Detection of hepatitis C virus in an exhumed body identified the origin of a nosocomial transmission that caused multiple fatal diseases.

BACKGROUND: Medico-legal conflicts arise when it is difficult to prove the cause of nosocomial infections. AIM: To report an outbreak of patient-to-patient transmission of hepatitis C virus (HCV) through the repeated use of a multi-dose saline flask during the rinsing of central venous catheters. METHODS: Blood samples were taken from each patient for the comparative analysis of their HCV RNA strains. No samples were available for one patient who died before the investigation started. Despite the known lability of HCV RNA, the body was exhumed four months after burial and postmortem samples were collected. HCV RNA was extracted successfully from liver and spleen samples. Genotyping of all the HCV strains was performed by sequence analysis of the 5'NC untranslated region, the E1 core conserved region and the E1/E2 hypervariable region. FINDINGS: Forensic investigators retraced the route used by two ward nurses, when saline catheter flushes were given to 14 patients with each nurse administering to seven patients. The comparative phylogenetic analysis of all case strains identified the deceased patient as the source of contamination to five patients. CONCLUSIONS: This study highlights the value of sequence analysis as a tool for solving medico-legal conflicts. The High Court of Justice found that a health worker's re-use of a contaminated needle resulted in the nosocomial transmission of HCV.

Stage-dependent induction of prenatal tumors in mice by the Kirsten and Moloney strains of murine sarcoma viruses.

The Moloney (MoMSV) and Kirsten (KiMSV) strains of murine sarcoma viruses are known to induce mesenchymal sarcomas upon infection of newborn rodents. To determine their activity in mouse embryos, 11- to 15-day-pregnant CD-1 mice were laparotomized, and the single implants were inoculated into the abdominal portion of the embryonal body with an average of 15 and 1500 focus-forming particles/g of body weight of the MoMSV and KiMSV viruses, respectively. Another group of less than 1-day-old pups was given a comparable amount of either virus. Tumors appeared in the young within the first few weeks of life with incidences and histological types dependent on the gestational day and the viral strain inoculated. Mixed mesenchymal sarcomas at or near the site of inoculation and vascular tumors of the brain were by far the most frequent neoplasms observed in the newborn. With MoMSV there was an increased incidence of sarcomas with advancing age at treatment, being 0% at 11 days of pregnancy and 96% in newborn (P for trend, less than 0.025). By contrast, KiMSV caused an incidence of sarcomas below 20% throughout (P for trend, greater than 0.05). Brain tumors were identified in the several MoMSV and KiMSV groups, with a peak value of 43% following the inoculation of both viruses into 13- and 15-day-old embryos, respectively. While the total incidence of these tumors was significantly different from controls, no positive trend by day of treatment was found among the MoMSV and KiMSV viruses (P less than 0.05). The tumors were mainly capillary angiomas, but a few cavernous angiomas were also detected. In addition, eight pups which were given injections of both viruses at developmental Days 11 to 13 had tumors of the choroid plexus. In many instances, newborn pups were affected by multiple vascular abnormalities of the brain, including capillary telangiectases and multiple hemorrhagic areas. No such lesions nor tumors at any site were found among the control animals. The present results are important not only because of the evidence that Swiss embryos respond selectively to the carcinogenic effects by murine sarcoma viruses, but also because they offer the opportunity to dissect directly in vivo the mechanisms underlying the stage-related sensitivity of prenatal mice to oncogenic retroviruses.

Improved detection of serum HIV p24 antigen after acid dissociation of immune complexes.

