Disseminated histoplasmosis presenting with cutaneous lesions in a patient with acquired immunodeficiency syndrome

OBJECTIVE

Presentation of a case of disseminated histoplasmosis, observed in a non-endemic area, in which cutaneous lesions and fever were the dominant clinical signs of the infection.

CASE

A 54-year-old homosexual man with acquired immunodeficiency syndrome (AIDS) related Kaposi's sarcoma presented with cutaneous lesions and fever due to disseminated histoplasmosis. The patient was successfully treated with itraconazole 200 mg/day. He died after 8 months from AIDS dementia complex: disseminated histoplasmosis relapse was not observed.

CONCLUSION

The case shows that infection with Histoplasma capsulatum must be considered by dermatologists in HIV/AIDS patients, even in non-endemic areas.

Intracavitary contact X-ray therapy of oral HIV-associated Kaposi's sarcoma

A retrospective study was performed to assess the efficacy and low mucosal toxicity of intracavitary contact X-ray therapy (ICRT), a proposed treatment of small/medium sized lesions of oral HIV-associated Kaposi's sarcoma (HIV-KS). Twenty-six patients with histologically confirmed oral HIV-KS underwent ICRT in the period 1986-1995. No patient received antiblastic or interferon therapy during the radiotherapy or follow-up periods. ICRT was performed according to the usual technical modalities of contact X-ray therapy, but the end of the source of ionizing radiations was introduced into the oral cavity. The total doses administered ranged from 10 to 50 Gy per field, in one or two weekly fractions of 5 Gy each. The follow-up ranged from 1 to 44 months (mean 7.5 months). Complete remission was obtained in 20 cases (76.92%), partial remission in 6 (23.08%) and relapse in one case (3.84%). Pain was relieved in all cases. Mucosal reaction was mild and did not result in any interruption of treatment. Our data suggest that ICRT is an effective and well tolerated treatment. It can be used in the management of oral HIV-KS instead of external radiotherapy, provided that the size and the location of the lesions and the conformation of the palate are suitable to this technique.

Absence of clinical, virological, and immunological signs of progression in HIV-1-infected patients receiving active anti-interferon-alpha immunization: a 30-month follow-up report

Twenty-seven HIV-1-infected patients, 16 at early stage of disease and without concomitant antiretroviral therapy and 11 at more advanced stage of disease receiving antiretroviral therapy, have been followed since their enrollment, November 1992 and July 1993, respectively, in phase I/II studies to evaluate safety and immunogenicity of an anti-interferon-alpha (IFN-alpha) vaccine, aimed at modulating the impaired cytokine network in AIDS patients by counteracting IFN-alpha overproduction. We compared clinical, virological, and immunological markers of disease progression, including circulating IFN-alpha levels in a 24- to 30-month follow-up period with those of 62 patients fulfilling the same enrollment criteria and comparable for sex, risk factor, and age, regularly followed at our center. Anti-IFN-alpha immunization consisted of four-six intramuscular injections 1 month apart of a water-in-oil emulsion of 500 micrograms formalin-inactivated recombinant IFN-alpha-2b (iIFN-alpha) followed by intramuscular injections of 250 micrograms iIFN-alpha adsorbed onto calcium phosphate every 3 months. Neither clinical deterioration nor a CD4+ cell count decrease from pretreatment values was observed in IFN-alpha-immunized patients in the follow-up period, whereas clinical and immunological disease progressions were observed among open-comparison patients. Furthermore, statistical analysis showed a strong association between occurrence of clinical manifestations and high circulating IFN-alpha titers, while nonprogression of IFN-alpha-immunized patients was associated with decreased levels of circulating IFN-alpha.

Distribution of human herpesvirus-8 sequences throughout the spectrum of AIDS-related neoplasia

OBJECTIVE

AIDS frequently associates with certain malignancies, including Kaposi's sarcoma, non-Hodgkin's lymphoma (NHL), and anogenital neoplasia. In this study we aimed to define the frequency of infection by human herpesvirus (HHV)-8 throughout the spectrum of AIDS-related neoplasia in Europe.

