Dual-site catalysts featuring platinum-group-metal atoms on copper shapes boost hydrocarbon formations in electrocatalytic CO2 reduction

Copper-based catalyst is uniquely positioned to catalyze the hydrocarbon formations through electrochemical CO₂ reduction. The catalyst design freedom is limited for alloying copper with H-affinitive elements represented by platinum group metals because the latter would easily drive the hydrogen evolution reaction to override CO₂ reduction. We report an adept design of anchoring atomically dispersed platinum group metal species on both polycrystalline and shape-controlled Cu catalysts, which now promote targeted CO₂ reduction reaction while frustrating the undesired hydrogen evolution reaction. Notably, alloys with similar metal formulations but comprising small platinum or palladium clusters would fail this objective. With an appreciable amount of CO-Pd₁ moieties on copper surfaces, facile CO^* hydrogenation to CHO^* or CO-CHO^* coupling is now viable as one of the main pathways on Cu(111) or Cu(100) to selectively produce CH₄ or C₂H₄ through Pd-Cu dual-site pathways. The work broadens copper alloying choices for CO₂ reduction in aqueous phases.

Comparison of Dose-Response Relationships for Two Isolates of SARS-CoV-2 in a Nonhuman Primate Model of Inhalational COVID-19

Background: As the COVID-19 pandemic has progressed, numerous variants of SARS-CoV-2 have arisen, with several displaying increased transmissibility. Methods: The present study compared dose-response relationships and disease presentation in nonhuman primates infected with aerosols containing an isolate of the Gamma variant of SARS-CoV-2 to the results of our previous study with the earlier WA-1 isolate of SARS-CoV-2. Results: Disease in Gamma-infected animals was mild, characterized by dose-dependent fever and oronasal shedding of virus. Differences were observed in shedding in the upper respiratory tract between Gamma- and WA-1-infected animals that have the potential to influence disease transmission. Specifically, the estimated median doses for shedding of viral RNA or infectious virus in nasal swabs were approximately 10-fold lower for the Gamma variant than the WA-1 isolate. Given that the median doses for fever were similar, this suggests that there is a greater difference between the median doses for viral shedding and fever for Gamma than for WA-1 and potentially an increased range of doses for Gamma over which asymptomatic shedding and disease transmission are possible. Conclusions: These results complement those of previous studies, which suggested that differences in exposure dose may help to explain the range of clinical disease presentations observed in individuals with COVID-19, highlighting the importance of public health measures designed to limit exposure dose, such as masking and social distancing. The dose-response data provided by this study are important to inform disease transmission and hazard modeling, as well as to inform dose selection in future studies examining the efficacy of therapeutics and vaccines in animal models of inhalational COVID-19.

Seroconversion and fever are dose-dependent in a nonhuman primate model of inhalational COVID-19

While evidence exists supporting the potential for aerosol transmission of SARS-CoV-2, the infectious dose by inhalation remains unknown. In the present study, the probability of infection following inhalation of SARS-CoV-2 was dose-dependent in a nonhuman primate model of inhalational COVID-19. The median infectious dose, assessed by seroconversion, was 52 TCID50 (95% CI: 23-363 TCID50), and was significantly lower than the median dose for fever (256 TCID50, 95% CI: 102-603 TCID50), resulting in a group of animals that developed an immune response post-exposure but did not develop fever or other clinical signs of infection. In a subset of these animals, virus was detected in nasopharyngeal and/or oropharyngeal swabs, suggesting that infected animals without signs of disease are able to shed virus and may be infectious, which is consistent with reports of asymptomatic spread in human cases of COVID-19. These results suggest that differences in exposure dose may be a factor influencing disease presentation in humans, and reinforce the importance of public health measures that limit exposure dose, such as social distancing, masking, and increased ventilation. The dose-response data provided by this study are important to inform disease transmission and hazard modeling, and, ultimately, mitigation strategies. Additionally, these data will be useful to inform dose selection in future studies examining the efficacy of therapeutics and vaccines against inhalational COVID-19, and as a baseline in healthy, young adult animals for assessment of the importance of other factors, such as age, comorbidities, and viral variant, on the infectious dose and disease presentation.

Simulated Sunlight Rapidly Inactivates SARS-CoV-2 on Surfaces

Previous studies have demonstrated that SARS-CoV-2 is stable on surfaces for extended periods under indoor conditions. In the present study, simulated sunlight rapidly inactivated SARS-CoV-2 suspended in either simulated saliva or culture media and dried on stainless steel coupons. Ninety percent of infectious virus was inactivated every 6.8 minutes in simulated saliva and every 14.3 minutes in culture media when exposed to simulated sunlight representative of the summer solstice at 40°N latitude at sea level on a clear day. Significant inactivation also occurred, albeit at a slower rate, under lower simulated sunlight levels. The present study provides the first evidence that sunlight may rapidly inactivate SARS-CoV-2 on surfaces, suggesting that persistence, and subsequently exposure risk, may vary significantly between indoor and outdoor environments. Additionally, these data indicate that natural sunlight may be effective as a disinfectant for contaminated nonporous materials.

Characterization of a head-only aerosol exposure system for nonhuman primates

A well-characterized exposure chamber is necessary to generate reproducible atmospheres for inhalation toxicology studies. The aim of the present study was to characterize a head-only exposure chamber for non-human primates. Aerosols containing bovine serum albumin (BSA) were used to characterize a 16-L dynamic airflow head-only exposure chamber. A 250-ml plastic bottle with a respirator attached located inside the chamber was used to simulate a breathing head. Chamber leak rate, mixing, and aerosol spatial distributions were quantified. The chamber concentration profile was measured at the chamber exhaust using an aerodynamic particle sizer. Aerosol spatial distribution was determined by collecting filter samples at several chamber locations. The particle size distribution was determined by collecting cascade impactor samples at several chamber locations. The estimated chamber leak rate was within standards suggested in the literature. The measured average aerosol residence time was similar to theoretical aerosol residence time, suggesting that the chamber was mixing well. Additionally, the average concentration measured at each of the sampling locations within the chamber was similar, and the within-run coefficients of variation (CV) across all sampling locations was similar to those reported in previously published studies, again suggesting that the aerosol concentration throughout the chamber was uniform. The particle size distribution was similar throughout the exposure chamber. Additionally, the BSA concentration and particle size distributions measured in the breathing zone of the simulated head were not significantly different from measurements made elsewhere in the chamber, suggesting that respiration does not affect the average aerosol concentration or particle size distribution at the mouth.

