Neopterin and beta 2-microglobulin as prognostic indices in human immunodeficiency virus type 1 infection

Neurochemical biomarkers to study CNS effects of COVID-19: a narrative review and synthesis

Neurological symptoms are frequently reported in patients suffering from COVID‐19. Common CNS‐related symptoms include anosmia, caused by viral interaction with either neurons or supporting cells in nasal olfactory tissues. Diffuse encephalopathy is the most common sign of CNS dysfunction, which likely results from the CNS consequences of the systemic inflammatory syndrome associated with severe COVID‐19. Additionally, microvascular injuries and thromboembolic events likely contribute to the neurologic impact of acute COVID‐19. These observations are supported by evidence of CNS immune activation in cerebrospinal fluid (CSF) and in autopsy tissue, along with the detection of microvascular injuries in both pathological and neuroimaging studies. The frequent occurrence of thromboembolic events in patients with COVID‐19 has generated different hypotheses, among which viral interaction with perivascular cells is particularly attractive, yet unproven. A distinguishing feature of CSF findings in SARS‐CoV‐2 infection is that clinical signs characteristic of neurotropic viral infections (CSF pleocytosis and blood–brain barrier injury) are mild or absent. Moreover, virus detection in CSF is rare and often of uncertain significance. In this review, we provide an overview of the neurological impact that occurs in the acute phase of COVID‐19, and the role of CSF biomarkers in the clinical management and research to better treat and understand the disease. In addition to aiding as diagnostic and prognostic tools during acute infection, the use of comprehensive and well‐characterized CSF and blood biomarkers will be vital in understanding the potential impact on the CNS in the rapidly increasing number of individuals recovering from COVID‐19.

Simultaneous determination of twelve polar pteridines including dihydro- and tetrahydropteridine in human urine by hydrophilic interaction liquid chromatography with tandem mass spectrometry

Pteridines and their derivatives are important cofactors in the process of cell metabolism, and the level of urinary excretion of these compounds is considered as an important clinical criterion. In this work, a new separation method involving hydrophilic interaction chromatography (HILIC) with tandem mass spectrometric detection has been developed for the simultaneous analysis of 12 pteridines including oxidized, di- and tetrahydroforms, namely neopterin, 7,8-dihydroneopterin, biopterin, 7,8-dihydrobiopterin, 5,6,7,8-tetrahydrobiopterin, dimethylpterin, dimethyltetrahydropterin, pterin, isoxanthopterin, xanthopterin, sepiapterin and pterin-6-carboxylic acid, in human urine without oxidative pretreatments. The stabilizing agent (dithiothreitol) at various concentrations and the stability of oxidized, di- and tetrahydroforms during the sample's short-term storage and processing and of the extracts were tested. In the developed method, 12 pteridines were chromatographically separated on an ZIC-HILIC column by gradient elution, and the run time was 20 min. Matrix effect was evaluated and several dilutions of urine were tested in order to study the evolution of signal suppression. Spiked recovery studies demonstrated that the technique was both accurate (83.1-116.7%) and precise (RSD 1.4-15.6%). Finally, several clinical urine specimens without oxidative pretreatments were examined with the new technique and compared with previous reports.

Temporarily controlled HIV-1 replication after intravenous immunoglobulin treatment of Guillain-Barré syndrome

HIV establishes a latent infection in resting CD4(+) T-lymphocytes. A possible strategy to eliminate cellular reservoirs in long-lived, HIV-1-infected quiescent CD4(+) T-lymphocytes might be to add T-cell-activating agents to potent antiretroviral therapy. In this report we describe a patient with Guillain-Barré syndrome treated with high dose intravenous immunoglobulin (IVIG) in addition to antiretroviral therapy. A transiently increased viral load and immunoactivation during the IVIG treatment suggest activation of latently infected cells and increased turnover rate of the latent viral reservoir. HIV replication was controlled with plasma viral load <20 copies/ml, for at least 3 months after antiretroviral treatment interruption. CSF neural markers reflecting degenerative processes in the brain during the symptomatic period and follow-up were also analysed. Very high CSF sulfatide concentrations were found indicating that the pathology involves severe demyelination.We hypothesize that IVIG in this case contributed to an activation of latently infected cells, which led to a transient increase in plasma HIV-1 RNA during the IVIG treatment and a long period of undetectable viral load after antiretroviral treatment interruption. Further, this is the first time, to our knowledge, that detailed CSF findings are described in HIV-1 associated GBS.

