HIV, syphilis infection, and sexual practices among transgenders, male sex workers, and other men who have sex with men in Jakarta, Indonesia

OBJECTIVES

To establish the prevalence of HIV, syphilis, and sexual risk behaviour among three groups of men who have sex with men in Jakarta, Indonesia, and to investigate sexual links between these men and broader heterosexual populations.

METHODS

Anonymous, cross sectional surveys among community recruited transgender and male sex workers and self recognised men who have sex with men (MSM) were undertaken in mid-2002 in Jakarta, Indonesia. Places where transgender and male sex workers sell sex and where men go to meet non-commercial male sex partners were mapped. Probability samples were selected for the sex worker populations, while a mixed probability and convenience sample was drawn for self recognised MSM. Blood was drawn for HIV and syphilis serology and community interviewers administered a standardised questionnaire.

RESULTS

HIV prevalence was 22% among transgender sex workers, 3.6% among male sex workers, and 2.5% among self recognised MSM, and syphilis prevalence was 19.3%, 2.0% and 1.1% respectively. 59.3% of transgender sex workers and 64.8% of male sex workers reported recent unprotected anal intercourse with clients, and 53.1% of other MSM reported unprotected anal sex with male partners. Some 54.4% of male sex workers and 18.3% of other MSM reported female partners in the preceding year.

CONCLUSION

HIV has reached substantial levels among transgender sex workers, and is not negligible in other MSM groups. Risk behaviour is high in all subpopulations, and bisexual behaviour is common, meaning the threat of a wider epidemic is substantial. Prevention programmes targeting male-male sex are needed to reduce this threat.

Importation of multiple HIV type 1 strains into West Papua, Indonesia (Irian Jaya)

HIV-1 from 16 sexually transmitted disease clinic patients in Timika, West Papua, Indonesia was amplified by RT-PCR and subtyped by a combination of envelope and gag region heteroduplex mobility analysis (HMA) and direct PCR DNA sequencing. HMA showed the presence of 14 subtype E (CRF01_AE) and 2 subtype B HIV-1. Phylogenetic analysis of a 540-bp V3-V4 region of gp120 showed that 9 of 10 CRF01_AE variants clustered tightly with a median distance of 1.3% (range, 0.5 to 2.2%) whereas 1 CRF01_AE variant diverged significantly from the others (median distance, 10.7%; range, 10.1 to 11.8%). One subtype B virus envelope was typical of United States/European strains whereas the other appeared to be related to Thai subtype B' variants. These results reflect the independent introduction of multiple HIV-1 strains into West Papua, with the rapid spread in the majority of infected patients tested of a single strain of HIV-1E (CRF01_AE).

Acute renal failure after radiofrequency liver ablation of metastatic carcinoid tumor

IMPLICATIONS

We report a case of prolonged radiofrequency liver ablation for metastatic carcinoid tumor complicated by hemolysis, rhabdomyolysis, and transient acute renal failure. Brief radiofrequency liver ablation procedures or those for a small number of tumor sites are not associated with these complications.

Adverse reactions to isosulfan blue during selective sentinel lymph node dissection in melanoma

BACKGROUND

Selective sentinel lymph node (SLN) dissection can spare about 80% of patients with primary melanoma from radical lymph node dissection. This procedure identifies the SLN either visually by injecting isosulfan blue dye around the primary melanoma site or by handheld gamma probe after radiocolloid injection.

METHODS

During selective SLN mapping, 1 to 5 ml of isosulfan blue was injected intradermally around the primary melanoma. From November 1993, to August 1998, 406 patients underwent intraoperative lymphatic mapping with the use of both isosulfan blue and radiocolloid injection. Three cases of selective SLN dissection, in which adverse reactions to isosulfan blue occurred, were reviewed.

RESULTS

We report three cases of anaphylaxis after intradermal injection with isosulfan blue of 406 patients who underwent intraoperative lymphatic mapping by using the procedure as described above. The three cases we report vary in severity from treatable hypotension with urticaria and erythema to severe cardiovascular collapse with or without bronchospasm or urticaria.

CONCLUSIONS

In our series, the incidence of anaphylaxis to isosulfan blue was approximately 1%. Anaphylaxis can be fatal if not recognized and treated rapidly. Operating room personnel who participate in intraoperative lymphatic mapping where isosulfan blue is used must be aware of the potential consequences and be prepared to treat anaphylaxis.

Risk factors for plasma cell endometritis among women with cervical Neisseria gonorrhoeae, cervical Chlamydia trachomatis, or bacterial vaginosis

OBJECTIVE

We sought to determine potential risk factors for upper genital tract inflammation in women with cervical Neisseria gonorrhoeae, Chlamydia trachomatis, or bacterial vaginosis.

STUDY DESIGN

In a case-controlled study we compared 111 women with cervical Neisseria gonorrhoeae, Chlamydia trachomatis, or bacterial vaginosis (the study group) with 24 women who had negative tests for each of these infections (the control group). We evaluated potential risk factors for upper genital tract inflammation by use of bivariate and then logistic regression analysis.

RESULTS

We found plasma cell endometritis in 53 of 111 women in the study group and 3 of 24 controls (odds ratio = 6.4, 95% confidence interval 1.7 to 35.0). On logistic regression, the study group women who were in the proliferative phase had increased likelihood of plasma cell endometritis (odds ratio = 4.5, 95% confidence interval 1.6 to 12.4).

CONCLUSION

The proliferative phase of the menstrual cycle seems to be the primary risk factor for ascending infection by organisms associated with pelvic inflammatory disease. This may be due to a hormonal effect or to the loss of the cervical barrier during menstruation.

