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Purpose: Cytomegalovirus (CMV) retinitis can have debilitating impacts on quality of life (QOL), but few contemporary studies have characterized these ramifications. This study assessed the impact of CMV retinitis on vision-related QOL for those living with HIV/AIDS in Thailand., Methods: QOL was assessed as part of a prospective interventional cohort study of patients referred to a tertiary hospital in Thailand for CMV retinitis screening. A validated vision-related QOL questionnaire was administered at the baseline screening visit and at the 6-month study visit. Multivariable linear regression models were performed to determine the effect of CMV retinitis diagnosis on QOL score., Results: A total of 152 participants completed the QOL questionnaire at their initial clinic visit. At baseline, a diagnosis of CMV retinitis diagnosis was significantly associated with decreased QOL score: unilateral retinitis was associated with a 0.11 (95% CI: -0.26-0.03) decrement in QOL, and bilateral retinitis was associated with a 0.33 (95% CI: -0.51-0.16) decrement (joint P-value = 0.0009). For the 78 participants with a 6-month visit, changes in QOL from baseline were small and not significant. A diagnosis of CMV retinitis was still associated with decreased QOL score at 6 months (joint P -value = 0.03)., Conclusions: This study found that vision-related QOL was lower in those with CMV retinitis, especially with bilateral involvement, and did not improve after treatment among those with follow-up. These findings reinforce the debilitating clinical manifestations of this disease, and support efforts for earlier screening to detect CMV retinitis before impacts on QOL have occurred.

Purpose: To explore the all-cause mortality in patients with acquired immune deficiency syndrome (AIDS) and Cytomegalovirus (CMV) retinitis., Methods: A retrospective cohort study of patients with CMV retinitis (CMVR) presented to a tertiary referral center in Singapore from January 1, 2004, through December 31, 2015., Results: A total of 144 patients were studied (87 survived, 11 lost to follow up, 46 died). Patients with bilateral CMVR and six-month follow up CD4 + T cell count < 50 cells/mm 3 have shorter time to mortality, compared to patients with CD4 + T cell count > 50 cells/mm 3 ( p < .001) and unilateral disease ( p = .043). Baseline CD4 + T cell count, size and zone of initial primary retinitis lesions, recurrences of retinitis, and timing of combined antiretroviral therapy (cART) are not significantly associated with mortality., Conclusion: Bilateral ocular involvement and lack of immune recovery in patients with AIDS and CMVR are associated with shorter survival time.

Purpose : To analyze the clinical characteristics and relevant prognostic factors of vitrectomy for retinal detachment (RD) secondary to cytomegalovirus retinitis (CMVR) in patients with acquired immune deficiency syndrome (AIDS). Methods : This study involved 39 eyes that underwent vitrectomy. Best-corrected visual acuity (BCVA), CD4 + cell counts, retinal attachment rate, and prognostic factors were assessed 1, 3, and 6 months postoperatively. Results : The rate of retinal attachment at 1 month (87.2%) was higher than at 3 (82.1%) and 6 (71.8%) months. Factors significantly related with recurrent RD at 6 months were CD4 + cell count <50 cell/µL ( p = .000) and relaxed retinotomy ( p = .002). Factors significantly related with the visual (≤logMAR1.0) prognosis at 6 months include band keratopathy ( p = .015) and macular involvement by the RD ( p = .012). Conclusion : CD4 + cell counts <50 cell/µL and relaxed retinotomy are associated with worse prognosis, while band keratopathy and macular involvement by the RD are related to poorer vision.

Purpose : To determine the incidence of contralateral eye involvement and retinal detachment in HIV-infected patients with cytomegalovirus retinitis treated with repeated intravitreous ganciclovir. Methods : In a prospective cohort study in Northern Thailand, HIV-infected patients with cytomegalovirus retinitis were treated with antiretroviral therapy and intravitreous ganciclovir injections and followed for 3 months for contralateral cytomegalovirus retinitis and retinal detachment. Results : Of 49 participants with unilateral cytomegalovirus retinitis at enrollment, 7 developed contralateral eye involvement (4.8/100 person-months, 95% CI 1.9-9.8). Of 105 eyes without a retinal detachment at enrollment, 6 developed a retinal detachment (2.0/100 eye-months, 95% CI 0.7-4.3). Baseline clinical factors were not associated with the development of either outcome. Conclusion : Eyes treated with intravitreous ganciclovir experienced retinal detachment at a rate similar to other populations treated with systemic antivirals. The risk of contralateral eye involvement was relatively high during the first 3 months after initial diagnosis despite the institution of antiretroviral therapy.

