Possible role of granulocyte-macrophage colony stimulating factor (GM-CSF) on the rapid progression of AIDS-related Kaposi's sarcoma lesions in vivo

Drug-related neutropenia is a common observation in AIDS patients. Haematological growth factors are therefore increasingly used in combination with myelotoxic agents to reduce the risk of infection and to improve the haematological tolerance of these regimens. We report a case of an AIDS patient with Kaposi's sarcoma who received GM-CSF for severe neutropenia due to anti-tumour chemotherapy combining alpha-interferon 2b and zidovudine. During GM-CSF administration there was a marked increase in the size of the Kaposi's sarcoma lesions as confirmed by ultrasonographic examination. As GM-CSF in vitro has been shown to promote Kaposi's sarcoma-like cell cultures, we discuss the potential role of this growth factor in increasing Kaposi's sarcoma lesions in vivo.

Survival differences in European patients with AIDS, 1979-89. The AIDS in Europe Study Group

OBJECTIVES

To examine the pattern of survival and factors associated with the outcome of disease in patients with AIDS.

DESIGN

Inception cohort. Data collected retrospectively from patients' charts.

SETTING

52 clinical centres in 17 European countries.

SUBJECTS

6578 adults diagnosed with AIDS from 1 January 1979 to 31 December 1989.

MAIN OUTCOME MEASURES

Survival after the time of diagnosis.

RESULTS

The median survival after diagnosis was 17 months, with an estimated survival at three years of 16% (95% confidence interval 15% to 17%). Patients diagnosed in southern Europe had a shorter survival, particularly immediately after the time of diagnosis, compared with patients diagnosed in central and northern Europe (survival at one year (95% confidence interval) 54% (52% to 56%) 66% (64% to 68%), 65% (63% to 66%), respectively. The three year survival, however, was similar for all regions. The regional differences in survival were less pronounced for patients diagnosed in 1989 compared with earlier years. Improved survival in recent years was observed for patients with a variety of manifestations used to define AIDS but was significant only for patients diagnosed with Pneumocystis carinii pneumonia. The three year survival, however, remains unchanged over time.

CONCLUSIONS

Survival of AIDS patients seems to vary within Europe, being shorter in southern than central and northern Europe. The magnitude of these differences, however, has declined gradually over time. Short term survival has improved in recent years, but the long term prognosis has remained equally poor, reflecting the fact that the underlying infection with HIV and many of the complicating diseases remains essentially uncontrolled.

Comparison of long-term prognosis of patients with AIDS treated and not treated with zidovudine. AIDS in Europe Study Group

OBJECTIVE

To determine the association between elapsed time since starting zidovudine and survival in patients with acquired immunodeficiency syndrome (AIDS).

DESIGN

Inception cohort and observational study of patients treated and not treated with zidovudine.

SETTING

Fifty-one centers in 17 European countries.

PATIENTS

A total of 4484 patients diagnosed as having AIDS from 1979 to 1989 who survived their initial AIDS-defining event and who had not started zidovudine before AIDS diagnosis.

MAIN OUTCOME MEASURES

Use of zidovudine and mortality.

RESULTS

Among patients who did not receive zidovudine, the death rate was approximately constant for the first 5 years after AIDS diagnosis. For patients treated with zidovudine, the death rate within the first year since starting zidovudine was markedly lower than for untreated patients who had developed AIDS at the same time (relative rate, 0.47; 95% confidence interval [CI], 0.42 to 0.51). For longer times since starting zidovudine, the association with reduced mortality rate was diminished, and for patients surviving more than 2 years since starting zidovudine, the death rate was greater than for untreated patients who had developed AIDS at the same time (relative rate, 1.35; 95% CI, 1.15 to 1.58). Adjustment for other prognostic factors failed to substantially affect this observation.

CONCLUSIONS

When initiated after the time of AIDS diagnosis, zidovudine was associated with improved prognosis but for no more than 2 years after starting therapy.

Successful treatment of progressive mucocutaneous infection due to acyclovir- and foscarnet-resistant herpes simplex virus with (S)-1-(3-hydroxy-2-phosphonylmethoxypropyl)cytosine (HPMPC)

The acyclic nucleoside phosphonate (S)-1-(3-hydroxy-2-phosphonylmethoxypropyl)cytosine (HPMPC) was used topically for the treatment of persistent mucocutaneous infections in two cases. One patient with AIDS suffered from a perineal lesion due to infection with herpes simplex virus type 2 (HSV-2) and did not respond to acyclovir and was intolerant of foscarnet. A bone marrow transplant recipient developed orofacial lesions due to infection with herpes simplex virus type 1 (HSV-1) that failed to respond to therapy with both acyclovir and foscarnet. After topical application of HPMPC, the HSV-2 lesions completely resolved. However, the lesions recurred 3 weeks later, and, upon subsequent treatment with HPMPC, regressed. On recurrence, the virus was found to be sensitive to acyclovir, which the patient was given. Again HSV-2, which was resistant to acyclovir, emerged; similar observations were made after another cycle of HPMPC therapy. The HSV-1 isolates were resistant to acyclovir and foscarnet. Following local HPMPC treatment, the lesions regressed, but after 1 week, a second course of topical HPMPC therapy had to be instituted for recurrent infection. The lesions again regressed, and as the recurrent virus was sensitive to acyclovir, the patient was successfully treated with the drug. The results of this study point to the potential usefulness of topical HPMPC in the treatment of immunocompromised patients with HSV-related mucocutaneous infections that are refractory to therapy with acyclovir and/or foscarnet.

