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

Human immunodeficiency virus (HIV)-related chronic relapsing inflammatory demyelinating polyneuropathy with multifocal unusual onion bulbs in sural nerve biopsy. A clinicomorphological study with qualitative and quantitative light and electron microscopy

This is obviously the first report on a case with a spontaneous sensu strictu relapsing variant of human immunodeficiency virus (HIV)-related polyneuropathy. Its manifestation preceded LAS. Intrathecal HIV-antibodies developed between the most severe third and fourth episode. Analysis of sural nerve biopsy was consistent with a multifocally accentuated chronic inflammatory demyelination, characterized by unusual onion bulb-like Schwann cell formations with irregular voluminous layers, electron density, aggregation of filaments, multiple indented nuclei, and numerous enclosed collagen pockets. A direct or immune-mediated indirect specific influence on Schwann cell morphology by HIV might be discussed. Virus-like particles and ultrastructural markers of HIV were not detectable.

Cholangitis in the acquired immunodeficiency syndrome: report of two cases and review of the literature

We report the cases of one patient with the acquired immunodeficiency syndrome as a result of human immunodeficiency virus type 1/lymphadenopathy associated virus type 1/human T-cell lymphotrophic virus type III (HIV-1/LAV-1/HTLV-III) infection and of another patient with AIDS related complex caused by human immunodeficiency virus type 2/lymphadenopathy associated virus type 2 (HIV-2/LAV-2) infection, who were suffering from cholangitis. The manifestations and possible mechanisms for cholangitis in these patients and in 10 previously reported similar cases are reviewed.

A calf thymus acid lysate improves clinical symptoms and T-cell defects in the early stages of HIV infection: second report

Thymomodulin is a calf thymus acid lysate capable of inducing T lymphocyte maturation. Fifteen patients with HIV infection at different stages according to the Walter Reed classification were treated with 60 mg/day of thymomodulin syrup for more than 50 days. Two WR6B subjects had clinical and immunological parameters unchanged and died, while the patient suffering from Kaposi's sarcoma presented an evident clinical and laboratory improvement with remission of the neoplasia. The other 12 patients ranging from WR2 to WR5B showed an improvement of clinical symptoms after thymomodulin therapy accompanied by the normalization of CD4/CD8 ratio (P less than 0.001). This helpers/suppressors increase was due to a significant increase of CD4 cells (P less than 0.01) and also to a decrease of the CD8 lymphocytes (P less than 0.05). Thymomodulin administration did not cause an enhancement of the urinary levels of neopterin, a marker of T-cell activation.

Dermatologic findings associated with human immunodeficiency virus infection

Both human immunodeficiency virus (HIV) infection and acquired immunodeficiency syndrome (AIDS) are associated with an increased prevalence of several dermatologic diseases. We studied healthy homosexual men with negative reactivity to HIV antibody, homosexual men without AIDS but with positive reactivity to HIV antibody, and homosexual men with AIDS to compare the prevalence of dermatologic disease in these groups. We found that five cutaneous disorders were increased in persons with HIV infection. Oral hairy leukoplakia was increased both in seropositive subjects without AIDS and in subjects with AIDS. Condylomata acuminata and seborrheic dermatitis were slightly increased in seropositive non-AIDS subjects and significantly increased in the AIDS group. Molluscum contagiosum and oral candidiasis were increased only in the AIDS group.

Long-term evaluation of HIV antigen and antibodies to p24 and gp41 in patients with hemophilia. Potential clinical importance

