This month’s Managing Managed Care reviews just a few of the many presentations from the International AIDS Conference that have some relevance to patient care today. One of the highlights was a discussion of the current status of HIV eradication.

As the 2008 election draws closer, the questions of candidates and campaign issues occupy more and more space in print media, minutes on radio and television, and bandwidth in the ubiquitous blogs and spam messages that have become the modern equivalent of brochures hung on the doorknob.

Cutaneous manifestations of immune recovery in response to highly active antiretroviral therapy may account for up to 54% to 78% of the clinical presentations of the immune reconstitution syndrome (IRS)

A 14-year-old boy of African origin with HIV infection presented to the emergency department complaining of sore, swollen eyes and a sore throat. His antiretroviral treatment at that time consisted of lopinavir/ ritonavir and abacavir/lamivudine fixed-dose combination.

We report a case of osteomyelitis due to Mycobacterium avium-intracellulare complex (MAC) in an AIDS patient shortly after the initiation of antiretroviral therapy with subsequent immune reconstitution inflammatory syndrome (IRIS).

An assessment of rapid HIV testing offered in emer­-gency department (ED) settings found the OraQuick ADVANCE Rapid HIV-1/2 Antibody Test produced a high rate of false-positives (Reuters. August 5, 2008).

A 42-year-old white woman with AIDS presented to the emergency department (ED) with a 5-day history of persistent, high-grade fever (temperature of 38.3°C to 40.0°C [101°F to 104°F]); generalized weakness; malaise; and mild headache. The previous night she noted the onset of nausea, emesis, and loss of appetite.

The skin is the most common organ to manifest immune reconstitution syndrome (IRS).1-3 While many viral dermatoses are described in the context of antiretroviral-induced immune recovery (eg, herpesvirus infections, molluscum, genital condylomata, verruca vulgaris),4,5 the case report by Iarikov and colleagues6 is the first report of verruca plana in this setting.

Now that baby boomers have reached the age of Medicare eligibility, joint replacements are on the rise. Because patients who undergo hip or knee arthroplasty require anticoagulation, primary care physicians have a key role in the care of these persons- before as well as after surgery.

It can be difficult to determine whether unusual, paroxysmal behavior represents a seizure or a nonepileptic event. Patients with sudden flailing movements or unresponsive staring may, in fact, be experiencing psychogenic events. Other types of pathological spells, such as syncope and migraine, can also be mistaken for epileptic seizures.

Levothyroxine is one of the most commonly prescribed medications for the treatment of hypothyroidism as well as the suppression of thyroid neoplasms.1 Most patients with hypothyroidism require lifelong therapy with levothyroxine; therefore, the likelihood of drug interactions is high.

Kaposi sarcoma was diagnosed in a 54-year-old woman who had had a renal transplant. These multiple purple patches, plaques, and nodules abruptly appeared on the patient’s abdomen when she was taking prednisone and azathioprine.

A 74-year-old man who had Parkinson disease dementia presented with constipation and bloating associated with abdominal pain.

Because widespread use of highly active antiretroviral therapyhas made it possible for persons with HIV infection to livelonger, the epidemiology of HIV/AIDS has shifted in severalways. The number of persons 50 years and older living withHIV/AIDS has risen in recent years, and there has been asubstantial increase in common comorbidities associated withaging in this population. These changes place new emphasis onthe important role of primary care in HIV/AIDS management.[Infect Med. 2008;25:477-480]

Community-acquired pneumonia is a frequent cause ofhospital admission in adults. It usually results from infectionwith pathogens such as Streptococcus pneumoniae, Haemophilusinfluenzae, Mycoplasma, and Chlamydia, among others. In a fewcases, pneumonia develops from infection with unusualpathogens, such as Pasteurella multocida, a gram-negativeorganism commonly found in the mouths of cats and dogs.We report a case of P multocida pneumonia associated with skintrauma caused by cat scratches in a woman with a history ofchronic obstructive pulmonary disease. [Infect Med. 2008;25:487-489]

Fungal infections are a major cause of morbidity and mortalityin immunosuppressed hosts, such as patients with HIV-1 infectionand those who are otherwise neutropenic. Thus, antifungalprophylaxis has become important in the care of patients withAIDS, transplant recipients, persons receiving chemotherapy,and other at-risk persons. This first installment in a 3-part serieson opportunistic fungal infections in the immunocompromisedperson reviews the pathogenesis of opportunistic fungal infectionsin select at-risk populations and the pharmacotherapeuticarmamentarium available for prophylaxis and treatment.[Infect Med. 2008;25:448-456, 473]

A zoonosis is any disease-bacterial, mycotic, viral, or parasitic-that is transmissible from an animal to a human. More than 200 zoonoses have been identified. The newly emerging zoonosis that has achieved star status in the medical press is avian influenza. Another emerging threat is Nipah virus, which is transmitted from pigs to humans in the agricultural setting and causes encephalitis. But animal to human transmission of zoonoses are multimodal: from exposure to animal secretions in the agricultural setting, to transmission through insect vectors and ingestion of contaminated animal products, to more insidious routes, such as petting or being scratched or nipped at by one's pet dog, bird, cat, lizard, or other creature. A few interesting cases are presented here.

Fonsecaea species have been reported as causative agents ofchromoblastomycosis, eumycetoma, and fungal pneumonitis.However, Fonsecaea rarely involves the CNS, with few cases ofcerebral infection reported in the literature. Fonsecaea monophoramay have greater neurotropic potential than other species ofthis genus. We describe a rare presentation of brain abscesscaused by F monophora in an immunocompromised renaltransplant patient. [Infect Med. 2008;25:469-473]

A 52-year-old woman presented with a 12-day history of diarrhea and mild stool incontinence that began 2 to 3 hours after a routine screening colonoscopy. Six or 7 bowel movements of liquid, orange-yellow feces occurred each day for 12 days. The patient reported that associated nausea, flatulence, and severe abdominal cramping were relieved by the bowel movements. She also reported that a small amount of mucus was occasionally observed in the stool and that bright red blood streaks appeared on used toilet paper, although the stool itself was not bloody. She was able to tolerate a full diet, although food exacerbated the urgency. She was afebrile during this illness.

ALTHOUGH ENDEMIC MEASLEStransmission has been eliminatedthanks to vaccination efforts,measles outbreaks nevertheless arebecoming increasingly common becauseof importation of measles viainternational travel and a growingpopulation of unvaccinated childrenin the United States. That the numberof reported cases of measles inthe first half of 2008 was the highestyear-to-date since 1996-131 cases-is a cause for alarm. The CDC notedthat measles is one of the first diseasesto reemerge when rates of vaccinationcoverage decline. In its reportand commentary in the August22 issue of Morbidity and MortalityWeekly Report (Update: Measles-United States, January-July 2008.MMWR. 2008;57:893-896), the CDCsuggested that these outbreaks reflecta trend among parents to optout of having their children vaccinatedfor either religious or philosophicalreasons.