The third pandemic: The respiratory syncytial virus landscape and specific considerations for the allergist/immunologist

BACKGROUND

Since its initial identification in 1956, respiratory syncytial virus (RSV) has been the second most common cause of mortality in infants <6 months of age and a major cause of morbidity and mortality associated with lower respiratory tract infection (LRTI) in older adults (ages >60 years) worldwide. Of particular interest to the allergist/immunologist is a growing body of evidence that suggests an association between LRTI caused by RSV in infants with later-life development of asthma, wheezing, or impaired lung function in adults. Efforts to develop a RSV vaccine have been thwarted for >70 years by the occurrence of enhanced respiratory disease (ERD), an adverse RSV vaccine reaction, in the 1960s, in which more-severe illness occurred on natural infection after vaccination of infants who were RSV naive and with a formalin-inactivated RSV vaccine. Recent advances in knowledge of the structural biology of the RSV surface fusion glycoprotein, however, have revolutionized RSV vaccine development for preventive interventions and have offered, at last, the hope of an effective and safe vaccine for the prevention of RSV disease.

OBJECTIVE

The purpose of this report was to examine the current evidence that supports the epidemiology, disease manifestations, molecular biology, treatments, and new vaccine development of RSV vaccines.

RESULTS

The host-immune response to RSV infection is carried out by two distinct but overlapping universes of mucosal and systemic immune systems in which a balanced set of B- and T-cell responses are involved in protective immunity that includes the mucosal immune system in which immunoglobulin A (IgA) prevails and the systemic immune system in which IgG neutralizing antibody predominates. The key to developing an effective vaccine is now thought to be linked to the availability of a stabilized prefusion F protein in the immunizing vaccine, which can perform a dual function of a balanced mucosal and/or systemic immune response as well as an effective antibody specifically directed to critical epitopes on the requisite prefusion F protein.

CONCLUSION

The unfortunate manifestation of RSV ERD that occurred in the 1960s has led to a better understanding of the structural biology of the RSV surface fusion glycoprotein and has provided a basis for the development of more effective and safer RSV vaccines and monoclonal antibody preparations for immunoprophylaxis of the dread effects of RSV disease. There are now a large number of clinical trials in progress that are evaluating these products, which include recombinant vector, subunit, particle-based, live-attenuated, chimeric, and nucleic acid vaccines; and monoclonal antibodies. This article givesan overview of the many aspects of RSV disease and development of virus (RSV) vaccines of particular interest to the allergist/immunologist.

Monkeypox viral infection and disease: A challenge for the allergist-immunologist

Background: Human monkeypox is a zoonosis caused by the monkeypox virus, an orthopoxvirus and close relative of variola virus, the causative agent of smallpox. The disease was first reported in central Africa in 1970, where it continues to be endemic and has historically affected some of the poorest and most marginalized communities in the world. The condition has recently attracted global attention due to >14,000 cases, including five deaths, reported by the World Health Organization, and a total of 5189 confirmed monkeypox cases in the United States reported by the Centers for Disease Control and Prevention as of July 29, 2022. On July 23, 2022, the World Health Organization declared the current monkeypox outbreak a Public Health Emergency of International Concern. Objective: The purpose of the present report was to review the epidemiology of monkeypox viral infection; its clinical manifestations; and current recommendations for diagnosis, treatment, and use of vaccines for prevention of the disease, with a focus on those aspects that have particular relevance to the allergist/immunologist. Results: Monkeypox was discovered in the early 1970s and, for years, has been well described by researchers in west and central Africa, where the disease has been present for decades. Although this outbreak thus far has mostly affected men who have sex with men, it is possible that the disease could become endemic and could begin spreading in settings where there is close physical contact, which is how the virus is transmitted. Conclusion: Monkeypox is a different viral infection from the coronavirus. Unlike the coronavirus, which is an extremely contagious respiratory pathogen, monkeypox is primarily transmitted through body fluids and/or prolonged skin-to-skin contact. Although the control of monkeypox will require renewed efforts and resources, we have learned much from the past and have the tools to stop this virus from becoming yet another serious illness with which Americans have to contend. The allergist/immunologist can play a significant role.

The global burden of vaccine-preventable infectious diseases in children less than 5 years of age: Implications for COVID-19 vaccination. How can we do better?

