I CORRESPONDENCE

LIVER BIOPSY IN PATIENTS WITH SERUM ANTIBODIESTO HIV To the Editor: We were very interested in the article by Cappell and co-workers (Am J Med 1990; 88: 123-30) on the clinical utility of liver biopsy in patients with serum antibodies to the human immunodeficiency virus (HIV). We would like to report our experience with this subject. Twenty-three patients with antibodies to HIV present in the serum underwent liver biopsy. Indications were unexplained fever in all cases. The ages of the patients ranged from 23 to 80 years, with a mean age of 30 years. The risk factors for HIV infection were intravenous drug abuse in 13 patients, post-transfusion in four, homosexuality in three, and no known HIV infection risk factor in three patients. Five patients were asymptomatic (Centers for Disease Control [CDC] group 2), four were symptomatic (CDC groups 3 and 4A), and 14 patients had acquired immunodeficiency syndrome. Normal serum levels of biochemical parameters of liver function were seen in eight patients. Aspartate and alanine aminotransferase values were greater than twice the upper limits of normal in four patients. The alkaline phosphatase serum level was greater than twice the upper limits in six patients, and five had mixed cholestatic and cytolytic hepatitis. Hepatitis B surface antigen was present in the serum of three patients, and one had delta antibodies. Standard cultures of biopsy specimens were performed for aerobic and anaerobic bacteria, mycobacteria, and fungi. Pathologic examination routinely included stains with hematoxylin and eosin, reticulum, Ziehl694

Neelsen for detection of acid-fast organisms, and Gomori methenamine silver for detection of fungi. Liver biopsy was diagnostic in six cases (27%), including documentation of hepatic infection by Mycobacterium avium-intraceUulare in three, Mycobacterium tuberculosis in two, and Leishmania donovani in one. None of these infections had been previously detected at an extrahepatic site. Only two patients had normal results of liver biopsy. Eight had nonspecific hepatitis and 12 had hepatic granulomas, including five with mycobacterial disease. Our study confirms the findings of Cappell et al. In patients with serum antibodies to HIV and unexplained fever with or without liver dysfunction, liver biopsy has great utility in the diagnosis of opportunistic infection. BRUNO TAILLAN, M.D. GEORGES GARNIER JEAN- GABRIEL FUZIBET ALAIN PESCE HENRI VINTI PAUL HOFFMAN PATRICE CASSUTO PIERRE DUJARDIN

Cimiez Hospital Nice, France Submitted May 25, 1990, and acceptedJune 14, 1990

ANTIBIOTIC-RELATED ADVERSE EFFECTSIN PATIENTS WITH LEUKEMIA To the Editor: I have read with interest the report of O'Hanley et al (Am J Med 1989; 87: 605-13) concerning the management of infectious disease in a cohort of 142 adult leukemic patients undergoing intensive chemotherapy at Stanford University between 1982 and 1986. C e r t a i n c l a r i f i c a t i o n s would be useful in the evaluation of this work and its conclusions.

November 1990 The American Journal of Medicine Volume 89

First, reference number 18 seems to have been inadvertently omitted. This reference apparently would have expanded upon the assignment of adverse clinical/ laboratory findings to the category of antibiotic-associated toxicities. Certainly, in these very complicated cases, the determination of the causation of a deterioration in hepatic or renal function in the face of multiple insults including c h e m o t h e r a p e u t i c agents, blood transfusions, other medications, ongoing infection, and the leukemia itself is a complex one, and more detail on how this deterioration in hepatic or renal function was assigned to antibiotics would be enlightening. Second, there seems to be a discrepancy in the number of deaths reported. The authors report a total of 46 deaths in 190 courses of antimicrobial therapy, and they later report 12 deaths in patients with hepatic/renal toxicity from antibiotics and 12 deaths in those patients without these toxicities (24 total). The authors report an association of excessive antibiotic usage and antibiotic changes with antibiotic-induced toxicities, and they further report an association of these toxicities with death. They conclude that excessive antibiotic use increases the risk of adverse outcome (i.e., renal/hepatic toxicity and death). Alternative conclusions could be drawn from these data. The fact that persistent fever was the major reason patients were subjected to multiple antibiotic agents and multiple changes of these antibiotic regimens, coupled with the fact that patients so treated had adverse outcomes, may all simply reflect that leukemic patients with persistent fevers despite antibiotics are a group with a poor prognosis, possibly be-

Liver biopsy in patients with serum antibodies to HIV.

I CORRESPONDENCE LIVER BIOPSY IN PATIENTS WITH SERUM ANTIBODIESTO HIV To the Editor: We were very interested in the article by Cappell and co-workers...
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