A highly virulent variant of HIV-1 circulating in the Netherlands

We discovered a highly virulent variant of subtype-B HIV-1 in the Netherlands. One hundred nine individuals with this variant had a 0.54 to 0.74 log₁₀ increase (i.e., a ~3.5-fold to 5.5-fold increase) in viral load compared with, and exhibited CD4 cell decline twice as fast as, 6604 individuals with other subtype-B strains. Without treatment, advanced HIV-CD4 cell counts below 350 cells per cubic millimeter, with long-term clinical consequences-is expected to be reached, on average, 9 months after diagnosis for individuals in their thirties with this variant. Age, sex, suspected mode of transmission, and place of birth for the aforementioned 109 individuals were typical for HIV-positive people in the Netherlands, which suggests that the increased virulence is attributable to the viral strain. Genetic sequence analysis suggests that this variant arose in the 1990s from de novo mutation, not recombination, with increased transmissibility and an unfamiliar molecular mechanism of virulence.

[Interferon-gamma. Therapy of recurrent furunculosis in HIV infections]

Four HIV-antibody-positive patients in stages CDC II to CDC IV C2 with furuncles that had so far proved refractory to treatment were successfully treated with systemic application of recombined gamma-interferon, 50 micrograms s.c. on days 1, 2 and 3 of the first week with a new cycle after 3 weeks. A significant clinical improvement was seen in all patients after three to five cycles. Side-effects of therapy with gamma-interferon were similar to the symptoms of influenza and improved during therapy. No changes in immunological parameters and white blood cells counts were observed. The general condition of the patients improved or remained unchanged. A few weeks after discontinuation of therapy two patients relapsed, but they were again successfully treated with gamma-interferon.

Quantitative assessment of the efficacy of oral ketoconazole for oral candidosis in HIV-infected patients

Fifteen male patients with manifest oral candidosis due to Candida albicans, suffering from AIDS-related complex (ARC) or full-blown AIDS, were investigated both clinically and microbiologically before and about 1 and 4 weeks after 7 to 10 days of treatment with 200 mg ketoconazole p.o. per day. Candida albicans was quantitated in mouthwash fluid. The antimicrobial susceptibility of the Candida albicans isolates was assessed using the IC30 test. In the short term, clinical cure was obtained in 87%, mycological cure in 53%. In the long term, the corresponding figures were 56 and 9%, respectively. Eradication of Candida albicans was not possible if IC30 values exceeded 256 micrograms ml-1. While pretreatment counts of Candida albicans in those patients also taking zidovudine did not differ from those in the rest of the study population, both the clinical and the mycological efficacy of ketoconazole seem to be higher both in the short and the long term when administered together with zidovudine. In consideration of the high relapse rate after about 4 weeks, an interval treatment protocol with oral ketoconazole is proposed.

Quantitative analysis of CD6, CD4 and CD8 cell surface molecules compared to the absolute numbers of CD6+, CD4+ and CD8+ T-cells in peripheral blood in patients with HIV-infection

T lymphocyte subsets were determined on blood samples from 16 HIV-seropositive patients with manifest AIDS (CDC IV), 24 HIV-seropositive patients with lymphadenopathy syndrome (LAS, CDC III), 16 HIV-seropositive clinical healthy persons (CDC II) and 11 HIV-seronegative homosexuals as control group. Absolute numbers of T-cells (CD6+), T-helper/inducer-cells (CD4+) and T-suppressor/cytotoxic-cells (CD8+), obtained by immunofluorescence staining were compared with the absolute amount of subset specific surface molecules, obtained by a T-cell-ELISA. With both, indirect immunofluorescence technique and ELISA technique a highly significant decrease of the absolute numbers of CD4+ cells and the absolute amount of CD4 surface molecules, respectively, was found in asymptomatic HIV-infection, LAS and in manifest AIDS. In all HIV-seropositive groups the relative decrease of CD4 surface molecules was significantly greater than the decline of CD4+ cells. This phenomenon however was not seen in HIV-seronegative homosexuals. The absolute number of CD6+ cells and the amount of CD6 surface molecules were found significantly lowered in AIDS compared to HIV-seronegative homosexuals. No significant changes were found for CD8+ cell numbers and CD8 surface molecule in the progression of the HIV-infection.

