Increased serum osteoprotegerin values in long-lived subjects: different effects of inflammation and bone metabolism

AIM

To evaluate serum osteoprotegerin (OPG) concentrations in relation to age-dependent changes in serum markers of bone metabolism and systemic inflammation.

METHODS

Two-hundred and eighty-three healthy subjects were evaluated for plasma estimated creatinine clearance (Cr-clearance), C-reactive protein (CRP), bone alkaline phosphatase, C-telopeptides of type-1 collagen (CrossLaps), nuclear factor-kappaB ligand (RANKL) and OPG concentrations.

RESULTS

In adult subjects (82 cases aged between 27 and 64 years) serum OPG concentrations were significantly and independently correlated with RANKL and Cr-clearance (R(2): 0.29), but not with CRP and biochemical markers of bone metabolism. In old subjects who were between 65 and 84 years of age (52 cases) serum OPG concentrations were significantly higher as compared with the adult subjects and correlated independently and significantly with serum RANKL, Cr-clearance and CrossLaps values (R(2): 0.63). The highest OPG values were found in the long-lived subjects (149 cases with ages between 85 and 110 years) who also showed increased serum CrossLaps and CRP concentrations as compared with the younger subjects. However, in the long-lived subjects serum OPG concentrations were significantly and independently correlated with Cr-clearance and CRP (R(2): 0.45) but not with CrossLaps values.

CONCLUSIONS

These data would suggest that different factors might be responsible for the age-dependent enhancement of OPG production. Bone metabolism would seem to be the most important factor influencing serum OPG concentrations in old subjects under 85 years of age, whereas in long-lived subjects the circulating values of this cytokine seem to be mainly correlated with serum CRP which could be a marker of inflammation and cardiovascular risk.

Serum thyrotropin receptor antibodies concentrations in patients with Graves' disease before, at the end of methimazole treatment, and after drug withdrawal: evidence that the activity of thyrotropin receptor antibody and/or thyroid response modify during the observation period

AIM AND METHODS

We performed a quantitative retrospective analysis of serum thyrotropin receptor antibody (TRAb) concentrations measured by a second-generation radioreceptor assay in 58 patients with Graves' disease (GD) at the onset of the disease, at the end of 18 month methimazole (MMI) treatment, and after MMI withdrawal in order to evaluate the correlation between the presence of these antibodies and the relapse of hyperthyroidism. Sixty healthy subjects were enrolled as a control group.

RESULTS

Before MMI treatment the best cutoff TRAb value for identifying patients with GD was 1.45 UI/L (specificity, 100%; sensitivity, 98.3%). At the end of MMI treatment, serum TRAb concentrations were significantly lower (p < 0.001) than those measured at baseline, but they were still significantly higher (p < 0.001) than those found in the control subjects. At the end of MMI treatment, 44 patients (75.9%) had positive TRAb values (>1.45 UI/L). After MMI withdrawal (median, 15 months), 34 patients (58.6%) became hyperthyroid, 4 patients (6.9%) became hypothyroid, and 20 patients (34.5%) remained euthyroid. There was a significant correlation between serum TRAb concentrations at the end of MMI treatment and the percentage of patients who became hyperthyroid (r: 0.56; p < 0.001) and the time of appearance of hyperthyroidism (r: -0.38; p = 0.03). All 4 patients with TRAb values below 0.9 UI/L at the end of MMI treatment remained euthyroid throughout the follow-up period. Among the 27 patients who had serum TRAb values higher than 4.4 UI/L, 23 developed hyperthyroidism and 4 hypothyroidism. The TRAb values between 0.9 and 4.4 UI/L did not discriminate between the 27 patients (46.6%) who remained euthyroid from those who had relapse of hyperthyroidism. Thus a different TRAb end of treatment cutoff was calculated to identify patients who became again hyperthyroid. This TRAb cutoff value was 3.85 UI/L (sensitivity, 85.3%; specificity, 96.5%). All but 1 patient who had serum TRAb values above 3.85 UI/L became hyperthyroid after MMI was withdrawn (positive predictive value, 96.7%). In these patients, relapse of hyperthyroidism was independent of the changes in serum TRAb concentrations (r: 0.27; p = 0.15) and occurred after a median period of 8 weeks (range, 4-48). Hyperthyroidism also developed in 5 of 24 patients who had serum TRAb concentrations lower than 3.85 UI/L at the end of MMI treatment. In these 5 patients the relapse of hyperthyroidism occurred after a median period of 56 weeks (range, 24-120) and was always accompanied by an increase in serum TRAb concentrations.

CONCLUSIONS

TRAb persist in the blood of most patients with GD after 18 months of MMI treatment. Both the frequency and the time of appearance of hyperthyroidism are closely correlated with serum TRAb concentrations at the end of MMI treatment. Our data would suggest that TRAb maintain stimulating activity after a full course of MMI treatment in the large majority of patients with GD. However, it is likely that the potency of these antibodies and/or the thyroid response to them change during treatment, as suggested by the different values measured in euthyroid control subjects and in euthyroid patients after MMI treatment.

Innate and acquired immune system in patients developing interferon-alpha-related autoimmune thyroiditis: a prospective study

OBJECTIVE

In this prospective study, we investigated whether the development of interferon (IFN)-alpha-related autoimmune thyroiditis (IFN-AT) was correlated with the sequential changes of cytokine pattern induced by IFNalpha in the peripheral lymphocytes.

PATIENTS AND METHODS

We enrolled 18 hepatitis C virus (HCV)-positive patients who developed IFN-AT, eight patients with euthyroidism [IFN-AT(Eu)] and 10 with thyroid dysfunction [IFN-AT(Dy)]. Twenty HCV-positive patients without IFN-AT acted as control group (Co-HCV+). Intracellular expression of IFNgamma and IL-4 was evaluated by multicolor flow-cytometry analysis in peripheral lymphocytes in vitro stimulated by phorbol-12-myristate-13-acetate (PMA) (25 ng/ml) and ionomycin (1 mug/ml) in presence of monensin (5 microm).

RESULTS

At the appearance of thyroid disease, both IFN-AT(Eu) and IFN-AT(Dy) patients showed a significant increase of IFNgamma expression in CD3+CD56+ and CD3-CD56+ cells but not in CD4+ and CD8+ cells. At this time point, IFN-AT(Eu) but not IFN-AT(Dy) patients also showed an increase of IL-4 expression in CD3+CD56+ cells and CD4+ cells. Six months later, IFN-AT(Eu) patients maintained high expression of IL-4 in CD4+ and CD3+CD56+ cells without any further increase in IFNgamma expression. By contrast, IFN-AT(Dy) patients showed an increase of IFNgamma expression in CD4+ and CD8+ cells, with a concomitant decrease of IL-4 expression in CD4+ cells.

CONCLUSIONS

Type 2 immune response is activated early and specifically in patients with IFN-AT who remain euthyroid throughout the follow-up. Predominant in patients developing thyroid dysfunction, by contrast, is the type 1 immune response that seems to occur earlier in innate than acquired immune system.

Recombinant human TSH modulates in vivo C-telopeptides of type-1 collagen and bone alkaline phosphatase, but not osteoprotegerin production in postmenopausal women monitored for differentiated thyroid carcinoma

In women monitored for thyroid carcinoma, short-term stimulation with rhTSH induced an acute decrease in serum C-telopeptides of type-1 collagen and an increase in serum BALP levels without any effect on OPG production. The inhibitory effect of TSH on bone resorption occurred only in postmenopausal women who showed low BMD and a high bone turnover rate as an effect of L-thyroxine suppressive therapy.

INTRODUCTION

It has been recently shown that thyrotropin (TSH) has an inhibitory activity on skeletal remodeling in in vitro conditions. Here, we have aimed at evaluating whether TSH has similar effects in vivo. For this purpose, we have evaluated the sequential profile of serum bone metabolism markers during acute stimulation with recombinant human TSH (rhTSH) in thyroidectomized women monitored for thyroid carcinoma.

MATERIALS AND METHODS

The study group included 66 thyroidectomized patients, of whom 38 were premenopausal and 28 postmenopausal, who underwent routine rhTSH-assisted whole body radioactive iodine scanning for differentiated thyroid carcinoma. The patients were sequentially evaluated for TSH, free triiodothyronine (FT3), free thyroxine (FT4), bone alkaline phosphatase (BALP), C-telopeptides of type-1 collagen (CrossLaps), and osteoprotegerin (OPG) levels during rhTSH stimulation. The samples were drawn just before and 2 and 7 days after the first administration of rhTSH. BMD was evaluated by ultrasonography at baseline. Seventy-one healthy women (41 premenopausal and 30 postmenopausal) acted as a control group.

RESULTS AND CONCLUSIONS

At study entry, all patients had subclinical thyrotoxicosis as effect of L-thyroxine (L-T4) treatment. The patients had higher serum CrossLaps and OPG levels and lower BMD than healthy subjects. Postmenopausal patients showed comparable serum FT4 and FT3 concentrations with those found in premenopausal patients. However, postmenopausal patients showed higher serum CrossLaps (p < 0.001), OPG (p = 0.03), and BALP (p < 0.001) levels and lower BMD (p < 0.001) than those measured in premenopausal patients. Two days after the first administration of rhTSH, all patients had serum TSH values >100 mUI/liter. At this time, serum CrossLaps levels decreased significantly (p < 0.001) and BALP values increased (p = 0.001) with respect to the baseline values in postmenopausal but not in premenopausal patients. rhTSH did not induce any significant change in serum OPG values either in premenopausal or in postmenopausal patients. One week after the first rhTSH administration, serum CrossLaps values decreased again to values comparable with those measured at baseline, whereas serum BALP values remained high. This study shows that subclinical thyrotoxicosis is accompanied by high bone turnover rate with an increase in serum OPG levels compared with euthyroid healthy subjects. Acute increase in serum TSH levels is accompanied by a reversible inhibition of bone resorption. This effect is characterized by a decrease in serum CrossLaps and an increase in BALP levels without any evident effect on OPG production. The activity of TSH occurs specifically in postmenopausal women in whom the negative effects of L-T4 suppressive therapy on bone mass and metabolism are more marked compared with premenopausal women.

