Acquired immunodeficiency syndrome in infants

An infant with simultaneous beta-lactamase-positive Haemophilus influenzae meningitis and beta-lactamase-negative H. influenzae septicemia, Escherichia coli pyelonephritis and herpes encephalitis

We describe an infant with meningitis and septicemia due to infection with two different strains of Haemophilus influenzae, with a urinary tract infection due to Escherichia coli and in whom herpes virus encephalitis was diagnosed within three days. Acinetobacter calcoaceticus septicemia developed three weeks later. No immunological deficiency could be demonstrated in the patient who recovered finally, albeit with sequelae due to encephalitis.

Persistence of multiply antibiotic-resistant Campylobacter jejuni in a patient with the acquired immune deficiency syndrome

Chronic diarrhea due to Campylobacter jejuni has been described in patients with hypogammaglobulinemia. A patient with the acquired immune deficiency syndrome (AIDS) and normal total serum immunoglobulins had persistent diarrhea and C. jejuni on stool culture for seven and a half months despite repeated antibiotic therapy. Antibiotic sensitivity studies revealed the C. jejuni to be multiply antibiotic-resistant. Evaluation of the mechanism of resistance showed the organism harbored a conjugative plasmid capable of transferring resistance to tetracycline, but not to other antibiotics. It is concluded that C. jejuni infection may rarely result in chronic diarrhea in patients with AIDS. The combination of an immune deficiency state including abnormal B cell function previously described in AIDS and multiple antibiotic resistance may have contributed to the persistence of the organism in this case.

Pulmonary disease in children with acquired immune deficiency syndrome and AIDS-related complex

Two major pulmonary diseases were defined on the basis of lung biopsies in 15 children with acquired immune deficiency syndrome (AIDS) or AIDS-related complex. Pneumocystis carinii pneumonia was observed in eight children, and pulmonary lymphoid hyperplasia in six. One child had nonspecific interstitial pneumonitis. Children with P. carinii pneumonia had more severe hypoxemia, with higher alveolar-arterial oxygen gradients, and higher isomorphic elevations of serum lactate dehydrogenase. Clinically, children with pulmonary lymphoid hyperplasia were older, and had digital clubbing, parotid gland enlargement, and elevated serum IgG levels. Results of serologic assays and lung tissue analysis were suggestive of persistent Epstein-Barr virus infection exclusively in patients with pulmonary lymphoid hyperplasia. Recognition of the clinical and laboratory findings characteristic of each entity may assist in the differential diagnosis without the need of surgical biopsy.

Screening for antibodies to HTLV-III amongst the semen donors of an AID programme

This study suggests that, at the present time, AID is not likely to be a significant risk factor in the transmission of AIDS in Britain, particularly in centres which are already practising careful screening of semen donors. New facilities which are becoming available for HTLV-III screening should help to provide reassurance that semen donations are free from the virus.

Hypogammaglobulinemia with hyper-IgM, severe T-cell defect, and abnormal recirculation of OKT4 lymphocytes in a girl with chronic lymphadenopathy

We describe here one 8-year-old girl with an unusual form of immunodeficiency, characterized by hypogammaglobulinemia with hyper-IgM, severe T-cell defect, and chronic lymphadenopathy. Patient's B cells failed to produce IgG or IgA in vitro following stimulation with either pokeweed mitogen or Epstein-Barr virus, suggesting an intrinsic B-cell defect. Abnormal T-cell function was demonstrated by impaired in vivo delayed type hypersensitivity, reduction of mitogen-induced proliferation and interleukin 2 production, reduction of interferon-gamma production, and marked decrease of circulating OKT4+ cells. The latter cells were found in normal proportion in the patient's lymph node tissue. This finding suggests that the decrease of OKT4+ cells in peripheral blood was due to the abnormal recirculation of these cells. The identity of this syndrome with the infantile form of the acquired immunodeficiency syndrome was apparently ruled out by the failure to demonstrate HTLV-III-related sequences in patient's lymphocytes or virus-specific serum antibodies.

