Cytomegalovirus infection in women attending a sexually transmitted disease clinic

To evaluate prospectively the relationship between current and past sexual practices and seroprevalence of cytomegalovirus (CMV) in adult women, 1481 women (1101 white, 301 black, 79 other) attending a sexually transmitted disease clinic underwent a standardized interview and genital examination. CMV seroprevalence was higher in black (78%) than in white (59%) women. In logistic regression models that adjusted for age and years of education, CMV seropositivity in white women was associated with younger sexual debut (P = .001), more lifetime sex partners (P = .025), recent new partner(s) (P = .003), and parity (P = .002), and was inversely associated with use of barrier contraception (P = .006). In black women, after adjustment for demographic characteristics, CMV antibody was associated with greater numbers of recent sex partners (P = .007), new sex partners (P = .04), and with cervical infection with Chlamydia trachomatis (P = .05). This study confirms that sexual activity is an important determinant of CMV infection in both white and black women; however, the relative contributions of sexual and nonsexual transmission of CMV apparently vary and require further investigation.

The safety and efficacy of zidovudine (AZT) in the treatment of subjects with mildly symptomatic human immunodeficiency virus type 1 (HIV) infection. A double-blind, placebo-controlled trial. The AIDS Clinical Trials Group

OBJECTIVE

To evaluate the efficacy and safety of zidovudine early in the treatment of human immunodeficiency virus type 1 (HIV) infection.

DESIGN

A double-blind, randomized, placebo-controlled trial with subject stratification by pretreatment CD4 T lymphocyte counts.

SETTING

Multicenter trial at AIDS Clinical Trial units.

SUBJECTS

Seven hundred eleven subjects with mildly symptomatic HIV infection.

INTERVENTION

Three hundred fifty-one subjects were assigned to placebo and 360 to zidovudine, 200 mg orally every 4 hours. The median duration of follow-up was 11 months.

MEASUREMENTS AND MAIN RESULTS

Fifty-one subjects developed the acquired immunodeficiency syndrome (AIDS), advanced AIDS-related complex, or death as a first critical event. For the stratum of subjects with more than 200 but less than 500 CD4 T lymphocytes/mm3 before treatment, 34 events occurred in placebo recipients and 12 in zidovudine recipients (P = 0.0002; relative risk [RR] estimate, 3.23 [95% CI, 1.67 to 6.24]). For the stratum of subjects with 500 to 799 CD4 T lymphocytes/mm3 before treatment, 2 events occurred in placebo recipients and 3 in zidovudine recipients. Candidiasis at study entry independently increased the risk for having an event (P = 0.005; RR estimate, 2.3 [95% CI, 1.29 to 4.12]); HIV antigenemia at study entry also increased this risk (P = 0.01; RR estimate, 2.1 [95% CI, 1.2 to 3.8]). Significant differences between the treatment groups in CD4 T-lymphocyte counts occurred in subjects with more than 200 but less than 500 CD4 T lymphocytes/mm3 after 4 weeks of therapy (P = 0.002). Differences persisted through week 52. Less prominent changes occurred in subjects with 500 or more CD4 T lymphocytes/mm3. Serum levels of HIV antigen decreased significantly in zidovudine recipients. Serious anemia and neutropenia occurred in 5% and 4% of zidovudine recipients, respectively, and in 0% and 1% of placebo recipients, respectively.

CONCLUSION

Zidovudine delayed progression of HIV disease and produced little toxicity in subjects with mildly symptomatic HIV disease and less than 500 CD4 T lymphocytes/mm3.

The role of age-dependent behaviors in the retention of an approach-avoidance response in preweanling rats

The role of age-dependent responses in infantile amnesia was examined. Ten- and 15-day old rats were trained in an approach-mother, avoid-shock paradigm and tested for retention immediately and after a 1-day delay. Ten-day-old rats were also tested after 6 days. Half of all the pups received a shock reactivation treatment before the delayed retention tests and half did not. In comparison to immediate retention, performance declined after 1 day but was reinstated by reactivation. A similar reactivation effect was found on 10-day-old pups tested after 6 days except that a different age-specific response was substituted for the original behavior. These effects were not found in untrained controls. These data show that learning may be expressed differently when acquisition and retention are measured at different developmental stages, a pattern that may be mistaken for infantile amnesia.

