[Knowledge and use of Pap-smear among HIV-positive women]

AIM

HIV-positive women are at increased risk for preneoplastic lesions and invasive cervical cancer (ICC). The occurrence of these lesions can be substantially reduced by appropriate cervico-vaginal screening protocols (i.e., Pap-test). The aim of study was to assess: 1) awareness of Pap-smear and 2) the association between awareness of Pap-smear and screening attitudes of HIV-positive women.

METHODS

Three-hundred and ninety HIV-positive women who attended the HIV outpatient gynecological unit of the National Institute for Infectious Diseases, Rome, from January 2003 to April 2005 were included in this investigation. These 390 women were interviewed to assess whether they were aware that Pap-test was a preventive tool against cervical cancer. In addition, past history of Pap-test, socioeconomic condition, history of HIV infection, and sexual habits were investigated. Odds ratios (OR) and 95% confidence intervals (CI) were used to assess the association between knowledge of Pap-test and covariates.

RESULTS

Of these 390 HIV-positive women, 54.6% were not aware that Pap-test could prevent ICC. Women with a low educational level (OR = 6.6) or women who originated from Africa (OR = 6.5) were more likely to be unaware of Pap-test. Lack of Pap-test awareness was strongly associated with negative history for lifetime Pap-test (OR = 4.7).

CONCLUSIONS

We showed that a large proportion of HIV-infected women are not aware that ICC could be prevented through Pap-test screening, and that lack of Pap-test screening is strongly associated with lack of awareness. The need for Pap-test counseling targeted to HIV-infected women clearly emerges from our findings.

Large de novo deletion in chromosome 12 affecting the PAH, IGF1, ASCL1, and TRA1 genes

Phenylketonuria is one of the most common genetic diseases in humans, affecting 1 in 10,000 whites. Deletions are generally uncommon in genes in which no long highly homologous segments are present, and in phenylalanine hydroxylase (PAH) deficiency they represent only 5% of cases. We present the case of a girl affected by classical phenylketonuria who has been screened for mutations in the PAH gene. During the molecular study a large de novo deletion has detected in 12qter, including PAH, and the genes for insulin-like growth factor 1 (IGF1), human achaete-scute homolog 1 (ASCL1), and tumor rejection antigen (TRA1). The patient showed phenylketonuria, short stature, and pathological electro-oculography results in both eyes, with high affectation of the relative electrogenesis of the photoreceptor-pigment epithelium complex. She had previously been misdiagnosed as homozygous for the IVS8nt-7A-G mutation, instead of heterozygous for a mutation and a de novo deletion. As a result incorrect genetic counseling had been given. The deletion of the PAH, IGF1, and ASCL1 genes could explain the patient's phenotype corresponding to a contiguous gene syndrome. We stress the relevance of polymorphic marker haplotype analysis and the importance of family study in genetic recessive diseases, such as phenylketonuria, to avoid incorrect diagnosis and genetic counseling.

Cervicovaginal shedding of TT virus in HIV-infected women

OBJECTIVE

TT virus (TTV) is frequently detected in the serum and in other body fluids of humans. Recently TTV-specific deoxyribonucleic acid has been detected in cervical specimens from apparently healthy women and in seminal fluid, suggesting that sexual transmission may be common.

STUDY DESIGN/METHODS

TT virus-deoxyribonucleic acid prevalence was assessed in paired samples of blood and cervical smears from 110 human immunodeficiency virus-positive women. Detection and typing of human papillomavirus (HPV) present in cervical smears was also performed.

RESULTS

The prevalence of TTV-deoxyribonucleic acid in cervical smears was 16.4%, without significant difference (p = 0.81) between HPV-positive (18.6%) and -negative (14.9%) samples. The distribution of high/middle and low-risk HPV types was similar in TTV-positive and -negative samples. On the contrary, women with multiple HPV infections had a significantly higher TTV-deoxyribonucleic acid prevalence (60.0%) than HPV-negative women (p = 0.04).

CONCLUSIONS

TT virus excretion in the female genital tract of human immunodeficiency virus-infected women is common, further supporting sexual transmission of this virus.

