Risk factors for trichomoniasis among women with human immunodeficiency virus (HIV) infection at a public clinic in Los Angeles County, California: implications for HIV prevention

Persons with human immunodeficiency virus (HIV) infection who subsequently develop an acute sexually transmitted disease have an increased probability of transmitting HIV. Therefore, characterizing such persons can help direct prevention efforts to a group who are likely to be continuing sources of HIV transmission. We assessed the incidence and factors associated with trichomoniasis in a cohort of HIV-infected women receiving care at a public clinic in Los Angeles County, California from 1992 through 1995. Demographic, clinical, and behavioral data were available from medical records and from patient interviews. Trichomonas infection was the most frequently identified sexually transmitted disease and was found in 37 (17.4%) of 212 women representing a crude incidence rate of 14.1 per 100 person-years experience. The crude rate of trichomoniasis was highest in black women (69.0 per 100 person-years), women with a history of trading sex for drugs or money (51.0 per 100 person-years), those using crack or cocaine (35.5 per 100 person-years), women with four or more sex partners (43.0 per 100 person years), and those born in the United States (23.3 per 100 person-years). Among women with severe immunosuppression (CD4+ count < 200), 18.4% (18 of 98) were diagnosed with trichomoniasis. After multivariate analysis using a Cox proportional hazards approach, black race (adjusted rate ratio [RR] = 5.6, 95% confidence interval [CI] = 2.3, 13.3) continued to be strongly associated with Trichomonas infection. Trading sex for money or drugs (adjusted RR = 25.2, 95% CI = 4.3, 148.6) and single marital status (adjusted RR = 3.7, 95% CI = 1.1, 13.0) were independent risk factors for trichomoniasis in nonblack women but not among black women. Data from this study indicate that Trichomonas may be a frequently acquired infection in HIV-positive women. Our findings suggest that HIV-infected women who are black, and nonblack women who trade sex for money or drugs or are unmarried, are at increased risk of trichomoniasis and therefore may be more likely to transmit HIV infection. Local HIV prevention strategies should target such women for intervention efforts.

Tuberculous meningitis in a five-week-old infant

We present the case of a five-week-old infant with tuberculous meningitis. The contact investigation and a review of the literature helped us differentiate congenital from acquired tuberculous meningitis. Though rare, we with to emphasize the importance of considering tuberculosis in any neonate with meningitis that fails to respond to conventional treatment, particularly in infants living in an environment where tuberculosis is prevalent.

HIV vertical transmission rate determinations are subject to differing definitions and therefore different rates. The Pediatric Pulmonary and Cardiovascular Complications of Vertically Transmitted HIV Infection Study Group

The HIV infection status of a cohort of 600 prospectively followed children born to HIV infected mothers was determined using HIV peripheral blood culture tests at 0, 3, and 6 months of age, HIV serology at > or = 15 months, and CDC AIDS criteria. We estimated transmission rates using five methods which differed in how HIV indeterminates are handled. These methods were applied at two points in time to illustrate effects of length of follow-up of the cohort on results. In January 1997, 30 months after the last birth, transmission rate estimates ranged from 15.5% (known positives/known positives x known negatives) to 18.1% (known positives x those with one positive culture x deaths/entire cohort minus those lacking negative cultures at age > or = 5 months). Estimates ranged from 14.8% to 20.7% using the subcohort of 284 children followed > or = 12 months as of May 1993. These results indicate that methods for assigning HIV infection status and for handling HIV indeterminates should be carefully defined when estimating transmission rates.

Mandibular metastatic hepatocellular carcinoma: a case involving severe postbiopsy hemorrhage

PURPOSE

To highlight the hemorrhagic character of metastatic hepatocellular carcinoma.

PATIENT AND METHOD

A case report of a patient with mandibular metastatic hepatocellular carcinoma, who had severe postbiopsy hemorrhagic episodes, and literature review is presented.

