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Background: Cyclosporiasis is a disease due to Cyclospora cayetanensis, an emerging coccidian parasite first described in 1979. It is an orally transmitted disease that is more frequent in tropical and subtropical areas. Cyclospora cayetanensis has been mainly described as a cause of travelers' diarrhea. This pathogen has given rise to a number of epidemic outbreaks attributable to ingestion of imported foods, particularly from tropical areas., Methods: Descriptive study of clinical and epidemiological data of a small epidemic outbreak of C cayetanensis-induced gastroenteritis., Results: Seven confirmed cases of C cayetanensis among Spanish nationals who had traveled to Antigua Guatemala are described. The incubation period was 6 days. Diarrhea, asthenia, anorexia, borborygmi, flatulence, and abdominal distension were present in all cases. Fever and heart burn in 85.7%. Weight loss in 71.4%. Abdominal pain, rectal tenesmus, and nausea in 42.8%. Vomiting and eructation in 14.2%. Heart burn was a frequent symptom, a finding not often previously described. The infection was probably acquired from raspberry juice. All cases improved with trimethoprim/sulphametoxazol., Conclusions: Cyclosporiasis is a cause of travelers' diarrhea. Parasitology laboratories must be advised of clinical suspicion of cyclosporiasis so that they can conduct a suitable targeted study; otherwise, false negative results may arise.

Introduction: Ciguatera poisoning is a clinical syndrome associated to consumption of marine fish with toxins as ciguatoxin, maitotoxin, scariotoxin, palytoxin and okadaic acid, produced by dinoflagellates present in seas with coral reefs. It has a wide distribution in tropic ans sub-tropic areas., Material and Methods: We review the clinical records of 8 patients diagnosed of ciguatera from 1993 of 2001. Diagnosis was based on clinical picture and the antecedent of eating fish from endemic area., Results: All patients were travelers, and all showed neurological symptoms, as parestesias and paradoxical dysesthesia. Five patients received treatment with intravenous mannitol, with fast improvement., Discussion: Travelers to danger zones, mainly Caribbean area, Indic Ocean and Pacific Ocean regions, should be noticed about the risk of ciguatera.

Cutaneous larva migrans (CLM) is a frequent dermal disease in travelers, caused by larvae of nonhuman ancylostoma. We describe 34 outside cases of CLM diagnosed since January 1991 to June 2002. Nineteen male and female. Age: 35.7 years (20-60). The total number of CLM infestations was 73, 83.5% in feet. In five cases the cutaneous lesion was vesiculoampollous (14.7%). Ivermectin, utilized in 3 cases with a single dose of 12 mg, failed in one patient (33.3%). Thiabendazole was effective in 6 (85.7%) of 7 cases and 4 (57.1%) patients showed side effects. Albendazole at doses of 400 mg/ 12 hours/3 days was effective in 22 (84.6%) of 26 cases. Possibly it is advisable to use albendazole more than 3 days in order to prevent the failures (15.4%) as those in our series.

Reported here are two new cases of imported cutaneous gnathostomiasis that occurred in two Spanish women. The first patient acquired the helminth infection while travelling in Southeast Asia and the second in Mexico. Although the highest prevalence of gnathostomiasis infection is in Southeast Asia, the disease is now an emerging public health problem in some countries of Latin America. The cases reported here demonstrate the increasing frequency with which human gnathostomiasis is being diagnosed in nonendemic countries as a result of more extensive international travel and migration.

Although resistance to Listeria monocytogenes infection requires intact T-cell mediated immunity, listeriosis is an infrequent problem in patients with HIV infection and only about 50 patients have been reported to date. Only two patients with HIV and L. monocytogenes have been attended in our hospital since the beginning of aids epidemic in 1981. Case 1: a man with HIV and 364 CD4+ cells/mm3 presented fever and occipital headache. The cerebral scan was normal and L. monocytogenes grew in licuor culture. He was outcome after treatment with ampicillin and tobramycin. Case 2: a 47 years old man with HIV, 44 CD4+ cells/mm3 and hepatic virus C cirrhosis was admitted to the hospital because fever and abdominal distension. He was on menstrual pentamidine prophylaxis for Pneumocystis carinii pneumonia (PCP). Bacterial peritonitis was diagnosed and the patient begun treatment with ceftriaxone. The patient dead 72 hours later with hepatic encepholopathy. Postmortem L. monocytogenes grew. Listeriosis is an infrequent disease in patients with HIV that causes difficult diagnostic problems, principally in patients without prophylaxis with cotrimoxazole for PCP.

