631
HMPAO SPET scans (horizontal slices). Left=patchy impairment of cortical uptake (eg, nght posterior parietal arrowed). Right= impaired right cerebellar uptake (arrowed)
We studied
a 21-year-old GH recipient who presented with an syndrome together with normal bedside testing of higher cognitive function and no extrapyramidal signs. Cranial CT was normal and EEG showed only minor slowing. An HMPAO SPET scan showed perfusion deficits in both cerebellar hemispheres, both frontal and temporal lobes, the right parietal lobe, the right basal ganglia, and thalamus (figure). The full clinical picture of GH-related CJD with dementia and myoclonus developed and he died three months after presentation. The pattern of perfusion deficits fits with the clinical picture seen in advanced GH-related CJD in which cerebellar ataxia, extrapyramidal signs, and impairment of higher cortical function including memory are prominently affected. This pattern of perfusion deficits may help in the diagnosis of the condition at an early stage when other diagnostic imaging and neurophysiological tests are normal. It may also prove useful in monitoring both progression of disease and the response to any future therapy.
ataxic
Departments of Neurology and Nuclear Medicine, University College and Middlesex Hospital School of Medicine, London W1N 8AA, U K
H. S. MARKUS M. J. H. HARRISON D. C. COSTA
1. Brown P. The decline and fall of Creutzfeldt-Jakob disease associated with human growth hormone therapy. Neurology 1988; 38: 1135-37. 2. Bonte FJ, Hom J, Tintner R, Weiner MF. Single photon tomography in Alzheimer’s disease and the dementias. Semin Nucl Med 1990; 20: 342-52. 3. Cohen D, Krausz T, Lossos A, Ben-David E, Atlan H. Brain SPECT imaging with Tc-99m HM-PAO in Creutzfeldt-Jakob disease. Clin Nucl Med 1989; 14: 808-10.
Neonatal
diagnosis of
HIV infection
SiR,—Dr Ehmst and colleagues (July 27, p 203) report findings that
they interpret as evidence for late vertical HIV transmission. However, we would like to discuss two important points. Firstly, a major concern is that none of the 27 newborn babies was HIV positive on culture. This result is somewhat surprising. In our institution, we started a prospective analysis of vertical HIV transmission.1,2 We developed a method with co-cultivation of the patient’s peripheral blood mononuclear cells (PBMC) with threeday phytohaemagglutinin-activated fresh normal human cord blood mononuclear cells. In these conditions, 95% of cultures from symptom-free HIV-seropositive patients are positive. We also observed 86% positivity in cultures for 73 seropositive pregnant women.’ Polymerase chain reaction (PCR) diagnosis (three primer pairs, gag, pol, env) improved our co-culture results, since all symptom-free HIV-positive individuals and 98% of seropositive pregnant women were PCR positive. Since January, 1990, 30 newborn babies have been studied. 7 were culture positive and PCR positive within the first 10 days of life (5 cord blood and 2 venepunctures at days 4 and 7) and had symptoms 6 months later. These results were always confirmed by a second culture and PCR
during the second month.
2,4
Second, Ehmst et al do not regard HIV as defniitely present in any fetus. These results are quite different from those of Mano and Chermann5 who found that fetal HIV-1 infection frequently took place in the second trimester of pregnancy. Moreover, Courgnaud et
al6 showed evidence of in-utero HIV-1transmission in 9
babies;
the putative maternal cell contamination was eliminated by use of primers specific for a polymorphic cellular locus.6 Thus, in-utero contamination is undoubtedly possible. The lack of positive viral culture in newborn babies Ehmst et al report is thus in contrast to our 6-year prospective experience. This discrepancy may be due to different culture protocols; for instance, we used normal cord blood lymphocytes, which might be more sensitive to HIV infection than PBMC harvested from adult blood donors. Moreover, the absence of fetal contamination might be related to the low number of cases studied (7 during the first trimester and 5 during the second). Indeed, 13 of the 41 fetuses investigated by Manos and Courgnaud6 and their co-workers were infected. We would emphasise that the association of PCR and culture is recommended for diagnosis of HIV infection in newborn babies 2 1,7 and might be of interest with respect to the rationale of early antiretroviral therapy. This work was supported by the Fondation de I’Avenir pour la Recherche Medicale Appliquee.
Laboratory of Experimental Neuropathology and Neurovirology, CRSSA, CEA, DPTE/DSV, 92265 Fontenay aux Roses, France
PIERRE ROQUES MARC HUMBERT
DOMINIQUE DORMONT
1. DiMaria
H, Courpotin C, Rouzioux C, et al. Transplacental transmission of human immunodeficiency virus. Lancet 1986; i: 215-16. 2. Parnet-Mathieu F, Mayohas MC, Roques P, et al. Prospective study of vertical transmission of HIV infection in 24 infant-mother couples (abstract WB2058). In. VIIth International Conference on AIDS, Florence, 1991: 196. 3. Courpotin C, Israel G, Dubeaux D, et al. Predictive value of HIV replication in cell culture in babies born to HIV seropositive mothers. Lancet 1988; ii: 1074-75. 4. Roques P, Vaslin B, Marcé D, Dormont D. PCR and virus isolation on HIV-infected individuals (abstract MA1128). In: VIIth International Conference on AIDS, Florence, 1991: 124. 5. Mano H, Chermann JC. Fetal human immunodeficiency virus type 1 infection of different organs in the second trimester. AIDS Res Hum Retroviruses 1991, 7: 83-88. 6. Courgnaud V, Lauré F, Brossard A, et al. Frequent and early in utero HIV-1 infection. AIDS Res Hum Retrovir 1991; 7: 337-41. 7. Weintrub PS, Ulrich PP, Edwards JR, et al. Use of polymerase chain reaction for the early detection of HIV infection m the infants of HIV-seropositive women. AIDS
1991; 5: 881-84.
