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Seventy-one patients with cryptococcal meningitis, 46 males and 25 females, aged 15-83 years, were included in this study. Their initial clinical manifestations, cerebrospinal fluid (CSF) features, and therapeutic results were analysed. Patients were treated with three different regimens: amphotericin B, fluconazole, and combination therapy. Based on the therapeutic results, the 71 patients were also divided into cured, improved, and failed groups. For statistical comparison, the clinical manifestations and CSF features, were compared according to therapeutic outcome. There was no statistical difference in outcome among the three different antifungal regimens. However, patients treated with fluconazole required 36% fewer days of hospitalization compared with those receiving amphotericin B. Significant prognostic factors, included low CSF glucose, high CSF lactate, high CSF crypt hydrocephalus, and central nervous system vasculitis. Multiple logistic regression analysis showed that only initial level of consciousness, and CSF antigen titre were strongly associated with therapeutic failure after other potentially confounding factors were adjusted for. Because some of the prognostic factors in cryptococcal meningitis can be corrected, early diagnosis, early use of appropriate antifungal treatment, and the correction of the underlying metabolic derangements are important in management.
Study of the aetiologic agents of meningitis in Kumasi, Ghana, with special reference to Cryptococcal neoformans
Tabour E; Cairns J; Gerety RJ; Bayley AC; National Cancer Institute,
National Institutes of Health, Bethesda, MD 20892
East-Afr-Med-J. 1998 Sep; 75(9): 516-9
- OBJECTIVE:
To evaluate the importance of Cryptococcus neoformans, an opportunistic in meningitis, in healthy and HIV infected patients in Kumasi, Ghana.- DESIGN:
A prospective study; isolating the aetiologic agents of meningitis from cerebrospinal fluid (CSF) using standard methods.- SETTING:
Kumasi city, Ashanti region of central Ghana.- SUBJECTS:
One thousand five hundred and seventy patients suspected of meningitis, including 28 HIV infected and AIDS patients. MAIN- OUTCOME MEASURE:
The pattern and distribution of the main etiologic agents of meningitis in Kumasi, Ghana shown. RESULTS: Of the 1570 CSF samples examined, 1256 (80%) showed no abnormality. Of the 314 (20%) with abnormalities, 147 were bacterial, and 167 diagnosed aseptic. No cryptococcal cells were found.- CONCLUSION:
There is a paucity of cryptococcal meningitis in Kumasi, Ghana, and it is not recommended to screen
Efficacy and adverse effects of higher dose amphotericin B monotherapy for cryptococcal meningitis in patients with advanced HIV infection
Hsieh-SM; Hung-CC; Chen-MY; Hsueh-PR; Chang-SC
Chung-Hua-Min-Kuo-Wei-Sheng-Wu-Chi-Mien-I-Hsueh-Tsa-Chih: 1998 Dec; 31(4): 233-9
Treatment with a low daily dose of amphotericin B (0.4 mg/kg) in AIDS patients with cryptococcal meningitis has been associated with low efficacy and high mortality. We report our successful clinical experiences on a higher daily dose of amphotericin B (0.8-1.0 mg/kg) monotherapy in treating cryptococcal meningitis from June 1994 to August 1997 in 13 cases of advanced HIV infection. Most of them (12/13) had at least one of several poor prognostic factors. The mean duration of amphotericin B administration was 26 days (range, 3 to 58 days). Both microbiologically and clinically successful rates of treatment at the end of amphotericin B therapy were high (85%, 11/13). The median duration of negative CSF culture post therapy was 17 days (range, 8 to 33 days). Bone marrow toxicities were; thrombocytopenia (46%) and significant anemia (92%) after a mean of 9 days of treatment. Both, and lipase values were present in 6 cases (46%). Our report reveals that a higher daily dose of amphotericin B can achieve a high efficacy in treatment of cryptococcal meningitis in AIDS patients, even though most cases had poor prognostic factors and were in severe immunocompromised states. However, clinicians should monitor higher dose-related adverse effects carefully.
HIV Infections and Seizures
Garg-RK
Postgrad-Med-J. 1999 Jul; 75(885): 387-90
New-onset seizures are frequent manifestations of central nervous system disorders in patients infected with human immunodeficiency virus (HIV). Seizures are more common in advanced stages of the disease, although they may occur early in the course of illness. In the majority of patients, seizures are of the generalised type. Status epilepticus is also frequent. Associated metabolic abnormalities increase the risk for status epilepticus. Cerebral mass lesions, cryptococcal meningitis, and HIV-encephalopathy are common causes of seizures. Phenytoin is the most commonly prescribed anticonvulsant in this situation, although several patients may experience hypersensitivity reactions. The prognosis of seizure disorders in HIV-infected patients depends upon the underlying cause.
