Role of CD40 ligand signaling in defective type 1 cytokine response in human immunodeficiency virus infection.

The pathogenesis of defective interleukin (IL)-12 and interferon (IFN)-gamma production in human immunodeficiency virus (HIV)-infected patients remains to be elucidated. This study investigated the possibility that perturbations in CD40 ligand signaling are involved in this defect. CD40 ligand trimer (CD40LT) stimulated peripheral blood mononuclear cell (PBMC) production of IL-12 in response to Toxoplasma gondii and cytomegalovirus (CMV). Regardless of the CD4 cell count, CD40LT restored IL-12 secretion in response to T. gondii in HIV-infected patients. In the presence of CD40LT, PBMC from both HIV-infected patients and control subjects produced high levels of IL-12 in response to CMV. CD40LT restored T. gondii- and CMV-triggered IFN-gamma secretion by T cells and PBMC from HIV-infected patients with a CD4 cell count >200 cells/microL. CD4 cells from HIV-infected patients, even those with a CD4 cell count >500 cells/microL, had defective CD40L induction after T cell stimulation mediated by antigen-presenting cells. Together, impaired CD40L induction is likely to contribute to defective IL-12 and IFN-gamma production in HIV infection.

The continuing utility of bronchoalveolar lavage to diagnose opportunistic infection in AIDS patients.

PURPOSE: To determine whether bronchoalveolar lavage (BAL) remains a useful technique in assessing human immunodeficiency virus (HIV)-infected patients with pulmonary symptoms. PATIENTS AND METHODS: All HIV-infected patients with pulmonary symptoms referred to a university hospital-based pulmonary service underwent bronchoscopy and BAL within 24 hours of referral. All samples were handled in a standardized fashion. The results of the lavage were compared with chest roentgenograms and clinical results. RESULTS: A total of 894 lavages were performed on HIV-infected patients over a 7-year period. The overall diagnostic yield was 60%, with 420 patients having Pneumocystis carinii. Infections other than P carinii were found in 185 cases, including 75 lavages with P carinii and another infection. The other infections included Mycobacterium tuberculosis (17 patients), Mycobacterium kansasii (15 patients), Histoplasma capsulatum (24 patients), Cryptococcus neoformans (17 patients), and bacterial infection (103 patients). For 364 lavages, no diagnosis was made. Chest roentgenograms were not useful in predicting what infection would be diagnosed. There was no difference in the yield of BAL over the 7-year period, despite the introduction of aerosol pentamidine prophylaxis and antiretroviral therapy. CONCLUSION: Bronchoscopy with BAL continues to have a role in the evaluation of HIV-infected patients with pulmonary symptoms.

Analysis of Pneumocystis carinii organism burden, viability and antigens in bronchoalveolar lavage fluid in AIDS patients with pneumocystosis: correlation with disease severity.

OBJECTIVES: We examined 96 bronchoalveolar lavage fluid (BALF) specimens from AIDS patients with proven Pneumocystis carinii pneumonia (PCP) in order to compare the relationship of organism burden, viability and antigen expression with disease severity at the time of clinical presentation. METHODS: Tinctorial analysis of BALF specimens with proven PCP using Diff-Quik, cresyl echt violet and erythrosin B stains to evaluate organism burden and viability. P. carinii antigen examination was performed by Western blot analysis. RESULTS: P. carinii cluster ratios were more sensitive than cyst counts as an indicator of organism burden, and correlated well with the alveolar-arterial oxygen gradient as a measure of disease severity. Erythrosin B, the vital stain used to measure P. carinii viability, displayed a wide range of values and provided little useful information. Antigens of 35-45 and 95kD, which were specific for P. carinii, were found by immunoblot analysis in BALF cellular fraction of most patients with pneumocystosis. By contrast, antigens of 52 and 66 kD, which were found in both BALF supernatant and cellular fractions of P. carinii patients and controls, most likely represented albumin and immunoglobulin G heavy chain, respectively, of host origin. The 35-45 kD antigen was found in 88% of the BALF specimens and appeared to represent an important marker of P. carinii infection. The 95 kD antigen was detected in 49% of the specimens. CONCLUSIONS: We conclude that analysis of P. carinii characteristics in BALF specimens of patients with pneumocystis may provide additional information. These data will also be helpful in developing more sensitive assays and in targeting specific P. carinii factors for future investigation.