Background: Infectious diseases are a leading cause of morbidity and mortality worldwide. As of 2018, the total world population of children < 5 years of age was roughly estimated at 679 million. Of these children, an estimated 5.3 million died of all causes in 2018, with an estimated 700,000 who died of vaccine-preventable infectious diseases; 99% of the children who died had lived in low- and middle-income countries. The infectious diseases that remain major causes of mortality for which vaccines have been shown to provide proven preventive success include, in order of prevalence, are those caused by Streptococcus pneumoniae, Rotavirus, Bordetella pertussis, measles virus, Haemophilus influenzae type b and influenza virus. Objective: The purpose of the present report was to address the global burden of these six vaccine-preventable infectious diseases in children < 5 years of age, together with implications for the prevention of coronavirus disease 2019 (COVID-19) infection in children. Methods: The current immunization strategies for the prevention of the six vaccine-preventable infectious diseases in children are reviewed as a framework for new strategies of vaccine prevention of COVID-19 in children. Results: The burden of addressing vaccine prevention of future infectious disease in children can be effectively pursued through knowledge gained from past experiences with vaccine usage in these six vaccine-preventable childhood infectious diseases. Conclusion: Issues with regard to the burden of disease mortality, disease transmission, and available vaccines as well as vaccine successes and shortcomings for specific pathogens can serve as important landmarks for effective use of future vaccines. Although much success has been made globally in preventing these childhood deaths, much remains to be done.

COVID-19 in children: Pathogenesis and current status

Background: Since its initial description in December 2019 in Wuhan, China, coronavirus disease 2019 (COVID-19) has rapidly progressed into a worldwide pandemic, which has affected millions of lives. Unlike the disease in adults, the vast majority of children with COVID-19 have mild symptoms and are largely spared from severe respiratory disease. However, there are children who have significant respiratory disease, and some may develop a hyperinflammatory response similar to that seen in adults with COVID-19 and in children with Kawasaki disease (KD), which has been termed multisystem inflammatory syndrome in children (MIS-C). Objective: The purpose of this report was to examine the current evidence that supports the etiopathogenesis of COVID-19 in children and the relationship of COVID-19 with KD and MIS-C as a basis for a better understanding of the clinical course, diagnosis, and management of these clinically perplexing conditions. Results: The pathogenesis of COVID-19 is carried out in two distinct but overlapping phases of COVID-19: the first triggered by the severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) itself and the second by the host immune response. Children with KD have fewer of the previously described COVID-19-associated KD features with less prominent acute respiratory distress syndrome and shock than children with MIS-C. Conclusion: COVID-19 in adults usually includes severe respiratory symptoms and pathology, with a high mortality. It has become apparent that children are infected as easily as adults but are more often asymptomatic and have milder disease because of their immature immune systems. Although children are largely spared from severe respiratory disease, they can present with a SARS-CoV-2-associated MIS-C similar to KD.

Electronic health records-Applications for the allergist/immunologist: All that glitters is not gold

A review of existing literature on electronic health records (EHR) demonstrates the lack of a comprehensive analysis of the current status of, and impediments for, physicians, including allergists/immunologists, to adopting a fully functioning system. For physicians to logically embrace the use of EHRs, a comprehensive but straightforward presentation of this complex subject would be helpful. In fact, although there is some evaluative information regarding data derived from EHRs about asthma epidemiology and practice guidelines as well as recording adverse allergic reactions, it is impossible to find one scholarly article that evaluated the use of fully functional EHRs from the perspective of an allergist or immunologist. This analysis presents a review of the background and goals of EHRs and describes the major problems that delayed their widespread acceptance. Necessary solutions to the problems are presented in this article. The potential benefits of better EHRs could foster widespread acceptance and use of these systems.

Implementation of a pertussis immunization program in a teaching hospital: an argument for federally mandated pertussis vaccination of health care workers

BACKGROUND

As pertussis disease becomes more common, health care-associated outbreaks have been reported with increasing frequency. Often, these clusters are costly and labor intensive to investigate and contain. It is clear that health care workers are among the adults who transmit pertussis to susceptible infants. Recent focus on patient safety, together with a concern for protecting employees in the workplace and those they expose elsewhere, has spurred interest in optimizing measures to prevent infection and disease transmission. Shortly after a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed booster was licensed and became available, we designed, launched, and analyzed a campaign to immunize the employees of our institution against pertussis.

