Herpes simplex virus hepatitis: expanding the spectrum of disease.

We describe 2 transplant patients with herpes simplex virus (HSV) hepatitis who were minimally symptomatic throughout their illness. The spectrum of disease caused by HSV hepatitis is more variable than previously reported in this population. HSV hepatitis should be considered in immunocompromised hosts with elevated transaminases without evidence of fulminant hepatic necrosis.

Myeloid-related protein (MRP)-8 from cervico-vaginal secretions activates HIV replication.

OBJECTIVES: To identify a substance found in female genital tract secretions that enhances HIV expression in infected cells. DESIGN: Cervico-vaginal lavages (CVL), collected in sterile normal saline, were fractionated and tested for HIV-inducing activity using HIV-infected monocytes. METHODS: To purify the component(s) of CVL that enhance HIV production, Mono-Q ion exchange chromatography followed by Superose-12 molecular sieve analysis, and SDS--PAGE were performed. The purified protein was identified by amino acid sequence analysis. RESULTS: SDS--PAGE of bioactive fractions showed a 14 kDa polypeptide band. Amino acid sequence analysis of selected peptides from the 14 kDa band showed 100% homology with the myeloid-related protein (MRP)-8, an inflammatory protein found in mucosal secretions. Western blot analysis revealed that bioactive CVL contained more immunoreactive MRP-8 than samples without bioactivity. The HIV-inducing activity of MRP-8 was further confirmed by showing that human recombinant MRP-8 increased HIV expression by up to 40-fold. CONCLUSIONS: MRP-8 in cervico-vaginal secretions stimulates HIV production. Strategies aimed at blocking MRP-8 activity in the genital tract could reduce risk of sexual as well as maternal--infant transmission of HIV.

HIV-1 reverse transcriptase mutations found in a drug-experienced patient confer reduced susceptibility to multiple nucleoside reverse transcriptase inhibitors.

HIV-1 reverse transcriptase (RT) genotypes were obtained from 13 patients treated with stavudine. No previously-reported mutations indicative of stavudine resistance were found in these patients and no novel mutations occurred in more than two patients. One patient, treated with stavudine for 1 month and treated previously with zidovudine, zalcitabine and lamivudine, carried a mutation at codon 75 of the RT (V75M). A chimeric virus, including the patient's RT sequence from codon 25 to codon 220, which carried the resistance mutations M41 L, D67N, T69D, K70R, L210W and T215Y in addition to V75M, displayed reduced susceptibility to multiple nucleoside RT inhibitors (NRTIs). Removal of V75M from this RT background resulted in a return of susceptibility to didanosine and lamivudine. Our data are in agreement with previous studies demonstrating the rarity of stavudine resistance mutations in stavudine-treated patients. However, we describe a new set of mutations, found in the RT of a heavily-treated patient, that can confer reduced susceptibility to multiple NRTIs. These results underscore the importance of increased vigilance for possible multiple-drug resistance in patients who have been heavily treated with NRTIs.

Body composition in HIV-infected women.

Although loss of lean body mass is a common complication of human immunodeficiency virus (HIV) infection that can occur across the disease trajectory, few studies have characterized the body composition of HIV-infected women. We used bioelectrical impedance analysis to characterize the body composition of HIV-infected (n = 56) and uninfected (n = 12) women who were matched on percentage of ideal body weight. The HIV-infected women did not differ from the uninfected women by height-adjusted fat mass or body cell mass. Intergroup comparisons among the HIV-infected women showed that underweight women had significantly less fat mass than did normal-weight women but did not significantly differ with respect to body cell mass. Among all HIV-infected women, CD4(+) lymphocyte count was positively correlated with fat mass (r = 0.32, P = 0.01) but not with body cell mass. No significant correlations were found between any body-composition parameter and plasma viral load. Our findings suggest that, unlike men, HIV-infected underweight women show a preferential loss of fat mass and a relative preservation of body cell mass. This altered pattern of weight loss may relate to higher premorbid fat stores in women and/or hormonal differences.

Association of indicators of bacterial vaginosis with a female genital tract factor that induces expression of HIV-1.

