Impact of Insertions in the HIV-1 P6 Ptapp Region on the Virological Response to Amprenavir

We evaluated the impact of genetic changes within p6Gag gene on the virological response (VR, mean decrease in plasma viral load at week 12) to unboosted amprenavir (APV). Gag-protease fragments, including gag p2, p7, p1, p6 regions and whole protease (PR) were sequenced from baseline plasma specimens of 84 highly pre-treated but APV-naive patients included in the NARVAL (ANRS 088) trial. The correlation between baseline p6Gag polymorphism, PR mutations, baseline characteristics and VR to APV was analysed in univariate analysis. Insertions (P459Ins) within p6 protein, leading to partial or complete duplication of the PTAPP motif, were significantly associated with a decreased VR (P459Ins versus wild-type; –0.3 ±0.8 vs –1.1 ±1.2 log copies/ml, P=0.007) and were more frequent when the V82A/F/T/S PR mutation was present ( P=0.020). In multivariate analysis, after adjustment on the predictive factors of the VR in the NARVAL trial and on the PR mutations linked with response, there was a strong trend to an association ( P=0.058) between the presence of P459Ins and an altered VR. In conclusion, these results suggest that insertions in the p6 region of HIV-1 gag gene may affect the VR, in highly pre-treated patients receiving an unboosted APV-containing regimen.

Association between mutations in the CARD15 (NOD2) gene and Crohn's disease in Israeli Jewish patients

Ulcerative colitis (UC) and Crohn's disease (CD) are heterogeneous disorders characterized by chronic intestinal inflammation. Genetic predisposition is a major risk factor in both diseases. The CARD15 (NOD2) gene has been implied as a candidate gene in the pathogenesis CD. Our aim was to delineate the frequency of three missense and one frameshift variant of CARD15 in Israeli Jewish CD and UC patients. DNA was extracted from blood samples from 238 unrelated inflammatory bowel disease (IBD) patients, 68 with UC and 170 with CD. The DNA was genotyped for two missense mutations, R675W and G881R, and one frameshift mutation, 980FS981X. Mutations in CARD15 were observed with significantly greater frequency in CD patients (46/170, 27%) than in UC patients (7/68, 10%) (P = 0.005). Homozygous and compound heterozygous carriers were restricted to seven (4%) patients with CD as compared to none of the UC patients (P = 0.01). Similar rates in Ashkenazi and non-Ashkenazi Jewish patients were observed. Age-of-onset of disease was lower in Ashkenazi mutation carriers as compared to non-carriers of Ashkenazi origin (18.7 +/- 8.6 years vs. 25.8 +/- 13.4 years, respectively, P = 0.03). No other phenotypic characteristics could distinguish mutation carriers from non-carriers. We conclude that germline mutations in the CARD15 gene are more frequently found in CD than UC patients and appear to predict an earlier age-of-onset in Ashkenazi Jewish patients. No association could be demonstrated between CARD15 mutations and specific disease course or behavior.

Impact of early-untreated HIV infection on chronic hepatitis C in intravenous drug users: a case-control study

OBJECTIVE

The impact of early-untreated HIV infection on chronic hepatitis C was determined in a case-control study, aimed at limiting factors associated with the progression of immunodeficiency.

METHODS

HIV-infected patients attending for a medical examination during 1995-1996 were systematically screened for: previous intravenous drug use without other HIV or Hepatitis C virus (HCV) risk factor, CD4 cell count > 200/microl, no AIDS, no antiretroviral treatment, positive anti-HCV antibody, negative hepatitis B surface antigen, abnormal aminotransferase activity. Thirty-eight consecutive eligible HIV-infected patients (cases) were included. Thirty-eight HCV-infected patients without HIV infection whose unique risk factor was intravenous drug use (controls) were paired to cases according to age, sex, and duration of HCV infection.

RESULTS

Cases and controls had similar ages, sex ratios, duration of HCV infection, and alcohol intake. They were infected predominantly by genotypes 1 and 3. Viraemia was higher in cases than in controls. METAVIR histological scores of activity and fibrosis in cases versus controls were 2.2 +/- 0.8 versus 1.6 +/- 0.7 (P = 0.0008) and 1.8 +/- 1 versus 1.5 +/- 0.8 (P = 0.06), respectively. The percentage of cirrhosis was higher in cases, without reaching statistical difference. The progression rate of fibrosis was higher in cases. Age at contamination and METAVIR activity score were significantly associated with the progression of fibrosis in cases.

