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We studied the production of IgG antibodies against eight pneumococcal polysaccharide serotypes (PPS) 1, 4, 6B, 9V, 14, 18C, 19F and 23F after vaccination of 50 HIV-infected adults with 23-valent Pneumovax((R))23 and the course of the antibodies against four PPS during the following years. Mean antibody concentrations against PPS 18C, 19F and 23F were sigificantly lower in the patients with CD4(+)-lymphocyte counts <200x10(6)/l than in healthy controls; mean antibody concentrations against PPS 1, 4, 9V, 6B and 14 were similar in HIV-infected individuals and controls. Although it has been assumed that polysaccharides induce a T-cell-independent immune response, our results indicate that some PPS are T-cell-independent type 2 antigens. The rates of decline of mean antibody concentrations in HIV-infected individuals and in healthy controls were similar during 5 y after vaccination. However, as a consequence of the low postvaccination antibody concentrations against several PPS, within 3 y after vaccination most HIV-infected individuals had antibody concentrations below the level which is assumed to be required for protection.

Infections with Salmonella species, including Salmonella typhi, are more frequently observed in HIV-infected individuals than in healthy individuals. HIV-infected individuals were vaccinated with polysaccharide vaccine against Salmonella typhi (Typhim-Vi) which is assumed to be a T-cell-independent antigen. We found that the antibody response in patients with < 200 x 10(6)/l CD4+ T lymphocytes was significantly lower compared with patients with > or = 200 x 10(6)/l CD4+ T lymphocytes and healthy controls. The antibody response after vaccination with the polysaccharide salmonella Vi-antigen was correlated with the number of CD4+ T lymphocytes and therefore Typhim-Vi can be considered to be a T-cell-independent type 2 antigen. The results of this study indicate that after vaccination the proportion of HIV-infected individuals with protective antibody concentrations against Salmonella typhi will be lower than in healthy controls.

In previous studies, we have shown that intact, heat-killed, gram-negative bacteria (GNB) and gram-positive bacteria (GPB) can stimulate the production of various proinflammatory and anti-inflammatory cytokines. The objective of the present study was to investigate whether the production of tumor necrosis factor alpha (TNF) and interleukin-10 (IL-10) by human monocytes stimulated by intact heat-killed or live Haemophilus influenzae or Streptococcus pneumoniae is mediated by CD14. Two anti-CD14 monoclonal antibodies (MAbs) were used to study the interaction between human monocytes and bacteria; lipopolysaccharide (LPS) was used to validate the effect of anti-CD14 MAb. MAb 18E12 decreased significantly TNF and IL-10 production upon stimulation with LPS or heat-killed bacteria and TNF production during stimulation by live bacteria. MAb My-4 decreased production of TNF and IL-10 by monocytes stimulated with LPS, IL-10 but not TNF production upon stimulation with heat-killed H. influenzae, and production of neither TNF nor IL-10 upon stimulation with S. pneumoniae. Together, these results led to the conclusion that CD14 is involved in the recognition and stimulation of human monocytes by intact GNB and GPB. Consequentially, the option for adjunctive treatment of severe infections with anti-CD14 MAb is postulated.

Since the mid-eighties an increase of severe infections with invasive group A streptococci (GAS) has been noticed throughout the world, not only in the elderly but in healthy adults as well. The acute presenting infection starts with fever, enanthema, generalised erythema, rapidly progressing into shock and multiorgan failure, and is called streptococcal toxic shock syndrome (STSS). Despite surgical and antibiotic therapy with penicillin and clindamycin the mortality is high. There are as yet insufficient data in patients with STSS to decide between penicillin en clindamycin. Intravenous administration of high dose gammaglobulin, advocated in the USA, might neutralize the exotoxins, but the effectiveness of this therapy has not been established yet.

In human immunodeficiency virus (HIV)-infected individuals the amount of antibodies formed after vaccination with T-cell-dependent recall antigens such as tetanus toxoid is proportional to the peripheral blood CD4(+) T-lymphocyte counts. To investigate whether the immunoglobulin G (IgG) subclass distribution and avidity of the antibodies produced after vaccination are affected as well, we gave 13 HIV-infected adults with low CD4(+) T-lymphocyte counts (<200 x 10(6)/liter; group I), 11 HIV-infected adults with intermediate CD4(+) T-lymphocyte counts (>/=200 x 10(6)/liter; group II), and 5 healthy controls booster immunizations with tetanus toxoid. The prevaccination antibody concentrations against tetanus toxoid were similar in the HIV-infected and healthy adults. After vaccination the total IgG and the IgG1 anti-tetanus toxoid antibody concentrations were significantly lower in group I than in group II and the controls. The avidity of the IgG1 anti-tetanus toxoid antibodies formed by HIV-infected adults was within the range for healthy controls, irrespective of their CD4(+) T-lymphocyte counts.

