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Background: Our aim is analyze the epidemiological factors of enteric fever in Madrid (Spain) over the last 30 years., Material and Methods: A retrospective review was conducted on cases of typhoid and paratyphoid fever studied in the Fundación Jiménez Díaz (Madrid) between 1980 and 2010. Two similar periods in time were studied (P1: 1980-1993; P2: 1994-2010)., Results: There was a total of 61 confirmed cases of enteric fever: 51 (84%) were typhoid and 10 were paratyphoid: 45 patients were native Spanish (40 belonging to P1) and 16 were immigrants (15 in P2, with 11 of them coming from the Indian sub-continent)., Conclusion: Enteric fever must be present in the differential diagnosis of persistent fever without clear focus in immigrants, mainly from the Indian subcontinent, and travelers from endemic areas., (Copyright © 2012 Elsevier España, S.L. All rights reserved.)

In recent years, a significant number of physicians want to spend part of their medical training in health facilities in developing countries. In this setting, clinical skills are extremely important due to the limited available diagnostic resources. Bacterial diseases are common, but bacterial cultures are rarely accessible. In Africa, tuberculosis affects over 200 cases per 100,000 persons, and more than 22 million people live with HIV infection; both diseases are a serious public health problem. Malnutrition is endemic in many countries in Africa and is compounded by the continuous humanitarian and food crisis. In this paper, basic concepts of epidemiology, clinical features, diagnosis and treatment of major diseases that can be found in a rural health post in the tropics are discussed., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

In recent years an increasing number of physicians want to spend part of their medical training in health facilities in developing countries. Working in these areas requires good clinical skills, particularly where diagnostic resources are limited. Trainees will attend patients with many different parasitic diseases such as malaria and soil transmitted helminthic infections. The aim of this work is to provide basic concepts of epidemiology, clinical characteristics, diagnosis and treatment of the principal parasitic diseases that could occur in a rural health post in the tropics., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

Background: The objective of this work is to study the impact of HAART at a population level and to identify socio-demographic factors that may affect it, which is essential for deciding interventions., Methods: An open, prospective cohort of HIV seroconverters recruited in the Centro Sanitario Sandoval (1986-2009), and followed up in collaboration with referral hospitals in the Comunidad Autónoma de Madrid. Cumulative incidence of AIDS and death was calculated by the multiple decrements method, and predictive Fine & Gray models were developed to identify associated factors. A calendar period (<1997; ≥ 1997) was introduced as a proxy of HAART availability., Results: A total of 479 HIV seroconverters were identified. Hazard Ratio (HR) for progression to AIDS was 0.215 (95% CI: 0.11-0.519; P<.01) for the period ≥ 1997. Risk increased with age at the time of seroconversion (for each year older HR=1.071; 95% CI: 1.038-1.105; P<.01), but only prior to 1997. In the following period, only a high educational level showed to be a protective factor (HR=0.982; 95% CI: 0.936-1.031; P=.06). HR for progression to death was 0.134 (95% CI: 0.052-0.346; P<.01) for the period after 1997, 0.383 (95% CI: 0.168-0.875; P=.02) in people with high educational level and 1.048 (95% CI: 1.014-1.084; P<.01) for each year increase in age at seroconversion, both latter effects being homogeneous throughout the two periods., Conclusion: HAART has had a great impact on the risk of progression to AIDS and death, but this benefit appears to be influenced by age at HIV infection and educational level of the patient, which highlights the importance of a global approach to case management and of the implementation of policies that address social inequities in health., (Copyright © 2011 Elsevier España, S.L. All rights reserved.)

