Prevalence of cytomegalovirus infection in homosexual men

Oral mucosal cytomegalovirus as a manifestation of the acquired immune deficiency syndrome

Cytomegalovirus (CMV) infection presenting as a painful palatal gingival ulcer was one of the initial clinical manifestations of the acquired immune deficiency syndrome (AIDS) in a male homosexual patient. The diagnosis of oral CMV infection was established when large intranuclear and smaller cytoplasmic CMV inclusions were observed in endothelial cells at the base of the mucosal ulcer. The identification of intranuclear and intracytoplasmic herpes-type viral particles in the infected cells was confirmed by electron microscopy. Cytoplasmic viral particles coexisted with paranuclear dense bodies resembling lysosomes. These features are characteristic of CMV-infected cells. A review of the English-language literature disclosed only three previously reported cases of CMV infection involving the oral mucous membranes. A vasculitis associated with the CMV-infected endothelial cells appears to be the underlying mechanism responsible for development of the oral ulcer. CMV should be considered a possible causative agent when oral ulcers are detected in immunocompromised patients. Likewise, the finding of CMV in oral ulcers should alert one to the possibility of an immunocompromised state.

Cytomegalovirus: epidemiology and infection control

Cytomegalovirus (CMV) causes asymptomatic infection in most individuals but can produce devastating illness in immunocompromised hosts and in a small proportion of congenitally infected babies. New techniques in molecular biology have provided insights into the epidemiology and transmission of CMV. Children in day care, their parents, and sexually active individuals, especially homosexual men, are now known to be at particular risk for acquiring CMV. Recent studies show that the risk of CMV acquisition by health care workers is similar to the risk to the general public. Health care workers should be aware of the wide range of clinical manifestations, methods of laboratory diagnosis, and current limitations of treatment of CMV. Careful handwashing and avoidance of excretions and secretions are recommended to decrease the transmission of CMV in the hospital.

Young children as a probable source of maternal and congenital cytomegalovirus infection

To identify possible sources of cytomegalovirus infection in pregnant women, we studied seven families with a recent case of congenital or maternal cytomegalovirus infection and a history of maternal contact with a young child shedding the virus. We used restriction-endonuclease techniques to compare the DNA of viral isolates collected from family members. Five families contained an infant who had congenital or perinatal infection, a mother who had had evidence of primary infection during her most recent pregnancy, and a child less than three years of age who was excreting cytomegalovirus. All five of the young children attended day-care centers at least part-time. In each of these five families, strains from family members were identical, and it is most likely that the toddler-aged child was the source of the virus for both the mother and the fetus or infant. In two other families, acquisition of cytomegalovirus by children in a day-care center was followed by seroconversion in the mother along with excretion of a strain of the virus identical to that in her child, as demonstrated by restriction-endonuclease analysis. Five of the seven fathers were tested for antibody to cytomegalovirus; four were seronegative, ruling them out as a source of infection in the mothers. These results not only strengthen evidence for the transmission of cytomegalovirus from child to mother but also indicate that infections acquired by a mother from a child can be transmitted to her fetus.

Cytomegalovirus infection in homosexual men. Relationship to sexual practices, antibody to human immunodeficiency virus, and cell-mediated immunity

To investigate the relationships among cytomegalovirus infection, sexual behavior, human immunodeficiency virus (HIV) seropositivity, and indexes of cellular immunity, 180 homosexual men and 26 heterosexual men were studied. Among the homosexual men, cytomegalovirus seropositivity was associated with increased T8 lymphocyte counts (p less than 0.001) and reduced T4/T8 ratios (p = 0.006); these results were independent of HIV infection. Cytomegalovirus seropositivity was also associated with increasing age, numbers of sexual partners, and the practice of anal-receptive intercourse. At the first visit, cytomegalovirus was isolated from none of 13 cytomegalovirus-seropositive heterosexual subjects, compared with 62 (36 percent) of 171 seropositive homosexual men (p less than 0.005). Viral isolation was most common from semen. Among 32 cytomegalovirus-seropositive homosexual subjects from whom culture specimens were obtained more than four times over 10 to 30 months, 72 percent of the specimens were culture-positive. The mean duration of cytomegalovirus excretion in semen was 22 months, and in urine, the duration was nine months. Cytomegalovirus excretion was associated with younger age and reduced lymphocyte proliferation in response to cytomegalovirus, but not with antibody to HIV. Cytomegalovirus infection is sexually transmitted among homosexual men, perhaps by rectal intercourse, and is associated with alterations in T lymphocyte subsets. Most seropositive homosexual men excrete cytomegalovirus intermittently, primarily in the semen.

Antiviral antibodies in the sera of homosexual men: correlation with their lifestyle and drug usage