Sero-prevalence of Taenia solium cysticercosis and Taenia solium taeniasis in California, USA

OBJECTIVES

Taenia solium Cysticercosis is a leading cause of epilepsy and neurological disability in the developing world. It is caused by ingestion of the eggs of the tapeworm, T. solium Taeniasis. The prevalence of either T. solium Cysticercosis or T. solium Taeniasis in the United States in populations at risk is poorly understood. The primary objectives of this study are to perform the first study of the sero-prevalence of T. solium Cysticercosis and T. solium Taeniasis in an at-risk community in the USA, specifically rural Southern California; identify T. solium Taeniasis positive individuals, and treat positive individuals for the tapeworm T. solium Taeniasis.

METHODS

Community based sero-prevalence study of antibodies to T. solium Cysticercosis and T. solium Taeniasis in 449 subjects living in a federally funded, predominantly Hispanic residential community; and in two migrant farm worker camps in rural Ventura County, California, USA. For this study, fingerstick blood samples were obtained. Serum immunoblots for both T. solium Cysticercosis and T. solium Taeniasis were performed.

RESULTS

The sero-prevalence of T. solium Cysticercosis was 1.8% and the sero-prevalence of T. solium Taeniasis by serum immunoblot was 1.1%. Taenia solium Cysticercosis and T. solium Taeniasis antibodies were not detected in children. The sero-prevalence of T. solium Taeniasis was highest in the migrant farm worker community. Handwashing frequency was correlated with T. solium Taeniasis sero-positivity.

CONCLUSION

The sero-prevalence of T. solium Cysticercosis and T. solium Taeniasis in this population, as detected by serum immunoblot, approximates the prevalence in some endemic areas of Latin America. Importantly, most patients likely had prior exposure, not active infection. This study establishes for the first time, the relative sero-prevalence of T. solium Cysticercosis and T. solium Taeniasis in at-risk populations in the United States.

Hashimoto's thyroiditis is associated with peripheral lymphocyte activation in patients with systemic sclerosis

OBJECTIVE

To investigate whether autoimmune thyroiditis [HT] (i.e., a TH1 disease) influences the pattern of peripheral lymphocyte activation in systemic sclerosis [SSc] (commonly regarded as a TH2 disease). Twenty SSc patients, 6 with (SSc+HT+) and 14 without HT (SSc+HT-) and 20 controls were investigated for the intracellular content of IFN-gamma and IL-4 in unstimulated and stimulated (25 ng/ml PMA and 1 microg/ml ionomycin) CD4+ and CD8+ T lymphocytes. Results Under basal conditions the percentages of CD4+IFN-gamma, CD4+IL-4+ and CD8+IFN-gammawere significantly higher in the patients than the control subjects, no significant differences being detectable between the two patient subgroups. Upon PMA stimulation, the 20 SSc patients showed a higher percentage of CD4+IFN-gamma+ and CD8+IFN-gamma+ than the control subjects. In particular, the 14 SSc+HT- patients showed a higher number of CD4+IFN-y+ and CD4+IL-4+ cells, while the SSc+HT+ patients showed higher percentage of CD8+IFN-gamma+ cells. The latter patients showed a reduced percentage of CD4+IL-4+ cells and an increased percentage of CD8+IFN-y+ in comparison with the SSc+HT- patients. Type-1 activation in the peripheral blood of SSc patients has been already pointed out by other authors and ourselves. This study shows that such activation mainly affects SSc patients with coexistent HT.

Effects of increased thyroxine dosage pre-conception on thyroid function during early pregnancy

OBJECTIVE

To compare the effects of pregnancy on the serum free thyroxine (FT4) levels in two cohorts of primary hypothyroid women treated with different levothyroxine (L-T4) doses before gestation.

DESIGN AND METHOD

Twenty-five women with compensated hypothyroidism of different aetiology (thyroidectomized and Hashimoto's thyroiditis) were enrolled in this prospective study. The women were receiving substitutive doses of L-T4 and were anticipating pregnancy. They were assigned to two groups: 14 patients (group I) were switched to partially suppressive treatment while 11 patients (group II) continued the same therapeutic regimen.

RESULTS

Pre-conceptional thyroid function evaluation demonstrated significantly higher FT4 and lower TSH in group I (P<0.001, for both hormones) and comparable free 3,5,3'-triiodothyronine (FT3) levels. The first post-conception thyroid function evaluation occurred at a median time of 6 (5-8) and 7 (5-9) weeks of gestation, for groups I and II respectively (P<0.05); all women in group I showed adequate serum FT4 levels while three patients in group II showed low-normal FT4 levels and one case was below normal levels. Statistical analysis demonstrated significantly higher frequencies (0% vs 36.4%; P<0.05) of low-normal FT4 levels in patients receiving substitutive doses of L-T4. None of the Hashimoto's-affected patients showed low or low-normal serum FT4 levels regardless of their therapeutic regimen.

CONCLUSION

Our results suggest that in hypothyroid women anticipating pregnancy (with serum TSH in the lower quartile of normal range), the pre-conception adjustment of L-T4 doses may result in adequate maternal thyroid function up to the first post-conception evaluation. The procedure seems safe and inexpensive; it may be a worthwhile treatment, at least in thyroidectomized women, in view of the well-known potential effects of even marginal maternal thyroid hypofunction on the subsequent IQ of the progeny.

High serum osteoprotegerin levels in patients with hyperthyroidism: effect of medical treatment

This study was aimed at evaluating serum osteoprotegerin (OPG) concentrations in a cohort of patients with hyperthyroidism before and after methimazole (MMI) treatment. One hundred fourteen hyperthyroid patients [93 with Graves disease (GD) and 21 with toxic nodular goitre (TNG)] and 68 matched for sex and age healthy subjects were evaluated for serum free-thyroxine (FT4), free-triiodiothyronine (FT3), thyrotropin (TSH), TSH receptor antibodies (TRAb), bone alkaline phosphatase (BALP), C-telopeptides of type-1 collagen (CrossLaps), OPG levels, and bone mineral density (BMD). In hyperthyroid patients, the biochemical evaluations were performed before and after 6 and 12 months of MMI treatment, whereas BMD was measured at baseline and after 12 months of treatment. Hyperthyroidism was more severe in GD than TNG patients. Serum OPG levels were found to be significantly higher in hyperthyroid patients than in the healthy subjects (4.3 pmol/l, range: 1.6-12.0, vs. 2.2 pmol/l, range: 1.4-6.0; P < 0.001), the values being higher in GD patients than TNG. A significant correlation between serum OPG levels and age was found in the healthy subjects (r: 0.48; P < 0.001) but not in hyperthyroid patients (r: -0.03; P = 0.8). In the healthy subjects, serum OPG levels were also positively correlated with both serum FT4 (r: 0.23; P = 0.03) and FT3 (r: 0.24; P = 0.04) levels. In hyperthyroid patients, however, serum OPG was still correlated with FT3 levels (r: 0.38; P < 0.001), whereas the correlation with serum FT4 was lost (r: 0.19; P = 0.06). In hyperthyroid patients, but not in the healthy subjects, serum OPG levels were correlated positively with CrossLaps (r: 0.20; P = 0.03) and negatively with BALP (r: -0.24; P = 0.01) and BMD (r: -0.33; P = 0.01). After 6 months of MMI treatment, serum OPG concentrations decreased significantly in TNG patients (from 3.5 pmol/l, range: 1.6-8.0, to 2.3 pmol/l, range: 1.0-4.3; P < 0.001), whereas a not significant change in OPG levels occurred in GD patients (from 4.8 pmol/l, range: 1.8-12.0, to 4.2 pmol/l, range: 1.0-14.0; P = 0.7). At Month 12 of treatment, serum OPG concentrations were significantly lower than those measured at baseline in both TNG (2.5 pmol/l, range: 1.0-3.1, vs. 3.5 pmol/l, range: 1.6-8.0; P < 0.001) and GD (2.1 pmol/l, range: 1.0-8.6, vs. 4.8 pmol/l, range: 1.8-12.0; P < 0.001). At this time, no significant differences in serum OPG, CrossLaps, and BALP values were found between patients and control subjects. At the end of follow-up, BMD was higher than those measured at baseline but still significantly lower than those measured in the control subjects. This study shows that hyperthyroid patients have serum OPG concentrations significantly higher in comparison with euthyroid subjects, in relation to thyroid hormone excess and high bone turnover. Medical treatment of hyperthyroidism normalizes serum OPG levels in temporal relationship with the normalization of bone metabolism markers, even in presence of persistent abnormal bone structure as determined by ultrasonography.