CONCLUSION

Early-untreated HIV infection is associated with higher HCV viraemia and more severe liver injury in intravenous drug users with chronic hepatitis C.

Differential pattern in circulating nitrogen derivatives, lactoferrin, and anti-lactoferrin antibodies in HIV type 1 and HIV type 2 infections

HIV-1 infection is associated with a dramatic reduction in antioxidative molecules both at the cellular level and in the circulation. This is particularly so for lactoferrin, an iron-binding protein involved in natural defenses (antimicrobial and antiviral activities, etc.) and found in whole secretions, including milk and mucus. In addition to its ability to chelate iron ions, lactoferrin inhibits hydroxy radical formation and interacts with nitric oxide (NO). Levels of plasma lactoferrin decreased in HIV-1-infected patients in correlation with progression of the disease, and highly specific anti-lactoferrin autoantibodies increased. This profile was specific to HIV-1 infection; it was not found in HIV-2-infected patients. In parallel with the drop in lactoferrin, a marked increase in circulating nitrogen derivatives was observed in HIV-1-infected patients, whereas low levels were found in normal donors and in HIV-2-infected patients. These data suggested hyperstimulation of the NO pathway throughout HIV-1 but not HIV-2 infection. This overproduction of NO could play an important role in the development of AIDS symptoms and signs.

Neurological complications of varicella-zoster virus infection in adults with human immunodeficiency virus infection

This multicentre retrospective study describes the clinical features and prognostic significance of Varicella-zoster virus (VZV)-associated neurological complications. The study was performed in patients with human immunodeficiency virus (HIV) infection, hospitalized for VZV neurological complications, confirmed in every case by positive VZV polymerase chain reaction (PCR) in cerebrospinal fluid (CSF). Between 1990 and 1995, 34 HIV-infected patients were included in the study. At diagnosis, 59% had AIDS, with a median CD4 count of 11 x 10(9)/l. A past history of zoster was noted in 35% of cases. A concomitant herpes zoster rash and/or acute retinal necrosis were noted in 71% and 12% of patients, respectively. The predominant neurological manifestations were encephalitis (13), myelitis (8), radiculitis (7) and meningitis (6). The mean CSF white blood cell count was 126/mm3 and the mean CSF protein concentration was 2.3 g/l. Interferon-alpha level was increased in 36% of patients. VZV was isolated from CSF cultures in 2/6 cases. Magnetic resonance imaging was abnormal, demonstrating encephalitis lesions. After intravenous antiviral therapy, complete recovery was obtained in 18 cases (53%), serious sequelae were observed in 10 cases (29%) and 6 patients died (18%). Severe symptoms and a low CD4 cell count appeared to be associated with death or sequelae. In conclusion, VZV should be considered as a possible cause of encephalitis, myelitis, radiculitis or meningitis in HIV-infected patients, especially in patients with a history of or concomitant herpes zoster or acute retinal necrosis. VZV-PCR in the CSF may allow rapid diagnosis and early specific antiviral treatment.

[A paraneoplastic acrosyndrome]

BACKGROUND

Paraneoplastic digital ischemia is an uncommon complication of metastatic adenocarcinomas.

CASE REPORT

Two years after remission of an uterine adenocarcinoma, the patient developed an acrosyndrome involving all four limbs with digital ischemia. Recurrent carcinoma was evidenced by a very high antinuclear antibody titer. Chemotherapy improved the acrosyndrome.

DISCUSSION

Vasomotor disorders which developed in older subjects with no other signs of autoimmune disorders should suggest a neoplastic origin. Icshemia of the fingers would be caused by vasculitis. An elevated antinuclear antibody titer may be a supplementary argument suggesting a neoplastic etiology.

Polyarthralgia-arthritis syndrome induced by low doses of rifabutin

We describe 2 cases of polyarthralgia-arthritis syndrome induced by rifabutin, an effective treatment for infections of Mycobacterium avium intracellulare complex. This syndrome has been reported with doses higher than 1 g per day when rifabutin is given in monotherapy. But our cases were treated with low doses, 300-450 mg per day, in combination with clarithromycin. The plasma concentration of rifabutin has been shown to be increased by clarithromycin, suggesting that co-prescription of clarithromycin could lead to development of rifabutin induced polyarthralgia-arthritis syndrome.