Retention and migration of alprostadil cream applied topically to the glans meatus for erectile dysfunction

Retention and migration of a specially designed alprostadil transdermal cream was assessed after single-dose administration to the glans meatus of the penis. Seven men were enrolled in this two-way crossover study. Three subjects self-administered the radio-labeled alprostadil transdermal cream (approximately 100 mg of cream containing 300 microg alprostadil) by inserting the tip of the dispenser into the meatus. In three others, the dose was administered by dispensing the cream dropwise into the metal opening without touching the penis (the preferred and directed method). Retention and migration of the cream mass was measured in the penis with a gamma scintillation camera. The alprostadil transdermal cream was retained in the fossa navicularis at or near 99% in five of six subjects regardless of the method of dosing, thus indicating that the cream formulation performed as designed. A mild, transient burning sensation in the penis was the most common adverse event.

The efficacy and safety of a topical alprostadil cream, Alprox-TD, for the treatment of erectile dysfunction: two phase 2 studies in mild-to-moderate and severe ED

In two multicenter, placebo controlled, phase 2 studies, patients with mild-to-moderate (n=161, Study 1) or severe (n=142, Study 2) erectile dysfunction (ED) were randomized to receive placebo, 0.05, 0.1, or 0.2 mg (Study 1) or placebo, 0.1, 0.2, or 0.3 mg (Study 2) of topically applied alprostadil (containing a proprietary skin permeation enhancer). The primary efficacy end point in both studies was the change in erectile function (EF) score from baseline to final visit. The changes from baseline for EF scores were -0.8+/-1.1, 1.8+/-1.1, 0.7+/-1.2, and 3.7+/-1.2 (P<0.01; Study 1) and 2.7+/-1.3, 6.29+/-1.4, 6.49+/-1.5, and 9.44+/-1.5 (P<0.001; Study 2) for ascending dose groups in each study. Topical alprostadil was well tolerated with the most common adverse event being urogenital pain. These results suggest this topical alprostadil formulation may be a potentially useful agent for the treatment of ED.

Cholesterol embolization syndrome: cutaneous histopathological features and the variable onset of symptoms in patients with different risk factors

Cholesterol embolization syndrome (CES) may not only be due to direct dislodgement of cholesterol crystals from atherosclerotic plaques on the walls of arteries by surgery, angiogram or trauma, but may occur after anticoagulant and thrombolytic therapy. The latter two therapies both weaken the fibrin clot that stabilizes the atheromas in place; however, these two therapies commonly have different onsets of CES after their institution. We present three patients with different risk factors for CES who all presented with the pathognomonic triad of leg and/or foot pain, livedo reticularis and good peripheral pulses. In all three patients cholesterol emboli were demonstrated in cutaneous biopsy sections. In two patients there was associated renal involvement, which was fatal in one case. These cases illustrate that cutaneous biopsy may be diagnostic in patients with livedo reticularis, which progresses to necrosis and gangrene. In addition, they illustrate the problems and contradictions involved in treating patients with CES.

Pseudocyst of the auricle: diagnosis and management with a punch biopsy

A case of pseudocyst of the ear diagnosed and treated with a punch biopsy is reported. Pseudocyst of the ear is considered to be a benign, asymptomatic condition seen infrequently in clinical practice. Our patient is a 45-year-old white man who presented with a 5-month history of a painless nodule on his left auricle without any preceding history of trauma. Although many treatments have been reported, none appear satisfactory, and many surgical treatment modalities are cumbersome. This is the first report, to our knowledge, of a case of a pseudocyst of the ear confirmed and treated with a 3-mm punch biopsy of the inferior border of the pseudocyst, followed by a pressure bolster.

Topical alprostadil in the treatment of Female Sexual Arousal Disorder: a pilot study

This study evaluated the efficacy and safety of three doses of topical alprostadil USP (prostaglandin E1) cream in 8 patients with Female Sexual Arousal Disorder (FSAD). Each patient was administered a single intravaginal dose of placebo followed by escalating intravaginal doses of the active drug at 2-week intervals. Alprostadil's effectiveness in enhancing subjective and physiological arousal during visual sexual stimulation was supported by patient ratings and physician assessments of vaginal erythema and transudate volume. Photoplethysmography measurement of vaginal pulse amplitude was not able to demonstrate treatment sensitivity in the present study. Adverse events included mild cases of vaginal itching and burning. The data support further investigation of the use of alprostadil for FSAD.

The effect of decreasing digital image resolution on teledermatology diagnosis

OBJECTIVE

To determine the effect of degraded digital image resolution (as viewed on a monitor) on the accuracy and confidence of dermatologic interpretation.

MATERIALS AND METHODS

Eight dermatologists interpreted 180 clinical cases divided into three Logical Competitor Sets (LCS) (pigmented lesions, non-pigmented lesions, and inflammatory dermatoses). Each case was digitized at three different resolutions. The images were randomized and divided into (9) 60-image sessions. The physicians were completely blinded concerning the image resolution. After 60 seconds per image, the viewer recorded a diagnosis and level of confidence. The resultant ROC curves compared the effect of LCS, level of clinical difficulty, and resolution of the digital image. One-way analysis of variance (ANOVA) compared the curves.