CONCLUSIONS

Mandibular metastatic hepatocellular carcinoma is a hemorrhagic tumor because of its hypervascular nature. Any rapidly enlarging swelling with ill-defined mandibular destruction suggestive of malignancy should be considered for metastatic hepatocellular carcinoma. Only a needle biopsy should be attempted in view of the hemorrhagic nature of the tumor. Palliative radiotherapy can be useful for the control of local expansile symptoms of the tumor and because of its possible role in the prevention of hemorrhage.

First astronomical detection of the cumulene carbon chain molecule H2C6 in TMC-1

The cumulene carbenes are important components of hydrocarbon chemistry in low-mass star-forming cores. Here we report the first astronomical detection of the long-chain cumulene carbene H2C6 in the interstellar cloud TMC-1, from observations of two of its rotational transitions: J(K,K') = 7(1,7) --> 6(1,6) at 18.8 GHz and 8(1,8) --> 7(1,7) at 21.5 GHz, using NASA's Deep Space Network 70 m antenna at Goldstone, California. In addition we also observed the shorter cumulene carbene H2C4 at the same position. The fractional abundance of H2C6 relative to H2 is about 4.7 x 10(-11) and that of H2C4 is about 4.1 x 10(-9). The abundance of H2C6 is in fairly good agreement with gas-phase chemical models for young molecular cloud cores, but the abundance of H2C4 is significantly larger than predicted.

Maternal serum vitamin A levels are not associated with mother-to-child transmission of HIV-1 in the United States

HIV-1 transmission from mother to child has been associated with maternal vitamin A status in studies of women living in Africa. This finding has raised the question of whether vitamin A supplementation might help reduce transmission in the United States as well as worldwide. In industrialized nations, however, both the vitamin A nutritional status of HIV-1-infected pregnant women and the association of vitamin A levels with vertical transmission were unknown. Furthermore, vitamin A is teratogenic, and supplements during pregnancy have caused birth defects. To investigate whether maternal serum levels of vitamin A (retinol) and three other micronutrients correlate with vertical transmission of HIV-1 in the United State, we studied 95 HIV-1-infected pregnant women and followed their infants to determine whether transmission occurred. Sera were obtained during the third trimester of pregnancy from 95 HIV-1-infected women living in the New York and Los Angeles metropolitan areas. The two cohorts were established to study vertical transmission of HIV-1 and to reflect the racial, ethnic, and socioeconomic status of HIV-1-infected in women in the United States. We measured serum levels of vitamin A (retinol) and three other micronutrients, vitamin E (alpha-tocopherol), beta-carotene, and lycopene, in the mothers using reverse-phase high-performance liquid chromatography and determined the HIV-1 infection status of their infants using virus cultivation and polymerase chain reaction. Sixteen of the 95 women transmitted HIV-1 to their infants. Statistical analysis of the data indicated that low maternal serum retinol levels during the third trimester of pregnancy were not associated with mother-to-child transmission of HIV-1. None of the women had retinol levels so low as to have clinical symptoms of vitamin A deficiency. The serum levels of alpha-tocopherol, beta-carotene, and lycopene, three micronutrients that act as antioxidants and enhance immune function, were also measured. Statistical analysis of the data revealed no association of the levels of these three micronutrients with vertical transmission of HIV-1. Analysis of the data obtained from 95 women in the United States indicates that vitamin A deficiency is rare, and serum retinol levels are not associated with risk of vertical HIV-1 transmission. In view of the teratogenic effects of vitamin A when taken as a supplement during pregnancy, pregnant HIV-1-infected women living in nations where vitamin A deficiency is not a public health problem should not be advised to take extra vitamin A supplements.

Bacterial infections

Non-opportunistic bacterial infections are an important cause of morbidity and mortality for HIV-infected adults and children. Factors associated with increased risk of these include altered B- and T-cell function; altered phagocytic cell function; skin and mucous membrane defects; and use of indwelling vascular catheters, antibiotics, or cytotoxic agents. The pathogens encountered most frequently are S. aureus, S. pneumoniae, H. influenzae, Salmonella sp., and Pseudomonas aeruginosa. Less commonly encountered organisms include Rhodococcus equi, Listeria monocytogenes, Shigella sp., and Nocardia asteroides, Strategies for prevention as well as diagnosis and treatment of these are discussed.