Role of viral load in heterosexual transmission of human immunodeficiency virus type 1 by blood transfusion recipients. Transfusion Safety Study Group

Eighteen transfusion recipients infected with human immunodeficiency virus type 1 (HIV-1) were followed prospectively with their 19 long-term sexual partners from 1986 to 1993 in California, Florida, and New York. Follow-up included clinical, behavioral, immunologic, serologic, and virologic evaluations. Two partners were already infected when seen 18 and 34 months after sexual contact began following the infectious transfusion. Four of 17 initially seronegative partners seroconverted during 23 person-years of observation. The recipient's clinical status, mononuclear cell subset variations, and time trend in CD4+ counts had no association with transmission. Individual plasma HIV-1 ribonucleic acid (RNA) loads were stable during observation, and sexual transmission was not attributable to an upward trend or transient burst in viremia. However, recipients who transmitted HIV-1 to their sexual partners had higher mean viral RNA levels than did nontransmitting recipients (4.3 vs. 3.6 log10 copies/ml; p = 0.05). Although this series was small, the prospective observations suggest that viral load was the only characteristic in the recipient that contributed to heterosexual infectiousness.

Development of oral lesions in human immunodeficiency virus-infected transfusion recipients and hemophiliacs

The authors used multivariate repeated-measures transition models to identify risk factors for two oral lesions related to human immunodeficiency virus (HIV)-candidiasis and hairy leukoplakia-in 152 HIV-infected blood transfusion recipients and hemophiliacs. Subjects were examined for occurrences of these lesions every 6 months from July 1985 through March 1993, yielding 1,076 study visits. It was found that, after adjustment for the CD4:CD8 T-lymphocyte ratio, patients with a history of candidiasis in the previous 18 months were at high risk of lesion recurrence. This risk increased with the number of prior episodes and with the recency of the episode(s). A history of hairy leukoplakia was less predictive of persistence of that lesion after adjustment for significant risk factors (including candidiasis and use of antifungal agents at the current examination, a low CD4:CD8 cell ratio, and age less than 40 years). The authors also found a high coprevalence of candidiasis and hairy leukoplakia in these subjects. These results suggest that HIV-infected patients with oral candidiasis should be carefully monitored for subsequent episodes over the next 12-18 months, and patients with either oral candidiasis or hairy leukoplakia and a low CD4:CD8 cell ratio should be carefully examined for the other type of lesion as well.

Screening potential corneal donors for HIV-1 by polymerase chain reaction and a colorimetric microwell hybridization assay

PURPOSE

Current screening of potential corneal donors for human immunodeficiency virus type 1 (HIV-1) involves serologic detection of antibodies to the virus. However, this approach cannot detect infection during the seronegative window period of the disease. We therefore evaluated the polymerase chain reaction (PCR) assay for viral nucleic acid as a possible alternative to screening cadaveric blood for HIV-1.

METHODS

Blood specimens from cadavers diagnosed at autopsy with acquired immunodeficiency syndrome (AIDS) (n = 21), at high risk for HIV-1 infection (n = 47), and at no known risk (n = 350) were screened by PCR for HIV-1 proviral DNA and human leukocyte antigen (HLA)-DQ alpha sequences, and for HIV antibodies.

RESULTS

All AIDS group samples were seropositive; of these, 18 (86%) and 20 (95%) of 21 were positive for HIV by PCR of proteinase K- and Chelex-extracted pellets, respectively. The seropositive samples negative by PCR testing were shown to inhibit PCR amplification. Nine (19%) of 47 high-risk specimens were HIV-positive. The no-known-risk group yielded negative results. The overall sensitivities for PCR in the proteinase K- and Chelex-treated groups were 90% and 97%, respectively, compared with Western blot reactivity. If PCR-inhibitory samples and HLA-DQ alpha-negative samples had been eliminated, sensitivity would have been 100%. Specificity was 100% for each group.

CONCLUSIONS

Screening cadaveric blood by PCR may be feasible, but further refinement of the assay and blood specimen collection practices will be necessary for it to become routine. Future studies should focus on optimizing specimen procurement and preparation to reduce or eliminate specimens that inhibit PCR.

Complementary therapies in HIV disease

This study was designed to determine whether a standardized program of complementary therapies combined with appropriate standard medical care would have a measurable influence on the course of HIV disease when compared with data from other groups. All 10 participants began this study in 1988 with a diagnosis of asymptomatic HIV-positive. They received a 1-month orientation to the program and were then seen at 3-month intervals for follow-up data collection. Data were compared with two groups that had not been trained in the comprehensive treatment program. After 30 months, the mean CD4 cell count of our study group declined by 4% (406 to 391). The mean red and white blood cell counts remained stable at 96% and 105% of baseline, respectively. The mean CD8 cell number rose by 28%. No mortality occurred. One opportunistic infection (pneumocystis carinii pneumonia) developed in the study group. No other significant symptoms, serious infections, or disease progression developed in the other 9 participants during the study period. At long-term follow-up 8 of the 10 study participants remained alive 7 years after beginning the study protocol. These data suggest that patients who are presented counseling on good nutrition, vitamin supplementation, stress reduction, exercising, and involving oneself in community potentially can continue to live asymptomatic lives that in quality and length exceed the lives of those HIV-positive individuals not presented such counseling.