OBJECTIVE: The aim of this study was to determine the relationship of bacterial vaginosis and bacterial vaginosis-associated microorganisms with an HIV-inducing factor (HIF) found in cervicovaginal lavage. DESIGN: A total of 26 cervicovaginal lavage specimens collected from 17 women were used in this study to determine if HIF was significantly associated with features consistent with bacterial vaginosis. METHODS: Patients were evaluated for various clinical features including age, HIV status and stage, CD4 cell counts, clinical diagnosis of gynecological infections, vaginal pH, Gram stains of vaginal fluid, phase of menstruation, and presence of cervical dysplasia. Cervicovaginal lavage specimens were analyzed for the presence of HIF by U1 bioassay. The presence of Gardnerella vaginalis, and general Mycoplasmataceae, and specifically Mycoplasma hominis, Ureaplasma urealyticum, M. fermentans, M. genitalium in cervicovaginal lavage were determined by semiquantitative PCR. RESULTS: Eleven cervicovaginal lavage samples from seven women were HIF-positive and 15 cervicovaginal lavage samples from 11 women were HIF-negative (patient No. 8 had two HIF-negative cervicovaginal lavage and one HIF-positive cervicovaginal lavage). The following parameters were significantly associated with HIF: abnormal vaginal fluid pH (>4.5) (P = 0.006), Gram stains indicative of bacterial vaginosis (P = 0.007), normal menstrual cycle (P = 0.0007) and PCR detection and relative quantity of M. hominis (P = 0.0003, P = 0.002). CONCLUSIONS: This study indicates that HIF is closely associated with features of bacterial vaginosis.

Bacterial vaginosis-associated microflora isolated from the female genital tract activates HIV-1 expression.

Alteration of cervicovaginal microbial flora can lead to vaginosis, which is associated with an increased risk of HIV-1 transmission. We recently characterized a soluble HIV-inducing factor (HIF) from the cervicovaginal lavage (CVL) samples of women. The goals of this study were to determine the effect of cervicovaginal microflora on HIV-1 expression and to elucidate the relationship between HIF activity and microflora. Physiologically relevant microorganisms, Mycoplasma, diphtheroid-like bacteria, Gardnerella vaginalis, Streptococcus agalactiae, and Streptococcus constellatus, cultured from the CVL of a representative woman with a clinical condition of bacterial vaginosis and possessing HIF activity, induced HIV-1 expression. The magnitude of virus induction varied widely with the greatest stimulation induced by diphtheroid-like bacteria and Mycoplasma. The transcriptional induction by Mycoplasma was mediated by activation of the KB enhancer, an activation mechanism shared with HIF. Also as with HIF, Mycoplasma induced AP-1 dependent transcription. Polymerase chain reaction (PCR)-based speciation showed that the isolate was M. hominis. Our data indicate that bacterial vaginosis-associated microflora can enhance HIV-1 transcription and replication and identify M. hominis as a potential source for HIF activity. The virus-enhancing activities associated with the microflora and HIF may increase genital tract viral load, potentially contributing to HIV transmission.

Thalidomide for the treatment of esophageal aphthous ulcers in patients with human immunodeficiency virus infection. National Institute of Allergy and Infectious Disease AIDS Clinical Trials Group.

A multicenter, double-blind, randomized, placebo-controlled clinical trial was conducted to determine the safety and efficacy of thalidomide for treating esophageal aphthous ulceration in persons infected with human immunodeficiency virus (HIV). Twenty-four HIV-infected patients with biopsy-confirmed aphthous ulceration of the esophagus were randomly assigned to receive either oral thalidomide, 200 mg/day, or oral placebo daily for 4 weeks. Eight (73%) of 11 patients randomized to receive thalidomide had complete healing of aphthous ulcers at the 4-week endoscopic evaluation, compared with 3 (23%) of 13 placebo-randomized patients (odds ratio, 13.82; 95% confidence interval, 1.16-823.75; P=.033). Odynophagia and impaired eating ability caused by esophageal aphthae were improved markedly by thalidomide treatment. Adverse events among patients receiving thalidomide included somnolence (4 patients), rash (2 patients), and peripheral sensory neuropathy (3 patients). Thalidomide is effective in healing aphthous ulceration of the esophagus in patients infected with HIV.

Incorporation of zidovudine into leukocyte DNA from HIV-1-positive adults and pregnant women, and cord blood from infants exposed in utero.

