The Walter Reed staging classification for HTLV-III/LAV infection

Methodological issues in the study of HIV+ individuals

Because of advances in the treatment of the human immunodeficiency virus (HIV), increased numbers of individuals infected with HIV are remaining in the work force longer. Ergonomists will be called upon soon to modify the work environment or job to allow these individuals to remain productive. Few data, however, exist that can help an ergonomist make such changes for HIV+ individuals. The ergonomist, therefore, either must extrapolate from existing data or collect relevant data. This paper addresses some of the issues that an ergonomist will confront when interpreting existing data or conducting research using HIV+ individuals.

Cytolytic response to HIV in patients with HIV disease treated with extracorporeal photochemotherapy: preliminary study

Extracorporeal photochemotherapy (photopheresis), an immunomodulatory therapy that targets circulating T helper lymphocytes, has been applied to the management of human immunodeficiency virus (HIV) disease. Any therapy that exerts its actions on CD4+ T cells has the potential of exacerbating HIV infection. Therefore, it was necessary to observe immune function during treatment. Because cytotoxic T lymphocytes (CTL) and natural-killer cells are thought to play an important role in the response against HIV infection, we examined the effect of photopheresis on HIV cytolytic activity. The study group consisted of seven patients with late-stage HIV disease who had not received any previous treatment for HIV infection. Patients were treated exclusively with photopheresis on two consecutive days each month for 14-32 months (average, 25 months). Peripheral lymphocytes, collected at various points during treatment, were used as effectors in a 51Cr release assay. Epstein-Barr virus (EBV)-transformed autologous B cell lines transfected with recombinant vaccinia vectors that expressed the HIV env (gp120, gp41) and gag (p24) proteins were used as target cells. All seven patients demonstrated relatively constant levels of cytolysis (>10% above controls) during treatment in the context of stable CD4+ T cell counts and a stable clinical status. These results suggest that extracorporeal photochemotherapy did not impair the cytolytic response to HIV infection and may have enhanced it in some patients.

The role of functional status in predicting inpatient mortality with AIDS: a comparison with current predictors

To assess the independent prognostic role of functional status, as reflected by a measure of an inpatient's global requirement for nursing assistance with basic activities of daily living (Global ADL), we compared Global ADL with three validated AIDS mortality predictors: the Clinical AIDS Prognostic Staging (CAPS); the Severity Classification System for AIDS Hospitalization--version 2 (SCAH-2); and CD4 cell count. Our study sample consisted of 1392 patients with AIDS and a hospital stay of 3 or more days at one of 20 hospitals in 11 U.S. cities with high AIDS incidence. Data were collected from September 1990 through December 1991. Two percent of patients refused participation, and 26% were eliminated due to incomplete data collection, leaving an analytic sample of 1003 patients. Only 30% of patients had a CD4 count measured at any time during hospitalization. Cox regression was used to measure the hazard of inpatient mortality adjusted for length of stay. Overall mortality was 12%. Mortality rates for patients in Global ADL stages I-IV were 3%, 8%, 19%, and 51%, respectively (p < 0.0001). Global ADL more effectively discriminated mortality than CAPS (p < 0.001), SCAH-2 (p < 0.001), or CD4 count (p < 0.001). Global ADL also added independent information in analyses adjusted for both CAPS and SCAH-2: a single stage increase of Global ADL demonstrated a 1.9-fold increased hazard of death (CI: 1.6, 2.3). SCAH-2, assigned at discharge, was not strongly correlated with admission predictors (Global ADL: r = 0.17; CI: 0.11, 0.23 or CAPS: r = 0.03, CI: 0.02, 0.17). We conclude that Global ADL, alone or in tandem with other severity systems, provides an excellent severity adjustment for inpatient mortality with AIDS. Finally, CD4 cell counts were not routinely available and were not as predictive as Global ADL in the patients for whom both were available.

Periodontal disease in HIV seropositive patients and its relation to lymphocyte subsets

This study was performed to determine the type of periodontal pathology found in a group of HIV+ patients and its relation to serum levels of CD4. The sample consisted of 101 individuals: intravenous drug users (84%), homosexuals (7%), and heterosexuals (10%). Each patient was examined clinically and radiographically. Periodontal clinical parameters included gingival index and probing depth and loss of attachment on four sites per tooth. Severity of disease was defined as the most severe lesion found: gingivitis, or early, moderate, or advanced periodontitis. CD4 counts were determined on 64 of these patients. Associations between severity of the disease and gender and CD4 counts were analyzed using the Mantel Haenszel chi square test, while associations between severity and age and CD4/CD8 ratio were analyzed using the Kruskal-Wallis test. No disease was found in 14.8% of the sample, gingivitis was found in 21.8%, early periodontitis in 43.6%, moderate periodontitis in 10.9%, and advanced periodontitis in 8.9%. Linear gingival erythema (LGE) was seen in 17.8% of all patients and necrotizing periodontitis (NUP) in 4.9%. No statistically significant differences were observed between the severity of the disease and CD4 counts.

Estimation of survival after AIDS diagnosis: CD4 T lymphocyte count versus clinical severity

We compared the relative contribution to estimating survival after AIDS diagnosis of a clinical severity measure, the Severity Index for Adults with AIDS (SIAA), and laboratory values at AIDS diagnosis that are often used prognostically. Three SIAA categories were defined from the first AIDS-defining condition and the most severe complication within 3 months. We studied 421 Italian patients surviving > or = 3 months after AIDS diagnosis. Survival curves for laboratory measures grouped by quartile showed poorest survival for CD4 count <100/microliter, hemoglobin <8 g/dl, total lymphocyte count <400/microliter, and albumin <3 g/dl. Adjusting for demographics and zidovudine therapy, the estimated hazard of death was 2.4 (95% CI, 1.6-3.5) for CD4 counts <100/microliter versus higher counts and 4.9 (95% CI, 3.0- 7.8) for the most versus the least severe SIAA category. SIAA offered greater prognostic discrimination than CD4 count at AIDS diagnosis.

Role of beta 2-glycoprotein I in the anticardiolipin antibody affinity for phospholipid in autoimmune disease

The binding capacity to cardiolipin and the functional affinity of affinity-purified anticardiolipin (aCL) IgG of patients with autoimmune disease have been compared with those of individuals with malaria and acquired immunodeficiency syndrome (AIDS). The binding of autoimmune IgG aCL was enhanced gradually by the incorporation of increasing amounts of beta 2-glycoprotein I (beta 2GPI) into the assay, in contrast to that of patients with infectious diseases. In addition, there were significant reductions of functional affinity in autoimmune disease, but not in malaria or in AIDS. These results indicate that beta 2GPI requirement for binding to the target antigen varies inversely with functional affinity in autoimmune disease when beta 2GPI was present, and suggest that IgG aCL are more heterogeneous in this type of disorder than in patients with infectious disease.