Zidovudine twice daily in asymptomatic subjects with HIV infection and a high risk of progression to AIDS: a randomized, double-blind placebo-controlled study. The European-Australian Collaborative Group (Study 017)

OBJECTIVE

To evaluate the efficacy of zidovudine given twice daily in subjects with asymptomatic HIV-1 infection and a high risk of progression to AIDS.

DESIGN

Randomized, double-blind placebo-controlled trial.

SETTING

Multicentre study in five European countries and Australia.

PATIENTS

Asymptomatic subjects (n = 329) with CD4 cell counts between 200 and 400 x 10(6)/l, or if > 400 x 10(6)/l, subjects with HIV p24 antigenaemia (> 10 pg/ml).

INTERVENTION

Patients were randomly assigned to receive zidovudine 500 mg or placebo twice daily for 104 weeks, following a 250 mg four times daily dose regimen for the first 4 weeks.

MAIN OUTCOME MEASURES

The primary end-point was the development of AIDS or severe AIDS-related complex (ARC). Before unblinding the study other end-points were defined: the development of Centers for Disease Control and Prevention (CDC) group IV disease (AIDS, severe ARC and other CDC stage IV disease) and the development of symptomatic HIV disease (AIDS, severe ARC, other CDC stage IV disease and minor HIV disease). Changes in CD4+ cell counts, p24 antigenaemia and toxicity were also reviewed.

RESULTS

Median treatment duration was 57 weeks for the placebo and 60 weeks for the zidovudine group, respectively. Progression to AIDS or severe ARC occurred in 17 placebo and 12 zidovudine recipients (log-rank P = 0.26). However, in the first of the 2 study years the rate of progression to AIDS or severe ARC was significantly higher in the placebo than in the zidovudine group. Zidovudine delayed progression to symptomatic HIV disease (P = 0.01); a trend in a delay in progression to CDC stage IV disease was observed (P = 0.08). Zidovudine recipients maintained CD4+ cell counts at or above baseline levels for longer than placebo recipients (P = 0.04). HIV p24-antigen levels decreased in the zidovudine group and returned to pretreatment levels by week 36. Substantial toxicity was not observed.

CONCLUSIONS

Zidovudine twice daily is effective in delaying progression to symptomatic HIV disease in high-risk, asymptomatic HIV-infected subjects. Modified definitions of clinical end-points may be useful for evaluating Phase III trials in comparable patient groups in the light of changes in the definition of AIDS and the increasing use of primary prophylaxis against opportunistic infections.

Zidovudine in persons with asymptomatic HIV infection and CD4+ cell counts greater than 400 per cubic millimeter. The European-Australian Collaborative Group

BACKGROUND

Zidovudine therapy is of benefit in the treatment of symptomatic and asymptomatic human immunodeficiency virus (HIV) infection in persons with CD4+ cell counts of less than 500 per cubic millimeter. The efficacy, safety, and duration of benefit of zidovudine in those with 500 or more CD4+ cells per cubic millimeter are uncertain.

METHODS

In a double-blind, placebo-controlled trial, 993 patients with asymptomatic HIV infection and CD4+ cell counts above 400 per cubic millimeter were randomly assigned to receive zidovudine (500 mg twice daily) or placebo for three years. The primary end point was progression of disease, as defined by the development of Centers for Disease Control and Prevention (CDC) group IV disease (including recurrent oral candidiasis, hairy leukoplakia, or progressive diarrhea) or two CD4+ cell counts below 350 per cubic millimeter. This outcome measure was changed from the original end point of the acquired immunodeficiency syndrome (AIDS) or advanced AIDS-related complex to reflect changes in recommendations for management. The study was terminated after the first interim analysis.

RESULTS

Disease progression was significantly less frequent in the zidovudine group (relative risk, 0.56; 95 percent confidence interval, 0.43 to 0.75; P < 0.001 by the log-rank test). The probability of disease progression at two years was 0.19 with zidovudine, as compared with 0.34 with placebo (95 percent confidence interval for the difference, -0.21 to -0.08). Progression to CDC group IV disease was reduced by half in the zidovudine recipients (relative risk, 0.49; P = 0.049) and decline in CD4+ cell counts to below 350 per cubic millimeter was reduced by 40 percent (relative risk, 0.60; P < 0.001). The inclusion of early HIV disease events (oral candidiasis, oral hairy leukoplakia, and herpes zoster) as end points confirmed the effects of zidovudine on the progression of clinical disease (relative risk, 0.55; 95 percent confidence interval, 0.37 to 0.84; P = 0.004). The median duration of treatment was 94 weeks. Severe hematologic or clinical side effects were rare.

