Trends in infectious diseases and cancers among persons dying of HIV infection in the United States from 1987 to 1992

Human Cytomegalovirus Promotes Survival of Infected Monocytes via a Distinct Temporal Regulation of Cellular Bcl-2 Family Proteins

Monocytes play a key role in the hematogenous dissemination of human cytomegalovirus (HCMV) to target organ systems. To infect monocytes and reprogram them to deliver infectious virus, HCMV must overcome biological obstacles, including the short life span of monocytes and their antiviral proapoptotic response to infection. We have shown that virally induced upregulation of cellular Mcl-1 promotes early survival of HCMV-infected monocytes, allowing cells to overcome an early apoptotic checkpoint at around 48 h postinfection (hpi). Here, we demonstrate an HCMV-dependent shift from Mcl-1 as the primary antiapoptotic player to the related protein, Bcl-2, later during infection. Bcl-2 was upregulated in HCMV-infected monocytes beginning at 48 hpi. Treatment with the Bcl-2 antagonist ABT-199 only reduced the prosurvival effects of HCMV in target monocytes beginning at 48 hpi, suggesting that Mcl-1 controls survival prior to 48 hpi, while Bcl-2 promotes survival after 48 hpi. Although Bcl-2 was upregulated following viral binding/signaling through cellular integrins (compared to Mcl-1, which is upregulated through binding/activation of epidermal growth factor receptor [EGFR]), it functioned similarly to Mcl-1, adopting the early role of Mcl-1 in preventing caspase-3 cleavage/activation. This distinct, HCMV-induced shift from Mcl-1 to Bcl-2 occurs in response to a cellular upregulation of proapoptotic Bax, as small interfering RNA (siRNA)-mediated knockdown of Bax reduced the upregulation of Bcl-2 in infected monocytes and rescued the cells from the apoptotic effects of Bcl-2 inhibition. Our data demonstrate a distinct survival strategy whereby HCMV induces a biphasic regulation of cellular Bcl-2 proteins to promote host cell survival, leading to viral dissemination and the establishment of persistent HCMV infection.

IMPORTANCE

Hematogenous dissemination of HCMV via infected monocytes is a crucial component of the viral survival strategy and is required for the establishment of persistent infection and for viral spread to additional hosts. Our system of infected primary human blood monocytes provides us with an opportunity to answer specific questions about viral spread and persistence in in vivo-relevant myeloid cells that cannot be addressed with the more traditionally used replication-permissive cells. Our goal in examining the mechanisms whereby HCMV reprograms infected monocytes to promote viral dissemination is to uncover new targets for therapeutic intervention that would disrupt key viral survival and persistence strategies. Because of this important role in maintaining survival of HCMV-infected monocytes, our new data on the role of Bcl-2 regulation during viral infection represents a promising molecular target for mitigating viral spread and persistence.

Murine cytomegalovirus protein pM79 is a key regulator for viral late transcription

Herpesvirus genes are temporally expressed during permissive infections, but how their expression is regulated at late times is poorly understood. Previous studies indicate that the human cytomegalovirus (CMV) gene, UL79, is required for late gene expression. However, the mechanism remains to be fully elucidated, and UL79 homologues in other CMVs have not been studied. Here, we characterized the role of the conserved murine CMV (MCMV) gene M79. We showed that M79 encoded a protein (pM79) which was expressed with early-late kinetics and localized to nuclear viral replication compartments. M79 transcription was significantly decreased in the absence of viral DNA synthesis but markedly stimulated by pM79. To investigate its role, we created the recombinant virus SMin79, in which pM79 expression was disrupted. While marker-rescued virus grew efficiently in fibroblasts, SMin79 failed to produce infectious progeny but was rescued by pM79 expression in trans. During SMin79 infection, representative viral immediate-early and early gene products as well as viral DNA accumulated sufficiently. Formation of viral replication compartments also appeared normal. Pulsed-field gel electrophoresis analysis indicated that the overall structure of replicating viral DNA was indistinguishable between wild-type and SMin79 infection. Viral tiled array and quantitative PCR analysis revealed that many late transcripts sensitive to a viral DNA synthesis inhibitor (phosphonoacetic acid) were markedly reduced by pM79 mutation. This study indicates that cytomegaloviruses use a conserved mechanism to promote transcription at late stages of infection and that pM79 is a critical regulator for at least a subset of viral DNA synthesis-dependent transcripts.

Development of non-natural flavanones as antimicrobial agents

With growing concerns over multidrug resistance microorganisms, particularly strains of bacteria and fungi, evolving to become resistant to the antimicrobial agents used against them, the identification of new molecular targets becomes paramount for novel treatment options. Recently, the use of new treatments containing multiple active ingredients has been shown to increase the effectiveness of existing molecules for some infections, often with these added compounds enabling the transport of a toxic molecule into the infecting species. Flavonoids are among the most abundant plant secondary metabolites and have been shown to have natural abilities as microbial deterrents and anti-infection agents in plants. Combining these ideas we first sought to investigate the potency of natural flavonoids in the presence of efflux pump inhibitors to limit Escherichia coli growth. Then we used the natural flavonoid scaffold to synthesize non-natural flavanone molecules and further evaluate their antimicrobial efficacy on Escherichia coli, Bacillus subtilis and the fungal pathogens Cryptococcus neoformans and Aspergillus fumigatus. Of those screened, we identified the synthetic molecule 4-chloro-flavanone as the most potent antimicrobial compound with a MIC value of 70 µg/mL in E. coli when combined with the inhibitor Phe-Arg-ß-naphthylamide, and MICs of 30 µg/mL in S. cerevesiae and 30 µg/mL in C. neoformans when used alone. Through this study we have demonstrated that combinatorial synthesis of non-natural flavonones can identify novel antimicrobial agents with activity against bacteria and fungi but with minimal toxicity to human cells.

Protection from direct cerebral cryptococcus infection by interferon-gamma-dependent activation of microglial cells

The brain represents a significant barrier for protective immune responses in both infectious disease and cancer. We have recently demonstrated that immunotherapy with anti-CD40 and IL-2 can protect mice against disseminated Cryptococcus infection. We now applied this immunotherapy using a direct cerebral cryptococcosis model to study direct effects in the brain. Administration of anti-CD40 and IL-2 significantly prolonged the survival time of mice infected intracerebrally with Cryptococcus neoformans. The protection was correlated with activation of microglial cells indicated by the up-regulation of MHC II expression on brain CD45(low)CD11b(+) cells. CD4(+) T cells were not required for either the microglial cell activation or anticryptococcal efficacy induced by this immunotherapy. Experiments with IFN-gamma knockout mice and IFN-gammaR knockout mice demonstrated that IFN-gamma was critical for both microglial cell activation and the anticryptococcal efficacy induced by anti-CD40/IL-2. Interestingly, while peripheral IFN-gamma production and microglial cell activation were observed early after treatment, negligible IFN-gamma was detected locally in the brain. These studies indicate that immunotherapy using anti-CD40 and IL-2 can augment host immunity directly in the brain against C. neoformans infection and that IFN-gamma is essential for this effect.

Increased risk of Pneumocystis carinii and community-acquired pneumonia with tobacco use in HIV disease

OBJECTIVES

Tobacco smoking-related diseases continue to be of great health concern for the public, in general, and may be particularly deleterious for immunosuppressed HIV-positive individuals, who exhibit widespread tobacco use.

