are seen, M. haemophilum should be considered as the infecting organism as well as other mycobacteria, and appropriate media and incubation conditions should be used., Infection with Mycobacterium (M.) haemophilum may be underreported because of the strict conditions required for diagnosis. Diagnosis involves culturing the organism for a longer time and at a lower temperature than other mycobacteria. M. haemophilum infection can be successfully treated with antibiotic drugs.Thirteen cases of M. haemophilum infection were diagnosed in New York City between Jan 1989 and Sep 1991. The patients all had severely impaired immune system function due to AIDS (11 patients) or bone marrow transplant (two patients). The initial symptom in eight patients was the presence of skin lesions. Other symptoms included painful and swollen joints, respiratory difficulties and night sweats. The infection in seven of the thirteen patients either improved or resolved with combination drug therapy. Physicians should consider the possibility of M. haemophilum infection in patients with AIDS or other immune deficiencies who also have skin lesions and joint symptoms.

* Objective: To compare the pathogenesis, clinical presentation, therapy, and prognosis of primary central nervous system lymphoma in immunocompetent persons with these characteristics of the disease in patients with AIDS. * Data Sources and Extraction: All English-language papers published between 1980 and 1992 dealing with either lymphoma and the central nervous system or AIDS were reviewed. Patient characteristics, clinical presentation, histologic findings, and treatment and survival data were extracted from each case report and review. * Data Synthesis: Data were available on 792 patients (from 40 reported series) with non-AIDS-associated primary central nervous system lymphoma and 315 patients (from 32 series) with AIDS-associated primary central nervous system lymphoma. Patients with AIDS initially consulted a physician more often when they had global neurologic symptoms compared with patients without AIDS, with more than 50% of the lesions on computed tomographic (CT) scans in patients with AIDS being ring-enhancing and multifocal, a pattern rarely described in immunocompetent patients. The overall survival of the patients without AIDS was 18.9 months compared with 2.6 months for patients with AIDS, with substantial differences remaining even for subgroups of patients similarly treated with radiation and chemotherapy. * Conclusion: Primary central nervous system lymphoma is probably a substantially different disease in persons with and without AIDS with regard to patient characteristics, clinical and radiographic presentation, and prognosis. Recent advances in the treatment of this disease in patients without AIDS have not largely affected patients with AIDS. Substantial improvements in survival in these patients await advances in controlling their human immunodeficiency virus-associated disease., The treatment and prognosis of central nervous system lymphoma depends on whether the patient has AIDS. Central nervous system lymphoma refers to tumors occurring in the brain or spine. These tumors are usually malignant. The number of cases of central nervous system lymphoma has increased since the beginning of the AIDS epidemic. The number of cases in patients without AIDS has also increased substantially. Records were reviewed for 792 patients with central nervous system lymphoma not associated with AIDS and 315 patients with AIDS-associated central nervous system lymphoma. Patients with AIDS-associated disease were likely to have ring-enhancing, multifocal lesions on computed tomographic (CT) scan. Treatment options include radiotherapy and chemotherapy. Patients without AIDS who received treatment survived an average of 18.9 months compared to 2.6 months for patients with AIDS. The majority of patients with AIDS-associated central nervous system lymphoma are at an advanced stage of HIV disease.

* Objective: To determine the incidence, cause, and characteristics of pleural effusions in hospitalized patients with the acquired immunodeficiency syndrome (AIDS). * Design: Retrospective. * Participants: A total of 222 patients with AIDS hospitalized between January 1986 and January 1992 at the Medical University of South Carolina hospitals. * Results: Pleural effusions occurred in 59 patients for an overall incidence of 27%. The mean age of the patients was 35 [+ or -] 2 years (SE) and the male to female ratio was 5:1. The cause was infectious in 39 (66%) patients, noninfectious in 18 (31%), and unknown in 2 (3%). Pleural effusions were caused by bacterial pneumonia in 18 (31%) patients, Pneumocystis carinii pneumonia in 9 (15%), Mycobacterium tuberculosis in 5 (8%), septic embolism in 2 (3%), Nocardia asteroides in 2 (3%), cryptococcus neoformans in 2 (3%), and Mycobacterium arium intracellulare in 1 (2%). Among noninfectious causes (n = 18), hypoalbuminemia was the cause in 11 patients (19%), cardiac failure in 3 (5%), and atelectasis, Kaposi sarcoma, uremic pleurisy, and adult respiratory distress syndrome in 1 (2%) each. Patients with AIDS who had pleural effusions had significantly lower serum albumin levels and had lower CD4 counts than did those without pleural effusions (P < 0.001). * Conclusions: Pleural effusions are common in hospitalized patients with AIDS. Bacterial pneumonia is the most common cause for pleural effusion in AIDS. Large effusions are associated with Kaposi sarcoma and tuberculosis. Hypoalbuminemia is a common cause of noninfectious pleural effusions., Pleural effusions occur quite frequently in AIDS patients with the most common cause being bacterial pneumonia. A pleural effusion is the presence of liquid in the membrane lining the chest cavity. The records of 222 patients diagnosed with AIDS and hospitalized between 1986 and 1992 were reviewed. Pleural effusions, which occurred in 27% of the patients, were most likely to be caused by an infectious organism. Bacterial pneumonia was the cause of the effusion in 31% of the patients, pneumocystis carinii pneumonia was present in 15% of the cases. Tuberculosis was also a cause of effusions in 8% of the patients. Noninfectious causes of effusions in AIDS patients included hypoalbuminemia and Kaposi sarcoma. Large pleural effusions are more likely to be caused by Kaposi sarcoma, tuberculosis and lymphoma.