CONCLUSIONS

Treatment with zidovudine benefits HIV-infected persons with CD4+ cell counts above 400 per cubic millimeter. Despite the use of doses larger than those now generally prescribed, zidovudine was well tolerated for up to three years by most of our patients.

Current use of anti-HIV drugs in AIDS

Since 1987 major advances have been made in our understanding of the pathogenesis of infection and the possible inhibition of the HIV virus. Various drugs targeted to the different steps of viral replication have been selected, but drugs such as soluble CD4 or dextran derivatives aimed to inhibit or interfere with the GP120-CD4 attachment step have shown little or no clinical benefit. Protease inhibitors or interferons acting at the post-transcriptional level are currently under phase I to II investigation. The only group of compounds clinically active belong to the nucleosides analogues that act as DNA chain terminators and by inhibiting viral reverse transcriptase. Zidovudine (AZT), didanosine (ddI) and dideoxycytidine (ddC) have been extensively studied, and used on a large clinical scale. Stavudine (D4T), deoxyfluorothymidine (FLT) and 3'thiacytidine (3TC) are entering phase I-II studies. Being the first nucleoside analogue discovered and used since early 1985, zidovudine remains the gold standard of anti-HIV therapy. Zidovudine is indicated at a dosage varying between 500 and 1000 mg in patients with AIDS and ARC, in asymptomatic patients with CD4 < 200/mm3 and in asymptomatic patients with CD4 between 200 and 500 cells/mm3 with a rapid decrease of CD4 cell count or a positive P24 circulating antigen. There is as yet no consensus concerning patients with more than 500 cell/mm3. ddI and ddC are currently indicated for patients intolerant to AZT or in those who have not responded (clinically or biologically) to AZT. Emergence of resistance to AZT has been reported in 30 to 80% of patients at various stages of the disease and after six to nine months of therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Comparison of atovaquone (566C80) with trimethoprim-sulfamethoxazole to treat Pneumocystis carinii pneumonia in patients with AIDS

BACKGROUND

Both trimethoprim-sulfamethoxazole and pentamidine are effective as treatments for Pneumocystis carinii pneumonia, but adverse effects frequently limit their use. Atovaquone (566C80) is a new hydroxynaphthoquinone with activity against P. carinii.

METHODS

We conducted a double-blind, multicenter study in patients with the acquired immunodeficiency syndrome and mild or moderately severe P. carinii pneumonia. They were randomly assigned to 21 days of orally administered treatment three times daily with either atovaquone (750 mg) or trimethoprim (320 mg) plus sulfamethoxazole (1600 mg).

RESULTS

Of the 322 patients with histologically confirmed P. carinii pneumonia, 160 received atovaquone and 162 received trimethoprim-sulfamethoxazole. Of those who could be evaluated for therapeutic efficacy, 28 of 138 patients given atovaquone (20 percent) and 10 of 146 patients given trimethoprim-sulfamethoxazole (7 percent) did not respond (P = 0.002). Treatment-limiting adverse effects required a change of therapy in 11 patients in the atovaquone group (7 percent) and 33 patients in the trimethoprim-sulfamethoxazole group (20 percent) (P = 0.001). Therapy involving only the initial drug was successful and free of adverse effects in 62 percent of those assigned to atovaquone and 64 percent of those assigned to trimethoprim-sulfamethoxazole. Within four weeks of the completion of treatment, there were 11 deaths in the atovaquone group (4 due to P. carinii pneumonia) and 1 death in the trimethoprim-sulfamethoxazole group (P = 0.003). Diarrhea at entry was associated with lower plasma drug concentrations (P = 0.009), therapeutic failure (P < 0.001), and death (P < 0.001) in the atovaquone group but not in the trimethoprim-sulfamethoxazole group.

CONCLUSIONS

For the treatment of P. carinii pneumonia, atovaquone is less effective than trimethoprim-sulfamethoxazole, but it has fewer treatment-limiting adverse effects.

The efficacy and safety of zidovudine alone or as cotherapy with acyclovir for the treatment of patients with AIDS and AIDS-related complex: a double-blind randomized trial. European-Australian Collaborative Group

OBJECTIVE

To evaluate the efficacy and safety of zidovudine (ZDV) at a maintenance dose of 250 mg every 6 h alone or as cotherapy with acyclovir (ACV; 800 mg every 6 h) as treatment for AIDS and AIDS-related complex (ARC).

DESIGN

Double-blind, randomized, placebo-controlled clinical trial of up to 1 year's therapy.

