Adult Acquired Immunodeficiency Syndrome Research Articles

HIV-child with disseminated Talaromyces Marneffei (Penicillium marneffei) infection: a rare severe case report

BackgroundTalaromyces Marneffei (Penicillium marneffei, T.marneffei) has been frequently reported in patients with adult acquired immunodeficiency syndrome. Still, cases of children with HIV combined with T.marneffei infection are very rare. This report describes the case of a HIV-child who is a girl from China. Her special clinical manifestations and laboratory diagnosis results can provide clinicians with the basis for diagnosis and treatment of T.marneffei related rare diseases.Case presntationWe reported a single case of 7-year-old Chinese female patient who presented with fever, abdominal pain, multiple lymphadenopathy, hepatosplenomegaly, left lower extremity ecchymosis, and bloody stool. The patient received anti-inflammatory therapy; however, her symptoms did not improve. Consequently, she was diagnosed with T.marneffei and HIV infection; it was also confirmed that her mother did not undergo HIV blocking therapy during pregnancy. Yet, the child’s family refused all treatment, after which the child was discharged from the hospital. The patient died a few days later.ConclusionThis case suggested that children with AIDS suffering from fever, lymphadenopathy and coagulation dysfunction, penicilliosis should be suspected. Clinicians should diagnose the disease early through laboratory and imaging results, which can help reduce the mortality, prolong the survival time and improve the quality of life of children.

Protective Role of BST2 Polymorphisms in Mother-to-Child Transmission of HIV-1 and Adult AIDS Progression.

Bone marrow stromal cell antigen-2 (BST-2)/Tetherin is a restriction factor that prevents Human immunodeficiency virus type 1 (HIV-1) release from infected cells and mediates pro-inflammatory cytokine production. This study investigated the risk conferred by single nucleotide polymorphisms (rs919266, rs9192677, and rs9576) at BST-2 coding gene (BST2) in HIV-1 mother-to-child transmission and in disease progression. Initially, 101 HIV-1+ pregnant women and 331 neonates exposed to HIV-1 from Zambia were enrolled. Additional BST2 single nucleotide polymorphism analyses were performed in 2 cohorts with acquired immunodeficiency syndrome (AIDS) progression: an adult Brazilian cohort (37 rapid, 30 chronic and 21 long-term non-progressors) and an Italian pediatric cohort (21 rapid and 67 slow progressors). The rs9576A allele was nominally associated with protection during breastfeeding (P = 0.019) and individuals carrying rs919266 GA showed slower progression to AIDS (P = 0.033). Despite the influence of rs919266 and rs9576 on BST2 expression being still undetermined, a preventive role by BST2 polymorphisms was found during HIV-1 infection.

Curative effect of hepatic portal venous administration of autologous bone marrow in AIDS patients with decompensated liver cirrhosis

