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To the Editor.— Systemic meningococcal infections are presumed to follow spread of meningococci from the nasopharynx into the blood and then to the cerebrospinal fluid.1However, there have been reports of at least 10 cases of systemic meningococcal infection in which the conjunctiva was the probable portal of entry.2-11The overall incidence of invasive meningococcal conjunctivitis has been estimated to be about 10% of the cases of primary meningococcal conjunctivitis.12 Neisseria meningitidiswas isolated from conjunctival exudate in 21 patients with acute bacterial conjunctivitis who were treated at our hospital during the last 5 years. During this period, 1030 patients with a microbiologically proved acute bacterial conjunctivitis were diagnosed, which gives an incidence forN meningitidisconjunctivitis of 2.0%. Six (28.6%) of our 21 patients with primary meningococcal conjunctivitis, after a mean interval of 27.1 (±23.8) hours from the appearance of the initial ocular symptoms, developed systemic

To the Editor .—We agree with Musher1 that physicians need to be reminded of the importance and occurrence of Q fever in endemic areas, as well as in urban hospitals where its occurrence may not be so frequent. We have reviewed our experience with 38 patients who had acute Q fever and were cared for at our hospital in the last 7 years. The Hospital de la Santa Creu i Sant Pau, Barcelona, Spain, is a 900-bed community hospital located downtown, and provides health care for an estimated population of 530 000. There were 35 men (92.1%) and 3 women (7.9%). All the patients represented sporadic cases. The majority of our patients (34[89.5%]) were living in Barcelona and 4 of them (10.5%) reported having visited the countryside. Twenty-one cases (55.2%) occurred during spring. Eighteen patients (47.3%) presented with clinical and roentgenographic features consistent with pneumonia, whereas 16 patients (42.1%) had

In order to evaluate the clinical aspects of gram-negative bacillary meningitis (GNBM) we reviewed the charts of 20 adult patients with the discharge diagnosis of meningitis caused by gram-negative bacilli (bacteriologically proved) seen between 1973 and 1984. Nine patients had post-neurosurgical (post-NS) GNBM and 11 patients spontaneous (S) GNBM; the mean age of the former was 42 +/- 16 years and of the latter 56 +/- 14 years (p less than 0.05). The overall mortality rate was 50% (33% in the post-NS group and 64% in the S group). The glucose levels in CSF were significantly lower in the patients who died. Patients treated with combined aminoglycoside therapy presented a lower mortality rate than those treated with intravenous aminoglycoside only (25% versus 70%). We suggest that if aminoglycoside therapy is employed, these antibiotics must be administered both intravenously and directly into CNS.

Objective: To study whether patients with HIV-1 associated lipodystrophy (LD) on highly active antiretroviral treatment (HAART) have more psychopathology and worse psychosocial adjustment than a similar group without this syndrome. Methods: In a cross-sectional, observational study we compared 47 HIV-1 infected patients with LD (LD group) with 39 HIV-1 infected patients without LD (non-LD group). All participants were on HAART. The Beck Depression Inventory (BDI), the State and Trait Anxiety Inventory (STAI) and the Goldberg Health Questionnaire (GHQ-60) were administered. Levels of familial, work and social adjustment and adjustment to stressful events were evaluated in a semi-structured interview. Clinical information was extracted from the clinical records. Results: In the univariate analysis patients with LD showed higher state anxiety scores (p = 0.009) and worse work adjustment (p = 0.019) than those without LD. A total of 45.3% of LD patients scored above the cut-off point on the trait anxiety scale, and over 33.3% scored above the cut-off point on the BDI, GHQ and state anxiety scales. However, in multi-variate analyses LD was not independently associated with psychopathology or with worse adjustment in the studied areas. Conclusions: The finding that LD was not a predictor of greater psychopathology or worse psychosocial adjustment in HIV-1 infected patients, despite the high scores found, suggests that factors not taken into account in this study, such as LD severity and self-perception should have been included in the analysis. Further studies including a greater number of variables and a larger sample size will advance our understanding of this complex condition. (c) 2013 Elsevier Editora Ltda. All rights reserved.