* Objective: To assess the efficacy and safety of itraconazole in preventing relapse of histoplasmosis after induction therapy with amphotericin B in patients with the acquired immunodeficiency syndrome (AIDS) and disseminated histoplasmosis. * Design: A prospective, multicenter, open-label clinical trial, with follow-up for at least 52 weeks. * Setting: Tertiary care hospitals participating in a clinical investigation sponsored by the National institutes of Allergy and infectious Diseases (AIDS Clinical Trial Group and Mycoses Study Group). * Patients: Forty-two patients with AIDS who had successfully completed induction therapy for disseminated histoplasmosis amphotericin B, at least 15 mg/kg body weight given over 4 to 12 weeks. * Interventions: Itraconazole, 200 mg given orally twice daily. * Main Outcome Measures: Response to therapy, specifically prevention of histoplasmosis relapse, was the main outcome measure. Secondary end points were survival and the effect of therapy on Histoplasma capsulatum variety capsulatum antigen levels in urine and serum. Plasma itraconazole concentrations were measured to document drug absorption and compliance with therapy. * Results: The median follow-up was 109 weeks, and median survival was 98 weeks. Two relapses occurred (5%; 95% Cl, 0.5% to 16%), one in a patient withdrawn from the study 18 weeks earlier and one in a patient who did not comply with the study therapy. Patients with elevated antigen levels at study entry showed clearance of antigen from urine and serum; urine specimens became negative in 43% of patients (Cl, 26% to 59%), and serum specimens became negative in 75% of patients (Cl, 56% to 94%). Only one-patient discontinued treatment because of itraconazole toxicity (hypokalemia). * Conclusions: Itraconazole, 200 mg twice daily, is safe and effective in preventing relapse of disseminated histoplasmosis in patients with AIDS. Antigen clearance from blood and urine correlates with clinical efficacy., The drug itraconazole appears to be effective in preventing relapse of histoplasmosis in AIDS patients. Histoplasmosis is an infection that results from the inhalation or ingestion of the spores Histoplasma capsulatum. Among AIDS patients, it is usually treated with amphotericin B, but maintenance therapy with intravenous amphotericin B to prevent relapse is complicated and expensive. Forty-two AIDS patients who had been successfully treated for histoplasmosis with amphotericin B took 200 milligrams of itraconazole orally two times a day. One patient had a confirmed relapse, and another had a possible relapse. Only one patient had to stop taking the drug because of toxicity. In the other 39 patients, itraconazole successfully suppressed a relapse.

* Objectives: To describe the clinical, demographic, radiographic, diagnostic, and therapeutic aspects of blastomycosis in patients with the acquired immunodeficiency syndrome (AIDS). * Design: A retrospective survey. * Setting: Ten university medical centers and community hospitals, six in geographic areas endemic for Blastomyces dermatitidis, and four outside the endemic area. * Patients: We identified 15 patients with blastomycosis and positive serologic test results for human immunodeficiency virus (HIV). * Measurements: A diagnosis of blastomycosis was based on a positive culture (14 patients) or typical histopathologic features (one patient) for B. dermatitidis in clinical specimens. * Results: Twelve of 15 patients had a previous or concomitant AIDS-defining illness at the time of diagnosis of blastomycosis, and only one patient had a CD4 lymphocyte count of greater than 200 cells/mm (3). Two patterns of disease emerged: localized pulmonary involvement (seven patients), and disseminated or extra-pulmonary blastomycosis (eight patients). Central nervous system involvement was common (40%). Six patients died within 21 days of presentation with blastomycosis, including four patients with disseminated and two with fulminant pulmonary disease. Among the nine patients who survived longer than 1 month, all received amphotericin B as initial antifungal therapy, and most received subsequent therapy with ketoconazole. Only two of these nine patients died with evidence of progressive blastomycosis. * Conclusions: Blastomycosis is a late and frequently fatal infectious complication in a few patients with AIDS. In these patients, overwhelming disseminated disease including involvement of the central nervous system is common, and it is associated with a high early mortality. Initial therapy with amphotericin B is appropriate in patients with AIDS and presumptive blastomycosis.

* As the largest lymphoid organ in the body, the gastrointestinal tract is a potential reservoir for human immunodeficiency virus (HIV), the causative agent of the acquired immunodeficiency syndrome (AIDS), and it is an important site for HIV-induced immunodeficiency. The resulting defects in cellular and humoral defense mechanisms predispose the gastrointestinal tract to a spectrum of viral, fungal, bacterial, and protozoan pathogens that cause relentless morbidity and, in some cases, death. With a thorough diagnostic evaluation, physicians can identify one or more of these pathogens in a majority of patients with AIDS who have gastrointestinal symptoms. The identification of enteric pathogens in patients with AIDS is important because an increasing array of therapeutic regimens is becoming available to treat many of these infections.

* Objective: To compare pyrimethamine plus clindamycin (PC) to pyrimethamine plus sulfadiazine (PS) as a treatment for toxoplasmic encephalitis (TE) in patients with the acquired immunodeficiency syndrome (AIDS). * Design: Randomized, unblinded phase II, multicenter trial with provision for crossover for failure or intolerance of the assigned regimen. * Setting: University hospitals. * Patients: Eighty-four patients with presumptive TE were entered. Thirteen were excluded when they were found to have another diagnosis, and 12 were excluded because they did not meet entry criteria. The baseline characteristics in the remaining 26 patients randomized to PC and 33 randomized to PS were comparable. * Interventions: Patients were treated for 6 weeks with pyrimethamine and folinic acid plus either sulfadiazine or clindamycin. Clindamycin was given intravenously during the first 3 weeks. * Measurements and Main Results: There was a trend toward greater survival in patients randomized to PS (hazard ratio, 3.25; 95% Cl, 0.63 to 16.8; P = 0.13), but most study deaths were not directly related to TE. In contrast, patients randomized to PC appeared more likely to achieve complete clinical (odds ratio, 0.67; Cl, 0.2 to 1.97; P > 0.2) and radiologic responses (odds ratio, 0.28; Cl, 0.08 to 0.96; P = 0.02). Multivariate analysis revealed drug effects to be largely independent of other variables. Similar efficacy of the treatments was also suggested by a hazard analysis of resolution of abnormal mental status, fever, and headache. Skin rash was the most common adverse event in both treatment arms. Because of toxicity, six patients randomized to PC and 11 patients randomized to PS had to switch to the alternate treatment, but only three were unable to complete therapy after crossover. * Conclusions: The results of several end points of efficacy, taken together, suggest that the relative efficacy of PC approximately equals that of PS. PC appears to be an acceptable alternative in patients unable to tolerate PS.