Ocular toxoplasmosis (OT) may be an initial manifestation of acquired immunodeficiency syndrome (AIDS) in human immunodeficiency virus (HIV)-infected patients. OT has different clinical manifestations and can mimic other intraocular infections. Clinical findings may show single or multifocal retinochoroidal lesions or panuveitis. Atypical presentations are associated with extensive uni- or bilateral areas of retinal necrosis. OT lesions not associated with preexisting retinochoroidal scars are usually due to acquired rather than congenital infection. When CD4+ T cell counts are <100 c/uL, vitritis is frequently mild. Isolated anterior uveitis has been reported in single cases. Positive immunoglobulin M (IgM) antibodies are rare but their presence can support the diagnosis. As atypical presentations of OT are common, anterior chamber puncture for multiplex polymerase chain reaction amplification of infectious DNA should be considered, as early diagnosis and treatment can prevent massive tissue destruction and preserve vision. This review provides an overview of OT in HIV-infected patients.

Purpose : Overview of treatment options for the most common intraocular opportunistic infections in patients with acquired immunodeficiency syndrome (AIDS), including ocular syphilis, ocular tuberculosis, toxoplasmic chorioretinitis, and viral retinitis. Method : Narrative Review. Results : Despite the huge advances in the development of combined antiretroviral therapy (cART) for the management of patients with human immunodeficiency virus (HIV) infection, opportunistic infections still represent a significant diagnostic dilemma and cause of ocular morbidity in patients with HIV. Conclusion : Although the treatment of intraocular infections in patients with AIDS may be challenging, prompt assessment of the clinical features and appropriate aggressive management of the underlying etiology are critical to avoid life and vision threatening.

Purpose: To describe the challenges faced by uveitis specialists when managing human immunodeficiency virus (HIV) -infected patients diagnosed with ocular opportunistic infections. Methods: Narrative Review Results: Management of opportunistic ocular infections in HIV-infected subjects still represents a diagnostic and therapeutic challenge. Atypical and aggressive clinical features can often mislead the correct diagnosis, leading to a delay in therapy and thus, a poor clinical outcome. The reliability of standard serological tests may be affected by the immune system response, further contributing to the diagnostic challenge. Life-long monitoring and long-term antimicrobial maintenance are necessary to avoid recurrences and disease dissemination. Conclusions: A multidisciplinary approach is needed to achieve the best standard of care for HIV patients with ocular opportunistic infections.

Purpose : To characterize the presenting features of cytomegalovirus (CMV) retinitis in HIV-positive patients in a developing country in the HAART era. Methods : Retrospective chart review of all patients with CMV retinitis seen at a tertiary-care referral center between January 2006 to June 2017. Demographic and clinical data were collected to study the presenting features and risk factors for blindness. Results : Fifty-five patients with treatment-naïve CMV retinitis were enrolled; 75% were males. CD4 counts were below 50 cells/µL in 51.1%. Bilateral presentation was seen in 61.5%. Half (50.6%) of the eyes were blind at first examination. Zone 1 involvement was present in 46% of the eyes. Retinal area involvement > 25% was the only factor associated significantly with higher incidence of blindness ( p  = 0.016). Conclusions : There was extensive and bilateral presentation of CMV retinitis due to delayed presentation. Screening for CMV retinitis, irrespective of CD4 counts, may help in developing nations.

Purpose : To investigate the prevalence and characteristics of ocular manifestations of human immunodeficiency virus/acquired immunodeficiency syndrome (HIV/AIDS) in patients treated at a tertiary referral center in Taiwan during a time of highly active antiretroviral therapy (HAART) Materials and Methods : A retrospective cohort study in Taiwan was performed between January 2006 and July 2016. Ocular examination and systemic information were recorded from the HIV-infected patients. Results : 1242 patients with HIV/AIDS were identified. Ninety patients had ophthalmic records, and HIV-related ocular manifestations were reported in 57 patients. The most prevalent ocular manifestations were cytomegalovirus (CMV) retinitis, ocular syphilis, and HIV microvasculopathy. Mean CD4 count was significantly lower in patients with HIV-related ocular manifestations compared to those without. Conclusion : We found that lower CD4 count, especially <200 cells/μL, was a significant factor for detecting HIV-related ocular manifestations. Comprehensive ophthalmic screening in high-risk group is helpful for early diagnosis and prompt treatment of sight-threatening ocular complications.

Purpose: To compare changes in the demographic profile and ocular manifestations in patients with HIV in the pre-HAART and HAART era in North India., Methods: In this single-center cross-sectional study, 100 HIV patients receiving HAART and 96 HIV patients in the pre-HAART era were enrolled. Prevalence of ocular manifestations of HIV was calculated for both cohorts., Results: The prevalence of ocular manifestations was not statistically different in the two eras (38%, SE: 4.85% in HAART era; 41.67%, SE: 5% in pre-HAART era) (p = 0.60). Mean CD4 counts were lower in the pre-HAART era compared with the HAART era (p < 0.001). In the HAART era, cytomegalovirus (CMV) retinitis and HIV retinopathy continued to remain the most common infectious and non-infectious cause of visual morbidity., Conclusions: While the introduction of HAART has resulted in a major impact on the overall health of patients with HIV, the spectrum of ocular disease remains largely unchanged in developing countries such as India.