AIDS-related Stomatococcus mucilaginosus infection SIR,-Many bacterial species have been reported
as
opportunistic agents in HIV-infected patients. Rhodococcus equi and Bordetella bronchiseptica are the latest to be described. We now report two cases of infection with an unusual bacterial pathogen, Stomatococcus mucilaginosus. Case 1-A 30-year-old HIV-positive homosexual man was first admitted with salmonella infection and weight loss. He recovered after treatment with ofloxacin. However, his CD4 lymphocyte count was 45/1. He was readmitted a few weeks later with a relapse of his diarrhoea, and stool examination showed cryptosporidium oocysts and Isospora belli but no salmonellae. Co-trimoxazole and spiramycin were given, together with antidiarrhoeal agents and parenteral nutrition. After three weeks of treatment, he became febrile and three blood cultures remained positive for a grampositive coccus that was identified as S mucilaginosus. His antibiotic regimen was changed to amoxycillin and clavulanic acid and he became apyrexial within three days with negative repeat blood cultures. Case 2-A 26-year-old HIV-positive homosexual man was admitted with fever, cough, and dyspnoea. On admission his CD4 lymphocyte count was 90/ul and bronchoalveolar lavage revealed Pneumocystis carinii and a gram-positive coccus. Treatment with co-trimoxazole led to resolution of dyspnoea and cough, but the fever persisted. Nine days after start of treatment, bronchoalveolar fluid culture showed a co-trimoxazole-resistant strain of S mucilaginosus. Amoxycillin treatment was started and he became afebrile within two days. S mucilaginosus is thought to be a human commensal of the mouth and upper respiratory tract. This gram-positive coccus is often misidentified for other gram-positive cocci or not identified at all. Previously called Micrococcus mucilaginosus and Staphylococcus salivarius,l its distinctive features include a strong adherence to
HMPAO SPET scans (horizontal slices). Left=patchy impairment of cortical uptake (eg, nght posterior parietal arrowed). Right= impaired right cerebellar uptake (arrowed)
We studied
a 21-year-old GH recipient who presented with an syndrome together with normal bedside testing of higher cognitive function and no extrapyramidal signs. Cranial CT was normal and EEG showed only minor slowing. An HMPAO SPET scan showed perfusion deficits in both cerebellar hemispheres, both frontal and temporal lobes, the right parietal lobe, the right basal ganglia, and thalamus (figure). The full clinical picture of GH-related CJD with dementia and myoclonus developed and he died three months after presentation. The pattern of perfusion deficits fits with the clinical picture seen in advanced GH-related CJD in which cerebellar ataxia, extrapyramidal signs, and impairment of higher cortical function including memory are prominently affected. This pattern of perfusion deficits may help in the diagnosis of the condition at an early stage when other diagnostic imaging and neurophysiological tests are normal. It may also prove useful in monitoring both progression of disease and the response to any future therapy.
ataxic
Departments of Neurology and Nuclear Medicine, University College and Middlesex Hospital School of Medicine, London W1N 8AA, U K
H. S. MARKUS M. J. H. HARRISON D. C. COSTA
1. Brown P. The decline and fall of Creutzfeldt-Jakob disease associated with human growth hormone therapy. Neurology 1988; 38: 1135-37. 2. Bonte FJ, Hom J, Tintner R, Weiner MF. Single photon tomography in Alzheimer’s disease and the dementias. Semin Nucl Med 1990; 20: 342-52. 3. Cohen D, Krausz T, Lossos A, Ben-David E, Atlan H. Brain SPECT imaging with Tc-99m HM-PAO in Creutzfeldt-Jakob disease. Clin Nucl Med 1989; 14: 808-10.
Neonatal
diagnosis of
HIV infection
SiR,—Dr Ehmst and colleagues (July 27, p 203) report findings that
they interpret as evidence for late vertical HIV transmission. However, we would like to discuss two important points. Firstly, a major concern is that none of the 27 newborn babies was HIV positive on culture. This result is somewhat surprising. In our institution, we started a prospective analysis of vertical HIV transmission.1,2 We developed a method with co-cultivation of the patient’s peripheral blood mononuclear cells (PBMC) with threeday phytohaemagglutinin-activated fresh normal human cord blood mononuclear cells. In these conditions, 95% of cultures from symptom-free HIV-seropositive patients are positive. We also observed 86% positivity in cultures for 73 seropositive pregnant women.’ Polymerase chain reaction (PCR) diagnosis (three primer pairs, gag, pol, env) improved our co-culture results, since all symptom-free HIV-positive individuals and 98% of seropositive pregnant women were PCR positive. Since January, 1990, 30 newborn babies have been studied. 7 were culture positive and PCR positive within the first 10 days of life (5 cord blood and 2 venepunctures at days 4 and 7) and had symptoms 6 months later. These results were always confirmed by a second culture and PCR
during the second month.
