Bone Marrow Culture Yield for the Diagnosis of Opportunistic Diseases in Patients with AIDS and Disseminated Kaposi Sarcoma.

BACKGROUND: Disseminated Kaposi sarcoma (DKS) is present in patients with advanced HIV infection in whom co-infection with other opportunistic pathogens can occur. Bone marrow (BM) aspirate and biopsy comprise a robust diagnostic tool in patients with fever, cytopenias, and abnormal liver tests. However, the yield in patients with DKS has not been determined. OBJECTIVE: The aim of this study was to evaluate the utility of BM aspirate and biopsy in patients with DKS. METHODS: We included 40 male patients with a recent diagnosis of DKS. BM aspirate and biopsy was performed as part of the workup to rule out co-infections. RESULTS: In four patients, Mycobacterium avium complex (MAC) was recovered from culture. In other four patients, intracellular yeasts were observed in the Grocott stain, diagnosed as Histoplasma. The yield of BM was calculated in 20%. Only 12 patients (30%) had fever and 11 (27.5%) had pancytopenia. Alkaline phosphatase (ALP) above normal values and C-reactive protein (CRP) were higher in patients with positive results for BM than in those with negative results (63% vs. 21.9%, and 3.0 vs. 1.2 mg/L; p = 0.03 in both comparisons). No differences were found when complete blood-count abnormalities were compared. CONCLUSION: We recommend performing a BM aspirate for stains, culture, and biopsy in all HIV patients with DKS, as this will permit the early diagnosis of co-infections and prevent further complications in those who receive chemotherapy.

Signatures of oral microbiome in HIV-infected individuals with oral Kaposi's sarcoma and cell-associated KSHV DNA.

Infection by Kaposi's sarcoma-associated herpesvirus (KSHV) is necessary for the development of Kaposi's sarcoma (KS), which most often develops in HIV-infected individuals. KS frequently has oral manifestations and KSHV DNA can be detected in oral cells. Numerous types of cancer are associated with the alteration of microbiome including bacteria and virus. We hypothesize that oral bacterial microbiota affects or is affected by oral KS and the presence of oral cell-associated KSHV DNA. In this study, oral and blood specimens were collected from a cohort of HIV/KSHV-coinfected individuals all previously diagnosed with KS, and were classified as having oral KS with any oral cell-associated KSHV DNA status (O-KS, n = 9), no oral KS but with oral cell-associated KSHV DNA (O-KSHV, n = 10), or with neither oral KS nor oral cell-associated KSHV DNA (No KSHV, n = 10). We sequenced the hypervariable V1-V2 region of the 16S rRNA gene present in oral cell-associated DNA by next generation sequencing. The diversity, richness, relative abundance of operational taxonomic units (OTUs) and taxonomic composition of oral microbiota were analyzed and compared across the 3 studied groups. We found impoverishment of oral microbial diversity and enrichment of specific microbiota in O-KS individuals compared to O-KSHV or No KSHV individuals. These results suggest that HIV/KSHV coinfection and oral microbiota might impact one another and influence the development of oral KS.

Granulomas in acquired immunodeficiency syndrome-associated cutaneous Kaposi sarcoma: evidence for a role for Mycobacterium tuberculosis.

BACKGROUND: Co-lesional acquired immunodeficiency syndrome-associated cutaneous Kaposi sarcoma (AIDS-KS) and Mycobacterium tuberculosis-associated granulomatous inflammation are undocumented. METHOD: Retrospective appraisal of skin biopsies with co-lesional AIDS-KS and microscopic tuberculosis (TB). RESULTS: Sixteen biopsies from nine males and seven females form the study cohort. Histological assessment confirmed nodular and plaque KS in 12 and 4 cases each, respectively. Necrotizing, non-necrotizing and a combination of necrotizing and non-necrotizing granulomatous inflammation were present in nine, two and five biopsies each, respectively. The identification of acid fast bacilli on Ziehl-Neelsen staining and M. tuberculosis on polymerase chain reaction confirmed co-lesional TB in 15/16 biopsies. Co-lesional AIDS-KS and lichen scrofulosorum, hitherto undocumented, were confirmed in one biopsy. The histopathological findings served as a marker of human immunodeficiency virus (HIV) infection, visceral TB, therapeutic noncompliance and multidrug resistant pulmonary TB in nine, eight, five and one patient, respectively. M. tuberculosis was cultured from sputum or nodal tissue of all patients. CONCLUSION: Granulomatous inflammation in KS requires optimal histopathological and molecular investigation to confirm an M. tuberculosis origin. The cutaneous co-lesional occurrence of AIDS-KS and microscopic TB may serve as the sentinel clue to HIV infection, systemic TB, therapeutic noncompliance or multidrug resistant TB.

