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Soil may be a source of organisms that can cause Mycobacterium avium complex (MAC) infection in HIV patients in San Francisco, but food and water may not be significant sources. Food, water, and soil samples were collected from the homes of 290 HIV-positive participants at risk for MAC in San Francisco. MAC organisms were cultured from 55% of potted plants, 2% of water samples and .5% of food samples. However, no direct connection could be established between the environmental presence of MAC and MAC infection in HIV patients.

* Pulmonary toxoplasmosis is a rarely recognized opportunistic infection in immunocompromised patients. A few case reports have described pulmonary toxoplasmosis in human immunodeficiency virus-infected patients in association with Toxoplasma gondii central nervous system disease. We encountered six cases of pulmonary toxoplasmosis in human immunodeficiency virus-infected patients, who presented with a protracted febrile illness, respiratory symptoms, and an abnormal chest roentgenogram in the absence of neurologic findings. No clinical or roentgenographic features distinguished T gondii pneumonitis from more common opportunistic pulmonary infections. As the acquired immunodeficiency syndrome epidemic progresses, the presenting illnesses have evolved. Toxoplasma gondii must be considered a potential cause of pulmonary disease during the evaluation of human immunodeficiency virus-infected patients with respiratory symptoms. (Arch Intern Med. 1992; 152:1073-1077)

The human immunodeficiency virus (HIV, the virus that causes AIDS) attacks and destroys the immune system, making individuals with AIDS very susceptible to other types of infection. Mycobacterium avium (M. avium) is a common bacterial cause of lung infection in patients with AIDS. Once M. avium infects the lungs it can spread (disseminate) to other parts of the body and cause M. avium complex infection (MAC). Many studies have reported that MAC reduces the survival time of patients with AIDS, but the validity of these studies has been challenged. In an attempt to gain a better understanding of the role that MAC plays in altering the survival time of AIDS patients, the medical records were reviewed of 137 AIDS patients attending the San Francisco General Hospital between 1983 and 1986. Thirty-four of the patients were diagnosed with lung infections caused by M. avium. In 22 of the 34 cases, the infection had spread to other parts of the body. When the infection spread to other parts of the body, the survival time of the patient was indeed shortened. It is concluded that a lung infection with M. avium predicts the development of disseminated MAC, and disseminated MAC reduces the survival time of patients with AIDS. (Consumer Summary produced by Reliance Medical Information, Inc.)

The human immunodeficiency virus is the virus that causes AIDS. The virus attacks and destroys the cells of the immune system (the body's natural defense system for fighting infection), and therefore patients with AIDS are at greater risk for developing life-threatening infections. Pneumonia caused by an infection with Pneumocystis carinii is one of the more common complications in patients with AIDS and it has been reported to be the cause of death in many cases. Many patients with AIDS develop simultaneous infections with several different microorganisms, and infection with Cytomegalovirus (CMV) is common in these patients. Several studies have tried to determine whether the rates of disease and death are greater in AIDS patients who have infections with both P. carinii and CMV than in those who have an infection with P. carinii alone. Two of these studies reported that infection with CMV did not increase mortality in AIDS patients with P. carinii pneumonia, while three other studies reported that patients with both CMV and P. carinii infection had a poorer outcome. To investigate this issue further, the effect of CMV infection on mortality and morbidity was determined in 111 AIDS patients with P. carinii pneumonia. Fifty-four of the patients had CMV infection and P. carinii pneumonia and 57 had P. carinii pneumonia without CMV infection. The length of hospitalization, long-term survival and death rate were the same for both groups of patients. It is concluded that CMV infection does not increase morbidity or mortality in AIDS patients with P. carinii pneumonia. These findings do not support the use of antiviral drugs for treating CMV infections in AIDS patients with P. carinii pneumonia. (Consumer Summary produced by Reliance Medical Information, Inc.)