Pharmacokinetics of zidovudine phosphorylation in peripheral blood mononuclear cells from patients infected with human immunodeficiency virus.

As part of an effort towards optimization of dosing of zidovudine (ZDV), formation and elimination of total phosphorylated ZDV (ZDVPt) in peripheral blood mononuclear cells were examined in 21 asymptomatic human immunodeficiency virus-infected patients during their first 24 weeks of therapy (AIDS Clinical Trials Group Protocol 161). Intracellular concentrations of ZDVPt were measured with a previously described and validated radioimmunoassay technique. Although ZDV phosphorylation occurred readily upon initiation of therapy, it declined with time; the area under the concentration-time curve (AUC) at week 4 (mean +/- standard deviation, 3.41 +/- 0.93 pmol.h/10(6) cells) was significantly greater than that at week 24 (2.19 +/- 1.10 pmol.h/10(6) cells). Plasma ZDV AUC did not change with time and did not correlate with ZDVPt AUC. In dose-response experiments (20 to 100 mg orally), phosphorylation did not proportionally increase with increasing plasma ZDV concentrations. Similarly, compared with a single dose, two doses of ZDV over an 8-h period resulted in little ZDVPt increase in cells relative to increase in plasma ZDV concentrations. The half-life of intracellular ZDVPt was twice that of plasma ZDV (4 versus 2 h), suggesting that an every-8-h dosing regimen is justifiable. These findings suggest that metabolism of ZDV to its active intracellular forms may be saturable in some patients, is poorly correlated with plasma concentrations, and diminishes over time. These findings have implications for future development and management of anti-human immunodeficiency virus nucleoside therapy.

Correlates of zidovudine phosphorylation with markers of HIV disease progression and drug toxicity.

OBJECTIVE: To determine the relationships between in vivo zidovudine (ZDV) phosphorylation in cells from HIV-infected patients and markers associated with disease progression and drug toxicity. DESIGN: A pharmacokinetic study of ZDV metabolism sponsored by the AIDS Clinical Trials Group (protocol 161). Plasma and intracellular pharmacokinetics following a 100 mg oral dose of ZDV were determined at weeks 4 and 24 of initial therapy in adult patients. Plasma concentrations and phosphorylated ZDV were determined by radioimmunoassay, and area under the concentration-time curves (AUC) were compared with clinical data collected during the pharmacokinetic study. SETTING: An outpatient setting at the University of Cincinnati AIDS Treatment Center, Cincinnati, Ohio, USA. PATIENTS: HIV-infected adults with CD4+ lymphocyte counts 200-500 x 10(6) cells/l with no prior history of anti-HIV therapy and no active infections requiring systemic therapy. Of 30 patients enrolled, 21 were evaluable. INTERVENTIONS: None. MAIN OUTCOME MEASURES: AUC of plasma ZDV and intracellular total phosphorylated ZDV were compared with change from baseline of the following surrogate markers: CD4+ lymphocyte count, %CD4+ lymphocytes, CD4+/CD8+ cell ratio, serum beta 2-microglobulin, serum neopterin, neutrophils, red cell count, and hemoglobin. RESULTS: No correlations between plasma AUC and markers of therapeutic response were observed. However, significant positive correlations were observed between the AUC of total phosphorylated ZDV and changes in the %CD4+ lymphocytes and CD4+/CD8+ lymphocyte ratio; a negative correlation was observed with change in hemoglobin. Patients who responded to ZDV therapy, as measured by these variables, demonstrated significantly higher intracellular AUC (> 3 pmol x h/10(6) cells) than those who did not (approximately 2 pmol x h/10(6) cells). CONCLUSIONS: The ability of HIV-infected patients to phosphorylate ZDV correlates with changes in markers associated with drug effect and toxicity. Potential individualization of therapy through monitoring of total phosphorylated ZDV in patients therefore warrants further exploration.

Zalcitabine compared with zidovudine in patients with advanced HIV-1 infection who received previous zidovudine therapy.