METHODS

A total of 521 HIV-infected subjects consecutively admitted to Jackson Memorial Hospital between 2001-2002 were enrolled in the study. Research data included a medical history, details of tobacco and illicit drug use and complete computerized hospital information. Blood was drawn to obtain T lymphocyte profiles and viral load levels. Statistical analysis methods included Pearson, Student's t- and Chi-square tests and SAS Proc CATMOD.

RESULTS

Tobacco use was prevalent, with 65% of the 521 HIV-positive hospitalized patients being current smokers. Overall, current tobacco users reported smoking an average of 15+/-13 cigarettes per day for an average of 15+/-14 years, with 40% smoking more than one pack per day. Pulmonary infections accounted for 49% of the total hospital admissions: 52% bacterial pneumonias, 24% Pneumocystis carinii pneumonia (PCP), 12% non-tuberculous mycobacterial diseases (NTM), 11% tuberculosis and 1% bronchitis. Many of the respiratory patients (46%) had been on highly active antiretroviral therapy (HAART) for over six months and 42% had received PCP and/or NTM prophylaxis. After matching the cases by HAART and CDC stage, the hazardous risk of being hospitalized with a respiratory infection was significantly higher for smokers than non-smokers (95% CI 1.33-2.83; p=0.003). Respiratory infections were noted in (37%) of the HAART-treated patients, and most (67%) occurred in smokers. CATMOD analyses controlling for HAART, viral load and CD4, indicated that HIV-infected smokers were three times more likely to be hospitalized with PCP and twice as likely to be hospitalized with community-acquired pneumonia than non-smokers, with increased risk related to the number of cigarettes/day in a dose-dependent manner.

CONCLUSIONS

Tobacco use, which is widespread among HIV-infected subjects, increases the risk of pulmonary diseases, particularly PCP and CAP, two respiratory infections with high prevalence and morbidity risks even in the era of HAART.

HIV and anesthesia

Human immunodeficiency virus [HIV disease or acquired immunodeficiency syndrome (AIDS)] is the greatest health crisis of the twentieth and early twenty-first century. In sub-Saharan Africa, the epidemic rivals the "Black Death" of fourteenth-century Europe. AIDS is a multiorgan disease that has broad implications for anesthesiologists. New drug therapies are highly effective in most cases and have significant potential for drug interactions. The purpose of this article is to help anesthesiologists better manage persons who have HIV/AIDS in the operating room, labor and delivery suite, and other areas in which this patient population will require an increasing amount of care.

Changing profiles of injecting drug users with AIDS in a Hispanic population

AIMS

To describe and assess the changing trends in socio-demographic, risk, clinical and immunological parameters in male intravenous drug users (IDU) with AIDS.

DESIGN, SETTING AND PARTICIPANTS

Baseline description by year of entry of 610 male IDU with AIDS who entered into a cohort study in Bayamón, Puerto Rico, from 1992 to 2000. Study participants were evaluated at in-patient health-care facilities in the University Hospital Ramón Ruiz Arnau or in the ambulatory immunology clinic facilities.

FINDINGS

The median age at which subjects entered the study and the proportion of patients with an educational level lower than a high school degree increased from 1992 to 2000. Upward trends were also observed in the practice of injecting non-prescription drugs during the last 12-month period, the practice of needle sharing and the use of a combination of heroin and cocaine ('speedballs'). Higher proportions of subjects were also diagnosed with wasting syndrome and bacterial pneumonia. The median CD4 count recorded at entry decreased over the course of the study.

CONCLUSIONS

Puerto Rican male IDU diagnosed with AIDS are arriving at health-care facilities in the latest stages of the disease. Better and early interventions with different health care approaches need to be developed.

Impact of HAART advent on admission patterns and survival in HIV-infected patients admitted to an intensive care unit

BACKGROUND

Several studies found increased survival times and decreased hospitalization rates since the introduction of highly active antiretroviral therapy (HAART).

OBJECTIVE

To examine the impact of HAART on admission patterns and survival of HIV-infected patients admitted to an intensive care unit (ICU).

DESIGN

Prospective observational cohort study.

SETTING AND SUBJECTS

All HIV-infected patients admitted from 1 January 1995 to 30 June 1999, to an infectious diseases ICU located in Paris.

MAIN OUTCOME MEASURES

ICU utilization and admission patterns, and survival.

RESULTS

A total of 426 HIV-related admissions were included. Sepsis increased from 16.3% to 22.6% from the pre- to the post-HAART era, whereas AIDS-related admissions decreased from 57.7% to 37% (P < 0.05). No significant difference in ICU utilization was found. In both periods, half of the patients were not on antiretroviral treatment at ICU admission. In-ICU mortality was 23%, without significant difference between the study periods. By multivariable analysis, in-ICU mortality was significantly associated with SAPS II > 40, Omega score > 75 and mechanical ventilation; and long-term survival with admission in the HAART era and AIDS at ICU admission. Cumulative survival rates after ICU discharge were 85.3% and 70.8% after 12 and 24 months, respectively.

CONCLUSIONS

HAART had little impact on ICU utilization by HIV-infected patients. After the introduction of HAART AIDS-related conditions decreased and sepsis increased as reasons for ICU admission. Whereas ICU survival was dependent on usual prognostic markers, long-term survival was clearly dependent on HIV disease stage and HAART availability. In both study periods, at least a half of the HIV infected patients were not on anti-retroviral treatment at the time of ICU admission.

Phase II trial of infusional cyclophosphamide, doxorubicin, and etoposide in patients with HIV-associated non-Hodgkin's lymphoma: an Eastern Cooperative Oncology Group Trial (E1494)

PURPOSE

To determine the effectiveness of an infusional chemotherapy regimen in patients with HIV-associated lymphoma treated before and after the use of highly active antiretroviral therapy (HAART) in routine clinical practice.

PATIENTS AND METHODS

Ninety-eight assessable patients with HIV-associated intermediate- or high-grade non-Hodgkin's lymphoma received cyclophosphamide 200 mg/m(2)/d, doxorubicin 12.5 mg/m(2)/d, and etoposide 60 mg/m(2)/d (CDE) given by continuous intravenous infusion for 4 days (96 hours) every 4 weeks plus filgrastim. Concurrent antiretroviral treatment consisted of the nucleoside analog didanosine in the first 43 patients enrolled before December 1996 (pre-HAART group), or HAART in the remaining 55 patients enrolled after that time (HAART group).

RESULTS

Complete response occurred in 44 patients (45%; 95% CI, 35% to 55%). Failure-free survival and overall survival (OS) at 2 years was 36% (95% CI, 26% to 46%) and 43% (95% CI, 33% to 53%), respectively. At the time of the analysis, 30% in the pre-HAART group were alive compared with 47% in the HAART group; when adjusted for varying length of follow-up, patients in the HAART group had improved OS (P =.039). Patients in the HAART group experienced less grade 4 nonhematologic toxicity (22% v 42%; P =.037), thrombocytopenia (31% v 52%; P =.033), and anemia (9% v 27%; P =.021), and had fewer treatment-associated deaths (0% v 10%; P =.013).

CONCLUSION

Infusional CDE is an effective and potentially curative regimen for patients with HIV-associated lymphoma. Patients treated in the HAART era have less chemotherapy-associated toxicity and improved survival.

The immunopathogenesis of meningococcal disease

This review describes the mechanisms of the immune response to meningococcal disease, examining the extent to which individual variation of the immune response can determine susceptibility. It concludes by summarising the difficulties encountered by recent efforts to develop new immunomodulatory treatments.