To the Editor. —We read with interest the report by Hyman and Westrick 1 in the May issue of theArchivesconcerning a patient with the syndrome of polyneuropathy, organomegaly, endocrinopathy, M-protein, and skin changes (POEMS), and we would like to add some comments with respect to this unique multisystemic syndrome. Although the great majority of patients reported with POEMS syndrome have λlight chains on serum immunoelectrophoresis, patients with κlight chains have also been reported; Nakanishi et al 2 recently reviewed the subject and, among 102 cases of what they named the Crow-Fukase syndrome , found three cases with IgA κlight chains and one with IgG K. Additionally, we have had the opportunity to treat a patient with POEMS syndrome in whom serum immunoelectrophoresis disclosed an IgG κ-paraprotein, which was also detected over the atypical bone marrow plasma cells by immunoperoxidase technique. 3 Coagulopathy has also been reported in the setting of

To the Editor.— Bacterial meningitis remains the second most frequent cause of death among reportable infectious diseases, 1 and Neisseria meningitidis is the second most common pathogen isolated from adult patients with purulent meningitis, 2 although in Europe it is probably the most common. 3 Appropriate therapy, given early, is of paramount importance in decreasing both acute and chronic morbidity and in improving the survival rate of patients with purulent meningitis. An etiologic diagnosis based on clinical grounds is often difficult and may lead to inadequate antibiotic therapy. Study.— We evaluated the diagnostic value of petechiae in adult patients with purulent meningitis by studying 139 patients with microbiologicallyproved bacterial meningitis. All of the patients had consistent clinical features and cerebrospinal fluid pleocytosis with more than 200 polymorphonuclear leukocytes per cubic millimeter (200 polymorphonuclear leukocytes per microliter). All of the cerebrospinal fluid samples were obtained by a spinal tap on

Nocardia farcinica is a rare Nocardia species causing localised and disseminated infections. A case of Nocardia farcinica infection is presented, and 52 cases previously reported in the literature are reviewed. The hosts usually had predisposing conditions (85%), and acquired the infection through the respiratory tract or skin; the infection then often spread to the brain, kidney, joints, bones and eyes. Pulmonary or pleural infections (43%), brain abscesses (30%) and wound infections (15%) which failed to respond to conventional antimicrobial therapy were the more frequent forms of infection. Nocardia farcinica was frequently isolated from pus (100% of samples), bronchial secretions (41%) and biopsy specimens (63%), but isolation from blood and urine, as in the case presented here, is rare. Antibiotic therapy was adequate in 61% of the patients in whom it was specified, the agents most frequently given being trimethoprim-sulfamethoxazole (54%), amikacin combined with imipenem (7%) and amoxicillin-clavulanate (7%). The high mortality (31%) can be attributed to the severe underlying diseases present, difficulties encountered in identifying the pathogen, inappropriate therapy and late initiation of therapy. Although an infrequent pathogen, Nocardia farcinica should be kept in mind as a cause of infection especially in immunosuppressed patients with indolent infections not responding to third-generation cephalosporins.