Infection with the human immunodeficiency virus (HIV) inexorably leads to the development of acquired immune deficiency syndrome (AIDS) after a variable latent period. AIDS is characterized by, among other things, recurrent opportunistic infections by a variety of bacterial microorganisms, including the causative agents in an AIDS-related form of pneumonia and toxoplasmosis (Pneumocystis carinii and Toxoplasma gondii, respectively). The commonly accepted treatment for toxoplasmosis, a class of drugs that interfere with folic acid metabolism, operates by the same biochemical mechanism as treatment for P. carinii; hence, it might be expected that AIDS patients undergoing treatment for toxoplasmosis might be expected to show a lower incidence of P. carinii infection than similar groups of patients not undergoing such treatment. To test this hypothesis, a group of 99 patients with cerebral toxoplasmosis (but no previous or simultaneous P. carinii infection) being treated for the condition with pyrimethamine and sulfonamides were compared with a group of 240 AIDS patients with other severe opportunistic infections, and with a group of 113 patients being treated prophylactically (with inhaled pentamidine) against P. carinii infection. Significantly fewer patients being treated for toxoplasmosis developed P. carinii infection than patients who were not receiving such treatment (6 percent versus 21 percent); 6 percent of the patients receiving P. carinii prophylaxis also became infected with the P. carinii microorganism. Hence, the drugs used to treat toxoplasmosis, pyrimethamine and sulfonamides, seem to be as successful at preventing P. carinii infection in AIDS patients as drugs more commonly used primarily to prevent the pneumonia infection. (Consumer Summary produced by Reliance Medical Information, Inc.)

The acquired immunodeficiency syndrome (AIDS) is characterized by frequent infections, and the most common of which is pneumonia caused by Pneumocystis carinii. Some patients with P. carinii pneumonia develop a complication known as pneumothorax, in which air collects within the chest cavity, causing at least partial collapse of the lung. A study of AIDS patients with P. carinii pneumonia was performed to assess the frequency of pneumothorax and the predisposing factors to this condition. Of 1,030 AIDS patients with probable P. carinii pneumonia, 20 (2 percent) developed pneumothorax spontaneously. Patients who had experienced previous episodes of P. carinii pneumonia had a significantly increased risk of developing pneumothorax compared with patients experiencing their first bout of pneumonia. Additionally, those patients who were receiving an aerosolized form of pentamidine, an anti-Pneumocystis drug, were also found to have a greater risk for pneumothorax. Pneumothorax carries greater morbidity for AIDS patients than for others. Typically, the AIDS patients required chest tubes to correct the pneumothorax for 20 days, rather than the average three to four days. Chest tube therapy was adequate for only 4 of the 20; 5 needed surgical correction, and 11 underwent sclerotherapy, in which drugs are injected into the chest cavity to form scar tissue and seal the air leaks that caused the pneumothorax. Of the 20 patients who developed spontaneous pneumothorax, 19 had clear evidence of ongoing P. carinii pneumonia, despite the use of pentamidine by 18 of these patients. Interestingly, patients who developed pneumothorax tended to survive AIDS approximately 150 days longer than average AIDS patients, suggesting that their extended survival permitted them the opportunity to develop this complication. Based on these data, treating any AIDS patient who develops a spontaneous pneumothorax as if he had P. carinii pneumonia is prudent. (Consumer Summary produced by Reliance Medical Information, Inc.)

Human immunodeficiency virus type I (HIV-1) is an incurable viral infection, resulting in compromised immune system function that ultimately leads to the development of AIDS. One of the many manifestations of HIV-1 is anemia, the reduction of the number of circulating red blood cells. Human B19 parvovirus is another infective microorganism that can cause impaired production of red blood cells. Infection with B19 parvovirus results in rheumatic symptoms in adults and fifth disease (an infectious disease characterized by skin rashes) in children; these conditions usually abate spontaneously following production of antibodies against the virus. In patients with HIV-1 infection, the failure to develop an adequate immune response to B19 infection can lead to particularly severe anemia. Seven patients diagnosed with both HIV-1 and B19 parvovirus infections, and who were severely anemic, underwent treatment with intravenous administration of commercially available immunoglobulin (a family of proteins that can act as antibodies). This resulted in an immediate reduction of blood levels of B19 parvovirus and normalization of red blood cell production. In two patients, blood chemistry tests predicted imminent relapse, which was successfully treated by continued immunoglobulin injections. It is concluded that B19 parvovirus infection is a treatable cause of anemia in patients infected with HIV-1 virus. (Consumer Summary produced by Reliance Medical Information, Inc.)

Patients with AIDS often have gastrointestinal complications of the disease that are frequently localized in the esophagus. Symptoms often include dysphagia (difficulty with swallowing) or odynophagia (pain with swallowing). Candida esophagitis, a fungal infection, is the most common. Recently, esophageal infection by cytomegalovirus (CMV) has been recognized, but accurate diagnosis has been difficult. Sixteen AIDS patients with odynophagia underwent esophageal endoscopy with biopsy. In all 16, the biopsy specimens showed large intranuclear inclusions, which is characteristic of CMV infection. Only eight of the patients had biopsy specimens which grew CMV in culture. The current therapy for CMV esophagitis is the antiviral compound ganciclovir, but not all patients respond favorably. Those who fail to respond to ganciclovir had a poor prognosis in general. AIDS patients with dysphagia should be presumed to have Candida esophagitis and should be treated with antifungal agents. Those who fail to respond to antifungal therapy, or who have odynophagia, should undergo endoscopy with biopsy and microscopic examination of the tissue for typical viral inclusions. (Consumer Summary produced by Reliance Medical Information, Inc.)