Background: Highly active antiretroviral therapy (HAART) effectively suppresses replication of HIV and is accompanied by an increase in CD4+ T lymphocytes. Whether the increase in CD4+ T lymphocytes in the blood is a reflection of a reconstitution of the immune functions is unknown. We investigated the recovery of the humoral immune response during HAART after immunization with T-cell-dependent influenza vaccine., Methods: Forty-one men and three women infected with HIV and treated with HAART, and 15 healthy hospital staff members were immunized with trivalent influenza subunit vaccine. Antibody titres were determined by haemagglutination inhibiting assay in sera obtained before and 30 days after immunization. Lymphocyte subsets were determined in blood samples taken at the time of vaccination., Results: In all HIV-infected individuals, treatment with HAART caused a median reduction of 2.3 log10 in HIV-1 load. The median increase of CD4+ T lymphocytes after initiation of HAART was 170 x 10(6)/l. The antibody response to influenza antigens was proportional to the number of memory CD4+ T lymphocytes in the blood at the time of vaccination. When a group of patients and healthy controls with approximately similar CD4+ T-lymphocyte counts were considered, the antibody titres after vaccination for influenza strain H1N1 and influenza B did not differ between patients and controls (P=0.12). Vaccination of patients with a CD4+ T-lymphocyte count of < 200 x 10(6)/l (mean 85 x 10(6)/l) before the start of HAART and with a mean of 282 x 10(6)/l CD4+ T lymphocytes at the time of vaccination as a result of HAART, demonstrated a substantial antibody response whereas patients with a CD4+ T lymphocyte count of < 200 x 10(6)/l (mean 56 x 10(6)/l) not treated with HAART (historical controls), and vaccinated with a similar influenza vaccine, failed to induce an antibody response., Conclusion: The present findings demonstrate a recovery of the humoral immune response to influenza antigens in HIV-infected individuals treated with HAART. This indicates that functional improvement of antigen specific CD4+ T helper cell reponses occurs.

Antibiotics with different mechanisms of action may vary with respect to their effects on the release and immunostimulatory activities of cell wall fragments from gram-positive bacteria. Therefore, after Staphylococcus aureus was cultured for 4 h in the absence of antibiotics (control) and in the presence of beta-lactam antibiotics (imipenem, flucloxacillin, or cefamandole) and protein synthesis-inhibiting antibiotics (erythromycin, clindamycin, or gentamicin), the lipoteichoic acid (LTA) and peptidoglycan (PG) levels in the bacterial supernatants were measured. beta-Lactam antibiotics greatly enhanced the release of LTA and PG (4- to 9-fold and 60- to 85-fold, respectively), whereas protein synthesis inhibitors did not affect PG release and even inhibited the release of LTA compared to the amount of LTA released in control cultures. The capacity of beta-lactam supernatants to stimulate the production of tumor necrosis factor alpha and interleukin-10 in human whole blood was significantly higher than that of protein synthesis inhibitor or control supernatants; the amounts of these cytokines released were directly proportional to the concentrations of PG and LTA in the supernatants. Enzymatic degradation of PG in the supernatants indicated that PG was mainly responsible for the observed biological reactivity.

This review of the literature on orbital infections focusses on bacterial infections of the preseptal space, subperiosteal abscesses, orbital phlegmon and orbital abscesses. The need for a timely diagnosis of and multidisciplinary approach to treatment of these infections, which may lead to life-threatening complications, is emphasized.

Interleukin-12 (IL-12) is a cytokine that promotes cell-mediated immunity to intracellular pathogens by inducing type 1 helper T cell (TH1) responses and interferon-gamma (IFN-gamma) production. IL-12 binds to high-affinity beta1/beta2 heterodimeric IL-12 receptor (IL-12R) complexes on T cell and natural killer cells. Three unrelated individuals with severe, idiopathic mycobacterial and Salmonella infections were found to lack IL-12Rbeta1 chain expression. Their cells were deficient in IL-12R signaling and IFN-gamma production, and their remaining T cell responses were independent of endogenous IL-12. IL-12Rbeta1 sequence analysis revealed genetic mutations that resulted in premature stop codons in the extracellular domain. The lack of IL-12Rbeta1 expression results in a human immunodeficiency and shows the essential role of IL-12 in resistance to infections due to intracellular bacteria.

It has been suggested that the antibiotic-induced release of lipopolysaccharide (LPS) is an important cause of the development of septic shock in patients treated for severe infections caused by gram-negative bacteria. Beta-lactam antibiotics change the integrity of the bacterial cell envelope by binding to penicillin-binding proteins (PBP) in the membrane and thus may affect the amount of LPS that is released and the kinetics of that release. In this respect, ceftazidime at intermediate concentrations binds with a high affinity to PBP 3 and PBP 1a and thus can induce filament formation in addition to killing, whereas imipenem preferentially binds to PBP 2 and PBP 1b, leading to spheroplast formation and rapid cell lysis. We investigated the effects of these antibiotics on the killing and the release of the radioactively labelled LPS of Salmonella typhi Ty 21A. A mathematical model was developed to calculate the delay between bacterial killing and LPS release, designated the lag time. At antibiotic concentrations inducing equal killing, the amount of LPS released was the same for both antibiotics. Only after 6 h of incubation at antibiotic concentrations above 0.5 microg/ml, the amount of 3H-LPS released was slightly higher (approximately 1.2-fold) in incubations with ceftazidime than in those with imipenem, and the maximum releases of the total label were 33.2% +/- 0.89% and 27.1% +/- 0.45%, respectively. Despite the clear concentration-dependent effect on the bacterial killing and subsequent LPS release, the lag time was independent of the antibiotic concentration. For ceftazidime as well as imipenem the lag time amounted to approximately 60 min. In conclusion, our findings imply that the mechanism of antibiotic-induced LPS release is independent of the PBP affinities for these beta-lactam antibiotics. Furthermore, once the organism is killed by either imipenem or ceftazidime, the rate of LPS release from S. typhi does not differ according to the antibiotic with which the organism is killed, and there is little difference in the relative amount of LPS released.