OBJECTIVE: To evaluate the safety and efficacy of zalcitabine (also known as dideoxycytidine [ddC]) in patients with advanced human immunodeficiency virus (HIV) infection. DESIGN: Open-label, randomized study. SETTING: AIDS Clinical Trials Units, university-affiliated medical centers, and private practice groups. PATIENTS: Patients with the acquired immunodeficiency syndrome (AIDS) or advanced AIDS-related complex who had tolerated zidovudine for 48 weeks or more. INTERVENTION: Fifty-nine patients received zidovudine (500 to 1200 mg/d) and 52 patients received zalcitabine (2.25 mg/d). MEASUREMENTS: The primary end points were survival and time to an AIDS-defining event or death. RESULTS: Because significantly more patients withdrew from zidovudine therapy, the median duration of treatment was greater in the zalcitabine group than in the zidovudine group (279.0 days compared with 174.5 days; P = 0.001). The estimated 12-month, event-free probabilities were 53% for the zalcitabine group and 57% for the zidovudine group (relative risk, 1.02; 95% CI, 0.5 to 2.2). The estimated 12-month survival rates were 81% for the zalcitabine group and 75% for the zidovudine group (relative risk, 1.39; CI, 0.5 to 3.8). The rate of decline in CD4 lymphocyte counts was significantly slower in the zalcitabine group than in the zidovudine group (-0.08 cells/day compared with -0.17 cells/day). Patients in the zalcitabine group had gained an average of 0.5 kg at week 20 and 0.4 kg at week 24, whereas patients in the zidovudine group had lost an average of 1.8 kg at week 20 and 2.4 kg at week 24 (P = 0.04 and P = 0.05, respectively). Moderate to severe peripheral neuropathy and ulcerative stomatitis occurred in 10 and 9 patients, respectively, in the zalcitabine group. CONCLUSIONS: The sample size for this study was smaller than planned, and no differences in survival and clinical end points were found. Slower rates of decline in CD4 lymphocyte counts and weight, however, were noted for the zalcitabine group.

Increased Pneumocystis carinii recovery from the upper lobes in Pneumocystis pneumonia. The effect of aerosol pentamidine prophylaxis.

STUDY OBJECTIVE: To determine the relative distribution of Pneumocystis carinii in the lungs of patients with P carinii pneumonia and to see the effect of aerosol pentamidine prophylaxis on this distribution. DESIGN: A prospective study of all human immunodeficiency virus-infected patients with pulmonary symptoms over a nine-month period. Patients were followed up for at least six weeks after bronchoscopy. SETTING: Inpatient and outpatient service at one referral center. PATIENTS: Human immunodeficiency virus-infected patients with pulmonary symptoms were referred for evaluation. Those patients subsequently found to have P carinii pneumonia were studied. INTERVENTION: Bronchoalveolar lavage was performed in the middle lobe (or lingula) and the apical segment of the same lung. MEASUREMENTS AND RESULTS: The aspirated fluids were kept separate and modified Wright-Giemsa-stained cytocentrifuge-prepared slides were made from each area, and the number of P carinii clusters per 500 nucleated cells was counted. Fifty patients were studied: 27 receiving pentamidine prophylaxis and 23 receiving no aerosol therapy. There was no significant difference in the amount of fluid retrieved by lavage from the middle or upper lobe for either group. Both groups had significantly lower numbers of P carinii clusters per 500 cells in the middle lobe (receiving pentamidine: 10 +/- 15.8 [SD]; not receiving pentamidine: 15 +/- 12.3) than in the upper lobe (receiving pentamidine: 22 +/- 19.8; not receiving pentamidine: 24 +/- 21.5; p < 0.02). In six patients, there were no P carinii organisms seen in the middle lobe lavage specimen. CONCLUSION: Pneumocystis carinii has a preference for the upper lobes which may be apparent even in patients not receiving aerosol pentamidine. In addition, yield for P carinii may be increased by performing lavage in the apical segment.

A controlled trial of trimethoprim-sulfamethoxazole or aerosolized pentamidine for secondary prophylaxis of Pneumocystis carinii pneumonia in patients with the acquired immunodeficiency syndrome. AIDS Clinical Trials Group Protocol 021.