Hepatitis in children with acquired immune deficiency syndrome. Histopathologic and immunocytologic features

Hepatic morphology and immunocytology were evaluated in 4 children with clinical and immunologic characteristics of the acquired immune deficiency syndrome or acquired immune deficiency syndrome related complex. All 4 children had hepatomegaly and increased serum alanine and aspartate aminotransferase activity. Both lobular and portal changes were noted. Lymphocytic infiltration, piecemeal necrosis, hepatocellular and bile duct damage, sinusoidal cell hyperplasia, and endothelialitis were prominent. Vesicular rosettes in sinusoidal lymphocytes and tubuloreticular structures in sinusoidal endothelial cells were demonstrated by electron microscopy. The lymphocytic infiltrate in both the lobular and portal spaces was characterized by a relative increase of cytotoxic/suppressor (T8) cells. Hepatitis may be a common feature of pediatric acquired immune deficiency syndrome and acquired immune deficiency syndrome-related complex. Although the histopathologic changes are consistent with chronic active hepatitis, the specific pathogenesis remains to be determined.

Opportunistic lymphoproliferations associated with Epstein-Barr viral DNA in infants and children with AIDS

Two types of lymphoproliferative disease associated with Epstein-Barr viral (EBV) DNA--central-nervous-system lymphoma and chronic lymphocytic interstitial pneumonitis (LIP)--were recognised in children with human T-lymphotropic virus type III/lymphadenopathy virus infection and the acquired immunodeficiency syndrome (AIDS). Eight of ten lung biopsy specimens from children with LIP contained EBV DNA. EBV DNA was not identified in lung biopsy specimens with Pneumocystis carinii, cytomegalovirus, or atypical mycobacteria but without LIP, nor was EBV found in lung biopsy specimens from five adults with AIDS. Children with these EBV-associated complications had raised serum antibody titres to the replicative EBV antigens, but most of them lacked antibody to the component of the EB nuclear antigen encoded by the Bam HI K fragment. EBV-associated lymphoproliferative disease is a common and important complication of childhood AIDS.

AIDS in two African children--one with fibrosarcoma of the liver

We report here on two black African girls who developed an acquired immune deficiency syndrome (AIDS). The first patient was a premature girl born to healthy parents. She suffered from interstitial pneumonitis during the first week of life and died of it at the age of 6 months. Her mother, although asymptomatic, had polyclonal hypergammaglobulinaemia, a reversed T-helper/T-suppressor ratio and a decreased lymphocyte response to mitogens. The second patient had the first symptoms at the age of 6 years, developed a primitive malignant fibrosarcoma of the liver at 8 years old and died 1 year later. AIDS can affect black African children who have not been transfused and whose family members are not considered as at a high risk for this disease. In children, AIDS and cancer can be associated. In the second patient, cytotoxic suppressor lymphocytes (OKT8 positive cells) were shown to behave in vitro as precursors of T-killer cells.

Neurological complications in infants and children with acquired immune deficiency syndrome

Neurological complications occurred in 6 children, aged 6 months to 5 years, with acquired immune deficiency syndrome who were followed for 14 months. The most frequent manifestations included encephalopathies, acquired microcephaly, and pyramidal tract signs. Computed tomographic examinations showed variable degrees of cortical atrophy with ventricular dilatation and calcification. Electrophysiological abnormalities were demonstrated. Two children had documented central nervous system infections. Neurological deterioration resulted in dementia in 3 children. Cognitive impairment and developmental delays were evident in the other 3. Postmortem examination of the 3 children who died showed subacute cytomegalovirus encephalitis in 1; nonspecific hemispheric white matter changes, calcific vasopathy of the basal ganglia, and striking bilateral corticospinal tract degeneration in the second; and extensive calcific vasopathy of the basal ganglia and frontal centrum semiovale, and bilateral attenuation of the frontopontine and corticospinal tracts in the third.