Background: An anti-inflammatory cytokine profile on whole-blood stimulation in vitro is associated with fatal outcome of meningococcal disease. We investigated whether an anti-inflammatory cytokine profile in the circulation is associated with adverse outcome in other infectious diseases., Methods: We enrolled 464 consecutive patients (272 men, 192 women) who presented to hospital with fever (> or = 38.2 degrees C). On admission we measured plasma interleukin 10 (IL-10) and tumour necrosis factor alpha (TNF alpha), and collected clinical and microbiological data on the febrile illness, then followed up all patients for clinical outcome., Findings: In at least 399 of the 464 patients fever was caused by infection. 33 patients died after a median hospital stay of 11 days (interquartile range 3-20). Concentrations of IL-10 were significantly higher in non-survivors (median 169 pg/mL [IQR 83-530]) than in survivors (median 88 pg/mL [42-235], p=0.042). When dichotomised around the median, the mortality risk was two times higher in patients who had high concentrations of IL-10 than in those with low concentrations (relative risk 2.39 [95% CI 1.07-5.33]), in patients with low and high concentrations of TNF alpha. In the 406 patients without haemodynamic deterioration in the first 24 h, IL-10 was higher and TNF alpha lower in patients who died than in those who survived. The ratio of IL-10 to TNF alpha was higher in non-survivors (median 6.9 [3.0-21.0]) than in survivors (median 3.9 [2.0-7.0], p=0.040). This ratio was highest in patients who died without underlying disease (median 21.5 [5.0-25.0]). Age, sex, and duration of fever before admission did not explain the differences in IL-10 and TNF alpha., Interpretation: An anti-inflammatory cytokine profile of a high ratio of IL-10 to TNF alpha is associated with fatal outcome in febrile patients with community-acquired infection. Our findings caution against a widespread use of proinflammatory cytokine inhibition in patients with sepsis.

Two patients are described with a mycotic aneurysm caused by streptococcus pneumoniae infection. The patients presented with back pain and fever, and had an antecedent history of lower respiratory tract infection; neither of them were suffering from endocarditis. Mycotic aneurysms are a rare disorder with, over the years, a changing spectrum of presentation, localisation and bacterial aetiology. S. pneumoniae infection has only very rarely been reported as a cause of mycotic aneurysms. Since 1986, 14 patients with a mycotic aneurysm were treated at the Leiden University Hospital. Of these patients, 5 had mycotic aneurysms caused by S. pneumoniae infection. The mortality in these patients was high. In this communication, we would like to draw attention to S. pneumoniae infections as an emerging cause of mycotic aneurysms.

A prospective study of antibody production by adults infected with human immunodeficiency virus (HIV) after vaccination with tetanus toxoid-conjugated Haemophilus influenzae type b (Hib) vaccine was conducted. Concentrations of antibodies to the two immunogenic components of the vaccine (i.e., polyribosylribitolphosphate [PRP] and tetanus toxin) were determined. Individuals were divided into three groups according to the CD4+ T lymphocyte count: group 1, < or =100 x 10(6)/L; group 2, 101-300 x 10(6)/L; and group 3, >300 x 10(6)/L. After vaccination, concentrations of IgM and IgG antibodies to PRP were significantly lower in group 1 than in the other patient groups and controls. A CD4+ T lymphocyte count of <100 x 10(6)/L and an impaired proliferative response of lymphocytes to monoclonal antibody to CD3 were independently associated with a less than threefold increase in concentrations of IgG antibody to PRP. Analysis of IgG subclasses demonstrated that the production of IgG1 antibodies was predominantly affected. Postvaccination concentrations of antibody to tetanus toxin were significantly lower in group 1 than in group 3 and controls. Both prevaccination and postvaccination concentrations of antibody to tetanus toxin were not correlated with the magnitude of the response of antibody to PRP. We conclude that HIV-infected individuals with CD4+ T Iymphocyte counts of <100 x 10(6)/L demonstrate an impaired antibody response after vaccination with conjugated Hib vaccine.

Production of exotoxins by staphylococci and streptococci may lead to the development of toxic shock syndrome (TSS). Because clindamycin inhibits exotoxin production, its use has been advocated for the treatment of TSS. However, the bacteriostatic action of clindamycin might be a disadvantage for the treatment of overwhelming infections. We investigated the effects of flucloxacillin and gentamicin on exotoxin production, because incubation with these antibiotics combines bactericidal action with protein synthesis inhibition. Staphylococcus aureus during the logarithmic and stationary phases of growth was incubated with either clindamycin, flucloxacillin, or a combination of flucloxacillin and gentamicin at concentrations of 2 or 10 times the MIC. In logarithmic-phase cultures clindamycin had a static effect on bacterial growth. After incubation with flucloxacillin, either alone or in combination with gentamicin, a rapid and large reduction in the number of viable bacteria was demonstrated. In stationary-phase cultures none of the antibiotics significantly changed the number of viable bacteria. TSS toxin 1 (TSST-1) production during logarithmic-phase growth was inhibited by > or =95% by all antibiotics. In stationary-phase cultures, clindamycin, flucloxacillin, and the combination of flucloxacillin and gentamicin inhibited TSST-1 production by 95, 30, and 75%, respectively, compared with the level of exotoxin production in the controls. The present results indicate that clindamycin inhibits TSST-1 production and exerts bacteriostatic activity in both bacterial growth phases. Because the combination of flucloxacillin and gentamicin combines the inhibition of exotoxin production with high bactericidal activity at least in logarithmic-phase cultures, it should be considered an alternative to clindamycin for the treatment of exotoxin-mediated diseases, especially in patients with overwhelming infections.