Micellar electrokinetic chromatographic and capillary zone electrophoretic methods for screening urinary biomarkers of human disorders: a critical review of the state-of-the-art

Human urine plays a central role in clinical diagnostic being one of the most-frequently used body fluid for detection of biological markers. Samples from patients with different diseases display patterns of biomarkers that differ significantly from those obtained from healthy subjects. The availability of fast, reproducible, and easy-to-apply analytical techniques that would allow identification of a large number of these analytes is thus highly desiderable since they may provide detailed information about the progression of a pathological process. From among the variety of methods so far applied for the determination of urinary metabolites, capillary electrophoresis, both in the capillary zone electrophoresis (CZE) and micellar electrokinetic chromatography (MEKC) modes, represents a robust and reliable analytical tool widely used in this area. The aim of the present article is to focus the interest of the reader on recent applications of MEKC and CZE in the field of urinary biomarkers and to discuss advantages and/or limitations of each mode.

Saliva and inhibition of HIV-1 infection: molecular mechanisms

Oral fluids are rarely a vehicle for HIV-1 infection in vivo, unlike other mucosal secretions. This unique property raises questions regarding (1) the molecular mechanisms responsible for the lack of salivary transmission, (2) the extent to which oral immunological responses mirror responses at other mucosal sites, (3) the use of promising salivary markers of HIV-1 disease progression, (4) the relationship between oral and blood viral loads, (5) cofactors that influence oro-genital transmission, and (6) the feasibility of oral-based antibody testing for HIV-1 diagnosis in the home. This paper discusses these questions and provides background summaries, findings from new studies, consensus opinions, practical relevance to developing countries, and suggestions for future research agenda on each of the key topics.

Pteridine analysis in urine by capillary electrophoresis using laser-induced fluorescence detection

Pteridines are a class of compounds excreted in urine, the levels of which are found to elevate significantly in tumor-related diseases. For the first time, we have developed a method, based on high-performance capillary electrophoresis (HPCE) and laser-induced fluorescence (LIF) detection, to monitor the pteridine levels in urine. HPCE provides better separation than high-performance liquid chromatography and the LIF detector enables us to detect minute amounts of pteridines in body fluid. Eight different pteridine derivatives were well separated in 0.1 M Tris-0.1 M borate-2 mM EDTA buffer (pH 8.75) using a 60-cm fused-silica capillary (50-micron i.d., 35-cm effective length), six of which were detected and characterized in urine samples from normal persons and different cancer patients. The detection limits of these pteridines are under 1 x 10(-10) M. The levels of neopterin, pterine, xanthopterin, and pterin-6-carboxylic acid were found to be significantly elevated in urine excreted by cancer patents, while the level of isoxanthopterin dropped in these patients. No significant change of biopterin level was found between healthy individuals and cancer patients. This method can be used in clinical laboratories either for cancer monitoring or for precancer screening.

Serum neopterin, beta2-microglobulin, soluble interleukin-2 receptors, and immunoglobulin levels in healthy adolescents

Serum biomarkers, such as neopterin, beta2-microglobulin (B2M), and soluble interleukin-2 receptors (sIL-2R), are elevated in viral infections, including HIV-1 infection, and in inflammatory conditions, autoimmune disease, and malignancies. For many of these conditions, serum levels correlate with disease activity. Application of these biomarkers in adolescents is limited by a lack of information on the range and determinants of variability (age, sex, race) for serum levels of these important molecules in this age group. To address this question, we analyzed serum samples from a well-characterized heterogeneous population of 111 healthy adolescents. White children had significantly higher serum levels of sIL-2R and IgM and lower levels of IgG (P </= 0.001) than black children. Boys had higher sIL-2R and B2M levels (P < 0.005) and lower IgM levels (P < 0.05) than girls. No significant age effect on B2M or neopterin level was observed over the age range of 12-19 years included in this analysis. However, stratification by race showed that serum sIL-2R level was significantly associated with age among whites, but not among blacks. Values of these biomarkers in this population are compared with age-stratified values in the previously analyzed 20- to 69-year-old population from whose households the adolescent subjects were recruited.