Cerebral infarction associated with vasculitis due to varicella zoster virus in patients infected with the human immunodeficiency virus

Cases of herpes zoster ophtalmicus (HZO) with delayed contralateral hemiparesis caused by hemispheric stroke secondary to granulomatous angiitis have been reported and are a well-recognized complication of herpes zoster. Similar cases have been reported more recently during infection with human immunodeficiency virus (HIV). We describe two HIV+ patients without any clinical history of zoster dermatitis who developed a sudden hemiparesis followed 2 weeks later for one by an acute retinal necrosis. Computerized tomography (CT) scan, magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA) were performed and showed a hemispheric stroke with evidence of a segmental arteritis of the carotid syphon. Varicella zoster virus (VZV) was found in the cerebro spinal fluid (CSF) in the two patients and after puncture of the vitreous fluid of the patient with the acute retinal necrosis. These two cases exemplify the difficulty of diagnosis of stroke in HIV+ patients, which seems to be more frequent than in similarly aged non-infected patients and demonstrates that VZV needs to be taken in consideration and identified even without any past history of zoster dermatitis.

HHV8 status in Kaposi's sarcoma associated with multiple myeloma

Kaposi's sarcoma in its sporadic or HIV-related form is due to a gamma herpesvirus, the human herpes virus 8 (HHV8). No data have been published on the potential role of the HHV8 in Kaposi's sarcoma occurring in multiple myeloma patients. A case is reported of a patient in whom four serum samples taken between the diagnosis of multiple myeloma and the occurrence of a Kaposi's sarcoma one year later tested positive for antibody to the HHV8. Similar findings have been reported in patients with other types of Kaposi's sarcoma. PCR studies for HHV8 DNA were positive on a Kaposi's sarcoma biopsy but negative on a bone biopsy, militating against a role for the HHV8 in the genesis of multiple myeloma.

[Mixed corticomedullary tumor]

BACKGROUND

Pheochromocytoma and primary hyperaldosteronism rarely occur simultaneously. Few cases have been reported in the literature.

CASE REPORT

A patient explored for hypertension was found to have hypokalemia related to primary hyperaldosteronism. Pathology examination of the ablated adrenal showed a co-existing pheochromocytoma suspected at history taking although urine catecholamines were normal.

DISCUSSION

Different pathogenic hypothesis have been proposed. Such dual tumors could be a simple coincidence, occur in a particular genetic setting, be related to direct contact between cortical and medullary tissue leading to reactional cortical hyperplasia, pheochromocytoma produced factors stimulating aldosterone synthesis, or factor X, a substance produced by cortical adenomas and favoring growth of the pheochromocytoma.

AIDS-related Kaposi's sarcoma patients with visceral manifestations. Response to human chorionic gonadotropin preparations

OBJECTIVE

In vitro cell culture studies and a murine model for human Kaposi's sarcoma (KS) have shown that human chorionic gonadotropin (hCG)-associated factor (HAF) isolated from commercial hCG preparations has antiproliferative and cell killing effects on neoplastic KS cells, without toxic effects on normal endothelial cells and lymphocytes. These findings prompted preliminary study of hCG preparations for patients with early-stage KS with skin lesions only and no known visceral involvement. Complete or partial regression of the skin lesions occurred after intralesional injections of hCG (hCG-Pregnyl, hCG-APL). The current study sought to extend these early observations to evaluation of the safety of hCG in acquired immunodeficiency syndrome (AIDS) KS patients with aggressive disease and visceral involvement. These patients present in a more advanced stage of the disease that is coupled with serious immunodeficiency. They commonly respond poorly to conventional chemotherapy and have a reduced median life expectancy of only 4 to 9 months.