To investigate the relation between human immunodeficiency virus (HIV) antigenemia and clinical manifestations of HIV infections, we studied 96 patients with hemophilia who were positive for HIV antibody, for a median of 34 months. Every 4 to 10 months a clinical and laboratory examination was performed and serum samples were tested for three HIV markers: HIV antigen, antibody to p24, and antibody to gp41. Twenty-two subjects (23 percent) were found to be positive for HIV antigen: 8 were positive upon entry and remained so (Group 1), and 14 became positive during the study, 4 to 26 months after HIV antibody appeared (seroconversion), 13 of whom remained positive for HIV antigen (Group 2). Most subjects positive for HIV antigen had low or undetectable titers of antibody to p24, whereas the antibody titer to gp41 remained high. In Group 2, patients with low p24 antibody titers had further decreases in their titers before or at the time HIV antigen appeared. Once present, HIV antigen persisted and tended to increase in concentration. In contrast to Group 3 (negative for HIV antigen, low anti-p24 titer) and 4 (negative for HIV antigen, high anti-p24 titer), the groups positive for HIV antigen had significantly higher incidences of acquired immunodeficiency syndrome (P = 0.05), immunodeficiency-related infections (P less than 0.001), and immune thrombocytopenia (P = 0.001), and had more severe disease as measured by the Walter Reed staging system (P less than 0.001). In this study, HIV antigen appeared to be a better predictive marker of HIV-related complications than the absolute T4+ count. These results suggest that HIV antigenemia indicates a poor clinical prognosis.

Densitometric analysis of Western blot (immunoblot) assays for human immunodeficiency virus antibodies and correlation with clinical status

Western blot assays for antibodies directed against components of human immunodeficiency virus (HIV) associated with acquired immunodeficiency syndrome (AIDS) were examined with a densitometer and integrator. Antibody responses to seven HIV proteins were determined from the areas under the peaks of bands on blots from 430 seropositive individuals. Antibody responses corresponded qualitatively and quantitatively with clinical status. The Western blot assays examined were done on single specimens from individuals in one of four clinical states: asymptomatic with no risk factor identified, asymptomatic with risk factor(s) identified, AIDS-related complex, and AIDS. The ratios of gp41 antibody to p24 antibody and of gp41 antibody to total HIV antibodies increased, and the number of total HIV antibodies decreased progressively in these populations. Parameters were assigned to characterize the typical response found in AIDS: gp41 antibody/p24 antibody ratio, greater than or equal to 2.0; gp41 antibody/total HIV antibodies ratio, greater than or equal to 0.30; and number of total HIV antibodies, less than or equal to 25.0 signal units. Parameter match increased with progression of clinical status. These parameters were applied in a brief follow-up study of 34 HIV-infected asymptomatic individuals who developed AIDS-related complex or AIDS. Initial specimens showed a stronger correlation than our population data base had predicted, suggesting that the parameters have prognostic value. Densitometric analysis of antibody responses on Western blot assays of single or serial specimens should prove useful to physicians in staging and monitoring HIV-infected individuals and in predicting which individuals will progress to AIDS.

Antiviral therapy in AIDS. Clinical pharmacological properties and therapeutic experience to date

The rapid spread of human immunodeficiency virus (HIV) infections and the grim outcome of these infections have focused interest on the possibilities for medical intervention. The end-stage of these infections, acquired immune deficiency syndrome (AIDS), was first recognised in 1981, and the causative agent isolated in 1983. Already several antiviral drugs have been investigated. One initially promising drug, suramin, was found to have a net harmful effect but another, zidovudine (azidothymidine) has been shown to prolong life in AIDS patients. The properties of these and several other antiviral drugs such as antimoniotungstate (HPA-23), foscarnet (phosphonoformate) ribavirin, dideoxynucleotides, and interferons, are reviewed. The role of immunomodulating modalities such as plasmapheresis, bone marrow transplantation, thymosin, interleukin-2, inosine pranobex (isoprinosine), and cyclosporin are also discussed. None of the currently available drugs hold promise as monotherapy. Through analysis of the experience with these drugs and the increasing knowledge of HIV pathogenesis, new drugs can be designed. It seems increasingly clear that drugs will eventually have to be used in combination in order to reduce toxicity, exploit therapeutic synergy, and reduce the risk of HIV resistance. The theoretical and experimental background for such combinations are currently being elucidated.