RESULTS

The areas beneath the ROC curves did not demonstrate any consistently significant difference between the digital image resolutions for all LCS and levels of difficulty. The only significant effect observed was amongst pigmented lesions (LCS-A) where the ROC curve area was significantly smaller in the easy images at high resolution compared to low and medium resolutions. For all other ROC curve comparisons within LCS-A, at all other levels of difficulty, as well as within the other LCS at all levels of difficulty, none of the differences was significant.

CONCLUSION

A 720 x 500 pixel image can be considered equivalent to a 1490 x 1000 pixel image for most store-and-forward teledermatology consultations.

Fixed drug eruptions to human immunodeficiency virus-1 protease inhibitor

Despite numerous drug interactions that occur with human immunodeficiency virus-1 protease inhibitors, there are relatively few drug reactions. We present two patients receiving saquinavir who developed fixed drug reactions. Both reactions cleared while patients received a therapeutic dose of the medication, and in one patient a flare was seen when the patient later stopped and then restarted the medication. Although fixed drug reactions are relatively inconsequential, it is important to know that these eruptions may clear when the patient is given uninterrupted therapy of a human immunodeficiency virus-1 protease inhibitor, with only post-inflammatory hyperpigmentation.

Micrococcus folliculitis in HIV-1 disease

Organisms with little pathogenic potential in immunocompetent hosts may produce disease in HIV-1 + patients. We describe three HIV-1 + patients in late disease who presented with pruritic papules with central ulceration over the face and arms. In all the patients the eruptions had been present for months, and the patients did not develop sepsis. Biopsy specimens in all the patients showed large Gram-positive cocci, forming tetrads. Colony morphology, catalase positivity and coagulase negativity, and resistance to nitrofurantoin were used to separate micrococci from staphylococci. Micrococcus species are usually considered normal inhabitants of the skin; however, in patients with HIV-1 disease, Micrococcus species can produce localized cutaneous infections.

Increased soft tissue in the posterior cervical and upper back area of patients on HIV-1 protease inhibitors

BACKGROUND

Corticosteroids as well as sex hormones affect the redistribution of subcutaneous fat and the percentage of lean body mass. In addition, some stromal cells express steroid receptors, and the quantity and distribution of these receptors vary at different body sites and between sexes. Inhibitors of HIV-1 protease may affect steroid hormone metabolism through their effect on cytochrome P450.

OBJECTIVES

To determine the changes in the tissue of the back in three HIV-1+ patients who developed increased soft tissue in posterior cervical and upper back areas while on HIV-1 protease inhibitors.

METHODS

Punch biopsies of the involved posterior cervical and upper back areas were done. These included subcutaneous adipose tissue. Routine hematoxylin and eosin-stained sections, along with special stains for elastic and stromal mucin, and immunohistochemical stains for CD34 (HPCA-1 and Factor XIIIa) were evaluated.

RESULTS

Histologically all three patients showed identical features. There was expansion of the dermis with decreased periadnexal fat and marked widening of the fibrous septa within the expanded subcutaneous fat.

CONCLUSIONS

The posterior cervical and upper back area appears to be a common site for localization of mesenchymal tumours that show some fat differentiation and produce an increase in stromal matrix material. Mesenchymal cell populations within this area are also affected by systemic diseases. A male predominance pattern occurs with these conditions, and steroid receptors are expressed on some mesenchymal cells, that vary with the body location. Thus, this observation may be related to the effects of protease inhibitors on steroid hormone metabolism through their inhibition of cytochrome P-450.

Is CD30 (Ki-1) immunostaining in cutaneous eruptions useful as a marker of Th1 to Th2 cytokine switching and/or as a marker of advanced HIV-1 disease?

CD30 is a member of the tumour necrosis factor/nerve growth factor receptor superfamily, which is expressed on CD4+ and CD8+ T-cell clones which produce T helper (Th) 2-type cytokines. It has been proposed that disease progression in HIV-1 is associated with Th1 to Th2 cytokine switching. In 70 cutaneous biopsies from HIV-1 positive patients in different stages of disease, we performed a battery of immunohistochemical stains. These included antibodies to CD3, UCHL-1, OPD-4, L-26, KP-1 and CD30 (Ki-1). In addition, we used a similar battery of stains on cutaneous biopsies of HIV-1 negative patients with inflammatory dermatoses which are established as Th1 or Th2 dominant, e.g. polar leprosy. CD30+ cells were rarely present in early stages of HIV-1 disease, but commonly present in later stages of disease. However, there were cases of late HIV-1 disease which did not contain CD30+ cells. Increased numbers of CD30+ cells were more commonly seen in later stages of HIV-1 disease. However, the expression of CD30 appeared to be better in predicting other established Th2 cutaneous infiltrates in HIV-1 negative patients than in predicting a Th2 cutaneous cytokine pattern in advanced HIV-1 disease.

Pruritus in HIV-1 disease: therapy with drugs which may modulate the pattern of immune dysregulation

BACKGROUND

Pruritus in HIV-1+ patients is common and increases with disease progression. The causes of pruritus are numerous including xerosis, drug and photoeruptions, follicular and papular eruptions as well as infestations and infections by a wide range of organisms. One other possible factor contributing to pruritus is the pattern of immune dysregulation. With advancing HIV-1 disease there is Th1 to Th2 cytokine switching.

METHODS

After some positive results with prostaglandin inhibitors, we undertook a study in which we randomly placed patients on four different forms of therapy for their pruritus. The therapies included hydroxyzine with or without doxepin at night, pentoxifylline, indomethacin and topical moisturization with medium-strength topical steroids. All patients were evaluated for both subjective relief as well as side effects.

RESULTS

Patients placed on indomethacin obtained relief more consistently and more completely. Patients on pentoxifylline had the fewest side effects of all oral therapies. Patients on antihistamines with or without doxepin had the highest incidence of side effects, although more of these patients reported a greater degree of relief than patients on pentoxifylline. All patients on oral therapy overall had greater relief than patients using topical steroids.