Background: Fever was frequently caused by opportunistic conditions in HIV-patients in the early years of the epidemic. Little is known about diagnostic spectrum and outcome of febrile episodes in patients with good access to antiretroviral therapy., Methods: We prospectively studied clinical presentation, diagnosis and outcome of febrile episodes in a contemporary cohort of HIV-patients with good access to antiretroviral therapy. Fever was defined as temperature 38.3 °C or higher, measured by a health care provider., Results: We found 220 febrile episodes in 146 patients. In 25.9% of episodes the patient had a CD4 less than 200/mm³ and in 78.6% the patient was on antiretroviral therapy. There were multiple episodes in 44 patients. A diagnosis was established in 91.8%. Infection accounted for 82.3%, mainly respiratory tract infections, viral syndromes and abdominal infections. Malignancy, drug reactions and inflammatory conditions accounted together for less than 12% of episodes. Fifteen percent were attributed to opportunistic conditions. Episodes in patients with CD4 less than 200 were less likely to be caused by infection, but more likely to be caused by malignancy, drug reactions and opportunistic conditions. In 6.4% the patient died within six months after the onset of fever. Risk factors for death at six months in multivariable analysis were higher age and lower CD4., Conclusions: HIV-patients with access to antiretroviral therapy present with fever mostly due to conditions common in the general population. HIV-patients with low CD4 remain at risk for fever due to opportunistic conditions and death.

Neurological complications in patients with human immunodeficiency virus infection/acquired immunodeficiency syndrome (HIV/AIDS) are still common, even in the era of highly active antiretroviral therapy. Opportunistic infections, immune reconstitution, the virus itself, antiretroviral drugs and neurocognitive disorders have to be considered when establishing the differential diagnosis. Toxoplasmic encephalitis remains the major cause of space-occupying lesions in the brain of patients with HIV/AIDS; however, spinal cord involvement has been reported infrequently. Here, we review spinal cord toxoplasmosis in HIV infection and illustrate the condition with a recent case from our hospital. We suggest that most patients with HIV/AIDS and myelitis with enhanced spine lesions, multiple brain lesions and positive serology for Toxoplasma gondii should receive immediate empirical treatment for toxoplasmosis, and a biopsy should be performed in those cases without clinical improvement or with deterioration.

Background: Cryptococcal meningitis (CM) is a relatively common opportunistic infection in patients with human immunodeficiency virus (HIV) infection and can also occur in patients with no underlying disease. The aim of this study was to evaluate the clinical manifestations, laboratory findings, diagnosis and misdiagnosis, treatment, and prognosis of CM at a tertiary care hospital., Methods: We performed a retrospective study of 55 patients at a tertiary care hospital from January 1, 1992 to December 31, 2013. All the patients had a definite diagnosis based on etiology., Results: All 55 patients had a positive cerebrospinal fluid (CSF) India ink staining result. The predominant change observed on magnetic resonance imaging (MRI) was leptomeningeal liner enhancement, which is also called 'lumbriciform-enhancing.' Only 15 patients were first diagnosed with CM, indicating a misdiagnosis rate of 72.7%. At the follow-up end point, 8 patients were cured, 33 had improved, and 14 had died. The overall response rate was 74.5%. The voriconazole group had a response rate of 100%, which was significantly higher than the other two groups., Conclusions: Most CM patients in China were previously healthy without any potential risk factors. CM was easily misdiagnosed due to the lack of specificity of early clinical symptoms. Repeated CSF India ink staining should be performed to identify the pathogen. Voriconazole could be administered to the patients with CM, especially to patients who had a treatment failure with amphotericin B alone or accompanied by fluconazole.

Introduction: Pneumocystis jirovecii pneumonia (PCP) is one of the most common opportunistic infections in HIV-infected adults. Although the microscopic demonstration of the organisms in respiratory specimens is still the golden standard of its diagnosis, recent advances in the diagnostic tools have been changing the situation., Areas Covered: Colonization of Pneumocystis is highly prevalent among the general population and could be associated with the transmission and development of PCP in immunocompromised individuals. Nested or conventional polymerase chain reaction (PCR) has a high sensitivity, detecting Pneumocystis DNA in induced sputum or oropharyngeal wash, but often produces false positives. Although quantitative real-time PCR is promising for discriminating colonization from PCP, the targeted DNA sequences and the cut-off values remain to be standardized. Serum β-D-glucan is useful as an adjunctive tool for the diagnosis of PCP. High-resolution computed tomography, which typically shows diffuse ground-glass opacities, is informative for evaluation of immunocompromised patients with suspected PCP and normal chest radiography., Expert Opinion: Although these new tools have been making the diagnosis of PCP less invasive and more accurate, any one of them can not make a definitive diagnosis by itself. The diagnostic criteria based on the combination of the testing ought to be established.

