Acquired immunodeficiency syndrome in infants

Serological study of subjects with seroconversion to human immunodeficiency virus

Twelve homosexual males who seroconverted to human immunodeficiency virus (HIV) were followed-up for over two years. Analysis of sera by immunoblotting showed that seroconversion was characterized by the presence of specific IgM that reacted mainly with viral polypeptides of molecular weights ranging from 17 Kd to 55 Kd. Specific IgG to all HIV proteins was detected. Immunoblotting showed that antibodies to 24 Kd core protein alone or in association with 17 Kd polypeptide appeared first in some cases. Virus antigen was detected in six patients: five subjects were positive at the time of seroconversion, and one became positive afterwards. It is concluded that detection of IgG and IgM antibody against the different viral polypeptides, together with detection of viral antigen is necessary in order to determine the stage of HIV infection.

Intravenous immune globulin in symptomatic paediatric human immunodeficiency virus infection

Seven paediatric patients with symptomatic human immunodeficiency virus (HIV) infection were prospectively studied for 6-24 months after the start of intravenous immune globulin (IVIG) therapy. There was substantial clinical benefit during IVIG treatment with marked reduction of febrile and infectious episodes, normalization of physical and psychomotor development, and absence of mortality. The immunologic monitoring revealed some discrete objective improvements. The results of this study favourably compare to previous reports. It is concluded that IVIG should be standard therapy for symptomatic childhood HIV infection.

Human immunodeficiency virus infection in multi-transfused patients with thalassaemia major

We investigated the incidence, clinical and immunological characteristics of human immuno-deficiency virus (HIV) infection in a group of multi-transfused patients with thalassaemia major who were exposed to transfusion-associated HIV infection. Seropositivity to HIV by Western blot and immunofluorescence analysis was detected in 26 out of 590 patients. At a follow up 21-40 months later, none of these seropositive patients had developed acquired immuno-deficiency syndrome (AIDS), and six manifested the AIDS related complex (ARC). ARC was unusually mild and consisted of moderate laterocervical and submandibular lymph node enlargement associated with hypergammaglobulinaemia and a reduced CD4/CD8 ratio resulting from the decreased number of CD4 lymphocytes. These findings suggest that multi-transfused patients with thalassaemia major are relatively resistant to the development of severe manifestations of HIV infection, presumably because their immune status is relatively better preserved than that of other infected populations. Longer follow up is, however, necessary to determine whether the incidence of AIDS will be lower in this population or whether overt AIDS merely takes longer to develop.

Infection of the fetus and the newborn: prevention, treatment and related handicap

Congenital infection is uncommon and the cause of only a small proportion of handicap seen in children but some infections may be preventable or even treatable. As an example, the congenital rubella syndrome first described in the 1940s is preventable by use of the vaccine but cases still occur. It is hoped that with the introduction of the measles, mumps, rubella immunization for young children, rubella will become as rare in the UK as it is in the USA. Cytomegalovirus is now a more common cause of handicap than rubella but no vaccine has been developed. Although antiviral drugs are available for herpes simplex virus and vaccinia, infection mortality in the newborn is high, even following the use of these agents; many HSV infections in the newborn arise following primary and asymptomatic maternal infections so that treatment may start late in the course of the illness. The obstetrician needs to understand the natural history as well as possible investigations available for congenital infections. There may be warning signs which require action, such as herpetic lesions in the genital tract of the mother. Less specific abnormalities during pregnancy, such as intra-uterine growth retardation and spontaneous onset of preterm labour, may point to congenital infection. This chapter describes both antenatal and postnatal management of the major congenital infections. We have included recent research data that should influence clinical practice; studies on HSV which suggest that, for women with a history of recurrent infection, routine viral culture of the genital tract at the end of pregnancy is unnecessary; reports from both the USA and the UK that rubella immunization performed inadvertently during early pregnancy has not resulted in the congenital rubella syndrome. The chapter would not have been complete without a discussion of human immunodeficiency virus, of concern to the obstetrician and midwife. There is still much to be learned about the natural history of this infection in both the mother and infant.

