BACKGROUND:We obtained estimates of the incidence of tuberculosis (TB) among patients receiving HAART and identified determinants of the incidence. METHODS:We analyzed the incidence of TB during the first 3 years after initiation of HAART among 17,142 treatment-naive, AIDS-free persons starting HAART who were enrolled in 12 cohorts from Europe and North America. We used univariable and multivariable Poisson regression models to identify factors associated with the incidence. RESULTS:During the first 3 years (36,906 person-years), 173 patients developed TB (incidence, 4.69 cases per 1000 person-years). In multivariable analysis, the incidence rate was lower for men who have sex with men, compared with injection drug users (relative rate, 2.46; 95% confidence interval [CI], 1.51-4.01), heterosexuals (relative rate, 2.42; 95% CI, 1.64-3.59), those with other suspected modes of transmission (relative rate, 1.66; 95% CI, 0.91-3.06), and those with a higher CD4+ count at the time of HAART initiation (relative rate per log2 cells/microL, 0.87; 95% CI, 0.84-0.91). During 28,846 person-years of follow-up after the first 6 months of HAART, 88 patients developed TB (incidence, 3.1 cases per 1000 person-years of follow-up). In multivariable analyses, a low baseline CD4+ count (relative rate per log2 cells/microL, 0.89; 95% CI, 0.83-0.96), 6-month CD4+ count (relative rate per log2 cells/microL, 0.90; 95% CI, 0.81-0.99), and a 6-month HIV RNA level >400 copies/mL (relative rate, 2.21; 95% CI, 1.33-3.67) were significantly associated with the risk of acquiring TB after 6 months of HAART. CONCLUSION:The level of immunodeficiency at which HAART is initiated and the response to HAART are important determinants of the risk of TB. However, this risk remains appreciable even among those with a good response to HAART, suggesting that other interventions may be needed to control the TB epidemic in the HIV-infected population.

SUBJECTAnalyze characteristics of neuromeningeal tuberculosis in the northeastern suburbs of Paris.MATERIAL AND METHODRetrospective study of 19 observations between 1988 and 1999.RESULTSThirteen cases of meningitis, 3 cases of meningitis associated with a tuberculoma and 3 cases with isolated tuberculoma were described. Young subjects (average age 46.4), foreign born (73.7%) were preferentially affected. Three patients were infected by the human immunodeficiency virus. Weight-loss and weakness (84%), fever (79%), headache (63%) dominate the clinical manifestations. The diagnosis delay was 56.6 days, and the therapeutic time, 8.6 days. The search for acid fast bacilli was positive only in one case on direct examination of the cerebrospinal fluid, whereas the culture was positive in 68.7% of the cases. Cerebral imagery was abnormal in13 patients. Average duration of antituberculous treatment was 13,4 months (range: 9-24). Corticosteroids were associated in 12 patients. Thirteen patients were cured, 3 died and 3 were lost to follow up.CONCLUSIONThe characteristics of neuromeningeal tuberculosis are not modified, but the diagnosis delay of the neuromeningeal tuberculosis, which conditions the prognosis, remains significant. The optimal duration of the antituberculous treatment and the conditions of the steroid therapy have to be specified.

Objective: To evaluate the safety and efficacy of a protease inhibitor sparing, quadruple therapy (Combivir + abacavir + efavirenz) in antiretroviral treatment-naive HIV-1-infected adults.Design: Multicenter open-label pilot study. Clinical and biological assessments were performed at baseline and at weeks 2, 4, 8, 16, 24, 32, 40, 48.Results: Thirty-one subjects enrolled with a median baseline viral load (VL) of 4.69 log(10) copies/mL and CD4 cell count of 322 cells/mm(3). At week 48, 90% (intention-to-treat [ITT] switch included) and 77% (ITT switch = failure) patients had a VL <50 copies/mL. These results were similar in the population (n = 13) with a VL >100,000 copies/mL at baseline. Combivir + abacavir + efavirenz demonstrated an early antiretroviral response: 58% of patients had plasma HIV-1 RNA <50 copies/mL at week 8. Using a modified assay, the percentage of patients with VL <5 copies/mL, at week 48 was 55% (17/31) and 42% (13/31) using ITT (switch included) and ITT (switch = failure), respectively. Median VL decreased by -4.0 log(10) copies/mL at week 48 (ITT). Median CD4+ cell count change from baseline at week 48 was +129 cells/mm(3) (ITT). Most patients experienced at least one drug-related adverse event that was not considered treatment-limiting by the investigator. There were no cases of abacavir hypersensitivity reactions.Conclusions: Safety and efficacy results from this study demonstrated that the quadruple regimen Combivir/abacavir/efavirenz is generally safe and displays potent and durable antiretroviral activity in antiretroviral treatment-naive HIV-1-infected patients, offering a promising therapeutic option in a PI-sparing strategy.