Pharmacokinetics of oral zidovudine (azidothymidine) in patients with AIDS when administered with and without a high-fat meal

Zidovudine is the only drug currently approved for the treatment of HIV infection. The present recommended doses found to be efficacious in patients with AIDS (200 mg every 4 h) achieve serum zidovudine concentrations greater than 0.267 micrograms/ml (1 mumol/l). Since patients often take zidovudine with food, we have investigated the effect of a liquid high-fat meal on the rate of absorption of zidovudine and on the peak serum concentration achieved. Eight patients received their usual dose of zidovudine (100 mg or 250 mg), with and without a liquid high-fat meal, on two separate study days, in a randomized crossover fashion. Blood and urine samples were collected over a 4-h period. In the absence of food, zidovudine is rapidly absorbed; the time to reach maximal serum concentration (Tmax) was 0.68 (+/- 0.25) h and the mean peak serum concentration (Cmax) achieved was 0.49 (+/- 0.3) micrograms/ml (dose normalized to 100 mg dose). In the presence of a high-fat meal, Tmax was significantly prolonged [1.95 (+/- 0.69) h; P less than 0.05] and the Cmax reduced [0.245 (+/- 0.12) micrograms/ml; P less than 0.05]. This demonstrates that to achieve maximal zidovudine serum concentrations, patients should take this medication on an empty stomach.

Plasma viremia in human immunodeficiency virus infection

To determine which markers of human immunodeficiency virus type 1 (HIV) replication correlate most closely with progressive disease, we compared the following: (1) the frequency of isolation of HIV from peripheral-blood mononuclear cells (PBMC), (2) the frequency of isolation of the virus from cell-free plasma (plasma viremia), (3) the presence and titer of p24 antigen in plasma, and (4) the presence and titer of antibody to p24 antigen. We studied 213 persons who were positive for HIV antibody and 71 who were negative. HIV was isolated from PBMC from 207 of the 213 antibody-positive patients (97 percent), regardless of the clinical stage of the infection. Plasma viremia, in contrast, was correlated with the clinical stage of the infection. It was detected in 11 of 48 patients (23 percent) with asymptomatic infection, 32 of 71 (45 percent) in Class IVa of the Centers for Disease Control (those with AIDS-related complex), and 75 of 92 (82 percent) in Class IVc (those with AIDS) (P less than 0.01). Plasma HIV titers ranged from 10(0) to 10(4.3) and rose from a mean of 10(1.4) in asymptomatic patients to 10(2.5) in those with AIDS (P less than 0.02). Only 45 percent of patients with plasma viremia had HIV p24 antigen in either serum or plasma, and no correlation was found between the amount of p24 antigen in plasma and the plasma HIV titers. Follow-up tests indicated that plasma viremia was associated with a more marked decline in the CD4-lymphocyte cell count and the development of symptomatic disease (P = 0.034). We conclude that plasma viremia is a more sensitive virologic marker of the clinical stage of HIV infection and viral replication than the presence of p24 antigen or antibody in plasma. Not only whole blood but cell-free plasma from HIV-infected patients should be considered potentially infectious.

Invasion of the central nervous system by Treponema pallidum: implications for diagnosis and treatment

STUDY OBJECTIVES

To determine the prevalence of Treponema pallidum in cerebrospinal fluid (CSF) of patients with syphilis, to determine the effect of concurrent HIV infection on central nervous system involvement by T. pallidum, and to examine the efficacy of conventional therapy for asymptomatic neurologic involvement.

PATIENTS

Fifty-eight patients with untreated syphilis who consented to lumbar puncture, representing approximately 10% of new cases of syphilis during the study period.

INTERVENTIONS

Lumbar puncture was done on all patients. Rabbit inoculation was used to test cerebrospinal fluid for viable T. pallidum. Patients with normal fluid received recommended benzathine penicillin therapy according to the stage of syphilis; patients with CSF abnormalities were offered 10-day therapy for neurosyphilis.

