[Skin diseases among refugees and immigrants. Four exotic case reports]. / Hudsygdomme hos flygtninge og indvandrere. Fire eksotiske eksempler.

The influx of immigrants from outside the Western world, has led to a wider spectrum of dermatological diseases seen by doctors in Denmark. We present four case histories, in which the disease was brought to Denmark from the patient's land of origin. Tropical diseases may present as a skin disease as such, or a generalised disease with skin manifestations, the commonest signs being ulcers, papules, exanthema, changes in pigmentation, and itching.

Risk factors for HIV-2 seropositivity among older people in Guinea-Bissau. A search for the early history of HIV-2 infection.

Because the seroprevalence of HIV-2 has been shown to be high in older age groups, we conducted a survey of all persons aged 50 years or over in two districts in Bissau, investigating the presence of HIV antibodies and possible risk factors for HIV infection with a particular emphasis on age, the impact of the war of independence (1963-74), traditional marital and extramarital sex patterns, blood contact and contact with monkeys. In 670 participants, the HIV-2 prevalence was 14.3%; 16.1% in women and 12.3% in men. The HIV-1 prevalence was only 0.5% (3/670). The HIV-2 prevalence peaked for men in the 60-69 years age group, and for women in the 50-59 years age group, declining markedly in the following age group for both men and women (OR = 0.09 (0.01-0.51), OR = 0.37 (0.15-0.82), respectively). This pattern could be due to differential mortality for HIV-2 infected individuals or to a cohort effect for a generation who were sexually active at the time of the war of independence in the 1960s and early 1970s in Bissau. Supporting the link with the colonial army, women who had had sex with a white man had a higher seroprevalence (OR = 3.63 (1.12-11.24)). The ethnic group indigenous to Bissau city had a much lower prevalence, but demographic and cultural risk factors such as marital status, religion, education and having lived outside Bissau were not associated with HIV-2. In the multivariate analyses for women, variables related to extramarital sex or prostitution (having sex with a white man, having lived in Senegal, not living with husband, and not marrying first sexual partner) were associated with higher risk. For men, previous spouses who had died or had divorced were associated with higher prevalence. Having married the first sexual partner was protective against HIV-2 infection for both men (OR = 0.29 (0.09-0.76)) and women (OR = 0.19 (0.04-1.00)). Hospitalizations, possibly due to transfusions, tended to be associated with higher risk, but only for women (OR = 1.83 (0.97-3.48)). The focus of the HIV-2 epidemic in Guinea-Bissau is likely to be endogenous, and the war of independence and the colonial army with its associated prostitution may have played an important part in propagating the virus.

[Investigation of malignant melanoma in an "open house" setting]. / Undersøgelse for malignt melanom ved et "åbent hus"-arrangement.

Individuals with a self-evaluated risk of malignant melanoma were invited to an "open house" where trained dermatologists examined suspected lesions. The attendants filled in a short questionnaire relating to skin cancer risk factors. Persons with skin changes suspected for malignancy were referred for excision in the dermatological department. The clinical evaluation included dermatoscopy. Nine hundred and eleven individuals attended. Among 16 individuals referred for excision one malignant melanoma, one lentigo maligna melanoma and two in situ melanomas were histologically verified. Furthermore, 21 basal cell carcinomas were identified clinically. The most frequent clinical diagnoses were melanocytic naevi and seborrhoic keratoses.

Declining HIV-2 prevalence and incidence among men in a community study from Guinea-Bissau.