Etiology of central nervous system infections in the Philippines and the role of serum C-reactive protein in excluding acute bacterial meningitis
Sutinen-J; Sombrero-L; Paladin-FJ; Julkunen-I; Leinikki-P; Hernandez-E; Saniel-M; Brato-D; Ruutu-P
Int-J-Infect-Dis. 1998-99 Winter; 3(2): 88-93
- OBJECTIVES:
The value of measurements of serum C-reactive protein (CRP) in differentiating central nervous system (CNS) infections of varying etiologies in the Philippines was investigated.- METHODS:
A wide array of bacteriologic and virologic methods as well as computed tomography, typical clinical presentation, and autopsy were used for etiologic diagnosis.- RESULTS:
Among 103 patients with CNS infection, etiology was identified in 60 (58%) cases. Bacteria were found in 19 (including 7 Streptococcus pneumoniae, 5 Haemophilus influenzae, 3 Neisseria meningitidis), tuberculosis in 4, viruses in 38 (including 20 coxsackievirus, 8 measles, 4 adenovirus, and 4 poliovirus infections), and brain abscess in 3 patients. C-reactive protein was elevated on admission in all 18 cases of bacterial meningitis tested, exceeding 50 mg/L in 17 (94%), and was not affected by prior antibacterial tr. In the viral group one third had CRP above 50 mg/L. In patients with tuberculous meningitis, brain abscess, or cryptococcal meningitis, CRP was moderately to highly elevated.- CONCLUSIONS:
In the presence of a normal CRP concentration (below 10 mg/mL) acute bacterial meningitis is excluded even in a developing country setting and antimicrobial therapy is not warranted.
Opportunistic infections of the central nervous system during HIV-1 infection (emphasis on cytomegalovirus disease)
Roullet-E
J-Neurol. 1999 Apr; 246(4): 237-43
Toxoplasma encephalitis, cryptococcal meningitis, progressive multifocal leukoencephalopathy (PML), and cytomegalovirus (CMV) encephalitis are the most common opportunistic infections of the central nervous system (CNS) in HIV-infected patients. They occur at variable degrees of immunosuppression, and their diagnosis is based on a systematic evaluation with includes, in a definite order, ongoing prophylactic therapies, extraneurological signs, neuroimaging and CSF studies, and an anti-Toxoplasma therapeutic trial. Concurrent neurological HIV-CNS disease (such as the AIDS dementia complex) is frequent. The development of reliable molecular biology techniques such as the polymerase chain reaction and their application to the CSF have made the diagnosis of virus-related opportunistic infections much easier and has limited the need for cerebral biopsy. The incidence of opportunistic!
Rapid diagnosis of cryptococcal meningitis by microscopic examination of centrifuged cerebrospinal fluid sediment.
Sato-Y; Osabe-S; Kuno-H; Kaji-M; Oizumi-K
J-Neurol-Sci. 1999 Mar 15; 164(1): 72-5
The classic India ink test is positive in only half of cryptococcal meningitis cases, and reliable, rapid cryptococcal antigen (CRAG) testing requires technical expertise and facilities not always available. We therefore examined cerebrospinal fluid (CSF) sediment using May-Giemsa, periodic acid-Schiff, and Gram stains in 16 patients with cryptococcal meningitis. The India ink test was positive in seven patients (44%), while microscopic examination of sediment revealed cryptococci in 13 (81%); in six of these 13 the India ink test was negative. Both methods failed to detect the pathogen in the remaining three patients. CRAG testing in CSF was negative in two patients (one with acquired immunodeficiency syndrome, one with diabetes mellitus) whose India ink test also was negative while cryptococci were identified in their CSF sediment. No false positives occurred with CSF May-Giem! icroscopic examination of centrifuged and stained CSF sediment proved more sensitive for rapid diagnosis of cryptococcal meningitis than the India ink method, and in two of our patients cryptococci were seen in centrifuged CSF sediment despite negative CRAG and India ink tests.
Risk factors for cryptococcal meningitis in HIV-infected patients
Oursler-KA; Moore-RD; Chaisson-RE
AIDS-Res-Hum-Retroviruses. 1999 May 1; 15(7): 625-31
To identify the risk factors for cryptococcal meningitis in patients with HIV disease we conducted a nested case-control study of 37 incident cases of cryptococcal meningitis and 74 controls, identified from a cohort of more than 2000 HIV-infected patients. Conditional logistic regression was used to study demographic and AIDS-related variables in addition to fluconazole and steroid use. No difference in demographic variables, HIV risk factors, or stage of AIDS was detected between cases and controls. Exposure to fluconazole for more than 90 days reduced the risk of cryptococcal meningitis by 82% (OR=0.18; 95% CI=0.04-0.85; p=0.03). We did not find a difference in steroid use between cases and controls for either the length or amount of steroid exposure (p=0.41). No difference in survival during follow-up in the clinic was observed by the log-rank test (p=0.74). Among the cases, cultures were positive in 81 and 44% of the samples, respectively. We conclude that demographic factors did not affect the risk of cryptococcal meningitis in an inner city United States population. While fluconazole use has a protective effect, steroid use was not associated with an increased risk of cryptococcal meningitis in HIV-infected patients.