Safety and pharmacokinetics of hyperimmune anti-human immunodeficiency virus (HIV) immunoglobulin administered to HIV-infected pregnant women and their newborns. Pediatric AIDS Clinical Trials Group Protocol 185 Pharmacokinetic Study Group

The pharmacokinetics and safety of hyperimmune anti-human immunodeficiency virus (HIV) intravenous immunoglobulin (HIVIG) were evaluated in the first 28 maternal-infant pairs enrolled in a randomized, intravenous immunoglobulin (IVIG)-controlled trial of HIVIG maternal-infant HIV transmission prophylaxis. Using 200 mg/kg, mean half-life and volume of distribution (Vd) in women were 15 days and 72 mL/kg, respectively, after one and 32 days and 154 mL/kg after three monthly infusions, with stable 4 mL/kg/day clearance. Transplacental passage occurred. Newborn single-dose half-life, Vd, and clearance were 30 days, 143 mL/kg, and 4 mL/kg/day, respectively. HIVIG rapidly cleared maternal serum immune complex-dissociated p24 antigen, and plasma HIV-1 RNA levels were stable. Mild to moderate adverse clinical effects occurred in 2 of 103 maternal and 2 of 25 infant infusions. No adverse hematologic, blood chemistry, or immunologic effects were seen. HIVIG is well-tolerated in HIV-infected pregnant women and their newborns, clears antigenemia, crosses the placenta, and exhibits pharmacokinetics similar to those of other immunoglobulin preparations.

Detection and Characterization of the Cumulene Carbenes H2C5 and H2C6

Two cumulene carbenes, H2C5 and H2C6, were detected in a supersonic molecular beam by Fourier transform microwave spectroscopy. Their rotational and leading centrifugal distortion constants were determined with high accuracy, such that the entire radio spectrum can now be calculated. Like the known carbenes H2C3 and H2C4, both molecules have singlet electronic ground states and linear carbon-chain backbones. They can be produced in sufficiently high concentrations in the laboratory that their electronic spectra, expected to lie in the visible, should be readily detectable by laser spectroscopy. The microwave spectra of other, more exotic isomers may be detectable as well.

[Tetanus: problems of differential diagnosis in the presence of contemporaneous administration of metoclopramide]

Here we report a clinical case concerning differential diagnosis between tetanus and metoclopramide intoxication. A 67 year old woman was admitted to our intensive care unit complaining of both trisma and four limbs hypertone soon after a massive metoclopramide bolus administration. The patient was affected by a chronicle renal insufficiency and a diagnosis of metoclopramide intoxication was made. The long lasting dystonic symptomatology together with respiratory insufficiency ruled out the hypothesis of drug overdose. The intensive care physicians would take into account that at least a 24 hours clinical observation is mandatory in order to perform a correct diagnosis.

Cytoplasmic sequestration of p53 in cytomegalovirus-infected human endothelial cells

Human umbilical vein endothelial cells were infected with human cytomegalovirus (HCMV) at a multiplicity of infection of 0.1 plaque-forming unit/cell and remained > 95% viable even after 10 days of infection. To induce apoptosis, control human umbilical vein endothelial cells and cells infected with HCMV for 3, 5, and 7 days were serum starved for 48 hours. Almost one-half of the uninfected cells lost viability after 48 hours of serum starvation whereas HCMV-infected cells were virtually unaffected (< 20% death, P < 0.05). Uninfected cells showed typical hallmarks of apoptosis, including unique morphological changes and DNA laddering. HCMV-infected cells, concomitant with their resistance to serum-starvation-induced death, displayed almost none of these characteristics. Active replication of HCMV was necessary for the anti-apoptotic effect, as cells treated with ultraviolet light-inactivated virus were not protected. p53, the G1/S phase cell cycle brake protein, was elevated in HCMV-infected cells. However, rather than accumulating in the nucleus, immunofluorescent and Western blot studies demonstrated remarkable and predominant cytoplasmic sequestration of p53 in HCMV-infected endothelial cells. Although HCMV proteins have already been shown to block apoptosis, we suggest that the aberrant subcellular pattern of p53 is the disturbed cellular mechanism that may be responsible for the anti-apototic properties of HCMV-infected cells. The selective resistance to apoptosis can be important during HCMV replication and may explain the oncogenic potential of HCMV as well as its pathogenic role in intimal-proliferation-mediated vascular diseases.