OBJECTIVE: To assess the present level of HIV-2 infection in an adult population in Bissau and to evaluate sex and age-specific changes in HIV-2 prevalence and incidence between 1987 and 1996. DESIGN AND METHODS: Sex and age-specific changes in HIV-2 prevalence were evaluated comparing a survey from 1987 in a sample of 100 houses with a survey performed in 1996 in an independent sample of 212 houses from the same study area. HIV-2 incidence rates were examined in an adult population (age > or = 15 years) from 100 randomly selected houses followed with four consecutive HIV serosurveys from 1987 to 1996. RESULTS: The HIV-2 prevalence in 1996 was 6.8% (men, 4.7%; women, 8.4%). Compared with the 1987 survey there was a significant decrease in prevalence among men [age-adjusted relative risk (RR), 0.50; 95% confidence interval (CI), 0.31-0.83], whereas it remained unchanged in women (RR, 1.00; 95% CI, 0.67-1.48). The male-to-female RR decreased from 0.99 (95% CI, 0.61-1.61) in 1987 to 0.51 (95% CI, 0.34-0.76) in 1996. The overall annual incidence rate was 0.54 per 100 person-years of observation (PYO), being higher in women (0.72 per 100 PYO) than in men (0.31 per 100 PYO). With the observation time divided into an early and a late period, there was a decrease in incidence with time among men (0.66 to 0.00 per 100 PYO), but no major change among women (0.59 to 0.85 per 100 PYO). The two trends differed significantly (P = 0.03). We observed a higher annual incidence rate amongst older women aged > 44 years (1.77 per 100 PYO) than among younger women (0.55 per 100 PYO; P = 0.05). CONCLUSION: There are no signs of an epidemic spread of HIV-2 in Bissau even though the HIV-1 prevalence is increasing rapidly. A significant reduction in the male HIV-2 prevalence and incidence rates has resulted in a major shift in the pattern of spread of HIV-2, from being equally distributed to being predominantly a female infection. Currently, older women in particular seem to have a high risk of getting infected.

HTLV-1 infection in a population-based cohort of older persons in Guinea-Bissau, West Africa: risk factors and impact on survival.

In 1989, a population-based cohort of persons aged > or = 50 years was established in an urban area of Guinea-Bissau, West Africa. Overall, 346 persons were interviewed in detail about risk behaviors and had capillary blood drawn. Among women, 12.4% were HTLV-1 seropositive, compared with 4.6% in men. No HTLV-2 was found. Seropositivity varied considerably according to place of birth and ethnic group. In women, but not in men, HTLV-1 seropositivity was strongly associated with early sexual debut (10-14 yrs, 33.3%; 15-17 yrs, 26.0%; 18-20 yrs, 6.5%; 21+ yrs, 0%; ptrend = 0.001), lifetime number of male partners (ptrend = 0.006), and the male partner's number of co-wives (ptrend = 0.006). There was also a 3.1-fold increased risk of being HTLV-1 seropositive if the woman was also HIV-2 seropositive. In a multivariate-risk-factor analysis, the strongest association with HTLV-1 was a history of having been bitten by a monkey (n = 11; combined OR adjusted = 10.1; 95% CI 2.3-44.4). Ornamental scarification was associated with a 3.3-fold increased risk. Ethnic affiliation also significantly influenced the risk of being HTLV-1 seropositive. Follow-up performed in January 1996 revealed no difference in survival between HTLV-1-seropositive and -seronegative individuals over 6 years (rate ratio = 1.4, 95% CI 0.7-2.8). In conclusion, this population, which has very high HIV-2 seroprevalence, is also highly endemic for HTLV-1. Whereas sexual behaviors are clearly important for HTLV-1 spread in women, non-sexual risk factors were the only ones of potential importance in men. HTLV-1 had no impact on survival in this older population.

PIP: HTLV-1 infections are particularly prevalent in parts of Japan, the Caribbean, and West Africa, with the virus apparently endemic in Africa for centuries with only a minor impact upon the population's health. Findings are reported from a study conducted to assess the impact of HTLV-1 infection upon overall survival and to investigate the risk factors for HTLV-1. In 1989, a population-based cohort of subjects at least 50 years old was established in an urban area of Guinea-Bissau. Overall, 346 people were interviewed in detail about their risk behaviors and had capillary blood drawn. 4.6% of men and 12.4% of women were HTLV-1 seropositive. No case of HTLV-2 was identified. Seropositivity varied considerably according to place of birth and ethnic group. Among women, but not men, HTLV-1 seropositivity was strongly associated with early sexual debut, the lifetime number of male sex partners, and the male partner's number of co-wives. There was also a 3.1-fold increased risk of being HTLV-1 seropositive if the woman was also HIV-2 seropositive. Multivariate analysis found the strongest association with HTLV-1 infection to be an history of having been bitten by a monkey. Ornamental scarification was associated with a 3.3-fold increased risk. Ethnic affiliation also significantly influenced the risk of being HTLV-1 seropositive. Follow-up performed in January 1996 found no difference in survival between HTLV-1-seropositive and -seronegative individuals over the course of 6 years. This population is highly endemic for both HTLV-1 and HIV-2 infection, with sex behaviors clearly being important in the spread of HTLV-1 among women, but nonsexual risk factors only of potential importance among men.

