Circulating human plasmacytoid dendritic cells are highly sensitive to corticosteroid administration

Plasmacytoid dendritic cells (pDC), the major interferon-producing cell type found in human blood, have been implicated in the pathogenesis of systemic lupus erythematosus (SLE). Previous studies in SLE have shown substantial deviations from normal in this minor but immunologically important leukocyte population. Many of the lupus patients studied were receiving corticosteroids. To determine the effects of steroid administration on pDC in healthy adults, four volunteers were given prednisone, 15-30 mg daily, for 4 days. Both counts of pDC, and their ability to produce IFN-alpha were significantly reduced (P = 0.02 and 0.004, respectively) during steroid administration, and rapidly recovered after discontinuation of the hormones. The overall reduction in pDC-derived IFN appeared to be attributable to falls of both number of circulating cells and of IFN produced per pDC. The effects observed with pDC were comparable in magnitude but opposite in direction to that observed for granulocytes. In contrast other blood leukocytes were little affected during steroid therapy.

Circulating, interferon-producing plasmacytoid dendritic cells decline during human ageing

Increased frequency and severity of infections in the elderly have been taken as indicative of declining immune function. Dendritic cells (DCs), the most important antigen-presenting cells, play a central role in initiating and modulating immune responses. One type, DC2, arises from precursor plasmacytoid DCs (pDCs), a rare population of circulating blood cells, whose hallmark function is rapid and copious production of interferon-alpha (IFN-alpha) upon microbial challenge. We found significant decreases of the circulating pDCs during ageing in healthy adult humans, as defined both by flow cytometry and IFN-alpha generation. Mean pDC/mm3 in peripheral blood declined from 7.8 for the youngest age group (18-39 years) to 4.2 for the oldest (60-91 years; P = 0.017). IFN-alpha generation declined similarly, from 3537 to 1201 IU/ml, respectively (P = 0.006). There was also a slight decline over the age range in the amount of IFN generated per pDC (slope = -0.0087; P = 0.046). CD4+ T cells decreased by approximately 20% over the same age range (P = 0.001), while there was no change in the total lymphocyte or monocyte counts.

Interferon-alpha generation and immune reconstitution during antiretroviral therapy for human immunodeficiency virus infection

OBJECTIVES

To quantify the effect of HIV infection and HIV-suppressive therapy on interferon-alpha (IFN-alpha) production by human blood mononuclear cells; to compare, in parallel, effects on CD4+ T-cell numbers; and to ascertain the relationship of these interferon and CD4 parameters to resistance to opportunistic infections.

DESIGN

Serial studies of 294 unselected patients with HIV infection during therapy, with outcomes analysis.

METHODS

Determination of IFN generation by blood mononuclear cells via bioassay, and T-lymphocyte subset analysis via flow cytometry; serial studies of individual patients; linear regression and chi2 contingency table analysis.

RESULTS

HIV burden is inversely related to interferon-alpha generation, much as it is to CD4+ T-cell counts. Both of these recover during HIV-suppressive therapy. Reconstitution of IFN-alpha generation to levels commensurate with protection against opportunistic infection occurs prior to similar restoration of CD4 counts. In the outcomes analyses, such immune reconstitution was associated with protection from recurrent or new opportunistic infection. Conversely, viral suppression without such immunologic recovery was not protective against opportunistic infection.

CONCLUSIONS

Rapidly responding IFN-alpha generating cells appear to participate in resistance to opportunistic intracellular infection. Recovery of IFN-alpha generation may be an early marker of immune reconstitution in AIDS.

Corticosteroids depress IFN-alpha-producing plasmacytoid dendritic cells in human blood

Glucocorticoids are strongly immunosuppressive and are associated with reactivation of some intracellular infections. The plasmacytoid dendritic cell is a rare blood mononuclear cell detected through its production of IFN-alpha in response to herpes simplex virus and by surface immunophenotyping. We here report that steroid administration results in a decrease of IFN-alpha generation of approximately 25-fold, accompanied by reduction in circulating plasmacytoid dendritic cell numbers. Both parameters return to normal within days after steroid cessation.

The nature of the principal type 1 interferon-producing cells in human blood

Interferons (IFNs) are the most important cytokines in antiviral immune responses. "Natural IFN-producing cells" (IPCs) in human blood express CD4 and major histocompatibility complex class II proteins, but have not been isolated and further characterized because of their rarity, rapid apoptosis, and lack of lineage markers. Purified IPCs are here shown to be the CD4(+)CD11c- type 2 dendritic cell precursors (pDC2s), which produce 200 to 1000 times more IFN than other blood cells after microbial challenge. pDC2s are thus an effector cell type of the immune system, critical for antiviral and antitumor immune responses.

Absence of age-related increase in systolic blood pressure in ambulatory patients with HIV infection

BACKGROUND

Systolic blood pressure is well known to increase significantly with age and is strongly correlated with stroke and coronary artery disease. We and other investigators have reported a low prevalence of hypertension in subgroups of patients with HIV infection. In the present study, we examined an ambulatory population of patients with HIV infection to determine whether in the outpatient setting they may lack an age-related increase in systolic blood pressure.