Human immunodeficiency virus infection in childhood

Acquired immunodeficiency syndrome is associated with considerable morbidity in infants and children. It is caused by human immunodeficiency virus (HIV) which can be transmitted vertically from mother to infant early in pregnancy. Transmission might also occur via breast milk. Although the exact transmission rate of HIV from mother to infant is not known, HIV can become a major threat to child survival. This threat is already present in Africa where high seroprevalences have been reported among infants and young children. Transmission via blood products is decreasing due to reliable methods of screening donors for HIV antibody. Where these tests are not available, parenteral transmission will increase the incidence of HIV infection. The clinical picture of HIV infection in children presents with failure to thrive, pulmonary interstitial pneumonitis, hepatosplenomegaly and recurrent bacterial infections. These are common manifestations of diseases prevalent in children in Africa where malnutrition and recurrent parasitic infections already cause immunosuppression. Recognition of the syndrome is therefore difficult. There is no available cure for HIV infection. Supportive treatment and relief of pain and suffering are the only means of management at present. Prevention of spread of the illness to infants and young children is therefore of paramount importance.

The human immunodeficiency virus: infectivity and mechanisms of pathogenesis

Infection with the human immunodeficiency virus (HIV) results in a profound immunosuppression due predominantly to a selective depletion of helper/inducer T lymphocytes that express the receptor for the virus (the CD4 molecule). HIV also has tropism for the brain leading to neuropsychiatric abnormalities. Besides inducing cell death, HIV can interfere with T4 cell function by various mechanisms. The monocyte serves as a reservoir for HIV and is relatively refractory to its cytopathic effects. HIV can exist in a latent or chronic form which can be converted to a productive infection by a variety of inductive signals.

What's new in pediatric dermatology

This report discusses some of the newly described diseases in pediatric dermatology and recent developments in other diseases that are pertinent to this field.

Human immunodeficiency virus infection among patients attending clinics for sexually transmitted diseases

To assess the prevalence and associated risk factors for human immunodeficiency virus (HIV) infection in patients attending inner-city clinics for sexually transmitted diseases in Baltimore, we screened 4028 patients anonymously, of whom 209 (5.2 percent) were seropositive for HIV. HIV-seropositivity rates were higher among men (6.3 percent) than women (3.0 percent) (P less than 0.001) and among blacks (5.0 percent) than whites (1.2 percent) (P less than 0.02). Among men, but not women, HIV seroprevalence increased markedly and steadily up to the age of 40. In men, HIV seropositivity was independently associated with increased age, black race, a history of homosexual contact, and the use of parenteral drugs. In women, a history of parenteral drug use or of being a sexual partner of a bisexual man or parenteral drug user were independently predictive of HIV seropositivity. In men, HIV seropositivity was also associated with a history of syphilis or a reactive serologic test for syphilis, and in women, with a history of genital warts. Since these associations were independent of the type and number of reported sexual partners, they raise the possibility that sexually transmitted diseases that disrupt epithelial surfaces may be important in the transmissibility of HIV. In addition, on a self-administered questionnaire, one third of HIV-infected men and one half of infected women did not acknowledge previous high-risk behavior for HIV exposure. These data suggest that patients at clinics for sexually transmitted diseases represent a group at high risk for HIV infection, and that screening, counseling, and intensive education should be offered to all patients attending such clinics.

Renal complications of acquired immunodeficiency syndrome in children

A low incidence of renal disease was noted in a retrospective analysis of pediatric patients with acquired immunodeficiency syndrome. Episodes of acute renal failure were attributable to dehydration or nephrotoxicity. One patient, however, had nephrosis with focal glomerular sclerosis. Focal sclerosis involving 10% to 20% of glomeruli was evident in autopsy tissue from three patients.

Activation of alveolar macrophages from children with the acquired immunodeficiency syndrome-related complex

The ability of alveolar macrophages (AM) to release hydrogen peroxide (H2O2), an indicator of AM function, was studied in five children with the acquired immunodeficiency syndrome (AIDS) related complex and, for comparison, in 11 children without disorders of the lung parenchyma. In the AIDS-related complex group, pulmonary manifestations were mild, and lung involvement was suspected by moderate clinical and/or radiological features. None had a past history of opportunistic infections; neither did any have lymphopenia. Cytologic study of the bronchoalveolar lavage (BAL) fluid revealed increased cellularity with increased percentage of lymphocytes. The study of H2O2 release was performed on unstimulated AM and on AM stimulated by phorbol myristate acetate (PMA). Under both experimental conditions, the amount of H2O2 accumulated in the medium was significantly increased in the group with AIDS-related complex (P less than 0.001). As no enhanced oxidative activity has been reported in AM from patients with full-blown AIDS, an increased ability of AM to release oxygen metabolites from children with AIDS-related complex may reflect an initial and temporary step in the course of the LAV/HTLV-III pulmonary disease. Determining AM activation might be a reliable method of assessing the evolution of lung disorder in AIDS.