To identify the risk factors associated with presentation for care with CD4 cell count ≤ 200 cells/mm(3) and death in HIV-infected patients in Lyon, France. Data were analyzed on participants from mid-1992 to December 2006 in the Lyon section of the French Hospital Database on HIV Infection. Patients were stratified into two categories according to CD4 cell count at first presentation for care in University of Lyon hospitals: Group 1 (Gr1) patients with CD4 ≤ 200 cells/mm(3) and Group 2 (Gr2) patients with CD4 >200 cells/mm(3). Multivariate logistic regression assessed the risk factors associated with first presentation for care with CD4 ≤ 200 cells/mm(3). Survival was analyzed according to the Cox regression model. Among 3569 eligible patients (838 females and 2731 males, mean age: 36.3 ± 10.3 years), 1139 (31.9%) were categorized as Gr1. The factors associated with first presentation for care with CD4 ≤ 200 cells/mm(3) were: older age, male gender, route of HIV transmission, migrant populations, geographical areas other than Rhône-Alpes, and access to care in 1992-1997. Overall mortality was higher in Gr1 than in Gr2 (24.4% [278/1139] vs. 4.1% [101/2430]; p<0.001). The risk of death was 5.81 [4.61-7.32] in Gr1 compared to Gr2. In addition to CD4 cell count, age and enrollment periods for care were factors independently related to death. Despite public health efforts in Lyon, one-third of HIV-infected patients reach the health care system with CD4 cell count ≤ 200 cells/mm(3), which was linked with higher mortality.

The purpose of this study is to estimate the survival probability of patients following their first admission for the treatment of AIDS to an infectious disease reference hospital in Belo Horizonte, Brazil, during 2005. Study subjects were monitored during a 12-month period to identify factors associated with survival probability. Late diagnosis was recorded among many of the 250 study subjects: almost half (44.8%) were diagnosed less than 30 days prior to or during their hospitalization. A high mortality rate was also detected: 39.6% of the subjects died during the 12 months of monitoring. The cumulative survival probability of the cohort group was estimated at 68.0% after 3 months and at 61.2% after 12 months. However, certain patient subgroups analyzed had even lower cumulative survival probabilities after 12 months of monitoring: if diagnosed during hospitalization, it was estimated at only 48.0% and those with no record of antiretroviral treatment had a 48.5% cumulative survival probability. Patients with severe anemia had the lowest survival probability, similar among the two lymphocyte count groups (<1000 mm(3) and ≥1000 mm(3)), the former with a 45.5% survival probability and the latter with a 46.7% one. The proportional death risk was 2.5-fold higher for men residing in other area than the capital city of the State of Minas Gerais and greater metropolitan region when compared with women residing there. The findings of this study highlight the importance of early diagnosis for predicting patient survival and reinforce the necessity of facilitating HIV diagnosis.

HIV-related immune reconstitution inflammatory syndrome (IRIS) is increasingly being recognized in regions with a high burden of opportunistic infections. We describe an unusual manifestation of IRIS- 'unmasking' cryptococcal lymphadenitis in a patient shortly after initiation of antiretroviral therapy. Epidemiology, clinical features and management of cryptococcal IRIS with reference to lymphadenitis presentation are briefly reviewed. Early and accurate diagnosis is essential for appropriate management. Standard antifungal therapy along with continuation of antiretroviral therapy is recommended. Cases with severe inflammation may benefit from anti-inflammatory drugs/corticosteroids. Unusual manifestations like lymphadenitis pose diagnostic difficulties in regions with a high prevalence of tubercular lymphadenitis.

HIV infection is associated with a number of opportunistic infections and malignancies frequently involving the lymph nodes. Lymphadenopathy may occur at any stage of HIV infection. We aimed to determine the utility of fine-needle aspiration cytology in evaluating the causes of lymphadenopathy in HIV-infected individuals. Three hundred HIV-infected individuals with lymphadenopathy were included in the study. Fine-needle aspiration (FNA) was performed on peripheral or deep-seated lymph nodes. The material was used for cytological examination using May-Grunwald-Giemsa and haematoxylin and eosin staining. Special stains such as modified Ziehl-Neelsen staining for acid-fast bacilli and periodic acid-Schiff staining for fungi were also performed. The mean age of the study group was 35.0 ± 8.0 y (range 13-74 y). The median CD4 count was 152 cells/μl. Out of the 300 FNA reports, acid-fast bacteria were reported in 130 and cytological findings indicating mycobacterial infection in a further 43 patients. Cryptococcosis was reported in 4 individuals, histoplasmosis in 2 and aspergillosis in 1. Reactive hyperplasia was seen in 89 individuals. Lymphoma was noted in 7 individuals and suppurative inflammation in 5. In conclusion, tuberculosis is the predominant cause of lymphadenitis in HIV-infected individuals in India, especially in those with low CD4 cell counts.

