Tomoko Uehira

Sustained High Levels of Serum Interferon-γ During HIV-1 Infection: A Specific Trend Different from Other Cytokines

The expression levels of various cytokines increase with the progression of HIV-1 infection. However, the effects of antiretroviral therapy (ART) on serum cytokine levels have not been fully determined. In this study we measured serum cytokine levels of 35 HIV-1-infected Japanese adults. We first performed a cross-sectional study and observed that TNF-α, IL-6, IL-10, IL-18, and IL-7 levels all showed significant increases in those with advanced disease, and that this had a significant negative correlation with the CD4 cell count. However, IFN-γ levels did not show this relationship. A longitudinal study in 18 HIV-1-infected patients with a CD4 cell count <350/μL revealed that the introduction of ART reduced cytokine levels. Significant reductions of IL-7, IL-10, IFN-γ, and IL-18 levels were observed on days 30, 60, 90, and 90 after the initiation of ART, respectively. These results indicate a discrepancy between cross-sectional and longitudinal studies of serum levels of IFN-γ. To clarify this, we investigated serum IFN-γ levels in each patient. In 5 of the 15 patients IFN-γ levels did not decrease, even after ART initiation, and remained at 5 pg/mL or higher on day 120 after ART initiation. Higher IFN-γ levels (>5 pg/mL) were also observed in 2 of 7 asymptomatic patients, and 2 of 11 patients who underwent ART for 1 year or longer. These data demonstrate that IFN-γ levels in some patients increased and remained high even after the initiation of ART, which was a specific observation different from those of the other cytokines.

A Hodgkin’s Disease Cell Line, KM-H2, Shows Biphenotypic Features of Dendritic Cells and B Cells

The origin of Reed-Sternberg (RS) cells, the neoplastic cells of Hodgkin’s disease, has long remained controversial. Dendritic cells (DCs) are highly specialized antigen-presenting cells that have the unique capacity to prime naive T cells, and they may be progenitors of RS cells in a population of Hodgkin’s disease cells. In this study, the KM-H2 cell line, previously established from a patient with Hodgkin’s disease of mixed cellularity, was reevaluated for its cellular derivation, particularly in terms of DCs. KM-H2 cells were demonstrated to carry the newly proposed DC-associated molecules fascin, CD83, and DEC-205, as well as costimulatory molecules such as CD40, CD80, and CD86. In addition, KM-H2 cells were shown to be able to potently stimulate peripheral blood T cells and to have the strong endocytotic activity of fluorescein isothiocyanate—dextran. On the other hand, KM-H2 cells were shown to have variable-diversity-joining recombination of the immunoglobulin H gene, although they did not express any subclasses of immunoglobulin and they were negative for CD79a and CD79b. In addition, KM-H2 cells produced the messenger RNA of thePax-5 gene.These findings lead to a hypothesis that KM-H2 cells originated from the cells that had differentiated through the possible common DC—B-cell progenitors along the newly proposed pathway.

Classification of AIDS-related lymphoma cases between 1987 and 2012 in Japan based on the WHO classification of lymphomas, fourth edition

The introduction of combined antiretroviral therapy (ART) has reduced the mortality of patients with human immunodeficiency virus‐1 infection worldwide. However, malignant lymphoma is a severe and frequent complication seen in patients with acquired immunodeficiency syndrome (AIDS). The diagnostic criteria for some categories of AIDS‐related lymphoma were revised in the World Health Organization International Classification of Lymphoma, fourth edition. The purpose of this study was to assess the clinicopathological characteristics of Japanese patients with AIDS‐related lymphoma according to the revised classification. In this retrospective study, 207 AIDS‐related lymphoma cases diagnosed between 1987 and 2012 in Japan were subjected to histological subtyping and clinicopathological analyses. Diffuse large B‐cell lymphoma (DLBCL) was the predominant histological subtype throughout the study period (n = 104, 50%). Among the DLBCL cases, 24% were of the germinal center (GC) type and 76% were of the non‐GC type. Non‐GC‐type cases showed a significantly lower 1‐year survival rate (43%) than the GC‐type cases (82%). Cases of Burkitt lymphoma (n = 57, 28%), plasmablastic lymphoma (n = 16, 8%), primary effusion lymphoma (n = 9, 4%), Hodgkin lymphoma (n = 8, 4%), and large B‐cell lymphoma arising in Kaposi sarcoma‐associated herpesvirus‐associated multicentric Castleman disease (n = 2, 1%) were also observed. Hodgkin lymphoma was more common in patients receiving ART (11.1%) than in ART‐naïve patients (1.4%). Statistical analyses identified CD10 negativity, BCL‐6 negativity, Epstein–Barr virus positivity, and Kaposi sarcoma‐associated herpesvirus positivity as risk factors for poor prognosis. This information will help in the early diagnosis of lymphoma in patients with AIDS.