Injury to the gastrointestinal system is common among patients with AIDS. The most frequent symptom of this injury is diarrhea and its concomitant weight loss. While it is possible that some intestinal injury may be a direct result of infection with the AIDS virus, many contend that the injury is more likely a result of infection with an unidentified bacteria, virus, or parasite. To learn more about the gastrointestinal pathology associated with AIDS, studies were conducted to assess the presence of pathogenic organisms, the physiological characteristics of the intestines, and the histopathologic appearance of biopsies taken from the jejunal region of the small intestine. The studies were performed on 43 patients with AIDS, 10 patients with AIDS-related complex, and six normal heterosexual controls. Examination of the biopsies revealed that 62 percent of the AIDS patients had evidence of small intestine damage which included partial atrophy. This was not seen in the controls. Further examination revealed the present of parasites in 70 percent of the patients with histopathological damage. These parasites were cryptosporidia or microsporidia. Furthermore, patients with these parasites were more likely to have abnormal results on the xylose absorption test, a measure of intestinal function, when compared with either normal controls or AIDS patients with diarrhea, weight loss, but no parasites. The results indicate that the AIDS patients with the most severe gastrointestinal disease are likely to be infected with parasites, most notably cryptosporidia and microsporidia. (Consumer Summary produced by Reliance Medical Information, Inc.)

In the United States, the most common type of mycobacterial infection in patients with AIDS is disseminated or widespread Mycobacterium avium complex infection. This infection is associated with bacteremia, or infection of the blood, and symptoms of weight loss, night sweats, chills, diarrhea, and fever. Agents commonly used to treat tuberculosis, an infectious disease caused by Mycobacterium tuberculosis, are ineffective in treating M. avium complex infection. The effects of combined treatment with the antibiotics amikacin, ethambutol, rifampin, and ciprofloxacin were assessed in 17 AIDS patients with disseminated M. avium complex infection. Amikacin was administered intravenously for 4 weeks and the remaining antibiotics were taken by mouth for 12 weeks. Fifteen patients completed at least four weeks of drug therapy. The combined antibiotic regimen decreased the colony count, or number of bacteria in the blood, from 537 per milliliter (mL) to 14 per mL after four weeks of treatment. The decrease in numbers of bacteria was maintained during drug treatment and was associated with an improvement in the symptoms of M. avium complex infection. Seven of 17 patients discontinued drug treatment early, at less than 12 weeks, due to gastrointestinal intolerance and adverse effects on the liver. These findings demonstrate that the combined antibiotic regimen of amikacin, ethambutol, rifampin, and ciprofloxacin is effective in decreasing bacterial numbers and symptoms associated with M. avium complex infection in patients with AIDS. (Consumer Summary produced by Reliance Medical Information, Inc.)

The acquired immunodeficiency syndrome (AIDS) reduces the function of the immune system, thereby making the patient vulnerable to life-threatening infections. Soon after AIDS was discovered, it was observed that some AIDS patients developed a type of cancer called non-Hodgkin lymphoma, and since then its occurrence in AIDS patients has been increasing steadily. Non-Hodgkin lymphoma is a cancer involving the lymph nodes of the body which may affect the brain. This study assessed the incidence of non-Hodgkin lymphoma in 55 patients with AIDS or AIDS-related complex (ARC) who were receiving antiretroviral drugs. The subjects were being treated with either AZT (azidothymidine) or zidovudine-containing regimens. Eight of the 55 patients (14.5 percent) developed non-Hodgkin lymphoma of the B-cell type an average of 24 months after starting antiretroviral treatment. It was estimated that AIDS patients being treated with antiretroviral drugs have a 29 percent chance of developing lymphoma after 30 months of therapy and a 46 percent chance after 36 months of therapy. It is concluded that AIDS patients being treated with antiretroviral drugs who survive for as long as three years on these drugs have a relatively high chance of developing non-Hodgkin lymphoma. It is possible that the antiretroviral treatment that prolongs life allows the lymphoma to occur at a higher rate, but more research will be needed to determine if this is in fact the mechanism behind the occurrence of the cancer. (Consumer Summary produced by Reliance Medical Information, Inc.)

Patients with acquired immunodeficiency syndrome (AIDS) are susceptible to a form of pneumonia resulting from infection with the organism Pneumocystis carinii. Treatment with intravenous pentamidine has been successful and a study was conducted comparing the effectiveness of reduced-dose pentamidine given intravenously and pentamidine by inhalation in these patients. Seventeen patients received aerosolized pentamidine and 22 patients received intravenous pentamidine. Although inhaled pentamidine is less toxic than the same drug given intravenously, treatment failures, return of symptoms, and a relapse rate of 24 percent occurred, leading to early termination of the study. Previously reported success rates have been variable, with a low of less than 20 percent and a high of 80 percent. The failure and relapse rates in this study with aerosolized pentamidine were considered unacceptably high; reduced-dose pentamidine, however, is considered an effective treatment for mild to moderate P. carinii pneumonia in AIDS patients. The rate of major toxicities from lower doses of intravenous therapy in this study was reduced 14 percent and thus low dose pentamidine is considered acceptable therapy. (Consumer Summary produced by Reliance Medical Information, Inc.)

Pentamidine is a drug administered by inhalation or intravenously to patients with pneumonia caused by the organism Pneumocystis carinii, which is commonly found in patients with acquired immunodeficiency syndrome (AIDS). Preliminary reports of the effectiveness of the administration of pentamidine by inhalation in this population have been encouraging; however, response rates have been variable. In a recent study, 10 patients received intravenous pentamidine and 11 received inhaled pentamidine. All patients who received pentamidine intravenously responded to therapy; however, only 6 of 11 patients responded to the inhaled doses. Therapeutic failure resulted in an increased rate of death in these patients. Drug delivery of inhaled pentamidine may vary in patients with respiratory distress and altered breathing patterns. In addition, patients with nonpulmonary sites of infection with P. carinii may require alternate methods of treatment. Inhaled pentamidine therapy is more successful in patients with milder disease; it cannot be used as sole therapy in patients with more severe disease in the presence of pulmonary difficulties. Greater adverse systemic effects occur with intravenous pentamidine; however, inhaled pentamidine, although less toxic, cannot be administered as an alternative to all patients. (Consumer Summary produced by Reliance Medical Information, Inc.)