Background: High-risk human Papillomavirus infection is a necessary factor for cervical squamous intraepithelial lesions and invasive cervical cancer. In HIV-1-infected women, HPV infection is more prevalent and a higher risk of cervical cancer has been identified. We aimed to calculate the prevalence of infection by HR-HPV, determine the factors associated with this infection and abnormal cytology findings and to describe the history of cervical cancer screening in HIV-1-infected women. Methods: We enrolled 479 HIV-1-infected women from the PISCIS cohort. Each patient underwent a gynecological checkup, PAP smear, HPV AND Hybrid capture, HPV genotyping, and colposcopy and biopsy, if necessary. We applied questionnaires to obtain information on sociodemographic, behavioral, clinical, and cervical screening variables. We present a cross-sectional analysis. Results: Median age was 42 years. The prevalence of HR-HPV infection was 33.2% and that of high-grade squamous intraepithelial lesions (HSIL) was 3.8%. The most common genotypes were 16(23%), 53(20.3%), and 52(16.2%). The factor associated with HR-HPV infection was age < 30 years (odds ratio[OR], 2.5; 95% confidence interval[CI], 1.1-5.6). The factors associated with the presence of HSIL or low-grade squamous intraepithelial lesions (LSIL) were CD4T-lymphocyte count < 200cells/mm(3) versus > 500cells/mm(3) (OR, 8.4; 95% CI, 3.7-19.2), HIV-1 viral load > 10,000copies/mL versus < 400copies/mL (OR, 2.1; 95% CI, 1.0-4.4), and use of oral contraceptives (OR, 2.0; 95% CI, 1.0-3.9). Sixty percent of HIV-1-infected women had had one Pap smear within the last 2 years. Conclusions: The high prevalence of HPV infection and cervical lesions in the HIV-1-infected population in Catalonia, as well as the low coverage and frequency of screening in this group, means that better preventive efforts are necessary and should include vaccination against HPV, better accessibility to screening programs, training of health care professionals, and specific health education for HIV-1-infected women.

Objective To carry out an exploratory evaluation of liver triglyceride content in HIV-1-infected patients receiving highly active antiretroviral therapy (HAART) using proton magnetic resonance spectroscopy and to study how both the treatment itself and the biochemical and physiological variables in which the treatment causes alterations are related to liver fat content. Methods Intracellular hepatic triglyceride content was determined in 29 HIV-1-infected patients on their first HAART regime by means of localized water-unsuppressed single voxel proton spectra. Other measurements were body mass index, waist-to-hip ratio, lipodystrophy assessment and a detailed blood biochemical analysis. The relationship between intracellular hepatic triglycerides and relevant descriptive, treatment and biochemical variables was studied by correlation and regression analysis. Results Intrahepatic triglycerides were detected in 58.6% of the patients and 13.8% showed a triglyceride content compatible with liver steatosis. Many variables (body mass index, waist-to-hip ratio, cumulative exposure to PIs, lactate, insulin, insulin resistance measured by the homeostasis model assessment method [HOMA-R index], pH, total triglycerides, high density lipoprotein cholesterol and very low density lipoprotein [VLDL] cholesterol) correlated individually with the amount of triglycerides. Stepwise multiple regression analysis showed that the combination of insulin or HOMA-R index and VLDL cholesterol accounted for up to 50.2% of the triglyceride liver variance. A positive relationship was found between the concomitant presence of the metabolic syndrome components (insulin resistance, dyslipidaemia and central obesity) and intrahepatic triglyceride content. Conclusions The study showed that intrahepatic triglyceride deposit appears to be a frequent feature of HIV-1-infected patients receiving HAART. A coherent multifactorial combination of biochemical and physiological factors associated with the deposit suggested that cumulative exposure to PIs might be a possible trigger event.

Pulmonary gangrene is an uncommon but life-threatening complication of bacterial pneumonia. Only four cases of pulmonary gangrene due to Mycobacterium tuberculosis have been described to date; another case of pulmonary gangrene was attributed to unidentified mycobacteria. We report a fetal case of tuberculous pulmonary gangrene (TPG) and review the literature on this infection. To our knowledge this is the first case of TPG documented by thoracic computed tomographic scanning. Radiological features of pulmonary gangrene are distinctive, and identification of pulmonary parenchyma in the mass on computed tomography may be considered as pathognomonic. Analysis of the six cases revealed that most of the patients were aged, and one-half of them were alcohol abusers. Right-upper-lobe involvement predominated. When performed, sputum smears disclosed acid-fast bacilli. M. tuberculosis was cultured from sputum or pathologic material in five of the six cases. Four patients (66.7%) died. Four of six patients with TPG received antituberculous therapy, and two of them survived; no patient underwent surgical intervention. Although surgical management has been successfully employed in cases of bacterial pulmonary gangrene, TPG has always been treated with medical therapy alone. In spite of administration of antituberculous therapy, mortality is high.