Recombinant human thyrotropin reduces serum vascular endothelial growth factor levels in patients monitored for thyroid carcinoma even in the absence of thyroid tissue

In this study, we have investigated in vivo the time-dependent effects of TSH on vascular endothelial growth factor (VEGF) production in patients monitored for thyroid carcinoma. Serum VEGF, thyroglobulin (Tg), and TSH levels were assayed at baseline and 6, 24, 30, 48, 72, and 96 h and 1 wk after administration of recombinant human TSH (rhTSH) in 45 thyroidectomized patients affected by differentiated thyroid carcinoma. At baseline, the patients with metastasis (18 cases) showed serum Tg and VEGF values significantly higher than those seen in the cured patients (27 cases). During rhTSH stimulation, the mean VEGF levels decreased significantly in both patient groups. In 60% of patients with metastasis, VEGF nadir occurred at the same time as serum TSH reached the highest values, whereas in 85.7% of the cured patients VEGF decreased after the TSH peak (P = 0.003). In conclusion, we demonstrate for the first time that short-term administration of rhTSH in patients monitored for differentiated thyroid carcinoma induces a significant reduction in serum VEGF values even in the absence of thyroid tissue. This result would suggest that TSH may be able in vivo to regulate VEGF production from tissues other than the thyroid gland.

Grey-scale analysis allows a quantitative evaluation of thyroid echogenicity in the patients with Hashimoto's thyroiditis

OBJECTIVE

In the present study we have performed a grey-scale quantitative analysis of thyroid echogenicity in the patients affected by Hashimoto's thyroiditis (HT), obtaining a numerical estimate of the degree of hypoechogenicity associated with the appearance of thyroid dysfunction.

MATERIALS AND METHODS

The study group included 89 patients with serum positivity for thyroglobulin (TgAb) and/or peroxidase (TPOAb) antibodies. Ultrasound (US) evaluation of thyroid gland and biochemical assay of serum thyrotropin (TSH), free-thyroxine (FT4) and free-triiodiothyronyne (FT3) were performed in all patients, and in 40 healthy subjects enrolled as control group. Thyroid echogenicity was compared with that of the surrounding neck muscles, using the grey-scale histogram analysis. The echogenicity was expressed in grey-scales (GWE).

RESULTS

In HT patients, the mean of thyroid echogenicity was lower when compared to the normal thyroid (61.9 +/- 8.3 GWE vs. 71.9 +/- 3.1 GWE; P = 0.01). In all HT patients the lowest limit of thyroid echo distribution was in the echogenicity range of the surrounding muscle, the overlapping ranging between 3.4% and 95.0% (mean +/- SD 48.4 +/- 20.9%). The extension of like-muscle hypoechogenicity into the thyroid gland was significantly correlated with serum TSH values (r = 0.37; P < 0.001), serum FT4 values (r = -0.60; P < 0.001), and serum TPOAb values (r = 0.31; P = 0.004). Nobody was hypothyroid when the hypoechogenicity was less than 38.0%, whereas hypothyroidism occurred in all cases with hypoechogenicity of more than 68.9%. The receiving operating characteristic curve demonstrated that 48.3% was the best cut-off for identifying hypothyroid patients with sensitivity, specificity and diagnostic accuracy of 88.9%, 86.3% and 87.6%, respectively.

CONCLUSIONS

In conclusion, the grey-scale quantitative analysis has provided a measure of thyroid hypoechogenicity associated with the appearance of hypothyroidism during the course of HT. The results of the present study would encourage the application of the computerized grey-scale analysis as complementary tool to US evaluation in the patients affected by HT.

Type-1 response in peripheral CD4+ and CD8+ T cells from patients with Hashimoto's thyroiditis

OBJECTIVE

In this study we performed single-cell analysis of the intracellular cytokine expression in peripheral CD4+ and CD8+ lymphocytes from patients with Hashimoto's thyroiditis (HT) to investigate the type-1 response separately for the two lymphocyte sub-populations.

DESIGN AND METHODS

Twenty-nine patients affected by HT and 20 healthy subjects, matched for sex and age, were enrolled. After the analysis of the lymphocyte sub-populations, the intracellular content of interferon-gamma (IFN-gamma) in phorbolmyristate acetate (PMA)-stimulated CD4+ and CD8+ lymphocytes was assayed. Moreover, the CD4+ lymphocytes were also evaluated for the intracellular expression of IL-4.

RESULTS

No significant differences in CD3+, CD4+ and CD8+ lymphocytes were found between HT patients and control subjects. However, the HT patients showed higher numbers of CD4+ IFN-gamma+, CD4+ IL-4+ and CD8+ IFN-gamma+ (t-test, P< or =0.001) cells than the control subjects. Analysing the intracellular expression of IFN-gamma and IL-4 in relation to thyroid function, we found that the euthyroid patients (18 cases) showed more expression of IL-4 in CD4+ lymphocytes than the control subjects, without any significant modification of IFN-gamma expression in CD4+ and CD8+ lymphocytes. However, the hypothyroid patients (11 cases) showed an increase of IFN-gamma expression in both CD4+ and CD8+ lymphocytes with respect to the control subjects and the euthyroid patients. Moreover, the expression of IL-4 in CD4+ cells from hypothyroid patients was significantly lower than that seen in the euthyroid cases and comparable to that found in the control subjects.

CONCLUSIONS

Our study has demonstrated that the peripheral CD4+ and CD8+ T lymphocytes from the HT patients show a type-1 activation strictly correlated to the occurrence of hypothyroidism. Further studies will be needed to clarify the exact role of peripheral lymphocytes in HT and whether they could provide a reliable marker of thyroid immune involvement.

Increased serum reverse triiodothyronine levels at diagnosis of hepatocellular carcinoma in patients with compensated HCV-related liver cirrhosis

OBJECTIVE

The aim of this study was to investigate changes in thyroid hormone metabolism in relation to the development of hepatocellular carcinoma (HCC) in patients with HCV-related liver cirrhosis.

MATERIALS AND METHODS

The study group (Group A) comprised 31 patients (25 M, 6 F; median age 62.1 years, range 54.0-81.5 years) affected by HCV-related liver cirrhosis with superimposed HCC. Acute and chronic systemic disease, other than cirrhosis, inducing 'euthyroid sick syndrome' was excluded in all patients. Serum TSH, FT4, FT3, rT3, and thyroxine-binding globulin (TBG) levels were retrospectively evaluated in frozen aliquots drawn at the time of tumour diagnosis and every 6 months for 3-7 years before HCC diagnosis. The control group (Group B) comprised 29 patients affected by HCV-related liver cirrhosis without HCC, matched for sex, age and grade of liver dysfunction.

RESULTS

At the time of HCC diagnosis, all patients in Group A were euthyroid with serum TSH, FT4, FT3 and TBG values not significantly different from those of cirrhotic patients of Group B. However, at diagnosis Group A patients had serum rT3 values that were significantly higher than those in Group B (35.0 ng/dl, range 12.0-162.0 vs. 19.0 ng/dl, range 10.0-51.0; Group A vs. Group B; P < 0.001). Serum rT3 values above the normal range were found in 12 patients in Group A (38.7%) but in only one of the patients from Group B (3.4%) (chi2 10.2; P = 0.001). The serum rT3 levels were not significantly correlated to the Child grade of liver cirrhosis (rho 0.1; P = 0.5). The intrasubject analysis demonstrated that a significant increase in serum rT3 levels occurred at the time of HCC diagnosis but serum FT4, FT3 and TSH values did not change significantly. A receiver operating curve (ROC) demonstrated that a 6-monthly increase in serum rT3 levels of at least +22.5% identified patients with HCC with a diagnostic accuracy of 81.7%.

CONCLUSIONS

Our study has demonstrated that development of hepatocellular carcinoma is accompanied by a significant increase in serum rT3 levels in patients with low-grade HCV-related liver cirrhosis who had no other illness causing the 'euthyroid sick syndrome'.

Serum insulin-like growth factor I evaluation as a useful tool for predicting the risk of developing hepatocellular carcinoma in patients with hepatitis C virus-related cirrhosis: a prospective study

BACKGROUND

Although experimental studies have demonstrated an important role of insulin-like growth factor I (IGF-I) in hepatocarcinogenesis, the clinical data about IGF-I in patients with hepatocellular carcinoma (HCC) are scarce and controversial. To the authors' knowledge, this is the first prospective study investigating the longitudinal correlation between modifications in serum IGF-I levels and the development of HCC in a cohort of patients with hepatitis C virus (HCV)-related cirrhosis.

METHODS

One hundred fourteen consecutive patients with HCV-related Child Grade A cirrhosis were followed prospectively at the Second University of Naples for 56.4 +/- 12.0 months with ultrasound examinations of the liver and serum alpha-fetoprotein determination every 6 months. At each clinical evaluation, the severity of disease was graded according to the established Child-Pugh scoring system. Serum IGF-I levels were measured prospectively at the study entry and at least every 12 months throughout follow-up.

RESULTS

Twenty patients (19.2%) developed HCC during follow-up. Eleven of these patients had persistent Child Grade A cirrhosis for the whole study, whereas the other 9 patients developed HCC after their cirrhosis progressed from Child Grade A to Grade B. In patients who remained free of HCC for the whole study, serum IGF-I concentrations did not modify significantly during follow-up. Conversely, in patients who developed HCC, IGF-I levels decreased significantly during follow-up (from 72.6 +/- 29.9 microg/L to 33.8 +/- 14.5 microg/L; P = 0.001). In these patients, the significant decrease occurred both in patients with persistent Child Grade A cirrhosis and in patients with cirrhosis that progressed from Child Grade A to Grade B. The reduction in IGF-I level preceded the diagnosis of HCC by 9.3 +/- 3.1 months.

CONCLUSIONS

This prospective study demonstrates that, in patients with HCV-related cirrhosis, 1) the development of HCC is accompanied by a significant reduction of serum IGF-I levels independent of the grade of impairment of liver function; and 2) modification of the IGF-I level precedes the morphologic appearance of HCC, permitting a precocious diagnosis of the tumor.