AIDS: "it's the bacteria, stupid!".

Acid-fast tuberculous mycobacterial infections are common in AIDS and are regarded as secondary "opportunistic infections." According to the National Institute of Allergy and Infectious Diseases, TB is the major attributable cause of death in AIDS patients. Could such bacteria play a primary or causative role in AIDS? Certainly, In screening tests for HIV, there is frequent, up to 70%, cross-reactivity, between the gag and pol proteins of HIV and patients with mycobacterial infections such as tuberculosis. By 1972, five years before gays started dying in the U.S., Rolland wrote Genital Tuberculosis, a Forgotten Disease? And ironically, in 1979, on the eve of AIDS recognition, Gondzik and Jasiewicz showed that even in the laboratory, genitally infected tubercular male guinea pigs could infect healthy females through their semen by an HIV-compatible ratio of 1 in 6 or 17%, prompting him to warn his patients that not only was tuberculosis a sexually transmitted disease, but also the necessity of the application of suitable contraceptives, such as condoms, to avoid it. Gondzik's solution and date of publication are chilling; his findings significant. Since 1982 Cantwell et al found acid-fast bacteria closely related to tuberculosis (TB) and atypical tuberculosis in AIDS tissue. On the other hand molecular biologist and virologist Duesberg, who originally defined retroviral ultrastructure, has made it clear that HIV is not the cause of AIDS and that the so-called AIDS retrovirus has never been isolated in its pure state. Dr. Etienne de Harven, first to examine retroviruses under the electron, agrees. In 1993 HIV co-discoverer Luc Montagnier reported on cell-wall-deficient (CWD) bacteria which he called "mycoplasma" in AIDS tissue. He suspected these as a necessary "co-factor" for AIDS. Remarkably, Montagnier remained silent on Cantwell's reports of acid-fast bacteria which could simulate "mycoplasma" in AIDS tissue. Mattman makes clear that the differentiation between mycoplasma and CWD bacteria is difficult at best and cites Pachas's 1985 study wherein one mycoplasma was actually mistaken for a CWD form of a bacterium closely related to the mycobacteria. It is important to realize that the statement "HIV is the sole cause of AIDS" is just a hypothesis. There are unanswered questions and controversy concerning the role of HIV "as the sole cause of AIDS." And until they are resolved, a cure is not possible. This paper explores the possible role of acid-fast tuberculous mycobacteria as "primary agents" in AIDS.

Electron microscopy reveals fungal cells within tumor tissue from two African patients with AIDS-associated Kaposi sarcoma.

Electron microscopic investigation of biopsy materials from Kaposi sarcoma (KS) skin lesions of 2 African AIDS patients occasionally revealed fungal cells within the tumor tissue. The spherical cells were surrounded by a triple-layered cell wall and were not encapsulated. The ultrastructural characteristics of the cells resemble those of Candida albicans organisms. Neither patient showed clinical signs of a generalized fungal infection. The presence of Candida albicans in the KS tissue specimens seems to represent an early and asymptomatic stage of cutaneous candidiasis in the 2 severely immunocompromised AIDS patients.

Mycobacterial spindle cell pseudotumor of the appendix vermiformis in a patient with aids.