Viral infections in the acquired immunodeficiency syndrome

The following communication is a tripartite synopsis of the role of viral infection in the acquired immunodeficiency syndrome (AIDS). The first section describes the impact of viral opportunistic infection in AIDS; for each virus, clinical presentation and diagnosis, laboratory diagnostic approaches (with emphasis on electron microscopy), and therapeutic interventions attempted to date are discussed. The second segment explores current theories on the pathogenesis of AIDS, and describes diagnostic and therapeutic approaches to the syndrome itself. The final section catalogues ultrastructural anomalies in the cells of AIDS patients, many of which have been mistakenly identified as etiologic agents.

Diagnostic bronchoalveolar lavage in children with AIDS

Between October, 1985 and May 1987, 29 children (mean age 22 +/- 22 months, range 2-54 months) with AIDS or ARC developed acute respiratory illness. The initial diagnostic procedure was flexible fiberoptic bronchoscopy, with bronchoalveolar lavage (BAL). BAL was positive for Pneumocystis carinii in 14 and for respiratory syncytial virus, Staphylococcus aureus, and Escherichia coli in 3 additional patients. Subsequent lung tissue analysis and/or clinical course suggested no false negative lavages. Complications possibly related to the procedure occurred in two patients. We find BAL an effective diagnostic technique in these patients, offering a less invasive alternative to open lung biopsy.

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.

HIV infection in children: sizing up the paediatric problem

Cases of paediatric AIDS have increased each year in the USA, as the disease has spread to the heterosexual community. In the USA the geographic distribution of perinatal AIDS cases mirrors the distribution of cases in women. To date, 503 HIV antibody positive women have been reported in the UK. It is likely that the increasing number of seropositive women will be reflected in an increase in the number of reports of perinatal HIV infection and AIDS. Although screening of blood donors and blood products has stopped further increase in infections from this route, as transfusion-infected children become symptomatic the burden on paediatric services will increase.

Pediatric human immunodeficiency virus infection and its cutaneous manifestations

Acquired immunodeficiency syndrome was first observed in children in 1982. Human immunodeficiency virus (HIV) is now known to be the etiologic agent of this disease complex. Children acquire the viral infection in utero or perinatally, or by receiving contaminated blood products. The cutaneous manifestations include persistent oral thrush, herpes simplex, herpes zoster, molluscum contagiosum, and a variety of fungal and bacterial skin infections. Vasculitis, unusual drug eruptions, and cutaneous manifestations of nutritional deficiencies are also seen.

AIDS in an infant causing severe failure to thrive

A nine-month-old female Jamaican infant presented with a history of severe failure to thrive, recurrent pneumonia and developmental delay. She was found to have hepatosplenomegaly, generalised lymphadenopathy and hypotonia. Investigations revealed polyclonal hypergammaglobulinaemia, cytomegalovirus in her urine, and patchy lung infiltrates on her chest radiographs. Three separate tests were positive for human immunodeficiency virus in both the infant and her mother, suggesting vertical transmission, and confirming AIDS as the cause of the severe failure to thrive.

Transfusion-associated viral infections

Viral infections are a frequent occurrence following transfusion of blood products. While generally benign, these infections are capable of causing significant morbidity and mortality. Therefore, it is prudent to follow several general approaches diligently to reduce the risks of these infections in patients undergoing transfusions of blood products. These suggested measures include the following: 1. Prescribe and administer blood and blood products only when absolutely needed. 2. Use volunteer blood donors only. 3. Avoid use of pooled blood products when possible. 4. Use only blood and blood products that have been appropriately tested for HBsAg and HIV. 5. Use ALT determinations to screen blood products and eliminate those with high level. 6. Avoid the use of clotting-factor concentrates but, if necessary, use only those which have been heat-treated. 7. Limit use of leukocyte transfusion. 8. Use only CMV seronegative blood and blood products or frozen deglycerolized red cells in patients at high risk for posttransfusion CMV infection.

