Cytomegalic inclusion disease and Pneumocystis carinii infection in an adult

The first postmodern pandemic: 25 years of HIV/ AIDS

Science responded to the challenge of AIDS by rapidly identifying aetiology, describing pathogenesis and transmission routes, and developing diagnostic tests and treatment. However, this did not prevent the global spread of HIV, with 25 million fatal cases so far, another 33 million infected, and disastrous socioeconomic and demographic consequences. In spite of unprecedented political attention and financial resources, the response is falling further behind the growth of the epidemic. This is partly due to the unique characteristics of the virus, such as persistent infection, vertical transmission and a variability that allows it to escape immunity and antiretroviral drugs, and partly due to human characteristics such as a strong procreative instinct, drug use and ostracism. Denial, myths and complacency are major obstacles to rational measures. With no cure or vaccine in sight, scaling up prevention is of paramount importance. To meet the goal of universal access to prevention, treatment and care by 2010 would require a quadrupling of funding to an estimated US$42 billion by 2010, including adequate overall strengthening of healthcare systems, but in any case, the world will have to learn to live with HIV for the foreseeable future.

Perineal ulcers in an infant: An unusual presentation of postnatal cytomegalovirus infection

Cytomegalovirus (CMV) disease can cause significant morbidity and mortality in neonates and immunosuppressed patients. Cutaneous disease is rare, even in at-risk patients. We report a case of CMV with perineal papules, erosions, and ulcers in a preterm but presumably immunocompetent patient, whose diagnosis was first suggested by skin biopsy and confirmed with serologic testing. The mode of transmission of CMV was unclear. The lesions resolved without CMV-specific therapy, and the child had no apparent systemic sequelae of infection. CMV disease should be considered in the differential diagnosis of perineal erosions and ulcers in infancy. In addition to the case, we briefly review the literature on cutaneous manifestations of CMV disease.

Detection of human viruses in patients with chronic periodontitis and the relationship between viruses and clinical parameters

BACKGROUND

Recent studies have demonstrated that various human viruses, especially cytomegalovirus (HCMV), Epstein-Barr virus type-1 (EBV-1), and herpes simplex virus (HSV), seem to play a part in the pathogenesis of human periodontitis. Little information is available on the relationship between these viruses and clinical periodontal parameters in patients with chronic periodontitis. This study examined the occurrence of HCMV, EBV-1, and HSV in patients with chronic periodontitis and the relationship between these viruses and clinical parameters.

METHODS

A nested polymerase chain reaction (PCR) method determined the presence of HCMV, EBV-1, and HSV. Subgingival plaque samples from 30 patients with chronic periodontitis and 21 randomly selected healthy controls were collected by paper points, and clinical measurements were recorded from both sampling sites and entire dentition. The following indices were measured: plaque index (PI), gingival index (GI), probing depth (PD), and clinical attachment loss (CAL).

RESULTS

HCMV was detected in 44.3% of chronic periodontitis patients and 14.3% of healthy persons (P < 0.05); EBV-1 in 16.7% of chronic periodontitis patients and 14.3% of healthy persons (P = 1.00); and HSV in 6.7% of chronic periodontitis patients and in no healthy persons. HCMV and EBV-1 detected and undetected sites in patients with periodontitis showed statistically significant differences in sampling clinical depth (SPD) and sampling clinical attachment loss (SCAL). Differences in the measurements of PI of entire dentition and GI of entire dentition between HSV detected and undetected sites were statistically significant.

CONCLUSIONS

Findings of the present study confirm the frequent presence of HCMV in crevicular samples of chronic periodontitis lesions, and suggest a strong relationship between the presence of HCMV and EBV-1 in subgingival areas and the measurements of probing depth and probing attachment loss.

An African HIV-1 sequence from 1959 and implications for the origin of the epidemic

There is considerable genetic diversity among viruses of different subtypes (designated A to J) in the major group of human immunodeficiency virus type 1 (HIV-1), the form of HIV that is dominant in the global epidemic. If available, HIV-1 sequences pre-dating the recognition of AIDS could be crucial in defining the time of origin and the subsequent evolution of these viruses in humans. The oldest known case of HIV-1 infection was reported to be that of a sailor from Manchester who died of an AIDS-like illness in 1959; however, the authenticity of this case has not been confirmed. Genetic analysis of sequences from clinical materials obtained from 1971 to 1976 from members of a Norwegian family infected earlier than 1971 showed that they carried viruses of the HIV-1 outlier group, a variant form that is mainly restricted to West Africa. Here we report the amplification and characterization of viral sequences from a 1959 African plasma sample that was previously found to be HIV-1 seropositive. Multiple phylogenetic analyses not only authenticate this case as the oldest known HIV-1 infection, but also place its viral sequence near the ancestral node of subtypes B and D in the major group, indicating that these HIV-1 subtypes, and perhaps all major-group viruses, may have evolved from a single introduction into the African population not long before 1959.