Penetrating trauma and emergency surgery in patients with AIDS

BACKGROUND

Several recent publications have suggested that emergency surgery in patients with acquired immunodeficiency syndrome (AIDS) is associated with extremely high morbidity and mortality.

PATIENTS AND METHODS

We reviewed the records of 21 patients with AIDS at the University of Miami/Jackson Memorial Medical Center in Miami, Florida, who underwent 24 emergency operations after sustaining penetrating trauma

RESULTS

Nineteen patients (90%) presented with gunshot wounds and 2 (10%) presented with stab wounds. Two patients underwent multiple surgical procedures to control hemorrhage from a complex liver injury and to drain a retained hemothorax, respectively. After surgery, patients were managed according to standard protocols, the same as those for non-AIDS patients. Wound infection was present in 4 patients (19%), and occurred only in patients with < 100 CD4+ cells/microL. Fifty-seven percent of patients had no prior knowledge of having AIDS or being seropositive for the human immunodeficiency virus. One patient died after surgery and 18 patients (86%) were still alive 6 months after discharge.

CONCLUSIONS

As the AIDS epidemic grows, general surgeons will be treating an increasing number of these patients. A low morbidity and mortality can be obtained with standard surgical care and techniques. Complications are not uncommon and should be treated as in any other surgical patient, unless it is a terminal condition or that posture runs against the patient's stated views or advance directives.

Cutaneous delayed-type hypersensitivity responsiveness in patients during and after Plasmodium falciparum and Plasmodium vivax infections

To assess cellular immune function in malaria, 61 patients admitted to the Bangkok Hospital for Tropical Diseases with Plasmodium falciparum (PF) or Plasmodium vivax malaria were examined with the MULTITEST CMI system (Merieux Institute, Florida) to evaluate delayed-type hypersensitivity (DTH) during and after acute disease over 4 weeks. All patients demonstrated significantly decreased responsiveness to seven commonly encountered recall antigens. This deficit was most severe immediately upon admission (prior to therapy). Uncomplicated Pf cases demonstrated significant hyporesponsiveness only during Week 1. Responses in moderate/severe falciparum and all vivax patients gradually increased in Weeks 2 and 3 but remained significantly below control values. This study confirms functional cell-mediated immune deficits in falciparum malaria and, for the first time, shows hyporesponsiveness in vivax malaria. We conclude that malaria causes a pronounced CMI deficit that is still detectable in some individuals for 3-4 weeks after treatment of acute infection. These changes in DTH should be a consideration in future vaccine development and in evaluation of immune status in endemic areas.

Increased soluble tumor necrosis factor receptor expression and release by human immunodeficiency virus type 1 infection

High levels of circulating soluble tumor necrosis factor receptors (sTNF-R) are associated with HIV-1 infection and disease. To understand better this association, we have investigated p55 and p75 TNF-R expression on peripheral blood mononuclear cell (PBMC) subsets and in the promonocytic cell line U937, with or without HIV infection. Using flow cytometry and monoclonal antibodies both to sTNF-R and to PBMC subsets, TNF-R were found to be expressed mostly by monocytes and in decreasing amounts and intensity in the following order: CD14+ cells > CD8+ cells > CD4+ cells. Expression of TNF-R was higher on cells obtained from HIV-infected than from noninfected subjects, and expression of p75 sTNF-R was much higher than that of p55 sTNF-R. Studying the U937 cells revealed that over 80% of the cells expressed both sTNF-R, but with greater fluorescence intensity in the HIV-1 chronically infected cells (U-937-IIIB). Treatment of the cells with PMA caused an accelerated release into the medium of both sTNF-R, with a sharp decline in their cell surface expression. Basal levels of mRNA transcripts for p75 TNF-R were higher in the U-937-IIIB cells than in the uninfected cells, but p55 TNF-R mRNA was expressed only in the HIV-1-infected cells. These findings show that HIV-1 infection is accompanied by predominant elevation of p75 TNF-R surface expression on monocytes and CD8+ lymphocytes, and results in both increased message and expression of these receptors in monocytes.(ABSTRACT TRUNCATED AT 250 WORDS)

Lower extremity lymphedema caused by acquired immune deficiency syndrome-related Kaposi's sarcoma: case report and review of the literature

A case of severe lymphedema of the lower extremity caused by obstruction by human immunodeficiency virus-associated Kaposi's sarcoma is presented. A review of the signs and symptoms of obstructive lymphedema and Kaposi's sarcoma is provided. Early recognition of this clinical entity may allow use of simple preventative measures and help to avoid this life- and limb-threatening situation.

Surgery for anal lesions in HIV-infected patients

Anorectal manifestations are commonplace in patients with HIV infection. However, standardized or rational treatment of these conditions has not been proposed and many patients are denied adequate treatment based on fear of complications. This review looks critically at the available literature to draw conclusions about treatment, results and complications of surgery for anorectal problems in these patients.

Total knee arthroplasty in human immunodeficiency virus-infected hemophiliacs

Twenty-six knee arthroplasties were performed in 15 patients with hemophilia A and human immunodeficiency virus infection from 1984 to 1991. Patient age range was 27 to 48 years. After an average follow-up period of 6.4 years (range, 1-9 years) all patients were alive and none of the implants had become infected. T4 lymphocyte counts showed some deterioration, which was not clinically significant. All of the patients were improved following surgery. Nineteen implants were rated excellent, four good, and three fair. Infection with human immunodeficiency virus did not adversely affect the clinical outcome of knee arthroplasty at follow-up periods up to 9 years.

Role of antigenemia assay in the early diagnosis and prediction of human cytomegalovirus organ involvement in AIDS patients

The role of an antigenemia assay in the diagnosis and prediction of human cytomegalovirus (HCMV) disease in AIDS patients was evaluated. The clinical history of 62 patients with advanced HIV infection from whom a total of 248 blood samples were drawn and tested by the HCMV antigenemia assay was examined retrospectively. Between December 1992 and January 1994, 28 episodes of HCMV disease with organ involvement were recorded; the antigenemia assay was positive in 23 of them (82.1%). In particular, this test was positive in 11 of 12 (91.6%) first episodes and in 3 of 3 (100%) recurrent episodes occurring in patients not receiving maintenance therapy. The same test was positive in 9 of 13 (69.2%) recurrent episodes occurring in patients receiving maintenance therapy. The first occurrence of HCMV disease was always preceded by a positive antigenemia assay 2 and 4 months before diagnosis (in all 7 patients of the 7 for whom a blood sample was available before HCMV disease). A positive antigenemia test result was not always followed by organ involvement, but a high positive cell count (> 100/200,000 polymorphonuclear leukocytes) strongly correlated with the appearance of HCMV disease in the following 1 to 3 months (100% of cases). The antigenemia assay is a useful and reliable indirect method for the diagnosis and prediction of HCMV end-organ disease in severely and persistently immunocompromised AIDS patients.