The human immunodeficiency virus (HIV) has contributed to an increase in tuberculosis (TB) worldwide. HIV voluntary counselling and testing (VCT) centres are cost-effective for HIV screening. Therefore there is a potential of tapping into the success of VCT centres by incorporating TB screening. The aim of this study was to determine the extent of TB and TB/HIV co-infection among VCT centre attendees. We enrolled 1318 consecutive subjects from 2 VCT centres in Dar es Salaam. The diagnosis of TB was based on evidence of Mycobacterium tuberculosis in sputum or tissue aspirates following microscopy or culture. In the absence of M. tuberculosis, the presence of 2 of the following was considered: clinical features of TB, suggestive chest radiographs and response to anti-tuberculosis trial therapy. HIV was diagnosed in 347 (26%) subjects. TB was present in 101 (7.7%) subjects of whom 63 (62%) were diagnosed at VCT centres and 38 (38%) were known TB cases who came for HIV testing. Pulmonary TB (PTB) was detected in 52 (83%) subjects. The diagnosis of PTB was based on sputum culture in 35 (67%), sputum microscopy in 20 (38%), and clinical and radiological findings in 17 (33%) subjects. TB/HIV co-infection was detected in 70 (5.3%) subjects. PTB was common in stand-alone VCT centres. Therefore VCT centres could serve as an entry point for TB screening.

Intracerebral relapse of Hodgkin lymphoma is a rare occurrence, with a reported incidence of < 0.5%. To the best of our knowledge, only 4 cases have been reported in the literature. We report the case of a human immunodeficiency virus (HIV)-seropositive man with disseminated Hodgkin lymphoma who presented with left facial weakness and sensory abnormalities as the only symptoms of disease progression 3 months after chemotherapy-induced disease remission. Because of the relative rarity of the condition, there are no randomized controlled trials or evidence-based strategies for managing patients with HIV and intracerebral Hodgkin lymphoma. The diagnostic difficulty of this case emphasizes the necessity for a high index of suspicion for the diagnosis of HIV-associated intracerebral lymphoma in the appropriate clinical setting. In the post-genomic era, the development of sophisticated clinical and/or molecular biomarkers could contribute to earlier diagnosis and potentially improve disease prognosis.

Purpose: To report a rare case of primary bilateral multifocal choroiditis due to disseminated cryptococcus infection in a HIV-positive patient., Methods: Retrospective report. A 30-year-old asymptomatic HIV-positive male referred to us for a routine ophthalmic evaluation had bilateral, multiple choroidal lesions. CSF confirmed cryptococcus by India ink preparation and antigen by latex agglutination. The lesions began to resolve with intravenous amphotericin B and oral fluconazole., Conclusions: Asymptomatic, primary, bilateral multifocal choroiditis due to cryptococcus is rare. A routine ophthalmic examination in HIV-positive patients can alert the treating physician to a possibility of a fatal disease.

Purpose: To describe the ophthalmic manifestations of immune reconstitution inflammatory syndrome (IRIS) associated with Cryptococcus neoformans., Methods: Four HIV-positive patients on highly active anti-retroviral therapy (HAART) presented with marked optic disk swelling., Results: Three months after the episode of IRIS, 2 of the patients maintained 20/20 visual acuity whose elevated intracranial pressure (ICP) was successfully managed, while 2 patients visual acuities were worse than 20/400 whose ICP was persistently elevated., Conclusion: Cryptococcus is another opportunistic infectious organism associated with IRIS with ophthalmic manifestations. Ophthalmologists have the opportunity to play a key role in the early diagnosis and management to prevent serious visual loss.

Purpose: To report a case of endogenous endophthalmitis caused by the gram-negative bacterium Salmonella choleraesuis as a first sign of HIV infection in a patient from Thailand., Method: Case description and literature review., Results: A 54-year-old male without systemic complaints developed non-painful panuveitis in his left eye accompanied by high intraocular pressure. On investigation, HIV serology was found positive, and aqueous and blood cultures revealed the bacterium Salmonella choleraesuis. Despite aggressive treatment with antibiotics, the affected eye did not improve, and his visual acuity decreased to no light perception., Conclusions: Endogenous endophthalmitis with the non-typhoidal Salmonellae can occur in the absence of systemic symptoms in an immunocompromised host.