OBJECTIVE: To evaluate an acid pretreatment method designed to dissociate HIV p24 antigen from immune complexes in serum. DESIGN: Patient sera and sera containing experimental immune complexes were quantified for p24 antigen before and after immune complex dissociation (ICD). The clinical application of ICD was assessed in 1328 serum and plasma samples collected from HIV-infected patients. METHODS: Immune complexes were created artificially by mixing purified p24 antigen with antibody-positive sera or a standardized concentration of human antibody to p24. ICD was achieved by incubation of samples with an equal volume of Glycine HCl for 90 min at 37 degrees C followed by neutralization with Tris NaOH. Samples were quantified for p24 antigen using a commercial enzyme-linked immunosorbent assay (ELISA) kit. RESULTS: ICD resulted in significant release of purified antigen from simulated immune complexes in antibody-positive sera. Variation in antigen sequestration and dissociation was related to anti-gag antibody titers. ICD resulted in complete recovery of 500 pg of antigen complexed with human anti-p24 antibody at concentrations up to 2.5 U/ml. In seropositive patients, the mean level of serum antigen was 3.5-fold higher after ICD, and an additional 21% were antigen-positive. CONCLUSIONS: Pretreatment greatly improved antigen detection in HIV-antibody-positive sera by effectively dissociating immune complexes without compromising reactivity of the antigen itself. The treatment also facilitated routine monitoring of patients by revealing fluctuations in serum antigen that were indistinguishable or poorly defined in untreated sera.

Parallel Western blot analysis for HIV-1 and HIV-2 antibodies: absence of HIV-2 infection in Italian subjects at risk for AIDS.

Since HIV-2 infection has been identified in some European countries, we investigated whether HIV-2 infection is present in groups of Italian subjects at risk for AIDS. Our results clearly indicate that the parallel Western blot assay for HIV-1 and HIV-2 antibodies can detect HIV-2 infection, which is presently not epidemic in Italy. Careful examination of the serological data is mandatory before announcing the detection of HIV-2-infected patients.

The effect of treatment with zidovudine with or without acyclovir on HIV p24 antigenaemia in patients with AIDS or AIDS-related complex.

OBJECTIVE: To evaluate changes in serum HIV p24-antigen levels in a subset of patients who participated in a European/Australian double-blind, placebo-controlled trial evaluating the efficacy of zidovudine (250 mg every 6 h) alone or in combination with acyclovir (800 mg every 6 h) in patients with AIDS, AIDS-related complex (ARC) or Kaposi's sarcoma (KS). DESIGN: Double-blind, placebo-controlled randomized clinical trial of less than or equal to 6 months' therapy. SETTING: Samples were obtained from patients attending teaching hospital outpatient clinics in seven European countries and Australia. SUBJECTS: One hundred and ninety-seven HIV-infected patients (60 with AIDS and 137 with ARC or KS). MAIN OUTCOME MEASURES: Serum HIV p24-antigen levels measured using the Abbott HIV solid-phase enzyme immunoassay. RESULTS: Of 76 ARC/KS patients who were initially HIV p24-antigen-positive, one out of 25 randomized to placebo, eight out of 23 to zidovudine and 11 out of 28 to the zidovudine/acyclovir combination became antigen-negative. The proportion of patients who became antigen-negative was significantly higher in both the zidovudine group (P = 0.016) and the zidovudine/acyclovir group (P = 0.004), compared with the placebo group. There were no statistical differences between the zidovudine and the zidovudine/acyclovir groups. During the trial p24-antigen levels in the zidovudine-treated patients reached their minimum after 4-8 weeks of therapy, and tended to increase gradually thereafter. Disease progression occurred irrespective of whether p24-antigen levels declined during therapy. No association between p24-antigen responses to therapy and baseline disease stage, Karnofsky score or baseline CD4 cell count was detectable. CONCLUSION: Acyclovir does not potentiate the effect of zidovudine on p24-antigen levels. Change in antigen level in response to antiviral therapy needs further investigation before it is used as a surrogate marker for clinical efficacy of antiviral therapy.

HIV and HTLV infections in 1305 transfusion-dependent thalassemics in Italy. The COOLEYCARE Cooperative Group.