Patients with aids are at increased risk of opportunistic and non opportunistic infections. It is now known that the incidence can be reduced by prophylactic measures and/or the use of vaccines. HIV infection produces an elevated frequency of severe pneumococcal disease with a rate of bacteriemia caused by Streptococcus pneumoniae 150-300 fold greater than rates reported in non-HIV infected people. For this reason, pneumococcal vaccine should be administered as early as possible in the course of the infection. Besides, the antibody response may be significantly higher for asymptomatic persons. Acute hepatitis caused by hepatitis B virus is milder than in non HIV infected patients but chronic disease is more frequent. The prognosis is worse and there is higher risk for infecting another persons. Hepatitis B vaccine is indicated for all the patients with HIV and negative serology for hepatitis B virus. Influenza vaccine is of limited effectiveness due to the high variability of the virus. Besides, influenza incidence is low among approximately young adults, HIV related immunodeficiency increased influenza risk only minimally, the vaccine is administered yearly and HIV-replication can increase in temporal association with vaccination. For all these reasons, fewer hospitalizations and deaths are prevented making it a far less cost-effective prevention strategy than pneumococcal vaccination. The risk of Haemophilus influenzae infections is elevated, but the vaccine is not routinely recommended because the more frequent serotype in HIV infected patients is b. For these subjects, passive immunization with immunoglobulin may also be necessary to provide protection. In conclusion, pneumococcal and hepatitis B vaccination is a reasonable prevention strategy for HIV infected patients at all stages of immunodeficiency. Influenza and H. influenzae vaccination are not recommended and alternative prevention strategies may be done.

The experience with 52 episodes of visceral leishmaniasis diagnosed in 43 patients is reported. The most common symptoms were fever (81%), splenomegaly (65%), hepatomegaly (63%), and pancytopenia (73%). In 79% of the patients, CD4+ cell counts were < 100 cells/mm3. Prior or simultaneous diagnosis of AIDS was made in 29 (67%) patients. Diagnosis was considered fortuitous in 19% of the episodes. In 27% of the episodes, the diagnosis was made on the basis of demonstration of parasites outside the reticuloendothelial system, chiefly blood (7 cases) and gastrointestinal mucosa (5 cases). Parasites were frequently observed or cultured from blood (22/37 episodes) or the digestive tract (8/9 episodes). High antimony doses were more effective than low doses in achieving clinical or parasitological cure (rate of cure, 80% vs. 40%, p = 0.11). Severe toxicity was observed in six (11.7%) of the 51 treated episodes. Severe AIDS-related diseases [odds ratio (OR) 10, p < 0.05] and CD4+ counts (OR 12, p < 0.05) were independent factors for early death. Prophylaxis with monthly pentamidine was not useful in reducing relapses of visceral leishmaniasis.

Objective: To describe all the clinical settings, endoscopic findings and response to therapy in a series of HIV-positive patients with biopsy proven gastrointestinal CMV disease., Patients: We retrospectively reviewed the medical records of all HIV-infected patients who underwent digestive endoscopies at our Hospital from June 1990 to October 1993., Results: Twelve (7.5%) of 158 HIV-positive patients had gastrointestinal CMV disease. Sites of prove infection included the esophagus (n = 6, 50%), stomach (n = 2, 17%), duodenum (n = 4, 33.3%), ileum (n = 1, 8.5%) and colon (n = 2, 17%). The most common endoscopic findings were focal or diffuse mucosal ulcers. Three patients had pseudotumoral mucosal lesions. Cytomegalic cells were observed in 11 patients (91.6%) and immunohistochemical staining was positive in 9 (81.8%) of 11 patients tested. Eight patients completed a course of treatment with ganciclovir or foscarnet and all of them showed clinical improvement. The median survival time of our AIDS patients with CMV gastrointestinal disease was 7 weeks (range 1-39 weeks)., Conclusions: Gastrointestinal CMV disease may damage any site of the digestive tract in AIDS patients. Routine histopathologic examination was better than immunohistochemical staining for the diagnosis. Treatment improves the clinical situation in most of them. The mean survival is low and it is related to the degree of immunosuppression.