The objective of this study was to analyze the clinical, immunitary and virological implications of an elevated erythrocyte sedimentation rate (ESR) in HIV-positive patients. A retrospective crossover study of 350 HIV-positive patients undergoing periodic evaluations (942 follow-ups) at the outpatient service of the Division of Infectious Diseases of the Fundación Jiménez Díaz in Madrid was carried out from January 1993 to July 1998. The relationship between the ESR (cut-off point: 20 mm/h), the clinical status (symptomatic or asymptomatic), the immune status (CD4, cut-off point: 200 cells/microl), and viral status (viral load, cut-off point: 3 log) of the patients was analyzed. Information on other possible confounding factors was also collected. It was found that in 667 cases (71%), the ESR was normal and in 275 (29%) it was >20 mm/h. In the univariate analysis, a statistically significant relation was found between the ESR and the clinical, immune and viral status of the patients: a normal ESR was associated with a CD4 >200 cells/ml, viral load <3 log, and an asymptomatic clinical status (p <0.05). A significant inverse relation was found between ESR and hematocrit (p <0.05, CI 95%: 3.87-5.1) and between ESR and gammaglobulin (p <0.05). The multivariate analysis did not show a significant relation between ESR and clinical status (OR: 1.98, IC95%: 1-3.9), nor between ESR and the CD4 level (in the case of hematocrit 42-43%, OR: 0.755, p >0.005). However, in patients with low hematocrit the risk of having CD4 < or = 200 cells/microl when the ESR was >20 mm/h was significant (OR: 9.34, IC95%: 4.56-11.35). When adjusting for clinical factors such as age, sex, gammaglobulin, hematocrit and co-infection with hepatitis C or B virus, we did not find a relation between the ESR and the clinical, immune or viral status of the seropositive patients. We believe that it is not necessary to determine the ESR when monitoring HIV-positive patients, since it does not appear to be a good marker for a deterioration in clinical, immune or viral status.

Thirty-one cases of human listeriosis seen from 1971-1999 were reviewed. cases were grouped as follows: Group I composed of 14 patients were studied in the period 1971-1984; and group II composed of 17 cases studied in the period 1985-1999. We tried to assess changes in the incidence, clinical findings and outcome in both periods. The incidence of listeriosis remained constant along the years, 1.2 cases/20,000 discharges. The mean age of the patients significantly increased along the years (55 11 years versus 68 12 years; p 0.002). 77% of cases had one or more underlying diseases predisposing to listeriosis. We observed an increasing number of listeriosis in patients without chronic diseases in recent years. Listeriosis presented as meningitis or primary sepsis. Mortality was 61% and was strictly associated with the severity of the underlying disease. Patients with meningoencephalitis and seizures had a worse prognosis. We did not observe differences in mortality of patients who were treated with beta-lactam monotherapy in comparison with those who were treated with beta-lactam/aminoglucoside combination. Cotrimoxazole was uniformly successful treatment of human listeriosis in this series.

Objective: Evaluation of epidemiologic, clinical and prognostic characteristics in cases of resistant tuberculosis (MRTB)., Methods: Retrospective longitudinal and observational study of resistant cases of tuberculosis at Fundación Jiménez Díaz (1991-1997). Statistical analysis of conventional tests and significance level at p < 0.05., Results: Twenty patients out of 558 with recovery of Mycobacterium tuberculosis showed resistance to some drugs (isoniazid, rifampicin, ethambutol, streptomycin or pyrazinamide). Information was gathered from 19 patients: eight (42%) HIV-positive patients; eight (42%) with the antecedent of tuberculosis (2 abandoned treatment). There were eleven cases (58%) of secondary resistance and eight of primary resistance but only five (25%) with multi-resistance criteria (1 primary and 4 secondary); five cases showed primary resistance to isoniazid. The number of resistances and HIV seropositivity or antecedent of prophylaxis was not statistically significant. In contrast, the higher number of resistances and tuberculosis antecedent were indeed statistically significant., Conclusions: There was a low resistance rate at our institution. All multi-resistant cases had antecedents of therapy or prophylaxis abandon or previous tuberculosis. Only one case was MRTB. The relevance of complying with a proper therapy is emphasized (consider therapies directly monitored if there is risk of abandon). In patients with epidemiologic risk factors susceptibility studies should be performed and also start therapy with four drugs. The objective is to decrease the percentages of resistance and morbi-mortality.

