Chlamydia pneumoniae strain TWAR pharyngitis in US Air Force basic trainees.

Chlamydia pneumoniae has recently been shown to be a cause of pharyngitis. Because the impact of this pathogen on United States Air Force basic trainees is unknown, the authors undertook a prospective study to evaluate the prevalence of C pneumoniae. Of 118 asymptomatic basic trainees, 43% had preexisting antibodies to C pneumoniae and 0.9% had serologic evidence of C pneumoniae infection. Of 226 symptomatic basic trainees, only four (1.8%) met the criteria for serologic evidence of acute C pneumoniae infection. No other cause of pharyngitis was found in three of four of these basic trainees. Three of the trainees with C pneumoniae infection had hoarseness and all had a dry cough. All symptoms resolved without specific antichlamydial therapy. Chlamydia pneumoniae was an uncommon cause of pharyngitis in basic trainees, appearing as a mild, self-limiting illness.

Nosocomial Legionnaires' disease: aspiration as a primary mode of disease acquisition.

PURPOSE: Nosocomial Legionnaires' disease remains a significant problem with many unresolved questions regarding transmission of legionella organisms to patients. We performed a case-control and environmental study to identify risk factors and modes of transmission of Legionella infection during an outbreak of nosocomial Legionnaires' disease in a military medical center. PATIENTS AND METHODS: During the calendar year 1989, 14 cases of nosocomial Legionnaires' disease were identified by active surveillance following the discovery of 2 culture-proven cases among organ transplant recipients. Four control patients were matched to each case by age, sex, and date of admission. Cases and controls were compared with respect to past medical history and hospital exposure variables. Odds ratios (ORs) and 95% confidence intervals (CIs) were calculated for matched variables. Environmental culturing of air and water supplies in and around the medical center was also performed. RESULTS: The case-control study revealed the following significant risk factors for the acquisition of nosocomial Legionnaires' disease: immunosuppressive therapy (OR = 32.7, CI = 4.5 to 302.6), nasogastric tube use (OR = 18.4, CI = 2.6 to 166.2), bedbathing (OR = 10.7, CI = 2.2 to 59.0), and antibiotic therapy (OR = 14.6, CI = 2.9 to 84.4). Shower use (OR = 0.1, CI = 0 to 0.4) appeared to be a negative risk factor. Water cultures revealed Legionella pneumophila serogroup 1, monoclonal antibody subtype Philadelphia (identical to all patient isolates) in the ground-water supply to the hospital, 1 hot-water tank, and 15% of 85 potable water sites tested. Air sampling of cooling towers, hospital air intakes, and medical air and oxygen supplies were negative for Legionella organisms. CONCLUSIONS: This study confirms the importance of potable water in transmitting nosocomial Legionnaires' disease and suggests that the organism gains access to the hospital via external water supplies. The risk factors identified in this case-control study provide evidence that Legionnaires' disease may act as a superinfection in a nosocomial setting and is likely acquired by aspiration, similar to other nosocomial pneumonias.

Human immunodeficiency virus infection in the US Air Force: seroconversions, clinical staging, and assessment of a T helper cell functional assay to predict change in CD4+ T cell counts.

As of January 1990, 933 persons with human immunodeficiency virus type 1 (HIV-1) infection were clinically evaluated at Wilford Hall US Air Force (USAF) Medical Center. The Walter Reed HIV staging system was used in these evaluations to describe disease status and progression. Most persons were diagnosed through mandatory HIV testing in the USAF and were asymptomatic at the time of diagnosis. As of May 1990, 161 HIV-positive seroconverters (estimated overall seroconversion rate of 0.156/1000 person-years between 30 June 1988 and 1 July 1990) had been identified among active-duty USAF personnel, as they had previously tested negative for antibody to HIV. Men constitute 95% of the USAF HIV-positive population. An in vitro T helper cell functional assay was assessed to predict rate of CD4+ T cell decline over the subsequent year (mean, 15 months) in patients with greater than 200 CD4+ T cells/mm3. This assay may prove useful for prognostication and comparisons of patients in clinical trials of anti-HIV interventions.

Immunization with subunit human immunodeficiency virus vaccine generates stronger T helper cell immunity than natural infection.