Analysis of clinical AIDS-free interval after CD4+ cell counts fall below 200 x 10(6) L-1 in Japanese haemophiliacs infected with HIV-1

We analysed the time from the date CD4+ cell counts fell below 200 x 10(6) L-1, defined as ti, to the onset of clinical AIDS, according to the 1987 Centers for Disease Control and Prevention case definition, in 129 Japanese haemophilia patients infected with HIV-1. The cumulative onset of clinical AIDS was analysed by the Kaplan-Meier method and proportional hazard model. Incorporated covariates were age of each patient at time ti, as well as CD4+ and CD8+ cell counts, serum levels of IgG, IgA, IgM, GOT and GPT at ti. The time of antiretroviral treatment initiation was also considered. The 50% AIDS-free interval after ti was 3.00 years (95% confidence interval (CI), range 0.49-5.51) and 1.71 years (95% CI, range 0.66-2.76) for the patients at CDC stage II and stage III, respectively (significantly different, P = 0.0013). Among the patients at CDC stage II at ti, higher levels of IgA were tightly associated with a shorter period from ti to onset of clinical AIDS (P < 0.0001), and relative hazard was 1.35 (95% CI, 1.11-1.64) with increase of IgA level by 1.0 g L-1. Thus there is a broad distribution in the time to onset of clinical AIDS in Japanese haemophiliacs even after CD4+ cell counts fall below 200 x 10(6) L-1. This should be taken into consideration in deciding upon the therapy and care of HIV-1 infected people.

Activated Cellular Immunity in Chronic Hepatitis C

The importance of local immune mechanisms in the development of chronic hepatitis C and its relation with systemic immune disorders is becoming clear and suggests a more generalized involvement of the immune response in this disease. For this reason, we have investigated the serum concentrations of the soluble immune activation markers neopterin, β2-microglobulin and interferon-γ in 28 patients with hepatitis C virus related chronic active hepatitis (n=20) or chronic persistent hepatitis (n=8). Increased levels of neopterin, β2-microglobulin and interferon-γ were found in a subgroup of the patients. Serum β2-microglobulin and neopterin concentrations were strongly related. Patients with chronic active hepatitis had higher β2-microglobulin levels than those with chronic persistent hepatitis. There were no significant differences in neopterin and interferon-γ levels between chronic active hepatitis and chronic persistent hepatitis. A strong association was found between older age and higher β2-microglobulin levels. Because patients with chronic active hepatitis were older than patients with chronic persistent hepatitis, older age may have at least partly contributed to the difference in β2-microglobulin. Because of the known association between cell-mediated immune activation and the production of interferon-γ, neopterin and β32-microglobulin, our results imply that a Th1-type immune response is stimulated in chronic hepatitis C.

Elevated concentrations of circulating intercellular adhesion molecule 1 (ICAM-1) and of vascular cell adhesion molecule 1 (VCAM-1) in HIV-1 infection

The aim of this study was to determine whether elevated levels of circulating forms of the soluble adhesion molecules, Intercellular Adhesion Molecule-1 (cICAM-1), Vascular Cell Adhesion Molecule-1 (cVCAM-1) and E-Selectin (cE-Selectin) are observed in the sera of HIV-1 infected individuals as compared to healthy HIV seronegative adults and whether these elevated levels can be correlated with disease progression. Significantly elevated levels of cICAM-1-ranging from 184 to 1116 ng/ml with a mean of 617 ng/ml-and cVCAM-1-ranging from 653 to 3456 ng/ml with a mean of 1500 ng/ml-were observed in the sera of 29 HIV-1 infected individuals as compared to controls-ranging from 152 to 354 ng/ml with a mean of 248 ng/ml for cICAM-1 and from 328 to 792 ng/ml with a mean of 560 ng/ml for cVCAM-1 (P < 0.001). The serum concentrations of cE-Selectin of the HIV-1 infected individuals did not differ from those of the healthy controls. The elevated levels of cICAM-1, cVCAM-1 did not correlate with the CD4 count or the serum concentration of C-reactive protein. However, a significant correlation was observed between the serum concentrations of cVCAM-1 and those of neopterin. Since cICAM-1 as well as cVCAM-1 can interfere with adhesion events leading to immunological functions, it can be suggested that the high amounts of these circulating forms of adhesion molecules, when present in the sera of HIV-1 positive individuals, can further disturb the immune system of these patients. In addition, the present study also suggests that the seric concentrations of cVCAM-1 can be used as pronostic indicators.

Serum soluble markers of immune activation and disease activity in systemic lupus erythematosus

We investigated a possible association between markers of immune activation and disease activity in 52 patients with systemic lupus erythematosus (SLE). Serum concentrations of neopterin, beta-2-microglobulin, 55 kD-type soluble tumor necrosis factor receptor, soluble interleukin-2 receptor and soluble CD8 were compared to the Index of European Consensus Lupus Activity Measurement (ECLAM). All markers of immune activation, except sCD8, significantly correlated with ECLAM. Stepwise multiple linear regression analysis revealed erythrocyte sedimentation rate and neopterin to correlate best with ECLAM (multiple correlation coefficient = 0.74, P < 0.001). The study shows that serum neopterin concentrations are a useful independent index for disease activity in SLE. The finding of enhanced concentrations of various parameters of immune activation in patients confirm a role of the T cell and macrophage activation in the pathogenesis of SLE.