An 11-y-old girl diagnosed with HIV-1, presented with prolonged pyrexia and a non-reactive tuberculin skin test. An INF-gamma assay (ELISpot) was positive and led to administration of tuberculosis treatment. Positive cultures for Mycobacterium tuberculosis followed 6 weeks later. INF-gamma assays should be considered as first line investigations in HIV-1 infected subjects when TB is a diagnostic possibility.

To assess the utility of booster testing and to identify factors associated with a positive booster test, two-step tuberculin testing was performed in drug users recruited from methadone treatment. Participants also received a standardized interview on demographics and testing for HIV and CD4+ lymphocyte count. Of 619 enrollees completing the protocol, 174 (28%) had a positive PPD and 24 of the remaining 445 (5%) had a positive booster test. On multivariate analysis, boosting was associated with older age (adjusted odds ratio [ORadj] 2.38/decade, 95% confidence interval [CI] 1.34-4.22), history of using crack cocaine (ORadj 2.61, 95% CI 1.10-6.18) and a history of working as a home health aide (ORadj 4.23, 95% CI 1.39-12.86). Two-step tuberculin skin testing increased the proportion of participants with latent tuberculosis infection from 22% to 25%. Given the effectiveness of chemoprophylaxis, booster testing should be considered when drug users are screened for tuberculosis infection.

The success of the WHO's '3 by 5' programme will depend on the ability of developing countries to provide antiretroviral therapy. The purpose of this study was to determine the current status of HIV care at a major teaching hospital in eastern Nepal. A retrospective cohort study was conducted of admitted HIV-infected patients at BPKIHS between 1993 and 2003, evaluating reasons for admission and the care received. There were 2, 2, 2, 3, 5 and 18 admissions, respectively, from 1998 to 2003. Only 4 were female patients. Two were children, both admitted in the last y studied. 10 admissions (31% of the total) were for opportunistic infections (OIs). Seven patients were prescribed OI prophylaxis, with incorrect dosages in 6. Four patients were prescribed antiretroviral therapy, all in inappropriate dosages or combinations. 13 patients were rapidly discharged without further care as soon as a diagnosis of HIV was made. Hospital admissions of HIV-infected individuals are increasing rapidly. Important segments of the HIV-infected population such as women and children are not receiving medical services. Most admissions are not due to OIs. The care of HIV-infected patients even at a major tertiary care teaching hospital in Nepal is sub-optimal.

The aim of the study was to characterize the value of combined endoscopy of tracheobronchial tree and oesophagus within 1 session for diagnosis of HIV-associated disorders. Hospitalized HIV-positive patients who underwent combined flexible broncho-oesophagoscopies between 1999 and 2002 in 2 units for infectious diseases were studied retrospectively. 54 HIV patients were analysed; 89% were at stage CDC C, 79% were male, mean age was 40 y. Bronchoscopy led to a diagnosis in 57.4% (95% CI 43.2-70.8). In 40.7%, these were AIDS-defining events (ADE) and 16.7% were general disorders (GD). Oesophagoscopy was diagnostic in 46.3% (95% CI 32.6-60.4). In 35.2% these were ADE, and 11.1% were GD. Patients with pathological oesophagoscopy had a significantly lower CD4 cell count and a higher viral load. There was no association of pathological bronchoscopy with pathological oesophagoscopy regarding ADE. No severe complication was recorded. It is concluded that combined flexible broncho-oesophagoscopy is a valuable and safe method for the diagnosis of HIV-associated disorders. The diagnostic output is highest in patients with advanced disease. A pathological finding in oesophagoscopy cannot be predicted by the presence of bronchoscopic abnormalities. Prospective studies are necessary to confirm these results.

We report the first 2 cases of visceral leishmaniasis in AIDS patients, which ocurred a few d after initiating antiretroviral therapy. The report raises the question whether a rapid immune reconstitution may convert a latent visceral leishmaniasis into a symptomatic one.

Cytomegalovirus (CMV) infection is a well-known frequent complication in HIV-infected patients. We report a case of thrombotic microangiopathy and severe hypothermia in a 21-y-old woman positive for HIV infection. CMV infection was diagnosed by PCR. The symptoms completely resolved after ganciclovir therapy which supports the role of CMV as a causative agent.

Non-tuberculous mycobacteria are considered important opportunistic infections in HIV-infected patients. In a large south-European HIV centre only 10 patients had non-tuberculous mycobacterial infection over a 5-y period. The importance of these infections in some areas, the usefulness of prophylaxis or routine use of mycobacterial blood cultures, may have to be re-considered.