Background: Although technical success rate of simultaneous pancreas kidney (SPK) transplantation in insulin-dependent diabetes mellitus (IDDM) patients with diabetic nephropathy has improved, morbidity remains high due to infection and rejection. The purpose of this study was to analyse infections encountered in our series of SPK transplants, using a restrictive antibiotic prophylaxis policy., Methods: We reviewed all infectious diseases after 66 consecutive bladder-drained SPK transplantations in 64 IDDM patients with end-stage renal disease due to diabetic nephropathy. During follow-up, the perioperative antibiotic regimen was altered (from 5 days preemptive therapy with multiple drugs to 1 day prophylaxis with cefamandole), and long-term viral prophylaxis (high-dose aciclovir) was introduced. For post-operative urinary tract or opportunistic infection, no prophylaxis was given., Results: Overall mean infection rate was 2.9 infections/ patient/year after a mean follow-up of 2.3 years. Surgical site infections (SSI) were seen in 30% of the patients, with Enterococci present in 47%. Logistic regression showed one day cefamandole prophylaxis to be associated with SSI, but there was no significant influence of SSI on either graft or patient survival. Forty-eight percent of all infections were lower urinary tract infections (UTI). There were 59 first UTIs (89%), probably related to long-term Foley catheter use, and 47 second UTIs (71%). Subsequent UTIs were not microbiologically related to first UTIs. Cytomegalovirus (10 patients) and other opportunistic agents did not cause mortality or graft loss. Five grafts were lost due to infection (SSI three times, post-transplant lymphoproliferative disease twice). Only one patient died because of infection (2%)., Conclusions: Infectious diseases after SPK transplantation caused significant morbidity but did not influence either patient or graft survival. A change in prophylactic policy for both SSI as well as recurrent UTI, combined with earlier Foley removal, may lower incidences of these infections.

The Netherlands' Ministry of Health and the health insurance companies have drawn up a list of preparations which will no longer be reimbursed. The ocular antibiotic preparations Polyspectran and Terramycin are on the list. However, there are no satisfactory alternative with respect to the broadness of the antibiotic spectrum required. In addition, some alternatives have serious side effects or may induce bacterial resistance.

A 56-year-old man with alcoholic liver cirrhosis (Child-Pugh class C), ascites and hepatocellular carcinoma developed acute diarrhoea and fever. Ascites granulocyte count was 5760 per microliters. Campylobacter jejuni grew in cultures from faeces, blood and ascites. The patient was successfully treated with erythromycin. Although the incidence of bacterial infections including peritonitis is high in patients with end-stage liver cirrhosis, this is one of very few cases in which Campylobacter jejuni has been identified as the causative microorganism.

A prospective study of antibody production by adults infected with human immunodeficiency virus (HIV) after vaccination with T lymphocyte-dependent diphtheria toxoid, tetanus toxoid, and inactivated trivalent poliovirus vaccine was conducted. Individuals were divided into three groups according to CD4+ T-lymphocyte count: group 1 had a count of < or = 100-300 x 10(6)/L; and group 3, > 300 x 10(6)/L. After vaccination, 61%, 70%, and 73% of the individuals in groups 1, 2, and 3, respectively, developed protective titers of antibody to diphtheria toxin; the mean postvaccination antibody titer of HIV-infected individuals was significantly lower than that of healthy controls not infected with HIV. Furthermore, the mean titers of antibodies to tetanus toxin and poliovirus were significantly lower in HIV-infected individuals with CD4+ lymphocyte counts of < 300 x 10(6)/L than in controls. Of the HIV-infected vaccinees, 83%-100% were protected against tetanus and 78%-100% against polio. We conclude that HIV-infected individuals with CD4+ lymphocyte counts of < 300 x 10(6)/L have an impaired (secondary) antibody response after receipt of T lymphocyte-dependent vaccines.

Mixed alveolar interstitial pneumonia is a much-feared complication in bone marrow transplant recipients because it carries a high mortality. Many cases in which an etiological agent is identified are due to fungi or cytomegalovirus; rarely, other infectious agents such as Pneumocystis carinii or (para)influenzavirus are involved. In this report we describe a patient who received intense chemotherapy followed by autologous bone marrow transplantation for relapse of testis seminoma and who developed a severe alveolar interstitial pneumonia caused by respiratory syncytial virus in the early posttransplant period. The patient fully recovered after treatment with ribavirin.

Various mutations including galE- in the S.typhi vaccine strain Ty21a are thought to prevent proliferation of these micro-organisms in the host, and elimination of Ty21a would occur independent of the immune system of the host. To investigate this issue, we determined whether Ty21a can proliferate in immunosuppressed mice, and assessed the role of phagocytes in the eradication of Ty21a from tissues. Mice were rendered lymphocytopenic and monocytopenic by hydrocortisone s.c., or were made leucocytopenic by whole body irradiation. Bacteria were injected into a tail vene to evaluate eradication from the blood, liver and spleen, and into thigh muscle, i.e. a tissue that lacks resident macrophages. Ty21a were grown overnight in glucose [glu], or galactose and glucose [gal.glu]; only the Ty21a [gal.glu] expressed somatic O-antigens. After i.v. injection of 10(4) to 10(6) micro-organisms, Ty21a were rapidly eliminated from the liver and spleen of normal and immunosuppressed mice, i.e. within 1 day a 95% reduction of bacterial counts was observed. After i.m. injection of 10(4) to 10(6) bacteria, the number of viable Ty21a decreased in normal and hydrocortisone-treated mice, but in irradiated mice the micro-organisms proliferated and caused generalized infection. In all cases, Ty21a [glu] was eliminated more rapidly than Ty21a [gal.glu], confirming reports that killing of bacteria that lack O-antigens is more rapid than that of smooth bacteria of the same species. These results indicate that elimination of the vaccine strain against typhoid fever, Ty21a, from host tissues is not due to an intrinsic property of the micro-organisms that prevents proliferation but instead depends on the action of resident macrophages and exudate monocytes and granulocytes.

