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Study objectives: To examine the significance of previously suggested risk factors and assess outcomes associated with Aspergillus identification in respiratory specimens from HIV-seropositive individuals. Design: This was a nested case-control [...]

Background: The resurgence of tuberculosis in the United States is largely linked to the human immunodeficiency virus CHINA epidemic. Despite this link, the epidemiology of tuberculosis and preventive strategies in patients infected with HIV are not completely understood. Objectives: To determine the incidence and predictors of tuberculosis in HIV-infected persons. Design: Prospective, multicenter cohort study. Setting: Community-based cohort of persons with and without HIV infection at centers in the eastern, midwestern, and western United States. Participants: 1130 HIV-seropositive patients without AIDS who were followed for a median of 53 months (814 homosexual men, 261 injection drug users, and 55 women who had acquired HIV through heterosexual contact). Measurements: Delayed hypersensitivity response to purified protein derivative (PPD) tuberculin and mumps antigen, CD4 T-lymphocyte counts, and frequency of tuberculosis. Results: 31 HIV-seropositive patients developed tuberculosis (0.7 cases per 100 person-years [95% CI, 0.5 to 1.0]). The most important demographic risk factor was location (adjusted risk ratio for eastern compared with midwestern and western United States, 4.1 [CI, 2.0 to 8.4]). Tuberculosis occurred more frequently in persons with CD4 counts of less than 200 cells/[mm.sup.3] (1.2 cases per 100 person-years [CI, 0.7 to 1.9]) than in those with higher counts (0.5 cases per 100 person-years [CI, 0.3 to 0.8]). The rate of tuberculosis was highest among tuberculin converters (5.4 cases per 100 person-years [CI, 1.1 to 15.7]), lower among patients who were PPD positive at first testing (4.5 cases per 100 person-years [CI, 1.6 to 9.7]), and lowest among patients who remained PPD negative (0.4 cases per 100 person-years [CI, 0.2 to 0.7]). Tuberculosis was not reported among persons who had PPD reactions of 1 to 4 mm. Compared with that of patients who tested positive for mumps, the risk for tuberculosis of those who tested negative was increased about sevenfold if they were PPD positive (p < 0.03) and fourfold if they were PPD negative (P < 0.02). Conclusions: Incidence of tuberculosis was higher in the eastern United States, in patients with CD4 counts of less than 200 cells/[mm.sup.3], and in PPD-positive patients. Analysis of tuberculin reaction size supports the current interpretive criteria of the Centers for Disease Control and Prevention. Nonreactivity to mumps antigen indicated increased risk for tuberculosis independent of PPD response., There appear to be some specific demographic and medical characteristics that increase the likelihood of developing tuberculosis among HIV-positive patients. Prevalence of tuberculosis, CD4 counts, sensitivity to mumps and tuberculosis, and geographic location were determined among 1130 HIV-positive patients during a 53-month period. Patients with low CD4 counts, those living in the eastern United States, and those with high sensitivity to tuberculosis were more likely to develop tuberculosis. Overall, there were 31 tuberculosis infections reported during the study period.

Objectives: HIV disease is frequently complicated by episodic acute bronchitis, suggesting the presence of chronic bronchial inflammation. To further examine this concept, we investigated the possible association of nonspecific airway [...]

Objective: To determine the use of chest radiographs in the screening of asymptomatic adults infected with the human immunodeficiency virus (HIV). Methods: A prospective, multicenter study of the pulmonary complications of HIV infection in a community-based cohort of persons with and without HIV infection. The subjects included 1065 HIV-seropositive subjects without the acquired immunodeficiency syndrome at the time of enrollment: 790 homosexual men, 226 injection drug users, and 49 women with heterosexually acquired infection. Frontal and lateral chest radiographs were performed at 3-, 6-, and 12-month intervals, CD4 lymphocyte measurements at 3- and 6-month intervals, tuberculin and mumps skin tests at 12-month intervals, and medical histories and physical examinations at 3- and 6-month intervals. Pulmonary diagnoses that occurred within 2 months following each radiograph were analyzed and correlated with the radiographic results. Results: Evaluable screening chest radiographs (5263) were performed in HIV-seropositive subjects while they were asymptomatic; of these, 5140 (98%) were classified as normal and 123 (2%) as abnormal. A new pulmonary diagnosis was identified within 2 months following a screening radiograph in 55 subjects. Only 11 of these subjects had abnormal radiographs; the sensitivity of the radiograph was 20%. The sensitivity was similarly low at baseline, within each transmission category, and in subjects whose CD4 lymphocyte counts were less than 0.2 X [10.sup.9]/L (200/[mu]L). The types of pulmonary diseases that occurred were similar in the subjects with normal and abnormal screening radiographs. Conclusion: Screening chest radiography in asymptomatic HIV-infected adults is unwarranted because the diagnostic yield is low.