OBJECTIVE: To evaluate the prevalence of antibodies to HIV-1/2 and HTLV-I/II in 1305 transfusion-dependent beta-thalassemics treated in 36 centres in Italy. DESIGN: Patient serum samples were collected during 1990 and tested in Milan. METHODS: Sera were screened using an enzyme-linked immunosorbent assay (ELISA) containing viral lysate antigens from HIV-1 and HIV-2, and a particle agglutination assay for the detection of antibodies to HTLV-I and HTLV-II. Repeatedly reactive samples were examined by Western blot (WB) assays containing recombinant and viral lysate antigens. Differential diagnosis was finally made by ELISA based on synthetic peptides. RESULTS: Samples from 36 of the 1305 patients (2.76%) contained anti-HIV-1 antibodies. In four patients seroconversion occurred after the implementation of anti-HIV-1 screening in blood donors in Italy (1985). Of the 36 HIV-1-antibody-positive samples, four were HIV-2 [corrected] WB indeterminate. These four samples were negative in assays based on specific synthetic peptides, suggesting cross-reactivity. Anti-HTLV-I antibodies were found in two patients from Sicily and one from Apulia, both southern Italian regions. Anti-HTLV-II antibodies were detected in another patient from Sicily. CONCLUSIONS: Antibodies to HIV-1, HIV-2, HTLV-I and HTLV-II were detected in 2.76, 0, 0.23 and 0.08% of patients, respectively. The residual risk of HIV-1 infection through blood transfusion after the implementation of anti-HIV-1 screening in blood donors in Italy was approximately 1:50,000 blood units; this is based on an approximate number of 200,000 blood units administered to our group of patients during 1986-1990 and the occurrence of four new anti-HIV-1 seroconversions. Seroconversions to HTLV-I/II suggest that these viruses are present in Italian blood donors.

Whole blood collection on filter paper is an effective means of obtaining samples for human immunodeficiency virus antibody assay.

The suitability of collecting whole blood specimens on filter paper disks for HIV antibody assay was evaluated. ELISA and Western blot assay results were in complete agreement for serum and blood spot disk samples. Sensitivity of the two methods was tested using diluted whole blood and sera from HIV-seropositive individuals. Results demonstrate that ELISA and Western blot assays performed on punched-out disks of the blood-impregnated papers had the same sensitivities as those obtained with serum samples. This study suggests that whole blood collection on filter paper can be effectively substituted for serum sampling in HIV antibody screening programs.

Deficiency of the autologous mixed lymphocyte reactions of non-T/T and T/T type in intravenous drug abusers infected by the human immunodeficiency virus (HIV).

In the present study both responsiveness and stimulatory capacity in autologous mixed lymphocyte reactions (AMLRs) of non-T/T and T/T type, as well as in allogeneic mixed lymphocyte reaction (MLR), were evaluated in 30 intravenous drug abusers (IDAs) infected by the human immunodeficiency virus (HIV) and in 10 HIV-negative IDAs. The production of interleukin 2 (IL2), and the expression of HLA Class II antigens and IL2 receptors by PHA-activated T lymphocytes were also evaluated. A severe impairment of both responsiveness and stimulatory capacity in MLR and AMLRs was found in the HIV-positive IDAs and not in the HIV-negative IDAs. The HIV-positive IDAs showed also a defective expression of HLA Class II antigens, whereas the IL2 production and the IL2 receptor expression were in the normal range. The present data are consistent with similar observations in male homosexuals with AIDS-related complex and confirm that the HIV infection induces a broad spectrum of immunological abnormalities leading to a progressive derangement of the immunocompetence.

Synthetic peptides in HIV antibody screening and typing.

We have defined continuous native epitopes of HIV proteins by using a systematic epitope-scanning technology. We have demonstrated that there is a highly immunoreactive continuous native epitope region in the transmembrane protein gp41 of HIV-1 that is immunoreactive with all studied HIV-1 antibody-positive sera. The corresponding region in HIV-2 gp34 behaves similarly. There is a clear difference, however, between HIV type 1 and type 2 transmembrane proteins in the number of highly immunoreactive regions, when presented properly as synthetic antigens in solid-phase EIA, can provide tests unusually suitable for early and reliable diagnosis of HIV-1 and HIV-2 infections and for type-specific distinction of the two types of HIV infections.

PIP: This article reviews the basic method used to define native epitopes from transmembrane proteins and the function of synthetic peptides in HIV screening and typing. Identification of continuous native epitopes from structural protein sequences of HIV-1 and HIV-2 involves the use of systematic scanning epitope technology. Scanning profiles of these two types of HIV demonstrated that there is a highly immunoreactive continuous native epitope region in the transmembrane protein gp41 of HIV-1 as well as in the corresponding region in HV-2 gp34. However, the number of highly immunoreactive regions differs in the structural proteins of the two types of HIV infections. These highly immunoreactive regions, when presented accurately as synthetic antigens in solid-phase enzyme immunoassay, can provide tests that are remarkably appropriate for the early and reliable diagnosis and type-specification of HIV-1 and HIV-2 infections.