SETTING

Teaching hospital ambulatory clinics in eight European countries and Australia.

SUBJECTS

A total of 131 patients with AIDS and 134 with ARC were enrolled and followed from 1986 to 1988.

MAIN OUTCOME MEASURES

Time to development of AIDS-defining opportunistic infections and AIDS-associated neoplasms, survival assessed at 1 year after entry, performance status, body weight, CD4+ cell counts.

RESULTS

During the study period, 46 (36%) ZDV recipients and 37 (27%) cotherapy recipients developed opportunistic infections. The probability of an ARC patient progressing to AIDS (1982 Centers for Disease Control criteria) was 0.18 and 0.15 [95% confidence interval (CI) for difference, -0.17 to 0.11] for the ZDV alone and cotherapy recipients, respectively. After excluding patients who experienced an opportunistic infection during the first 4 weeks of therapy, the probability was 0.13 and 0.099 (95% CI for difference, -0.16 to 0.10) for the ZDV and cotherapy recipients, respectively. Thirty-six patients treated with single-agent therapy [28 (41%) AIDS and eight (12%) ARC patients] and 15 cotherapy recipients [13 (21%) AIDS and two (3%) ARC patients] died during the study. There was a significant difference in time to death between the cotherapy and ZDV alone groups for both AIDS (P = 0.014) and ARC (P = 0.045) patients, with cotherapy patients surviving longer. Infections related to herpesviruses, but not cytomegalovirus, were reduced in patients receiving ACV therapy. CD4+ cell counts in both arms generally increased initially and then declined. Forty-six per cent of patients in the ZDV group (59% of AIDS and 31% of ARC patients) and 52% of patients in the cotherapy group (69% of AIDS and 34% of ARC patients) experienced bone-marrow suppression. Red cell transfusions were administered to 33% of ZDV alone recipients and 34% of cotherapy recipients.

CONCLUSION

These data show that the addition of high-dose ACV cotherapy to ZDV for patients with AIDS and advanced ARC results in a statistically significant improvement in survival with minimal increase in the risk of toxicity.

Pharmacokinetics of R 82913 in AIDS patients: a phase I dose-finding study of oral administration compared with intravenous infusion

The pharmacokinetics of oral administration of R 82913, or tetrahydroimidazol [4,5,1-jk]-benzodiazepin-2(1H)-one or -thione (TIBO), was compared with those of intravenous administration in five AIDS patients. TIBO was administered as a single daily 1-h infusion of 100 mg for 29 days and orally as a single daily dose for 14 days with three consecutive regimens of 100, 200, and 100 mg with probenecid (1 g) daily. Each cycle was followed by a wash-out period. Oral bioavailability of TIBO appears to be low and is not improved by the adjunction of probenecid. Trough levels obtained with oral administration systematically remained far below the 90% inhibitory concentration of TIBO against human immunodeficiency virus type 1 (HIV-1). Tolerance of TIBO was excellent. No clinical efficacy could be demonstrated. p24 antigenemia decreased significantly in one patient under intravenous therapy. TIBO derivatives are promising anti-HIV-1 agents in vitro, but improvement of oral bioavailability is needed before implementation of long-term efficacy and tolerability studies. Moreover, rapid emergence of resistance, which has been recently documented, constitutes a major problem with most nonnucleoside reverse transcriptase inhibitors.

Treatment of toxoplasmic encephalitis in patients with AIDS. A randomized trial comparing pyrimethamine plus clindamycin to pyrimethamine plus sulfadiazine. The California Collaborative Treatment Group

OBJECTIVE

To compare pyrimethamine plus clindamycin (PC) to pyrimethamine plus sulfadiazine (PS) as a treatment for toxoplasmic encephalitis (TE) in patients with the acquired immunodeficiency syndrome (AIDS).

DESIGN

Randomized, unblinded phase II, multicenter trial with provision for crossover for failure or intolerance of the assigned regimen.

SETTING

University hospitals.

PATIENTS

Eighty-four patients with presumptive TE were entered. Thirteen were excluded when they were found to have another diagnosis, and 12 were excluded because they did not meet entry criteria. The baseline characteristics in the remaining 26 patients randomized to PC and 33 randomized to PS were comparable.

INTERVENTIONS

Patients were treated for 6 weeks with pyrimethamine and folinic acid plus either sulfadiazine or clindamycin. Clindamycin was given intravenously during the first 3 weeks.

MEASUREMENTS AND MAIN RESULTS

There was a trend toward greater survival in patients randomized to PS (hazard ratio, 3.25; 95% CI, 0.63 to 16.8; P = 0.13), but most study deaths were not directly related to TE. In contrast, patients randomized to PC appeared more likely to achieve complete clinical (odds ratio, 0.67; CI, 0.2 to 1.97; P greater than 0.2) and radiologic responses (odds ratio, 0.28; CI, 0.08 to 0.96; P = 0.02). Multivariate analysis revealed drug effects to be largely independent of other variables. Similar efficacy of the treatments was also suggested by a hazard analysis of resolution of abnormal mental status, fever, and headache. Skin rash was the most common adverse event in both treatment arms. Because of toxicity, six patients randomized to PC and 11 patients randomized to PS had to switch to the alternate treatment, but only three were unable to complete therapy after crossover.

