Are Næss

Antiretroviral therapy at a district hospital in Ethiopia prevents death and tuberculosis in a cohort of HIV patients

BackgroundAlthough highly active antiretroviral therapy (HAART) reduces mortality in the developed world, it remains undocumented in resource-poor settings. We assessed the effect of HAART on patient mortality and tuberculosis incidence rate under routine clinical care conditions in Ethiopia. The objective of this study was to assess the effect of HAART on patient mortality and tuberculosis incidence rate under routine clinical care conditions in a resource-limited setting in south Ethiopia. Starting in January 2003, we followed all consecutive adult HIV infected patients who visited the HIV clinic. Since August 2003, we treated patients with HAART. Only basic laboratory services were available.ResultsWe followed 185 patients in the pre-HAART cohort and 180 patients in the HAART cohort. The mortality rate was 15.4 per 100 person-years of observation (PYO) in the HAART group and tuberculosis incidence rate was 3.7 per 100 PYO. In the pre-HAART group, the mortality rate was 58.1 per 100 PYO and the tuberculosis incidence rate was 11.1 per 100 PYO. HAART resulted in a 65% decline in mortality (adjusted hazard ratio [95%CI] = 0.35 [0.19–0.63]; P < 0.001). Tuberculosis incidence rate was lower in the HAART group (adjusted hazard ratio [95%CI] = 0.11 [0.03–0.48]; P < 0.01). Most of the deaths occurred during the first three months of treatment.ConclusionHAART improved survival and decreased tuberculosis incidence to a level similar to that achieved in the developed countries during the early years of HAART. However, both the mortality and the tuberculosis incidence rate were much higher in terms of absolute figures in this resource-limited setting. Attention should be paid to the early weeks of treatment when mortality is high. The high tuberculosis incidence rate, when coupled with the improved survival, may lead to increased tuberculosis transmission. This highlights the need for strengthening tuberculosis prevention efforts with the scale-up of treatment programmes

Sequelae one year after meningococcal disease

Of 99 consecutive patients with meningococcal disease, 6 died during the acute stage. The 93 survivors were examined one year after hospitalization. 21 (40%) of the adults and 6 (15%) of the children had definite sequelae, and an additional 27% and 11% possible sequelae. 6 adults (12%) and 1 child (2%) had definite neurological sequelae. Electroencephalography (EEG) abnormalities were observed in 7 adults (14%) and 2 children (5%). Epileptogenic activity was present in 3 of these, but none had experienced seizures. 8 adults (19%) and 5 children (14%) had sensorineural hearing loss or impaired vestibular function. Cerebral computerized tomography (CT) scan showed definite and possible abnormalities in 1 (3%) and 6 (18%), respectively, of the 34 patients tested. Neuropsychological tests were performed in 9 patients, 2 of these showed definite impairment. The frequency of neurological abnormalities was higher than in many previous studies, probably reflecting the more comprehensive examinations performed in the present study. However, only 3 patients had serious sequelae. The results suggest that the occurrence of sequelae after meningococcal disease is related to the severity of the acute disease. This may explain the higher rate of sequelae in adults, who have a higher proportion of seriously ill patients. The presence of meningitis is not required for the occurrence of neurological sequelae.

A longitudinal study of phagocyte function in HIV-infected patients

ObjectiveTo study the influence of HIV infection on phagocyte function. To date, the results of phagocyte function studies in HIV-infected patients have been contradictory. This is the first longitudinal study of these functions in HIV infection. DesignWe followed 50 individuals with HIV infection for 2–51 months (mean, 28 months) and examined polymorphonuclear leukocyte (PMNL) and monocyte functions at intervals of 0.5–1 years. MethodsPMNL random migration and chemotaxis were assessed using an under-agarose method, and PMNL and monocyte oxidative metabolism by chemiluminescence production during phagocytosis of opsonized zymosan. ResultsPMNL random migration and chemotaxis were impaired at entry into the study by 15 and 19%, respectively. After 3 years the reduction was 35 and 32%, respectively. The mean chemiluminescence production by PMNL was reduced by 6% at entry into the study. After 4 years a decrease of 18% was observed. The decrease in PMNL function was most marked in patients with lymphadenopathy syndrome or AIDS. No significant change in monocyte chemiluminescence production was detected at any time during the study. ConclusionsA distinct and progressive decrease of PMNL function occurs during HIV infection. This may contribute to increased susceptibility to opportunistic infections in HIV-infected patients. For monocytes, chemiluminescence production is not influenced by HIV infection.

