Disseminated toxoplasmosis in AIDS is a rare condition. We present an unusual case of a fulminant form of disseminated toxoplasmosis in a young male homosexual. He was a 30-year-old HIV-positive (diagnosed 4 months earlier), admitted with a 5-day history of diarrhea, vomiting, fever, and cough. He had been generally healthy except for an 8-week history of weight loss and malaise. On admission, except for a temperature of 37.6 degrees C, the physical examination was normal. He was treated symptomatically. Four days after admission he suddenly became short of breath. Despite intensive management, he continued to deteriorate and expired 6 h later. Postmortem examination revealed disseminated toxoplasmosis involving the heart, lungs, brain, stomach, small intestine, and colon. This is an unusual presentation of disseminated toxoplasmosis because of its rapid course with no prior indication of infection. To our knowledge, such an atypical and rapid downhill course of toxoplasmosis (with minimal clinical and laboratory features) has not been reported previously. Increased awareness of this infection in all HIV patients and its possibly rapid course is needed.

Prosthetic grafts have become an acceptable alternative to the autogenous arteriovenous dialysis fistula. The major drawback in their use for the dialysis patient is infection. We present a case of infected polytetrafiuoroethylene arteriovenous fistula (endarteritis) with signs of unilateral splinter hemorrhage, Janeway lesions in the affected limb and septic venous embolization to the lungs. The graft eventually ruptured requiring emergency surgery. Staphylococcus aureus is by far the most common implicated organism. An otherwise non-threatening infection at a fistula site can lead to more serious complications such as infective endocarditis.

A patient with severe type V hyperlipoproteinemia and chronic end-stage renal disease received a renal transplant and therapy with cyclosporine. Concentrations of the drug in plasma as determined by liquid chromatography appeared extraordinarily high for the dose ingested. When we measured the drug in the plasma, plasma cleared by ultracentrifugation, leukocytes, erythrocytes, and whole blood, we found that the high concentrations of cyclosporine were associated with the chylomicrons that always were present in this patient's blood. Cyclosporine added directly to this patient's plasma was less associated with the plasma lipids. Isolated lymphocytes and kidney slices incubated with plasma from this patient bound no more drug than when incubated with nonhyperlipemic plasma containing cyclosporine at a normal therapeutic concentration. We conclude that the cyclosporine associated with the chylomicrons in this patient was not biologically available to either lymphocytes or kidney tissue. We strongly recommend the use of chylomicron-cleared plasma for therapeutic drug monitoring of cyclosporine in type V hyperlipoproteinemic patients.

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