Seborrheic dermatitis and atopic eczema in human immunodeficiency virus infection

Diseases of the skin and visible mucous membranes are important signs of HIV infection. Dermatitis and eczema present mostly as seborrheic dermatitis. Thirty-one % of asymptomatic patients in seropositive latency period and up to 83% of AIDS patients present with this common symptom of HIV infection. Up to now there is no clear answer about the importance of atopic manifestations in AIDS. In children with pediatric AIDS, atopic eczema has been described in up to 50% of cases. In adult patients however there are contradictory results about the frequency of atopic diseases.

[Diagnosis and therapy of ulcus molle today. Case report and review of the literature]

Chancroid, an ulcerous disease of the genitalia caused by Haemophilus ducreyi, occurs rarely but regularly in Germany. Exact diagnosis is based on the clinical features and a direct smear, and in particular on cultivation of the organism, showing its unique macromorphological characteristics. The sensitivity of cultivation has increased due to the development of selective media for primary isolation. Resistance problems during the last decade meant that a change to new therapeutic strategies was unavoidable. The work presented here includes a case report and a review of the recent literature, it illustrates modern methods of diagnosis and treatment of Haemophilus ducreyi infections 100 years after the first description of the organism.

Dissociated nystagmus as a common sign of ocular motor disorders in HIV-infected patients

In order to determine if ocular motor disturbances due to brainstem and cerebellar dysfunction provide a frequent and early marker for HIV infection of the brain, neurological examination was performed in 133 HIV-infected persons who were consecutively admitted to our hospital. In 22 patients (17%) we found no other reason for cerebellar or pontomesencephalic signs than HIV encephalopathy. Ocular motor disorders accounted for the most frequent signs of cerebellar and pontomesencephalic dysfunction. Ocular motor disorders mainly consisted of dissociated nystagmus (n = 12), gaze-evoked nystagmus (n = 10) and impaired smooth pursuit (n = 6). Cerebellar ataxic gait and dysmetria were present in 3 patients. Since dissociated nystagmus was the primary ocular motor disorder, we assume that the medial longitudinal fasciculus may be a predilected circumscribed area for HIV infection of the brain. We suppose that cerebellar and pontomesencephalic disorders may be an early marker for HIV encephalopathy because they were the only neurological signs found in 12 patients.

In vitro susceptibilities and biotypes of Candida albicans isolates from the oral cavities of patients infected with human immunodeficiency virus

Candida albicans strains were isolated from the oral cavities of 62 human immunodeficiency virus (HIV)-infected patients at different stages of HIV infection. Only patients with persistent generalized lymphadenopathy-acquired immunodeficiency syndrome (AIDS)-related complex or full-blown AIDS showed typical clinical symptoms for oral candidiasis. In general, the microbiological recovery of Candida strains from the oral cavity increased with more advanced stages of HIV infection. The antifungal activity of ketoconazole, itraconazole, nystatin, amphotericin B, and flucytosine against all 62 strains was evaluated by means of a photometer-read broth microdilution method for determination of the 30% inhibitory concentrations of the drugs. The 95% ranges of 30% inhibitory concentrations were as follows: less than or equal to 0.063 to 32 micrograms/ml for ketoconazole, less than or equal to 0.063 to 8 micrograms/ml for itraconazole, 0.5 to 4 micrograms/ml for nystatin, less than or equal to 0.063 to 4 micrograms/ml for amphotericin B, and less than or equal to 0.063 to 8 micrograms/ml for flucytosine. Two strains were resistant to flucytosine, one was resistant to ketoconazole, and three were resistant to itraconazole. Isolates from patients with full-blown AIDS showed significantly less susceptibility to itraconazole, amphotericin B, and flucytosine. Strains were biotyped by using the API 20C carbohydrate assimilation system. The major biotype accounted for 63.9% of the isolates. At repeated evaluation, a change in biotype pattern was seen in 27.3%.

