Cardiac morphologic observations after operative closure of acquired ventricular septal defect during acute myocardial infarction: analysis of 16 necropsy patients

Certain cardiac morphologic findings are described in 16 necropsy patients having operative closure of an acquired ventricular septal defect (VSD) during acute myocardial infarction (AMI). Of the 16 patients, 6 were women (mean age 69 +/- 7 years) and 10 were men (mean age 60 +/- 11 years). The AMI associated with the VSD was the first coronary event in 13 patients (81%). At least 6 patients had a history of systemic hypertension. Conduction disturbances were diagnosed by electrocardiogram in 5 patients (31%). The median interval from the onset of the AMI to death was 11 days, and from the onset of the AMI to operative closure of the VSD, 4 days. Eight patients died in the operating room or within 2 hours of operation. Coronary artery bypass grafting was performed simultaneously with the VSD closure in 7 patients. Death was attributed to unsuccessful VSD closure in 5 patients, to inadequate left ventricular cavity after resection of necrotic myocardium in 5 patients and to inadequate viable left ventricular myocardium in 4 patients. Heart weights were increased in 14 patients (88%). The AMI associated with the VSD was anterior in 9 patients and posterior (inferior) in 7. Healed myocardial infarcts were present in 3 patients. All 16 patients had severe (greater than 75% in cross-sectional area) narrowing of 1 or more of the 4 major epicardial coronary arteries.

Human immunodeficiency virus infection and routine childhood immunisation

Current experience with the safety and efficacy of vaccines in infected children and adults is reviewed to examine the basis for decisions about routine immunisations of children infected with the human immunodeficiency virus (HIV). No adverse reactions to inactivated vaccines have been noted, but complications with live vaccines have been recorded with both BCG and smallpox. Limited experience with live poliomyelitis and measles vaccines in HIV-infected children has not yet shown any severe complications from these vaccines. Theoretical concerns that immunisation might accelerate the course of HIV infection are not supported by available data. Serological response to most inactivated and live vaccines is reduced in HIV-infected persons, and is related to the degree of immunosuppression present. Preliminary evidence suggests that the severity of some vaccine-preventable diseases is increased in HIV-infected children. This review finds general support for recommendations on immunisation of HIV-infected children that have been developed by the World Health Organisation.

Persistent diarrhea, strongly associated with HIV infection in Kinshasa, Zaire

Ninety-eight (40%) of 243 acquired immune deficiency syndrome inpatients at Mama Yemo Hospital, Kinshasa, Zaire, presented with a history of diarrhea for at least 1 month. To determine the predictive value of persistent diarrhea for human immune deficiency virus (HIV) infection, 128 consecutive patients presenting at Mama Yemo Hospital with persistent diarrhea were tested for the presence of HIV antibodies. One-hundred seven (84%) of the 128 patients with diarrhea lasting at least 1 month were found to be HIV seropositive. HIV seropositive patients with persistent diarrhea more often had a generalized papular pruritic eruption (p = 0.02), a genital herpes simplex infection (p = 0.05), a history of herpes zoster (p = 0.08), and infection with cryptosporidia (p = 0.006) than HIV seronegative patients with persistent diarrhea. Bacterial enteric pathogens were found in 5 (7%) of the 76 seropositive and in none of the 14 seronegative patients in whom stool cultures were performed. Presently persistent diarrhea in adults in central Africa is strongly associated with HIV infection, but the pathophysiological mechanisms causing this diarrhea remain unclear.

Generalized papular pruritic eruption in African patients with human immunodeficiency virus infection

Of 284 patients hospitalized with HIV infection, 52 (18%) presented with a generalized pruritic papular eruption. No significant association between this eruption and other HIV manifestations or any opportunistic infection was found. Fifty-three of 61 (87%) consecutive African patients referred for a generalized papular pruritic eruption of unknown etiology of at least 1 month's duration were HIV seropositive, including 15 (65%) of 23 in good general condition. Thirty-seven (95%) of 38 patients with this eruption and severe weight loss (greater than 10% of normal body weight) were seropositive. The initial skin lesions were small, firm, intensely pruritic papules which released a small drop of clear fluid when scratched. Scratched papules became later hyperpigmented macules. Lesions were symmetrically distributed over the body and were most frequently found on the extensor surfaces of the arm, the dorsal surface of the hands, the inferior part of the legs, the ankles and the dorsum of the feet. Histologic examination showed a non-specific inflammatory reaction. Thirty-three (51%) patients reported that the skin eruption was their initial disease manifestation. In African patients, the presence of an unexplained generalized pruritic papular eruption is highly indicative of HIV infection.

Detection of human T cell leukemia virus type I and human immunodeficiency virus in cultured lymphocytes of a Zairian man with AIDS

We report the detection of human T cell leukemia virus type I (HTLV-I) and human immunodeficiency virus (HIV) in the cultured lymphocytes of a 45-year-old Zairian man with AIDS. HIV was successfully isolated and analyzed by SDS-PAGE and competition radioimmunoassay. However, by the culture techniques used, HTLV-I could not be separated from the HIV. Western blot analysis of the patient's serum showed the presence of both HTLV-I- and HIV-specific antibodies. The finding of this dual infection may explain reports that greater than or equal to 30% of patients with AIDS are positive for antibodies to HTLV-I.

