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Health care workers are caring for an increasing number of persons infected with human T-cell lymphotropic virus type III (HTLV-III), the primary etiologic agent of the acquired immunodeficiency syndrome (AIDS). We studied 361 health care and clinical laboratory personnel from institutions in several metropolitan areas with both high and moderate levels of HTLV-III infection among high-risk group members to evaluate routes of exposure to and seropositivity for HTLV-III. Protection of the privacy of subjects and prospective determination of risk factors were integral components of the study design. Six (26%) of 23 health care workers with recognized risk factors for AIDS had HTLV-III antibodies. Thirty-nine (14%) of 278 workers at one institution as well as a total of five workers from other institutions reported possible percutaneous exposure to HTLV-III, usually injuries with needles that had been used on AIDS patients. There were three HTLV-III seropositive subjects who reported possible parenteral exposure to HTLV-III but no recognized AIDS risk factors. One was a symptomatic female, subject A, and her apparent sources of HTLV-III exposure were two puncture wounds, without injection of blood, made with needles used on AIDS patients. Human T-cell lymphotropic virus type III was cultured from her asymptomatic, seronegative long-term sexual partner, apparently representing female-to-male transmission. For the two other seropositive workers (subjects B and C) with nosocomial parenteral exposure, we could not rule out heterosexual transmission as a possible source of HTLV-III exposure. These latter two cases as well as the identification of seropositive health care providers from known risk groups point to the need for thorough case investigation to identify routes of exposure in health care workers. The risk of nosocomial HTLV-III transmission appears to be low and related to percutaneous exposure. Medical personnel should be trained systematically in the proper techniques and handling of instruments for phlebotomy and similar procedures to decrease occupational exposure to HTLV-III. ( JAMA 1985;254:2089-2093)

The acquired immune deficiency syndrome (AIDS) has focused renewed interest on cytomegalovirus (CMV) both as an infectious complication of the syndrome and as a potential etiologic agent in the pathogenesis of the immunosuppression. We studied 30 healthy homosexual men in New York City to determine the prevalence of virus excretion and its relationship to CMV-IgM antibodies and to T-lymphocyte subsets. Cytomegalovirus was detected in the urine and/or semen of 11 subjects. Eight of 11 CMV shedders were CMV-IgM positive, but CMV IgM was found in only one of 19 not shedding the virus. While homosexuals as a group had lower 0KT4/0KT8 ratios (0.8 ±0.4, mean±SD) than heterosexual controls (1.8 ±0.4, mean ± SD), there was no significant difference in ratios between homosexuals excreting virus and those not excreting virus. Cytomegalovirus excretion by homosexual men seems to be more prevalent than previously appreciated and may pose a significant risk for sexual transmission. ( JAMA 1984;252:1908-1910)

Central-nervous-system toxoplasmosis developed in 7 of 269 patients with the acquired immunodeficiency syndrome reported to the New York City Health Department through July 1982. Focal neurologic abnormalities, mass lesions on computed-tomographic brain scans, lymphocytic cerebrospinal fluid pleocytosis, and detectable IgG antibody to Toxoplasma gondii were common; but IgG titers of 1:1024 or more, IgM antibody to T. gondii, and positive open brain biopsies were uncommon. Serologic findings suggested that the disease resulted from recrudescent rather than primary infection. Four of five patients improved when treated with sulfonamides and pyrimethamine, but 2 had relapses. An aggressive diagnostic approach and sometimes even empiric therapy are warranted when central-nervous-system toxoplasmosis is suspected in a seropositive patient with the acquired immunodeficiency syndrome.

In Reply.— The study of Mabray et al1was not included in my report because it had been published in May 1982, which was too late for my review. It was concerned with the use of subcutaneous neutralization with progesterone to relieve dysmenorrhea, premenstrual syndrome, midcycle pain, and nausea and vomiting during pregnancy. Thirty-two patients were studied with the single-blind technique and were reported to be able to select a progesterone dilution as their visualizing end point as compared with placebo. In view of the lack of scientific evidence to support progesterone allergy and the failure to use a double-blind trial to evaluate subjective symptoms, I do not believe that this study would have warranted inclusion in my review, which focused predominantly on inhalant and food sensitivities. The remaining four articles referred to by Dr Podell deal principally with sublingual provocative testing and desensitization. The article by Dr King

Excerpt To the editor: In 1975 a virus with the morphologic characteristics of a parvovirus was found in the serum of asymptomatic blood donors (1) and was found to meet the requirements for classi...