Clinical manifestations of HIV infections

The wide clinical spectrum of HIV infection is reflected in the new CDC classification. Presentations range from acute infection, asymptomatic carriage and persistent lymphadenopathy through constitutional upset and neurological disease to the opportunistic infections and cancers of AIDS. AIDS is an enigmatic disease which presents special clinical diagnostic and management problems. Although any system may be affected the lungs and the brain are the most important target organs. Though the underlying disease is currently untreatable, many of the complications of AIDS are amenable to prompt therapy. Seropositive patients should be monitored to detect early signs of significant HIV disease. Skilled counselling about the avoidance of co-factors which may potentiate HIV infection, is important.

Nonrandom development of immunologic abnormalities after infection with human immunodeficiency virus: implications for immunologic classification of the disease

Blood specimens from 165 intravenous drug users who were seropositive for the human immunodeficiency virus (HIV), from 158 seropositive homosexual men with lymphadenopathy, and from 77 patients with acquired immunodeficiency syndrome (AIDS) were assessed immunologically. Immunologic parameters were analyzed by the Guttman scalogram technique to determine if immunologic abnormalities occurred in a nonrandom pattern. The following four patterns emerged: (i) seropositivity for HIV with no immunologic abnormalities; (ii) seropositivity for HIV with a depressed T4/T8 cell ratio; (iii) seropositivity with a depressed T4/T8 cell ratio and T4-cell depletion; and (iv) seropositivity with a depressed T4/T8 cell ratio, T4-cell depletion, and lymphopenia. Ninety-two to 100% of subjects in each of the three groups of patients were found "to scale" because the abnormalities occurred in the cumulative, ordered fashion described. This nonrandom occurrence of abnormalities indicates an ordered progression of immunologic abnormalities in individuals infected with HIV, a finding useful in the staging of both symptomatic and asymptomatic HIV-seropositive subjects.

HIV and HBV infection in intravenous drug addicts from northeastern Italy

Three hundred and two intravenous drug addicts (IVDA) from five towns in Northeastern Italy were studied. Of the males, 37/249 (14.8%) were homosexuals and of the females, 29/53 (54.7%) were prostitutes; 118 (39.0%) were alcoholics. AST levels were abnormal in 31.8%, ALT in 45.7%, GTP in 36.4%, and bilirubin in 14.6%. The prevalence of HBsAg (13.9%) and HBeAg (21.4% of HBsAg positive) was significantly higher than in 2,983 controls (4.2% and 6.3%, p less than .001 and p less than .02, respectively). Of the HBsAg positive subjects, 51.7% had anti-HDV antibodies. Among 260 HBsAg negative cases, 146 (56.2%) were anti-HBs and anti-HBc positive, 76 (29.2%) were anti-HBc positive and anti-HBs negative (25 anti-HBe positive and 51 anti-HBe negative), and 38 had no HBV markers. Anti-HIV ELISA positive subjects came to 70.5% (triplicate determination with absolute concordance) and Western blot analysis confirmed the results in 99.1% of ELISA positive and 100% of ELISA negative subjects. The prevalence of anti-HIV was significantly higher in anti-HBc positive than negative cases (p less than .02), even excluding HBsAg positive subjects. Cases negative for HIV and HBV had a significantly lower median duration of drug abuse than those with past or present infection (36 vs 60 months, p less than .001). HIV-related diseases were present in 56.3% of the cases (120/213; PGL in 94, ARC in 24, and AIDS in two).(ABSTRACT TRUNCATED AT 250 WORDS)

Autopsy findings in AIDS--a histopathological analysis of fifty cases

Fifty consecutive AIDS autopsy cases were evaluated. All subjects showed one or more opportunistic infections and malignancies included in the AIDS case definition with cytomegalovirus and Kaposi's sarcoma being most prevalent. Mycobacterial and cryptococcal infections occurred only infrequently. Most patients of our series after successful treatment of Pneumocystis carinii pneumonia or cerebral toxoplasmosis later succumbed to less treatable conditions like disseminated cytomegalovirus or fungal infections or malignant lymphoma. In the absence of specific treatment for the HIV infection leading to these lethal complications special emphasis must be put on the prevention of HIV transmission and spread.