Healthy homosexual men between the ages of 21 and 65 years, from the Washington, DC (n = 162), and New York City (n = 89) areas, were studied for antibodies in the serum against cytomegalovirus (CMV), herpes simplex virus (HSV) types 1 and 2, and Epstein Barr virus (EBV) viral capsid antigen (VCA). CMV-specific antibodies were assayed by enzyme-linked immunosorbent assay (ELISA), anti-HSV-1 and -2 antibodies were measured by indirect hemagglutination (IHA), and antibodies to EBV VCA were measured by the immunofluorescence assay. Antibodies to human T lymphotrophic virus III (HTLV-III) were detected by ELISA and Western blot procedures. T lymphocytes were enumerated using OKT4 monoclonal antibody. Healthy male volunteer blood donors (n = 90) matched for age range and race proportions were used as controls. The percentage of seropositive individuals in the homosexual group was higher (90-98%) for all the viruses tested than in the control group (47-87%). Comparisons of the geometric mean titers, expressed as reciprocal serum dilutions, of seropositive individuals in homosexual (H) vs control (C) group were as follows: CMV-IgG (ELISA) H = 1:794, C = 1:68; HSV-1 (IHA) H = 1:248, C = 1:14; HSV-2 (IHA) H = 1:56, C = 1:17; EBV-VCA (IFA) H = 1:385, C = 1:131. The homosexual group also showed a higher frequency of individuals with elevated titers than the control group. The CMV IgM antibody was prevalent in 17.7% of the homosexual group and 5% of the control group; arithmetic means for ELISA values for CMV IgM were 0.207 for the homosexual group and 0.05 for the control group. In the homosexual group, the anti-CMV antibody titers increased with age (P = 0.01) and with numbers of sex partners (P = 0.06). Both anti-HSV-1 and anti-HSV-2 antibodies correlated with the number of sex partners (P = 0.04 and P = 0.05, respectively). Neither age nor partner number correlated with response to EBV, and no particular sex act was related to the EBV VCA titer level. HTLV-III seropositivity was associated with higher herpes virus group antibody titers, probably because of life style cofactors. Among the HTLV-III-seropositive subjects, those with less than or equal to 400 T-helper lymphocytes/mm3 had lower antibody titers than those with greater than 400 T-helper lymphocytes/mm3 counts, suggesting an impaired immune response secondary to immunosuppression.

Infection with human immunodeficiency virus (HIV) and cytomegalovirus in a London health district 1980-4

By testing serum samples taken between 1980 and 1984 from men attending a department of sexually transmitted diseases, it was shown that antibodies to human immunodeficiency virus (HIV) first appeared in 1981. Homosexual men were significantly more likely to have antibodies to HIV and to cytomegalovirus (CMV) than were heterosexual men attending the same clinic. This shows that homosexuals are exposed to both HIV, the cause of the acquired immune deficiency syndrome (AIDS), and to CMV, which can reactivate to cause life threatening disease once immunosuppression has developed. All homosexuals, not just those with antibodies against HIV, had raised levels of CMV antibodies. This suggests that they experience frequent antigenic stimulation after reinfections with CMV or reactivation of endogenous virus.

Inflammatory demyelinating peripheral neuropathies associated with human T-cell lymphotropic virus type III infection

Nine patients with inflammatory demyelinating polyneuropathies (IDP) were found to have human T-cell lymphotropic virus type III (HTLV-III) infection. The 8 men, 6 of whom were homosexual, and 1 woman, a former intravenous drug user, presented with progressive weakness. Two had lymphadenopathy but all were otherwise asymptomatic. Six had chronic IDP and 3 had Guillain-Barré syndrome. In addition to an elevated cerebrospinal fluid (CSF) protein level (mean, 193 mg/dl), most patients had cerebrospinal fluid pleocytosis (mean, 23 cells/mm3), a distinctive feature. All had reduced T4:T8 T-cell ratios. Results of nerve conduction studies were characteristic of demyelination. Nerve biopsies revealed intense inflammatory cell infiltrates and macrophage-mediated demyelination. The patients recovered either spontaneously or following treatment with corticosteroids or plasmapheresis. During a mean interval of 20 months after presentation, only 1 patient had developed acquired immune deficiency syndrome. Patients with HTLV-III infection have disordered immune function, and the mechanism of the development of the IDP is likely to be immunopathogenic. As a result of our experience, we suggest that all patients with IDP be tested for evidence of HTLV-III infection. We also found, although in uncontrolled trials, that treatment with either prednisone or plasmapheresis was followed by clinical improvement; since plasmapheresis is not likely to further depress cell-mediated immunity, we suggest that it be the initial therapy.

In situ hybridization analysis of cytomegalovirus lytic infection in Kaposi's sarcoma associated with AIDS. A study of 14 autopsy cases

Cytomegalovirus (CMV) was assayed by in situ hybridization with commercially available biotin-labeled CMV-DNA probes in 45 formalin-fixed paraffin-embedded autopsy specimens with Kaposi's sarcoma from 14 cases of the acquired immune deficiency syndrome (AIDS). In seven of the 14 cases, a few scattered hybridizing cells were detected in Kaposi's sarcoma, but not all specimens from the same case showed such cells. Most of the positive cells were peculiarly swollen and not typical of Kaposi's sarcoma cells. All positive cases had at least some CMV-infected organs with typical cytomegalic cells containing nuclear inclusions while five of the 7 negative cases revealed no CMV-infected tissue by conventional light microscopy. Our results suggest that this in situ hybridization procedure using biotin-labeled DNA probes only reveals generalized CMV infection that is a consequence of impairment of immune mechanisms in AIDS patients.

Cytomegaloviral epididymitis in a patient with the acquired immune deficiency syndrome

We report on a patient with cytomegaloviral epididymitis and the acquired immune deficiency syndrome. The diagnosis was suggested by epididymitis that was refractory to antibiotics, and by isolation of cytomegalovirus from the urine and semen. The definitive diagnosis was made with immunohistochemical staining for cytomegaloviral antigens in the epididymal ductal cells. Because of the ineffectiveness of antimicrobial agents in this disorder, epididymectomy is the current treatment of choice.