OBJECTIVE: The nucleoside analog 3'-azido-3'-deoxythymidine (ZDV) has widespread clinical use but also is carcinogenic in newborn mice exposed to the drug in utero and becomes incorporated into newborn mouse DNA. This pilot study was designed to determine ZDV incorporation into human blood cell DNA from adults and newborn infants. DESIGN: In this prospective cohort study, peripheral blood mononuclear cells (PBMC) were obtained from 28 non-pregnant adults and 12 pregnant women given ZDV therapy, six non-pregnant adults with no exposure to ZDV, and six non-pregnant adults who last received ZDV > or = 6 months previously. In addition, cord blood leukocytes were obtained from 22 infants of HIV-1-positive, ZDV-exposed women and from 12 infants unexposed to ZDV. There were 11 mother-infant pairs involving HIV-1 -positive women. METHODS: DNA was extracted from PBMC obtained from non-pregnant HIV-1-positive adults taking ZDV, pregnant HIV-1-positive women given ZDV during pregnancy, and from adults not taking ZDV. Cord blood leukocytes were examined from infants exposed to ZDV in utero and from unexposed controls. DNA samples were assayed for ZDV incorporation by anti-ZDV radioimmunoassay (RIA). RESULTS: The majority (76%) of samples from ZDV-exposed individuals, pregnant women (8 of 12), non-pregnant adults (24 of 28), or infants at delivery (15 of 22), had detectable ZDV-DNA levels. The range of positive values for ZDV-treated adults and infants was 25-544 and 22-452 molecules ZDV/10(6) nucleotides, respectively. Analysis of 11 mother-infant pairs showed variable ZDV-DNA incorporation in both, with no correlation by pair or by duration of drug treatment during pregnancy. Two of the 24 samples from individuals designated as controls were positive by anti-ZDV RIA. The 20-fold range for ZDV-DNA values in both adults and infants suggested large interindividual differences in ZDV phosphorylation. CONCLUSIONS: Incorporation of ZDV into DNA was detected in most of the samples from ZDV-exposed adults and infants. Therefore, the biologic significance of ZDV-DNA damage and potential subsequent events, such as mutagenicity, should be

Levels of proinflammatory cytokines in plasma after pneumoccoccal immunization in human immunodeficiency virus type 1-infected patients.

To ascertain if immunization with pneumococcal polysaccharide vaccine is associated with rises in the levels of proinflammatory cytokines in the plasma of human immunodeficiency virus type 1 (HIV-1)-infected patients, the levels of tumor necrosis factor alpha (TNF-alpha) and interleukin-6 (IL-6) were measured serially after immunization. IL-6 levels rose an average of 2.2- and 2.1-fold 6 and 8 h after immunization, respectively, but TNF-alpha levels remained unchanged. The levels of these cytokines were stable in unimmunized controls. Immunization with pneumococcal polysaccharide vaccine induces increases in the levels of IL-6 in the plasma of persons with HIV-1 infection.

A human immunodeficiency virus (HIV)-inducing factor from the female genital tract activates HIV-1 gene expression through the kappaB enhancer.

Virus-enhancing factors present in the female genital tract may influence the transmission of human immunodeficiency virus type 1 (HIV-1). Previously, the presence of a heat-stable soluble factor in the cervicovaginal lavage (CVL) fluid of both HIV-infected and -uninfected women that induces HIV-1 expression in T cells and monocytes was reported. Now this CVL factor was shown to increase HIV-1 gene expression through the activation of the kappaB enhancer in the viral long terminal repeat (LTR). DNA binding studies, together with functional studies using mutant LTR reporter constructs, indicate the requirement for an NF-kappaB-dependent pathway in the CVL-mediated activation of HIV-1 expression. CVL samples that activated HIV-1 expression also stimulated AP-1-dependent transcription. These data demonstrate that an HIV-inducing factor, distinct from heat-labile cytokines, present in the female genital mucosa can activate AP-1 and NF-kappaB and increase HIV-1 gene expression through the kappaB enhancer, possibly contributing to HIV-1 transmission.

Chemokines are present in the genital tract of HIV-seropositive and HIV-seronegative women: correlation with other immune mediators.