Loss of periodontal attachment in HIV-seropositive military personnel

The cross-sectional relationship between severe loss of periodontal attachment (LPA) and worsening immune status due to HIV infection was evaluated in 474 HIV-infected subjects (416 men, 58 women) aged 18 to 49 years who had been classified at stages 1 through 6 of the Walter Reed Army Institute of Research (WR) Staging Classification System. LPA was measured at four sites per tooth using a manual probe; severe LPA was defined as > or = 1 site/subject exhibiting > or = 5 mm LPA. Severe LPA was found in 94 (20%) of the subjects. Modeling with multiple logistic regression analysis revealed that WR stage and peripheral CD4+ lymphocyte cell counts were not significant independent predictors of severe LPA. Severe LPA was more common in subjects at WR stage 5 or 6 who exhibited oral candidiasis (OC), a marker of immune system damage, than in persons at those WR stages without OC (odds ratio = 7.85; 95% confidence interval (CI) = 1.94-31.81). After the analysis controlled for WR stage, younger subjects receiving AZT had greater odds of severe LPA than same-age subjects not taking the drug (e.g., odds ratio for subjects aged 30 years = 2.59; 95% CI = 1.22, 5.49). Other significant predictors in the model included male sex; retired military status; cigarette smoking; and presence of cratered, ulcerated, or necrotic interdental papillae. HIV-associated immune deficiency may be associated with localized severe LPA, but this may be an indirect association due to medication use, opportunistic infection, or other factors not captured by the WR staging system or peripheral CD4+ cell counts.(ABSTRACT TRUNCATED AT 250 WORDS)

Dysfunction of visual pathways in HIV-1 infection

Foveal and conventional full field pattern-shift visual evoked potentials (f-VEPs and c-VEPs) were recorded bilaterally in 100 HIV seropositive homosexual men (HIVs) and in 40 age-matched healthy controls. In HIVs, both f-VEPs and c-VEPs revealed a significant mean increase in P100 latency (p < 0.001). In stage WR2 early conduction changes were detected in 17% of the stimulated eyes by f-VEPs and in 3% by c-VEPs. In patients with CD4 cell counts below 100/microliters a 33% reduction in the mean c-VEP amplitude was found (ANOVA p < 0.01). Multivariate analyses (MANCOVA) revealed that CD4 cell depletion was independently associated with lower (p < 0.01) and zidovudine treatment with higher c-VEP amplitudes (p < 0.05). Also patients with severe CD4 cell depletion showed a trend towards higher c-VEP amplitudes (p = 0.09) and lower f-VEP latencies (p = 0.08) after long lasting zidovudine treatment (Kruskal-Wallis test). Our data suggest that f-VEPs are a sensitive measure of subclinical optic fiber dysfunction in early HIV-1 infection and that axonal loss of optic fibers emerges with manifest immune deficiency. The inverse correlation of VEP changes and zidovudine treatment merits further studies on the question, whether inhibition of HIV replication may preserve visual pathway function.

Neuropsychological studies of asymptomatic human immunodeficiency virus-type-1 infected individuals. The HNRC Group. HIV Neurobehavioral Research Center

The current review was conducted to address the ongoing debate regarding the presence or absence of neuropsychological impairment in asymptomatic HIV-Type 1 (HIV-1) seropositive individuals. Results were summarized from 57 studies that compared the performances of seropositive asymptomatic and seronegative individuals. Overall, the differences observed between median rates of impairment for asymptomatic (35%) and seronegative (12%) groups provided the clearest indication of deficits in asymptomatics. In addition, five variables were examined as possible contributors to inconsistencies found in the literature: mode of infection, test battery type, test battery size, sample size, and method of data analysis. Of these variables, only mode of infection and test battery size appeared to substantially influence the outcome of the studies reviewed with regard to identifying neuropsychological impairment in asymptomatics.

Prevalence of HBV, HDV and HCV hepatitis markers in HIV-positive patients

Since HIV infection could condition the natural history of parenterally transmitted viral hepatitis (HBV, HCV, HDV), with possibly differing effects in different risk groups, we decided to retrospectively examine sera from a cohort of 637 HIV seropositive patients in different stages of infection, seen from 1985 to 1992, to study the prevalence and temporal course of these infections. Virological markers of HBV, HCV and HDV were determined by ELISA and RIBA methods. The severity of HIV infection was higher in homosexuals than in drug addicts. Prevalence of antiHBc antibodies was 82% in drug addicts and 77% in homosexuals, whereas antiHCV antibodies prevalence was 72% in drug addicts and only 7% in homosexuals (p < 0.000001). When only antiHBc-positive patients were considered, there was a significant difference in antiHBs antibodies between drug addicts (DA) and homosexuals (OR for DA 0.29, 95% CI 0.08/0.83, p = 0.02), suggesting that drug addicts are less able to produce a protective response. This fact cannot be explained by the severity of HIV infection (which was higher among the homosexual group) and suggests some immunodepressive effect of drug abuse. Delta infection was only detected in the drug addict group, and the prevalence was low. Finally, we cannot confirm the interference of HCV infection with the speed of HBsAg clearance: in this study the prevalence of HBsAg was almost the same in HCV-positive and negative patients.

QEEG in hemophiliacs with HIV infection

Conventional visual analysis of the EEG was performed on 320 hemophiliacs infected with HIV, who spanned the range of the Walter Reed (WR) system for classifying clinical stage of HIV infection, and on 50 HIV seronegative hemophiliac controls. Intermittent or paroxysmal slowing was the conventional EEG abnormality most commonly seen in early stages of HIV infection (stages WR1 and 2), with increased focal epileptiform activity and generalized slowing appearing in patients with the full clinical syndrome of AIDS (WR6). Slowing of the manually measured alpha rhythm was noted in stages WR2 and above. Quantitative EEG (qEEG) was obtained in a subset of 103 male HIV seropositive male hemophiliacs and 35 male HIV seronegative hemophiliac controls. The principal findings were a progressive relative increase in theta power with a tendency towards an anterior topographic distribution, and a progressive decline of spectral power in fast alpha relative to slow alpha with increasing severity of HIV disease. Significant qEEG differences from controls were apparent in WR2 subjects (seropositive with lymphadenopathy and without other constitutional symptoms), and were relatively greater in WR3-6 subjects. These results suggest sensitivity of qEEG to early CNS involvement with HIV infection.

Deficits in perimetric performance in patients with symptomatic human immunodeficiency virus infection or acquired immunodeficiency syndrome

PURPOSE

We measured the perimetric performance in patients with either acquired immunodeficiency syndrome (AIDS) or human immunodeficiency virus (HIV) disease but without AIDS.

METHODS

Light-difference sensitivity in the central field was measured in 74 eyes of 37 patients. The Humphrey Field Analyzer 640, program 30-2 was used. Additionally, 143 eyes of 143 normal control subjects were studied.

