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Cytomegalovirus retinitis is the most frequent ocular opportunistic infection in AIDS patients. Untreated, it is always a progressive and destructive disease of the retina that results in blindness. Specific treatment is therefore mandatory to halt the progression of the retinal lesions. The authors report their experience in the treatment of CMV retinitis with foscarnet in 25 AIDS patients; the drug is an analog of pyrophosphate, virostatic against all herpes-class viruses including CMV. Foscarnet was successful in halting the progression of CMV retinitis during induction treatment (180 mg/kg/day) by either a TID (three times a day) or a BID (twice a day) regimen, and in healing retinal lesions during maintenance (90 mg/kg/day) in 14 out of 19 patients. Five patients had a relapse of retinitis during maintenance. In these patients a brief course of intravitreal foscarnet, in association with the lowest dosage of the drug administered systematically (90 mg/kg/day), was effective in healing the retinal lesions. The main systemic side effects, such as renal impairment and electrolytic disturbances, were observed only during the induction treatment, and only in one case was it necessary to stop the therapy.

13 patients with HIV-related immune thrombocytopenia (HIV-ITP) and 10 patients with chronic idiopathic thrombocytopenic purpura (C-ITP) were treated with a single course of alpha-2b-Interferon (IFN 3 x 10(6) IU subcutaneously for 12 d). The patients had platelet counts lower than 40 x 10(9)/L and thrombocytopenia persisting for over 1 year (range 1-22 years); 7 patients were refractory to previous conventional therapy, 5 were responsive, and 11 had not been previously treated. The response to IFN was complete in 8 patients (platelets > 100 x 10(9)/L), partial in 7 (platelets 50-100 x 10(9)/L); 8 patients showed no response. The treatment with IFN was stopped after 4 d in one patient due to a fall in platelet count. The maximal platelet count (median peak 116 +/- 55 SD x 10(9)/L platelets) was obtained after 13.7 +/- 2.98 d and the improvement in platelet count was maintained for 22.8 +/- 8.6 d. No difference in platelets response was observed between HIV-ITP and C-ITP. The response to IFN seems to be related to the one obtained with previous treatments. Indeed 80% of the patients who were responsive to previous steroids, high dose immunoglobulins or azidothymidine (HIV-ITP) showed a complete or partial response while only 43% of the refractory patients showed a partial response; the positive response rate in previously untreated patients was 73%.

Sir: Recent studies have shown that primary hepatocellular carcinoma (PHC) in childhood is aetiologically related to hepatitis B virus (HBV) infection [1]. So far, there are no prospective studies, however, of the development of PHC in children with chronic type B hepatitis, and little is known about risk factors and early diagnosis of the turnout in this population. In 1976 in Padua we started a longitudinal study of biopsy-proven chronic type B hepatitis, and since 1985 we have introduced alpha-fetoprotein determination among routine tests to be performed every 6 months during follow up. Overall 103 children, including 5 with histological features of cirrhosis, have been followed up for a mean period of 6.1 _+ 2.9 years (mean + SD). During the observation period none of the patients had signs of liver failure or portal hypertension, but one out of five children with cirrhosis developed high alpha-fetoprotein levels and was found to have PHC, before the appearance of any clinical symptoms. We report here the clinical history of this patient. The first child of apparently healthy, non-consanguineous parents, was born in 1978 after an uncomplicated gestation and full-term delivery. He was found to be HBsAg positive at the age of 15 months when his younger brother died of fulminant hepatitis B. At this time his mother was also found to be HBsAg positive. The boy came to our attention at the age of 24 months: he was a well grown asymptomatic child with moderate hepatomegaly and a threefold increase of alanine aminotransferase (ALT) levels. Liver function tests were normal, hepatitis Be antigen (HBeAg) was negative while antiHBe was positive. Six months later liver biopsy showed features of chronic active hepatitis with associated cirrhosis, while HBV DNA was undetectable in serum. By the age of 36 months ALT had become normal and 15 months later liver biopsy was consistent with inactive cirrhosis. Since then the patient has remained asymptomatic, with normal ALT levels. He was followed at regular intervals up to October 1985 when alpha4etoprotein levels were normal. During subsequent years we received information about the child's health but could not see the patient until February 1989.

Summary Cryptococcosis and aspergillosis in immunocompromised patients are extremely difficult clinical conditions to manage and treatment with available antifungal drugs often fails. Itraconazole, R-51211, Janssen Pharmaceutica, a new orally absorbed triazole, is a possible alternative drug which is potentially effective and nontoxic. Preliminary experience with 28 patients, eight with cryptococcosis and 20 with aspergillosis, is reported. Of these patients, 16 were immunocompromised (seven with the acquired immune-deficiency syndrome (AIDS), five heart transplant recipients and four with leukaemia or lymphoma). Overall, results of treatment were good (18 in remission, four markedly improved, four moderately improved and two failed). Prevention of relapses of cryptococcosis was obtained in all patients with AIDS on long-term itraconazole monotherapy (3 mg/kg). Treatment of invasive aspergillosis required a higher dosage (about 5 mg/kg) and prolonged administration. Besides its efficacy this antifungal agent allowed outpatient management.

