Leonardo Calza

Infective endocarditis associated with human immunodeficiency virus (HIV) infection occurs almost exclusively in intravenous (i.v.) drug users and usually involves the tricuspid valve, with an increased mortality rate among patients with a severe degree of immunosuppression. The first reported case of recurrent tricuspid endocarditis sustained by Streptococcus agalactiae and Enterococcus faecalis in an i.v. drug addict during HIV infection is presented. Antimicrobial therapy with i.v. ampicillin, gentamicin and teicoplanin led to complete clinical and echocardiographical recovery.

Stenotrophomonas (Xanthomonas) maltophilia has been increasingly reported as a nosocomial opportunistic pathogen, responsible for serious infectious complications in immunocompromised patients. At present very limited information is available concerning its clinical significance in the setting of HIV infection. A retrospective survey of clinical and microbiological records of 1,374 HIV-infected patients referring to our tertiary care center during a 10-year period (1991-2000) was performed to identify all episodes of S. maltophilia infection and analyze epidemiological, clinical and laboratory variables. The episodes of S. maltophilia bacteremia were compared with those caused by non-typhoid Salmonella spp. occurring in HIV-infected patients referring to our center during the same period, in order to evaluate eventual predisposing risk factors. 61 episodes of S. maltophilia infection were observed in 59 HIV-infected patients: sepsis/bacteremia in 48 cases (78.7%), lower airways infection in five, urinary tract infection in four, pharyngitis in two, lymphadenitis and liver abscess in one case each. 47 of 61 episodes (77%) of S. maltophilia infection occurred as nosocomial disease (i.e. were diagnosed after the 3rd day of hospitalization) and bacterial isolates showed an elevated resistance profile against many beta-lactam compounds, aztreonam, imipenem and aminoglycosides. At the same time, 38 episodes of bacteremia due to non-typhoid Salmonella spp. were diagnosed in our patients, 13 of which were nosocomial infections. When compared with non-typhoid Salmonella spp. bacteremia, a significantly higher risk of developing S. maltophilia disseminated infection was seen in association with advanced immunodeficiency, leukopenia-neutropenia, central venous catheterization, prior broad-spectrum antimicrobial therapy and/or corticosteroid treatment.

Although HIV infection is often associated with several rheumatic diseases, the coexistence of this retroviral infection and systemic lupus erythematosus (SLE) is extremely uncommon. Generally, HIV-related immunosuppression improves SLE symptoms, and antiretroviral therapy may lead to an autoimmune disease flare subsequent to the increase of circulating CD4+ cell number. Two HIV-infected female patients with SLE and discoid lupus erythematosus (DLE) diagnosed a few months after the highly active antiretroviral therapy initiation, are described. To our knowledge, this is the second case of DLE and the twenty-seventh case of SLE reported to date in association with HIV infection.

Disseminated histoplasmosis is recognized as a common AIDS‐defining opportunistic disease in endemic areas (Americas, Africa, East Asia), while it is rarely described in Europe, usually in individuals returning from endemic regions, or following endogenous reactivation of a latent infection imported long before from overseas countries. However, reports of autochtonous cases in Europe suggest the possible, endemic presence of Histoplasma capsulatum in some European regions, such as the South of France or the Po valley in Italy. A case of disseminated histoplasmosis with atypical, papular and ulcerate skin lesions in an Italian HIV‐infected patient, without history of travels outside his native region, is described. Our patient represents the fifth autochtonous case of AIDS‐associated histoplasmosis described in Italy.

The incidence of Hodgkin's disease appears to progressively increase in human immunodeficiency virus (HIV)-infected patients, with the relative risk of developing this malignancy rising from the early phase to the advanced stage of HIV disease. Clinical and pathological features of Hodgkin's lymphoma in HIV-positive subjects differ from those of the general population, showing a higher frequency of unfavourable histological subtypes, advanced stage with frequent extranodal involvement at initial diagnosis, and a poor therapeutic outcome. The optimal therapeutic strategy is still controversial, and median overall survival is short, ranging from 12 to 18 months. In this report cases of Hodgkin's disease are described among over 1,000 HIV-infected patients referring to a tertiary care centre during a 6 y study period.

A cross-sectional study was carried out in our tertiary care hospital between January 1998 and December 2001. All 161 consecutive patients naive to nelfinavir and who had received a nelfinavir-based highly active antiretroviral therapy (HAART) of at least 24-week duration were extrapolated from the 802 adult HIV-infected subjects treated with antiretroviral therapy. All cases of virologic failure were considered and viral genotyped. Virologic failure occurred in 80 out of 161 nelfinavir-treated patients, all belonging to the experienced group. On the whole, only 11 patients (7%) developed the D30N substitution, whose 6 was in association with the N88D mutation. Among the 80 failed patients, the M184V mutation was detected in 52 (65%), while only 7 patients showed simultaneously the M184V, T215Y and K103N substitutions. In our HIV-infected population receiving a nelfinavir-based HAART, the D30N mutation has shown a low absolute frequency, while the detection of M184V substitution and the simultaneous occurrence of M184V, T215Y and K103N mutations were related to a more favorable virological response.

Pyogenic sacro-iliitis is an uncommon osteo-articular infection that occurs usually in immunocompromised patients and is associated with gram-positive cocci. It is very rarely linked with a gram-negative aetiology. The first case of Pseudomonas aeruginosa sacro-iliitis is described, which occurred in a previously healthy young man, without history of prior traumatic events, hospitalisation or chronic underlying disease.