Bridging the Gap: Conference Record [Abstract book, International Conference on AIDS (12th: 1998: Geneva, Switzerland)]

12th World AIDS Conference

Abstracts 22223-22228 307

(Iz). Following resolution, most (75%) P did not use maintenance therapy (Tx),
and Tx only symptomatic episodes. However, Fz was the commonest form of
suppressive therapy prescribed. (65-73%). Fz refractory OPC was Tx with AMB
IV (40-47%) and Iz (29-34%). In Jan-March 1996, >80% of P had seen at least
1 pt with azole refractory OPC, -30% had seen 3-4 pts, and >85% reported
OPC due to non albicans Candida spp., C. glabrata. After exposure to patients
with azole-refractory OPC, P's use significantly less 20 suppressive Fz. P also
rarely use MICs in the management of refractory OPC/EC.
Conclusion: Knowledge of refractory mucosal candidiasis in HIV was
widespread in 1995/96, influencing the use and selection of antifungals.
[22223 |The impact of cryptococcal disease and therapy
implications in the community in Africa
Eric Stephen Lugada1, N. French2, C.F. Gilks2, C. Watera3, A. Mujugira3. 1PO
BOX 12777, Kampala, 3Uganda Virus Research Institute, Kampala, Uganda;:'Liverpool School of Tropical Medicine Liverpool, UK
Background: Hospital based studies show cryptococcus as a major opportunistic
pathogen in HIV-1 infections, accounting for 6-10% of deaths in developed nations. It has been reported as a leading cause of meningitis in the HIV-1 infected
in Africa, but little information exists on rates of disease.
Method: A prospective community based natural history cohort study of HIV-1
infected adults ( -17 yrs) in Entebbe Uganda. Individuals are followed up six
monthly or whenever sick. Set protocols of investigation are followed. Cryptococcus is identified by culture of capsulated yeasts which are urea positive.
Results: Between October 1994 to August 1997 we have recruited 1091 HIV-1
infected adults (73% female) contributing a total of 1083 person years of observation (pyo). The cohort has a high percentage of advanced disease, 43%
with CD4-T-cell counts of less than 200. 240 deaths have occurred. Cryptococcal
disease has occurred in 27 (11.3% of all deaths) at a rate of 26/1000 pyo and has
been universally fatal. Disease is strongly CD4 associated; rates in <200 65/1000,
in -200 0.2/1000. Cryptococcal infection was the first AIDS defining illness in all
but 2 cases, Although initial presentation in these cases was meningitic in only 14
(52%), all but one died with features of meningitis. Median duration of symptoms
at presentation was 7 days and median survival from presentation was 12 days.
Discussion: Cryptococcus is a common cause of death in this cohort, occurring in the latter stages of HIV infection, but often before any other AIDS defining
illness, Presentation is not always with meningitis but usually develops before
death. Survival following diagnosis is short as most individuals are unable to
pay for effective anti-fungal therapy and it is otherwise unavailable. Preventive
strategies with chemo-prophylaxis merit investigation in this setting.
L22224 Disseminated histoplasmosis in AIDS patients
Liliana Puga1, A. Montecelli2, G. LeviHara3, R. Negroni4, S. Carnovale2,
H. Jauregui2. 1Pueyrredon 1051 1o-B 1118, Hospital Militar Central, Buenos
Aires;,FAIVIH/S Buenos Aires; 3Hospital Duran Buenos Aires; 4Hospital Muhiz
Micology Unit, Buenos Aires,, Argentina
Objectives: Because of the global incidence of disseminated histoplasmosis
(DH) in AIDS patients (pts) is: 0.9%, and in Argentina: 4% and in South America
more than 80% of the patients with DH present cutaneous lesions, it was decided
to make this study with the following objectives: 1) risk behavior, 2) immunological
involvement, 3) time of the clinical manifestations before the diagnosis, 4) fever,
weight loss, cutaneous and mucous lesions, hepatomegaly, espenomegaly, respiratory alterations and others clinical manifestations, 5) to evaluate the scarification
sensitivity of the lesions and blood culture, 6) treatment response, and finally 7)
mortality associated with DH.
Methods: 33 patients: since Jan 93 to Nov 97 from Hospital Militar Central,
Hospital Duran and FAIVIH/S (Bs.As. Argentina). The clinic and radiological parameters were evaluated. The diagnostic was done by scarification, blood culture
and bone marrow culture. Treatment: Itraconazol or Anfotericina B.
Results: 1) Homo/bisexual 43%, injection drug user:39%, heterosexual 18%.
2) CD4 of 32 (97%) pts, x = 71 cells/mi. 3) Time of the clinical manifestations
before the diagnosis: 4 to 138 days (x = 43).4) Weight loss: 32 (97%) pts, fever:
31 (94%) pts, cutaneous lesions: 27 (82%) pts, hepatomegaly: 27 (79%), espenomegaly: 23 (70%) pts, polyarthralgia:14 (42%) pts, odynophagia: 11 (33%)
pts, palate compromise:11 (33%) pts, mucous ulcers: 9 (27%) pts, myalgias: 6
(18%) pts, pathological X-ray chest with infiltrations: 15 (46%) pts. 5) Scarification
of cutaneous lesions in 27 pts, 24 (89%) pts were positive for Histoplasma capsulatum var. capsulatum, blood culture (+): 11 pts: 100%. 6) Treatment: 31 pts,
with Amphotericin 12 (38%) pts, with Itraconazole 20 (63%) pts and the response
was satisfactory in 28 (88%) pts. 7) Mortality associated with DH: 30%.
Conclusions: To suspect DH in patients with severe immunological involvement that present fever, weight loss and compatible cutaneous lesions, mainly
in endemic area. The scarification allows early diagnostic, meanwhile the highy
sensitive blood culture contribute to a later diagnostic.

