The incidence of human herpes virus-8 expression in lymph node biopsies from human immunodeficiency virus-positive patients.

AIMS: Human immunodeficiency virus (HIV)-related lymphadenopathy is characterized by a wide spectrum of histological changes. Three patterns have been described which correspond to clinical stages of HIV/acquired immune deficiency syndrome (AIDS). Castleman disease is a heterogeneous group of disorders. A recently described variant, multicentric Castleman disease (MCD), of which some cases are associated with human herpes virus-8 (HHV-8), has been reported in both HIV-seropositive and -negative patients. Considerable morphological overlap occurs between one of the patterns of HIV lymphadenopathy and this variant. METHODS AND RESULTS: This retrospective histopathological study on 95 cases of HIV-reactive lymphadenopathy assessed the incidence of the different patterns and HHV-8 on immunohistochemistry (IHC). Of the 95 cases, 78 (82.1%) were HHV-8-negative, of which 46 (59.0%) were classified as pattern A, 20 (25.6%) as pattern B and 12 (15.4%) as pattern C. Nine (31.0%) of 29 cases with pattern B and 8 (40.0%) of 20 cases with pattern C were HHV-8 positive. In total 15 cases of MCD were diagnosed in this series. CONCLUSION: This study draws attention to the overlap between HIV lymphadenopathy and MCD. We recommend that cases of HHV-8-associated MCD should be investigated for HIV infection.

[Clinicopathologic correlation between CD4-positive T lymphocyte counts and superficial lymphadenopathy in HIV-positive/AIDS patients].

OBJECTIVE: To explore the clinicopathological correlation between CD4(+) T lymphocyte count and superficial lymphadenopathy HIV/AIDS patients. METHODS: A total of 1066 HIV/AIDS patients were included in this study. The incidence of superficial lymphadenopathy, peripheral blood CD4(+) T lymphocyte counts and histological features of superficial lymphadenopathy were analyzed. RESULTS: Among 1066 patients, 126 cases (11.8%) presented with superficial lymphadenopathy. Of the 126 cases, there were 69 cases with CD4(+) T lymphocyte counts < 100/µl and clinical diagnoses including tuberculosis (37 cases), reactive hyperplasia (8 cases), AIDS-related lymphadenopathy (18 cases), penicillium diseases (12 cases), fungal infection (5 cases) and non-tuberculous mycobacterial infection (1 case). Twenty-six cases had CD4(+) T lymphocyte counts between 100/µl to 200/µl and clinical diagnosis including tuberculosis (12 cases), reactive hyperplasia (8 cases), AIDS-related lymphadenopathy(6 cases), penicillium disease (2 cases) and non-Hodgkin lymphoma (1 case). Twenty-nine cases had CD4(+) T lymphocyte counts > 200/µl and clinical diagnoses including tuberculosis (11 cases), reactive hyperplasia (12 cases), AIDS-related lymphadenopathy (3 cases), Penicillium diseases (1 case) and non-Hodgkin lymphoma (4 cases). The CD4(+) T lymphocyte counts among patients with tuberculosis, AIDS-related lymphadenopathy and Penicillium diseases were significantly different (χ(2) = 8.861, P = 0.012). A significant correlation between the incidence of superficial lymphadenopathy and CD4(+) T lymphocyte counts was found (χ(2) = 375.41, P = 0.000). CONCLUSIONS: The most common cause of superficial lymphadenopathy in HIV/AIDS patients is tuberculosis, followed by lymph node reactive hyperplasia, AIDS-related lymphadenopathy and Penicillium disease. Low CD4(+) T lymphocyte count correlates with an increased incidence of superficial lymphadenopathy and the risk of opportunity infection. Therefore, determination of peripheral blood CD4(+) T lymphocyte count should become an integral marker for the early diagnosis and treatment of superficial lymphadenopathy in HIV/AIDS patients.

Central pontine myelinolysis complicating treatment of multicentric Castleman's disease and Kaposi's sarcoma in a patient with AIDS.

An HIV positive black African woman presented with widespread lymphadenopathy and pancytopenia that had been ascribed to tuberculosis. Lymph node biopsy showed both Kaposi's sarcoma and multicentric Castleman's disease. Despite antiretroviral therapy and chemotherapy the patient deteriorated, developing confusion and dysphasia. A cranial magnetic resonance scan showed central pontine myelinolysis. Despite supportive therapy the patient died.

Localisation of HHV-8 in AIDS related lymphadenopathy.