We describe five cases of gastrointestinal leishmaniasis in patients with human immunodeficiency virus infection and review 10 additional cases reported in the literature. All of the patients had CD4+ cell counts of < 200/mm3, and AIDS had been previously diagnosed for 12 patients. Fever and splenomegaly were present in 46% of cases. Thirteen patients had digestive symptoms; these symptoms included diarrhea (6), dysphagia and/or odynophagia (6), abdominal pain (2), epigastric pain (2), gastrointestinal hemorrhage (1), and rectal discomfort (1). The regions of the digestive tract most frequently affected by Leishmania organisms were the duodenal mucosa (90%) and the gastric mucosa (75%). Endoscopy showed normal-appearing mucosa in 45% of cases. In 10 cases the diagnosis of visceral leishmaniasis was first made by biopsy of the gastrointestinal mucosa. In most cases treatment with antimonial agents was not effective.

We report on 11 patients with HIV infection and visceral leishmaniasis and who were treated with meglumine antimoniate plus allopurinol for 3 weeks (six patients) or 4 weeks (five patients). Clinical and parasitological cures were achieved in four of the five patients treated for 4 weeks and in one of the six patients treated for 3 weeks. Only one patient developed a severe maculopapular rash. Allopurinol plus meglumine antimoniate was found to be a safe combination of drugs for the treatment of visceral leishmaniasis in patients infected with HIV. The optimal length of this treatment is unknown but a course of at least 4 weeks' duration would appear to be necessary for obtaining parasitological cure in most cases.

We evaluate retrospectively 38 patients with AIDS and Cytomegalovirus (CMV) retinitis. In 72.5% (45 from 62 eyes) it carried an important sight risk; 50% of the end of the follow-up. Evidence of extraocular illness in 28.5% of the patients. Using control groups the AIDS microvasculopathy is neither more frequent in CMV-retinitis nor associated with a special risk group (p greater than 0.05), we review treatment, follow-up and complications. The median survival was 6 months without significan differences (p greater than 0.05) with or without the finding of microvasculopathy, bilaterality or extraocular illness.

We describe the characteristics of 6 adult patients with meningitis by Listeria monocytogenes. Five of them had previous disease and only one of these was being treated with immunosuppressors. All of them presented meningeal syndrome with cephalorhachidean fluid's pleocytosis and five of them, polymorphonuclear predominance. The empirical treatment was correct only in two cases. The mortality rate reached 50%.

A distinction has to be made in the treatment of the acquired immune deficiency syndrome (AIDS), on one hand there is the treatment of the associated pathology that these patients suffer when their immune system is unable to cope with diseases such as opportunistic infections and neoplasms; on the other there is the treatment of the human immune deficiency virus (HIV) itself. In this work we review the state-of-the-art of both therapies, paying special attention to the treatment of opportunistic infections, because they hold responsibility for the deaths in 80% to 90% of these patients; the importance of the concept of prophylactic treatment, primary as well as secondary, in these diseases is outlined. The treatment of associated neoplasms has a worse outcome. Finally the antiviral therapies against HIV itself, are discussed, paying special attention to zidovudine (AZT) and didexosinosine, two of the more currently widely used drugs in the treatment of these patients. We end with the review of combined therapy, which probably will become, in the next future, the solution in the treatment of this disease.

We discuss 19 cases of infection due to Cryptococcus neoformans diagnosed in 438 AIDS patients admitted to our center (4%). Fourteen of them showed meningitis confirmed by culture of C. neoformans in CSF. Clinical features were rather unspecific and disorders in CSF parameters were non striking. The diagnostic techniques performed with best results were culture of C. neoformans and antigen determination, especially in serum. Survival probability at one year was 75%. Treatment response was good. Treatment with fluocytosine did not seem to provide additional benefits versus amphotericin alone, neither in respect to clinical evolution nor regarding survival probability at one year. Fluconazole has shown effectiveness in maintenance therapy, being not be possible to evaluate it as an acute phase therapy because the low number of cases in which it was studied. It is advisable to follow a suppressive treatment, having found a 10% relapse rate in patients following therapy and a 50% in those who interrupted it.