22225 Conditioning factors of mortality from cryptococcosis
Aldo Maranzana, A. Thwaites, G. Prada, O. GarciaMessina, G. Ortega,
O.M. Bases, J. Benetucci. Hospital Muhiz, Ward 17/FUNDAI Foundation,
Buenos Aires, Argentina
Objective: To analize the relationship between clinical form, CD4 cells count and
time prior to diagnosis and mortality from cryptococcosis (C).

Method: From 1986, 214 cases were assessed as regards epidemiology,
clinical forms and mortality. The diagnosis of HIV was carried out through EIA
and W.blot. The CD4 cells count was determined in 148 patients. The diagnosis
of cryptococcal meningitis (CM) was done through direct examination and CSF
culture, whereas the diagnosis of non neurological cryptococcosis (NNC) was
performed through blood culture and biopsies. The risk behaviours were: IVDU
60%, homo/bisexual 23%, heterosexual 16%. CM: 188 patients (195 events):
male 175, female 13. NNC: 18 patients (19 events): male 15, female 3. The
average age in the CM cases was 37 while in the NNC cases it was 31.7.
Results: In the CM group, the CD4 average was 111 cells and 54 cells for the
NNC group. When analyzing mortality in both groups, in relation to CD4, we did
not find any significative differences (p = 0.33). Neither were there any differences
in mortality from CM as regards the CD4 cells count whether they had more or
less than 100 cells (p = 0.28). As regards the average time prior to evolution, it
was observed that for the CM it was only 25 days while for the NNC it was 43
days (CM p = 0.14; NNC p = 0.69). Mortality in patients with CM was 167/195
(85.6%), 97 of which (49.7%) took place because of mycosis and 70 (35.9%)
were due to other causes. Among the NNC, 13/20 patients died (65%), 8 from
NNC and 5 from other causes. When comparing mortality between CM and NNC,
we found a significative difference (p = 0.071).
Conclusion: Mortality from C was not related to the initial CD4 cells count or
the time delay for diagnosis. The clinical form was related to mortality, the latter
being higher in the NNC.
22226 Amphotericin combined with itraconazole is superior to
amphotericin alone in cryptococcal meningitis
Somsit Tansuphasawadikul. Bamrainaradura Hospital Nontaburi 11120, Thailand
A 2:1 open randomised study of (A) amphotericin B and itraconazole combined
compared with (B) amphotericin B alone was conducted in 147 adult patients with
cryptococcal meningitis and AIDS. 134 patients (74 in group A and 60 in group B)
survived for 7 days and 105 completed follow-up (58 A, 47 B) and were eligible for
analysis. The two groups were similar in admission characteristics. The mortality
was 12% in group A and 21% in group B (P = 0.2). Therapeutic success, defined
as CSF culture negativity within 8 weeks, in survivors was significantly more likely
in group B; 44/53 (83%) versus 16/38 (42%); RR 2.0 (95% CI 1.3 to 2.9): P =
0.0001. The additional of itraconazole was well tolerated.