A novel and innovative quantitative kinetic software for virological colorimetric assays.

This study addresses the limited range of quantification with colorimetric assays (ELISA) starting from the analysis of color production in a reference external curve. An automatic ELISA management software, designated Quanti-Kin Detection System (QKDS) is described, which retains the sensitivity of the end-point reading and extends the dynamic range up to five logarithms with mathematical interpretation of color production. The QKDS software is a generic system suitable for different types of ELISA with substrate incubation at room temperature, does not require dedicated instruments, performs accurate quantification (including assay quality control) and has a user friendly interface. Specific applications were developed for three types of analytes: antibodies, viral antigens and nucleic acids. Data are presented on three representative QKDS applications to HIV antibodies, p24 antigen and proviral DNA kits. The precision of quantification is strictly correlated with the precision of the kit; however, for almost all samples with known analyte amount, the error percentage was below 10%, only for two cases in quantification of HIV proviral DNA the error percentage was around 25%. The necessity for a wide quantification range has been demonstrated by measuring clinical samples, which showed a distribution in all possible quantification ranges for all kits.

Monitoring antiretroviral activity using ICDp24 and CD4 counts in HIV infection.

The fluctuations of HIV-1 p24 antigen concentration have been monitored in the follow-up of 118 subjects in different clinical stages and compared to their CD4 cell count; 104 patients received antiretroviral therapy. Persistent (65%) or sporadic (28%) antigenaemia has been detected in most patients in different clinical stages. The variations of the p24 Ag level are significantly correlated with the CD4 cell count and therapy administration (P = 0.0001). In patients with relatively conserved immune function (CDC II and III), antiretroviral therapy shows the best efficacy and can be efficiently monitored by p24 and CD4 surrogate markers. The data here suggest that although the informative value of p24 Ag is not representative of an AIDS-defining event, it can be used as a short-term and relatively inexpensive virological marker of antiviral activity in vivo, to support the routine management of patients.

Drug resistance testing in PBMCs of HIV infected patients.

HIV infected patients are considered a sort of reservoir having different genetically distinct viral variants (quasispecies), that evolve from the starting virus inoculum. Frequently, during replication, HIV can generate nucleotide differences in the new viral population; such genetic changes may be uninfluential in viral "fitness" (replication capacity) or give the virus some advantages under a selective pressure, due to immune response or drug treatment. The use of potent combination therapy for the treatment of HIV infections has certainly improved the "quality of life" for patients, decreasing the viral load in the plasma (HIV RNA). In our study, we investigated whether detection of drug resistance-related mutations was possible in circulating PBMCs, which represent a sort of genetic archive of viral drug resistances, when the levels of viral RNA were reduced to below 400 or 50 copies/ml, since, generally, plasma samples with more than 1,000 copies/ml of HIV RNA are needed to generate some results. The study was successfully performed sequencing proviral HIV DNA in PBMCs from 32 samples belonging to 25 patients, using a new modified protocol, that showed a good reproduciblity and very interesting data, also in patients with low or without circulating HIV RNA levels.

Perinatal transmission of HIV-2 infection in malnourished children in Guinea Bissau.

Since there have been a few reports of pediatric HIV-2 infection. We therefore investigated the perinatal transmission of HIV-2 in 147 malnourished and 164 well-nourished children attending a health center in the northern part of Guinea Bissau. Specific HIV-2 antibodies were detected in 17 mothers and in 2 malnourished children, one of them with pediatric AIDS. This study demonstrates that mother to child transmission of HIV-2 infection occurs in Guinea Bissau and suggests that there is an increased likelihood of detecting HIV-2 infection in malnourished children. The high seroprevalence of HIV-2 in a rural population without known risk factors may represent a hidden threat to mother/child health.

PIP: The authors tested blood samples of 147 malnourished children, 164 well-nourished children, and their 205 mothers with the goal of exploring the extent to which HIV-1 and HIV-2 were being transmitted perinatally in Guinea-Bissau. The children were attending a health center in the northern part of Guinea-Bissau and had been breast fed from birth to 20 months of age or longer. Analysis found antibodies to HIV-2 in 17 mothers and 2 malnourished children, one with pediatric AIDS. These findings demonstrate the occurrence of mother-to-child transmission of HIV-2 in the country and suggest a possible increased likelihood of detecting HIV-2 infection in malnourished children. The high seroprevalence of HIV-2 infection in a rural population without known risk factors may represent a hidden threat to the health of mothers and children.