Tumor necrosis factor (TNF) plays a pivotal role in meningococcal disease. The TNF response to endotoxin, however, differs between individuals and can be determined in whole blood samples ex vivo. The release of TNF in whole blood samples from 50 survivors of meningococcal disease 6-58 months after hospital discharge was studied. The TNF response was higher in patients who had experienced a moderately severe disease course compared with patients with a mild course. The TNF response was low again in the survivors of fulminant disease, who on original hospital admission presented with risk factors exposing them to a high chance of mortality (50% overall). On admission, the patients who did not survive had initial TNF levels three times higher than those in survivors with a clinical disease presentation of similar severity. Overall interpretation of these findings is that the innate TNF response may contribute to the outcome of meningococcal disease.

This study concerns the effect of anti-tumor necrosis factor (TNF) antibodies on the course of a sterile inflammatory reaction in the peritoneum and a generalized infection with gram-positive bacteria. Mice received an intravenous injection of rabbit anti-TNF serum or normal rabbit serum 24 h before an intraperitoneal injection of heat-killed Listeria monocytogenes or an intramuscular injection of live L. monocytogenes. The course of the leukocytes in blood and the peritoneal cavity was followed for 72 h; the infection was evaluated for 144 h. The results lead to the conclusion that anti-TNF inhibits the migration of granulocytes and monocytes from bone marrow to the circulation and from the circulation to the peritoneal cavity during an acute inflammation. Furthermore, treatment of mice with anti-TNF serum enhanced the growth of Listeria monocytogenes in thigh muscle, liver, and spleen. The results of this study indicate that treatment with anti-TNF antibodies can inhibit the development of a cellular inflammatory exudate and can have a deleterious effect on the course of an infection with gram-positive bacteria.

Objective: To establish when the formation of antibodies against T-lymphocyte-dependent and -independent antigens is impaired during HIV infection., Design: Prospective study on antibody formation before and 30 days and 60 days after vaccination with tetravalent influenza vaccine, tetanus toxoid and pneumococcal vaccine; booster with influenza vaccine was administered 30 days after initial vaccination., Setting: Outpatient clinic of University Hospital Leiden., Participants: Fifty-one HIV-infected individuals and 10 healthy controls., Results: In HIV-infected individuals with < 100 x 10(6)/l CD4+ lymphocytes almost no influenza antibodies were formed; CD4+ counts between 100 and 300 x 10(6)/l correlated with suboptimal antibody formation; CD4+ counts > or = 300 x 10(6)/l yielded more individuals with protective antibody titres. Thirty days after vaccination, protective antibody titres against the four influenza strains had been achieved in 24% of all HIV-infected individuals for A/Beijing (H3N2) (controls, 90%), 59% for A/Taiwan (H1N1) (controls, 80%), 18% for B/Beijing (controls, 30%) and 37% for B/Panama (controls 90%). Booster vaccination after 1 month did not increase antibody levels. Anti-tetanus toxin antibody formation, which is also T-lymphocyte-dependent, was correlated with the number of CD4+ lymphocytes. After pneumococcal vaccination (T-lymphocyte-independent), normal antibody formation was observed in HIV-infected individuals, including those with low CD4+ counts., Conclusions: Influenza vaccination should not be administered to HIV-infected individuals with CD4+ counts < 100 x 10(6)/l; pneumococcal vaccination can be offered to all HIV-infected individuals and a tetanus toxoid booster should be administered when indicated.

The induction of reactive nitrogen intermediates (RNI) and toxoplasmastatic activity of murine macrophages by recombinant gamma interferon (rIFN-gamma) is mediated by an autocrine pathway involving tumor necrosis factor alpha (TNF-alpha). To investigate whether cytokines other than TNF-alpha play a role in the activation of these effector functions, granulocyte-macrophage colony-stimulating factor (GM-CSF) was studied. Recombinant GM-CSF (rGM-CSF) could stimulate peritoneal macrophages, since this cytokine stimulated the production of prostaglandin E2 by these cells. However, rGM-CSF did not induce either the release of RNI by or the toxoplasmastatic activity of macrophages. rGM-CSF in combination with various concentrations of rIFN-gamma did not enhance these effector functions more than rIFN-gamma alone. Furthermore, neutralization of endogenously produced GM-CSF by monoclonal antibodies did not affect the release of RNI by or the toxoplasmastatic activity of rIFN-gamma-activated macrophages. Together these results indicate that GM-CSF is not involved in RNI production by and toxoplasmastatic activity of IFN-gamma-activated murine macrophages.

Three patients are described with giant cell arteritis (GCA) of multiple medium sized and large blood vessels including the temporal artery and the aorta. The patients presented with malaise, myalgias and different symptoms due to decreased local blood flow. Progression of the disease could be blocked with immunosuppressive drugs in all 3 patients. With this report we want to emphasize that GCA is associated with a wide ranging disease spectrum in which temporal arteritis and Takayasu's arteritis represent two subsets.