Antiretroviral-associated liver injury

ART-related hepatotoxicity can manifest in a variety of ways. Although benign, asymptomatic LEEs predominate, liver injury occurring in the context of either hypersensitivity or hyperlactatemia, represents a medical emergency and mandates immediate cessation of ART. Underpinning this broad spectrum of presentations are several, as yet poorly understood, mechanisms of liver damage that reflect contributions by constituents of HAART and host factors. Thus far, the most significant predisposing condition to emerge from clinical studies is chronic viral hepatitis. A more precise understanding, however, of the processes and factors that underlie ART-related hepatotoxicity is critical not only to the management of liver injury from current antiretroviral drugs but also to the design of safer drugs in the future.

13. HIV-1 infection

This review is intended to provide a fundamental perspective on the dynamic interplay between HIV-1 and the immune system, an essential aspect in defining the pathogenesis and treatment of AIDS. HIV-1 infection, the cause of AIDS, is a worldwide pandemic with enormous adverse heath and economic implications, particularly in the developing world. This bloodborne and sexually transmitted disease, which evolved from simian immunodeficiency virus, infects and replicates in helper T cells and macrophages and utilizes CD4 and a chemokine coreceptor for entry. Immune deficiency occurs as a result of virally induced attrition of CD4 T cells, resulting in the development of opportunistic infections and malignancy. Prophylaxis against opportunistic infections is required according to the extent of immune deficiency. HIV-specific immunity can control viral replication and delay disease progression but does not clear infection. Antiretroviral treatment consists of inhibitors that target for viral entry, reverse transcriptase, and viral protease. Therapy can control viral replication, restore immunity, and delay disease progression, but it cannot eliminate infection. Thus chronic infection persists even in treated patients. Antiretroviral drugs have been highly effective in preventing mother-to-child transmission and for postexposure prophylaxis. Several novel vaccines in development hold promise for either effective infection prevention or attenuation of disease progression.

Genetic analyses of gene function and pathogenesis of murine cytomegalovirus by transposon-mediated mutagenesis

Murine cytomegalovirus (MCMV) has a linear genome of 230 kb and encodes more than 170 genes, many of which have not been extensively studied for their functions in pathogenesis in vivo. A Tn3-based transposon was constructed and used to generate MCMV mutants by disrupting viral gene targets. The functions of the mutated genes were investigated by studying the viral mutants in cultured cells and in immunocompetent Balb/c and immunodeficient SCID mice. A pool of MCMV mutants that contained the transposon sequence randomly inserted at the viral genome was generated. Studies of several mutants (e.g. a viral mutant with the transposon inserted at open reading frame m09) in cultured cells and in mice indicate that the presence of the transposon sequence per se in the viral genome does not significantly affect viral growth in vitro and in vivo. Moreover, the genome structures of the viral mutants, including the transposon insertion regions, were stable during replication in cultured cells and in animals. Several viral mutants (e.g. a viral mutant with the transposon at M27) that are attenuated in growth and virulence in animals were identified. These results suggest that the genes mutated in these viral mutants may be important for viral virulence and pathogenesis. The Tn3-based system may be a useful tool for the systematic construction of CMV mutants and for studies of CMV gene functions in viral replication in vitro and in pathogenesis in vivo.

AIDS related opportunistic infections, going but not gone

It is now more than two decades since the AIDS epidemic began with a cluster of Pneumocystis carinii pneumonia (PCP) in a community of homosexual men. Since then, many other infections have been characterized as opportunistic infections secondary to HIV infection. These include, but are not limited to, infections with Toxoplasma gondii, Cytomegalovirus (CMV), Mycobacterium avium complex (MAC), and Cryptococcus neoformans. Over the last two decades, there have been dramatic improvements in diagnosis, prevention and treatment of all these infections. As a result, in North America and Western Europe the rates of opportunistic infections secondary to AIDS have decreased substantially. We will review these common opportunistic infections below.

Trends in diseases reported on U.S. death certificates that mentioned HIV infection, 1987-1999

To examine trends in the proportions of deaths with various diseases among deaths with HIV infection, we analyzed multiple-cause death certificate data for all deaths in the United States from 1987 through 1999. Disease proportions were adjusted to control for demographic changes. Deaths reported with HIV infection increased from 15,331 in 1987 to 47,977 in 1995 and then decreased to 16,061 in 1999. Among these reported deaths, new trends during the period from 1995 through 1999 included decreases in the proportions with cytomegalovirus disease (from 6.8% to 2.8%), wasting/cachexia (9.8% to 6.8%), and dementia/encephalopathy (6.3% to 3.9%) and increases in the proportions with septicemia/septic shock (from 9.2% to 13.4%) and diseases of the liver (4.9% to 11.6%), kidney (6.3% to 9.1%), and heart (4.2% to 6.9%). Continuations of pre-1995 trends included decreases in the proportions with nontuberculous mycobacteriosis (7.1% to 3.1%) and Kaposi sarcoma (5.3% to 2.6%). Advances in antiretroviral therapy probably caused deaths due to HIV infection to decrease after 1995. Consequently, the proportions of deaths with HIV that were caused by other conditions increased. Improved prophylaxis or treatment of some opportunistic infections could also have reduced the proportions of deaths with those diseases, whereas antiviral drug toxicity could have contributed to increases in the proportions with noninfectious organ diseases.

Engineered RNase P ribozymes inhibit gene expression and growth of cytomegalovirus by increasing rate of cleavage and substrate binding

We have previously employed an in vitro (genetic) selection procedure to select RNase P ribozyme variants for their activity in cleaving a mRNA substrate from a pool of ribozymes containing randomized sequences. In this study, one of the variants was used to target the overlapping region of the mRNAs encoding the major transcription regulatory proteins, IE1 and IE2, of human cytomegalovirus (HCMV). The ribozyme variant exhibited an enhanced substrate binding and rate of chemical cleavage, and was at least 25 times more efficient in cleaving the target mRNA in vitro than the ribozyme derived from the wild-type sequence. Our results provide the first direct evidence that a point mutation at nucleotide 86 of RNase P catalytic RNA from Escherichia coli (A(86)-->C(86)) increases the rate of chemical cleavage while another mutation at nucleotide 205 (G(205)-->C(205)) enhances substrate binding of the ribozyme. Moreover, the variant was also more effective in inhibiting IE1 and IE2 expression and HCMV growth in cultured cells. A reduction of more than 97% in IE1 and IE2 expression and a reduction of 3000-fold in viral growth were observed in cells expressing the variant. Thus, RNase P ribozyme variant is highly effective in inhibiting HCMV gene expression and growth. Our results provide the direct evidence that increasing the rate of chemical cleavage and substrate-binding affinity of the ribozymes should lead to an improvement of their anti-HCMV efficacy. Moreover, our data also suggest that highly effective anti-HCMV ribozyme variants can be developed using genetic engineering approaches including in vitro selection.

The prevalence of distress in persons with human immunodeficiency virus infection

The purpose of this study was to assess the prevalence of distress, anxiety, and depression in persons with human immunodeficiency virus (HIV) infection and determine the feasibility of screening in an urban HIV primary care setting. A convenience sample of 101 patients in the waiting room of an acquired immunodeficiency syndrome clinic completed two questionnaires, the Hospital Anxiety and Depression Scale (HADS) and the Distress Thermometer. The patient's demographic, medical, and psychiatric histories were obtained through chart review. The results of the Distress Thermometer revealed that 72.3% had a score of 5 or greater, demonstrating high distress. The results of the HADS revealed that 70.3% had high anxiety, with a score of 7 or greater. On the HADS depression questions, 45.5% had a score of 7 or greater, indicating depression. Analysis of the total HADS scores, including anxiety and depression, revealed that 53.5% had a score of greater than 15 and were experiencing significant distress. Patients with high viral loads were more likely to be distressed (P < 0.0005). Patients with high viral loads were also more likely to have higher anxiety or depression scores on the HADS. Patients who had CD4 counts higher than 500/mm(3) were less likely to be depressed. This study demonstrates a high prevalence of distress, anxiety, and depression among persons with HIV. The HADS and the Distress Thermometer showed a good correlation with each other (P < 0.0005), and these questionnaires can provide a simple and efficient method for rapid screening in an HIV clinic setting.