Transmission of human immunodeficiency virus from parents to only one dizygotic twin

The acquired immunodeficiency syndrome-related complex was identified in a mother and one of her nonidentical twins. Generalized lymphadenopathy was first noted in the infant at age 17 months, and that of the mother was incidentally discovered 6 months later. The father, who had had homosexual contacts before the conception of the twins, appeared to be in good health. No one in the family had constitutional symptoms or showed signs of opportunistic infection. Both parents and the patient had hypergammaglobulinemia, low T-helper-to-suppressor-cell ratio, and positive serum antibody to human immunodeficiency virus. Attempts to isolate the virus from all family members were unsuccessful. The twin brother was in good health with a normal immunologic profile and negative antibody to human immunodeficiency virus.

Prematurity, hypogammaglobulinemia, and neuropathology with human immunodeficiency virus (HIV) infection

Infection with the human immunodeficiency virus (HIV) is characteristically associated with hypergammaglobulinemia in both adult and pediatric cases. We report herein four infants who had an HIV infection in association with severe hypogammaglobulinemia and did not exhibit antibodies against HIV. HIV was isolated antemortem or postmortem in all four infants from either peripheral blood, cerebrospinal fluid, or body tissues. HIV infection could be presumed to be acquired transplacentally in two infants and by way of infected blood transfusions during the neonatal period in the other two. Each infant became symptomatic within the first year of life and developed rapidly progressive manifestations of the disease. Features that were common to all four infants include premature birth, failure to thrive, hepatomegaly, and progressive neurological abnormalities that were associated with intracranial calcifications. We concluded that, when infection occurs early in development either by transplacental exposure to the virus or from blood transfusion in small premature infants, hypogammaglobulinemia and deficiency of antibody production leading to the absence of antibody responses on which diagnosis is usually based can occur. Furthermore, progressive central nervous system disease may be a frequent finding in such infants, and this may lead to cerebral calcifications that must be attributed to the HIV infection itself and not to complicating infections--e.g., toxoplasmosis. It is suggested that patients with hypogammaglobulinemia, antibody deficiency syndrome, and central nervous system disease have an extremely bad prognosis.

Perinatal viral infections

In comparison to older children and adults, neonates are immunologically incompetent. They are susceptible to infections caused by a variety of microorganisms, including bacteria, fungi and viruses. These infectious agents may be acquired by neonates either prenatally, during the intrapartum period or postnatally. The purpose of this review is to emphasize the potential impact of viral infections contracted by neonates at the time of delivery or within the neonatal period. The viruses reviewed include the herpes group of viruses (cytomegalovirus, herpes simplex viruses and varicella-zoster virus), type B hepatitis virus, human immunodeficiency virus, respiratory viruses, enteroviruses, rotavirus and human papilloma virus. For each virus the potential sources and incidence of the infection, the common manifestations of the illness, and possible means of prevention and therapy are discussed. Although infections caused by bacteria tend to be more clinically dramatic and more immediately life-threatening, it is emphasized that infections caused by viruses are common and associated with substantial long-term morbidity. Perinatal viral infections need to be recognized as early in life as possible so that their natural history can be more completely defined and any possible intervention made.

Infants born to mothers seropositive for human immunodeficiency virus. Preliminary findings from a multicentre European study

As part of a project within the European Community research activities on acquired immunodeficiency syndrome (AIDS), infants born to human-immunodeficiency-virus-seropositive mothers are being followed up from birth. By October, 1986, 71 infants from Padua, Berlin, and Edinburgh had been followed up to a median age of 6 months (range 1-15 months). Symptoms of AIDS or AIDS-related complex (ARC) had developed in 5, 3 of whom had died. The median age at antibody loss was during the 10th month. An estimated 75% will have lost maternal antibody by 12 months, but loss of antibody did not exclude infection confirmed by virus culture. Numbers were too small to draw conclusions about the risk of AIDS/ARC and mode of delivery or breast-feeding. The study suggested that the risk of AIDS/ARC is higher in infants born to mothers who have AIDS symptoms during pregnancy.

Atopic manifestations in the acquired immune deficiency syndrome: response to recombinant interferon gamma

Six patients with the acquired immune deficiency syndrome (AIDS) had exacerbations or recurrences of previously quiescent atopic disease when they developed immunodeficiency. Four developed a different atopic illness from that suffered previously. Atopic symptoms developed within three months after the patients developed AIDS or during prodromal illness. Two of the patients were treated with recombinant interferon gamma: both showed a striking improvement in symptoms and cellular immunity. These results indicate that cellular immunity, through interferon gamma, may have a role in regulating atopic disease.