People with AIDS (acquired immunodeficiency syndrome) almost always have positive blood tests for cytomegalovirus (CMV), a virus that can cause inflammation of the retina of the eye (retinitis), colon (colitis), esophagus (esophagitis), or liver (hepatitis), or a generalized condition of virus in the blood (viremia). An antiviral drug, ganciclovir, controls but does not cure these infections. To reduce the high rate of clinical and virologic relapse, the drug must be given intravenously over the long term. It may cause anemia, however. Zidovudine (also known as AZT) prolongs the survival and reduces the disease rate (morbidity) of patients with AIDS or AIDS-related complex, but it also causes anemia. It seemed possible that combination therapy with ganciclovir and zidovudine might improve the treatment of CMV disease; but there was concern that the two drugs used together would be toxic. Indeed, that turned out to be the case. In a study of 40 patients with both AIDS and serious CMV disease, 82 percent developed severe to life-threatening blood system (hematologic) toxic effects. Survival was not significantly improved, at a median time of six months. These effects were not the result of drug interaction, but rather the combined toxicity of the drugs. (Consumer Summary produced by Reliance Medical Information, Inc.)

Patients with the acquired immunodeficiency syndrome (AIDS) are infected with the human immunodeficiency virus (HIV). As a result of their impaired immune systems, many of these patients become infected with 'opportunistic' microorganisms that do not usually cause disease. The most frequent complication of AIDS is the development of a potentially fatal lung infection called pneumocystis carinii pneumonia. Pneumocystis pneumonia eventually develops in almost 80 percent of HIV-infected patients, and in AIDS patients with respiratory failure, the fatality rate is 20 percent. A number of reports have suggested that the administration of corticosteroids, which decrease inflammation, may decrease the mortality rate of pneumocystis pneumonia and improve the gas-exchanging properties of the lungs. This study assessed the ability of oral corticosteroids to prevent the deterioration seen in AIDS patients with moderately severe pneumocystis pneumonia. Of the 18 patients treated with corticosteroids, only one (6 percent) developed early deterioration, as compared with eight (43 percent) of the 19 patients who received a sugar pill (placebo). All patients who initially received the placebo promptly responded to the corticosteroid treatment. Of those patients on corticosteroid therapy, all exhibited an increase in their tolerance to exercise. This study indicates that corticosteroids are useful in treating AIDS patients with moderately severe pneumocystis pneumonia. (Consumer Summary produced by Reliance Medical Information, Inc.)

Acquired immunodeficiency syndrome (AIDS) is a disease that involves a defect in the immune system and results in infections by organisms that do not usually produce disease. This disease affects almost every organ in the body and has a very poor prognosis. Between 30 and 50 percent AIDS patients will develop a chronic, watery, nonbloody diarrhea that is associated with progressive weight loss and malnutrition. A recent study compared the efficacy and cost effectiveness of different methods of evaluating and treating diarrhea in AIDS patients. Three evaluation strategies were compared: a full evaluation costing $5,419 and involving the direct visualization and sampling of material from the colon; a limited evaluation costing $1,997 and involving blood tests and stool samples to detect microorganisms; and a minimal evaluation costing $1,700, and involving only a stool sample. Patients who did not receive a specific diagnosis were treated for their symptoms with the anti-diarrheal medicine diphenoxylate hydrochloride. Patients who received a specific diagnosis were treated with an appropriate antibiotic, which kills the responsible microorganism. In all three evaluation groups, almost 75 percent of the patients had remission from their diarrhea. The most cost effective strategy for managing AIDS-related diarrhea was the minimal evaluation which was inexpensive, easy to perform, and did not cause the patient any discomfort. (Consumer Summary produced by Reliance Medical Information, Inc.)

A common complication of human immunodeficiency virus (HIV) infection is infection of the lungs with the microorganism Pneumocystis carinii. Transbronchial biopsy (tissue sampling of the airways) is used to diagnose P. carinii pneumonia, but may be associated with a small risk of bleeding and pneumothorax, the collection of air within the lung cavity. Some studies suggest that bronchoalveolar lavage (BAL), the washing out of the airways and alveoli (gas-exchanging units of the lungs), may be used without transbronchial biopsy to diagnose P. carinii pneumonia. However, previous use of aerosolized pentamidine, a drug used to treat P. carinii pneumonia, may decrease the yield of BAL for diagnosis of P. carinii pneumonia. The effect of previous pentamidine treatment on the diagnosis and characteristics of P. carinii pneumonia was assessed in 52 patients with P. carinii pneumonia and HIV infection, including 21 patients previously treated with aerosolized pentamidine. The yield of BAL for P. carinii pneumonia was 62 percent for pentamidine-treated patients and 100 percent for untreated patients, whereas the yield of transbronchial biopsy was similar in both groups. Accumulation of abnormal substances, collection of air, and formation of cysts within the lungs were detected more often in pentamidine-treated patients, although the severity of the disease was similar in both groups of patients. BAL should be combined with other diagnostic methods to optimize diagnosis of P. carinii pneumonia in HIV-infected patients. (Consumer Summary produced by Reliance Medical Information, Inc.)

Infection with human immunodeficiency virus (HIV) is associated with an increased incidence of zoster, an inflammatory disease caused by varicella-zoster virus and characterized by skin lesions developing near skin nerves. Dermatomal or skin zoster is more severe and prolonged in patients with acquired immunodeficiency syndrome (AIDS) and AIDS-related complex (ARC), which are associated with HIV. The antiviral agent acyclovir has been shown to be effective in treating patients with zoster in the presence or absence of HIV infection. Four cases are described of patients with HIV infection who received long-term oral therapy with acyclovir for recurrent varicella zoster or herpes simplex infection. These patients developed persistent, widespread hyperkeratotic lesions, characterized by overgrowth of the horny layer of the epidermis (the outer skin layer), despite high-dose acyclovir treatment. Varicella zoster virus resistant to acyclovir was isolated from the skin lesions of these patients. Greater than normal doses of the antiviral agents acyclovir, vidarabine, and foscarnet were required to prevent the continued growth of resistant virus in the four patients with zoster and HIV infection. These cases demonstrate that acyclovir-resistant varicella zoster virus infection is associated with the formation of hyperkeratotic skin lesions, and may complicate acyclovir therapy in patients with AIDS. (Consumer Summary produced by Reliance Medical Information, Inc.)