Children hospitalized for varicella: a prevaccine review

OBJECTIVES

To describe varicella complications in healthy and previously ill children hospitalized for varicella and to explore trends in group A beta-hemolytic streptococcus complications of varicella.

METHODS

A retrospective record review of children hospitalized for varicella between January 1, 1990, and March 31, 1994, was conducted in nine large acute care hospitals in Los Angeles County, California.

RESULTS

We identified 574 children hospitalized for varicella in study hospitals during the 4.25-year study period (estimated risk of hospitalization, approximately 1 in 550 cases of varicella); 53% of the children were healthy before the onset of varicella and 47% were previously ill with underlying cancers or other chronic illnesses. Children were hospitalized for treatment of complications (n = 427, 74%) or for prophylactic antiviral therapy or observation (n = 147, 26%). Systems involved in complications included skin/soft tissue (45%), neurologic (18%), respiratory (14%), gastrointestinal (10%), and hematologic, renal, or hepatic (8% or less). The mean age of children with skin/soft tissue infections was 2.7 years (range < 1 to 16 years) compared with 4.7 years (< 1 to 18 years) for other complications. Children with skin/soft tissue and neurologic complications were more often previously healthy (p < 0.05), whereas those with respiratory complications were more often previously ill (p < 0.001). Hospitalizations for skin/soft tissue infections increased during the study period. The proportion of complications as a result of group A beta-hemolytic streptococcus infection increased from 4.7% before 1993 to 12.2% for the remainder of the study period (p = 0.02).

CONCLUSIONS

Prior health status was predictive of the type of complications experienced by children with varicella requiring hospitalization. Our data suggest a recent increase in skin/soft tissue complications of varicella requiring hospitalization and an increase in the proportion of complications related to group A beta-hemolytic streptococcus. Wide-scale vaccine use should reverse this trend and reduce the overall impact of varicella on both healthy and previously ill children.

Presence of cell-free human immunodeficiency virus in cervicovaginal secretions is independent of viral load in the blood of human immunodeficiency virus-infected women

OBJECTIVE

The purpose of this study was to establish virologic or molecular criteria for evaluating the rate of transmission of human immunodeficiency virus type 1 and for defining the role of virus burden in the development of gynecologic diseases in human immunodeficiency virus-infected women.

STUDY DESIGN

Paired samples of blood and cervicovaginal secretions from 63 human immunodeficiency virus-seropositive women were evaluated for cell-free and cell-associated virus load by several methods, including quantitative cultures and reverse transcription polymerase chain reaction.

RESULTS

All women showed evidence of virus infection in both blood and cervicovaginal secretions by a combination of in vitro culture and molecular detection methods. The CD4+ cell counts in these women ranged from < 200/microliter to > 500/microliter. Blood plasma of 26% women (12/46) did not show detectable levels of human immunodeficiency virus ribonucleic acid by reverse transcription polymerase chain reaction (< 10(2)/100 microliters). These same women had significant amounts of human immunodeficiency virus in the cell-free cervicovaginal secretions (10(2) to 10(5) copies per 100 microliters). In contrast, 17% (8/46) women with significant quantity of human immunodeficiency virus ribonucleic acid in the blood plasma had negative results for human immunodeficiency virus in the cervicovaginal secretions. Further, treatment of women with the antiviral drug zidovudine did not change the human immunodeficiency virus-1 detection rate in plasma ribonucleic acid but showed significant reduction in the ability to detect human immunodeficiency virus ribonucleic acid in cell-free cervicovaginal secretions (p = 0.036).