METHODS

To optimize acceptance of a tetanus toxoid, reduced diphtheria toxoid and acellular pertussis vaccine adsorbed booster by employees, we adopted a program consisting of a 3-phase publicity and educational model and a 3-phase vaccine delivery approach.

RESULTS

Despite extraordinary resources dedicated to this program, and our institution's better than average annual uptake of influenza vaccine, less than one third of our eligible employees were immunized. A significant number of employees declined to be vaccinated for inappropriate reasons.

CONCLUSION

A campaign of this kind is quite labor intensive and expensive, yet limited overall vaccine uptake was achieved. A federal mandate to require pertussis immunization of all health care workers appears to be a more effective way to protect our patients, employees, families, and society.

Live viral vaccines in the control of highly infectious diseases: measles and varicella

It is possible that by the end of this decade, measles and varicella two of the most infections and previously universal diseases of children, with massive levels of morbidity and significant mortality, may become of historical interest only. To accomplish this success, it is imperative that all involved parties do what is required. The vaccine supply must be assured, parents must be appropriately educated and reinforced by the media to bring their children to be immunized, and healthcare personnel must both aggressively ascertain and administer needed immunizations.

A case of severe monkeypox virus disease in an American child: emerging infections and changing professional values

Monkeypox virus disease is a rare zoonosis that until recently was limited to Central Africa. We describe the clinical features of the third child in the United States reported with this newly emerging infection. This child was part of a large cluster of individuals in the Midwest infected by prairie dogs that had contracted the virus when housed with infected small mammals imported from Africa. The differential and laboratory diagnoses and the difficulty finding physicians and nurses to care for this patient are discussed.

More laboratory testing: greater cost but not necessarily better

BACKGROUND

The bacterial latex agglutination assay is ordered predominantly on the pediatric population, for rapid screening for bacterial surface antigens in cerebrospinal fluid (CSF) or urine specimens. The high cost of this assay and questions raised in the literature regarding its accuracy led to a retrospective review of the use of this assay at a medium-sized midwest teaching hospital. The results of 6,370 bacterial latex agglutination tests performed between May, 1995, and November, 1996, and charts of patients being tested were reviewed.

RESULTS

This study demonstrated a sensitivity and specificity of 28.6% and 86.7% for urine specimens and 70.0% and 99.4% for CSF specimens. A total of 11 pathogens were accurately detected (7 CSF and 4 urine). There were 13 false negatives and 59 false positives. None of the true positives had a discernible effect on either treatment or hospital course; however, several of the erroneous tests resulted in delayed or unnecessary treatment and workup of the involved patients. The annual billed cost of this test at this institution (fiscal years 1995 to 1997) averaged $167,000 per annum. This does not include indirect costs associated with increased length of hospital stay, overutilization of antibiotics and excess laboratory tests ordered as a result of false positives.

CONCLUSIONS

Bacterial antigen latex agglutination testing is neither sufficiently sensitive nor specific to be used as a screening test. Accurate results have no demonstrable clinical impact, whereas numerous inaccurate results are often generated at great cost. The continued use of the latex agglutination assay should be seriously questioned in an era when cost containment and clinical efficiency are becoming increasingly important.

Effect of the HIV-1 syncytium-inducing phenotype on disease stage in vertically-infected children

The syncytium-inducing (SI) capability of HIV-1 isolates from 48 HIV-infected children was determined in order to examine the association of the SI phenotype with an AIDS diagnosis and/or with other clinical parameters in HIV-infected children. In a retrospective cross-sectional analysis, phenotypic data were linked to clinical and immunologic data from each patient. Multiple longitudinal samples were analyzed from 14 patients. Children with SI viruses were older than children with nonsyncytium-inducing (NSI) strains. Twelve of 13 children less than 2 years old carried NSI viruses, seven of the 12 already had a diagnosis of AIDS. Two children under 2 years of age died within 1 month of NSI virus isolation. Although plasma p24 antigen levels tended to be higher in the NSI group, the difference appeared to reflect high p24 levels in children under 2 years old with AIDS. When children under 2 were omitted, differences in age, CD4+ cell counts, p24 antigenemia, and clinical parameters were not significant. The SI phenotype of HIV-1 did not occur more frequently in children with an AIDS diagnosis. Four children remained stable with SI isolates overtime periods of 16 to 31 months. Three children's isolates converted from NSI to SI and 2 converted from SI to NSI. These data indicate that SI viruses do not play a significant role in progression to AIDS during the first 2 years of life. Furthermore, for children above the age of 2, the association between advanced disease stage and the SI phenotype in adults may not apply.

