HIV AIDS

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For a week, a 39-year-old woman with a history of intravenous heroin use had generalized pain, fever, chills, and a nonproductive cough. She rated the pain at 10 on a scale of 1 to 10; it was sharp, constant, and unrelieved by heroin. She also reported dyspnea at rest, pleuritic chest pain, and a 15-lb weight loss over the past month. She had no significant medical history or drug allergies, smoked a half pack of cigarettes per day, and denied alcohol use.

A recent editorial in The New York Times heralded the conclusion, from 2 large sub-Saharan African studies, that male circumcision dramatically suppresses HIV acquisition rates as the "most important development in AIDS research since the debut of antiretroviral drugs."1 The editorial went on to state that while a "real [AIDS] vaccine is years away . . . we know its near equivalent [now] exists."1But Anthony Fauci, director of the National Institute for Allergy and Infectious Disease, was more circumspect. "These results could be negated by a small decrease in condom use or the addition of more sexual partners," he cautioned.2

SEATTLE -- For women, infection with a common sexually transmitted disease sharply increases the risk of contracting HIV, according to researchers here.

BOSTON -- For women in developing countries who are HIV-positive, a dose of Viramune (nevirapine) during labor to prevent mother-to-child viral transmission does not preclude the safe renewed use of Viramune-based antiretroviral therapy after a six-month delay.

SEATTLE -- Persons newly released from prison, within their first two weeks of freedom, have a nearly 13-fold higher risk of death than those in the general population.

LOS ANGELES -- Older patients admitted to a large academic medical center on busy shifts may have a greater mortality risk than those who come to the hospital on less frenetic days, suggested investigators here.

The introduction of effective antiretroviral therapy has resulted in dramatic clinical benefits for those persons who have access to it. Adherence to such therapy has emerged as both the major determinant and the Achilles' heel of this success. Many patients have levels of adherence too low for durable virologic control.

The first issue of the year 2007 marks thestart of 2 changes for The AIDS Reader. Thefirst is obvious-it’s in front of your noseright now: each month, I will provide a few editorialnotes on what you can expect in the issue.The second change is less conspicuous but moreimportant: a statement of any potential conflictof interest will now appear with each publishedarticle.

The elimination of perinatal HIV transmission in the United States is within reach. When antiretroviral therapy is effective in controlling maternal viremia during pregnancy, the risk of perinatal transmission is less than 1%.

HIV can be transmitted from an infected mother to her child during pregnancy or labor and postnatally through breast milk. Nearly 25 years after the first documented case of HIV infection, the decrease in perinatal HIV infections in the United States represents a major success in public health.

Liver disease, particularly hepatitis C, has emerged as a major cause of morbidity and mortality for people with HIV/AIDS in the era of potent antiretroviral therapy. Mortality is increased in patients with HIV–hepatitis C virus (HCV) coinfection compared with that in patients with HIV alone.1,2

The title of this column is the slogan from World AIDS Day 2006, and as we look to 2007 and a new Congress, a more appropriate slogan could not have been chosen. However, rather than keeping the promise, we are only slightly farther ahead than we were 1, 5, 10, or even 20 years ago and at some risk of going backward, as evinced by the sobering information made available through the World Health Organization (WHO) and the CDC.

Salivary gland enlargement, most commonly involving one or both parotid glands, is sometimes seen in association with HIV infection. Enlargement of the parotid gland may be due to diffuse infiltrative lymphocytosis syndrome; lymphoepithelial cysts; or malignant tumors, such as squamous cell carcinoma, Kaposi sarcoma, and Hodgkin and non-Hodgkin lymphomas.1,2 Non–HIV-related causes of parotid enlargement include acute and chronic viral infection, granulomatous disease, malnutrition, alcoholism, and diabetes mellitus.3,4 Here we report the case of a 41-year-old HIV-infected man with fat maldistribution syndrome associated with type 2 diabetes and hyperlipidemia. Sialadenosis developed presumably as a result of HIV infection and hypertriglyceridemia.