Class II (DR) antigen expression on CD8+ lymphocyte subsets in acquired immune deficiency syndrome (AIDS)

In a selected group of human immunodeficiency virus (HIV)-infected patients we confirm the expansion of a CD8+ T-lymphocyte subset, i.e., the CD8+/Leu7+ cells, which account for 30% of the lymphocytes, compared to 3% in the control donors. In addition, a CD8+ T-lymphocyte subset that coexpresses class II (DR) antigens, i.e., CD8+/DR+ cells, is also increased from 1.5% in controls to 27% in the HIV-infected patients. Using three-color immunofluorescence and flow cytometry we can demonstrate that the CD8+/Leu7+ and the CD8+/class II+ cells are not distinct but overlapping subsets. In the HIV-infected patients 42% of the CD8+/Leu7+ cells were strongly positive for class II and these CD8+/Leu7+/class II+ cells accounted for 13% of all lymphocytes. These findings indicate that the expanded CD8+/Leu7+ cells are activated and hence might be actively involved in immune defense in acquired immune deficiency syndrome (AIDS).

T4/T8 ratio and absolute T4 cell numbers in different clinical stages of Kaposi's sarcoma in AIDS

Thirty-seven men (36 homosexual or bisexual and one heterosexual) with epidemic Kaposi's sarcoma and underlying HIV infection were followed up over a period of up to 32 months. Fourteen patients (38%) died, with a median survival time of 7.2 months after the diagnosis of AIDS. Seventeen patients (46%) presented with one or more opportunistic infections, mostly Pneumocystis carinii pneumonia. Eighteen patients (49%) had lymphadenopathy syndrome according to the definition of the CDC. Using the Laubenstein-classification of Kaposi's sarcoma, all patients either remained stable or deteriorated, improvement was never observed. Absolute T4 lymphocyte counts and the T4/T8 ratio were not related to the disease stage. With the onset of B symptoms (systemic symptoms), however, the absolute T4 numbers and the T4/T8 ratio markedly decreased. Delayed type hypersensitivity also showed no relationship to the clinical stages of Kaposi's sarcoma. Thus, the clinical progression of Kaposi's sarcoma lesions seems to be largely independent of the immunological parameters investigated. However, the onset of B symptoms was observed to be related to changes in immune status.

[Virus-specific antibody profile in various stages of HIV-1 infection. Western blot analysis of 170 patients]

The western blot analysis of 170 patients with HIV-1-infection demonstrated that 47% of the patients in latent stage, 58% of the patients with lymphadenopathy-syndrome and only 25% of the patients with the full-blown picture of AIDS showed the complete pattern of HIV-specific antibody response. This antibody response is mainly directed against the env-encoded envelope proteins gp160, gp120 and gp41, against the gag-encoded core proteins p55, p24 and p17 as well as against the pol-encoded enzymatic proteins p66, p51 and p31. Antibodies against gp160 and gp120 were present in nearly all patients, whereas the prevalence of the other antibodies decreased with the stage of the disease. Statistical significant differences were found particularly between patients with LAS or AIDS respectively. Antibodies against p17 were detected in 74% of the patients with LAS but only in 25% of the patients with AIDS. The lack of antibodies against p17, p24 or p51 was significantly associated with lower mean CD4/CD8-ratios (p less than 0.007) and higher mean serum levels of IgA (p less than 0.001) and beta-2-microglobulin (p less than 0.001). One third of the patients with LAS and this reduced pattern of antibody response developed AIDS within six months. These results demonstrate that the detection of antibodies against p17, p24 or p51 is of prognostic importance. A serological profile which lacks the antibody response against at least two of those three viral antigens indicates a progression of the disease activity.