Use of cerebrospinal fluid shunt for the management of elevated intracranial pressure in a patient with active AIDS-related cryptococcal meningitis
Mylonakis-E; Merriman-NA; Rich-JD; Flanigan-TP; Walters-BC; Tashima-KT; Mileno-MD; van-der-Horst-CM
Diagn-Microbiol-Infect-Dis. 1999 Jun; 34(2): 111-4
]. Persistently elevated intracranial pressure (ICP) is one of the most accurate predictors of a poor prognosis in patients with AIDS-related cryptococcal meningitis. We present a severe case of persistent cryptococcal meningitis in a patient with advanced AIDS, complicated by elevation of ICP. A ventriculoperitoneal shunt was placed that successfully lowered the ICP and alleviated the associated symptoms. The elevated ICP secondary to AIDS-related cryptococcal meningitis should be treated aggressively. Despite the risk of shunt complications, cerebrospinal fluid shunts can be considered in these patients if they do not respond to other treatment.
Early mycological treatment failure in AIDS-associated cryptococcal meningitis
Robinson-PA; Bauer-M; Leal-MA; Evans-SG; Holtom-PD; Diamond-DA; Leedom-JM; Larsen-RA
Clin-Infect-Dis. 1999 Jan; 28(1): 82-92
Cryptococcal meningitis causes significant morbidity and mortality in persons with AIDS. Of 236 AIDS patients treated with amphotericin B plus flucytosine, 29 (12%) died within 2 weeks and 62 (26%) died before 10 weeks. Just 129 (55%) of 236 patients were alive with negative cerebrospinal fluid (CSF) cultures at 10 weeks. Multivariate analyses identified that titer of cryptococcal antigen in CSF, serum albumin level, and CD4 cell count, together with dose of amphotericin B, had the strongest joint association with failure to achieve negative CSF cultures by day 14. Among patients with similar CSF cryptococcal antigen titers, CD4 cell counts, and serum albumin levels, the odds of failure at week 10 for those without negative CSF cultures by day 14 was five times that for those with negative CSF cultures by day 14 (odds ratio, 5.0; 95% confidence interval, 2.2-10.9). Prognosis is three components that, along with initial treatment, have the strongest joint association with early outcome. Clearly, more effective initial therapy and patient management strategies that address immune function and nutritional status are needed to improve outcomes of this disease.
Treatment of hydrocephalus secondary to cryptococcal meningitis by use of shunting
Park-MK; Hospenthal-DR; Bennett-JE
Clin-Infect-Dis. 1999 Mar; 28(3): 629-33
Hydrocephalus can be associated with increased morbidity and mortality in cryptococcal meningitis if left untreated. Both ventriculoperitoneal and ventriculoatrial shunting have been used in persons with cryptococcosis complicated by hydrocephalus, but the indications for and complications, success, and timing of these interventions are not well known. To this end, we reviewed the clinical courses of 10 non-human immunodeficiency virus-infected patients with hydrocephalus secondary to cryptococcal meningitis who underwent shunting procedures. Nine of 10 patients who underwent shunting had noticeable improvement in dementia and gait. Two patients required late revision of their shunts. Shunt placement in eight patients with acute infection did not disseminate cryptococcal infection into the peritoneum or bloodstream, nor did shunting provide a nidus from which Cryptococcus organi ocephalus in patients with cryptococcal meningitis and need not be delayed until patients are mycologically cured.
A comparison of itraconazole versus fluconazole as maintenance therapy for AIDS-associated cryptococcal meningitis. National Institute of Allergy and Infectious Diseases Mycoses Study Group
Saag-MS; Cloud-GA; Graybill-JR; Sobel-JD; Tuazon-CU; Johnson-PC; Fessel-WJ; Moskovitz-BL; Wiesinger-B; Cosmatos-D; Riser-L; Thomas-C; Hafner-R; Dismukes-WE
Clin-Infect-Dis. 1999 Feb; 28(2): 291-6
This study was designed to compare the effectiveness of fluconazole vs. itraconazole as maintenance therapy for AIDS-associated cryptococcal meningitis. HIV-infected patients who had been successfully treated (achieved negative culture of CSF) for a first episode of cryptococcal meningitis were randomized to receive fluconazole or itraconazole, both at 200 mg/d, for 12 months. The study was stopped prematurely on the recommendation of an independent Data Safety and Monitoring Board. At the time, 13 (23%) of 57 itraconazole recipients had experienced culture-positive relapse, compared with 2 relapses (4%) noted among 51 fluconazole recipients (P = .006). The factor best associated with relapse was the patient having not received flucytosine during the initial 2 weeks of primary treatment for cryptococcal disease (relative risk = 5.88; 95% confidence interval, 1.27-27.14; P = .04) coccal disease. Flucytosine may contribute to the prevention of relapse if used during the first 2 weeks of primary therapy.