Introduction: HIV infection is common in young persons and its clinical picture, outcome and response to antiretroviral therapy is well known, but it is not the case in the elderly., Objectives: To evaluate the clinical characteristics and response to antiretroviral therapy of HIV elderly patients., Design: Retrospective study of 37 patients elder than 60 years. The control group comprised of 64 HIV positive patients with less than 60 years. None of them were drug abusers., Results: The mean age of patients was 65 years (range 60-79), 86% were males. The most frequent causes for HIV testing were: wasting (22%), P. carinii pneumonia (19%), tuberculosis (13%) and Kaposi sarcoma (10%), but in the control group voluntary testing was the most common reason (64%). The mean CD4 count at diagnosis was lower in the elderly group (233 cells/microL vs 323 cells/microL). During follow up, the most frequent complications for those with less than 200 CD4 cells were: oral candidiasis (44%), P. carinii pneumonia (27%), Kaposi sarcoma (22%) and esophageal candidiasis (22%), while in the young group P. carinii pneumonia (22%), Kaposi sarcoma (9%) and esophageal candidiasis (9%) were less frequent. 67% of the elderly received antiretroviral therapy. Zidovudine had to be discontinued due to anaemia in half of them. Survival at 6 and 12 months was significantly longer in treated patients compared to those who did not received antiretrovirals (100% vs 14% at 6 months, P < 0.001; and 54% vs 0% at 12 months, p = 0.03); and at 2 years it was almost similar to that of the young group (36% vs 52%, p = 0.38)., Conclusions: HIV infection in the elderly is generally diagnosed in an advance stage, but antiretroviral therapy prolongs survival. Zidovudine should be reserve as a second line drug because its frequent haematological toxicity.

The characteristics of two cases of histoplasmosis in AIDS patients in our institution are presented together with a review of the 11 cases published in Spain since 1988 in addition to the current knowledge on histoplasmosis in patients with human immunodeficiency virus infection (HIV). In all except 2 of the 13 patients there was epidemiologic history of a stay in a country in which histoplasmosis is endemic. The 12 cases described in which this information is available had CD4 counts under 100/microL. The clinical manifestations of presentation were fever (92.3%) associated or not with other unspecific symptoms (asthenia, anorexia, cough, diarrhea) with a subacute course of two or three months. Physical examination demonstrated hepatosplenomegaly in 76.9% of the cases and 61.5% of the patients presented cutaneous lesions. Thoracic radiography was abnormal in 55% (61.5% had respiratory symptoms). Diagnosis was achieved by isolation of the fungus in the cutaneous biopsies in all the patients with dermatologic involvement and in 7 cases identification was performed in the bone marrow. In all the cases induction treatment was with anphotericin B and in those who reached the maintenance phase itraconazol was used in 7 cases and ketoconazol in one case. None of the patients treated with itraconazol, including the two in our center, presented recurrence at the time of completion of follow up. In conclusion, histoplasmosis is frequently presented as a prolonged febrile syndrome with unspecific characteristics, thus emphasizing the importance of including travel history to other countries in the anamnesis. The increase in journeys to endemic countries and immigration from these areas had led to an increase in the number of cases of histoplasmosis in patients with HIV infection in Spain.

Introduction: Clinical, microbiological, therapeutic and prognostic characteristics of brain abscesses were analyzed as well as the influence of CT in their evolution., Materials and Methods: Retrospective study of 59 patients with the diagnosis of brain abscess of bacterial source before (group A) and after (group B) the introduction of CT (25 and 34 patients, respectively)., Results: The most common symptom was headache (76.3%) and the most common abnormality in physical examination was a decrease in the level of consciousness (61%) and this abnormality was associated with a higher mortality rate (13% versus 41.6%; p < 0.05) and also a higher proportion of neurologic sequelae (50% versus 85.7%; p < 0.05). The diagnosis was obtained earlier in group B. The hematogenous source predominated (32.2%); an adjacent source was identified in 28.8% and an apparent source was not recognized in 27.2% (40% in group A versus 17.6% in group B). Anaerobic and microaerophilic streptococci were the bacteria recovered most frequently. Gram-negative aerobic bacteria were the most common in otogenic abscesses. The use of corticosteroids had no influence upon mortality, but it was associated with a lower percentage of neurological sequelae (40% versus 14%; p < 0.05). The introduction of CT decreased mortality (40% in group A versus 23.5% in group B, although this difference was not significant) and also sequelae (86.6% in group A versus 57.6% in group B; p < 0.05). Leaving apart cases of bacterial endocarditis, in which death was due to the underlying heart disease and a systemic sepsis picture, mortality attributed to brain abscess was 20.3%., Conclusions: The introduction of CT has meant a significant breakthrough for the diagnosis, treatment and follow-up of these patients and has contributed to improvement in survival. In our series, the diagnosis of brain abscess was obtained earlier and the number of brain abscesses with no apparent source has decreased since the introduction of CT. Moreover, CT sensitivity is really good for locating multiple abscesses. Overall, the prognosis of these patients has improved since the introduction of this technique. Nevertheless, brain abscess is still associated with a relevant morbi-mortality rate.

