Dose-escalation, phase I/II study of azithromycin and pyrimethamine for the treatment of toxoplasmic encephalitis in AIDS.

OBJECTIVE: To assess the safety, tolerance and activity of increasing doses of azithromycin in combination with pyrimethamine for the treatment of toxoplasmic encephalitis (TE) in patients with AIDS. DESIGN: A phase I/II dose-escalation study of oral azithromycin in combination with pyrimethamine. SETTING: Eight clinical sites in the United States. PATIENTS: Forty-two adult HIV-infected patients with confirmed or presumed acute TE. METHODS: Patients were enrolled into three successive cohorts receiving azithromycin 900, 1200 and 1500 mg a day with pyrimethamine as induction therapy. The induction period was 6 weeks followed by 24 weeks of maintenance therapy. MAIN OUTCOME MEASURES: Patient response was evaluated clinically and radiologically. RESULTS: Of the 30 evaluable patients, 20 (67%) responded to therapy during the induction period. Ten experienced disease progression. Of the 15 patients who received maintenance therapy, seven (47%) relapsed. Six patients discontinued treatment during the induction period as a result of reversible toxicities. Treatment-terminating adverse events occurred most frequently among the patients receiving the 1500 mg dose. CONCLUSION: The combination of azithromycin (900-1200 mg a day) and pyrimethamine may be useful as an alternative therapy for TE among patients intolerant of sulfonamides and clindamycin, but maintenance therapy with this combination was associated with a high relapse rate. The combination was safe, but low-grade adverse events were common.

Genetic diversity of ospC in a local population of Borrelia burgdorferi sensu stricto.

The outer surface protein, OspC, is highly variable in Borrelia burgdorferi sensu stricto, the agent of Lyme disease. We have shown that even within a single population OspC is highly variable. The variation of ospA and ospC in the 40 infected deer ticks collected from a single site on Shelter Island, New York, was determined using PCR-SSCP. There is very strong apparent linkage disequilibrium between ospA and ospC alleles, even though they are located on separate plasmids. Thirteen discernible SSCP mobility classes for ospC were identified and the DNA sequence for each was determined. These sequences, combined with 40 GenBank sequences, allow us to define 19 major ospC groups. Sequences within a major ospC group are, on average, <1% different from each other, while sequences between major ospC groups are, on average, approximately 20% different. The tick sample contains 11 major ospC groups, GenBank contains 16 groups, with 8 groups found in both samples. Thus, the ospC variation within a local population is almost as great as the variation of a similar-sized sample of the entire species. The Ewens-Watterson-Slatkin test of allele frequency showed significant deviation from the neutral expectation, indicating balancing selection for these major ospC groups. The variation represented by major ospC groups needs to be considered if the OspC protein is to be used as a serodiagnostic antigen or a vaccine.

Toxoplasma pneumonia.

Toxoplasma gondii, an obligate intracellular parasite, is the causal agent of significant morbidity and mortality worldwide. In the presence of a normal immune response, the pathogen becomes latent and the immunocompetent host remains chronically infected throughout life, often without clinical disease. In the case of the patient with the acquired immunodeficiency syndrome (AIDS) or other defects in cell-mediated immunity, the infection reactivates and is most often manifest as toxoplasmic encephalitis. Toxoplasmic pneumonitis follows the same pathogenetic mechanism, but occurs less frequently than either toxoplasmic encephalitis or other opportunistic pneumonias, such as a Pneumocystis carinii pneumonia (PCP). During the past decade the incidence of toxoplasma pneumonia has increased in immunocompromised patients and as a result, it has become essential that clinicians include this infectious agent in the diagnostic testing and differential diagnostic of pneumonia in T gondii seropositive patients. Most patients present with clinical and radiographic findings suggestive of PCP. The onset of disease tends to be more rapid, however. Diagnosis is based upon a high degree of clinical suspicion and demonstration of T gondii in bronchioalveolar lavage fluid and/or lung biopsy specimens. Effective therapy, pyrimethamine and sulfadiazine or trisulfapyrimidine with folinic acid, is available if initiated promptly.