Meningitis in a community with a high prevalence of tuberculosis and HIV infection
Silber-E; Sonnenberg-P; Ho-KC; Koornhof-HJ; Eintracht-S; Morris-L; Saffer-D
J-Neurol-Sci. 1999 Jan 1; 162(1): 20-6
- OBJECTIVES:
To evaluate the spectrum of aetiologies, and distinguishing clinical and laboratory features, of meningeal infection in a community with a high prevalence of tuberculosis (TB) and HIV infection. SETTING: A hospital serving mineworkers, originating from rural areas of Southern Africa.- DESIGN:
Prospective cohort of 60 consecutive lumbar punctures (LPs), performed for suspected meningitis.- MEASUREMENTS:
Clinical history and examination; concurrent cerebrospinal fluid (CSF) and blood samples; mortality status six months after entry to study. RESULTS: 38 of 57 patients (66.7%) were HIV-1 positive, 59.5% of whom had a CD4 count <200 cells/mm3. Nine patients had tuberculous meningitis (TBM) and two had tuberculomas; four developed disease while on TB therapy. There was one case of multidrug, and two of isoniazid-resistant TBM. There were nine episodes of cryptococcal meningitis and four with AIDS dementia complex (ADC). Ten patients with meningococcal infection, part of a larger outbreak, were significantly younger (p=0.004). All patients with tuberculous, cryptococcal (most immune-suppressed p<0.001) and aseptic meningitis were HIV-1 positive. Within six months, 19 patients had died. Death was associated with HIV positivity (p=0.004), low CD4 count (p<0.001) and a diagnosis of cryptococcal meningitis, CNS TB or ADC.- CONCLUSION:
HIV has a major impact on the burden of disease and mortality, with a predominance of opportunistic chronic meningitides, despite a meningococcal outbreak, in this community. Of concern is the development of TBM despite therapy, and the emergence of drug-resistant strains.
Cryptococcus meningoencephalitis in AIDS: parenchymal and meningeal forms
Berkefeld-J; Enzensberger-W; Lanfermann-H
Neuroradiology. 1999 Feb; 41(2): 129-33
CT and MRI in one case of Cryptococcus neoformans infection showed contrast-enhancing parenchymal lesions resembling granulomata or abscesses. After an initial phase without contrast enhancement, the full extent of the lesions was visible within 2 weeks of presentation. The enhancing masses were assumed to represent intracerebral cryptococcomasDespite evidence of massive meningeal infection on cerebrospinal fluid (CSF) examination, no radiological signs of meningitis, invasion of the Virchow-Robin spaces or ventriculitis could be demonstrated. With antimycotic treatment the contrast enhancement disappeared and cystic, partly calcified lesions remained. Recurrence of meningeal infection without radiological correlates was apparent in this stage. In a second case of proven cryptococcus meningitis, dilation of Virchow-Robin spaces or cysts in the adjacent parenchyma were the main nt. reactions of the immunocompromised hosts to infection with C. neoformans: widening of the perivascular spaces as a correlate of the more typical meningeal infection and enhancing parenchymal lesions as a sign of further invasion from the CSF spaces. Enhancement of cryptococcomas, indicating an inflammatory response in the surrounding brain, is not typical in patients with impairment of immune function.
Pulmonary cryptococcosis in patients without HIV infection
Aberg-JA; Mundy-LM; Powderly-WG need citation
Chest. 1999 Mar; 115(3): 734-40
- PURPOSE:
To further elucidate the diagnostic and therapeutic approaches to patients with pulmonary cryptococcosis who are not HIV-infected.- SUBJECTS:
All of the patients without HIV infection who received care at two Midwest hospitals between January 1986 and February 1996 and had a respiratory isolate of Cryptococcus neoformans.- METHODS:
The medical records of the study patients were reviewed for demographic data, host immune status, respiratory symptoms, diagnostic studies, treatment, and follow-up.- RESULTS:
Forty-two patient presentations comprised the overall study group. Thirty-six patients (85.7%) had no evidence of dissemination, and six patients (14.3%) had disseminated disease. Seven of the 36 patient presentations were definitive pulmonary cryptococcosis, 15 were presumptive disease, and 14 were colonization with C neoformans. A serum cryptococcal antigen (sCRAG) was positive for 7 of 18 patients, 3 of whom were proven by culture to have a disseminated infection. A negative sCRAG was observed in 11 patients, one of whom had proven dissemination. Fifteen patients underwent a lumbar puncture as part of their evaluation, and cryptococcal meningitis was diagnosed in three of these patients, all of whom had positive blood cultures for C neoformans. The majority of the patients did not receive antifungal therapy.- CONCLUSION:
In the majority of the patients, the lung appeared to be the sole organ involved, and a workup for systemic infection was rarely helpful. A positive sCRAG was not specific for dissemination. Antifungal therapy should be reserved for symptomatic patients, for patients with a positive sCRAG, and for patients with underlying immunosuppression.
