To the Editor:
Although spine infections are rare in HIV positive patients, they are
important because a prompt medical treatment can prevent serious
morbidity. We congratulate Drs. Weinstein & Eismont for their study
“Infections of the spine in patients with Human Immunodeficiency Virus”(1). They have concluded from the study
that there is a significantly higher risk of developing spine infections
in patients who are HIV positive, that the CD4+ count has a positive
correlation with pathogenicity of the infective organism, and that these
patients usually respond well to standard treatment. May we ask the
authors to clarify some questions?
There were 346,874 admissions during the 6 years of the study out
of which 265,635 were ‘unique’. Could the authors please clearly state as
to what characterized these ‘unique’ admissions?
Presumably, not all the patients classified as HIV negative were
actually tested for HIV, either because there was no indication to do so
or due to a lack of consent from patients. It would be helpful to know
how many of the 183 HIV negative patients with spine infections were
actually tested for HIV, especially the 74 patients with spinal
tuberculosis and pyogenic epidural abscess. We know from the study that
such infections usually develop in immunocompromised patients in the
absence of other risk factors. If these patients were never tested,
and if they did not have any other risk factors, then they could
potentially add to the number on the HIV positive side, thereby further
increasing the relevance of this study.
Belzunegni, et al, (2) reported that nearly half of their HIV positive
patients (5 of 11) had osteoarticular tuberculosis as a result of a
recurrence of a previous infection. It would be interesting to know
how many patients in the present study had been treated for similar
infections in the past and whether the CD4+ counts in such patients (if
there were any) were high or low. Bearing in mind that the present study
has refuted the previous claim (3) that the increased risk of osteoarticular
infections is more directly related to parenteral drug abuse rather than
presence of HIV infection, this assumes further importance. A patient
developing infection due to intravenous drug abuse is more likely to get
it as a result of fresh inoculation compared to the immunocompromised HIV
positive patients who can develop infection due to latent foci or
rejuvenation of previous inadequately treated infections.
Finally, it is unclear from the paper whether the CD4+ counts were
recorded at the time when the spine symptoms occurred or at the time of
making the diagnosis of HIV positivity. It is important to know this in
view of the evidence (4) that prophylaxis against atypical mycobacteria is
useful when CD4+ counts are low and can be stopped when the counts rise as
a result of anti-retroviral therapy.
References
1. Weinstein MA, Eismont FJ. Infections of the Spine in Patients with
Human Immunodeficiency Virus. J Bone Joint Surg Am. 2005;87:604-609.
2. Belzunegui J, Santisteban M, Gorordo M, Barastay E, Rodriguez-
Escalera C, Lopez-Dominguez L, Gonzalez C, Figueroa M. Osteoarticular
mycobacterial infections in patients with the human immunodeficiency
virus. Clin Exp Rheumatol. 2004 May-Jun;22(3):343-5.
3. Ventura G, Gasparini G, Lucia MB, Tumbarello M, Tacconelli E,
Caldarola G, Cauda R. Osteoarticular bacterial infections are rare in HIV-
infected patients. 14 cases found among 4,023 HIV-infected patients. Acta
Orthop Scand. 1997 Dec;68(6):554-8.
4. Currier JS, Feinberg J. Bacterial infections in HIV disease. AIDS
Clin Rev.1995; 96:131 -52.
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