Pulmonary pathology in patients with AIDS: an autopsy study from Mumbai

OBJECTIVE

Although India has a high prevalence of HIV/AIDS, the associated pathologies responsible for morbidity have not been evaluated previously in a representative study. Hence, an autopsy study was carried out to analyse the spectrum of pulmonary lesions in patients with HIV/AIDS.

METHODS

A retrospective and prospective autopsy study was carried out during 1988-2000 at Mumbai, India. Lungs from 143 adults, with at least 10 sections from each case, were examined using routine and special stains.

RESULTS

The risk factors for 97 men (68%) and 38 women (27%) included: heterosexual sex with multiple partners (135 cases, 95%); blood transfusions (three cases; 2%); sex between men (two cases; 1%); and unknown risk factors (three cases, 2%). Pulmonary pathology was observed in 126 (88%) cases. The lesions identified were tuberculosis (85 cases, 59%), bacterial pneumonia (26 cases, 18%), cytomegalovirus (CMV) infection (10 cases, 7%), cryptococcosis (eight cases, 6%), Pneumocystis carinii pneumonia (seven cases, 5%), aspergillosis (four cases, 3%), toxoplasmosis (two cases, 1%), Kaposi's sarcoma (one case, 1%), squamous cell carcinoma (one case, 1%). Two or more infections were observed in 18 (13%) cases.

CONCLUSIONS

Pulmonary diseases and risk factors among patients with AIDS in India differ from those reported in industrialized countries. Tuberculosis was the most frequently observed pulmonary infection, followed by bacterial pneumonia and CMV pneumonitis. In contrast with industrialized countries, PCP remains less common in our patients. The information on opportunistic infections obtained in this study will be useful for managing HIV/AIDS cases at district level hospitals where diagnosing specific HIV-associated diseases is not always possible.

Prophylaxis with trimethoprim-sulfamethoxazole for human immunodeficiency virus-infected patients: impact on risk for infectious diseases

Trimethoprim-sulfamethoxazole (TMP-SMZ) is widely prescribed as prophylaxis for Pneumocystis carinii pneumonia (PCP) in human immunodeficiency virus (HIV)-infected persons. Its efficacy against other infections has not been thoroughly evaluated. To compare the risk for infectious diseases for persons who were prescribed TMP-SMZ with that for patients who were not prescribed TMP-SMZ, we examined data collected from the medical records of HIV-infected patients (January 1990 through September 1999) who were enrolled in the Adult and Adolescent Spectrum of HIV Disease Project. During intervals when patients had CD4(+) T lymphocyte counts of <200 cells/microL (19,081 persons; 22,801 person-years), prescription of TMP-SMZ was associated with significant protection from toxoplasmosis, salmonellosis, infection with Haemophilus species, invasive or any staphylococcal infection, and PCP, but not from Shigella, pneumococcal or nonpneumococcal Streptococcus, Klebsiella, or Pseudomonas species. We demonstrate that prescription of TMP-SMZ for PCP prophylaxis in persons with HIV infection is associated with significantly decreased risk for several infectious diseases. These findings may be of interest to HIV prevention programs in resource-poor countries.

Use of cidofovir in progressive multifocal leukoencephalopathy

BACKGROUND

Progressive multifocal leukoencephalopathy (PML) is a subacute demyelinating illness caused by the JC virus, a polyomavirus that occurs in 4-5% of HIV-positive patients. Mortality is high, and no useful therapy has been identified. Highly active antiretroviral therapy (HAART) has been reported to be effective in halting progression of the disease in some, but not all, patients. Cidofovir has been shown to be active against polyomaviruses.

OBJECTIVE

To review data on the use of cidofovir to treat PML.

DATA SOURCES

English-language case reports and clinical studies were located through a literature search (MEDLINE and AIDSLINE, 1995-July 2000).

STUDY SELECTION AND DATA EXTRACTION

Relevant case reports and studies describing the use of cidofovir for PML were reviewed.

DATA SYNTHESIS

Most case reports describing the use of cidofovir have shown that the drug is effective in the treatment of PML. Some patients were also receiving HAART concurrently; therefore, it is not clear which treatment modality had a greater impact on PML. However, cidofovir may be effective in patients whose disease has progressed despite HAART or who are-unable to tolerate these regimens. A pilot study of cidofovir for treating PML has completed enrollment, but preliminary results showed no benefit.

CONCLUSIONS

Cidofovir may be the most reasonable treatment option for PML in HIV-infected individuals who fail to improve with HAART or who are unable to tolerate these regimens. Patients who receive cidofovir should be monitored for renal and ocular toxicity.

Bone marrow aspiration, biopsy, and culture in the evaluation of HIV-infected patients for invasive mycobacteria and histoplasma infections

Bone marrow (BM) aspiration and biopsy are used commonly in clinical practice to diagnose invasive tissue infections caused by Mycobacterium avium intracellulare (MAC), Mycobacterium tuberculosis (TB), and Histoplasma capsulatum (HC) in patients with human immunodeficiency virus-1 (HIV) infection. However, the value of these invasive procedures relative to other diagnostic approaches has not been clearly defined. To determine the value of BM culture and BM histology in the diagnosis of opportunistic MAC/TB and HC infections in immunosuppressed patients with HIV, we retrospectively reviewed the records of 56 adult patients with HIV who underwent a single BM aspiration, biopsy, and culture because of unexplained fever and/or other clinical features suggestive of MAC/TB or HC infection. Thirty-two patients (57%) were ultimately diagnosed with MAC/TB or HC infection by positive cultures of BM, blood, sputum, or bronchoalveolar lavage fluid or by the histologic detection of organisms in biopsies of BM or other tissues. The diagnostic sensitivity of BM cultures was equal to that of blood cultures (20/32, or 63%). Granuloma and/or histologically apparent organisms were seen in BM biopsy specimens in 11 of 32 individuals (34%) ultimately diagnosed with MAC/TB or HC infections. Among these 11 cases, both granuloma and acid-fast staining organisms were found in the BM biopsy specimens of 2 individuals for whom both BM and blood cultures were negative. Certain clinical symptoms and signs at the time of BM examination were found by logistic regression analysis to be significantly associated with a subsequent diagnosis of MAC/TB or HC infections; these included high fever, long duration of febrile days prior to BM examination, and elevated direct bilirubin. In conclusion, while the diagnostic sensitivity of BM cultures was found to be no greater than that of blood cultures in detecting MAC/TB or HC infections in immunosuppressed HIV+ patients, histopathologic examination of BM specimens resulted in the relatively rapid identification of nearly one third of infected patients who underwent BM examination, and also identified infections in some patients who were culture negative. These findings support the continued use of BM aspiration, biopsy, and culture for the diagnosis of opportunistic MAC/TB or HC infections in immunosuppressed HIV+ patients, particularly when selected clinical features are present.