Dear Editor, Acquired immunodeficiency syndrome (AIDS) caused by human immunodeficiency virus type 1 (HIV-1) infection remains a major public health threat worldwide.1 Although the antiretroviral therapy (ART) improved the life quality and increased longevity of HIV-infected patients, comorbidities of liver diseases have assumed far greater importance as a cause of morbidity and mortality in AIDS patients.2 As their CD4+T-cell-based immune response is attenuated, HIV-infected patients are often coinfected with hepatitis B virus (HBV) or hepatitis C virus (HCV), which, in addition to the hepatotoxicity of ART, leads to the development of liver cirrhosis and failure.3, 4 Traditional treatment has low rates of sustained antiviral response in coinfected patients. Thus, effective treatment strategies tailored to meet the needs of these AIDS patients with liver cirrhosis are urgently in demand. Recent studies have employed the bone marrow-derived stem cells to treat end-stage liver diseases in clinical settings.5 However, the low efficiency in obtaining autologous stem cells hindered the progress in this application. Thus, it is considered feasible to directly transfuse fresh bone marrow (bone marrow transplantation (BMT)) to achieve therapeutic goals.6, 7 To assess the efficacy and safety of transfusing autologous bone marrow in AIDS patients accompanied by advanced liver cirrhosis, we conducted a single-arm trial. The protocol was approved by the Ethics Committee of the Public Health Clinical Center Affiliated with Fudan University. Upon obtaining informed consent, four AIDS patients with decompensated liver cirrhosis caused by HBV or HCV were recruited (Supplementary Table 1). Although the viral loads in peripheral blood of the four patients were under control after ART, their conditions were still progressing with dramatically decreased CD4+ T-cell count. Their Child-Pugh scores were B or C. Owing to portal hypertension induced by liver cirrhosis, all patients suffered from splenomegaly and hypersplenism with low counts of white blood cells and platelets. Thus, splenectomy was performed in each patient to alleviate portal vein hypertension and avoid internal blooding. During the surgical procedure, a catheter was placed in the superior mesenteric vein in preparation for BMT. One week later, 40 ml bone marrow was aspirated by puncture of the iliac crest. Bone marrow cells were suspended in saline without further manipulation and directly transfused through the attached catheter into the portal vein (Figure 1a). One or two BMTs were administrated to each patient at 1-month interval. Figure 1 (a) Schematic illustration of splenectomy and BMT in AIDS patient with decompensated liver cirrhosis. (b and c) Albumin and CD4+ T-cell count in AIDS patient with decompensated liver cirrhosis were assayed before splenectomy and at different times ... The outcome of BMT is surprisingly rewarding. During a 24-month follow-up in patient 1, 2, and 3 and a 3-month follow-up in patient 4 (the most recent patient), the portal vein transfusion of autologous bone marrow cells did not result in any observable side effect and complication. Besides recovery of serum albumin levels and diminishment of ascites, total white blood cell and platelet counts were also significantly improved (Figure 1b and Supplementary Figures 1a–c). Although the prothrombin time and total bilirubin in all patients did not recover completely, the absolute indexes demonstrated stable decrease (Supplementary Figures 1d and e). Moreover, their Child-Pugh scores became A in patient 1, 2 and 3, 1 year after the first transfusion and in patient 4, 3 months after the first transfusion (Supplementary Figure 1f). Surprisingly, 1 month after the first transfusion, CD4+ T-cell count in the peripheral blood of each patient began to increase (Figure 1c). Interestingly, this increasing tendency was maintained in the remaining follow-up period, which is extraordinary in AIDS patients with common ART. Taken together, our data demonstrated the efficacy and safety of autologous BMT on treating advanced liver cirrhosis and recovering CD4+T cells in AIDS patients. Although splenectomy might participate in regaining total white blood cells in peripheral blood, the stable increase of CD4+ T cells in AIDS patients after autologous BMT indicated a possibility that autologous BMT through the hepatic portal vein may reactivate the hematopoietic supportive capability of the liver in adult AIDS patients, which is an exciting research direction warranting further exploration. Importantly, the feasible surgical procedure will make autologous BMT an effective adjuvant therapy to bring benefits to AIDS patients.

Intravitreal Ganciclovir for Neonatal Cytomegalovirus-Associated Retinitis: A Case Report

Congenital cytomegalovirus (CMV) infection is a major cause of birth defects and childhood disorders in the United States. Retinitis occurs in 25% of infants with severely symptomatic congenital CMV and in ∼1% of asymptomatic infants. Intravitreal ganciclovir is recommended in adults with CMV retinitis (CMVR) refractory or noncompliant to intravenous therapy. No literature is available discussing the use of intravitreal ganciclovir for CMVR in neonates. We report a term neonate who received intravenous and intravitreal ganciclovir for treatment of CMVR. Three doses of intravitreal ganciclovir (2 mg per dose in each eye) were administered. Intravitreal injections of ganciclovir appeared to be well tolerated and improvement of the retinitis was appreciated. Intravitreal ganciclovir is an effective treatment of CMVR in adult acquired immunodeficiency syndrome (AIDS) patients. We report one case of intravitreal ganciclovir in a term neonate with promising results.