Healthy, human immunodeficiency virus seronegative (HIV-) volunteers were multiply immunized with a recombinant gp160 (rgp160) candidate acquired immunodeficiency syndrome (AIDS) vaccine. Peripheral blood lymphocytes from volunteers immunized with 40 micrograms or with 80 micrograms (two volunteers per group) of rgp160, as well as from control donors, were tested for T helper (Th) cell function either prior to immunization, 8 to 12 months after the third immunization, or 2 to 5 months after the fourth immunization. The Th cell functional tests included antigen-induced in vitro interleukin 2 (IL 2) production and proliferation in response to influenza A virus (FLU) and to four synthetic peptides of HIV gp120 and gp160, previously demonstrated to be recognized by T cells from HIV naturally infected patients. Our results demonstrate the following: (a) immunization of HIV- individuals with rgp160 results in IL 2 production and T cell proliferation in response to HIV determinants; (b) boosting with rgp160 enhances Th function; (c) HIV-specific Th function is up to 100-fold greater in the multiply immunized volunteers than that observed in asymptomatic, HIV-infected individuals; and (d) multiple immunization with rgp160 does not impair Th function to a non-HIV antigen such as influenza A virus. These results indicate that immunization of uninfected individuals with an HIV subunit vaccine results in much stronger Th cell immunity than does natural infection and suggests that vaccination against HIV may be possible.

Multiple patterns of alloantigen presenting/stimulating cell dysfunction in patients with AIDS.

The APC/stimulating cell (APC/SC) potential of PBMC from Walter Reed stage 1 and 2 patients and patients with AIDS was tested by using these PBMC as stimulators in an allogeneic MLR. The responding cells were PBMC from unrelated, HIV- donors that were either unfractionated or depleted of APC by plastic and nylon wool adherence. Using this approach, we observed no defect in the APC/SC potential of PBMC from Walter Reed stage 1 and 2 patients. However, PBMC from AIDS patients used as allogeneic stimulators exhibited three different patterns of APC/SC function: 1) no defect in alloantigen (ALLO) APC/SC potential; 2) a defect in ALLO APC/SC function that was detected only if the responder cells were depleted of APC (presenting cell defect); and 3) a defect in ALLO APC/SC function, irrespective of whether the responder cells were depleted of APC (stimulating cell defect). These results indicate that in addition to Th cell defects associated with AIDS, the PBMC from AIDS patients can also exhibit a defect in APC/SC function. This study provides an approach that permits the testing of Ag-presenting function in all AIDS patients, and is therefore not limited to testing patients for whom HIV-, HLA-identical T cells and APC are available.

Detection of cytotoxic T lymphocytes specific for synthetic peptides of gp160 in HIV-seropositive individuals.

Four synthetic peptides corresponding to the IIIB sequence of gp160 of HIV were recently reported to stimulate Th cell function by PBL from HIV-infected, asymptomatic patients. In the present report, we used these same peptides to demonstrate CTL activity in a similar patient population. EBV-transformed B-cell lines from asymptomatic, HIV seropositive and seronegative control donors were pre-incubated with the peptides. Fresh PBL from 19 (76%) of 25 HIV seropositive donors lysed autologous targets pulsed with at least one of the four peptides. Autologous targets pulsed with two non-immunogenic peptides were not lysed. PBL from none of the eight HIV seronegative controls lysed peptide-preincubated autologous targets. The CTL activity was mediated by T cells, was predominantly MHC class I restricted, and was increased by in vitro restimulation of PBL with the peptides. HLA A-2 was identified as a restricting element for all four peptides in different patients, and for three of the peptides in the same donor. HLA-A1 or -B8 may also present some of the peptides. Thus, the same peptides can be recognized by human Th cells and class I MHC-restricted CTL.

Negative correlation between blood cell counts and serum neopterin concentration in patients with HIV-1 infection.

Hematopoietic disturbances are common in patients with HIV-1 infection. Recent studies on immune activation markers such as neopterin demonstrate that HIV-1 infection is associated with chronic immune activation. We investigated a possible association between serum neopterin concentrations and blood cell counts (CD4+ T cells, white blood cells, platelets, red blood cells) and hemoglobin and hematocrit in 94 HIV-1-seropositive individuals [52 Walter Reed (WR) stage 1, 31 WR2, one WR5, and 10 WR6]. There were significant negative correlations between neopterin concentrations and CD4+ T cells, hemoglobin, hematocrit and platelets. These correlations were also significant if either only WR1 and WR2 patients or the entire set of data were considered for calculations. Thus, hematological abnormalities are associated with chronic immune activation in patients with HIV-1 infection. Large amounts of neopterin are released by human macrophages on stimulation with interferon-gamma (IFN gamma), and tumor necrosis factor alpha (TNF alpha) further enhances the effect of IFN gamma. Therefore, our data suggest that activated immune cells and specific cytokines such as IFN gamma and TNF alpha are involved inhibiting hematopoiesis.

Patterns of antibody reactivity to selected human immunodeficiency virus type 1 (HIV-1) gp160 epitopes infected individuals grouped according to CD4+ cell levels.