Whole brain radiation alone produces favourable outcomes for AIDS‐related primary central nervous system lymphoma in the HAART era

Primary central nervous system lymphoma (PCNSL) related to acquired immunodeficiency syndrome (AIDS) is a lethal disorder, but the recent application of highly active antiretroviral therapy (HAART) has significantly improved prognosis. This retrospective cohort study of AIDS‐related PCNSL examined the actual clinical outcomes and prognostic variables affecting overall survival (OS) in the HAART era. Twenty‐three newly diagnosed AIDS‐related PCNSL at 12 regional centre hospitals for HIV/AIDS in Japan between 2002 and 2008 were consecutively enrolled. The estimated 3‐yr OS rate of the entire cohort was 64% (95%CI, 41.0–80.3%). Whole brain radiation therapy (WBRT) had an independent positive impact on survival (WBRT ≥30 Gy vs. others, P = 0.02). Nine of 10 patients with a good performance status (PS) (0–2) remained alive with complete response, whereas 10 (77%) of 13 of those with a poor PS (3–4) died mostly after a short period. The estimated 3‐yr OS rate of the groups with a good and poor PS was 100% and 38% (95%CI, 14–63%), respectively (P = 0.01). Leukoencephalopathy (grade ≥ 2) developed in 21% of those that survived more than 12 months after radiation. The patients receiving a curative intent radiation dose (≥30 Gy) of WBRT achieved prolonged survival while maintaining a good quality of life in the HAART era, especially among patients with a favourable PS.

The prevalence of opportunistic infections and malignancies in autopsied patients with human immunodeficiency virus infection in Japan

BackgroundOpportunistic infections and malignancies such as malignant lymphoma and Kaposi sarcoma are significant complications of human immunodeficiency virus (HIV) infection. However, following the introduction of antiretroviral therapy in Japan in 1997, the incidence of clinical complications has decreased. In the present study, autopsy cases of HIV infection in Japan were retrospectively investigated to reveal the prevalence of opportunistic infections and malignancies.MethodsA total of 225 autopsy cases of HIV infection identified at 4 Japanese hospitals from 1985–2012 were retrospectively reviewed. Clinical data were collected from patient medical records.ResultsMean CD4 counts of patients were 77.0 cells/μL in patients who received any antiretroviral therapy during their lives (ART (+) patients) and 39.6 cells/μL in naïve patients (ART (−) patients). Cytomegalovirus infection (142 cases, 63.1%) and pneumocystis pneumonia (66 cases, 29.3%) were the most frequent opportunistic infections, and their prevalence was significantly lower in ART (+) patients than ART (−) patients. Non-Hodgkin lymphoma and Kaposi sarcoma were observed in 30.1% and 16.2% of ART (−) patients, and 37.9% and 15.2% of ART (+) patients, respectively. Malignant lymphoma was the most frequent cause of death, followed by cytomegalovirus infection regardless of ART. Non-acquired immunodeficiency syndrome (AIDS)-defining cancers such as liver and lung cancer caused death more frequently in ART (+) patients (9.1%) than in ART (−) patients (1.5%; P = 0.026).ConclusionsThe prevalence of infectious diseases and malignancies were revealed in autopsy cases of HIV infection in Japan. The prevalence of cytomegalovirus infection and pneumocystis pneumonia at autopsy were lower in ART (+) patients than ART (−) patients. Higher prevalence of non-AIDS defining malignancies among ART (+) patients than ART (−) patients suggests that onsets of various opportunistic infections and malignancies should be carefully monitored regardless of whether the patient is receiving ART.