Incidence and determinants of bacterial infections in HIV-positive patients receiving anti-Pneumocystis carinii/Toxoplasma gondii primary prophylaxis within a randomized clinical trial

We assessed the incidence and determinants of bacteremia, pneumonia, and sinusitis/otitis in HIV-positive people receiving cotrimoxazole (CTX) or dapsone-pyrimethamine (DP) for primary prophylaxis of Pneumocystis carinii pneumonia (PCP) and toxoplasmic encephalitis (TE) within a randomized clinical trial. In total, 244 patients were randomized: 122 were assigned to CTX and 122 to DP. In the cohort, 22 bacteremia, 63 pneumonia, and 39 sinusitis/otitis cases were observed. Incidence rates of bacteremia, pneumonia, and sinusitis/otitis as well as the 2-year probability of remaining free from any bacterial infection were not significantly different between the two groups. At multivariate analysis, the risks of developing bacteremia and pneumonia were found to be independently increased by the use of a central venous catheter (hazard ratio [HR], 4.48; p <.05 and HR, 4.13; p <.01, respectively) and by hospitalization (HR, 28.82; p <.05 and HR, 10.15; p <.05, respectively). In conclusion, CTX at the dosage employed for primary PCP/TE prophylaxis does not seem to protect against bacterial infections more than second-line DP.

Murine cytomegalovirus open reading frame M27 plays an important role in growth and virulence in mice

Using a Tn3-based transposon mutagenesis approach, we have generated a pool of murine cytomegalovirus (MCMV) mutants. In this study, one of the mutants, RvM27, which contained the transposon sequence at open reading frame M27, was characterized both in tissue culture and in immunocompetent BALB/c mice and immunodeficient SCID mice. Our results suggest that the M27 carboxyl-terminal sequence is dispensable for viral replication in vitro. Compared to the wild-type strain and a rescued virus that restored the M27 region, RvM27 was attenuated in growth in both BALB/c and SCID mice that were intraperitoneally infected with the viruses. Specifically, the titers of RvM27 in the salivary glands, lungs, spleens, livers, and kidneys of the infected SCID mice at 21 days postinfection were 50- to 500-fold lower than those of the wild-type virus and the rescued virus. Moreover, the virulence of the mutant virus appeared to be attenuated, because no deaths occurred among SCID mice infected with RvM27 for up to 37 days postinfection, while all the animals infected with the wild-type and rescued viruses died within 27 days postinfection. Our observations provide the first direct evidence to suggest that a disruption of M27 expression results in reduced viral growth and attenuated viral virulence in vivo in infected animals. Moreover, these results suggest that M27 is a viral determinant required for optimal MCMV growth and virulence in vivo and provide insight into the functions of the M27 homologues found in other animal and human CMVs as well as in other betaherpesviruses.

Clinical manifestations and survival trends during the first 12 years of the AIDS epidemic in Mexico

BACKGROUND

Our objective was to evaluate survival trends (1984-1995), the prevalence of AIDS-defining conditions, and the role of treatment with zidovudine and/or prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) in survival following AIDS diagnosis.

METHODS

We reviewed the clinical charts and postmortem studies of all patients admitted to the HIV Clinic from 1984-1995. Three groups were identified according to the following dates of HIV diagnosis: 1) 1984-1988; 2) 1989-1992, and 3) 1993-1995.

RESULTS

We studied 909 charts. During the study period, 744 (81.6%) patients developed AIDS. Median survival increased from 11.7 months in group 1 to 15.4 and 17.5 months in groups 2 and 3, respectively (p <0.05). We observed the following important changes in the frequency of AIDS-defining conditions over the study period: Pneumocystis carinii pneumonia (PCP) decreased from 24.8 to 17 and 14% in groups 1, 2, and 3, respectively, (p = 0.008), and Kaposi's sarcoma (KS), from 31.1 to 10.5 and 13.5% (p <0.001). On the other hand, there was an increase in cytomegalovirus disease with 12.4, 20.4, and 18.6% (p = 0.04) and wasting syndrome with 36, 45, and 57% (p <0.001). In the proportional hazard model for death, zidovudine or TMP-SMX use was associated with a protective effect.

CONCLUSIONS

Survival is improving among patients with HIV infection at our institution. The prevalence of AIDS-defining conditions has changed over the last 12 years. There has been a diminution of PCP and KS, whereas cases of CMV disease and wasting syndrome increased.

Community-acquired bacterial pneumonia in human immunodeficiency virus-infected patients: validation of severity criteria. The Grupo Andaluz para el Estudio de las Enfermedades Infecciosas

Severity criteria for community-acquired pneumonia (CAP) have always excluded patients with human immunodeficiency virus (HIV) infection. A 1-yr, multicenter, prospective observational study of HIV-infected patients with bacterial CAP was done to validate the criteria used in the American Thoracic Society (ATS) guidelines for CAP, and to determine the prognosis-associated factors in the HIV-infected population with bacterial CAP. Overall, 355 cases were included, with an attributable mortality of 9.3%. Patients who met the ATS criteria had a longer hospital stay (p = 0.01), longer duration of fever (p < 0.001), and higher attributable mortality (13.1% versus 3.5%, p = 0.02) than those who did not. Three factors were independently related to mortality: CD4(+) cell count < 100/microl, radiologic progression of disease, and shock. Pleural effusion, cavities, and/or multilobar infiltrates at admission were independently associated with radiologic progression. A prognostic rule based on the five criteria of shock, CD4(+) cell count < 100/microl, pleural effusion, cavities, and multilobar infiltrates had a high negative predictive value for mortality (97.1%). The attributable mortality for severe pneumonia was 11.3%, as compared with 1.3% for nonsevere disease (p = 0.008). The ATS severity criteria are valid in HIV-infected patients with bacterial CAP. Our study provides the basis for identification of patients who may require hospitalization determined by clinical judgment and the five clinical criteria of shock, a CD4(+) cell count < 100/microl, pleural effusion, cavities, and multilobar involvement. These prognostic factors should be validated in independent cohort studies.

In vitro and in vivo characterization of a murine cytomegalovirus with a transposon insertional mutation at open reading frame M43

We have recently generated a pool of murine cytomegalovirus (MCMV) mutants by using a Tn3-based transposon mutagenesis approach. In this study, one of the MCMV mutants, RvM43, which contained the transposon inserted in open reading frame M43, was characterized. Our results provide the first direct evidence to suggest that M43 is not essential for viral replication in vitro in NIH 3T3 cells. Moreover, RvM43 exhibited a titer similar to that of the wild-type virus in the lungs, livers, spleens, and kidneys of both BALB/c and SCID mice and was as virulent as the wild-type virus in killing SCID mice that had been intraperitoneally infected with the viruses. In contrast, titers of the mutant virus in the salivary glands of the infected animals at 21 days postinfection were significantly (100 to 1,000-fold) lower than those of the wild-type virus and a rescued virus that restored the M43 region and its expression. Thus, M43 appears to be not essential for viral growth in vivo in the lungs, livers, spleens, and kidneys of infected animals and is also dispensable for virulence in killing SCID mice. Moreover, our results suggest that M43 is an MCMV determinant for growth in the salivary glands. Studies of viral genes required for replication in the salivary glands are important in understanding the mechanism of viral tropism for the salivary glands and shedding in saliva, which is believed to be one of the major routes of CMV transmission among healthy human populations.

Impact of HAART on causes of death of persons with late-stage AIDS

CONTEXT

The increasing use of highly active antiretroviral therapies (HAARTs) has changed the course of AIDS-related illnesses and enhanced the quality of life of patients infected with human immunodeficiency virus (HIV) and may have changed the causes of deaths in patients with acquired immunodeficiency syndrome (AIDS).

