Opportunistic infections in Edinburgh AIDS patients: 1984-1994
Laing, Robert Bruce Stirling
AIM: To examine the frequency, clinical features and outcome of major AIDSrelated opportunistic infections in a cohort of HIV-seropositive patients attending Edinburgh's City Hospital between 1984 and 1994. To determine which clinical features are ofprognostic significance in opportunistic infections and the effect of antiretroviral therapy and prophylaxis on patients recovering from an AIDS-related opportunistic infection. To compare, wherever possible, the morbidity and survival of those who have developed specific opportunistic infections with HIV-seropositive patients who have remained free from such infections.MATERIALS AND METHODS: A cohort of 702 HIV seropositive patients (249 of whom had developed an AIDS illness) in regular attendance at Edinburgh's City hospital were examined. Most data was collected retrospectively from examination of patient records. Patients who had developed the following opportunistic infections were included in the study - Pneumocystis carinii pneumonia (PCP), Cytomegalovirus (CMV) disease, Cerebral toxoplasmosis, Oesophageal candidiasis and Disseminated Mycobacterium avium intracellulare (DMAC) infection.PRINCIPAL RESULTS: Injection drug users (IDUs) with PCP were more likely to present with hypercapnia as a feature of their illness and this was associated with a poor prognosis. Survival following recovery from PCP was poorer in IDUs than the rest but any survival difference was lost if analysis was based only on those who received antiretrovirals following recovery. Survival was significantly poorer in patients who developed a pneumothorax as a consequence of their PCP infection. Patients who developed opportunistic infections other than PCP had a similar outcome and survival regardless of their risk category for HIV acquisition. Survival from CMV disease was poorer in patients with a history of prolonged hospitalisation prior to developing CMV disease. In patients with cerebral toxoplasmosis a history of intolerance to first line anti-toxoplasma treatment was associated with reduced survival. A lack of clinical response to azole antifungal agents was associated with previous azole exposure and predictive of a significantly reduced survival from oesophageal candidiasis. DMAC was associated with a higher incidence of weight loss >10%, leucopenia, anaemia and elevated serum alkaline phosphatase. Patients who received no antimicrobial therapy for DMAC had a significantly poorer survival than those who were treated, did. Those with CMV disease, DMAC and cerebral toxoplasmosis could be matched to control groups from within the study cohort. The morbidity (time post-AIDS spent in hospital) and survival was found to be similar in the disease groups and their matched controls.CONCLUSIONS: Some of the clinical features associated with opportunistic infections can serve as clinical predictors for survival and some features appear to be related to the patient's risk behaviour for HIV acquisition. The severity of immune deficiency - as reflected in the absolute CD4+ cell count - appears to be a useful prognosticator in patients who have suffered an AIDS opportunistic infection. Antiretroviral therapy prolongs survival following AIDS opportunistic infections. The morbidity and mortality of AIDS or advanced immunodeficiency is not significantly altered by the development of CMV disease, DMAC or cerebral toxoplasmosis - as long as these conditions are treated.