CONCLUSION

The systemic therapies which may modulate the pattern of immune dysregulation seen in HIV-1 disease may be beneficial in the pruritus seen in late-stage patients.

Lymphoid markers, activation markers, and adhesion molecules in cutaneous biopsy specimens from HIV+ patients with disease progression. The Military Medical Consortium for the Advancement of Retroviral Research

BACKGROUND

One important factor in understanding the pathogenesis of human immune deficiency virus (HIV) disease is documenting the patterns of immune dysregulation present in HIV-positive patients. The cells which home to skin are mainly certain subsets of T cells and, as opposed to the peripheral blood, where circulating factors may inhibit terminal phenotypic differentiation, the cutaneous environment potentiates differentiation during cutaneous eruptions.

OBJECTIVE

The authors' aim was to characterize the inflammatory dermatoses in biopsy specimens from HIV-positive patients with immunohistochemical stains for lymphoid markers, activation markers, and adhesion molecules and to determine if there was any correlation with the type of dermatosis and the HIV-disease stage.

METHODS

Lymphoid and activation markers as well as adhesion molecules were studied on cutaneous biopsy specimens from 96 inflammatory dermatoses in HIV-positive patients. The dermatoses included psoriasiform dermatoses with and without a lichenoid component, perivascular lymphoid dermatoses, perivascular and periadnexal inflammatory dermatoses, spongiotic dermatoses, granulomatous dermatoses, and neutrophilic dermatoses with and without vasculitis.

RESULTS

Although there was a decrease in CD4/CD8 ratios in the cutaneous inflammatory dermatoses with progression of the disease, the ratios of CD4/CD8 cells were far higher than those in the peripheral blood. There were also increasing numbers of CD23+ cells and increased E-Selectin expression on endothelial cells from the early stages of disease, with no consistent pattern of ICAM-1 expression on epithelial cells with disease progression.

CONCLUSIONS

The expression of lymphoid markers, activation markers, and adhesion molecules in the skin with progression of HIV disease, is consistent with a T helper (Th)1 to Th0/Th2 cytokine pattern of immune dysregulation. This cytokine pattern may be modified by the cytopathic effects of HIV on lymphoid and dendritic populations and by effects of other concurrent infections. Significant numbers of CD4+ T cells in skin infiltrates, with low peripheral CD4 T-cell counts, suggest that the cutaneous T-cell populations may be distinctive.

Increased cutaneous toxicity to ionizing radiation in HIV-positive patients. Military Medical Consortium for the Advancement of Retroviral Research (MMCARR)

BACKGROUND

There are reports of increased reactions in HIV-1+ patients to ultraviolet light sometimes in association with medication. In addition, there are also reports of increased morbidity associated with radiation therapy in HIV-1+ patients.

METHODS

Three HIV-1+ patients developed cutaneous toxic reactions to radiation therapy; two with Kaposi's sarcoma (KS) and one with non-Hodgkin's lymphoma.

CONCLUSIONS

Although the mechanisms which resulted in these reactions are not clear, they may be related to depletion of endogenous scavengers and may be accentuated by the pattern of immune dysregulation present in HIV-1 disease.

Histopathologic features seen in cutaneous photoeruptions in HIV-positive patients. Military Medical Consortium for the Advancement of Retroviral Research (MMCARR)

BACKGROUND

There have been scattered reports of HIV+ patients with increased reactions to light as well as anecdotal reports of HIV+ patients with increased morbidity secondary to radiation therapy.

METHODS

As a part of a military study of HIV+ patients, we followed 987 patients for cutaneous disease for 4 years. All patients were questioned on a periodic basis about increased sensitivity to light. These patients received a physical examination at each protocol visit, and they were given the opportunity to receive all their dermatologic care within the HIV clinic. Fourteen of the patients with photo-induced eruptions were evaluated clinically at the time of the eruption, and 11 of these were biopsied.

RESULTS

Thirty-three of the patients reported photo-induced reactions unrelated to oral medications. Although sensitivity to light often began in the early stages of HIV disease, reactions became more severe and more chronic with disease progression. Histologic features varied from few to numerous apoptotic/necrotic keratinocytes within the mid to upper levels of the epidermis associated with a perivascular inflammatory infiltrate, to apoptotic/necrotic keratinocytes throughout an acanthotic epidermis with a lichenoid/interface infiltrate.

CONCLUSIONS

Although the pathogenesis of these light reactions is not known, these reactions may be related to depletion of endogenous scavengers which results in increased oxidative stress and is modulated by the pattern of immune dysregulation and metabolic dysregulation induced by HIV disease.

Histologically distinctive papular neutrophilic xanthomas in HIV-1 + patients

Xanthomas may be associated with benign or malignant lymphoproliferative diseases, often with associated hypergammaglobulinema. In human immunodeficiency virus type 1 (HIV-1) disease, there is a high lymphoproliferative rate despite the immunodeficiency and increased cell death. We report three HIV-1-positive patients with facial papular xanthomatosis eruptions associated with hypergammaglobulinema, and an immunoglobulin A (IgA) gammopathy. Histopathologic features include lipid-laden macrophages, extracellular nuclear dust with phagocytosized nuclear debris, and hyalinization with areas of hyaline necrosis of collagen fibers. These distinctive papular xanthomas may be a marker of HIV-1 disease and of a pattern of immunodysregulation, immunodeficiency, and lymphoid proliferation seen in HIV-1 disease.