RESULTS

Treponema pallidum was isolated from the CSF of 12 (30%) of 40 patients (95% CI, 17 to 46) with untreated primary and secondary syphilis; isolation of T. pallidum was significantly associated (P = 0.008) with the presence of two or more abnormal laboratory variables (among leukocyte count, protein concentration, and CSF-Venereal Disease Research Laboratory [VDRL] test). Two (67%) of 3 early latent (CI, 13 to 100) and 3 (20%) of 15 late latent syphilis patients (CI, 5 to 47) also had reactive CSF-VDRL tests and elevated cell and protein levels, although T. pallidum was not isolated. Concurrent infection with the human immunodeficiency virus (HIV) was not associated with isolation of T. pallidum, increased number of CSF abnormalities, or reactive CSF serologic tests for syphilis, although CSF pleocytosis was commoner in subjects infected with HIV. Treatment with conventional benzathine penicillin G (2.4 mIU) failed to cure 3 of 4 patients with secondary syphilis from whom T. pallidum was isolated before therapy; all 3 patients in whom treatment failed were HIV seropositive when treated or seroconverted during follow-up.

CONCLUSIONS

Central nervous system invasion by T. pallidum is common in early syphilis, and is apparently independent of HIV infection. Examination of the CSF may be beneficial in patients with early syphilis, and therapy should be guided by knowledge of central nervous system involvement. Conventional benzathine penicillin G therapy may have reduced efficacy in patients with early syphilis who are also infected with HIV.

Plasma corticosterone fluctuations in an infant-learning paradigm

Plasma corticosterone fluctuations of infant rats were examined in a learning task. A blood sample for analysis of plasma corticosterone was collected from groups of 10- and 15-day-old pups following either no disturbance, standard maternal deprivation only, or deprivation and training in an established approach-mother, avoid-shock conflict task. In the latter condition, pups remained in the goalbox either alone or with an anesthetized dam for either 15 or 60 min before blood sample collection. Plasma corticosterone levels were elevated following deprivation plus training in pups of both ages and following deprivation only in the 15-day-old pups. Further, the presence of the dam in the goalbox reduced plasma corticosterone elevations, particularly among 15-day-old pups and at 60 min. These findings suggest that the mother's capacity to moderate the pup's plasma corticosterone response may contribute to her reinforcement value in infant-learning paradigms.

Antibody to human immunodeficiency virus (HIV) and suboptimal response to hepatitis B vaccination

STUDY OBJECTIVE

To analyze the relation between human immunodeficiency virus (HIV) infection and the antibody response to plasma-derived hepatitis B vaccine.

DESIGN

Open-label longitudinal cohort study; blinded laboratory studies.

SETTING

University-affiliated municipal hospital.

PATIENTS

Homosexually active men with negative assays for hepatitis B surface antigen (HBsAg), hepatitis B core antigen, and antibody to HBsAg; recruited in a sexually transmitted disease clinic or referred from community practitioners.

INTERVENTIONS

Immunization with 20 micrograms of plasma-derived hepatitis B virus vaccine intramuscularly, repeated after 1 and 6 months; standardized evaluation at entry and at 1, 2, 6, and 7 months.

MEASUREMENTS AND MAIN RESULTS

Low antibody response or nonresponse to vaccination occurred in 7 of 16 HIV-seropositive patients, compared with 6 of 68 HIV-seronegative patients (P = 0.002). Median levels of antibody to HBsAg 7 months after the first vaccine dose were 205.3 sample ratio units for HIV-seronegative patients and 15.5 sample ratio units for HIV-seropositive patients. By multivariate analysis, vaccine response was associated with HIV antibody status and not with cytomegalovirus infection, lymphocyte subset results, or impaired cutaneous delayed hypersensitivity.

CONCLUSIONS

Infection with HIV is associated with suboptimal antibody response to plasma-derived hepatitis B virus vaccine. Determination of antibody levels after vaccination in HIV-seropositive patients may be warranted.