Detection of hepatitis C after liver transplantation. Four serologic tests compared

To determine the best method for detecting HCV infection in immunosuppressed patients, stored frozen serum from 101 liver transplant recipients was tested for hepatitis C virus. Each sample was tested by four assays. HCV RNA was detected by both polymerase chain reaction (PCR) and branched DNA signal amplification. Antibody to HCV was determined using second-generation enzyme-linked immunoassay (EIA) and recombinant immunoblot assay. Forty one transplant recipients met the working definition for true positives of HCV infection. Of these "true positives," 98% were positive by HCV RNA PCR assay, 88% by b-DNA signal amplification assay, 88% by anti-HCV EIA, and 63% demonstrated two or more reactive bands on recombinant immunoblot. Five of 57 (9%) HCV-antibody negative recipients had HCV RNA detected by both methods. Of 44 HCV enzyme-linked immunoassay (EIA) repeatedly reactive samples, the recombinant immunoblot was negative in 2 and indeterminate in 13. HCV RNA was present in 9 of 13 recombinant immunoblot indeterminate sera. Nine EIA repeatedly reactive sera were negative by both tests for HCV RNA. In liver transplant recipients, HCV infection is best determined by measurement of HCV RNA. Antibody formation may be delayed or suppressed in a minority of patients despite > 10(9) equivalents/L (> 10(6)/mL) of HCV RNA in serum. Recombinant immunoblots with a single reactive band pattern often indicate HCV infection in immunosuppressed patients.

Commonly used diagnostic criteria for pelvic inflammatory disease have poor sensitivity for plasma cell endometritis

BACKGROUND

The majority of women with tubal damage do not have a history of acute pelvic inflammatory disease. The prevalence of upper genital tract inflammation was evaluated in women deemed not to have pelvic inflammatory disease by common diagnostic criteria.

GOAL OF THIS STUDY

To compare clinical signs and laboratory tests used to diagnose pelvic inflammatory disease with endometrial biopsy histopathology.

STUDY DESIGN

Endometrial biopsy and commonly used physical and laboratory tests were performed on 52 women with pelvic tenderness, 51 with vaginosis or cervicitis, and 22 control subjects who had no evidence of infection with Neisseria gonorrhoeae or Chlamydia trachomatis and who tested negative for bacterial vaginosis using vaginal swab Gram's stain.

RESULTS

Thirty-six of 52 patients (69%) with pelvic tenderness, compared with 22 of 51 patients (43%) with vaginosis or cervicitis and two of 22 control subjects (9%), had plasma cell endometritis. The Centers for Disease Control and Prevention minimal diagnostic criteria for pelvic inflammatory disease had a sensitivity of 33% for plasma cell endometritis.

CONCLUSIONS

The clinical diagnosis of pelvic inflammatory disease using published criteria correlates poorly with plasma cell endometritis.

Human immunodeficiency virus type 1 infection: relationship of risk group and age to rate of progression to AIDS. Transfusion Safety Study Group

Age differences among risk groups may account for rate differences in progression of human immunodeficiency virus type 1 (HIV-1) infection to AIDS. Institutions in 6 US cities used a common protocol to study infected homosexual blood donors, recipients of blood components, and factor VIII-treated hemophiliacs. Follow-up was every 6 months. Actuarial risk for AIDS 8 years after infection was 51% among blood recipients, 36% among homosexual donors, and 24% among hemophiliacs. Significant risk group differences were explained by age differences among cohorts (medians of 61, 29, and 22 years, respectively). When age was adjusted for and both CD4 cell value and zidovudine treatment were used as time-dependent covariates, homosexual donors had more rapid progression than the other groups. Omitting Kaposi's sarcoma as an AIDS-defining condition removed any significant differences among risk groups except CD4 cell count and age. Thus, major factors in AIDS progression are age-related.

Transient increase in circulating donor leukocytes after allogeneic transfusions in immunocompetent recipients compatible with donor cell proliferation

Donor leukocytes in therapeutic blood components are implicated in transfusion-related complications ranging from alloimmunization to graft-versus-host disease (GVHD) to viral transmission and reactivation. To further characterize the kinetics of donor leukocyte clearance after allogeneic transfusion, we developed allele-specific polymerase chain reaction (PCR) assays directed at a single-copy Y chromosome gene and HLA class II alleles. These assays enable sensitive detection and quantitation of donor leukocytes at concentrations ranging from one cell to greater than 1,000 cells per 125 microL of recipient blood. When applied to serial samples from five consecutive orthopedic surgery patients who met study criteria, we observed 99.9% clearance of donor leukocytes over the initial 2 days posttransfusion, followed by a transient, 1-log increase in circulating donor leukocytes on days 3 to 5. This phenomenon was reproduced in a canine transfusion model, where the transient donor leukocyte expansion phase was prevented by gamma irradiation of donor blood, and was not observed after transfusions into alloimmunized dogs. We hypothesize that this transient increase in circulating allogeneic donor cells represents one arm of an in vivo mixed lymphocyte reaction, with activated donor T lymphocytes proliferating in an abortive GVHD reaction to HLA-incompatible recipient cells. Further investigation of this phenomenon should provide insight into the mechanisms involved in donor-recipient leukocyte interactions posttransfusion and the relationship of these interactions to leukocyte-induced complications.

Effect of low- and intermediate-purity clotting factor therapy on progression of human immunodeficiency virus infection in congenital clotting disorders. Transfusion Safety Study Group

Low- and intermediate-purity clotting-factor therapies are believed to accelerate human immunodeficiency virus (HIV) progression in hemophiliacs through adverse immune effects of the other plasma proteins in the preparations. To investigate this postulate, we evaluated data from six clinical centers that observed persons with congenital factor deficiencies at 6-month intervals. The present analysis is based on HIV-infected subjects who received intermediate purity factor VIII or factor IX concentrates, or cryoprecipitate. For long-term outcome, we classified 374 subjects by the type and amount of treatment during our first year of observation, and determined the subsequent rate of progression to a CD4 count less than 200 cells/microL. A second analysis of this group used a repeated-measures, random-effect model that allowed for individual differences in CD4 decline. Finally, we compared short-term rates of change in CD4 count in each treatment interval of 525 subjects with the type and amount of factor therapy received in the same interval. There was no overall or dose-related deleterious effect of any form of treatment on CD4 trend. The CD4 decrease was less when cryoprecipitate was administered alone or combined with concentrate, but not significantly so. Our results counter the assertion that low- and intermediate-purity products accelerate the rate of CD4 decrease in HIV-1-infected hemophiliacs.