A qualitative process theory based model of the HIV-1 virus-cell interaction.

We present a qualitative model of the interaction between the HIV-1 virus and the human cell, based on qualitative process theory. This model takes into account a previous qualitative model of the cell growth. The model presented here can be regarded as a first step for setting up a comprehensive model of the HIV-1 virus-cell interaction in which the possible points where a drug can attack the virus are evident. The first simulation trials indicate that the presented model reproduces (even though in a simplified way) the features of the real behaviour that have been considered in the modelling phase. Although our simulation is limited in the knowledge it expresses, it still gives a stimulating opportunity for the evaluation of the criteria chosen as discriminant in the interaction between virus and cell.

Application of neural networks to the follow-up of AIDS patients.

The present work aims to obtain groups of patients with similar profiles of p24 antigen concentration and of CD4+ cell counts. These two markers were chosen because their evaluation represents a significant step in the clinical follow up of HIV-1 infected subjects. The classifications were obtained by a Kohonen neural net trained in three ways: with p24 antigen profiles only, with CD4+ cell count profiles only and with both sets of profiles. The results show that the clustering fashion of the two parameters closely resembles the clustering fashion of CD4+ only rather than the one of p24Ag, both with reference to cluster formation and with reference to distance among clusters.

ArchAIDS connects a clinical department and a virological laboratory to automatize the follow up of AIDS patients.

A communication system for the automation of the follow up of AIDS patients set up by DIST at the Molecular Virology Unit in the Advanced Biotechnology Centre of Genova and at the Department of Internal Medicine of the Medical School of Genova is presented. This system includes a distributed database to store both clinical and virological data and a set of procedures to transfer patient data with a complete respect of requirements about completeness and privacy.

Urinary JCV-DNA testing during natalizumab treatment may increase accuracy of PML risk stratification.

The risk of progressive multifocal leukoencephalopathy (PML) in patients treated with natalizumab for multiple sclerosis (MS) is a serious concern. The presence of anti-JC virus antibodies is a risk factor for PML development, but 2.5 % of the patients result falsely-negative, while the prognostic relevance of testing JCV-DNA in biological fluids of treated patients is debated. Aim of this work was to evaluate the utility of testing JCV-DNA, together with anti-JCV antibodies, in biological samples of treated patients as a tool for PML risk stratification. 126 subjects from 5 MS Centers in Italy were included in the study. We performed a cross-sectional study in 63 patients testing JCV-DNA in blood, peripheral blood cells and urine. We longitudinally assessed the presence of JCV-DNA in a cohort of 33 subjects, one of which developed PML. We could test retrospectively serum samples from another PML case occurred during natalizumab therapy. Anti-JCV antibodies and urinary JCV-DNA were both tested in 73 patients. No changes in JCV-DNA status occurred during natalizumab treatment. The subject who developed PML in the longitudinal cohort had detectable JCV-DNA in urine at all time-points while serum or blood from both PML patients were always negative before the onset of disease and, in one case, after. Four subjects with JCV-DNA in urine and undetectable anti-JCV antibodies were retested for anti-JCV antibodies and three out of four resulted positive. In conclusion, testing JCV-DNA in urine is complementary to testing anti-JCV antibodies in identifying patients at risk of PML.

Rapid diagnosis of tuberculosis and multidrug resistance with the microscopic observation drug susceptibility assay in Ecuador.

A collaborative project was established between the Alli Causai Foundation in Ambato, Ecuador, and the University of Genoa, Italy, to introduce the microscopic observation drug susceptibility (MODS) assay for the rapid identification of Mycobacterium tuberculosis in Ecuador. A total of 507 samples were evaluated during a 10-month period, and DNA was extracted from each isolate and sent to Genoa for confirmatory molecular analysis. M. tuberculosis was identified in 45 samples by MODS, and drug resistance was observed in approximately 21% of the isolates, with four multidrug-resistant strains detected in two patients.