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To evaluate the situation and perspectives of progressive multifocal leukoencephalopathy (PML) in human immunodeficiency virus (HIV)-infected patients, we investigated changes in the incidence, causes, and long-term outcome of this disease in 72 acquired immunodeficiency syndrome (AIDS) patients who were diagnosed with PML from 1996 to 2011. Patients were classified according to the date of diagnosis in the first (1996-2000, n = 35), second (2001-2006, n = 26), and recent or third highly active antiretroviral therapy (HAART) period (2007-2011, n = 11). Overall, the incidence of PML decreased from 14.8 cases/1,000 patients/year in 1996 to 2.6 in 2005 and 0.8 in 2011, and nearly two-thirds of recent cases (64 %) were observed in HIV patients not attending clinical visits. The baseline median CD4+ count was higher in recently PML-diagnosed patients (77 vs. 86 vs. 101 cells/mm(3); p < 0.01), and this fact was associated with a cerebrospinal fluid (CSF) inflammatory profile (from 11 to 31 to 55 %, p = 0.007) and with a significantly longer survival (attributable death, 54 vs. 35 vs. 36 %, respectively, p < 0.01). Thus, the overall 1-year and 3-year survival rates were 55 and 50 %, respectively, increasing to 79 % at 1 year for patients with CD4+ count above 100 cells/mm(3) at diagnosis. In a Cox regression analysis, an older age (hazard ratio, HR 0.76), a baseline CD4+ count above 100 cells/mm(3) (HR 0.33), and a CSF inflammatory profile (HR 0.12) were significantly associated with a longer survival. The clinical presentation and outcome of PML in AIDS patients continue to change dramatically. Now, a declining incidence and long-term survival is observed.

Adenosine deaminase activity (ADA) determination in cerebrospinal fluid (CSF) is considered a specific test for the diagnosis of tuberculous meningitis. In order to study the variability of this marker in patients with different neurological disorders associated with HIV infection, and its utility for the diagnosis of tuberculous meningitis in these patients, the ADA levels in 417 CSF samples from HIV-infected patients with neurological symptoms were reviewed. HIV infection, HIV-associated neurological disorders, and progressive multifocal leukoencephalopathy were not associated with elevated ADA in CSF. Among patients with meningitis, receiver operating characteristic curve analysis gave an optimal ADA cut-off point of 8.5 IU/l for the diagnosis of tuberculous meningitis, with 57% sensitivity, 87% specificity, and an area under the curve of 0.747 (similar to that for CSF glucose concentration). False-positive results were found in patients with neurological CMV disease and cryptococcal, lymphomatous, and probable candidal meningitis. The results of this study indicate that ADA determination in CSF has limited utility for the diagnosis of tuberculous meningitis in HIV-infected patients.

Neurological complications caused by varicella-zoster virus (VZV) were diagnosed in 13 human immunodeficiency virus (HIV)-infected patients in our hospital. There was a favorable influence of highly active antiretroviral therapy (HAART) in the prevalence of these disorders among acquired immunodeficiency syndrome (AIDS) patients: Since 1996, only 1 of 961 AIDS patients had VZV neurological disease, compared to 9 of 1088 patients before that year (P =.02). Polymerase chain reaction (PCR) detected VZV DNA in cerebrospinal from 4 of 5 patients with VZV neurological disease, and from 2 of 130 HIV-infected patients with other neurological diseases (sensitivity 0.8, specificity 0.98 [95% confidence intervals 0.45-1 and 0.96-1, respectively], positive predictive value 0.94).

In order to describe the clinical features and outcome of Staphylococcus aureus meningitis, the charts of 44 cases seen at one teaching hospital during a 20-year period were retrospectively reviewed. Staphylococcus aureus was the fifth most common cause of bacterial meningitis (10.2% of cases). There were 28 (63%) cases of postoperative meningitis and 16 (37%) of spontaneous meningitis. Patients with postoperative meningitis were younger than patients with spontaneous meningitis (mean age, 40.3 vs. 59.3 years; P=0.04) and had a lower frequency of community-acquired infection (32.1% vs. 93.8%; P<0.01), severe underlying diseases (28% vs. 87%; P<0.01) and associated staphylococcal infection (35% vs. 75%; P=0.01). The clinical presentation was similar in both groups, but patients with postoperative meningitis had a lower frequency of altered mental status (39% vs. 75%; P=0.02), meningeal signs (28% vs. 62%; P=0.02), petechial rash (0% vs. 18%; P=0.04), bacteremia (7% vs. 75%; P<0.01), and septic shock (0% vs. 44%; P<0.01). Most patients were treated with cloxacillin or vancomycin, with or without rifampicin, for a mean period of 22.5 days (range, 1-100 days). Overall mortality was 27%, and the mortality rate was higher for cases of spontaneous than postoperative meningitis (50% vs. 14%; P=0.01). Mortality correlated significantly with advanced age, spontaneous meningitis, altered mental status, and the presence of severe underlying diseases, bacteremia, and septic shock.

