[A case of primary HIV infection with oral candidiasis not diagnosed by western blot].

Seroconversion to human immunodeficiency virus(HIV) associated with an illness characterized by fever, sore throat, and lymphadenopathy, sometimes with rash, diarrhea, and vomiting. Leukopenia and liver dysfunction also can occur in some patients. The antibody response associated with HIV infection is directed against a variety of viral proteins. Western blot analysis(WB) is used currently for determining HIV-1 infection. A 47-year-old man whose wife was infected with HIV was found to have contracted primary HIV infection. His first HIV antibody examination 4 weeks after speculated exposure was negative by particle agglutination(PA) method and WB. Approximately 2 weeks later he experienced fever, general fatigue, oral candidiasis. His second laboratory examination showed positive PA and indeterminate WB tests, an HIV-RNA PCR of 4.4 x 10(5) copies/ml, 223 CD4+ lymphocytes/microliter, and liver dysfunction. Two weeks later, all of his symptoms and the abnormal lab data had improved with antifungal therapy alone and no anti-HIV therapy. Subsequently, it took 16 more weeks before HIV infection could be diagnosed by WB. It is necessary to adopt an appropriate HIV-1 PCR method to shorten the diagnostic window in primary HIV infection.

[Quantitation of human immunodeficiency virus type 1 RNA by ultrasensitive method in the analysis of samples with low viral load].

With the introduction of combination therapy to the patients with Human Immunodeficiency Virus Type 1(HIV-1) infection, HIV-1 RNA levels in plasma have been reduced, frequently to less than limit of quantitation(400 copies/ml). To achieve enhanced sensitivity, a modified specimen preparation procedure that allows the quantitation of plasma HIV-1 RNA levels as low as 50 copies/ml was developed. Of 67 samples with less than 400 copies/ml of HIV-1 RNA by standard method, 39(58.2%) were not detected by the "ultrasensitive" method. Among 5 samples obtained from patients who were treated with 2 nucleoside reverse transcriptase inhibitors, 4 samples still had detectable copies of HIV-1 RNA. Those suggest that the ultrasensitive assay for HIV-1 RNA has advantage for clinical practice.

[Changes of factor XIII a and b subunit in patients with disseminated intravascular coagulation syndrome].

Factor XIII is composed of two distinct proteins, a and b subunit. The dimers of each subunit form a tetrameric complex of a2b2 in plasma. Two separate ELISA systems were developed to measure either factor XIII a or b subunit in plasma. Sensitivity of the ELISAs was 3.0% of factor XIII a and b subunit in normal plasma. The ELISA for factor XIII b subunit quantitate free b2 and a2b2 complex in a equimolar manner. In order to evaluate the changes of each factor XIII subunit in a state of hypercoagulation, 16 plasmas from proteins with disseminated intravascular coagulation syndrome (DIC) were examined. Factor XIII a and b subunit showed 56.5 +/- 30.5% and 63.4 +/- 22.5%, respectively in the DIC subjects compared to normal pooled plasma as 100%. The ratio of factor XIII a and b subunit (a/b ratio) were between 0.5 and 1.0 in DIC cases which improved after treatment. However, the ratios were less than 0.5 in the cases with DIC which deteriorated in spite of the treatment. These results suggest that the a/b ratio would indicate the prognosis of patients with DIC.

Determinants of substrate specificity for factor XIII.

Plasma factor XIIIa (A*2) is a regulator in balancing the opposing coagulation and fibrinolytic processes. Its enzymatic activity is to catalyze epsilon-(gamma-glutamyl)lysyl bonds between certain substrate molecules to link them by strong bonds. The primary physiological substrates are crosslinks between the gamma and alpha chains of fibrin that produce gamma-gamma-dimer and alpha-polymer, between alpha 2-plasmin inhibitor (alpha 2-PI) and alpha chains of fibrin, and between fibronectin and fibrin. We have characterized a unique factor XIII antibody that is specific for the middle 54-kDa section of A*2. It does not react with the zymogen (A2) or the inactive intermediate (A'2), and it does not inhibit the active center, as do most patient antibodies to factor XIII. This antibody inhibits the formation of A*2-fibrin complexes. Because of this specificity, the antibody was used to study other substrate interactions. It inhibited formation of fibronectin-factor XIIIa complexes, similarly to fibrin, and there was very little crosslinking of fibronectin to a fibrin clot. However, the amount of alpha 2-PI crosslinked to a fibrin clot was normal. It was concluded that this antibody interferes with exosite binding of fibrin and fibronectin interferes with exosite binding of fibrin and fibronectin in a similar way, while at least one critical exosite binding domain for alpha 2-PI is different from those of the other two substrates. Furthermore, with this antibody, it was shown that both alpha 2-PI-alpha chain crosslinking and alpha-polymer formation are necessary to normalize the rate of fibrinolysis.