We examined sera from 160 HIV-infected individuals for antibodies reactive to HIV-1 gp160 epitopes defined by seven synthetic peptides. Seropositive individuals were placed into three groups based upon levels of circulating CD4+ cells. These groups consisted of individuals with (1) more than 400 CD4+ cells, (2) 200-400 CD4+ cells, and (3) fewer than 200 CD4+ cells/mm3. The percentage of sera containing antibodies reactive with two immunodominant gp160 epitopes (a.a. 304-321 and 600-611) was unchanged between groups, regardless of CD4 cell numbers. The percentage of sera containing antibodies reactive with weakly immunogenic gp160 epitopes, such as those defined by peptides 425-448 and 846-860, declined in the groups as CD4 values decreased. Our results suggest that the patterns of antibody reactivity to gp160 epitopes change as CD4 levels decline. A narrowing of the humoral immune response to epitopes on the envelope of HIV-1 appears to occur with disease progression.

Proctologic management of the HIV-positive patient.

With the adoption of mandatory testing for human immunodeficiency virus (HIV) in military personnel, a large number of HIV-positive individuals have been identified. From January 1986 to February 1988, 677 HIV-positive patients were evaluated at Wilford Hall USAF Medical Center. Most of these patients had disease in the Armed Forces Walter Reed stage I or II. Other sexually transmitted diseases were found in 407 patients (more than 60%). Of 163 patients (24%) with treatable anorectal conditions, 44 had nonsexually related anorectal conditions and 119 had anal condylomata. Patients with disease in early Walter Reed stages I and II did well with therapy of their anorectal diseases. We present our methods of evaluation, infection control, treatment, and results.

[Hemodynamic changes in varicoceles and their relation to fertility]. / Hemodynamické zmeny pri varikokéle a ich vzt'ah k fertilite.

Hemodynamic changes in the vascular bed of the affected testis were studied in 45 sterile and 6 fertile patients with varicocele. The examination method used was modified abdominal angiography. The most frequently recorded change in the arterial bed was persistence of the contrast medium in the left internal testicular artery (5 patients). All these patients were from the group of sterile subjects. The most frequent finding in the venous bed was venous reflux from the left renal vein into the left internal testicular vein (45 sterile and 2 fertile patients). In some sterile patients pathologic opening or origin of the vessels was observed. The substantially higher rate of hemodynamic changes in sterile patients suggests their direct relationship to spermiogenesis.

Circumvention of defective CD4 T helper cell function in HIV-infected individuals by stimulation with HLA alloantigens.

PBL from approximately 50% of asymptomatic individuals infected with HIV have been previously demonstrated to exhibit defective in vitro Th function that is selective for influenza A virus (FLU), but not for HLA alloantigens (ALLO). In this report, we have further studied HIV+ individuals with this selective Th defect, and demonstrate that defective in vitro CTL responses to FLU can be restored by costimulation with FLU + ALLO. In contrast, HIV+ patients who have lost Th responses to ALLO were unable to correct CTL responses to FLU by this costimulation procedure. These findings indicate that intact Th responses to ALLO can be used in vitro to provide Th signals necessary to activate the T effector cell response to a potential pathogenic virus. Our results raise the possibility that a program of in vivo coimmunization with ALLO plus antigens of potential pathogens (including HIV) can be useful in HIV+ patients exhibiting selective defects in Th function. Furthermore, this approach could be incorporated in vaccine trials aimed at enhancing immunity to HIV in patients who have been infected previously with this virus.

Increased serum neopterin in patients with HIV-1 infection is correlated with reduced in vitro interleukin-2 production.

Recently we have observed that the CD4+ T cell response of peripheral blood mononuclear cells (PBMC) to soluble antigens is the first to be lost in the course of HIV-1 infection followed by the loss of response to HLA alloantigens. In this study we compared serum neopterin concentrations of individuals with early stages of HIV-1 infection (stages WR1 and WR2, Walter Reed staging system) with in vitro interleukin-2 (IL-2) production of PBMC in response to stimulation with soluble antigens (influenza A virus and tetanus toxoid) and alloantigens. Neopterin concentrations were significantly higher in HIV-1-seropositive individuals who showed deficient IL-2 production in response to recall antigens only or to all of the stimuli tested in vitro, compared with HIV-1-seropositive individuals who exhibited no CD4+ T cell defects. No difference in serum neopterin concentrations was observed between the group that was functionally deficient to soluble antigens only versus those who were unresponsive to both types of stimuli. It appears that the selective loss of the MHC self-restricted CD4+ T cell function is associated with an increase in serum neopterin levels. Neopterin concentrations are an estimate of the activation status of macrophages. We conclude that defective in vitro production of lymphokines by T lymphocytes is associated with activated macrophages in vivo.