Heterosexual transmission of human immunodeficiency virus type 1 from transfusion recipients to their sex partners

Using lookback procedures and other methods, we identified and then prospectively followed human immunodeficiency virus type 1 (HIV-1)-infected transfusion recipients and their sex partners to determine AIDS incidence and risks of heterosexual transmission of HIV-1. At enrollment, 7 of 32 (21.9%) female partners of male recipients were themselves infected with HIV-1, as compared with none of 14 male partners of female recipients (p = 0.08). No additional episodes of transmission were observed. The prevalence of advanced immunodeficiency at enrollment was similar in male and female recipients. Male recipients with advanced immunodeficiency (CD4+ lymphocyte count < or = 0.20 x 10(9)/L or a history of clinical AIDS) at enrollment were more likely to have infected their female partners (odds ratio = 7.9; p = 0.03) than men with neither condition. Similarly, AIDS-free survival, as estimated by the product-limit method, was lower among male transmitters than among male nontransmitters (p = 0.01). Transmission was not associated with frequency of unprotected vaginal intercourse. Our data suggest that HIV-1-infected men who develop immunodeficiency rapidly are more likely to infect their sex partners and that the greater efficiency of male-to-female HIV-1 transmission is not explained by a greater number of sexual contacts or more advanced immunodeficiency in index subjects.

Transfusion transmission of retroviruses: human T-lymphotropic virus types I and II compared with human immunodeficiency virus type 1

BACKGROUND

The incidence of transfusion transmission of human T-lymphotropic virus type I (HTLV-I) and HTLV type II (HTLV-II) has not been compared directly or to that of human immunodeficiency virus type 1 (HIV-1). The effects of refrigerator storage of the blood component on infectivity of the viruses needs definition.

STUDY DESIGN AND METHODS

The circumstances influencing the transmission of HTLV-I, HTLV-II, and HIV-1 via blood of donors whose sera were stored in a repository and who were retrospectively documented as having been infected at blood donation were examined. Confirmation and typing of anti-HTLV positivity in donors and recipients used polymerase chain reaction, supplemented by specific peptide testing.

RESULTS

Overall, 27 percent (26/95) of the recipients of blood components from anti-HTLV-I- and -II-positive donors became infected (9 with HTLV-I and 17 with HTLV-II). No recipients of acellular blood components became infected with HTLV-I or -II. There was no probable transmission by components stored > 10 days. The rates of transmission for both viruses were similar: 0 to 5 days' storage, 17 (74%) of 23; 6 to 10 days, 8 (44%) of 18; and 11 to 14, 0 (0%) of 10 (trend, p = 0.0002). In comparison, 89 percent (112/126) of the recipients of anti-HIV-1-positive blood were infected regardless of component type, and no effect on transmission occurred with storage for < 26 days.

CONCLUSION

Transfusion-transmitted HTLV-I and -II are similar. The data suggest that a donor's lymphocytes become noninfectious when they lose the ability to be activated or to proliferate.

Effect on lymphocyte subsets of clotting factor therapy in human immunodeficiency virus-1-negative congenital clotting disorders. The Transfusion Safety Study Group

Patients with hemophilia A without human immunodeficiency virus type 1 (HIV-1) infection have lower CD4+ counts and CD4+/CD8+ ratios than controls. This is usually interpreted as a therapy-induced immunodeficiency. Our data re-examine the effect of therapy on peripheral blood mononuclear cell immunophenotypic subpopulations in all congenital clotting disorders. Since late 1985 we have prospectively observed HIV-1 uninfected persons with all types and severity of disorder. Controls were household members without clotting disorders or HIV-1 infection. Analyses of immunophenotype and treatment included a longitudinal random effects model. Compared with controls, age-adjusted CD4+ counts were significantly lower in treated patients (P < .0001) and in patients with all types of clotting disorders who were seldom or never treated (P = .0005). Significantly lower values among both treated and untreated clotting disorder subjects (P < .05) were likewise found for total lymphocytes, several other T-cell subsets, and the CD4+/CD8+ ratio. For most indexes, including the CD4+ count and CD4+/CD8+ ratio, the type of clotting deficiency was not a significant variable. Comparing persons who had no or minimal therapy with those having the most showed increases in CD8+ (P = .0017) and CD20+ CD21- counts (P = .0255), and a lower CD20+ CD21+/CD20+ ratio (P = .0106) in the latter. Controls and persons with clotting disorders differ in CD4+ count. Among those with clotting factor disorders, there is no difference attributable to type of clotting disorder or factor therapy. Large amounts of treatment increased CD8+ and CD20+ CD21- counts, but were not associated with a change in CD4+ count.