Diagnosis and treatment of a case of cutaneous cytomegalovirus infection with a dramatic clinical presentation

A patient receiving long-term immunosuppressive treatment of systemic lupus erythematosus developed multiple large painful ulcers on her upper body. Histologic analysis showed cytopathic changes typical of cytomegalovirus infection that was confirmed by immunoperoxidase staining and polymerase chain reaction analyses. Treatment with ganciclovir and foscarnet resulted in clinical resolution. No recurrence was evident 6 months later.

Oral mucosal ulceration due to cytomegalovirus associated with human immunodeficiency virus infection. Case report and brief review

Reports of oral lesions associated with cytomegalovirus (CMV) infection in human immunodeficiency virus (HIV) infected patients are uncommon. In this article a case of CMV infection associated with oral mucosal ulceration and a brief review of the subject is presented. Establishing the cause of ulceration is important in determining a definitive diagnosis and prescribing appropriate therapy. It is important to recognize that CMV associated oral mucosal ulceration may be the initial manifestation of human immunodeficiency virus (HIV) infection.

HIV infection among seafarers in Denmark

The purpose of this study was to estimate the minimal magnitude of the HIV problem among seafarers in Denmark. The material is based on case records from the 6 medical departments in Denmark that undertake treatment of HIV patients. Retrospectively, all case records of HIV infection among seafarers--and of their sexual contacts--have been identified. 33 seafarers with HIV infection or AIDS were identified; 17 had no other known risk factor than heterosexual contacts in high-endemic areas. These results show that HIV infections have entered into the heterosexual group of seafarers. HIV-infected seafarers are a risk group for carrying HIV infection into the heterosexual population in non-endemic areas. In 5 known cases, this has actually taken place in Denmark. The majority of the heterosexually infected seafarers were probably infected early in the AIDS era. We do not know if Danish seafarers are still acquiring HIV abroad.

Cytomegalovirus: a virus of increasing relevance to oral medicine and pathology

Human cytomegalovirus (HCMV) is a ubiquitous herpesvirus, emerging as an opportunistic pathogen in immunocompromised persons, particularly those infected with human immunodeficiency viruses (HIV). Clinical syndromes caused by HCMV are usually not specifically identifiable without laboratory investigations. However, it is now apparent that HCMV may cause oral ulceration in immunocompromised persons and it may play a role in other diverse conditions in these and other patients.

Oral infections due to cytomegalovirus in immunocompromised patients

Herpes group virus infections in the immunocompromised host are associated with significant morbidity and mortality. Herpes simplex virus (HSV) and to a lesser extent varicella zoster virus (VZV) have long been recognized as causes of oral and peri-oral lesions in subjects undergoing bone marrow transplantation and in individuals infected with the Human Immunodeficiency Virus (HIV). A role for Cytomegalovirus (CMV) in such lesions is less clear and not well documented. This report describes two bone marrow transplant recipients and one individual infected with HIV in whom CMV was implicated as the cause of oral lesions. Diagnostic and management issues as well as clinical implications are discussed.

Concurrent oral cytomegalovirus and herpes simplex virus infection in association with HIV infection. A case report

Recurrent oral herpes simplex virus lesions are common in both immunocompetent and immunocompromised persons. In contrast, cytomegalovirus-associated intraoral lesions are rarely seen, even in the immunocompromised host. We report a case of concurrent oral herpes simplex virus and cytomegalovirus infection, appearing as an ulcerative lesion of the labial mucosa in a patient with acquired immunodeficiency syndrome. Herpes simplex virus type 1 was shown to be present in the lesion by culture tests, histopathologic examination, immunohistochemistry findings and a direct immunofluorescence assay, and cytomegalovirus by histopathologic examination and immunohistochemistry findings. We deduce that the lesion was due to concurrent herpes simplex virus-1 and cytomegalovirus infection. The patient responded well to 2 weeks of treatment with a high dose of acyclovir.

Oral manifestations of cytomegalovirus infection

Disease caused by cytomegalovirus is reported with increasing frequency. Cytomegalovirus is an important pathogen in immunocompromised and immunosuppressed patients. The most common manifestation of cytomegalovirus infection of the gastrointestinal tract including the oral mucosa is ulceration. The role of cytomegalovirus in xerostomia, Sjögren's syndrome, and Kaposi's sarcoma is continuing to be investigated. This article reviews the oral manifestations of cytomegalovirus, including recently reported oral manifestations.