A population genetic study of Borrelia burgdorferi sensu stricto from eastern Long Island, New York, suggested frequency-dependent selection, gene flow and host adaptation.

Eastern Long Island, New York, is one of the major foci of Lyme disease in the United States. As in almost all other parts of North America, Lyme disease in this region is caused by a single genomic species of spirochete, Borrelia burgdorferi sensu stricto. For three consecutive years, natural populations of Lyme Borrelia in this region were sampled and studied for gene flow among different locations, changes in population structure over time, and selective forces. The genetic diversity of Borrelia populations was measured at the outer surface protein A (ospA) locus using Cold Single-Stranded Conformation Polymorphism (Cold SSCP) analysis. The Borrelia populations were found to be highly polymorphic within any of thirteen local populations. Ewens-Watterson tests of neutrality revealed that the high level of genetic diversity within local Borrelia populations is maintained by balancing selection. Frequency-dependent selection for the different strains distinguished by the ospA alleles is likely the mechanism of the balancing selection. Allele frequency distributions of Borrelia populations were homogeneous across the region in any particular year, although different infection rates of local tick (Ixodes scapularis) populations suggested that the Borrelia populations were at least partially isolated. Since the allele frequency distribution changed over time, while remaining homogeneous over space, the nearly uniform allele frequency distribution across the region cannot be explained by recent geographic expansion from a single population. This uniform distribution across the region thus may be maintained by selection, or by a significant amount of migration or both. The genetic structure of B. burgdorferi sensu stricto also differed between spirochetes infecting nymphal ticks and those infecting adult ticks. Since larval and nymphal ticks have distinctly different host feeding preferences, host adaptation of spirochete populations is implied. This distinction and an animal study using chipmunks suggest that ticks infected by Borrelia as larvae may have high mortality in the wild. This study represents a genetic analysis of local populations of a bacterial species.

Azithromycin compared with amoxicillin in the treatment of erythema migrans. A double-blind, randomized, controlled trial.

OBJECTIVE: To determine whether azithromycin or amoxicillin is more efficacious for the treatment of erythema migrans skin lesions, which are characteristic of Lyme disease. DESIGN: Randomized, double-blind, double-dummy, multicenter study. Acute manifestations and sequelae were assessed using a standardized format. Baseline clinical characteristics and response were correlated with serologic results. Patients were followed for 180 days. SETTING: 12 outpatient centers in eight states. PATIENTS: 246 adult patients with erythema migrans lesions at least 5 cm in diameter were enrolled and were stratified by the presence of flu-like symptoms (such as fever, chills, headache, malaise, fatigue, arthralgias, and myalgias) before randomization. INTERVENTION: Oral treatment with either amoxicillin, 500 mg three times daily for 20 days, or azithromycin, 500 mg once daily for 7 days. Patients who received azithromycin also received a dummy placebo so that the dosing schedules were identical. RESULTS: Of 217 evaluable patients, those treated with amoxicillin were significantly more likely than those treated with azithromycin to achieve complete resolution of disease at day 20, the end of therapy (88% compared with 76%; P=0.024). More azithromycin recipients (16%) than amoxicillin recipients (4%) had relapse (P=0.005). A partial response at day 20 was highly predictive of relapse (27% of partial responders had relapse compared with 6% of complete responders; P<0.001). For patients treated with azithromycin, development of an antibody response increased the possibility of achieving a complete response (81% of seropositive patients achieved a complete response compared with 60% of seronegative patients; P=0.043). Patients with multiple erythema migrans lesions were more likely than patients with single erythema migrans lesions (P<0.001) to have a positive antibody titer at baseline (63% compared with 17% for IgM; 39% compared with 16% for IgG). Fifty-seven percent of patients who had relapse were seronegative at the time of relapse. CONCLUSIONS: A 20-day course of amoxicillin was found to be an effective regimen for erythema migrans. Most patients were seronegative for Borrelia burgdorferi at the time of presentation with erythema migrans (65%) and at the time of relapse (57%).