Negative selection of human monocytes using magnetic particles covered by anti-lymphocyte antibodies

We have developed a standardized procedure for the isolation of monocytes from peripheral blood by negative selection using magnetic polymer particles coated with monoclonal antibodies against T and B lymphocytes. The average purity of the monocyte suspension was 85%, and monocyte recovery was 72% from Ficoll-Hypaque gradient separated mononuclear cells and 32% from whole blood. In a lucigenin enhanced chemiluminescence assay there was no significant difference between cells separated immunomagnetically and those separated on a gradient. Nor did electron microscopy show any significant difference in morphology between such monocytes. Negative selection using magnetic polymer particles is an efficient method for the separation of monocytes with intact morphology and function as measured by chemiluminescence.

IgG subclass antibodies to serogroup B meningococcal outer membrane antigens following infection and vaccination

IgG and IgG subclass antibodies to the outer membrane antigens from Neisseria meningitidis (serogroup B., serotype 15:P1.16) were quantitated by an enzyme‐linked immunosorbent assay (ELISA) in sera from 40 patients with group B:15:P1.16 meningococcal disease and 24 volunteers immunized with a serotype 15:P1.16 outer membrane vesicle vaccine. A second injection was given 6 weeks after the first immunization. Patient sera obtained two and six weeks after onset of the disease had significantly higher levels of total IgG, IgG1, IgG2, and IgG3 antibodies to the outer membrane antigens than acute sera, convalescent sera from patients with systemic non‐meningococcal bacterial infections and sera from healthy controls. The levels of total IgG and IgG 1 remained high one and three years later. Sera from the vaccinees showed high levels of total IgG and IgG 1 6, 12 and 26 weeks after the first immunization and high levels of IgG3 6 weeks after the second immunization. No increase of IgG2 or IgG4 levels was observed in the postimmunization sera. Immunoblotting of three convalescent sera demonstrated individual patterns of IgG subclass binding to various outer membrane antigens with most distinct binding of IgG 1 and IgG3 antibodies to the class 1 protein, the H.8 lipoprotein and the lipopolysaccharide. Since IgGl and IgG3 are the most effective antibodies for complement activation and phagocytosis, group B meningococcal disease and immunization with the serotype 15:P1.16 outer membrane vesicle vaccine stimulate production of those IgG subclasses which have the strongest opsonic and bactericidal activity.

Flow cytometric assay for the measurement of serum opsonins to Neisseria meningitidis serogroup B, serotype 15

A flow cytometric phagocytosis assay has been developed for the measurement of human serum opsonins to serogroup B meningococci. Live bacteria and bacteria inactivated by heat, formalin or ethanol were labelled with fluorescein-isothiocyanate (FITC). The bacteria were opsonized with sera from patients with group B meningococcal disease and sera from healthy controls, and phagocytosis determined by combined measurements of FITC-fluorescence and forward angle light scatter. Optimal sensitivity was obtained using viable bacteria, 5% serum, 20 bacteria per leukocyte capable of phagocytosis, 7.5 min opsonization time, 5 min phagocytosis time, 37 degrees C, and continuous agitation during opsonization and phagocytosis. The opsonic activity of sera from convalescent patients was markedly higher than that of sera from patients with acute illness. Only minor day-to-day and interindividual variations were observed. The flow cytometric phagocytosis technique is a rapid and reproducible method for the measurement of serum opsonins to meningococci.

