Eosinophilic Ascites-Rarest Presentation of a Rare Disease, Eosinophilic Gastroenteritis.

Eosinophilic gastroenteritis (EGE) is an uncommon disease of unknown etiology reported in both adult and pediatric age group. Here we report a case of a 46-year-old HIV positive female who presented to us with ascites and abdominal distension with peripheral eosinophilia and diagnosed as EGE.

Idiopathic Pyoderma Gangrenosum as a Novel Manifestation of the HIV Immune Reconstitution Inflammatory Syndrome: A Report of Three Cases.

The initiation of antiretroviral treatment for individuals with HIV may be accompanied by a paradoxical flare of underlying inflammatory diseases, the recurrence of dormant infections, or worsening of prior treated opportunistic infections, termed the immune reconstitution inflammatory syndrome (IRIS). Cutaneous manifestations of IRIS are common. Pyoderma gangrenosum is a neutrophilic dermatosis postulated to reflect disrupted innate immune regulation causing altered neutrophil chemotaxis. It is uncommonly reported in association with HIV. In this case series, we present three cases of IRIS manifesting with pyoderma gangrenosum in individuals with HIV from India and the United States to raise awareness of this previously undescribed presentation and discuss the treatment challenges in the management of these patients.

Primary HIV-1 infection--a "window of opportunity" for healthcare providers.

The diagnosis of primary HIV-1 infection (PHI) is often missed and requires a high index of suspicion and a thorough knowledge of laboratory methods. We report the case of a young promiscuous male who presented with fever, rash and neurological symptoms 8 weeks after unprotected sexual exposure. Clinical and laboratory investigations showed the presence of leucopenia and thrombocytopenia with elevated transaminases, and a normal cerebrospinal fluid analysis, while CNS imaging revealed a vasculitis-like involvement of the corpus callosum. Symptoms resolved spontaneously over 3 weeks. Fourth generation ELISA with p24 antigen assay was positive with high HIV-1 RNA load while Western-Blot was negative, thus confirming the diagnosis of PHI. The patient was subsequently started on antiretroviral therapy (ART) and showed undetectable viral load after 8 weeks of therapy. We present the differential diagnoses which need to be entertained as well as the pros and cons of very early ART intervention.

Nevirapine-induced fulminant hepatitis.

Nevirapine induced hepatotoxicity is known but fatality is rare. We report a case of a young individual who developed nevirapine (NVP) induced fatal hepatitis without apparent risk factors or preceding rash. Exacerbation of underlying silent chronic liver dysfunction possibly contributed to the fatal outcome. This case stresses the need for careful evaluation, regular monitoring and prompt omission of drug on suspicion of hepatotoxicity.

The epidemiology of HIV in India.

India is the first country outside Africa where an HIV-2 epidemic is running in parallel to an HIV-1 epidemic, resulting in a significant proportion of double infections. HIV is spreading rapidly, mainly by heterosexual contact, but also among intravenous drug users. Genetic analyses of the HIV variants circulating in India point towards HIV-1 and HIV-2 having been introduced into the country recently.

PIP: The genetic strains of HIV which have been uncovered in India have a different origin from those present in Thailand. Also, both HIV-1 and HIV-2 have been detected in India. In a 1991-93 study of clients of a sexually transmitted disease clinic in Bombay, it was found that seroprevalence of HIV in 241 clients was 39%, the 78.5% positive for HIV-1, 6.5% for HIV-2, and 15% for both. Distribution was even for males and females, reflecting heterosexual transmission. HIV-2 has also been detected in other parts of India, and HIV-1 is spreading throughout the country. HIV in children is a sequelae to blood transfusion. The prevalence of HIV in areas where IV drug use is rampant is increasing rapidly and is spreading to the general population. Genetic analysis revealed that the most closely related genetic sequence to the Indian HIV-1 from Bombay occurs in a strain of the virus from South Africa. One subtype of HIV-2 and several subtypes of HIV-1 have been found, with HIV-1 subtype C and HIV-2 subtype A the most frequently encountered. An examination of phylogenetic trees shows the relationships among these different strains. The close genetic relationship between isolates of HIV-1 and HIV-2 from patients in different parts of the country reflects the recent introduction of these strains. Thus, India is an ideal site for studying the efficacy of a vaccine designed specifically for a population of highly similar strains (the high similarity among HIV-2 isolates is unique in India). Since HIV-2 strains are diverging at a rate of 1% per year, any such research would have to occur soon.

Penicillium marneffei infection: an AIDS-defining illness.

A 29-year-old HIV seropositive male patient from Manipur presented with fever, cough, weight loss and asymptomatic papules and nodules all over the body. Differential diagnoses of secondary syphilis, histoplasmosis, cryptococcosis and penicilliosis were considered. Histopathological and mycological study of the skin biopsy tissue, and blood culture confirmed the diagnosis of penicilliosis. Although penicilliosis, an AIDS-defining illness, is restricted to Southeast Asia, more and more cases are being recognized in non-endemic countries.