Objective: To analyze the causative factors, clinical and microbiological characteristics, and prognosis in spontaneous meningitis caused by Gram-negative rods in adult patients., Methods: Descriptive and retrospective study of all clinical records and microbiological findings in patients diagnosed of meningitis by Gram-negative bacilli, from 1973 to 1995, at Fundación Jiménez Díaz., Results: Twenty patients had spontaneous meningitis caused by Gram-negative bacilli (2.1% of all diagnosed meningitis during this period). Fourteen patients were older than 65 years (range: 36-81; p < 0.05). Ninety-five percent of cases had an extranosocomial origin (p < 0.001). Ninety percent of patients had some underlying disease (p < 0.001). Twelve patients were immunosuppressed. Seven patients had changes in the urinary tract or repeated UTI infections. The most common clinical symptoms were a decrease in consciousness level, fever, and neck stiffness. Cerebrospinal fluid (CSF) in 18 patients showed cellular and biochemical changes. The CSF smear revealed the presence of Gram-negative bacilli in 15 patients. E. coli was the microorganism recovered most frequently. Immunosuppression (p < 0.05), septic shock (p < 0.001) and antimicrobial therapy not including a third generation cephalosporin (p < 0.01) were independently associated with mortality., Conclusions: Spontaneous meningitis by Gram-negative bacilli is an uncommon infection. It occurs mainly in immunosuppressed patients older than 65 years or with changes in the urinary tract. It usually has an extranosocomial origin. The investigation of CSF is a highly effective for diagnosis. Therapy with third generation cephalosporins has notably improved its prognosis.

We present here 6 patients with Fasciola hepatica infection, all from rural origin, and with the risk factors of eating wild watercress. The more common symptoms were: fever (83%), abdominal pain (100%), weight loss (83%) and generalized myalgia and joint pain (67%). All patients presented with an absolute eosinophil count above 1,000 cell/mm3. The diagnosis was established in five cases by means of serologic techniques (haemagglutination) and with direct visualization of adult worms while surgery in one case. A CT abdominal scan was performed in five patients, revealing specific lesions of tissue infiltration in four of them. Praziquantel was used in four patients, achieving clinical cure in three cases. In two patients, bithionol was used, with clinical cure in both cases. We review also some newer diagnostic and therapeutic approaches to this parasitic disease.

We have reviewed 15 cases of splenic abscesses diagnosed using a histopathological and microbiological study. Mean age was 48 years (range 18-78). Eight of them were male and 7 female. Eighty per cent of them had predisposing diseases, amongst which the most frequent were endocarditis and bacteriemia of other origin (26.6% in both cases). All patients presented fever and in 7 of them (47%) splenomegaly was appreciated. The most frequently isolated germs were gramnegative bacteria (33%), anaerobics (20%), and with a similar incidence grampositive bacteria, tuberculosis and fungii; in only one case cultures were sterile. Seven patients had multiple splenic abscesses and 8 patients single abscesses. Thorax x-ray showed alterations in more than half of the patients (53%). Abdominal echography was the diagnostic method in 67% of the patients and TAC in all the cases in which it was performed. Eight patients underwent splenectomy and one was surgically drained being the mortality rate of this group of 22%. Overall mortality was 33% and was related to the presence of multiple splenic abscesses (5/7, 71.4%), positive hemocultures (6/6, 100%), extrasplenic abscesses (7/8, 87.5%), and endocarditis (4/4, 100%), fungii infections (2/2, 100%), and late diagnosis (6/6, 100%).

Septic thrombophlebitis of the large veins of the neck is an uncommon, but extremely severe, complication in carriers of central venous catheters. Treatment of these cases is difficult and, generally, the clinical condition does not permit surgical approach. Four patients with septic central vein thrombophlebitis are reported. They were treated with conservative measures including catheter removal and high-dose parenteral antibiotics for at least four weeks, with excellent results in all. The relevant literature and the therapeutic alternatives are reviewed.