Jonathan W. M. Gold

Severe Acquired Immunodeficiency in Male Homosexuals, Manifested by Chronic Perianal Ulcerative Herpes Simplex Lesions

Four homosexual men presented with gradually enlarging perianal ulcers, from which herpes simplex virus was cultured. Each patient had a prolonged course characterized by eight loss, fever, and evidence of infection by other opportunistic microorganisms including cytomegalovirus, Pneumocystis carinii, and Candida albicans. Three patients died; Kaposis sarcoma developed in the fourth. All were found to have depressed cell-mediated immunity, as evidenced by skin anergy, lymphopenia, and poor or absent responses to plant lectins and antigens in vitro. Natural-killer-cell activity directed against target cells infected with herpes simplex virus was depressed in all patients. The absence of a history of recurrent infections or of histologic evidence of lymphoproliferative or other neoplastic diseases suggests that the immune defects were acquired.

Bronchoalveolar Lavage in the Diagnosis of Diffuse Pulmonary Infiltrates in the Immunosuppressed Host

The usefulness of bronchoalveolar lavage in the diagnosis of pulmonary infiltrates in the immunosuppressed patient was studied in 97 patients. In immunosuppressed patients, the available diagnostic procedures are often invasive and have variable yield and a potential for serious complications. Bronchoalveolar lavage had an overall diagnostic yield of 66% (61 of 92 diseases). It was most effective in the diagnosis of opportunistic infections, including infection with Pneumocystis carinii (18 of 22 cases), cytomegalovirus pneumonia (10 of 12 cases), fungal pneumonia (5 of 6 cases), and mycobacterial disease (4 of 5 cases). The technique was also helpful in suspected pulmonary hemorrhage (7 of 9 cases) but was less useful for diagnosing malignancy (10 of 22 cases) and drug-induced toxicity (6 of 15 cases). Findings of bronchoalveolar lavage could be combined with those of transbronchial biopsies, brushings, and washings in the diagnosis of most of the diseases. The procedure was safe, even in thrombocytopenic patients and those requiring mechanical ventilatory support. Bronchoalveolar lavage is a valuable procedure for evaluation of pulmonary disease in the immunosuppressed host.

Mycobacterium avium Complex Infections in Patients with the Acquired Immunodeficiency Syndrome

Disseminated infection with Mycobacterium avium complex developed in 67 patients with the acquired immunodeficiency syndrome (AIDS) who were followed at Memorial Sloan-Kettering Cancer Center. Twenty-nine patients were treated with two or more antimycobacterial drugs for a mean of 6 weeks, and 7 patients received therapy for less than 1 month. Most patients received ansamycin, clofazimine, and ethionamide or ethambutol. Clinical improvement did not occur in treated patients, and microbiologic cure was never obtained. Mycobacterial bacteremia persisted in 24 of 26 treated patients. Colony counts of M. avium complex in sequential blood cultures decreased in 3 patients. Every autopsied patient with M. avium complex infection diagnosed before death, whether treated or not, had disseminated M. avium complex infection at autopsy.

Bacterial Pneumonia in Patients with the Acquired Immunodeficiency Syndrome

Eighteen episodes of community-acquired bacterial pneumonia were diagnosed in 13 patients among 336 with the acquired immunodeficiency syndrome (AIDS) cared for at Memorial Sloan-Kettering Cancer Center since 1979. Bacterial pathogens isolated in 16 of 18 episodes were Haemophilus influenzae in 8, Streptococcus pneumoniae in 6, group B streptococcus in 1, and Branhamella catarrhalis in 1. Eight episodes were presumed Pneumocystis carinii pneumonia until cultures obtained at bronchoscopy confirmed a bacterial cause. Specific antibacterial therapy was curative in 16 of 18 episodes; 2 patients died. Given an estimated yearly incidence of pneumococcal pneumonia in the general population of 2.6/1000, 1.09 cases were expected in our patients with AIDS; we saw 6 (p = 0.001), for an attack rate of 17.9/1000. Bacteria associated with B-cell defects should be anticipated when formulating empiric antibiotic therapy, pending a definitive diagnosis, for pulmonary infiltrates in patients with AIDS.

A randomized controlled trial of a reduced daily dose of zidovudine in patients with the acquired immunodeficiency syndrome

Abstract Background. The initially tested dose of zidovudine for the treatment of patients with advanced disease caused by the human immunodeficiency virus type 1 (HIV) was 1500 mg. Although this dose is effective, it is associated with substantial toxicity. Methods. To evaluate the efficacy and safety of a reduced dose, we conducted a randomized controlled trial in 524 subjects who had had a first episode of Pneumocystis carinii pneumonia. The subjects were assigned to receive zidovudine in either a dose of 250 mg taken orally every four hours (the standard-treatment group, n = 262) or a dose of 200 mg taken orally every four hours for four weeks and thereafter 100 mg taken every four hours (the low-dose group, n = 262). Results. The median length of follow-up was 25.6 months. At 18 months the estimated survival rates were 52 percent for the standard-treatment group and 63 percent for the low-dose group (P = 0.012 by the log-rank test). At 24 months the estimated survival rates were 27 percent for the st...

