                   AIDS INFORMATION NEWSLETTER
                   Michael Howe, MSLS, Editor
                     AIDS Information Center
                VA Medical Center, San Francisco
                     (415) 221-4810 ext 3305
                        September 8, 1995

              Opportunistic Infections (Part VIII)
                              Fever

             Information Sheet for Patient Education
                          June 16, 1995

Fever occurs when your body temperature rises above normal.  It may
be accompanied by chills, increased sweating, muscle and joint
aches, and fatigue.  You should see your doctor if fever lasts more
than three days, is unusually high, or is associated with other
symptoms and signs of serious illness.  Fever has many causes,
including infections, tumors, inflammatory conditions, and
prescription and alternative medications.  In people with early HIV
disease, fever does not usually indicate a serious HIV-related
condition.  In people with advanced HIV disease, fever is more
likely to be caused by unusually or opportunistic diseases, such
as Pneumocystis carinii pneumonia (PCP), Mycobacterium avium
complex infection (MAC), or lymphoma.


What is fever?

Fever is a higher than normal body temperature.  Usually the human
body temperature is controlled within a narrow range near 37
degrees Centigrade or 98.6 degrees Fahrenheit by turning on and off
mechanisms that produce and release heat.  Normally a person's
temperature is lower in the morning and rises during the day by
about one degree Fahrenheit (0.5 degrees Centigrade).


What are the common causes of fever?

Fever occurs in response to a variety of infections caused by
viruses, bacteria, fungi, and parasites.  It may occur in
association with infection of the blood and other organs or
tissues, such as the gums (gingivitis, tooth abscesses), upper
respiratory tract (colds, sinusitis), heart (endocarditis), lungs
(bronchitis, pneumonia), liver (hepatitis), gut (gastroenteritis),
kidney (pyelonephritis, cystitis), skin (cellulitis, abscess), and
brain and spinal cord (meningitis, encephalitis).

Certain tumors such as lymphomas may cause fever.  Fever also
occurs with some inflammatory conditions, such as blood clots in
large vessels (thrombophlebitis) and red and swollen joints
(arthritis).  In addition, fever may be a side effect of many
medications.


What conditions cause fever in HIV-infected persons?

In person with early stages of HIV disease (T-cell count greater
than 500), fever is usually caused by the same self-limited
conditions, such as viral upper respiratory infections, as in non-
HIV infected persons.  However, it may also be associated with more
serious problems including bacterial pneumonia, sinusitis, and
shingles (herpes zoster).  Tuberculosis (TB) is a highly
contagious, treatable infection that is a potential cause of fever
in persons who live in crowded conditions or who have been in
contact with others with TB.

In persons with later stage HIV disease (T-cell count less than
200), any of the above problems may cause fever, but it may also
indicate the presence of unusual conditions such as PCP, MAC, and
cytomegalovirus (CMV).  An abnormally low white blood cell count
(neutropenia) and a permanent intravenous catheter are common
conditions in advanced HIV disease that increase the risk for
serious infections associated with fever.  Prescription,
nonprescription, or alternative medications are also possible
causes of fever.  Other conditions should always be ruled out
before attributing fever to HIV disease itself.


What should you do if you have a fever?

A new fever is a reason for concern because it may indicate a
serious infection that can cause harm if not identified and treated
rapidly.  You should see your doctor if you develop a mild fever
that lasts more than three days.  For a new fever that is unusually
high (above 39.5 degrees Centigrade or 103 degrees Fahrenheit) or
associated with other symptoms and signs of significant illness,
it is important to contact your doctor immediately.

In order to help your doctor determine what is causing the fever,
you should think about and have ready the following information:

1) Is the fever a continuing problem or has it been present only
a few days?
2) Do you have other signs of illness, such as cough, diarrhea, or
localized pain, that will give clues about the medical condition
causing the fever?
3) Are you severely ill or only mildly uncomfortable?
4) What prescription and alternative medications are you taking?

The answers will guide your doctor to choose what tests to do and
how quickly they should be done.  Tests may include blood tests;
cultures of blood, sputum, or urine; skin tests; x-rays or scans;
or diagnostic bronchoscopy (insertion of a flexible tube into the
lungs).  In general, if you are only mildly ill, then simple,
noninvasive (not painful or risky) tests will be done.  If the
condition is an emergency or if you have advanced HIV disease,
extensive testing and hospital admission are much more likely.