Oral CMV lesions and the HIV infected. Early recognition can help prevent morbidity

Although they are rare, oral ulcers caused by cytomegalovirus infection can occur in immunocompromised people, including those infected with HIV. Once recognized, however, oral CMV lesions can be successfully treated in most cases. Moreover, early recognition permits prompt evaluation for CMV retinitis or disseminated CMV infection, and may help prevent morbidity caused by CMV.

Cytomegalovirus infections of the oral cavity. A report of six cases and review of the literature

Cytomegalovirus is responsible for a significant percentage of asymptomatic viral infections worldwide. Although virtually any cell or organ may be infected, involvement of the oral cavity is uncommon. Only nine well-documented examples of intraoral cytomegalovirus infections were found in a review of the English-language literature. We report six additional examples, five of which possessed unique clinical and histopathologic characteristics. The light and electron-microscopic features of cytomegalovirus are discussed, as well as diagnostic adjuncts such as immunohistochemistry and deoxyribonucleic acid in situ hybridization.

Erratum: AIDS and the Polio Vaccine

A 17 July News & Comment article by David P. Hamilton (p. 318) incorrectly placed a 20 July talk by Bernard Davis. That talk was held at the Woods Hole Marine Biological Laboratory, not the Woods Hole Oceanographic Institute.

The simultaneous occurrence of oral herpes simplex virus, cytomegalovirus, and histoplasmosis in an HIV-infected patient

Numerous publications have reviewed the oral manifestations of HIV infection and AIDS. Although uncommon, herpetic infections and histoplasmosis are among the diseases reported. The case that follows presents the first description of the simultaneous occurrence of oral herpes simplex virus, cytomegalovirus, and histoplasmosis in an HIV-infected person. These infections appeared as extensive oral ulcerations and were the only clinical manifestation of HIV infection. Eleven months after the initial presentation, the patient died of complications of AIDS.

Intraoral cytomegalovirus lesion and HIV-associated periodontitis in a patient with acquired immunodeficiency syndrome

Exposure to cytomegalovirus (CMV) is common in persons infected with the human immunodeficiency virus. Autopsy studies have documented the presence of CMV in multiple organs, but CMV is seldom indicated as the causative agent in specific diseases. Few reports have described localized CMV infection in the oral cavity. This may be due to the occult histopathologic appearance during oral mucosal CMV infections and to a lack of awareness of CMV infection as a potential etiologic agent in nonspecific oral ulcerations and other oral disease entities. This report describes an intraoral ulceration with documented presence of a localized CMV infection in association with human immunodeficiency virus-associated periodontitis in a patient with acquired immunodeficiency syndrome. A causative relationship between these two entities, however, cannot be established or excluded.

Viruses and chronic disorders involving the human oral mucosa

Viruses have been implicated in the etiology of several chronic disorders of the oral mucosa. Most of these associations have been with DNA viruses, particularly certain herpesviruses, which are associated, for example, with some cases of erythema multiforme and with hairy leukoplakia. Papillomaviruses are associated with various papillomatous lesions, focal epithelial hyperplasia, and possibly with some carcinomas. Viruses may possibly be associated with recurrent aphthae, Behçet's syndrome, and some dermatoses. The literature concerning these possible associations is reviewed. However, much more research needs to be done before the full story of viral associations with oral mucosal disorders can be written.

Cytomegalovirus ulceration of the oropharynx

Cytomegalovirus (CMV) is a common opportunistic infection in both iatrogenic and HIV-induced immunosuppression. The usual sites of involvement are the gastro-intestinal tract, retina and lung. We present three cases of CMV ulceration of the oropharynx. All three patients presented with symptoms localized to the oropharynx and in each case the diagnosis was only made on histological examination of ulcer biopsy specimens. The patients all responded well to ganciclovir treatment and at writing none have required maintenance therapy (7-11 months post diagnosis).

Diagnosis of cutaneous cytomegalovirus infection: a review and report of a case

Cytomegalovirus infections are a major source of morbidity and mortality in immunocompromised patients. We report a case of cutaneous cytomegalovirus in a patient with the acquired immunodeficiency syndrome, in which routine light microscopy was suggestive but not diagnostic of cytomegalovirus. Immunohistochemical studies of the specimen for cytomegalovirus antigens revealed numerous intracytoplasmic and intranuclear viral inclusions. This case illustrates the utility of immunoperoxidase techniques to diagnose cytomegalovirus infection of the skin rapidly. Immunohistochemistry, DNA in situ hybridization, and polymerase chain reaction have been added to the more routine methods of viral culture and light microscopy to diagnose cytomegalovirus. In this report we review the cases of cutaneous cytomegalovirus in the literature and the laboratory detection methods available to establish this diagnosis.

