Immunosuppression and mycobacteria other than Mycobacterium tuberculosis: results from patients with and without HIV infection

Infections caused by mycobacteria other than Mycobacterium tuberculosis (MOTT) have often been described as common in AIDS patients. To evaluate whether infections with MOTT are specific for HIV related immunosuppression or are also frequent in patients with immunosuppression of different aetiology, data on the frequency of isolation from immunosuppressed patients with HIV infection are important. Blood, stool and urine specimens from 134 patients with non-HIV related immunosuppression, and from 55 immunocompetent subjects were examined for mycobacteria. MOTT have been isolated from one immunocompetent person but from none of the immunosuppressed patients. Since in AIDS patients an initial colonization of the gastrointestinal tract (GI-tract) with MOTT is common, GI-tract biopsy specimens from an additional 80 patients were examined microscopically and histologically for mycobacteria. Mycobacteria were not isolated from these specimens. In the same period of time 72 AIDS patients have been examined; 7 (10%) had infections with M. tuberculosis whereas MOTT have been isolated from 16 (22%) of these patients. Mycobacteria have been found only rarely in immunocompetent patients and have not been isolated from patients with non-HIV related immunosuppression. The isolation of MOTT is highly correlated with an HIV-related immunosuppression.

Mycobacteremia in AIDS patients. Results of a prospective study

The importance of blood cultures in diagnosing disseminated mycobacteriosis in AIDS patients was evaluated. Blood samples were screened for mycobacteria by culture and microscopic techniques. Mycobacteremia was proven in 20/136 (14.7%) AIDS patients, the agent being M. avium-M. intracellulare (MAI) in 16 cases and M. tuberculosis in four cases. The rate of cases with positive blood samples in disseminated MAI infection was 59.3% (16/27 cases) and in disseminated tuberculosis 57.1% (4/7 cases). To detect mycobacteria buffy-coat was slightly superior to lysated cell pellets, obtained by a lysis-centrifugation technique. In 4/16 cases with MAI bacteremia, the agent was proven by positive blood smears for acid-fast bacilli only; in these four patients MAI was demonstrated at other body sites. These results illustrate the diagnostic role of blood culture and its use in early diagnosis of disseminated mycobacteriosis, with microscopic examination of blood smears being an important adjunct.

Influence of sulfated carbohydrates on the accessibility of CD4 and other CD molecules on the cell surface and implications for human immunodeficiency virus infection

The modulatory activity of dextran sulfate with a relative molecular mass of 8 and 500 kDa and pentosan polysulfate with a relative molecular mass of 6 kDa on human T cell surface molecules CD2, CD3, CD4, CD8 and HLA-DR was investigated by analytical flow cytometry. The 500-kDa dextran sulfate induces a complete disappearance of the CD4 and a 50% diminution of CD2 immune reactivity on peripheral blood lymphocytes after a 4-h incubation while the low molecular mass polyanions do not. This modulation of the CD4 immune reactivity includes all CD4 epitopes investigated. It does not correlate with the antiviral effect of polyanions against human immunodeficiency virus infection. The interaction of polyanions with the CD4 presentation is temperature dependent and differs between fresh lymphocytes and immortal cell lines. From our data it can be concluded that mechanisms other than cell surface effects are responsible for the antiviral potency of these drugs. Implications for the modes of antiviral action of sulfated carbohydrates are discussed.

Regression of oral Kaposi's sarcoma in a case of AIDS on zidovudine (AZT)

A case with oral Kaposi's sarcoma (KS) is reported that regressed during therapy with Zidovudine (AZT) which was started 5 months after the first dermal and oral tumours were noted. After 6 months of treatment the absolute number of T-helper cells had increased from 54/microliters to 232/microliters and the ratio of T-helper to T-suppressor cells from 0.15 to 0.3. During the same time the lesions of KS on the gingiva, uvula and the body as well as the face disappeared. The lesion of KS on the hard palate regressed.

Incidence and clinical features of community-acquired legionellosis in hospitalized patients

In a two-year prospective study of patients hospitalized because of community-acquired pneumonia, the incidence of legionellosis was found to be 3.8% (17/442 cases). After S. pneumoniae, M. pneumoniae and influenzae viruses, legionellae were the fourth most frequently identified pneumonia agents. We evaluated the clinical data from 41 cases with legionellosis, 17 diagnosed in this prospective study and 24 prior to the study. The age range of all patients (22 women, 19 men) was 24-78 yrs (median 61.3 yrs), 14 of 41 cases (34.1%) had extrapulmonary organ involvement. Twelve patients (29.3%) died. The fatality rate was 4.5% (1/22 cases) in patients treated with erythromycin, and 57.9% (11/19 cases) in patients treated with other antibiotics. Antibiotics effective in legionellosis should be added to the routine therapy of community-acquired pneumonia when this aetiology can not be excluded.