Iodized salt improves the effectiveness of L-thyroxine therapy after surgery for nontoxic goitre: a prospective and randomized study

OBJECTIVE

To investigate whether the addition of iodized salt to daily diet in thyroidectomized patients for nontoxic goitre could influence the effectiveness of nonsuppressive L-thyroxine (L-T4) therapy on thyroid remnant size, during 12 months' follow-up after thyroid surgery.

DESIGN AND PATIENTS

A consecutive series of selected 139 patients (26 males, 113 females; median age 45 years, range 30-69 years) living in a moderate iodine-deficient area, and undergoing thyroid surgery for nontoxic multinodular goitre, was enrolled. Patients were assigned randomly to two different therapeutic regimens: 70 patients received L-T4 therapy alone (Gr. L-T4), while the remaining 69 patients took iodized salt on a daily basis in addition to L-T4 treatment (Gr. L-T4 + I). In both groups, the initial L-T4 dose was 1.5 microg/kg/day, which, in our experience, has been shown to be intermediate between suppressive and replacement doses. To avoid the risks of mild thyrotoxicosis and to limit the excessive TSH stimulation of the thyroid remnant, the L-T4 dose was adjusted in those patients with serum TSH levels outside the lowest two-thirds of the normal range (0.3-2.5 mU/l). An ultrasound evaluation of thyroid remnant size was performed after thyroid surgery and 12 months later.

RESULTS

After surgery, the median thyroid remnant volume was 3.5 ml (range 0.4-13.9 ml) in Gr. L-T4 and 4.6 ml (range 0.5-12.7 ml) in Gr. L-T4 + I (P = 0.06). After 1 year of follow-up, the patients treated with L-T4 + I obtained a remnant volume reduction (-39.7%, range -87.0% to +91.2%) significantly (P = 0.006) greater than that observed in patients assuming L-T4 alone (-10.2%, range -89.4% to +85.0%). However, the percentage of patients showing an increase in remnant size in the months following surgery was higher in Gr. L-T4 than in Gr. L-T4 + I (22/60 vs. 9/66; P = 0.01). In Gr. L-T4 patients the thyroid remnant volume variation throughout 12 months of treatment was correlated significantly with the size of the thyroid remnant found at the first ultrasound evaluation (R(2) = 0.3; P < 0.001). No such correlation was found in Gr. L-T4 + I patients, for whom the therapy maintains a similar effectiveness in patients with either a large or a small postsurgery thyroid remnant. In patients treated with L-T4 alone, the remnant volume variation was correlated significantly with the median serum TSH values attained in the course of treatment (R2 = 0.4; P < 0.001). The highest reduction in remnant volume was observed only by lowering the serum TSH concentrations. In patients treated with L-T4 plus iodine, instead, the thyroid remnant volume reduction occurred independently of the plasma TSH levels attained in the course of treatment.

CONCLUSIONS

Our short-term prospective and randomized study leads us to conclude that, in patients living in a moderate iodine-deficient area and undergoing thyroid surgery for nontoxic goitre: (1) the iodine prophylaxis improves the effects of postsurgery nonsuppressive L-T4 therapy on thyroid remnant size. (2) In patients treated with L-T4 alone the therapeutic effectiveness decreases in the presence of a large postsurgery thyroid remnant. With the addition of iodine, the L-T4 maintains a similar efficacy in patients with either a large or a small remnant. (3) During treatment with L-T4 alone the highest therapeutic effectiveness is attained by lowering the plasma TSH concentration. With the addition of iodized salt to the daily diet the effects of L-T4 on remnant size are relevant independently of the TSH levels.

Temporal relationship between the appearance of thyroid autoantibodies and development of destructive thyroiditis in patients undergoing treatment with two different type-1 interferons for HCV-related chronic hepatitis: a prospective study

In this prospective study we performed repeated evaluations of thyroid status in patients undergoing treatment with different preparations of recombinant interferons (IFNs), in order to identify early markers of thyroid dysfunction. Moreover, we aimed to investigate whether the development of thyroid dysfunction was related to the appearance of thyroid autoimmunity. Our study included 51 consecutive patients without pre-existing thyroid disease, admitted to our hospital for Hepatitis C virus (HCV)-related chronic hepatitis. Thirty-six patients (Gr. A) were treated with IFN-alpha 2b plus ribavirin (RIBA), whereas 15 patients (Gr. B) underwent treatment with IFN-alphacon-1 (CIFN) plus RIBA. Thyroid autoimmunity and function were prospectively evaluated before, every month during treatment and for 6 months after IFN withdrawal. At study entry, all patients were euthyroid and negative for thyroid autoantibodies. In Gr. A, 10 patients developed thyroid autoimmunity after a median period of 3 months (range: 1-6) treatment with IFN-alpha+RIBA. At the time of appearance of thyroid autoantibodies, 4 patients developed destructive thyrotoxicosis (overt in one case, subclinical in 3 cases), while other 4 patients showed a high reduction of serum TSH levels (median decrease: -75.7%, range: -61.9- -84.2), which reached the low values of normal range. After a median period of 2 months (range: 1-3) from these biochemical abnormalities, 6 patients continuing antiviral treatment developed hypothyroidism (overt in 3 cases and subclinical in the other 3). In Gr. B, 5 patients developed thyroid autoimmunity after a median period of 3 months (range: 2-10) of treatment with CIFN+RIBA. Soon after the appearance of thyroid autoantibodies, all patients developed an overt thyrotoxicosis (with hyperthyroidism in 2 cases). Antiviral treatment was discontinued in all 5 cases. Thereafter, thyroid function recovered spontaneously without significant modifications of serum TGAb and TPOAb levels until the end of the study. In conclusion our prospective study demonstrated that: 1) the appearance of thyroid autoantibodies during treatment with IFN was accompanied in most cases by the occurrence of a destructive process in the thyroid gland; 2) The clinical expression of destructive thyroiditis was more evident in patients treated with CIFN than that in patients treated with IFN; 3) The thyroid clinical outcome of these patients was strictly correlated to the continuation of cytokine treatment.

The addition of ribavirin to interferon-alpha therapy in patients with hepatitis C virus-related chronic hepatitis does not modify the thyroid autoantibody pattern but increases the risk of developing hypothyroidism

OBJECTIVE

The aim of this study was to investigate whether the addition of ribavirin (RIBA) to interferon-alpha (IFN-alpha) therapy increases the risk of developing thyroid autoimmunity and/or dysfunction.

DESIGN AND METHODS

The study group (group A) included 72 patients undergoing treatment with IFN-alpha (3-6 million units three times weekly) plus RIBA (1.0-1.2 g/day) for chronic hepatitis C (CHC), as first line therapy (30 cases) or as a second therapeutic attempt after a previous ineffective IFN-alpha treatment (42 cases). The control group (group B) encompassed 75 age- and sex-matched patients affected by CHC, undergoing treatment with IFN-alpha alone as first line therapy (35 cases) or as a second therapeutic attempt (40 cases). Thyroid autoimmunity and function were retrospectively evaluated on frozen aliquots, drawn before, after 6 months, and at the end of the antiviral treatment. In patients receiving two antiviral treatments (42 cases in group A and 40 cases in group B) thyroid parameters were also assayed on serum samples drawn before and at the end of the first IFN-alpha therapy.

RESULTS

Thyroid autoimmunity rate (17/72 for group A and 17/75 for group B) as well as anti-thyroglobulin antibodies (TgAb) and anti-thyroid peroxidase antibodies (TPOAb) serum levels were comparable between the two groups. Similarly, in patients undergoing two consecutive antiviral treatments (42 cases in group A and 40 cases in group B) the percentage of positivity for thyroid autoantibodies did not change significantly from the first to the second therapeutic schedules in both groups, with no significant increase of median TgAb and TPOAb levels. By the same token, all but one patient negative for thyroid autoantibodies at the end of the first treatment remained so also during the subsequent treatment. In group A patients, the rate of hypothyroidism (11/72) was significantly higher than that observed in group B (3/75). Similarly, in patients undergoing two consecutive antiviral treatments the percentage of hypothyroidism increased significantly from the first to the second therapeutic schedule in group A (from 4.8% to 19.0%; P<0.05) but not in group B (from 4.7% to 7.1%; not significant). In group A, the occurrence of hypothyroidism during treatment with IFN-alpha+RIBA was significantly correlated with a long-term remission of CHC.

CONCLUSIONS

Our study shows that: (i) the addition of ribavirin to IFN-alpha therapy for CHC does not modify the thyroid autoantibody pattern but it is associated with a higher risk of hypothyroidism; (ii) the patients without thyroid autoantibodies at the end of a previous treatment with IFN-alpha alone are protected from the development of thyroid autoimmunity and/or dysfunction in a second course of antiviral treatment with IFN-alpha+RIBA; (iii) the development of hypothyroidism in patients with thyroid autoantibodies undergoing treatment with IFN-alpha+RIBA is significantly associated with the long-term remission of CHC.