Opportunistic infections occur when infectious agents that are normally present in the body and kept in check by the immune system are able to cause infection because of the immune system's inability to function properly. Persons who are infected with HIV, the human immunodeficiency virus, are particularly susceptible. Because many of these infections affect the bone marrow, individuals who are known to be or suspected of being HIV-infected may undergo diagnostic bone marrow examination. While the information gathered from such examinations has been useful in the diagnosis of certain infections, little is known about the range of possible infections that can be detected in this way. A retrospective study was performed in which records were examined of 387 patients who underwent bone marrow examinations. In each of these cases, the primary reason for doing bone marrow examination was because the physician believed there might be an HIV-related opportunistic infection present. It was found that no infections were diagnosed using bone marrow examination that could not have been identified using other, less invasive procedures such as blood tests. However, it is important to note that the accuracy of diagnostic bone marrow examination was similar to blood cultures, so it is an effective technique even if it is not the first choice. In the case of lymphomas (tumors of lymph tissue), however, bone marrow examination was not a useful diagnostic tool but it was able to provide information regarding the extent of lymphoma that had been diagnosed by other techniques. (Consumer Summary produced by Reliance Medical Information, Inc.)

Persons infected with human immunodeficiency virus (HIV, which causes AIDS) appear to be at high risk for pneumococcal disease. Failure of the humoral immune system, important in immunity to pneumococcal disease, and the progressive loss of cell-mediated immunity occur in HIV-infected patients. The extent of involvement, the clinical course of infection, and the serotypes of pneumococcal bacteria most frequently encountered have not been widely studied in this vulnerable population. (Serotypes are combinations of foreign antigens.) To evaluate the risk of pneumococcal disease in these patients and develop methods of prevention, the authors conducted a retrospective review of male and female patients with pneumococcal bacteremia, based on medical records of 10 San Francisco hospitals from 1983 to 1987. (Bacteremia involves bacteria in the blood and may be life-threatening.) HIV seropositivity, an indication of HIV infection, was reviewed for patients between 20 and 55 years of age. A total of 294 cases (62 women and 232 men) conformed to the study parameters. Pneumococcal bacteremia resulted from pneumonia, meningitis, peritonitis, otitis media, pericarditis, septic arthritis, and sinusitis. At the time of diagnosis, 32 patients had AIDS; 43 were HIV-positive, but did not have AIDS; and 12 HIV-positive patients developed AIDS following pneumococcal bacteremia. The most common pneumococcal serotypes identified are among those included in the currently available pneumococcal vaccine. Further, these serotypes were identified in 82 percent of HIV-infected patients, and 90 percent of non-HIV patients. These findings indicate that, if the current pneumococcal vaccine is effective in HIV-positive patients, it may provide them with significant protection against pneumococcal disease. (Consumer Summary produced by Reliance Medical Information, Inc.)

Patients with pneumococcal pneumonia were studied to determine if severely ill patients benefit more from massive dosages of penicillin compared with moderate dosages. Severity of illness and response to treatment were evaluated, and sputum was monitored for pathogens. Twenty-two of the 59 patients assigned to receive 20 million units of penicillin daily and 19 of the 64 assigned to receive 1,200,000 units of penicillin G procaine daily were considered severely ill. In the high-dosage group, there were five deaths, three patients with superinfections, and 22 with pathogen colonizations, and in the moderate-dosage group, six deaths, two patients with superinfections and eight with pathogen colonizations. There was no significant difference (P <.75) in outcome between the groups. We conclude that there is no advantage in treating patients with more than 1,200,000 units of penicillin G procaine daily.(JAMA 230:409-413, 1974)