BACKGROUND: Many lymph node abnormalities have been described in AIDS. These include opportunistic infections that sometimes result in spindle cell pseudotumours, Kaposi's sarcoma (KS), malignant lymphoma (Hodgkin's and non-Hodgkin's), and florid reactive hyperplasia. Among these, reactive hyperplasia is the most common manifestation of AIDS related lymphadenopathy. AIM: To examine whether human herpesvirus 8 (HHV-8), the aetiological agent of KS, can be localised in AIDS related lymphadenopathy and whether its appearance in such nodes is predictive of Kaposi's sarcoma development. METHODS: A series of human immunodeficiency virus (HIV) positive men (n = 21) with AIDS related lymphadenopathy who at the time of presentation had KS or subsequently developed KS (n = 5) were examined. The prevalence of HHV-8 was assessed in these patients using solution phase polymerase chain reaction (PCR), real time TaqMan quantitative PCR, and in cell amplification techniques (PCR in situ hybridisation (PCR-ISH) and labelled primer driven in cell amplification). RESULTS: Using standard solution phase PCR in a nested format, only two of the 21 patients with AIDS related lymphadenopathy were positive for HHV-8. The lymph node of one of these patients contained KS lesions. Three HHV-8 positive patients were identified using TaqMan PCR (the original two positive patients and one additional patient). All of the positive patients either subsequently developed KS (n = 2) or had KS at the time of diagnosis (n = 1). Two additional patients subsequently developed KS, but were negative for HHV-8 by solution phase PCR and TaqMan PCR. Using PCR-ISH, HHV-8 amplicons were identified in some lymphoid cells (in one patient) and in spindle cells of the KS lesion in another. The positive lymphoid cells were predominantly concentrated in B cell areas of the affected lymph nodes, confirming the B cell tropism exhibited by HHV-8. CONCLUSIONS: The presence of HHV-8 in AIDS related lymphadenopathy is predictive of KS development and probably represents seeding of HHV-8 infected B cells from the peripheral blood. These findings support a role for HHV-8 in the pathobiology of KS.

Evolução da síndrome de imunodeficiência adquirida (AIDS - SIDA) na clínica odontológica. O papel do cirurgião-dentista / The evolution of the acquired immunodeficiency syndrome in dental clinc and the dental team role

Evolução da infecção pelo HIV na clínica odontológica, mostrando a sua transmissão e seus diferentes estágios. A epidemiologia no mundo e Brasil, em especial, na clínica odontológica, o papel do cirurgião-dentista, discutindo os seus procedimentos, diante dos pacientes e suas manifestações bucais como a sua própria biossegurança durante o trabalho

Concurrent Sweet's syndrome and Löfgren's syndrome.

Concurrent Sweet's syndrome and acute sarcoidosis (Löfgren's syndrome) has been reported in 4 cases. We describe a 40-year-old woman with biopsy confirmed lesions of Sweet's syndrome and erythema nodosum together with arthritis and hilar and mediastinal adenopathy. We review the association of Sweet's syndrome and malignancy or hematologic disorders, and the need to exclude malignancy when hilar adenopathy is found. Aggressive diagnostic procedures can be avoided with prompt recognition of Löfgren's syndrome.

HIV-associated Hodgkin's disease. Biologic and clinical aspects.

The incidence of HD appears to have increased in HIV-infected individuals, with HIV-seropositive intravenous drug users most likely to develop the disorder. All groups at risk for HIV, however, may develop HD. The pathologic spectrum of HD in the setting of HIV infection is distinct from that seen in "de novo" HD in the United States, with the majority of patients diagnosed with the mixed cellularity subtype, as opposed to the more usual occurrence of nodular sclerosis in "de novo" disease. The presence of fibrohistiocytic stromal cells within involved tissues is also a distinct characteristic of HIV-associated HD. Epstein-Barr viral genome has been detected within tumor cell nuclei, and it may be involved in the pathogenesis of disease. Clinically, patients often present with systemic "B" symptoms and widely disseminated extranodal disease, seen in 75% to 90%. Bone marrow is involved in 40% to 50% of cases at diagnosis. Complete remission may be achieved in approximately 50% of patients after use of combination chemotherapy, but median survival is short, in the range of 12 to 18 months. Death is often due to bacterial or opportunistic infection (or both), often occurring in the setting of chemotherapy-induced neutropenia.

Isolated lymphadenopathy on chest radiographs of HIV-infected patients.