Mycobacterial pseudotumor (MP) is a rare pathologic presentation of both Mycobacterium tuberculosis and non-tuberculous mycobacterial disease, hitherto reported to occur only in immunosuppressed patients with or without human immunodeficiency virus infection. This lesion shares close pathologic resemblance to certain mesenchymal neoplasms, particularly Kaposi's sarcoma (KS), from which it must be properly differentiated due to distinct prognosis and therapy. We report a case of MP obliterating the lumen of the appendix vermiformis in a 34-year-old patient who died of complications of AIDS at our hospital in Rio de Janeiro. A total of 24 cases of MP (including our patient) have been described in the literature. MP has been found especially in lymph nodes, but extranodal lesions have been described in the skin, spleen, lung, bone marrow, brain and, in our patient, the appendix vermiformis. We offer a review of the other 23 published case reports of MP in both HIV-infected and uninfected patients and discuss the pathologic features that differentiate MP from KS.

Unidentified bacterial microorganisms entrapped within blood capillary spaces of tissue from different epidemiological types of Kaposi's sarcoma.

Tissue specimens of different epidemiological types of Kaposis sarcoma (KS) from various geographical regions were investigated by transmission electron microscopy. Freshly fixed KS biopsies originated from 9 German patients: 3 classic KS cases, 5 AIDS-associated KS cases, and 1 atypical classic KS case. Additionally, KS autopsy material from the brain of a German AIDS patient was examined. Further biopsies came from 29 Ugandan patients: 16 endemic KS cases and 13 AIDS-associated KS cases. While investigating the ultrastructure, we discovered relatively small-sized bacterial microorganisms within blood capillary spaces of tumor tissue from 5 KS cases of different epidemiological type. The microorganisms often occurred in clusters. They were of coccoid-bacillary form and limited by a wrinkled multilayered cell wall. Many of them were encapsulated. They were not observed outside of the capillary lumen. The bacterial structures were often seen attached to capillary endothelial cells, which sometimes showed blistering into the capillary lumen. The observed bacterial microorganisms obviously represented agents of a bloodstream infection and must have been entrapped and accumulated within capillary spaces of KS tissue. The bacteria, which had an almost identical morphology in all 5 KS cases, could not be identified. If they are of pathogenic significance, it remains unknown.

Kaposi's sarcoma-associated herpesvirus: from cell biology to pathogenesis.

Kaposi's sarcoma-associated herpesvirus (KSHV or HHV-8) is linked to the etiopathogenesis of Kaposi's sarcoma, a plasma-blastic variant of Castleman's disease and primary effusion lymphoma. KSHV is related to a number of non-human primate viruses. Only a limited number of KSHV proteins are expressed in tumor cells. Here we discuss the putative role of these proteins in KSHV pathogenesis.

[Infection and angiomatous cutaneous lesions]. / Infection et lésions cutanées angiomateuses.

The occurrence of angiomatous cutaneous lesions in the presence of an infective process is not a frequent phenomenon. Most infectious diseases are associated with an exanthematous reaction. The combination of an infective illness and angiomatous lesions is seen essentially in the bartonelloses and in Kaposi's disease. Bartonelloses: group of infections due to alpha-proteobacteria such as Bartonella. Bartonella bacilliformis (BB), is the causal agent of Carrion's disease, the chronic cutaneous form of which (verruga peruana), in which the vector is an arthropod of the Lutzomyia species found in South America, presents superficial and deep angiomatous cutaneous nodules. Spontaneous regression occurs in a few months or years. Bartonella henselae (BH) and Bartonella quintana (BQ), are the causal agents of bacillary angiomatosis (BA), described in 1983, in which angiomatous papules or nodules with an appearance like botryomycomas, are associated with visceral lesions. The characteristic histological features (with the demonstration or the bacilli by Warthin-Starry stain) together with culture of the bacterium in various tissues (including the blood) are diagnostic. BA occurs most commonly, but not exclusively, in patients with HIV infection. Furthermore, BH is responsible for cat scratch disease while BQ causes trench fever. The reservoir of BH is the cat. The bartonella produce angiogenic factors responsible for the neovascularisation seen in angiomatous lesions. The differential diagnosis is between botryomycomas and Kaposi's disease. Numerous antibiotics are effective against botryomycomas, particularly chloramphenicol and penicillin for BB and macrolides, cyclins and fluoroquinolones for BH and BQ. Kaposi's disease (KD): whether classical, endemic or epidemic (due to HIV infection) is characterised by cutaneous and visceral angiomatous lesions: these are associated with multifocal tumorous proliferations (of endothelial and fusiform cells) affected by angiogenic growth factors (PDGF, FGF, IL6, alphaTGF, HIVtat, androgens) and strongly linked to the lymphocytic and endothelial tropism of a gamma herpes virus (HHV8, Chang and Moore 1994). HHV8 infection, probably sexually transmitted, is also the cause of lymphomas occurring in cavities and of Castleman's disease. The course of KD is very variable: from the indolent form in elderly HIV-ve patients, to the explosive forms in the immunodepressed (particularly in HIV+ve patients.