In this cross-sectional study, 53 cervicovaginal lavage samples (CVL) from 41 women were analyzed for the chemokines interleukin-8 (IL-8), regulated-on-activation normal T-expressed and secreted (RANTES) factor, and macrophage inflammatory protein-1alpha (MIP-1alpha) by enzyme-linked immunosorbent assay (ELISA). IL-8 was detected in 81% of CVL, whereas RANTES was detected in 32%, and MIP-1alpha in 15% of the CVL. The mean levels of IL-8, RANTES, and MIP-1alpha in positive samples were 396 pg/ml, 102 pg/ml, and 34 pg/ml, respectively. IL-8 levels correlated positively with IL-1beta and IgG in a subset of CVL samples. RANTES levels correlated positively with complement protein levels. Additionally, the levels of RANTES, but not MIP-1alpha, reached levels reported in previous studies of the effects of beta chemokines to inhibit HIV replication. These results suggest that measuring chemokines in CVL specimens can provide important information regarding immune responses in the genital tract.

Mechanisms of resistance of HIV-1 primary isolates to complement-mediated lysis.

Previous studies suggested that HIV-1 primary isolates (PI) were resistant to complement-mediated lysis (CML), while virus produced in certain T cell lines and virus taken directly from the plasma of HIV+ persons were both susceptible to CML. The purpose of this study was to investigate the mechanism(s) of PI resistance. PI were resistant to CML using pooled seropositive serum as an antibody source. Additionally, PI obtained from two patients at several times over 2 years were resistant to CML using autologous antibody. PI were also resistant to CML induced by monoclonal antibodies which neutralize a broad range of PI. Resistance to CML was associated with low binding of antibody to PI but was not due to low gp120 levels. Cell-line-derived virus and PI were equally sensitive to CML induced by antibody to host-cell proteins, suggesting that PBMC do not contribute properties to virions which make them more physically resistant to CML in general but that PI resistance is restricted to CML induced by antiviral antibody. These studies show that PI are resistant to CML mediated by various antiviral antibodies and indicate that low binding of antibody to virus is an important factor contributing to resistance.

Evaluation of immunologic markers in cervicovaginal fluid of HIV-infected and uninfected women: implications for the immunologic response to HIV in the female genital tract.

We analyzed 21 cervicovaginal lavage (CVL) specimens from 19 women participating in the Women's Interagency HIV Study to characterize levels of antibody, cytokine, and complement and to determine associations between these levels and stage of the menstrual cycle, HIV status, and the presence of concurrent genital infection and genital dysplasia. Sixteen samples were collected from HIV-infected women and five from high-risk HIV-seronegative women. CVL fluid was assayed for levels of IgG, secretory IgA (s-IgA), interleukin 2 (IL-2), IL-10, IL-6, tumor necrosis factor alpha (TNF-alpha), IL-1beta, interferon gamma (IFN-gamma), C3, C1q, and C4. Women with HIV were more likely to have cervicovaginal dysplasia (9/16 vs. 0/5; p = 0.027) but were not more likely to have concurrent vaginal infection (10/16 vs. 2/5; p = 0.38). Antibody, cytokine, and complement were detectable in all samples, although not all samples had measurable IL-10, C3, or C4. HIV-infected women demonstrated a trend toward higher levels of IFN-gamma than did uninfected women (p = 0.098); no differences were noted in other parameters. HIV-infected women with vaginal infections had significantly higher CVL levels of IgG (p = 0.023) and IFN-gamma (p = 0.02) than did HIV-infected women without genital infections. HIV-infected women with cervicovaginal dysplasia were found to have higher levels of IL-1beta (p = 0.045) and IFN-gamma (p = 0.039) than those without. Analysis of the HIV-infected cohort by CD4 cell count revealed higher levels of IgG and IFN-gamma in CVL from women with lower CD4 cell counts, although these differences were not statistically significant. Higher levels of proinflammatory cytokines in CVL fluid of women with genital infection or cervicovaginal dysplasia may affect local HIV replication and may influence the risk of acquisition or transmission of HIV for women with these underlying conditions.

Immunologic and virologic evaluation after influenza vaccination of HIV-1-infected patients.