Hepatitis C and B in liver transplantation

Hepatitis B recurrence remains a major problem facing liver transplantation programs. The risk of infection varies depending upon the HBV load. High doses of HBIg may reduce the risk of occurrence but it remains expensive. Finally, apparently new infections may occur posttransplantation, which may have been transmitted by organs or blood from HBsAg (-), HBcAb (+) donors, or may reflect reactivation of latent infections in patients who were HBsAg (-). HCV infections are common in patients undergoing liver transplantation, and HCV infection recurs in > 90% of patients; however, recurrent hepatitis C occurs in less than half of these patients. HCV is not an important cause of fulminant non-A, non-B hepatitis, but appears to be the most common cause of posttransplant hepatitis. So what is in the future? For hepatitis B, we still believe the efficacy of HBIg, and in which patients with hepatitis B HBIg should be used, remains to be defined. The effects of antivirals on posttransplant hepatitis B, as well as in prevention of HBV recurrence, also remain to be determined. In the United States, insurance companies are likely to play an important role in determining the future of transplantation for hepatitis B. Medicare recently excluded patients who were HBsAg (+) from coverage for liver transplantation, and a number of private insurers have subsequently followed suit. For HCV, newer screening tests for the virus are likely to decrease the rate of HCV acquisition following liver transplantation, from the current 35% incidence of HCV acquisition. The impact of antiviral treatment on posttransplant hepatitis remains to be determined and deserves study. Finally, the development of regimens that might allow prevention of recurrent HCV infections in patients undergoing liver transplantation also should be a matter of future study.

Bacterial and fungal contamination of human fetal liver collected transvaginally for hematopoietic stem cell transplantation

Transplantation of fetal hematopoietic stem cells is a new therapy for fetuses diagnosed in utero with inherited disorders. However, prior to transplantation of fetal stem cells, the cells must be free of microbial contamination. In order to investigate the contamination of human fetal liver tissue, we determined the rate and types of bacterial and fungal contamination of human fetal liver tissue collected transvaginally for use in stem cell transplantation by using the US Pharmacopoiea Assay. We found a high rate of contamination with bacteria or fungi (12 of the 14 fetal livers, or 85%). Non-fermenting gram-negative rods were the predominant contaminants. The high rate of microbial contamination of fetal tissue suggests that techniques for tissue collection need to be improved before fetal stem cells are used for clinical transplantation.

Effect of age on human immunodeficiency virus type 1-induced changes in lymphocyte populations among persons with congenital clotting disorders. Transfusion Safety Study Group

Children other than neonates infected with human immunodeficiency virus type 1 (HIV-1) have low rates of progression to acquired immunodeficiency syndrome (AIDS). Through 1989, 5.3% of 95 infected hemophiliacs aged 5 to 13 years developed AIDS, compared with 20.3% of 364 aged greater than or equal to 25 years. We asked whether the HIV-1 impact on peripheral blood mononuclear cell subpopulations differed with age using pairwise comparisons of uninfected and infected male children and adult hemophiliacs. Infected children had lesser reductions of total lymphocytes than adults, but proportionately lower numbers of CD2+, CD4+, CD2+CD26+, and CD4+CD29+ counts. CD4+CD45RA+ cell counts were greater than twofold higher in uninfected and infected children than adults; with infection, the CD4+CD45RA+/CD4+ proportion increased by 1.4-fold in adults, but was unchanged in children. Infected adults had highly significantly increased total CD8+ counts; both age groups had elevated CD8+HLA-DR+ counts. Infected children had significantly higher total B-cell counts than infected adults, with a disproportionately lower number of resting B cells (CD20+CD21+). During 2 years of follow-up, infected children and adults had lymphocyte changes in the same directions and these were proportionately equal. The lower rate of HIV-1 progression in children may be partly associated with differences in lymphocyte populations compared with adults; functional properties of immune cells may be equally or more important.

Recurrent and acquired hepatitis C viral infection in liver transplant recipients

To examine the postliver transplant recurrence of hepatitis C virus (HCV) infection in patients with pretransplant infection, as well as its acquisition in patients without prior infection, we used the polymerase chain reaction to amplify HCV RNA in serum and/or liver samples of 89 patients with alcoholic and cryptogenic cirrhosis undergoing liver transplantation. Results were correlated with histologic findings from posttransplant liver biopsies. Ninety-five percent of patients with pretransplant infection had posttransplant viremia. In contrast, 35% of patients without pretransplant infection acquired the virus (P less than 0.0001). Pretransplant HCV infection predisposed patients to hepatitis in the new graft. HCV RNA was present in serum of 96% of patients with posttransplant hepatitis. Fifty-six percent of patients with posttransplant HCV infection had no evidence of liver damage at least 1 year posttransplant. However, of those patients with histologic hepatitis, chronic active hepatitis was common. It is concluded that although HCV infection recurs posttransplant in almost all infected patients, acquisition of the HCV infection with transplant is common. Pretransplant HCV infection is an independent risk factor for the development of posttransplant hepatitis. HCV infection accounts for the majority of posttransplant hepatitis not due to cytomegalovirus, and although many patients with posttransplant viremia have little evidence of histologic hepatitis, significant hepatic damage may occur.

New developments in serologic screening of corneal donors for HIV-1 and hepatitis B virus infections

PURPOSE

The authors evaluated different methods to serologically screen potential cadaveric corneal donors for human immunodeficiency virus type 1 (HIV-1) and hepatitis B virus (HBV) infections.

METHODS

Three commercially available enzyme-linked immunosorbent assays (ELISAs) for antibodies against HIV-1, a supplemental ELISA test for HIV antigen, and a radioimmunoassay and two ELISAs for hepatitis B surface antigen were compared using serum from cadavers with acquired immune deficiency syndrome (AIDS), cadavers with high risk factors for HIV infection, and cadavers with no known risk of HIV infection, along with respective confirmatory testing.

RESULTS

The ELISA tests for HIV antibodies from Abbott Laboratories, Electro-nucleonics, and Organon-Teknika showed sensitivities of 94.3%, 94.3%, and 97.1%, respectively, compared with the autopsy diagnosis of AIDS in 35 cadavers. The sensitivities of the HIV-1 antibody ELISAs ranged between 73% and 87% compared with positive Western blots in testing 118 sera from cadavers at high risk of HIV-infection, but not manifesting AIDS at the time of death. Supplemental ELISA testing for HIV-1 antigen, in an effort to close the seronegative window, failed to identify any HIV antigen-positive sera confirmed by neutralization that were not also positive for antibodies to HIV-1 by ELISA and Western blot. The ELISA for HBV surface antigen had an overall sensitivity of 92.9% and specificity of only 81.3% compared with radioimmunoassay in testing 409 sera. Monoclonal ELISAs for HIV-1 antigen and HBV surface antigen paradoxically had lower specificity than polyclonal ELISAs, with false positivity correlating with hemolysis and with increasing death to puncture time.