Gastrointestinal manifestations of the acquired immunodeficiency syndrome

The increasing frequency of acquired immunodeficiency syndrome (AIDS) mandates that all physicians be aware of the diverse nature of problems that affect this group of patients. The gastrointestinal tract is involved in approximately 50% of patients with AIDS, although not all are symptomatic. Common problems include diarrhea, malabsorption, and weight loss. These can be due to enteric infection, neoplasia, or an ill-defined enteropathy. Gastrointestinal bleeding can also become problematic either as a presenting manifestation of the illness or during the prolonged periods of debilitation that many of these individuals experience. An aggressive diagnostic approach is necessary to recognize treatable abnormalities in the digestive tract of AIDS patients.

Multiple transforming regions of human cytomegalovirus DNA

The transforming (focus forming) activity of defined cloned DNA fragments from human cytomegalovirus Towne and AD169 was carried out in immortalized rodent cells. The frequency of focus formation in NIH 3T3 cells by Towne XbaI fragment E was 80- to 100-fold higher than that observed with Towne XbaI fragments AO, O, C, or carrier DNA alone but was similar to that observed with pCM4127, a transforming fragment from HCMV AD169 (J. A. Nelson, B. Fleckenstein, D. A. Galloway, and J. K. McDougall, J. Virol. 43:83-91, 1982; J. A. Nelson, B. Fleckenstein, G. Jahn, D. A. Galloway, and J. K. McDougall, J. Virol. 49:109-115, 1984). Foci were first detected in Towne XbaI fragment E-transfected NIH 3T3 cells at 5 to 6 weeks posttransfection, whereas foci were detected at 2 to 3 weeks after transfection with AD169 pCM4127. Digestion of Towne XbaI fragment E with BamHI did not significantly reduce its focus-forming activity. When BamHI subclones of Towne XbaI fragment E were assayed individually for focus formation in NIH 3T3 and Rat-2 cells, transforming activity was localized within each terminal fragment (EJ and EM). Foci induced by EJ or EM DNA alone were smaller compared with those induced by Towne XbaI fragment E. Isolated focal lines exhibited growth in soft agar and were tumorigenic in immunocompetent syngeneic animals. High-molecular-weight DNAs from transformed and tumor-derived lines were analyzed by Southern blot hybridization with intact EM and a 1.5-kilobase subfragment lacking cell-related sequences. Virus-specific EM sequences were detected at less than one copy per cell in Towne XbaI fragment E-transformed NIH 3T3 cells and at multiple copies in rat tumor-derived cell lines. In contrast, virus-specific EJ sequences were barely detected in EJ-transformed and tumor-derived lines with intact EJ as probe.

Elimination of toxicity and enhanced cytomegalovirus detection in cell cultures inoculated with semen from patients with acquired immunodeficiency syndrome

Although semen is a particularly rich source of cytomegalovirus (CMV) and is useful for monitoring CMV shedding, its culturing is associated with extensive monolayer toxicity, isolation failures, and lengthy detection times. Inoculation of fractionated semen with immunoperoxidase staining of monolayers eliminated virtually all toxicity, increased isolation rates and monolayer infectivity, and greatly reduced detection times. Semen specimens (n = 73) were processed conventionally (C) or separated into supernatant (SF) and cellular pellet (PF) fractions, and 35% of C and SF inocula produced extensive toxicity. In contrast, virtually no toxicity was observed in monolayers inoculated with PF. C and SF isolation rates were 41 of 73 and 38 of 73, respectively, whereas that for PF was 51 of 73. Although monolayer infectivity at initial CMV detection was often less than 10% for C and SF, it was as much as 25% for PF. Average detection times were reduced from 13 days for C and SF to 6 days with PF and were further reduced to 3 days when PF inoculation was combined with immunoperoxidase staining. Thirty percent of specimens negative by C were positive by PF.

Normal T cell subsets in homosexual men living in a community without endemic AIDS

The cause of the abnormal T lymphocyte subsets reported in healthy homosexual men is not known. Frequent sexually transmitted infections including human T cell lymphotropic virus type III/lymphadenopathy-associated virus (HTLV-III/LAV) are possible causes. To determine if the T lymphocyte subsets were abnormal in this population in an area without endemic acquired immune deficiency syndrome (AIDS), T lymphocyte subsets of 52 homosexual men in Rochester, New York, were enumerated, and evidence of infections known to cause these abnormalities was sought. Unlike the findings in previous reports, relative numbers of T helper and T suppressor cells and helper/suppressor T cell ratios were normal. Prevalence of cytomegalovirus infection (86 percent) was similar to that found in analogous populations, but only 9 percent had seropositive results for HTLV-III/LAV. Men with serologic evidence of nonprimary cytomegalovirus disease had lower helper/suppressor T cell ratios (1.5 +/- 0.2 versus 2.2 +/- 0.2; p less than 0.01). Hence, despite frequent infections with cytomegalovirus and other sexually transmitted pathogens, T cell subsets are normal in homosexual men in an area without endemic AIDS. Therefore, HTLV-III/LAV is primarily responsible for the T cell abnormalities observed elsewhere.

Confirmation of human cytomegalovirus by reverse passive hemagglutination with monoclonal antibodies reactive to the major glycosylated peptide (GP-66)

Sheep erythrocytes coated with three monoclonal antibodies, each reactive to a different epitope of the 66-kilodalton cytomegalovirus (CMV) matrix protein, were used in a reverse passive hemagglutination test with CMV-infected cell lysate to identify and confirm the CMV. The test is specific only for CMV, since 5 laboratory strains of CMV (AD169, Davis, Espilat, C-87, and Towne) and 10 clinical isolates reacted well, but uninfected MRC-5 cell lysate, lysates of herpes simplex virus types 1 and 2, varicella-zoster virus, and adenoviruses did not react. The reactive CMV lysate was confirmed by the pretreatment of CMV lysate with the three monoclonal antibodies followed by the addition of antibody-coated erythrocytes. The reverse passive hemagglutination test and the confirmatory blocking test are performed at the same time, requiring 2 h to complete. Since V-bottom microtiter 96-well plates and a 25-microliter pipette can be used to perform the test, it is ideal for CMV confirmation, especially when the equipment to read the fluorescent-antibody test or enzyme-linked immunosorbent assay is not available.