RESULTS

Mean deviation was significantly reduced in patients with HIV disease compared with control subjects (mean +/- S.E.M., -4.30 +/- 0.52 vs -0.77 +/- 0.15, respectively; P < .0001). Analysis of subgroups demonstrated that patients with lymphadenopathy syndrome or AIDS-related complex (N = 40 eyes; -3.52 +/- 0.41; P < .0001) as well as patients with AIDS (N = 34 eyes; -5.23 +/- 0.97; P < .0001) had a reduced mean deviation. Those comparisons remained significant (P < .0001) when data were analyzed independently for the right eyes and for the left eyes. Corrected pattern standard deviation (3.15 +/- 0.30 vs 1.39 +/- 0.09; P < .0001) was higher in patients with HIV disease compared with control subjects. Again, analysis of subgroups disclosed a significant increase in patients with lymphadenopathy syndrome or AIDS-related complex (2.55 +/- 0.36; P < .0001) as well as in patients with AIDS (3.85 +/- 0.51; P < .0001). Both comparisons remained significant when data were analyzed independently for the right and left eyes.

CONCLUSIONS

This study demonstrates visual dysfunction despite normal visual acuity in patients with HIV disease. Our results are consistent with the hypothesis of damage at the neuroretinal level.

Reaction time slowing in HIV-1-infected individuals: role of the preparatory interval

Psychomotor speed and directed attention were evaluated in 83 human immunodeficiency virus-1-infected individuals (HIV+) and 50 HIV-1 seronegative (HIV-) control participants using simple and choice reaction time (RT) tasks. The simple RT task included 1- and 3-s, irregularly varied preparatory intervals (PI) between the warning and target lights. Relative to the HIV- group, simple and choice RT were significantly slowed in the HIV+ group. Further, again relative to the HIV- controls, the HIV+ group did not show expected faster RT with increased response preparation time in the simple RT task. This also occurred in some HIV+ subjects who did not have psychomotor slowing. These findings suggest that RT performance in HIV-1-infected individuals may reflect separate processes associated with psychomotor slowing and impaired ability to direct attention. Possible neural mechanisms associated with control of these processes are discussed.

Serologic evaluation of human immunodeficiency virus type 1-infected individuals from Argentina and the United States indicates a similar distribution of subgroup B isolates

Utilizing peptides based on the V3 region of gp120, we undertook a serologic examination of human immunodeficiency virus type 1 (HIV-1)-infected individuals from Argentina to determine if prevalent HIV-1 isolates could be identified in this population. Our findings suggest that a similar pool of HIV-1 subgroup B isolates exists in both Argentina and the United States.

Human immunodeficiency virus infection and hepatitis C pathology

To investigate the possible influence of human immunodeficiency virus (HIV) infection on hepatitis C virus-related liver disease, liver morphology was evaluated in 160 HBsAg-negative patients with chronic hepatitis C, including 68 HIV-positive and 92 HIV-negative cases. No differences were detected in the severity of necro-inflammatory hepatic lesions between HIV-negative and HIV-positive patients when the CD4+ lymphocytes count exceeded 400 cells/mm3. In contrast, HIV-positive patients with CD4+ lymphocytes below 400 cells/mm3 showed a significantly lower grade of portal inflammation and piecemeal necrosis. These results suggest that liver lesions in hepatitis C may largely depend on immunomediated mechanisms.

Serum concentrations of soluble intercellular adhesion molecule-1 and progress towards disease in patients infected with HIV

Intercellular adhesion molecule-1 (ICAM-1) is a membrane-bound molecule that is primarily involved in cell to cell adhesive interactions of the immune system. Concentrations of soluble ICAM-1 (s-ICAM-1) shed into the circulation were measured by a quantitative ELISA in HIV-infected persons without AIDS, patients with AIDS with or without evidence of acute opportunistic infection at the time of sampling, and HIV-seronegative patients with toxoplasmosis, community-acquired pneumonia, leishmaniasis and rickettsial infections. Patients were classified on the basis of clinical condition and CD4+ T-cell counts according to the 1993 revised HIV classification of the USA Centers for Disease Control. Concentrations of s-ICAM-1 in the serum of HIV-infected persons without AIDS-indicator conditions (categories A1, A2, B1 and B2) as well as in the serum of patients with AIDS (categories A3, B3, C1, C2 and C3) were significantly higher than normal (mean +/- S.E.M. 469 +/- 23, n = 60 and 780 +/- 73, n = 56, respectively, versus 329 +/- 15 ng/ml, P < 0.0001 and < 0.0001 respectively) and differed also significantly from each other (P < 0.0001). Raised concentrations of s-ICAM-1 in the serum of afebrile patients with AIDS but without acute opportunistic infection at the time of sampling (mean +/- S.E.M. 672 +/- 76, n = 29) did not differ from those of the remaining patients with AIDS or from those of HIV-seronegative patients with the infections studied. A steady and significant increase of serum concentrations of s-ICAM-1 with progress of disease according to clinical category (categories A-->B-->C, p = 0.0007) as well as with the loss of circulating CD4+ T-cells (categories 1-->2-->3, p = 0.009) was observed. Individual serum concentrations of s-ICAM-1 showed negative correlations with individual total lymphocyte (P = 0.004), CD4+ T-cell (P = 0.05), CD8+ T-cell counts (P = 0.03) as well as positive correlation with serum concentrations of soluble interleukin-2 receptors (P < 0.0001), an indirect marker of progress of HIV-related disease. Serum concentrations of s-ICAM-1 did not differ between patients with AIDS who were receiving or not receiving zidovudine at the time of sampling. A longitudinal survey is needed in order to determine whether measuring serum concentrations of s-ICAM-1, although not specific, has any predictive or prognostic value in these patients as well as whether this bioactive molecule has any pathogenetic role in the progress of disease in HIV infection.

Neuropsychological performance and CD4 levels in HIV-1 asymptomatic infection

The performance of 68 HIV-1 seropositive asymptomatic (HIV+) subjects stratified on CD4 levels were compared with 82 HIV-1 seronegative (HIV-) subjects on a battery of neuropsychological, mood state, and perceived health status measures. The neuropsychological test battery included measures of attention, reaction time, memory, intellectual ability, psychomotor speed, frontal lobe or "executive" function, and decision time. None of the HIV+ subjects were taking antiviral agents. The groups did not differ for age, mood state, or WAIS-R Verbal and Performance IQ scores. Due to group differences for education and weekly ethanol consumption, both variables were used as covariates in multivariate analyses of variance. Relatively few differences were observed between subgroups of HIV+ patients or between these subgroups and control subjects. These data suggest that factors other than absolute levels of immunosuppression as expressed by CD4 levels alone, appear to be responsible for the deficits observed in HIV+ asymptomatic patients.