The influence of parity on multinodular goiter prevalence in areas with moderate iodine deficiency

Despite the observation that parity may increase the risk of thyroid carcinoma, very few studies have investigated the possible repercussion of parity on thyroid benign pathology. Recently, parity has been identified as one of the factors contributing to a larger thyroid size in healthy females. The aim of this work was to investigate a possible role for parity on the prevalence of multinodular goiter in iodine deficient areas. For this purpose, the reproductive histories of 2 cohorts of women, normal (Group I, 235 cases) and non-toxic multinodular goiter (NTMNG) affected (Group II, 274 cases) were compared. All subjects were euthyroid and had no previous history of thyroid function abnormalities. The number of full-term previous pregnancies (2.55+/-0.11 vs 1.77+/-0.10) and age (47.7+/-0.76 vs 42.3+/-0.83 yr) were found significantly higher (p<0.001) in multinodular goiter (MNG) patients than controls. Parity and age were found to be directly correlated (p<0.001), nevertheless the partial correlation coefficients demonstrated an independent and statistically significant difference for both variables between normal and NTMNG. Therefore, the independent effects of parity and age were further investigated. The effect of age on NTMNG prevalence seems to be weaker, in fact significant differences (p<0.001) for age between patients and controls were detected only when the effect of parity was absent (nulliparous), while with increasing gestations the effect of age disappeared. Our results indicate that age plays a minor role compared to parity which can therefore be considered as a stronger risk factor. In conclusion, the present study shows that, at least in iodine deficient regions, non-toxic multinodular goiter women show a statistically significant higher parity rate than healthy controls. Age may play a certain role but only when additional stronger risk factors are absent.

HIV-infected American Indians/Alaska natives in the Western United States

OBJECTIVE

We sought to describe HIV-infected American Indians/Alaska Natives (AI/ AN) in the western United States.

DESIGN

One hundred fifty-one Al/AN and 11,344 non-AI/AN HIV-infected patients in Seattle, Denver, and Los Angeles were followed by medical record review from January 1989 through June 1998 for the Adult/Adolescent Spectrum of HIV-related Diseases study.

METHODS

Bivariate and multivariate statistical analyses comparing HIV-infected Al/AN and non-AI/AN were performed.

RESULTS

There were 103 (68%) male and 48 (32%) female Al/AN patients, while non-Al/AN patients were 86% male and 14% female (P<.001). The median age among AI/ AN was 32 years vs. 34 years among non-AI/AN (P = .05). Male Al/AN were more likely than male non-AI/AN to report the dual risks of having sex with men and injection drug use (32% vs. 14%; P<.001) compared with other HIV risks. Median CD4 cell counts were higher in Al/AN than in non-AI/AN (P< or =.001). AI/AN were more likely to be diagnosed with an acute sexually transmitted disease (STD) than were non-AI/AN (11% vs. 4%, P<.001). Five (6%) of AI/AN with AIDS had active pulmonary tuberculosis (TB) compared with 132 (2%) of non-AI/AN with AIDS (P = .02). While 52% of Al/AN and 44% of non-AI/AN had a psychiatric illness (P = .04), and 13% of AI/AN, and 6% of non-AI/ AN had suicidal ideation (P<.001), these associations became non-significant in analyses stratified by alcohol and drug use (P>.05). In adjusted models, survival and progression to opportunistic infection or CD4 cell count less than 200/mm3 did not significantly differ between Al/AN and non-AI/AN.

CONCLUSIONS

HIV-infected AI/AN were younger than non-AI/AN, and a greater proportion of Al/AN were women relative to non-AI/AN. AI/AN were more likely to be diagnosed with STDs and TB. In adjusted models, their risks of death and developing AIDS did not significantly differ from those of non-AI/AN.

Long-term effects of lanreotide SR and octreotide LAR on tumour shrinkage and GH hypersecretion in patients with previously untreated acromegaly

BACKGROUND AND OBJECTIVE

The therapeutic efficacy of lanreotide SR and octreotide LAR has been studied widely in patients treated previously with neurosurgery and/or radiotherapy. These therapies limit the evaluation of the long-term effects of somatostatin analogues on tumour shrinkage. Neurosurgical and radiotherapy treatments cause irreversible anatomical changes in pituitary morphology, which can make accurate evaluation of tumour shrinkage difficult. The aim of this study was to investigate the therapeutic efficacy of lanreotide SR and octreotide LAR in previously untreated patients with acromegaly. We aimed to investigate the long-term effects of these drugs on tumour shrinkage and growth hormone (GH) hypersecretion without the confounding influences of previous therapy.

PATIENTS AND METHODS

Twenty-three newly diagnosed patients with acromegaly (14 women, nine men) with active disease began the study; of these, three were lost for follow-up, leaving a total of 20 patients to complete the study. Patients were assigned randomly to lanreotide SR (12 patients) and octreotide LAR (eight patients), and the randomization stratified patients to assure a balance between the groups with respect to baseline tumour dimension, age and sex. Tumour volume was evaluated by magnetic resonance imaging of the sella, and calculated with the rotating ellipsoid formula. A morphological and biochemical evaluation was performed at baseline, 12 and 24 months after beginning lanreotide SR and octreotide LAR treatment. A reduction of tumour volume of at least 10% was considered significant.

RESULTS

Biochemical control increased progressively throughout the study in patients with microadenomas more than in patients with macroadenomas (70% vs. 10%; P < 0.05) and without a difference between lanreotide SR and octreotide LAR (41.0% vs. 37.5%; P not significant). After 12 months of treatment, mean tumour shrinkage was 28.3 +/- 18.0%. A greater reduction was observed in macro- vs. microadenomas (40.5 +/- 17.0% vs. 16.1 +/- 8.0%, respectively; P < 0.05). No statistical difference in the tumour shrinking effects of lanreotide SR vs. octreotide LAR was observed (26.5 +/- 17.3% vs. 31.1 +/- 16.1%, respectively). At the 24th month of therapy, no further overall shrinkage was observed, compared to the 12-month evaluation (31.9 +/- 17.2% vs. 28.3 +/- 18.0%) at which there was no difference between lanreotide SR and octreotide LAR (30.0 +/- 17.2% vs. 34.8 +/- 16.5%, respectively).

CONCLUSIONS

This study showed that the new long-acting somatostatin analogues, lanreotide SR and octreotide LAR, cause significant shrinkage of pituitary GH-secreting adenomas in previously untreated patients with acromegaly. This effect was more marked in macroadenomas than microadenomas, and did not correlate with control of GH hypersecretion.

Long-term outcome of interferon-alpha-induced thyroid autoimmunity and prognostic influence of thyroid autoantibody pattern at the end of treatment

Thyroid autoimmunity and dysfunction have been widely reported as side effects of interferon-alpha (IFN-alpha) treatment, but the literature lacks data regarding the long-term course of these complications, clinical observation being limited to 6-12 months off therapy. Our study is the first that has aimed to evaluate the natural history of IFN-related thyroid autoimmunity during a 6.2-yr follow-up after the IFN-alpha withdrawal as well as to investigate the potential role of the autoantibody pattern at the end of treatment to predict the long-term outcome. Our study group included 114 patients (79 males, 35 females), mean age 48 yr (range 23-67 yr) with no preexisting thyroid disease, undergoing a 12-month treatment with recombinant IFN-alpha for C virus-related chronic active hepatitis. Thyroid autoimmunity (serum TgAb and TPOAb) and function (serum FT(4), FT(3), TSH) were retrospectively evaluated at the end of IFN therapy, 6 months after IFN withdrawal and after a median period of 6.2 yr (range 5.5-8.4 yr). At the end of treatment, 78 patients were negative for thyroid autoantibodies (Abs-) and all but one of them remained so for the following evaluations. The remaining 36 patients had thyroid autoantibodies (Abs+) at the end of treatment, and they subsequently showed a heterogeneous behavior: 16 patients remained Abs+ for the whole length of the study (persistent thyroiditis); 10 patients became Abs- 6 months off therapy but were again Abs+ 6.2 yr later (remitting/relapsing thyroiditis); 10 patients reverted to autoantibody negativity at different observation times (transient thyroiditis). The absence of thyroid autoantibodies at the end of treatment was a protective factor for the successive development of thyroiditis (odds ratio: 0.02, confidence interval (CI) 95%: 0-0.1). On the contrary, the positivity for TgAb and/or TPOAb at high titers at the end of IFN treatment was significantly related to the highest risk of having chronic thyroiditis (odds ratio: 17.3, CI 95%: 3.2-91.7 for TgAb levels > 50 degree percentile; odds ratio: 7.3, CI 95%: 1.5-35.2 for TPOAb levels > 50 degree percentile). None of the patients showed overt thyroid dysfunction throughout the study, whereas a subclinical hypothyroidism was found in 12 patients. In all 12 cases, the functional abnormality was accompanied by the presence of thyroid autoantibodies. Eight of these 12 patients belonged to the group with persistent thyroiditis (P < 0.05). The absence of thyroid autoantibodies at the end of treatment was a protective factor for the successive development of thyroid dysfunction (odds ratio: 0.06, CI 95%: 0.01-0.56). On the contrary, the positivity for both TgAb and TPOAb at the end of IFN therapy was significantly correlated with the highest risk of having subclinical hypothyroidism 6.2 yr. later (odds ratio: 38.7; CI 95%: 6.2-242). Our study demonstrates that in patients undergoing an IFN-alpha therapy for chronic hepatitis C and with no evidence of preexisting thyroid disease: 1) the negativity for thyroid autoantibodies after IFN treatment is a protective factor for the developing thyroid autoimmunity and/or dysfunction in following years; 2) the IFN-alpha-related thyroid autoimmunity is not a complete reversible phenomenon because some patients can develop chronic thyroiditis; 3) high autoantibody levels at the end of IFN therapy are related to the risk of having chronic thyroid autoimmunity; and 4) the coexistence of TgAb and TPOAb at the end of treatment is a predictive factor for the presence of thyroid dysfunction, even if subclinical, many years after IFN withdrawal.

Interferon-related thyroid autoimmunity and long-term clinical outcome of chronic hepatitis C

BACKGROUND

A high incidence of thyroid autoantibodies and/or disorders was observed in subjects with hepatitis C virus-related chronic hepatitis during interferon-alpha therapy.