Demonstration of T Lymphocytes in Cerebrospinal Fluid

Cerebrospinal fluid (CSF) was allowed to drop straight into Hankss balanced salt solution. After centrifugation the pellet was resuspended and mixed with sheep erythrocytes. The mixture was further handled as in the E‐rosette test with peripheral blood lymphocytes. CSF from 20 individuals were investigated, and rosette‐forming cells (RFC) were found in all. Six patients with normal fluid had between 46% and 83% RFC. Four patients with multiple sclerosis had increased numbers of RFC (94%–96%). Low numbers of RFC were found in one patient with cerebellar ataxia and in one of two patients with acute viral meningitis. With this technique RFC can be counted even in normal CSF with a 3‐ml sample.

Immunization against serogroup B meningococci

One hundred and thirteen healthy volunteers were immunized twice (six weeks apart) with four different doses (12.5, 25, 50 and 100 μg, measured as protein content) of an outer membrane vesicle vaccine from a serogroup B meningococcal strain (44/76, B:15:P1.16) complexed to serogroup C meningococcal polysaccharide and/or Al(OH)3 i.e. 12 different vaccines. Serum opsonic activity against the serogroup B strain was measured using a chemiluminescence method. A significant rise in serum opsonic activity was demonstrated in 84 volunteers (74%) six weeks after the first injection and in 97 (86%) six weeks after the second. All vaccinees with low preimmunization values (<25 mVs) experienced a significant increase in opsonic activity. A dose‐related response was most evident for the vaccines containing adjuvant, and these vaccines were associated with a maximum response six weeks after the second injection, while the vaccines without Al(OH)3 induced a peak response six weeks after the first injection. The postimmunization opsonic activity was similar to that found in convalescent sera, indicating that the vaccines may protect against serogroup B meningococcal disease.

Pandemic influenza vaccination elicits influenza-specific CD4+ Th1-cell responses in hypogammaglobulinaemic patients: four case reports.

In these case reports, we investigated pandemic influenza 2009 vaccination of primary hypogammaglobulinaemic patients. Three combined variable immunodeficiency (CVID) patients and one X‐linked agammaglobulinaemia (XLA) patient were vaccinated with the pandemic vaccine A/California/7/2009 (H1N1)‐like split virus (X179a) adjuvanted with the oil‐in‐water emulsion AS03. Subsequently, serum and peripheral blood mononuclear cells were sampled and used to measure the haemagglutination inhibition (HI) and antibody‐secreting cell (ASC) responses. In addition, the IFN‐γ, IL‐2 and TNF‐α producing CD4+ Th1‐cell response was determined as these cytokines are important indicators of cell‐mediated immunity. Two of the CVID patients responded to vaccination as determined by a >4‐fold rise in HI antibodies. These subjects also had influenza‐specific ASC numbers, which, albeit low, were higher than prevaccination levels. In addition, vaccination induced CD4+ Th1‐cell responses in both the XLA patient and the CVID patients, although the frequency of influenza‐responsive cells varied amongst the patients. These results suggest that hypogammaglobulinaemia patients can mount a CD4+ Th1 cell‐mediated response to influenza vaccination and, additionally, that influenza vaccination of some hypogammaglobulinaemia patients can produce an influenza‐specific humoral immune response. The findings should be confirmed in larger clinical studies.

Serum Opsonins to Serogroup B Meningococci in Meningococcal Disease

The opsonic activity to serogroup B meningococci (B:15:P1.16) was measured in sera from 101 patients with meningococcal disease using a chemiluminescence method. On admission to hospital the opsonic activity was lower in 12 patients who died than in survivors (p = 0.0007). A close association was observed between the opsonic activity and the duration of symptoms before admission, the severity of the disease, and the levels of IgG antibodies to the outer membrane complex (15:P1.16). The opsonic activity was low in 2 premorbid sera compared to healthy controls. The mean opsonic activity peaked 2 weeks after admission and was still high 3-5 years later. Meningococcal strains of different serogroups, serotypes and subtypes induced a similar increase in opsonic activity to B:15:P1.16 meningococci. No increase in activity was observed in sera from patients with meningitis and septicemia caused by other bacteria. Serum opsonins seem to be of significant importance in the host defence against serogroup B meningococci.