A review and proposal for the etiology of acute necrotizing gingivitis

There are numerous correlations between features of acute necrotizing gingivitis (ANG) and virus infections, notably cytomegalovirus (CMV) infections. The age range of occurrence of seroconversions to CMV positive and occurrence of ANG correlate both in industrialized countries (young adults) and in underdeveloped countries (young children). A depression in cell-mediated immunity, as evidenced by a decrease in T-lymphocyte helper/suppressor ratio and decreased responsiveness to the mitogen ConA, has been shown to occur in both CMV infection and ANG. There is a higher incidence of both CMV infection and ANG in young male homosexuals. These and other correlations, taken together, argue for a fundamental role for virus in ANG etiology.

Screening to reduce transmission of sexually transmitted diseases in semen used for artificial insemination

The practice of artificial insemination by donor semen is increasing in the United States. Many sexually transmitted organisms are found in semen, but screening procedures for the detection of these agents in donor semen have not been standardized. Sexually transmitted organisms have been transmitted during artificial insemination by donor, and such transmission can cause local, disseminated, or fatal disease in the recipient woman and may harm the fetus or newborn. Therefore, screening of both the donor and the donated semen is necessary to avoid infectious complications. Because semen samples cannot be evaluated completely on the day of donation, the use of fresh semen for artificial insemination should be discouraged. Until accurate, rapid diagnostic tests are available, only frozen semen that has been appropriately screened should be used.

Immunologic aspects of the acquired immunodeficiency syndrome and male homosexuality

The acquired immunodeficiency syndrome (AIDS) is the most common and best characterized disorder of T cells leading to enhanced susceptibility to infection. Current hypotheses hold that infection with human T-cell lymphotropic virus type III/lymphadenopathy virus (HTLV-III/LAV) is a necessary but not a sufficient condition for the development of AIDS, and that a variety of cofactors participate in the pathogenesis of the syndrome. This article reviews the immunologic aspects of AIDS and the AIDS-related syndromes, as well as concepts of etiology and pathogenesis. Predisposing factors for this disease in the homosexual or bisexual host are emphasized.

Management of opportunistic infections complicating the acquired immunodeficiency syndrome

Therapy of opportunistic infection in patients with the acquired immunodeficiency syndrome is frustrating, and there is no convincing evidence that aggressive treatment and/or prophylaxis other than for Pneumocystis infection can significantly prolong life. While much clinical effort is expended on treating sequential life-threatening infections, the overall course is usually progressively downhill. Thus, any real impact on the disease should be aimed at the causative viral agent, because it is destruction of a critical component of the immune system that predisposes to opportunistic infections.

Antibody levels for cytomegalovirus, herpes simplex virus, and rubella in patients with acquired immune deficiency syndrome

Significantly higher proportions of patients with acquired immune deficiency syndrome (AIDS) or lymphadenopathy syndrome (LAS) were positive for antibodies to cytomegalovirus (CMV) and herpes simplex virus (HSV) compared with control groups of commercial blood donors. In contrast, no differences were found in the incidence of individuals positive for antibodies to rubella in these groups of subjects. Of those positive for antibodies to CMV and HSV in each group, the mean antibody levels were significantly higher in AIDS-LAS patients compared with the controls. The entire distribution of antibody concentrations to CMV and HSV in AIDS patients was shifted upward, so that significantly more patients showed high values and significantly fewer showed low values, indicating hyperactive humoral immune responses to these viruses. In sharp contrast, the AIDS patients with antibody levels for rubella showed the same distribution of antibody levels as did two groups of controls. No correlation was found between concentrations of CMV and HSV antibodies in individual AIDS-LAS patients.

Oral findings in people with or at high risk for AIDS: a study of 375 homosexual males

A total of 375 homosexual males were studied to assess the dental findings, life-style, and risk factors during a 4-year period. At baseline, 136 of the patients were diagnosed as having AIDS, 116 were considered at risk for AIDS, and 123 were considered healthy. In a mean follow-up time of 23 months, nine of the patients at risk for AIDS and five of the patients considered healthy were diagnosed as having AIDS. Kaposi's sarcoma was the most common oral neoplasm, and candidiasis was the most frequent oral infection. Hairy leukoplakia was found in 28% of the patients, and periodontal disease was found in 17% of the patients. Carriers of the AIDS virus may not be identified easily and control measures in the dental office must be followed.

Infection control and the pregnant health care worker

Health care workers may be exposed to a variety of infectious agents in the workplace. The pregnant health care worker presents additional concerns because of the potential risk of infection to the developing fetus. Health care workers often misunderstand the basic elements of infection transmission. The result of this misinformation is that personnel are most often concerned about the agents that are least transmissible. To develop an infection control program that is rational and workable, the infection control practitioner must have a thorough understanding of the mechanisms of disease transmission. With this foundation, an infection control program for the pregnant health care worker will rarely involve transfer to alternative assignments or work restriction based on pregnancy alone. The approach outlined in this article stresses a more generic approach to infection control by isolating the disease and not the employee.