Objetivo: Actualizar las recomendaciones sobre la evaluación y el manejo de la afectación renal en pacientes con infección por el virus de la inmunodeficiencia humana (VIH). Métodos: Este documento ha sido consensuado por un panel de expertos del Grupo de Estudio de Sida (GESIDA) de la Sociedad Española de Enfermedades Infecciosas y Microbiología Clínica (SEIMC), de la Sociedad Española de Nefrología (S.E.N.) y de la Sociedad Española de Química Clínica y Patología Molecular (SEQC). Para la valoración de la calidad de la evidencia y la graduación de las recomendaciones se ha utilizado el sistema Grading of Recommendations Assessment, Development and Evaluation (GRADE). Resultados: La evaluación renal debe incluir la medida de la concentración sérica de creatinina, la estimación del filtrado glomerular (ecuación chronic kidney disease epidemiological collaboration [CKD-EPI]), la medida del cociente proteína/creatinina en orina y un sedimento urinario. El estudio básico de la función tubular ha de incluir la concentración sérica de fosfato y la tira reactiva de orina (glucosuria). En ausencia de alteraciones, el cribado será anual. En pacientes tratados con tenofovir o con factores de riesgo para el desarrollo de enfermedad renal crónica (ERC), se recomienda una evaluación más frecuente. Se debe evitar el uso de antirretrovirales potencialmente nefrotóxicos en pacientes con ERC o factores de riesgo para evitar su progresión. En este documento se revisan las indicaciones de derivación del paciente a Nefrología y las de la biopsia renal, así como las indicaciones y la evaluación y el manejo del paciente en diálisis o del trasplante renal. Conclusiones: La función renal debe monitorizarse en todos los pacientes con infección por el VIH y este documento pretende optimizar la evaluación y el manejo de la afectación renal.

To the Editor .—We have read with interest the article by Behrman and associates' 1 concerning central nervous system infections in elderly patients, which has been published in the July 1989 issue of theArchives. We would like to add some comments with respect to the prognostic factors in elderly patients with acute bacterial meningitis. From 1974 to 1988, 291 adult patients (aged 15 years or more) with acute bacterial meningitis have been cared for at the Hospital de la Santa Creu i Sant Pau, Barcelona, Spain. Fifty-nine of these patients (20.27%) were aged 65 years or more. There were 26 men and 33 women. The mean age of the group was 71.4±5.72 years (range, 65 to 87 years). Twenty-six patients (44%) had underlying diseases predisposing them for acquiring acute bacterial meningitis. An etiologic diagnosis could be made in 50 (84.7%) patients. Nineteen patients (32.2%) had a pneumococcal meningitis, 11

Highly active antiretroviral therapy has remarkably improved quality of life of HIV-1-infected patients. However, this treatment has been associated with the so-called lipodystrophic syndrome, which conveys a number of adverse metabolic effects and morphological alterations. Among them, lipoatrophy of subcutaneous fat in certain anatomical areas and hypertrophy of visceral depots are the most common. Less frequently, lipomatous enlargements of subcutaneous fat at distinct anatomic areas occur. Lipomatous adipose tissue in the dorso-cervical area ("buffalo hump") has been associated with a partial white-to-brown phenotype transition and with increased cell proliferation, but, to date, lipomatous enlargements arising in other parts of the body have not been characterized. In order to establish the main molecular events associated with the appearance of lipomatosis in HIV-1 patients, we analyzed biopsies of lipomatous tissue from "buffalo hump" and from other anatomical areas in patients, in comparison with healthy subcutaneous adipose tissue, using a marker gene expression approach. Both buffalo-hump and non-buffalo-hump lipomatous adipose tissues exhibited similar patterns of non-compromised adipogenesis, unaltered inflammation, non-fibrotic phenotype and proliferative activity. Shorter telomere length, prelamin A accumulation and SA-beta-Gal induction, reminiscent of adipocyte senescence, were also common to both types of lipomatous tissues. Buffalo hump biopsies showed expression of marker genes of brown adipose tissue (e.g. UCP1) and, specifically, of "classical" brown adipocytes (e.g. ZIC1) but not of beige/brite adipocytes. No such brown fat-related gene expression occurred in lipomatous tissues at other anatomical sites. In conclusion, buffalo hump and other subcutaneous adipose tissue enlargements from HIV-1-infected patients share a similar lipomatous character. However, a distorted induction of white-to-" classical brown adipocyte" phenotype appears unique of dorso-cervical lipomatosis. Thus, the insults caused by HIV-1 viral infection and/or antiretroviral therapy leading to lipomatosis are acting in a location- and adipocyte lineage-dependent manner.