Plasma corticosterone fluctuations in an infant-learning paradigm

Plasma corticosterone fluctuations of infant rats were examined in a learning task. A blood sample for analysis of plasma corticosterone was collected from groups of 10- and 15-day-old pups following either no disturbance, standard maternal deprivation only, or deprivation and training in an established approach-mother, avoid-shock conflict task. In the latter condition, pups remained in the goalbox either alone or with an anesthetized dam for either 15 or 60 min before blood sample collection. Plasma corticosterone levels were elevated following deprivation plus training in pups of both ages and following deprivation only in the 15-day-old pups. Further, the presence of the dam in the goalbox reduced plasma corticosterone elevations, particularly among 15-day-old pups and at 60 min. These findings suggest that the mother's capacity to moderate the pup's plasma corticosterone response may contribute to her reinforcement value in infant-learning paradigms.

Abnormal antibody responses in patients with persistent generalized lymphadenopathy

Persistent, generalized lymphadenopathy (PGL) is a recognized component of human immunodeficiency virus (HIV) infection. We conducted longitudinal studies of B and T cell function in seven homosexual men with HIV infection and PGL. All seven had abnormal antibody-mediated immunity as studied by sequential assessment of in vivo antibody responses after immunization with the T-dependent neoantigens bacteriophage phi X 174 and keyhole limpet hemocyanin (KLH), the T-independent tetradecavalent pneumococcal polysaccharide vaccine, and the recall antigens diphtheria and tetanus toxoid. Compared to HIV-negative heterosexual controls, PGL patients responded with lower antibody titers and, following immunization with phage, failed to develop immunologic memory and to switch from IgM- to IgG-isotype antibody. In vitro antigen-induced antibody production was markedly diminished; and some patients showed depressed mitogen responses. There was a correlation between the degree of compromised immunity and the clinical condition; those with the most severe symptoms showed the most extensive immune deficiency. Yet despite obvious immunologic impairment five of the seven men have remained clinically stable over a 3-year follow-up period.

Cytomegalovirus infection in homosexual men. Relationship to sexual practices, antibody to human immunodeficiency virus, and cell-mediated immunity

To investigate the relationships among cytomegalovirus infection, sexual behavior, human immunodeficiency virus (HIV) seropositivity, and indexes of cellular immunity, 180 homosexual men and 26 heterosexual men were studied. Among the homosexual men, cytomegalovirus seropositivity was associated with increased T8 lymphocyte counts (p less than 0.001) and reduced T4/T8 ratios (p = 0.006); these results were independent of HIV infection. Cytomegalovirus seropositivity was also associated with increasing age, numbers of sexual partners, and the practice of anal-receptive intercourse. At the first visit, cytomegalovirus was isolated from none of 13 cytomegalovirus-seropositive heterosexual subjects, compared with 62 (36 percent) of 171 seropositive homosexual men (p less than 0.005). Viral isolation was most common from semen. Among 32 cytomegalovirus-seropositive homosexual subjects from whom culture specimens were obtained more than four times over 10 to 30 months, 72 percent of the specimens were culture-positive. The mean duration of cytomegalovirus excretion in semen was 22 months, and in urine, the duration was nine months. Cytomegalovirus excretion was associated with younger age and reduced lymphocyte proliferation in response to cytomegalovirus, but not with antibody to HIV. Cytomegalovirus infection is sexually transmitted among homosexual men, perhaps by rectal intercourse, and is associated with alterations in T lymphocyte subsets. Most seropositive homosexual men excrete cytomegalovirus intermittently, primarily in the semen.

Relationship between antibody to LAV/HTLV-III and the natural course of subclinical cellular immune dysfunction in homosexual men