AIM: To determine the aetiology of isolated intrathoracic lymphadenopathy on chest radiographs of HIV-infected patients. PATIENTS AND METHODS: Over a 40 month span in 1990-1993, 18 HIV-infected patients (13 men, 5 women) from our New York City adult HIV outpatient clinic development isolated intrathoracic lymphadenopathy (defined as intrathoracic nodal enlargement without other persistent abnormalities on chest radiographs). Serial chest radiographs (n = 18), CT scans when available (n = 7), and clinical charts (n = 18) were reviewed retrospectively. RESULTS: Median patient age was 34 (range 25-49) years. The diagnoses associated with adenopathy were Mycobacterium tuberculosis (Mtb) in eight (44%), Mycobacterium avium intracellulare complex (MAC) in four (22%), and Mtb and MAC co-infection in three (17%). Cryptococcal infection, thymic hyperplasia, and spontaneous resolution without diagnosis or treatment occurred in one patient each. In 16 (89%) of the 18 patients, lymphadenopathy was present in more than one nodal station. Enlarged nodes were found in the following sites: paratracheal/tracheobronchial (n = 14), aortopulmonary window (n = 9), hilar (n = 7), anterior mediastinum (n = 3), subcarinal (n = 2), and left paraesophageal (n = 2). CONCLUSION: Mycobacterial infection was the aetiology of isolated intrathoracic lymphadenopathy in 15 of 18 (83%) HIV-infected patients. When an inner city HIV-infected patient presents with isolated intrathoracic lymphadenopathy, we recommend an aggressive work-up for mycobacterial disease.

AIDS and cerebrovascular disease.

BACKGROUND: Although neurological complications of human immunodeficiency virus (HIV) infection are common, the presence of cerebrovascular disease (CVD) has been seldom reported. The purpose of this report is to review available data on the association between stroke and acquired immunodeficiency syndrome (AIDS). SUMMARY OF REVIEW: A review of all literature published between mid-1976 and December 1994 was performed through a MEDLINE search with the following key words: AIDS, CVD, human T-cell lymphotropic virus type III, and HIV-1. Only reports of clinical stroke in patients with AIDS or HIV infection and autopsy series with stroke findings were selected. The type of study, population, number of stroke patients, subtype and etiology of stroke, and associated AIDS conditions were described. Six clinical series and 11 autopsy series were found, with a total of 1885 cases with AIDS, AIDS-related complex, and HIV carriers. Forty percent had a neurological complication, but only 1.3% had a stroke syndrome. Ischemic infarcts were more common than intracerebral hemorrhages. Cerebral infarcts were generally due to nonbacterial thrombotic endocarditis or concomitant opportunistic central nervous system infection, and intracerebral hemorrhages were usually associated with thrombocytopenia, primary central nervous system lymphoma, and metastatic Kaposi's sarcoma. Autopsy findings of CVD were generally not related with clinical stroke before death. Data are not available to determine the role of risk factors for AIDS in CVD. CONCLUSIONS: Because of limitations of the available data, it is still not clear whether there is an association between AIDS and stroke. Further studies are needed to better define the epidemiology of CVD in association with AIDS.

Rhodococcus equi infection in HIV-positive subjects: a retrospective analysis of 24 cases.

Rhodococcus equi causes a rare infection in immunocompromised hosts. We describe 24 cases of infection in patients with AIDS-related complex (ARC)/acquired immunodeficiency syndrome (AIDS). Pneumonia was always the first manifestation of R. equi infection, but extrapulmonary involvement was also observed. The main sources of bacteria were sputum, bronchial washings and blood. The strains isolated were mainly susceptible to erythromycin, vancomycin, teicoplanin, rifampicin, imipenem and aminoglycosides. Initial treatment should involve an intravenously administered antibiotic combination therapy including imipenem or vancomycin or teicoplanin, followed by orally administered maintenance combination therapy. Drug combinations should be investigated for serum bactericidal activity in vitro. Surgery does not increase survival time and should only be performed in cases that do not respond to antibiotic treatment. Presumptive risks of infection (contact with horses or farm dust, or cohabiting with people affected by R. equi infection) were present in more than 50% of patients. This finding, and the frequency of bacteria in the sputum, are not sufficient proof of transmission between humans, but do suggest the need for respiratory isolation of patients affected by R. equi pneumonia.

Importance of human immunodeficiency virus-associated lymphadenopathy and tuberculous lymphadenitis in patients undergoing lymph node biopsy in Zambia.