CONCLUSIONS

The results of several end points of efficacy, taken together, suggest that the relative efficacy of PC approximately equals that of PS. PC appears to be an acceptable alternative in patients unable to tolerate PS.

Anticardiolipin antibodies (ACA) are most often not associated with lupus-like anticoagulant (LLAC) in human immunodeficiency virus (HIV) infection

Anticardiolipin antibodies (ACA) and lupus-like anticoagulant (LLAC) have been studied in a group of 142 non-hospitalized and a group of 72 hospitalized HIV infected patients. We observed a variable frequency of ACA positivity ranging from 7.7% to 30.3% according to the groups of patients and the isotype of immunoglobulin fraction containing ACA activity. None of the patients investigated presented a prolongation of the activated partial thromboplastin time (APTT) compatible with the presence of a LLAC. Some patients presented a weak anticoagulant activity only detected by the tissue thromboplastin inhibition (TTI) test. No positive correlation was found between this latter test and ACA. We conclude that, like in syphilitic patients, ACA present in HIV infected patients are most often not associated with LLAC.

The efficacy and safety of zidovudine with or without acyclovir in the treatment of patients with AIDS-related complex. The European-Australian Collaborative Group

Our objective was to evaluate the efficacy and safety of zidovudine (250 mg every 6 h) alone or in combination with acyclovir (800 mg every 6 h) as treatment for AIDS-related complex (ARC). A double-blind, controlled clinical trial of 6 months therapy was conducted at teaching hospital ambulatory clinics in eight European countries and Australia; 199 patients were studied. Time to development of AIDS-defining opportunistic infections (OI) and AIDS-associated neoplasms, survival, performance status, body weight and CD4+ cell counts were measured. During the study six (9%) zidovudine recipients, five (7%) combination recipients and 12 (18%) placebo recipients developed AIDS-defining OI; the probability of developing an OI was 0.23, 0.09 and 0.08 for the placebo, zidovudine and combination recipients, respectively. Four patients in the placebo group, three in the zidovudine group and one in the combination group died during the study. Patients receiving zidovudine with or without acyclovir had moderate increases in CD4+ cell counts compared with placebo recipients and serum HIV p24 antigen level decreased significantly in all those receiving zidovudine. Fourteen (21%) patients in the zidovudine group and 16 (24%) in the combination group experienced bone-marrow suppression compared with three (5%) placebo recipients. Red-cell transfusions were administered to 6, 19 and 13% of placebo, zidovudine and combination recipients, respectively. These data confirm the efficacy of zidovudine therapy after 4 weeks' treatment in the reduction of development of OI in patients with ARC and support the use of a maintenance dose of 250 mg zidovudine 6-hourly. Given the increased development of OI in the treated groups compared with placebo during the first 4 weeks of therapy, we cannot exclude an initial adverse effect of zidovudine and recommend caution in the use of a loading dose of zidovudine. At 6 months there was no apparent difference in efficacy between the combination of zidovudine and acyclovir compared with zidovudine alone. Moreover, the addition of high-dose acyclovir resulted in a minimal increase in the risk of toxicity.

Efficacy of oral fluconazole in the treatment of AIDS associated oesophageal candidiasis

To assess the efficacy and tolerance of fluconazole in the treatment of oesophageal candidiasis, 47 AIDS patients with this infection were enrolled in an open prospective study using fluconazole 100 mg given orally once daily. Clinical cure was obtained in all of 41 evaluable patients, with confirmation of cure in all of 31 patients who underwent post-treatment oesophagoscopy. Forty patients were followed up for at least 30 days; none suffered a relapse of oesophagitis but seven had a recurrence of stomatitis which was effectively treated with fluconazole. Fluconazole was well tolerated. Nausea was noted in three patients one of whom interrupted therapy. Transient mild elevation of ALT/AST was noted in five of 41 patients (12%). Fluconazole appears to be a safe and effective agent for oral therapy of oesophageal candidiasis associated with AIDS.

[Current aspects of AIDS]

HIV epidemic is still expanding all over the world. Heterosexual transmission into the general population is of particular concern mostly in Africa and Western countries. So far, pathogenesis of the syndrome is best explained by the likely role of co-factors that interfere with the latency phase of the virus. In this setting early treatment by specific antiviral therapy such as zidovudine, will probably slow down the evolution of HIV infection.

Some aspects of the epidemiology of toxoplasmosis and pneumocystosis in AIDS in Europe

The incidence and prevalence of Toxoplasma gondii and Pneumocystis carinii infections among AIDS patients in Europe are different from those observed in the USA. These differences are probably causally related to differences in host exposure, and sociocultural and nutritional habits.