Unusual cutaneous lesions associated with acquired immunodeficiency syndrome

We review a spectrum of unusual infectious, nutritional, and malignant processes that have been observed in the skin of patients with acquired immunodeficiency syndrome.

Cytomegalovirus presence and salivary composition in acquired immunodeficiency syndrome

Parotid and whole saliva was collected from nine patients with acquired immunodeficiency syndrome (AIDS) and nine controls. Cytomegalovirus (CMV) was cultured from both salivary samples in six of the AIDS patients but was not present in any of the controls. In the AIDS samples parotid sodium (p less than 0.05), IgG (p less than 0.01), and albumin (p less than 0.05) were higher than in control samples. Parotid potassium (p less than 0.05) and total protein (p less than 0.05) were lower than control values, whereas flow rate, lactoferrin, lysozyme, IgA, and IgM levels were similar in both sets of samples. AIDS does not appear to affect secretory IgA levels. Sodium (p less than 0.01) and IgA (p less than 0.05) were higher in the whole saliva of AIDS patients. Serum IgG, IgM (p less than 0.01), and IgA (p less than 0.05) were also elevated when compared with the controls. The prevalence of CMV in parotid and whole saliva of AIDS patients is consistent with the known susceptibility of this group to adventitious infection and the predilection of this virus for the salivary glands. The changes in salivary composition suggest a low level of inflammation, which occurs independently of the virus.

Acquired immune deficiency syndrome (AIDS) and consultation-liaison psychiatry

Acquired Immune Deficiency Syndrome (AIDS) is a new highly lethal transmissible syndrome that occurs primarily in identified high-risk groups. The number of AIDS cases has been doubling approximately every 6 months in the United States since 1981. A large number of healthy HTLV-III seropositive individuals, and a significant number of individuals with AIDS-related complex (ARC), who are at increased risk for eventual development of AIDS, have been identified. At least one third of AIDS patients develop neurologic disease prior to death. Organic mental disorders are frequent in AIDS and can have devastating consequences. Severe psychologic distress and functional psychiatric syndromes are also common. The psychosocial effects of AIDS for patients, family and friends, and health-care professionals are discussed in relationship to the psychosocial consequences of other serious medical illnesses including cancer. An ideal comprehensive program to meet the needs of "AIDS affected" individuals is presented, as are the authors' views on the tasks of C-L psychiatrists in participating in the comprehensive care of these individuals.

Developmental abnormalities in infants and children with acquired immune deficiency syndrome (AIDS) and AIDS-related complex

Children with acquired immune deficiency syndrome (AIDS) display two types of clinical picture: a full-blown AIDS characterized by the presence of opportunistic infections and/or Kaposi's sarcoma and a prodromal stage now identified as AIDS-related complex (ARC). Neurological complications have been identified in infants and children with the disease. This paper discusses the developmental abnormalities in 16 pediatric patients, seven with AIDS and nine with ARC, ranging in age from six months to six years. In all cases, the mothers of these children either had ARC, AIDS and/or used intravenous drugs. Developmental histories showed delayed acquisition of milestones in most children following the diagnosis of AIDS or ARC, with delayed motor milestones consistently noted in both groups. Several children with AIDS actually lost milestones as their illness progressed; this has not occurred in the ARC group. Psychometric testing revealed more severe cognitive dysfunction in the group with AIDS. Involvement of the central nervous system was documented clinically, radiologically, and/or electrophysiologically in all patients with AIDS. In the ARC group the course of the illness has shown greater variability. Medical and social factors that may contribute to the developmental abnormalities are discussed.

Pressor effects of alcohol in normotensive and hypertensive subjects

The effects of acute alcohol consumption and abstinence on blood pressure were studied in normal healthy subjects and in non-drinking and regularly drinking hypertensive patients. All subjects drank alcohol (1 g/kg body weight daily) for 5 days then abstained for 5 days. There was no significant difference in blood pressure in normal subjects during and after alcohol ingestion. However, in hypertensive non-drinkers both systolic and diastolic pressures when standing were significantly higher during the period of alcohol intake; supine blood pressure was not significantly higher. In hypertensive patients who drank regularly, standing and supine systolic and diastolic blood pressures were significantly higher during the period of drinking.