Qualitative and quantitative analysis of T lymphocytes during normal human pregnancy

PROBLEM

Human reproduction involves contact between cells which are allogeneic to one another, however the fetus not only survives but thrives.

METHODS

Aspects of T-cell-mediated immunity during normal human pregnancy were studied. PBMNCs of pregnant and nonpregnant women were stimulated with PHA and cytomegalovirus antigens (CMV). The capacity of stimulated cells to proliferate, to produce IL-2 and IFN-gamma, to express IL-2 receptor (IL2R1) and the effect of rIL2 on the proliferation rate of lymphocytes were examined. FACS was utilized for T-cell subset comparisons.

RESULTS

The proliferation rate, IL-2, and IFN-gamma synthesis were all significantly impaired at suboptimal concentration of PHA throughout pregnancy. Exogenous rIL-2 corrected this depression of cell-mediated immunity (CMI). At optimal concentration of PHA, proliferation rate and production of IFN-gamma and IL-2 were all decreased. Exogenous rIL-2 corrected these deficits only in the third trimester. Third trimester pregnant women demonstrated a significant depression of proliferation as well as IL-2 and IFN-gamma production after CMV stimulation, which was partially corrected by exogenous rIL-2. FACS analysis suggested that after stimulation by CMV and optimal concentration of PHA, T cells were activated and both CD4+ and CD8+ lymphoblasts expressed normal density of IL-2R1. With suboptimal PHA, the number of activated CD4+ and CD4+IL2R1+ cells were diminished and CD4+ and CD8+ T lymphoblasts expressed lower number of IL2R1.

CONCLUSIONS

CD4 T helper (Th1) cell function is down regulated progressively during the three trimesters of pregnancy without changes in the quantity of T cell subsets.

Human immunodeficiency virus infection presenting as pancytopenia in an infant

CASE REPORT

A 14-month-old infant presented with pancytopenia and Mycobacterium avium intracellularae (MAI) as the initial manifestation of acquired immunodeficiency syndrome (AIDS).

CONCLUSION

Human immunodeficiency virus (HIV-1) infections should be considered in the differential diagnosis of infants and children with cytopenias.

Clinical immunology and infectious diseases

Without the application of immunology, understanding of the pathogenesis and pathophysiology of infectious diseases would be severely retarded. The development new vaccines for the prevention of infectious diseases has been based on new immunologic findings. Immunodiagnostic modalities have provided for the growth of diagnostic techniques for infectious diseases. Clinical immunology also has laid the groundwork for immunotherapies using the old intravenous immunoglobulin preparations and the new monoclonal antibodies, cytokines, and interferons.

Congenital syphilis

Congenital syphilis offers many parallels with perinatal HIV infection. Both affect multiple organs including the central nervous system, may be asymptomatic for months to years, and pose diagnostic dilemmas, especially from a laboratory perspective. Syphilis is a co-infection in some cases of HIV. Public policy issues raised by the AIDS epidemic, including stigmatization, discrimination, and denial of access to health care, have their antecedents in syphilis.

Perinatal HIV infection and AIDS

This article provides a comprehensive review of the current understanding of the epidemiologic trends, diagnosis, and management of pediatric HIV infection and AIDS. Special emphasis is placed on the multisystem manifestations of pediatric HIV disease, and a rational systematic approach to management is discussed.

