How to recognize and treat acute HIV syndrome.

The diagnosis of acute human immunodeficiency virus (HIV) syndrome requires a high index of suspicion and proper laboratory testing. Patients with the syndrome may have fever, fatigue, rash, pharyngitis or other symptoms. Primary HIV infection should be considered in any patient with possible HIV exposure who presents with fever of unknown cause. The diagnosis is based on a positive HIV-1 RNA level (more than 50,000 copies per mL) in the absence of a positive enzyme-linked immunosorbent antibody assay (ELISA) and confirmatory Western blot antibody test for HIV. Early diagnosis permits patient education as well as treatment that may delay disease progression. Triple-combination antiretroviral therapy should be started immediately and continued indefinitely. Compliance with medication regimens is essential to maximize benefit and discourage the development of viral resistance.

Expansion of clonotypic T-cell populations in the peripheral blood of asymptomatic Gran Chaco Amerindians infected with HTLV-IIB.

Peripheral blood mononuclear cells from asymptomatic HTLV-II-infected and uninfected Gran Chaco Amerindians were analyzed using polymerase chain reaction (PCR) for expansions of T-cell receptor (TCR) V-beta gene clonotypes. Analyses were performed using primer pairs designed to identify expanded T-cell familial clonotypes based on their unique TCR beta gene rearrangements. Of the 30 HTLV-IIB-positive samples tested, five showed evidence of V-beta clonotypic T-cell expansion. Of the five expansions, two were monoclonotypic and the remaining three were oligoclonotypic. In comparison, 30 HTLV-II-negative Amerindians showed no evidence of clonotypic T-cell expansion. Amplified DNA from one of the monoclonotypic samples was subsequently cloned and sequenced and was found to have uniform variable/ diversity/joining sequences confirming its unique monoclonal T-cell expansion. This method of detecting clonal TCR beta gene rearrangements has the advantage over traditional Southern blot techniques of being more sensitive and specific even with suboptimal specimens. The prognostic significance of clonotypic T-cell expansion in a group such as the HTLV-II-infected Gran Chaco Amerindians remains to be determined.

Helical CT of talar fractures.

Since the degree of comminution, fracture alignment, and articular congruity of talar fractures are important determinants of treatment, we review the helical CT technique for detecting and assessing the extent of acute talar fractures. Helical CT can be used to classify talar neck fractures which often cannot be determined by radiography. It is also useful in detecting posterior process, lateral process, and avulsion fractures, as well as acute osteochondral fractures. Multiplanar CT using 1-mm acquisitions allows optimal evaluation, detects fractures initially missed on radiographs, and determines further extent of fractures.

Prevalence of human T cell lymphotropic virus (HTLV) types I and II and human immunodeficiency virus type 1 infections among persons with Hansen's disease in New York City.

One-hundred seven consecutive patients attending a New York Hansen's disease clinic from November 1990 through June 1991 were tested for retroviruses. This cohort included 58 patients diagnosed with Hansen's disease after the onset of the AIDS epidemic, 54 of whom immigrated to the United States before diagnosis of Hansen's disease (median, 7 years). The overall rate (1.9%) of human T cell lymphotropic virus (HTLV) type I infection was low. Two (3.6%) of 55 Caribbean-born patients had polymerase chain reaction (PCR)-documented HTLV-I infection, but this incidence was not higher than expected in persons without Hansen's disease. No patient had PCR-documented evidence of either HTLV-II or human immunodeficiency virus (HIV) type 1 infection. The low rate of HIV-1 among those studied was likely related to an absence of classic HIV risk behavior because about half of the cohort could have incubated Mycobacterium leprae for a prolonged period while infected with HIV-1.

Genetic heterogeneity in human T-cell leukemia/lymphoma virus type II.

