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In a retrospective study, we examined the association between cytomegalovirus (CMV) infection and non-neutropenic fever immediately following autologous peripheral blood stem cell transplantation for a variety of haematological malignancies and solid tumours. Sixty non-neutropenic febrile episodes (41 in CMV-seropositive and 19 in CMV-seronegative patients) were evaluated. CMV reactivation, documented by CMV antigenaemia, was detected in 16 out of 41 (39%) seropositive patients compared with 0 out of 19 seronegative patients. In 12 of these 16 patients, CMV infection was considered the sole cause of fever. Thirteen patients had maximum antigenaemia levels > 5 cells/slide. Specific antiviral treatment led to the resolution of the fever in all, but two, patients, who developed fatal CMV pneumonia. Patients with multiple myeloma and lymphoma, possibly owing to a combination of disease-related characteristics and prior immunosuppressive treatment, had high rates of CMV reactivation and may require more frequent diagnostic evaluation and prompt therapeutic intervention.

A murine pulmonary infection with Cryptococcus neoformans (Cne) has been used to determine mechanisms regulating effective T cell-mediated immunity in the lungs. In BALB/c and C.B-17 mice, following intratracheal deposition of Cne, the fungus initially grows rapidly and is then progressively cleared from the lungs. Cne clearance in C.B-17 mice requires CD4 and CD8 T cells, IFN-gamma, and NO. Clearance in congenic BALB/c mice proceeds more slowly than in C.B-17 mice, even though the only genetic difference between these strains is at the Ig H chain-containing region of chromosome 12. Examination of the pulmonary immune response in the two strains revealed that both cleared lung Cne by T cell-dependent mechanisms and generated equivalent levels of NO. Furthermore, both strains recruited equal numbers of macrophages, lymphocytes, and neutrophils to the lungs, although BALB/c mice recruited higher numbers of eosinophils. Notably, leukocytes isolated from BALB/c lungs during infection secreted lower levels of IFN-gamma and higher levels of the Th2 cytokines IL-4 and IL-5 as compared with lung leukocytes from C.B-17 mice. Furthermore, serum levels of IgM, IgG1, IgG2a, and IgG3 anti-Cne Abs generated during infection were significantly greater in BALB/c mice than C.B-17 mice. These data suggest that although both BALB/c and C.B-17 mice clear pulmonary cryptococcosis through T cell-mediated mechanisms, Ig H chain-linked genes in BALB/c mice are associated with a decreased effectiveness of the host response, which we suggest might influence the balance in Th1/Th2 T cell subset development or increase anti-Cne Abs, or both.

Understanding how lung immunity develops against pulmonary pathogens should lead to more rational approaches in vaccine design and to the use of recombinant cytokines in lung disease. T lymphocytes are central to the development of effective immune responses; therefore, understanding how lung immunity develops will require a study of how and where T cells respond to respiratory antigens. Our laboratory has helped define the phenotype and function of lung dendritic cells, which likely play an essential role in stimulating naive T cells to respond to antigens. We found that both interstitial and alveolar macrophages can regulate the function of these cells, the former to enhance activity, the latter to suppress. In addition, we developed a murine pulmonary infection model using the fungus, Cryptococcus neoformans, in which T-cell-mediated immunity is essential for effective host clearance of the organism. The role of T cells in this model is to recruit and activate effector cells to resolve the lung infection; both CD4 and CD8 T-cell subsets are required for optimal effector cell recruitment. These studies are summarized as examples of current approaches to understanding pulmonary immunity.

Although C5a-induced intravascular pulmonary sequestration of neutrophils has been investigated with regards to lung injury, relatively few studies have addressed the possible role for this mechanism in the intravascular clearance of circulating microorganisms. A murine model was used in which the complement-fixing, encapsulated yeast Cryptococcus neoformans (Cne) was inoculated intravenously (IV), and lung clearance of the organism was measured 24 h later. In normal mice, clearance was remarkably effective, but in leukocyte-depleted or C5-deficient (C5-) animals, clearance was significantly decreased. In vitro assays indicated that C5 was necessary for neutrophils to kill encapsulated Cne and evidence was obtained that C5a was involved. In vivo studies using light and electron microscopy demonstrated that 30 min after an IV inoculation of encapsulated yeast into C5-sufficient (C5+) mice, neutrophils accumulated in pulmonary vessels and engulfed Cne. However, in C5- mice, neutrophils failed to accumulate in pulmonary vessels and there was no endocytosis of encapsulated yeasts. These studies suggested that following Cne interaction with complement in the blood, release of C5a activated circulating neutrophils to adhere to Cne, and perhaps to adjacent endothelium, which facilitated rapid phagocytosis and killing of the organism. In contrast to the IV infection model, when Cne was inoculated into the tracheas of C5+ and C5- mice, no evidence was obtained for an early PMN-C5-dependent clearance mechanism. C5a-dependent neutrophil killing in the lung vasculature may provide important host protection against Cne during vascular dissemination and perhaps against other disseminating microorganisms that activate complement.