METHODS

In an ambulatory outpatient practice, medical records of 178 consecutive patients with HIV infection and those of 200 control subjects were examined. Systolic and diastolic blood pressure and other clinical and laboratory variables were recorded. Scatter plots were generated to compare age with systolic blood pressure. Spearman rank correlation analysis was carried out to determine the relationship between systolic blood pressure and age and other variables.

RESULTS

Patients ranged in age from 13 to 69 years. There was only a very slight increase (which did not achieve statistical significance) in systolic blood pressure with aging in the patients with HIV infection, in contrast to the control population, in which an age-related increase in systolic blood pressure was seen that was comparable to published Framingham data. Mean systolic blood pressure for the group as a whole was 118.2 +/- 1.1 mm Hg. Mean serum albumin was 4.2 +/- 0.04 g/dL and was only slightly diminished in older patients. Mean serum cholesterol was 176.8 +/- 3.4 mg/dL and this bore no relationship to aging. More advanced stages of HIV infection also did not correlate with the lack of age-associated systolic hypertension.

CONCLUSION

The present population of ambulatory patients infected with HIV seem to lack an age-related increase in systolic blood pressure; this may be caused by such variables as autonomic dysfunction or factors that may attenuate the development of atherosclerosis.

AIDS-associated membranous nephropathy with advanced renal failure: response to prednisone

We report the case of a patient with acquired immunodeficiency syndrome (AIDS) who developed nephrotic syndrome and progressive renal failure mimicking human immunodeficiency virus (HIV)-associated focal segmental glomerulosclerosis (FSGS) who required initiation of hemodialysis and was found on renal biopsy to have membranous nephropathy. Hepatitis B and C serologies were negative. Although she required hemodialysis, she was treated with prednisone and experienced a progressive decline in her serum creatinine from 10.1 mg/dL to 1.9 mg/dL, which permitted the discontinuation of hemodialysis. After she abruptly discontinued prednisone, her creatinine level increased to 4.8 mg/dL, and she experienced marked worsening of her nephrotic syndrome. Resumption of prednisone resulted in normalization of serum creatinine and reduction in urine protein excretion. No adverse effects of prednisone occurred during this time. She remains off of hemodialysis for 1 year with a serum creatinine level of 1.0 mg/dL and urine protein excretion of 0.4 g/d. Although most patients with HIV infection, nephrotic-range proteinuria, and renal failure have FSGS, a minority may have membranous nephropathy. Although typically not a steroid-responsive lesion in the setting of advanced renal failure, membranous nephropathy may be a highly steroid-responsive lesion in the HIV-infected patient, and treatment may help avert the need for dialysis in a patient population that generally has a poor outcome on dialysis.

Early clinical markers and CD4 percentage in subjects with human immunodeficiency virus infection

In a clinical trial involving asymptomatic, HIV-seropositive subjects treated with either the HIV-1 immunogen (an inactivated, gp120-depleted HIV-1 virus in incomplete Freund's adjuvant) or an adjuvant control, we examined the relationship between changes in the percentage of CD4 cells over time and early clinical markers of HIV disease progression. Subjects who had an early clinical event were more likely to have a greater decline in the percentage of CD4 cells than those subjects who did not have a clinical event (p = 0.054). The greatest decline in CD4 percentage occurred within 10 weeks prior to a clinical event (mean 11% decrease from baseline). Subjects from the quartile with the greatest decline in CD4 percentage had a fivefold greater risk of having a clinical event than subjects from the quartile with the second largest decline (p = 0.045). These results demonstrate a relationship between changes in the percentage of CD4 cells and early clinical events. Further validation of this association may be useful in clinical monitoring and in evaluating therapies to treat HIV infection.

Rifabutin prophylaxis for Mycobacterium avium complex infection in patients with AIDS

Rifabutin, a macrophage-penetrating lipophilic rifamycin, has a long half-life and activity in vitro against Mycobacterium avium complex (MAC). Preliminary studies of patients with AIDS and those with AIDS-related complex defined dose-limiting toxic effects (arthralgia/arthritis and uveitis) and suggested that rifabutin alone might reduce the incidence of MAC infections. Two double-blind, randomized, placebo-controlled trials involving 1,100 subjects confirmed the safety and efficacy of low doses of rifabutin; this therapy halved the rate of MAC bacteremia and significantly reduced symptoms associated with disseminated MAC infections. Subsequent experience with rifabutin as prophylaxis for and treatment of MAC infections has generally supported its safety profile. Emergence of drug-resistant MAC causing infection in patients receiving rifabutin therapy has not been reported. Interactions with azoles and macrolides increase blood levels of rifabutin and have led to the development of uveitis in certain patients. Studies of the cost-effectiveness of rifabutin prophylaxis for MAC infection suggest that it is comparable with other preventive interventions employed in clinical practice.

