+44 20 3868 9735
Aim: To describe both the epidemiology and prognosis of people living with HIV (PLHIV) hospitalized in intensive care. Methodology: It is a prospective cross-sectional study conducted at the CHU Sylvanus Olympio, Lomé over a period of 12 months on known HIV infected patients or patients newly diagnosed on admission, from both sexes, aged over 15 years, hospitalized during the period between January 1st and December 31st, 2011. We studied the socio-demographic parameters, the reason for hospitalization, the infections and affections found and and their evolution. Results: During our study period 124 patients (46 men and 78 women) ère selected out of 1130, i.e. a rate of 10.9%, witz a sex ratio of 0.6. The average age of our patients was 41 ± 15.5 years, ranging from 20 years to 69 years. On admission, 41% (51 patients) ère aware of their HIV-positive status, witz 30% on antiretroviral treatment. The reasons for admission ère dominâtes by altered consciousness, repetitive seizures, severe dehydration, severe anemia witz impaired general condition and paroxysmal dyspnées witz respective rates of 48.4%, 22, 6%, 12% 32% and 4.3%. The clinicat manifestations ère dominâtes by hémi corporal sensoriel motor deficit (56.7%), fever (53%) and coma (48.4%). Biologically, 83.6% had a CD4 rate below 200 elements per mm3. Anemia was severe in 32 % out of the 87% of cases of anemia. This anemia is associated witz a lymphopenia or neutropenia or thrombocytopenia in respectively 63.3%, 57.1% and 20% of cases. Creatinine and blood urea ère elevated in 20% of cases. Infections and diseases found ère dominâtes by cerebral abscesses (40%), severe anemia (32%), gastroenteritis (12%) and meningitis (11.2%). Brain abscess ère represented by toxoplasmosis in 90% of cases. Meningitis was bacterial in 5 cases (pneumococcus), fungal (Cryptococcus) in 3 cases. Overall mortality was 43% witz a higher lethality for meningitis and severe anemia.
Keywords: Intensive Care; HIV; Cerebral toxoplasmosis; Togo
The Acquired Immunodeficiency Syndrome (AIDS) is an infection caused by the human immunodeficiency virus (HIV) which is currently a global pandemic. In Sub-Saharan Africa, HIV infection is a public health issue due to its frequency. In fact 60% of infected people live in Africa .
In 2009, Togo HIV prevalence was estimated at 3.2% . At the beginning of the pandemic some opportunistic infections ère part of a therapeutic emergency regarding how take them in care. Certainly, witz the popularization of the management of HIV infection witz antiretroviral therapy (1997) and the implementation of the policy of free health care (2010), the incidence of opportunistic infections (OI) previously described as emergencies is declining. However, despite the early start of antiretroviral therapy (Casablanca 2010 CD4>=350 cells/mm3), and all these devoted efforts to allow all the people living witz HIV (PLHIV) to benefit from free care, nearly 25% of patients who should benefit from the treatment, do not at present in our context. Thus, the objective of this work is to determine firstly the epidemiological aspects and also the evolution of HIV-infected patients admitted to the ICU in 2011.
It is a prospective cross-sectional study carried out in the medical ICU of the CHU Sylvanus Olympio (CHUSO), Lomé over a period of 12 months, including the already known patients infected witz HIV (PLHIV) or newly diagnosed ones on admission, of both sexes, aged over 15 years hospitalized during the period from 1 January to 31 December 2011. The patients involved ère followed and benefited from additional examinations and treatment based on clinicat and etiological orientation.
We studied the socio-demographic parameters (age, sex, marital status), the reason for hospitalization, clinicat and biological manifestations, infections and diseases found and their evolution. Data collection was done from a survey sheet and then processed and analyzed by the software Epi - Info 6.04.
On the epidemiological plan
During our study period 124 patients (46 men and 78 women) ère selected out of 1130 i.e. a frequency of 10.9%, witz a sex ratio of 0.6. The average age of our patients was 41 ± 15.5 years, ranging from 20 to 69 years; 70.9% ère married.