HIV-2 genetic variation and DNA load in asymptomatic carriers and AIDS cases in Guinea-Bissau.

The purpose of this study was to document which genetic subtypes of HIV-2 are present in Guinea-Bissau and to investigate whether asymptomatic HIV-2 carriers and AIDS patients carry distinct genetic variants. A secondary aim was to correlate proviral DNA load to clinical and immunologic status of the patients. Thirty-eight asymptomatic HIV-2 carriers and 11 AIDS patients from Bissau, Guinea-Bissau were included in a cross-sectional study in which HIV-2 env V3 sequences, HIV-2 DNA load, and CD4-positive (CD4+) lymphocyte counts were determined. Phylogenetic analyses showed that all investigated subjects carried subtype A HIV-2 variants and that the sequences from AIDS patients and asymptomatic carriers did not form distinct subclusters in the tree. As expected, patients with AIDS had significantly higher median HIV-2 DNA load than did asymptomatic carriers (4.6 vs. 2.0 log10 HIV-2 DNA copies/10(6) CD4+ lymphocytes). Our study indicates that the HIV-2 epidemic in Guinea-Bissau is almost exclusively caused by subtype A HIV-2 variants and that the HIV-2 infections among the asymptomatic carriers and AIDS cases included in the study do not have distinct epidemiologic histories.

PIP: HIV-2 is associated with AIDS but is less pathogenic than HIV-1. HIV-2 is endemic in West Africa, with the highest prevalence in Guinea-Bissau; epidemiologic studies in the country have found HIV-2 seroprevalence in the general population to be 8-10%. HIV-2 seroprevalence increases with age and peaks near age 50-59 years, although the mean age of HIV-2-associated AIDS cases is near 40 years. Only scattered cases of HIV-2 have been reported outside of West Africa, with some concentration in Portugal, France, and India. 38 asymptomatic HIV-2 carriers and 11 AIDS patients from Bissau were included in a cross-sectional study in which HIV-2 env V3 sequences, HIV-2 DNA load, and CD4-positive lymphocyte counts were determined. Phylogenetic analyses showed that all investigated subjects carried subtype A HIV-2 variants and that the sequences from AIDS patients and asymptomatic carriers did not form distinct subclusters in the tree. Subjects with AIDS had significantly higher median HIV-2 DNA load than did asymptomatic carriers.

9-year HIV-2-associated mortality in an urban community in Bissau, west Africa.

BACKGROUND: Community studies with 1-3 years of follow-up have reported four to five times higher mortality in HIV-2-infected than in uninfected adults. In a cohort study of HIV-1, an increasing difference in mortality rates of HIV-1-infected and uninfected individuals is expected over time, because of rising mortality with advancing HIV-1 infection. We therefore investigated long-term survival of HIV-2-infected adults. METHODS: Adults enrolled in 1987 in a community study of HIV-2 infection in Guinea-Bissau were followed up with serological surveys in 1989 and 1992. Survival was assessed in 1995, 9 years after enrollment. FINDINGS: The annual incidence of HIV-2 was 0.7% for adults and tended to be higher for older individuals than for participants aged 15-44 years (relative risk 3.21 [95% CI 0.91-11.37]). With control for age, HIV-2-infected adults had twice as high mortality as uninfected individuals (mortality ratio 2.32 [1.18-4.57]); the mortality ratio was highest in the first year of the study (4.50 [1.31-15.43]). The difference between infected and uninfected individuals was stronger for adults under 45 years of age (mortality ratio 4.72 [1.86-11.97]) than for older people (1.35 [0.51-3.56]). HIV-2-infected individuals living with an infected spouse had significantly higher mortality than HIV-2-infected individuals living with an uninfected spouse (p = 0.027). INTERPRETATION: HIV-2-associated mortality is not increasing with length of follow-up. Mortality in HIV-2-infected adults is only twice as high as that in uninfected individuals. In the majority of adults, HIV-2 has no effect on survival.