Paracoccidioides brasiliensis causing a rib lesion in an adult AIDS patient

Paracoccidioidomycosis is a systemic mycosis with a geographic distribution that is limited to Central and South America; Brazil has the highest number of cases. Severe disseminated disease caused by paracoccidioidomycosis was observed in acquired immunodeficiency syndrome patients who live or have resided in endemic paracoccidioidomycosis areas. Here we describe a male patient admitted to a large public hospital with diffuse nodular infiltrates observed in chest radiographs and with erosion at the second rib near the sternum. Blood tests showed anti-human immunodeficiency virus antibodies, a human immunodeficiency virus viral load of 59,700 (4.8 log), and CD4 144/mm(3), with negative serology result for fungal infections. Aspirate of the rib lesion showed cells with a typical morphology of Paracoccidioides brasiliensis, aside from benign inflammatory cells. The histology of the rib biopsy showed typical granulomas and immunostained fungal cells. Although there was no growth in the Sabouraud cultures, Paracoccidioides brasiliensis gp43 and rDNA genes were detected in the aspirate by polymerase chain reaction. Therapy with amphotericin resulted in complete recovery. This type of bone lesion is rare and has been described primarily in the juvenile form of paracoccidioidomycosis; it must be included in the differential diagnosis of bone lesions in adult acquired immunodeficiency syndrome patients of endemic areas.

A retrospective cohort study on reduction of AIDS mortality among patients enrolled in national-free antiretroviral treatment programme in two cities in China

To determine the effect of national free highly active antiretroviral treatment (HAART) on reduction of mortality and relevant risk factors among adult Acquired immunodeficiency syndrome (AIDS) patients. A retrospective cohort study was conducted and all AIDS patients diagnosed before Aug. 30th, 2008 in Zhumadian, Henan province, and Fuyang, Anhui province were enrolled in this study, where HAART initiated in early time. The data and information were collected such as AIDS progress, diagnosis, treatment, death and et al. Among 10,394 AIDS patients, the mean age was (41.7 +/- 9.3) year-old, 50.3% (5233/10,394) were male, 85.0% (8808/10,394) were married, 95.1% (9880/10,394) were farmers, and 81.2% (8438/10,394) were former plasma donors (FPDs). The coverage of HAART increased from 5.2% in 2002 to 66.5% in 2008. Conversely, the overall mortality declined from 35.4/100 person-years in 2002 to 5.9/100 person-years in 2008. In a multivariate Cox proportional hazards analysis, the greatest risk factor for mortality was non-HAART, with a hazard ratio (HR) 4.3 (95%CI: 4.0 - 4.7). Among treated patients, compared with higher CD(4)(+) T cell counts (> 200 cells/microl), those initiating therapy with lower CD(4)(+) T cell counts, were at greater risk to death (< 50 cells/microl, HR = 7.9; 50 - 199 cells/microl, HR = 2.8). Number of opportunistic infections (OIs) was risk to mortality (HR = 2.1). In addition, other risk factors included male, age (>or= 50 years old), and other infection way except FPDs (HR were 1.4, 1.6 and 1.8). The national free treatment program has significantly reduced the AIDS mortality rate among HIV-infected FPDs through the use of generic antiretroviral drugs in rural clinical settings. The effective reduction of AIDS mortality could be realized through increased coverage of therapy.