CONCLUSION

ELISA testing for antibodies against HIV-1 is relatively but not absolutely effective, should be accompanied by historical screening for risk factors, and does not appear to benefit from supplemental ELISA testing for HIV-1 antigen. ELISA testing for HBV surface antigen has lower specificity in screening cadaveric sera when compared with radioimmunoassay.

Hepatitis B virus and apparent fulminant non-A, non-B hepatitis

While there is evidence that hepatitis C virus (HCV) does not cause fulminant non-A, non-B hepatitis, the causal agent remains unknown. To evaluate the role of hepatitis B virus (HBV) in this disease, we used a two-step polymerase chain reaction (PCR) to amplify the surface and core regions of HBV DNA in serum and liver samples taken prospectively from twenty-six patients (mean age 36 years, range 1 to 64) with acute hepatic failure undergoing liver transplantation. HBV DNA was absent from the serum of all patients before transplantation. Seventeen patients were diagnosed as having non-A, non-B hepatitis because they lacked serological evidence of hepatitis A virus or HBV infection. Liver samples were taken from twelve of these patients, and six samples were positive for HBV DNA. By contrast HBV DNA was not detected in liver from three patients with acute liver failure caused by hepatitis A or toxins. HCV RNA was not found in pretransplant samples by PCR. Four of the six patients with detectable HBV DNA in liver and presumptive non-A, non-B hepatitis had detectable HBV DNA in serum after transplantation. One additional patient who did not donate pretransplant liver had HBV DNA in a post-transplant serum sample. Thus, HBV DNA was present before or after transplantation in seven of seventeen patients with apparent non-A, non-B hepatitis. Three of five patients with detectable post-transplant serum HBV DNA were serologically positive for HBV surface antigen. These findings indicate that HBV may be a common cause of fulminant hepatic failure in patients lacking serological evidence of HBV infection.

Transmission of human T-lymphotropic virus type I by blood components from a donor lacking anti-p24: a case report. The Transfusion Safety Study Group

The present criteria for confirmation of human T-lymphotrophic virus types I and II (HTLV-I/II) infection in blood donors are based on seroreactivity to p24 (gag) and gp46 and/or gp61 (env) on Western blot (WB) and radioimmunoprecipitation assays (WB/RIPA). Any single band and other combinations are classified as indeterminate. This case report documents infection in a donor with a repeatedly indeterminate pattern. The blood donor was anti-HTLV-I/II positive on enzyme-linked immunoassay, and two sera taken 5 years apart were WB/RIPA-indeterminate (p19 and gp68 only). His donations in the interval were associated with transmission of HTLV-I to four of the six recipients available for study. Other recipients of blood from donors whose WB/RIPA results were indeterminate by present criteria should be examined to determine if additional patterns are at least occasionally associated with transmission. The likelihood that such donors are infected is important to those who are counseling them and making decisions concerning recipients of their bloody.

Hepatitis C in patients undergoing liver transplantation

OBJECTIVE

To determine the prevalence of antibodies to hepatitis C virus (anti-HCV) among patients undergoing liver transplantation and the relation between anti-HCV and post-transplant hepatitis.

DESIGN

Retrospective cohort.

PATIENTS

Serum samples from 128 patients who underwent liver transplantation. Sixty-six patients who had 6 months of follow-up and for whom both pretransplant and post-transplant serum samples were available were included in a study to asses the relation between anti-HCV and post-transplant hepatitis.

MEASUREMENTS

Sera were tested for anti-HCV using an enzyme-linked immunosorbent assay (ELISA) and, if positive, two confirmatory tests were done. Patients had a biopsy every week until two specimens showed no abnormal findings.

MAIN RESULTS

Only patients with chronic non-A, non-B hepatitis (15 of 30; 50%), alcoholic cirrhosis (7 of 19; 37%), and chronic hepatitis B infection (3 of 11; 27%) were anti-HCV positive. No patient with another form of chronic liver disease or with acute liver failure due to non-A, non-B hepatitis was anti-HCV positive. After transplantation, loss of anti-HCV was frequent and acquisition rare. Hepatitis developed in the graft in 17% of patients, but the incidence was similar among anti-HCV negative and anti-HCV-positive patients.

CONCLUSIONS

Hepatitis C virus is a common cause of chronic liver disease in patients requiring liver transplantation, but anti-HCV is rarely found in patients with acute liver failure. Previous HCV infection, based on detection of anti-HCV, is not an independent risk factor for post-transplant hepatitis.

Hepatitis C in liver transplant recipients

HCV infection is commonly found in patients with chronic liver disease undergoing liver transplantation. However, the presence of antibody to HCV does not appear to be associated with the development of hepatitis posttransplant. No other risk factors were identified that appear to predispose patients to development of hepatitis in the posttransplant period, including amount of blood product exposure. The role of immunosuppression in the acquisition and expression of liver disease caused by HCV remains to be determined.

Hemolytic transfusion reaction following transfusion of frozen and washed autologous red cells

A case of hemolytic transfusion reaction, accompanied by hypotension and followed by transient renal failure, occurred after the transfusion of 1 unit of previously frozen autologous red cells. Subsequent investigation revealed the probable cause of the hemolysis to be inadequate deglycerolization of the unit. The cause of the associated symptoms is unknown. Possibilities include nephrotoxic effects of hemoglobin or stroma, toxic effects of glycerol, or release of vasoactive or thrombogenic substances from lysed red cells. This case of a hemolytic reaction adds to the known risks of autologous transfusion.