DESIGN

A tumour panel representative of the distinct types of AIDS-related neoplasms was tested for the presence of HHV-8 DNA sequences. Autologous uninvolved tissues were also tested in selected cases.

METHODS

The presence of HHV-8 DNA sequences was assayed by a combination of polymerase chain reaction followed by oligohybridization and Southern blot hybridization of genomic DNA with an HHV-8-specific probe.

RESULTS

HHV-8 sequences were detected in 100% of AIDS-related Kaposi's sarcoma (all 35 cases). Among AIDS-related NHL, HHV-8 sequences selectively clustered with body-cavity-based lymphomas (BCBL; all three cases), although they were consistently negative in small non-cleaved cell lymphomas (none in 18 cases), diffuse large cell lymphomas (none in seven), or anaplastic large cell lymphomas (none in three). No HHV-8 sequences were found in cases of anogenital neoplasia (out of 14) or Hodgkin's disease (out of three). HHV-8 DNA sequences were also positive in the uninvolved skin of all six AIDS-related Kaposi's sarcoma patients, but not in the circulating lymphocytes of a BCBL patient. Positivity for HHV-8 sequences occurred in patients belonging to all major AIDS risk categories.

CONCLUSIONS

These data confirm that HHV-8 sequences associate at high frequency with selected types of AIDS-related neoplasia, namely Kaposi's sarcoma and BCBL, although they are consistently absent in other types of AIDS-NHL and AIDS-related anogenital neoplasia.

Combination chemotherapy with doxorubicin, bleomycin, and vindesine for AIDS-related Kaposi's sarcoma

BACKGROUND

Kaposi's sarcoma is the most common neoplasm in patients with human immunodeficiency virus (HIV) infection. Although the best therapeutic approach is still unclear, patients with advanced KS are usually treated with systemic chemotherapy.

METHODS

A prospective multiinstitutional Italian study evaluated the efficacy and toxicity of combination chemotherapy with doxorubicin, bleomycin, and vindesine (ABVi) in patients with progressive and extensive HIV-related KS. Patients were given doxorubicin, 20 mg/m2 on Day 1; bleomycin, 15 mg on Day 1, and vindesine, 4 mg on Day 1 biweekly +/- granulocyte-colony stimulating factor.

RESULTS

Overall, 21 of 38 evaluable patients (55%) achieved an objective response (OR): there was 1 complete response and 20 partial responses. The most important bone marrow toxicity was granulocytopenia in 61% of the evaluable patients; 34% had Grades 3-4 toxicity, according to the World Health Organization Classification. The majority of patients (64%) developed some type of opportunistic infection (OI) during chemotherapy or the follow-up, with cytomegalovirus infection being the most frequent OI observed. The median duration of survival from KS diagnosis and from the start of ABVi therapy was 19 months (range, 3.4-88.5 months) and 9.9 months (range, 0.1-42.4 months), respectively.

CONCLUSIONS

The high rate of OI during ABVi chemotherapy and the follow-up is of concern, although these infections possibly could be due to our patients' low CD4+ lymphocyte counts. However, no toxic death was observed in our patients, suggesting that ABVi could be used in patients with aggressive disease, especially those who were previously untreated.

Role of radiotherapy in the treatment of epidemic Kaposi's sarcoma: experience with sixty-five cases

BACKGROUND

Treatment of Kaposi's sarcoma (KS) associated with HIV infection should improve often disfiguring lesions, with an acceptable cosmetic outcome; relieve associated signs and symptoms (pain and edema); and have no adverse effects on the patient's already impaired immune status.

OBJECTIVE

Our purpose was to determine the role of x-ray therapy in the treatment of KS.

METHODS

Contact x-ray therapy and half-deep x-ray therapy were used to treat 594 lesions in 65 patients with KS, who were observed for 1 to 43 months (mean, 9 months).