The addition of itraconazole to amphotericin B appears to be beneficial in
cryptococcal meningitis.
122227 1 Clinical manifestation of AIDS-associated histoplasmosis
in Uruguay
Mariela Mansilla, A.D. Dutra da Silveira, H.N. Laca, R. Balleste, A.T. Braselli.
Clinica de Enfer Medades Infecciosas Mendez Nuhez 2669 11600 Montevideo,
Uruguay
Objective: to describe the evolutive-clinical features of AIDS-asssociated histoplasmosis in Uruguay- South America.
Methods: a restrospective analysis of medical records of 803 patients with
AIDS, assisted in two centers which provide health care to them at Montevideo
city from october of 1988 to december of 1997, was carried out. Thirty one cases
of histoplasmosis, with demonstration of H. capsulatum by microbiologic (direct
or culture) and/or histopathologic findings, were selected.
Results: most patients were male: 24 (77%). The average age was years
34 (20 to 63). Histoplasmosis was the initial AIDS-defining illness in 18 (58.1%)
patients. The median CD4 lymphocites count at this time, was 94 cel/mm3, in
19 patients whom it was made this study to. The more frequent symptoms were:
fever, weight loss, skin lesions and dyspnea. The clinical feature was disseminated in 30 (97%). Skin involvement prevailed in 24 (77%) patients; respiratory
involvement in 17 (55%): lungs, laringeal, nasal and sinusal; digestive involvement in 2 (6%): palate and intestinal; and ganglionic involvement in 5 patients.
The largest diagnostic yielding was got by histopathologic study from samples of
biopsy on lesions in 17 (55%) patients. The skin lesion's scrap was performed in
12 patients, which was able to identify the fungus. Another samples availables for
the diagnostic were: broncho-alveolar lavage fluid and blood. The treatment was
made with amphotericin B or itraconazol. Toxicity by amphotericin B obliged to
stop it in 8 (33%). All patients went on with suppresive treatment with itraconazol
and no relapses were registered. Mortality by histoplasmosis was 38.7%. The
median survival after disseminated histoplasmosis ocurred, was 10 months.
Conclusions: Disseminated histoplasmosis was presented like the first opportunistic AIDS-defining illness in the more than a half of studied cases. However the
invasive methods were useful for the diagnosis, when there were skin lesions the
scrapping of same to be studied had a high yielding diagnosis with the advantage
of being little cruel, quick and of little costs.
22228 Acute disseminated histoplasmosis and Pneumocystis
carinii pneumonia in a patient with AIDS

Marcelo Corti1, P. Esquivel2, M. Villafane2, I. Soto2, R. Masini2. Hospital FJ.
Muniz, Rivadavia 8326, 1407 Buenos Aires, Argentina
Background: Pulmonary coinfection with Histoplasma capsulatum and Pneumocystis carinii presented in a patient with advanced HIV-1 disease.
Methods: A heterosexual male, HIV-1(+), with no history of opportunistic
infections, was admitted for fever, productive cough and dyspnea. Physical ex