PIP: While HIV-2 infection can lead to AIDS, it takes longer than HIV-1 to induce immunosuppression and AIDS, it is less transmissible, and it is associated with lower mortality than HIV-1 infection. 1329 people from among 100 houses in Guinea-Bissau participated in a 1987 study of HIV seroprevalence in their community. 8.9% of the family members older than age 14 years were infected with HIV-2, as well as 0.6% of the 677 children, but no one was infected with HIV-1. All subjects enrolled in the 1987 study over age 14 were followed up with serological surveys in 1989 and 1992, with their survival assessed in 1995. HIV-2 associated mortality did not increase over time and mortality in HIV-2-infected adults was only twice as high as that among uninfected individuals. In the majority of adults, HIV-2 has no effect upon survival. The difference in mortality between the infected and the uninfected was greater for adults under age 45 years than for older people. Furthermore, HIV-2-infected individuals living with an infected spouse had significantly higher mortality than those living with an uninfected spouse.

Serial CD4 and CD8 T-lymphocyte counts and associated mortality in an HIV-2-infected population in Guinea-Bissau.

In an urban community in Guinea-Bissau, we followed a cohort of human immunodeficiency virus type 2 (HIV-2) seropositive individuals (N = 47) and seronegative controls (N = 82). T-lymphocyte subset determinations were done in 1988, 1990, and 1992. Serial determinations of CD4 percentages, CD8 percentages, and CD4/CD8 ratios for the same individual were stable for 31 seropositive and 51 seronegative individuals with repeated measurements. We found no significant differences in the changes during a 2- or 4-year period in CD4 percentages, CD8 percentages, absolute CD8 T-lymphocyte counts, CD4/CD8 ratio, white blood cell counts, lymphocyte percentages, and absolute lymphocyte counts for HIV-2-seropositive compared with HIV-2-seronegative individuals. Only absolute CD4 T-lymphocyte counts changed more for the HIV-2-seropositive than for HIV-2-seronegative individuals (p = 0.037). HIV-2-infected individuals who lived with an HIV-2-infected spouse had a lower CD4/CD8 ratio and had higher mortality than HIV-2 infected individuals who lived with an uninfected spouse. However, there were no significant differences in immunological and hematological values for the 8 HIV-2 seropositive individuals who died and the 39 who survived in the 8-year follow-up period. In conclusion, progression of immunosuppression in HIV-2 infection seems to be slower than in HIV-1 infection and may not be inevitable in all individuals.

HIV-2 infection in Bissau, West Africa, 1987-1989: incidence, prevalences, and routes of transmission.

In a community study, the HIV-1 and HIV-2 antibody status of the inhabitants of 100 randomly chosen houses in Bissau, West Africa, were followed from 1987 to 1989. There was no HIV-1 infection alone, while the HIV-2 seroprevalence in adults was 8.9% (58 of 652) in 1987 and 10.1% (61 of 603) in 1989. HIV-2 seroprevalence in 15- to 39-year-olds was 6.1% in 1987 and 11.3% in newcomers in 1989 [the Mantel-Haentzel weighted relative risk (RRMH) = 1.86; 95% confidence interval (CI): 1.07-3.24]. Three hundred thirty adults who were HIV-2 seronegative in 1987 were reexamined in 1989; seven had seroconverted. Follow-up time was 700 person years, giving an incidence of HIV-2 infection of 1 per 100 person years. With a history of sexually transmitted disease (STD), the RR of seroconverting was 9.95 (2.31-42.80). Blood transfusions received since 1987 did not result in seroconversions. No case of vertical transmission of HIV-2 was seen. There was an excess mortality in those who were HIV-2 seropositive; however, it was statistically significant only for children (RR = 22.27; 95% CI: 6.92-71.70; p < 0.0001), not for adults (RR = 2.16; 95% CI: 0.81-5.76; p = 0.23), when considering death from disease only.

HIV-2 infection in Denmark.