Yield of large-volume blood cultures in patients with early Lyme disease

To improve yield, 6 3-mL plasma cultures (18 mL total) were established for adult patients with early Lyme disease associated with erythema migrans. Borrelia burgdorferi was recovered from the blood of 22 (44.0%) of 50 evaluable patients. The recovery rate per plasma culture and the frequency of positive results for plasma cultures for individual patients were consistent with a level of spirochetemia of approximately 0.1 cultivable cell/mL of whole blood. Our findings suggest that, if further improvements in the yield of blood cultures are possible, they probably will depend on enhancing the sensitivity of the culture method rather than increasing the volume of material cultured.

Failure of treatment with cephalexin for Lyme disease

CONTEXT

Lyme disease typically presents with a skin lesion called erythema migrans (EM), which though often distinctive in appearance may be confused with cellulitis. The first-generation cephalosporin, cephalexin monohydrate, is effective for treating bacterial cellulitis but has not been recommended or studied for treating Lyme disease because of poor in vitro activity.

OBJECTIVE

To describe the outcome of patients with EM who were treated with cephalexin.

PATIENTS AND METHODS

Patients presenting with EM to the Lyme Disease Diagnostic Center in Westchester, NY (May 1992-September 1997). A 2-mm punch biopsy specimen of the leading edge of the EM lesion and/or blood was cultured for Borrelia burgdorferi.

RESULTS

Eleven (2.8%) of 393 study patients had been initially treated with cephalexin prior to our evaluation; 9 (82%) were originally diagnosed with cellulitis. Cephalexin was administered for 8.6 days (range, 2-21 days) prior to presentation. All 11 patients had clinical evidence of disease progression, including 8 whose rash enlarged, 2 who developed seventh-nerve palsy (1 with new EM lesions), and 1 who developed new EM lesions. Borrelia burgdorferi grew in cultures from 5 patients despite a mean of 9.8 days of treatment with cephalexin (range, 5-21 days).

CONCLUSION

Cephalexin should not be used to treat early Lyme disease and should be prescribed with caution during the summer months for patients believed to have cellulitis in locations where Lyme disease is endemic.

Comparison of the yields of blood cultures using serum or plasma from patients with early Lyme disease

In an initial experiment, culture-grown Borrelia burgdorferi was added to freshly collected uninfected human blood. This in vitro study demonstrated that more spirochetes were distributed into the plasma than into the serum fraction. In a subsequent clinical study, B. burgdorferi was recovered from plasma cultures of approximately 50% of 42 patients with early Lyme disease associated with erythema migrans. The rate of recovery from plasma cultures was significantly greater than that from serum cultures (P < 0.001).

Diagnosis and follow-up of a case of peroxisomal disorder with peroxisomal mosaicism

Peroxisomal disorder phenotypes are the result of mutations that cause defective peroxisomal assembly or alterations in the import mechanism of peroxisomal proteins that lead to multiple peroxisomal dysfunctions, or the result of a peroxisomal enzymatic deficiency with a single peroxisomal dysfunction. With complementation analysis, 16 groups have been found. Assignment of the genetic defect has been described for some of the complementation groups. We describe the clinical evolution and follow-up over 10 years of a patient who belongs to complementation group 4, although he showed a milder clinical course. It has been found in fibroblasts different peroxisome populations, normal processing and expression of beta-oxidation PTS1 and PTS2 proteins, abnormal ALD protein distribution and normal plasmalogen biosynthesis; abnormal beta-oxidation metabolites have also been detected in serum. Ultrastructural studies in liver showed peroxisomal mosaicism as in fibroblasts. It has been taken into account that peroxisomal mosaicism may lead to variability in peroxisomal diagnostic parameters, making difficult the final diagnosis in these patients.

Distribution of Trichinella spiralis larvae in muscles from a naturally infected horse

Epidemiological investigations conducted during 10 trichinellosis outbreaks between 1975 and 1994 showed that horse-meat was the probable source of infection. Though hundreds of thousands of horses have been examined at abattoirs in America and Europe to detect Trichinella infection by artificial digestion or trichinelloscopy, an infected horse has never been detected during routine analysis, which consists of examining 1 g of tissue muscle from the diaphragm. In November 1996, a naturally infected horse imported from Romania was detected in Southern Italy. The parasite was identified as Trichinella spiralis by random amplified polymorphic DNA analysis. Artificial digestion of tissue samples from 60 different muscles from 13 different sites of the infected horse carcass showed that M. levator Labii maxillaris, M. hyoideus transversus, and M. buccinator were the 3 most infected muscles. Muscles from the tongue, the masseter, and the diaphragm, which have normally been considered the muscles of choice for diagnosis, were the 4th, 6th and 13th most infected muscles, respectively. When comparing body sites, muscle tissues from the head showed the highest level of infection, followed by muscles from the neck. This finding may explain the negative results that have been obtained in the past during routine examination of the diaphragm of horses.