Human and rodent hantavirus infection in New York State: public health significance of an emerging infectious disease.

BACKGROUND: A case of hantavirus pulmonary syndrome with possible exposure in New York and/or Rhode Island was confirmed in February 1994. OBJECTIVE: To conduct four studies to determine the historical and geographic distribution of human and small-mammal infection with hantaviruses in New York State. METHODS: Enzyme-linked immunosorbent assays were performed on serum samples obtained from 130 humans during a 1978 babesiosis survey, 907 small mammals collected in New York State since 1984, 12 rodents collected in 1994 near the residences of the patients with hantavirus pulmonary syndrome, and 76 New York patients with acute respiratory distress syndrome-like illness (as suspected cases of hantavirus pulmonary syndrome). RESULTS: None of the human serum samples from the 1978 serosurvey showed evidence of hantavirus exposure by enzyme-linked immunosorbent assay. Statewide historical serum samples from white-footed mice showed evidence of Sin Nombre virus infection in 12.0% (97/809) and Seoul-like virus infection in 9.6% (78/809). Site-specific seropositivity rates were as high as 48.5% with Sin Nombre virus during 1 year (1984). Two of 12 mice captured near the residences of a human patient were positive for Sin Nombre virus by enzyme-linked immunosorbent assay, yet were negative for viral RNA by polymerase chain reaction. None of the patients with suspected hantavirus pulmonary syndrome was serologically reactive for Sin Nombre virus. CONCLUSIONS: We provide serologic evidence of small-mammal infection with hantaviruses in New York State as long ago as 1984. Human cases of hantavirus pulmonary syndrome are rare in New York, and data indicate that transmission to humans is probably infrequent. A unique set of host, agent, and environmental factors may be necessary to cause hantavirus pulmonary syndrome in humans.

Multiple infections of Ixodes scapularis ticks by Borrelia burgdorferi as revealed by single-strand conformation polymorphism analysis.

The genetic heterogeneity of the spirochete Borrelia burgdorferi within single adult black-legged ticks from Shelter Island, N.Y., was determined by cold, single-strand conformation polymorphism (SSCP) analysis. The central region of the ospA gene of B. burgdorferi from infected ticks was amplified by nested PCR. Amplified product of the correct size was obtained from 20 to 45 ticks (44%). This is the fraction of ticks that is expected to be infected with B. burgdorferi. Four variant classes were determined by SSCP analysis. Eight ticks were infected with a single variant, nine ticks were infected with two variants, two ticks were infected with three variants, and one tick was infected with all four variants. DNA from each variant was sequenced. Five different sequences were found. The sequence of each variant was different from that of another variant by a single base. SSCP analysis could distinguish three of the four single-base changes found in the region.

Acquired resistance in dogs to repeated infestation with Ixodes scapularis (Acari: Ixodidae) reduces tick viability and reproductive success.

The purpose of this study was to determine whether dogs develop acquired resistance to adult Ixodes scapularis infestation in an experimental model. Five dogs were each infested with ten mating pairs of ticks every week for 7 consecutive weeks, another five dogs were each infested with ten mating pairs once every 2 weeks for 10 weeks and four dogs served as controls not exposed to ticks. All ticks were allowed to feed to repletion and were collected only after dropping from the host. Several variables were measured to determine the extent of blood feeding success. Regression analysis indicated that the engorgement success, survival and mean tick engorgement weight declined with repeated infestation in both groups of dogs (p < 0.05). Tick oviposition as well as the F1 viability declined with each successive infestation in both groups. These results suggest that repeated infestation with I. scapularis elicits a protective immune response against tick feeding and could serve as a limiting factor in the spread and transmission of Borrelia burgdorferi.

Mosquito-transmitted malaria in New York City, 1993.