OBJECTIVE

The aim of the present study was to investigate causes of deaths in long-term care hospital patients with late-stage AIDS who expired at the Coler-Goldwater Memorial Hospital in New York City in 1995, and in 1998 and 1999, that is, immediately before and the two most recent years after the advent of HAART.

METHODS

Analysis of causes of deaths as recorded on the death certificates of 232 AIDS patients.

RESULTS

The overall mortality rate declined from 75.6 deaths per 100 person-years in 1995 to 33.2 deaths per 100 person-years in 1998-1999 (P < .001). The number of AIDS patients who expired because of sepsis and opportunistic infections, which included Pneumocystis carinii pneumonia (PCP), decreased significantly from 30 (26.1%) and 24 (20.9%) in 1995 to 15 (12.8%) and 10 (8.5%) in 1998-1999, respectively (P < .05). In contrast, deaths from hepatic failure increased from 0 (0%) in 1995 to 7 (6%) in 1998-1999 (P < .05). Increases, although not significant statistically, were associated with pneumonias excluding PCP, end-stage AIDS, renal failure, and malignancies. Analysis of cause-specific mortality by gender between 1995 and 1998-1999 revealed very little difference between men and women. This analysis showed, however, that the infectious processes taken together (pneumonias excluding PCP, sepsis, and opportunistic infections including PCP) were significantly less frequent causes of death in 1998-1999 than in 1995 (P < .01).

CONCLUSION

These findings indicate that HAART affected the causes of deaths in patients with AIDS, with "traditional" opportunistic infections diminishing in importance relative to chronic medical conditions and malignancies.

Suppression of murine cytomegalovirus (MCMV) replication with a DNA vaccine encoding MCMV M84 (a homolog of human cytomegalovirus pp65)

The cytotoxic T-lymphocyte (CTL) response against the murine cytomegalovirus (MCMV) immediate-early gene 1 (IE1) 89-kDa phosphoprotein pp89 plays a major role in protecting BALB/c mice against the lethal effects of the viral infection. CTL populations specific to MCMV early-phase and structural antigens are also generated during infection, but the identities of these antigens and their relative contributions to overall immunity against MCMV are not known. We previously demonstrated that DNA vaccination with a pp89-expressing plasmid effectively generated a CTL response and conferred protection against infection (J. C. Gonzalez Armas, C. S. Morello, L. D. Cranmer, and D. H. Spector, J. Virol. 70:7921-7928, 1996). In this report, we have sought (i) to identify other viral antigens that contribute to immunity against MCMV and (ii) to determine whether the protective response is haplotype specific. DNA immunization was used to test the protective efficacies of plasmids encoding MCMV homologs of human cytomegalovirus (HCMV) tegument (M32, M48, M56, M82, M83, M69, and M99), capsid (M85 and M86), and nonstructural antigens (IE1-pp89 and M84). BALB/c (H-2(d)) and C3H/HeN (H-2(k)) mice were immunized by intradermal injection of either single plasmids or cocktails of up to four expression plasmids and then challenged with sublethal doses of virulent MCMV administered intraperitoneally. In this way, we identified a new viral gene product, M84, that conferred protection against viral replication in the spleens of BALB/c mice. M84 is expressed early in the infection and encodes a nonstructural protein that shares significant amino acid homology with the HCMV UL83-pp65 tegument protein, a major target of protective CTLs in humans. Specificity of the immune response to the M84 protein was confirmed by showing that immunization with pp89 DNA, but not M84 DNA, protected mice against subsequent infection with an MCMV deletion mutant lacking the M84 gene. The other MCMV genes tested did not generate a protective response even when mice were immunized with vaccinia viruses expressing the viral proteins. However, the M84 plasmid was protective when injected in combination with nonprotective plasmids, and coimmunization of BALB/c mice with pp89 and M84 provided a synergistic level of protection in the spleen. Viral titers in the salivary glands were also reduced, but not to the same extent as observed in the spleen, and the decrease was seen only when the BALB/c mice were immunized with pp89 plus M84 or with pp89 alone. The experiments with the C3H/HeN mice showed that the immunity conferred by DNA vaccination was haplotype dependent. In this strain of mice, only pp89 elicited a protective response as measured by a reduction in spleen titer. These results suggest that DNA immunization with the appropriate combination of CMV genes may provide a strategy for improving vaccine efficacy.

Bacterial pneumonia in hospitalized patients with HIV infection: the Pulmonary Complications, ICU Support, and Prognostic Factors of Hospitalized Patients with HIV (PIP) Study

STUDY OBJECTIVES

To describe the causative organisms and factors associated with bacterial pneumonia and to assess its impact on the outcome of hospitalized patients with HIV.

DESIGN

Prospective, observational.

SETTING

A university-affiliated medical center.

METHODS

We included 1,225 consecutive hospital admissions, from April 1995 through March 1998, of 599 adults with HIV. We collected data on APACHE II (acute physiology and chronic health evaluation II) score, leukocyte and CD4+ lymphocyte counts, length of hospital stay, ICU admission rate, and case-fatality rate. Chest radiographs and laboratory results were reviewed. The presence of bacterial pneumonia was noted.

RESULTS

Bacterial pneumonia was diagnosed in 111 hospitalizations (9%): 80 (72%) were community-acquired infections. The CD4+ lymphocyte count was lower (median, 38 vs 66/microL, p = 0.0027), APACHE II score higher (17 vs 13, p < 0. 0001), length of hospital stay longer (median, 6 vs 4), and ICU admission (28% vs 9%) and case-fatality rates (21% vs 4%) higher in patients with bacterial pneumonia compared with those without bacterial pneumonia. The most common pathogen was Pseudomonas aeruginosa (32 admissions), followed by Streptococcus pneumoniae (22 admissions), Staphylococcus aureus (16 admissions), and Haemophilus influenzae (11 admissions). Thirty-three (30%) of the pneumonias were bacteremic. Bacteremia was more common in pneumococcal than in pseudomonal pneumonia (95% vs 9%, p < 0.0001). Compared with patients with pneumococcal pneumonia, patients with pseudomonal pneumonia had lower leukocyte and CD4+ lymphocyte counts, longer hospital stay, and similar case-fatality rate.

CONCLUSIONS

P aeruginosa is becoming a common cause of both community-acquired and nosocomial bacterial pneumonia in hospitalized patients with HIV, especially in those with low leukocyte and CD4+ lymphocyte counts.

Opportunistic AIDS-associated malignancies in HIV-infected patients

Three major neoplasms are associated with AIDS definition in the course of HIV infection due to their increased incidence. The relationship between the immune system and the epidemiology of these virus-induced tumors is of importance in order to identify new therapeutic approaches for treating or preventing these neoplasms. Major improvements in the understanding of the pathogenesis have already been performed. The impact of highly active antiretroviral therapy (HAART) on their incidence likely confirms the concept of 'opportunistic malignancies'. Other neoplasms are likely more prevalent in HIV-infected individuals, but their relative importance requires further prospective case-control cohort studies.