Nonbronchoscopic lung lavage for diagnosis of opportunistic infection in AIDS

Thirty patients known to have or suspected of having acquired immunodeficiency syndrome (AIDS) were evaluated for opportunistic pulmonary infection using a double lumen lavage catheter (DLL). Lavage specimens obtained were cytocentrifuged and initially stained by the Papanicolaou technique as a means of rapid evaluation for Pneumocystis carinii. If no opportunistic organism was identified, the patient underwent further diagnostic investigations. In 18 patients receiving mechanical ventilatory support, the procedure was performed via the endotracheal tube. Twelve patients who were less severely ill underwent the procedure via the transnasal route. In 43 percent (13/30), opportunistic infections were diagnosed by DLL. Twelve had P carinii, one of whom had cytomegalovirus and another of whom had Herpes simplex viruses, and one with Toxoplasma gondii. Thus, the sensitivity for all opportunistic infections was 86 percent (12/14). The volume of fluid recovered averaged 93 percent of that instilled. There was no significant difference between prelavage and postlavage PaO2. In this group of patients, double lumen lavage obviated the need for more invasive and expensive procedures.

Evaluation of a clinical case-definition of acquired immunodeficiency syndrome in Africa

A provisional clinical case-definition for acquired immunodeficiency syndrome (AIDS) developed by the World Health Organisation (WHO) for use in Africa was tested on 174 inpatients at Mama Yemo Hospital, Kinshasa, Zaire. In this hospital population with a 34% infection rate of human immunodeficiency virus (HIV), the clinical case-definition had a specificity of 90%, a sensitivity of 59%, and a predictive value of 74% for HIV seropositivity. These results support the use of the WHO clinical definition for AIDS in Africa. However, since HIV prevalence and disease expression vary, similar evaluations should be carried out in different regions.

Absence of association between Plasmodium falciparum malaria and human immunodeficiency virus infection in children in Kinshasa, Zaire

The possible associations between Plasmodium falciparum malaria and HIV (human immunodeficiency virus) seropositivity were investigated in 1986 at the Mama Yemo Hospital in Kinshasa, Zaire. No significant difference was found in the HIV seropositivity rate of 164 children presenting with P. falciparum malaria (1.2%) and 169 healthy controls (0.6%). Secondly, no association was found between P. falciparum slide positivity (51.6%) and HIV seropositivity (3.8%) among 1046 children presenting to the hospital with medical complaints. Infants less than 6 months old had the lowest slide-positivity rate, but among infected children the younger ones more frequently had high parasitaemias. HIV seropositivity rates were highest for children less than 6 months old. In older children, seropositivity was strongly associated with a history of blood transfusion. Thus, in Kinshasa children, P. falciparum malaria is a major public health problem; perinatal transmission and blood transfusions constitute important mechanisms of HIV infection; and P. falciparum does not appear to act as an opportunistic agent in children infected with HIV.

Septicemic plague in New Mexico

Eighteen of the 71 cases of plague reported in New Mexico from 1980 to 1984 were septicemic. We reviewed these cases to better describe the clinical presentation of this disorder and to identify risk factors for developing septicemic plague. The symptoms (fever, chills, malaise, headache, and gastrointestinal symptoms) and signs (tachycardia, tachypnea, and hypotension) of septicemic plague are similar to those of other forms of gram-negative septicemia. Abdominal pain was reported in nearly half of the cases, and differential white blood cell counts revealed a marked shift to the left. The risk of developing septicemic plague was higher for persons greater than 40 years of age. Because of empirical antibiotic treatment of older persons, deaths from septicemic plague occurred primarily among persons less than 30 years old. Deaths from septicemic plague could be reduced by aggressive antibiotic therapy for patients with a clinical presentation suggesting gram-negative septicemia, especially patients less than 30 years old.

HIV seroprevalence among hospital workers in Kinshasa, Zaire. Lack of association with occupational exposure

A study of seroprevalence of the human immunodeficiency virus involving 2384 (96%) of Mama Yemo Hospital's (Kinshasa, Zaire) 2492 personnel found 152 (6.4%) to be seropositive. Prevalence was higher among women than among men (8.1% vs 5.2%); in women peak seroprevalence (13.9%) occurred in 20- to 29-year-olds. Workers most likely to be seropositive were those who were relatively young, those who were unmarried, those reporting a blood transfusion or hospitalization during the previous ten years, and those receiving medical injections during the previous three years. Medical, administrative, and manual workers had similar seroprevalence (6.5%, 6.4%, and 6.0%, respectively), and seropositivity was not associated with any measure of patient, blood, or needle contact. These findings are consistent with other hospital-based studies indicating low risks for occupational transmission of human immunodeficiency virus.