CONCLUSIONS

We conclude that the replication kinetics of human immunodeficiency virus in the blood and cervicovaginal cells are unrelated, independent events. Further, there is no correlation between the virus load or the CD4+ cell counts in the blood and the presence or absence of quantifiable human immunodeficiency virus in cervicovaginal secretions.

Triple helix-forming oligonucleotide corresponding to the polypyrimidine sequence in the rat alpha 1(I) collagen promoter specifically inhibits factor binding and transcription

Type I and III fibrillar collagens are the major structural proteins of the extracellular matrix found in various organs including the myocardium. Abnormal and progressive accumulation of fibrillar type I collagen in the interstitial spaces compromises organ function and therefore, the study of transcriptional regulation of this gene and specific targeting of its expression is of major interest. Transient transfection of adult cardiac fibroblasts indicate that the polypurine-polypyrimidine sequence of alpha 1(I) collagen promoter between nucleotides - 200 and -140 represents an overall positive regulatory element. DNase I footprinting and electrophoretic mobility shift assays suggest that multiple factors bind to different elements of this promoter region. We further demonstrate that the unique polypyrimidine sequence between -172 and -138 of the promoter represents a suitable target for a single-stranded polypurine oligonucleotide (TFO) to form a triple helix DNA structure. Modified electrophoretic mobility shift assays show that this TFO specifically inhibits the protein-DNA interaction within the target region. In vitro transcription assays and transient transfection experiments demonstrate that the transcriptional activity of the promoter is inhibited by this oligonucleotide. We propose that TFOs represent a therapeutic potential to specifically influence the expression of alpha 1(I) collagen gene in various disease states where abnormal type I collagen accumulation is known to occur.

Frequent recurrence and persistence of varicella-zoster virus infections in children infected with human immunodeficiency virus type 1

OBJECTIVE

To examine complications and treatment of varicella-zoster virus (VZV) infections in children infected with human immunodeficiency virus type 1 (HIV-1).

METHODS

Cases of VZV infection were identified retrospectively by reports to the department of health services and review of medical charts. The CD4+ cell counts were correlated with severity and frequency of VZV episodes.

RESULTS

We identified 117 episodes of VZV infection in 73 HIV-1-infected children between Aug. 21, 1986, and Dec. 1, 1993. The most common complications were recurrence and persistence; 38 children (53%) had 69 recurrent episodes of VZV infection. The majority of children (61%) had zoster during the first recurrent episode, and 32% had a disseminated eruption typical of varicella. There was a strong association between an increasing number of episodes of VZV infection and low CD4+ cell count (p = 0.0008). In a subgroup followed for at least 2 years after their primary varicella episode, 10 of 22 children had a recurrence. Persistence of VZV infection was documented in 10 of 73 children, whereas other complications were rare. Thirty-three children (45%) were hospitalized and received acyclovir intravenously.

CONCLUSION

Primary, recurrent, and persistent VZV infections are a frequent cause of morbidity and hospitalization for HIV-1-infected children. Studies of improved preventive and therapeutic agents are urgently needed in this population.

Comparison of a rapid nonisotopic polymerase chain reaction assay with four commonly used methods for the early diagnosis of human immunodeficiency virus type 1 infection in neonates and children