Surgical management of anal condylomata in the HIV-positive patient.

A retrospective review of 677 patients who tested positive for the human immunodeficiency virus, evaluated from January 1986 to February 1988, demonstrated 119 patients (18 percent) with anal condylomata. Demographics of these patients were similar to the total human immunodeficiency virus group; ages ranged from 19 to 86 years (mean, 25 years). Ninety-four percent of patients were men, 62 percent were white, 30 percent were black, and 10 percent were other races, primarily Hispanic. Ten percent of the patients admitted to homosexual activity and 2 percent admitted to intravenous drug abuse. Sixty percent of the population had another sexually transmitted illness. The majority of patients were in early Walter Reed Classes (Stage I or II). With follow-up of 4 to 26 months (mean = 12 months), the recurrence rate for anal condylomata was 26 percent after local treatment with podophyllin and 4 percent after fulguration and excision. There were no operative complications. Our study confirmed that anal condylomata and sexually transmitted diseases are common in patients who test positive for the human immunodeficiency virus and that patients who test positive for the human immunodeficiency virus with early Walter Reed stages can be expected to do well with appropriate therapy.

Accessory cell function in asymptomatic human immunodeficiency virus-infected patients.

Peripheral blood mononuclear cells from human immunodeficiency virus seropositive (HIV+) individuals who did not exhibit symptoms of acquired immunodeficiency syndrome (AIDS) (Walter Reed Stage 1 patients) were tested for accessory cell function for presentation of recall antigens to autologous T lymphocytes and for presentation of HLA alloantigens to T lymphocytes from healthy, HIV- donors. Neither experimental model indicated a defect in accessory cell function at this early stage after HIV infection, although our study does not exclude the possibility of accessory cell dysfunction at a later stage of AIDS development.

Synthetic peptides define the fine specificity of the human immunodeficiency virus (HIV) gp160 humoral immune response in HIV type 1-infected chimpanzees.

The fine specificities of antibodies produced against human immunodeficiency virus type 1 (HIV-1) gp160 were examined in sera from 23 HIV-1-infected chimpanzees. These animals had been infected with one of six isolates of HIV-1. Sera were screened by enzyme-linked immunosorbent assay for reactivity against seven synthetic peptides corresponding to regions of gp160. Chimpanzees appear to remain healthy after infection with HIV-1, suggesting that these animals may prevent extensive spread of the virus in vivo through immunologic mechanisms. Antibody specificity to gp160 epitopes may play a key role in the defense against HIV-1-related disease. Approximately one-half of all chimpanzee sera contained antibodies reactive with peptide 846-860, which corresponds to the carboxyl terminus of gp41. Less than 10% of sera from HIV-1-infected humans that were examined contained antibodies reactive with peptide 846-860, suggesting that this region is not highly immunogenic in humans. Of the human sera containing antibodies reactive with this peptide, all were from individuals classified as Walter Reed stages 1 to 3. No sera from humans with advanced stages of the disease contained antibodies reactive with peptide 846-860. Peptide 600-611, which reportedly reacts with nearly all sera from HIV-infected humans, was reactive with less than one-half of sera from HIV-1-infected chimpanzees. The observed differences in antibody reactivity to gp160 peptides in sera from HIV-1-infected chimpanzees and humans suggest that each may generate antibodies against differing sets of HIV-1 epitopes. These differences may contribute to the lack of disease progression in chimpanzees after infection with HIV-1.

Hepatitis C antibody in a non-hemophiliac cohort infected with the human immunodeficiency virus.

Development of a serologic test which detects antibody to hepatitis C virus (anti-HCV) allowed us to compare the seroprevalence of hepatitis C and hepatitis B in 493 persons infected with the human immunodeficiency virus (HIV). These persons, none of whom are hemophiliacs, are part of the US Air Force HIV Natural History Study. We found that Hepatitis B core antibody (anti-HBc) was far more prevalent (59%) than anti-HCV (8%). Anti-HBc prevalence was not different between those with and those without anti-HCV, being present in the majority of persons in both groups. In addition, we compared anti-HCV+ and anti-HCV negative persons in terms of syphilis serologies (Reactive Plasma Reagent [RPR] and Fluorescent Treponemal Antibody Absorption [FTA-ABS]), hepatic transaminase levels, and racial composition. In this cohort, we found that anti-HCV+ persons are significantly more likely to have a positive RPR but not FTA-ABS, increased hepatic transaminase levels, and to be Black rather than Caucasian.