Ilya Spigland

Disseminated Kaposi's Sarcoma in Homosexual Men

Nineteen cases from an epidemic of disseminated Kaposis sarcoma in homosexual men were studied by clinical, virologic, immunologic, and genetic methods. The patients were all male homosexuals ranging in age from 29 to 52 years, with histories of multiple sexually transmitted diseases and exposure to both prescription and recreational drugs. Sites of disease included skin (16 of 19 patients), lymph nodes (13 patients), gastrointestinal tract (12 patients), spleen (three patients), and lung (one patient). Most patients had elevated levels of serum immunoglobins, positive antibody titers to hepatitis A and B virus, cytomegalovirus and Epstein-Barr virus, and impairment of cell-mediated immunologic reactions. The frequency of HLA-DR5 in these patients was significantly elevated. Two of the 19 patients died. Although the precise cause of this epidemic is unknown, it is likely that a genetic predisposition, an acquired immunoregulatory defect, and one or more infectious agents and drugs may be involved.

Opportunistic infections and immune deficiency in homosexual men.

A syndrome of opportunistic infections and acquired immune deficiency occurred among four previously healthy homosexual men. Fever, leukopenia, and diminished delayed hypersensitivity were accompanied by various degrees of proctitis, perianal ulcerations, and lymphadenopathy. The infectious agents included Pneumocystis carinii, Cryptococcus neoformans, Candida albicans, herpes simplex virus, and cytomegalovirus. The immune deficiency was characterized as a persistent and profound selective decrease in the function as well as number of T lymphocytes of the helper/inducer subset and a possible activation of the suppressor/cytotoxic subset. Three patients died despite aggressive anti-infective therapy.

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.

Community-acquired opportunistic infections and defective cellular immunity in heterosexual drug abusers and homosexual men.

Fourteen previously healthy young patients with unusual community-acquired opportunistic infections were seen over a period of three years. They differ from patients previously described in that 11 were heterosexual drug abusers (including two women) and only three were homosexual men. There were eight Puerto Ricans, five blacks, and one white. Infections included Pneumocystis carinii pneumonia (seven), disseminated Mycobacterium intracellulare infection, histoplasmosis, cryptococcosis, and cytomegalovirus infection (one each), oral thrush (13), and Candida esophagitis (two). All patients had impaired cellular immunity manifested by cutaneous anergy and lymphopenia, and all 11 tested had a markedly decreased ratio of T helper/inducer cells to T suppressor/cytotoxic cells. Twelve had evidence of associated viral infection (Epstein-Barr virus in nine, cytomegalovirus in five, Herpes simplex type 2 in two). Clinical presentation was with a severe opportunistic infection or with a prodrome consisting of oral thrush and nonspecific findings including malaise, fever, lymphadenopathy, or cough. The syndrome of immunodeficiency and opportunistic infection occurs in nonwhite heterosexual drug abusers, not exclusively in white homosexual men, and patients may present for medical care before the onset of a severe opportunistic infection.

ADENOVIRUS ISOLATES FROM URINE OF PATIENTS WITH ACQUIRED IMMUNODEFICIENCY SYNDROME

13 adenoviruses (Ad) from the urine of 10 patients with acquired immunodeficiency syndrome (AIDS) were characterised by haemagglutination inhibition and restriction endonuclease analysis of their DNA. The haemagglutinin (HA) for 6 of these isolates was found to be that of Ad34/35. 3 other isolates were found to have Ad7 HA and the remaining 4 viruses were found to have both phenotypes. In contrast, the restriction patterns were more homogeneous than anticipated from the serological analysis. 11 isolates had a SmaI-restriction pattern identical to Ad35, and 2 isolates, which lacked one of the 9 Ad35 SmaI-restriction sites, were identical to Ad34. Analyses with other restriction enzymes reinforced the conclusion that the genomes of all isolates resemble that of Ad35 (and Ad34) more than they resembled the previously isolated Ad7 subtypes. The discrepancy between the restriction endonuclease and the serological analyses is best explained by assuming that some of these new isolates are recombinants between a small part (less than 10%) of the Ad7 genome coding for HA and greater than 90% of the Ad35 genome. It is therefore important to characterise both the genotype and the HA for this potentially important group of pathogens in AIDS patients.