Intracellular killing of catalase-positive bacteria by murine resident macrophages requires the presence of extracellular serum, whereas killing of catalase-negative bacteria can occur in the absence of serum. To find out whether the intracellular killing of bacteria by rIFN-gamma-activated macrophages also requires serum stimulation, we investigated the handling of ingested catalase-negative and -positive Listeria monocytogenes by peritoneal macrophages of normal Swiss mice and mice injected i.p. with 1 x 10(4) U rIFN-gamma 18 h earlier. In the absence of extracellular serum, rIFN-gamma-activated macrophages killed ingested catalase-negative Listeria more efficiently (P < 0.01) than normal resident macrophages. Maximal killing of catalase-negative bacteria by rIFN-gamma-activated macrophages required an extracellular serum concentration of only 1.0 to 2.5% compared with the 10% needed by normal macrophages. No differences were observed in the rates of intracellular killing of catalase-positive Listeria by rIFN-gamma-activated and normal resident macrophages: both populations of macrophages required 10% extracellular serum for maximal killing of these bacteria, and killing was minimal in the absence of serum. The rIFN-gamma-activated macrophages displayed enhanced O2-consumption after stimulation with phorbol myristate acetate and heat-killed Listeria compared with macrophages from normal mice. These findings indicate that, under suboptimal stimulation by extracellular serum, rIFN-gamma enhances the intracellular killing of catalase-negative Listeria which lack endogenous catalase acting as a scavenger of reactive oxygen intermediates. The mechanism underlying the enhancement is probably the amplification of the respiratory burst by IFN-gamma.

We report a case of refeeding-associated hypophosphatemia in a 24-year-old malnourished male patient with anorexia nervosa but no history of alcoholism. He was given tube feeding with a low-calory preparation supplemented with phosphate. During refeeding, a severe hypophosphatemia developed after 5 days, i.e., serum phosphate 0.00-0.01 mmol/l for 2 days, accompanied by a reduction in red-cell ATP and 2,3-diphosphoglycerate, mild hemolytic anemia and transient changes in cardiac repolarization; there was, however, a striking lack of clinical symptomatology. Parenteral replacement with phosphate initially was complicated by an unexpected high urinary phosphate excretion due to an extremely low TmP/GFR (0.02 mmol/l) for over 2 days. Only after an increase of the TmP/GFR to supranormal values, i.e. up to 2.5 mmol/l, unrelated to changes in serum PTH or vitamin D3, the serum phosphate concentration became normal. The case report shows that severe hypophosphatemia can occur in nonalcoholic patients after oral feeding, and may induce reversible changes in renal phosphate handling that complicate replacement therapy.

We describe a 35-year-old woman with arthralgias and skin lesions suggesting sarcoidosis. No pulmonary lesions were present. The diagnosis was established by histological examination of a swollen and discolored scar. We review the literature of "scar sarcoidosis" and discuss the similarities between this entity and silica granuloma.

The effect of recombinant human interferon-gamma (rHuIFN-gamma) and interferon-alpha (rHuIFN-alpha) as in vivo stimuli for the activation of human monocytes was investigated on the basis of the bactericidal activity of peripheral blood monocytes in 11 patients with metastatic melanoma before and during treatment with interferons. Patients received increasing doses of rHuIFN-gamma and a fixed dose of rHuIFN-alpha, both administered subcutaneously three times a week. The rates of intracellular killing of Listeria monocytogenes and Salmonella typhimurium after in vitro phagocytosis by monocytes collected from melanoma patients before interferon treatment were increased (P less than 0.01) by a factor of 1.7 and 1.4, respectively, relative to the rate constants in blood monocytes of healthy donors. During treatment with the interferons, the rates of intracellular killing of the bacteria by patients' monocytes did not further increase. The findings underscore the immunogenicity of malignant melanoma and put into question the macrophage activating activity of IFN-gamma with respect to the bactericidal activity of monocytes.

The phagocytosis and intracellular killing by synovial fluid (SF) polymorphonuclear cells (PMN) of 10 patients with rheumatoid arthritis was studied. PMN phagocytosis was assessed by morphologic and microbiologic methods and intracellular killing was measured independently of continuous phagocytosis of Staphylococcus aureus. Phagocytosis of S aureus by SF PMN or peripheral blood (PB) PMN was as effective in the presence of synovial fluid as in the presence of serum. On average, SF PMN ingested S aureus opsonized with synovial fluid and serum more efficiently than patient or donor PB PMN did. Enhanced ingestion of S aureus was associated with increased expression of C3 receptors on the membrane of SF PMN. In the presence of heat-inactivated synovial fluid, the capacity of SF PMN to ingest S aureus was greater than that of patient or donor PB PMN. Under these conditions, phagocytic activity was correlated with Fc receptor expression. SF PMN was found to be as active in killing S aureus as PB PMN from healthy donors.

The regulatory mechanisms that determine the course of an inflammation induced by an intraperitoneal injection of kaolin were investigated in Listeria-susceptible CBA and Listeria-resistant B10 mice. The magnitude of the granulocyte inflammatory response in the peritoneal cavity was high in B10 mice (area under the curve; AUC0-48 h: 210.9 x 10(6) granulocytes/mouse x h) and lower in CBA mice AUC0-48 h: 136.8 x 10(6) granulocytes/mouse x h), whereas the reverse was seen for the granulocyte response in the peripheral blood (AUC0-48 h: 30.5 and 80.7 x 10(6) granulocytes/mouse x h, respectively). With respect to the presence of humoral factors that affect the number of granulocytes in the circulation, sera of both mouse strains sampled 24 h after the kaolin injection had granulocytosis-inducing effect in CBA recipient mice and did not induce a response in the B10 recipient mice. This divergent sensitivity to serum factors inducing granulocytosis is consistent with the difference in the blood granulocyte response of B10 and CBA mice but does not explain the divergent inflammatory responses in the peritoneal cavity. Computer simulation showed that at least two factors must be taken into consideration to explain the differences in the inflammatory response, i.e., a factor regulating the release of granulocytes from the bone marrow and a factor governing the rate of granulocyte efflux from the site of inflammation.