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.

Characterization and clinical association of antibody inhibitory to HIV reverse transcriptase activity

Reverse transcriptase activity of the human immunodeficiency virus (HIV) was blocked in vitro by immunoglobulin G (IgG) derived from certain individuals infected with this retrovirus. A heterogeneous immune response for inhibition of enzyme function was noted. Catalytic activity was depressed by 50% or more with the use of 10 micrograms of IgG from 11 of 16 HIV-seropositive asymptomatic carriers, but from 0 of 8 seronegative controls and 2 of 12 patients with acquired immune deficiency syndrome (AIDS) or the AIDS-related complex (ARC). The inhibitor was confined to the F(ab')2 fragment. It was not directed against the poly(rA) X oligo(dT) template, nor against major envelope or structural viral antigens, and did not cross-react with bacterial, avian, or other mammalian DNA polymerases. It did not correlate with recognition of polymerase antigens by radioimmunoprecipitation. Loss of this inhibitor may be associated with development of clinical disease. Ten asymptomatic HIV-seropositive carriers with high titers of IgG antibodies to reverse transcriptase were followed for a mean of 3 years. All of four lost inhibitory capability prior to development of AIDS or ARC, while titers persist in the six who remain clinically healthy.

Predictors of the acquired immunodeficiency syndrome developing in a cohort of seropositive homosexual men

In a cohort of 1835 homosexual men who were seropositive for human immunodeficiency virus (HIV) on entry into a prospective study, the acquired immunodeficiency syndrome (AIDS) developed in 59 during a median follow-up of 15 months. We matched 5 seropositive controls to each case according to study center and date of enrollment and performed a case-control analysis to determine factors predictive of AIDS. In a multivariate analysis, a decreased number of T helper lymphocytes, an increased number of T suppressor lymphocytes, a low level of antibody to HIV, a high titer of cytomegalovirus antibody, and a history of sex with someone in whom AIDS developed were independently associated with subsequent AIDS. Separate analyses of risk factors for Kaposi's sarcoma and opportunistic infections failed to support previously reported associations between the use of nitrites or an elevated cytomegalovirus-antibody titer and Kaposi's sarcoma. These variables may be markers rather than determinants of disease progression. A vigorous antibody response to HIV infection may confer at least temporary protection against the progression of immunodeficiency to AIDS, or a low level of antibody to HIV may reflect a later stage of infection. The increased risk associated with a history of sex with someone in whom AIDS developed may indicate earlier infection in cases or infection with a more virulent strain of HIV. These results may be useful in counseling HIV-seropositive persons and in designing studies of clinical interventions.

Complete nucleotide sequences of functional clones of the AIDS virus

To examine the mechanism of lymphocytotoxicity induced by human T-lymphotropic virus type III/lymphadenopathy associated virus (HTLV-III/LAV), an in vitro model has been developed. Introduction of an HTLV-III/LAV proviral clone, HXB2, into normal lymphocytes results in the production of virions and cell death. The complete nucleotide sequence of the proviral form of HXB2 has now been determined. Its structure is quite similar to that previously determined for HTLV-III/LAV clones whose biological capacities had not previously been demonstrated. The biological function of two additional clones of HTLV-III/LAV, BH10 and HXB3, are reported. Clone BH10 which lacks the 5' long terminal repeat sequences (LTR) and a portion of the 3' LTR is reconstituted by substituting the corresponding sequences of HXB2 and is shown to be capable of generating infectious cytopathic virions. Clone HXB3, which has been partially sequenced, is also found to be capable of producing lymphocytopathic virus. Clone HXB3 differs from HXB2 in its lack of a termination codon in 3' orf, demonstrating that 3' orf plays no major role in virus replication or cytopathic activity. These data provide the necessary background to allow the identification of viral determinants of replication, cytopathic activity, and antigenicity using these functional proviral clones.