Apoptotic depletion of CD4+ T cells in idiopathic CD4+ T lymphocytopenia

Progressive loss of CD4+ T lymphocytes, accompanied by opportunistic infections characteristic of the acquired immune deficiency syndrome, ahs been reported in the absence of any known etiology. The pathogenesis of this syndrome, a subset of idiopathic CD4+ T lymphocytopenia (ICL), is uncertain. We report that CD4+ T cells from seven of eight ICL patients underwent accelerated programmed cell death, a process facilitated by T cell receptor cross-linking. Apoptosis was associated with enhanced expression of Fas and Fas ligand in unstimulated cell populations, and partially inhibited by soluble anti-Fas mAb. In addition, apoptosis was suppressed by aurintricarboxylic acid, an inhibitor of calcium-dependent endonucleases and proteases, in cells from four of seven patients, The in vivo significance of these findings was supported by three factors: the absence of accelerated apoptosis in persons with stable, physiologic CD4 lymphopenia without clinical immune deficiency; detection of serum antihistone H2B autoantibodies, one consequence of DNA fragmentation, in some patients; and its selectivity, with apoptosis limited to the CD4 population in some, and occurring among CD8+ T cells predominantly in those individuals with marked depletion of both CD4+ T lymphocytes linked to clinical immune suppression have evidence for accelerated T cell apoptosis in vitro that may be pathophysiologic and amenable to therapy with apoptosis inhibitors.

Impaired interferon alpha response in hairy cell leukemia is corrected by therapy with 2-chloro-2'-deoxyadenosine: implications for susceptibility to opportunistic infections

Patients with hairy cell leukemia (HCL) are susceptible to opportunistic intracellular infections, suggesting defects in cellular immunity. Prior studies have indicated an association between failure of IFN-alpha generation by peripheral blood mononuclear cells (MNC) and susceptibility to such infections. We here present results on IFN-alpha generation in HCL patients pre- and post-therapy. Prior to treatment with 2-chloro-2'-deoxyadenosine (CdA), MNC from 24 HCL patients with active disease produced little or not IFN-alpha (geometric mean < 40 IU/ml) compared with controls (n = 140, geometric mean 1730 IU/ml, p < 0.0005). After treatment with CdA, IFN-alpha generation was studied in 16 patients, with a geometric mean value of 650 IU/ml (p < 0.0005 compared with pre-CdA levels). The severe depression of IFN-alpha generation improved progressively following CdA therapy-induced clinical remission. We propose that deficiency of IFN-alpha production may play a role in the susceptibility to intracellular infections of patients with active HCL.

Enriched HLA-DQ3 phenotype and decreased class I major histocompatibility complex antigen expression in recurrent respiratory papillomatosis

Respiratory papillomas, caused by human papillomaviruses, are benign tumors that recur following removal. We evaluated immune function and major histocompatibility complex (MHC) phenotype and expression in these patients. MHC-independent immune function appeared normal. The frequency of peripheral blood MHC class II phenotypes was highly enriched for DQ3 and DR11, one split of DR5. Class I MHC antigen expression on papilloma tissue was markedly reduced. Together, these phenomena may facilitate papillomavirus evasion of the cellular immune response.

Interferon-alpha generation in mice responding to challenge with UV-inactivated herpes simplex virus

In humans with advanced human immunodeficiency virus (HIV) infection, an interferon-alpha (IFN-alpha) response by a specialized blood mononuclear cell to herpes simplex virus (HSV) in vitro is associated with resistance to opportunistic infections. A cell type of unknown lineage, designated the natural IFN-producing cell (NIPC), has been identified preliminarily as the source of these IFNs and may have a role in other host defense functions. Earlier studies suggested the existence of analogous HSV-responsive cell populations in mice. The role specifically of IFN-alpha in the murine system, however, has not been characterized. Using IFN bioassay and neutralization with antisera against Type I IFNs and IFN-beta, we have defined the types and sources of IFNs produced by mice in response to in vivo and in vitro challenge with UV-inactivated HSV. After intraperitoneal inoculation with HSV, BALB/c and C57Bl/6 strains produced characteristically different levels of serum IFNs that appeared principally to be IFN-alpha. The response of mononuclear cells from these mice differed from that of the intact mouse. Isolated cells from bone marrow and spleen released detectable IFNs much later than did whole animals, and the IFNs produced by marrow, spleen, and peritoneal cells were usually neutralized by the anti-IFN-beta. Only bone marrow cells produced detectable amounts of IFN-alpha. Both intact mice and their cells became refractory to restimulation with similar kinetics.

Progressive nemaline rod myopathy in a woman coinfected with HIV-1 and HTLV-2

Nemaline-rod myopathy was recently reported in eight young males infected with human immune deficiency virus type 1 (HIV-1). A 41-year-old woman had a 2-year history of progressive proximal-muscle weakness. Muscle biopsy demonstrated the presence of nemaline rods, predominantly in type 1 fibers. She was coinfected with HIV-1 and HTLV-2, as evidenced by positive polymerase chain reaction and serology. There was no lymphopenia or CD4 lymphopenia, despite an abnormal T-cell subset ratio, high CD8 count, skin anergy, and depressed in vitro response to mitogens. This case raises the possibility that dual infection may play a role in the pathogenesis of the rare nemaline-rod myopathies of HIV-infected patients.