Infection with human immunodeficiency virus type 1 (HIV-1) among recipients of antibody-positive blood donations

OBJECTIVE

To assess the incidence of human immunodeficiency virus type 1(HIV-1) transmission by antibody (anti-HIV-1)-positive blood components, and to determine the immunologic and clinical course in HIV-1-infected recipients.

DESIGN AND SUBJECTS

We retrospectively tested approximately 200,000 donor blood component specimens stored in late 1984 and 1985 for anti-HIV-1, and we contacted recipients of positive specimens to determine their serologic status. They were compared with both recipients of HIV-1-negative transfusions and healthy (untransfused) controls. Subjects were seen at 3- to 6-month intervals for up to 4 years for clinical and immunologic evaluations.

MEASUREMENTS AND MAIN RESULTS

Of 133 recipients, 9 had other possible exposures. Excluding these cases, 111 of 124 (89.5%) were anti-HIV-1-positive (95% CI, 84.1% to 94.5%). The recipient's sex, age, underlying condition, and type of component did not influence infection rates. The cumulative risk for developing the acquired immunodeficiency syndrome (AIDS) within 38 months after transfusion was 13% (CI, 7.5% to 21.6%). At 36 +/- 3 months after the index transfusion, seropositive recipients had lower counts of CD2+CDw26+, CD4+, CD4+CD29+, and CD4+CD45RA+subsets and more CD8+I2+ lymphocytes than did recipients of anti-HIV-1-negative transfusions. The CD4+ and CD2+CDw26+subsets changed the most rapidly. The absolute CD8+ count remained normal.

CONCLUSIONS

Transfusion of anti-HIV-1-positive blood infected 90% of recipients. The rate of progression to AIDS within the first 38 months after infection was similar to that reported for homosexual men and hemophiliacs. Although most lymphocyte subset counts changed over time, CD8+ counts were constant.

Effects of counselling on knowledge about HIV-1 among transfusion recipients and their partners. Transfusion Safety Study Group

The present study determined how much HIV-1-positive persons knew about AIDS, and HIV-1 transmission and prevention, in comparison with HIV-1-negative controls in a predominantly heterosexual cohort. The subjects were blood donors, blood recipients, hemophiliacs, and their sexual partners. A 16-item questionnaire about AIDS, HIV-1 transmission, and knowledge of safe sexual practices was administered to 228 subjects to determine background information. The HIV-1-positive cohort answered more questions correctly (mean = 8.5) than did the HIV-1-negative cohort (mean = 6.5), largely as a result of general information about AIDS among those with steady sexual partners. All persons, however, were poorly informed about HIV-1 transmission and safe sexual practices. Thus, there is a great need for effective counselling.

Epidemiologic background of blood donors with antibody to human T-cell lymphotropic virus. Transfusion Safety Study Group

We interviewed 51 blood donors in four major US metropolitan areas subsequently found to have had antibodies to human T-cell lymphotropic virus (anti-HTLV) in late 1984-early 1985. Sixteen donors (31%) reported that they or a sexual contact had a history of blood transfusion. Twelve donors (24%) reported that they or a sexual contact used intravenous drugs. Ten donors (20%) were blacks born in the southeastern US. Four of the male donors (15%) reported homosexual contact. The most common characteristic was an association with Japan or the Caribbean basin (61%). These results show a broader variation of epidemiologic backgrounds than anticipated.

Antibody to c antigen consequent to renal transplantation

A case of apparent red cell (RBC) autoimmunity due to anti-c is described in the recipient of a cadaveric renal transplant. Although the patient suffered little hemolysis as a result, a strong direct anti-c agglutinin was detectable on the patient's RBCs 8 days after transplantation and in his serum only 4 days after transplantation. We believe that the antibody was produced by passively transferred B lymphocytes in the donor kidney, and that the recipient may have been protected from more serious hemolysis by immunosuppressive agents administered at the time of transplantation. The donor received multiple transfusions before transplantation, but his serum lacked anti-c in a screen performed shortly before his death. This case raises the possibility that donor alloantibodies to other Rh antigens on recipient RBCs can arise after transplantation, if the donor has been transfused.

Diagnosis of Kaposi's sarcoma by fine-needle aspiration biopsy

Fifteen cases of Kaposi's sarcoma diagnosed by fine-needle aspiration biopsy were reviewed. The diagnosis was confirmed by tissue biopsy in eight of the cases. All of the patients were homosexual males, and 13 had a previous diagnosis of AIDS. The aspirates were obtained from enlarged lymph nodes (five cases), soft-tissue masses (two cases), oral cavity lesions (seven cases), and an abdominal mass. The most characteristic cytologic features were intact tissue fragments composed of overlapping spindle cells with nuclear distortion and ill-defined cytoplasmic borders. Smaller groups of loosely cohesive spindle-shaped cells and individual spindle cells with cytoplasm were also helpful features. In the appropriate clinical setting, these cytologic features on FNAB are felt to be diagnostic of Kaposi's sarcoma.