HIV-1 and HIV-2 infections in a high-risk population in Bombay, India: evidence for the spread of HIV-2 and presence of a divergent HIV-1 subtype.

A high-risk population (patients of a sexually transmitted disease clinic and the GT hospital in Bombay) was tested for antibodies against HIV-1 and HIV-2. Among 405 serum samples, 226 had previously been classified HIV-positive in India using different locally available enzyme-linked immunosorbent assay (ELISA) tests. The serology of 179 samples was unknown. All 405 samples were tested at the Georg-Speyer-Haus (GSH) with the Pasteur HIV-1/2-Combi-ELISA. Positive samples were further analyzed with HIV-1 and HIV-2 Western blot kits from Dupont and Pasteur, respectively. A very high seroprevalence of HIV was found in this population. Among the 179 unscreened samples, 69 (38.5%) were positive in the ELISAs as well as the Western blots for HIV-1 or HIV-2. Among the prescreened samples, only 174 (77%) were confirmed HIV-positive. Altogether, 243 of 405 sera were HIV-positive. Of these, 184 (76%) were reactive with HIV-1, 10 (4%) were reactive with HIV-2, and 49 (20%) had dual reactivity to HIV-1 and HIV-2. Previous data from the Indian Council of Medical Research had already suggested a possible high prevalence of HIV-1 in India. Our results confirm this view. The finding of a substantial spread of HIV-2 infection was, however, totally unexpected in India, but confirms our previous study which had already demonstrated the existence of HIV-2 in this country. Asia can thus no longer be considered free of HIV-2, and testing for HIV-2 appears mandatory, at least in India.(ABSTRACT TRUNCATED AT 250 WORDS)

HIV-1 variants in South and South-East Asia.

HIV spread in South and South-East Asia is most alarming, and genetic variability of HIV-1 is an important consideration in vaccine development. In this study, we examined the third variable (V3) region of env gene of HIV-1 variants prevalent in Thailand, Malaysia, India, and the Philippines. By phylogenetic tree analyses, an HIV-1 variant from an injecting drug user (IDU) in Thailand belonged to subtype B, and HIV-1 variants from 2 IDUs in Malaysia were classified into 2 subtypes, B and E. One HIV-1 variant from a male homosexual in the Philippines belonged to subtype B. Out of 8 HIV-1 variants from sexually transmitted disease patients in India, 7 belonged to subtype C, and one to subtype A. Although the total number of individuals examined in this study was limited, 4 HIV-1 subtypes were found in South and South-East Asia and large international movements of HIV-1-infected individuals in this region could induce global dissemination of these HIV-1 variants.

Seronegative HIV-2 carriers in India.

The discordant cases of seronegative, but culture and proviral HIV-2 DNA positive were found in Mumbai, India. This was corroborated by the successful isolation of HIV-2-RNA in culture medium, HIV-2 cDNA sequence determination and the detection of the antigen. The sequence of the isolated HIV-2 genomic RNA does not seem to be altered to the extent that the change will alter antibody binding. Furthermore, antibody from the same individual (even at 8 months from initial sampling) from whom HIV-2 was isolated did not react with the antigen of this strain. Those evidences imply that extremely low or non-production of the antibody may be due to suboptimal immune stimulation due to extremely slow HIV-2 replication. This low virus-load may be responsible for the negative antibody results in the HIV-2 carriers.

PIP: This paper describes the characteristics of HIV-2 seropositive and seronegative cases in Mumbai, India, and characterizes the differences between HIV-1 and HIV-2. More than 200 outpatients considered to be at high risk of HIV infection were screened for HIV-1 and HIV-2 antibody and proviral DNA. The study found 11 cases that were discordant for antibody test and HIV proviral DNA (i.e., negative for anti-HIV but positive for HIV-2 proviral DNA). The presence of this provirus was further corroborated by the detection of HIV-2 RNA in the culture medium upon HIV isolation, HIV-2 cDNA sequencing, and antigen detection. The sequence of the isolated HIV-2 genomic RNA did not seem to be altered to the extent that the change would affect antibody binding. Moreover, antibody from the same person in whom HIV-2 was detected did not react with the antigen of this strain even 8 months after the initial sampling. These findings indicate that extremely low production or non-production of the antibody may be brought about by suboptimal immune stimulation due to very low HIV-2 replication speed. This low virus load may account for the negative antibody results in the HIV-2 carriers in India.

Parasitic diarrhoea in patients with AIDS.

BACKGROUND: Diarrhoea is a common clinical manifestation of HIV infection regardless of whether or not patients have AIDS. Two newly recognized opportunistic coccidial protozoa are parasitic pathogens in AIDS patients. We attempted to determine the common parasites in Indian patients with AIDS. METHODS: Between October 1994 and December 1996, a total of 110 stool specimens from 94 AIDS patients with acute or chronic diarrhoea were examined by microscopy of wet mounts and smears stained by a modified Ziehl-Neelsen's (cold) staining method. RESULTS: Isospora belli was the most frequently encountered parasite in 17% of patients, followed by Entamoeba histolytica in 14.9% and Cryptosporidium in 8.5%. Strongyloides stercoralis and Giardia lamblia were detected in 5.3% and 4.3% of patients, respectively. CONCLUSION: The presence of different parasites in 56.4% of stool specimens of patients with AIDS indicates that their specific diagnosis is essential. This will help initiate therapy to reduce the morbidity and mortality among such patients due to these pathogens.