A glucan synthase FKS1 homolog in cryptococcus neoformans is single copy and encodes an essential function
Thompson-JR; Douglas-CM; Li-W; Jue-CK; Pramanik-B; Yuan-X; Rude-TH; Toffaletti-DL; Perfect-JR; Kurtz-M
J-Bacteriol. 1999 Jan; 181(2): 444-53
Cryptococcal meningitis is a fungal infection, caused by Cryptococcus neoformans, which is prevalent in immunocompromised patient populations. Treatment failures of this disease are emerging in the clinic, usually associated with long-term treatment with existing antifungal agents. The fungal cell wall is an attractive target for drug therapy because the syntheses of cell wall glucan and chitin are processes that are absent in mammalian cells. Echinocandins comprise a class of lipopeptide compounds known to inhibit 1,3-beta-glucan synthesis, and at least two compounds belonging to this class are currently in clinical trials as therapy for life-threatening fungal infections. Studies of Saccharomyces cerevisiae and Candida albicans mutants identify the membrane-spanning subunit of glucan synthase, encoded by the FKS genes, as the molecular target of echinocandins. In order to examine why C. neoformans cells are less susceptible to echinocandin treatment, we have cloned a homolog of S. cerevisiae FKS1 from C. neoformans. We have developed a generalized method to evaluate the essentiality of genes in Cryptococcus and applied it to the FKS1 gene. The method relies on homologous integrative transformation with a plasmid that can integrate in two orientations, only one of which will disrupt the target gene function. The results of this analysis suggest that the C. neoformans FKS1 gene is essential for viability. The C. neoformans FKS1 sequence is closely related to the FKS1 sequences from other fungal species and appears to be single copy in C. neoformans. Furthermore, amino acid residues known to be critical for echinocandin susceptibility in Saccharomyces are conserved in the C. neoformans FKS1 sequence.
A retrospective study on the efficacy and safety of amphotericin B in a lipid emulsion for the treatment of
cryptococcal meningitis in AIDS patients
Torre-D; Banfi-G; Tambini-R; Speranza-F; Zeroli-C; Martegani-R; Airoldi-M; Fiori-G
J-Infect. 1998 Jul; 37(1): 36-8
To evaluate the efficacy and safety of Amphotericin B dissolved in dextrose (Amb) or in a lipid emulsion (Intralipid, Amb-IL) in AIDS patients with cryptococcal meningitis, we conducted a retrospective study in 30 AIDS patients with cryptococcal meningitis. A clinical complete resolution was obtained in 11 patients (55%) treated with Amb, and in six patients (60%) treated with Amb-IL. Intralipid did not decrease the infusion-related adverse effects, in particular nephrotoxicity and anaemia. Our results indicate that Amb-IL formulation is useful in the treatment of cryptococcal meningitis in AIDS patients, but it does not reduce the infusion-related adverse events.
Causes of death in a rural, population-based human immunodeficiency virus type 1 (HIV-1) natural history cohort in Uganda
Okongo-M; Morgan-D; Mayanja-B; Ross-A; Whitworth-J
Int-J-Epidemiol. 1998 Aug; 27(4): 698-702
- BACKGROUND:
While human immunodeficiency virus (HIV)-related causes of death have been well documented in developed countries, in Africa data are scanty and mainly based on autopsy studies from city hospitals which are highly selective and may not represent causes of HIV-associated deaths in the general population. This study, from a rural population, describes the causes of death in HIV-positive people and their HIV-negative controls.- METHODS:
A natural history cohort comprising HIV-1 infected participants and HIV-negative controls was established in rural Uganda in 1990. Causes of death were determined by reviewing the premorbid clinical and laboratory findings and from information obtained from relatives. Blindness to the deceased's HIV serostatus was maintained throughout.- RESULTS:
In all, 78 deaths occurred over a 6-year period: 63 deaths occurred in the HIV-positive cases !t cases, 56%, and 9% the incident cases enrolled died, compared with 7% of the HIV-negative controls. Of the 55 HIV-positive cases with sufficient data to establish cause of death, 52 (95%) were assessed as having HIV-associated deaths and 48 (87%) died in WHO stage 4 (AIDS). The main causes of death were wasting syndrome (31%), chronic diarrhoea (22%), cryptococcal meningitis (13%) and chest infection (11%).- CONCLUSIONS:
Our results represent an unbiased selection of deaths in a rural area. The HIV-positive cases have high death rates and die of HIV-related pathologies. The main causes of death reflect the WHO clinical case definition of AIDS. Cryptococcal meningitis is also a common cause of death in this population.