We observed a human immunodeficiency virus (HIV)-infected homosexual male with AIDS related complex (ARC) who had a serum globulin level of 80 g/L. Serum protein electrophoresis revealed a gamma globulin fraction of 40 g/L, of which 50% (20 g/L) was contained within a paraprotein spike, comprised predominantly of IgG kappa. This patient also had high titer anti-HIV antibodies in his serum, which were Western blot reactive at a final dilution of 1:500,000, and recognized gp120env, p66po1, p55gag, p53pol, p41gag, and P24gag. Because paraproteins in the past have been shown to be directed against specific antigens, we purified this patient's paraprotein using a modified high performance liquid chromatography (HPLC)-hydroxylapa-tite procedure and tested the purified paraprotein for anti-HIV antibody activity. The purified paraprotein retained anti-HIV antibody activity to a final dilution of 1:100,000, and recognized p66pol, p55gag,p53pol, p41gag, and P24gag. The recognition of both “gag” and “pol” gene products suggested that the purified paraprotein might not be monoclonal in origin. Sodium dodecyl sulfate-polyacryl-amide gel electrophoresis (SDS-PAGE) demonstrated that the purified paraprotein contained at least two immunoglobulin light chain species (Mol wt 30 to 33 Kd). Affinity chromatography of the purified paraprotein using a p24-Sepharose 4B matrix separated the “gag” and “pol” antibody activities. Immunoglobulin gene rearrangement analysis of a bone marrow aspirate (which contained 15% plasma cells) failed to reveal a clonal population of immunoglobulin producing cells. We conclude that this patient's paraprotein accounted for most of the anti-HIV activity present in whole serum, and that this paraprotein was not monoclonal in origin.

• Endocarditis in a 2-year-old child was caused by a penicillin-resistant Streptococcus constellatus. Viridans streptococci in general and those associated with endocarditis in particular are usually believed to be penicillin sensitive. Although the patient did not receive prophylactic antibiotics, the child had recently been treated with an oral penicillin. Penicillin-resistant viridans streptococci are usually sensitive to the synergistic effects of penicillin and an aminoglycoside, but this organism was not. Clindamycin was ultimately shown to demonstrate admirable bactericidal activity against this patient's S constellatus.(Am J Dis Child 1982;136:42-45)

Delayed cutaneous hypersensitivity (DCH) of 12 normal adult subjects to purified protein derivative (PPD) of Mycobacterium tuberculosis, streptococcal streptokinase-streptodornase (SK-SD), and Candida albicansDermatophytin O (DO) was assayed in vivo by skin testing and compared with such in vitro correlates of cellular immunity as lymphocyte transformation (LT) and inhibition of leukocyte migration (ILM) from microcapillary tubes or in agarose gel. LT was shown to be the best in vitro correlate of specific lymphocyte sensitization with all antigens. In the ILM assays, PPD showed good correlation with in vivo DCH and in vitro LT; SK-SD showed partial correlation; DO showed no correlation, not being active in any of the ILM tests. Cell distribution and morphology of stained migration patterns, ILM tests performed on separated populations of lymphocytes and polymorphonuclear leukocytes (PMN), as well as the ability of test antigens to stimulate PMN cells to reduce nitroblue-tetrazolium dye, indicated that in ILM tests mononuclear cells were not inhibited in their migration, whereas migration of PMN cells appeared to depend on their direct reaction with the test antigens.

• We performed autopsies and serologic tests in 189 subjects (152 men and 37 women) between 20 and 50 years of age with no history of immunosuppression who died unexpectedly and whose bodies were referred to the San Francisco coroner's office. Forty-eight of the 88 single men for whom addresses were available lived in areas of the city with a high incidence of the acquired immunodeficiency syndrome (AIDS). In addition, 36 of the subjects (30 men) were intravenous drug abusers. Antibody to the retrovirus associated with AIDS was present in 23 (18%) of the 121 subjects whose sera were tested. However, neither pathologic nor laboratory manifestations of AIDS were present in any of the 189 subjects who underwent autopsy. These results suggest that antibody to the retrovirus is common but subclinical manifestations of AIDS are uncommon in San Francisco, a city where the incidence of clinical AIDS is high.(Arch Intern Med 1986;146:713-715)

An expandable plastic sponge is used to collect a uniform sample of fluid from the conjunctival sac. The uptake of fluid by the sponge and recovery of particles from the sponge is highly reproducible. The kinds of bacteria collected by the sponge were the same as those collected by a moistened swab. Collection with the sponge provides a rapid, precise, and highly reproducible method of sampling conjunctival bacteria in normal and inflamed eyes. This technique will be used in the study of the stages of disease severity and evaluation of the role of therapy in reducing bacterial counts.