We report 15 cases of visceral leishmaniasis in adults, diagnosed by visualization of the parasite in 14 of them and in one case, based on clinic, serology and good response to treatment. Thirteen patients developed an acute clinical state and two patients, a subacute-chronic state. All of them had fever, half of them, a constitutional syndrome and 12, visceromegaly. Fifteen had anemia, 13, leukopenia and 10, thrombopenia. Serology was positive in 75% of cases. All patients were treated with meglumine antimoniate. No adverse effects were observed and in 14 patients, the treatment was successful. There were no recurrences. A patient died due to septic shock by Pneumococcus with DCI.

The presence of antibodies against HIV-2 was analyzed in serum samples from high-risk individuals for retrovirus infection, who were seropositives for HIV-1. Out of a total of 842 samples, 344 presented positive absorbency and 16, threshold ranges, in an enzymatic immunoassay (EIA) designed to detect simultaneously antibodies against HIV-1 and HIV-2. The Western Blot (WB) analysis confirmed the presence of antibodies against HIV-1 in 324 samples with positive or threshold EIA, while it was indetermined in 15 samples. WB was negative in 11 samples. In the 15 samples with indetermined WB and in the 16 samples with threshold EIA, the presence of antibodies against HIV-2 was investigated with an specific WB and a test designed with synthetic peptides (Pepti-lav). Three samples met the isolated seropositivity criteria for HIV-2. Those samples were from 3 african immigrants living in Madrid, which, until now, were asymptomatic, although one of them presented biological signs of immunodeficiency. None of them referred high-risk infectious practices, such a homosexuality or drug-addiction, although all of them referred heterosexual contacts in their native countries. Samples from native subjects meeting serum positivity criteria for HIV-2 were not identified.

A descriptive trial and an analysis of global survival, in relation to the different risk's groups and the type of clinical onset, was carried out in 401 patient diagnosed of AIDS in our hospital form 1984 to 1990. The males with addiction to parenteral drugs account for the most numerous group. Extrapulmonary tuberculosis was the most frequent presentation. During the period mentioned before, the survival distribution using the Kaplan-Meyer method was 52% for 12 months (SE = 0.0347). The survival rate was significantly higher (p less than 0.01) in those patients who presented an extrapulmonary tuberculosis as an onset of his disease.

From January 1984 to October 1990, 140 of 392 (35.7%) patients with the acquired immunodeficiency syndrome (AIDS) were found to have had tuberculosis. One hundred and sixteen were intravenous drug abusers and 16 were homosexual men. Fever, cough, weight loss and generalised lymphadenopathy were common features of their illness. Tuberculin skin tests were negative in 74% and 55% had intraabdominal lymphadenopathy. The chest radiographs showed hilar lymphadenopathy and lower lobe interstitial or alveolar infiltrates, but rarely cavitation. Forty-one of our patients had pulmonary tuberculosis, 38 had extra pulmonary and in 61 it was disseminated. In 80 cases tuberculosis was the presenting feature of AIDS. Tuberculosis usually responded well to chemotherapy.

All the cases of HIV infected patients diagnosed in our department during 1987 of Salmonella bacteremia are included in this report. Out of a total of 10 patients with both conditions, six were diagnosed of AIDS, three of AIDS related complex, and one presented an asymptomatic HIV infection. The mean age was 32.9 years (range 22 to 56). Eight of them were males, seven were intravenous drug addicts, and three were homosexual. Fever was observed in all cases and diarrhea in four of them. Salmonella enteritidis was isolated from the blood culture of nine patients and salmonella typhimurium from one. Salmonella enteritidis was isolated from the stool culture of 5 patients and Salmonella typhimurium and Campylobacter from the stool culture of one patient. Of the 10 patients 6 have died, 4 of them within the three weeks after the diagnosis of Salmonella non-typhi bacteremia, 2 have not relapsed and two patients were lost during follow up.