Successful medical therapy of mitral anular abscess complicating infective endocarditis.

A case of staphylococcal endocarditis with the echocardiographic findings of mitral anular abscess is described. The anular mass resolved after 9 weeks of antibiotic therapy. This case illustrates that perivalvular abscess complicating infective endocarditis may respond to medical therapy.

Clinical effect of aerosol triamcinolone acetonide in bronchial asthma.

In a double-blind, 12-week study of corticosteroid-dependent reversible bronchial asthma, 20 of 31 (64.5%) patients receiving triamcinolone acetonide aerosol, 800 microgram daily, were able to discontinue oral steroid therapy. This compares with three of 29 (10.3%) treated with aerosol placebo. At the end of the 12-week period, the mean 8 AM plasma cortisol level had increased from 5.3 +/- 4.1 to 8.6 +/- 5.2 microgram/dl in those receiving triamcinolone acetonide. The mean percent predicted values in the triamcinolone group for forced expiratory volume in the first second rose from 44.8 to 62.4 at two weeks (P less than .005), for forced vital capacity from 64.1 to 79.9 (P less than .005), and for maximum midexpiratory flow rate from 26.7 to 46.7 (P less than .005). The improved pulmonary function values persisted while the oral prednisone equivalent daily dose decreased from a mean of 13.3 to 2.9 mg at 12 weeks. Significant oral candidiasis was detected in two patients. Aerosol triamcinolone acetonide appears to be an effective alternative to beclomethasone dipropionate for use in patients with bronchial asthma.

Cross-sectional study of immunologic abnormalities in intravenous drug abusers on methadone maintenance in New York City.

One hundred and ninety-nine patients with a history of intravenous drug abuse, and enrolled on the St Luke's-Roosevelt Hospital Center Methadone Program, had baseline evaluations performed from September 1984 to April 1987. The study was designed to examine immunologic parameters associated with HIV seropositivity and those predictive of progression to AIDS-related complex (ARC) and AIDS. Sixty-four patients (32%) had antibodies to HIV by enzyme-linked immunosorbent assay (ELISA), with confirmation by Western blot and none of these patients had ARC or AIDS at the time of initial evaluation. The mean values for white blood-cell count, absolute lymphocyte count, proportion and absolute CD4, and CD4/CD8 ratio were decreased significantly in the HIV-seropositive group compared with the HIV-seronegative group. On the other hand, levels of circulating beta 2-microglobulin, SCD8, SIL-2R, and HIV p24 antigen were significantly elevated in the HIV-seropositive group compared with the HIV-seronegative group.

Tumor necrosis factor and HIV P24 antigen levels in serum of HIV-infected populations.

Tumor necrosis factor (TNF) and HIV P24 antigen levels were determined in the serum of intravenous drug abusers (IVDAs), homosexuals, and patients with lymphadenopathy or acquired immune deficiency syndrome (AIDS). The mean TNF level in the serum of normal controls was 12 +/- 5 compared to 112 +/- 25 pg/ml in the serum of HIV-seronegative asymptomatic IVDAs. This increase of TNF may be due to the variety of infections that these people are exposed to persistently. The mean TNF level in the serum of HIV-seropositive asymptomatic IVDAs was 112 +/- 79 pg/ml, 31 +/- 24 pg/ml in lymphadenopathy, and 55 +/- 19 pg/ml in patients with AIDS. The mean P24 level in the serum of patients with AIDS was 50 +/- 13 pg/ml compared to 0 pg/ml in HIV-seronegative subjects, while the other HIV-seropositive groups had relatively low levels. The P24 antigen levels may reflect viral load in these patients. SIL-2R and beta2-microglobulin levels were also elevated in patients with HIV infection . The TNF may play a role in the antiviral activity against HIV virus and in the development of full-blown disease after HIV infection.

Human immunodeficiency virus type-1 infection of homosexual men is accompanied by a decrease in circulating B cells.

As part of the multidisciplinary effort to characterize the natural history of human immunodeficiency virus type 1 (HIV-1) infection, the cell-surface phenotypes of lymphocytes from a cohort of homosexual men were analyzed in detail and related to clinical and laboratory parameters associated with HIV-1 infection. The present study represents a cross-sectional analysis of coded specimens from 153 homosexual men, of whom 74 were seronegative and 79 seropositive for HIV-1. Fewer circulating B lymphocytes (CD19+) were found in HIV-1-seropositive subjects relative to a seronegative reference group. HIV seropositivity was not associated with decreased numbers of CD8+ T cells or activated T cells, which suggests that the number of circulating B cells specifically decreased. In addition to CD19, B cells were measured by CD20 and CD21 in a subset of subjects, and decreases in circulating CD20+ and CD21+ B cells were also apparent in HIV-1-seropositive subjects. The decrease in B-cell numbers was present at the earliest stages of HIV-1 infection (asymptomatic, clinically silent) and became more pronounced at more advanced stages of HIV-1 infection. The absolute B-cell numbers correlated with absolute CD4+ cell numbers (r = 0.59, p less than 0.001). These data suggest that HIV-1 infection is associated with progressive, selective decreases in the numbers of circulating CD4+ T cells and B cells.

Elevated soluble interleukin-2 receptor levels in serum of human immunodeficiency virus infected populations.