To initiate antiretroviral therapy and prophylaxis for Pneumocystis carinii pneumonia, it is important to identify human immunodeficiency virus (HIV-1)-infected infants as soon after birth as possible. This study was undertaken to evaluate a novel 5-hour nonisotopic (NI) polymerase chain reaction (PCR) assay (Amplicor PCR; Roche Molecular Systems) and four other commonly used HIV-1 diagnostic tests including culture, oligonucleotide hybridization PCR, p24 antigen and immune complex-dissociated (ICD) p24 antigen tests and to determine the optimal age at which to perform these tests for the early and rapid diagnosis of HIV-1 in infants and children. We prospectively evaluated 225 infants and children, including 114 neonates, for HIV-1 infection. HIV-1 infection was defined as 2 positive HIV cultures. Of the 225 infants and children, 57 were infected, 138 were uninfected and 30 were of unknown (Centers for Disease Control and Prevention Classification P0) status. The sensitivity of NI PCR was 60% in cord blood, 40% at 0 to 2 days, 67 to 80% in the neonate (3 to 30 days) and 95 to 100% after 1 month of age. NI PCR was as sensitive as oligonucleotide hybridization PCR, culture, p24 antigen and ICD p24 antigen in the first 2 months of life and was more sensitive than p24 antigen or ICD p24 antigen thereafter. Specificity was 94% for cord blood and 99 to 100% for all age groups. The majority of HIV-1-infected newborns can be identified with NI PCR if testing is performed at birth and again between the third and fourth weeks of life. For older infants and children 2 NI PCR tests can correctly diagnose 98.5% of infected and uninfected infants and children. NI PCR of umbilical cord blood might also be useful as an initial screening test to identify infants who may be infected with HIV-1.

Emerging patterns of HIV transmission: the value of alternative surveillance methods

OBJECTIVE

To assess the current patterns of HIV transmission in Los Angeles County and determine if AIDS surveillance data accurately reflect these patterns.

DESIGN

Records-based cohort study.

METHODS

The demographic and HIV risk characteristics of persons considered to be recently infected with HIV (CD4+ count > 700 x 10(6)/l) were determined and compared with the characteristics of persons meeting the Centers for Disease Control and Prevention (CDC) 1993 AIDS case definition. Data were obtained for patients with HIV infection enrolled from four HIV outpatient clinics and analyzed between August 1991 and July 1993.

RESULTS

The patient cohort included 1857 persons with HIV infection; 1096 (59.1%) met the CDC 1993 AIDS case definition and 134 (7.2%) had a CD4+ lymphocyte count > 700 x 10(6)/l. The median CD4+ count for the group presumed to be recently infected was 809 x 10(6)/l. Persons considered recently infected with HIV were more likely than those meeting the AIDS case definition to be female (26.1 and 14.5%, respectively; P < 0.001), black (28.4 and 18.2%, respectively; P = 0.001), or male homosexual injecting drug users (IDU; 6.7 and 3.4%, respectively; P = 0.05). After controlling for confounding variables by logistic regression, persons recently infected were more likely to be female [adjusted odds ratio (OR), 3.4; 95% confidence interval (CI), 1.8-6.5; P < 0.001], black (adjusted OR, 1.6; 95% CI, 1.1-2.5; P = 0.02) or male homosexual IDU (adjusted OR, 2.4; 95% CI, 1.1-5.2; P = 0.02) than persons with AIDS.

CONCLUSIONS

Our results suggest that the HIV epidemic in Los Angeles County is currently advancing into different subpopulations and indicate that the current patterns of HIV transmission in the County are not fully reflected in standard AIDS surveillance activities. However, our data must be interpreted cautiously because of potential selection and misclassification biases. These findings illustrate the benefits of alternative surveillance mechanisms in detecting important changes in HIV transmission and defining groups at risk, especially in jurisdictions without HIV reporting.

Specific loss of chromosomes 1, 2, 6, 10, 13, 17, and 21 in chromophobe renal cell carcinomas revealed by comparative genomic hybridization

We analyzed 19 chromophobe renal cell carcinomas by means of comparative genomic hybridization. Two tumors revealed no numerical abnormalities. In the remaining 17 cases we found loss of entire chromosomes with underrepresentation of chromosome 1 occurring in all 17 cases; loss of chromosomes 2, 10, and 13 in 16 cases; loss of chromosomes 6 and 21 in 15 tumors; and loss of chromosome 17 in 13 cases. The loss of the Y chromosome was observed in 6 of 13 tumors from male patients, whereas 1 X chromosome was lost in 3 of 4 tumors obtained from females. Comparative genomic hybridization results were verified by interphase cytogenetics. We conclude that a specific combination of multiple chromosomal losses characterizes chromophobe renal cell carcinomas and may help to differentiate them unequivocally from other types of kidney cancer.