HIV has played a key role in TB, modifying its incidence and clinical presentation. This study describes the prevalence of HIV among TB patients attending health facilities in the southern region of Ethiopia. The HIV prevalence was 18% for female and 21% for male TB patients. 15% and 30%, respectively, of the rural and urban patients with TB were HIV positive (p<0.05). 19% (51/261) smear-positive PTB, 26% (36/137) smear-negative PTB and 11% (10/94) of the extrapulmonary TB patients were HIV positive. The proportion of patients with extra-PTB varied from 11% to 38% across the centres and was highest in the zones with the lowest HIV prevalence. In the light of limited diagnostic facilities, clinicians often make a clinical diagnosis of TB without laboratory confirmation. The increase in the number of TB cases could be due to HIV. However, the number of health facilities offering TB treatment in the area also increased (from 53 to 236) during the same period and the increase in TB is likely to be the result of a combination of factors, including improved detection and HIV. It is important to consider this multi-factorial phenomenon when interpreting the increase of TB in a geographical area.

Enterocytozoon bieneusi is an agent of intestinal microsporidiosis leading to chronic diarrhoea in AIDS patients. Pulmonary involvement may occur but remains rare with only 4 cases reported in the literature. We report here the fifth case of pulmonary localization of E. bieneusi in a severe immunocompromized HIV-infected patient with intestinal and pulmonary symptoms.

Suppurative thyroiditis is a rare condition caused mostly by Staphylococcus aureus and streptococci. Both tuberculous and cryptococcal thyroid abscess are even rarer. The incidence of extrapulmonary forms of tuberculosis and cryptococcosis has increased in areas with a high prevalence of human immunodeficiency virus (HIV) infection. A case is reported of dual infection by M. tuberculosis and Cryptococcus neoformans presenting as a thyroid abscess in a 32-y-old woman with symptomatic HIV infection. Atypical presentations of both tuberculosis and cryptococcosis should be considered in areas with a high incidence of these diseases.

Hypoxemic pneumonia in AIDS patients is mainly caused by Pneumocystis carinii, Toxoplasma gondii and CMV, although the significance of CMV recovery in BALF is often unclear. Since lung involvement generally occurs during reactivation, T. gondii is not expected to be demonstrated in patients without evidence of past infection with this agent. We report a fatal case of pneumonia revealing a T. gondii primary infection diagnosed thanks to the PCR analysis of the BALF.

The case is described of a 51-y-old man with uveitis as the first clinical manifestation of syphilis and in whom laboratory work-up disclosed human immunodeficiency virus infection and asymptomatic brain gummata. The case illustrates the need for a comprehensive work-up in previously asymptomatic patients with uveitis.

CMV-colitis is rare in HIV positive patients with CD4 counts higher than 100 microl(-1). We report a patient who was suffering from extensive CMV-colitis despite modest immune defect. The diagnosis was confirmed by repeated biopsies. The patient experienced an unusually long recovery which was only achieved after initiation of HAART.

We present the case of an HIV-infected patient who developed reactivation of CMV retinitis after a local steroid injection for the treatment of immune recovery uveitis. He responded promptly to reinduction with ganciclovir and recovered. To our knowledge this is the first case of CMV retinitis reactivation in an HIV-infected patient receiving steroids for immune recovery uveitis.

HIV-1 RNA was quantified in intraocular specimens and plasma from AIDS patients with CMV retinitis undergoing therapeutic vitrectomy and in 8 control subjects undergoing cataract surgery using the Amplicor RT-PCR-based assay. The HIV-1 RNA concentration in the intraocular specimens was significantly lower than in plasma. Patients with CMV retinitis and plasma HIV-1 RNA concentrations > 100,000 copies/ml generally had detectable HIV-1 RNA in their intraocular specimens. These findings point to the risk of percutaneous injury from a sharp instrument used in HIV-infected patients during ophthalmic surgery and possible transmission of HIV during such surgery. Prevention of percutaneous contact will require the use of surgical instruments that reduce the likelihood of injury, as well as the wearing of double gloves during surgery.

A DNA hybridization test (the Amplicor CMV test) for CMV DNA was used to detect CMV DNA in paired plasma and aqueous humor specimens from 37 AIDS patients with ophthalmoscopically diagnosed CMV retinitis. CMV was detected in 25/37 (67.6%) plasma specimens and in 32/37 (86.5%) aqueous humor specimens. Thus, the Amplicor CMV test using aqueous humor specimens seems to be a useful diagnostic test for CMV retinitis and one that is more sensitive than determination of CMV DNA in plasma specimens.

We report the first case of S. bovis bacteremia related to endoluminal colonization of a venous access port in a setting of advanced HIV infection, neutropenia and co-infection with HBV. The patient had no bowel abnormalities. The clinical picture was mild and was resolved by removal of the device.