2,4
Second, Ehmst et al do not regard HIV as defniitely present in any fetus. These results are quite different from those of Mano and Chermann5 who found that fetal HIV-1 infection frequently took place in the second trimester of pregnancy. Moreover, Courgnaud et
al6 showed evidence of in-utero HIV-1transmission in 9
babies;
the putative maternal cell contamination was eliminated by use of primers specific for a polymorphic cellular locus.6 Thus, in-utero contamination is undoubtedly possible. The lack of positive viral culture in newborn babies Ehmst et al report is thus in contrast to our 6-year prospective experience. This discrepancy may be due to different culture protocols; for instance, we used normal cord blood lymphocytes, which might be more sensitive to HIV infection than PBMC harvested from adult blood donors. Moreover, the absence of fetal contamination might be related to the low number of cases studied (7 during the first trimester and 5 during the second). Indeed, 13 of the 41 fetuses investigated by Manos and Courgnaud6 and their co-workers were infected. We would emphasise that the association of PCR and culture is recommended for diagnosis of HIV infection in newborn babies 2 1,7 and might be of interest with respect to the rationale of early antiretroviral therapy. This work was supported by the Fondation de I’Avenir pour la Recherche Medicale Appliquee.
Laboratory of Experimental Neuropathology and Neurovirology, CRSSA, CEA, DPTE/DSV, 92265 Fontenay aux Roses, France
PIERRE ROQUES MARC HUMBERT
DOMINIQUE DORMONT
1. DiMaria
H, Courpotin C, Rouzioux C, et al. Transplacental transmission of human immunodeficiency virus. Lancet 1986; i: 215-16. 2. Parnet-Mathieu F, Mayohas MC, Roques P, et al. Prospective study of vertical transmission of HIV infection in 24 infant-mother couples (abstract WB2058). In. VIIth International Conference on AIDS, Florence, 1991: 196. 3. Courpotin C, Israel G, Dubeaux D, et al. Predictive value of HIV replication in cell culture in babies born to HIV seropositive mothers. Lancet 1988; ii: 1074-75. 4. Roques P, Vaslin B, Marcé D, Dormont D. PCR and virus isolation on HIV-infected individuals (abstract MA1128). In: VIIth International Conference on AIDS, Florence, 1991: 124. 5. Mano H, Chermann JC. Fetal human immunodeficiency virus type 1 infection of different organs in the second trimester. AIDS Res Hum Retroviruses 1991, 7: 83-88. 6. Courgnaud V, Lauré F, Brossard A, et al. Frequent and early in utero HIV-1 infection. AIDS Res Hum Retrovir 1991; 7: 337-41. 7. Weintrub PS, Ulrich PP, Edwards JR, et al. Use of polymerase chain reaction for the early detection of HIV infection m the infants of HIV-seropositive women. AIDS
1991; 5: 881-84.
AIDS-related Stomatococcus mucilaginosus infection SIR,-Many bacterial species have been reported
as
opportunistic agents in HIV-infected patients. Rhodococcus equi and Bordetella bronchiseptica are the latest to be described. We now report two cases of infection with an unusual bacterial pathogen, Stomatococcus mucilaginosus. Case 1-A 30-year-old HIV-positive homosexual man was first admitted with salmonella infection and weight loss. He recovered after treatment with ofloxacin. However, his CD4 lymphocyte count was 45/1. He was readmitted a few weeks later with a relapse of his diarrhoea, and stool examination showed cryptosporidium oocysts and Isospora belli but no salmonellae. Co-trimoxazole and spiramycin were given, together with antidiarrhoeal agents and parenteral nutrition. After three weeks of treatment, he became febrile and three blood cultures remained positive for a grampositive coccus that was identified as S mucilaginosus. His antibiotic regimen was changed to amoxycillin and clavulanic acid and he became apyrexial within three days with negative repeat blood cultures. Case 2-A 26-year-old HIV-positive homosexual man was admitted with fever, cough, and dyspnoea. On admission his CD4 lymphocyte count was 90/ul and bronchoalveolar lavage revealed Pneumocystis carinii and a gram-positive coccus. Treatment with co-trimoxazole led to resolution of dyspnoea and cough, but the fever persisted. Nine days after start of treatment, bronchoalveolar fluid culture showed a co-trimoxazole-resistant strain of S mucilaginosus. Amoxycillin treatment was started and he became afebrile within two days. S mucilaginosus is thought to be a human commensal of the mouth and upper respiratory tract. This gram-positive coccus is often misidentified for other gram-positive cocci or not identified at all. Previously called Micrococcus mucilaginosus and Staphylococcus salivarius,l its distinctive features include a strong adherence to