SETTING: Peritoneal tuberculosis did not disappear from France during the 1990s.OBJECTIVE: To determine the characteristics of peritoneal tuberculosis in the north-eastern suburbs of Paris.METHOD: A retrospective study of cases diagnosed with peritoneal tuberculosis between 1990 and 1998 in five suburban hospitals in the north-cast region of Paris.RESULTS: Twenty-seven cases of adult peritoneal tuberculosis were diagnosed. There were nine women and 18 men, with a mean age of 37.5 years, 88.9% of whom were foreign born. General and digestive symptoms-abdominal pain and/or ascites-were present in 96.3% of the cases. The mean delay in treatment was 30 days. Peritoneal involvement was isolated in 25.9% of cases, and associated with pulmonary tuberculosis in 40.7% or hepatic tuberculosis in 25.9%. Co-infection with HIV (human immunodeficiency virus) was present 14.8% of cases. Culture of ascites fluid, laparoscopy and/or laparotomy (n = 17), with directed biopsy, aided in the formal diagnosis of peritoneal tuberculosis in 59.2%. One relapse and one case of multiresistance were observed. The mean duration of treatment was 9 months (range 6-12 months). Three patients received treatment with corticosteroids, and 91.2% of the patients achieved cure without sequelae.

Septic arthritis due to Mycobacterium kansasii is rare; only 40 cases have been published. A French national inquiry revealed the occurrence of 10 new cases between 1992 and 1997 (8 men and 2 women: mean age, 37 years; range, 25-54 years). Seven had an underlying condition: AIDS (n=4), chronic skin psoriasis and AIDS (n=2), or a renal transplant (n=1). Trauma to the joint, use of intra-articular corticosteroid(s) 1 month to 2 years after the event, and chronic skin psoriasis were risk factors. The mean interval between appearance of the first symptoms of arthritis and the diagnosis was 5 months. Monarthritis was localized to the knee (n=4), wrist (n=3), finger (n=1), elbow (n=1), or ankle (n=1). The main diagnostic procedure was culture of a synovial biopsy specimen. In all cases, debridement was associated with antimycobacterial treatment. Three patients died of AIDS during treatment, and another is still undergoing treatment; the other 6 patients were cured. M. kansasii infection should be considered in all cases of indolent arthritis with any of the following risk factors: local trauma, local or systemic corticosteroid therapy, chronic skin psoriasis, and immunodepression, especially that due to human immunodeficiency virus infection.

Objective:To assess the clinical and economic consequences of the use of protease inhibitors in the treatment of HIV infection. Design:Multicentric, observational, retrospective cohort study. Setting:Ten AIDS reference centres in France. Patients:All patients followed in each centre from September 1995 through October 1996. Main outcome measures:AIDS-defining events, death, health-care resources use, administration of antiretroviral therapy. Results:Data from 7749 patients in 10 centres showed a drop in hospitalization days by 35%, new AIDS cases by 35%, and deaths by 46%. In the same period, the proportion of patients receiving antiretrovirals rose from 36 to 53% including highly active antiretroviral therapy (HAART), which rose from 0.3 to 18%. Overall cost evaluation showed a slight increase of monthly treatment cost of US$ 12 per patient. Comparison of the three centres that used HAART earliest to the three centres that used it latest showed a clear benefit to early HAART with a drop in hospitalization days by 41%, new AIDS cases by 41% and deaths by 69%. The proportion of patients with HAART rose to 27% and monthly health-care cost decreased by US$ 248 852 (i.e., by US$ 101 per patient per month). Late prescribing centres experienced a less marked effect with a drop in hospitalization days by 22%, new AIDS cases by 31%, and deaths by 32.5%. Proportion of patients with HAART rose to 12% and monthly health-care costs increased by US$ 113 578 (i.e., by US$ 38 per patient per month). Conclusions:This study supports the extensive use of HAART in HIV-infected patients.

We determined the safety and efficacy of deoxycholate-amphotericin B (d-AmB) mixed with Intralipid (IL) as the initial treatment of AIDS-associated cryptococcal meningitis in a phase II, multicentre, non-comparative open study, assessing two dosages of ILd-AmB: 1 mg/kg (group A, n = 9) and 1.5 mg/kg (group B, n = 6). Patients were treated daily for 2 weeks, then three times weekly for 4 weeks. The ILd-AmB dosage was decreased due to toxicity in three patients in each group. Serum creatinine increased significantly on day 14 in group A and on day 7 in group B. Nephrotoxicity, (serum creatinine level > 165 mumol/L) was noted in two and five patients in groups A and B, respectively. Nine adverse haematological events were noted (seven cases of anaemia requiring transfusion, and two cases of neutropenia < 750/mm). Two patients had an increase in serum alkaline phosphatase. In each cohort, 15% of the infusions were associated with fever and/or chills. Successful outcome was obtained in half of the patients. We conclude that, in AIDS patients with cryptococcosis, tolerance to ILd-AmB was acceptable when the daily dosage did not exceed 1 mg/kg, but the higher 1.5 mg/kg daily dosage was associated with an unacceptable rate of nephrotoxicity. Neither of these relatively high daily dosages of ILd-AmB achieved an improved rate of successful outcomes compared with lower daily dosages of conventional d-AmB in glucose.