Cryptococcal Lymphadenitis as a Manifestation of Immune Reconstitution Inflammatory Syndrome in an HIV-Positive Patient: A Case Report and Review of the Literature

Cryptococcus neoformans infections are typically associated with T-cell deficiencies, including acquired immunodeficiency syndrome (AIDS). Although highly active antiretroviral therapy (HAART) has strongly reduced AIDS-related opportunistic infections, the restoration and reactivation of CD4+ cells can induce an immune reconstitution inflammatory syndrome (IRIS), consisting in a deregulated inflammatory response to latent infectious pathogens and/or to their residual antigens. Cryptococcal lymphadenitis has occasionally been documented in IRIS. Here we report a case of histology- and culture-negative cryptococcal lymphadenitis associated with IRIS in an adult AIDS patient with a history of disseminated cryptococcosis, after the start of fully adherent HAART. Appropriate diagnosis was established on nested-PCR and sequence analysis of the interspacer region 2 of C. neoformans ribosomal DNA, and detection of slow-growing blastospores in enrichment cultures of fine-needle lymph node aspirate. Review of recent literature and our case findings suggest that IRIS-associated cryptococcal lymphadenitis is more likely the flare up of a latent infection rather than an immunopathological response to residual antigen of unviable cryptococci.

Ventriculitis: a rare case of primary cerebral toxoplasmosis in AIDS patient and literature review

Cerebral toxoplasmosis remains the most important neurological opportunistic infection and the most common cause of intracerebral mass lesion in patients with acquired immunodeficiency syndrome (AIDS). We report a case of an adult AIDS patient with an atypical pattern of toxoplasma encephalitis, presenting with ventriculitis and obstructive hydrocephalus without any focal parenchymal lesion.

Treatment Strategies for HIV‐Infected Patients with Tuberculosis: Ongoing and Planned Clinical Trials

Currently, there are limited data to guide the management of highly active antiretroviral therapy (HAART) for human immunodeficiency virus type 1 (HIV-1)-infected patients with active tuberculosis (TB), the leading cause of death among individuals with acquired immunodeficiency syndrome (AIDS) in resource-limited areas. Four trials to take place in Southeast Asian, African, and South American countries will address the unresolved question of the optimal timing for initiation of HAART in patients with AIDS and TB: (1) Cambodian Early versus Late Introduction of Antiretrovirals (CAMELIA [ANRS 1295/NIH-CIPRA KH001]), (2) Adult AIDS Clinical Trials Group A5221, (3) START, and (4) a trial sponsored by the World Health Organization/Special Programme for Research and Training in Tropical Diseases. Two other clinical questions regarding patients with TB and HIV-1 coinfection are also undergoing evaluation: (1) the benefits of short-term HAART when CD4 cell counts are >350 cells/mm(3) (PART [NIH 1 R01 AI051219-01A2]) and (2) the efficacy of a once-daily HAART regimen in treatment-naive patients (BKVIR [ANRS 129]). Here, we present an overview of these ongoing or planned clinical studies, which are supported by international agencies.

Longitudinal Changes in Sexual Risk Behavior Among HIV+ and HIV− Male Injecting Drug Users

Injecting drug users (IDUs) play a prominent role in the transmission of human immunodeficiency virus (HIV), particularly in urban areas such as New York City, where they comprise nearly half of all adult acquired immunodeficiency syndrome (AIDS) cases. Intervention studies have demonstrated that IDUs are responsive to safer sex messages, but sexual behavior appears to be more resistant to change than drug use behavior. This multidisciplinary study (without an intervention component) assesses changes in sexual risk behavior as a function of time, HIV status, and disease progression in a cohort of HIV+ and HIV− male IDUs (N = 144) for 4 years. Results: For HIV+ and HIV− men, there were increases in abstinence and monogamy, with decreases in the frequency of unprotected vaginal/anal sex and sexual risk index scores. With the exception of monogamy, HIV+ men reported lower levels of risk. Although there was also a decline in substance use, this accounted for only some of the decline in sexual risk behavior. Among the HIV+ men, a CD4 level below 200 was associated with more abstinence and monogamy. HIV-related medical symptoms were associated with increased abstinence, less unprotected sex, and lower sexual risk index scores. Lower neuropsychological memory test scores were associated with increased abstinence and lower sexual risk index scores. Neurological impairment and depression were not associated with sexual risk behavior. Conclusion: IDU men in New York City have modified their sexual behavior toward safer practices. Lower levels of risk are found among HIV+ men, particularly those with more progressed HIV illness. Nevertheless, a substantial amount of sexual risk behavior remained in this cohort, indicating the continued need for education and intervention.