Improving the yield of blood cultures for patients with early Lyme disease

This study was designed to improve the recovery of Borrelia burgdorferi from blood. With the techniques used, B. burgdorferi could be recovered from the blood of approximately 25% of patients with early Lyme disease associated with erythema migrans. Serum was a better source of culture material than whole blood. The volume of blood cultured correlated directly with yield, particularly for patients with a single erythema migrans lesion.

Normal pubertal development in a female with carbohydrate deficient glycoprotein syndrome

A girl is reported who presented with many of the clinical and biochemical characteristics of type I carbohydrate deficient glycoprotein syndrome. Unusually, however, she experienced a normal pubertal development.

Protection of dogs from Lyme disease with a vaccine containing outer surface protein (Osp) A, OspB, and the saponin adjuvant QS21

A vaccine consisting of purified Escherichia coli-expressed recombinant full-length outer surface proteins A (OspA) and B (OspB) and the saponin adjuvant QS21 was evaluated for protection against Borrelia burgdorferi infection. Eleven beagles were vaccinated twice and then challenged with 10 field-collected adult female Ixodes scapularis. Xenodiagnosis revealed that all 11 nonvaccinated control dogs and 2 of 10 vaccinated dogs were infected with B. burgdorferi. Six of 11 control dogs also developed fever (0.75 +/- 0.38 degrees C) and were lethargic. One of the control dogs also developed a limp. Both of the infected vaccinated dogs were asymptomatic. Thus, the vaccine prevented tick-vectored infection and associated symptoms of Lyme disease.

Antigens of Lyme disease of spirochaete Borrelia burgdorferi inhibits antigen or mitogen-induced lymphocyte proliferation

Modulation of cellular immune responses by the spirochaete Borrelia burgdorferi, the bacteria that causes Lyme disease, was demonstrated. When cultured in the presence of sonicated Borrelia preparation (Bb), the mitogen- or antigen-stimulated proliferative responses of normal lymphocytes were consistently lowered. Bb caused the greatest reduction in Concanavalin A (ConA) or antigen-stimulated proliferation, where almost 100% reduction in proliferation could be achieved. Bb also reduced phytohemagglutinin-M (PHA) or pokeweed mitogen (PWM)-stimulated peripheral blood lymphocyte (PBL) proliferation, with the PWM proliferation being the least affected. This regulatory activity was not due to toxicity and was determined to be caused by Bb protein antigens. The degree of the proliferation reduction was directly proportional to both Bb quantity and length of exposure to lymphocytes. IL-2 production was significantly reduced from Bb-exposed lymphocytes. The entry of lymphocytes into the proliferating phases of the cell cycle was also shown to be blocked. These results have demonstrated an immune suppressive mechanism of B. burgdorferi. The magnitude of host immune responses may be dependent on the degree of suppression which is related to the spirochaete quantity and their length of presence in the host.

Polymerase chain reaction amplification of culture supernatants for rapid detection of Borrelia burgdorferi

A combination of culture and polymerase chain reaction (PCR) amplification was employed to detect Borrelia burgdorferi in in vitro cultures of skin biopsy specimens. Spirochetes were observed by microscopic examination in 56% (20/36) of the cultures from patients with erythema migrans who had not received prior antibiotic treatment. No growth of Borrelia burgdorferi was detected in control cultures or those from patients who had received antibiotics. PCR analysis of culture supernatants agreed with microscopic evaluation in 50/51 evaluable cultures tested (both positive and negative). At two weeks of incubation Borrelia burgdorferi could be detected by PCR in 19/20 cultures (95%) compared to 14/20 (70%) by visual inspection. This study indicates that a combined culture-PCR test for detection of Borrelia burgdorferi is more rapid and specific than culture alone.