Update and future perspectives of a thymic biological response modifier (Thymomodulin)

Thymomodulin (Ellem Industria Farmaceutica spa, Milan, Italy) is a calf thymus acid lysate with immunomodulating activities. It is composed of several peptides with a molecular weight range of 1-10kD. Extensive studies in animal systems showed that Thymomodulin exhibited no, or very little toxicity even when used at high doses. Studies done in vitro and in vivo demonstrated that Thymomodulin is a biologically active compound which regulates the maturation of human and murine pre T lymphocytes, as well as modulate the functions of apparently mature human and animal B and T lymphocytes. It was observed that Thymomodulin can promote myelopoiesis as demonstrated by an increase of granulocyte-macrophage colonies in agar. Although additional studies to examine its target cell lineage are required, it appears that Thymomodulin exhibits specificity toward T cells. Therefore, enhancement of other cell lineage functions by Thymomodulin may be indirect, and mainly due to its effect on T cells. Of major importance is to note that Thymomodulin is prepared in a manner which allows it to maintain its biological activity when administered orally.

Management of infectious and immunological complications of acquired immunodeficiency syndrome (AIDS). Current and future prospects

AIDS is caused by a newly recognised virus (human immunodeficiency virus; HIV) which induces a profound defect in cellular immune function associated with increased susceptibility to opportunistic infections and certain malignancies. The clinical presentation of HIV ranges from asymptomatic infection to severe immunodeficiency manifesting as severe life-threatening infectious diseases or malignancies. While major research efforts are being directed toward development of vaccine and discovery of effective antiretroviral drugs, clinicians are faced with AIDS patients with multiple and complicated medical problems including opportunistic infections and certain malignancies. Currently, efforts are directed toward early diagnosis, treatment, and prevention of recurrence of these opportunistic infections. The current approaches are reviewed in this article. Major recent developments in AIDS research include the isolation of the HIV on culture and the availability of the antibody test. Aside from vaccine and antiretroviral drugs, other measures that may be of benefit in the treatment of AIDS patients are immunological enhancement and reconstitution. Several studies are underway to evaluate antiviral agents in the treatment of HIV infection. Those undergoing clinical trial include suramin, ribavirin, antimoniotungstate, phosphonoformate and azidothymidine. Immune enhancers that have been used include alpha- and gamma-interferon and interleukin-2. HLA-matched lymphocyte transfusions and bone marrow transplantations have been used alone and in combination to replace the AIDS patient's defective immune system.

Human immunodeficiency virus: the eighth gene

Human T-lymphotropic virus type III (HTLV-III/LAV) has been shown to contain at least four extra genes in addition to the three essential genes (gag, pol, env) for replication of most retroviruses. These genes are expressed by complex splicing mechanisms and utilization of overlapping reading frames. We now demonstrate that there is an eighth gene which encodes a protein which is immunogenic and recognized by sera of some HTLV-III seropositive people. The gene is highly conserved among all known HTLV-III isolates and exhibits a polymorphism at the 3' end which distinguishes several molecular clones of the HTLV-IIIB cell line from those of other HTLV-III/LAV isolates. The function of this gene is unknown.

Variations in Western blot banding patterns of human T-cell lymphotropic virus type III/lymphadenopathy-associated virus

Serum samples from 27 patients infected with human T-cell lymphotropic virus type III (14 with acquired immune deficiency syndrome [AIDS] and 13 with AIDS-related complex) were examined for antibodies to viral proteins by the Western blot method and with four different commercial solid-phase enzyme-linked immunosorbent assays (ELISAs). Virus-specific bands on blots at molecular masses of 64, 55, 53, 41, 31, 24, and 17 kilodaltons were observed. Rank correlation matrices were calculated to relate the intensity of viral bands, stage of illness, and ELISA kit optical densities (ODs). Groups of bands tended to covary in intensity: p17, p24, and p55 (gag gene products); p53 and p64 (pol gene products); and p31 (pol/endonuclease gene product) and p41 (env gene product). Blots of sera from AIDS-related complex patients usually showed strong activity against all viral proteins, while those of sera from AIDS patients characteristically showed strong reactivity only at the pol/endonuclease and env bands. For one ELISA kit (Abbott Laboratories, North Chicago, Ill.), ODs correlated well with the env and pol band intensity scores, while ELISA ODs with other kits (from Litton Industries, Sunnyvale, Calif.; Electro-Nucleonics, Inc., Fairfield, N.J.; and E.I. du Pont de Nemours & Co., Inc., Wilmington, Del.) correlated closely with gag band intensity scores. We conclude that human T-cell lymphotropic virus type III Western blot patterns are determined by (i) viral protein processing pathways and (ii) the stage of illness of the patient and may reflect (iii) the ELISA method used for serum screening.