Infectious and sexually transmitted diseases: implications for dental public health

The Acquired Immunodeficiency Syndrome (AIDS) has stimulated renewed attention toward infectious diseases and dental public health. Currently, AIDS is defined as individuals with Kaposi's sarcoma and/or pneumocystis carinii pneumonia and/or other life-threatening opportunistic infections (e.g., specific forms of tuberculosis or meningitis, candidal esophagitis), and associated immunosuppression that cannot be accounted for by another disease process and/or medications. As of January 1986, the AIDS epidemic has afflicted over 16,000 persons in the United States and has taken over 8,000 lives. All present indications point toward a much more extensive epidemic based on the lack of a vaccine and effective forms of treatment, the large number of carriers in the population, and variable modes of transmission.

An update on the acquired immunodeficiency syndrome (AIDS). Associated disorders of the alimentary tract

The pandemic, acquired immunodeficiency syndrome (AIDS) has been described in 40 nations throughout the world. This paper describes the wide spectrum of gastrointestinal tract manifestations seen in this syndrome, with particular attention to the epidemiology, etiology, and measurement of these problems. Discussion of candidiasis, herpes simplex, "hairy" leukoplakia, Kaposi's sarcoma, cytomegalovirus, anal warts and carcinoma, chlamydial proctitis (LGV), coccidiosis, and mycobacterial diarrhea, as well as "gay bowel syndrome," demonstrates the complex management problems associated with this condition.

Treatment of disseminated cytomegalovirus infection with 9-(1,3 dihydroxy-2-propoxymethyl)guanine: evidence of prolonged survival in patients with the acquired immunodeficiency syndrome

Disseminated cytomegalovirus (CMV) infection is a common complication of the acquired immunodeficiency syndrome (AIDS) and contributes significantly to its morbidity and mortality. Dihydroxypropoxymethyl guanine, DHPG, is an antiviral agent that has been shown to inhibit CMV replication and to provide clinical benefit in patients with CMV infections, especially retinitis. In this study, the clinical characteristics, results of diagnostic evaluations, and survival were compared in 11 AIDS patients with disseminated CMV infections who were seen between August 1981 and October 1984 and were not treated with DHPG, and in 18 AIDS patients seen since that time who were treated with DHPG. The study groups were similar though the untreated group was somewhat more tissue depleted. Survival from diagnosis was significantly prolonged with DHPG therapy based upon life table analysis (p = 0.001). Therapy improved the quality of life, as 12 of 18 treated patients and only 2 of 11 untreated patients could be discharged from the hospital. Progression of CMV infection did not appear to play a role in the mortality of patients who died during DHPG therapy. We conclude that DHPG prolongs survival in patients with AIDS who have disseminated CMV infections.

Rapid diagnosis of cytomegalovirus infection

Several assays are in preparation for the diagnosis of cytomegalovirus infection in acquired immune deficiency syndrome and other immunocompromised patients. In particular, ELISA and DNA probes look to be particularly promising for testing body fluids and tissue sections respectively but these assays are not currently available. The technique of detection of early fluorescent antigen foci (DEAFF) has for some time been available as a diagnostic service to immunocompromised patients served by the author's laboratory. Although it requires cell culture and immunofluorescent techniques it is capable of detecting most patients with productive infection. In particular, the rapid availability of results has allowed patients to be entered into trials of new antiviral agents.

The epidemiology of AIDS: current status and future prospects

The reported incidence of acquired immune deficiency syndrome (AIDS) continues to increase in countries throughout the world. On the basis of a polynomial model for extrapolation, the cumulative number of cases diagnosed and reported since 1981 in the United States is expected to double during the next year with over 12,000 additional cases projected to be diagnosed by July 1986. The annual incidence rates for single (never-married) men in Manhattan and San Francisco, intravenous drug users in New York City and New Jersey, and persons with hemophilia A ranged from 261 to 350 per 100,000 population during 1984. For single men aged 25 to 44 years in Manhattan and San Francisco, AIDS was the leading cause of premature mortality in 1984 as measured by years of potential life lost. Infection with HTLV-III/LAV is considerably more common than reported AIDS in high-risk populations and can persist at least for several years, so the presence of specific antibody should be considered presumptive evidence of current infection. The screening of donated blood and plasma for antibody to HTLV-III/LAV and use of safer clotting factor concentrates should greatly reduce HTLV-III/LAV transmission through blood and blood products. Most HTLV-III/LAV infections occur through sexual transmission, use of contaminated needles, and as a result of infected mothers passing the virus to newborns. Continued research commitment is needed to develop an HTLV-III/LAV vaccine and therapy for this infection. In the interim, widespread community efforts are needed to minimize transmission.

Cytomegalovirus and herpes simplex virus ascending myelitis in a patient with acquired immune deficiency syndrome

Progressive ascending myelitis was the presenting feature of the acquired immune deficiency syndrome (AIDS) in a homosexual man who also had Kaposi's sarcoma, Pneumocystis pneumonia, and disseminated cytomegalovirus (CMV) infection. Neuropathological studies showed profuse cytomegalic cells throughout the brain and spinal cord, but no inflammatory response. At postmortem examination, CMV and herpes simplex virus, type 2 (HSV-2), were recovered from multiple sites throughout the central nervous system (CNS). HSV-2 was isolated from the anus, but from no other extraneural site; in contrast, pathology typical of CMV was also seen in the liver, gastrointestinal tract, adrenals, and lungs. Although histopathological evidence suggesting prior CMV infection has been seen in the brains of AIDS patients, the virus has never been cultured from the CNS in these immunosuppressed hosts, nor has it been known to infect the spinal cord. The absence of an inflammatory response suggests that the pathogenesis of CNS viral infections is altered in AIDS patients. Evidence for CMV infection of the CNS in AIDS patients is no longer circumstantial.