The influence of halothane 0.8-1.2% inspired on the peripheral hypoxic chemoreflex was investigated in 13 cats subjected to artificial brain stem perfusion (ABP). This technique allows for an independent control of blood gas tensions and halothane concentration between blood perfusing the brain stem (central) and the systemic circulation (peripheral). In six cats the ventilatory response to isocapnic hypoxia was assessed during overall halothane anesthesia (HO) before and during ABP. Before ABP, systemic and brain stem circulations both were rendered hypoxic. During ABP, hypoxia was induced systemically while the brain stem was maintained hyperoxic. The ventilatory response in non-ABP cats (mean 698 ml . min-1 at PaO2 6.6 kPa; 50 mmHg) was about half the response in ABP cats (mean 1,194 ml . min-1 at PaO2 6.5 kPa; 49 mmHg), indicating that in the presence of halothane, central hypoxia depressed ventilation appreciably. Compared with chloralose-urethane anesthesia (CU), halothane reduced the ventilatory response to hypoxia in both perfusion conditions but never abolished it. To assess the influence of halothane on peripheral and central mediation of the CO2 response during hypoxia, each was assessed during CU anesthesia, during HO, and with halothane applied exclusively peripherally against a background of CU (CUHP). In all drug states, the periphery was kept hypoxic and brain stem hyperoxic. Compared with CU anesthesia, HO and CUHP anesthesia reduced both peripheral (Sp) and central (Sc) CO2 sensitivity but not the Sp/Sc ratio. Similarly, the extrapolated PaCO2 at zero ventilation was not detectably different among these three states.(ABSTRACT TRUNCATED AT 250 WORDS)

The present results challenge the view that macrophage activation leads to a general, non-specific increase of microbicidal activity of these cells. Instead, it was found that the interactions between activated macrophages and micro-organisms are dependent on the kind of activation and the type of target micro-organism.

A simple tissue culture dish is described which permits the use of oil immersion optics (X 100) while maintaining access to cells in culture. In combination with a micro-CO2-incubator (Ince et al. 1983) long-term as well as short-term experiments can be performed under microscopical control. The teflon dish is re-usable, resistant to sterilization procedures, and easy to assemble. Standard glass coverslips with adherent cells are secured to the dish by an aluminium ring with a bayonet fitting. Both phase-contrast and interference-contrast microscopy with high magnification can be used. The dish is of particular use in electrophysiological investigations where the patch-clamp technique is used and frequent exchange of cultures is required. With this unit, single ion channel activity in cultured human monocytes was measured. The dish has also been used in studies in which membrane potential measurements were performed with glass microelectrodes in small cells under culture conditions. The applications described include video time-lapse sequences of phagocytosis with micro-organisms presented to mouse peritoneal macrophages with broken-tipped pipettes. This easy to use, multi-purpose dish offers the cell physiologist a valuable aid for the manipulation and observation of single cells in culture.

To determine the underlining mechanism of the difference in innate susceptibility of mouse strains to infection by Salmonella typhimurium, the ingestion and in vitro intracellular killing of S. typhimurium by resident peritoneal macrophages of mouse strains that differ in natural resistance to this microorganism has been studied. The results revealed that the rate constants of in vitro phagocytosis (Kph) in the presence of inactivated rabbit immune serum did not differ between macrophages of susceptible C57BL/10 and resistant CBA mice (for both strains: Kph = 0.021 min-1). The rate constant of in vitro intracellular killing (Kk) was determined 1) after in vivo phagocytosis (CBA, Kk = 0.055 min-1; C57BL/10, Kk = 0.031 min-1), 2) after in vitro phagocytosis of preopsonized bacteria (CBA, Kk = 0.020 min-1; C57BL/10, Kk = 0.012 min-1), and 3) during continuous phagocytosis in vitro (CBA, Kk = 0.029 min-1; C57BL/10, Kk = 0.013 min-1). With all three approaches, the initial rate of intracellular killing by normal macrophages of Salmonella-resistant CBA mice amounted to about 1.7 times the value found for macrophages of susceptible C57BL/10 mice (p less than 0.01). This trait difference was independent of the previous way of ingestion of the bacteria, unaffected by the kind of opsonization, and specific for S. typhimurium, because Staphylococcus aureus and Listeria monocytogenes were killed by macrophages of these mouse strains with equal efficiency (p greater than 0.50). These findings indicate that a difference in genetic background expressed in the efficacy of intracellular killing by resident peritoneal macrophages immediately upon ingestion of S. typhimurium is relevant for the innate resistance of mice against S. typhimurium.