How can fever be controlled?

Fever is a symptom.  The best way to treat fever is to work with
your doctor to identify and treat the condition causing it.  Fever
can usually be controlled with medications, including acetaminophen
(Tylenol), or nonsteroidal anti-inflammatory drugs (NSAIDs), such
as aspirin, ibuprofen (Motrin), or naproxen (Naprosyn).  NSAIDs
tend to have more side effects, particularly stomach distress, than
acetaminophen.  Drinking plenty of liquids when you have a fever
is important to prevent dehydration from increased body fluid loss.


[Editor's Note:  This is one of a series of Information Sheets
prepared by the National AIDS Treatment Information Project (NATIP)
with funding from the Henry J. Kaiser Family Foundation.  The
materials are designed for self-education by HIV-infected persons
and for counseling by community advisors, case managers, social
workers, and clinicians.  For more information about NATIP, call
617-667-5520 or write:  Helen E. Woods Wogan, Project Manager,
Libby 317, Beth Israel Hospital, 330 Brookline Avenue, Boston, MA
02215.  Fax: 617-667-2885.  Internet:  hwoods@bih.harvard.edu]


                       Fever - References

AU   -  Barat LM ; Gunn JE ; Steger KA ; Perkins CJ ; Steinberg JL
        ; Viner BL ; Craven DE
TI   -  Bacterial infections are the most common cause of fever in
        HIV-infected patients admitted to a municipal hospital.
AB   -  OBJECTIVE: To determine the etiology of fever and its
        relationship to risk category in HIV-infected people
        admitted with a febrile illness to the medical inpatient
        service of a municipal hospital. METHODS: We prospectively
        monitored all HIV-infected patients admitted with fever
        (greater than 100.4 degrees F) to determine the source of
        their illness and outcome. RESULTS: Of the 204 patients
        followed, a fever source was documented in 177 patients
        (87%), who were predominantly male (70%), non-white (78%),
        and reported a history of injecting drug use (IDU-66%); 83%
        had CD4 counts of less than 200/mm3. Of 195 documented 
        fever sources, 117 (60%) were bacterial infections (BI).
        Pneumonia accounted for 59%, skin and soft tissue
        infections for 10% and endocarditis for 8% of all BI.
        Streptococcus pneumoniae (N = 23) and Staphylococcus aureus
        (N = 15) were the most frequently isolated pathogens.
        Twenty-seven patients (23%) had bacteremia, S. pneumoniae
        (26%) and S. aureus (33%) were again the predominant
        isolates. Patients with a history of IDU were more likely
        to have a BI (p = 0.05). When compared to 65 patients with
        other diagnoses (tumors, opportunistic infections, etc.),
        those with BI had significantly higher median white blood
        cell (WBC) count (6.4 vs. 4.0/mm3, p less than 0.0001) and
        CD4 count (95 vs 20/mm3, p less than 0.005). Patients with
        BI also had shorter median duration of fever (2.0 vs 3.0
        days, p less than 0.01) and hospital stays (8 vs 12 days,
        p less than 0.0001). Although mortality rates of patients
        with BI were three-fold higher than those with other
        diagnoses, the difference was not statistically significant
        (3% vs 9%, p = 0.07). CONCLUSIONS: BI were the most common
        diagnoses in HIV-infected patients requiring
        hospitalization for fever, particularly in those with a
        history of IDU. BI occurred at usual sites and common
        pathogens were isolated. Patients with BI had distinct
        presentations and improved outcomes, as compared to those
        with fever from other sources.
SO   -  Int Conf AIDS. 1992 Jul 19-24;8(2):B229 (abstract no. PoB
        3832).