A collection of 3019 selected serum samples (ss), comprising 329 ss from intravenous drug abusers, 558 ss from homosexual men, 682 samples from persons attending a STD clinic, 100 ss from individuals of African origin, 300 ss from sexual contacts to Africans, 650 ss from Danish blood donors who resided in Africa greater than 2 years prior to donating the ss, and 400 ss with equivocal antibody reactions in an HIV-1 Western blot was tested for antibodies against HIV-2 by in-house HIV-2 ELISA and Western blot. Four ss were positive for antibodies against HIV-2. Three of the ss originated from West African men, the fourth belonged to the spouse of one of these men. Three of the samples presented with an uncharacteristic reaction in a HIV-1 Western blot. The study indicates that HIV-2 infection is not yet widespread in Denmark and that it remains closely related to West Africa.

PIP: Clinicians drew blood samples from 3019 people living in Denmark to determine whether HIV-2 had reached that country. The groups tested included drug users from Copenhagen, healthy HIV-1 positive and negative homosexual men from Copenhagen, patients at a clinic for sexually transmitted diseases (STDs), healthy Africans, Danes who had sexual intercourse with an African, Danish blood donors who went to Africa more than 2 years before they gave a blood sample, and people who had inconclusive HIV-1 Western Blot (WB) patterns. Laboratory personnel used an in-house HIV-1 ELISA and an in-house HIV-2 ELISA to test all samples and an in-house HIV-2 test. 4 (.13%) samples tested positive for HIV-2. 3 of the serum samples were from men from the Ivory Coast, Guinea Bissau and Senegal. The 4th sample belonged to the wife of one of these men. She was positive only for HIV-2 while the 3 men also tested positive for HIV-1. The serum of 2 of the 3 people who tested ELISA HIV-1 reactive had inconclusive HIV-1 WB patterns who tested ELISA HIV-1 reactive had inconclusive HIV-1 WB patterns which made the researchers suspect HIV-2 infection. The woman's serum reacted to the core and env proteins in both the HIV-1 Wb and HIV-2 WB, the HIV-1 ELISA was negative. RIPA and immunofluorescence tests confirmed HIV-2 infection. Her case demonstrates the need to do both HIV-1 and HIV-2 ELISA tests. None of the 650 blood donors who had been in Africa within the last 10 years tested positive for HIV-2. These findings indicated that HIV-2 was not prevalent in Denmark and was limited to West Africa. Health workers whose patients have ties with West Africa and have an inconclusive HIV-1 WB pattern should request testing for HIV-2. The researchers suggested that serological surveillance for HIV-2 should be done at regular intervals.

Lack of evidence of vertical transmission of human immunodeficiency virus type 2 in a sample of the general population in Bissau.

Twenty-nine human immunodeficiency virus type 2 (HIV-2) seropositive women identified in a cross-sectional study in Bissau in 1987 participated in a follow-up study in 1988, where each was matched for age and marital status with two HIV-2 seronegative women. Detailed information about all pregnancies was obtained. The HIV-2 seropositive women and their controls had similar mean numbers of pregnancies, live children, children who died, and abortions. The HIV-2 seropositive women did not have a greater risk of having had an abortion or a child who died than did the HIV-2 seronegative women. No difference in survival was seen between children born to HIV-2 seropositive and HIV-2 seronegative women. The H/S-ratios and CD4 numbers were lower in the seropositive group, but none had values lower than 0.4 and 0.4 x 10(9)/L, respectively. Seven prospectively observed children born to HIV-2 seropositive mothers showed no sign of infection. The lack of evidence of transmission of HIV-2 from mother to child is suggested to be due to the absence of marked immunodeficiency in this random sample of the general population.

Immunodeficiency in HIV-2 infection: a community study from Guinea-Bissau.

In a community study in Guinea-Bissau, West Africa, 47 HIV-2-seropositive cases and 87 matched controls were evaluated immunologically using immuno-alkaline phosphatase linked to avidin-biotin complex for the assessment of CD4 and CD8 status. HIV-2-seropositive individuals had significantly lower total numbers of CD4 cells and CD4/CD8 ratios, 38% having a total number of CD4 cells less than or equal to 0.5 x 10(9)/l and 36% having a CD4/CD8 ratio less than or equal to 0.8. Total numbers of CD4 cells less than or equal to 0.5 x 10(9)/l or CD4/CD8 ratio less than or equal to 0.8 were found in 53% of the HIV-2 seropositives compared with 11% among controls [odds ratio (OR) = 7.3; 95% confidence interval (CI): 3.1-17.1]. Lymphadenopathy was significantly more frequent among HIV-2 seropositives than among controls (OR = 3.4; 95% Cl: 1.5-7.6). HIV-2 seropositives with lymphadenopathy had significantly fewer lymphocytes (P = 0.008) and lower total CD4 (P = 0.029) and total CD8 number (P = 0.011) than HIV-2 seropositives without lymphadenopathy. This study indicates that HIV-2 has a significant immunosuppressive effect.