Transmission from one child to another of human immunodeficiency virus type 1 with a zidovudine-resistance mutation

BACKGROUND AND METHODS. We describe a child who apparently acquired human immunodeficiency virus type 1 (HIV-1) infection in the home setting. The suspected source of infection was a child with the acquired immunodeficiency syndrome who had received zidovudine and whose virus contained a mutation associated with in vitro zidovudine resistance. The children were born to different HIV-1-infected mothers, but they lived in the same home between the ages of two and five years. Child 1 was infected perinatally; Child 2 was not and was repeatedly found to be seronegative. Child 2 was examined because of acute lymphadenopathy and had seroconverted to HIV-1 positivity. HIV-1 proviral DNA was amplified from peripheral-blood mononuclear cells and subjected to sequence analysis. Sequences from Child 2 were compared with those from Child 2's mother, Child 1, and local HIV-1-infected control children.

Rapid culture confirmation of herpes simplex virus by a monoclonal antibody-based enzyme immunoassay

Rapid confirmation of herpes simplex virus (HSV) is essential in many clinical settings. Viral isolation in cell culture is the standard method for diagnosing HSV infection, with confirmation by specific immunological staining. The performance of the Rapid Absorbent Matrix Pad (RAMP) HSV culture confirmation test was evaluated with specimens obtained from 71 patients with suspected HSV infection and inoculated into African green monkey kidney cell lines. Forty-one culture-positive specimens were confirmed to be HSV by both the RAMP HSV test and the Bartels HSV immunoperoxidase test. Thirty immunoperoxidase-negative specimens were also negative in the RAMP HSV test. The sensitivity and specificity of the RAMP HSV test were 100%. Twelve specimens positive for cytomegalovirus, adenovirus, or enterovirus tested negative by the RAMP HSV test. Thus, the RAMP HSV test was faster than, easier to perform than, as sensitive as, and as specific as other well-documented confirmation methods.

Cytomegalovirus infection in children with AIDS

Data for 38 children perinatally exposed to human immunodeficiency virus (HIV) were evaluated to determine the impact of cytomegalovirus (CMV) infection on the course of perinatally acquired HIV infection. Thirteen children belonged to the P0 (indeterminate) group, one to the P1 (asymptomatic) group, and 24 to the P2 (symptomatic) group, per the classification of the Centers for Disease Control. Of the 24 children in the P2 group, 10 died. The mean follow-up time was 22.8 months for the 10 children who died and 16.3 months for the 13 children in the P0 group. Serial cultures of urine were performed for all 38 patients. CMV was isolated from seven of 10 children who died and from four of 14 children who survived (P less than .05). Only one of the 13 P0 children was culture-positive for CMV, as compared with 11 of 24 P2 children (P less than .05). All CMV-infected children continued to demonstrate CMV viruria in serial cultures. The mean age at the time of the first culture positive for CMV was 13 months. Microcephaly was present in 15 (65%) of 23 P2 children but in none of the P0 and P1 children (P less than .05). Eight of 11 CMV-infected children were microcephalic; seven of 12 children not infected with CMV were microcephalic (P greater than .05). These data suggest that the prevalence of active CMV infection is significantly higher in P2 children than in P0 and P1 children. In addition, there is a significant association between CMV infection and mortality among P2 children.

Routine immunizations for American children in the 1990s

It has been suggested that one of the major advances in medicine, and for society at large, has been the development of vaccines and the adoption of routine immunization by the vast majority of responsible health care practitioners in the developed nations. Thankfully, there continue to be rapid advances in our ability to diagnose and treat infectious diseases. However, with these rapid advances come necessary changes in the dogma of medical practice, including changes in the routine immunization procedures recommended by various authoritative bodies in the United States. New immunizing agents will be developed and will achieve routine use. Unexpected adverse reactions and complications of our immunization reagents must constantly be sought and described. Previously unrecognized subgroups of hosts at special susceptibility to adverse and untoward vaccine effects will be recognized; the pathogenesis of their special susceptibility needs to be understood and then will have to be appropriately addressed. Individual health care practitioners will need to keep abreast of routine immunization recommendations and the application of these recommendations in an organized and thorough fashion to infants, children, adolescents, and adults. A crucial link in the chain of optimal preventive health care will continue to involve those who prescribe, order, and administer vaccines.

Can parents do a throat culture?