AU   -  Bissuel F ; Leport C ; Perronne C ; Longuet P ; Vilde JL
TI   -  Fever of unknown origin in HIV-infected patients: a
        critical analysis of a retrospective series of 57 cases.
AB   -  OBJECTIVES. The aim of the study was to assess the
        incidence and aetiology of fever of unknown origin in human
        immunodeficiency virus (HIV)-infected patients, and to
        evaluate the usefulness of the main diagnostic procedures.
        DESIGN. A retrospective study. SETTING AND SUBJECTS. We
        reviewed the records of 270 HIV-infected patients who were
        hospitalized for the first time in a department of
        infectious and tropical diseases during the 27 month study
        period. MAIN OUTCOME MEASURES. Fifty-seven patients (21%)
        had a history of fever of unknown origin. RESULTS. The
        aetiology was found in 49 cases (86%). The major cause of
        the fever was mycobacteriosis: atypical mycobacteria in 10
        cases, Mycobacterium tuberculosis in 10, mycobacteria of
        unspecified type in two, and BCG strain in one. A liver
        biopsy and a thoracic CT scan greatly contributed to the
        diagnosis of mycobacterial infection. Seventeen patients
        were given empiric antimycobacterial therapy as a
        therapeutic test, of whom seven had a favourable response.
        The other main causes of fever were cytomegalovirus
        infection in five patients, leishmaniasis in four, and
        lymphoma in four. CONCLUSIONS. Fever of unknown origin is
        a frequent occurrence in the course of HIV infection, and
        mycobacterial infection should be considered as a
        first-line diagnosis in such cases. The place of empiric
        antimycobacterial therapy in the diagnostic strategy
        requires further evaluation, but appears to be an
        alternative to multiple investigative procedures.
SO   -  J Intern Med. 1994 Nov;236(5):529-35.

AU   -  Durack DT ; Street AC
TI   -  Fever of unknown origin--reexamined and redefined.
SO   -  Curr Clin Top Infect Dis. 1991;11:35-51.

AU   -  Hambleton J ; Aragon T ; Modin G ; Northfelt DW ; Sande MA
TI   -  Outcome for hospitalized patients with fever and
        neutropenia who are infected with the human
        immunodeficiency virus.
AB   -  We conducted a retrospective cohort study to evaluate the
        occurrence of bacteremia and associated mortality among
        hospitalized patients who were seropositive for the human
        immunodeficiency virus (HIV) and who developed fever and
        neutropenia following antineoplastic chemotherapy or for
        other reasons. Review of medical records revealed 224
        episodes in 142 patients. Of these episodes, 57% occurred
        following antineoplastic chemotherapy, and 43% occurred
        under other circumstances. Members of the chemotherapy
        group had significantly less-advanced HIV disease, a lower
        mean absolute-neutrophil-count nadir, and a shorter
        duration of hospitalization. There was no difference
        between the two groups in the frequency of bacteremia or
        mortality due to all causes when they were compared by
        multivariate analysis. Statistically significant univariate
        and multivariate predictors of bacteremia included sepsis
        syndrome and concurrent infection. Predictors of mortality
        included sepsis syndrome, concurrent infection, bacteremia, 
        and antimicrobial therapy. This study suggests that the
        cause of neutropenia in HIV-seropositive patients is not
        a predictor of the outcome of fever and neutropenic
        episodes. Instead, clinical presentation and concomitant
        illnesses have a greater impact on outcome for a patient.
SO   -  Clin Infect Dis. 1995 Feb;20(2):363-71.

AU   -  Kirby AJ ; Munoz A ; Detels R ; Armstrong JA ; Saah A ;
        Phair JP
TI   -  Thrush and fever as measures of immunocompetence in
        HIV-1-infected men.
AB   -  The occurrence of Pneumocystis carinii pneumonia (PCP) in
        human immunodeficiency virus type 1 (HIV-1)-infected
        individuals with high CD4+ counts indicates poor
        immunologic function. Thrush and persistent fever, easily
        recognized clinically, are potential measures of
        immunocompetence. This analysis establishes the complex
        interactions of CD4+ count, thrush, and persistent fever
        to predict the occurrence of PCP. Analyses used 20,632
        person visits from 2,568 HIV-1-seropositive homosexual or
        bisexual men participating in the Multicenter AIDS Cohort
        Study (MACS). Comprehensive examinations were conducted
        semiannually, while occurrences of PCP were assessed
        continuously. The occurrence of thrush and fever increase
        in frequency as CD4+ levels decrease. The relative hazard
        of PCP in the presence of thrush compared with the absence
        of thrush rises (p < 0.05) from 1 for the lowest CD4+
        category to approximately 5 in the highest categories. The
        relative hazard of PCP in the presence of fever compared
        with the absence of fever is above one (p < 0.05) in all
        CD4+ categories. No cases of PCP occurred in individuals
        on PCP prophylaxis with CD4+ counts > 200/mm3. These
        results suggest that HIV-1-related symptoms provide a
        measure of failing immune function that is not reflected
        by enumeration of CD4+ lymphocytes alone and support the
        United States Public Health Service recommendation that
        symptomatic individuals with CD4+ counts > 200/mm3 should
        be considered for PCP prophylaxis. 
SO   -  J Acquir Immune Defic Syndr. 1994 Dec;7(12):1242-9.

