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A 10 1/2-year-old girl with Haemophilus-meningitis was found to have hypogammaglobulinemia. Further immunologic evaluation revealed common variable immunodeficiency. Patients suffering from severe or recurrent infections should always be suspected to have immunodeficiency disease.
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Regarding the staging of HIV infection, there are several classification systems, but neither of them has universally been accepted. We tested a new staging system with 4 parameters: HIV antibodies, CD4/CD8 ratio, absolute count of CD4 + lymphocytes, and absolute count of leukocytes. This classification indicates a regular progression of immunodeficiency, 294 blood specimens were used for immunological staging. The correlation between the immunological staging and the severity of the disease proved the usefulness of this classification system.
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AIDS is a transmissible immunodeficiency syndrome which has first been observed less than a decade ago and since that time has spread in an epidemic manner. Usually it manifests itself by opportunistic infections and/or neoplasias. After courses of a few years, approximately 100% of cases have a lethal outcome. Sometimes, neuropsychiatric disturbances are the presenting symptoms and signs of AIDS. One of the first important observations was, that certain behavioural patterns such as homosexuality and intravenous drug abuse were apparently associated with a high risk for acquiring AIDS. The occurrence of AIDS in a number of haemophiliacs and recipients of blood transfusions suggested an important role of the haematogenous route of transmission. Not more than two years after the first clinical reports on AIDS a retrovirus was identified as the etiological agent. On the basis of different criteria this retrovirus can be classified as a slow virus. Subsequently, virological tests were developed which allowed an early diagnosis of this viral infection, even prior to the evolution of clinical symptoms. Immunological features of this new syndrome include disturbances of cellular as well as humoral immune functions. As we have no effective chemotherapy for AIDS and the successful development of a vaccine is delayed by a number of virological problems, it is of special importance to prevent transmission of the disease.
We report here on a 36-year old, HIV-positive patient, who was sent to hospital with an anal fistula. A short time later during the course of an extensive diagnosis the anal fistula was recognized as an extrapulmonary manifestation of a miliary tuberculosis stemming from an immunodeficiency syndrome. A rapid conversion of the sputum, a normalization of the radiological findings and the absence of relapse are the results of the classic systemic fourfold therapy with myambutol, isoniazid, rifampicin and streptomycin. The danger of overlooking the fact that an anal fistula can be the clinically primary manifestation of a tuberculosis and the problems of a mixed infection within the scope of the acquired immunodeficiency syndrome are discussed. Tuberculosis as a frequent complicating infection of HIV-positive patients--often diagnosed some time before the AIDS-infection as in our patient--can be successfully cured by a high dose of intravenous pharmacotherapy, even when additional complications (parasitic stomatitis, increasing deterioration of the immunological parameters) are present. In order to show the large spectrum of the problems involved in the diagnosis, the therapy and the course of the active acquired immunodeficiency syndrome, we have focused here on the detailed description of the case report.
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Manuel born in June 1984 is presented for the first time at the age of 6 months with the following symptoms: Otitis purulenta, enlargement of lymph-nodes, swelling of liver and spleen, enteritis, failure to thrive and candida albicansdermatitis. Immunoglobulins and the total serumprotein are elevated. At the age of 9 months a new Hospital admission was necessary. The following symptoms are present: severely enlarged lymph-nodes at different sites, enlargement of liver and spleen, interstitial pneumonia and enteritis. Body weight is below the third percentile. Tine-Test negative. The baby was BCG vaccinated after birth and at 3 months the Tine-Test was positive. The serologic antibody tests (Elisa and Western Blot) for HTLV III are positive, the index helper: suppressor T cells is 1,1 (normal above 1,5). The antibody titers in the maternal blood are higher than in the child. The mother was a regular drug user. A vertical perinatal transmission from the affected mother to her baby is postulated. The start of clinical illness was the 5th month of life. AIDS was fully developed at 9 months of age. Cotrimoxazol treatment resulted in clinical improvement.
The authors report on two patients who presented with sudden loss of vision, due to irodocyclitis and retinochoroiditis in one patient and optic neuritis in the other. AIDS was diagnosed in both patients on the basis of a positive HIV antibody assay, lymphopenia, and a reduced helper-to-suppressor subset ratio. Soon afterwards, the patient with retinochoroiditis developed the full-blown picture of AIDS with cerebral involvement. Neither anticytomegaly treatment with DHPG nor triple therapy for toxoplasmosis was able to prevent the fatal course. The patient died within six months. In contrast, the patient with optic neuritis recovered full visual acuity. So far there has been no relapse, nor any opportunistic infection in other organs.
Pneumocystis carinii pneumonia is one of the most frequent infectious complications in patients with the acquired immunodeficiency syndrome (AIDS). A prospective trial was initiated to compare azidothymidine alone with azidothymidine plus aerosolized pentamidine as a secondary prophylaxis for pneumocystis carinii pneumonia. 27 patients (24 male, three female, average age 39 years) were enrolled, 14 patients receiving azidothymidine and pentamidine aerosol and 13 azidothymidine alone. After 166 days of follow-up, this trial had to be terminated prematurely, since the efficacy of pentamidine aerosol in the prevention of pneumocystis carinii pneumonia was clearly demonstrated in two recently published studies. Two patients died during the study period, one in either group, but neither due to pneumocystis carinii pneumonia. Two patients developed histologically proven pneumocystis carinii pneumonia; both patients were allocated to the azidothymidine arm. Pneumocystis carinii pneumonia was suspected clinically but not proven in four patients, three were randomized in the azidothymidine arm. Pentamidine was well tolerated and produced no severe side effects. The sample size is too small to draw definitive conclusions concerning the efficacy of pentamidine aerosol in AIDS patients.
Tuberculosis is the most frequent infectious complication of AIDS and HIV infection in countries where che prevalence of tuberculous infection is high. HIV infection is the strongest risk factor for developing tuberculosis in individuals infected removly or recently with tubercle bacilli. An increased incidence of tuberculosis has been already documented in several African countries with a high prevalence of both tuberculous and HIV infections (Tanzania, Malawi). The increase in the incidence of tuberculosis is mainly due to the depression of cellular immunity caused by HIV infection in subjects infected with M. tuberculosis. The occurrence of tuberculosis in HIV-seropositive persons is more frequent in those remotely infected than in those recently infected or reinfected with M. tuberculosis. In developed countries, HIV infection will cause tuberculosis in only a relatively small number of persons, since the prevalence of tuberculosis infection is low in the age group up to approximately 45 years. HIV infection will, therefore, not substantially increase the number of tuberculosis cases.
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The immunopathogenesis of AIDS and the problems arising from the infection of immunocompetent cells with the human immunodeficiency virus (HIV) are being discussed. Recent investigations point at the fact that CD4-positive T cells are not the only targets of HIV, but that also other cells of the immune system which are involved in the generation of the immune answer might be affected by the infection. This could result from a direct effect of HIV upon the respective cell function or as a consequence of other cells involved in the regulation of the immune response. Although many efforts are being undertaken, no clear-cut therapeutic modality has been yet discovered to counter the effects of HIV upon the immune system.
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The gastrointestinal tract is a major target organ of the acquired immunodeficiency syndrome. Opportunistic infections or Kaposi's sarcoma within the gastrointestinal tract are the two most frequent lesions. Diarrhoea, weight loss or odynophagy may be the presenting symptoms or signs for which a gastroenterological consultation is sought. In this report we present our own observations of patients with AIDS. Diagnostic and therapeutic aspects of this new syndrome are discussed.