STUDY DESIGN/METHODS

After approval by the local institutional review boards, 13 patients with advanced AIDS-KS gave informed consent and were treated with hCG preparations. These hCG preparations are known to have antiproliferative activity in laboratory tests. Patients were monitored for tumor size by clinical evaluation, ultrasonography, radiography, respiratory functions, and endoscopic examination. Histologic examinations of biopsied tissues were used for studies of apoptosis using in situ hybridization techniques. The patients were also monitored for CD4+ T-cell numbers and human immunodeficiency virus type 1 (HIV-1) plasma viral load according to common clinical practice.

RESULTS

Thirteen patients with advanced AIDS-KS and visceral KS were treated with hCG. Five of 13 (38%) patients had dramatic responses to therapy, and overall tolerance to the drug was excellent for all patients. Some hCG preparations also showed beneficial effects against HIV-associated markers. An accompanying decrease in viral load (plasma HIV-1 RNA) was observed in one patient, a dramatic increase in CD4+ cells occurred in another, and significant weight gain was seen in seven patients.

CONCLUSIONS

These clinical observations suggest that patients with aggressive visceral forms of KS, usually indicative of an extremely poor prognosis and poor response to combined chemotherapy, can benefit from this new therapeutic approach. In some patients, these preparations also induce several other beneficial effects, such as weight gain, reduction in HIV-1 RNA load, or increase in the CD4+ T-cell count. Additional controlled clinical trials comparing this new therapeutic option with standard cytotoxic chemotherapy are needed. These trials should be extended to patients with KS not related to HIV-1 infection. Because we showed elsewhere that pure hCG had no effect on KS, identification and subsequent clinical use of the active molecules in hCG preparations is urgently needed.

[Cerebral arteritis in AIDS. Demonstration with MRA in 2 patients]

Two cases of cerebral arteritis related to varicella-zoster virus in seropositive patients are presented. Diagnosis of arteritis was made by conventional angiography. However, 3D Time of Flight MR Angiography demonstrated an excellent sensitivity in detection of cerebral arterial stenosis located at the skull base.

[Pulmonary toxoplasmosis in patients with human immunodeficiency virus infection. 21 cases]

OBJECTIVES

Assess expression of pulmonary toxoplasmosis, the second most frequent localization after brain, in patients infected with the human immunodeficiency virus (HIV).

METHODS

Twenty-one HIV-infected patients (18M, 3F) were admitted for pulmonary toxoplasmosis between September 1987 and February 1995. Mode of HIV transmission was unprotected homosexual sexual activity (n = 16), intravenous drug abuse (n = 3) and transfusion (n = 2).

RESULTS

Isolated pulmonary toxoplasmosis was found in 11 patients. In 10 patients pulmonary toxoplasmosis was associated with cerebral (n = 4), bone marrow (n = 2), ocular (n = 1) and multifocal (n = 3) localizations. Seven patients were admitted for acute pulmonary distress. Fever (reported for 20 patients) and nonproductive cough (reported for 16 patients) were the most common clinical symptoms. Chest roentgenogram revealed bilateral pulmonary infiltrates in 16 (76%) patients. Mean absolute CD4 count was 25 +/- 57 (range 0-110). Serologic evidence of past infection was observed in 18 patients. Serology tests were not done for two patients and negative for one. Two patients presented co-infection with Pneumocystis carinii. Fourteen patients had elevated serum lactic dehydrogenase (LDH) concentration. Among those, 4 patients whose LDH concentration was elevated more than ten fold died of respiratory distress. Patients received pyrimethamine and sulfadiazine (n = 13) or clindamycin (n = 8). Seven patients died during the first month after diagnosis was made. For the other patients, mean survival was 8 months. No relapse of toxoplasmosis was observed. All the patients took a secondary prophylaxis.

CONCLUSION

No difference between patient with isolated pulmonary toxoplasmosis and patients with associated extra-pulmonary localization was noted for clinical, biological, radiological presentations and outcome.