Background: Induction-maintenance strategies were associated with a low response rate. We compared the virological response with two different induction regimens with trizivir plus efavirenz or lopinavir/ritonavir. Methods: A randomized, multicentre, open-label clinical trial with 209 antiretroviralnaive HIV-infected patients assigned to trizivir plus either efavirenz or lopinavir/ ritonavir during 24–36 weeks. Patients reaching undetectable plasma viral loads during induction entered a 48-week maintenance on trizivir alone. The primary endpoint was the proportion of patients without treatment failure at 72 weeks using an intent to treat (ITT) analysis (switching equals failure). Results: Patients were randomly assigned (efavirenz 104; lopinavir/ritonavir 105), and 114 (55%) entered the maintenance phase (efavirenz 54; lopinavir/ritonavir 60). Baseline characteristics were balanced between groups. The response rate at 72 weeks was 31 and 43% (ITT analysis, P ¼ 0.076) and 63 and 75% (on-treatment analysis, P ¼ 0.172) in the efavirenz and lopinavir/ritonavir arms, respectively. Virological failure occurred in 27 patients: six during induction (efavirenz, three; lopinavir/ritonavir, three; P ¼ 1.0) and 21 during maintenance (efavirenz, 14; lopinavir/ritonavir, seven; P ¼ 0.057). Thirty-four patients in the efavirenz arm switched treatment because of adverse events compared with 25 in the lopinavir/ritonavir arm (P ¼ 0.17). Conclusion: Trizivir plus either efavirenz or lopinavir/ritonavir followed by maintenance with trizivir achieved a low but similar response at 72 weeks, with a high incidence of adverse events leading to drug discontinuation during the induction phase in both arms. The study showed a trend towards an increased virological failure rate in the efavirenz arm during the maintenance phase. 2008 Wolters Kluwer Health | Lippincott Williams & Wilkins AIDS 2008, 22:377–384

More than 15 years after the introduction of highly active antiretroviral therapy, HIV/HAART-associated lipodystrophy syndrome still shadows the indisputable efficacy of antiretroviral therapy. Several issues related to this complication (prevalence, diagnosis, pathogenesis, prevention, or clinical management) have not been completely clarified. However, in the last years, substantial progress has been made in elucidating some of these basic aspects. This includes a better knowledge of the pathogenic mechanisms underlying HIV/HAART-associated lipodystrophy syndrome such as genetic host determinants, the impact of HIV infection per se, as well as the contribution of antiretroviral therapy. In regard to treatment, we have learned that certain drugs are especially prone to cause HIV/HAART-associated lipodystrophy syndrome (i.e. thymidine analogues). Pharmacological interventions to treat this condition have yielded mostly disappointing results, and the only intervention which offers an immediate aesthetical improvement for patients with HIV/HAART-associated lipodystrophy syndrome is plastic surgery. Even under the most favorable conditions (ideal host genetic make-up, and the timely initiation of HIV therapy with less toxic drugs), current data show that HIV/HAART-associated lipodystrophy syndrome is a complication of HIV infection and/or antiretroviral treatment that we are unable to avoid. In the context of HIV-1-infected patients under long-term antiretroviral therapy, fat toxicity is still the dark side of the rainbow.

We describe three adults who had hemorrhagic strokes during the acute phase of bacterial meningitis (BM). We also report the results of a literature review and a review of the charts of 296 adults treated at our hospital for acute BM. The diagnosis of hemorrhagic stroke was made based on the results of cerebral computed tomography (CT) for two of 92 patients with BM who had CT performed and by means of lumbar puncture and a postmortem study in one other case. Two patients died of cerebral bleeding. Although the frequency of hemorrhagic stroke was only 2.1% among adults with acute BM, it is a major determinant of prognosis for such patients.