The effect of adjunctive corticosteroids for the treatment of Pneumocystis carinii pneumonia on mortality and subsequent complications
Gallant-JE; Chaisson-RE; Moore-RD
Chest. 1998 Nov; 114(5): 1258-63
- OBJECTIVE:
To assess the long-term safety of adjunctive corticosteroids in the treatment of Pneumocystis carinii pneumonia (PCP).- DESIGN:
Analysis of data from a large prospective observational database.- SETTING:
HIV clinic at a large urban teaching hospital.- PATIENTS:
One hundred seventy-four patients who developed PCP after being enrolled in the database.- RESULTS:
Fifty-three patients (30%) received adjunctive corticosteroids and 121 (70%) did not. Survival did not differ between groups after adjusting for CD4 count (relative risk for adjunctive corticosteroids = 0.74, p = 0.13). There were no differences in the incidence of cytomegalovirus disease (adjunctive corticosteroids: 18.5 cases per 100 person-years vs no adjunctive corticosteroids: 15.7, p = 0.22), Mycobacterium avium complex (23.4 vs 27.0, p = 0.73), cryptococcal meningitis (1.8 vs 4.1, p = 0.58), toxoplasmosis (3.6 vs. 0.66), herpes zoster (3.8 vs 6.9, p = 0.71), oropharyngeal candidiasis (18.9 vs 10.9, p = 0.09), or non-Hodgkin's lymphoma (3.5 vs 4.2, p = 0.92). Esophageal candidiasis was more common among adjunctive corticosteroid recipients (45.1 vs 26.6, p = 0.01). Results were similar for time to development of opportunistic conditions.- CONCLUSIONS:
Adjunctive corticosteroids do not increase mortality or the risk of most common HIV-associated complications.
Combination therapy with fluconazole and flucytosine for cryptococcal meningitis in Ugandan patients with AIDS
Mayanja-Kizza-H; Oishi-K; Mitarai-S; Yamashita-H; Nalongo-K; Watanabe-K; Izumi-T; Ococi-Jungala; Augustine-K; Mugerwa-R; Nagatake-T; Matsumoto-K
Clin-Infect-Dis. 1998 Jun; 26(6): 1362-6
We performed a randomized trial in which combination therapy with fluconazole and short-term flucytosine was compared with fluconazole monotherapy in 58 patients with AIDS-associated cryptococcal meningitis (CM). Thirty of these patients were randomized to receive combination therapy with fluconazole, 200 mg once a day for 2 months, and flucytosine, 150 mg/(kg.d) for the first 2 weeks, and 28 were randomized to receive monotherapy with fluconazole at the same dose for 2 months. Patients in both groups who survived for 2 months received fluconazole as maintenance therapy at a dose of 200 mg three times per week for 4 months. The combination therapy prevented death within 2 weeks and significantly increased the survival rate among these patients (32%) at 6 months over that among patients receiving monotherapy (12%) (P = .022). The combination therapy also resulted in a significant! .005). No serious adverse reactions were observed in patients receiving either regimen. These data indicate that treatment with fluconazole and short-term flucytosine is a cost-effective and safe regimen that improves the quality of life for patients with AIDS-associated CM in developing countries where human immunodeficiency virus is endemic.
Coping Strategies:
Church members give help in the form of food, transport and visit the patient. Neighbours give food and also visit the patient. Nevertheless, this assistance to the family ceases when the person dies. Only female-headed households were aware of government aid and less than 20% of them were actually receiving government assistance. The currently employed household-level coping strategies are shown in the following behaviors at the two sites:
Suggested Strategies and Conclusion:
From focus group discussions and experiences from other countries come these suggestions for coping:
Poverty intensifies the impact of adult mortality and morbidity in these two Zambian suburban sites, particularly in Zambia Compound, where constraints on capital and work opportunities prevent households from diversifying their incomes. Thus, besides intensifying AIDS awareness, programmes are needed to develop the social infrastructure of Zambia Compound as a long-term mitigation strategy.
This study is part of a wider household impact study in Southern Africa coordinated by Dr. Gladys Mutangadula, Programme Officer, SAFAIDS. At the time of writing this article, Douglas Webb was Research Officer for UNICEF in Lusaka, Zambia. He is currently based in the UK.
| Message | Intake | Follow-up (6 months) | |
|---|---|---|---|
| Female condom | 26% | 75% | |
| Male condom | 28% | 70% | |
| HierarchyK | 32% | 75% |
In the male condomonly group, the educational message included male condom usage and negotiation skills. In the female condomonly group, women received information on the body, skills for female condom use and raising motivation and comfort levels in using it.