Biochemical thyroid profile in patients infected with the human immunodeficiency virus

Over a 2-year period, thyroid function was studied in 102 patients infected with the human immunodeficiency virus (HIV) and in 102 age- and sex-matched controls with various infectious diseases. Biochemical abnormalities were observed in 1-20% of the patients, depending on thyroid indices, but thyroid disease (hypothyroidism) was diagnosed in only 1. Compared to controls, patients, especially those with the acquired immunodeficiency syndrome (AIDS), had a significant increase in serum thyroxine-binding globulin, a lower T3 and free thyroxine index, and a higher frequency of thyroglobulin antibodies.

Pancreatic disturbances and typhoid fever

During an 8-year period, 14 adult patients were hospitalized with typhoid fever confirmed by positive blood cultures for Salmonella typhi. Among these patients, we have retrospectively (n = 7) and prospectively (n = 7) evaluated pancreatic disturbance by serum amylase and lipase measurements at the time of admission. In 7 (50%) biological signs of pancreatitis were noted: mean amylase level 81 IU (range 30-201 IU, normal value less than 40 IU), mean lipase level 949 IU (range 468-2,000 IU, normal value less than 300 IU). Clinical signs of pancreatitis were observed in 4 cases, one of whom had a concomitant salmonella biliary tract infection and gall stones demonstrated by laparotomy and the others a normal biliary ultrasonographic examination with a swelling of the pancreas. No alcohol or drug use or other infection were noted before admission. This study suggests that biological or clinical pancreatitis should be considered as a frequent complication of typhoid fever. S. typhi should therefore be added to the list of pathogens implicated in the pathogenesis of non-alcoholic or non-lithiasic pancreatitis.

[Computed tomography aspects of cerebral toxoplasmosis in AIDS]

We followed by CT 19 AIDS patients with cerebral toxoplasmosis. Diagnosis of cerebral toxoplasmosis was assessed on radiological and clinical basis, including the therapeutic response. CT allowed to confirm brain lesions (40 lesions in 19 patients) and to follow the evolution with treatment. Analysis of the CT features of these brain lesions permits to define some characteristic findings, though not pathognomonic. These lesions share common characteristics with other granulomatous diseases or with brain abscesses. The most frequently observed features are: target lesions (74%) with contrast enhancement (95%), frequently multiple (53%), associated with a hypodense area of oedema (100%), and responsible for a mass effect (79%). Under treatment, we observed improvement in 89%, resulting either in complete disappearance of the lesions (16%), disappearance of one or more contrast enhancing (46%) or hypodense (6%) areas, or volumetric regression of the hypodensities (50%). We conclude that CT is a good first-step examination for the detection and follow-up of cerebral toxoplasmosis in AIDS patients. MRI, a method with a higher sensitivity but still less accessible, may be considered at the present time as a second-step examination for those patients with solitary lesions on CT, or for symptomatic patients with normal CT.

[Heterosexual transmission of AIDS]

Heterosexual bidirectional transmission of HIV is now clearly proved. In Western countries, and in particular in Belgium, the existence of clusters of heterosexual transmission demonstrates that, as in Central Africa, the epidemic could spread among heterosexuals. Sexual contacts with partners who belong to different high risk groups for HIV may introduce the virus in the general population. This is mainly true with bisexual men, IV drug users or people originating from endemic areas. Prostitutes are also at high risk to be infected and to transmit HIV. Prevention campaigns toward heterosexuals should begin at a pre-epidemic stage and focus on counselling of infected individuals, voluntary testing of contacts of these subjects and selected screening programmes.

Comparison of fluconazole and ketoconazole for oropharyngeal candidiasis in AIDS

In a randomised, double-blind study the efficacy and toxicity of oral fluconazole 50 mg daily and ketoconazole 200 mg daily were compared for the treatment of oropharyngeal candidiasis in patients with acquired immunodeficiency syndrome (AIDS) and AIDS-related complex (ARC). 20 episodes (18 patients) were treated with fluconazole and 20 episodes (19 patients) with ketoconazole. Pretreatment clinical features and laboratory test results were similar in both groups. 17 episodes (85%) in the fluconazole group and 16 (80%) in the ketoconazole group could be evaluated. There was clinical cure at the end of therapy in all fluconazole-treated and 12 of 16 (75%) ketoconazole-treated episodes. Cultures were negative at the end of therapy in 87% of the fluconazole group and 69% of the ketoconazole group. 1 patients stopped taking fluconazole because of severe nausea. 1 of 18 fluconazole-treated and 4 of 19 ketoconazole-treated patients had transient rises in alanine or aspartate aminotransferase. Fluconazole seemed more effective than ketoconazole in the treatment of oral thrush among AIDS and ARC patients.