DNA from the peripheral blood mononuclear cells of 17 different individuals infected with human T-cell lymphoma/leukemia virus type II (HTLV-II) was successfully amplified by the polymerase chain reaction (PCR) with the primer pair SK110/SK111. This primer pair is conserved among the pol genes of all primate T-cell lymphoma viruses (PTLV) and flanks a 140-bp fragment of DNA which, when used in comparative analyses, reflects the relative degree of diversity among PTLV genomes. Cloning, sequencing, and phylogenetic comparisons of these amplified 140-bp pol fragments indicated that there are at least two distinct genetic substrains of HTLV-II in the Western Hemisphere. These data were confirmed for selected isolates by performing PCR, cloning, and sequencing with to 10 additional primer pair-probe sets specific for different regions throughout the PTLV genome. HTLV-II isolates from Seminole, Guaymi, and Tobas Indians belong in the new substrain of HTLV-II, while the prototype MoT isolate defines the original substrain. There was greater diversity among HTLV-II New World strains than among HTLV-I New World strains. In fact, the heterogeneity among HTLV-II strains from the Western Hemisphere was similar to that observed in HTLV-I and simian T-cell lymphoma/leukemia virus type I isolates from around the world, including Japan, Africa, and Papua New Guinea. Given these geographic and anthropological considerations and assuming similar mutation rates and selective forces among the PTLV, these data suggest either that HTLV-II has existed for a long time in the indigenous Amerindian population or that HTLV-II isolates introduced into the New World were more heterogeneous than the HTLV-I strains introduced into the New World.

Correctional health care: a public health opportunity.

The approximately 1.2 million inmates in U.S. correctional institutions have a high prevalence of communicable diseases, such as human immunodeficiency virus (HIV) infection, tuberculosis, hepatitis B virus infection, and gonorrhea. Before their incarceration, most inmates had limited access to health care, which, together with poor compliance because of lifestyle, made them difficult to identify and treat in the general community. Because of the high yearly turnover (approximately 800% and 50% in jails and prisons, respectively), the criminal justice system can play an important public health role both during incarceration and in the immediate postrelease period. A public policy agenda for criminal justice should include an epidemiologic orientation, as well as resources for education, counseling, early detection, and treatment. Taking advantage of the period of confinement would serve both the individual and society by controlling communicable diseases in large urban communities.

Sexually transmitted diseases in postpubertal female rape victims.

Seventy-six postpubertal women were referred from a municipal hospital emergency room within 60 h of sexual assault for evaluation. Of the 76 victims, 20 (26%) had active Chlamydia trachomatis infection detected by culture (11 subjects), a fourfold serologic titer rise (6), or both (3). The risk of acquiring C. trachomatis infection after sexual assault was 3%-16%. Pelvic inflammatory disease was detected in 8 (11%) of the 76 victims. Bacterial vaginosis was diagnosed in 38 women (50%), at least 8 of whom appeared to have been infected during the assault. Trichomoniasis was found in 17 victims (22%), at least 5 of whom may have acquired the infection at the time of the assault. In view of the high rates of these infections and the poor compliance with follow-up (76% [58/76] kept their appointments), all postpubertal victims of sexual assault should be offered treatment with ceftriaxone, 250 mg intramuscularly, followed by 100 mg of oral doxycycline and 500 mg of oral metronidazole twice daily for 7 days.

Zidovudine improves response to pneumococcal vaccine among persons with AIDS and AIDS-related complex.

Antibody responses to 23-valent pneumococcal vaccine were studied in 38 individuals infected with human immunodeficiency virus (HIV), including 6 with asymptomatic infection, 24 with AIDS or AIDS-related complex (ARC) receiving treatment with zidovudine, and 8 untreated AIDS/ARC patients. Antibody responses were significantly higher for asymptomatic persons (aggregate geometric mean, 972 ng of antibody nitrogen (AbN)/ml; P less than .001) and AIDS/ARC patients receiving a median of 12 weeks (range, 4-54) of zidovudine therapy (mean, 369 ng of AbN/ml; P less than .001) when compared with untreated AIDS/ARC patients. Antibody responses among zidovudine-treated AIDS/ARC patients were independent of the dose (mean, 629.2 mg/day; range, 100-1200 mg) or duration of zidovudine therapy. For zidovudine-treated AIDS/ARC patients, persistence of an aggregate antibody response 8 months after vaccination was associated with survival at 14 months after vaccination, whereas waning of response was not. Pneumococcal vaccine should be administered as early as possible in the course of HIV infection. Immunization should be delayed for at least 4 weeks for AIDS/ARC patients initiating zidovudine therapy.

Multiple sclerosis, retroviruses, and PCR. The HTLV-MS Working Group.