Interleukin-9 receptor alpha chain mRNA formation in CD8+ T cells producing anti-human immunodeficiency virus type 1 substance(s).

A search for gene(s) associated with anti-human immunodeficiency virus type 1 (HIV-1) activity of CD8+ T cells was attempted using molecular cloning and the relation between the anti-HIV activity of CD8+ T cells and the interleukin-9 receptor alpha chain (IL-9R-alpha) mRNA expression from the cDNA clones obtained was examined. The anti-HIV-1 activity of CD8+ T cell culture supernatants was assessed by measuring the level of HIV-1 replication of a CD4+ T cell line transfected with an infectious HIV-1 DNA clone. IL-9R-alpha mRNA was assayed by reverse transcriptase-polymerase chain reaction (RT-PCR). Of 5 cases showing high level of anti-HIV-1 activity (more than 80% suppression of HIV-1 replication), the mRNA was detected in 4 cases. Of 10 cases showing low level of anti-HIV-1 activity (less than 80% suppression of HIV-1 replication), the mRNA was detected in one case. Soluble recombinant human IL-9 receptor (rhIL-9sR) did not suppress HIV-1 replication at a concentration of 1 microgram/ml. These data suggest that the IL-9R-alpha mRNA formation in CD8+ T cells may correlate with and play some role in the anti-HIV-1 activity of CD8+ T cells from HIV-1-infected individuals.

Cyclospora infection in acquired immunodeficiency syndrome.

BACKGROUND: Diarrhea is a common clinical manifestation of human immunodeficiency virus (HIV) infection. The important protozoan pathogens causing diarrhea include cryptosporidium, microsporidium, Isospora belli and cyclospora besides giardia lamblia and entamoeba histolytica. OBJECTIVE: The objective of the present study was to determine the incidence of cyclospora (a coccidian protozoan) infection in HIV infected patients. METHODOLOGY: Faecal smears were stained by modified acid fast staining method to demonstrate oocysts of cyclospora. RESULTS: Out of 334 faecal specimens which were studied, cyclospora were identified in 22 cases (6.6 percent); and in 50 percent of the patients, there was a mixed infection with another protozoan parasite namely cryptosporidium. CONCLUSION: Identification of this parasite is important because cyclosporiasis can be treated with trimethoprim-sulfamethoxazole. Outbreaks of cyclospora infection have been linked to waterborne transmission. Though adequately chlorinated water is free of coliforms, it can still contain cyclospora.

An approach to leprosy work in south Bombay--a preliminary communication.

The city of Bombay with its teeming eight million citizens is characterised by varied types of living pattern in its different parts and the approach to leprosy control work should be flexible to suit these facets of living conditions. Earlier reports (Ganapati and Girija 1979) have indicated the possibility of the successful application of techniques based on mass surveys in North Bombay where people belonging to low socio-economic strata live in somewhat organised slums or shanty towns. However, extreme South Bombay is marked by the paucity of such vast slums and one is struck by the more permanent multistoreyed housing structures. Living in commercial establishments as well as footpath dwelling are common. This presentation consists of an attempt to gauge the leprosy problems in this part of the city taking advantage of 425 patients registered at a leprosy clinic run in conjunction with the dermatology out patient department of a big general hospital over a period of 40 months. 212 cases (50%) hailing from South Bombay proper were the subject matter for analysis. 66% (140) belonged to progressive types of leprosy classifiable as BT through LL and of the Ridley-Jopling classification and 30.7% were bacteriologically positive. 42.9% of the patients had some degree of deformity. Males formed 80% of the sample and 76% were above 15 years of age. Analysis of duration of residence revealed that 68% were living in Bombay for over six years and 53.5% were residing in the city for 11 years or more. This finding is contrary to the expectation of leprosy patients in Bombay belonging to a "floating population". Attempts at field work revealed the following findings: Slum pockets being few (only four), patients were expected to live in residential buildings; but it was found that 25% of population were staying in work places. 17% were footpath dwellers and 18.9% shared their accommodation with people other than family members. 10.4% were domestic servants staying in the residences of their employees. The labour class constituted 50.5% the unemployed housewives group formed 21.7% and beggers 0.9%. 4.2% only were slum dwellers. Locating and examining contacts of patients was difficult as 42.9% could not be traced owing to faulty addresses or patients having changed residences or shifted to native places. Of the 111 patients (52.3%) contacted, 26.4% were living with families and 26.1% were staying alone or with others.(ABSTRACT TRUNCATED AT 400 WORDS)