Screening for HIV infection: risks, benefits, and the burden of proof

In 1984, scientists isolated a new pathogen, now called human immunodeficiency virus (HIV), that is almost certainly the etiological agent for the acquired immunodeficiency syndrome (AIDS). It has been estimated that there are between 500,000 and 1,750,000 asymptomatic, chronically HIV-infected individuals in the United States. In a remarkably short time, investigators developed a number of blood tests that indicate whether an individual is likely to be infected with this virus. These assays are now being used to test patients with symptoms suggesting AIDS or related syndromes, to screen donated blood, to evaluate individuals concerned about their infection status, and to screen new military recruits, active-duty soldiers, and ROTC students. Almost weekly, new proposals are advanced for screening different subsets of the population.

Acquired immunodeficiency syndrome: epidemiology and significance for the obstetrician and gynecologist

A retrovirus, variously named human T-lymphotropic virus type III or lymphadenopathy-associated virus, is now recognized as the etiologic agent of the acquired immunodeficiency syndrome. As of January, 1986, more than 16,000 cases of acquired immunodeficiency syndrome have been reported, and it is estimated that greater than or equal to 1 million Americans are now infected with human T-cell lymphotropic virus/lymphadenopathy-associated virus. Most cases of overt acquired immunodeficiency syndrome still fall within well-defined "high-risk groups," that is, homosexual or bisexual men, intravenous drug users, recipients of transfused blood or blood components, and persons with hemophilia. Also at risk are heterosexual partners of persons who have overt acquired immunodeficiency syndrome or who are at risk for acquired immunodeficiency syndrome, as are children born to mothers who either have acquired immunodeficiency syndrome or are members of a "high-risk group." Transmission of the virus may occur via sexual contact, via parenteral exposure to contaminated blood products, or from an infected mother to her child. Of special concern to the practicing obstetrician are recent reports suggesting bidirectional heterosexual transmission, transmission via artificial insemination, and perinatal transmission. In addition, the isolation of human T-cell lymphotropic virus/lymphadenopathy-associated virus from human breast milk raises concerns regarding potential transmission by this route.

Genetic variation in HTLV-III/LAV over time in patients with AIDS or at risk for AIDS

In a study of genetic variation in the AIDS virus, HTLV-III/LAV, sequential virus isolates from persistently infected individuals were examined by Southern blot genomic analysis, molecular cloning, and nucleotide sequencing. Four to six virus isolates were obtained from each of three individuals over a 1-year or 2-year period. Changes were detected throughout the viral genomes and consisted of isolated and clustered nucleotide point mutations as well as short deletions or insertions. Results from genomic restriction mapping and nucleotide sequence comparisons indicated that viruses isolated sequentially had evolved in parallel from a common progenitor virus. The rate of evolution of HTLV-III/LAV was estimated to be at least 10(-3) nucleotide substitutions per site per year for the env gene and 10(-4) for the gag gene, values a millionfold greater than for most DNA genomes. Despite this relatively rapid rate of sequence divergence, virus isolates from any one patient were all much more related to each other than to viruses from other individuals. In view of the substantial heterogeneity among most independent HTLV-III/LAV isolates, the repeated isolation from a given individual of only highly related viruses raises the possibility that some type of interference mechanism may prevent simultaneous infection by more than one major genotypic form of the virus.