POEMS syndrome is an unusual plasma cell dyscrasia with multisystemic manifestations featuring polyneuropathy, organomegaly, endocrinopathy, M protein and constant skin involvement. We have seen a 58-year-old white man presenting with generalized eruptive angiomas as a rare skin manifestation of this syndrome. We review the literature and discuss the pathogenesis of vascular proliferation in this unusual entity.

To describe the efficacy and tolerability of switching to raltegravir (RAL) in virologically suppressed HIV-1-infected patients during routine clinical practice.A total number of 263 subjects (189 men, median age 48.1 years) with HIV-1 RNA50 copies/mL for ≥ 6 months were switched to RAL (400 mg b.i.d). Reasons for change were toxicity (49.0%), drug interactions (6.1%) or convenience (28.6%) (switch from subcutaneous to oral treatment 22.4%, improvement of posology 3.4%). Patients were followed up to 24 months after switching to RAL. Primary end-points were tolerability and virological failure defined as two consecutive measures of HIV-1 RNA50 copies/mL.After a median of 12.4 months (range 2.8-26.4 months), virological failure was observed in 6 (2.3%) patients (2.2 per 100 person-years [95%CI 0.9-4.6]), while AIDS occurred in 1, drug discontinuation in 4, 3 patients died and 10 were lost to follow-up. The median CD4+ T cell count increased from 460 cells/mm3 to 508.6 cells/mm3 (P0.001).Switching to RAL in clinical practice was mainly driven by toxicity, convenience or interactions, they were well tolerated and secured virologic suppression in the vast majority of patients.

ObjectiveHuman adipose depots contain remnant brown adipocytes interspersed among white adipocytes, and disturbances of brown with respect to white adipocyte biology have been implicated in highly active antiretroviral therapy (HAART)-induced lipo matosis. Brown adipocytes express the uncoupling protein-1 (UCP1) and contain a large number of mitochondria, potential targets of HAART toxicity. The aim of this study was to evaluate the effects of reverse transcriptase inhibitors (RTIs) on primary brown adipocytes differentiated in culture.Design and methodsWe analysed the effects of RTIs, nucleoside analogues (NRTIs: stavudine, zidovudine, didanosine and lamivudine) and non-nucleoside analogues (NNRTIs: nevirapine and efavirenz), on differentiation, mitochondrial biogenesis and gene expression in brown adipocytes.ResultsNone of the NRTIs altered brown adipocyte differentiation whereas NNTRIs had differing effects. Efavirenz blocked lipid deposition and expression of adipose marker genes but nevirapine induced lipid accumulation and adipose gene expression, promoted mitochondrial biogenesis and increased UCP1. Stavudine, zidovudine and didanosine reduced mitochondrial DNA (mtDNA) content. However, mitochondrial genome expression was only impaired in didanosine-treated adipocytes. Stavudine, but not zidovudine, induced expression of the mitochondrial transcription factors and this may explain compensatory mechanisms for the depletion of mtDNA by up-regulating mtDNA transcription. Stavudine caused a specific induction of UCP1 gene expression through direct interaction with a retinoic acid-dependent pathway.ConclusionsSpecific disturbances in brown adipocytes in adipose depots may contribute to HAART-induced lipomatosis. Mitochondrial depletion does not appear to be the only mechanism explaining adverse effects in brown adipocytes because there is evidence of compensatory mechanisms that maintain mtDNA expression, and the expression of the UCP1 gene is specifically altered.