AU   -  Leach RM ; Davidson AC ; O'Doherty MJ ; Nayagam M ; Tang
        A ; Bateman NT
TI   -  Non-invasive management of fever and breathlessness in HIV
        positive patients.
AB   -  In a prospective study of 72 human immunodeficiency virus
        (HIV) positive patients presenting with fever and
        breathlessness, a non-invasive management protocol,
        incorporating a scanning technique using radioactively
        labelled diethylenetriamine penta acetate (DTPA) and sputum
        induction, was found to be highly sensitive and specific
        in the early detection of Pneumocystis carinii pneumonia
        (PCP). At presentation, the DTPA scan was abnormal in 34
        of 36 cases of PCP, irrespective of smoking history, whilst
        the chest radiograph was diffusely abnormal in 21 cases.
        Sputum induction identified 7 of 14 patients with PCP in
        the first six months of its use and 7 of 10 patients over
        the last six months. The DTPA lung scan and induced sputum
        examination are non-invasive techniques which can be used
        to investigate out-patients. In combination they detected
        all cases of PCP at presentation, reduced the need for
        bronchoscopy, resulted in a low case fatality (5.4%) and
        reduced the need for admission.
SO   -  Eur Respir J. 1991 Jan;4(1):19-25.

AU   -  Levin M ; Hertzberg L
TI   -  Kaposi's sarcoma of the bone marrow presenting with fever
        of unknown origin.
AB   -  Kaposi's sarcoma (KS) has become more common in the United
        States with the spread of the Acquired Immunodeficiency
        Syndrome (AIDS) epidemic. The epidemic form associated with
        AIDS involves primarily skin and visceral organs. Bone
        marrow involvement is rare. We present a case of Kaposi's
        sarcoma that was diagnosed upon bone marrow biopsy, without
        skin or visceral involvement, that presented with fever of
        unknown origin which responded to indomethacin and anti-KS
        chemotherapy. Kaposi's sarcoma of the bone marrow should
        be considered in the differential of febrile illness of
        unknown origin in patients with AIDS.
SO  - Med Pediatr Oncol. 1994;22(6):410-3.

AU   -  Liu YC ; Cheng DL ; Liu WT ; Liu CY ; Yen MY ; Wang RS ;
        Lin HH ; Chen YS
TI   -  AIDS presenting as fever of undetermined origin: report of
        four cases.
SO   -  Int J STD AIDS. 1993 Sep-Oct;4(5):303-6.

AU   -  Lozano F ; Pujol E ; Torres-Cisneros J ; Bascunana A ;
        Canas E ; Garcia-Ordonez MA ; Hernandez-Quero J ; Vergara
        A ; Marquez M ; Diez F ; et al
TI   -  Fever of unknown origin in HIV-infected patients. A      
        multicentric-prospective study of 116 cases. Andalusian
        Group for Study of Infectious Diseases.
AB   -  OBJECTIVE: HIV-associated FUO is an entity with peculiar
        significance and not yet adequately studied till now. Our
        purpose was to document the occurrence, etiology, prognosis
        and profitability diagnosis of FUO. METHODS: A prospective
        2-year (92-93) study was realized with 116 in-patients from
        14 hospitals of Andalusia. They fullfilled following
        criterion: 1) Proved HIV infection, 2) Fever > 38.3 degrees
        C, more of three weeks of duration, 3) Not etiologic
        diagnosis after one week hospitalization, 4) Not evidence
        of clinical or radiologic data of focal point infection at
        admission moment. RESULTS: Frecuency of HIV-associated FUO
        was 3.1%. The average patient's age was 31.2 + 8.4 years.
        88% of them were males, 82% intravenous drug abusers and
        40% were AIDS diagnosis previously. Mean duration of fever
        and hospitalization was 68 + 38.3 days and 40.1 + 25.3
        respectively. Mean number of CD4 lymphocites was 98.7 +
        145/mm3 (76% had < 100/mm3 and 59% had < 50/mm3). A sure
        diagnosis was achieved in 75% of patients. Most common
        entities were: tuberculosis (37%), visceral leishmaniasis
        (19%), MAI infection (8%) and lymphomas (7%). Diagnosis was
        probably suspected in 19% of patients (tuberculosis was
        suspected in 65% of them) and in a 6% any etiologic
        diagnosis was obtained. The most valuable investigations
        was hepatic biopsy (67%) and bone marrow puncture (38%).
        During hospitalization period 10% of patients died.
        DISCUSSION AND CONCLUSIONS: 1) HIV-associated FUO is a
        relatively common entity that appears in advanced
        HIV-infection and bears a high economic cost. 2) More
        prevalent etiologies in our country are tuberculosis and
        visceral leishmaniasis. 
SO   -  Int Conf AIDS. 1994 Aug 7-12;10(2):197 (abstract no.
        PB0803).