Bacterial infections in adult patients with the acquired immune deficiency syndrome (AIDS) and AIDS-related complex

Sixty-four episodes of bacterial infection were identified over a 44-month period in 16 of 28 patients with the acquired immune deficiency syndrome (AIDS) and 14 of 31 patients with AIDS-related complex. Nineteen of the 30 infected patients were parenteral drug abusers, 10 were from Caribbean Islands and had no identified risk factor, and one was a homosexual male. Fourteen patients had 21 episodes of community-acquired pneumonia: Streptococcus pneumoniae (10), Haemophilus influenzae (three), other Haemophilus species (three), group B beta-hemolytic streptococci (one), Staphylococcus aureus (one), Branhamella catarrhalis (one), Legionella pneumophila (one), and Mycoplasma pneumoniae (one). Seven patients had eight episodes of nosocomial pneumonia caused by gram-negative bacilli. Twenty-five episodes of community-acquired bacteremia and nine episodes of nosocomial bacteremia were associated with specific sites of infection. Other infections included meningitis (two), urinary tract infection (one), and abscesses involving subcutaneous and deep tissues (12). Sixteen patients had recurrent infections; 11 of these had or eventually had AIDS. Community-acquired bacterial infections in patients with AIDS or AIDS-related complex are common and may be recurrent but have low fatality rates. In comparison, nosocomial bacterial infections occur primarily in patients with AIDS and have high fatality rates.

Pathogenicity of HIV in lymphatic organs of patients with AIDS

HIV antigens were searched for in the thymus, lymph nodes, bone marrow, and spleen of AIDS patients, by means of immunofluorescence technique. Human IgG against HIV and monoclonal antibodies against viral gag P24 protein yielded strong cytoplasmic fluorescence of cells in sections of the thymus, lymph nodes and spleen. Some cells containing HIV antigens were morphologically multinucleated giant cells. They reacted with monoclonal antibodies against helper/inducer T-cells (OKT4+), and were complexed with antibody or with complement as demonstrated by double-staining immunofluorescence technique. A large number of inflammatory cells infiltrated the thymus in areas containing cells expressing HIV antigens. These studies demonstrated an association of HIV virus with cytopathic and immunopathogenic reactions in lymphatic organs of AIDS patients, and are consistent with previous results, as well as indicative of a primary aetiologic role for the virus.

Acquired immunodeficiency syndrome (AIDS)

The Acquired Immunodeficiency Syndrome (AIDS), caused by the human immunodeficiency virus (HIV), also called the human T-lymphotropic virus type III/lymphadenopathy-associated virus [HTLV-III/LAV], has affected over 23,000 people; more than half of those with the disease have died. The actual case fatality rate approaches 100%. AIDS affects all groups and classes of people, although some are at special risk. Distribution of the disease is worldwide. The illness' effects on the body are widespread; of special interest are the ophthalmologic manifestations. The eye may be infected by various viruses (cytomegalovirus, varicella-zoster virus, herpes simplex virus or HIV itself), toxoplasma gondii, candida sp, cryptococcus neoformans, M. tuberculosis, or M. avium-intracellulare. Kaposi's sarcoma may affect the eye as well. Retinal vascular abnormalities (e.g., cotton-wool spots, vasculitis) are not uncommon in AIDS. The syndrome may present with neuro-ophthalmologic manifestations. No effective treatment for the illness is currently available, although several hold promise and there is hope for an AIDS vaccine. Prevention of infection through reduction of risks appears to be the only defense against AIDS at this time.

Expression of human immunodeficiency virus in cerebrospinal fluid of children with progressive encephalopathy

The retrovirus that causes acquired immune deficiency syndrome (AIDS) is now designated the human immunodeficiency virus (HIV). The cerebrospinal fluid (CSF) of 27 children with HIV infection was assayed for intra-blood-brain barrier (IBBB) synthesis of HIV-specific antibodies and for the presence of HIV antigen. In this cohort, 11 children had a progressive encephalopathy (PE), 9 had a static encephalopathy (SE), and 7 had normal neurological findings (N). IBBB synthesis of HIV-specific antibodies was identified (using matched serum and CSF specimens) in 7 of 11 children with PE, 4 of 9 children with SE, and 2 of 7 children with N. HIV antigen was found (using a highly sensitive solid-phase enzyme immunoassay) in the CSF of 8 of 11 children with PE, none of the children with SE, and none of the 7 children with N. On the basis of these data, we conclude that: IBBB synthesis of HIV antibodies indicates invasion of the central nervous system but may reflect prior or current infection; and HIV antigen in CSF indicates viral expression and correlates with the occurrence of PE. These findings strongly implicate HIV as the causative agent of PE in these children. The assay for HIV antigen in the CSF may be of value in determining the prognosis of children with HIV infection and for evaluating the efficacy of therapeutic agents against this retrovirus.