Throat swabs for Group A beta-hemolytic Streptococcus were obtained from 98 patients, ages 4 to 17 years, both by their parents and by physician investigators. Compared with results obtained by physicians, there was a false negative rate of 32% (P less than 0.001) for the parents. The discrepancy was greater in the youngest age group (38% false negative rate in the 4- to 8-year-olds) compared with older children (P less than 0.001). The overall sensitivity and negative predictive value for the parent-obtained swabs were 68 and 45%, respectively. In the 4- to 8-year-old group, these values were 62 and 37%, respectively. Because there were no false positives the positive predictive value was 100%. We conclude that the false negative rate for untrained parents obtaining throat swabs is too high to warrant the implementation of home testing for Group A streptococci.

Once-daily administration of ceftriaxone for the treatment of selected serious bacterial infections in children

Ceftriaxone treatment (50 to 80 mg/kg once daily) was given to 201 children between 1 month and 18 years of age. There were 201 serious bacterial infections, including epiglottitis, pneumonia, cellulitis, osteomyelitis, septic arthritis, pyelonephritis, sepsis, and meningitis. The common pathogens responsible for pediatric infections isolated from these patients included Haemophilus influenzae, Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae, and Escherichia coli. The overall clinic cure rate was 94%. Ten patients were clinically improved but not cured. There were two clinical failures. Bacteriologic failure occurred in six patients. The overall bacteriologic cure rate was 97%. Twenty patients (10%) experienced adverse effects; none required discontinuation of therapy. The efficacy, safety, spectrum, and convenience of ceftriaxone monotherapy make this antimicrobial agent a candidate for the treatment of choice of selected serious pediatric infections.

Evaluation of routine lumbar punctures in newborn infants with respiratory distress syndrome

Infants with respiratory distress syndrome are routinely evaluated for infection which commonly includes a lumbar puncture. In this study cerebrospinal fluid (CSF) examination failed to elicit evidence for meningitis in 238 consecutively admitted infants with respiratory distress syndrome evaluated during the first 24 hours of life. Blood cultures were obtained in all; suprapubic or catheterized urine was obtained in 163 infants; CSF was collected successfully in 203 infants. Seventeen infants demonstrated positive blood cultures: 7 Streptococcus, 5 Staphylococcus, 3 Haemophilus influenzae, 1 Bacillus subtilis and 1 diphtheroid infection. CSF obtained from 14 of those infants had normal examinations and sterile cultures. Factors associated with bacteremia were birth weight (P less than 0.01), gestational age (P less than 0.01), prolonged rupture of membranes (P less than 0.05) and leukopenia below 10 000/mm3 (P less than 0.05). In view of the negative CSF examinations in infants with positive blood cultures and the potential complications of lumbar puncture (hypoxia, trauma, infection, epidermoid tumor), the potential risks of CSF evaluation may exceed the assessed benefit for the infant with respiratory distress syndrome.

Postoperative infection caused by an unusual serotype of Streptococcus pneumoniae associated with multiple drug resistance

A 15-month-old child developed an infectious pulmonary complication of open heart surgery. Cultures of the respiratory secretions showed growth of a 9L serotype of Streptococcus pneumoniae which was resistant to penicillin, tetracycline, and chloramphenicol. There was no evidence that the organism was spread among the family of the patient or hospital personnel.

Unusual eye abnormalities associated with congenital cytomegalovirus infection

Seven children with congenital cytomegalovirus infection demonstrated a higher than expected incidence of "rare" ophthalmological abnormalities, including anophthalmia and Peters' anomaly. These data suggest that appropriate investigation for evidence of cytomegalovirus infection should be instituted in any child with congenital ocular defects.

Clinical anophthalmia associated with congenital cytomegalovirus infection

Three cases of congenital clinical anophthalmia associated with congenital cytomegalovirus infection were diagnosed by positive viral cultures and immunologic studies. Ultrasonography in one infant with clinically detected anophthalmia showed the presence of severe microphthalmia with cyst. These findings suggest that maternal infection occurred within the first trimester of gestation.