To assess the epidemiology and natural history of persistent generalized lymphadenopathy (PGL) and subclinical immunodeficiency in relation to serologic evidence of lymphadenopathy-associated virus/human T-lymphotropic virus type III (LAV/HTLV-III) infection, 109 homosexual men with PGL, 47 homosexual men without lymphadenopathy who attended a sexually transmitted disease (STD) clinic, 25 homosexual male university students, and 26 heterosexual men who attended the STD clinic were studied. In 1982-1983 antibody to LAV/HTLV-III was present in 97%, 35%, 21%, and 4% of the four groups, respectively (P less than .001). Subclinical immunodeficiency was more closely associated with LAV/HTLV-III seropositivity than with lymphadenopathy. Cohorts of 78 homosexual subjects with PGL, 35 homosexual subjects from STD clinic, and 15 homosexual university students were followed for median periods of 13.5, 20, and 14.5 months, respectively. The seroconversion rate was 23% per year among seronegative subjects, and 4% of seropositive subjects developed overt acquired immunodeficiency syndrome (AIDS). Among seronegative subjects, there was significant improvement in T4:T8 ratios (P = .001), whereas most seropositive subjects continued to have subnormal total counts of T4 lymphocytes and low T4:T8 ratios. Some cases of subclinical cellular immunodeficiency apparently are unrelated to LAV/HTLV-III infection, and the presence of antibody to this virus is associated with an unfavorable immunologic prognosis.

Prevalence of antibody to LAV/HTLV-III among homosexual men in Seattle

The prevalence of antibody to LAV/HTLV-III among homosexual men attending a community clinic and a sexually transmitted disease clinic in Seattle, Washington in early 1985 was 42 per cent and 32 per cent, respectively. Seropositivity was apparently not related to age or number of sexual partners. The high prevalence of LAV/HTLV-III seropositivity in an area where overt AIDS (acquired immune deficiency syndrome) is still relatively uncommon suggests that public health measures to prevent acquisition and transmission of LAV/HTLV-III should be a high priority even in areas with low incidences of AIDS.

Comparative study of ceftriaxone and spectinomycin in the treatment of uncomplicated gonorrhea in women

Single-dose ceftriaxone, 125 mg given intramuscularly, was compared with spectinomycin 2.0 g given intramuscularly in the treatment of women with uncomplicated gonorrhea. Cervical or anorectal gonococcal infection was eradicated in 54 (98 percent) of 55 women treated with ceftriaxone and 22 (96 percent) of 23 treated with spectinomycin. Cure rates for pharyngeal gonococcal infections were nine of 10 for ceftriaxone and four of eight for spectinomycin (p = 0.18). Neither agent eradicated concurrent Chlamydia trachomatis infection. The geometric mean minimal inhibitory concentration for ceftriaxone was 0.0038 microgram/ml for 65 pretreatment cervical isolates of beta-lactamase-negative Neisseria gonorrhoeae and all isolates were inhibited by 0.063 microgram/ml. Neither drug caused perceptible toxicity, but patient acceptance was better for ceftriaxone than for spectinomycin. A single 125 mg dose of ceftriaxone is an excellent regimen in the treatment of uncomplicated gonorrhea in women.

Oculomotor cranial nerve palsey associated with acquired immunodeficiency syndrome

This report describes the case of a homosexual man with non-Hodgkin's lymphoma, whose primary complaint involved his ocular system.

Acquired immune deficiency syndrome

The acquired immune deficiency syndrome (AIDS) has been reported in more than 2800 persons in the United States (70 per cent of whom are homosexually active men). AIDS is manifested by impaired cell-mediated immunity that results in various opportunistic infections (especially pneumonia caused by Pneumocystis carinii) or malignant disease (especially disseminated Kaposi's sarcoma). The cause is unknown, and effective treatment is not yet available. AIDS apparently is not highly infectious for persons outside the acknowledged high-risk groups.

The ontogenesis of defensive reactions to shock in preweanling rats

Behavioral observations were made on the reaction to tailshock and footshock in 5- to 20-day-old hooded rats. For detection thresholds, age differences were found for footshock but not for tailshock. During intershock intervals, more generalized activity and freezing were elicited by footshock, whereas more responding directed to the shock source was elicited by tailshock. The unconditional responding to shock indicated that the older animals had a larger behavioral repertoire of defensive reactions and responded differentially to different shock intensities. The younger animals appeared to have a more limited and stereotyped repertoire of defensive reactions and to be more sensitive to the same nominal shock level. These normative data should prove useful in evaluating motivational and response repertoire problems when assessing learning processes developmentally.