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Biomedical subjects

L B Reichman

Publications and source records attributed to L B Reichman.

At least 55 records · Page 3Linked to original sources
PubMed1995

Pulmonary function tests in HIV-infected patients without AIDS. Pulmonary Complications of HIV Infection Study Group.

To determine the prevalence, incidence, and types of lung diseases that occur in association with HIV infection, 1,353 subjects, including HIV-seropositive homosexual men, injection drug users, female sexual partners of HIV-positive men, and HIV-seronegative control subjects from the first two transmission categories were evaluated prospectively in a multicenter study. Patients with AIDS at the time of initial evaluation were excluded. One thousand two-hundred ninety-four subjects who had no AIDS-defining diagnosis within 3 mo of enrollment had measurements of FVC, FEV1 and DLCO at the time of enrollment. As a group, all subjects had mean values of FVC and FEV1 close to 100% predicted. Those with CD4 counts below 200/mm3 had slightly reduced DLCO compared with the others. Subjects with a history of HIV-associated symptoms (thrush, weight loss, herpes zoster) also had a reduced DLCO compared with those without symptoms. Injection drug users had reduced FVC, FEV1 and DLCO compared with homosexual men and female sexual partners of HIV-infected men, with DLCO more substantially reduced. Part of the reduction in DLCO in drug users was attributable to factors other than HIV infection, especially cigarette smoking and race. Using predicted values that take cigarette smoking into account, the prevalence of abnormality in DLCO was higher among injection drug users (33.3%) than among homosexual men (11.2%) and female sexual partners (12.7%). These results show that advanced HIV infection, characterized by CD4 count < 200/mm3 or HIV-associated symptoms, and factors unrelated to HIV infection, including race, cigarette smoking, and injection drug use, are all associated with reductions in DLCO measurements.

Bisexuality↗
PubMed1994

Multidrug-resistant tuberculosis: meeting the challenge.

Both public and private institutions are mobilizing to combat drug-resistant TB--indeed, to eliminate all TB. Meeting this goal will require a three-pronged approach: 1) prophylactic isoniazid treatment of latent TB, 2) multidrug (at least six agents in some cases) treatment of active TB to eradicate resistant strains, and 3) correction of the social conditions that have contributed to the current epidemic.

AIDS-Related Opportunistic Infections↗
PubMed1994

Tuberculosis among patients with AIDS and a control group in an inner-city community.

BACKGROUND: Tuberculosis, the largest single cause of death of any infectious disease worldwide, has undergone a startling resurgence in the United States, partially related to the acquired immunodeficiency syndrome (AIDS) epidemic. METHODS: To compare the clinical, roentgenographic, and bacteriologic characteristics of patients with AIDS and the general population, we retrospectively analyzed the clinical records of all patients with tuberculosis in an inner-city population over a 4-year period. Forty-six patients with AIDS (including 38 injecting drug users [83%]) were identified and matched with a control group of 46 patients with tuberculosis who did not have AIDS. RESULTS: Forty-one patients with AIDS (89%) had pulmonary tuberculosis; 10 (22%) had disseminated disease and 13 (28%) had concurrent extrapulmonary disease. Among the patients without AIDS, two (4%) had disseminated disease and four (9%) had extrapulmonary disease. Patients with AIDS were far more likely to be black. Thirty-seven patients with AIDS (80%) had negative purified protein derivative skin test results compared with eight controls (17%). Seventeen (41%) of 41 patients with AIDS presented with classic post-primary upper-lobe disease compared with 32 (73%) of 44 patients in the control group. Primary tuberculosis features occurred predominantly in the AIDS group. Four (10%) of 41 patients with AIDS presented with clear chest films despite positive smears and cultures. Nine patients with AIDS (20%) were drug-resistant compared with three controls (7%). Seven patients with AIDS with drug resistance were born in the United States (78%), while all controls with drug resistance were foreign-born. CONCLUSIONS: We found vast differences in the clinical, roentgenographic, and drug susceptibility characteristics of patients with tuberculosis who did and did not have AIDS.