Risk factors for isolation of Streptococcus pneumoniae with decreased susceptibility to penicillin G from patients infected with human immunodeficiency virus

We conducted a retrospective study of all hospitalized human immunodeficiency virus (HIV)-infected patients from whom a strain of Streptococcus pneumoniae was isolated (n = 45) between January 1992 and September 1994, in order to determine the clinical manifestations and outcome of and risk factors for infection by S. pneumoniae with decreased susceptibility to penicillin G. Such strains were isolated from 14 patients (31%), of whom 8 had pneumonia, 2 had bronchial superinfection, 2 had sinusitis, and 2 were colonized. All infected patients made a clinical recovery regardless of the MIC of the isolate. Indexes of HIV disease stage (CD4+ cell count and p24 antigenemia), antiretroviral treatment, and hospital admission in the previous 3 months did not influence the susceptibility of the isolates. For HIV-infected patients, treatment with antibacterial agents--particularly trimethoprim-sulfamethoxazole--in the previous 3 months is associated with an increased risk for isolation of S. pneumoniae with decreased susceptibility to penicillin G (relative risk, 5.0; 95% confidence interval, 1.9-13.3).

[Acid-alcohol-resistant bacilli detected by microscopic analysis of exhaled air from HIV-infected patients: tuberculosis or mycobacteriosis?]

OBJECTIVES

The incidence of atypical mycobacterial infections has increased with the AIDS epidemic. To present, microscopic examinations of airway specimens positive for acid-fast bacteria were highly suggestive of tuberculosis. However, since the AIDS epidemic, certain authors have reported an increase in Mycobacterium avium intracellulare found in respiratory specimens. The aim of this work was to determine what factors might distinguish between these two infections revealed discovery of an acid-fact bacilli.

METHODS

Hospital files of all HIV seropositive patients seen between November 1992 and March 1995 and with at least one airway specimen positive for acid-fast bacilli were studied retrospectively.

RESULTS

Mycobacterium tuberculosis was isolated in 19 patients, Mycobacterium avium intracellulare in 8 and culosis and M. avium intracellulare. There was no difference for age, sex, geographical origin, transmission mode, antigen positivity, radiologic findings or clinical signs between patients with the different types of mycobacterium. The CD4 count was however significantly lower in patients with an atypical mycobacteriosis (14.5/mm3) than in patients with tuberculosis (91.7 +/- 83.7) (p = 0.004).

CONCLUSION

These findings show that in HIV-infected patients with a CD4 count under 100/mm3, the presence of acid-fact bacilli can indicate either M. tuberculosis or M. avium intracellulare. Combined anti-tuberculosis and antimycobacteriosis therapy thus would appear to be justified until the germ can be identified.

Changes in systemic gonadal and adrenal steroids in asymptomatic human immunodeficiency virus-infected men: relationship with the CD4 cell counts

Serum sex hormone-binding globulin (SHBG), testosterone, non-SHBG-bound testosterone, androstenedione, dihydrotestosterone (DHT), dehydroepiandrosterone (DHEA), follicle-stimulating hormone (FSH), luteinizing hormone (LH) and cortisol were measured in 58 homosexual men seropositive for human immunodeficiency virus (HIV), all clinically asymptomatic (Centers for Disease Control 1993 classification stage A). The HIV patients were divided into four groups according to the CD4 lymphocyte count--group 1 (more than 500/microliters, N = 14), group 2 (between 350 and 500/microliters, N = 16), group 3 (between 200 and 349/microliters, N = 22) and group 4 (less than 200/microliters, N = 6)--and compared with 11 antibody-negative men as controls. The SHBG levels were significantly increased in groups 1, 2, 3 (p < 0.01) and 4 (p < 0.05) compared with controls, with no differences between groups of patients. Compared with controls, testosterone concentrations were significantly lower in group 4 (p < 0.05) and non-SHBG-bound testosterone levels were significantly lower in groups 1 (p < 0.05), 2 (p < 0.01), 3 (p < 0.001) and group 4 (p < 0.001); DHT and androstenedione levels were significantly lower in group 4 (p < 0.05) and DHEA levels were significantly lower in group 2, group 3 (p < 0.01) and group 4 (p < 0.05) than in controls. Cortisol levels were significantly increased in groups 1 and 4 (p < 0.05) and FSH and LH concentrations were not significantly higher in HIV-infected men than in controls. Also, the DHEA, androstenedione, non-SHBG-bound testosterone and DHT levels were correlated with CD4 cell counts, showing that hypogonadism occurs as the CD4 lymphocytes decrease.(ABSTRACT TRUNCATED AT 250 WORDS)

[Histoplasmosis, caused by Histoplasma capsulatum, and AIDS]

Histoplasma capsulatum histoplasmosis occurs frequently in endemic areas and with the AIDS outbreak, it appears as an opportunistic fungus involved in disseminated disease. We report the clinical, biological and treatment features of seven cases diagnosed in the CISIH of the Eastern part of Paris. Clinically, four patients were suffering from pulmonary symptoms, in three cases digestive disorders and in three cutaneous lesions. In all cases, the mycologic diagnosis was necessary. Amphotericin B and itraconazole were used as treatment for five patients (two died before the diagnosis was completed). Among these five subjects, four died (death was attributed to histoplasmosis in only one case). These observations emphasize the importance of this infection in HIV-infected patients coming from endemic areas.