Emergent abdominal surgery in AIDS: experience in San Francisco

Several recent reviews have suggested that aggressive surgical intervention can reduce morbidity and mortality associated with intra-abdominal crises in AIDS patients. We reviewed our experience with 57 AIDS patients with 63 emergent laparotomies performed at 4 hospitals affiliated with the University of California in San Francisco. Fifty-five patients (96%) were homosexual men. Thirty-nine (68%) had been treated for an opportunistic infection. Indications for exploration included right lower quadrant pain consistent with appendicitis in 24 patients (38%), visceral perforation or obstruction in 11 (17%), right upper quadrant pain in 9 (14%), diffuse peritonitis in 8 (13%), and uncontrollable hemorrhage in 8 (13%). Perioperative mortality was 12% (7/57). Fifteen patients (26%) suffered major complications including pneumonia, sepsis, multi-organ failure, and intra-abdominal abscess. Forty-five of 50 survivors (90%) were receiving some type of chronic antimicrobial or antineoplastic chemotherapy, compared to only 2 of the 7 patients who died (28.6%) (P < 0.001). Lack of ongoing prophylactic treatment for AIDS-related disease, active opportunistic infections, Walter Reed VI classification, and ongoing sepsis at the time of exploration were noted to be associated with increased morbidity and mortality.

Improved body weight status as a result of nutrition intervention in adult, HIV-positive outpatients

OBJECTIVE

Malnutrition is an important consequence of infection with the human immunodeficiency virus (HIV); involuntary weight loss greater than 10% is one criterion that the Centers for Disease Control and Prevention uses for the diagnosis of acquired immunodeficiency syndrome (AIDS). This study was designed to determine whether nutrition intervention in a group of adult, HIV-positive outpatients affected weight maintenance.

METHODS

We undertook a retrospective review of 175 patient charts from the AIDS Reproductive Health Clinic and the Center for Special Studies at The New York Hospital. Forty-nine charts were excluded because the patient expressed a desire to reduce weight, discontinued medical care, or died. Seven charts were eliminated because of missing data. In the remaining patients (n = 119), weights were recorded for the initial clinic contact and for a follow-up visit at least 6 months later. Nutrition intervention completed by a registered dietitian was indicated on 42 patient charts (intervention group); intervention included dietary assessment, intake analysis, appropriate counselling, follow-up, and provision of supplements as needed. The remaining 77 charts did not indicate nutrition intervention; this group was called the nonintervention group. Differences between the intervention and nonintervention groups were analyzed using the two-tailed Fisher exact test and the Mann-Whitney nonparametric test.

RESULTS

Forty-two subjects (35% of the total) recieved nutrition intervention, including all of those with gastrointestinal problems (n = 10) and wasting (n = 11). Individuals in the intervention group gained a significant (P < .02) 1.2 +/- 11.4 lb (mean +/- standard deviation; median = +3 lb) compared with those in the nonintervention group who lost a mean of 3.5 +/- 12.8 lb (median = -4 lb). Twenty-six subjects (63%) in the intervention group maintained or gained weight compared with 32 subjects (42%), in the nonintervention group.

CONCLUSION

The results of this study suggest that nutrition intervention in HIV-infected persons can improve nutritional status and may lead to an enhanced ability to fight infection.

Changes of blood CD16/CD56 (NK) and HLA-DR/CD3-positive lymphocyte amounts in HIV-infected children, as related to clinical progression and p24-antigen/p24-antibody presence

This study describes a series of immunological investigations carried out on a group of 37 HIV-seropositive children, aged 3-4 years, in two different stages of disease defined according to the CDC classification; the Primary stage, an asymptomatic one, showing abnormal immune function (P1-Class, B-Subclass) and the Secondary stage, 6-8 months later, in which patients exhibited non-specific findings, i.e., loss of weight, persistent generalized lymphadenopathy and hepatosplenomegaly, associated with abnormal immune function (P2-Class, A-Subclass). In both stages, immune function was considered 'abnormal' when lymphopenia and a decrease of the CD4/CD8-cell ratio were found. The phenotypes CD16+/56+ (NK) and HLA-DR+/CD3+ (T-activated?)-positive cells, were assessed by flow cytometry, and the following supplementary systemic humoral markers were investigated in homologus serum samples; total HIV(gp)-antibody, HIV(p24)-antibody and p24-antigen presence. If at the primary stage, no significant difference from to the reference values corresponding to the age was noticed, at the Secondary stage the obtained data is presented separately in two subgroups, namely the A-subgroup characterized by the presence of total HIV(gp)-antibody, the presence of HIV(p24)-antibody and the absence of p24-antigenaemia, and the B-subgroup, where total HIV(gp)-antibody was present, HIV(p24)-antibody absent and p24-antigenaemia present. A significant decrease of CD16+/56+ (NK)-cells was found within the two subgroups. As far as HLA-DR+ from CD(3+)-cells was concerned, only those within the B-subgroup showed a high percentage level, compared to the reference values. The importance of the present findings, linked to immune monitoring of HIV infection among children, is discussed.

Hairy leucoplakia and HIV-2--a case report and review of the literature

Type 2 human immunodeficiency virus (HIV-2), originally confined to West Africa, has lately appeared with increasing frequency in Europe. Oral lesions affect a large proportion of patients with AIDS. Hairy leucoplakia (HL), a clinical expression of Epstein-Barr virus (EBV), is a lesion of the oral mucosa (usually the lateral margin of the tongue) that is observed in patients who are immunocompromised due to HIV or, more rarely, due to immunosuppressive medication or other causes. We review the definition, clinical signs, histopathology, diagnosis, prognosis and treatment of HL, and report the (to our knowledge) first detailed description of an HIV-2-seropositive patient with HL, which affected the lateral and dorsal tongue and was the first clinical sign of HIV infection (this patient was at that time only the second native Spaniard in whom unique HIV-2 infection had been detected). EBV detection and subtyping by in situ hybridization and polymerase chain reaction were performed in paraffin-embedded tissue from the HL lesion of the dorsal tongue; EBV-1 and EBV-2 were detected by the latter technique.

Immunologic status in patients infected with HIV with oral candidiasis and hairy leukoplakia

Although numerous studies of oral manifestations associated with HIV have been reported, only a few refer to the correlation of these lesions with laboratory parameters. In this study we investigated the relationships between the two most common HIV-associated oral lesions, oral candidiasis and hairy leukoplakia, with the stage of the disease, circulating CD4+ cell counts, and the presence of anti-p24 antibodies in serum and stimulated whole saliva in 43 known HIV-1-infected persons. Although oral candidiasis and hairy leukoplakia were exclusively observed in subjects who were classified as Centers for Disease Control and Prevention group IV, only the prevalence of oral candidiasis is strongly associated with circulating CD4+ counts less than 200/mm3 (p < 0.02). The prevalence of oral candidiasis and hairy leukoplakia was significantly related to the absence of anti-p24 antibodies in serum (p < 0.01 and p < 0.01, respectively), but was only statistically significant for hairy leukoplakia in stimulated whole saliva (p < 0.02). The results suggest that oral candidiasis and hairy leukoplakia in correlation with immunologic status as indicated by low circulating CD4+ cell counts and the absence of anti-p24 antibodies in serum and the loss of secretory anti-p24 antibodies in subjects with hairy leukoplakia, may constitute prognostic markers for the progression of HIV-infection to AIDS. Our results also indicate that the absence of anti-p24 antibodies is not only influenced by the low levels of circulating CD4+ cells but probably by the presence of oral candidiasis or hairy leukoplakia as well.