Incidence and clinical features of community-acquired legionellosis in hospitalized patients

In a two-year prospective study of patients hospitalized because of community-acquired pneumonia, the incidence of legionellosis was found to be 3.8% (17/442 cases). After S. pneumoniae, M. pneumoniae and influenzae viruses, legionellae were the fourth most frequently identified pneumonia agents. We evaluated the clinical data from 41 cases with legionellosis, 17 diagnosed in this prospective study and 24 prior to the study. The age range of all patients (22 women, 19 men) was 24-78 yrs (median 61.3 yrs), 14 of 41 cases (34.1%) had extrapulmonary organ involvement. Twelve patients (29.3%) died. The fatality rate was 4.5% (1/22 cases) in patients treated with erythromycin, and 57.9% (11/19 cases) in patients treated with other antibiotics. Antibiotics effective in legionellosis should be added to the routine therapy of community-acquired pneumonia when this aetiology can not be excluded.

Nosocomial legionella pneumonia: demonstration of potable water as the source of infection

From January 1983 until December 1985, 35 cases of sporadic nosocomial legionella pneumonia, all caused by Legionella pneumophila, were diagnosed in a university hospital. L. pneumophila serogroup (SG) 1 was cultured from 12 of the 35 cases and compared to corresponding L. pneumophila SG 1 isolates from water outlets in the patients' immediate environment by subtyping with monoclonal antibodies. The corresponding environmental isolates were identical to 9 out of 12 (75%) of those from the cases. However, even in the remaining three cases identical subtypes were found distributed throughout the hospital water supply. From the hospital water supply four different subtypes of L. pneumophila SG 1 were isolated, three of which were implicated in legionella pneumonia. Of 453 water samples taken during the study 298 (65.8%) were positive for legionellae. Species of Legionella other than L. pneumophila have not been isolated. This may explain the exclusiveness of L. pneumophila as the legionella pneumonia-causing agent. Our results suggest that the water supply system was the source of infection.

[Side effects of trimethoprim-sulfamethoxazole in patients with AIDS]

Forty-nine episodes of Pneumocystis carinii pneumonia, treated with trimethoprim-sulfamethoxazole among 46 patients with AIDS were analysed retrospectively for any side effects. For only two were there insufficient data. There were 39 toxic reactions, 15 of them serious: leukopenia (n = 23), abnormal liver functions (n = 14), skin changes (n = 12), gastrointestinal complaints (n = 10) and thrombocytopenia (n = 9). In nine patients the treatment had to be discontinued, in six of them so early that a switch to pentamidine was necessary. Gastrointestinal symptoms occurred as early as the sixth day of treatment, while leukopenia and thrombocytopenia were first observed after 12-13 days. Despite the high rate of side effects trimethoprim-sulfamethoxazole remains the drugs of choice, other regimens not having been found to be any better.

Fatal Legionnaires' pneumonia: frequency of legionellosis in autopsied patients with pneumonia from 1969 to 1985

In 89 of 3027 (2.9 per cent) patients in whom pneumonia was found at autopsy during the period from 1969 to 1985, legionella pneumonia was diagnosed. Legionellae were demonstrated through the direct fluorescent antibody test by screening lung tissue sections. All 89 cases were caused by Legionella pneumophila. Suspicious typical rod-shaped organisms were demonstrated in all cases by the modified Dieterle stain whereas conventional histological stains failed to detect causative bacteria. The frequency per year of legionellosis in patients with pneumonia at autopsy ranged from 1.4 per cent (3/212 cases) to 6.8 per cent (12/177 cases). In patients who have died of unexplained pneumonia, examinations for the demonstration of legionellae should be carried out.

Fatal legionellosis in patients with malignant hematologic diseases

Pneumonia was present in 70/157 (44.6%) autopsied patients with malignant hematologic diseases. In 16/70 patients (22.9%), legionellae were found to be the causative agents by screening lung tissue specimens with the direct fluorescent antibody method. In 5/16 patients with Legionella pneumonia, in whom legionellosis had been suspected clinically, the diagnosis had already been established by serology, urinary Legionella antigen detection, and culture. These results provide evidence that legionellosis is an important pneumonia etiology in patients with malignant hematological diseases. Thus, Legionella diagnostics should be applied routinely, and antibiotics effective in the treatment of legionellosis should be added to the usual therapy in patients with etiologically unexplained pneumonias. In view of the common occurrence of relapses of Legionella pneumonia, antibiotic therapy should be continued for an extended period.