The epidemic proportion of acquired immunodeficiency syndrome (AIDS) in developing countries is having an impact on the control of tuberculosis in those countries. Although tuberculous infection and tuberculosis are already common in some populations in such countries, the introduction and spread of AIDS compounds the problem because the rate of tuberculosis can increase markedly; moreover, human immunodeficiency virus (HIV) infection may be increasingly common in patients with tuberculosis. For example, the percentage of in- and outpatients with tuberculosis who had HIV in their blood (were seropositive) was 59 percent in Zambia, 58 percent in Uganda, 34 percent in Zimbabwe, and 16 percent in Nairobi. Of children with pulmonary tuberculosis in Zambia, 24 percent were found to be HIV-seropositive. In Florida, 75 to 91 percent of migrant workers had positive skin tests for tuberculosis; the prevalence of HIV seropositivity among Haitians with tuberculosis exceeded 45 percent. There are additional problems: in developing areas, tuberculosis control programs are stretched because of scarce resources, and drug-based tuberculosis prevention programs have a low priority in developing countries, yet this may be the most cost-effective way to approach the dual problem. There is an urgent need for studies to determine the most cost-effective way to control tuberculosis in the face of an already high or increasing rate of HIV infection. (Consumer Summary produced by Reliance Medical Information, Inc.)

Patients suffering from human immunodeficiency virus (HIV) infection frequently develop, as a result of their impaired immune systems, 'opportunistic infections' with microorganisms that do not usually cause disease. Infection with a bacteria called pneumocystis carinii is a frequent complication of HIV infection; this causes pneumocystis pneumonia. A patient who has had a prior history of pneumocystis pneumonia, and is taking only the antiviral drug zidovudine, has a 60 percent chance of developing a recurrence of pneumocystis pneumonia. Even patients receiving the antiviral drugs pentamidine and zidovudine have a relapse rate as high as 20 percent. Despite drastic improvements in drug therapy and survival rates, the fatality rate of pneumocystis pneumonia is still 10 percent. Currently, the antibiotic combination of trimethoprim-sulfamethoxazole, and the antiviral agent pentamidine, are the best therapies to cure and prevent recurrent infection with pneumocystis carinii. Drug treatment of pneumocystis pneumonia in HIV-infected patients often leads to a lowering of the oxygen content of the lung, which may lead to respiratory distress and death. This cascade of events is thought to occur because of a drug-induced inflammation of lung tissue. Agents called corticosteroids that reduce inflammation, but also inhibit the immune system, may help decrease the inflammation produced by anti-pneumocystis carinii drugs. However, they may also suppress the immune system even further. Currently, there are conflicts in the literature regarding the adjunct use of corticosteroids in the management of pneumocystis pneumonia, but this may reflect differences among studies in experimental design. Well designed clinical trials to assess the efficacy of corticosteroids in this condition are clearly needed before the treatment strategy for pneumocystis pneumonia is changed. (Consumer Summary produced by Reliance Medical Information, Inc.)

A previous report by these authors described patients with AIDS (acquired immunodeficiency syndrome) who developed severe aphthous ulcers on the mucus membranes of the mouth, pharynx, and esophagus. The aphthous ulcers responded to treatment with steroids. These patients suffered severe disease due to ulcer-related pain and difficulty swallowing. This report describes another six AIDS patients with giant aphthous ulcers in the esophagus and colon. All of the patients developed symptoms due to the ulcers, including severe depletion of CD4 cells (helper T cells), a type of immune cell. Biopsies of these ulcers revealed inflammation, but no viral or fungus infection. Five patients responded rapidly to treatment with high doses of the steroid prednisolone. One patient with ulcers in the colon suffered a gastrointestinal hemorrhage. Although it is not known whether the esophageal and colonic ulcers are caused by the same factor, their microscopic features and response to therapy were similar. Infection with human immunodeficiency virus (HIV, which causes AIDS) is associated with more severe and persistent aphthous ulcers of the mouth, pharynx, and other regions in the gastrointestinal tract. These ulcers may be mistaken for lesions caused by herpes simplex virus and cytomegalovirus, but they will not respond to antiviral agents. Although various medications have been used to treat these lesions, corticosteroid drugs have been shown to be consistently effective for aphthous ulcer treatment. Clinicians who treat patients with AIDS should be aware of this syndrome. (Consumer Summary produced by Reliance Medical Information, Inc.)

Kaposi's sarcoma is the formation of multiple areas of cell overgrowth on the skin and other body sites; these areas develop into sarcomas or cancerous growths arising from connective tissue such as bone or muscle. The disease is thought to result from the weakened immune function associated with acquired immunodeficiency syndrome (AIDS). The effectiveness and toxicity of the combined drug regimen of zidovudine and interferon-alpha was assessed in 39 patients with Kaposi's sarcoma and AIDS. Interferon, a protein produced after exposure of cells to viruses or foreign nucleic acids, is involved in immune and antitumor reactions. The results show that the ability of patients to tolerate interferon-alpha was related to the dose of zidovudine. Toxic effects of the combined zidovudine and interferon-alpha regimen included: neutropenia, a decrease in a type of white blood cells called neutrophils; fatigue; thrombocytopenia, a decrease in the number of platelets, blood cells involved in clotting; and impaired liver function. Among 22 patients who received a stable dose of both drugs over 12 weeks, the combined regimen was completely or partially effective against Kaposi's sarcoma in 11 patients and against infection with the human immunodeficiency virus (HIV) in eight patients. The results show that the combined drug regimen of zidovudine and interferon-alpha can be effective against Kaposi's sarcoma and HIV infection in patients with AIDS; this treatment may have a role in the management of these individuals. (Consumer Summary produced by Reliance Medical Information, Inc.)

