Long-term valacyclovir suppressive treatment after herpes simplex virus type 2 meningitis: a double-blind, randomized controlled trial.

BACKGROUND: Herpes simplex virus type 2 (HSV-2) is a common cause of acute and recurrent aseptic meningitis. Our aim was to determine the impact of antiviral suppression on recurrence of meningitis and to delineate the full spectrum of neurological complications. METHODS: One hundred and one patients with acute primary or recurrent HSV-2 meningitis were assigned to placebo (n = 51) or 0.5 g of valacyclovir twice daily (n = 50) for 1 year after initial treatment with 1 g of valacyclovir 3 times daily for 1 week in a prospective, placebo-controlled, multicenter trial. The primary outcome was time until recurrence of meningitis. The patients were followed up for 2 years. RESULTS: The first year, no significant difference was found between the valacyclovir and placebo groups. The second year, without study drugs, the risk of recurrence of verified and probable HSV-2 meningitis was significantly higher among patients exposed to valacyclovir (hazard ratio, 3.29 [95% confidence interval, 10.06-10.21]). One-third of the patients experienced 1-4 meningitis episodes during the study period. A considerable morbidity rate, comprising symptoms from the central, peripheral, and autonomous nervous system, was found in both groups. CONCLUSIONS: Suppressive treatment with 0.5 g of valacyclovir twice daily was not shown to prohibit recurrent meningitis and cannot be recommended for this purpose after HSV meningitis in general. Protection against mucocutaneous lesions was observed, but the dosage was probably inappropriate for the prevention of HSV activation in the central nervous system. The higher frequency of meningitis, after cessation of active drug, could be interpreted as a rebound phenomenon.

HIV transmission by blood transfusions in Stockholm 1979-1985: nearly uniform transmission from infected donors.

Thirty-five out of approximately 800 known HIV-seropositive people in Stockholm by mid-1986 were blood donors during the period 1979-1986. Almost all, i.e. 349 recipients of their blood components (red blood cells, platelets, plasma) could be traced. One hundred and eighty were still alive and 112 of these on further analysis, were suspected of being infected. They were contacted and all but one agreed to be tested for HIV antibodies. Fifty recipients were found to be seropositive. They had been transfused with blood components from 14 of the 35 donors. The earliest observed transmission occurred in June 1982. The patterns of HIV transmission showed, with only one exception, that each donor who had transmitted HIV to one recipient had also transmitted it to all later recipients. Appropriate preserved sera and clinical records from five of the donors who had not transmitted the virus were found and analysed. The result indicated that these donors had acquired their HIV infection after their last blood donation. In conclusion, our study indicates that every antibody-positive donor transmits HIV to almost every recipient.

Rubella immunity testing by mixed hemadsorption.

A mixed hemadsorption (MH) test for naturally acquired rubella immunity and immune responses after rubella vaccination has been compared with the hemagglutination-inhibition (HI) test, the immunodiffusion (ID) test, the neutralization test (NT), the hemolysis-in-gel (HIG) test and the indirect immunofluorescence (IF) test. The MH test was approximately equivalent to the HI test and the NT as to sensitivity for the early response to rubella vaccination, and all three tests are thought to measure protective antibodies, i.e. antibodies supposedly directed against envelope antigens, to about the same extent. The MH test for rubella antibodies is especially suited for laboratories in which this type of test is routinely used for other purposes, e.g. rabies, respiratory syncytial virus, herpes simplex, varicella and certain auto-antibodies. Where the method is already standard it may be preferable to the NT which, although of similar clinical value requires tedious standardization. Both tests may be necessary in cases where the HI test is equivocal or hampered by non-removable on-specific inhibitors.

Endonuclease cleavage pattern of cytomegalovirus DNA of strains isolated from congenitally infected infants with neurologic sequelae.

A prospective study of congenital cytomegalovirus infection in Malmö, Sweden, was performed from 1977 through 1985. The diagnosis was based on isolation of cytomegalovirus soon after birth. Congenital cytomegalovirus infection was identified in 76 infants, and as of September 1986 CNS symptoms have been experienced by nine of them. In at least seven of these infants, the disturbances can be referred to the cytomegalovirus infection. The strains from eight of the nine infants have been further studied by restriction endonuclease analysis of cytomegalovirus DNA. The cleavage patterns obtained with BamHI, EcoRI, and HindIII showed a unique pattern for each one of the eight strains. No common pattern could be associated with these eight strains in comparison with strains from postnatally infected children.