AIM

To evaluate whether thyroid autoimmunity and dysfunction, induced by interferon-alpha therapy, could be viewed as predictors for treatment response and as valid prognostic markers of liver disease progression.

PATIENTS

A total of 136 subjects (96 males/40 females; median age 48 years; range 23-64) affected by biopsy-proven chronic hepatitis C (33.1% with compensated liver cirrhosis).

METHODS

All subjects were treated with interferon-alpha therapy at 6 MU 3 times weekly for 12 months and then followed up for an average period of 60 months (range 12-108). Routine laboratory tests, virological assessment, liver ultrasound, thyroid function tests (serum free-triiodothyronine, free-thyroxine, serum thyrotropin), and autoimmunity were performed for all subjects.

RESULTS

Percentage of thyroid autoimmunity and thyroid dysfunction in long-term responders was not significantly different compared to that in non-responders (47.0% and 11.8% vs 35.3% and 5.9%, respectively; non significant). The multivariate model demonstrated that the absence of cirrhosis was the only factor significantly related to successful response to therapy (odds ratio: 14.9; 95% confidence interval: 1.9-115.0 for chronic hepatitis C vs presence of cirrhosis). Moreover, the occurrence of thyroid autoimmunity during interferon therapy was similar both in patients with or without worsening of liver disease (33.3% and 39.8%, respectively; p = not significant). No subject with on-going liver disease developed thyroid dysfunction during treatment, as opposed to the 10/118 (8.4%) with a better course of liver disease; however, this difference was not statistically significant. The multivariate model showed that age was the only covariate significantly associated with unfavourable outcome of liver disease (odds ratio: 18.6; 95% confidence interval: 2.3-151.9, for those over 48 years vs younger patients).

CONCLUSIONS

There is no evidence that the immune mechanism involved in the pathogenesis of thyroid autoimmune phenomena is the same as that regulating the therapeutic clearance of HCV or modulating the unfavourable course of HCV-related chronic hepatitis. However, our study confirmed that liver disease seems to progress more slowly in younger subjects.

Incidence and determinants of Pseudomonas aeruginosa infection among persons with HIV: association with hospital exposure

BACKGROUND

Little information exists on risk factors for Pseudomonas aeruginosa infection in persons with HIV. We assessed the incidence and factors associated with P aeruginosa among persons with HIV enrolled in a large observational cohort study in Los Angeles.

METHODS

Data were analyzed from 4825 persons aged > or =13 years with HIV infection enrolled from 4 outpatient facilities from 1990 to 1998. The association between P aeruginosa infection and demographic, risk behavior, and clinical factors was assessed.

RESULTS

P aeruginosa was diagnosed in 72 (1.5%) patients representing a crude incidence rate of 0.74 per 100 person-years. The most frequent site of infection was pulmonary (47%). In multivariate analysis, prior hospitalization (adjusted rate ratio = 7.9, 95% CI, 3.8-16.2), and both dapsone (adjusted rate ratio = 4.0, 95% CI, 2.2-7.4) and trimethoprim-sulfamethoxazole (adjusted rate ratio = 2.5, 95% CI, 1.2-5.3) use were independently associated with higher rates of infection. Increasing days of inpatient stay (P <.01) and decreasing CD4(+) counts (P <.01) were strongly associated with P aeruginosa. Azithromycin use decreased the risk of infection by nearly 70%.

CONCLUSION

Although the overall observed incidence of P aeruginosa was low, hospital exposure, declining CD4(+) levels, and the use of dapsone or trimethoprim-sulfamethoxazole increased the risk of P aeruginosa disease, and azithromycin use was protective in this population. These findings may assist in the early recognition and diagnosis of persons likely to be at increased risk of P aeruginosa infection.

Trichomonas vaginalis, HIV, and African-Americans

Trichomonas vaginalis may be emerging as one of the most important cofactors in amplifying HIV transmission, particularly in African-American communities of the United States. In a person co-infected with HIV, the pathology induced by T. vaginalis infection can increase HIV shedding. Trichomonas infection may also act to expand the portal of entry for HIV in an HIV-negative person. Studies from Africa have suggested that T. vaginalis infection may increase the rate of HIV transmission by approximately twofold. Available data indicate that T. vaginalis is highly prevalent among African-Americans in major urban centers of the United States and is often the most common sexually transmitted infection in black women. Even if T. vaginalis increases the risk of HIV transmission by a small amount, this could translate into an important amplifying effect since Trichomonas is so common. Substantial HIV transmission may be attributable to T. vaginalis in African-American communities of the United States.

Permanence of Fungi-Fluor epifluorescence stain to detect microsporidia

OBJECTIVE

Epifluorescence microscopy, a methodology for the screening of bodily fluids and tissue specimens for microsporidia species, was directed to evaluate the retention of epifluorescence of fixed and stained specimens over time.

METHODS

Thirty samples of stool, bodily fluids, duodenal touch preparations, and biopsies, were tested for the retention of their epifluoresence using the Fungi-Fluor procedure. Specimens were examined under a 330- to 380-nm UV filter at the time of preparation, 3 wk later, and then at monthly intervals for 18 months. All specimens were reevaluated for the presence or absence of fluorescence and any decrement of fluorescence over time. No special preservation techniques were used on any of the slides.

RESULTS

All 30 specimens maintained their epifluorescence from the time of slide preparation to 18 month later. No decrement in fluorescence was noted in any sample examined. Accuracy and ease of spore identification was maintained.

CONCLUSIONS

Epifluorescence microscopy demonstrates the utility of this technique for archival study of microsporidia-containing specimens over prolonged periods of time.

Pneumonia in HIV-infected patients: a case-control survey of factors involved in risk and prevention

OBJECTIVE

To assess the factors that increase or decrease the risk of pneumonia with particular attention to immunization with pneumococcal and influenza vaccines in a group of HIV-infected persons.

DESIGN

A retrospective, case-control study based on information entered into a standard database and the medical record.

SETTING

Patients attending a referral clinic specializing in AIDS/HIV care at a public hospital.

PATIENTS

Among over 2000 subjects entered into a database in 8 years, 127 incidents of pneumonia were identified from the record. These cases were matched with 127 CD4 cell count matched, concurrent controls.

INTERVENTIONS

None.

MAIN OUTCOME MEASURE

The principal hypothesis was that chart review would find a decreased frequency of pneumococcal immunization in the pneumonia cases compared with matched controls.

RESULTS

Pneumococcal immunization was associated with a reduction of the risk of pneumonia by nearly 70%. The effect was seen even when immunization was given with a CD4 cell count of less than 100/mm3. Injection drug users and African-Americans had a twofold increased risk of pneumonia.

CONCLUSION

The study provides data to support the current recommendation for pneumococcal immunization of all HIV-infected persons. Although this conclusion could lead to renewed enthusiasm for increasing pneumococcal immunization rates in HIV-infected persons, it must be recognized that the study is observational and ascertainment bias cannot be excluded.

Successful outcome of pregnancy in a thyroidectomized-parathyroidectomized young woman affected by severe hypothyroidism

Severe hypothyroidism was discovered in a young woman in her 29th week of pregnancy. Previously, at the age of 12 years, she had undergone thyroid surgery for Graves' disease that resulted in persistent hypothyroidism and hypoparathyroidism. After surgical excision, the patient started levothyroxine replacement therapy and had regular control of thyroid function with normal findings throughout the years. The dose of levothyroxine had not been adjusted when the pregnancy started, and at the 29th week of gestation the patient had a thyrotropin (TSH) of 72.4 microU/mL. Ultrasound studies were performed in order to monitor fetal development. The fetal parameters analyzed before the adjustment of levothyroxine therapy showed growth retardation of various degrees. All analyzed fetal parameters (biparietal diameter, cranial and abdominal circumference, humerus and femur length) improved during the last 6 weeks of gestation, showing a good correlation with the newly achieved euthyroid state of the mother. The infant was clinically euthyroid at birth and was found normal at all evaluations of the neonatal hypothyroidism screening program (1, 5, 30 days).

Diabetes insipidus and increased serum levels of leptin and lactate-dehydrogenase (LDH) in an adolescent boy with a primary intracranial germinoma. Case report and an endocrinological revaluation of literature

A 16-year-old boy presented with a four-month history of polyuria-polydipsia and a diplopia which had reverted after treatment. The neuroimaging studies performed had been strongly suggestive of an optic nerve glioma, while endocrinological investigation (beta-hCG 420 IU/L) has lead to the correct diagnosis later confirmed at the immunohystochemical analysis performed at biopsy. The high serum level of hCG was unaffected by bromocriptine nor octreotide, while the PRL level (80.0 microg/L) was reduced only by bromocriptine. Among the several tumor markers which may be secreted by such lesions, ours is the first reported case of an elevation of serum LDH for a primary intracranial germinoma. Moreover, the elevated value of serum leptin reported by us might be due to the insensitivity of the hypothalamic structures to endogenous leptin.

Prevalence of unprotected sex among men with AIDS in Los Angeles County, California 1995-1997

OBJECTIVE

To determine the prevalence of unprotected sex among men with AIDS in Los Angeles County.

DESIGN

Cross-sectional study.

METHODS

All men aged > or = 18 years who were newly reported to the local health department with AIDS and completed a standardized interview between January 1995 and June 1997 were included in the study. Men were classified as having unprotected sex if they reported one or more sex partners during the past year with whom they had vaginal or anal sex and did not always use a condom.