Finally, in the hierarchy group, the women were taught skills in the use of each method (female condom, male condom, diaphragm, cervical cap, spermicides), the relative effectiveness of the different methods (the methods were organised vertically, from most to least efficacious against STD/HIV), and how to insert a barrier method. The hierarchy arm stressed two points: one, among protection options, female and male condoms are the most protective when used properly and consistently, and therefore should be used when at all possible; two, some protective option is better than using nothing. Free protection supplies were distributed throughout the study.The percentage of women retained in the study at 6 months was the poorest for the singlemessage arms: 51% for the female condom and58% for the male condom arm, as compared with 75% for the hierarchy. This difference in women appearing for follow-up was attributed to the relative lower acceptability, on a population basis, of a restricted method policy. Across all subgroups, large and statistically significant changes were seen in the proportion of protected vaginal sex acts with a main partner, from intake to follow-up (see table). Using any method which attempts to adjust for loss-to-follow-up, such as imputing missing follow-up protection values based on intake values of protection, results in a higher overall level of protection for the hierarchy arm. This is because intake levels of protection for the hierarchy arm were similar enough to those of the female condom only and male condom only arms.
Because the hierarchy arm defined protection as protection from any method, the study looked at the level of condomprotected acts. Women over-whelmingly reported use of condoms, even if they had not done so at study intake. Eleven women (13% of the follow-up sample) reported no condom use, of whom 5 (6%) used spermicide as their sole method of protection (no one reported exclusive use of diaphragm or cervical cap). Of the 34 hierarchy women who reported no condom use at intake, 76% reported use of either male or female condom at study end. By comparison, of the 40 women who reported any condom use at intake, 3 women, or 8% reported no use of either male or female condoms in the last follow-up interval. In summary, there was no evidence to support the notion that exposure to greater choice for women resulted in less condom use.
This study also confirmed findings of many female condom studies already conducted. Eighty-six percent of women were interested in trying the female condom after the first counselling session. At six months, 51% of women were still using the female condom. The most well-liked aspects were: high level of protection, its natural feel, and woman's control. Dislikes included: insertion, appearance and the inner ring.
Finally, in initial analyses of laboratory confirmed disease recurrence rates among the 292 subjects, there was a non-statistically significant 20% lower rate of recurrence (of trichomonas, early syphilis, chlamydia, or gonorrhoea) among hierarchy women (15%), as compared with women assigned to either of the single message arms (18.5%).
Facts related to the female condom:
Sources:
The female condom and AIDS:point of view, UNAIDS, 1998
Safer sex just got better: the female condom, The Female Health Company, 1998.
If a person has artery and heart disease, what are the signs?
The signs vary from one disease to the other.
HEART FAILURE
HEART PAIN (ANGINA) AND HEART ATTACK:
If the arteries to the heart (coronary arteries) of a person become narrow or completely blocked and enough blood is not reaching the heart muscles, he may have heart pain (angina) or heart attack. The signs are:
HYPERTENSION
A person has hypertension when his blood pressure remains persistently higher than it should normally be. It occurs when pressure builds up in the arteries as the heart pumps the blood round. Hypertension is a silent killer. Usually, there are no symptoms. Everybody, especially anyone who suspects he has hypertension, should see a health worker to check his blood pressure every year. What are the signs? After a person has been having hypertension for some time, without knowing, and it is getting dangerously serious, he may:
STROKE
Stroke is another silent killer. It happens suddenly and usually to people who have hypertension. It occurs when an artery inside the brain is blocked by blood clot or gets damaged and bleeds. What are the signs that someone has a stroke? When it strikes;
If the person survives, what marks does stroke leave on him?
How can one avoid having a stroke? To avoid having a stroke, anybody who has hypertension should take the medicine prescribed by the doctor regularly and obey his other instructions diligently. What should be done if someone shows signs of having any artery or heart disease? Take him to the doctor for treatment immediately! Is he likely to live long? If he gets proper treatment promptly and obeys the doctor's instructions, he has a good chance of living long.
A blood transfusion must be given if: · haemoglobin levels are less than 5g/dl and the child is in heart failure - enlarged liver, fast pulse, rapid breathing, cyanosis, pulmonary oedema (crackles in the lungs) or the child has a high number of malaria parasites in the blood. This will result in further destruction of red blood cells and the child will become increasingly anaemic.