Beta interferon therapy for chronic hepatitis C in patients with haemophilia and other haemorrhagic disorders.

Beta interferon therapy was given to seven chronic hepatitis C patients with haemophilia or other haemorrhagic disorders who had received clotting factor replacement therapy. Serum alanine aminotransferase (ALT) levels ranged from 82 to 275 UL(-1) and hepatitis C virus (HCV)-RNA ranged from 10(6) to 10(9) copies mL(-1) . HCV-genotypes were I+II in one patient, II in one, II+III in four and IV in one. Patients received 6 mega units (MU) daily of natural type beta interferon by intravenous infusion for 6 weeks. In three of seven patients, the protocol was modified to intermittent administration because neutrocytopenia (under 500 × 10(6) L(-1) ) developed in two patients and thrombocytopenia (under 50 × 10(9) L(-1) ) was observed in one during treatment. No modification was necessary with regard to daily and total dose. All patients received administration without any haemorrhagic complications. Six of seven patients showed improvement in serum ALT levels, and one of the patients showed normalization of ALT levels for 6 months after treatment. HCV-RNA disappeared in four patients by the end of treatment, although no one remained negative 6 months after treatment. The results of our study were similar to those reported in previous papers which described the use of alpha interferon in haemophiliacs. The reason none of the patients showed sustained loss of HCV-RNA after therapy might be associated with high HCV-RNA levels, characteristics of the HCV-genotype and prolonged duration of the disease.

[Two cases of sensory neural hearing loss as a manifestation of HIV infection].

In patients with HIV infection, oral and pharyngeal pathology frequently occurs, but there have been no reports on cases of deafness in Japan. Herein, the authors report two cases of sensory neural hearing loss in hemophilia A patients infected with HIV through factor VIII concentrates. Case 1 was a 16-year-old male with hemophilia A. He had been administered factor VIII concentrates starting at 6 months after birth. At 8 years of age, HIV antibodies were positive. He was diagnosed as having AIDS after suffering from pneumocystis carinii. He complained of right otalgia and slight vertigo during treatment for a relapse of the pneumocystis carinii. He underwent otological examinations at our department. The right tympanic membrane showed opacification and serous otorrhea was noted. Acute otitis media was diagnosed and tympanotomy was conducted. Afterwards, the right tympanic membrane developed a large perforation and sensory neural hearing loss occurred. Case 2 was a 49-year-old male with hemophilia A. He had been administered factor VIII concentrates from the age of 23 years. At 48 years of age, HIV antibodies were positive. The patient complained of sudden deafness in the right ear and slight vertigo. He underwent otological examinations at our department. The tympanic membrane was normal bilaterally, but sensory neural hearing loss was found in the right ear. It was presumed that acute otitis media directly involving the inner ear had caused a perceptive disorder in case 1 while a pattern of sudden onset of deafness was apparent in case 2.

Factor VIII inhibitor developed in a 60-year-old patient with mild hemophilia A after surgery for colon cancer.

Most factor VIII inhibitors are developed at an early age and in patients with severe type of hemophilia A. We report a case of newly developed factor VIII inhibitor in a 60-year-old patient with mild hemophilia A who had been treated with several kinds of factor VIII concentrates. The patient was treated with a total of 103,580 units of recombinant factor VIII concentrate by continuous and bolus infusions for the open surgery of sigmoid colon cancer. On the 95th postoperative day, the patient had right low limb muscle bleeding and was infused with 1,000 units of recombinant factor VIII concentrate for three days. Subsequently, the level of factor VIII inhibitor in the patient's plasma was 2 Bethesda units (BU)/ml. Since then numerous subcutaneous hemorrhages developed, but an adequate hemostatic effect was not obtained even with the administration of a high dose of recombinant factor VIII concentrate. The patient was switched to bypass therapy using human plasma-derived factor VIIa concentrate, which showed a favorable hemostatic effect.

[Phase III clinical trial of KRN8601 (rhG-CSF) for neutropenia in patients with human immunodeficiency virus infection].