8 children, known to have been hepatitis B surface antigen (HBsAg) and hepatitis B e antigen (HBeAg) positive for more than 6 months and with chronic active hepatitis on biopsy, received 2.5 mg levamisole/kg/day, 2 days a week for 6-18 months. In 6 of the 8 children transaminases normalized within 4-18 months of therapy, with seroconversion to antibody to HBeAg (anti-HBe) and disappearance of HBV-DNA polymerase from serum and of hepatitis B core antigen (HBcAg) from liver. In these cases liver biopsies taken after treatment showed histological regression to chronic persistent hepatitis. Two distinct patterns of response to levamisole were noted: patients having higher pretreatment transaminase levels and lower expression of HBcAg in the liver showed an early transaminase normalization and anti-HBe seroconversion with therapy, while in patients with less active disease and more diffuse HBcAg positivity in pretreatment liver biopsies, longer treatment periods were necessary to achieve these effects. Our results suggest that long-term levamisole therapy may be beneficial in HBeAg-positive chronic hepatitis type B.

EEGs of 18 cases of measles (uncomplicated, with seizures, with encephalitides) were obtained through an underground cable connection between the Infections Diseases Department and the EEG unit. The varions EEG features of the disease have been studied during the evolution of the illness. An occasional EEG does not offer specific information on either the severity or the evolution of the disease. Marked EEG abnormalities appeared in the encephalitic group. The Authors emphasize the importance of serial prolonged EEG follow-up of measles in order to define precisely the stage and the evolution of the disease.

A prospective study of acute symptomatic viral hepatitis in childhood was started at the Department of Infectious Diseases of Padua (Italy) in 1978. During an 8-year period, 93 consecutive patients (aged 3 months to 12 years) fulfilled the diagnostic criteria, including five (5.5%) cases classified as non-A, non-B hepatitis. This figure is lower than that generally reported in adult patients, probably because of a lower exposure of children to blood and contaminated materials. Two of the five children with non-A, non-B hepatitis had received blood transfusions, while three had no history of parenteral exposure. Although the outcome of the illness was favorable in all five patients, a variety of clinical features could be observed: two children had a mild, short-lasting disease, anicteric in one case, while three had a polyphasic pattern of transaminases with delayed biochemical resolution, including one patient with deep jaundice and severe early phase features. These findings suggest that in children, as well as in adults, non-A, non-B hepatitis is probably a heterogeneous entity induced by different agents with different modes of transmission.

Clinical, virological, and histological features of hepatitis B virus infection have been examined in 35 children, aged 1 to 11 years, known to be hepatitis B surface antigen (HBsAg) carriers for at least six months when entering the study. Only 10 patients had a history of acute unresolved hepatitis: in the remaining cases the detection of HBsAg had been an occasional finding. Although 77% of the patients were asymptomatic, all had evidence of hepatic involvement and liver history showed the features of chronic persistent hepatitis in 18 cases and of chronic active hepatitis in 16 cases, with associated cirrhosis in two of them. One patient had only minimal histological changes. A high percentage of children with both chronic persistent and chronic active hepatitis had evidence of active virus replication throughout the observation period. During the follow-up study of one to eight years (mean 3.1 +/- 1.7 years), transaminase levels became consistently normal in five patients with chronic persistent hepatitis, and inflammatory infiltrates disappeared in three of them. However, only one of these children cleared HBsAg from serum. Eleven of 16 patients with chronic active hepatitis received immunosuppressive treatment but only one of them achieved a complete and protracted remission, although active viral replication persisted. On the other hand, two of five untreated patients reached complete remission after two and three years of follow-up respectively and one of them cleared HBsAg three years later. These results would suggest the possibility of a spontaneous complete remission of HBsAg positive chronic active hepatitis in children but also raise doubts about the usefulness of immunosuppressive therapy in such patients.

A follow-up of 23 patients with measles encephalitis was carried out six months to ten years after the onset of the disease. Neurological and electroencephalographic features have been examined together with specific psychological tests. Clinical and electsroencephalographic abnormalities, frequently observed during the acute phase of the disease, were rarely detected during the follow-up. However intellectual performances with specific visuo-spatial and attentional involvement are often impaired. Specific psychological tests are required to evaluate visuo-spatial and attention performances, frequently impaired as a consequence of the disease; these are often considered minor psychological disturbances as they are limited to scholastic performances. The Authors conclude that, although measles encephalitis is a fairly serious illness during its acute phase, it tends to improve with time until recovery is complete. The psychological residual deficits, detected during the follow-up, should not be considered as minor disturbances.