Increased drug reactions in HIV-1-positive patients: a possible explanation based on patterns of immune dysregulation seen in HIV-1 disease. The Military Medical Consortium for the Advancement of Retroviral Research (MMCARR)

Drug reactions are common in HIV-1 disease, with the incidence having been reported to increase with increasing stage and with CD4+ T-cell counts below 200/microliters. However, there have been numerous reports of patients in which rechallenge, dosing changes or continued therapy have resulted in no recurrence or else clearing of the eruption. We followed 974 HIV-1-positive patients for 46 months as a part of a military study of HIV-1 disease. Within this group there were a total of 283 drug eruptions, with cutaneous manifestations in 201 patients in which clinical characteristics were noted and 86 patients in which cutaneous biopsies were performed. Serological evidence of reactivation or acute Epstein-Barr virus (EBV) or cytomegalovirus (CMV) infections were also noted, as well as peripheral eosinophilia. The incidence of drug eruptions significantly increased with increasing Walter Reed stage and decreasing CD4 counts and CD4/CD8 ratio, as well as with increasing age and in patients with increased numbers of other dermatological diagnoses. In addition, white patients had significantly more drug eruptions than did black. Serological or culture evidence of acute or reactivated EBV or CMV was significantly increased in patients with drug eruptions. The majority of the eruptions were maculopapular or morbilliform with a predominantly perivascular mononuclear cell infiltrate. HIV-1 positive patients have an increased incidence of drug reactions, the incidence having been reported to increase in patients with less than 200 CD4+ T cells/microliter. However, at very low T4 counts, especially those less than 25/microliter, and at a CD4/CD8 ratio of less than 0.10, the probability of reactions to trimethoprim-sulphamethoxazole (TMP-SMZ) is decreased in late-stage HIV-1 patients. Maculopapular or morbilliform eruptions are the most common clinical presentations, often accompanied by one or more of the following: fever, arthralgias, eosinophilia, and serum transaminase elevation. Histologically the majority of these eruptions show a perivascular mononuclear cell infiltrate, sometimes with focal interface changes and apoptotic, necrotic cells within the epidermis. Acute hypersensitivity reactions and toxic epidermal necrolysis (TEN) or Stevens-Johnson's syndrome (SJS) with diffuse epidermal apoptosis and necrosis have also been less commonly described. In a study of cutaneous manifestations in an HIV-1 positive military population, drug reactions were evaluated in terms of clinical features, histopathology, demographic features and laboratory findings.

Pityriasis lichenoides et varioliformis acuta in HIV-1+ patients: a marker of early stage disease. The Military Medical Consortium for the Advancement of Retroviral Research (MMCARR)

BACKGROUND

The high incidence of cutaneous disease in HIV-1+ patients may be a marker of the chronic state of immune activation. In addition, specific cutaneous diseases may be related to the pattern and degree of immune dysregulation present in the patients at the time of the eruption. We have observed that HIV-1+ patients with pityriasis lichenoides et varioliformis acuta (PLEVA) were in the early to midstage of HIV-1 disease.

MATERIALS AND METHODS

To determine if there was a correlation between the phenotype of the lymphoid infiltrate and surface markers of the epidermis and the known changes in early or late-stage HIV-1 disease, we studied five HIV-1+ patients with PLEVA. Cutaneous biopsy specimens were obtained and immunohistochemical stains were used to determine the expression of ELAM-1, ICAM-1, and HLA-DR and the phenotype of the lymphoid infiltrate.

RESULTS

The HIV-1+ patients showed increased expression of HLA-DR on keratinocytes as well as on the mononuclear and dendritic cell populations in the epidermis and dermis. The majority of T cells were activated CD8+ cells.

CONCLUSIONS

Immunophenotyping of the inflammatory infiltrate in these patients is consistent with a pattern of immune dysregulation seen only in earlier stages of HIV-1 disease. Thus, PLEVA may be useful as a marker of early to midstages of HIV-1 disease.

The effects of swaddling versus standard positioning on neuromuscular development in very low birth weight infants

A randomized control design was used to compare the effect of swaddling to standard positioning on neuromuscular development in very low birth weight (VLBW) infants (< 1,250 gm). The outcome of neuromuscular development was measured at 34 weeks postconceptional age using the Morgan Neonatal Neurobehavioral Exam (MNNE). The sample included 50 infants who met criteria for birth weight, age and who were classified as appropriate for gestational age. Exclusion criteria were also used. The infants were randomly assigned to the experimental group or the comparison group. Data analysis included descriptive and inferential statistical techniques. The results demonstrated that swaddled infants had higher total scores on the MNNE as compared to infants with standard positioning. Swaddling appears to be a positioning technique that can enhance neuromuscular development of the very low birth weight infant.

Clinical and histopathologic features of hair loss in patients with HIV-1 infection

BACKGROUND

Hair loss is common in patients with HIV-1 infection, and in black patients this loss may be associated with straightening. Possible causes are frequently present in patients with HIV-1. These causes include chronic HIV-1 infection itself and recurrent secondary infections, nutritional deficiencies, immunologic and endocrine dysregulation, and exposure to multiple drugs. However, histopathologic features have rarely been reported in these patients.

OBJECTIVE

The objective was to evaluate the changes in the hairs of a group of these patients and to identify the light microscopic and ultrastructural changes in the hairs and the histologic changes in the scalp.

METHODS

Hair plucks and pulls with scanning electron microscopy of the hairs were done on 10 patients with late-stage HIV-1 infection. In addition, scalp biopsy specimens were examined in both vertical and transverse sections.

RESULTS

All patients had telogen effluvium. Numerous apoptotic or necrotic keratinocytes were seen in the upper external root sheath follicular epithelium in addition to a mild to moderate perifollicular mononuclear cell infiltrate often containing eosinophils. Variable dystrophy of the hair shafts was also a consistent feature.

CONCLUSION

Although telogen effluvium is a common response to a wide spectrum of biologic stresses, the presence of apoptotic or necrotic keratinocytes within the upper end of the external root sheath epithelium and dystrophy of hairs may be markers of hair loss in patients with HIV-1 infection.