Soil may be a source of organisms that can cause Mycobacterium avium complex (MAC) infection in HIV patients in San Francisco, but food and water may not be significant sources. Food, water, and soil samples were collected from the homes of 290 HIV-positive participants at risk for MAC in San Francisco. MAC organisms were cultured from 55% of potted plants, 2% of water samples and .5% of food samples. However, no direct connection could be established between the environmental presence of MAC and MAC infection in HIV patients.

* Objective: To determine the prevalence and predictors of reactivity to tuberculin purified protein derivative (PPD) and skin test anergy in patients with human immunodeficiency virus (HIV) infection and in HIV-seronegative controls. * Design: Cross-sectional analysis of baseline data from a prospective, multicenter study of pulmonary complications of HIV infection. * Setting: Community-based cohort of persons with and without HIV infection. * Patients: A total of 1171 HIV-seropositive patients without AIDS (841 homosexual men, 274 intravenous drug users, and 56 women with heterosexually acquired infection); 182 HIV-seronegative persons (125 homosexual men and 57 intravenous drug users). * Measurements: Delayed-type hypersensitivity response to tuberculin PPD, trichophytin, mumps, and Candida antigens; T-lymphocyte subsets. * Results: The prevalence of tuberculin PPD reactivity was higher among intravenous drug users than among homosexual men, in both HIV-seronegative (19.1% compared with 6.8%, P = 0.03) and HIV-seropositive persons (15.1% compared with 2.5%, P< 0.001). Among HIV-infected patients, the prevalence of tuberculin reactivity varied directly and that of anergy inversely with the absolute CD4 lymphocyte count. Prevalences were 1% and 72%, respectively, in patients with fewer than 200 CD4 cells/[mm.sup.3], and 8.4% and 25.5%, respectively, in those with 600 CD4 cells/[mm.sup.3] (P< 0.001 for both comparisons). Patients with HIV infection and fewer than 400 CD4 lymphocytes/[mm.sup.3] had a lower prevalence of PPD reactivity than HIV-seronegative controls (2.7% compared with 10.0%, P < 0.001). The strongest predictors of tuberculin reactivity were intravenous drug use, black race, a previous positive PPD test result, and a history of Calmette-Guerin bacillus vaccination. The strongest predictor of anergy was HIV seropositivity. * Conclusions: The response to delayed-type hypersensitivity antigens depends on immune status. The value of PPD and anergy testing in HIV-seropositive patients depends on the ability of such testing to predict subsequent tuberculosis, which is imprecisely known. Until more data or better methods are available, these tests should be done as early as possible in the course of HIV infection., Reliability of the tuberculin purified protein derivative (PPD) test may vary depending on the immune status of HIV-infected individuals. Some HIV-positive individuals may not react to the tuberculin PPD test despite exposure to tuberculosis. Failure to respond in these individuals is caused by anergy. Of 1,445 individuals who had the tuberculin PPD test, 1,171 were HIV-positive homosexual men or intravenous (IV) drug users without AIDS and 182 were HIV-negative homosexual men or IV drug users. Reactivity to the test was higher among intravenous drug users than homosexual men in both groups. HIV-positive individuals were less likely to react to the test than HIV-negative individuals. Among the HIV-positive patients, the likelihood of a reaction to the test decreased with the patient's blood levels of CD4 T cells. The likelihood of anergy increased as the patient's levels of CD4 T cells declined.

* Pulmonary toxoplasmosis is a rarely recognized opportunistic infection in immunocompromised patients. A few case reports have described pulmonary toxoplasmosis in human immunodeficiency virus-infected patients in association with Toxoplasma gondii central nervous system disease. We encountered six cases of pulmonary toxoplasmosis in human immunodeficiency virus-infected patients, who presented with a protracted febrile illness, respiratory symptoms, and an abnormal chest roentgenogram in the absence of neurologic findings. No clinical or roentgenographic features distinguished T gondii pneumonitis from more common opportunistic pulmonary infections. As the acquired immunodeficiency syndrome epidemic progresses, the presenting illnesses have evolved. Toxoplasma gondii must be considered a potential cause of pulmonary disease during the evaluation of human immunodeficiency virus-infected patients with respiratory symptoms. (Arch Intern Med. 1992; 152:1073-1077)