Preliminary results on clinical and immunological effects of thymus hormone preparations in AIDS

The human immunodeficiency virus (HIV) is the newly recognized agent of the acquired immunodeficiency syndrome (AIDS). Global defects of the immune functions, including T- and B-cell immunity, macrophage functions and cytokine production, are commonly observed among patients with HIV infection. Many studies have shown thymus involvement and endocrine function impairments among these patients. Clinical trials with thymic compounds aiming at restoring the immune dysfunctions will be reviewed.

Antiviral drugs other than zidovudine and immunomodulating therapies in human immunodeficiency virus infection. An overview

Although the management of patients with human immunodeficiency virus infections has focused on the treatment of opportunistic infections, or acquired immune deficiency syndrome (AIDS)-related cancers in end stages of the disease, therapies now aim at preventing the natural progression of the underlying disease. In addition to zidovudine many investigational drugs are proposed to treat AIDS-related complex patients. Most of these therapies can be divided into two major groups: (1) The first group includes agents with antiretroviral properties: nucleoside analogues, such as 2'-3'-dideoxycytidine and ribavirin, suramin, antimoniotungstate (heteropolyanion-23), foscarnet (phosphonoformate), interferons, peptide T, castanospermine, dextran sulfate, AL721, or ampligen. (2) The second group aims to restore the defective immune system; it includes thymosin (thymopentin), interleukin-2, cyclosporine, plasmapheresis, bone marrow transplantation, inosine, sodium diethyldithiocarbamate, methionine-enkephalin and carrisyn. At present, no drug other than zidovudine has proved as monotherapy to lengthen survival of human immunodeficiency virus-infected patients.

Human immunodeficiency virus transmission among heterosexual couples in Central Africa

From February to June 1986, 150 heterosexual couples with at least one HIV-seropositive member were recruited in the 'Centre Hospitalier de Kigali', Kigali, Rwanda. Of the 138 HIV-seropositive couples in whom both members were tested, 124 (90%) were sexual unions between two antibody-positive partners, illustrating the high efficiency of the heterosexual transmission of HIV. A comparison of these 124 couples with 150 HIV-seronegative couples showed that, in the husbands, seropositivity is significantly associated with sexual contacts with prostitutes and history of sexually transmitted disease (STD) within the past 2 years. Seropositive wives were less likely to be in their first marriage and reported more episodes of STD than seronegative ones. Seropositive couples were similar to seronegatives in their history of blood transfusion, male circumcision and overall use of contraception but not in their use of oral contraceptive pills, which was more frequent; they were more often in polygamous unions. Discriminant analysis showed that STD, sexual contacts with prostitutes and the number of previous unions are the most powerful independent variables associated with the seropositivity of the couples. Most of the risk factors for the couples were the risk factors for the husband, suggesting that in most cases the husband acquired the HIV infection and passed it to his wife.

Salmonella bacteremia in African patients with human immunodeficiency virus infection

During a two-year period, 26 Central African patients with AIDS or AIDS-related complex were seen in two Belgian hospitals and five of these patients presented with non-typhoid Salmonella bacteremia. Three additional patients were observed in a Rwandese hospital. These eight African patients were compared with 16 non-AIDS patients with non-typhoid Salmonella bacteremias. The patients with AIDS or AIDS-related complex did not have gastroenteritis, but they did have a high recurrence rate and high prevalence of Salmonella typhimurium. Long-term antibiotic prophylaxis seems warranted for such patients despite the high frequency of side effects from antibiotics.

Current problems in the management of AIDS patients

Human immunodeficiency virus infection has numerous clinical manifestations and affects patients from a broad spectrum of social, ethical, cultural and psychological backgrounds. As a result the practising physician has to face multiple, recurrent and complicated problems. This review focuses on the means of early diagnosis, treatment and prevention of opportunistic infections. It also stresses the need for a comprehensive multidisciplinary approach to provide optimal care and to diminish the sense of frustration in treating young patients with an ultimately fatal disease.

Teicoplanin compared with vancomycin in methicillin-resistant Staphylococcus aureus infections: preliminary results

Twenty-one patients were included in an open randomized study comparing vancomycin 1 g bd with teicoplanin 400 mg daily in severe methicillin-resistant Staphylococcus aureus infections. The median duration of therapy was 15 days for vancomycin and 21 days for teicoplanin. Most patients presented with severe underlying conditions, such as major surgery (8), solid tumours (5), multiple trauma (3). The infections treated, included septicaemia, osteomyelitis, bronchopneumonia, cellulitis and acute pyelonephritis. Mean MICs of the strains were 0.39 mg/l for vancomycin and 0.195 mg/l for teicoplanin. Mean trough and peak serum concentrations of vancomycin were 14.3 +/- 5 mg/l and 34.3 +/- 13 mg/l, while the teicoplanin values were 7.5 +/- 4 mg/l and 17 +/- 7 mg/l. The cure rate was seven of 12 in the teicoplanin group and six of nine in the vancomycin group, with four and three cases, respectively, of improvement and one failure in the teicoplanin group. Transient renal impairment occurred in two cases with both regimens; superinfection and colonization in three patients and one patient, respectively, with both regimens.