AU   -  Mijch AM ; Hoy JF
TI   -  Unexplained fever and drug reactions as clues to HIV
        infection. 
AB   -  Unexplained fever, usually self-limiting and often due to
        a viral infection, is commonly seen in many medical
        practices. When should a doctor consider HIV in relation
        to a patient's fever? 
SO   -  Med J Aust. 1993 Feb 1;158(3):188-9.

AU   -  Oehler R ; Loos U ; Ferber J ; Fischer HP
TI   -  Diagnostic value of liver biopsy in HIV patients with 
        unexplained fever.
AB   -  A common problem in HIV patients is fever which remains
        unexplained even with careful diagnostic examination.
        Besides the lungs and brain which show a broad spectrum of
        diseases, the liver is most often involved in HIV-related
        diseases. During the last 2 years 15 patients with serum
        antibodies to HIV underwent diagnostic liver biopsy in our
        department because of fever which could not be explained
        by non-invasive procedures. Seven of the 15 patients were
        HIV-positive but without AIDS prior to admission. Thirteen
        of 15 patients had abnormal biochemical liver function
        tests, but only in one patient ultrasound showed focal
        lesions in the liver. We found Pneumocystis carinii in the
        biopsy of the patient with multiple small focal lesions in
        the liver, one patient had Hodgkin's disease which had not
        been diagnosed prior to liver biopsy. Four patients were
        diagnosed of having disseminated mycobacteriosis in the
        liver with granuloma and acid-fast bacilli. In two of the
        patients with mycobacteriosis epithelioid-cell granuloma
        could also be found in bone marrow biopsy, and in two
        patients acid-fast bacilli were found in duodenal biopsy
        at endoscopic examination. Only 2 of the 4 patients with
        mycobacteriosis had AIDS prior to liver biopsy. We found
        non-specific toxic hepatopathy in 2 cases, hepatosteatosis
        in 2 and cirrhotic parenchymal lesions due to hepatitis C
        in 2 patients. Three patients had a nondiagnostic liver
        biopsy. In one of them we could find meningitis due to
        cryptococcosis, one had cerebral toxoplasmosis and in the
        other patient fever was possibly due to disseminated
        Kaposi's sarcoma which did not involve the liver. RESULTS:
        In 40% of our patients liver biopsy led to the diagnosis
        of a specific AIDS-related disease. Additional 40% of the
        patients were diagnosed of having liver diseases that had
        not been diagnosed before. Only in 20% of the patients
        liver biopsy did not show any abnormalities. In conclusion,
        liver biopsy proved to give important additional
        information with therapeutic consequences in HIV-positive
        patients with fever which remained unexplained after
        non-invasive diagnostic procedures.
SO   -  Int Conf AIDS. 1992 Jul 19-24;8(2):B211 (abstract no. PoB
        3722).