The human immunodeficiency virus (HIV), which causes AIDS (acquired immunodeficiency syndrome), can produce symptoms in many parts of the body, including the brain, mouth, eyes, skin, gastrointestinal tract, lungs, muscles, bones, and connective tissues. The rheumatologic (concerned with the connective tissues) effects include arthritis (inflammation of joints), arthralgia (pain in joints), myositis (inflammation of muscles), vasculitis (inflammation of the blood vessels), the sicca syndrome (dryness of the eyes and mouth) and various autoimmune phenomena, including systemic lupus erythematosus. HIV infection is associated with several types of arthritis, most commonly Reiter syndrome or reactive arthritis, which is characterized by severe, persistent arthritis in the large joints of the lower extremities, and is associated with conjunctivitis and urethritis. Psoriatic arthritis with lesions of the skin and nails, arthritis due to infection with bacteria, and acute arthralgia may also occur with HIV infection. A type of arthritis that may be specific to AIDS has been described. Autoantibodies directed against normal body components are produced by individuals infected with HIV, including antibodies against various types of blood cells, such as platelets, lymphocytes, granulocytes, and red blood cells, as well as against components of the cells, including the nucleus and cardiolipin, a molecule found in the cellular organelle mitochondria. Infection with HIV may cause clinical symptoms similar to the autoimmune disease systemic lupus erythematosus. The Reiter syndrome, reactive arthritis, polymyositis, and the sicca syndrome may be one of the first clinical signs of HIV infection and may occur before the clinical signs of immunodeficiency. These rheumatic diseases may also occur in patients with full-blown AIDS. Physicians need to be aware of the possibility of HIV infection when patients develop rheumatological disorders. The drugs that are used to treat these disorders further suppress the immune system, which can have very serious adverse effects on an individual who is infected with HIV, leading to a faster progression to AIDS. (Consumer Summary produced by Reliance Medical Information, Inc.)

Male patients with AIDS (acquired immunodeficiency syndrome) who have been effectively treated for meningitis caused by the fungus Cryptococcus neoformans, can develop a persistent infection of the prostate gland by the fungus, without any immediate clinical symptoms. This occurred in 9 out of 41 (29 percent) patients with meningitis caused by C. neoformans. The fungus was detected in urine specimens of the patients and in prostate secretions in four of the patients. Three patients who were treated with amphotericin B, one of the drugs used in the original treatment regimen for the meningitis, had persistent infection but it did not become systemic. Six of the patients were treated with fluconazole, another drug that was used to treat the original meningitis; four of those patients no longer have the infection and two suffered a relapse, which was systemic. The presence of C. neoformans in the urine after adequate treatment for meningitis indicates that the fungus can sequester in the urinary tract, probably in the prostate gland. Infection of the prostate gland is often difficult to treat, since many drugs do not reach high enough levels in the prostate gland to be effective. The fungi can cause a systemic relapse that can affect the central nervous system, making the infection very serious. The use of alternatives to fluconazole, which did not inhibit systemic infections in a proportion of the patients, and longer treatment with amphotericin B, which did not allow systemic infections but was not effective in eradicating the urinary tract infection, are being investigated. (Consumer Summary produced by Reliance Medical Information, Inc.)

Opportunistic infections, which occur because of a patient's altered physiological state, are the major cause of life-threatening disease and death in patients infected with the human immunodeficiency virus (HIV). HIV infection depletes CD4 or helper T cells, a type of immune cell involved in increasing the production of antibodies, immune proteins that bind to and inactivate foreign particles. The depletion of CD4 cells results in a weakened immune system and increased risk of developing opportunistic infections. The number of CD4 cells has been shown to be a good indicator of the immune activity in HIV-infected patients, and have been used to predict whether an HIV-infected patients will develop AIDS (acquired immunodeficiency syndrome). The usefulness of CD4 counts in diagnosing pneumonia in 100 HIV-infected patients was assessed. CD4 counts were less than 200 cells per cubic millimeter before 46 of 49 cases of pneumocystis pneumonia, before all eight cases of cytomegalovirus pneumonia, all seven cases of Mycobacterium avium-intracellular infection, and 19 of 21 cases of infection with Cryptococcus neoformans. Thus, pneumocystis pneumonia, cytomegalovirus pneumonia, and lung infection by C. neoformans and M. avium-intracellular are not likely to occur in patients with CD4 counts greater than 200 to 250 cells per cubic millimeter, or a CD4 percent of circulating lymphocytes of 20 to 25 percent. Patients with CD4 counts less than 200 cells per cubic millimeter may benefit from prophylaxis against pneumocystis infection. (Consumer Summary produced by Reliance Medical Information, Inc.)

Opportunistic infections and secondary malignancies often occur in the gastrointestinal tract in patients who are infected with human immunodeficiency virus (HIV), which causes AIDS (acquired immunodeficiency syndrome). Patients infected with HIV suffer gastrointestinal symptoms such as weight loss, diarrhea, and abdominal pain. The cause of these symptoms is not clear. Recently, HIV has been isolated in the mucosa of the intestines and it is thought that the virus itself may be the cause of the gastrointestinal symptoms. However, there has not been a complete correlation between the presence of HIV in the intestinal mucosa and the presence of clinical symptoms. A study was conducted to see if HIV infection caused impairment of structure and function of the small intestine. Duodenal biopsies from 45 patients who were infected with HIV and had gastrointestinal symptoms were examined for morphological changes under the microscope and with enzyme histochemical techniques. In 15 out of 38 patients, HIV-infected cells were found in the intestinal mucosa. Low-grade atrophy, or degeneration of cells, as evidenced by morphological changes in the intestinal tissue was detected. Fifteen out of 25 patients had decreased or no detectable lactase activity in the brush border cells of the intestine, which is indicative of decreased enzymatic activity of these cells, which in turn could be a reason for malabsorption of patients infected with HIV. HIV-infected patients without additional intestinal infections had low levels of mitosis in the intestine, indicating low numbers of dividing cells and perhaps a maturational defect in the cells of the intestine. Therefore, the symptoms in the gastrointestinal tract may, at least in part, be caused by HIV itself. (Consumer Summary produced by Reliance Medical Information, Inc.)