To compare the efficacy and patient tolerance of amoxicillin to that of erythromycin in the treatment of lower genital tract chlamydia infections during pregnancy.A double-blind, randomized study was conducted comparing oral amoxicillin 500 mg three times daily versus oral erythromycin 500 mg four times daily for 7 days. One hundred forty-three women with positive cervical cultures for chlamydia at less than 36 weeks' gestation were enrolled. A test-of-cure culture was obtained 4 weeks after entry into the study and side effects were assessed. Success of the regimen was defined as completing the course of medication and having a negative test-of-cure culture.Thirty of the 65 women in the erythromycin group (46.1%) developed symptoms while taking the medication and 15 of them were unable to continue treatment (23.1%). In contrast, five of the 65 women (7.7%) in the amoxicillin group became symptomatic, with only one of these patients intolerant of the side effects (1.5%) (P.001). Of the 50 patients in the erythromycin group who were able to complete their course of medication, only three had a positive test of cure (6.0%). In comparison, nine of the 64 patients (14.1%) taking amoxicillin who completed their course had positive cultures at test of cure. This difference was not statistically significant (P = .14). Forty-seven of the 65 patients (72.3%) in the erythromycin group successfully completed their regimen, compared to 55 of the 65 women (84.6%) in the amoxicillin group. This difference was not statistically significant.These findings suggest that amoxicillin is a reasonable alternative for the treatment of chlamydia in pregnant patients intolerant to erythromycin. The incidence of side effects and intolerance to therapy for amoxicillin are less than those for erythromycin.

The cost-effectiveness of screening for pharyngeal gonorrhea (PG) in an adolescent clinic population was examined in the context of dramatically decreasing prevalence. Chart review revealed that the apparent PG prevalence had decreased from 15/555 (2.7%) 8 years ago to 0/319 (0.0%) recently in the clinic population studied. The earlier high prevalence of PG probably represented poor laboratory test specificity. Cost analysis showed that only at very high prevalence of PG (greater than 8%) would pharyngeal screening be cost-effective unless PG can be shown to be an important source of genital infection. We concluded that continued pharyngeal screening is not justified in our clinic because prevalence is so low.

The prevalence of Chlamydia trachomatis genital infection was studied in a sexually active urban Baltimore adolescent population. Possible risk factors such as age, past history of sexually transmitted disease, number of sexual partners, contact with sexually transmitted disease, oral contraceptive use, and concomitant gonococcal infection were also evaluated. The prevalence of chlamydial infection in the 280 adolescents studied was 26%: 35% in male adolescents, 27% in pregnant female adolescents, and 23% in nonpregnant female adolescents. Chlamydia was almost three times as prevalent as gonorrhea in the same population. Age, past history of sexually transmitted disease, oral contraceptive use, and concomitant gonorrhea were not significantly associated with chlamydial infection. However, multiple current sexual partners, contact with sexually transmitted disease, genitourinary symptoms, and cervical ectopy were significantly associated with chlamydial infection. Testing for chlamydial infection in sexually active urban teenagers is recommended for those with genitourinary symptoms, those with cervical ectopy, or those who are contacts of persons with sexually transmitted disease. Considering the reservoir of infection in the asymptomatic female adolescents, screening for chlamydial infections in family planning clinics warrants consideration.

The finding that the relationship of the in vitro and in vivo responses of different strains of mice is under genetic control indicates that at least two mechanisms must operate under in vivo conditions to control 19S antibody synthesis. One is involved in the termination of 19S antibody synthesis; the other has a regulatory role on the magnitude of the response. In light of these findings, various concepts based on other genetically controlled immune responses and on the limiting dilution technique should be reassessed. Furthermore, the suppressive in vivo mechanism may be an important type of control in the resistance or susceptibility to the establishment or maintainance of neoplasms.