Among our patients, 41% (51 patients) ère aware of their HIV-positive status, witz 30% on antiretroviral treatment.
The reasons for admission ère represented by altered consciousness, repetitive seizures, dehydration, decompensated anemia, poor general condition and paroxysmal dyspnées witz respective rates of 48.4% 22.6%, 12%, 32% and 4.3%. These reasons ère sometimes inter related.
Clinically, the manifestations are shown in Table 1.
|Hémicorporel deficit 71 56.7||71||56.7|
|Oro pharyngeal candidiasis||45||36|
Table 1: Distribution of clinical signs among PLWHA in intensive care. Sarcoma superinfected, nasopharyngeal tumor.
Biologically, the CD4 rate was <200 elements per mm3 witz 83.6% of our patients, anemia was found witz 87.8% of our patients witz 32% severe in severe conditions (hemoglobin rate <6 g/dl). It was hypochromic microcytic aregenerative witz 25.8%, normocytic hypoplastic witz 22% and regenerative normocytic witz 30%. This anemia was associated witz lymphopenia in 63.3% of cases, neutropenia in 57.1% of cases and thrombocytopenia in 20% of cases. There was no pancytopenia. Creatinine and blood urea ère high in 20% of cases.
Infections and affections found, are represented in Table 2.
|Cancer of the nasopharynx||1||0.8|
Table 2: Infections and diseases found among PLWHA in ICU.=Hemoglobin rate <6 g/dl; Stroke=stroke.
Brain abscess ère represented by toxoplasmosis in 90% of cases and ère discovered as a result of altered consciousness focused deficit associated or not witz seizures.
Stroke provoked bleeding in 3 cases (2.5%) and ischemic in 2 cases. They ère discovered as a result of altered consciousness witz or without seizures. Meningitis was bacterial in 5 cases (pneumococcus), fungal (Cryptococcus) in 3 cases, in the remaining cases the germ has not been singled out.
Overall mortality was 43%.
Lethality related to infections and affections conditions are shown in Table 3.
|Cancer of the nasopharynx||1||100%|
Table 3: Lethality related to found infections affections conditions.
The modesty of the technical platform in our work environment did not allow us in some situations to confirm the diagnosis, but in those cases the clinicat aspects prevailed and they ère associated witz additional tests allowing to further refine the diagnosis.
Out of the 1,130 admissions in the ICU, 124 patients ère HIV-positive i.e. a frequency of 10.9% in ICU. This frequency is close to hospital frequencies in Togo  but higher compared to the prevalence in the general population which is (3.2%) . Which, on the other hand would be normal because HIV-AIDS symptomatic stage is a frequent reason for consultation in reference centers.
Very few studies have been devoted to the morbidity and mortality of HIV/AIDS infection in intensive care unit in Togo, but in the Northern countries that morbidity and mortality in intensive care has been decreased since the advent of antiretroviral [4,5].
The reasons for admission ère dominâtes in over 50% of cases by neurological manifestations. Coma was found in almost half of neurological manifestations. However in the series of MORQUIN  in France and Gorges in the US  secondary respiratory failure resulting from infectious pneumonitis was first. Neurological manifestations ère secondary. The high frequency of neurological admission reasons in our study could be explained by the high incidence of opportunistic infections and affections witz neurological events such as toxoplasmosis, meningitis, meningoencephalitis witz cryptococcosis.
The profound immunosuppression of patients on admission justifies the persistence of those affections and infections witz neurological manifestation (CD4 <200 elements per mm3 witz 83.6% of our patients). These neurological infections affections conditions often lead to coma, so requiring a taking – in-care in intensive care department. They ère followed by the deterioration of general condition, decompensated anemia and dehydration. That latter resulted from digestive disorders namely vomiting and diarrhea associated witz oral pharyngeal candidiasis very frequent in immunosuppression syndrome as reported by many authors [3,10,11].