Hepatitis B virus DNA sequences in lymphoid cells from patients with AIDS and AIDS-related complex

A lymphotropic virus HTLV-III/LAV was recently identified as the etiologic agent of the acquired immune deficiency syndrome (AIDS). In a study of concomitant hepatitis B infections in patients with AIDS or the AIDS-related complex, DNA sequences of hepatitis B virus (HBV) were found in fresh and cultured lymphocytes from patients with AIDS even in the absence of conventional HBV serological markers. Furthermore, the restriction DNA pattern was consistent with the integration of the viral DNA. These results should prompt additional studies to reevaluate a possible role of HBV as a cofactor in AIDS in addition to the HTLV-III/LAV causal agent.

AIDS and parasitic infections, including Pneumocystis carinii and cryptosporidiosis

AIDS is a disorder that the pediatrician must consider when evaluating children with a variety of clinical conditions, including overwhelming infection with a number of parasites. This article discusses these opportunistic parasitic infections, focusing on their link with AIDS.

Progressive encephalopathy in children with acquired immune deficiency syndrome

We are reporting the cases of four children with a diagnosis of acquired immune deficiency syndrome (AIDS) who demonstrated a progressive encephalopathy manifested by loss of motor milestones or intellectual abilities, and weakness with pyramidal tract signs. Two patients were ataxic. One child was cortically blind and suffered myoclonic jerks before his death. Two of the patients had isolated seizures at some time during the disease course. Two patients developed secondary microcephaly and all four patients showed cortical atrophy on computed tomographic scanning. Three of the patients died. Postmortem neuropathological findings included gross cortical atrophy, microglial nodules, and intranuclear inclusions, as are described in the subacute encephalitis reported in adult AIDS patients. We propose that the possible pathogenetic mechanisms of this encephalopathy include opportunistic or persistent viral infection of the brain.

Postnatal transmission of AIDS-associated retrovirus from mother to infant

The third child of a previously healthy woman was delivered by caesarean section. Because of intraoperative blood loss, a blood transfusion was given after the delivery. The baby was breast-fed for 6 weeks. One unit of blood came from a male in whom the acquired immunodeficiency syndrome (AIDS) developed 13 months later. On recall, the mother proved to have lymphadenopathy, serum antibody to the AIDS virus, and a reduced T4/T8 ratio. The infant, who failed two thrive and had atopic eczema from 3 months, has likewise proved to have antibody to the AIDS virus. Since his mother was transfused after his birth, he is presumed to have been infected via breast milk or by way of some other form of close contact with his mother.

Pathologic pulmonary findings in children with the acquired immunodeficiency syndrome: a study of ten cases

Lung tissue and tissue from the lymphoreticular system obtained at open biopsy and/or autopsy were studied in ten children with the acquired immunodeficiency syndrome (AIDS). One or both parents of nine of the children had AIDS or risk factors for AIDS. The remaining child had hemophilia. The following pulmonary lesions were seen: 1) diffuse alveolar damage (DAD), 2) Pneumocystis carinii and/or cytomegalovirus pneumonitis, 3) lymphoid interstitial pneumonitis (LIP), and 4) desquamative interstitial pneumonitis (DIP). Combinations of such factors as mechanical ventilation, oxygen therapy, and opportunistic infection played a role in the pathogenesis of DAD. Opportunistic infections were related to the defective cell-mediated immunity in these children. The clinical, epidemiologic, immunologic, and pathologic features of the thymuses of these patients indicate that the immune deficiency was unlikely to have been of congenital origin. The immunologic abnormalities may also have been related to the pathogenesis of LIP and DIP. Neither LIP nor DIP has been described in adults with AIDS. Open lung biopsy is of practical importance in the diagnosis and treatment of pulmonary disease in children with AIDS.