Decreased CD7 expression in cutaneous infiltrates of HIV-1+ patients. Military Medical Consortium for the Advancement of Retroviral Research (MMCARR)

CD7 is an early T-cell marker that has been used in the diagnosis of stem cell leukemias. Loss of expression of CD7 with a battery of other mature T-cell markers has also been used as one criteria in the diagnosis cutaneous T-cell lymphomas. More recently, CD7-negative T cells have been shown to be a normal population of T cells in the peripheral blood and the skin, and may represent a mature T-cell population with a different pattern of maturation and activation. In addition, in HIV-1 disease expansion of CD7-negative T cells has been found in the peripheral blood. We evaluated the number of CD7-negative T cells in skin infiltrates to determine whether there was an increase of CD7-negative T cells. We studied T-cell markers including CD3, CD4, CD7, CD8, CD20, CD29, and HLA-DR on cutaneous biopsy material from inflammatory dermatoses in 57 patients with HIV-1 disease in Walter Reed stages (WR) 1-6, and in 14 HIV-1-negative patients WR0. The inflammatory infiltrates showed a moderate to marked decrease in CD7 expression on CD3+ T cells in benign inflammatory infiltrates of the majority of HIV-1+ patients. The majority of HIV-1-negative patients showed no decrease in CD7 expression, although 5 of 14 showed a moderate decrease and 1 of 14 showed a marked decrease. Although the nature of CD7- T cells has not been clearly defined, this population of mature T cells appears to have distinct immunologic properties as well as a trophism for skin. Better characterization of these T cells, as well as factors that promote their maturation and activation, may give clues to the high incidence as well as the pathogenesis of skin disease in HIV-1+ patients.

Cutaneous findings in HIV-1-positive patients: a 42-month prospective study. Military Medical Consortium for the Advancement of Retroviral Research (MMCARR)

BACKGROUND

Cutaneous disease is common in patients infected with HIV-1.

OBJECTIVE

The aim of our study was to identify cutaneous markers associated with HIV-1 infection and disease progression as measured by Walter Reed (WR) stage.

METHODS

For 42 months we have observed 912 HIV-1-positive patients in all WR stages. All patients had an extensive past and present medical history taken as well as a complete physical examination, periodic visits, and appropriate diagnostic procedures.

RESULTS

Increasing dryness of the skin and seborrheic dermatitis are early findings in a large percentage of patients in WR stage 1; the occurrence and severity of both conditions increase with disease progression. Tinea infections, condylomata acuminata, and verrucae are seen early, but with disease progression, although there is no clear increase in occurrence, these infections become more diffuse and resistant to treatment. Flares in acne vulgaris and folliculitis show a peak occurrence in early and mid-stage disease with a decreased occurrence in late-stage disease. Herpes simplex infections, oral candidiasis, molluscum contagiosum, Staphylococcus aureus infections, and oral hairy leukoplakia show a marked increase in occurrence with advanced disease. Conditions that have a statistically significant association with disease progression as measured by a change in a stage include drug eruptions, seborrheic dermatitis, oral candidiasis, oral hairy leukoplakia, molluscum contagiosum, herpes zoster, and hyperpigmentation (nail, oral, skin).

CONCLUSION

The most frequent and persistent cutaneous disorders were asteatosis (with or without asteatotic eczema) and seborrheic dermatitis. Conditions that were associated with a change in WR stage include drug eruptions, seborrheic dermatitis, oral candidiasis, oral hairy leukoplakia, molluscum contagiosum, herpes zoster, and hyperpigmentation. In addition to Kaposi's sarcoma, patients with HIV-1 disease have an increased potential for the development of both cutaneous epithelial and probably melanocytic malignancies. Epithelial tumors were seen in patients in all stages of disease.

Helistat absorbable collagen hemostatic sponges in cutaneous surgery in HIV-1+ patients. Military Medical Consortium for the Advancement of Military Medicine (MMCAR)

BACKGROUND

While biopsies are often required for adequate diagnosis of skin lesions in HIV-1 infected patients, these procedures result in the possible exposure of medical personnel to blood and contaminated instruments. To reduce exposure of medical personnel to contaminated needles we have used collagen sponges instead of sutures to control bleeding from punch biopsy sites in HIV-1 infected patients.

METHODS

A collagen sponge was placed in all punch biopsy sites in HIV-1 infected patients. In cases where there was clinical evidence of local infection the sponges were removed 5-6 minutes after hemostasis was obtained.

RESULTS

In over 500 biopsies in which Helistat collagen sponges were used, there have been no cases of secondary infection, and there have been no delays in healing.

CONCLUSIONS

We believe that the use of these sponges provides a high degree of safety for the physician, which may assure that the commonly atypical clinical lesions seen in HIV-1 disease are biopsied. In addition, these sponges provide hemostasis, particularly significant in this patient population, and convenience, without a significant risk of secondary infection, and may provide some benefit in healing.

Concurrent HPV-16 infection of the nipple and perianal area in an HIV-1+ patient. Military Medical Consortium for the Advancement of Retroviral Research (MMCARR)

BACKGROUND

In patients with HIV-1 disease there has been an increasing association with human papilloma virus (HPV) infections in multiple locations as well as an increase in associated tumors. In addition, there has been increased recovery of HPV in individuals with decreasing T4 cell counts.

CASE REPORT

Recently we have seen an HIV-1+ patient with a cutaneous lesion on the nipple, as well as multiple perianal lesions in which HPV-16 was demonstrated by in-situ hybridization. Although these lesions contained the same subtype of HPV virus, they had very different clinical and histopathologic morphologies, and this represents the first reported association of HPV-16 in a nipple lesion.

DISCUSSION

Our patient illustrates that in HIV-1 disease, HPV infections may present in more diffuse and atypical locations. In addition, the diffuse staining with the in-situ probe for HIV-16 within the lesions, tends to support the findings of others, that viral recovery increases with the immune suppression induced by HIV-1.