Factors influencing serum neopterin and beta 2-microglobulin levels in a healthy diverse population

Sera and questionnaire data from a population-based random sample of healthy adults was used to evaluate factors influencing neopterin and beta 2-microglobulin (beta 2m) values. Both neopterin and beta 2m levels increased with age and were higher among white than blacks (mean values for whites and blacks: neopterin, 5.06 vs 4.49 nmol/L; beta 2m, 1.36 vs 1.28 mg/L). Gender differences were noted for beta 2m but not neopterin values (beta 2m males vs females: 1.37 vs 1.29 mg/L). Neopterin values were lower among current smokers than among nonsmokers (4.32 vs 5.16 nmol/L) and were higher among users of antihistamines (5.46 among users vs 4.65 nmol/L among nonusers). Neopterin and beta 2m were correlated in this healthy adult population (adjusted r = 0.53, P = 0.001), yet no other interrelationships with numerous biologic markers except between beta 2m and serum-soluble interleukin-2 receptor levels (adjusted r = .41, P = 0.05) were observed. These findings provide important baseline information to consider before planning or evaluating studies utilizing neopterin or beta 2m levels.

Management of antiretroviral drug therapy in human immunodeficiency virus infection

Nucleoside analog reverse transcriptase inhibitors, including zidovudine, didanosine, and zalcitabine, remain the cornerstone of therapy against human immunodeficiency virus (HIV) infection, the cause of AIDS. Although therapeutic regimens have been designed that are effective in slowing the progression of disease, therapy with these agents has not been optimized. Ultimately, therapy is destined to fail in most patients. Decisions regarding when to begin therapy and the course of action to take when failure of therapy occurs are largely in the hands of the patient's physician, and currently must be made without the support of conclusive clinical data. In addition to an understanding of the recommended dosing guidelines, proper management of AIDS therapy requires a fundamental knowledge of the disease process, the pharmacology and limitations of the agents employed against the virus, and close cooperation with the clinical laboratory. Therefore, this article reviews the pharmacology of the three drugs currently approved for treatment of HIV infection, and the current guidelines for their use. The article also reviews the clinical and laboratory management of these agents, including the use of surrogate markers and the potential for pharmacokinetic optimization of therapy.

Zidovudine. An update of its pharmacodynamic and pharmacokinetic properties, and therapeutic efficacy

Zidovudine remains the mainstay in the treatment of patients infected with human immunodeficiency virus (HIV). The drug delays disease progression to acquired immunodeficiency syndrome (AIDS) and to AIDS-related complex (ARC), reduces opportunistic infections, and increases survival in patients with advanced HIV infection. There is evidence to suggest that zidovudine also delays disease progression in patients with mild symptomatic disease. Although one study has shown zidovudine to have no significant beneficial effects on survival or disease progression in patients with asymptomatic HIV infection, several other studies have shown zidovudine to delay disease progression in this patient group. Results from related ongoing studies are awaited with interest. Zidovudine reduces the incidence of AIDS dementia complex (ADC) and appears to prolong survival in these patients, and improves other neurological complications of HIV infection. The drug also appears to enhance the efficacy of interferon-alpha in patients with Kaposi's sarcoma. Although zidovudine is widely used as postexposure prophylaxis following accidental exposure to HIV, its efficacy in preventing seroconversion is unclear. Whether zidovudine prevents vertical transmission also remains to be determined. The overall efficacy of zidovudine in the treatment of children with HIV infection appears similar to that in adults despite more rapid disease progression in younger patients. Zidovudine-resistant isolates can emerge as early as after 2 months' therapy, and primary infection with zidovudine-resistant strains has been documented. Both zidovudine resistance and the syncytium-inducing HIV phenotype appear to be associated with poor clinical outcome. However, zidovudine resistance may revert on drug withdrawal or switching to an alternative therapy. Zidovudine-associated haematotoxicity may be dose-limiting. Nonhaematological adverse events associated with zidovudine therapy are generally mild and usually resolve spontaneously. Dosages of approximately 500 to 600 mg/day appear to be at least as effective as dosages of 1200 to 1500 mg/day and are better tolerated in patients with less advanced disease. However, optimal dosage are unclear. Despite beneficial effects, zidovudine monotherapy is not curative. There is evidence to suggest that the concomitant administration of zidovudine with didanosine or zalcitabine is effective in patients with HIV disease progression despite receiving zidovudine monotherapy, and there is some evidence that concomitant zidovudine plus didanosine therapy is more effective than alternating monotherapy. However, results from studies of combination therapy in asymptomatic patients, and from comparative combination therapy studies are awaited. Cotherapy with agents that augment haematopoiesis allows the continuation of therapeutic zidovudine dosages.(ABSTRACT TRUNCATED AT 400 WORDS)

Surrogate markers for assessing treatment response in HIV disease

OBJECTIVE

To provide an awareness of the issues surrounding the selection and utility of surrogate markers to evaluate treatment response for new antiretroviral therapies for HIV infection.