The relative importance of human immunodeficiency virus (HIV)-associated lymphadenopathy amongst patients presenting for lymph node biopsy in Central Africa is unknown. HIV-1 serology and histology of patients undergoing superficial lymph node biopsy during 1989-1990 in Lusaka, Zambia, were examined in a prospective cohort study of HIV serology and by retrospective review of laboratory records. Of 727 lymph nodes biopsied in Lusaka in 1989-1990, 380 (52 per cent) showed tuberculous lymphadenitis, 160 (22 per cent) histology suggestive of primary HIV lymphadenopathy and 66 (9 per cent) nodal Kaposi's disease. HIV serology was tested in 280 adults and was positive in 91 per cent (255 patients), including 89 per cent (153 of 171) of those with tuberculous lymphadenitis, 98 per cent (63 of 64) of those with histology suspicious of primary HIV lymphadenopathy and all (24 of 24) with nodal Kaposi's disease. Other HIV-associated lymphadenopathy included nodal lymphomas and lymphoepithelial cysts. HIV serology was tested in 22 children and was positive in eight, including four of 14 with tuberculous lymphadenitis. It is concluded that HIV-associated lymphadenopathy, especially tuberculous lymphadenitis, is very common amongst patients presenting for lymph node biopsy in Central Africa.

PIP: Data from a prospective cohort study conducted during 1989-1990 of HIV serology and from a retrospective review of laboratory records of 727 patients presenting for superficial lymph node biopsy at the University Teaching Hospital in Lusaka, Zambia, were analyzed to determine the relative significance of HIV-associated lymphadenopathy among patients undergoing lymph node biopsy. 380 (52%) of the 727 biopsy patients had tuberculous lymphadenitis (secondary HIV lymphadenopathy). Another 160 (22%) had presumed primary HIV lymphadenopathy. The remaining 66 (9%) had nodal Kaposi's disease. 280 adults were tested for HIV antibodies. 91% tested positive for HIV. The HIV rate was 89% for patients with tuberculous lymphadenitis, 98% for suspected primary HIV lymphadenopathy cases, and 100% for those with nodal Kaposi's disease. As for the 22 children 0-16 years old, 8 were HIV positive. 50% of HIV-positive children who underwent lymph node biopsy had tuberculous lymphadenitis. Three had suspected primary HIV lymphadenopathy and 1 had nodal Kaposi's disease. These findings show that HIV-associated lymphadenopathy, particularly tuberculous lymphadenitis, is very prevalent in patients undergoing lymph node biopsy. They stress the importance of investigating further HIV-positive patients with suspicious asymmetrical nodes in central Africa. Simple, appropriate methods (e.g., wide-needle aspiration) are needed for the diagnosis of tuberculous lymphadenitis in this region, with its dearth of facilities for surgery and histopathology.

Hyponatremia in pediatric patients with HIV-1 infection.

Hyponatremia has been recognized as a complication in adults with acquired immunodeficiency syndrome (AIDS). We did a retrospective study evaluating the medical records of 86 children (age 4 months to 21 years) with human immunodeficiency virus (HIV-1) infection to determine the frequency and clinical associations of hyponatremia. Twenty-two children (26%) developed hyponatremia (serum sodium < 135 mEq/L; range 104 to 134 mEq/L; mean 130 mEq/L). Fourteen were male; 18 of the 22 patients were black and 4 were white. At the time of hyponatremia, the children frequently had comorbid associations, including 8 (35%) with AIDS encephalopathy; 3 (14%) with cardiomyopathy; 3 (14%) using diuretics; 1 (5%) using pentamidine; 3 (14%) with bacterial pneumonia; 2 (9%) requiring gastric lavage feedings; 2 (9%) with tuberculosis meningitis; 2 (9%) with gastroenteritis; 1 (5%) with infection caused by Mycobacterium avium-intracellulare; 1 (5%) each with brain tumor and tumor metastasis to brain. The cause of hyponatremia was attributed to syndrome of inappropriate antidiuretic hormone in 8 children; poor sodium intake and/or excessive diarrheal losses in 5; and the use of diuretics in 3 patients. Mild hyponatremia with no identifiable cause was found in 5 patients.

Relapsing fever in an HIV-infected man.

AIDS: The diagnosis of a relapsing fever of unknown origin (FUO) in a middle-aged HIV-infected male is discussed. The author notes that many of these fevers occur in HIV-infected and AIDS patients with low CD4 counts who have occult infections or malignancies typical of the early stages of HIV. At later stages of AIDS, virtually any opportunistic infection may present with fever alone. In the case of the middle-aged male who did not have low CD4 counts, the author suggests the use of protocols for evaluating FUO in the absence of AIDS, as well as for the usual HIV-associated diagnoses, before assuming that HIV is the cause of the problem. In this case, the diagnosis was finally found to be Hodgkin's disease, with a delayed diagnosis probably due to seeking a more obvious infection in an HIV-infected patient.^ieng

Pathology of AIDS in children.