Peripheral blood of AIDS patients contains cells capable of providing accessory function for the natural killer cell-mediated, lysis of herpes simplex virus-infected targets despite low interferon-alpha production

We have previously demonstrated that in vitro production of interferon-alpha (IFN-alpha) in response to herpes simplex virus (HSV) by peripheral blood mononuclear cells PBMCs from patients infected with the human immunodeficiency virus (HIV-1) decreases dramatically with disease progression, with extremely low levels of IFN-alpha preceding and predictive of opportunistic infections. Natural killer (NK) lysis, however, was found to decay later in disease and often was within normal limits even when IFN-alpha production was severely compromised. The NK lysis of HSV-infected fibroblasts (HSV-FS) is dependent on an HLA-DR+ accessory cell (AC) population that shares the phenotype of the predominant IFN-alpha-producing cell (IPC) population. To determine whether there is a correlation between AC activity and IFN-alpha production in these patients, we tested the ability of PBMCs from AIDS patients to provide AC help to NK cells from heterologous donors. While NK cells were highly sensitive to gamma irradiation, AC activity was relatively radioresistant. Therefore, NK cells from healthy donors were depleted of HLA-DR+ ACs and added to irradiated PBMCs from either healthy or AIDS donors to test for the function of ACs in the irradiated populations. Irradiated cells from AIDS patients were found to provide normal AC activity despite decreased IFN-alpha production in the majority of the patients. We failed to observe NK augmenting activity in supernatants of irradiated PBMCs from IFN-deficient patients that had been stimulated with HSV-FS.(ABSTRACT TRUNCATED AT 250 WORDS)

Acquired immunodeficiency without evidence of infection with human immunodeficiency virus types 1 and 2

There have been three published cases of acquired immunodeficiency in which no evidence for infection with human immunodeficiency virus (HIV) types 1 and 2 was found. We have identified five other individuals, from the New York City area (four who have known risk factors for HIV infection), with profound CD4 depletion and clinical syndromes consistent with definitions of the acquired immunodeficiency syndrome (AIDS) or AIDS-related complex. None had evidence of HIV-1, 2 infection, as judged by multiple serologies over several years, standard viral co-cultures for HIV p24 Gag antigen, and proviral DNA amplification by polymerase chain reaction.

Dose-limiting toxicity of rifabutin in AIDS-related complex: syndrome of arthralgia/arthritis

We studied the tolerance of humans to rifabutin, a rifamycin with antimycobacterial and in vitro anti-HIV activity. Sixteen subjects with AIDS-related complex were treated for 4-66 weeks with stepwise increasing oral doses of rifabutin from 300 to 2400 mg/day. The highest dose attained was twice that previously reported for humans. Serum and cerebrospinal fluid levels of drug were detected by high-pressure liquid chromatography. A reversible syndrome of arthritis/arthralgia, not previously described, was seen in most (nine out of 10) of those given doses exceeding 1050 mg/day. Uveitis and aphthous stomatitis developed at doses of approximately 1800 mg in two of those with joint manifestations. Typical manifestations of Reiter's syndrome were not seen in any patient. An orange-tan skin pigmentation was almost universal. Other toxicities resembled those previously associated with rifampin. Serum levels did not approach those found to inhibit HIV significantly in vitro. No consistent antiviral or immunological effects were observed; even at the highest doses, rifabutin did not appear to inhibit cellular immunity. Rifabutin was well tolerated at daily doses blow 1 g.

Hypouricemia in acquired immunodeficiency syndrome

Clinical evaluations of hypouricemia in patients with the acquired immunodeficiency syndrome (AIDS) have shown that it is a common disorder resulting from defective renal handling of uric acid. We prospectively studied renal urate handling in 23 patients and reviewed the records of 73 consecutive patients with AIDS or AIDS-related complex (ARC), who were seen in our AIDS clinic between March 1985 and April 1988, to determine the incidence, significance, and, when possible, the cause of hypouricemia. Hypouricemia was defined as serum urate less than or equal to 0.18 mmol/L (3 mg/dL). Renal clearance studies were performed in 23 patients, 10 hypouricemic and 13 nonhypouricemic. Eight patients (six with hypouricemia) underwent central venous pressure (CVP) monitoring, which was performed for clinical signs and symptoms of extracellular volume depletion. Fourteen (eight with hypouricemia) had daily urine urate measured. Hypouricemia was found in 21 (21.9%) of 96 patients. It was more common in females and intravenous (IV) drug abusers, and was associated with more opportunistic illnesses, particularly mycobacterium avium intracellulare (MAI) and cytomegalovirus (CMV) infections. Hypouricemia occurred in three patients with ARC and 18 patients with AIDS and was associated with cerebral atrophy in all 12 hypouricemic and 14 of 28 nonhypouricemic patients who had cranial computed tomography (CT) scans. During a comparable follow-up period, 71.4% of the hypouricemic as compared with 38.7% of nonhypouricemic patients died. Eleven developed hypouricemia as outpatients. Fractional excretion of uric acid (FEua) was elevated in the eight patients with CVP less than 1 cm of water, and in 10 of 10 with and nine of 13 without hypouricemia, despite CVP less than 1 cm water in eight.(ABSTRACT TRUNCATED AT 250 WORDS)