DATA SOURCES

A MEDLINE search of applicable articles published between 1987 to the present, including clinical trials, commentaries, and editorials, was performed.

DATA SYNTHESIS

Surrogate markers are proximal indicators that are predictive of rare or distant outcomes and can be used in clinical trials to decrease sample size and study duration. Characteristics of potential surrogate endpoints include relevance to disease state, face validity, ability to be detected in the majority of patients, and correlation between treatment-induced changes and terminal endpoints. Potential surrogate markers for assessing treatment response in HIV infection can be categorized as either virologic (p24 antigen, plasma viremia, proviral DNA) or immunologic (CD4+ lymphocytes, neopterin, beta 2-microglobulin, soluble interleukin-2 receptors, immunoglobulin A [IgA]). The CD4+ lymphocyte count and the p24 antigen have been evaluated in most of the clinical trials examining antiretroviral agents and have the greatest documentation supporting their use. Neopterin and beta 2-microglobulin are nonspecific markers, but may improve the predictive value of the CD4+ count when used in combination. Other markers (i.e., soluble interleukin-2 receptors, IgA) remain relatively unstudied at this point.

CONCLUSIONS

There is no current consensus regarding the selection of surrogate markers for HIV disease. On the basis of the present literature, the CD4+ lymphocyte count has the greatest endorsement: however, combination with several surrogate markers may prove to be useful in clinical trials. Studies are needed to verify the reliability of surrogate markers used alone and in combination to predict therapeutic response from antiretroviral therapy.

Raised levels of tumour necrosis factor-alpha and neopterin, but not interferon-alpha, in serum of HIV-1-infected patients from Ethiopia

Serum levels of tumour necrosis factor-alpha (TNF-alpha), neopterin and interferon-alpha (IFN-alpha) were determined by immunoradiometric assays in 60 HIV-1+ and 20 HIV-1- subjects from Ethiopia. Swedish samples were used as reference material. The Ethiopian HIV-1+ subjects were found to have significantly increased TNF-alpha and neopterin, but not IFN-alpha levels. Increased levels of TNF-alpha and neopterin were frequently found in Ethiopian asymptomatic subjects (37% and 47%), and the concentration increased in patients with AIDS (83% and 90% respectively). The levels of the two substances and the proportion of patients with higher TNF-alpha values were lower in the corresponding Swedish subjects. The proportion of sera with raised levels of IFN-alpha was very low (asymptomatic 4%, and AIDS 7%) in Ethiopian subjects. These results suggest a very early increase in the TNF-alpha production and activation of the cellular immune response, and a low level of IFN-alpha synthesis in the natural course of HIV infection in Ethiopia. The aberrations may contribute to a rapid progress of immunodeficiency and cachexia often seen in Ethiopian patients.

The role of neopterin as a monitor of cellular immune activation in transplantation, inflammatory, infectious, and malignant diseases

The accumulated knowledge about the organization and function of the human immune system contributes to a better understanding of the pathogenesis of most diverse disorders and is opening new avenues for therapeutic regimens. To gain further insight into the complex interactions within the components of the immune system, it has become increasingly necessary to develop rapid and simple methods to monitor the status of the immune system in patients. The determination of neopterin concentrations in human body fluids allows to investigate sensitively the cell-mediated immune status to be investigated with considerable sensitivity. In recent years it was shown that production and release of neopterin is inducible in human monocytes/macrophages by interferon gamma. Increased neopterin levels indicate endogenous formation of gamma interferon, and monitoring of neopterin levels therefore permits the activation status of the cell-mediated immune system to be examined. Neopterin concentrations in serum and in urine increase in parallel to the clinical course of infections with viruses, intracellular bacteria, and parasites. In patients with human immunodeficiency virus infection neopterin concentration in serum and urine is a significant predictor of disease progression, the statistical power being similar to CD4+ T-cell numbers. In patients with autoimmune disorders, neopterin levels correlate with the extent and the activity of the disease. Neopterin concentrations are also sensitive indicators of immunological complications in allograft recipients. In certain malignant diseases neopterin concentrations correlate with the stage of the disease and bear prognostic information. Results of neopterin measurements agree with the important role that the cellular immune system plays in these disorders.