Extensive T8-positive lymphocytic visceral infiltration in a homosexual man

Lymphocytic visceral infiltration has recently been noted in association with lymphadenopathy-associated virus infection. A homosexual man, who had clinical and immunologic features of the acquired immune deficiency syndrome (AIDS)-related complex, is described. The patient presented not only with peripheral blood lymphocytosis but also with extensive lymphocytic infiltration involving lungs, lymph nodes, nerves, muscles, and esophagus. Lymphocyte subset immunostaining analysis showed that the lymphocytes were T8-positive. Thirty months after the clinical onset of the disease, no evidence of progression to AIDS was seen. Moreover, clinical improvement was observed, even though the patient did not receive long-term treatment. The clinical history of this patient suggests that lung T8-positive lymphocytic infiltration is associated with an increased risk of infectious episodes such as pneumonia and bronchitis.

Acquired immune deficiency syndrome in childhood: impaired production of interleukin-2 by HIV (LAV/HTLV III) infected patients

The phenotype and functions of T lymphocytes and of natural killer (NK) cells have been investigated in four children and five adults from three Italian families infected with HIV (LAV/HTLV III). The results show a heterogeneous pattern of immunological derangements involving distribution of T and natural killer subsets, proliferation in response to T cell mitogens and natural killer activity. However, all infected patients tested showed a very low or absent phytohaemagglutinin induced interleukin-2 production regardless of age and clinical conditions, while concanavalin A-induced interleukin-2 production was within the normal range. The impaired interleukin-2 production in response to phytohaemagglutinin in some patients is not related to phytohaemagglutinin-induced proliferation, to clinical conditions or to a defective distribution of T cell subsets. These results suggest that, in our patients, both adults and children, HIV (LAV/HTLV III) has an "early" tropism for a subset of T cells involved in interleukin-2 production.

Dermatologic findings and manifestations of acquired immunodeficiency syndrome (AIDS)

We present a review of the spectrum of human T-lymphotropic virus type III (HTLV-III) infection with particular emphasis on cutaneous manifestations in 217 patients. Correlations are made with immunodeficiency as measured by absolute T-helper cell number. A classification is presented of these dermatologic findings.

Acquired immunodeficiency syndrome of childhood

AIDS of childhood is reviewed in this timely article, including care of the child with infectious complications, and other current and future management concerns.

Transfusion-acquired HIV infection among immunocompromised hosts

This survey suggests that HIV infection in immunocompromised hosts is characterized by a high attack rate, short incubation time to clinical sequelae, and WB and RIP seropositivity which may precede evidence of antibodies by ELISA by weeks or months. The functional properties of patients' serum antibodies, such as neutralizing activity against HIV in vitro, may correlate with clinical course.

AIDS in two African infants born in Belgium

Two African infants born in Belgium, dying from the acquired immune deficiency syndrome are reported. The first patient was a premature baby girl born to healthy parents. However, her asymptomatic mother was found to have polyclonal hypergammaglobulinaemia, a reversed T-helper/T-suppressor ratio and a decreased lymphocyte response to mitogens. The second patient's mother was treated for pneumocystis carinii pneumonia during the fourth month of gestation and was subsequently diagnosed with AIDS. The rapid clinical evolution of the acquired immunodeficiency syndrome in infancy suggests that the incubation period is shorter than in adults.