Efficacy of rifabutin in the treatment of AIDS-related complex

We performed a phase 1-2 antiviral dose escalation trial of rifabutin, a rifamycin antibiotic with anti-HIV-1 activity in vitro. We followed 16 men with AIDS-related complex (ARC) for a mean duration of 29 weeks; the maximum toxicity-limited dose of rifabutin was 2400 mg/day, which was achieved in two patients. There was some evidence of anti-HIV-1 activity in two patients, one of whom had an improvement in immune status, but 11 of the 16 patients showed a deterioration in either virologic or immunologic status. The majority of the patients under study remained clinically stable during the trial, but there was clinical deterioration in the three who entered with CD4 cell counts of less than 100 x 10(6)/l. On the basis of this trial, rifabutin as a single antiviral agent does not appear to be beneficial to ARC patients.

Resolution of intestinal cryptosporidiosis after treatment of AIDS with AZT

Intestinal cryptosporidiosis commonly results in severe protracted diarrhea that contributes significantly toward morbidity and mortality in patients with acquired immunodeficiency syndrome. No satisfactory therapy for cryptosporidiosis currently exists. We describe a patient with severe secretory diarrhea and malabsorption who had clinical, microbiologic, and histologic resolution of cryptosporidiosis after therapy with zidovudine.

Isoferritins in HIV infection: relation to clinical stage, CD8 lymphocyte binding and the pathogenesis of AIDS

Placental isoferritins (PLF), known to be immunosuppressive in Hodgkin's disease and other states, were found to be increased in sera of subjects infected with HIV. We assayed for PLF using a 'sandwich' antigen capture enzyme-linked immunosorbent assay (ELISA) employing two monoclonal antibodies. Individuals with lymphadenopathy, with or without symptoms suggestive of AIDS-related complex, had the highest serum levels, which declined with progressive immunodeficiency. Total (normal) ferritins, in contrast, increased progressively with stage of disease. PLF was found on a subset of CD8 lymphocytes and appeared to block detection of the CD8 antigen by specific monoclonal antibodies. Elution of PLF by incubation with levamisole, but not by culture medium alone, led to the unblocking of the CD8 determinant on these cells. Profiles of isoferritins in HIV infection may provide clues to prognosis. PLF, a physiologic down-regulator of hematopoiesis and cellular immunity, could play a role in the progressive immune deficiency, marrow suppression and HIV expression that lead to AIDS.

Comparison of antigen immunoassay and reverse transcriptase assay for monitoring human immunodeficiency virus infection in an antiviral trial

We compared the Abbott enzyme immunoassay for human immunodeficiency virus (HIV) antigen with the reverse transcriptase assay (RTA) as a means of monitoring HIV infection during an antiviral trial. The Abbott enzyme immunoassay detected HIV earlier than RTA whether or not the patients were antigenemic and appears to be superior to RTA for detecting HIV in cultures used for monitoring clinical trials.

A glycoprotein inhibitor of in vitro granulopoiesis associated with AIDS

Patients infected with the human immunodeficiency virus (HIV) often present with neutropenia. To elucidate the mechanism(s) of this HIV-related neutropenia, we assessed the proliferative capacity of the granulocyte-macrophage progenitor cell (CFU-GM) from the bone marrow (BM) of 78 patients within the AIDS spectrum manifesting symptoms or signs related to HIV infection. Of these, 70 had a significant deficit in the growth of this committed progenitor when compared with normal controls (P less than .01). Further analysis revealed that the nucleated bone marrow cells from AIDS and AIDS-related complex (ARC) patients inhibited the growth of CFU-GMs from normal individuals when cocultured in agar (P less than .001). Control CFU-GMs were also inhibited when they were cultured over feeder layers containing patients' BM cells (P less than .001). Conditioned media obtained from the liquid culture of patients' BM cells did not inhibit normal control CFU-GM growth to a degree different from that of the cells themselves (P greater than .4). Analysis of these conditioned media by polyacrylamide gel electrophoresis (PAGE) revealed a unique glycoprotein (gp) with a mol wt of 84 kd. Further studies revealed that this gp possessed the inhibitory activity. These data suggest that this gp may be an important factor in HIV-related neutropenia. The presence of gp84 was independent of drugs administered to the patients.

Incidence of cancer in 98 patients with common varied immunodeficiency

Ninety-eight patients with common varied immunodeficiency have been observed for periods of 1-13 years. In 1986, 78 were alive, 19 had died, and 1 could not be located. Eleven patients in the group had developed cancer; two patients had had two cancers. Of the total number of neoplastic malignancies, seven were non-Hodgkin's lymphoma, one patient had a Waldenstrom's macroglobulinemia, and nine of the patients who developed cancer were female. Cancer developed in the fifth or sixth decade of life for 10 of the 11 patients. These data show an 8- to 13-fold increase in cancer in general for patients who have this immunodeficiency and a 438-fold increase in lymphoma for females.