Successful treatment of disseminated cutaneous cytomegalic inclusion disease associated with Hodgkin's disease

A case of disseminated cutaneous cytomegalic inclusion disease associated with Hodgkin's disease is described. The patient had a diffuse eruption of pruritic, erosive erythematous nodules. Histologically, many inclusion bodies were observed in perivascular areas of the skin lesions. Immunohistologically, the inclusion bodies positively stained with both anticytomegalovirus antibody and anti-factor VIII-related antibody. On electron microscopy many virus particles and dense bodies were found in the area where inclusion bodies were observed. Treatment with high-dose intravenous acyclovir and a large amount of immunoglobulin resulted in prompt healing of the skin lesions. Subsequently, the patient's Hodgkin's disease was well controlled on chemotherapy. The patient steadily improved without relapse of skin lesions 1 year after antiviral therapy was administered.

Cytomegalovirus associated oral ulcerations in HIV-infected patients

Oral ulcerations associated with disseminated cytomegalovirus (CMV) infection were observed in four patients with AIDS manifestations showing low CD4 counts. Virus cultures of urine and saliva samples were positive for CMV in all cases. The lesions were characterized by a punched-out appearance, non-indurated borders, low bleeding tendency and lack of inflammatory wall. Light microscopy revealed granulation tissue containing "owl's eye" like cells in all specimens. Presence of CMV was confirmed by immunohistochemistry and in situ hybridization. The ulcerations were infiltrated with T-lymphocytes of the helper, suppressor and cytotoxic subset, most were positive for HLA DR. Despite the local invasion with immunocytes and high serum titers of serum antibodies the patients experienced progressive CMV disease.

Clinically occult cytomegalovirus present in skin biopsy specimens in immunosuppressed hosts

Three patients with acquired immunosuppression in whom skin biopsy specimens were obtained to aid in the diagnosis of varying cutaneous eruptions are described. Amphophilic, granular, intranuclear inclusions within endothelial cells compatible with the presence of cytomegalovirus were found unexpectedly. Clinically, occult cytomegalovirus in the skin may be more common than generally appreciated and may not be the sole cause of the eruption for which biopsy specimens are obtained. Also, the need to remain alert for polymicrobial cutaneous infections in the immunocompromised host is emphasized.

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.

Vesiculobullous lesions caused by cytomegalovirus infection in an immunocompromised adult

Skin involvement in cytomegalovirus (CMV) infection is very rare. Reported cutaneous manifestations are nonspecific and include petechial, purpuric, and morbilliform rashes. We describe an immunocompromised patient who developed a vesiculobullous eruption. A simple Tzanck preparation from the base of a blister revealed multinucleate giant cells suggestive of a viral infection. Subsequent viral cultures and electron microscopic studies confirmed the diagnosis of CMV infection. Consideration of this infection should be included in the differential diagnosis of multinucleate giant cells seen on Tzanck preparations of cutaneous vesicles.

Histologically specific skin lesions in disseminated cytomegalovirus infection

A diabetic renal transplant recipient developed fever, generalized rash, and genital ulcers which showed typical histologic changes of cytomegalovirus (CMV) infection in the dermal vascular endothelium. This infection was confirmed by rising serologic titer of specific antibody, positive viral cultures, and typical nuclear inclusion bodies in pulmonary and hepatic tissue at autopsy. Biopsy of the patient's skin lesions provided the opportunity for early diagnosis of this fatal systemic CMV infection. Two clinical patterns of specific cutaneous involvement in disseminated CMV infection are discussed.

Cutaneous cytomegalovirus vasculitis: an unusual clinical presentation of a common opportunistic pathogen

A case of cutaneous leukocytoclastic cytomegalovirus (CMV) vasculitis arising in a man with acute myelogenous leukemia is described. An antemortem biopsy specimen of ulcerated skin and an open lung biopsy specimen showed leukocytoclastic vasculitis and nonspecific diffuse interstitial pneumonitis, respectively, neither tissue demonstrating viral infection. Autopsy material revealed CMV vasculitis with typical intranuclear inclusions identified in enlarged endothelial cells associated with thrombus formation and luminal narrowing, in addition to florid CMV pneumonitis. This case represents an unusual although clinically relevant expression of a common opportunistic pathogen.