Previously reported serologic and polymerase chain reaction (PCR)-based findings have suggested an association between the human retrovirus, HTLV-I, and multiple sclerosis (MS). Due to the inherent ability of PCR to produce false-positive results, we developed a set of physical and procedural safeguards to minimize the possibility of molecular carryover. These were applied as part of a blinded, large-scale, multipopulation, multiplex PCR-based study designed to examine this issue of association. Our results do not support the hypothesis that HTLV-I, which plays a role in the pathogenesis of an encephalomyeloneuropathy, HTLV-II, or closely related agents are associated with MS. A concomitant review of the current literature supports this view.

Infectious diseases of geriatric inmates.

The number of geriatric inmates is rapidly growing because of more frequent incarceration of older offenders as the number of the elderly in the general population increases nationally. The increase is also due to recent changes in sentencing patterns (e.g., longer sentences and tightened parole) that affect younger, long-term inmates. Geriatric inmates often have chronic medical illnesses that may result in hospitalization for infectious complications. These infectious conditions may be related to factors such as institutionalization (e.g., tuberculosis and influenza), chronic medical illness (e.g., pneumococcal pneumonia), and a history of alcohol or drug use (e.g., hepatitis B virus and retrovirus infection). The epidemiology of these conditions is reviewed. Since infectious complications among geriatric inmates will add stress to a correctional health care system that is already burdened by inmates with AIDS-related illnesses, clinical recognition of these complications and preventive measures are of great importance.

Prevalence of human T-cell leukemia/lymphoma virus (HTLV) type II infection among high-risk individuals: type-specific identification of HTLVs by polymerase chain reaction.

The extent of human T-cell leukemia/lymphoma virus type II (HTLV-II) infection and its rate of spread have been difficult to determine owing to the serological cross-reactivity between HTLV-I and HTLV-II. The present study overcame this problem by directly detecting type-specific proviral sequences by means of the polymerase chain reaction (PCR) and liquid hybridization. Screening was performed on a cohort of primarily white intravenous drug abusers (IVDAs), and individuals of other behaviorally defined risk groups from the New York City area. Eleven percent (19 of 169) of the individuals in these high-risk groups were determined by PCR to have HTLV-II proviral infections. One of these patients displayed an exfoliative erythrodermatitis. Thirteen of the 19 subjects were positive in an HTLV-II enzyme-linked immunosorbent assay (ELISA). The remaining six individuals, although negative in the HTLV-II ELISA, were confirmed as HTLV-II positive by analyzing their DNA with a second HTLV-II-specific primer detector system. Four additional individuals were reactive in the HTLV-II ELISA but were PCR-negative for HTLV-II. PCR analysis for HTLV-I revealed that all four were positive for that virus. Thirty-seven percent (seven of 19) of the HTLV-II PCR-positive subjects were also PCR-positive for HTLV-I, and 84% (16 of 19) of the HTLV-II positive individuals were infected with human immunodeficiency virus (HIV-1). Six individuals were triply infected with HTLV-I, HTLV-II, and HIV-1.

Detection of anti-HTLV-I Tax antibodies in HTLV-I enzyme-linked immunosorbent assay-negative individuals.

The HTLV-I tax gene protein (Tax) is not packaged within the mature viral particle from which the proteins for the commercially available enzyme-linked immunosorbent assay (ELISA) are derived. Screening of 162 individuals within a cohort of white intravenous (IV) drug abusers, previously identified as having an increased incidence of HTLV-I infection, demonstrated that seven of them had antibodies to the HTLV-I Tax protein but tested negative in HTLV-I ELISAs and Western blots prepared from purified virion proteins. Three out of 35 individuals in other behaviorally defined high-risk groups also displayed this limited pattern of reactivity to HTLV-I proteins. The presence of the anti-HTLV-I p40/Tax antibodies was determined by radioimmunoprecipitation assay (RIPA), which also revealed low levels of anti-env reactivity. The specificity of the anti-p40 reactivity was confirmed on specific Tax ELISAs and Western blots prepared from recombinantly produced Tax. In vitro gene amplification by the polymerase chain reaction (PCR) was used to establish the presence of sequences homologous to HTLV-I proviral DNA in four/four of these HTLV-I ELISA negative, Tax ELISA/Tax western blot/RIPA positive individuals. These data suggest that the true incidence of HTLV-I infection within high-risk cohorts is greater than previously reported.