The DNA-binding protein P52 of human cytomegalovirus reacts with monoclonal antibody CCH2 and associates with the nuclear membrane at late times after infection.

Monoclonal antibody CCH2 is commonly used for the detection of human cytomegalovirus (HCMV) infected cells in tissue sections as well as in cultured cells. The specificity of CCH2 was determined by screening a recombinant lambda-gt11 cDNA gene bank from HCMV-infected fibroblasts. By sequencing a reactive clone, the antigen was identified to be the non-structural DNA binding protein p52 of HCMV (UL44 reading frame). The viral insert from the lambda clone was recloned in bacterial expression vectors. For this, a new vector, pRos-RS, was constructed. The resulting clones were tested in immunoblot analyses. They were reactive with CCH2 as well as with reconvalescent sera positive for antibodies against HCMV, by this proving the specificity of CCH2. Using this monoclonal antibody in confocal microscopy, the subcellular localization of p52 in infected cells was analyzed. In these analyses, p52 was found to be nuclear and to be associated with the nuclear membrane at late times after infection.

Detection of cytomegalovirus by in situ hybridisation and immunohistochemistry using new monoclonal antibody CCH2: a comparison of methods.

In situ hybridisation, immunohistochemistry, and morphological analysis for the detection of cytomegalovirus (CMV) were compared in routinely processed tissue sections from a patient with acquired immune deficiency syndrome (AIDS) and widespread CMV infection. Both in situ hybridisation and immunohistochemistry with the monoclonal antibody CCH2 labelled all "owl's eye" cells intensely and, in addition, nuclei of some morphologically normal cells. Quantitative evaluation of the results showed that in situ hybridisation and immunohistochemistry with CCH2 were considerably more sensitive than purely morphological analysis, particularly in tissues with only a few cells infected by CMV. It is further shown that immunohistochemistry with CCH2 detected a higher figure of CMV infected cells than in situ hybridisation. In conclusion, both in situ hybridisation and immunohistochemistry are rapid, sensitive, and specific methods for CMV detection. For routine purposes, however, immunohistochemistry seems to be more suitable.

Screening of blood donors for cytomegalovirus (CMV) antibodies: an evaluation of different tests.

The incidence of transfusion-associated cytomegalovirus (CMV) infections is related to the number of donors and the volume of blood. In immunosuppressed patients primary CMV infection is associated with a high morbidity and/or mortality. These infections can be prevented by the use of CMV negative blood products. A test for screening of CMV antibodies should have a high sensitivity and specificity and in addition be rapid and easily automated. In the present study the routine method in the laboratory, a CMV ELISA using a nuclear CMV antigen, was compared with Vironostika CMV anti-IgG MicroELISA, CMVSCAN, a latex agglutination test and a new ELISA from Organon Teknika, Vironostika CMV one-step MicroELISA. Sera from 419 blood donors were tested by all four tests. Discordant results were resolved by Western blot analysis using a glycine-extracted CMV antigen. The sensitivity was 100% for CMV ELISA and CMVSCAN and 99 and 96% for the CMV anti-IgG and CMV one-step tests respectively. The specificity was 100, 99, 94 and 100%, respectively. The ELISAs are suitable for screening of large numbers of serum samples and the CMV one-step test in particular was rapid and easy to perform although the sensitivity has to be increased. The latex agglutination test has the advantage of being extremely rapid.

Early detection of cytomegalovirus in cell culture by a monoclonal antibody.

A commercially available monoclonal antibody directed against early cytomegalovirus (CMV) antigen was used for the demonstration of CMV by immunofluorescence (IF) in cell culture within 2 days. The results were compared with the appearance of CMV-specific cytopathogenic effect (CPE). Urine specimens from 31 healthy children in day-care centers were inoculated on human embryonic fibroblasts. In addition, 45 CMV strains that had been stored at -70 degrees C were reinoculated. CMV was detected in 8/31 urine specimens by IF and 7 of these gave a specific CPE at an average of 16 days post-inoculation. One specimen was negative by IF but specific CPE was found at day 13. After reinoculation, CMV was detected in 76% by IF while 44 specimens developed CPE within a 6-week period. Demonstration of early CMV antigen in cell culture was found to be a rapid method for early diagnosis of CMV. Since the conventional cell culture with detection of CPE was more sensitive it may be useful to combine the two methods.