BackgroundHigh pill burden and side effects often impact on the long-term success of highly active anti-retroviral therapy (HAART), which has led clinicians to search for more convenient regimens.Patients and methodsA prospective, multicentre, open, comparative study in which HIV-1-infected patients on HAART and with plasma HIV-1 RNA 1000 copies/ml discontinued the study.ResultsA total of 390 patients were included in the trial (309 in the QD arm and 81 in the control arm). The main baseline characteristics were well balanced between groups. In the QD arm, 41% of patients received high (standard) didanosine doses and 59% received reduced doses. At 12 months, plasma HIV-1 RNA +cell count change at 12 months was -26 and +27 cells/μl in QD patients and controls, respectively ( P=0.001). In individuals who attained HIV-1 RNA +cell changes were -25 and +15 cells/μl in QD patients and controls, respectively ( P=0.001). Moreover, CD4+cell declines in the QD arm were significantly greater in patients taking high versus low didanosine doses (-59 versus -15 cells/μl; P=0.04). The lipid profile improved significantly in the QD arm, particularly in patients who were on protease inhibitors prior to simplification.ConclusionsSimplification to didanosine–tenofovir–efavirenz provides a virological suppression rate at 12 months similar to that seen in patients who do not change therapy, as long as low didanosine doses are administered. Decreases in CD4+cell levels in patients in the QD arm (especially decreases seen with high didanosine doses) and dyslipidaemias along with less convenient pill burden and schedules in controls were the main long-term concerns for each option.

To the Editor.—Report of a Case.— A 50-year-old woman was admitted to the hospital because of fever, purulent sputum, dyspnea, and pleuritic pain; she had not taken antibiotics prior to admission. Her medical history was unremarkable. On admission her blood pressure was 80/50 mm Hg, her temperature was36.8 °C, her pulse rate was 120 beats per minute and regular, and her respirations were 28/min. Physical findings were normal except for bibasilar rales, and there were no signs of meningeal irritation. An x-ray film of the chest showed an alveolar pattern in both lower lobes and a rightsided pleural effusion. The blood picture profile was normal except for a leukocyte count of 20,300/cu mm with 18% band forms. Thoracocentesis disclosed serosanguineous fluid and a Gram-stained smear showed no organisms. Four hours later her temperature rose, her consciousness became impaired, and she developed mild nuchal rigidity without other focal neurologic signs.

To the Editor. —We read with interest the report by Backes et al in the AprilArchives 1 concerning group B streptococcal (GBS) infective endocarditis. Recently, we have had the opportunity to attend two patients with GBS infective endocarditis who developed complications and died. Report of Cases. —Both were women, aged 71 and 63 years. They had not undergone manipulations prior to admission. The diagnosis was made on the basis of three blood cultures that yielded two strains of group B β-hemolytic streptococci ( Streptococcus agalactiae ), fever, petechiae, heart murmurs, splenomegaly, and echocardiographic findings compatible with valvular vegetations affecting the mitral valve in both cases. Both strains had a minimal inhibitory concentration of 0.06 mg/L of penicillin G sodium and the peak serum acid level was 1:1,028 in both cases. On admission, treatment was started with 24 million units of penicillin G sodium and 240 mg of gentamicin sulfate (daily) for

In Reply.— We greatly appreciate the comments by Dr Ratner. Although it has been reported that the demonstration of meningococci on smears of petechiae is infrequent,1the diagnostic procedure suggested by Dr Ratner may be useful in selected cases, ie, in those patients with a presumptive clinical diagnosis of meningococcal meningitis and a negative Gram's stain smear of cerebrospinal fluid. In a series of 45 adult patients with meningococcal meningitis,2we found that the Gram's stain smear of cerebrospinal fluid was positive in 31 (69%) patients. We therefore think that when a diagnosis of meningococcal meningitis is considered, the most accurate, quick, and early diagnostic technique is the spinal tap.

