[Don't miss the primary HIV-infection]. / Die akute HIV-Infektion darf nicht verpasst werden.

Primary HIV-infection (PHI) encompasses the first 6 months after HIV infection. Phylogenetic analysis demonstrates that PHI accounts for approximately half of onward transmissions. Between 25 and 90 % of patients with PHI present with an acute retroviral syndrome, but asymptomatic or atypical manifestations of PHI are substantially underestimated and occur in up to one third. Signs and symptoms include fever, fatigue, sore throat, exanthema, lymphadenopathy and diarrhea. The unspecific nature of these signs and symptoms preclude a reliable clinical diagnosis. Therefore, an HIV test should be performed routinely amongst persons at risk. The 4th generation Combo test detects PHI in most cases within two to three weeks after infection and should be used for screening. A routine use of the HIV-specific PCR for screening purposes is discouraged. During the last decade early antiretroviral therapy has been recognized as beneficial for patients with PHI and therefore is recommended.

Prevalence of HIV-1 infection among patients with leprosy and pulmonary tuberculosis in a semi-arid region, Nigeria.

Much evidence exists on pulmonary tuberculosis (PTB) as a presenting feature of HIV infection or AIDS-related complex, while few reports exist of a direct association between HIV infection and leprosy. This study was carried out to see whether or not an association between leprosy and HIV infection existed, similar to that of PTB in the region of Maiduguri, Nigeria. Of 105 patients with leprosy, 11(10.5%) were positive for HIV antibody. Of 58 patients with suspected PTB, 11(19%) were positive for HIV antibody. Twenty-seven (47%) of the 58 had active PTB, with results of sputum smear and culture positive for mycobacterium, and six of these (22.2%) were also positive for HIV antibody. Odds ratios (OR) obtained by conditional logistic regression (matched) analysis were 3.52 (95%, CI 1.03-12.07) and 2.53 (95%, CI 1.04-6.15) for association between HIV-1 and PTB and leprosy, respectively. HIV infection was more prevalent among leprosy patients aged under 30 years, OR = 4.25 (95%, CI 1.25-14.42). The prevalence of HIV-1 infection was at borderline significance, higher in PTB and leprosy patients than in blood donors, Fisher's exact test (two-tailed) p = 0.07 and p = 0.05, respectively.

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.

The relationship of psychological variables and disease progression among long-term HIV-infected men.

This study investigated the contribution of psychological factors to disease progression among long-term HIV-1 infected gay men. Participants completed self-report measures including coping strategies, life events, social support, personality and psychological morbidity and were followed clinically for up to 30 months. Cox proportional hazards survival analyses were carried out to CD4<200 x 106/1 and AIDS-related complex (ARC) or AIDS diagnosis controlling for viral load, antiretroviral drug use and CD4 count. Only acceptance coping was a significant predictor of time to ARC or AIDS diagnosis: the risk of ARC or AIDS was almost 5 times greater for those scoring within the lowest tertile compared with those scoring in the highest tertile (HR=4.7, 95% CI 1.8-12.3).

Risk factors for tuberculosis among human immunodeficiency virus-infected persons. A case-control study in Belo Horizonte, Minas Gerais, Brazil (1985-1996).

The objective of this study was to identify tuberculosis risk factors and possible surrogate markers among human immunodeficiency virus (HIV)-infected persons. A retrospective case-control study was carried out at the HIV outpatient clinic of the Universidade Federal de Minas Gerais in Belo Horizonte. We reviewed the demographic, social-economical and medical data of 477 HIV-infected individuals evaluated from 1985 to 1996. The variables were submitted to an univariate and stratified analysis. Aids related complex (ARC), past history of pneumonia, past history of hospitalization, CD4 count and no antiretroviral use were identified as possible effect modifiers and confounding variables, and were submitted to logistic regression analysis by the stepwise method. ARC had an odds ratio (OR) of 3.5 (CI 95% - 1.2-10.8) for tuberculosis development. Past history of pneumonia (OR 1.7 - CI 95% 0.6-5.2) and the CD4 count (OR 0.4 - CI 0. 2-1.2) had no statistical significance. These results show that ARC is an important clinical surrogate for tuberculosis in HIV-infected patients. Despite the need of confirmation in future studies, these results suggest that the ideal moment for tuberculosis chemoprophylaxis could be previous to the introduction of antiretroviral treatment or even just after the diagnosis of HIV infection.

Relationship between viral load in blood, cerebrospinal fluid, brain tissue and isolated microglia with neurological disease in macaques infected with different strains of SIV.