In August, 1993, 3 cases of Plasmodium falciparum malaria in people without recent travel histories or bloodborne exposure were reported in New York City. An epidemiological investigation confirmed the absence of risk factors for acquisition of malaria in two cases. The third case could not be definitively classified as locally acquired malaria because the patient had travelled to Thailand two years before malaria was diagnosed. The 3 individuals lived in separate houses in the same neighbourhood of Queens, New York and had onset of illness within a day of each other. The investigation consisted of patient interviews, active case finding, reviewing recent New York flight and shipping arrivals, and an entomological survey for anopheline mosquitoes and breeding sites. No other cases were identified. The 3 patients lived several miles from air and sea ports and prevailing winds would have carried any mosquitoes at those sites away from the patient's homes. By the time of the environmental investigation (September, 1993), the area was dry and neither adult nor larval anophelines were found. However, weather conditions at the probable time of infection (July, 1993) were very different. Malaria was probably transmitted to these 2 patients by local anopheline mosquitoes that had fed on infected human hosts. Mosquito-control measures were not implemented because there was no evidence of ongoing transmission. The occurrence of mosquito-transmitted malaria in New York City demonstrates the potential for reintroduction of malaria transmission into areas that are no longer endemic and emphasises the need for continued surveillance and prompt investigations, if cases without risk factors are reported.

Toxoplasmosis in individuals with AIDS.

Toxoplasmosis remains an important complication of AIDS. Recent advances in both diagnosis and treatment have decreased the immediate mortality. New innovations in prophylaxis will ultimately decrease incidence of this disease.

Toxoplasmic encephalitis in patients with the acquired immunodeficiency syndrome. Members of the ACTG 077p/ANRS 009 Study Team.

BACKGROUND: In patients with the acquired immunodeficiency syndrome (AIDS), toxoplasmic encephalitis is usually a presumptive diagnosis based on the clinical manifestations, a positive antitoxoplasma-antibody titer, and characteristic neuroradiologic abnormalities. A response to specific therapy helps to confirm the diagnosis, but it is unclear how rapid the response should be. We studied the course of patients treated for acute toxoplasmic encephalitis and evaluated objective clinical criteria for this empirical diagnosis. METHODS: A quantifiable neurologic assessment was used prospectively to evaluate the clinical outcome of patients with AIDS and toxoplasmic encephalitis who were treated with oral clindamycin (600 mg four times a day) and pyrimethamine (75 mg every day) for six weeks. RESULTS: Thirty-five of 49 patients (71 percent) responded to therapy, and 30 of these (86 percent) had improvement by day 7. Thirty-two of those with a response (91 percent) improved with respect to at least half of their base-line abnormalities by day 14. Improvement in neurologic abnormalities within 7 to 14 days after the start of therapy was strongly associated with the neurologic response at 6 weeks. The four patients in whom treatment failed and the two patients with lymphoma had progressing neurologic abnormalities or new abnormalities during the first 12 days of therapy. Nonlocalizing abnormalities (headache and seizure) improved regardless of the clinical outcome. CONCLUSIONS: Oral clindamycin and pyrimethamine are an effective treatment for toxoplasmic encephalitis. Patients who have early neurologic deterioration despite treatment or who do not improve neurologically after 10 to 14 days of appropriate antitoxoplasma therapy should be considered candidates for brain biopsy.

Biopsy of canine ear tissue for detection of Borrelia burgdorferi following Ixodes dammini feeding.

A punch biopsy method was developed to detect and cultivate Borrelia burgdorferi from canine ear tissue. The biopsy procedure was sensitive in that spirochetes were detected in 100% of the dogs upon which infected ticks had fed. B. burgdorferi could be cultured as early as 6 days after tick feeding at which time the organisms could not be concurrently recovered from peripheral blood. The ear punch biopsy provides a reliable method for sampling live canines and should prove useful for detecting early B. burgdorferi infection and for monitoring duration of non-disseminated infection. Additionally, the procedure will aid in the development of an animal model for evaluation of preventive and therapeutic treatment modalities.