Medical problems of the homosexual adolescent

Physicians treating adolescents should take a complete sexual history, including sexual orientation and practices, to determine whether their patients are homosexually active. Lesbians are at very low risk for sexually transmitted diseases, but they do have other health concerns. Four general groups of conditions may be encountered in homosexually active men: classical sexually transmitted diseases (gonorrhea, infections with Chlamydia trachomatis, syphilis, herpes simplex infections, genital warts, pubic lice, scabies); enteric diseases (infections with Shigella species, Campylobacter jejuni, Entamoeba histolytica, Giardia lamblia, hepatitis A, hepatitis B, hepatitis non-A, non-B, and cytomegalovirus); trauma (fecal incontinence, hemorrhoids, anal fissure, foreign bodies, rectosigmoid tears, allergic proctitis, penile edema, chemical sinusitis, inhaled nitrite burns, and sexual assault of the male patient); and the acquired immunodeficiency syndrome (AIDS). Clinicians can assist homosexual teenagers by understanding their special health needs, by counseling them about safe sexual practices, and by accepting their relationships nonjudgmentally.

Impaired mononuclear-cell proliferation in patients with the acquired immune deficiency syndrome results from abnormalities of both T lymphocytes and adherent mononuclear cells

Peripheral blood mononuclear cells from patients with acquired immune deficiency syndrome proliferate poorly after stimulation with soluble mitogens. The present study was undertaken to assess the relative contributions of T lymphocytes and of plastic adherent mononuclear cells to the impaired mononuclear cell responses. We employed a four-step separation procedure including terminal depletion using a monocyte-specific monoclonal antibody (61D3) to derive populations of highly purified T cells from patients and from normal subjects. Highly purified T cells proliferated poorly in response to phytohemagglutinin and pokeweed mitogen. The addition of autologous adherent cells to highly purified T cells markedly improved mitogen-driven proliferation in all subjects; however, mononuclear cells from patients with AIDS responded less well than normals (P less than or equal to 0.01) for both phytohemagglutinin and pokeweed. Allogeneic normal adherent cells fully restored both phytohemagglutinin and pokeweed responses in normal highly purified T cells. Adherent cells from patients were comparable to normal adherent cells in phytohemagglutinin-driven proliferation but performed significantly less well when pokeweed was used to stimulate normal highly purified T-cell responders (4308 cpm after coculture with patients' adherent cells vs 8244 cpm after coculture with allogeneic normal adherent cells; P = 0.05). Similarly, when patient's highly purified T cells were stimulated with pokeweed mitogen, control adherent cells functioned substantially better than patient adherent cells (1198 cpm for allogeneic patient adherent cells vs 2324 cpm for normal adherent cells; P = 0.05). Although the addition of normal adherent cells to patients' highly purified T cells significantly improved pokeweed mitogen responses, these values did not reach normal. Suppression by patients adherent cells was not demonstrated.(ABSTRACT TRUNCATED AT 250 WORDS)

Intestinal infection with Mycobacterium avium in acquired immune deficiency syndrome (AIDS). Histological and clinical comparison with Whipple's disease

At endoscopy, a 30-year-old man with acquired immune deficiency syndrome (AIDS), Kaposi's sarcoma, diarrhea, and unexplained malabsorption showed erythematous macular duodenal lesions consistent with Whipple's disease by histology and electron microscopy. Symptoms did not respond to tetracycline. Subsequent cultures revealed systemic Mycobacterium avium (M. avium) infection. Tissue from this patient, from patients with Whipple's disease and from a macaque with M. avium were compared. All contained PAS-positive macrophages but M. avium could be distinguished by positive acid-fast stains and a difference in pattern of indirect immunofluorescence staining with bacterial typing antisera. PAS-positive macrophages in the intestinal lamina propria are no longer pathognomonic of Whipple's disease. Ultrastructural and histological similarities between Whipple's disease and M. avium infection suggest that both are manifestations of immune deficits limiting macrophage destruction of particular bacteria after phagocytosis. M. avium must be considered in the differential diagnosis of diarrhea in patients with AIDS and other immunosuppressed conditions.

Neurological manifestations of the acquired immunodeficiency syndrome (AIDS): experience at UCSF and review of the literature

In this review of the acquired immunodeficiency syndrome (AIDS), the authors have evaluated a total of 352 homosexual patients with AIDS or generalized lymphadenopathy managed at the University of California, San Francisco (UCSF), between 1979 and 1984. Of an initial unselected group of 318 patients, 124 (39%) were neurologically symptomatic, and one-third already had their neurological complaints at the time of presentation. An additional 210 AIDS patients with neurological symptoms have been reported in the literature. Thus, a total of 366 neurologically symptomatic patients with AIDS or lymphadenopathy are reviewed. Central nervous system (CNS) complications, encountered in 315 patients, included the following viral syndromes: subacute encephalitis (54), atypical aseptic meningitis (21), herpes simplex encephalitis (nine), progressive multifocal leukoencephalopathy (six), viral myelitis (three), and varicella-zoster encephalitis (one). Non-viral infections were caused by Toxoplasma gondii (103), Cryptococcus neoformans (41), Candida albicans (six), Mycobacteria (six), Treponema pallidum (two), coccidioidomycosis (one), Mycobacterium tuberculosis (one), Aspergillus fumigatus (one), and Escherichia coli (one). Neoplasms included primary CNS lymphoma (15), systemic lymphoma with CNS involvement (12), and metastatic Kaposi's sarcoma (three). Cerebrovascular complications were seen in four patients with hemorrhage and five with infarction. Five patients in the UCSF series had multiple intracranial pathologies, including two cases of simultaneous Toxoplasma gondii infections and primary CNS lymphoma, two cases of coexistent Toxoplasma gondii and viral infections, and one case of combined Toxoplasma gondii and atypical mycobacterial infection. Cranial or peripheral nerve complications, seen in 51 patients, included cranial nerve syndromes secondary to chronic inflammatory polyneuropathy (five), lymphoma (five), and Bell's palsy (five). Peripheral nerve syndromes included chronic inflammatory polyneuropathy (12), distal symmetrical neuropathy (13), herpes zoster radiculitis (six), persistent myalgias (two), myopathy (two), and polymyositis (one). In light of the protean behavior of AIDS and the problems related to the clinical, radiological, and serological diagnosis of the unusual and varied associated nervous system diseases, patients with AIDS and neurological complaints require a rigorous and detailed evaluation. The authors' experience suggests that biopsy of all CNS space-occupying lesions should be performed for tissue diagnosis prior to the institution of other therapies.