Acquired immune deficiency syndrome in childhood

The acquired immunodeficiency syndrome has been observed with increasing frequency in children with associated hemophilia, high-risk environmental backgrounds, and blood transfusions. AIDS should be considered in the differential diagnosis of childhood immunodeficiency, and it must be distinguished from congenital disorders. We emphasize the importance of epidemiologic, clinical, and laboratory data in diagnosis and aggressive management of infectious complications. The relationship between human retrovirus infection and AIDS remains to be precisely defined, especially with regard to cofactors that may play a role in the development of severe immunodeficiency following exposure to the agent.

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.

Lymphadenopathy in drug addicts. A study of the distribution of T lymphocyte subsets in the lymph nodes

Lymph node biopsies from 24 male heroin addicts and 9 control patients were studied using immunohistochemical, and in 1/3 of cases, quantitative methods. 5 out of these 24 patients were also homosexual. All presented diffuse lymphadenopathy but none had any signs or symptoms of opportunistic infections nor Kaposi's sarcoma. Histologically the lymph nodes showed a very peculiar follicular hyperplasia with atrophy of the paracortex. The germinal centers appeared irregular, ill defined and contained clusters of small lymphocytes. The mantle zone was atrophic. Immunolabelling of T lymphocytes by monoclonal antibodies showed that germinal centers were invaded by small nests of Leu 2a (and OKT8) positive lymphocytes, i.e. chiefly cytotoxic-suppressor phenotype; the number of these cells increased by about 100 times in the follicles. OKT4 (and Leu 3a) positive cells, i.e. chiefly helper-inducer phenotype, appeared to decrease. These histological and immunohistochemical changes are considered to be suggestive of drug addicts' lymphadenopathy, and also possibly of other conditions increasing the risk of AIDS.

Transfusion-associated acquired immune deficiency syndrome in infants

Two preterm infant boys not known to be at risk developed clinical, laboratory, and pathologic features of acquired immune deficiency syndrome (AIDS) after receiving multiple blood transfusions in the neonatal period. Their clinical courses were characterized by failure to thrive, recurrent otitis media, hepatomegaly, and fatal interstitial pneumonia. Laboratory evaluation revealed progressive lymphopenia, reversed T helper/suppressor ratios, increased percentages of B-lymphocytes, decreased lymphoproliferative responses to mitogens, hyperimmunoglobulinemia, and high levels of circulating immune complexes. At postmortem examination thymic involution, lymphocyte depletion in spleen and lymph nodes, and micronodular mineralization in the central nervous system were seen. The findings were not specific for other known congenital immune deficiencies and were most indicative of AIDS. The lack of other risk factors suggests transmission of AIDS via blood transfusions in the neonatal period.

Oral candidiasis in high-risk patients as the initial manifestation of the acquired immunodeficiency syndrome

We studied the frequency with which unexplained oral candidiasis led to unequivocal acquired immunodeficiency syndrome (AIDS) in patients at risk. Twenty-two previously healthy adults with unexplained oral candidiasis, of whom the 19 tested had a reversed T4/T8 ratio and 20 had generalized lymphadenopathy, were compared with 20 similar patients with a reversed T4/T8 ratio and generalized lymphadenopathy who did not have oral candidiasis. All were intravenous-drug abusers, homosexual or bisexual men, or both. Thirteen of the 22 patients with oral candidiasis (59 per cent) acquired a major opportunistic infection or Kaposi's sarcoma at a median of three months (range, 1 to 23) as compared with none of 20 patients with generalized lymphadenopathy and immunodeficiency but without candidiasis who were followed for a median of 12 months (range, 5 to 21) (P less than 0.001). AIDS developed in 12 of 15 patients with candidiasis and T4/T8 ratios less than or equal to 0.51, as compared with none of four with ratios equal to or greater than 0.60 (P less than 0.01). We conclude that in patients at high risk for AIDS, the presence of unexplained oral candidiasis predicts the development of serious opportunistic infections more than 50 per cent of the time. Whether the remainder will have AIDS is not yet known.