Seroepidemiological study on sexually transmitted diseases and hepatitis B in African promiscuous heterosexuals in relation to HTLV-III infection

A seroepidemiological study was performed on HTLV-III, T. pallidum, C. trachomatis and Hepatitis B virus (HBV), in Butare, Rwanda, among 33 female prostitutes, 25 male customers of prostitutes, and 60 male and female controls. As compared with female controls the prostitutes had a higher prevalence of antibodies to HTLV-III (29/33 versus 4/33, p less than 0.001), T. pallidum (TPHA: 27/33 versus 6/33, p less than 0.001; RPR: 19/33 versus 2/33, p less than 0.001; FTA-Abs: 27/33 versus 5/33, p less than 0.001) and C. trachomatis (IgG IF: 31/33 versus 13/33, p less than 0.001). HBV serological markers were more often detected in the prostitutes than in the female controls (31/33 versus 18/33, p less than 0.001) although HBs antigen carriage rate was similar in both groups. As compared with male controls, the male customers of prostitutes had more frequently detectable antibodies to HTLV-III (7/25 versus 2/27, p = 0.05), and a positive RPR (10/25 versus 1/27, p less than 0.01). Among the 118 individuals studied, odds ratios and trend analysis disclosed a significant association between HTLV-III seropositivity and a positive TPHA, RPR, FTA-Abs, Chlamydia IgG IF test and serological markers to HBV. No association was found between HTLV-III seropositivity and HBs Ag carriage. This study suggests that HTLV-III has to be considered as an infectious agent transmitted among promiscuous Central African heterosexuals by sexual contact and/or parenteral contact with unsterile needles used for STD treatments.

Absence of antibodies to HIV-2/HTLV-4 in six central African nations

We studied 1508 individuals from Zaire, Burundi, Tanzania, Zambia, Kenya, and Cameroon for antibodies to HIV-2/HTLV-4. AIDS, ARC, other disease or tumor patients and healthy people were sampled from 1984-1986. By radioimmunoprecipitation and SDS/PAGE analysis and/or Western blot we failed to find any samples with specific antibodies to HIV-2/HTLV-4 indicative of infection. In contrast, 363 of these 1508 individuals demonstrated antibodies to HIV-1/HTLV-3B by the same serologic assays. HIV-2/HTLV-4 infection appears to be quite rare in Central Africa. AIDS and related syndromes in this study were exclusively correlated with HIV-1 infection. Studies in West Africa have shown high rates of infection with HIV-2/HTLV-4 where cases of AIDS are still relatively uncommon. These results indicate that HIV-2/HTLV-4 has a distinct geographic distribution from that of HIV-1 in Africa. Further studies are necessary to better define the pathogenicity and natural history of this distinct new virus, HIV-2/HTLV-4.

Seroepidemiological studies of HTLV-III antibody prevalence among selected groups of heterosexual Africans

T-lymphocyte subsets and human T-cell lymphotropic virus type III antibody prevalence were studied in African patients with the acquired immunodeficiency syndrome (AIDS) or AIDS-related complex (ARC), and in female prostitutes. African blood donors and healthy Zairian and Rwandese persons matched for age, sex, and annual income served as controls. Seropositivity was noted in 46 (87%) of 53 patients with AIDS, 29 (88%) of 33 patients with ARC, 67 (80%) of 84 prostitutes, and five (12.5%) of 40 and eight (15.5%) of 51 healthy controls and blood donors, respectively. Patients with AIDS and ARC had a significantly lower OKT4/OKT8 ratio than healthy African controls. These studies suggest that human T-cell lymphotropic virus type III infection has already spread extensively into the general African population and that female prostitutes could be an important human reservoir of AIDS virus in the heterosexual population.

Female prostitutes: a risk group for infection with human T-cell lymphotropic virus type III

In July, 1984 33 female prostitutes in Rwanda and 25 male customers of prostitutes were assessed clinically and for their T-lymphocyte subsets and frequency of antibodies to human T-cell lymphotropic virus type III (HTLV-III). 27 healthy males who denied contact with prostitutes, 33 healthy women who were not prostitutes, and 51 Rwandese prostitutes seen in 1983 served as controls. Only 6 prostitutes were symptom-free (group I), 13 had unexplained generalised lymphadenopathy (LAP) (group II), and 14 had LAP and constitutional symptoms (group III). Mean OKT4/OKT8 ratio in groups II and III was significantly lower than that in group I or in female controls. HTLV-III antibodies were detected in 29 of 33 prostitutes, 4 female controls, 7 male customers, and 2 male controls. In male customers, HTLV-III seropositivity increased according to the number of different sexual partners per year. This study suggests that in Central Africa prostitutes are a high-risk group for HTLV-III infection.