The acquired immunodeficiency syndrome (AIDS) dementia complex is a devastating complication of AIDS, which is caused by the human deficiency virus, type 1 (HIV-1). AIDS dementia complex occurs in approximately 60 percent of AIDS patients. The clinical symptoms of the AIDS dementia complex include decreased memory, difficulty concentrating, apathy and social withdrawal, and headaches. Less commonly seen are problems with psychomotor functions, such as balance difficulties, clumsiness, and weakness. There is a decrease in verbal skills, without impairment of naming and vocabulary skills. Seizures occur in approximately 10 percent of the patients. Psychiatric symptoms such as depression, psychosis and mania may also be manifest. There is a normal level of consciousness, even in late stages of disease. The pathology of the nervous system includes disease in the brain, spinal cord, peripheral nerves and muscles. These neurological disorders are found in 80 to 90 percent of the cases, which is more frequent than the number of patients who have clinical symptoms of neurologic disease. The neuropathological findings include gliosis, or large numbers of a type of cell of the brain known as astroglial cells; areas of dead neurons; lesions which contain immune cells involved in inflammation; formation of nodules; the presence of multinucleated giant cells; and loss of myelin, the substance which surrounds and is necessary for the function of neurons. Infections, especially with the cytomegalovirus, but also by fungi, parasites and bacteria, also cause neuropathologic symptoms. HIV-1 has been found primarily in monocyte-macrophage cell types, which are immune system cells that engulf and usually destroy foreign organisms. However, the virus is not killed in these cells, which may actually act as a reservoir for the virus and may be involved in the transport of virus throughout the body and into the nervous system. Additional research is needed to understand the mechanism by which HIV-1 causes disease in the nervous system, so that different strategies can be developed for treatment of AIDS and AIDS dementia complex. (Consumer Summary produced by Reliance Medical Information, Inc.)

Histoplasmosis is a widespread infection caused by the fungus Histoplasma capsulatum, and may occur as a mild, self-healing infection or develop into a severe fatal disease. The severe form of histoplasmosis is associated with fever, anemia (the reduction in red blood cells), enlargement of the spleen and liver, leukopenia (an abnormal decrease in white blood cells), involvement of the lungs, deterioration of the adrenal gland, and ulcers of the gastrointestinal tract. The antifungal agent amphotericin B given intravenously or directly into the circulation is used to treat histoplasmosis. The effectiveness and toxic effects of amphotericin B were evaluated in 22 patients with acquired immunodeficiency syndrome (AIDS) and disseminated histoplasmosis. Sixteen patients completed the study, five patients died, and one patient was switched to a different treatment regimen. Out of 16 patients, only one patient died from a relapse of histoplasmosis, two died from other causes, and the remaining 13 remained free of relapse. The average follow-up period was 14 months, and there were no differences in the outcome of patients treated weekly or biweekly with amphotericin B. Sixty-three percent of patients developed complications related to injection into a blood vessel. The results show that amphotericin B is effective and well-tolerated in patients with AIDS and disseminated histoplasmosis. (Consumer Summary produced by Reliance Medical Information, Inc.)

The protozoan parasite Isospora belli may cause acalculous cholecystitis in patients with AIDS. Acalculous cholecystitis is an inflammation of the gallbladder without gallstones. Six years after diagnosis with AIDS, a 39-year-old man experienced abdominal pain, nausea, vomiting and diarrhea. His gallbladder was surgically removed and showed evidence of chronic cholecystitis. Pathologic examination of the gallbladder found no disease-causing organisms. The patient died following colon surgery four months after the gallbladder surgery. Two years later, however, the gallbladder was reexamined as part of a study of gallbladder disease in AIDS patients and Isospora belli parasites were identified. Isospora belli infection is treatable with the antibiotic trimethoprim-sulfamethoxazole. Although the infection is most commonly found in tropical or subtropical areas, it has been found in the US. Diagnosis of gallbladder disease in AIDS patients should include evaluation for Isospora belli infection.

Megestrol acetate treatment for cachexia in AIDS patients should be evaluated further before being widely endorsed. Cachexia is a state of ill health and malnutrition that can lead to wasting. Megestrol acetate is an appetite stimulant. Two studies have shown that megestrol acetate treatment can increase appetite and caloric intake in AIDS patients, resulting in weight gain. The patients who took megestrol acetate also reported improved well-being. The patients selected for these two trials had weight loss without identifiable cause, such as diarrhea or infection. Including these patients would provide a better assessment of the efficacy of megestrol acetate. Also, evaluating quality of life and functional measures besides just psychological well-being would be valuable. Megestrol acetate is a costly drug, and a more thorough understanding of its benefits is warranted before it can be recommended.

AIDS patients appear to have increased susceptibility to a strain of mycobacterium tuberculosis that is resistant to the anti-tuberculosis drugs rifampin, isoniazid and ethambutol, and the antibiotic streptomycin. Superinfection can occur in patients who are already undergoing treatment for drug-resistant tuberculosis. Diagnosis and differentiation of the drug-resistant strain requires the polymerase chain reaction method of DNA fingerprinting. Three patients diagnosed with drug-resistant tuberculosis showed varying levels of susceptibility and unique polymerase chain reaction patterns. The weakened immune systems of AIDS patients render them vulnerable to drug-resistant strains of tuberculosis. Consequently, those undergoing treatment for drug-resistant tuberculosis should not share a hospital room.

The first incident of blood-borne transmission of tuberculosis (TB) may have occurred. A 48-year-old female nurse developed TB of the skin after a needlestick injury. The needle had previously been inserted into the catheter line of an AIDS patient. The patient was being treated for respiratory failure after a severe episode of Pneumocystis carinii pneumonia. He was diagnosed with TB the day of the needlestick accident. The nurse immediately bled the wound and washed it out with water and iodine solution. She tested negative for HIV infection the day of the incident and began treatment with zidovudine within two hours. Symptoms of TB developed several weeks later. She was diagnosed with TB six weeks after the needlestick accident. She was treated with a combination of drugs for TB over a six-month period. Her HIV-antibody tests were still negative one-year after the incident.