Inverted ratio of inducer to suppressor T-lymphocyte subsets in drug abusers with opportunistic infections

Abstract Six patients with a history of drug abuse presented with community-acquired opportunistic infections. Four of these patients had Pneumocystis carinii pneumonia, one had disseminated histoplasmosis, and one had oral candidiasis as his only opportunistic infection. The patients with P. carinii were also infected with other organisms. All six patients had a markedly reduced percentage of T4 + (inducer) lymphocytes in peripheral blood compared to our controls and five of the six patients also showed an increased percentage of T8 + (suppressor) lymphocytes. This imbalance in T-lymphocyte subsets resulted in a marked reduction in the ratio of T4 + T8 + lymphocytes. All six patients also had cutaneous anergy to recall antigens and subnormal proliferative responses to phytohemagglutin, providing further evidence for compromised immune status.

Liver disease in the drug-using adolescent

Evaluation of 7,272 presumably well adolescent users of heroin, sedatives and airplane glue revealed abnormalities in liver function in 37 per cent. Elevation of the concentration of serum glutamic pyruvic transaminase was the most common abnormality, while elevation of serum bilirubin levels was recorded in less than 10 per cent. These abnormalities were prevalent in the patients who used heroin and sedatives. Inhalation of airplane glue was not associated with abnormalities in liver function tests. The substances commontly abused by our patients did not appear toxic when tested in an in vitro system designed to evaluate acute hepatotoxicity. The long-term prognosis of chronic persistent hepatitis in teen-agers who abuse drugs is still unknown.

Are There Risk Factors for Hepatitis B Infection in Inner-City Adolescents That Justify Prevaccination Screening?

PURPOSE This study was undertaken to determine if homelessness could serve as a marker for previous hepatitis B infection (HBI), and thus justify prevaccination screening. METHODS One hundred sexually active 13-21-year-olds (mean = 17 years), 74% female, attending an inner-city hospital-based adolescent clinic (HOSP), and 48 sexually active 13-21-year-olds (mean = 19 years), 40% female, attending a clinic based at an urban drop-in center (UDC) for street youth were consecutively enrolled, screened for HBI serum markers and administered a structured interview about sexual practices, sexual abuse, prior sexually transmitted diseases (STDs), and injection drug use. RESULTS For the HOSP group, 7% were homeless and 4% were HBI positive. In the UDC group, 96% were homeless and 23% were HBI positive. Homelessness was significantly associated with HBI (p < 0.001), and this was corroborated by logistic regression analysis (p < 0.01). Other factors significantly associated with HBI in adolescents included a history of anal sex (p < or = 0.002), anal-receptive sex (p < or = 0.01), genital Chlamydia (p < or = 0.03), prostitution (p < or = 0.03), and sexual abuse (p < or = 0.002). For both populations, gender, sexual orientation, intravenous drug use, and genital sex were not related to HBI. CONCLUSION These data indicate that homelessness and associated high-risk sexual practices may be indications for prevaccination screening for HBI in adolescents.

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.

Comparison of rapid diagnostic methodologies for chlamydia and gonorrhea in an urban adolescent population: A pilot study

PURPOSE To compare a combination DNA probe test which detects both N. gonorrhoeae (GC) and C. trachomatis (CT) to the current culture methodologies among a population of female adolescents at an urban teaching center. In addition, the probe test for CT was compared to a direct immunofluorescence test. METHODS All sexually active female adolescents between the ages of 13-21 years who sought care at an urban teaching center from June 1991 through November 1991 and who required testing for sexually transmitted diseases (STDs) were recruited for this study. RESULTS The probe test was demonstrated to be 66.6% sensitive and 94.9% specific when compared to tissue culture for CT and 50% sensitive and 98.2% specific when compared to culture for GC. We found an overall prevalence of 23.5% for CT and 3.5% for GC. CONCLUSIONS The two rapid diagnostic tests for CT evaluated in this study demonstrated similar sensitivities. However the probe test offers advantages in that it is easier to perform, skill at reading fluorescence is not required, and one specimen yields results for both CT and GC.