Cutaneous neoplasms in a military population of HIV-1-positive patients. Military Medical Consortium for the Advancement of Retroviral Research

BACKGROUND

In HIV-1-positive patients there have been no prospective studies that show an increase in cutaneous neoplasms.

OBJECTIVE

We observed HIV-1-positive patients to determine whether or not there was an increased incidence of cutaneous malignancies.

METHODS

A total of 724 HIV-1-positive patients were examined during a 36-month period for the development of cutaneous malignancies.

RESULTS

The most common cutaneous neoplasm found was Kaposi's sarcoma, especially in patients with late-stage disease. Basal cell carcinomas were the next most frequent tumor. We have also seen three malignant melanomas and two squamous cell carcinomas. Five patients had malignant lymphoma. One patient had a primary lymphoma of subcutaneous soft tissue; in one patient multiple cutaneous lesions developed.

CONCLUSION

The distribution and prevalent types of cutaneous neoplasms in HIV-1-positive patients appear to differ from those found in other immunosuppressed populations. This may be the result of the different patterns and periods of immunosuppression in these patients and/or associated cocarcinogens to which these patients frequently are exposed.

Immunohistochemical features in inflammatory linear verrucous epidermal nevi suggest a distinctive pattern of clonal dysregulation of growth. Military Medical Consortium for the Advancement of Retroviral Research

BACKGROUND

We studied biopsy material from four patients with inflammatory linear verrucous epidermal nevi (ILVEN) that had a psoriasiform appearance histologically and seven cases of linear epidermal nevi (LEN). Of the seven LEN, five showed hyperkeratosis, papillomatosis, and varying degrees of acanthosis; two had features of epidermolytic hyperkeratosis. Because these lesions have distinctive histologic patterns, we wanted to determine whether we could also demonstrate a distinctive pattern of immunohistochemical markers.

METHODS

On all 11 cases we performed immunohistochemical stains for PCNA, factor XIIIa, MAC-387, UCHL-1, and OPD-4. In addition, on one case of ILVEN we performed ICAM-1, ELAM-1, and HLA-DR stains.

RESULTS

The pattern of staining of PCNA, factor XIIIa, MAC-387, UCHL-1, and OPD-4 was distinctly different in ILVEN and LEN. Staining for ICAM-1 was present on keratinocytes, and ELAM-1 was present on endothelial cells in two cases of ILVEN. HLA-DR in these same two cases of ILVEN stained mainly dendritic cells in the epidermis.

CONCLUSION

The different pattern of staining of PCNA, factor XIIIa, MAC-387, UCHL-1, and OPD-4 in LEN and ILVEN indicates a different mechanism of growth dysregulation. Stains for ICAM-1, ELAM-1, and HLA-DR in ILVEN suggest that an inability to down-regulate the inflammatory infiltrate may be important in the growth dysregulation in ILVEN. In addition, the onset of ILVEN at the time of HIV-1 infection in one patient suggests that HIV-1 infection may be one of many factors that initiates ILVEN in a susceptible person.

Histologic features of foreign body reactions in patients infected with human immunodeficiency virus type 1. The Military Medical Consortium for Applied Retroviral Research

BACKGROUND

Within a large population of patients seropositive for human immunodeficiency virus type 1 (HIV-1), seven had biopsy specimens that showed foreign body reactions with histologic features different from those seen in non-HIV-1-positive patients.

OBJECTIVE

These cases were reviewed to determine whether there was a specific pattern of response to foreign bodies in HIV-1 infection and whether this pattern was related to the stage of disease.

METHODS

Biopsy specimens were reviewed to identify ruptured epidermal cysts. These were studied in routine hematoxylin-and-eosin-stained sections and with immunohistochemical stains to characterize the inflammatory infiltrate.

RESULTS

The lesions in HIV-1-infected patients contained abundant macrophages with evidence of decreased function and a lack of giant cells.

CONCLUSION

These histologic features suggest an early functional deficit before there is a significant decrease in the number of T4 lymphocytes.

Clinical features of inflammatory dermatoses in human immunodeficiency virus type 1 disease and their correlation with Walter Reed stage. Military Medical Consortium for Applied Retroviral Research

BACKGROUND

As part of a military study of the natural history of human immunodeficiency virus type 1 (HIV-1) disease, all patients entered in the study were examined for cutaneous changes associated with HIV-1 infection.

OBJECTIVE

Our purpose was to characterize and record the types of inflammatory dermatoses in a large number of HIV-1-infected patients to determine whether there was a correlation with the stage of disease.

METHODS

The clinical findings in each case were compared with the results of cultures and biopsy specimens and correlated with Walter Reed stage.

RESULTS

Most of the inflammatory dermatoses were maculopapular eruptions often with prominent follicular involvement, and in some there was a lichenoid component. With increasing Walter Reed stage, many eruptions become papulosquamous, some with psoriasiform scale and some with a hypertrophic lichenoid appearance.

CONCLUSION

Although most of the inflammatory eruptions were nonspecific clinically, most cases showed features resembling those in graft-versus-host disease.

Histopathologic and immunohistochemical findings associated with inflammatory dermatoses in human immunodeficiency virus type 1 disease and their correlation with Walter Reed stage. Military Medical Consortium for Applied Retroviral Research

BACKGROUND

Cutaneous lesions are common in patients with human immunodeficiency virus type 1 (HIV-1) infection. In many cases they are nonspecific inflammatory dermatoses.

OBJECTIVE

Our goal was to determine whether features of these inflammatory dermatoses were characteristic of HIV-1 infection and whether the changes correlated with the stage of disease.

METHODS

Biopsy specimens of inflammatory dermatoses from 176 HIV-1-infected patients in all Walter Reed stages were reviewed and the changes were compared with each WR stage.

RESULTS

The changes found were nonspecific but were suggestive of features described in graft-versus-host disease and became more prominent in late-stage disease.