The relationship between the resting membrane potential and the intracellular ionic concentrations in human monocytes was investigated. Cell volume, cell water content, and amount of intracellular K+, Na+, and Cl- were measured to determine the intracellular concentrations of K+ (Ki), Na+ (Nai) and Cl- (Cli) of monocytes, and of lymphocytes and neutrophils. Values found for monocytes were similar to those for neutrophils, i.e., cell volumes were 346 and 345 micron3, respectively, cell water content 78%, and Ki, 128 and 125, Nai, 24 and 26, and Cli, 102 and 103 mmol/l cell water, respectively. Lymphocytes, however, had different values: 181 micron3 cell volume, 77% cell water content, and for Ki, Nai, and Cli, 165, 37, and 91 mmol/l cell water, respectively. The resting membrane potential of cultured human monocytes (range -30 to -40 mV), determined by measurement of the peak potential occurring within the first milliseconds after microelectrode entry, was most dependent on extracellular K+, followed by Cl-, and Na+. The membrane permeability ratio of Cl- to K+ was estimated by use of the constant field equation to be 0.23 (range 0.22 to 0.30).

The effect of recombinant murine interferon-gamma (rIFN-gamma) as single stimulus for the activation of antibacterial activity of macrophages was investigated on the basis of the rate of intracellular killing of Listeria monocytogenes and Salmonella typhimurium by normal and rIFN gamma-activated peritoneal macrophages of CBA and C57BL/10 mice, which differ in natural resistance to infection by these bacteria. Eighteen hours after i.p. injection of 10 to 1 X 10(4) U rIFN-gamma, resident and exudate peritoneal macrophages which had phagocytosed L. monocytogenes or S. typhimurium in vivo, killed both species in vitro just as efficiently as did resident macrophages of normal mice. Similar results were obtained after 18 hr of in vitro incubation of resident or exudate peritoneal macrophages with 0.1 to 1 X 10(4) U/ml rIFN-gamma. Consistent with the in vitro findings, two i.v. injections of 5 X 10(4) U rIFN-gamma did not affect the rate of in vivo proliferation of L. monocytogenes or S. typhimurium in the spleens of mice during the first 2 days after i.v. injection of the bacteria. Compared with the effect on the controls, two i.p. injections of 5 X 10(2) to 5 X 10(4) U rIFN-gamma did not decrease the numbers of viable S. typhimurium in either the peritoneal cell suspension or the spleen 24 hr after i.p. injection of the bacteria. Checking the state of activation of rIFN-gamma-activated macrophages on the basis of two commonly used criteria for macrophage activation showed that rIFN-gamma-activated macrophages inhibited the intracellular replication of Toxoplasma gondii and displayed enhanced O2 consumption and H2O2 release after stimulation with phorbol myristate acetate compared with macrophages from normal CBA and C57BL/10 mice. The present findings show that as single activating stimulus, rIFN-gamma is not capable of activating the antibacterial effector functions of peritoneal macrophages against facultative intracellular pathogens such as L. monocytogenes and S. typhimurium.

In an established double layer clonogenic assay, the PHA-leukocyte feeder colony assay, hairy cell leukemia (HCL) cells formed strong aggregates simulating colonies. After irradiation with 50 Gy, colony formation persisted. Even in a modified colony assay consisting of agar 0.5% overlayered by methylcellulose 0.9%, cell aggregation was still possible due to increasing fluidity of the methylcellulose during the culture period. Time-lapse video recordings confirmed prominent cell motility leading to pseudo-colony formation. Studies with bromodeoxyuridine incorporation showed a low proliferation index (up to 13%) of hairy cells. In conclusion, any assay that facilitates cell motility is unsuitable to study HCL colony growth.

To find out whether activated macrophages display a nonspecific enhancement of antibacterial activity, we determined the intracellular killing of bacteria by peritoneal macrophages from CBA and C57BL/10 mice infected with BCG and challenged with mycobacterial antigens (purified protein derivative (PPD]. After in vivo phagocytosis, the rate of in vitro intracellular killing of Listeria monocytogenes by bacillus Calmette-Guérin (BCG)-PPD-activated macrophages from CBA mice increased by a factor of 1.7 and that of those from C57BL/10 mice by a factor of 2.0, relative to the rate in normal resident macrophages. The increased listericidal activity of BCG-PPD-activated macrophages could not have been due to an increased number of peroxidase-positive macrophages because exudate macrophages obtained after i.p. injection of proteose peptone into BCG-infected mice or PPD into control mice, killed ingested Listeria about as efficiently as normal resident macrophages did. In contrast, BCG-PPD-activated macrophages from both mouse strains killed Salmonella somewhat less efficiently and Escherichia coli and Staphylococcus aureus with the same efficiency as normal resident macrophages did. These cells, however, inhibited the intracellular replication of Toxoplasma gondii. Activated peritoneal macrophages from listeria-infected mice showed a similar increase of the rate of intracellular killing of Listeria and absence of change in rate of intracellular killing of Salmonella. Consistent with the in vitro findings, the number of viable L. monocytogenes in the spleen and liver of BCG-infected CBA and C57BL/10 mice decreased during the first 2 days after i.v. injection, whereas Salmonella typhimurium proliferated in these organs of both mouse strains. Checking the state of activation of BCG-PPD-activated macrophages showed that these cells displayed enhanced O2-consumption and H2O2 release after stimulation with phorbol myristate acetate compared with resident macrophages. The present findings show that the antimicrobial activity of immunologically activated macrophages is not uniformly increased: for certain microorganisms (L. monocytogenes, T. gondii), this effector function is enhanced, whereas for others (S. typhimurium, S. aureus, E. coli), it is not.

A short review of current concepts concerning the origin and kinetics of monocytes and macrophages is given, and the humoral regulation of monocyte production by FIM, a factor synthesized and secreted by macrophages, is discussed. Genetic control of the responsiveness of monocyte precursors to FIM and that of the phagocytosis and intracellular killing of bacteria is dealt with.