Comparison between a commercial ELISA, Rubazyme, and hemolysis-in-gel test for determination of rubella antibodies.

A commercial enzyme-linked immunosorbent assay, Rubazyme, was compared with the hemolysis-in-gel (HIG) test for antibodies to rubella in 826 sera. The results were in agreement for 99.4% of the 725 sera tested for immunity. However, the Rubazyme assay was no more efficient that either the hemagglutination-inhibition or HIG test in discriminating between sera with low levels of antibody and negative sera. Thus, it was concluded that the HIG test is the method of choice for immunity testing because of the low cost and simplicity. Rubazyme may be of value to confirm equivocal HIG results.

Early detection of cytomegalovirus in cell culture by a new monoclonal antibody, CCH2.

A CMV monoclonal antibody, CCH2, produced in this laboratory was evaluated for rapid detection of CMV. Two staining procedures, immunofluorescence and an immunoenzymatic technique using biotin-streptavidin peroxidase, were compared. The CCH2 monoclonal antibody was used to demonstrate early CMV antigen in cell culture 24 h after inoculation of 598 urine samples from kidney transplanted patients by indirect immunofluorescence in comparison with virus isolation. One hundred and sixty of the specimens were stained additionally by an immunoenzymatic technique and the results were compared. CMV was isolated from 170 out of 598 specimens within 6 weeks. Early CMV antigen was demonstrated in 114 of these specimens by immunofluorescence giving a sensitivity of 67% and a specificity of 95%. In the comparison with the immunoenzymatic staining procedure the results for all three tests agreed for 81% (130/160) of the specimens. After resolving discordant results into true positives and true negatives, the sensitivity was 87, 85 and 70%, respectively for virus isolation, immunoenzymatic staining and immunofluorescence and the specificity 100, 96 and 99%. The CCH2 monoclonal antibody proved to be useful for rapid detection of CMV in urine specimens and using immunoenzymatic staining with biotin-streptavidin a sensitivity comparable to that of virus isolation was found.

Nosocomial spread of hepatitis B virus (HBV) in a haemodialysis unit confirmed by HBV DNA sequencing.

An outbreak of hepatitis B virus (HBV) infection in a haemodialysis unit is described. Four patients in the unit contracted subclinical HBV infection within three months. DNA sequence analysis of the S gene of HBV isolates from chronic carriers and newly infected patients in the unit aided in tracing possible transmission pathways. Three newly infected patients had received partial or complete HBV vaccination previously. HBV was rapidly cleared from all three although the anti-HBs titre had not reached 10 IU L-1 in any of them at the time of infection.

Chlamydia test monitoring during therapy.

Forty-eight women with chlamydial cervicitis were followed with chlamydial culture and antigen tests (immunofluorescence and enzyme immunoassays) during the course of therapy to study the rate of disappearance of viable organisms and chlamydial antigen. On treatment day 2, two-thirds of the patients were positive by one or more of the tests while 81% were negative by all tests on day 4. All screening methods used had turned negative on the 6th day of therapy. The antigens were found to persist somewhat longer than viable organisms. This persistance should, however, be of no clinical significance.

Human immunodeficiency virus infection and syphilis in Hondurian female prostitutes.

The seroprevalence of human immunodeficiency virus (HIV) infection and syphilis was investigated in 181 female prostitutes in Tegucigalpa, Honduras. One particle agglutination test and two enzyme immunoassays, as well as one immunofluorescence test were used for the screening of HIV antibodies. Confirmation of positive results by the screening tests was carried out by Western blot. The prevalence of HIV seropositivity was 4% (8 women). Specific treponemal antibodies were found in 50% (90/181) of the prostitutes as judged by Treponema pallidum haemagglutination assay (TPHA) and/or fluorescent treponemal antibody-absorption (FTA-ABSIgG) test. As estimated by the positivity of any or both non-treponemal tests (VDRL and RPR), a total of 31 (17%) out of the 181 women had active syphilis. A good correlation was found between the results obtained by TPHA and FTA-ABSIgG. IgM antibodies were found in 72% of sera positive by TPHA and/or FTA-ABSIgG. Four out of the 181 women were found to have antibodies to both HIV and Treponema pallidum.