Invasive aspergillosis. Progress in early diagnosis and treatment.

Ninety-one patients with documented invasive infections due to an Aspergillus species were identified at Memorial Sloan-Kettering Cancer Center from July 1, 1971, through December 31, 1976. Of the 29 patients in whom the diagnosis was made during life, 10 had successful treatment and survived the Aspergillus infection by two to 17 months. An immunodiffusion test was useful in the early diagnosis of invasive aspergillosis, and in 11 patients in whom the diagnosis was supported by seroconversion and who underwent treatment, the survival rate was 64 percent. Cultures of respiratory secretions were not reliable because they often reflected only colonization. In one year, only 9 percent of he patients with Aspergillus species isolated from the sputum had an invasive infection. The lung was the commonest site of involvement, 91 percent of the patients having pulmonary lesions. The most frequently affected extrapulmonary organ was the brain (18.3 percent). Eight patients had nonpulmonary aspergillosis as the only manifestation of this infection. Most of the 91 patients had hematologic neoplasms as the underlying disease, and neutropenia and antibacterial therapy preceded the diagnosis of aspergillosis in the majority of cases.

Central-Nervous-System Toxoplasmosis in Homosexual Men and Parenteral Drug Abusers

Central-nervous-system toxoplasmosis developed in 7 of 269 patients with the acquired immunodeficiency syndrome reported to the New York City Health Department through July 1982. Focal neurologic abnormalities, mass lesions on computed-tomographic brain scans, lymphocytic cerebrospinal fluid pleocytosis, and detectable IgG antibody to Toxoplasma gondii were common; but IgG titers of 1:1024 or more, IgM antibody to T. gondii, and positive open brain biopsies were uncommon. Serologic findings suggested that the disease resulted from recrudescent rather than primary infection. Four of five patients improved when treated with sulfonamides and pyrimethamine, but 2 had relapses. An aggressive diagnostic approach and sometimes even empiric therapy are warranted when central-nervous-system toxoplasmosis is suspected in a seropositive patient with the acquired immunodeficiency syndrome.

AIDS-related lymphoid neoplasia. The memorial hospital experience

The clinical features and laboratory results of 63 patients with or at risk for AIDS with lymphoid neoplasias seen from November 1980 through November 1986 are reviewed. Forty‐three had systemic non‐Hodgkins lymphoma (NHL), nine had primary large cell lymphomas of the brain, 11 had Hodgkins disease (HD), and one had plasmacytoma evolving to myeloma. Those with systemic NHL included 40 (93%) with intermediate or high‐grade histologies, 35 (81%) with advanced stage (III, IV), and 28 (65%) with extranodal disease at presentation (predominantly marrow and meninges). Overall survival was short (median, 10.5 months from diagnosis) with the majority of deaths attributable to AIDS‐related opportunistic infections (OI). However, 17 patients with diffuse NHL achieved a complete clinical remission, and nine now have been disease‐free for more than 1 year (median follow‐up, 28 months; range, 12 to 73 months). Early stage and lack of systemic symptoms were features associated with prolonged disease‐free survival. Primary brain NHL was a uniformly lethal manifestation of AIDS, being diagnosed at postmorten in seven of nine severely immunosuppressed homosexual men. As with NHL, a propensity towards advanced disease and extranodal involvement was also observed in HD, suggesting that the atypical clinical behavior of HD may be an additional epiphenomenon of AIDS. This experience tends to argue for the use of intensive therapy in at least some patients with AIDS‐related systemic NHL since it has resulted in a proportion of long‐term disease‐free survivors.

Bacteremia and Fungemia in Patients with the Acquired Immunodeficiency Syndrome

Forty-nine episodes of bacteremia and fungemia occurred in 38 of 336 patients with the acquired immunodeficiency syndrome seen at our institution since 1980. There were five types of infections. Infections commonly associated with a T-cell immunodeficiency disorder comprised 16 episodes and included those with Salmonella species, Listeria monocytogenes, Cryptococcus neoformans, and Histoplasma capsulatum. Infections commonly associated with a B-cell immunodeficiency disorder included those with Streptococcus pneumoniae and Haemophilus influenzae. Infections occurring with neutropenia were caused by Pseudomonas aeruginosa, Staphylococcus epidermidis, and Streptococcus faecalis. Other infections occurring in the hospital were caused by Candida albicans, Staphylococcus epidermidis, enteric gram-negative rods, Staphylococcus aureus, and mixed S. aureus and group G streptococcus. Other infections occurring out of the hospital included those with S. aureus, Clostridium perfringens, Shigella sonnei, Pseudomonas aeruginosa, and group B streptococcus. Because two thirds of the septicemias were caused by organisms other than T-cell opportunists, these pathogens should be anticipated during diagnostic evaluation and when formulating empiric therapy.

Transfusion-Associated Acute Chagas Disease Acquired in the United States

Excerpt Although a significant problem in Latin America (1), the transmission ofTrypanosoma cruziinfection by transfusion has not been unequivocally documented in the United States. We report a cas...