Incidences of antibodies to hepatitis B, herpes simplex and cytomegalovirus in prostitutes

The 170 prostitutes registered by the local public health authority (165 female, 5 male; ages 17-61) were serologically investigated by ELISA and CFT for the presence of hepatitis B virus (HBV) markers (n = 170), anti-CMV (n = 118) and anti-HSV 2 antibodies (n = 117). 4.7% (1.2%) were found to be HBs- (HBe-)antigen carriers; 1.2% revealed an acute hepatitis B (seroconversion of anti-HBc or IgM-anti-HBc highly positive); 17.1% presented a past and resolved hepatitis B (anti-HBs positive). These rates exceeded those of 125 female age-matched control persons considerably, out of whom only 2.4% (0.8%) presented HBs-(HBe-) antigen and 3.2% anti-HBs antibodies. 90% of the prostitutes investigated proved to be anti-CMV IgG (1.7% IgM) antibody positive and were compared to healthy blood donors (47% IgG, 0% IgM-anti-CMV antibody carriers) and other CMV risk groups: pregnant women 56 (13), patients in hemodialysis 61 (0), hemophiliac patients 69 (0), patients after kidney transplantation 90 (16) and after open-heart surgery 87 (4) % anti-CMV IgG (IgM) antibody carriers. An AIDS patient suffered from simultaneous HBV and CMV infections. The risk of HSV 2 infection is among prostitutes (38.5% seropositives) five times as high as among female age-matched control persons (7.2% seropositives, n = 125). These results confirm that prostitutes must be regarded as a risk for the spread of hepatitis BV and CMV- and HSV 2-caused diseases in the population.

Testicular cancer in homosexual men with cellular immune deficiency: report of 2 cases

Embryonal cell carcinoma of the testis was seen in 2 homosexuals with peripheral lymphadenopathy of the head and neck, and abnormal cellular immunity measured by reduced T helper cells and increased T suppressor cells. One patient had no history of venereal disease but had taken marijuana, nitrites and methyl-dextroamphetamines regularly. The other patient had a history of syphilis, gonorrhea, hepatitis and venereal warts but rarely used inhalant recreational drugs. Both patients had smoked cigarettes. Neither patient had any known risk factors that predisposed to testicular cancer. Biopsy of a supraclavicular lymph node in 1 patient showed histological features of reactive follicular hyperplasia similar to those described previously in the acquired immune deficiency syndrome. These cases of testicular cancer increase the spectrum of rare cancers developing in young male homosexuals with acquired cellular immune abnormalities.

Acquired immunodeficiency syndrome and the emergency physician

Aids is a new public health disaster that is unlikely to be resolved quickly. It is manifested by a profound immune deficiency accompanied by the development of KS, PCP, and/or other opportunistic infections. A retrovirus, HTLV-III, is the probable cause of the immunosuppression, and it is transmitted in a manner similar to hepatitis B virus. Groups at highest risk include homosexual men, intravenous drug abusers, Haitians, and hemophiliacs. Therapy is largely experimental, and mortality is high. The emergency physician must be familiar with the signs, symptoms, and early management of AIDS. He should be able to offer guidance on disease prevention to both health care workers and members of high-risk groups. Allocation of major financial resources and intensive investigation are necessary to abort this cruel epidemic that affects primarily younger persons. Such investigation will undoubtedly produce new advances in virology, oncology, and immunology that will benefit medicine and society as a whole.

AIDS and the gut

The epidemiological, immunological and early virological observations on the acquired immune deficiency syndrome (AIDS) suggested that an agent was involved which was sexually, parenterally and perinatally transmitted and perhaps tropic for T helper lymphocytes. A new subgroup of human T lymphotropic retroviruses have been identified ans seroepidemiological studies suggest that they are aetiologically related to AIDS. The syndrome is characterised by the development of tumors: such as Kaposi's sarcoma and non-Hodgkins lymphoma, with an aggressive clinical course and infection by a wide spectrum of opportunistic organisms. Both the tumours and the infections commonly involve the gut.

