Pruritic skin lesions. A common initial presentation of acquired immunodeficiency syndrome.

During July 1983 to December 1984, we observed that 62 (46%) of 134 Haitian patients with acquired immunodeficiency syndrome had intensely pruritic eruptions for which neither specific causative nor categoric diagnoses could be established. These lesions were a presenting manifestation of acquired immunodeficiency syndrome in 79% of the patients and appeared a mean of 8 months before the diagnosis of either Kaposi's sarcoma or opportunistic infection. Lesions included erythematous round macules, papules, or nodules that first appeared on the extensor surface of the arms, but subsequently involved the legs, trunk, and face. Histologically, the lesions were characterized by varying degrees of mixed (predominantly eosinophilic) perivascular and perifollicular inflammatory cell infiltrates of the dermis. The lesions did not respond to any therapeutic regimens used and usually persisted throughout the acquired immunodeficiency syndrome illness. Demographic and laboratory data did not distinguish these patients from those without pruritic skin lesions.

Risk factors associated with AIDS in Haiti.

A total of 121 acquired immunodeficiency syndrome (AIDS) patients diagnosed in Haiti were studied between June 1979 and December 1983. Risk factors were identified in 65% of 34 patients evaluated in a standardized manner since July 1983 and included: bisexuality, 38%; blood transfusion, 21%; and intravenous drug abuse or a spouse with AIDS, 6%. These risk factors were reported by only 20% of the 85 patients studied between June 1979 and June 1983. AIDS patients also reported more frequent parenteral injections prior to the onset of their illness than control subjects (e.g., siblings, friends, sexual partners). Heterosexual activity among female AIDS patients was also greater than in their female controls. It was concluded that, in contrast to the experience reported among Haitians with AIDS in the USA, risk factors are present among most patients with AIDS in Haiti.

The acquired immunodeficiency syndrome in Haiti.

Two hundred twenty-nine patients in Haiti with the acquired immunodeficiency syndrome were studied between 1979 and 1984. The clinical spectrum of the syndrome in Haitians was similar in most aspects to that in patients with the disease in the United States. However, in contrast to findings in the United States, accepted risk factors (bisexuality, blood transfusions, intravenous drug abuse) were identified in only 43% of Haitian patients. Patients in Haiti with and without these risk factors were similar to each other but differed from age- and sex-matched siblings and friends in the number of heterosexual contacts and receipt of intramuscular injections. These latter activities were commoner in patients than in their siblings and friends, and represent potential modes of transmission of infection with the human T-lymphotropic virus type III.

Precocious thymic involution manifest by epithelial injury in the acquired immune deficiency syndrome.

Thymuses from six heterosexual Haitian patients with the acquired immune deficiency syndrome (AIDS) were studied by light microscopy and the findings were compared with those from three control groups. The control groups included 1) five age-matched Haitian hospital patients; 2) ten age- and sex-matched Montreal patients who had died suddenly or had had brief illnesses; and 3) 20 middle-elderly Montreal patients who had experienced chronic, wasting illnesses or prolonged hospitalization. Thymuses from patients with AIDS demonstrated pronounced involution, effacement of the cortex and medulla, marked thymocyte depletion, variable degrees of plasma cell infiltration and fibrosis, and, above all, absence of Hassall's corpuscles. Thymuses from Haitian and Montreal control subjects who had died suddenly or had brief illnesses demonstrated minimal involution and abundant Hassall's corpuscles. Although thymuses from 12 of the chronically ill control subjects demonstrated marked involution, architectural effacement, and absence of Hassall's corpuscles, partial architectural preservation and variable numbers of Hassall's corpuscles were observed in eight of these subjects. Thus, the extent of thymic involution observed in patients with AIDS antedates that incurred with aging and supersedes that induced by sustained stress and inanition. The loss of Hassall's corpuscles in patients with AIDS suggests that the thymic epithelium either incurs a form of injury or undergoes precocious involution during the illness. Whether this lesion is central to the pathogenesis of AIDS or merely a reflection of intense, sustained stress coupled with accelerated physiologic involution is unknown. It is possible that the disappearance of Hassall's corpuscles may indicate important, although as yet cryptic events within the thymic microenvironment in this syndrome.