RESULTS

Of 617 men interviewed, 29% reported unprotected sex in the past year. The prevalence of unprotected sex was highest among men < 30 years of age (43%) and those who had first learned of their HIV-positive status < 12 months prior to interview (44%). In all, 323 (52%) men reported one or more male sex partners in the past year. Of these, 22% reported unprotected insertive anal sex and 27% unprotected receptive anal sex. One or more female partners in the past year was reported by 131 (21%) men. Of these, 53% reported unprotected vaginal sex and 18% unprotected anal sex.

CONCLUSIONS

The findings highlight the importance of early HIV detection efforts, coupled with targeted and sustained HIV prevention services for those who test positive, to prevent ongoing transmission of the virus.

Use of protease inhibitors among persons with AIDS in Los Angeles County

We evaluated the access to, and the factors associated with, protease inhibitor use among persons with AIDS in Los Angeles County. A population-based sample of adult persons with AIDS is routinely interviewed in Los Angeles County and includes a 30% random sample of men who have sex with men and all other persons reported with AIDS. Since May of 1996, all participants were asked if their physician had ever prescribed a protease inhibitor for their use. The possible association between protease inhibitor use and sociodemographic, temporal and health care factors was assessed for the 12-month period May 1996 through April 1997. Logistic regression was employed for multivariate analysis. Over the 12-month study period, 61.7% (209/339) persons interviewed reported that their physician had prescribed a protease inhibitor as part of their therapy. In bivariate analysis, treatment with protease inhibitor use was more common for whites (71.4%) and US-born Latinos (68.2%) than blacks (53.4%) and foreign-born Latinos (56.6%), among person of higher income (71.2%) than lower (< $10,000) income (50.3%), in those who reported having insurance (66.7%) than those uninsured (47%) and among persons receiving care at private clinics (86.4%) than at HMOs (63.4%) or public clinics (55.2%). An increasing trend of protease inhibitor use with higher educational level and declining CD4+ count was observed. A temporal increase was noted and this trend was most pronounced for persons receiving care at public clinics. In multivariate analysis, persons receiving care at private facilities (adjusted OR = 2.9, 95% CI 1.0, 8.2) and those with higher incomes (adjusted OR = 2.5, 95% CI 1.5, 4.3), were more likely to report that their physician had prescribed a protease inhibitor. The effect of facility type was modified by time. During the first six months of the study period (May 1996-October 1996) persons with AIDS receiving care at public facilities and HMO sites were substantially less likely to report having been offered a protease inhibitor (adjusted OR = 0.13, 95% CI 0.03, 0.58 and adjusted OR = 0.23, 95% CI 0.05, 1.2, respectively). However, no significant facility-specific differences were observed over the last six-month period (November 1997-April 1997) evaluated. Our findings suggest that substantial differences exist in the prescribing and use of protease inhibitors among persons with AIDS in Los Angeles County. Several factors, including facility of HIV care, calendar time, income, education level and level of immunosuppression were independently associated with protease inhibitor use and suggest the existence of important barriers to access. Efforts should be made to identify and remove barriers that will ensure the widest possible access to protease inhibitors for patients with a clinical indication for their use.

Sociodemographic and behavioral characteristics of African-American women with HIV and AIDS in Los Angeles County, 1990-1997

African-American women have the highest AIDS rate of any racial/ethnic group of women in both Los Angeles County (LAC), California and in the United States. Limited population-based epidemiologic studies of African-American women with HIV and AIDS describe this group and examine the factors associated with the excessive rates. Interview data collected from 1990 to 1997 on a population-based sample of AIDS cases and a group of HIV-infected women in LAC were analyzed to highlight the sociodemographic and behavioral characteristics of African-American women. This group of African-American women with HIV or AIDS in LAC were unemployed (88%), single mothers (64%), living on public assistance (86%) with annual household incomes <$10,000 U.S. (76%). A history of crack use predominated (50%). Compared with women of other races with HIV and AIDS, African-American women reported more sexual partners; reported more infections with sexually transmitted diseases; sought treatment for their HIV infection later; were more likely to trade sex; and were almost five times more likely to have ever used crack cocaine. HIV prevention for African-American women in LAC should focus on improving self-esteem and negotiation skills within the context of the crack cocaine culture and the disadvantaged social and economic situation described.

Seasonality and factors associated with cryptosporidiosis among individuals with HIV infection

The seasonality and factors associated with Cryptosporidium infection were assessed in a cohort of HIV-infected patients in Los Angeles County to better define the epidemiology of cryptosporidiosis among individuals with HIV. Data were analysed from a cohort of 4247 patients > or = 13 years of age with HIV infection enrolled from four outpatient facilities in Los Angeles, 1990-6. Cryptosporidiosis was diagnosed in 120 (2.8%) patients. Among the 1296 individuals with complete follow-up until death, cryptosporidiosis occurred in 69 (5.3%). The seasonal rate of cryptosporidiosis showed a modest bimodal trend with the highest rates occurring in March-May and September-October. There was no difference in the rate of cryptosporidiosis for the periods of heaviest rainfall (December-March) and low rainfall (April-November). Infection rates were higher among males (1.59 per 100 person-years) than females (0.92) and lower in blacks (0.98) than other racial/ethnic groups (1.80). A significant trend of decreasing cryptosporidiosis was observed with increasing age, with the highest rate (2.34) in the 13-34 year age group. A strong association between cryptosporidiosis and CD4+ count was noted. These data suggest that cryptosporidiosis among HIV-infected individuals in Los Angeles County exhibits a modest spring and fall seasonality. This pattern of occurrence of cryptosporidiosis appears temporally unrelated to local rainfall patterns. Our findings suggest that HIV-infected men, individuals in younger age groups and those with CD4+ lymphocyte counts < 100 x 10(6)/l are at increased risk of cryptosporidiosis. Blacks with HIV infection appear less likely than other racial/ethnic groups to be diagnosed with Cryptosporidium infection. These results may provide insight into possible routes of transmission and sources of cryptosporidiosis infection in individuals with HIV.

Risk factors for trichomoniasis among women with human immunodeficiency virus (HIV) infection at a public clinic in Los Angeles County, California: implications for HIV prevention

Persons with human immunodeficiency virus (HIV) infection who subsequently develop an acute sexually transmitted disease have an increased probability of transmitting HIV. Therefore, characterizing such persons can help direct prevention efforts to a group who are likely to be continuing sources of HIV transmission. We assessed the incidence and factors associated with trichomoniasis in a cohort of HIV-infected women receiving care at a public clinic in Los Angeles County, California from 1992 through 1995. Demographic, clinical, and behavioral data were available from medical records and from patient interviews. Trichomonas infection was the most frequently identified sexually transmitted disease and was found in 37 (17.4%) of 212 women representing a crude incidence rate of 14.1 per 100 person-years experience. The crude rate of trichomoniasis was highest in black women (69.0 per 100 person-years), women with a history of trading sex for drugs or money (51.0 per 100 person-years), those using crack or cocaine (35.5 per 100 person-years), women with four or more sex partners (43.0 per 100 person years), and those born in the United States (23.3 per 100 person-years). Among women with severe immunosuppression (CD4+ count < 200), 18.4% (18 of 98) were diagnosed with trichomoniasis. After multivariate analysis using a Cox proportional hazards approach, black race (adjusted rate ratio [RR] = 5.6, 95% confidence interval [CI] = 2.3, 13.3) continued to be strongly associated with Trichomonas infection. Trading sex for money or drugs (adjusted RR = 25.2, 95% CI = 4.3, 148.6) and single marital status (adjusted RR = 3.7, 95% CI = 1.1, 13.0) were independent risk factors for trichomoniasis in nonblack women but not among black women. Data from this study indicate that Trichomonas may be a frequently acquired infection in HIV-positive women. Our findings suggest that HIV-infected women who are black, and nonblack women who trade sex for money or drugs or are unmarried, are at increased risk of trichomoniasis and therefore may be more likely to transmit HIV infection. Local HIV prevention strategies should target such women for intervention efforts.

Incidence and factors associated with extrapulmonary cryptococcosis among persons with HIV infection in Los Angeles County

OBJECTIVE

To determine the incidence and factors associated with extrapulmonary cryptococcosis among a cohort of persons with HIV in Los Angeles County.

DESIGN

Records-based cohort study.

METHODS

Data were analysed from a cohort of 3836 persons aged > or = 13 years with HIV infection enrolled from four outpatient facilities in Los Angeles from 1990 to 1995. The potential association between cryptococcosis and demographic risk behavior and clinical factors was assessed. Possible seasonal clustering was evaluated and an estimate of survival following cryptococcosis was calculated. Multivariate analysis was performed using a Cox proportional hazards approach.

RESULTS

Cryptococcosis was identified in 112 patients (2.9%) representing a crude incidence rate of 1.7 cases per 100 person-years experience. The rate of cryptococcosis was higher among men than women (1.9 and 0.6, respectively; P < 0.01) and in Hispanics than in whites (2.3 and 1.2, respectively, P < 0.01). A significant trend of decreasing cryptococcosis was observed with increasing age (P < 0.01). Cryptococcosis increased with declining CD4+ lymphocyte count, with risk being greatest at CD4+ cell counts below 100 x 10(6)/l (P < 0.001). In bivariate analysis persons with a history of antifungal medication had a marginally lower rate of cryptococcosis, but this difference was not statistically significant. The rate of cryptococcosis was significantly higher in fall and winter months [rate ratio (RR), 1.45; 95% confidence interval (CI), 1.0-2.3; P = 0.05]. After controlling for other variables, cryptococcosis was more common in men than women (adjusted RR, 3.2; 95% CI, 1.0-10.4) and in Hispanics than whites (adjusted RR, 1.6; 95% CI, 0.9-2.7). Both CD4+ count and age continued to be strongly associated with the occurrence of cryptococcosis. After controlling for other factors a substantial protective effect was observed for antifungal therapy (adjusted RR, 0.48; 95% CI, 0.29-0.79).