Ocular disease in children with vertically acquired human immunodeficiency virus infection

Background: Clinical reports suggest that ocular disease in infants and children vertically infected with human immunodeficiency virus (HIV) is different from that in adults. Pediatric patients with acquired immunodeficiency syndrome (AIDS) and HIV infection are being treated more aggressively and are living longer, but current literature on the incidence of AIDS-related ocular disease in vertically acquired HIV infection is limited. Methods: Thirty-three children with culture-positive, vertically acquired HIV infections were prospectively followed with ophthalmic examinations between September 1991 and August 1996 at the University of Massachusetts. Patients were categorized as having symptomatic or asymptomatic HIV disease according to the U.S. Centers for Disease Control and Prevention guidelines. Absolute CD4 counts and other measures of immune function were obtained. Results: The average length of follow-up was 30 months, and the average number of ophthalmic examinations per patient was 4.8. Ten patients developed ophthalmic findings. Nine of 18 (50%) patients with symptomatic AIDS disease developed ophthalmic findings. One of 15 asymptomatic HIV-infected patients developed ocular findings. Two patients with absolute CD4 counts less than 10 developed cytomegalovirus retinitis. Conclusions: These results suggest that AIDS-related ophthalmic disease is less common in vertically infected children than in adult AIDS patients. It also supports intensified clinical surveillance for cytomegalovirus retinitis in children with end-stage disease and very low CD4 counts.

Human parvovirus B19 in bone marrows from adults with acquired immunodeficiency syndrome: A comparative study using in situ hybridization and immunohistochemistry

Human parvovirus B19, which infects and lyses erythroid precursors, can cause severe anemia in patients with immunodeficiency. The incidence of parvovirus infection in adult acquired immunodeficiency syndrome (AIDS) patients is unknown. Eighty-one archival formalinfixed, paraffin-embedded (FFPE) bone marrow biopsies from 73 AIDS adults were immunostained with monoclonal R92F6 against B19 VP1 and VP2 capsid proteins using streptavidin peroxidase and streptavidin alkaline phosphatase techniques. In addition, the same tissues were hybridized in situ with a digoxigenin-labeled parvovirus B19 DNA probe. Five FFPE bone marrows, from 3 HIV-negative patients with positive immunoglobulin M (IgM) serology for parvovirus B19, and 1 parvovirus B19-infected fetal liver were positive controls. By immunoperoxidase, all tissues were negative with R92F6 except the fetal liver, which exhibited strong positivity predominantly in viral inclusions. With immunoalkaline phosphatase, all positive controls were immunoreactive with R92F6; however, the AIDS marrows were negative. With in situ hybridization (ISH), all positive controls and 7 of 81 (8.6%) of AIDS marrows were positive for B19 parvovirus DNA. We conclude that ISH is more sensitive than R92F6 immunohistochemistry in parvovirus B19 detection. A small but significant number of bone marrows from AIDS adults shows evidence of human parvovirus B19 infection.

