Although clinical immunology has contributed greatly to diagnostic precision and laboratory science, it has not yet made any truly significant inroads into treatment which is, after all, the bottom line. We still administer nonspecific and highly toxic drugs like corticosteroids and immunosuppressives. We employ methods like lymphoplasmaphoresis or total lymphoid irradiation, understanding very little about why they work or if they work. Transfer factor, thymic hormones, interferon and the like have been around for over ten years but are still largely experimental. Clinical immunologists are treating cancer and autoimmune disorders as we did a decade ago. It is my thesis that acquired immunodeficiency syndrome, popularly known as AIDS, indirectly offers a challenge and hope that this situation might change in this decade. For one thing, AIDS has made the general public more aware of clinical immunology. Secondly, this condition with complex and multifactorial etiology seems to validate the theoretical foundation upon which the clinical science of immunology is based. In AIDS, environmental, genetic, viral and sociological factors interact in an unfortunate combination that results in devastating immunodeficiency, high risk for opportunistic infections, and susceptibility for Kaposi 's sarcoma in almost epidemic proportions (Table I). Clinical immunology is undergoing a transition from a descriptive science to one devoted more to modulation and restoration. We recognize that even immunologically hyperactive states like autoimmunity arise as a consequence of deficiencies in regulatory cells, factors and function. Stimulated by enormous technological advances and supported by industry as well as by government and academia, we have launched an effort to develop new drugs and biological agents that could lead to therapeutic advances in autoimmunity and cancer. Nowhere are these new modalities more critically needed than today in major US cities where the mortality from AIDS is approximately 50%. More individuals have died from AIDS than from Legionnaire 's disease and toxic-shock syndrome combined. The basic facts of AIDS are as well known to the general public as they are to physicians. There have been over 1 200 known cases since the first reports appeared two years ago '-3. 87 % of cases occur in male homosexuals, spreading anxieties, fears and new psychological problems in this population. Other groups at risk are intravenous-drug users, hemophiliacs maintained on lyophilized factor-VIII concentrate prepared from pooled plasma, Haitians (Haiti is a vacation spot for homosexuals), and women and children in contact with these populations 4. 5% of cases do not belong to any definable ' at risk' category. The disease, probably the greatest medical mystery of the modern era, is almost certainly associated with a transmissible agent, perhaps a defective virus, possibly a mutated cytomegalovirus or hepatitis B virus (Table II). There is a prodromal syndrome characterized by fever, malaise, diarrhea, weight loss and generalized lymphadenopathy. The progression from this stage to the fullblown syndrome is not a frequent event. Pneumocystis carinii pneumonia is the most common infection, but unusual viruses (cytomegalovirus [CMV], Epstein-Barr virus [EBV], herpes simplex virus), fungi (Candida, Aspergillus, CO~ptococcus), protozoa (Toxoplasma) O r bacteria (Mycobacterium tuberculosis) may establish themselves in the immunocompromised and thus defenseless host 5. There is a marked impairment of cell-mediated immunity and T-cell effector functions leading to lymphopenia, skin anergy and impaired proliferative response to antigens, alloantigens and mitogens 6'7. Helper T cells are greatly decreased with a variable effect on suppressor T cells. They are often normal but can be increased, reducing the helper:suppressor (T4:T8) ratio. P r o duction of interleukin-2 (IL-2) and )'-interferon is diminished, but thymosin a, levels are elevated in patients with the prodrome 6. Natural killer cell and antibodydependent killer-cell activities are impaired. B-cell function is generally spared and some few instances of autoimmune thrombocytopenic purpura have been reported s,9.
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