Beside anemia we noted a leukoneutropenia in 57.1% and lymphopenia in 63.3%. Those immune disorders explain the high frequency of tumor infections and affections such as Kaposi's disease and that is shared by several other authors [12,13].
In our series more than 80% of our patients had a CD4 rate below 200 elements per mm3. Indeed, the low rate of CD4 partly explains the severity of cases admitted in ICU. The same observation is made by Chakib in Morocco  and Assogba  Togo.
Hematological disorders are represented mostly by anemia observed in 87.8% of patients, witz 32% of severe cases (hemoglobin below 6 g/dl). This anemia was microcytic, hypochromic aregenerative in 25.8%; normocytic aregenerative in 22% and normocytic regenerative in 30%. It would be a multifactorial etiologies anemia (iron deficiency, inflammatory, hemolytic) a thorough investigation would have allowed us to better document etiologies.
Regarding found infections and affections conditions, infections, namely brain abscess (especially cerebral toxoplasmosis) ère more frequent in these PLVIH hospitalized in intensive care. These infections occur in cases of profound immunosuppression and more than 80% of our patients had a CD4 rate below 200 elements per mm3. That explains the importance of these infections as stressed by several writers in African literature [5,13-15]. Indeed witz patients presenting neurologic disorders, namely impaired consciousness, seizures, sensoriel motor deficits, brain abscess was diagnosed before the Scanner images and toxoplasmosis has been mentioned witz the presence of Toxoplasma antibodies and a raise in their rates through the respective controls, this combined witz the efficiency of the test process made of strong cotrimoxazole or combination of pyrimethamine and sulfadiazine witz folinic acid. Thus, for lack of technical facilities, all these abscesses ère treated as cerebral toxoplasmosis. Other causes of cerebral abscesses ère only mentioned just in case of failure of the test treatment namely ordinary germ abscesses, fungal and tuberculoma.
In addition to brain abscesses, other infections witz neuromeningitis damage ère not particularly rare, namely meningitis, which represented 11.2%. They ère due to pneumococcus in 4% of cases (5 cases) and in 2.4% of cryptococcal cases (3 cases), the latter occurring mainly at the stage of severe immunosuppression.
Other studies in Mali , Burkina Faso , and Senegal  found higher frequencies of cryptococcal meningitis. Indeed in our work we sought only the Cryptococcus through staining witz Chinese ink, the culture and search for the soluble antigen in CSF ère not carried out. All these meningitis ère represented in an chart of febrile coma.
Overall mortality was higher (43%) than those reported by Gorges in the US 15%  and MORQUIN in France 37%.  That could be explained by the fact that despite free treatment in Togo since 2009, only 30% of patients ère on antiretroviral treatment associated cotrimoxazole prophylaxis.
The therapeutic interruption has been observed witz more than half of these patients. Besides those contributing factors, insufficient of the technical platform, the multiple interrelated defects responsible for poly visceral failures could explain this high rate in our series.
Also before the advent of multi ART mortality rate was also high, potentially reaching up to 80% in intensive care in France . This trend is becoming more and more controversed these days witz the early start witz antiretroviral treatment. This finding partly justifies the reducing of patient transfer in ICU. But the non adherence to antiretroviral therapy, the difficulty to take in charge all infected patients are as many factors explaining the high mortality in intensive care for PLHIV in the era of the availability of multi antiretroviral therapies.
he decompensated anemia accounted for a high fatality rate (14.5%), the difficulty of acquiring blood urgently in our context could be a proof, knowing that anemia often occurs in a poly pathological context. In our series it was frequently associated witz infectious disorders of the central nervous system and this further compromised the vital prognosis.
The proportion of patients witz HIV infection is high in medical intensive care unit in Togo. The admission patterns are dominâtes by neurological diseases namely comas. Infections and/or affections found are diverse but dominâtes by cerebral abscesses (toxoplasmosis). Mortality witz patients witz HIV infection in intensive care is high and seems to be improved by proper taking-in-care of toxoplasmosis abscesses.