The human immunodeficiency virus (HIV, the virus that causes AIDS) attacks and destroys the immune system, making individuals with AIDS very susceptible to other types of infection. Mycobacterium avium (M. avium) is a common bacterial cause of lung infection in patients with AIDS. Once M. avium infects the lungs it can spread (disseminate) to other parts of the body and cause M. avium complex infection (MAC). Many studies have reported that MAC reduces the survival time of patients with AIDS, but the validity of these studies has been challenged. In an attempt to gain a better understanding of the role that MAC plays in altering the survival time of AIDS patients, the medical records were reviewed of 137 AIDS patients attending the San Francisco General Hospital between 1983 and 1986. Thirty-four of the patients were diagnosed with lung infections caused by M. avium. In 22 of the 34 cases, the infection had spread to other parts of the body. When the infection spread to other parts of the body, the survival time of the patient was indeed shortened. It is concluded that a lung infection with M. avium predicts the development of disseminated MAC, and disseminated MAC reduces the survival time of patients with AIDS. (Consumer Summary produced by Reliance Medical Information, Inc.)

The tuberculin skin test was developed almost a century ago for the diagnosis of tuberculosis caused by an infection with Mycobacterium tuberculosis (M. tuberculosis). Although this test is not 100 percent accurate, it is the only available method for diagnosing tuberculosis. The test involves placing a small amount of purified protein, called tuberculin, on the skin. If the patient has been infected with M. tuberculosis, the test area on the skin will turn red and may become swollen. The tuberculin test is used to identify people who may benefit from preventive treatment with isoniazid, and as a surveillance method to identify new cases of tuberculosis among people who were not previously infected. It has been reported that the skin reaction to tuberculin may decrease over time. This means that some people who initially test positive may test negative several years later. It has become common practice to retest people who fall into this latter category. However, it is not clear if additional tuberculin tests (called boosters or boosted reactions) produce accurate and stable results. To determine the validity of boosted reactions, 380 hospital patients with positive test results were studied. Of these patients, 244 tested positive and 136 tested negative for tuberculosis. A second test was immediately performed on the 136 patients who tested negative and 94 of these patients now tested positive. After having two negative test results in a row, the remaining 42 patients tested positive on their third try. When all patients were retested one year later, 82 percent of the 244 patients who tested positive on their first test had a positive test again, while only half of the patients who did not test positive until their third test had a positive test one year later. Also, it was found that older patients were more likely to have a negative test one year after having a positive test than younger patients. These findings indicate that boosted reactions are unstable and that their clinical significance is questionable. It is proposed that no more than two sequential tests be used for tuberculosis testing. (Consumer Summary produced by Reliance Medical Information, Inc.)

The human immunodeficiency virus is the virus that causes AIDS. The virus attacks and destroys the cells of the immune system (the body's natural defense system for fighting infection), and therefore patients with AIDS are at greater risk for developing life-threatening infections. Pneumonia caused by an infection with Pneumocystis carinii is one of the more common complications in patients with AIDS and it has been reported to be the cause of death in many cases. Many patients with AIDS develop simultaneous infections with several different microorganisms, and infection with Cytomegalovirus (CMV) is common in these patients. Several studies have tried to determine whether the rates of disease and death are greater in AIDS patients who have infections with both P. carinii and CMV than in those who have an infection with P. carinii alone. Two of these studies reported that infection with CMV did not increase mortality in AIDS patients with P. carinii pneumonia, while three other studies reported that patients with both CMV and P. carinii infection had a poorer outcome. To investigate this issue further, the effect of CMV infection on mortality and morbidity was determined in 111 AIDS patients with P. carinii pneumonia. Fifty-four of the patients had CMV infection and P. carinii pneumonia and 57 had P. carinii pneumonia without CMV infection. The length of hospitalization, long-term survival and death rate were the same for both groups of patients. It is concluded that CMV infection does not increase morbidity or mortality in AIDS patients with P. carinii pneumonia. These findings do not support the use of antiviral drugs for treating CMV infections in AIDS patients with P. carinii pneumonia. (Consumer Summary produced by Reliance Medical Information, Inc.)

AIDS is an immunodeficiency syndrome caused by infection with the human immunodeficiency virus (HIV). AIDS patients suffer from a large number of opportunistic infections, which carry out their destructive actions unopposed by normal immune defenses. The most common opportunistic infection in AIDS patients is pneumonia caused by the microorganism Pneumocystis carinii; 80 percent of AIDS patients become infected with P. carinii during the course of their disease. In spite of frequently successful treatment with drugs such as trimethoprim-sulfamethoxazole, 20 percent of patients with P. carinii pneumonia (PCP) die from respiratory failure. Early in the AIDS epidemic, the usual treatment was mechanical ventilation (use of a breathing machine) for PCP patients suffering from respiratory failure, but mortality approaching 100 percent in these cases made physicians wary of such treatment. In recent years, published reports have documented an increased survival rate among PCP patients who received mechanical ventilation. To determine whether these reports reflect a true improvement in survival rate, and to what this improvement might be attributed, a retrospective study was done of AIDS patients with PCP admitted to the intensive care unit at San Francisco General Hospital from 1981 to 1988. Patients admitted from 1981 to 1985 were compared with a similar group admitted from 1986 to 1988. The in-hospital survival rate for the 42 patients with respiratory failure in the earlier time period was 14 percent, compared with 40 percent for the 35 patients admitted in the later period. There were no discernible differences between the two patient populations. It is concluded that the survival rate for patients with PCP and respiratory failure has improved. It is also noted that corticosteroid treatment was frequently used in the later time period, and that patients who received steroids had an in-hospital survival rate of 46 percent, compared with 22 percent for those who did not. The usefulness of corticosteroids for PCP patients should be investigated further. (Consumer Summary produced by Reliance Medical Information, Inc.)