The role of the viral burden in the brain for the pathogenesis of human immunodeficiency virus-associated neurological disorders is still unclear. To address this issue, we have quantified the viral load in plasma, cerebrospinal fluid (CSF) and brain tissue of macaques infected with simian immunodeficiency virus (SIV). We discovered that the viral strain used for infection determines the replicative capacity in microglial cells as well as the extent of neuropathological lesions and the occurrence of neurological symptoms. Moreover, the viral load in the brain parenchyma correlated with the development of overt neurological disease whereas the one in plasma did not. By comparing the viral load in three different compartments, we demonstrated that the viral burden in the CSF is influenced both by the viral replication in the periphery as well as in the brain parenchyma. According to these results, it is not the absolute amount of viral load in the CSF but rather the viral antigen contributed by the viral production within the brain which correlates with the development of neurological disease. In longitudinal studies, we observed that this autochthonous virus production, as evidenced by a ratio of the viral load in CSF to the one in plasma, takes place for a prolonged period of time before overt neurological signs are manifested. This finding suggests that this ratio could be used as a prognostic marker for immunodeficiency virus-induced neurological disease.

Risk Factors for tuberculosis among human immunodeficiency virus-infected persons. A case-control study in Belo Horizonte, Minas Gerais, Brazil (1985-1996)

The objective of this study was to identify tuberculosis risk factors and possible surrogate markers among human immunodeficiency virus (HIV)-infected persons. A retrospective case-control study was carried out at the HIV outpatient clinic of the Universidade Federal de Minas Gerais in Belo Horizonte. We reviewed the demographic, social-economical and medical data of 477 HIV-infected individuals evaluated from 1985 to 1996. The variables were submitted to an univariate and stratified analysis. Aids related complex (ARC), past history of pneumonia, past history of hospitalization, CD4 count and no antiretroviral use were identified as possible effect modifiers and confounding variables, and were submitted to logistic regression analysis by the stepwise method. ARC had an odds ratio (OR) of 3.5 (CI 95 per cent - 1.2-10.8) for tuberculosis development. Past history of pneumonia (OR 1.7 - CI 95 0.6-5.2) and the CD4 count (OR 0.4 - CI 0.2-1.2) had no statistical significance. These results show that ARC is an important clinical surrogate for tuberculosis in HIV-infected patients. Despite the need of confirmation in future studies, these results suggest that the ideal moment for tuberculosis chemoprophylaxis could be previous to the introduction of antiretroviral treatment or even just after the diagnosis of HIV infection.

Orofacial disease: update for the dental clinical team: 11. Cervical lymphadenopathy.

By far the most common causes of lumps in the neck are swollen lymph nodes. The most common cause of cervical lymphadenopathy is infection in the area of drainage (virtually anywhere in the head and neck). Most frequent of all is an enlarged jugulodigastric (tonsillar) lymph node, inflamed secondary to a viral upper respiratory tract infection. Enlarged cervical lymph nodes may also be a manifestation of systemic infection (e.g. HIV/AIDS), or related to malignant disease in the drainage area (e.g. carcinoma) or elsewhere (e.g. leukaemia or lymphoma). These and less common causes are discussed in this, the last article in this series.

[Intraparotid lymphoepithelial cysts and the human immunodeficiency virus]. / Quistes linfoepiteliales intraparotídeos y virus de la inmunodeficiencia humana.

Lymphoepithelial lesions in the parotid gland are an uncommon benign entity, with an increasing incidence since 1980 due to the involvement of HIV infected patients. We report here three cases recorded at the ORL service in Viladecans Hospital, with cytologic investigation with echo-guided fine needle aspiration. A discussion follows on the theory that these cysts are part, together with persistent polyadenopathies, of the immune response to HIV infection. The course towards malignancy is exceptional and conservative management is most accepted.

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.

Detection of human immunodeficiency virus-1 DNA, RNA and antibody, and occult blood in inactivated saliva: availability of the filter paper disk method.

