Opportunistic infections and malignancies in 231 Danish AIDS patients

Factors associated with the CD4+ lymphocyte count at diagnosis of acquired immunodeficiency syndrome. The AIDS IN EUROPE Study Group

To assess which factors are associated with the CD4+ lymphocyte count at the time of AIDS diagnosis we studied 3046 patients in the AIDS IN EUROPE study who were diagnosed with AIDS in 1 of 17 European countries between 1979 and 1989 and for whom the CD4 count at AIDS diagnosis was known. Data were extracted retrospectively from patient case notes, using a standardized form. There was a wide range of average CD4+ lymphocyte counts at AID diagnosis, according to which diseases were present at diagnosis. The highest geometric mean CD4+ lymphocyte counts at AIDS diagnosis were associated with the diagnosis of extrapulmonary tuberculosis, Kaposi's sarcoma, and non-Hodgkin's lymphoma while the lowest counts were found when histoplasmosis and cytomegalovirus (CMV) retinitis were present. There were no appreciable differences between CD4+ lymphocyte counts at AIDS in patients according to the three major transmission route categories (sex, age, or region of diagnosis) but there was a marked trend (p < 0.005) toward lower CD4+ lymphocyte counts at AIDS diagnosis in more recent years. These associations remained largely unchanged after adjustment for other factors.

Epidemiology of cryptosporidiosis among European AIDS patients

OBJECTIVE

To study epidemiology and possible risk factors associated with the development of cryptosporidiosis among European patients with AIDS.

METHODS

An inception cohort of 6548 patients with AIDS, consecutively diagnosed from 1979 to 1989, from 52 centres in 17 European countries was studied. Data on all AIDS defining events were collected retrospectively from patients' clinical records. Kaplan-Meier estimates, log rank tests and Cox proportional hazard models were used to examine for possible risk factors associated with cryptosporidiosis.

RESULTS

Cryptosporidiosis was diagnosed in 432 (6.6%) patients, 216 at time of the AIDS diagnosis and 216 during follow-up. The probability of being diagnosed with cryptosporidiosis at AIDS diagnosis was significantly lower for intravenous drug users (1.3%) than for homosexual men (4.1%) and for patients belonging to other transmission categories (4.0%) (p < 0.001). The probability was also higher for patients from Central Europe compared with patients from South Europe (4.1% versus 2.5%, p = 0.005). The rate of developing cryptosporidiosis after the diagnosis of AIDS was 3 per 100 patient years of follow-up. The rate was significantly lower for intravenous drug users than for homosexual men (relative risk 0.34, 95% confidence limits 0.22-0.54) and for women compared with men (RR 0.43 (0.21-0.87)). The risk was higher in North Europe than in South and Central Europe. In a multivariate analysis only transmission category remained a significant predictor for the development of cryptosporidiosis.

CONCLUSION

The development of cryptosporidiosis in AIDS patients may be associated with sexual risk behaviour.

An eleven year follow-up of delayed-type hypersensitivity testing for the identification of HIV-1 infected patients at increased risk of developing AIDS

The objective of this study was to investigate whether testing of delayed-type hypersensitivity (DTH) to recall antigens could be used to identify HIV-1 infected patients at increased risk of death or developing AIDS. Eighty-five HIV-1 infected Swedish homosexual men were tested for DTH using a commercially available kit with 7 recall antigens (Multitest, Mérieux). The patients were followed prospectively for 11 years or until death. The 11-year actuarial progression rate to AIDS was 69% and to death 60%. Older age was identified as a factor predisposing to rapid progression independent of cell-mediated immunity measured by DTH. Patients with a subnormal DTH had a significantly more rapid progression to AIDS and death than did patients with normal DTH, and the time between AIDS diagnosis and death was shorter. For patients with a multiscore (MS) < 10 mm, the median time to AIDS was 59 months, the median time to death 88 months, and the median time from AIDS diagnosis to death 11 months, compared to 106, 139, and 25 months, respectively, for patients with MS > or = 10 mm. Of the individual antigens, only a negative reaction to tuberculin was independently predictive of progression to all 3 endpoints, while a negative reaction to tetanus was independently predictive of progression to death. Thus, determination of DTH improves the early recognition of patients at increased risk of progressive disease.

HIV-related non-Hodgkin's lymphoma among European AIDS patients. AIDS in Europe Study Group. AIDS in Europe Study Group

The epidemiology of HIV associated non-Hodgkin's lymphoma (NHL) was investigated in 6550 European patients with AIDS. NHL was diagnosed in 3.5% of all patients at the time of the AIDS diagnosis. Although the probability of being diagnosed with NHL at AIDS diagnosis was significantly higher among intravenous drug users than among homosexual men, and was associated with increasing age, the observed incidences of NHL were more strikingly similar than any differences. The rate of developing NHL after a previous AIDS diagnosis was 2.4 per 100 patient years of follow-up, and remained constant during a 5-year follow-up period. While primary brain lymphomas comprised only 9% of NHL diagnosed at the time of AIDS, they comprised 38% of NHL diagnosed after AIDS (p < 0.001). The prognosis for patients with NHL at AIDS diagnosis was poor with a median survival of 5 months. A diagnosis of primary brain lymphoma was uniformly associated with a poor outcome. It is concluded that the probability of developing NHL in late stage HIV infection is lower than previously anticipated from the results of small studies on patients receiving long-term anti-retroviral therapy.