The aim of this prospective study was to compare a model based on clinical variables with the clinical judgment of infectious disease specialists to identify HIV-infected patients requiring isolation at admission in order to prevent the nosocomial transmission of tuberculosis. Clinical, epidemiological and radiological variables available at admission were recorded for 362 admissions of 274 HIV-infected patients. Using multiple logistic regression analysis, a model to identify patients with tuberculosis was developed based on four clinical variables (node enlargement, constitutional symptoms, intravenous drug use, history of previous correct therapy for tuberculosis) and a positive auramine sputum stain. This model was applied to each of the 362 admissions studied. The decision made by the infectious disease specialist at admission was also recorded. The results indicate that application of the model would have allowed physicians to correctly identify and isolate 24 of 27 patients with tuberculosis, while 5.4 patients without tuberculosis would have been unnecessarily isolated for every patient with tuberculosis. The results for the infectious disease specialists were slightly better, with 26 of 27 patients with tuberculosis being identified and isolated correctly and only 3.2 patients being isolated unnecessarily for every patient with tuberculosis. Thus, a simple model based on clinical variables may be useful in helping physicians identify tuberculosis carriers among HIV-infected patients, but infectious disease specialists are able to identify them more efficiently.

The aim of the study presented here was to describe the clinical presentation and outcome of invasive pulmonary aspergillosis (IPA) in a cohort of HIV-infected patients and to assess factors associated with survival by means of a longitudinal study of all HIV-infected adults with IPA who attended the infectious diseases service of a tertiary center between January 1985 and December 1998. The outcome measure was the time to death after diagnosis of IPA. The endpoint for data collection and survival analysis was 31 December 1998. Nineteen of 1,605 HIV-infected patients were identified, resulting in an overall IPA attack rate of 1.12%. Most patients had AIDS (95%). Unilateral cavitary disease was the most frequent radiographic presentation (37%). Median survival was 148 days (95% confidence interval [95% CI], 0-402), but it exceeded 12 months in 37%. In patients in whom antiretroviral treatment (ART) was initiated or modified in relation to the IPA diagnosis, median survival increased to 906 days (95% CI, 754-1,058; 1-year survival, 83%) compared with 86 days in those who did not take any ART (95% CI, 55-117; 1-year survival, 8%; P=0.0002). Survival was even longer when ART changes included only nucleoside reverse transcriptase inhibitors, prior to the availability of protease inhibitors (833 days, 95% CI, 369-1,297; 1-year survival 75%; P=0.003). Three (16%) patients are still alive after a mean time of 36 months postdiagnosis. Although IPA is a life-threatening complication of advanced AIDS, it does not always lead to short-term death. An adequate management of HIV infection together with antifungal treatment may prolong survival and, as described for other AIDS-related disorders, a significant decrease in its occurrence can be expected.

To investigate the clinical and radiographic features and the response to therapy of Mycobacterium kansasii infection in human immunodeficiency virus-infected patients, the clinical charts of 19 cases diagnosed during a 15-year period were reviewed retrospectively. Most patients were male intravenous drug abusers. Mycobacterium kansasii infection occurred late in the course of HIV disease and was associated with advanced immunosuppression. Thirteen patients had pulmonary disease, three extrapulmonary disease (2 with pulmonary involvement), and three pulmonary colonization. Most of them had fever and nonspecific respiratory symptoms; interstitial and alveolar infiltrates were the most common radiographic findings. Fourteen patients were given antituberculous treatment; among these, a clinical response was observed in 85%. Overall mortality was 63%, but only four patients died from active Mycobacterium kansasii disease. HIV infection has become the most important risk factor for Mycobacterium kansasii disease in our setting. Pulmonary infection is the most frequent form of disease and is usually responsive to antituberculous therapy.

A case of thyroid abscess due to Rhodococcus equi in an HIV-positive patient with previous pulmonary abscess is reported. Rhodococcus equi is a gram-positive rod that can cause infections in both immunocompetent and immunocompromised patients, though it occurs more frequently in patients with dysfunctional cellular immune systems. Several cases of Rhodococcus equi infection in persons infected with HIV have been reported. In these patients Rhodococcus equi usually invades the lungs, producing pneumonia. These infections often relapse, accompanied by intermittent bacteremia, despite conventional treatment. Extrapulmonary abscesses can occur.

Fifty episodes of oropharyngeal candidiasis in HIV-infected patients were analyzed prospectively in order to evaluate the clinical response to fluconazole. The minimum inhibitory concentrations (MICs) of fluconazole for the Candida strains isolated from the pharynx were correlated with the clinical response. Treatment with fluconazole (100 mg/day) was successful in 86% of the cases. A good clinical outcome followed in 97% of the cases when a strain sensitive to fluconazole was isolated. This figure fell to 22% when the strain was resistant to fluconazole (p < 0.001). The rate of post-treatment colonization was high (87%), and selection of non-albicans Candida species occurred in 23% of the cases. In conclusion, fluconazole treatment for oropharyngeal candidiasis of HIV-infected patients was useful in most cases, but less sensitive non-albicans species can be selected. Most treatment failures were associated with increased MICs of fluconazole for the strains isolated before treatment; therefore, susceptibility testing is recommended as an aid in clinical decision-making for the use of the azole group of drugs.