Spindle cell tumors associated with mycobacteria in lymph nodes of HIV-positive patients: 'Kaposi sarcoma with mycobacteria' and 'mycobacterial pseudotumor'.

Patients infected with HIV often have unusual manifestations of common infections and neoplasms. One such example is "mycobacterial pseudotumor," an exuberant spindle cell lesion induced in lymph nodes by mycobacteria. Kaposi sarcoma also produces a spindle cell proliferation in lymph nodes of HIV-positive patients. These two entities must be differentiated from one another because of differences in treatment and prognosis. We report here, however, three cases of intranodal Kaposi sarcoma with simultaneous mycobacterial infection, the occurrence of which has not been clearly documented. For comparison, we also studied three cases of mycobacterial pseudotumor, of which 14 cases have been described to date. There was considerable histologic overlap between these two lesions. Acid-fast bacilli were present in all cases, predominantly in the more epithelioid histiocytes in the cases of Kaposi sarcoma, and in spindle and epithelioid cells in the cases of mycobacterial pseudotumor. The morphologic features that favored Kaposi sarcoma over mycobacterial pseudotumor were the prominent fascicular arrangement of spindle cells and slitlike spaces, the lack of granular, acidophilic cytoplasm, and the presence of mitoses. Immunohistochemistry was a reliable adjunct study in the differential diagnosis, as the spindle cells in mycobacterial pseudotumor were positive for S-100 protein and CD68 whereas those of Kaposi sarcoma were CD31- and CD34-positive but negative for S-100 protein and CD68. Awareness that Kaposi sarcoma may coexist with mycobacterial infection in the same biopsy specimen is important because these lesions may be misdiagnosed as mycobacterial pseudotumor. The clinical impact of distinguishing between Kaposi sarcoma with mycobacteria and mycobacterial pseudotumor is significant because the presence of Kaposi sarcoma alters treatment and prognosis.

Infectious agents and the etiology of chronic idiopathic diseases.

At the end of the nineteenth century, the field of microbiology was born, and the infectious nature of many previously unexplained diseases was illuminated as powerful new technology was applied. At the end of the twentieth century, the etiology of myriad chronic diseases remains unexplained. We have argued that many of these diseases have clinical, epidemiological, and pathological features that suggest a role for microbes in their pathogenesis. Although definitive evidence of microbial disease causation is lacking, we believe that new technologies, such as sequence-based microbial identification, will successfully be applied to many of these chronic idiopathic diseases in the near future. As novel pathogens and previously described pathogens are revealed as the causative agents for some of these conditions, new diagnostic, preventive, and therapeutic modalities may emerge, transforming some diseases from idiopathic and chronic, to infectious and curable.

[Detection of human herpesvirus 8 in patients with Kaposi's sarcoma or Castleman's disease associated with AIDS]. / Detección del herpesvirus humano 8 en pacientes con sarcoma de Kaposi o enfermedad de Castleman asociados al sida.