BACKGROUND: Pneumocystis carinii pneumonia (PCP) continues to be the most common index diagnosis in the acquired immunodeficiency syndrome (AIDS), but it is not clear which of several available agents is the most effective in preventing a recurrence of PCP. METHODS: We conducted a comparative, open-label trial in 310 adults with AIDS who had recently recovered from an initial episode of PCP and had no treatment-limiting toxic effects of trimethoprim-sulfamethoxazole or pentamidine. All the patients were treated with zidovudine and were randomly assigned to receive either 800 mg of sulfamethoxazole and 160 mg of trimethoprim once daily or 300 mg of aerosolized pentamidine administered every four weeks by jet nebulizer. The participants were followed for a median of 17.4 months. RESULTS: In the trimethoprim-sulfamethoxazole group (n = 154) there were 14 recurrences of PCP, as compared with 36 recurrences (including 1 extrapulmonary recurrence) in the aerosolized-pentamidine group (n = 156). The estimated recurrence rates at 18 months were 11.4 percent with trimethoprim-sulfamethoxazole and 27.6 percent with pentamidine (P < 0.001). The risk of a recurrence (adjusted for initial CD4 cell count) was 3.25 times higher in the pentamidine group (P < 0.001, 95 percent confidence interval, 1.72 to 6.16). There were no significant differences between the groups in survival or in hematologic or hepatic toxicity. Crossovers from trimethoprim-sulfamethoxazole to aerosolized pentamidine were more common than the reverse (27 vs. 4 percent), partly because of the study protocols for the management of leukopenia. There were 19 serious bacterial infections in the trimethoprim-sulfamethoxazole group and 38 in the pentamidine group. The time to a first bacterial infection was significantly greater for those assigned to trimethoprim-sulfamethoxazole (P = 0.017). CONCLUSIONS: In patients with AIDS who are receiving zidovudine, trimethoprim-sulfamethoxazole is more effective than aerosolized pentamidine in conventional doses for the prevention of recurrent pneumocystis infection.

Pharmacokinetics of zidovudine phosphorylation in patients infected with the human immunodeficiency virus.

The relationship between zidovudine phosphorylation inside mononuclear cells and plasma zidovudine pharmacokinetic was assessed in six subjects. Plasma and intracellular concentrations were measured by radioimmunoassay over an 8-h period after administration of 100 or 200 mg of zidovudine. Plasma pharmacokinetics followed expected patterns, with considerable interpatient variability in area under the concentration-versus-time curve (AUC), and a terminal half-life of 1.5 h. Intracellular AUC was even more variable than plasma AUC, but the data suggested a crude linear relationship between these parameters. The intracellular half-life of 3.5 h was consistently longer than the plasma half-life, and varied little between patients. The prolonged intracellular half-life suggested that total phosphorylated zidovudine, as measured by the method described, is not greatly dominated by the 5'-monophosphate as predicted from the in vitro studies reported in the literature. Plasma concentrations of zidovudine have shown little correlation with clinical effect. Study of the relationship between phosphorylated zidovudine and clinical outcome could lead to a more effective management of therapy.

Detection of cryptococcal antigen in bronchoalveolar lavage fluid: a prospective study of diagnostic utility.

Cryptococcal pneumonia is associated with significant morbidity and mortality in immunocompromised patients. We examined the utility of screening bronchoalveolar lavage (BAL) fluid for cryptococcal antigen. In a pilot study, we found that cryptococcal antigen was always positive in unprocessed BAL specimens of seven patients with cryptococcal pneumonia and negative in 44 patients with other granulomatous diseases who acted as the control subjects. A prospective study was done of 220 immunocompromised patients (188 with human immunodeficiency virus infection, 32 with other causes of immunosuppression) undergoing BAL for fever and pulmonary symptoms. The eventual diagnosis of cryptococcal pneumonia was made in eight patients. All eight patients had a cryptococcal antigen titer greater than or equal to 1:8. There were four patients without cryptococcal pneumonia who had cryptococcal antigen titers of 1:8, there were none with higher titers. For a titer of cryptococcal antigen titer of greater than or equal to 1:8, there was 100% sensitivity, 98% specificity, a positive predictive value of 67%, and a negative predictive value of 100%. The measurement of cryptococcal antigen in the BAL can be a rapid, simple way to make a diagnosis of cryptococcal pneumonia in immunosuppressed patients with pneumonia.

Generalized immune response to Pneumocystis carinii infection in the lung.