Opportunistic infections in acquired immune deficiency syndrome result from synergistic defects of both the natural and adaptive components of cellular immunity

We evaluated the cellular immunity of 408 clinically stratified subjects at risk for acquired immune deficiency syndrome (AIDS), to define the role of interferon-alpha production deficits in the pathogenesis of opportunistic infections (OI). We followed 115 prospectively for up to 45 mo. Onset of OI was associated with, and predicted by, deficiency both of interferon-alpha generation in vitro, and of circulating Leu-3a+ cells. Interferon-alpha production is an index of the function of certain non-T, non-B, large granular lymphocytes (LGL) that are independent of T cell help. Leu-3a+ cell counts are a marker of T cell function. OI did not usually develop until both of these mutually independent immune functions were simultaneously critically depressed, leading to a synergistic interaction. These data suggest that the AIDS virus affects a subset of LGL, and that cytokine production by these cells is an important component of the host defense against intracellular pathogens that becomes crucial in the presence of severe T cell immunodeficiency.

Natural killer cell function and interferon generation in patients with primary immunodeficiencies

Patients with primary immunodeficiency disorders were evaluated for three aspects of natural defense: natural killer (NK) cells which lyse HSV-infected fibroblasts [NK(HSV-FS)], NK cells which lyse K562 tumor targets [NK(K562)], and interferon-alpha generation. In addition, capacity to make interferon upon challenge with other commonly used inducers was also evaluated. Most patients with severe combined immunodeficiency disease (SCID) and deficits of both T- and B-cell function demonstrated normal NK function with one or both targets. Six of eight SCID patients generated interferon-alpha at or below the lower limit of normal while only two made clearly normal levels. Six of 10 patients with Wiskott-Aldrich syndrome (WAS) had normal NK(K562) and five of 10 generated normal levels of interferon-alpha but all had severely deficient NK(HSV-FS). Patients with Bruton's agammaglobulinemia demonstrated normal NK and interferon generation, as did patients with common variable immunodeficiency, even when subdivided into patients with T-cell proliferative deficiencies and those with only hypogammaglobulinemia. Natural defense parameters may help categorize patients with SCID and WAS and help define these heterogeneous diseases.

Cell replication in an immunologically(?) Stimulated cell population in human bone marrow

In AIDS, although there is a lack of humoral responsiveness in vitro and in vivo, many patients persistently have an increased number of B cells which continue to produce increased amounts of immunoglobulin. An objective, reproducible morphologic classification scheme for B cells was devised. Comparison of cell kinetic parameters in various disease states will require such a classification. Although not immunologically responsive to new stimuli, the marrow B cells in the AIDS patients were shown to be replicating and turning over. The latter may be due to either death in situ or to migration. Plasmacytic lymphocytes and lymphocytic plasma cells, morphologic transitions between lymphocytes and mature plasma cells, had the largest fractions in DNA synthesis. Because of their relative cell numbers, the lymphocytic plasma cells contained most of the cells in DNA synthesis. The position of plasmablasts in the sequential compartments is unclear. Only small numbers are dividing. Within a given morphologic category, large cells were more likely to be in DNA synthesis than smaller cells. These studies can serve as a basis for comparison with marrow B-cell proliferation in other disease states.

Elevation of serum CA 125 prior to diagnosis of an epithelial ovarian carcinoma

In a single fortuitous case it has been possible to measure serum levels of CA 125 during 3 years preceding the diagnosis of an epithelial ovarian carcinoma. CA 125 levels were elevated 10-12 months prior to clinical detection of the malignancy. CA 125 deserves further evaluation as a marker for early detection of ovarian cancer.

Acquired immunodeficiency syndrome. Distinctive features of bone marrow biopsies

Bone marrow biopsies from 30 patients with acquired immunodeficiency syndrome (AIDS), diagnosed according to accepted clinical criteria, were studied in order to determine if characteristic histopathologic features were present. The biopsies were compared with 20 biopsy specimens submitted from patients with fever of unknown origin or with known neoplastic disease, including four biopsies from patients with a history of narcotics addiction being treated in the methadone clinic, and with biopsies from three homosexual men who did not have AIDS. Characteristic biopsy features were recognized in 31 (86%) of 36 biopsy specimens from AIDS patients. Nineteen of 36 patients (53%) showed a distinctive pattern of hypercellularity in which hematic cells (immature granulocytic cells, megakaryocytes, eosinophils, and large lymphocytes) separated, but did not efface, fat cells; these cells were designated as "AIDS-pattern." Twelve specimens showed a less complete (probable-AIDS) bone marrow change. Reticulin fibers were increased in 28 of 36 biopsies.

Recurrent Salmonella typhimurium bacteremia associated with the acquired immunodeficiency syndrome

Seven Haitian and one white patient with the acquired immunodeficiency syndrome and Salmonella typhimurium bacteremia were identified over a 28-month period. In three patients bacteremia developed concurrently with an opportunistic infection associated with the acquired immunodeficiency syndrome. The remaining five patients had their initial episodes of bacteremia 3 to 11 months before the diagnosis of the acquired immunodeficiency syndrome. These five patients had signs suggestive of the syndrome, plus evidence of disordered cellular immune function (lymphopenia, anergy, decreased T-helper cells, decreased proliferative responses, and a deficiency in mononuclear-cell alpha interferon production). Salmonella typhimurium bacteremia in the appropriate clinical setting may be an opportunistic pathogen associated with the acquired immunodeficiency syndrome.