Diagnosis of Pneumocystis carinii pneumonia in human immunodeficiency virus-infected patients with polymerase chain reaction: a blinded comparison to standard methods

Pneumocystis carinii pneumonia (PCP) is an important cause of morbidity and death among persons with human immunodeficiency virus (HIV) infection. Polymerase chain reaction (PCR) analysis of respiratory specimens has been investigated as a rapid diagnostic method. We have previously reported on the utility of this technique for diagnosing PCP in HIV-infected patients. In this report we evaluate PCR used in a blinded study design to avoid biases inherent to retrospective and nonblinded studies. The diagnosis of PCP was established on the basis of clinical findings and morphological studies of bronchoalveolar lavage (BAL) and/or lung biopsy specimens before PCR testing. PCR was performed without knowledge of the diagnosis. PCR results were graded from "negative" to 3+ on the basis of intensity of the banding pattern. Forty-seven patients were enrolled in the study, including 18 with proven PCP and 29 with other conditions. PCR was positive at grade 1 or higher for all 18 patients with PCP (100% sensitivity), at grade 2 or higher for 13 patients (72.2% sensitivity), and at grade 1 or higher for 4 of the 29 control patients (specificity of 86.2%). If a grade 2 or higher was required for diagnosis, the specificity improved to 100%. Results were reproducible with testing of a second aliquot for 46 of 47 patients (97.8%). Our findings confirm that PCR is a sensitive and reproducible test for detection of P. carinii in BAL specimens. Problems with false-positive results for control patients, however, limit the applicability of this method.

Simian AIDS-associated lymphoma in rhesus and cynomolgus monkeys recapitulates the primary pathobiological features of AIDS-associated non-Hodgkin's lymphoma

Non-Hodgkin's lymphomas occur with increased frequency (3-6%) in HIV-infected individuals. These AIDS-associated lymphomas (AALs) exhibit characteristics that distinguish them from lymphomas in the general population. A proposed model for the pathogenesis of AAL includes the following: (1) Tumorigenesis is multistep; (2) tumors occur in long-term survivors; (3) tumors are of clonal B cell origin; (4) HIV acts early and is an indirect effector; (5) tumor cells are infected with EBV; and (6) specific genetic lesions occur in tumor cells. Many aspects of this process remain to be tested in an animal model system. Since 1984, necropsy examinations have been performed on more than 1000 SIV-infected rhesus and cynomolgus monkeys at the Tulane Regional Primate Research Center. Lymphoid malignancies were detected in a proportion of SIV-infected animals. These SAIDS-associated lymphomas (SALs) have been studied to determine the extent to which their pathological features recapitulate a working model for the pathogenesis of AAL. The results show that lymphomas occur in SIV-infected rhesus macaques at 4% incidence, similar to that of AAL, and that the incidence of SAL in cynomolgus macaques is eightfold higher. Analysis of SAL from both species of macaques demonstrated significant similarity to the hallmark pathobiological features of AAL. These findings indicate that the HIV-infected human and the SIV-infected macaque share a common pathobiology and mechanism of lymphomagenesis.

Changing conditions and treatments in a dynamic cohort of ambulatory HIV patients: the HIV outpatient study (HOPS)

PURPOSE

Most HIV-infected persons are now treated as ambulatory patients. Obtaining continually updated data about these patients' changing conditions, therapies, and reimbursement is essential to health care provision and planning. The systematic tracking of patient medical and laboratory information in an ongoing commercial data collection program (The Health Research Network) allows clinicians to better understand health outcomes, practice patterns, and epidemiologic trends for their patients.

METHODS

To evaluate trends in conditions and therapies of ambulatory HIV-infected patients, we analyzed such data electronically and prospectively collected in the HIV Outpatient Study (HOPS) from 1992 through 1996 from 1876 patients seen in 11,755 clinic visits to ten HIV clinical practices.

RESULTS

Patients were as likely to be diagnosed with Mycobacterium avium complex ([MAC] 5.4 cases per 100 person-years) or wasting syndrome (7.8 cases per 100 person-years), as Pneumocystis carinii pneumonia ([PCP]; 7.6 cases per 100 person-years) or Kaposi sarcoma ([KS]; 6.9 cases per 100 person-years). A nested analysis showed that HIV-infected cigarette smokers were at substantially greater risk of pneumonia (relative hazard [RH] = 2.3), bronchitis (RH = 1.7) and hairy leukoplakia (RH = 1.9) than nonsmokers. By 1996, 35 (56%) of 62 patients with PCP, 9 (30%) of 30 patients with other pneumonias, 28 (90%) of 31 patients with KS, 35 (73%) of 48 patients with MAC, and 24 (63%) of 38 patients with cytomegalovirus retinitis were treated without hospitalization.

CONCLUSIONS

The HOPS provides continually updated information on the changing characteristics, conditions, and therapy of ambulatory HIV-infected patients.

Downward trends in bronchoscopies performed between 1991 and 1997

STUDY OBJECTIVE

To examine the frequency of bronchoscopy performance in a large tertiary medical center over a period of 8 years.

DESIGN

Retrospective data analysis.

SETTING

Academic medical center.

MATERIALS AND METHODS

Using a computerized database of all bronchoscopies performed between 1991 and 1997, we analyzed trends in (1) the total number of bronchoscopies; and (2) the numbers of bronchoscopies performed for patients on the basis of the postbronchoscopic diagnosis in the following three main disease groups: AIDS, interstitial lung disease (ILD), and lung cancer. We measured the following outcomes in the patients of high-volume and low-volume bronchoscopists: procedure length (time to perform procedure), nondiagnostic rate, and repeat-bronchoscopy rate. In addition, we compared total admissions, outpatient visits, and insurance status of the patients during the same period.

RESULTS

In total, 5,580 bronchoscopies were performed. A 17% decline in the number of procedures was noted between 1991 and 1997 (from 943 to 783, respectively; p < 0.05). The number of AIDS-related bronchoscopies fell from 235 (25% of 943) to 96 (12% of 783), a 59% decline during this period (p < 0.05). There was a corresponding 76% decrease in the number of bronchoscopies associated with a diagnosis of Pneumocystis carinii pneumonia (PCP; p < 0.05). During the same period, no similar decrease was noted in the number of bronchoscopies associated with a diagnosis of ILD or lung cancer. Moreover, no significant differences were noted in the procedure length, nondiagnostic rate, or repeat-bronchoscopy rate between high-volume and low-volume bronchoscopists. Although there was no significant change in the number of total admissions between 1991 and 1997, there was a 48% increase in the number of managed-care patients and a 25.4% increase in the number of Medicaid health insurance program for California patients between 1991 and 1997.

CONCLUSIONS

We noted a significant decline in the number of bronchoscopies performed between 1991 and 1997. The significant reduction in the number of AIDS-associated bronchoscopies accounted for 87% of the decline. Other possible factors include the introduction of a management pathway for the empiric treatment of PCP in 1996, a reduction in the number of pulmonary admissions, an increase in the number of managed care patients, and a reduction in the remuneration for the performance of bronchoscopy.

TORCH testing in HIV-infected women

The issue of TORCH testing in pregnant women infected with the HIV virus remains confusing, even more so than it is in the non-HIV-infected gravida. Unfortunately, the data presented in this article make the recommendations of how to test for these various infections in pregnancy that much more difficult. Patients who are newly diagnosed as being HIV-infected and referred for prenatal care or who have not had TORCH testing probably should be tested. Thus, the prenatal patient with newly diagnosed HIV infection should be tested for T. gondii IgG antibodies. If positive for IgG antibodies, IgM antibodies should be obtained in an attempt to rule out acute T. gondii infection. Patients who test negative do not require any further testing until after the pregnancy unless they are severely immunocompromised and show signs and symptoms of toxoplasmosis. Antibodies (IgG) to CMV should be obtained in the HIV-infected gravida who is at high risk for CMV disease, i.e., patients with CD4+ T cell counts less than 100/mm3. Unfortunately, the previously described problems with antibody detection make this testing less than ideal; thus, it is not routinely recommended in the HIV-infected pregnant patient who presents for prenatal care except for those at risk of disease reactivation. As for herpes simplex virus testing, there is no value in routinely testing patients prenatally for evidence of the disease. Finally, syphilis testing in the HIV-infected gravida is of major importance. Once tested, the patient who tests negative and who remains at risk for infection should probably be retested in the third trimester. Patients who are found to have the disease and who are treated need to be tested serially to rule out re-infection or treatment failure.