Isolation of Mycoplasma species from bronchoalveolar lavages of patients positive and negative for human immunodeficiency virus

The rates of isolation of Mycoplasma species from bronchoalveolar lavages of human immunodeficiency virus (HIV)-infected patients and HIV-negative patients were compared. Mycoplasma species were more frequently isolated from HIV-positive patients. In most cases, a known pulmonary pathogen was also identified. All samples tested negative for Mycoplasma fermentans by PCR.

Candida and oral candidosis: a review

Candida species are the most common fungal pathogens isolated from the oral cavity. Their oral existence both as a commensal and an opportunist pathogen has intrigued clinicians and scientists for many decades, and recent investigations have revealed many attributes of this fungus contributing to its pathogenicity. In addition, the advent of the human immunodeficiency virus infection and AIDS has resulted in a resurgence of oral Candida infections. Clinicians are witnessing not only classic forms of the diseases but also newer clinical variants such as erythematous candidosis, rarely described hithertofore. Therefore, this review is an attempt at detailing the current knowledge on Candida and oral candidoses together with the newer therapeutic regimes employed in treating these mycoses.

Working memory in individuals with HIV infection

The central executive component (CE) of Baddeley's working memory model (Baddeley, 1992) was evaluated in 26 asymptomatic human immunodeficiency virus-infected individuals (HIV+) and 23 HIV-control subjects using a dual-task working memory paradigm. The HIV+ and HIV- groups showed an equivalent reduction in performance on both the primary task (visual vigilance) and the secondary task (letter span) when they were performed concurrently relative to when either task was performed alone. This result suggested normal CE functioning in these HIV+ subjects. In contrast, the HIV+ subjects had significantly longer response latencies on reaction time measures relative to the HIV- control group. These findings indicated that slowed processing in early stage HIV-infected individuals is not associated with a working memory deficit.

AIDS-free survival and overall survival in HIV infection: the new CDC classification system (1993) for HIV disease and AIDS

The clinical history of 1538 HIV positive patients was analyzed on the basis of the new CDC classification system of HIV disease and AIDS. This classification system combines three CD4 cell categories (1, 2, and 3) with three clinical categories (A, B, and C) into nine subgroups A1-C3. We examined the overall survival for all subgroups and the AIDS-free survival for subgroups A1-B3. AIDS-free survival for patients in subgroups A1, A2, and B1 was considerably longer than survival in patients from subgroups A3, B2, and B3 (P < 0.0001). According to these findings, the new CDC classification system could be simplified into three stages, stage I and II comprising the above mentioned six subgroups, and stage III comprising clinical AIDS defining categories C1, C2, and C3. These three stages correspond to different periods in the management of HIV positive patients, i.e., period of observation, period of prophylaxis, and period of treatment.

Serum antibody for somatostatin-14 and prodynorphin 209-240 in patients with obsessive-compulsive disorder, schizophrenia, Alzheimer's disease, multiple sclerosis, and advanced HIV infection

Patients with obsessive-compulsive disorder (OCD) demonstrated significant levels of antibody for somatostatin-28, its C-terminal fragment somatostatin-14, and prodynorphin. In contrast there were lower levels of reactivity for somatostatin-28(1-14) (the N-terminal fragment of somatostatin-28) and negligible reactivity for several other peptides including beta-endorphin and corticotropin. Healthy volunteers and disease controls [schizophrenia, Alzheimer's disease, multiple sclerosis, and subjects with advanced human immunodeficiency virus (HIV) infection] exhibited negligible reactivity. These data raise the consideration of an autoimmune mechanism for some OCD.

Incidence of cardiac arrhythmias during intravenous pentamidine therapy in HIV-infected patients

STUDY OBJECTIVE

There have been 15 published cases of probable pentamidine-induced torsade de pointes (TdP). A prospective analysis of this complication of therapy is valuable considering the high frequency of Pneumocystis carinii pneumonia in the AIDS population, and the role of pentamidine in its therapy.

DESIGN

Open, nonrandomized, prospective study of HIV-infected patients receiving intravenous pentamidine in a 12-month period.

SETTING

Walter Reed Army Medical Center, a tertiary care, referral-based facility in Washington, DC.

PATIENTS

Eighteen HIV-infected patients were enrolled with informed consent; four were withdrawn from statistical analysis after receiving only one or two doses of empiric intravenously administered pentamidine.

MEASUREMENTS AND RESULTS

Daily 12-lead electrocardiography, echocardiography, weekly signal-averaged electrocardiography, and weekly 24-h ambulatory electrocardiography were performed on each patient. Of the 14 subjects, 3 developed TdP. These 3 patients and 2 others developed a prolonged rate corrected, QT interval (QTc) to greater than 0.48 s (max QTc mean, 0.55 s, mean increase, 0.12 s). The QTc prolongation was noted in all five patients by the fourth daily dose (4 mg/kg/d) of pentamidine. The other 9 patients developed minimal change in QTc intervals throughout therapy (max QTc mean, 0.45 s; mean increase, 0.03 s). The maximum QTc increase was significantly different between these two cohorts (p < 0.03). The occurrence of TdP in the subgroup of patients developing prolonged QTc intervals to greater than 0.48 s (3 of 5 patients), or a change in QTc of greater than 0.08 s (3 of 4 patients) over individual baseline also was significant (p = 0.03 and p = 0.01, respectively). No baseline clinical variables associated with TdP or QTc prolongation were identified.

CONCLUSION

Intravenously administered pentamidine frequently results in QTc prolongation with a subsequent risk of TdP in HIV-infected patients. All patients treated with intravenously administered pentamidine should be evaluated with baseline and daily ECGs, at least during the first week of therapy, and should be closely monitored for a change in the QT interval. An increase in QTc to above 0.48 s or greater than 0.08 s above baseline carries a significant risk for proarrhythmia, and in this instance, continuous electrocardiographic monitoring or an alternative antibiotic regimen should be considered.