Eighty three samples of saliva were collected from 60 subjects who were asymptomatic carriers of AIDS related complex (ARC) and AIDS. They included hemophiliacs, homosexuals and heterosexuals. Occult blood, human immunodeficiency virus-1 (HIV-1) antibody and DNA were assayed after heat treatment at 56 degrees C by strip method, particle agglutination and polymerase chain reaction (PCR), respectively. HIV-1 RNA was assayed by reverse transcription (RT)-PCR after heat treatment at 56 degrees C or 90 degrees C, or after application to filter paper disks with drying and heat treatment at 90 degrees C. Positive results were found in 53% (occult blood), 73% (HIV-1 antibody), 23% (HIV-1 DNA, 56 degrees C), 34% (HIV-1 RNA, 56 degrees C), 33% (HIV-1 RNA, 90 degrees C) and 25% (HIV-1 RNA, 90 degrees C, filter paper disk), respectively. The results did not depend on the stage of the disease or the route of infection. Other studies have reported the use of the filter paper disk method to detect antibodies against HIV and HIV genomes in blood samples. The present study demonstrated that it could also be used for the detection of HIV genomes in saliva samples.

The increased burden of tuberculous lymphadenitis in central Africa: lymph node biopsies in Lusaka, Zambia, 1981 and and 1990.

In order to assess the effect of the HIV epidemic on lymph node biopsies in Central Africa, HIV-1 serology was tested on a cohort of patients undergoing node biopsy in Lusaka in 1990, and the histology of all lymph nodes biopsied in Lusaka in 1981 and 1990 was reviewed. One hundred and eighteen lymph nodes were biopsied in 1981 and 351 in 1990. Cases of tuberculous lymphadenitis increased from 52 (31 children and 21 adults) in 1981 to 186 (22 children, 160 adults, four patients unknown age) in 1990. Sixty-eight of 77 adults (88%) with tuberculous lymphadenitis in 1990 tested HIV-positive. Cases of histology suspicious of primary HIV lymphadenopathy and nodal Kaposi's disease also increased. Cases of malignant lymphadenopathy and overall number of surgical biopsies remained equivalent for 1981 and 1990. The study concludes that the HIV epidemic has led to a large increase in diagnostic lymph node biopsies in Lusaka, mostly through an increase in HIV-related adult tuberculous lymphadenitis.

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

Clinical evaluation of Amplicor HIV-1 test for detection of human immunodeficiency virus type 1 proviral DNA in peripheral blood mononuclear cells.

We report here the clinical evaluation of Amplicor polymerase chain reaction (PCR) assay for the detection of the human immunodeficiency virus type 1 (HIV-1) in peripheral blood mononuclear cells (PBMCs). Results obtained with Amplicor HIV-1 test were compared to serological status and a standard PCR assay using SK38/SK39 and oligomer hybridization with SK19. A panel of 208 well-characterized specimens was analyzed, including PBMC lysates from 47 antibody-negative high-risk individuals, eight antibody-negative low-risk subjects, two subjects with acute retroviral disease, 35 asymptomatic seropositive subjects (59 samples) with CD4 counts > 400/mm3, 31 patients (46 samples) with AIDS-related complex (ARC), 30 patients (40 specimens) with AIDS, and six seropositive patients with unknown clinical status. Amplicor demonstrated a specificity of 100% and a sensitivity of 98.7%. Of the two false-negative samples with Amplicor, one was negative for beta-globin amplification, whereas a dilution of the other sample turned positive for HIV-1. Inhibitors of Taq polymerase were thus believed to be responsible for the negative results. This study demonstrates that commercialized nonisotopic PCR assays reach adequate levels of sensitivity and specificity for diagnosis of HIV-1 infection and could be considered in clinical situations in which serology is not helpful.

[HIV infection in servicemen (the work experience of a specialized hospital department)]. / VICh-infektsiia u voennosluzhashchikh (po opytu raboty spetsializirovannogo otdeleniia gospitalia).

PIP: In 1987, under the aegis of the governmental campaign against AIDS, military hospitals in Moscow established a department for the diagnosis and treatment of HIV-infected and AIDS patients among the military and their families. Clinical and laboratory examinations showed that 96 people out of 130 examined either were positive for HIV or were suffering from symptoms of AIDS. 77 were military from African countries, 15 from Russia, and 4 were their family members. Out of these 15 patients from Russia, 8 had been infected via sexual intercourse: 1 via homosexual and 7 via heterosexual intercourse. In 10 patients, HIV infection had been diagnosed 1-2 years after being infected, in 3 patients 3-6 years later, and in 2 patients more than 10 years afterwards. Every other patient exhibited symptoms of the second stage of AIDS: persistent generalized lymphadenopathy. 4 patients had lost body weight, 8 patients had prolonged fever, 2 had diarrhea, 4 had various dermatological symptoms, 4 had opportunistic infections, 5 had other infections (viral hepatitis, acute pneumonia, and salmonella), and 3 patients had other ailments (paranephritis, salpingoophoritis, endometritis, purulent otitis). The cases of 3 patients are described in detail. 4 out of 5 patients who were transferred to this special department demonstrated severe inflammatory processes as a consequence of their HIV-infection: paranephritis, pneumonia, purulent cholangitis, and salmonella. All patients also evinced damage to their immune system: the reduction of T-lymphocyte count and T-helper cells and the reduction of the index of T-helper/T-suppressor cells (to 0.31 from the norm of 1.1-2.2). The treatment of AIDS patients consisted of the use of azidothimidine, which inhibits the activity of reverse transcriptase; the stimulation of the immune system by means of timalin (10 mg for 5 days im); and treating secondary fungal infections (up to 8 million IU of nystatin/day, up to 4 million IU of levorin, and up to 200 mg of diflucan).^ieng