Failure in intrauterine contraception. Analysis of 137 cases of unfavourable outcome

137 cases of unfavourable outcome in IUD insertion (i.e. early removal or expulsion because of complications) were investigated as regards age, parity, previous intrauterine contraception, previous induced abortion, type of device inserted, and type of complications observed. Moreover, this group was compared for each feature mentioned with a control group of 454 women who successfully concluded the prescribed period from the insertion. All the devices were inserted with a significantly higher rate of favourable outcome in pluriparous versus nulliparous patients; age probably didn't affect the outcome, but strongly conditioned the prevalence of particular complications such as PID and abnormal bleeding. Progesterone-loaded IUD didn't show a more favourable outcome than copper devices.

Spanish multicenter clinical trial of recombinant growth hormone produced in mammalian cells for treatment of growth failure due to idiopathic growth hormone deficiency. Spanish Multicenter Study Group

A total of 17 patients (14 boys, 3 girls) with poor growth due to idiopathic growth hormone deficiency (IGHD) were treated for 12 months with recombinant human growth hormone (rhGH; Saizen), 0.5 IU/kg body weight per week administered by subcutaneous injection on a daily basis. Therapy significantly increased growth velocity (GV) from 4.0 +/- 1.5 to 10.1 +/- 2.4 cm/year (p < 0.001). Correspondingly, GV standard deviation score (GV SDS) for chronological age (CA) increased from -2.7 +/- 1.6 to +4.5 +/- 2.8; GV SDS for bone age (BA) increased from -4.0 +/- 2.0 to +3.6 +/- 3.3; and patient height SDS-CA increased from -3.5 +/- 1.1 to -2.4 +/- 0.7. Changes in these parameters were significant at p < 0.001. During the course of the study, mean plasma IGF-1 levels rose significantly from 0.3 +/- 0.2 IU/ml to 1.3 +/- 1.2 IU/ml (p < 0.01). BA maturation proceeded at approximately 1 year per treatment year. Therapy was well tolerated. Anti-hGH antibodies were seen in only 1 patient at a low concentration, and did not appear to affect GV. This study demonstrates that rhGH is safe and efficacious when used to increase height in patients with IGHD.

Concurrent neuroborreliosis and Alzheimer's disease: analysis of the evidence

Several recent reports have claimed a possible association between Borrelia burgdorferi infection and Alzheimer's disease (AD). Herein, we describe our search for additional evidence of neuroborreliosis in AD. Brain tissue from neuropathologically confirmed cases of AD was cultured for B burgdorferi using standard microbiologic methods. Material derived from culture was further examined using electron microscopy, direct immunofluorescence and acridine orange fluorescence. Previous studies have shown high titers of antiborrelia antibodies in CSF in all cases of confirmed neuroborreliosis; therefore, we tested CSF from neuropathologically confirmed cases of AD by indirect immunofluorescence and enzyme-linked immunoassay. In addition, imprint preparations from AD and control brain tissues were studied by direct immunofluorescence using a monoclonal antiborrelia antibody. Finally, a Western blot method was used to analyze protein extracts from cultures and AD brain tissue for the presence of borrelia antigen. Contrary to previous studies, our results do not support an association between infection with B burgdorferi and AD.

Suppression of murine allogeneic cell interactions by sex hormones

Investigations have been carried out on the action of several steroid hormones on lymphocyte functions in inbred strains of mice. The recognitive, proliferative and effector phases of allogeneic cell interactions in vitro were assessed using a mixed lymphocyte reaction (MLR) and cell-mediated lympholysis (CML). In MLR containing Balb/c (responder) and C57bl/6 (stimulator) splenocytes DNA synthesis was markedly reduced in the presence of progesterone, cortisol or estradiol. In CML, progesterone and estradiol (1-5 microgram/ml) blocked in vitro generation of cytotoxic lymphocytes, while cultures with cortisol were partially inhibited. None of these hormones suppressed the cytotoxic activity of previously sensitized effector cells generated in vitro. Cultures containing testosterone expressed both normal DNA synthesis in MLR and cytotoxic activity in the CML test. These findings suggest a selective pattern of immunosuppression by sex hormones which may be important in preventing graft rejection or graft-versus-host interactions which may arise as a consequence of fetal engraftment during pregnancy.