To the Editor. —In a recent report in the Archives Errichetti et al1described their 4½-year experience with oral anticoagulant therapy in 141 patients. The incidence of major hemorrhagic complications in this series was 5% of the treatment courses. We would like to emphasize that the incidence of these complications diminishes as the number of patients studied increases; on the other hand, unusual and life-threatening hemorrhagic complications are most frequently seen in large series of patients and/or when patients are being managed for extended periods, as our figures suggest. From 1974 to 1983, 2,012 patients receiving oral anticoagulant therapy were treated in our anticoagulant clinic. Forty-eight percent of these courses were of six months' duration or less, corresponding to deep venous thrombosis of the lower extremities, pulmonary embolism, and cerebro vascular disease, whereas 52% represented long-lasting treatment courses in patients with valvular heart disease with one or more embolic

Address: 1Hospital Clinic Universitari, Barcelona, Spain, 2Hospital de Bellvitge, Barcelona, Spain, 3Hospital de Sant Pau, Barcelona, Spain, 4Fundacio IrsiCaixa, Barcelona, Spain, 5Hospital Vall d'Hebron, Barcelona, Spain, 6Hospital General Universitario de Elche, Elche, Spain, 7Hospital del Mar, Barcelona, Spain, 8Hospital Gregorio Maranon, Madrid, Spain, 9Hospital Principe de Asturias, Madrid, Spain, 10Hospital Clinico San Carlos, Madrid, Spain and 11Hospital Clinic Universitari, Barcelona, Spain * Corresponding author

of results Median CD4 282 cells/μl (IQR:252), HIV-1 VL 4.17 log10 (IQR 1.35), and duration of HIV infection 13 years. Number of NRTI, NNRTI and PI RAMs: 5 (IQR:4), 1 (IQR:1), and 6 (IQR:4), respectively. Patients exposed to LPV/r had received more HAART regimens (p < 0.001), PIs (p < 0.001), and NRTIs (p < 0.001). RAMs significantly associated with prior or current LPV/r exposure were: L10I/F (p = 0.02, p = 0.001), K20R (p = 0.023), L24I (p = 0.01), L33F (p < 0.001), M36I (p = 0.029), M46I/L (p = 0.023, p = 0.003), I47V (p = 0.022), G48V (p = 0.08), F53L (p = 0.017), I54V (p < 0.001), A71V (p < 0.001), G73S (p = 0.008), V82A (p < 0.001), I84V (p < 0.001), and L90M (p = 0.037). Two NRTI mutations were also associated with LPV/r failure: E44D (p = 0.002) and V118I (p = 0.048). L76V was found in only one sample. RAMs associated only with current (and not previous) LPV/r failure were: L33F, M36I, M46I, I47V, G48V, A71V, G73S, I84V, L90M. These RAMs are all included in the IAS-USA LPV/r list, except M36I and G48V, found to be associated with prior saquinavir use (p = 0.02 and p < 0.001, respectively). Mutations included in the IAS-USA list for LPV but not found to be associated with LPV/r previous or current failure: L10R/V, K20M, V32I, I47A, I50V, I54L/A/M/T/S, L63P, A71T, I76V, and V82F/T/S.

It is estimated that around 15% of HIV infected patients are being followed in HIV units for disease evolution and need of treatment. Data on the demographics and HIV disease status of these patients are scarce. Supplement: Abstracts of the Tenth International Congress on Drug Therapy in HIV Infection http://www.biomedcentral.com/content/pdf/1758-2652-13-S4-info.pdf Conference: Tenth International Congress on Drug Therapy in HIV Infection 7-11 November 2010 Glasgow, UK (Published: 8 November 2010) doi:10.1186/1758-2652-13-S4-P53 Cite this article as: Domingo et al.: Epidemiological description of the demographic and HIV disease characteristics of HIV patients who are in care but not on treatment in Spain. Journal of the International AIDS Society 2010 13(Suppl 4):P53. Full text: PubMed Central: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3113057/

ss Open Acce Poster presentation Risk factors for end-stage liver disease among HIV and hepatitis C virus co-infected patients in the Spanish VACH Cohort R Teira*1, P Geijo2, J Cosin3, A Munoz-Sanz4, P Viciana5, I Suarez-Lozano6, J Lopez-Aldeguer7, E Pedrol8, F Vidal9, T Sanchez10, F Lozano11, A Terron12, A Vergara13, MJ Galindo14, P Domingo15, E Ribera16, B Roca17, ML GarciaAlcalde18, M Garrido19 and P Munoz-Sanchez20