The efficacy of KRN8601 for neutropenia associated with HIV infection was evaluated in 24 patients. KRN8601 was infused intravenously at a dosage of 200 micrograms/m2 for 14 consecutive days. Neutrophil counts recovered in 19 (90.5%) out of 21 evaluable patients by KRN8601 treatment. The concomitant myelosuppressive agents for the treatment of HIV infection and complications could be continued without dose reduction in 15 (88.2%) out of 17 patients. The clinical improvement was observed in 66.7% (12/18) of patients who were treated with anti-microbial agents for opportunistic infections which indicates that KRN8601 shows an additive effect on infections when it was given with anti-microbial agents. Adverse events and abnormal laboratory findings were observed in 3 and 7 patients, respectively, and they were reversible and tolerable. This study demonstrated that KRN8601 improved neutropenia with HIV infection, made possible to continue the full dose of myelosuppressive treatments and have additive effect on the treatment of secondary infections.

[HIV-1 seropositive hemophilia A complicated by disseminated intravascular coagulation syndrome and acute pancreatitis during treatment of Pneumocystis carinii pneumonia].

Pneumocystis carinii pneumonia (PCP) is a major opportunistic infection in acquired immunodeficiency syndrome (AIDS) and is treated with co-trimoxazole, pentamidine and others. The severe adverse reactions, including bone marrow suppression, by these therapeutic agents often preclude their continued use. A 14-year-old male HIV-positive hemophilia A patient, who was complicated by disseminated intravascular coagulation syndrome (DIC) following acute pancreatitis during treatment for PCP, was treated with proteinase inhibitors and anticoagulant agents. He was improved and discharged. As pentamidine may cause pancreatitis and develop DIC, it is important that pancreatic enzymes should be carefully followed when this agent administrated. In this case, granulocyte colony-stimulating factor and erythropoietin were effective for the bone marrow suppression, suggesting that importance of these agents for the prophylaxis of other secondary infections during the treatment.

A unique factor XIII inhibitor to a fibrin-binding site on factor XIIIA.

An 81-year-old woman, who presented with sudden episodes of spontaneous bleeding, was found to have a specific inhibitor of factor XIII. Her fibrin clots had approximately 70% gamma-gamma and no alpha polymer formation, under conditions where normal fibrin was fully cross-linked; the patient's clots were soluble in urea or monochloroacetic acid. Factor XIII activity in her plasma was 24%, measured by the dansylcadaverine incorporation assay. When mixed with normal plasma, the patient's plasma inhibited fibrin cross-linking; however, in mixtures of patient and normal plasma, there was no inhibition of factor XIII activity when assayed by the incorporation of dansylcadaverine into casein. Thus, this inhibitor was active against fibrin cross-linking but not against ligation of small molecules to casein. Consequently, gel electrophoresis of reduced, sodium dodecyl sulfate-solubilized fibrin clots was a simple, quantitative method that was used to measure inhibitor activity. This inhibitor is unique and has been designated inhibitor New Haven. It was neutralized by anti-IgG and anti-kappa. It did not inhibit the activation of factor XIII but did inhibit fibrin cross-linking. There was complex formation between the inhibitor and activated factor XIII (A', A*) but not between A2 or fibrinogen. Only A', A* and the 56-Kd fragment bound to affinity columns made with this IgG. The inhibitor significantly decreased the binding of A', A* to fibrin clots. These data indicate that the epitope for this inhibitor is in a fibrin binding site. It is hidden in the zymogen and expressed on A' and A*, indicating that the conformational change occurring with the cleavage of the activation peptide is sufficient to expose the fibrin binding site.

Bombesin and bradykinin increase inositol phosphates and cytosolic free Ca2+, and stimulate DNA synthesis in human endometrial stromal cells.

The present studies were carried out to investigate the effect of several growth factors on human endometrial stromal cells. In human endometrial stromal cells, bombesin and bradykinin provoked an increase in intracellular free Ca2+ and in labelled inositol phosphates when pre-incubated with [3H]myoinositol. Some or possibly all of the initial increase in intracellular free Ca2+ represented a mobilization of Ca2+ from intracellular stores and the second phase of the response depended on Ca2+ influx from the extracellular medium. [3H]Thymidine was added to human cultured endometrial stromal cells with bombesin, bradykinin, epidermal growth factor (EGF), prostaglandin F2 alpha, vasopressin and platelet-derived growth factor. Bombesin, bradykinin and EGF stimulated the incorporation of [3H]thymidine into DNA in quiescent cells. In conclusion, bombesin and bradykinin are growth factors which activate phospholipase C in human endometrial stromal cells, while EGF stimulates DNA synthesis without the activation of phospholipase C.