Family Influences on Latino and Anglo Adolescents' Sexual Behavior

Sexual intercourse in absence of birth control has resulted in an epidemic of over one million teen pregnancies annually (Forrest & Singh, 1990), costing $17 billion in medical and social services each year (Hayes, 1987). About 1 in 7 teens have contracted one or more sexually transmitted diseases (STDs) (Quackenbush, 1987), accounting for 25% of the reported STD cases (Hingson et al., 1990). Among the nearly 285,000 adolescent and adult acquired immunodeficiency syndrome (AIDS) cases in the United States (Center for Disease Control, 1993a), nearly 11,000 were diagnosed between the ages of 13 and 24 (Center for Disease Control, 1993a). However, the actual number of adolescents infected with human immunodeficiency virus (HIV) is estimated to be much higher and doubling each year (Brooks-Gunn, Boyer, & Hein, 1988). Given a latency period as long as 10 years, the 20% of AIDS cases diagnosed in adults between the ages of 20 and 29 were most likely acquired during adolescence (Center for Disease Control, 1992; Rotherum-Borus & Koopman, 1992). HIV infection rates among larger samples range from .10% among military recruits to .65% among Job Corps residents (Select Committee on Children, Youth, and Families, 1992). Higher rates have been reported for select risk groups: One percent of females under 19 giving birth, 2.2% of youths attending STD clinics, and 6.7% of runaways (Rotherum-Borus & Koopman, 1992).Incomplete understanding of sexual development has limited our ability to effect public health programs to control teen pregnancies, STDs, or the AIDS epidemic. Biological and behavioral theories have proposed models of sexual development from which these epidemics might be controlled (Hagenhoff, Lowe, Hovell, & Rugg, 1987; Rugg, Hovell, & Franzini, 1989). However, though sexual practice is generally recognized as a function of both biological (e.g., hormonal changes with puberty) and social processes (e.g., peer pressure) (Panzarine & Santelli, 1987), the role of the family in determining sexual development has not been fully investigated. The family plays a key role in the formation of sexual attitudes and behavior by providing role models, a social and economic environment, and norms for sexual conduct (Thornton & Camburn, 1987). Parental and sibling sexual behavior, family structure, socioeconomic status, and religiosity are among the family's contributions to the development of adolescent sexual attitudes and behaviors. The degree to which parents communicate about sexual issues, express love and affection, or set rules to be followed by their adolescent children may influence their children's sexual behavior. Parental influence on sons' sexual behavior is less well studied and may be more subtle than that exerted on daughters' behavior, with male sexuality possibly more influenced by culture (Yarber & Greer, 1986). Family influence probably decreases during the adolescent years and, by college age, the previous impact of parents has probably become insignificant (Yarber & Greer, 1986).Adolescents traditionally report that their parents' role as a source of sexual information is minor; parents typically do not discuss sexual issues with their adolescent children (Hayes, 1987; Roberts & Holt, 1980). Instead, family communication regarding sex consists of rule making and the exercise of authority (Scales & Everly, 1977). Darling and Hicks (1982) found that most parental sexual messages tend to be negative, and convey double standards regarding sons' versus daughters' behaviors. Adolescent sexual attitudes are influenced by the frequency and type of communication that occurs within the family (Akpom, Apkom, & Davis, 1976; Darling & Hicks, 1982; Fisher, 1985; Fox, 1981; McNab, 1976; Rothenberg, 1980; Shelley, 1981). Fox (1981) reported that the frequency of discussions about sex and birth control was highest among those without a high school diploma, women no longer married to the adolescent's father, and those from low-income families. …