Seroprevalence of antibodies to Borrelia burgdorferi in a population of horses in central Texas.

Four hundred sixty-nine serum samples were obtained from horses admitted to the internal medicine service of the Texas Veterinary Medical Center between Jan 1 and Dec 31, 1990. Serum samples were tested by ELISA for antibody to Borrelia burgdorferi. Of these 469 samples, 1 (0.2%) was repeatedly seropositive for the organism by ELISA. Confirmatory testing by protein immunoblot was negative. The observed seroprevalence was 0%; the upper bound of the 95% confidence interval was 0.6%. These findings indicate the evidence of infection with B burgdorferi is presently uncommon in horses in central Texas.

Effectiveness of selected granular acaricide formulations in suppressing populations of Ixodes dammini (Acari: Ixodidae): short-term control of nymphs and larvae.

Applications of selected granular acaricide formulations to the shrub layer of forested habitats during the peak activity periods of Ixodes dammini Spielman, Clifford, Piesman & Corwin nymphs and larvae significantly reduced the abundance of these stages on Peromyscus leucopus. The granules effectively penetrated growing vegetation and suppressed populations of subadult ticks questing in the leaf litter. The use of granular acaricide formulations provides the only documented method of control of free-living I. dammini nymphs and larvae in dense vegetation. As such, this technique will serve as a major component of any integrated control program against this vector tick species.

The geographic spread and temporal increase of the Lyme disease epidemic.

OBJECTIVE: To describe the temporal and geographic progression of the Lyme disease epidemic in New York State from 1977 through 1989. DESIGN: Communicable disease surveillance system. SETTING: Statewide. MAIN OUTCOME MEASURES: The progression of the epidemic was examined by analyzing trends in Lyme disease cases reported to the state surveillance system, town and county Lyme disease incidence rates, Lyme disease hospital discharge rates, and the distribution of Ixodes dammini ticks obtained from surveillance efforts and submitted for identification. MAIN RESULTS: The number of confirmed Lyme disease cases in New York has increased with concurrent increases in the number of hospital discharges. The number of counties endemic for Lyme disease increased from four to eight between 1985 and 1989. The number of counties with documented I dammini ticks increased from four in 1985 to 22 in 1989. Incidence of the disease also increased within known endemic counties. CONCLUSIONS: Tick surveillance indicated that the range of I dammini has expanded annually into areas up to 384 km from the original known endemic areas of Long Island, NY, and Connecticut. Cumulative data from human surveillance resources document both temporal increases and geographic expansion of the Lyme disease epidemic in New York.

Increased population densities of Amblyomma americanum (Acari: Ixodidae) on Long Island, New York.

Lone star ticks, Amblyomma americanum comprised a significantly greater proportion of total ticks flagged on eastern Long Island and Fire Island, New York, in 1986 and 1990 than in samples reported by other authors from the 1940s (when A. americanum was not collected by flagging or from hosts) and the 1970s. Therefore, population densities of A. americanum apparently have increased in recent years on southeastern Long Island, where this species now is distributed widely.

Lyme disease: a proposed ecological index to assess areas of risk in the northeastern United States.

BACKGROUND: Recent public awareness has resulted in a demand for information about ways to reduce the risk of acquiring Lyme disease. METHODS: Twenty-two school properties and recreational areas within a Lyme disease endemic area of central Monmouth County, New Jersey were evaluated for risk of transmission using an ecological index on the suitability, amount, and access to Ixodes dammini habitat by target human populations and the abundance of infected adult ticks. RESULTS: The characterization of tick habitat accurately predicted the elimination of 11 sites from concern. Of the remaining 11 sites, six were classified high risk and five as moderate risk. On-site tick surveys identified infected I. dammini adults at only four sites (three risk; one moderate risk). CONCLUSIONS: These results indicate that the use of selected ecological parameters provides a cost-effective method to rapidly identify areas at risk for Lyme disease transmission.