Impairment of circulating lactoferrin in HIV-1 infection

Levels of plasma lactoferrin are decreased in HIV-1-infected patients in relation to the progression of the disease. Plasma lactoferrin concentrations were determined using a specific and sensitive enzyme immunoassay. 97 plasma were studied (22 asymptomatic, 45 symptomatic patients compared to 30 healthy controls) and the results showed a highly significant decrease (p < 0.001) of the level of lactoferrin in HIV-1-infected patients (respectively 2.79 +/- 1.2 and 0.68 +/- 0.22 micrograms/ml) compared to controls (4.37 +/- 0.83 micrograms/ml). Since it is well established that plasma lactoferrin level could be influenced by the number of neutrophils, the experiments were reproduced in neutropenic patients who represent 10% of recruitment (6 among 45 symptomatic patients). The plasma from neutropenic symptomatic patients (neutrophils < or = 1,300/mm3) showed their mean lactoferrin level at 0.36 micrograms/ml still far above the normal values. In view of the different reported biological effects of lactoferrin that are of great importance in the non-specific defences, the real biological place of the lack of such a molecule could be one important component of the multifactorial nature of HIV-1 infection.

HIV-1 soluble antigens induced CD8+ cytotoxic T-cell responses in an immunized individual

In an attempt to determine whether immunization of healthy HIV-1 seronegative individuals with a soluble gp160 candidate vaccine could induce an anti-HIV specific immune response, volunteers were immunized by two injections of a water-in-oil emulsion containing a mixture of gp160 antigen together with selected peptides. Following immunization, lymphocytes were collected and stimulated in vitro with autologous HIV-1-infected cells. The results showed that immunization with soluble HIV-1 envelope was able to generate CD3+ CD8+ CTLs directed to gp160 antigen. The CTL response was restricted to class I molecule HLA-A2. The CTL response was comparable to that elicited by immunization with HIV-1-envelope recombinant vaccinia virus.

A prospective evaluation of clinical criteria and polymerase chain reaction assay of cerebrospinal fluid for the diagnosis of cytomegalovirus-related neurological diseases during AIDS

OBJECTIVE

To study the predictive value of clinical criteria and polymerase chain reaction (PCR) assay of cerebrospinal fluid (CSF) for the diagnosis of cytomegalovirus (CMV)-related neurological disorders during AIDS.

SETTING

Four infectious diseases departments in two tertiary referral teaching hospitals in Paris, France.

DESIGN AND PARTICIPANTS

One-year prospective study involving 164 consecutive immunosuppressed HIV-seropositive patients undergoing lumbar puncture (LP).

METHODS

A tentative diagnostic classification, based on strict operational criteria and PCR assay of CSF, was performed at the time of LP. At the end of the study, tentative diagnoses and PCR results were blindly and independently compared with the firm diagnoses, based on central nervous system histology, clinical outcome and/or viral culture of CSF.

RESULTS

The tentative diagnosis showed CMV-related neurological disease in 38 patients, and CMV DNA was detected in 42. Among the 88 patients for whom a firm diagnosis was possible, 26 had a diagnosis of CMV-related neurological disease. The concordance between the tentative and firm diagnoses was 61%, with a kappa index of 0.40. In contrast, the sensitivity and specificity of PCR were respectively 92 and 94%, with positive and negative predictive values of 86 and 97%. The presence of CMV DNA in CSF was associated with an increased risk of death (P < 0.0001).

CONCLUSIONS

Unlike clinical criteria, PCR detection of viral DNA in CSF can be used reliably for antemortem diagnosis of CMV-related neurological disease, a frequent complication of AIDS in this study. This rapid method should make a major impact on the management of these patients.