Histopathology and immunohistology of HTLV-III/LAV related lymphadenopathy and AIDS

Fifty-nine lymph node biopsies from homosexual men with serum antibodies to HTLV-III/LAV were the subject of a detailed histopathological and immunohistochemical study. The histological findings were correlated to the patients clinical status, and the T4/T8 ratios in blood and lymph nodes. Four histological patterns predominated and were defined as follicular hyperplasia (FH), follicular fragmentation (FF), follicular atrophy (FA), and follicular depletion (FD). Immunocytochemical studies indicated that destruction of follicular dendritic cells is related to the initiation of follicular involution from FH to FF, but the possible role of follicular infiltrating T-cells cannot be excluded. Marked individual variations in lymph node angiogenesis increasing during involution were observed, which suggests that the degree of angiogenic host response may predispose for evolution of Kaposi's sarcoma. The majority of the patients with the clinical diagnosis of persistent generalized lymphadenopathy (PGL) were morphologically staged as FH or FF (89%), whereas most of the AIDS patients showed lymph node changes compatible with FA and FD (89%). Patients with AIDS-related complex (ARC) had a wider spectrum of morphological lymph node changes but a majority of cases (62%) were also classified as FA or FD. Clinical follow-up showed progression from PGL to ARC in seven of 21 cases with the FF pattern and only in three of 19 cases with FH, indicating a possible prognostic value in differentiating between FH and FF. Three cases with FD and one with FA progressed to AIDS during the time of observation. T4/T8 ratios in blood and lymph nodes were significantly lower in patients with FD histology compared to patients of the other histological groups. At autopsy, all AIDS cases showed the FD pattern of lymphadenopathy. Autopsy findings in seven patients emphasized the importance of post-mortem studies in clarifying the spectrum of opportunistic diseases, including tumors which afflict the AIDS patients.

Progressive cytomegalovirus encephalopathy following congenital infection in an infant with acquired immunodeficiency syndrome

Congenital central nervous system infection with cytomegalovirus (CMV) usually results in a nonprogressive encephalopathy. Ninety percent of patients with clinically apparent infections at birth have a permanent neurological disability. It has been suggested that some infants may have persistent infection manifested by progressive encephalopathy during infancy. In the present case, clinical and pathological findings suggest the reactivation of a prior intrauterine CMV infection in a child with human T-lymphotrophic virus type III (HTLV-III) infection. The presence of HTLV-III may have reduced the immune surveillance of this infant, allowing the CMV to reactivate.

Longitudinal study of 18 children with perinatal LAV/HTLV III infection: attempt at prognostic evaluation

We performed a longitudinal study (mean follow-up 19.5 months, range 3 to 42 months) in 18 consecutive children with clinical symptoms of LAV/HTLV III infection. Twelve patients were born to mothers infected with LAV/HTLV III, and six were infected by blood products administered during the first weeks of life. Immunologic studies included lymphocyte markers, in vitro responses to mitogens and antigens with corresponding skin tests, and antibody response with isoagglutinins, post-vaccination antibodies, and Candida. A serologic profile of antibody to GP110, P18, and P25 LAV/HTLV III antigens by radioimmunoprecipitation assay was also performed. The antigen-induced proliferative responses were normal in 10 patients who had a stable course, but were profoundly impaired in eight others who died or had poor condition with opportunistic infections. These in vitro measurements were well correlated with antigen skin tests. An abnormal antibody response to antigens, a low level of isoagglutinins, and a peculiar profile of LAV/HTLV III antibodies were also frequently observed in these eight patients. These measurements appear to be of prognostic value because they were noticed soon after onset of clinical symptoms.

LAV/HTLV-III infection in children of African origin: experience in Belgium

From December 1982 to June 1985, we diagnosed LAV/HTLV-III infection in 16 children of African origin living in Belgium or referred to one of the hospitals participating in this study. Diagnosis was proven in seven of them by isolation of virus of the LAV/HTLV-III group. In the nine others, LAV/HTLV-III infection was highly probable because of the presence of antibodies against the virus (seven subjects) or clinical and immunological evidence of immune deficiency associated with a parental history of LAV/HTLV-III infection (two subjects). Five of these children had a severe illness starting in the first months of life (range 20 days--4 months) and died within 4 months (range 19 days--10 months). Eight children presented later in life (mean age 35 months, range 2-66 months) with a milder and more chronic disease characterized by the presence of generalized lymphadenopathy (6/8), hepatomegaly (5/8), splenomegaly (5/8), interstitial pulmonary infiltration (4/8), parotid swelling (3/8), CSF lymphocytosis (3/5), diarrhoea without pathogen isolated (1/8) and fever (1/8). At least one of the parents of each child was of African origin. At the time of birth of their child two mothers and one father had an AIDS-related complex. After a mean period of 34 months (range 3-87 months) five fathers and six mothers had a symptomatic LAV/HTLV-III infection (AIDS or AIDS-related complex).