Acquired immune deficiency syndrome: specific aspects of the disease in Haiti.

PIP: This paper presents clinical data on 41 patients (29 male and 12 female) from Haiti who presented with acquired immunedeficiency syndrome (AIDS). Their mean age was 32 years (range 17-61 years). 4 of thes cases were homosexual or bisexual; none was an illicit drug user or a hemophiliac. In addition, 3 of the female patients had sexual contact with a male partner with AIDS. 4 patients had received blood transfusions before their illness. The most prominent clinical symptom in this series was chronic diarrhea of 2-33 months' duration, which occurrred in 39 patients (95%). Also reporte were marked weight loss (95%), fatigue (95%), prolonger fever (90%), and nodular or maculopapular skin lesions (54%). Opportunistic infections in this series included oroesophageal candidiasis (88%) and intestinal cryptosporidiosis (31%). Tuberculosis developed in 22% of patients. Immunologic evaluation revealed profoundly depressed T-helper cells and an inverted T-helper/T-suppressor cell ratio. Biologic markers included elevated alpha-1 thymosin and beta-2 microglobulin levels, elevated immune complexes, and the presence of acid-labile interferon. Of interest were differences in the clinical expression of AIDS between this series and cases in the US. The Haitian data suggest a higher incidencs of female cases,a predominance of gastrointestinal symptoms rather than respiratory symptoms and lymphadenopathy, a frequent association with tuberculosis, and a relatively low incidence of Kaposi's sarcoma or P. carinii pneumonia compared to the situation in the US. As in the US, where most AIDS cases are concentrated in New York and California, most AIDS cases in Haiti are found in residents of Port-au-Prince and Carrefour, which are centers for male and female prostitution.^ieng

Characteristics of the acquired immunodeficiency syndrome (AIDS) in Haiti.

To identify the characteristics of the acquired immunodeficiency syndrome (AIDS) as it occurs in Haiti, we studied 61 previously healthy Haitians who had diagnoses of either Kaposi's sarcoma (15), opportunistic infections (45), or both (1) established in Haiti between June 1979 and October 1982. The first cases of Kaposi's sarcoma and opportunistic infections in Haiti were recognized in 1978-1979, a period that coincides with the earliest reports of AIDS in the United States. We do not believe that AIDS existed in Haiti before this period. The types of opportunistic infections and the clinical course in Haitians with Kaposi's sarcoma and opportunistic infections were similar in most aspects to those in patients with AIDS in the United States. The median age of Haitians with Kaposi's sarcoma and opportunistic infections was 32 years, and 85 per cent were men. The interval between diagnosis and death was six months in 80 per cent of the patients. Diarrhea was the most common reason for seeking medical attention in patients with opportunistic infections. Lymphopenia and skin-test anergy were observed in 86 and 100 per cent of patients, respectively. Potential risk factors (bisexual activity or blood transfusions) were identified in 17 per cent of male and 22 per cent of female patients. Demographic information suggests that patients belonged to all socioeconomic strata of Haitian society.

Acquired immunodeficiency syndrome with severe gastrointestinal manifestations in Haiti.

29 patients (19 males and 10 females) in Haiti were diagnosed as having acquired immunodeficiency syndrome. Their clinical presentation was characterised by unexplained chronic diarrhoea, prolonged fever, extreme weight loss, anorexia, and severe infections. The infectious agents included: Candida albicans (27 patients), Mycobacterium tuberculosis (7 patients), Cryptosporidium (11 patients), Pneumocystis carinii (2 patients), cytomegalovirus (4 patients), and herpes virus (3 patients). In 1 woman Kaposi's sarcoma developed during the course of her disease. Immunological studies of 20 patients revealed profound cell-mediated immune deficiency with cutaneous anergy, marked decrease in the number of T helper cells, and impairment of lymphocyte proliferation. 18 patients died.