Human immunodeficiency virus (HIV) attacks and weakens the immune system, thereby increasing host susceptibility to opportunistic infection. The later stages of HIV infection are often accompanied by pneumonia. Recent reports have indicated that tuberculosis may be related to HIV infection. HIV-positive intravenous drug users in New York city were reported to have an increased incidence of tuberculosis. In order to examine the relationship between tuberculosis and HIV, blood samples from patients diagnosed with tuberculosis were screened for the presence HIV antibodies. The study group was selected from 128 diagnosed cases of tuberculosis reported at the San Francisco Department of Public Health Tuberculosis Clinic between July 1986 and May 1988. Out of the 128 patients diagnosed with tuberculosis, 60 agreed to participate in the study. The mean time between tuberculosis diagnosis and HIV testing was three months. Twenty-eight percent of the tuberculosis patients participating in the study had antibodies to HIV. Ten percent of the 68 patients diagnosed with tuberculosis who did not participate in the study were diagnosed as having AIDS. Therefore, out of all the diagnosed cases of tuberculosis, 19 percent had antibodies to HIV. Tuberculosis was the first opportunistic infection to occur in 88 percent of those diagnosed as HIV-positive. The were no clinical or pathological differences in the tuberculosis diagnosed in the HIV-positive and the HIV-negative patients. Risk factors associated with HIV included homosexual behavior and intravenous drug use. It is concluded that tuberculosis is an important early opportunistic infection occurring in HIV patients. It is recommended that patients with tuberculosis be tested for HIV, especially those living in areas were HIV infection is prevalent. (Consumer Summary produced by Reliance Medical Information, Inc.)

It is ironic at best for one of the world's oldest known microbes, Mycobacterium tuberculosis, to be considered an 'emerging' pathogen. Skeletal abnormalities thought to have been caused by tuberculosis [...]

Background: To decrease tuberculosis case rates and cases due to recent infection (clustered cases) in San Francisco, California, tuberculosis control measures were intensified beginning in 1991 by focusing on prevention of Mycobacterium tuberculosis transmission and on the use of preventive therapy. Objective: To describe trends in rates of tuberculosis cases and clustered cases in San Francisco from 1991 through 1997. Design: Population-based study. Setting: San Francisco, California. Patients: Persons with tuberculosis diagnosed between 1 January 1991 and 31 December 1997. Measurements: DNA fingerprinting was performed. During sequential 1-year intervals, changes in annual case rates per 100 000 persons for all cases, clustered cases (cases with M. tuberculosis isolates having identical fingerprint patterns), and cases in specific subgroups with high rates of clustering (persons born in the United States and HIV-infected persons) were examined. Results: Annual tuberculosis case rates peaked at 51.2 cases per 100 000 persons in 1992 and decreased significantly thereafter to 29.8 cases per 100 000 persons in 1997 (P [is less than] 0.001). The rate of clustered cases decreased significantly over time in the entire study sample (from 10.4 cases per 100 000 persons in 1991 to 3.8 cases per 100 000 persons in 1997 [P [is less than] 0.001]), in persons born in the United States (P [is less than] 0.001), and in HIV-infected persons (P = 0.003). Conclusions: The rates of tuberculosis cases and clustered tuberculosis cases decreased both overall and among persons in high-risk groups. This occurred in a period during which tuberculosis control measures were intensified., Tuberculosis control measures begun in San Francisco, CA, in 1991 reduced rates of the disease, even among high-risk population groups. The number of cases of tuberculosis peaked in 1992, then fell steadily and by 50% by 1997. Efforts to prevent transmission of the disease and provide preventive therapy to high-risk patients were effective. Cases among HIV patients, at high risk for developing tuberculosis, fell from 1992 to 1997, as well.

Aerosolized pentamidine has proven to be safe and effective in the pre ention (1) and treatment (2,3) of Pneumocystis carinii pneumonia (PCP) in patients with the acquired immunodeficiency syndrome (AIDS). [...]