We studied inflammatory cells retrieved by bronchoalveolar lavage (BAL) from immunocompromised patients with or without Pneumocystis carinii pneumonia (PCP). Twenty-four patients with PCP, and 20 patients without PCP underwent lavages of both an uninvolved lobe and the lobe involved in pulmonary infection. Patients without P. carinii, had a significant increase (p less than 0.02) in the percentages of neutrophils (22 +/- 7.1%, mean +/- SEM) and lymphocytes (16 +/- 3.8%) in the involved lobe compared to those in the uninvolved area (neutrophils: 9 +/- 4.8%; lymphocytes: 10 +/- 2.4%). Patients with PCP, had no differences between the % neutrophils or % lymphocytes in the involved vs. uninvolved lobes. Patients with PCP had more (p less than 0.01) P. carinii in the upper lobe (23 +/- 4.6 P. carinii clusters/500 cells) than the middle lobe (11 +/- 3.6). In PCP, despite regional infections, there was a diffuse inflammatory response.

Open-label efficacy and safety trial of 42 days of 566C80 for Pneumocystis carinii pneumonia in AIDS patients.

Pneumocystis carinii pneumonia continues to be a cause of morbidity and mortality in AIDS patients. Current therapies have a high rate of toxicity and failure. Compound 566C80 is a 1-4,hydroxynaphthoquinone with potent antiprotozoal activity which shows good efficacy and safety in 21-day treatment trials of P. carinii pneumonia (PCP) in AIDS patients. Because there is a generally high recurrence rate after treatment of PCP and there may be a possible advantage in decreasing the P. carinii burden in the lung with extended anti-Pneumocystis therapy, we performed an open label-trial of the safety and efficacy of 42-day therapy with 566C80 for PCP in AIDS patients. Ten patients were enrolled and one was lost to follow-up. Eight of the remaining nine patients successfully completed 42 days of therapy with minimal toxicity. This trial suggests that 566C80 for 42 days can be an effective, safe, and well-tolerated oral therapy for PCP in AIDS patients.

Concentrations of phosphorylated zidovudine (ZDV) in patient leukocytes do not correlate with ZDV dose or plasma concentrations.

Zidovudine (ZDV) elicits its antiviral effect through intracellular metabolism to the 5'-triphosphate, which interferes with viral replication. Monitoring of the active metabolites of ZDV in cells could lead to an intracellular therapeutic range. This study was performed to determine whether a radioimmunoassay, previously used for in vitro quantitation of total phosphorylated ZDV inside peripheral blood leukocytes, could be used for similar determinations in patient samples. The relationship between ZDV dose, plasma concentrations, and intracellular metabolite concentrations was also examined. Ten-milliliter blood samples were drawn from each of 13 human immunodeficiency virus-infected patients and were assayed. Intracellular concentrations of phosphorylated ZDV ranged from 0.33 to 3.54 pmol/10(6) cells, similar to those observed in vitro. Phosphorylated ZDV was independent of dose, and did not correlate with plasma concentrations. Intracellular concentration in the patient population as a whole did not change during the 4-h dosing interval, while plasma concentration decayed normally. Later determinations in the same patients gave intracellular values within 31% of earlier values. Intraassay variability was less than 10%. Thus, the method is valid for measurement of phosphorylated ZDV in patient cells. Although individual concentrations showed no clear change during the 3-month study period, intracellular concentrations decreased with increasing length of therapy (up to 3 years) in the population as a whole. This suggests a decreased cellular ability to phosphorylate ZDV after prolonged exposure to drug. The lack of intracellular decay implies a half-life longer than the 1-h half-life of plasma ZDV. These data suggest that smaller doses or longer dosing intervals might maintain intracellular concentrations once steady state is achieved.(ABSTRACT TRUNCATED AT 250 WORDS)

Follow-up bronchoalveolar lavage in AIDS patients with Pneumocystis carinii pneumonia. Pneumocystis carinii burden predicts early relapse.