A new herpesvirus provisionally termed as KSHV or HHV-8 has been detected in lesions from AIDS-based Kaposi's sarcoma (KS) and from other KS clinical forms, and also in other tumors such as body cavity-based lymphomas or Castleman's disease (CD). We have assessed the presence of this novel herpesvirus in specimens from patients diagnosed with either AIDS and KS or AIDS and CD. DNA samples from skin lesions and peripheral blood obtained from 8 patients diagnosed with AIDS, seven with KS and one with multicentric CD were analyzed; skin specimens and peripheral blood samples from volunteer blood donors or from KS and CD free HIV seronegative patients were used as controls. Detection of the virus was done by PCR amplification of KS330 region, one of the HHV-8 sequences first reported. All skin lesions analysed tested positive for KS330; peripheral blood samples from 5 of the patients, including the one diagnosed with CD, showed also the virus sequence. All skin specimens and peripheral blood samples from controls were negative. From our results it can be concluded that the novel herpesvirus HHV-8 can also be detected in patients with AIDS-associated KS and AIDS-associated CD in Spain.

[Mycoplasmas and AIDS]. / Micoplasmas y SIDA.

AIDS is a complex illness due to HIV type 1 and 2 infection. It is characterized by an important immunodeficiency mainly caused by depletion of CD4+ T lymphocytes. The reasons for this depletion have not been sufficiently clarified yet. In 1986, Shy Ching Lo astonished the scientific community with reported evidence concerning the direct role played by mycoplasma in the etiopathology of AIDS. Since then, different theories have pointed to mycoplasma as cofactors, commensals or opportunistic agents. Although in vivo and in vitro experiments are controversial they suggest a possible mechanism that would explain the synergism between both agents: the mycoplasma belonging to normal intestinal flora could move to urethra, oropharynx or blood due to high risk sexual practice. There it would proliferate favoured by early immunological disorders related to HIV. It has been speculated that several microorganisms including mycoplasma, acting as superantigens, could induce a chronic CD4+ and CD8+ T lymphocytes activation resulting in apoptosis of the infected lymphocytes. The release of cytokines induced by mycoplasma could influence the progression of the disease.

Open reading frame 26 of human herpesvirus 8 encodes a tetradecanoyl phorbol acetate- and butyrate-inducible 32-kilodalton protein expressed in a body cavity-based lymphoma cell line.

DNA sequences corresponding to a novel herpesvirus (human herpesvirus 8 [HHV8]) are associated with Kaposi's sarcoma (KS), Castleman's disease, and body cavity-based lymphomas (BCBL). Studies of a BCBL-derived cell line suggest a direct correlation between seropositivity against antigens specifically present in such lines and the development of KS. We have generated recombinant proteins corresponding to open reading frame (ORF) 26 of HHV8 and have produced affinity-purified antibodies. Using these antibodies, we studied the expression of HHV8 ORF26 in a BCBL-derived cell line and found that it encodes a cytoplasmic protein whose expression is induced 16-fold by treatment with phorbol ester or sodium butyrate. This protein induction correlates with a significant induction of viral RNA transcripts. Interestingly, under our experimental conditions minimal increases in viral DNA were observed. No antibodies to the ORF26 protein of HHV8 were found in the sera from two human immunodeficiency virus-positive patients with KS as determined by immunoprecipitation analysis. However, antibodies in the sera from the two KS patients immunoprecipitated a 34-kDa protein found in extracts from induced BCBL1 cells that was not recognized by the control sera.

Presence of human herpesvirus 8 variants in the oral tissues of human immunodeficiency virus-infected persons.

A 210-bp DNA segment specific to the human herpesvirus 8 (HHV-8) genome was amplified by nested polymerase chain reaction from 10 of 14 archived oral biopsy samples of HIV-positive patients in London who had no evidence of oral Kaposi's sarcoma (KS). Various oral sites were represented. Oral tissues from 20 general dental patients not known to be HIV-infected were negative. When DNA sequences of these products were compared with sequences derived from 5 oral KS tissues of AIDS patients in London and 10 skin biopsies of Italian patients with Mediterranean KS (total number of positive tissues = 25), 11 were found to be unique. DNA and predicted peptide motifs of these sequences were also different from those in 28 of 36 HHV-8-positive lesions previously reported from American and African patients. HHV-8 is tropic for the oral mucosa of HIV-infected persons, and HHV-8 variants, though diverse, may be geographically restricted.