Transfuse 15-20ml/kg of whole blood over four hours. Frusemide 1 mg/kg IV may be given halfway through the transfusion to prevent cardiac failure. If the child has pulmonary oedema, nurse in a semi-upright position, give oxygen if it is available and give a single dose of frusemide 1 mg/kg IV or IM. Keep a strict fluid balance record so as not to overload the circulation further.
Urine flow should be monitored. A child should pass at least 1 ml of urine/kg/hr. Urine flow is encouraged by giving adequate fluids to correct dehydration. If fluid input is sufficient but urine is not passed, a diuretic (frusemide 1 mg/kg IV or IM once only) should be given. If, despite these precautions, acute kidney failure occurs, urgent specialist care will be needed.
Suggestive Care
In meningitis, it is easy to overhydrate a child. This may worsen the brain swelling which is already present due to the infection. Intravenous fluids should be carefully monitored to ensure they are not given too quickly. Most doctors reduce the amount of IV fluid in the first two to three days of the illness to no more than 70 per cent of the usual recommended daily requirements. A sick child needs feeding after the first two days. If the child does not have a gag reflex, the best and safest way of feeding the child is with a nasogastric tube. Careful explanation should be given to the mother about this procedure.
An unconscious child should be nursed on his or her side to prevent aspiration of any stomach contents into the lungs. Aspiration can occur when the child lies on his or her back, even without obvious vomiting. Encourage the mother to turn the child every two to three hours from one side to the other and to try to change soiled or urine soaked linen. If the child is conscious and has a fever above 38.50C, give paracetamol (15mg/kg) orally, three to four times a day. This will make the child feel better and drink more as the temperature comes down. Tepid sponging is not effective in lowing temperatures and is no longer recommended for fever.
Things to look for in an ill child
Severe and complicated malaria
Malaria accompanied by:
Monitor Progress
Key Messages with Meningitis
Key issues with Severe Malaria
Elizabeth Molyneux
Associate Professor of Paediatrics, College of Medicine
University of Malawi
| Aberg, J.A. | Perfect, J.R. | Julkunen, I. | |
| Airoldi, M. | Kaji, M. | Pramanik, B. | |
| Augustine, K | Koornhof, H.J. | Powderly, W.G. | |
| Banfi, G. | Kund, H. | Reiser, L. | |
| Bauer, M. | Kurtz, M. | Rich, J.D. | |
| Bennett, J.E. | Lanfermann, H. | Robinson, P.A. | |
| Berkefeld, J. | Larsen, R.A. | Ross, A. | |
| Brato, D. | Lartey, R.A | Roullet, E. | |
| Chaisson, R.E. | Leal, M.A. | Rude, T.H. | |
| Chang-H.W. | Leedom, J.M. | Ruutu, P. | |
| Chang-S.C. | Leinikk, P. | Saag, M.S. | |
| Chaung-YC. | LI, W. | Saffer, D. | |
| Chen-My | LU-CH | Sato, Y. | |
| Cloud, G.A. | Martegani, R. | Saniel, M. | |
| Cosmatos, D. | Matsumoto,K. | Silber, E. | |
| Diamond, D.A. | Mayanja, B | Sobel, J.D. | |
| Dismukes, W.E. | Mayanja, Kizza, H. | Sombrero, L. | |
| Douglas, C.M. | Merriman, N.A. | Sonnewberg,P. | |
| Eintracut, S. | Milendo, M.D. 13 | Speranza, F. | |
| Enzenberger, W. | Mitarai, S. | Sutinen, J. | |
| Evans, S.G. | Molyneux, E. | Tambini, R. | |
| Fessel, W.J. | Moore, R.D. | Tashima, K.T. | |
| Flanigan, T.P | Morgan, D. | Thomas, C. | |
| Flori, G. | Morris, L. | Thompson, J.R. | |
| Frimpong, E.H. | Moskovitz, B.L. | Toffaletti, D.L. | |
| Gallant, J.E | Mugerwa, R. | Torre, D. | |
| Garg-R.K. | Mundy, L.M. | Tuazon, C.U. | |
| Gollub, E.L. | Mutangadura, G. | Van-der-Host,CM | |
| Graybill, J.R. | Mylonakis, E. | Walters, B.C. | |
| Hafner, R. | Nagatake, T. | Watanabe, K. | |
| Hernandez, E. | Nalongo, K. | Webb, D. | |
| Holtom, P.D. | Ococi, J. | Whitworth, J. | |
| Hospenthal, D.R. | Oishi, K. | Wiesinger, B. | |
| Hsieh-S.M. | Oizumi, K. | Yamashita, H. | |
| Hsueh-P.R. | Okongo, M. | Yuan, X. | |
| Hung-C.C. | Osabe, S. | Zeroli, C. | |
| Izumi, T. | Oursler, K.A. | ||
| Johnson, P.C. | Paladin, F.J. | ||
| Jue, C.K. |
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Last updated February 14, 2000