CONCLUSION

A correlation was found between the changes and the stage of disease, and the findings add support to prior reports that at least some of the changes in HIV-1 infection may be autoimmune in origin.

Iontophoresis of vinblastine into normal skin and for treatment of Kaposi's sarcoma in human immunodeficiency virus-positive patients. The Military Medical Consortium for Applied Retroviral Research

BACKGROUND

Patients who test positive for human immunodeficiency virus type 1 (HIV-1) and who have disfiguring and/or painful cutaneous lesions of Kaposi's sarcoma (KS) may not be candidates for systemic chemotherapy and/or immunotherapy. Intralesional vinblastine sulfate, as a single-agent chemotherapeutic drug, has been used with some success to treat KS in patients who are HIV-1 positive. However, some patients may not tolerate the pain associated with injection of vinblastine. Transcutaneous iontophoresis of vinblastine was evaluated for therapy of KS in HIV-1-infected patients. Prior to therapy of patients, we iontophoresed vinblastine into the normal skin of volunteers who were not infected with HIV-1 to document the clinical and histologic features that occurred.

OBSERVATIONS

Iontophoresis produced a localized erythematous papular eruption in non-HIV-infected volunteers but not in HIV-1-infected patients. Histologic changes in the biopsy specimens taken from non-HIV-infected volunteers consisted primarily of scattered necrotic keratinocytes and a mild to moderate superficial lymphohistiocytic infiltrate. Thirty-one lesions of KS were treated with partial to complete clearing and symptomatic improvement.

CONCLUSION

Clinical and histologic features of iontophoresed normal skin suggest an immunologic mechanism of action. Iontophoresis of vinblastine for KS is well tolerated and results in symptomatic improvement as well as varying degrees of clearing of the lesions.

Molluscum contagiosum. Ultrastructural evidence for its presence in skin adjacent to clinical lesions in patients infected with human immunodeficiency virus type 1. Military Medical Consortium for Applied Retroviral Research

BACKGROUND AND DESIGN

Molluscum contagiosum in acquired immunodeficiency disease, although not life threatening, is often a marker of late-stage disease and may lead to disfiguring cutaneous lesions. Although most current therapy results in at least temporary clearing of individual lesions, lesions frequently recur and new lesions arise. Examination of hematoxylin-eosin-stained histologic sections in two patients showed changes suggestive of viral infection in the epidermis 0.5 cm and 1 cm lateral to obvious clinical lesions. These areas were clinically free of any lesions. Both routine histopathologic examination and ultrastructural examination were performed in two patients infected with human immunodeficiency virus type 1 (HIV-1) and three non-HIV-1-infected patients.

RESULTS

All patients showed histologic changes diagnostic of molluscum contagiosum. In addition, the sections from HIV-1-infected patients showed areas of acanthosis, hyperkeratosis, and nuclear atypia. Electron microscopy of these areas revealed rare viral organisms in these areas. Similar acanthotic, hyperkeratotic areas were not seen in the biopsy specimens from the non-HIV-1-infected patients and no viral particles were found in the epidermis around the lesions.

CONCLUSION

Viral structures consistent with molluscum contagiosum are present within the clinically normal epidermis around lesions of molluscum contagiosum in some HIV-1-infected patients. This may explain the large number of lesions seen in these patients and the difficulty in controlling the spread and recurrence of molluscum contagiosum in HIV-1-infected patients.

Cutaneous histopathologic, immunohistochemical, and clinical manifestations in patients with hemophagocytic syndrome. Military Medical Consortium for Applied Retroviral Research (MMCARR)

BACKGROUND AND DESIGN

The hemophagocytic syndrome (HPS) is characterized by fever, wasting, generalized lymphadenopathy, hepatosplenomegaly, and pancytopenia, often with associated coagulopathy. The most common cutaneous manifestations are panniculitis and purpura. Cytophagic histiocytic panniculitis fits within the spectrum of HPS, and the most consistent histopathologic feature in HPS is a proliferation of mature histiocytes that exhibit prominent erythrophagocytosis and cytophagocytosis. The clinical spectrum, the underlying causes, and the histopathologic features found in HPS are broad. The characteristic phagocytic histiocytes seen in HPS have been confused with malignant histiocytes in the past, but are now known to be reactive. The clinical findings, histologic, and immunohistochemical features of 10 cases of HPS with cutaneous lesions were reviewed. Immunohistochemical markers included KP-1, beta F-1, UCHL-1, L-26, MAC-387, factor XIIIa, and S100 protein.

RESULTS

The HPS was associated with T-cell lymphoma and/or viral infection. Most biopsy specimens showed edema and hemorrhage with a lymphohistiocytic infiltrate and prominent histiocytic cells showing erythrophagocytosis and, in some cases, cytophagocytosis. The histiocytic cells showed positive reactions for KP-1 and negative reactions for the lymphoid markers. In all cases the lymphoid cells showed a mixed pattern with most cells positive for beta F-1 and UCHL-1, and a small percentage positive for L-26.

CONCLUSION

In HPS, the prominent phagocytic histiocytes are reactive and are stimulated by T-cell lymphocytes, either neoplastic or in response to viral infection. Many of the findings in the HPS may also be due directly or indirectly to cytokines produced by proliferating T-cell lymphocytes and/or reactive phagocytic histiocytes.

Cutaneous lesions of listeriosis in a newborn

Although HIV-infected patients are commonly infected by organisms that require an intact T cell immune system for control or eradication, there are some exceptions. The intracellular pathogen Listeria monocytogenes is one such organism. Listeriosis occurs primarily in neonates, elderly patients, patients on immune suppressive medications, cancer patients, and during pregnancy. However, listeriosis is an uncommon opportunistic infection in HIV-infected patients. We report a case of listeriosis with cutaneous lesions in a neonate born to an HIV-infected woman.