Immune reconstitution to parvovirus B19 and resolution of anemia in a patient treated with highly active antiretroviral therapy

Immune reconstitution inflammatory syndrome (IRIS) is an unsolved problem in the treatment of human immunodeficiency virus (HIV)-1 infection. Despite the high seroprevalence of parvovirus B19 (PVB19) among HIV-1-positive patients, reports on PVB19-induced anemia, especially that associated with PVB19-related IRIS, in these patients are limited. We present the case of a man with acquired immunodeficiency syndrome who developed severe transfusion-dependent anemia and was seropositive and borderline positive for immunoglobulin-M and IgG antibodies against PVB19, respectively. PVB19-DNA was also detected in his serum. The patient was diagnosed with pure red cell anemia (PRCA) caused by a primary PVB19 infection and was treated with periodical blood transfusions. However, he subsequently tested negative for IgG antibodies and developed chronic severe anemia with high levels of PVB19 viremia. This indicated a transition from primary to persistent infection. After initiation of highly active antiretroviral therapy, the patient showed an inflammatory reaction with rapid deterioration of anemia and seroconversion of the IgG antibody to PVB19. Subsequently, PRCA was completely resolved, but the patient’s serum still contained low levels of PVB19-DNA. Thus, this was a case of IRIS associated with PVB19 infection. Our report highlights the significance of seroconversion to PVB19 in the diagnosis of IRIS and re-emphasizes the finding that persistently high levels of PVB19 viremia after primary infection are probably because of the lack of protective antibodies.

Cellular HIV-1 DNA levels in patients receiving antiretroviral therapy strongly correlate with therapy initiation timing but not with therapy duration.

BackgroundViral reservoir size refers to cellular human immunodeficiency virus-1 (HIV-1) DNA levels in CD4+ T lymphocytes of peripheral blood obtained from patients with plasma HIV-1-RNA levels (viral load, VL) maintained below the detection limit by antiretroviral therapy (ART). We measured HIV-1 DNA levels in CD4+ lymphocytes in such patients to investigate their clinical significance.MethodsCD4+ T lymphocytes were isolated from the peripheral blood of 61 patients with a VL maintained at less than 50 copies/ml for at least 4 months by ART and total DNA was purified. HIV-1 DNA was quantified by nested PCR to calculate the copy number per 1 million CD4+ lymphocytes (relative amount) and the copy number in 1 ml of blood (absolute amount). For statistical analysis, the Spearman rank or Wilcoxon signed-rank test was used, with a significance level of 5%.ResultsCD4 cell counts at the time of sampling negatively correlated with the relative amount of HIV-1 DNA (median = 33 copies/million CD4+ lymphocytes; interquartile range [IQR] = 7-123 copies/million CD4+ lymphocytes), but were not correlated with the absolute amounts (median = 17 copies/ml; IQR = 5-67 copies/ml). Both absolute and relative amounts of HIV-1 DNA were significantly lower in six patients in whom ART was initiated before positive seroconversion than in 55 patients in whom ART was initiated in the chronic phase, as shown by Western blotting. CD4 cell counts before ART introduction were also negatively correlated with both the relative and absolute amounts of HIV-1 DNA. Only the relative amounts of HIV-1 DNA negatively correlated with the duration of VL maintenance below the detection limit, while the absolute amounts were not significantly correlated with this period.ConclusionsThe amounts of cellular HIV-1 DNA in patients with VLs maintained below the detection limit by the introduction of ART correlated with the timing of ART initiation but not with the duration of ART. In addition, CD4+ T lymphocytes, which were newly generated by ART, diluted latently infected cells, indicating that measurements of the relative amounts of cellular HIV-1 DNA might be underestimated.