AIDS in Africa: an epidemiologic paradigm

Cases of the acquired immune deficiency syndrome (AIDS) have been reported in countries throughout the world. Initial surveillance studies in Central Africa suggest an annual incidence of AIDS of 550 to 1000 cases per million adults. The male to female ratio of cases is 1:1, with age- and sex-specific rates greater in females less than 30 years of age and greater in males over age 40. Clinically, AIDS in Africans is often characterized by a diarrhea-wasting syndrome, opportunistic infections, such as tuberculosis, cryptococcosis, and cryptosporidiosis, or disseminated Kaposi's sarcoma. From 1 to 18% of healthy blood donors and pregnant women and as many as 27 to 88% of female prostitutes have antibodies to human immunodeficiency virus (HIV). The present annual incidence of infection is approximately 0.75% among the general population of Central and East Africa. The disease is transmitted predominantly by heterosexual activity, parenteral exposure to blood transfusions and unsterilized needles, and perinatally from infected mothers to their newborns, and will continue to spread rapidly where economic and cultural factors favor these modes of transmission. Prevention and control of HIV infection through educational programs and blood bank screening should be an immediate public health priority for all African countries.

Altered erythrocyte C3b receptor expression, immune complexes, and complement activation in homosexual men in varying risk groups for acquired immune deficiency syndrome

We studied levels of erythrocyte C3b receptors (E-CR1) and correlated them to the level of circulating immune complexes (CIC) and complement activation in patients with or at risk for acquired immunodeficiency syndrome (AIDS). A significant reduction was found in patients with AIDS (185 +/- 93 CR1/cell), AIDS-related complex, and generalized lymphadenopathy, whereas healthy male homosexuals or normal controls had 434 +/- 193 and 509 +/- 140 CR1/cell, respectively (P less than 0.001). Family studies indicate that this defect is acquired. Reduction in E-CR1 was associated with increased levels of CIC when assayed by binding to Raji cells, but not when tested by C1q binding. Complement activation was assessed by levels of C3bi/C3d-g in plasma, measured with a monoclonal antibody specific for a neoantigen in C3d. AIDS patients had increased C3 activation (2.68 +/- 1.67%) when compared with normal controls (0.9 +/- 0.22%) (P less than 0.01). The decreased E-CR1, the presence of CIC, and C3 activation suggest that complement activation by immune complexes may play a role in the clinical expression of the disease.

Circulating thymulin and thymosin-alpha 1 activity in pediatric acquired immune deficiency syndrome: in vivo and in vitro studies

Twenty-five children with acquired immune deficiency syndrome (AIDS) or AIDS-related complex had a characteristic pattern of T cell deficiency. Abnormally low plasma thymulin levels preceded the development of peripheral blood T cell abnormalities. In contrast to patients with congenital T cell deficiencies, our patients had elevated serum levels of thymosin-alpha 1. Treatment with thymosin fraction 5 in three children with AIDS resulted in only transient clinical and immunologic improvement.

Laboratory investigation of pediatric acquired immunodeficiency syndrome

Unique laboratory abnormalities, found in pediatric patients with clinical features of immunodeficiency, led to the original observation that a syndrome of acquired immunodeficiency (AIDS) was also occurring in pediatric populations. Initial observations which demonstrated the nonspecific findings of polyclonal hypergammaglobulinemia and T-cell deficiency were followed by confirmatory findings when testing for the AIDS retrovirus became available. In the pediatric population availability of antibody testing and viral isolation became critical in differentiating primary immunodeficiency disorders which involved both the B- and T-cell systems from AIDS associated with retrovirus infection. At this time based upon clinical, epidemiologic, immunologic, and serologic studies, the syndrome of pediatric AIDS can be distinguished from other primary and secondary pediatric immunodeficiency disorders.

The epidemiology of pediatric acquired immunodeficiency syndrome

HTLV III infection of children exhibits a relatively narrow spectrum in which the majority of patients develop clinical manifestations before the age of 2 years. In most instances the disease is transmitted in utero, whereby 35-65% of HTLV III-positive women give birth to an infected child. Discordant infection in twins is described. In fewer cases the disease is acquired through blood transfusions. In exceptional cases transmission via sexual abuse or use of needles may occur in young children. We have no evidence of intrafamilial horizontal disease transmission from child to child. The number of children with the disease may increase sharply. Around 2000 pregnancies in HTLV III-infected women are projected in New York City in the next year. Should all these pregnancies be completed, several hundred additional cases of pediatric AIDS may be expected in 1986.