Marek's disease virus-mediated enhancement of avian leukosis virus gene expression and virus production

Direct interaction between two viruses in coinfected cells may promote replication and pathogenesis of one or both virus types. Synergism between herpesviruses and retroviruses is an important factor in diagnosis, treatment, and prevention of animal and human diseases. In birds, Marek's disease virus (MDV) may be an important cofactor in avian leukosis virus induced disease. Infection of susceptible cells with non-oncogenic serotype 2 MDV, an avian herpesvirus, and Rous-associated virus type 2 (RAV-2 ALV), a leukemogenic avian retrovirus, results in enhanced (greater than 3-fold) transcription of retroviral genes, relative to infection with ALV alone. A direct relationship between concentrations of retroviral gene expression and amount of input MDV suggests that MDV-encoded or -induced factors are responsible for enhanced ALV gene expression, ultimately leading to increased accumulation of ALV-specific RNA (greater than 5-fold) and protein (greater than 10-fold). At lower doses of input MDV, ALV virus production increased over 3-fold, relative to cells infected with ALV alone. Interactive laser cytometry was used to detect accumulation of both MDV and ALV antigens within single cells from coinfected cultures. These results suggest a direct role for MDV-encoded or -induced factors in enhancement of ALV gene expression and demonstrate the importance of herpesviruses as cofactors in retrovirus replication and pathogenesis in coinfected cells.

HIV-associated lymphoma: histopathology and association with Epstein-Barr virus genome related to clinical, immunological and prognostic features

All 51 cases of HIV-related malignant lymphoma in Denmark diagnosed from 1983 to 1989 were reviewed. There were 12 Burkitt-type lymphomas, 30 immunoblast-rich lymphomas and 9 other lymphomas. Patients with immunoblast-rich lymphomas had significantly lower CD4 cell counts (median 60 vs. 188 x 10(6)/l, P less than 0.05), and more often a history of previous AIDS-defining illnesses (50% vs. 0%, P less than 0.005), compared with patients with Burkitt-type lymphomas. Epstein-Barr virus (EBV) DNA was demonstrated in 14 of 19 immunoblast-rich tumours, and in 2 of 7 Burkitt-type lymphomas (P = 0.10). Compared with EBV DNA-negative tumours EBV DNA-positive tumours were associated with lower CD4 cell counts (median 39 vs. 188 x 10(6)/l, P = 0.01). It is concluded that two main types of HIV-related malignant lymphoma exist. One is associated with severe immunosuppression, is often of immunoblast-rich morphology, and may be linked to EBV, whereas the other may occur in the absence of immunosuppression, is often of Burkitt-type morphology, and is probably not linked to EBV. In addition to these two main types, other non-Hodgkin lymphomas and Hodgkin's disease do occur.

Nosocomial outbreak of cryptosporidiosis in AIDS patients

OBJECTIVE

To describe a nosocomial outbreak of cryptosporidiosis during four months after June 1989.

SETTING

A department of infectious diseases in Copenhagen, seeing about half the patients with AIDS in Denmark.

SUBJECTS

73 HIV antibody negative subjects and 60 antibody positive subjects admitted as inpatients during the transmission period of the outbreak (20 June-14 August), of whom 18 (17 with AIDS, one with AIDS related complex), developed cryptosporidiosis. Two further HIV negative subjects (one departmental secretary, one visiting relative) developed cryptosporidiosis.

MAIN OUTCOME MEASURES

Cryptosporidia in stool samples, clinical symptoms, CD4 cell count, HIV antigen concentration, chemotherapeutic treatment.

RESULTS

The source of the outbreak was identified as ice from an ice machine in the ward, contaminated by an incontinent, psychotic patient with cryptosporidiosis picking out ice for cold drinks. The mean incubation time was at least 13 days-that is, twice that in HIV-negative patients. Of the 18 patients with AIDS who developed cryptosporidiosis, five recovered, two were symptomless carriers, three died of unrelated causes, and eight died after prolonged diarrhoea. Among the 57 exposed HIV antibody positive inpatients (excluding two patients and the index case with cryptosporidiosis diagnosed elsewhere), significantly more of those who developed symptomatic cryptosporidiosis received oral sulphonamides than those who did not (91%, 10/11 v 48%, 21/44, p less than 0.05).

CONCLUSIONS

The clinical and epidemiological findings indicate that infection was the consequence of very small inocula. Increased sensitivity to cryptosporidiosis may be an unrecognised side effect of oral sulphonamide treatment in patients with AIDS.

Gram-negative bacterial pneumonia with secondary aspergillosis in an AIDS patient

A 40-year-old, HIV-infected female patient received antibiotic treatment for a urinary tract infection. After the initial success of therapy and a symptom-free period, she developed pneumonia with septic shock and adult respiratory distress syndrome (ARDS). In spite of intensive care and respirator therapy with positive end-expiratory pressure (PEEP), she died of infectious toxic shock. Autopsy findings showed relapsing, gram-negative, bacterial pneumonia (morphologically compatible with Klebsiella pneumonia) and secondary, invasive aspergillosis. The pathogenesis and epidemiology of these unusual complications of AIDS are discussed.

Low yield of screening for cryptococcal antigen by latex agglutination assay on serum and cerebrospinal fluid from Danish patients with AIDS or ARC

From July 1, 1989 to September 5, 1990, 530 serum specimens and 50 cerebrospinal fluid (CSF) specimens from 334 HIV-1 infected patients, most of whom had AIDS or ARC, were analysed in a cryptococcal antigen latex agglutination assay, and all were negative. Three cases of meningitis due to Cryptococcus neoformans diagnosed by microscopy and culture in 3 HIV-1 infected patients are presented. Stored specimens of serum and CSF from these patients were assayed for cryptococcal antigen, and in all 3 the onset of meningitis was preceded by the presence of cryptococcal antigen in serum. It is concluded that the low occurrence of cryptococcosis in our patient population does not justify a routine serum screening for cryptococcal antigen.