The calcofluor stain (CF), the monoclonal antibody (MAb) 3B6 indirect immunofluorescence assay (IFA) and the modified trichrome blue stain (MT) were compared in terms of their reproducibility in a routine laboratory and in order to evaluate the percentage of cases of microsporidiosis in Portuguese HIV patients. A total of 166 faeces samples, 71 pulmonary specimens and 43 urine samples were studied using the 3 techniques. CF had a high sensitivity and a moderate specificity when applied to faeces samples. The sensitivity was lower with pulmonary specimens. The method is easy and quick to perform but readings take a long time to obtain. The MAb 3B6 IFA had a good to excellent sensitivity when applied to faeces and urine samples, but moderate sensitivity in pulmonary specimens. Readings were quick and easy to obtain, but the assay took longer to perform than the other 2 techniques. There was a greater correlation between the results obtained with the MT and MAb 3B6 IFA techniques than between those obtained with the MT and CF techniques. In conclusion, the MT performed better than the MAb 3B6 IFA and CF and continues to have an important place in a routine laboratory for the diagnosis of microsporidiosis. This work also confirms the existence of a relatively high proportion (30%) of cases of infection with Microsporidia, especially intestinal microsporidiosis, in HIV patients in Portugal.

Bordetella bronchiseptica is an important veterinary pathogen but a rare cause of opportunistic respiratory tract infection in humans. We describe a case of pleural effusion caused by B. bronchiseptica in a patient with AIDS who was coinfected with Mycobacterium tuberculosis. To the best of our knowledge this is the first case in the medical literature in which the microorganism has been isolated from pleural fluid.

CMV disease is an important cause of morbidity and mortality in patients with AIDS. The purpose of this study was to investigate the incidence of CMV disease in a well-defined population of AIDS patients with a high rate of autopsy. No such study has previously been published from Scandinavia. A total of 248 patients who developed clinical AIDS in Oslo during the period 1 January, 1983 to 31 December, 1995 were included. Autopsy was performed in 152 of 213 deaths (71.3%). CMV disease was diagnosed in 95 patients. In the autopsy group, 73 patients (48%) had CMV disease, and in 52 of these patients CMV disease was first detected at autopsy. Retinitis was the most frequent manifestation, followed by adrenalitis, pneumonitis, encephalitis and gastrointestinal disease. No intravenous drug users (IVDUs) were diagnosed alive with CMV disease. All patients diagnosed with CMV disease before death had evidence of CMV disease at autopsy despite anti-CMV treatment. CMV disease was associated with increased risk of death. We conclude that CMV disease was frequent in patients with AIDS during the study period, was associated with increased mortality and was often diagnosed too late for the administration of appropriate therapy.

Central retinal vein occlusion (CRVO) due to herpes zoster has rarely been reported. Varicella zoster virus is a common opportunistic infection in patients with AIDS. This case report is about a 40-year-old man with herpes zoster ophthalmicus and central retinal vein occlusion of the right eye who is HIV-positive. Although the lesion resolved following treatment with intravenous acyclovir and oral steroid, the patient subsequently developed florid disc neovascularization and vitreous hemorrhage. The paper highlights CRVO as the initial presentation in an AIDS patient with herpes zoster ophthalmicus.

It is important but sometimes difficult to establish a diagnosis of toxoplasma encephalitis (TE) in an HIV-positive immunodeficient patient. The most promising non-invasive method is polymerase chain reaction (PCR) for Toxoplasma gondii in cerebrospinal fluid (CSF). In a retrospective study PCR was used to analyse CSF for the presence of T. gondii DNA in 5 HIV-infected patients with a clinical suspicion of TE (group 1), 8 patients with other HIV-associated symptoms (group 2) and 7 other patients with neurological disorders (group 3). PCR was positive in 2/4 patients with a final diagnosis of TE and negative in all remaining patients in all 3 groups. The 2 patients with positive PCR had a fulminant course and experienced treatment failure. The albumin index was elevated in 4/5 patients in group 1, of whom 3/4 had a final diagnosis of TE, with suspected TE in 1. This small study confirms earlier data indicating that the PCR test has a low sensitivity but a high specificity.

Although tuberculosis was unknown in sub-Saharan Africa before the 19th century, rapid spread of infections due to Mycobacterium tuberculosis occurred during the 20th century and could be found in up to 50% of the adult population by the 1950s. Owing to changes in age structure, rapid urbanization associated with overcrowding living conditions, increasing poverty and the HIV epidemic a 300-400% increase in tuberculosis cases and deaths has been reported from sub-Saharan Africa. Persons dually infected with HIV and tuberculosis may have active tuberculosis with typical or atypical clinical features and/or involving multiple organ systems. In addition, mycobacteraemia associated with non-specific clinical features is common among HIV-infected persons, especially if they are severely immunocompromised. Because of the atypical clinical features these patients are easily misdiagnosed and are therefore likely to die from what is otherwise a curable illness. Consequently there is a need to better characterize the clinical features of all forms of tuberculosis, especially in the presence of HIV infection.