RESULTS

Complete remission was achieved with pigmentation in 405 lesions (68.3%), with good cosmetic results in 105 (17.7%), and with hypopigmentation in three (0.5%). In 80 lesions (13.5%) only size reduction or pain palliation were achieved. Fourteen lesions (2.4%) relapsed 2 to 9 months after treatment.

CONCLUSION

X-ray therapy is well tolerated and meets the specified requirements for the treatment of KS.

Non-pathogenic entamoeba histolytica in Italian HIV-infected homosexuals

A cohort of 51 homosexuals who were either HIV-positive or had AIDS was followed prospectively with parasitologic stool examination and in vitro culture in order to determine the incidence of E. histolytica infection. Amoebic isolates were further characterized by electrophoretic isoenzyme study. Five subjects (9.8%) were found to be infected with E. histolytica. None of the amoebic isolates were found to be pathogenic by isoenzyme analysis.

[Results of radiotherapy in 22 patients with epidemic Kaposi's sarcoma]

Radiotherapy is a first choice treatment of skin and oral cavity lesions of epidemic Kaposi sarcoma. It has cosmetic aims in the early stages of the disease, and palliative ones to reduce soreness and associated oedema in the lesions of a more advanced disease. This treatment modality has few side effects and does not modify the immunological condition of the patients. These statements, as they result from the review of the related literature, are here assessed by the experience of the Authors in a series of 22 patients, treated by means of orthovoltage radiotherapy, which allows intracavitary treatments (contact X-ray therapy) and small-sized irradiation fields.

Oral hairy leukoplakia

Oral hairy leukoplakia was first described in homosexual men infected with the human immunodeficiency virus. It is thought to be caused by infection with both the Epstein-Barr virus and human papillomavirus. We report 59 cases of oral hairy leukoplakia. The disease was diagnosed in patients in all risk groups and was categorized in all classes of the Walter Reed classification without significant differences in prevalence. Epstein-Barr virus could be demonstrated in all tissue samples examined; human papillomavirus was found in only a few specimens. In our series oral hairy leukoplakia had a chronic course, although temporary spontaneous healing occurred in some cases. Its appearance was a poor prognostic sign because acquired immunodeficiency syndrome developed in a significant proportion of patients within a few months of onset.

Mucocutaneous manifestations in patients infected with human immunodeficiency virus

The mucocutaneous manifestations observed in 516 patients infected with human immunodeficiency virus attending an outpatient clinic for acquired immunodeficiency syndrome in Milan, Italy, from July 1985 to March 1987 are listed, and the clinicopathologic aspects of these disorders are reported. The prognostic significance of some human immunodeficiency virus-associated dermatoses is also discussed.

Atypical early syphilis in an hiv-infected homosexual male

A homosexual male, seropositive to HIV and with previously documented syphilitic infections, developed a slowly growing nodule on his left wrist (possibly a chancre) followed, after 2 months, by a few scattered, large papular lesions. Serological evidence of active syphilis was obtained and treponema were identified in the initial lesion by means of immunofluorescent staining. Treatment with both aqueous crystalline penicillin G and benzathine penicillin G healed the lesions. This represents a further case of an atypical presentation of early syphilis in an immunocompromised host.

Heterogeneity of dermal OKT6+ cells in inflammatory and neoplastic skin diseases

This immunopathologic study of both normal and pathologic skin specimens (contact dermatitis [CD], lichen planus [LP], cutaneous T cells lymphoma [CTCL], and histiocytosis X [HX]) allowed as to differentiate four types of dermal OKT6+ cells: (1) cells with the same morphologic features as epidermal Langerhans cells (LCs), rarely found in either normal or pathologic dermis; (2) cells structurally similar to LCs but lacking Birbeck granules (BGs), found mainly in CD and LP; (3) larger cells rich in cytoplasmic organelles, only 5% of which contained BGs. They were especially common CTCL; and (4) cells typical of HX.