Clinical comparison of adult and pediatric NeuroAIDS

Human Immunodeficiency Virus type-1 (HIV-1)-associated neurologic disease occurs as the initial presenting clinical manifestation of acquired immunodeficiency syndrome (AIDS) in 3-7% of infected patients, but in up to 18% of children and adolescents (Janssen, 1992; Janssen et al., 1992; Scott et al., 1989; Mintz et al., 1989a; Epstein et al., 1986). The overall prevalence of dementia in adult AIDS patients is 7.3-11.3% (Janssen, 1992), but up to 30-60% of children with AIDS manifest an analogous progressive encephalopathy (Epstein et al., 1986; Belman et al., 1988; Mintz, 1992; The European Collaborative Study, 1990). As a result of both direct and indirect effects of HIV-1 infection of the central nervous system (CNS), a distinct clinical and pathologic picture has emerged of insidious and severe neurologic deterioration, termed "AIDS Dementia Complex" (ADC) in adults, and "HIV-1-associated Progressive Encephalopathy" (PE) in children (Working Group, 1991) (see Table 1). In the severe manifestations of this pariah, there is little dispute as to the necessity of CNS HIV-1 infection for precipitating the cascade of adverse neurologic symptoms, although the pathogenic mechanisms of neurologic dysfunction and destruction--whether a result of direct cellular infection of HIV, secondarily produced and upregulated cytotoxic cytokines, or co-infection with opportunistic pathogens--remains an area of active research (Epstein and Gendelman, 1993; Fiala et al., 1993; Wiley and Nelson, 1988; Saito et al., 1994; Koenig et al., 1986; Sharer, 1992). Furthermore, the existence of systemic immune deficiency renders the CNS susceptible to opportunistic infection (OI), particularly in adult patients, adding further to morbidity and mortality (Clifford and Campbell, 1992). With the introduction of antiretroviral nucleoside analogues, there have been reports of a decreasing incidence of ADC (Portegies et al., 1989; Day et al., 1992), and amelioration--at least temporarily--of PE in children (Pizzo et al., 1988; Mintz and Epstein, 1992; Brouwers et al., 1990; Mintz et al., 1990). This appends further evidence to the central precipitating role of CNS HIV-1 infection.

Identification of cytoplasmic tubular structures in Pneumocystis carinii

Pneumocystis carinii (PC) is an extracellular organism which frequently causes pneumonia in immunocompromised patients. In the United States more than 60% of patients with acquired immunodeficiency syndrome (AIDS) have at least one episode of PC pneumonia. The earliest published ultrastructural study of PC was undertaken by Dickmann et al. in 1954. A few articles which studied the ultrastructure of PC continued to appear in the German medical literature in the late 1950’s and early 1960’s. With the development of immunosuppressive chemotherapy for cancer patients and in later years the onslaught of the AIDS epidemic, the ultrastuctural literature concerned with PC has expanded. The internal morphology of PC has proved to be difficult to preserve and although extensively examined questions remain concerning the intracellular contents of PC. In this study we report the presence of cytoplasmic tubular structures (CTS) in PC. These structures have been identified in hepatocytes of Chimpanzees infected with non-A,non-B hepatitis and in the lymphocytes of humans with adult T-cell leukemia or AIDS.

Survival with AIDS in Massachusetts, 1979 to 1989.

The goal of the study was to determine survival time after diagnosis of acquired immunodeficiency syndrome (AIDS) and to identify predictors of survival. We conducted a population-based prospective survival analysis of all Massachusetts-resident adult AIDS patients diagnosed from January 1, 1979, through December 31, 1988. Median survival was 406 days, with a 5-year survival rate of 3%. Age older than 40 years (P = .001), a diagnosis other than Kaposi's sarcoma (P = .001), and a history of intravenous drug use (P < or = .01) were associated with shorter survival after confounding was controlled. Survival increased as year of diagnosis became more recent (P < .0001). This temporal effect was strongest for patients with Pneumocystis carinii pneumonia. Individuals with Kaposi's sarcoma, Hispanics, homosexual men who were concurrent intravenous drug users, and residents of the greater Boston standard metropolitan statistical area, excluding the city of Boston, did not experience increases in survival over time. With the exception of cases initially defined by Kaposi's sarcoma, recently diagnosed AIDS case subjects survive longer than those diagnosed earlier in the epidemic. Further work is needed to determine whether this effect is due to lead-time bias or better treatment after diagnosis.