Soluble interleukin-2 receptor (SIL-2R) levels in sera were quantitated in asymptomatic intravenous drug abusers (IVDA) and in patients with lymphadenopathy or AIDS. The mean SIL-2R level in serum of normal controls was 158 +/- 19 compared to 368 +/- 35 U/ml in serum of HIV-seronegative asymptomatic IVDA. The mean SIL-2R in serum of HIV-seropositive asymptomatic IVDA was 609 +/- 85 U/ml and in patients with lymphadenopathy was 745 +/- 79 U/ml. In addition, AIDS patients with Pneumocystis carinii pneumonia, Kaposi's sarcoma, or both had elevated mean levels of SIL-2R values with a broad range. This elevated level of SIL-2R may reflect excessive cell surface IL-2R expansion by the infected cells.

Open study of AL-721 treatment of HIV-infected subjects with generalized lymphadenopathy syndrome: an eight week open trial and follow-up.

AL-721 is a lipid compound composed of neutral lipids, phosphatidylcholine and phosphatidylethanolamine in a 7:2:1 ratio. The objective of this open study was to evaluate the effects of AL-721 in vivo in an 8-week open trial in which 10 g twice daily was administered on a low fat diet to eight HIV-infected subjects with lymphadenopathy syndrome (LAS). Serial lymphocyte cocultivation studies in 7 patients with initial culture positivity appeared to demonstrate reduction of reverse transcriptase peak counts in 5 with the trough noted in 4 at 8 weeks and in one at 4 weeks following termination of therapy. The mean values for all 7 patients revealed a baseline value of 73,419 with decrease to a low of 27418 at 8 weeks. Mean levels of total lymphocytes, T-4, T-8 and T-11 cells were not altered but lymphoproliferative responses to concanavalin A and pokeweed mitogens appeared to be augmented in 4 of the 8 subjects in association with AL-721 treatment. No side effects were noted. In a subsequent follow-up study using a normal diet in the same subjects lymphocyte cocultivation and mitogen-induced responses were less consistently affected when 15 g twice daily AL-721 was readministered. In addition, serum HIV p24 antigen and CD4 levels were not altered during both the 8-week open and subsequent AL-721 readministration. Four of the 8 patients have progressed to AIDS over the subsequent 14 months.

Evaluation of infection control measures in preventing the nosocomial transmission of multidrug-resistant Mycobacterium tuberculosis in a New York City hospital.

OBJECTIVE: To evaluate the efficacy of Centers for Disease Control and Prevention (CDC)-recommended infection control measures implemented in response to an outbreak of multidrug-resistant (MDR) tuberculosis (TB). DESIGN: Retrospective cohort studies of acquired immunodeficiency syndrome (AIDS) patients and healthcare workers. The study period (January 1989 through September 1992) was divided into period I, before changes in infection control; period II, after aggressive use of administrative controls (eg, rapid placement of TB patients or suspected TB patients in single-patient rooms); and period III, while engineering changes were made (eg, improving ventilation in TB isolation rooms). SETTING: A New York City hospital that was the site of one of the first reported outbreaks of MDR-TB among AIDS patients in the United States. PARTICIPANTS: All AIDS patients admitted during periods I and II. Healthcare workers on nine inpatient units with TB patients and six without TB patients. RESULTS: The epidemic (38 patients) waned during period II and only one MDR-TB patient presented during period III. The MDR-TB attack rate among AIDS patients hospitalized on the same ward on the same days as an infectious MDR-TB patient was 8.8% (19 of 216) during period I, decreasing to 2.6% (5 of 193; P = 0.01) during period II. In a small group of healthcare workers with tuberculin skin test data, conversions during periods II through III were higher on wards with than without TB patients (5 of 29 versus 0 of 15; P = 0.15), although the difference was not statistically significant. CONCLUSIONS: Transmission of MDR-TB among AIDS patients decreased markedly after enforcement of readily implementable administrative measures, ending the outbreak. However, tuberculin skin-test conversions among healthcare workers may not have been prevented by these measures. CDC guidelines for prevention of nosocomial transmission of TB should be implemented fully at all US hospitals.

Erythropoietin and granulocyte-macrophage colony-stimulating factor (GM-CSF) levels in sera of patients with HIV infection.

Levels of erythropoietin and granulocyte-macrophage colony-stimulating factor (GM-CSF) were measured in sera of 28 HIV-seronegative heterosexual non-intravenous drug using controls, 57 HIV-seronegative and 42 HIV-seropositive asymptomatic intravenous drug users (IVDU) and 36 HIV-seronegative and 36 HIV-seropositive homosexuals, 79 patients with lymphadenopathy, 11 patients with AIDS-related complex (ARC) and 110 patients with AIDS. Serum erythropoietin levels were significantly elevated in HIV-seronegative and HIV-seropositive asymptomatic homosexuals and in patients with lymphadenopathy, ARC and AIDS when compared to controls. However, in asymptomatic HIV-seronegative and HIV-seropositive IVDU the erythropoietin levels were not significantly different from the control group. GM-CSF mean levels in both HIV-seronegative and HIV-seropositive IVDU were elevated compared with the level in controls, whereas the mean levels in both the HIV-seronegative and HIV-seropositive homosexuals were decreased relative to the level in controls. GM-CSF levels in patients with lymphadenopathy, ARC and AIDS were not significantly different from the control value. It appears that male homosexuals have mildly increased erythropoietin levels which rise substantially with the development of ARC and AIDS, which suggests that AIDS patients have intact capacity to produce erythropoietin. In contrast, GM-CSF levels are increased in association with IVDU but are not increased in association with HIV infection including ARC or AIDS. The difference in circulating levels of erythropoietin and GM-CSF may reflect the tissue sources of erythropoietin predominantly in the kidney and GM-CSF being a product of the immunological and inflammatory systems.