Characteristic early electroencephalographic changes in herpes simplex encephalitis

We review electroencephalograms taken from 17 patients with severe meningoencephalitis within seven days of onset of CNS symptoms and prior to cortical brain biopsies. All patients had CNS disease clinically compatible with the diagnosis of herpes simplex encephalitis (HSE). The diagnosis was demonstrated by the isolation of virus from the brain in five patients (group 1) but considered highly unlikely in the other 12 patients (group 2) by negative immunofluorescent studies and failure of viral isolation from the brain tissue. Abnormal but nonspecific EEGs with diffuse or focal slowing were found in all patients. Distinctive high-voltage, 1-cycle-per-2-to-3 seconds periodic sharp waves from unilateral temporal lobes were seen only in three of the five patients with virologically proved HSE but in none of the 12 patients without viral isolation. This EEG pattern is strikingly similar in all three patients, regardless of their age, and may be specific for the early diagnosis of HSE prior to brain biopsy. The EEGs of the other two patients with proved HSE did not contain such abnormalities. Athough periodic EEGs with some resemblance to those previously described may occur in other CNS disorders, their presence strongly suggests the diagnosis of HSE when recorded from patients with viral meningoencephalitis. Moreover, EEGs may help locate the best site for cerebral biopsy since maximal yield of the virus in this study was from unilateral temperoal lobes corresponding with the site of local EEG changes.

Specific impairment of cell-mediated immunity in mothers of infants with congenital infection due to cytomegalovirus

Specific lymphocyte-mediated cytotoxicity to cytomegalovirus (CMV) in eight infants (six to 27 months old) with congenital CMV infection and in the mothers of six of these infants was evaluated with use of a 51chromium (51Cr)-release microassay. The control population consisted of 25 normal newborns, children, and adults. The titers of indirect hemagglutinating (IHA) antibody to CMV in the infected infants ranged from 1:16 to 1:1,024. All of these infants had detectable specific immune release of 51Cr that ranged from 3.3% to 48.9% (mean +/-SE, 21.0%+/-5.6%). The mothers of these infants demonstrated significantly elevated titers of IHA antibody to CMV (geometric mean titer, 1:410) as compared with a mean titer of 1:22 in controls (t = 5.71; P less than 0.001) but showed significantly depressed specific immune release (9.2% +/- 3.2%) compared with that of normal seropositive controls (24.8% +/- 2.8%; t = 3.31; P less than 0.001). In addition, two adult nulliparous women with persistent CMV viruria were also found to have depressed specific immune release to CMV (10.8% and 16.2%). These data suggest that a specific impairment in cell-mediated immunity to CMV occurs in mothers of infants with congenital CMV infection and in some persons who persistently excrete CMV.

Antiviral chemotherapy and neonatal herpes simplex virus infecition: a pilot study--experience with adenine arabinoside (ARA-A)

Among 13 neonates with herpes simplex virus (HSV) infection, eight had disseminated disease, one localized CNS disease, and in four the infection was confined to the skin and eyes. Ara-A, a purine nucleoside with anti-viral activity against DNA-VIRUSES, WAS GIVEN (10 TO 20 MG/MG/DAY) BY A CONTINUOUS 12-HOUR INTRAVENOUS DRIP FOR 10 TO 15 DAYS. In all, ara-A administration was begun within three to eight days after the appearance of skin vesicles which represented the hallmark of the disease. Both diagnosis and ara-A treatment were much delayed in one infant without skin vesicles and four infants whose skin vesicles appeared late, long after the occurrence of CNS damage. In this group of infants with disseminated disease, four died and one infant was left with severe neurological deficits. Eight infants (four with disseminated and four with localized skin disease) with skin vesicles as the earliest sign of infection received ara-A early, within three days after the onset of neurologic signs. All survived with no neurologic deficit at 6 months to 1 year of age. There was no apparent toxicity of ara-A to the bonemarrow, liver, or kidney.

Ascorbic acid for the common cold. A prophylactic and therapeutic trial

Three hundred eleven employees of the National Institutes of Health volunteered to take 1 gm of ascorbic acid or lactose placebo in capsules three times a day for nine months. At the onset of a cold, the volunteers were given an additional 3 gm daily of either a placebo or ascorbic acid. One hundred ninety volunteers completed the study. Dropouts were defined as those who missed at least one month of drug ingestion. They represented 44% of the placebo group and 34% of those taking ascorbic acid. Analysis of these data showed that ascorbic acid had at best only a minor influence on the duration and severity of colds, and that the effects demonstrated might be explained equally well by a break in the double blind.