Syphilitic pneumonitis in an HIV-infected patient

Pneumonitis and symptomatic hepatitis are very rare complications of syphilis. Symptomatic hepatitis and subclinical reticulonodular pulmonary infiltrates were observed when an HIV-infected patient presented with secondary syphilis. The Jarisch-Herxheimer reaction included a flare of hepatitis symptoms, resembling cholangitis. In a patient with syphilis, it may be appropriate to delay an aggressive evaluation for suspected pneumonitis or cholangitis pending the outcome of specific antitreponemal therapy.

High-dose intravenous immunoglobulins in the treatment of adolescent and adult HIV-infected hemophiliacs

In children infected with human immunodeficiency virus (HIV) placebo-controlled trials with intravenous immunoglobulins have resulted in a significant reduction in morbidity; however, the results of small trials in adolescents and adults have been inconsistent. In this study 17 HIV-infected hemophiliacs aged 9-30 years were treated with monthly intravenous immunoglobulins for an average of 32 months. At the end of the study, 8 years after the HIV infection, three patients (18%) had progressed to the acquired immunodeficiency syndrome (AIDS), and the average decrease in CD4 cells was 81 cells/microliter per year. The natural history of HIV infection in hemophiliacs in this age group shows a manifestation rate of AIDS between 11% and 26% 6-8 years after seroconversion and an average yearly decrease in CD4 lymphocytes of 68-110 cells/microliters. In conclusion, we observed no difference either in the manifestation rate of AIDS or in prognostic markers in this small cohort of HIV-infected hemophiliacs treated for more than 30% of their latency period with intravenous immunoglobulins compared to the well-documented natural history of HIV-infected hemophiliacs. However, none of the patients developed severe bacterial infections during the study period.

Comparison of anthropometric measures of men with HIV: asymptomatic, symptomatic, and AIDS

OBJECTIVE

Anthropometric measures were performed to determine differences in estimated fat mass, lean body mass, and body weight among three groups of men infected with human immunodeficiency virus (HIV).

DESIGN

This study was cross-sectional.

SETTING

Local centers of community services and support groups for persons infected with HIV in the province of Quebec, Canada.

SUBJECTS

Thirty-seven HIV-positive men were recruited; 11 were asymptomatic (T helper cells [CD4+ count] > 400 cells/mm3), 8 were symptomatic (CD4+ < 400 cells/mm3), and 17 were clinically stable but met the criteria of the Centers for Disease Control and Prevention for acquired immunodeficiency syndrome (AIDS).

MAIN OUTCOME MEASURES

Self-reported usual weight, actual weight, body mass index, midarm circumference, and triceps and subscapular skinfolds were recorded. From those we derived the percentage of body fat, the midarm muscle, and fat areas. Daily energy and protein intakes were determined from a 7-day food record. Clinical signs and symptoms were assessed by a structured questionnaire.

STATISTICAL ANALYSES PERFORMED

For statistical comparisons, analysis of variance was used, with P < .05 being significant.

RESULTS

We found a trend toward a decrease in body weight and in the fat mass indicators as the disease progressed. Lower energy intakes were observed among symptomatic and AIDS groups. The number of nutrition-related clinical signs and symptoms experienced by each individual correlated with the magnitude of weight loss (P < .0004, r = -.69).

APPLICATIONS

The findings suggest that anthropometric measures can be used in routine clinical practice to assess changes in body weight and in estimated fat mass among men infected with HIV. Symptoms and energy intakes should be assessed to identify subjects at high risk of greater weight loss.

Impairment of colour contrast sensitivity and neuroretinal dysfunction in patients with symptomatic HIV infection or AIDS

Ophthalmic and neurological complications are frequent findings in patients with AIDS. Little is known about neuroretinal dysfunction in patients with HIV infection. The purpose of this study was to measure and evaluate colour vision in patients with HIV infection or AIDS. Colour contrast sensitivity tests were performed on 75 patients (150 eyes) in different stages of HIV infection. A highly sensitive computer graphics system was used to measure tritan, deutan, and protan colour contrast thresholds. Patients were classified into three clinical groups: (a) asymptomatic HIV infection, (b) lymphadenopathy syndrome or AIDS-related complex, and (c) AIDS. Overall, tritan (p < 0.0001), deutan (p = 0.003), and protan (p = 0.009) colour contrast sensitivities were significantly impaired in patients with HIV infection compared with normal controls. Colour thresholds in patients with asymptomatic HIV infection (mean tritan threshold: 4.33; deutan: 4.41; protan: 3.97) were not impaired compared with normal controls. Colour vision was slightly impaired in patients with lymphadenopathy syndrome or AIDS-related complex (tritan: 6.25 (p < 0.0001); deutan: 4.99 (p = 0.02); protan: 4.45 (p = 0.05)). In patients with AIDS the impairment was even more marked (tritan: 7.66 (p < 0.0001); deutan: 5.15 (p < 0.0009); protan: 4.63 (p = 0.004)). Analysis of covariance controlling for age demonstrated a close association between impairment of tritan colour contrast sensitivity and progression of HIV disease (p < 0.0001). Following Köllner's rule, our study suggests that neuroretinal dysfunction occurs in patients with symptomatic HIV infection or AIDS. This is emphasised by the finding that the relative impairment in tritan vision compared with deutan/protan vision might reflect the difference in the number of cones or receptive fields. Measurement of tritan colour contrast sensitivity appears to be an appropriate and easily applicable method to detect early neuroretinal dysfunction in patients with HIV disease.

B cell activation and human immunodeficiency virus infection. V. Phenotypic and functional alterations in CD5+ and CD5- B cell subsets

B cell dysregulation is a hallmark of human immunodeficiency virus infection. Since B lymphocytes comprise two distinct subpopulations, CD5+ and CD5- cells, we addressed their individual phenotypic and functional behavior. Seropositive patients with both limited and advanced disease progression had an increased percentage of peripheral blood CD5+ B cells, compared to seronegative controls (20.1 +/- 2.1 and 22.7 +/- 5.7, respectively, vs 17.0 +/- 3.4 in controls); however, due to the lymphopenia and reduced number of circulating B cells in infected individuals, the absolute number of CD19+CD5+ lymphocytes was actually reduced. Although HIV-specific antibodies were synthesized spontaneously in vitro only by CD5- B cells, a 10-fold lower degree of spontaneous, non-HIV-specific activation was also displayed by unstimulated CD5+ B cells. These findings indicate that B cell dysregulation during HIV infection involves both the CD5- and the CD5+ B cell compartments; moreover, in view of the putative role of CD5+ B cells in autoimmune phenomena and IL-10 production, these data reinforce the possibility that B cell dysfunction might be causally involved in AIDS pathogenesis.