PIP: The seroprevalence of human immunodeficiency virus (HIV) infection and syphilis was investigated among 181 female prostitutes in Tegucigalpa, Honduras. 1 particle agglutination test and 2 enzyme immunoassays, as well as 1 immunofluorescence test, were used for the screening of HIV antibodies. Confirmation of positive results by the screening tests was carried out by western blot. The prevalence of HIV seropositivity was 4% (8 women). Specific treponemal antibodies were found in 50% (90/181) of the prostitutes as judged by Treponema pallidum hemagglutination assay (TPHA) and/or fluorescent treponemal antibody-absorption (FTA-ABSIgG) test. As estimated by the positivity of any or both nontreponemal tests (VDRL and RPR), a total of 31 (17%) of 181 women had active syphilis. A good correlation was found between the results obtained by TPHA and FTA-ABSIgG. IgM antibodies were found in 72% of sera positive by TPHA and/or FTA-ABSIgG. 4 of 181 women were found to have antibodies to both HIV and Treponema pallidum.

Syphilis and human immunodeficiency virus seroconversion during a 6-month follow-up of female prostitutes in Mogadishu, Somalia.

A total of 155 prostitutes inhabiting 4 different districts in Mogadishu, Somalia, were enrolled in a 6 month prospective study of syphilis and HIV infection. Blood samples were taken on entry, at 3 months and at 6 months. Differences were seen between the prostitutes in the 4 districts regarding possible risk factors for the acquisition of STDs. Initially 107 (69%) were found to have syphilis serum markers and 47% had active syphilis as judged by positivity in both Treponema Pallidum Haemagglutination (TPHA) test and non-treponemal (VDRL and RPR) tests. TPHA positivity was correlated to the number of sexual partners. Sixty-nine prostitutes were followed for 6 months. Two of the 16 initially TPHA negative women seroconverted for syphilis during the follow-up. HIV antibodies were detected in one (0.6%) of the 155 prostitutes at the start of the study and one out of 68 seroconverted during the 6 months follow-up. To control the spread of HIV infection health education targeting the risk groups like prostitutes must be given a high priority.

Sexually transmitted diseases in men in Mogadishu, Somalia.

The prevalence of viral and bacterial sexually transmitted diseases were studied in 101 men attending a dermatovenereal outpatient clinic in Mogadishu. A control group of 103 healthy adult men were included for the serological part of the study. Serological markers of hepatitis B virus (HBV), human immunodeficiency virus (HIV), cytomegalovirus (CMV) and herpes simplex virus (HSV) were studied. All sera were tested for syphilis markers. HBV serum markers were detected in 84% of the men in the study group and 66% of the healthy controls (P less than 0.005). Hepatitis B virus carriers were detected more frequently in the study group than among the controls. Also, 96% of the men in both groups had CMV antibodies and all of them had antibodies to HSV. No sera were found to contain HIV antibodies. The TPHA-positivity was 10% and 3% in the study and control groups respectively, and 5% of the patients had syphilis IgM antibodies. Sexual contact with prostitutes was recorded in 54% and 48% respectively of patients and controls, and such contact was correlated with TPHA-positivity in the study group. Chlamydia trachomatis antigen was detected in urogenital specimens of 14% of the men in the study group and gonococcal culture was positive in 53% of those with urethral discharge.

[Cytostatic therapy reduces the immune defense. Children treated for leukemia have impaired immunity against measles and rubella]. / Cytostatikaterapi sänker immunförsvaret. Leukemibehandlade barn förlorar sin immunitet mot mässling och röda hund.

A study is summarized analyzing the levels of serum antibodies against vaccination antigens in 43 children treated for acute lymphoblastic leukemia. Two different therapeutical regimens were used. All children had been immunized against measles and rubella before being diagnosed with leukemia. Eight of the 24 children treated 1986-1991 lacked protective levels of antibodies against measles; four of the 24 children lacked antibodies against rubella. In the second cohort of children (n = 16) treated from 1992 and onwards, nine lacked protective levels of antibodies against measles, eight lacked antibodies against rubella.