Evaluation of VZV‐specific cell‐mediated immunity in adults infected with HIV‐1 by using a simple IFN‐γ release assay

The development of herpes zoster is associated with reduced varicella zoster virus (VZV)‐specific cell‐mediated immune (CMI) reactions. In this study, VZV‐specific CMI reactions in 42 anti‐VZV‐IgG antibody‐positive adults infected with HIV‐1 were evaluated by measuring the IFN‐γ production levels in whole blood in response to stimulation with ultraviolet light‐inactivated live attenuated VZV vaccine. The median VZV‐specific IFN‐γ production level in all patients was 63 pg/ml. Antiretroviral therapy (ART)‐naïve patients with an AIDS‐defining illness (HIV classification category C) had significantly lower IFN‐γ production than ART‐naïve patients in categories A and B and patients receiving ART (P = 0.0194 and P = 0.0046, respectively). IFN‐γ production increased significantly in patients within 1 month of the onset of recurrent VZV disease and at more than 1 year from onset, compared with patients who had never had recurrent VZV disease (P = 0.0396 and P = 0.0484, respectively). In multivariate analyses, category C and history of recurrent VZV disease were significant factors affecting IFN‐γ production. Levels of IFN‐γ were measured before and after ART in seven ART‐naïve patients with no history of recurrent VZV disease, and no significant changes were observed. The results indicate that VZV‐specific CMI reactions were reduced in patients with an AIDS‐defining illness and enhanced in patients with a history of recurrent VZV disease, but not enhanced by ART alone. Vaccination may be necessary to inhibit the development of herpes zoster in patients receiving ART; this IFN‐γ releasing assay is one useful method for evaluating VZV‐specific CMI reactions in clinical settings. J. Med. Virol. 85:1313–1320, 2013.

Non-AIDS-defining hematological malignancies in HIV-infected patients: An epidemiological study in Japan

Objective:To clarify the incidence and clinical outcomes of non-AIDS-defining hematological malignancies (NADHMs), excluding non-Hodgkins lymphomas, in HIV-infected patients. Design:A nationwide epidemiological study was conducted to evaluate the incidence and clinical outcomes of NADHMs. Methods:Questionnaires were sent to 429 regional AIDS centers and 497 educational hospitals certified by the Japanese Society of Hematology. Data from 511 institutes were obtained. Results:From 1991 to 2010, 47 patients with NADHMs were detected (median age, 42.0 years; male, 93.6%). The median CD4-positive T-cell count was 255/&mgr;l, and the median duration from the diagnosis of HIV infection to development of hematological malignancy was 28.0 months. Most patients with acute leukemia were treated with standard induction chemotherapy. Complete remission rates and median overall survival periods for acute myeloblastic leukemia (AML) and acute lymphoblastic leukemia (ALL) were 70.0 and 85.7% and 13 and 16 months, respectively. Three of four patients with chronic-phase chronic myeloid leukemia (CML-CP) were well controlled with imatinib. Five patients (2 AML, 1 ALL, 1 accelerated-phase CML, and 1 myeloma) were treated with autologous or allogeneic stem-cell transplantation. Comparison of patients over the two periods (1991–2000 and 2001–2009) revealed a 4.5-fold increase in the incidence of hematological malignancies. Conclusion:The incidence of NADHMs has increased in the past decade. The prognosis of these patients was similar to that of HIV-negative patients; therefore, standard chemotherapy may be a feasible treatment option for HIV-infected patients with hematological malignancies.

Subjective adverse reactions to metronidazole in patients with amebiasis.

Subjective adverse reactions to metronidazole were analyzed in 111 patients with amebiasis. Metronidazole was administered to 36 patients at a daily dose of 2250 mg and 75 patients at daily doses lower than 2250 mg. The reactions reported included nausea without vomiting in 11 (9.9%) patients, nausea with vomiting in 2 (1.8%), dysgeusia in 2 (1.8%), diarrhea in 1 (0.9%), headache in 1 (0.9%), numbness in 1 (0.9%), dizziness in 1 (0.9%), urticaria in 1 (0.9%), exanthema in 1 (0.9%), and discomfort in 1 (0.9%). Nausea was reported by 28% (10/36) of the patients receiving metronidazole at a daily dose of 2250 mg and 4% (3/75) of the patients receiving lower daily doses. The duration of the metronidazole administration in days was not associated with the appearance of nausea. No life-threatening adverse reactions were identified, and good clinical therapeutic effects were observed in 96% (107/111) of the patients. While metronidazole appears to be a safe anti-protozoal agent for patients with amebiasis, our results indicate that a daily metronidazole dose of 2250 mg is excessive for amebiasis, as it often induces nausea.