Screening cornea donors for antibodies against human immunodeficiency virus. Efficacy of ELISA testing of cadaveric sera and aqueous humor

Coded cadaveric sera from 35 patients with acquired immunodeficiency syndrome (AIDS), from 45 cadavers at high risk of human immunodeficiency virus (HIV) infection, and from 262 cadavers without known signs or risk of AIDS were assessed using three commercially available enzyme-linked immunosorbent assays (ELISA) kits and Western blot analysis. Greater than 94% sensitivity and 99% specificity was achieved with each of the ELISA test kits using cadaveric sera. The Western blot method gave 97.1% sensitivity compared with the autopsy-proven diagnosis of AIDS. Positive results were obtained on sera from AIDS cadavers even if the time of blood draw was delayed 35 hours from death and the time of sera preparation was delayed up to 176 days. False-negative or false-positive ELISA results did not appear to correlate with hemolysis or any parameter of sera preparation. In contrast to the high sensitivity in testing sera, only 16 to 26% of aqueous humor samples from AIDS cadavers were ELISA-positive and 79% were positive by Western blot. These results indicate that three commercially available ELISA test kits are an effective means of screening cadaveric sera for antibodies to HIV, but that aqueous humor cannot be reliably substituted for cadaveric sera to screen potential cornea donors by an ELISA assay.

Aspiration cytology characterization of inflammatory masses

Fine-needle aspiration biopsy smears are useful in the workup of patients with abscesses and inflammatory masses. We report 37 cases classified into three groups: group I, in which a causative organism was seen on the smear; group II, in which a causative organism was cultured from a smear where organisms were not seen microscopically, and group III, in which the organism was not seen or cultured, but the smear findings were useful in determining further workup.

The role of fine needle aspiration in the management of the thyroid nodule

The role of fine needle aspiration (FNA) in the management of the patient with a thyroid nodule continues to be controversial. We present a retrospective study of 69 patients who underwent FNA for thyroid nodules over a two-year period. No false positive or false negative fine needle aspirations are reported in 22 patients who underwent surgery. From the results of this study and other studies in the literature, we feel that ultrasonography and thyroid scans are of minimal additional benefit in determining whether a nodule is benign or malignant. It is our opinion that FNA, along with clinical assessment, should be the diagnostic test to determine the management of the thyroid nodule in centers with personnel experienced in FNA.

Chlamydia trachomatis-induced salpingitis in mice

Inoculation of the mouse pneumonitis biovar of Chlamydia trachomatis into the ovarian bursa of mice resulted in salpingitis. An acute inflammatory response in the bursa and contiguous oviduct peaked at six to nine days postinoculation. At day 14, most animals showed an acute and chronic infiltrate that occluded the oviductal lumen in some sections. Inflammatory exudate and debris accumulated in the periovarial space near the ostium of the oviduct. Inclusions were demonstrated in the lumenal epithelial cells of the oviduct and uterus. The mouse pneumonitis agent could be recovered from genital tissues for up to 21 days postinoculation but not from other organs. IgG antibodies to the mouse pneumonitis agent were detected at seven days postinoculation and reached peak titers by 21-30 days. By 25-30 days postinoculation, the inflammatory reaction declined and hydrosalpinx was observed. This model for salpingitis may be useful in understanding some aspects of the pathogenesis of C trachomatis genital infections.

Experimental chlamydial salpingitis in the guinea pig

Acute self-limited salpingitis developed when guinea pigs' fallopian tubes were infected with the guinea pig inclusion conjunctivitis agent (Chlamydia psittaci). The disease peaked at approximately 8 days post infection and had diminished markedly by day 14. The inflammatory reaction was concentrated at the luminal surface. Chlamydial replication was demonstrated and inclusions were found in epithelial cells.

Orphan airlift. Enteric pathogens isolated from Vietnamese children immigrating to the United States

Isolation studies for bacterial and parasitic agents were carried out on stool specimens from Vietnamese infants at the time of their mass airlift to the United States. One or more bacterial pathogens were found in 49% of the 367 stool specimens cultured. The isolates included enteropathogenic Escherichia coli (161), Shigella (16), Salmonella (15), but no Salmonella typhi or Vibrio cholerae. Parasites identified in 88 stool specimens included Giardia lamblia (10), Ascaris lumbricoides (7), and Entamoeba histolytica (1). Transmission of agents to volunteers probably occurred, because 48% of 272 adults questioned had diarrhea shortly after caring for the children, and stool cultures from these adults resulted in the isolation of E coli (105), Salmonella (1), and Shigella (3).

Second positive phototropic response patterns of the oat coleoptile

1.During second positive irradiation, bending increases steadily with time. Under optimal conditions, the lag between onset of illumination and beginning of parabolic bending behavior is about 3 min. - 2. Shortly after irradiation ceases, bending becomes linear with time. On a clinostat, bending continues for about 2.5 hr. Auxanometric measurements show that the ultimate cessation of bending is not due to failing growth rate. - 3. The second positive response shows a striking dependence on intensity of irradiation. Inactivation occurs when irradiation approaches the intensity of full daylight. - 4. Induction is linear with duration of illumination, both at purely activating intensities and at partially inactivating intensities. - 5. Induction at 2°, while somewhat slower than at 25°, retains linear dependence on exposure duration. This suggests that the reactions immediately following light reception are slowed but not stopped at low temperature. - 6. Growth, which drops to about 0.5 μ/min at 2°, resumes at about 18 μ min(-1) as soon as plants are warmed to 25°. Curvature does not seem to begin for about 10 min. Combined with information about lag time for primary auxin action, this suggests that lateral auxin transport, as well as growth, is strongly inhibited at near-freezing temperatures. - 7. The induced transport system is highly stable at 2°. - 8. Under optimal conditions, the lag between onset of irradiation and induction of capacity to produce measurable curvature is only a few seconds. The length of the lag is dependent on the rate of induction. The lag is thought to be due to the requirement that enough induction be accumulated to overcome resistance of the coleoptile. - 9. Induction is dependent on the gradient of light across the coleoptile, whether measured for purely activating or partially inactivating intensities. The light received is probably integrated either across individual cells or across the entire width of the coleoptile.