Carol Harris

Oral candidiasis in high-risk patients as the initial manifestation of the acquired immunodeficiency syndrome.

We studied the frequency with which unexplained oral candidiasis led to unequivocal acquired immunodeficiency syndrome (AIDS) in patients at risk. Twenty-two previously healthy adults with unexplained oral candidiasis, of whom the 19 tested had a reversed T4/T8 ratio and 20 had generalized lymphadenopathy, were compared with 20 similar patients with a reversed T4/T8 ratio and generalized lymphadenopathy who did not have oral candidiasis. All were intravenous-drug abusers, homosexual or bisexual men, or both. Thirteen of the 22 patients with oral candidiasis (59 per cent) acquired a major opportunistic infection or Kaposis sarcoma at a median of three months (range, 1 to 23) as compared with none of 20 patients with generalized lymphadenopathy and immunodeficiency but without candidiasis who were followed for a median of 12 months (range, 5 to 21) (P less than 0.001). AIDS developed in 12 of 15 patients with candidiasis and T4/T8 ratios less than or equal to 0.51, as compared with none of four with ratios equal to or greater than 0.60 (P less than 0.01). We conclude that in patients at high risk for AIDS, the presence of unexplained oral candidiasis predicts the development of serious opportunistic infections more than 50 per cent of the time. Whether the remainder will have AIDS is not yet known.

Immunodeficiency in Female Sexual Partners of Men with the Acquired Immunodeficiency Syndrome

Because the current outbreak of acquired immunodeficiency syndrome (AIDS) among previously healthy adults may be caused by a transmissible biologic agent, and because it may be preceded by immunologic abnormalities with or without a prodromal illness, we studied seven female sexual partners of male patients with the syndrome. The male patients were all drug abusers. One of the seven women was found to have the full-blown syndrome, a second had an illness consistent with the prodrome of AIDS (generalized lymphadenopathy, lymphopenia, and a decreased ratio of helper to suppressor T cells), and four others had generalized lymphadenopathy or lymphopenia, with or without a decreased ratio of helper to suppressor T cells. Only one woman had no abnormalities. These findings suggest that AIDS may be transmitted between heterosexual men and women.

Acquired Immunodeficiency Syndrome: Ophthalmic Manifestations in Ambulatory Patients

Twenty-five ambulatory patients with acquired immunodeficiency syndrome (AIDS) were studied over a 6-month period. Fourteen (56%) of the patients were heterosexuals with a history of intravenous drug abuse. Ocular involvement was seen in 40% of patients, cotton-wool spots being the major manifestation. Findings consistent with cytomegalovirus retinitis were seen in only one patient. Ophthalmologists should be aware of the ocular findings and epidemiology of AIDS.

Serologic, immunologic, and clinical features of parenteral drug users from contrasting populations

We screened inpatient and outpatient parenteral drug users with no clinical evidence of AIDS for immunodeficiency and antibodies to HTLV-III by ELISA. Among 20 outpatient drug users, 5 (25%) were seropositive. Three of these (and 2 who were seronegative) had low T-cell ratios. Over 6 months, 1 seropositive patient with a low ratio developed oral thrush and weight loss. We also studied 13 parenteral drug users hospitalized for conditions other than AIDS. Eight had low T-cell ratios, and at least 6 of these developed AIDS or ARC within 4 months. Serum from 8 of 13 inpatients was available for HTLV-III testing: 6/8 were seropositive and 3 of these 6 were among those developing AIDS or ARC. Abnormal T-cell ratios among all patients were associated with abnormal HTLV-III serology (p = .02). Of the 7 patients who developed AIDS or ARC, 4 were tested for both antibodies and T-cell ratios: all 4 were seropositive and had low ratios. A low ratio (p = .0004), a positive ELISA (p = .014), and abnormalities of both tests (p = .001) were associated with the development of AIDS or ARC. Of the 26 patients without AIDS or ARC, 3 were lost to follow-up and 23 did not develop AIDS or ARC. Six of these 26 had abnormal ratios. Of the 21 patients who did not develop AIDS or ARC and who were tested for HTLV antibodies, 2 were lost to follow-up. Seven of 21 were seropositive and 2/21 were both seropositive and had a low ratio. One of these 2 seropositive patients with low ratios also had lymphadenopathy, but he was lost to follow-up. The other had no adenopathy and remained well until her death from trauma a year later. This study found two populations with very different risks. Six of 13 hospitalized parenteral drug users and only 1 of 20 healthy outpatients developed AIDS or ARC.

Quality Assurance for HIV-Related Care

Now that models of care for numerous HIV-related conditions have been defined, a knowledge base exists for developing protocols of appropriate, high-quality care for HIV-infected patients. Bronx Municipal Hospital Center in New York City plans to implement a monitoring and evaluation program for HIV-related care that would establish protocols and indicators of quality and appropriateness, monitor compliance with protocols, and generate recommendations for improving care. At present, Bronx Municipals AIDS consultation service has drafted guidelines for developing indicators of appropriate diagnosis, clinical course, and drug usage for HIV-infected patients, as well as guidelines for reviewing medical records.

An unusual cause of community-acquired pneumonia

Highlights • A. baumannii community-acquired pneumonia incidence and prevalence is unknown in temperate regions.• It potentially has a rapidly progressive course and poor outcome.• Progression of disease may be due to immune dysfunction in certain hosts.• Studies are conflicting on the role and regimen of antibiotics on disease progression.