In Reply.— I am pleased that Dr Miller has chosen to comment on the intradermal provocative-neutralization method. The text of my review of "Controversial Practices in Allergy" clearly indicated that the method outlined by Rinkel et al 1 in 1964 was summarized in Table 5. It is unlikely that this method was abandoned before publication. My article inThe Journaldid not state that Miller's positive double-blind study results were followed by four controlled studies unable to support the efficacy of this method. The text stated "However, four controlled studies were unable to support the efficacy of this method." There is no indication of the priority of publication. Dr Miller's suggestion that his study of the therapy for eight patients published in 1977 2 that used his version of the technique is adequate support for this procedure is unacceptable. Multiple and reproducible studies designed to eliminate bias must remain the

We examined the long-term safety and efficacy of zidovudine therapy in 229 subjects with acquired immunodeficiency syndrome (AIDS) and AIDS-related complex who previously participated in a placebo-controlled study of zidovudine. One hundred two placebo recipients (delayed treatment group) and 127 zidovudine recipients (original treatment group) were followed up while receiving zidovudine therapy for a mean of 21 months. Survival rates for the original treatment group were 84.5% and 57.6% at 12 and 21 months, respectively; for the delayed treatment group, 78.8% and 64.6% at 12 and 18 months, respectively; and 78.8% and 47.5% at 12 and 21 months, respectively, for 77 subjects with AIDS and 93.0% and 71.8%, respectively, for 50 subjects with AIDS-related complex in the original treatment group. Adverse reactions decreased over time and newly observed toxic reactions were unusual. The clinical course of these subjects suggests continued survival benefits with long-term zidovudine therapy. ( JAMA . 1989;262:2405-2410)

The clinical practice of modern allergy has a sound foundation in a scientific understanding of the pathogenesis of hypersensitivity disorders. However, several practices continue to be regarded as controversial. Controlled studies have failed to establish the effectiveness of intracutaneous or low-level modified radioallergosorbent titration as a guide to immunotherapy. In addition, controlled studies do not support the clinical usefulness of provocative subcutaneous or sublingual testing procedures or the leukocytotoxicity assay for the diagnosis of food allergy. Food additives have not been clearly shown to influence hyperkinesis, and autogenous urine immunotherapy is without supporting evidence of effectiveness and is potentially harmful. Since allergic diseases are common and the economic impact of medical care for these patients is great, it is important for physicians to understand the basis for these procedures and to advise patients accordingly. ( JAMA 1982;247:3106-3111)

During the 21-month period from October 1968 to July 1970, Serratia marcescens was recovered from the sputum of 65 patients. Many of these infections resulted from contaminated sodium chloride solution used as diluting fluid for medication nebulizers. Five patients in the sixth decade or older were suspected of having developed pneumonitis. There were no distinctive signs or symptoms, and pseudohemoptysis was not noted in spite of the presence of pigmented strains in three of the patients. Mild leukocytosis was characteristic, and roentgenograms usually revealed moderate lobular infiltration of the upper or lower lobes that was not cavitary, but often was accompanied by metapneumonic pleural effusion. The present antibiotic of choice is gentamicin. Many respiratory infections are the result of nonpigmented strains that must be distinguished from other gram-negative paracolon bacilli.

Allergic reactions to penicillin occur in approximately 1% to 10% of patients. 1 The frequency of anaphylaxis, the most severe type of reaction, is also variable but one recent study revealed nonfatal anaphylaxis in 0.11% of cases of which 0.035% were considered severe. 2 From Welch's study in 1957, it is estimated that 10% of severe penicillin anaphylactic reactions are fatal. 3 The problem of penicillin hypersensitivity has been approached in two separate ways. First, an intensive effort has been made to define an objective and dependable method for detecting penicillin allergy. Multiple studies have been published dealing with the use of penicillin and several metabolites in an attempt to demonstrate skin-sensitizing antibody, 4,5 hemagglutinating antibody, 6,7 indirect basophil degranulation, 8 histamine release from leukocytes, 9 rabbit passive cutaneous anaphylaxis, 10 and increase of lymphocyte size with tissue culture of sensitized lymphocytes. 11 A well-defined testing procedure has not yet been evolved. 1 Since all penicillin derivations, including penicillin O

Five patients with presumptive bacteremia or meningitis whose routine cultures were negative were found to harbor aberrant forms of bacteria or fungi. In each instance, organisms grew initially from blood, tissue, or spinal fluid specimens only in hypertonic salt or sucrose media. Upon reversion to the parent organism, two were found to be Corynebacterium strains; two, α-hemolytic streptococci; and one, Cryptococcus neoformans . In one instance, a coagulasenegative Staphylococcus albus was recovered in addition to αhemolytic streptococcus. In four of the five patients, serologic studies supported the bacteriologic findings. In two of the five, no antibiotic had been administered prior to isolation of the aberrant forms. Therapy directed against the aberrant form was beneficial in one patient, and the condition of two others improved following treatment directed against the parent strain or against both the parent and the transitional forms.