Shortly after the introduction of combination antiretroviral therapy, it was noted that a significant fraction of patients, from 8% to 17%, had poor CD4+ T-cell recovery despite suppression of HIV RNA to undetectable levels for at least 6 to 12 months.1

The authors report a case of adult-onset acute lymphoblastic leukemia (ALL) presenting with a right upper lobe infiltrate associated with acute fibrinous and organizing pneumonia (AFOP), which resolved spontaneously during the course of chemotherapy.

abstract: Pulmonary disease caused by nontuberculous mycobacteria (NTM) can be challenging to diagnose and manage. Patients typically present with nonspecific symptoms, such as cough and fever, and they often have underlying lung disease, which further complicates both diagnosis and treatment. To avoid treating pseudoinfection, the diagnosis should be based on a combination of the history and results of physical examination, radiographic imaging, and smears and cultures of at least 3 sputum samples. Occasionally, it is necessary to perform bronchoalveolar lavage or obtain tissue via transbronchial or open lung biopsy for histopathology and to assess for tissue invasion. Treatment involves a long course of often costly multiple antimycobacterial drugs. However, treatment with the second-generation macrolides, clarithromycin and azithromycin, has significantly improved cure rates for specific NTM infections. (J Respir Dis. 2007;28(1):7-18)

A 44-year-old man presented to the emergency department with complaints of neck swelling, bothersome cough, and difficulty in breathing. His breathing difficulty began 3 days earlier and progressively worsened.

US researchers recently reported initial phase 1 results from 2 vaccine candidates that successfully produced immune responses in healthy uninfected adults (Gibian JJ. United Press International. November 16, 2006). Eventually, the approach may be used to protect against HIV infection. Barney Graham of the NIH Vaccine Research Center and colleagues performed the tests (Graham BS, Koup RA, Roderer M, et al. J Infect Dis. 2006;194:1650-1660; Catanzaro AT, Koup RA, Roderer M, et al. J Infect Dis. 2006;194:1638-1649).

An agitated and confused 51-year-old man is brought to the emergency departmentby his family and friends. Recently, he had been drinking heavilyand smoking cocaine. He stopped using alcohol and cocaine 2 days earlier,after he began to vomit.

For the past week, a 16-year-old boy has had a progressively worsening dry, irritating cough; dyspnea on exertion; and intermittent fever and chills. During the past 24 hours, he has had no appetite and has vomited greenish material 3 or 4 times.

A thin 26-year-old man has hadintermittent diarrhea with abdominalpain, nausea, vomiting, and occasionalepisodes of hematochezia for8 months. He also complains of weaknessand fatigue and has lost 4.5 kg(10 lb) in the past year. The patientis homosexual and admits to havinghad unprotected sexual intercourse.He denies any significant travelhistory.

For the past 3 days, a 45-year-old man has had discomfort andloss of hearing in one ear. There is no fever or history of trauma. The manwas recently treated for an ear infection at a local clinic. Physical examinationreveals erythema of the postauricular area and purulent exudate from the earcanal.

abstract: The keystone of influenza prevention is still vaccination. The 2 available types of influenza vaccine--the inactivated vaccine, which is administered intramuscularly, and the attenuated vaccine, which is delivered via nasal spray--have efficacy rates of 70% to 80%. Unfortunately, only about 65% of persons who should receive the influenza vaccine are, in fact, vaccinated. The neuraminidase inhibitors oseltamivir and zanamivir are 70% to 90% effective in preventing influenza. These antivirals also are effective in reducing the severity of influenza symptoms and the duration of illness when administered within 48 hours of the onset of clinical disease. Some patients have difficulty in self-administering zanamivir because the inhalation process is fairly complicated. Because of the resistance pattern observed in 2005, amantadine and rimantadine are not currently recommended for prophylaxis or therapy. (J Respir Dis. 2007;28(1):21-29)

An asymptomatic 42-year-old woman who has HIV/AIDS presents for aroutine check-up. She denies abdominal pain, nausea, vomiting, diarrhea,paresthesias, and muscle weakness.