Effect of trimethoprim-sulfamethoxazole as Pneumocystis carinii pneumonia prophylaxis on bacterial illness, Pneumocystis carinii pneumonia, and death in persons with AIDS

To measure the effect of trimethoprim-sulfamethoxazole (TMP-SMX) in preventing bacterial illness, Pneumocystis carinii pneumonia (PCP), and death in people with AIDS, we conducted a retrospective medical record review of 1078 persons who were observed for 3 years on average who attended nine outpatient facilities in Seattle, Washington between January 1990 and April 1996. We calculated relative risk estimates to measure the protective effect of TMP-SMX on the development of major bacterial illnesses, PCP, and death. Use of TMP-SMX decreased the risk of PCP (relative risk [RR] = 0.23; 95% confidence interval [CI], 0.14-0.36) and deaths not attributable to PCP (RR = 0.59; 95% CI, 0.47-0.73). Prevention of major bacterial illnesses of known etiology was of borderline significance (RR = 0.77; 95% CI, 0.57-1.05) and became statistically significant with the addition of patients with infections of unknown etiology (RR = 0.77; 95% CI 0.61-0.97). Use of TMP-SMX PCP prophylaxis significantly reduced the risks of death and of PCP and was associated with a trend toward reduced risk of major bacterial infections.

Epidemiology, etiology and pathogenesis, clinical presentations and therapeutic approaches in Kaposi's sarcoma: 15-year lessons from AIDS

Kaposi's sarcoma (KS) is a leading cause of morbidity among 25-30% of AIDS patients and is by far the most common AIDS-associated malignancy. Since the beginning of the 1990s the incidence of KS continuously declined, but it was the introduction of protease inhibitors that markedly reinforced this phenomenon. In our experience, the annual incidence was 59/1,000 patient-years in 1984 vs 21.2/1,000 patient-years in 1990, 12.5/1,000 patient-years in 1996, with a drop to 3.2/1,000 patient-years in 1997. One of the peculiar characteristic of this tumor is the sexual susceptibility, which could be the consequence of a hormonal protection in females. The in vitro models of KS-like cell culture promoted and sustained in vitro with a conditioned medium containing several pro-inflammatory cytokines, the characterization of human herpes virus-8 (HHV-8) in almost all the cases of AIDS-KS as the putative KS-agent and the determination of a putative role of hCG-associated factors in the control of KS growth are among the leading discoveries of this last decade in this field.

Clearance of Pneumocystis carinii cysts in acute P carinii pneumonia: assessment by serial sputum induction

STUDY OBJECTIVES

To determine the feasibility of repeat sputum induction in acute Pneumocystis carinii pneumonia (PCP) and to define the rate of clearance of P carinii cysts from the respiratory tract of HIV-seropositive patients with acute PCP.

DESIGN

Prospective cohort evaluation.

SETTING

University medical center.

PARTICIPANTS

Twenty-four HIV-seropositive subjects with acute PCP.

MEASUREMENTS

Sputum induction for P carinii 2, 3, 4, and 6 weeks after initial diagnosis, and follow-up for 1 year.

RESULTS

Eighty-eight percent of subjects had residual cysts at 2 weeks, 76% at 3 weeks, 29% at 4 weeks, and 24% at 6 weeks postdiagnosis. A prior AIDS-defining illness (p = 0.033) or prior PCP (p = 0.004) predicted relapse within 6 months, but persistent cysts at 3 weeks did not; 8 of 16 sputum-positive subjects and 1 of 5 sputum-negative subjects experienced a relapse within 6 months (p = 0.34). Secondary prophylaxis with trimethoprim-sulfamethoxazole was associated with a reduced risk of relapse.

CONCLUSIONS

Serial sputum induction coupled with direct fluorescent antibody staining is a feasible, noninvasive method of respiratory tract surveillance for the eradication of P carinii during and after acute PCP. Three-quarters of HIV-seropositive patients with acute PCP have persistent cysts in their lungs at the end of antimicrobial treatment, despite clinical recuperation, but only one quarter have residual cysts 6 weeks postdiagnosis. A prior AIDS-defining illness and prior PCP are positively associated, and subsequent trimethoprim-sulfamethoxazole prophylaxis is negatively associated, with relapse within 6 months, while persistent organisms at 3 weeks do not appear to be a significant predictor of relapse risk.

Pneumocystis carinii pneumonia incidence and chemoprophylaxis failure in ambulatory HIV-infected patients. HIV Outpatient Study (HOPS) Investigators

BACKGROUND

Pneumocystis carinii pneumonia (PCP) remains the most frequently reported serious opportunistic infection in AIDS patients and the second highest cause of mortality among persons with AIDS in the United States, despite the availability of effective chemoprophylaxis.

METHODS

To evaluate incidence of PCP and determinants of PCP chemoprophylaxis failure, we analyzed data from 2842 patients visits to infectious diseases physicians at 10 HIV clinics (eight private and two public) in eight U.S. cities from January 1992 through June 1996 as part of the HIV Outpatient Study (HOPS). We performed a time-dependent regression analysis to examine potential determinants of PCP chemoprophylaxis failure.

RESULTS

The incidence of chemoprophylaxis failure was 4.6 PCP cases/100 person-years on chemoprophylaxis; these cases represent 67% of all incident episodes of PCP. In a multivariate analysis, the only significant predictors of chemoprophylaxis failure were the use of agents other than trimethoprim-sulfamethoxazole (TMP-SMX), history of prior PCP, and a CD4+ T-lymphocyte cell count of <50 cells/microl. Dosing or frequency of TMP-SMX did not seem to influence risk of chemoprophylaxis failure.

DISCUSSION

Chemoprophylaxis failure, especially among those with the most advanced immunosuppression or history of prior PCP, was the most significant source of new PCP cases in the HOPS cohort and thus represents one of the largest contributors to morbidity and mortality in this cohort.

Kaposi's sarcoma in HIV infection: impact on opportunistic infections and survival

OBJECTIVE

To determine the effect of Kaposi's sarcoma on survival of HIV-infected patients.

METHODS

Retrospective cohort study to compare the survival of 241 HIV-infected homosexual patients with Kaposi's sarcoma (cases) with that of 241 HIV-infected homosexual patients without Kaposi's sarcoma (control subjects) but with a similar level of immunosuppression (measured by the absolute CD4+ lymphocyte count).

RESULTS

Cases and control subjects were similar in age, occurrence of previous opportunistic infections, and the use of antiretroviral therapy. The mean CD4+ lymphocyte counts were similar for cases and control subjects (185 x 10(6) versus 184 x 10(6)/l, respectively). Cases had a higher incidence of opportunistic infections (5.95 versus 3.88 infections, respectively, per 100 person-months of observation) and a greater number of infections typical of late-stage HIV infection. Cases had a shorter overall survival than did control subjects (P=0.0025). Kaposi's sarcoma was associated with an increased risk of death (odds ratio, 1.28), even when adjusting for age, previous opportunistic infection, baseline CD4+ lymphocyte count, and antiretroviral therapy.

CONCLUSION

Kaposi's sarcoma appears to accelerate the clinical course of HIV infection. Opportunistic infections develop earlier and more often in patients with the disease than in control subjects. Survival was significantly shorter in patients with Kaposi's sarcoma.