AIDS in children is a multisystem disease. The various infections, degenerative, proliferative and vascular lesions can be classified into three categories based on the known, presumed or undetermined pathogenesis. The primary lesions are due to HIV infection. The associated lesions are related to direct or indirect sequelae of HIV infection or its treatment. The third category is of lesions of undetermined pathogenesis. The pediatric pathologist plays an important role in the study and management of AIDS by demonstrating new pathologic lesions, by making the etiologic diagnosis of infection in children with AIDS, and by providing clinicopathologic correlation which leads to better understanding of the disease process and its natural history. Diagnosis of neoplastic disorders is also made by the pathologist. There is a dearth of systematic pathologic study of AIDS in children in developing countries. Although no basic differences between pathologic lesions in pediatric AIDS in Western countries, and in developing countries is expected, such a study would lead to better understanding and better management of the disorder as it affects children from the developing countries.

PIP: AIDS in children is a multisystem disease with primary lesions due to HIV infection, associated lesions related to the direct or indirect sequelae of HIV infection or its treatment, and other lesions of undetermined pathogenesis. The pediatric pathologist plays an important role in the study and management of AIDS by demonstrating new pathologic lesions, by making the etiologic diagnosis of infection in children with AIDS, and by providing clinicopathologic correlation leading to a better understanding of the disease process and its natural history. The diagnosis of neoplastic disorders is also made by the pathologist. Few studies have been conducted in developing countries which systematically examine the pathology of AIDS in children. Although no difference is expected between the pathological lesions observed in the West and those in developing countries, a study would nonetheless improve the understanding and management of the disorder as it affects children from developing countries.

Appropriate and inappropriate prescribing of narcotics for ambulatory HIV-positive patients.

OBJECTIVE: To assess the appropriateness of narcotic-prescribing practices in an ambulatory clinic for patients infected with HIV. DESIGN, SETTING, AND PATIENTS: The medical records of 220 (190 HIV-positive) patients, seen in a clinic primarily designed for the long-term follow-up of ambulatory HIV-infected patients and located in an inner-city, public teaching hospital, were retrospectively reviewed to determine the prevalence and appropriateness of prescribing Drug Enforcement Administration schedule 2 narcotics. Appropriateness was based on published guidelines for the use of narcotics in the treatment of cancer patients. MEASUREMENTS AND MAIN RESULTS: The prevalence of narcotic use among the HIV-positive patients was 15%. Narcotics were prescribed for 38% of the patients who died, 33% of those with AIDS [Centers for Disease Control and Prevention (CDC) clinical class C], 4% of those with AIDS-related complex (ARC) (CDC clinical class B), and 5% of asymptomatic HIV-positive patients (CDC clinical class A). None of the HIV-negative patients seen in the clinic received narcotics. Narcotics were more likely to be prescribed for patients with AIDS than for patients with ARC (p < 0.001) or for HIV-positive patients (p < 0.001). For the three CDC clinical classes, there was no significant difference among the proportions of patients receiving narcotics inappropriately (p = 0.108). Among the risk groups, intravenous drug abusers were more likely to be prescribed narcotics inappropriately than were men who were homosexual (p < 0.001) or individuals who were heterosexual (p = 0.013); transfusion recipients were also more likely to be prescribed narcotics inappropriately than were homosexual men (p = 0.026) or heterosexual men or women (p = 0.032). Narcotics were more likely to be prescribed for patients with disseminated histoplasmosis (p = 0.022), Pneumocystis carinii pneumonia (p = 0.001), candidal esophagitis (p = 0.020), Kaposi's sarcoma (p < 0.001), or wasted appearance (p = 0.043). Inappropriate prescriptions were more likely to be given to patients with dementia (p = 0.005) or wasted appearance (p = 0.019). CONCLUSIONS: Physicians tend to prescribe narcotics inappropriately to patients known to have previously abused drugs and to those who appear wasted or have dementia. Physicians have a duty to prescribe narcotics appropriately as guided by recognized medical indications and the patients' views concerning their current medical needs.

Hematologic manifestations of infection with the human immunodeficiency virus.

Selective tropism of human immunodeficiency virus (HIV) for cells with CD4 receptors and especially for TH lymphocytes--key cells in hematopoiesis--has from the clinico-biologic point of view a great many hematologic manifestations of which knowledge is essential for a good diagnosis and treatment as well as for a judicious estimation of prognosis. Thus the study presents the hematologic entities specifically associated with HIV infection (such as ITP, NHML) as well as the hematologic entities associated with HIV infection without presenting a causal relationship with the latter. The study also discusses the quantitative and morphologic changes of peripheral blood and of bone marrow often enlightening for the disease and its complications. An important chapter in the study is devoted to the hematologic changes induced by the HIV infection therapy as well as by the manners of therapeutic approach to the complex hematologic problems raised by the disease.