AIDS-Related Opportunistic Infections↗
PubMed1994

Routine analysis of induced sputum is not an effective strategy for screening persons infected with human immunodeficiency virus for Mycobacterium tuberculosis or Pneumocystis carinii. Pulmonary Complications of HIV Infection Study Group.

A prospective multicenter cohort study comprising 1,171 individuals who were seropositive for human immunodeficiency virus (HIV) but did not have AIDS at the time of enrollment and 182 HIV-seronegative controls, was studied by means of routine induced-sputum analysis in an attempt to detect occult tuberculosis or Pneumocystis carinii pneumonia. One occult case of tuberculosis was discovered upon the patient's enrollment (at baseline); none were discovered during follow-up. Two additional Mycobacterium tuberculosis isolates were recovered (one at baseline, one during follow-up) from subjects with symptoms or abnormalities evident on chest roentgenograms. Three specimens were false-positive (one for M. tuberculosis, two for P. carinii). Five pathogenic nontuberculous mycobacteria isolates were recovered during follow-up. Nonpathogenic, nontuberculous mycobacteria were recovered from 51 (4.6%) of 1,113 baseline specimens and 56 (3.7%) of 1,518 follow-up specimens, primarily at a center where the water supply was contaminated. We conclude that routine induced-sputum analysis is not an effective strategy for screening HIV-infected asymptomatic subjects for tuberculosis or P. carinii pneumonia before the onset of clinically recognizable disease activity.

Female↗
PubMed1994

Preventive therapy for contacts of multidrug-resistant tuberculosis. A Delphi survey.

OBJECTIVE: Several outbreaks of multidrug resistant tuberculosis (MDR-TB) have recently occurred in which healthcare workers and others have become infected. Given the lack of clinical data to guide preventive therapy for such contacts, a Delphi survey of a panel of 31 TB therapy experts was undertaken to identify a consensus regimen. DESIGN: An initial questionnaire presented three scenarios describing persons with significant exposure to MDR-TB and with new tuberculin skin test reactions > 15 mm (except one anergic patient) without evidence of disease. Panelists were asked to suggest possible preventive therapy regimens. METHODS: During a second round survey, the panel members were asked to review the suggested regimens provided for each scenario and to rank them from one to nine as extremely inappropriate to extremely appropriate. Results of this second survey were tabulated and shared with the members of the panel who were then asked to rerank each regimen in light of the previous cumulative panel responses. RESULTS: No specific regimen achieved initial positive consensus by predefined criteria. In two of the three scenarios the no treatment option, however, was deemed clearly inappropriate. The data were also analyzed by what percentage of respondents who ranked a regimen as at all appropriate (ie, six or more on the nine point scale). For scenarios involving a nurse, an HIV-positive tuberculin reactor, and a patient who was anergic HIV-positive, treatment with pyrazinamide 1,500 mg daily with ciprofloxacin 750 mg twice a day for 4 months received a somewhat appropriate rating from more than 50 percent of respondents. CONCLUSIONS: The management of persons exposed to and infected by patients with MDR-TB has become a serious problem in the context of MDR-TB outbreaks. This panel of experts agreed that some form of preventive therapy was warranted; however, they were not able to reach defined consensus on what regimen should be used, although a regimen of pyrazinamide 1,500 mg daily with ciprofloxacin 750 mg twice a day for 4 months was considered somewhat appropriate. Clinical data on the efficacy of alternative preventive therapy regimens for such contacts are urgently needed.

Adult↗
PubMed1993

Tuberculin and anergy testing in HIV-seropositive and HIV-seronegative persons. Pulmonary Complications of HIV Infection Study Group.