Two black patients who were infected with the human immunodeficiency virus (HIV) and who had hereditary deficiency of OKT4 epitope were investigated. The patients' lymphocytes lacked the OKT4 surface antigen but reacted with other monoclonal antibodies recognizing the CD4+ helper-inducer T lymphocytes. The CD4 lymphocyte count is a surrogate marker for clinical progression of HIV disease, but it could be unreliable in regard to patients with partial or complete OKT4 epitope deficiency.

Interferon-γ Associated with Conventional Therapy for Recurrent Visceral Leishmaniasis in a Patient with AIDS Get access O. Lortholary, O. Lortholary Département de Médecine Interne, Hopital, Delafontaine, Saint Denis; Laboratoire d'Etude des Injections Expérimentales et des Traitements Anti-Infectieux; INSERM U 294, Université, Paris VII; and Laboratoires Roussel UCLAF, Romainville, France Search for other works by this author on: Oxford Academic PubMed Google Scholar D. Mechali, D. Mechali Département de Médecine Interne, Hopital, Delafontaine, Saint Denis; Laboratoire d'Etude des Injections Expérimentales et des Traitements Anti-Infectieux; INSERM U 294, Université, Paris VII; and Laboratoires Roussel UCLAF, Romainville, France Search for other works by this author on: Oxford Academic PubMed Google Scholar D. Christiaens, D. Christiaens Département de Médecine Interne, Hopital, Delafontaine, Saint Denis; Laboratoire d'Etude des Injections Expérimentales et des Traitements Anti-Infectieux; INSERM U 294, Université, Paris VII; and Laboratoires Roussel UCLAF, Romainville, France Search for other works by this author on: Oxford Academic PubMed Google Scholar M. Gougerot Pocidalo, M. Gougerot Pocidalo Département de Médecine Interne, Hopital, Delafontaine, Saint Denis; Laboratoire d'Etude des Injections Expérimentales et des Traitements Anti-Infectieux; INSERM U 294, Université, Paris VII; and Laboratoires Roussel UCLAF, Romainville, France Search for other works by this author on: Oxford Academic PubMed Google Scholar M. Brandely, M. Brandely Département de Médecine Interne, Hopital, Delafontaine, Saint Denis; Laboratoire d'Etude des Injections Expérimentales et des Traitements Anti-Infectieux; INSERM U 294, Université, Paris VII; and Laboratoires Roussel UCLAF, Romainville, France Search for other works by this author on: Oxford Academic PubMed Google Scholar P. Babinet P. Babinet Département de Médecine Interne, Hopital, Delafontaine, Saint Denis; Laboratoire d'Etude des Injections Expérimentales et des Traitements Anti-Infectieux; INSERM U 294, Université, Paris VII; and Laboratoires Roussel UCLAF, Romainville, France Search for other works by this author on: Oxford Academic PubMed Google Scholar Reviews of Infectious Diseases, Volume 12, Issue 2, March-April 1990, Pages 370–371, https://doi.org/10.1093/clinids/12.2.370 Published: 01 March 1990

Les auteurs rapportent le premier cas de spondylodiscite à Eikenella corrodens, révélant une néoplasie rénale sous-jacente et l'efficacité de la péfloxacine dans cette indication.

Un cas de tuberculose osseuse pure des extrêmités, survenant chez un sujet âgé atteint d'un cancer digestif, est présenté et discuté. La localisation et le mode évolutif sont inhabituels. Les éléments épidémiologiques, tenant notamment à l'âge et à l'immuno-dépression, sont envisagés.

Several animal studies have demonstrated that pain is modulated by spinal mechanisms involving prostaglandins and that acetylsalicylic acid (ASA) administered intrathecally has an analgesic effect. We report our experience of this treatment in 60 patients with proven and advanced cancer. An isobaric solution of lysine acetylsalicylate was administered by lumbar puncture in doses ranging from 120 to 720 mg of ASA. The results were evaluated using the habitual criteria: scoring system, behaviour, consumption of analgesic drugs. In this trial the method proved astonishingly effective (78% of the cases). Analgesia was strong, almost immediate and without influence on motricity. No thermic or neurovegetative changes were noted. The effect of one injection lasted from 3 weeks to 1 month on average; it was reproduced and often more prolonged after a repeat injection. Pain associated with bone metastases seems to constitute the best indication, notably in breast and lung cancer and in myeloma. Visceral (pancreas) or neural pain requires higher doses to respond. Failures (22%) were due to such factors as insufficient dosage at the very beginning of our experience or severe depressive syndrome. The perineal and sphincteral pain of rectal cancer often resists treatment. This simple, inexpensive and very effective method with no other complication than a frequent tendency to fatigue should rank among other analgesic measures in cancer. The lack of respiratory depression is a major advantage over catheter spinal opiate analgesia. We consider that its main indications are pain associated with osteolytic metastases of adenocarcinomas, and myelomas. Owing to the absence of formal toxicological data, its use must be limited to cancer pain and to patients with a life expectancy of less than 2 years.