OBJECTIVE: The present study was designed to determine the effect of immune activation, achieved by influenza vaccination, on plasma HIV RNA levels and immunological parameters including CD4 cell levels, antigen-stimulated T-cell function and apoptotic death of peripheral blood mononuclear cells. DESIGN AND METHODS: Thirty-four HIV-infected individuals and nine uninfected controls were immunized with influenza vaccine and blood was collected at weeks 0, 2, 4 and 16. Plasma was isolated and used for HIV RNA and influenza-specific antibody qualifications. CD4 cell counts, activation and maturation markers of T-lymphocyte subsets were determined by flow cytometry. In vitro T-helper responses, spontaneous- and activation-induced cell death assays were also performed. RESULTS: Influenza-specific humoral and cellular immune responses correlated with CD4 count. Only in patients with CD4 counts > 300 x 10(6)/l there was a modest increase in T-cell responses to influenza virus, which was less than control subjects, observed after vaccination. Immunization had no significant effect on CD4 counts or plasma viral levels in the HIV-positive patients. Baseline apoptosis inversely correlated with CD4 counts and directly correlated with viral load. Activation-induced apoptosis did not change appreciably after vaccination and spontaneous apoptosis increased only in the < 300 CD4 group. CONCLUSION: These results indicate that immune stimulation resulting from influenza vaccination did not significantly change the levels of plasma virus, CD4 cell counts, or activation-induced apoptosis in HIV-infected individuals, although an increase in the T-cell response to influenza and spontaneous apoptosis was observed in the > 300 and < 300 CD4 groups, respectively.

Susceptibility of HIV-1 plasma virus to complement-mediated lysis. Evidence for a role in clearance of virus in vivo.

This study was undertaken to directly assess the susceptibility of HIV-1 plasma virus to C-mediated lysis. Plasma from HIV-infected individuals was collected and ultracentrifuged over 20% sucrose to isolate virions from plasma components including anticoagulants, which inhibit C activity. Treatment with C alone in the absence of exogenously added Ab caused lysis of virus from all patients (n = 18) (range 14 to 86%). This lysis occurred via the classical C pathway and was not due to cross-reactive Abs in the C source. Protein A bound a fraction of isolated plasma virus and this binding was blocked by purified human Ig suggesting that anti-HIV Abs bound to plasma virus could be responsible for inducing C activation. A portion of virus bound to CR2 on cells in the absence of exogenously added C indicating that virus activated C in vivo. C levels from six of six patients were determined to be sufficient to lead to lysis of virus in vivo. Since plasma virus appeared more sensitive to C than primary isolates, isolated virus was evaluated for the presence of C control proteins. While primary isolate virions contained CD46, CD55, and CD59, only CD59 was detected on plasma virus. The results of this study strongly suggest that C is activated by a portion of plasma virus in vivo due to the binding of Ab. The resultant opsonization plus subsequent lysis may be important routes of clearance and destruction of plasma virus in infected persons.

HIV infection in women: an observational study of clinical characteristics, disease progression, and survival for a cohort of women in Chicago.

To further characterize the natural history of HIV infection in women in the antiretroviral era, we performed a longitudinal, descriptive analysis of demographic features, clinical characteristics, patterns of antiretroviral and prophylactic therapy, disease progression, and survival in a cohort of women followed at a university medical center from 1986 to 1992. Eighty-two women (39 white [non-Hispanic], 33 African-American, 10 Hispanic) were followed for a median of 13 months (range 3-61 months). Sixty-two women received antiretroviral therapy, 34 through participation in a clinical trial. Candida esophagitis and Pneumocystis carinii pneumonia were the most common AIDS-defining conditions, accounting for 77% of all initial AIDS-defining diagnoses. Gynecologic complications affected 34 women (41%) and included recurrent Candida vaginitis in 26, abnormal PAP smears/cervical intraepithelial neoplasia in 10, and recurrent genital herpes simplex virus disease in seven. Median survival (Kaplan-Meier) from the time of HIV serodiagnosis was > 59 months; median survival following an AIDS diagnosis was 27 months. No survival differences were detected based on race, insurance status, or mode of HIV transmission. Women who participated in antiretroviral therapy clinical trials had a statistically significantly longer duration of survival compared with nonparticipants. Candida infections and gynecologic diseases were common in this population. Overall survival was similar to that reported for men.