OBJECTIVE: To determine the prevalence and predictors of reactivity to tuberculin purified protein derivative (PPD) and skin test anergy in patients with human immunodeficiency virus (HIV) infection and in HIV-seronegative controls. DESIGN: Cross-sectional analysis of baseline data from a prospective, multicenter study of pulmonary complications of HIV infection. SETTING: Community-based cohort of persons with and without HIV infection. PATIENTS: A total of 1171 HIV-seropositive patients without AIDS (841 homosexual men, 274 intravenous drug users, and 56 women with heterosexually acquired infection); 182 HIV-seronegative persons (125 homosexual men and 57 intravenous drug users). MEASUREMENTS: Delayed-type hypersensitivity response to tuberculin PPD, trichophytin, mumps, and Candida antigens; T-lymphocyte subsets. RESULTS: The prevalence of tuberculin PPD reactivity was higher among intravenous drug users than among homosexual men, in both HIV-seronegative (19.1% compared with 6.8%, P = 0.03) and HIV-seropositive persons (15.1% compared with 2.5%, P < 0.001). Among HIV-infected patients, the prevalence of tuberculin reactivity varied directly and that of anergy inversely with the absolute CD4 lymphocyte count. Prevalences were 1% and 72%, respectively, in patients with fewer than 200 CD4 cells/mm3, and 8.4% and 25.5%, respectively, in those with 600 CD4 cells/mm3 (P < 0.001 for both comparisons). Patients with HIV infection and fewer than 400 CD4 lymphocytes/mm3 had a lower prevalence of PPD reactivity than HIV-seronegative controls (2.7% compared with 10.0%, P < 0.001). The strongest predictors of tuberculin reactivity were intravenous drug use, black race, a previous positive PPD test result, and a history of Calmette-Guérin bacillus vaccination. The strongest predictor of anergy was HIV seropositivity. CONCLUSIONS: The response to delayed-type hypersensitivity antigens depends on immune status. The value of PPD and anergy testing in HIV-seropositive patients depends on the ability of such testing to predict subsequent tuberculosis, which is imprecisely known. Until more data or better methods are available, these tests should be done as early as possible in the course of HIV infection.

Adolescent↗
PubMed1993

A decline in the pulmonary diffusing capacity does not indicate opportunistic lung disease in asymptomatic persons infected with the human immunodeficiency virus. Pulmonary Complications of HIV Infection Study Group.

We enrolled 1,353 subjects in a multicenter study to evaluate the spectrum of pulmonary complications associated with human immunodeficiency virus (HIV) infection and the feasibility of detecting pulmonary infections in asymptomatic members of this group. There were 1,171 who were HIV-seropositive; the remaining 182 were HIV-seronegative, but they belonged to high-risk transmission groups (homosexual/bisexual, or injection drug users). Single-breath carbon monoxide diffusing capacity (DLCO) was measured serially (at 3- to 12-month intervals) in a prospective fashion to determine whether a decline of > or = 20% predicted the presence of Pneumocystis carinii pneumonia or other pulmonary infections in the absence of new pulmonary symptoms and no new abnormalities on chest roentgenograms. In 64 subjects (6% of the group who had two or more measurements) DLCO declined > or = 20% from a prior value within 2 yr of entry, unassociated with fever, increased cough or dyspnea, or new chest roentgenogram abnormalities. Induced sputum was analyzed for the presence of P. carinii and mycobacteria in 44; fiberoptic bronchoscopy was performed with bronchoalveolar lavage in 14, six of whom also had transbronchial lung biopsy. All 64 subjects with the asymptomatic decline in DLCO were followed for an additional 3 to 12 months with additional clinical evaluations, chest roentgenograms, and DLCO determinations, or until death (one subject). In no case was the decline in DLCO due to P. carinii pneumonia or other pulmonary infection.(ABSTRACT TRUNCATED AT 250 WORDS)

AIDS-Related Opportunistic Infections↗
PubMed1993

Respiratory illness in persons with human immunodeficiency virus infection. The Pulmonary Complications of HIV Infection Study Group.

Although the pulmonary complications of advanced human immunodeficiency virus (HIV) infection have been well described, there is little information on respiratory manifestations of earlier disease. This report describes the respiratory disorders diagnosed over an 18-month period in a cohort of persons with or at risk for HIV infection with variable immunologic status. Cohort members were followed routinely and evaluated for respiratory disease by standard diagnostic algorithms. The 18-month incidence of each respiratory diagnosis was determined, and for frequent diagnoses, incidence by transmission category, location of residence, smoking status, CD4 count, and performance score at entry were compared. The most frequent respiratory diagnoses in HIV-seropositive cohort members were common to the general population: upper respiratory infection (33.4%), acute bronchitis (16.0%), acute sinusitis (5.3%), and bacterial pneumonia (4.8%). Pneumocystis carinii pneumonia occurred in 3.9%. Ambulatory respiratory illnesses were reported frequently regardless of immunologic status. The rates of P. carinii pneumonia and bacterial pneumonia were significantly greater in cohort members with entry CD4 counts < 250. Bacterial pneumonia occurred more frequently in injecting drug users and in cohort members with entry Karnofsky scores < 90. Disease stage and demographic and exposure factors are important variables affecting the respiratory manifestations of HIV infection.