Fatal Legionella pneumonia: retrospective examination of lung tissue using direct and indirect fluorescent-antibody methods

Lung tissue sections of patients who died of pneumonia within one year were screened retrospectively for Legionnaires' disease bacteria using simultaneously a direct fluorescent antibody test (DFA) and an indirect fluorescent antibody system (IFA). The IFA has shown to provide a rapid screen for the increasing number of known Legionella species and serogroups recently. In 10/168 (6%) of our cases legionellae were the pneumonia causing agents detected with both methods. Although we should have been able to detect 25 serological variants of Legionella species and serogroups with the IFA, we found Legionella pneumophila serogroup 1 only. The IFA test has proven to be a reliable means for the screening of lung tissue sections.

Demonstration of Legionella antigen in the urine: significance for differential diagnosis

The most effective techniques presently in use for the early diagnosis of Legionnaires' disease are RIA- and ELISA-tests detecting Legionella antigen in urine specimens. We are reporting on our experience with the RIA for the detection of L. pneumophila serogroup 1-antigen in the urine of 30 patients with suspected legionellosis.

Rapid detection of Legionella antigen in tissues and body fluids

We report on a study in which a modification of the enzyme-linked immunosorbent assay (ELISA) using solid-phase microtiter plates has been applied to detect Legionella pneumophila (serogroup 1) antigen in urine, secretions and tissue homogenates. The radioimmunoassay (RIA) and ELISA techniques were compared with respect to sensitivity and range of detection of individual species' antigens. We present results of adsorption studies in which positive specimens were treated with specific IgG fractions raised in the rabbit against individual Legionella species. The advantage of the rapid ELISA or RIA diagnosis over the more time-consuming diagnostic measures is discussed.

[Neurologic symptoms in Legionella infection. A case report of the clinical aspects and diagnosis of legionellosis]

In patients with infection from Legionella pneumophila, it must be taken into consideration that the nervous system may be involved. This involvement can precede the pneumonia by several days. Headache, acute mental status changes and cerebellar dysfunctions are the most common neurological symptoms. In the case reported, extrapyramidal disturbances were also observed that are rarely found in association with Legionella infection. There are grounds for the assumption that Legionella toxins cause impairment to the nervous system. The neurological symptoms are not specific enough to allow differentiation of this infection from pneumonia of other etiologies.

[Penetration of ceftizoxime (FK 749) into the cerebrospinal fluid (author's transl)]

After the cytology and the chemistry of the CSF had returned to normal, the concentration of ceftizoxime was determined in the CSF and in the serum of 27 patients who had suffered from purulent or serous meningitis. The patients were divided into four groups. The concentration in the CSF was mean = 0.87 mg/l two hours after a bolus injection of 2 g ceftizoxime. After an infusion of 2 g ceftizoxime over 30 minutes, the concentration in the CSF was mean = 0.32 mg/l one hour and mean = 0.99 mg/l two hours after the infusion was started. The highest concentrations in the CSF were obtained six hours after a bolus injection of 2 g ceftizoxime. The peak value was 4.3 mg/l and the mean 1.78 mg/l. Based on these pharmacokinetic data, additional injections could have a cumulative effect on the concentration of ceftizoxime in the CSF. With the exception of Staphylococcus sp., Pseudomonas sp. and some anaerobes, it can be expected that ceftizoxime will be effective against other organisms causing meningitis. The results of clinical applications remain to be seen.

[Longtime therapy of congenital factor XIII deficiency using factor XIII concentrate]

Factor XIII was determined by enzymatic and immunochemical methods in 3 patients with congenital factor XIII deficiency. Factor XIII activity measured by trans-glutaminase assay was below 1% of normal value in each of these cases. Immunelectrophoresis determination revealed the absence of the functionally active subunit A, whereas subunit S was only slightly diminished (30 to 50% of the normal value). Substitution with factor XIII concentrate caused a parallel increase of factor XIII activity and subunit A concentration. No uptake of factor XIII activity or of subunit. A by platelets could be demonstrated. Despite discontinuous substitution over a period of six years no antibody against factor XIII activity could be demonstrated in one patient with congenital factor XIII deficiency.