We performed an analysis of the value of repeat bronchoalveolar lavage (BAL) at 21 days to identify patients at risk for early relapse with Pneumocystis carinii pneumonia. Patients with P. carinii pneumonia and the acquired immunodeficiency syndrome (AIDS) were asked to participate in this study. All patients had P. carinii identified on methenamine silver stain of BAL fluid. BAL fluid was also stained with a modified Wright-Giemsa technique. The Wright-Giemsa stain was done to determine the cell differential count, and the number of P. carinii clusters associated with 500 nucleated cells was used as an estimate of P. carinii burden in the BAL. Initial and follow-up lavage was performed in 56 patients. Patients were classified based on their clinical response to anti-P. carinii therapy at 21 days. Nonresponders were patients with persistent or worsening symptoms. Responders were patients who improved and had therapy discontinued. Responders were further classified as responders with relapse if P. carinii pneumonia recurred within 6 months of the initial episode or responders without relapse if they remained disease free during the follow-up period. Responders without relapse reduced P. carinii cluster counts more than 50% in 24 of 25 cases. In responders with relapse P. carinii cluster counts were unchanged. The responders as a group had a significant decrease in the percentage of neutrophils in the BAL, with only 2 of 32 still having increased neutrophils in the follow-up lavage compared to 17 of 24 nonresponders (p less than 0.0001).(ABSTRACT TRUNCATED AT 250 WORDS)

Bronchoscopy with bronchoalveolar lavage in tuberculosis and fungal infections.

STUDY OBJECTIVE: To determine the utility of bronchoscopy with bronchoalveolar lavage for diagnosing M tuberculosis and fungal infections. DESIGN: Retrospective review of patients over a six-year period. SETTING: In- and outpatients of one University hospital and affiliated Veterans Administration Medical Center. PATIENTS: Those who were subsequently found to have either M tuberculosis or fungal infections. INTERVENTIONS: Bronchoscopy with bronchoalveolar lavage specimens were compared to prebronchoscopy sputum, when available. Specimens were sent for smear and culture for both acid-fast bacilli and fungi. In the case of lavage, an aliquot also was studied for cellular differential. MEASUREMENTS AND RESULTS: For TB, sputum was smear-positive in 6/47 (34 percent) and culture positive in 24/47 (51 percent), while bronchoscopy was smear positive in 34/50 (68 percent) and culture positive in 46/50 (92 percent). For fungal infections, no sputum was smear-positive and only 1/22 (5 percent) was sputum culture-positive, while bronchoscopy was smear-positive in 14/41 (34 percent) and culture positive in 35/41 (85 percent). Bronchoscopy washings and BAL provided complementary specimens. Eighty-three patients had adequate lavages and the cellularity was significantly different from controls (lymphocytes: TB 18 +/- 11.2 percent [mean +/- SD]; fungal: 13 +/- 11.1 percent; controls 6 +/- 3.1 percent; p less than 0.001; neutrophils: TB 9 +/- 11.5 percent; fungal: 6 +/- 9.1 percent controls: 2 +/- 1.5 percent, p less than 0.01); however, there was overlap and no pattern was characteristic for TB or fungal infections. CONCLUSION: Bronchoscopy with BAL is useful in diagnosing tuberculosis and fungal infections.

Semiquantitative technique for estimating Pneumocystis carinii burden in the lung.

We developed a technique to estimate the amount of Pneumocystis carinii found in bronchoalveolar lavage fluid. P. carinii associated with 500 nucleated cells in the bronchoalveolar lavage fluid had little between-observer and within-observer variation. Varying the technique of the lavage did not change the amount of P. carinii recovered. This technique was used in patients treated for P. carinii pneumonia. Those patients who did not respond to treatment had more P. carinii in their bronchoalveolar lavage fluid than those who responded.

Histoplasma capsulatum polysaccharide antigen detection in diagnosis and management of disseminated histoplasmosis in patients with acquired immunodeficiency syndrome.

PURPOSE: Disseminated histoplasmosis is a serious and often rapidly progressive, opportunistic infection in patients with acquired immunodeficiency syndrome (AIDS), supporting the importance of rapid diagnostic tests. We investigated Histoplasma capsulatum polysaccharide antigen (HPA) detection, a promising new method for rapid diagnosis of histoplasmosis. PATIENTS AND METHODS: Sixty-one cases of disseminated histoplasmosis in patients with AIDS form the basis of this report. Control cases were patients with AIDS who had other opportunistic infections and whose cultures were negative for H. capsulatum. A slightly modified radioimmunoassay procedure was used to measure the levels of HPA in urine and blood specimens. RESULTS: High levels of HPA were detected in the urine of 59 of 61 (96.7%) and the blood of 37 of 47 (78.7%) patients with AIDS complicated by disseminated histoplasmosis. Treatment with amphotericin B reduced levels of HPA in the urine in 19 of 21 (90.5%) and the serum of all 10 patients tested. HPA levels increased in the urine in all eight and in the serum in all five patients with culture-proven relapse. CONCLUSION: In conclusion, HPA detection offers a rapid method for diagnosing disseminated histoplasmosis. Additional experience is required to establish the role of this test in monitoring the effects of treatment and in identifying relapse in patients with AIDS.