AIDS-Related Opportunistic Infections↗
PubMed1993

Preventive therapy for the patient with both universal indication and contraindication for isoniazid.

BACKGROUND: The delphi method of decision making was used to address an unusual clinical case in which various aspects of the case required opposing management strategies. METHODS: A panel of 30 pulmonary experts was surveyed repeatedly until a convergence of treatment approaches was reached for a patient who was considered to have both a universal indication for and a universal contraindication against prevention therapy. Participants were asked to evaluate the appropriateness of proposed treatments on a scale from 1 to 9, with 1 being extremely inappropriate, 5 being equivocal, and 9 being extremely appropriate. The delphi survey data responses were compared using measures of central tendency (ie, the mean and median) and measures of variability (ie, the standard deviation and interquartile range). RESULTS: Although no treatment was wholeheartedly supported by the experts, analysis of the three-round delphi survey responses resulted in two possible treatments: rifampin, 600 mg daily, for four months, or no treatment with close observation. Interestingly, the experts working in a non-university setting favored the rifampin treatment, and those working in a university setting favored no treatment with close observation. CONCLUSIONS: The delphi method has the potential to be used for clinical decision making.

Adult↗
PubMed1993

Pulmonary complications of asbestos exposure.

Except for benign pleural effusion, asbestos-related pulmonary complications, including asbestosis, malignant mesothelioma and bronchogenic carcinoma, usually occur more than 20 years after exposure. Pleural plaques and pleural thickening serve as markers for asbestos exposure, but they are not associated with an increased risk of malignancy. Clinical criteria for the diagnosis of asbestosis include a reliable history of asbestos exposure, an appropriate interval between exposure and disease detection, radiographic evidence of pulmonary fibrosis, decreased vital capacity and diffusing capacity, and bilateral posterior inspiratory crackles. A lung biopsy is indicated only to rule out other causes of interstitial lung disease. A history of dyspnea, pleuritic chest pain, fatigue, weight loss and pleural effusion in a former asbestos worker is suggestive of mesothelioma. Cigarette smoking greatly increases the risk of lung cancer in asbestos workers.

Asbestos↗
PubMed1992

Liver transplantation: an unheralded probable risk for tuberculosis.

We present a patient who underwent orthotopic liver transplantation and died of previously undiagnosed pulmonary tuberculosis (TB). TB is known to complicate liver transplantation in rare circumstances. Liver transplantation is an unheralded risk factor for development of TB because of possible activation of latent infection or primary TB in immunosuppressed hosts. A tuberculin skin test should always be performed preoperatively. Preventive treatment with isoniazid is indicated when immunosuppressive therapy is started in patients with high TB risk. Radiographic signs of previous granulomatous disease may be important when tuberculin skin test is negative, unknown or anergy is present. TB is preventable--with a high degree of suspicion where TB is endemic and proactive programs, most TB cases in transplant recipients can be avoided.

Adult↗
PubMed1992

Long-term follow-up of tuberculoma of the brain in an AIDS patient.

Human immunodeficiency virus infection and extrapulmonary TB are defined as AIDS. The clinical manifestations of the TB are related to the interplay of the organism and the host's immune system. A seven-year follow-up of a woman successfully treated for biopsy- and culture-documented tuberculous brain abscess is described. Antibodies to HIV have been positive on repeated testing, yet CD4 counts remain over 500. Aggressive diagnostic and therapeutic maneuvers for all forms of TB in AIDS are warranted since long-term prognosis may be good.

Acquired Immunodeficiency Syndrome↗