Deficiency of interferon-alpha generating capacity is associated with susceptibility to opportunistic infections in patients with AIDS

Acquired immune deficiency syndrome (AIDS) is a newly described syndrome in which patients are susceptible to certain malignancies and opportunistic infections (OI) usually found only in immunosuppressed individuals. Patients with AIDS have been found to have deficiencies of virtually all of their host defense systems. In this report, the natural resistance systems have been discussed. Although a deficiency of NK-cell function has been found in many patients with AIDS, this deficiency failed to distinguish patients susceptible to OI or malignancy from male homosexual controls. A deficiency of interferon-alpha generation by mononuclear cells upon exposure to HSV-1 infected fibroblasts was the best correlate with susceptibility to OI in AIDS patients. This deficiency failed to correlate with serum levels of acid-labile interferon-alpha in these patients. Although the interferon generating deficiency may be caused by the infections in these patients, it is more likely that the deficiency lays the groundwork for the establishment of the opportunistic infections.

Efficacy of intravenous immunoglobulin in primary humoral immunodeficiency disease

Twenty-one patients with primary humoral immunodeficiency were treated for 1 year with a chemically intact immunoglobulin, 300 mg/kg body weight given intravenously every 3 weeks, to compare immunoglobulin levels and clinical status with results achieved after standard treatment with intramuscular immunoglobulin given previously for 1 year. A substantial reduction of specific acute illnesses and antibiotic use was found for 18 of the 21 patients, particularly during the second 6 months of treatment. Average IgG levels before intravenous infusion were increased 243 mg/dL over previous intramuscular pre-injection levels. Adverse effects were recorded for 2.5% of infusions.

Severe acquired immune deficiency syndrome in male homosexuals: diminished capacity to make interferon-alpha in vitro associated with severe opportunistic infections

Natural killer cell function, directed against either K562 tumor targets or herpes simplex virus type 1-infected fibroblasts, was often low in patients with acquired immune deficiency syndrome (AIDS) but failed to distinguish these patients from either male homosexual controls or patients with lymphadenopathy. Mononuclear cells from patients with AIDS and opportunistic infections generated diminished levels of interferon-alpha in response to herpes simplex virus type 1-infected fibroblasts. This deficiency discriminated patients with severe opportunistic infections from most individuals with either generalized lymphadenopathy or Kaposi's sarcoma only and from male homosexual control subjects. The deficiency in interferon-alpha generation may be the consequence of the opportunistic infections that these individuals have contracted or may be a direct manifestation of AIDS itself.

Chemically induced congenital thymic dysgenesis in the rat: a model of the DiGeorge syndrome

The DiGeorge syndrome, a variable complex of thymic aplasia, congenital heart disease, hypoparathyroidism, and anomalies of the face and neck, is thought to result from exposure to teratogenic agents. A group of congenital defects closely resembling this syndrome can be produced in newborn rats by the administration of the fat-soluble zinc chelating agent WIN 18,446, a bis-dichloroacetylamine. This drug, nontoxic to adult animals, is a powerful teratogen when administered to pregnant rats during days 9-12 of the 21-day gestation period. Our animal data suggest that the human syndrome results from exposure in utero to agents like WIN 18,446, which damage the fetus during a critical period of organogenesis.

Helper cell function of Leukemic Leu-2a+, histamine receptor+, T gamma lymphocytes

Leukemic cells from a patient with an 11-yr history of chronic lymphocytic leukemia (CLL) were found to have the surface phenotype Leu-1+, Leu-2a+, Leu-3a-, sheep erythrocyte rosette+, IgGFc receptor+. The cells also bore a receptor for histamine inhibitable by cimetidine (H-2). The clonal nature of the proliferation was documented by the presence of a consistent marker chromosome (22-trisomy) in metaphases elicited by culture with T cell growth factors. Although the surface phenotype suggested that these cells might function as suppressor lymphocytes, they had an enhancing effect on the pokeweed- mitogen- (PWM) driven generation of plasma cells and reverse hemolytic plaque-forming cells in vitro. This helper activity was modified neither by irradiation of the leukemic cells nor by removal of a minor population of Leu-3a+ cells, suggesting that the effects were attributable to the CLL cells themselves. In addition to these functions, the CLL cells were active in antibody-dependent cellular cytotoxicity (ADCC) assays in association with expression of Fc receptors for IgG. The ADCC was diminished when a transient loss of the Fc receptor expression was observed. No activity in natural killer cell assays employing K-562 cells or herpes simplex virus- (HSV) infected cells as targets could be attributed to the leukemic clone. These studies indicate that the cell surface phenotype, as defined by monoclonal antibodies, may not always predict the functional state of a particular cell, and suggest that within the Leu-2a+ (TH-2+) population of human lymphocytes, some helper as well as suppressor/cytotoxic cells are to be found.