AU   -  Rogeaux O ; Priqueler L ; Hoang C ; Cadranel JF ; Opolon
        P ; Gentilini M
TI   -  Diagnostic usefulness of liver biopsy for unexplained fever
        in HIV patients.
AB   -  OBJECTIVE: Isolated fever or fever (F) with abnormalities
        of liver function tests (LFT) are common in HIV patients
        (pts). The aim of this prospective work was to evaluate the
        utility of liver biopsy (LB) with microbiological studies
        for unexplained fever in HIV pts. PATIENTS: From January
        1991 to June 1992, 21 pts (20 male) underwent LB. A liver
        biopsy was performed during the same period in 4 pts with
        LFT abnormalities and without F. In the remaining 17 pts
        (T4 < or = 100/mm3; n = 12), LB was performed for
        unexplained F. These pts were separated in 2 groups (G).
        G1: 15 pts had unexplained F for at least 15 days with LFT
        abnormalities, ie: alkaline phosphatase 1.5 x upper limit
        of normal range and/or ALT > or = 2N. In all pts AIDS
        related cholangiopathy had been ruled out by morphological
        methods. Group 2 consisted of 2 pts without LFT
        abnormalities. METHODS: The diagnosis of unexplained F
        required the absence of pathogens in a location outside the
        liver. RESULTS: G1: in 7 pts out of 15 (46.6%) LB showed
        epithelioid granuloma. The discovery of hepatic granuloma
        was followed by antituberculosis therapy that led to relief
        of fever in all 7 pts. In one pt in this group, LB showed
        inclusions consistent with cytomegalovirus infection. G2:
        LB was not contributory in these 2 pts. CONCLUSION: LB
        enabled a positive diagnosis in 53.3% of pts (8/15) when
        F was associated with LFT abnormalities. It authorized a
        diagnosis of infection leading to the immediate institution
        of specific therapy.
SO   -  Int Conf AIDS. 1993 Jun 6-11;9(1):446 (abstract no.
        PO-B19-1867).

AU   -  Sepkowitz KA ; Telzak EE ; Carrow M ; Armstrong D
TI   -  Fever among outpatients with advanced human
        immunodeficiency virus infection.
AB   -  BACKGROUND: Fever is common among persons with human
        immunodeficiency virus (HIV) infection. However, the
        clinical implications of fever in this population have not
        been evaluated. We therefore undertook a prospective study
        of fever in persons with advanced HIV infection to
        determine the incidence and etiology of fever in this
        patient group. METHODS: Prospective natural history study
        of 176 patients with advanced HIV infection followed up at
        Memorial Sloan-Kettering Cancer Center, New York, NY, from
        April 1, 1990, through December 31, 1990. RESULTS: Fever
        occurred in 46% of patients. A diagnosis was made in 83%
        of episodes, with acquired immunodeficiency virus-defining
        illnesses accounting for half of the diagnosed cases.
        Patients whose conditions required more than 2 weeks to
        diagnose most often had lymphoma, Mycobacterium avium-
        intracellulare bacteremia, or Pneumocystis carinii
        pneumonia. Four patients had persistent unexplained fever
        without a clear source. Only one patient had fever that
        clearly responded to antiretroviral therapy. CONCLUSIONS:
        Fever is common among outpatients with advanced HIV
        infection. Human immunodeficiency virus itself is rarely
        the cause of fever in such patients; the cause of the fever
        should be thoroughly evaluated.
SO   -  Arch Intern Med. 1993 Aug 23;153(16):1909-12.

AU   -  Zylberberg H ; Le Gal FA ; Robert F ; Zylberberg L ;
        Dupouy-Camet J ; Viard JP
TI   -  Isolated fever due to disseminated toxoplasmosis under
        cotrimoxazole prophylaxis.
AB   -  We report a case of prolonged and clinically unexplained
        fever in one AIDS patient with a CD4 cell count of 70/mm3,
        and who had received cotrimoxazole for several months as
        primary prophylaxis. Tests performed to investigate this
        fever and especially the presence of Toxoplasma infection
        included chest X-rays, BAL, ophthalmoscopy, cerebral CT 
        scan and MRI, cardiac echography, blood cultures for
        mycobacteria, fungi and CMV, cryptococcus antigenemia, bone
        marrow biopsy, liver function tests, LDII and CPK blood
        levels, and were normal or negative, except the polymerase
        chain reaction (PCR) for Toxoplasma gondii, which was
        positive in the blood on two occasions. After a few days
        of anti-toxoplasmic therapy (pyrimethamine plus
        clindamycin) the patient became afebrile and the Toxoplasma
        PCR became repeatedly negative. This patient probably had
        disseminated toxoplasmosis attenuated by cotrimoxazole. We
        point out the interest of Toxoplasma PCR in the screening
        of unexplained fever in AIDS patients, particularly when
        they receive cotrimoxazole prophylaxis. 
SO   -  Int Conf AIDS. 1994 Aug 7-12;10(2):154 (abstract no.
        PB0631).
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