Smooth Muscle Tumors in Children With Human Immunodeficiency Virus Infection

Neoplastic disease is an increasing problem in adults with the acquired immunodeficiency syndrome (AIDS). Kaposi's sarcoma is the indicator disease in 9% and lymphoma in 3% of adult AIDS cases.1 Indeed, the estimated incidence rate of non-Hodgkin's lymphomas (NHLs) reaches almost 50% in adult patients who have survived for up to 3 years while receiving antiretroviral therapy and who have a CD4 count below 50 cells/mm3.2 Children with human immunodeficiency virus (HIV) infection have also been treated and followed up for an extended period of time, but a similar increase in the incidence of malignancies has not yet been described. Through December 1990, only 17 children with NHL and 1 child with Kaposi's sarcoma as AIDS-indicator disease have been reported to the Centers of Disease Control.1

Report of the symposium on the use of intravenous gammaglobulin in adults infected with the human immunodeficiency virus

On July 27, 1989, the International Conference on Molecular Aspects of Immune Response and Infectious Diseases devoted a symposium to the subject of the use of intravenous gamma globulin (IVIG) in acquired immunodeficiency syndrome (AIDS). The information presented confirmed that IVIG benefits human immunodeficiency virus (HIV)-infected children with recurrent infections and that much remains to be learned about the influence of IVIG in adult AIDS. The symposium participants recognized the urgent need to develop randomized clinical trials using a control group to assess the efficacy of a treatment with IVIG in PGL (persistent generalized lymphadenopathy), ARC (AIDS-related complex), and AIDS. To prepare this report, a committee was established, including individuals with expertise in immunology, immunopharmacology, microbiology, virology, infectious diseases, general medicine, and pediatrics and representing research experience in academia and hospitals. After an introduction to the report with a summary of immunotherapeutic agents under evaluation to treat HIV infection, section 1 lays out the present understanding of the disease pathogenesis. Section 2 then outlines the treatment of HIV-seropositive individuals, discussing the uncertainties that any treatment entails. Section 3 discusses the rationale for treating HIV-infected individuals with IVIG, and Section 4 examines the major differences between IVIG and hyperimmunoglobulins for the treatment of HIV infection. Section 5 looks at IVIG as a mean to delay the emergence of opportunistic infections and restore immunocompetence in AIDS and related illnesses, and Sections 6 and 7 suggest a pilot protocol on the use of IVIG in association with low-dose or standard-dose zidovudine (AZT).(ABSTRACT TRUNCATED AT 250 WORDS)

A severity classification system for AIDS hospitalizations.

The authors describe a new model for classifying hospitalized patients with acquired immunodeficiency syndrome (AIDS) according to their severity of illness. In the first phase of the project, a clinical model indicating the relative severity of AIDS complications was formulated, based on the clinical literature and expert opinion. In the second phase, the model was tested empirically using data on in-patient mortality of over 6,000 adult AIDS hospitalizations in New York State during 1985. The ordering of AIDS-related complications in the clinical model was revised to reflect a continuum of increasing likelihood of death in the hospital. The final classification system for AIDS hospitalizations has 20 substages, grouped into three stages, with in-patient mortality rates increasing from 6% to 60%. The system is automated and can be applied to different AIDS populations to analyze resource use and outcomes of hospital care.

Concurrent Cytomegalovirus and Herpes Simplex Virus Infections in Skin Biopsy Specimens from Two AIDS Patients with Fatal CMV Infection

Cytomegalovirus (CMV) infection involving the skin is rare. Only a few cases have been documented by skin biopsies, including three patients with acquired immunodeficiency syndrome (AIDS). We report concurrent CMV and herpes simplex virus (HSV) infections in skin biopsy specimens from nonanogenital sites in two adult AIDS patients with fatal CMV infection. In one case, a nonhealing ulcer on the lower lip provided the first clue to systemic CMV infection. In the other case, two necrotic papules developed on the legs during the course of systemic CMV infection. Microscopically diagnostic findings for both infections were present. Immunoperoxidase stains were positive for CMV in both cases and HSV in one case. In both cases, the infections were not appreciated in the original interpretations of the biopsy material. This may reflect either a low index of suspicion and/or unfamiliarity of the microscopic features of CMV and, to a lesser extent, of HSV infection in the skin. Familiarization with the diagnostic cytopathic changes of these viral infections and a high index of suspicion are essential for correct diagnosis in evaluation of skin lesions of immunocompromised hosts.