Activated interferon system in healthy homosexual men

More than 50% of a group of healthy homosexuals in Israel were found to have an activated interferon (IFN) system as evidenced by markedly elevated blood IFN levels, increased in vitro production of IFN by unstimulated peripheral blood mononuclear cells and HuIFN-alpha and HuIFN-gamma production by appropriately stimulated cells, and a surprisingly high incidence of an antiviral state of cells. This pattern resembles that found in persons with acute viral illness, and is unlike that found in normal healthy controls. The type of IFN in the blood was found to be unusual in that it was mainly HuIFN-alpha, pH 2-labile, a type of IFN found in certain collagen diseases as well as in homosexual men suffering from Kaposi's sarcoma or lymphadenopathy. Natural killer (NK) cytotoxic activity was found to be somewhat lower than that found in normal controls, although no correlation was found between blood IFN levels and NK activity. Mean (2'-5')-oligoisoadenylate synthetase levels in cell extracts were intermediate between normal controls and patients with viral illness. Likewise no correlation was found between enzyme levels and blood IFN levels. The highly activated IFN system found in certain homosexuals, as well as the increased spontaneous production of IFN by unstimulated mononuclear cells, suggest the possibility of the presence of a virus, active or latent, in these individuals. This virus could be a retrovirus such as HTLV-III or LAV which have recently been isolated from AIDS patients. The special type of IFN present could be the response to a novel virus in an unusual situation. On the basis of recent reports, we speculate that homosexuals with highly activated IFN systems who produce pH 2-labile HuIFN-alpha could be at increased risk for developing AIDS.

Small noncleaved B cell Burkitt-like lymphoma with chromosome t(8;14) translocation and Epstein-Barr virus nuclear-associated antigen in a homosexual man with acquired immune deficiency syndrome

This case report describes new manifestations of the acquired immune deficiency syndrome (AIDS) in a promiscuous homosexual man. Investigation of upper gastrointestinal bleeding in the patient lead to discovery of a high-grade, small, noncleaved cell (Burkitt-like) gastroduodenal lymphoma with visceral and extralymphatic extension. Specific phenotyping of the lymphoma revealed that it was a monoclonal B cell lymphoma of mu kappa isotype. An in vitro cell line was established that was Epstein-Barr virus nuclear-associated antigen-positive. The lymphoma cells displayed a t(8;14) translocation similar to endemic African Burkitt lymphoma. Epstein-Barr virus genomes were identified in the lymphoma and an axillary lymph node biopsy specimen by molecular hybridization. These data strongly suggest that Epstein-Barr virus actively infected this patient. However, he showed normal Epstein-Barr virus-specific serologic responses, indicating an immune defect against the virus.

Homosexual men in London: lymphadenopathy, immune status, and Epstein-Barr virus infection

By November 7, 1983, 24 cases of AIDS in the United Kingdom had been reported to the Communicable Disease Surveillance Centre. At the same time an increasing number of homosexual men with unexplained lymphadenopathy syndrome (LAS) have been seen in our department. Between December 1982 and July 1983, 14 homosexual men with LAS and 11 healthy homosexual men were studied. Patients with LAS had a high number of lifetime episodes of sexually transmitted diseases, a history of recent sexual activity in the United States (9 of 14), sexual contact with British AIDS patients or other persons with LAS (7 of 14), and hypergammaglobulinemia. Low T-helper/T-suppressor ratios (less than 0.8), due mainly to a decrease in T-helper cells, were found in both groups. Lymph node biopsies showed follicular hyperplasia and hypocellular pattern. All 25 patients studied had antibodies to Epstein-Barr virus capsid antigen (anti-VCA) and 11 had antibodies to early antigen (anti-EA); 13 of 17 were excreting the virus; and two showed no Epstein-Barr-virus-specific regression. Peripheral blood immunoglobulin-producing B-cells from six patients with hypergammaglobulinemia were negative for the Epstein-Barr virus nuclear antigen (EBNA). Five lymph node biopsies showed no EBNA-positive cells. Epstein-Barr virus reactivation is common in the patients with LAS and healthy homosexual men in London, but would not seem to be the cause of the polyclonal B-cell activation or lymphadenopathy.

Pediatric acquired immunodeficiency syndrome

Approximately 40 to 50 infants and children with similar epidemiologic, clinical, and laboratory features of AIDS have been described. The occurrence of significant numbers of patients with PAIDS in geographic areas that are associated with similar risk factors and clinical features of AIDS suggests a common cause. Immunologic evaluation reveals hypergammaglobulinemia, decreased or absent antibody responses after immunization, normal to decreased T-cell numbers, decreased helper/suppressor cell ratios, and abnormal results of functional studies of T-cells. None of the patients described has the clinical or laboratory features of well-established congenital immunodeficiency disorders. No consistent viral agent has been documented except for antibody to ARV and HTLV III. The frequent finding of T-cell abnormalities in the mothers of infants with PAIDS is in contrast to the absence of such abnormalities in the mothers of infants with congenital immunodeficiency disorders. Future studies in PAIDS should be directed toward uncovering the etiology and risk factors as well as determining the response to treatment with various methods of immunologic reconstitution.

Nonurban male homosexuals: epidemiologic, immunologic and virologic characteristics

Twenty asymptomatic male homosexuals living in North Carolina were evaluated looking at epidemiologic, immunologic and virologic characteristics. In ten subjects selected for inhalant nitrite use a significantly higher frequency of multiple drug abuse and a trend toward greater sexual promiscuity was found in comparison with ten nonnitrite users. None of the 20 subjects had chronic lymphadenopathy. Cytomegalovirus (CMV) was not found in urine, blood or throat washings, but was found in 29% of the subjects' semen specimens--a finding that was significantly linked (P less than .05) to the presence of CMV IgM antibody in serum. There were no abnormal helper lymphocytes: suppressor T lymphocyte ratios (all greater than 1.3) and lymphocyte mitogen stimulations were not different from heterosexual controls in contrast to frequent abnormalities reported in male homosexuals in metropolitan areas. If these immunologic findings are reproducible, they may be important in understanding why the Acquired Immunodeficiency Syndrome has clustered in large cities.