Characterization of the acquired immune deficiency syndrome at the cellular and molecular level

The acquired immunodeficiency syndrome (AIDS) is a new disease characterized by severe dysfunction of both the T cell and B cell systems, occurring in previously healthy individuals. Affected individuals may have recurrent and chronic opportunistic infections and/or Kaposi's sarcoma or other malignancy. Analysis of the cellular and subcellular components of immunity demonstrates a profound depression in the number and function of helper/inducer T cells bearing the OKT4 (Leu 3) differentiation antigen and a concomitant defect in the synthesis of the immuno-enhancing soluble growth factor, interleukin 2 (IL-2). Hypotheses to explain the etiology of the immunological dysfunction and implications for future therapy of AIDS are discussed.

Unregulated production of virus and/or sperm specific anti-idiotypic antibodies as a cause of AIDS

A network of idiotypic and anti-idiotypic antibodies is often suggested as the basis for cellular interactions that maintain a steady-state immunological equilibrium. This hypothesis proposes that repeated exposure to certain external antigens--ie, both viral and sperm--stimulates an unregulated production of a uniquely potent immunomodulating idiotypic antibody(ies). In a genetically predisposed individual, this particular antibody(ies), which is also an autoantibody(ies), results in a cellular immune deficiency. This disruption in the immune system permits opportunistic infection and thus the acquired immune deficiency syndrome. This hypothesis, which is readily testable and which does not involve a primary pathogen, can explain both the active induction of this disease in, as well as its passive transfer to, all at-risk populations.

The acquired immune deficiency syndrome: an international health problem of increasing importance

The Acquired Immune Deficiency Syndrome (AIDS) is a new disease which first appeared in human populations about 1979. The disease is defined by the development of unusual types of cancer (e.g. Kaposi's sarcoma), or severe cellular immunodeficiency manifested by opportunistic infections (e.g. Pneumocystis carinii infection), or both. Although the etiology of AIDS is unknown, the epidemiologic evidence is consistent with an infectious agent transmitted by blood (e.g. transfusion, needle sharing) or sexual intercourse. Over three-quarters of the cases have been in homosexual or bisexual males and in intravenous drug abusers; about 5% of cases do not have recognized risk factors. A small number of cases have resulted from transfusion of blood or blood products. The early clinical manifestations are non-specific, and may include asymptomatic skin lesions, dyspnea and dry cough, weight loss, chronic diarrhea, and focal and non-focal central nervous system findings. Treatment for the associated cancers and opportunistic infections may be successful in individual instances, but the underlying immunosuppression of AIDS appears to progress inexorably and the fatality rate approaches 100% within a few years from diagnosis. Although nosocomial transmission has not been documented, infection control guidelines have been developed by analogy with hepatitis B infection.

Frequent detection and isolation of cytopathic retroviruses (HTLV-III) from patients with AIDS and at risk for AIDS

Peripheral blood lymphocytes from patients with the acquired immunodeficiency syndrome (AIDS) or with signs or symptoms that frequently precede AIDS (pre-AIDS) were grown in vitro with added T-cell growth factor and assayed for the expression and release of human T-lymphotropic retroviruses (HTLV). Retroviruses belonging to the HTLV family and collectively designated HTLV-III were isolated from a total of 48 subjects including 18 of 21 patients wih pre-AIDS, three of four clinically normal mothers of juveniles with AIDS, 26 of 72 adult and juvenile patients with AIDS, and from one of 22 normal male homosexual subjects. No HTLV-III was detected in or isolated from 115 normal heterosexual subjects. The number of HTLV-III isolates reported here underestimates the true prevalence of the virus since many specimens were received in unsatisfactory condition. Other data show that serum samples from a high proportion of AIDS patients contain antibodies to HTLV-III. That these new isolates are members of the HTLV family but differ from the previous isolates known as HTLV-I and HTLV-II is indicated by their morphological, biological, and immunological characteristics. These results and those reported elsewhere in this issue suggest that HTLV-III may be the primary cause of AIDS.