CONCLUSION

Our data suggest that HIV-infected men, Hispanics, persons aged under 45 years and those with CD4+ counts under 100 x 10(6)/l have an increased risk of extrapulmonary cryptococcosis. A fall-winter seasonality in the occurrence of cryptococcosis may exist. Significant primary protection against cryptococcal disease is afforded by antifungal therapy. These results may provide insight into possible routes of transmission and sources of cryptococcal infection and help guide both primary prophylaxis and early recognition and diagnosis in persons likely to be at increased risk.

Differences in participation in experimental drug trials among persons with AIDS

To measure participation in experimental drug trials among persons with acquired immunodeficiency syndrome (AIDS), we interviewed 4,604 persons at least 18 years of age who were reported to have AIDS to 11 state and city health departments in the United States. Ten percent reported that they were currently in a trial. Current enrollment differed significantly (p < 0.05) by race/ethnicity (blacks, 5%; whites, 14%; Hispanics, 15%), gender (women, 7%; men, 11%), exposure mode (injection drug use, 5%, men who have sex with men, 14%), annual household income (< $10,000, 8%, > or = $10,000, 14%), education (< 12 years, 6%; > or = 12 years, 12%), health care (no regular care, 1%, public care, 8%; private care, 17%), and time since AIDS diagnosis (< or = 6 months, 9%; > 6 months, 12%). Adjusting for all factors and time since AIDS diagnosis, blacks (adjusted odds ratio [AOR] = 0.35, 95% confidence interval [CI] 0.26, 0.47), persons with less than 12 years of education (AOR = 0.71, CI 0.53, 0.96), and those without regular health care (AOR = 0.24, CI 0.10, 0.61) remained less likely to be in a trial. Blacks, those with less than 12 years of education, and persons without regular health care were less likely than other persons with AIDS to be currently enrolled in AIDS trials. To increase enrollment of these persons, researchers must address barriers to participation for these groups.

Emerging patterns of HIV transmission: the value of alternative surveillance methods

OBJECTIVE

To assess the current patterns of HIV transmission in Los Angeles County and determine if AIDS surveillance data accurately reflect these patterns.

DESIGN

Records-based cohort study.

METHODS

The demographic and HIV risk characteristics of persons considered to be recently infected with HIV (CD4+ count > 700 x 10(6)/l) were determined and compared with the characteristics of persons meeting the Centers for Disease Control and Prevention (CDC) 1993 AIDS case definition. Data were obtained for patients with HIV infection enrolled from four HIV outpatient clinics and analyzed between August 1991 and July 1993.

RESULTS

The patient cohort included 1857 persons with HIV infection; 1096 (59.1%) met the CDC 1993 AIDS case definition and 134 (7.2%) had a CD4+ lymphocyte count > 700 x 10(6)/l. The median CD4+ count for the group presumed to be recently infected was 809 x 10(6)/l. Persons considered recently infected with HIV were more likely than those meeting the AIDS case definition to be female (26.1 and 14.5%, respectively; P < 0.001), black (28.4 and 18.2%, respectively; P = 0.001), or male homosexual injecting drug users (IDU; 6.7 and 3.4%, respectively; P = 0.05). After controlling for confounding variables by logistic regression, persons recently infected were more likely to be female [adjusted odds ratio (OR), 3.4; 95% confidence interval (CI), 1.8-6.5; P < 0.001], black (adjusted OR, 1.6; 95% CI, 1.1-2.5; P = 0.02) or male homosexual IDU (adjusted OR, 2.4; 95% CI, 1.1-5.2; P = 0.02) than persons with AIDS.

CONCLUSIONS

Our results suggest that the HIV epidemic in Los Angeles County is currently advancing into different subpopulations and indicate that the current patterns of HIV transmission in the County are not fully reflected in standard AIDS surveillance activities. However, our data must be interpreted cautiously because of potential selection and misclassification biases. These findings illustrate the benefits of alternative surveillance mechanisms in detecting important changes in HIV transmission and defining groups at risk, especially in jurisdictions without HIV reporting.

Who are the primary caretakers of children born to HIV-infected mothers? Results from a multistate surveillance project

OBJECTIVE

To determine the primary caretakers of children born to women with human immunodeficiency virus (HIV) infection.

METHODS

We interviewed women at least 18 years of age who have been reported with HIV infection or acquired immunodeficiency syndrome to local health departments in 10 cities and states regarding the primary caretaker of their children born since 1977.

RESULTS

Of 541 HIV-infected women who had been pregnant since 1977, 88% had living children. These women comprised 478 family units (mother and children); 234 (49%) of these units consisted of two or more children. The most common primary caretakers for all children within a family unit were the mother alone (46%), grandparents (16%), and both mother and father (15%). When the mother used injection drugs or lived alone, in a shelter, or with friends, almost one quarter of all children were cared for by their grandparents. Only 30% of the mothers knew about child care assistance services, and only 8% had contacted or used these services.

CONCLUSIONS

Mothers with HIV, often alone, are the primary caretakers of their children. Increased provisions for child care assistance and planning for future permanent placement of orphaned children are urgently needed.

Municipal drinking water and cryptosporidiosis among persons with AIDS in Los Angeles County

To assess unfiltered drinking water as a source of cryptosporidium infection in patients with the acquired immunodeficiency syndrome (AIDS) the prevalence of cryptosporidiosis among persons with AIDS in Los Angeles County was assessed by water service area. One water distributor, serving approximately 60% of the county's residents (area B), has consistently employed filtration. The other company, which serves the remainder of the county (area A), did not institute filtration until mid-December 1986. This difference provided a 'natural experiment' in which to assess the effect of municipal water filtration on the level of cryptosporidiosis among persons with AIDS. The prevalence of cryptosporidiosis among AIDS patients was compared for the two water service areas for the time period (1983-6) preceding the implementation of filtration in area A. From 1983 to 1986 the age-standardized prevalence of cryptosporidiosis among AIDS patients was 32% lower in area A (4.2%), which received unfiltered water, than in area B (6.2%). Following addition of filtration in area A, the prevalence of cryptosporidiosis among AIDS patients decreased by 20%; however, a decline, of 47%, was also observed in area B. The similar baseline levels of cryptosporidiosis and the corresponding post-filtration decline in both areas suggest that filtration had no effect on levels of cryptosporidiosis among persons with AIDS. Thus it does not appear that municipal drinking water is an important risk factor for cryptosporidiosis in AIDS patients residing in Los Angeles County.

Risk behaviors of persons with heterosexually acquired HIV infection in the United States: results of a multistate surveillance project

To describe past risk behaviors among persons with heterosexually acquired human immunodeficiency virus (HIV) infection, we interviewed 497 persons > or = 18 years of age with heterosexually acquired HIV infection reported to 11 state and city health departments in the United States. Thirty-nine percent of persons reported using noninjection drugs in the past 5 years; noninjection drug use was highest among men whose sex partners injected drugs (53%). Sixteen percent of all persons used crack, and 17% were classified as potential alcoholics; among men, 29% were classified as potential alcoholics. Of the 49% of men who reported paying a woman for sex, 86% did so multiple times. Most persons had multiple sex partners in the past 5 years; however, 35% of the women had only one sex partner. Thirty-four percent of the women and 50% of the men had been treated for a sexually transmitted disease in the past 10 years. Seventy-four percent of the women and 68% of the men had never used condoms in the 5 years before they knew they were HIV positive. Among these people with heterosexually acquired HIV, noninjection drug use was common, many men have paid someone for sex, and many women have not had multiple sex partners. These findings have important implications for the types of prevention programs that can most successfully lessen the spread of HIV among heterosexuals.

Fatal listeria meningitis in an immunocompromised infant: therapeutic implications

Infection with Listeria monocytogenes is rare in infants and children. Listeriosis has been made a notifiable condition in the State of California since 1985. From January 1985 to December 1990, only seven cases of listeriosis have been reported in children less than or equal to 13 years of age. This brief report summarises the features of a fatal case of listeria meningitis in an immunocompromised 4-month-old infant, discusses diagnostic and therapeutic implications, and describes the other six cases.

Surveillance of listeriosis in Los Angeles County, 1985-1986. A first year's report

After a large food-borne outbreak of listeriosis in Los Angeles County, California, in 1985, the California State Department of Health Services instituted mandatory reporting of Listeria monocytogenes by clinical laboratories. From September 1, 1985, through August 31, 1986, 94 cases of listeriosis were reported in Los Angeles County for an annual crude incidence rate of 12 cases per million persons. Of the 94 cases, 37 (39%) were in neonates and/or their mothers and 57 (61%) were nonperinatal. The overall case fatality rate was 31%, with a perinatal case fatality of 16% (6 fetal and 23 nonperinatal); this compares with an epidemic perinatal case fatality rate of 32%. No significant differences were observed in age-adjusted, race-specific incidence rates among nonperinatal cases or race-specific incidence rates among perinatal cases. All but 2 of the nonperinatal patients had a known predisposing risk factor for the development of listeriosis, the most common of which was a prior history of steroid therapy. A clustering of cases was not identified. No common food sources were apparent. Patients presenting as perinatal cases were more likely to have ingested Mexican-style cheese, ice cream, and yogurt than those presenting as nonperinatal cases. Improved case ascertainment through mandatory reporting and laboratory-based surveillance will establish meaningful baseline levels of listeriosis.