Twelve cases of histoplasmosis in HIV-infected patients were found in a retrospective analysis at the Hospital Universitário Cassiano Antônio de Moraes of the Universidade Federal do Espírito Santo (HUCAM), Vitória (ES), from June 1999 to May 2001. The frequency of histoplasmosis among HIV-positive patients was 2.1% in the infectious diseases division of the hospital during this period. Histoplasmosis compromised mainly males (11/12), 27 to 44 years old, and residents of the metropolitan urban area (10/12). Alcohol abuse and tobacco smoking were described in 10 of the 12 patients. For all patients, this was the first opportunistic infection. Two of the 12 patients died; 10 patients had disseminated disease, one patient had an intestinal presentation and one had disease restricted to the lungs. The most frequent clinical manifestations were weight loss, fever, hepatomegaly and splenomegaly, coughing, abdominal pain, and diarrhea. Six of the 12 patients had skin lesions. Time of symptoms preceding the diagnosis varied from two months to one year. CD4 counts were below 200 cells/mm(3) in 9 of 10 patients. Diagnosis was made by histology in two thirds of the patients. The typical adult patient with HIV infection and histoplasmosis in our series was male, had a CD4 count below 200 cells/mm(3), had fever, weight loss, cough, abdominal pain and hepatomegaly in the last two months or more, had a high probability of alcohol and tobacco addiction, was having his first opportunistic infection, and had no identifiable environmental exposure risk.

BackgroundA paradoxical immunologic response (PIR) to Highly Active Antiretroviral Therapy (HAART), defined as viral suppression without CD4 cell-count improvement, has been reported in the literature as 8 to 42%, around 15% in most instances. The present study aims to determine, in a cohort of HIV infected patients in Brazil, what factors were independently associated with such a discordant response to HAART.MethodsA case-control study (1:4) matched by gender was conducted among 934 HIV infected patients on HAART in Brazil. Cases: patients with PIR, defined as CD4 < 350 cells/mm3 (hazard ratio for AIDS or death of at least 8.5) and undetectable HIV viral load on HAART for at least one year. Controls: similar to cases, but with CD4 counts ≥ 350 cells/mm3. Eligibility criteria were applied. Data were collected from medical records using a standardized form. Variables were introduced in a hierarchical logistic regression model if a p-value < 0.1 was determined in a bivariate analysis.ResultsAmong 934 patients, 39 cases and 160 controls were consecutively selected. Factors associated with PIR in the logistic regression model were: total time in use of HAART (OR 0.981; CI 95%: 0.96-0.99), nadir CD4-count (OR 0.985; CI 95%: 0.97-0.99), and time of undetectable HIV viral load (OR 0.969; CI 95%: 0.94-0.99).ConclusionsPIR seems to be related to a delay in the management of immunodeficient patients, as shown by its negative association with nadir CD4-count. Strategies should be implemented to avoid such a delay and improve the adherence to HAART as a way to implement concordant responses.

SUMMARYSome patients under antiretroviral therapy (ART) do not reach immune recovery when the viral load becomes undetectable. This is called discordant immunologic and virologic responses. Its prevalence varies between 8% and 24%. This study describes its prevalence and the characteristics of the affected subjects in the outpatient clinic of a Brazilian specialized-care center. Of 934 patients on ART, 536 had undetectable viral loads. Prevalence was 51/536 or 9% (95% confidence interval: 6.6% to 11.4%). Median age at the beginning of ART was 37 years (interquartile range -IQR: 31 to 45). Male gender and mixed race predominated (76.5% and 47.1% respectively). AIDS-defining illnesses were absent at the beginning of ART in 60.8%. Fifty-one percent were taking protease inhibitors, 43.2% Efavirenz and 5.8% both. Median time on ART was 36 months (IQR: 17-81 months). Irregular treatment was recorded for 21.6%. ART had been modified for 63% prior to the study, and 15.7% had used monotherapy or double therapy. Median CD4 count was 255 cells/mm . Median viral load before ART was 4.7 log 10 copies/mL (IQR: 4.5-5.2). Discordant responders were not different from AIDS patients in general, but there was a high frequency of multiple schedules of treatment.

Introduction: the need for optimal adherence to Highly Active Antiretroviral Therapy (HAART) is essential for successful treatment in Acquired immune deficiency syndrome (aids). Objective: assess HAART's adherence and related socio-demographic, clinical and laboratory variables. Methods: crosssectional study. Sample calculation: 81 among 870 patients using HAART. Data collected between 14/09/2009 and 20/10/2009 at HIV/aids Outpatient Clinic of Federal University of Espírito Santo, Vitória -ES. Standardized forms and CEAT-VIH questionnaire translated and adapted to Brazilian language were used to access data and adherence, respectively. Considering the strict adherence outcomes (≥ 85% in the CEAT-VIH) and the presence or absence of possibly associated factor, univariate and multivariate analysis (binary logistic regression) were used and odds ratio (OR) was the association measure assessed. Results: strict adhesion was found in 42% of patients and mean adhesion was 81.1%. Medication use failure was reported by 76.5% of interviewed and main reasons were: forgetfulness (37%) and being away from home (30.9%). Strict adhesion was significantly associated with a higher number of completed years of study and a longer duration of undetectable viral load. Conclusion: despite an acceptable mean adhesion, strict adherence was poor. Better adherence was associated with a higher educational level and longer virological suppression. Keywords: aids, adherence, antiretroviral therapy, DST RESUMO Introdução: uma ótima adesão ao esquema antirretroviral de alta eficácia (HAART) é imprescindível para o sucesso terapêutico na síndrome da imunodeficiência adquirida humana (Aids). Objetivo: verificar a adesão ao HAART e identificar variáveis sociodemográficas, clínicas e laboratoriais relacionadas a esta. Métodos: estudo de inquérito simples com cálculo amostral de 81 pacientes dentre os 870 usando HAART no Serviço Especializado em HIV/Aids da Universidade Federal do Espírito Santo, Vitória -ES. Os dados foram coletados entre 14/09/2009 a 20/10/2009. Formulário padronizado e a versão traduzida e adaptada à realidade brasileira do questionário CEAT-VIH foram utilizados para acessar os dados e a adesão, respectivamente. Os desfechos foram adesão estrita (≥ 85% no CEAT-VIH) ou não, e presença ou ausência de fator possivelmente associado, utilizaram-se análises uni e multivariada (regressão logística binária) e cálculo da Odds Ratio (OR) como medida de associação. Resultados: adesão estrita foi encontrada em 42% dos pacientes, com a média de adesão de 81,1%. Falha no uso da medicação ocorreu em 76,5% dos entrevistados, cujos principais motivos foram: esquecimento (37%) e estar longe de casa (30,9%). Adesão estrita esteve estatisticamente associada a um maior número de anos completos de estudo e a um maior tempo de carga viral indetectável. Conclusão: apesar de uma média de adesão aceitável, a adesão estrita foi insatisfatória. Melhor adesão esteve associada a um maior grau de escolaridade e maior tempo de supressão virológica.

This is a case report about the only confirmed death in the State of Espírito Santo due to acute Chagas-related myocarditis in a 2-year-old child living in the rural area of Guarapari. He presented with fever, abdominal pain, headache, and vomiting, resulting in death 21 days after the presentation of symptoms. Amastigote forms were observed in the myocardial fibers in histological examination. The boy's mother had reported finding "kissing bugs" in the child's hand. This case highlights the need to include Chagas disease in the differential diagnosis in health care to provide early treatment and avoid death in affected individuals.