The use of an indirect fluorescent antibody test for detecting Pneumocystis carinii.

Pneumocystis carinii pneumonia is a major cause of morbidity and mortality in immunocompromised patients. An indirect fluorescent antibody (IFA) test has been developed using monoclonal antibodies specific for antigens on the surface of P carinii. We tested the sensitivity and specificity of this IFA test for detecting P carinii in respiratory specimens of immunocompromised patients with pulmonary symptoms undergoing bronchoscopy. Both the bronchial wash and bronchoalveolar lavage specimens of patients with and without P carinii pneumonia were studied. The bronchoalveolar lavage and bronchial wash specimens were examined using modified Wright-Giemsa and methenamine silver stains. In addition, aliquots of the specimen were fixed and stained with IFA and read with a fluorescent microscope. Fifty-nine patients were found to have P carinii organisms. The bronchial wash specimen has been shown to be less sensitive than the bronchoalveolar lavage specimen for detecting the presence of P carinii. In the bronchial wash specimen from these 59 patients, only 60% had positive modified Wright-Giemsa stains, and 70% had positive methenamine silver stains. The IFA stain was positive in 93% of the specimens tested (significantly higher than the other two stains). There was only one false-positive IFA test result among the 54 patients tested with negative results. We found the IFA stain to be superior to conventional stains when examining less-than-adequate specimens, such as those from bronchial washes.

Recovery of human immunodeficiency virus and detection of p24 antigen in bronchoalveolar lavage fluid from adult patients with AIDS.

Published reports indicate that HIV is recovered from BAL fluid of patients with AIDS who have LIP but not with other AIDS-related pulmonary disease. Our experience has been different. Ten BAL specimens from nine patients with AIDS were cultured directly in peripheral blood mononuclear cells, and all ten cultures were positive for HIV as indicated by examination of the culture supernatant by reverse transcriptase assay and enzyme immunoassay for HIV antigen. Five of the specimens were also positive for Pneumocystis carinii, and other pulmonary diagnoses included histoplasmosis, lymphoma, Kaposi's sarcoma, and aspiration pneumonia. Five additional BAL specimens were cultured after freezing at -70 degrees C, but only two were culture-positive for HIV (p = 0.022; FET). This study indicates that HIV can be recovered from the BAL fluid in most patients with AIDS, unrelated to the type of pulmonary disease. In contrast to cultures, HIV antigen was detected in the BAL fluid of only one patient, and that patient had LIP with noncaseating granulomas. Therefore, HIV culture is not useful in the diagnosis of LIP, but HIV antigen detection should be studied further. All BAL fluids should be considered potentially infectious.

Bronchoalveolar lavage for diagnosing acute bacterial pneumonia.

The utility of gram stain and semiquantitative culture of the fluid retrieved by bronchoalveolar lavage (BAL) in identifying the causative agent in acute bacterial pneumonia was initially assessed in 92 patients. Fifteen of these patients presented with clinically active bacterial pneumonia; the remaining patients underwent bronchoscopy to evaluate other processes in the lung. Thirteen of the 15 patients with clinically active bacterial pneumonia had a BAL culture greater than or equal to 10(5) colony-forming units per milliliter of BAL fluid, whereas none of the other groups had a positive culture (chi 2 = 70.7, P less than .001). Gram stain of cytocentrifuged BAL fluid was positive (one or more organisms seen per 1,000 X field) only in those patients with an active bacterial pneumonia. Applying this technique, we studied 59 immunocompromised patients presenting with pulmonary infiltrates. Eight (21%) of the 39 patients presenting with microbial-related infiltrates proved to have acute bacterial pneumonia by BAL culture; the pneumonia resolved with appropriate antimicrobial therapy.