[Prognostic significance of antibodies to HIV nuclear proteins in patients with the lymphadenopathy syndrome]

A total of 219 sera from HIV-infected patients were tested by a competitive immunoassay for the presence of antibodies to env and core protein. Whereas antibodies to the HIV envelope protein (gp41) were detected in all patients, only 84% of the patients with latent infection, 73% of the patients with LAS and 48% of the patients with AIDS had antibodies to the core protein (p 24). The prognostic importance of the decline of antibody reactivity to HIV core protein was further investigated in patients with lymphadenopathy syndrome or AIDS-related complex and correlated with other serological and immunological parameters. In those patients with no detectable anti-core reactivity, we found more frequently pathological and significantly higher serum levels of beta-2-microglobulin and IgA, but significantly lower numbers of leucocytes and lymphocytes and T4/T8 ratio than in patients with both gp41 env and p24 core antibodies. These results demonstrate that the determination of antibodies to HIV core proteins in sera of HIV-infected patients, especially with lymphadenopathy syndrome or AIDS-related complex, appears to be of great value for monitoring prognosis and disease activity.

[Serological and immunological diagnosis of HIV-1 infection. Studies of 198 infected cases]

Since 1985, a total of 4281 patients at the Department of Dermatology, University of Munich, were tested for HIV-1 antibodies. Using the ELISA test, 273 were found to be positive, of whom 198 were examined clinically. At the time of the first serological test, 76 of these 198 patients (38.4%) had no clinical symptoms, 98 (49.5%) had a lymphadenopathy syndrome, and 29 had the full-blown picture of AIDS (12.1%). The following additional tests were performed on the 198 patients: antibodies against virus envelope and core proteins, concentration of serum immunoglobulins G, A and M and beta 2-microglobulin, absolute leukocyte and lymphocyte counts, T4/T8 ratio, and intracutaneous cellular immune reaction. Antibodies against virus envelope proteins were present in all the patients. Antibodies against virus core proteins were present in 82% of patients in the latent stage, 64% of patients with the lymphadenopathy syndrome, but only 45% of those with AIDS. Clearcut deviations within the three groups were also present with respect to serum levels of IgG and beta 2-microglobulins, as well as the T4/T8 ratio and the intracutaneous reaction against recall-antigens.

[Sex behavior and sexually transmissible diseases]

Sexually transmitted diseases (STD) are no longer limited to the classic venereal diseases. A great number of viral and bacterial infections can be transmitted by sexual intercourse. Changes in social structures and advances in medicine in recent decades have resulted in greater liberality among the heterosexual and homosexual populations. The acquired immunodeficiency syndrome (AIDS) has introduced a new dimension to discussions on sexual behavior.

[Surgical treatment of the snapping hip]

Snapping hip (Coxa saltans) is the abrupt sliding of the iliotibial tract over the greater trochanter. In the case of pain, which cannot be alleviated by a conservative treatment, an operation is advised. The methods of operation applied up to this day showed--especially because of their high recidive-quotas--great disadvantages. In a detailed post-operational check-up over the past 20 years the new method of "diagonal notching" (27 cases) developed at the Orthopedic Hospital München-Harlaching was compared to the old method of fixing the tract according to M. Lange (24 cases). After "diagonal notching" the snapping occurred again seven times less than after fixing the tract. After "diagonal notching" only 4% of the patients had to be re-operated, however, after fixing the tract a re-operation was necessary on 38% of the patients. 91% of the patients were relieved from their pain almost completely after "diagonal notching", compared to only 50% after fixing the tract. Considering that the "diagonal notching" offers simple technics of operation and better results than other methods, the "diagonal notching" should be used as method of choice to eliminate a snapping hip.