Histopathologic features in the central nervous system of 400 acquired immunodeficiency syndrome cases: implications of rates of occurrence

Histopathologic lesions in the central nervous system (CNS) of 400 autopsy cases of the acquired immunodeficiency syndrome (AIDS) collected from 1982 to 1990 were studied. Lesions most closely associated with human immunodeficiency virus (HIV) infection in the CNS (perivascular macrophages, nodular encephalomyelitis, diffuse leukoencephalopathy, necrotizing encephalitis, and long-tract degeneration) were found in 20% of the cases. The group of vascular and inflammatory lesions and of opportunistic infections was seen in 25% of cases. These two lesion groups were found together in 32% of cases, and none of these lesions was present in 23% of cases (most of the latter having no significant CNS lesions). Length of survival increased in the last group of 100 cases compared with the first 300 cases. The homosexual and bisexual risk groups showed continuously increasing lengths of survival for each category of HIV-associated CNS lesions throughout the study, while the lengths of survival in the other risk groups varied. Patients in the last group of 100 autopsy cases with any HIV-associated lesion survived longer than patients without these lesions. The AIDS patients with no CNS lesions had the shortest mean length of survival. The results suggest that although survival is prolonged as specific therapy is given, there is an increase in CNS lesions in AIDS patients with longer survival. This may indicate that CNS lesions in AIDS are generally dependent on systemic disease progression over many months as immune function decreases.

Elevated levels of xanthine oxidase in serum of patients with inflammatory and autoimmune rheumatic diseases

Sera of patients with various inflammatory and autoimmune rheumatic diseases were screened for the presence of xanthine oxidase (XOD) and compared to sera from healthy donors and patients with nonrheumatic diseases including AIDS, internal diseases, and different carcinomas. Up to 50-fold higher levels of XOD were detected in rheumatic sera (P < 0.001). In addition, serum sulfhydryls (SH) were determined as sensitive markers of oxidative stress. The SH status in rheumatic patients was diminished by 45-75% (P < 0.001) and inversely correlated to the concentration of serum XOD (R = 0.73), suggesting a causal interrelation. The depletion of serum sulfhydryls by the oxyradical-producing XOD/acetaldehyde system was mimicked successfully ex vivo in human serum from healthy donors. Cortisone treatment of patients suffering from systemic lupus erythematosus and rheumatoid arthritis impressively normalized elevated XOD concentrations in rheumatic sera to those of healthy controls. The participation of xanthine oxidase in the depletion of serum antioxidants in rheumatic patients is discussed in the light of substrate availability and Km values.

Resting energy expenditure and weight loss in human immunodeficiency virus-infected patients

Resting energy expenditure (REE) and body composition were investigated in 60 clinically stable patients with human immunodeficiency virus (HIV) infection varying with respect to immune impairment. REEs differed significantly from predicted values (> or < 10% of the Harris-Benedict [HB] equation) in 40% of patients. Seven percent of patients showed markedly increased REE (> +20% of HB prediction), whereas REE was decreased in 13% (< -10%). Increased REE was found during all clinical stages of the disease (Walter Reed [WR] 2 through 6) and was not strictly associated with the degree of immune impairment, presence of diarrhea or Kaposi's sarcoma, nutritional state, or anamnestic wasting. Twenty-seven patients were evaluated for a mean period of 319 days; 11 lost more than 5% of their initial body weight during the observation period. Weight-losing patients were normometabolic before but showed a significantly increased REE (+7% of predicted values or +8% when compared with previous measurements) during weight loss. The degree of deviation from estimated REE was strongly associated with the degree of weight loss. We summarize that increased REE is not a constant feature of HIV infection. It is not associated with clinical and laboratory parameters of immune deficiency, but may occur during weight loss. Thus increased REE represents an inadequate adaptation to malnutrition and contributes to wasting.

Cutaneous neoplasms in a military population of HIV-1-positive patients. Military Medical Consortium for the Advancement of Retroviral Research

BACKGROUND

In HIV-1-positive patients there have been no prospective studies that show an increase in cutaneous neoplasms.

OBJECTIVE

We observed HIV-1-positive patients to determine whether or not there was an increased incidence of cutaneous malignancies.

METHODS

A total of 724 HIV-1-positive patients were examined during a 36-month period for the development of cutaneous malignancies.

RESULTS

The most common cutaneous neoplasm found was Kaposi's sarcoma, especially in patients with late-stage disease. Basal cell carcinomas were the next most frequent tumor. We have also seen three malignant melanomas and two squamous cell carcinomas. Five patients had malignant lymphoma. One patient had a primary lymphoma of subcutaneous soft tissue; in one patient multiple cutaneous lesions developed.

CONCLUSION

The distribution and prevalent types of cutaneous neoplasms in HIV-1-positive patients appear to differ from those found in other immunosuppressed populations. This may be the result of the different patterns and periods of immunosuppression in these patients and/or associated cocarcinogens to which these patients frequently are exposed.

A screening test for subtle cognitive impairment early in the course of HIV infection

The authors report on the use of the Rey-Osterrieth Complex Figure Copy (ROC) and Memory (ROM) test as a bedside screening measure of cognitive impairment in 67 HIV-seropositive persons (43 men, 24 women). HIV-seropositive individuals scored significantly worse than 49 HIV-seronegative matched individuals (33 men, 16 women) in the control group on the ROC (P = 0.045, effect size = 0.39), but not on the ROM test. The scores did not correlate with stage of HIV infection, CD4a cell counts, cerebrospinal fluid parameters, or measures of affective state. No gender effects on performance were noted. It is concluded that while cognitive deficits may occur early in asymptomatic HIV disease, the ROC/ROM test as the authors used it is not a useful screening tool for clinicians. The study also suggests that the growing number of HIV-positive women should be included in neuropsychological studies of early HIV disease.

Consequences of human immunodeficiency virus type 1 superinfection of chronically infected cells

Infection of T cell lines by the type 1 human immunodeficiency virus (HIV-1) is associated with downregulation of the CD4 receptor and resistance to further HIV-1 infection, the phenomenon of viral interference. The ACH2 cell line, a model for chronic HIV-1 infection, possesses a single integrated copy of the HIV-1 strain LAI, is essentially CD4 negative, and can be induced to make virus by a variety of stimuli. We utilized the known sequence differences between HIVLAI and HIVRF to devise a polymerase chain reaction (PCR) strategy that permits reliable and quantitative discrimination between the two strains. We demonstrate that ACH2 cells can be superinfected by HIVRF at a frequency of 60-300 HIVRF genomes/10(4) ACH2 cells and that the frequency of superinfection appears to increase with time. Reverse transcription of ACH2 mRNA from days 13, 27, and 38 postinfection allowed a similar PCR strategy (RT-PCR) to be used to analyze full-length HIVRF- and HIVLAI-specific transcripts. These data suggested that superinfection of ACH2 with HIVRF results in an increase in expression of both HIVRF and HIVLAI mRNA. From day 13 to day 38 postinfection there was an increase in the relative expression of HIVRF compared with HIVLAI. By day 38, when only 1.1% of HIV DNA sequences were HIVRF derived, roughly 80% of the HIV-specific full-length mRNA was HIVRF in origin, with a concomitant decrease in HIVLAI transcription.