Immunofluorescence assay for detection of antibodies to human immunodeficiency virus type 2.

A total of 215 serum samples were tested for antibodies against human immunodeficiency virus type 2 (HIV-2) with an immunofluorescence assay (IFA). Some samples originated from Denmark and some originated from Guinea-Bissau. The IFA results were compared with enzyme-linked immunosorbent assay (ELISA) and Western (immuno-) blot (WB) results. Twenty-nine serum samples were found to be true positive for HIV-2 antibodies as judged from WB and radioimmunoprecipitation results; all of these were also found to be positive in the HIV-2 IFA. Of 80 serum samples originating from HIV-1-infected persons, 60% showed reactivity in the HIV-2 ELISA, and 51% cross-reacted with at least one band in the HIV-2 WB. None of the sera cross-reacted in the HIV-2 IFA. A total of five serum samples (three African and two Danish) gave unspecific results in the HIV-2 IFA. It is concluded that the HIV-2 IFA is more specific and at least as sensitive as a first-generation ELISA and that IFA is superior to WB in discriminating between HIV-1 and HIV-2 infections.

Prevalence of and mortality from human immunodeficiency virus type 2 in Bissau, West Africa.

In a community based prevalence study of HIV infection in Bissau, West Africa, 1987, the population in 100 randomly selected "houses" was asked to participate. 89% (1329/1499) were examined and had a blood sample taken. None was HIV-1 seropositive but 4.7% were seropositive for HIV-2 (0.6% in children, 8.9% in those aged 15 years and over, and 20% in those aged 40 years and over). There was no significant difference in seroprevalence between areas or ethnic groups or between individuals of different civil status when age was taken into account. Sexual contact and blood transfusions were the dominant transmission routes, and no case of vertical transmission was identified. The HIV-2 seroprevalence in spouses of HIV-2 seropositive index persons was 40%. For a history of blood transfusion the relative risk of being HIV-2 seropositive was 103.6 in children and 2.4 for adults. After exclusion of spouses, no clustering of HIV-2 seropositivity was seen. At follow-up, after a mean observation time of 325 days, there was an excess mortality for HIV-2 seropositives. The relative risk of dying for HIV-2 seropositive children was 60.8 and for adults 5.0.

Humoral and cellular responses to Pneumocystis carinii, CMV, and herpes simplex in patients with AIDS and in controls.

The titers of IgG and IgA to Pneumocystis carinii in 36 AIDS patients did not differ significantly from those in 31 controls. Only 2/15 patients (13%) with P. carinii pneumonia (PCP) had titers of IgM antibodies greater than or equal to 5, which is significantly less frequent than in 32 controls (62%) and in 21 AIDS patients without PCP (43%). The risk of PCP was 5 times higher in patients without IgM antibodies to P. carinii than in patients who had these antibodies. A significantly higher percentage of those without PCP (57%) showed increasing titers of IgM antibodies to P. carinii in the second of paired samples taken about 6 months apart, compared with whose with PCP (9%; p = 0.05). All patients had high titers of antibodies to CMV and HSV and normal total concentrations of immunoglobulins. None of the patients responded in lymphocyte transformation to P. carinii, CMV, or HSV antigens. There is no obvious explanation to the selective lack of IgM antibodies to P. carinii in patients with PCP. Lack of IgM antibodies may be a marker for an immunodeficiency to P. carinii.

Efficacy and safety of two different dose levels of ganciclovir for the treatment of cytomegalovirus chorioretinitis in AIDS patients.

The effect of different dosages of ganciclovir on proved cytomegalovirus chorioretinitis was tested in a randomized trial on 11 homosexual men with AIDS. The effect of 5 mg/kg/day was as good as 10 mg/kg/day. The lower dosage had less toxicity.