Predictive ability of acute physiology and chronic health evaluation II scoring applied to human immunodeficiency virus-positive patients.

OBJECTIVE: To evaluate the predictive ability of the Acute Physiology and Chronic Health Evaluation II (APACHE II) prognostic scoring system when applied to human immunodeficiency virus (HIV) seropositive patients in the medical intensive care unit (ICU). DESIGN: A retrospective chart review. SETTING: An urban university hospital serving the local community population and also functioning as a tertiary care referral center. PATIENTS: All HIV-positive patients who were discharged from the Yale-New Haven Hospital medical ICU between October 1, 1986 and September 30, 1991. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: APACHE II scoring significantly underestimated the mortality rate in our patient population (n = 161) (35.5% estimated vs. 44.1% observed, p < .025). When patients were evaluated according to total lymphocyte count, APACHE II scores accurately predicted the mortality rate of all patients with a total lymphocyte count of > or = 201 cells/mm3 (n = 112) (32.6% estimated vs. 33.0% observed). However, APACHE II scoring significantly underestimated the mortality rate in the group of patients with a total lymphocyte count of < or = 200 cells/mm3 (n = 36) (44.2% expected vs. 61.1% observed, p < .05), particularly those patients with pneumonia or sepsis (n = 14) (50.5% expected vs. 85.7% observed, p < .01). CONCLUSION: APACHE II scoring significantly underestimates mortality risk in HIV-positive patients admitted to the medical ICU with a total lymphocyte count of < or = 200 cells/mm3. This finding is particularly true regarding patients admitted due to pneumonia or sepsis.

Onset of clinical signs in children with HIV-1 perinatal infection. Italian Register for HIV Infection in Children.

OBJECTIVE: To investigate the timing of onset of each clinical sign in infants and children with HIV-1 perinatal infection. DESIGN AND METHODS: A total of 200 HIV-1-infected children followed-up from birth were studied. Failure and conditional probabilities were estimated by the Kaplan-Meier product-limit method. Cox proportional hazard analysis was used to evaluate independently associated factors. Results of 934 seroreverters were used to calculate reference values of CD4+ cell counts and predictivity of early signs. RESULTS: Median age at the onset of any sign was 5.2 months (range, 0.03-56 months). The probability of remaining asymptomatic was 19% [95% confidence interval (CI), 14-25.1] at 12 months and 6.1% (95% CI, 2.6-11.7) at 5 years. Lymphadenopathy (69.5%), splenomegaly (62.4%) and hepatomegaly (58.4%) were the most common signs in the first year of life. Peculiar to the first year of life (compared with subsequent ages) was the onset of primary HIV-1 hepatitis and diarrhoea (rate ratios, 23.3 and 15.2, respectively). When CD4+ cell counts in the asymptomatic stage (age, 2 months; range, 0.03-5.9 months) were below rather than above the fifth percentile in seroreverters, onset of signs was earlier [3 range, 0.03-19) versus 5 (range, 0.03-56) months]. Children manifesting signs before the 5.2-month breakpoint had a lower survival rate [74% (range, 65.9-82%) at 12 months and 45% (range, 32.9-57%) at 5 years] than children manifesting signs later [98% (range, 92.2-100%) at 12 months and 74% (range, 60.3-87.7%) at 5 years]. Children whose birthweight was < or = 2400 g had an earlier onset (24 months; range, 1-57 months) of severe conditions than children with higher birthweight (71 months; range, 1-71 months). Development of lymphadenopathy or hepatosplenomegaly within 3 months of life were reliable indicators of infection. CONCLUSIONS: This study describes the sequence of onset of signs in perinatal HIV-1 infection. Infection is shown to progress faster than in adults and in a different manner. Low birthweight, early decreased CD4+ cell counts, and early onset of signs are predictive of rapid progression.