Helper cell function of Leukemic Leu-2a+, histamine receptor+, T gamma lymphocytes

Leukemic cells from a patient with an 11-yr history of chronic lymphocytic leukemia (CLL) were found to have the surface phenotype Leu-1+, Leu-2a+, Leu-3a-, sheep erythrocyte rosette+, IgGFc receptor+. The cells also bore a receptor for histamine inhibitable by cimetidine (H-2). The clonal nature of the proliferation was documented by the presence of a consistent marker chromosome (22-trisomy) in metaphases elicited by culture with T cell growth factors. Although the surface phenotype suggested that these cells might function as suppressor lymphocytes, they had an enhancing effect on the pokeweed- mitogen- (PWM) driven generation of plasma cells and reverse hemolytic plaque-forming cells in vitro. This helper activity was modified neither by irradiation of the leukemic cells nor by removal of a minor population of Leu-3a+ cells, suggesting that the effects were attributable to the CLL cells themselves. In addition to these functions, the CLL cells were active in antibody-dependent cellular cytotoxicity (ADCC) assays in association with expression of Fc receptors for IgG. The ADCC was diminished when a transient loss of the Fc receptor expression was observed. No activity in natural killer cell assays employing K-562 cells or herpes simplex virus- (HSV) infected cells as targets could be attributed to the leukemic clone. These studies indicate that the cell surface phenotype, as defined by monoclonal antibodies, may not always predict the functional state of a particular cell, and suggest that within the Leu-2a+ (TH-2+) population of human lymphocytes, some helper as well as suppressor/cytotoxic cells are to be found.

Opportunistic infection in previously healthy women. Initial manifestations of a community-acquired cellular immunodeficiency

Opportunistic infections and unusual tumors have been reported in an unprecedented outbreak of community-acquired cellular immune deficiency among homosexual and drug-abusing men. We report five women with the same syndrome. The women were residents of metropolitan New York City closely associated with drug abuse either by personal use (our patients) or close sexual contact with an abuser (one patient). One patient was bisexual. All five patients developed Pneumocystis carinii pneumonia as well as combinations of other opportunistic infections including oral candida, disseminated mycobacteria, and ulcerative herpes simplex infections. All patients had marked depression of cellular immune function. Three patients died. The appearance of this syndrome in women has important implications with regard to the epidemiology and etiology of this emerging syndrome.

Lichen planus in two immunodeficient hosts

The exact pathogenic mechanism involved in lichen planus (LP) remains obscure. Two patients who have severe immunodeficiency diseases and who developed LP during the course of their illness are reported here. Both patients had hypogammaglobulinemia and disturbed immune function prior to the development of LP. Although such an association could be coincidental, the development of LP may be related to the underlying immune disturbances. Association of LP with several other disorders of the immune system has been previously observed. Other evidence for the possible involvement of an immunopathogenic mechanism in LP includes (1) deposition of immunoglobulin within the colloid bodies and at the dermoepidermal junction, (2) predominantly T cell dermal infiltrate in LP lesions, and (3) existence of clinical and histologic similarities between graft-versus-host disease and LP.

Impaired proliferative response to B-lymphocyte activators in common variable immunodeficiency

The cell-mediated immune responses of 39 patients with common variable immunodeficiency (CVI) were studied in vitro, using Staphylococcus aureus and Escherichia coli prepared as whole cells and Candida albicans extract. These microbial activators wee found to require intact B-lymphocyte function for normal proliferative response. The patient group was observed to have significantly depressed lymphocyte responses compared wit those of controls studied in parallel (P less than 0.01). Negative lymphocyte response to one activator and strongly positive response to another were found in individual patients. Examination of patients' lymphocyte response to S. aureus and E. coli in association with serum IgG levels demonstrated that a rough correlation could be drawn, showing that patients with serum IgG less than 125 mg/dl had markedly lower (P less than 0.01) lymphocyte responses than those with serum IgG greater than 300 mg/dl. No similar correlation with phytohaemagglutinin activation was observed. Since depressed lymphocyte responses did not correlate with reduced B-cell number in these patients, intrinsic B-lymphocyte deficiency was indicated. These preparations of microbial activators are potentially useful tools in exploring lymphocyte subpopulation functions in primary immunodeficiency diseases.

Severe acquired immunodeficiency in male homosexuals, manifested by chronic perianal ulcerative herpes simplex lesions

Four homosexual men presented with gradually enlarging perianal ulcers, from which herpes simplex virus was cultured. Each patient had a prolonged course characterized by eight loss, fever, and evidence of infection by other opportunistic microorganisms including cytomegalovirus, Pneumocystis carinii, and Candida albicans. Three patients died; Kaposi's sarcoma developed in the fourth. All were found to have depressed cell-mediated immunity, as evidenced by skin anergy, lymphopenia, and poor or absent responses to plant lectins and antigens in vitro. Natural-killer-cell activity directed against target cells infected with herpes simplex virus was depressed in all patients. The absence of a history of recurrent infections or of histologic evidence of lymphoproliferative or other neoplastic diseases suggests that the immune defects were acquired.