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ABNORMAL OCULAR MOTILITY AS EARLY SIGN OF CNS INVOLVEMENT IN HIV INFECTION
512 with a combination of parenteral amoxycillin or penicillin and gentamicin.4,s It is clearly important to maintain a register of all cases of failed endocarditis prophylaxis so that the frequency of failure and important contributory factors can be better determined. In our view, however, given the seriousness of staphylococcal prosthetic valve endocarditis, the present cases call into question the use of oral amoxycillin or penicillin for dental procedures in patients with prosthetic valves. Prophylaxis which may be appropriate against both oral streptococci and staphylococci would probably be provided by a combination of vancomycin and gentamicin, but this often would not be practical. More time is needed to determine how much risk there is of staphylococcal endocarditis after dental procedures. Details of cases of apparent failure of endocarditis prophylaxis should be sent to: United Kingdom-Dr D. C. Shanson (Microbiology, St Stephen’s Hospital London SW10 9TH); or Dr S. J. Eykyn (Microbiology, St Thomas’ Hospital London SE1); rest of Europe-Dr J. Etienne (Hopital Cardiologique, 69394 Lyon Cedex 3, France). J. ETIENNE J. FLEURETTE Hôpital Cardiologique, J. F. NINET 69394 Lyon Cedex 3,
prophylaxis
France
P. FAVET
Department of Community Medicine, University of Glasgow
L. D. GRUER
of a working party of the European Society of Cardiology. Prophylaxis of infective endocarditis for dental procedures. Eur Heart J 1985; 6: 826-28. 2. Russel C. A review. Bacteria in the human mouth. J Appl Microbiol 1978; 44: 163-81. 3. Durack DT, Kaplan EL, Bisno AL. Apparent failures of endocarditis prophylaxis. Analysis of 52 cases submitted to a national registry. JAMA 1983; 250: 2318-33. 4. Committee on rheumatic fever and infective endocarditis of the council on cardiovascular disease m the young. Prevention of bacterial endocarditis. Circulation 1984; 70: 1123A-27A. 5. Schweizerische Arbeitsgruppe fur Endokarditis Prophylaxe. Prophylaxe der bakteriellem Endokarditis. Schweiz Med Wschr 1984; 114: 1246-52. 1.
Report
CSF FINDINGS IN FIRST PATIENT WITH OCULAR MOTILITY ABNORMALITIES
became infected in Africa, probably in 1982. His HIV infection was at the stage of AIDS when confirmed in April, 1985. Ocular fundi, eye movements, and visual acuity were normal at that time. Slowly progressing dementia and polyneuropathy were observed in the summer of 1985. In December he complained of inability to see downwards. Visual acuity was normal 10 (20/20). Horizontal movements were nearly normal. A few cottonwool spots were observed in both ocular fundi. The CSF total protein and IgG levels were slightly raised (557 and 44 mg/1, respectively). The CSF cell count and albumin concentration were normal but the serum/CSF HIV antibody ratio was 25, indicating virus-specific antibody synthesis within the CNS. Magnetic resonance imaging (MRI) revealed diffuse white-matter changes consistent with HIV encephalopathy bilaterally in central areas and basal ganglia. Atrophy progressed in the temporal and occipital lobes within 3 months as shown by two subsequent MRI examinations. A week before his death in June, 1986, the patient could not produce any voluntary eye movements. There was no convergence. Both patients had severe ocular motility disorders probably due to HIV-induced subacute encephalopathy. Ocular motility disorders of brain origin may appear together with CSF changes and before macroscopic morphological changes of the brain are neuroradiologically demonstrable. In HIV-infected patients ocular motility should be evaluated. TIMO TERVO IRINA ELOVAARA HILLEVI KARLI SIRKKA-LIISA VALLE JUKKA SUNI JUHANI LÄHDEVIRTA MATTI IIVANAINEN
ABNORMAL OCULAR MOTILITY AS EARLY SIGN OF CNS INVOLVEMENT IN HIV INFECTION
SIR,-Several ocular manifestationsl have been described in HIV (human immunodeficiency virus) infected patients. Cranial nerve palsies affecting eye movement2 have also been reported. We
following up HIV patients both neurologically and ophthalmologically and so far have seen one patient with AID Srelated complex (ARC) and four AIDS patients with ocular motility disorders of brain origin but not cranial nerve palsy. Two of these patients are reported here in detail. A 39-year-old male homosexual diagnosed as having ARC in January, 1985, complained in December, 1985, of impaired visual acuity, near-vision problems, intermittent polyopia, and mild photophopia. His refraction was checked and new spectacles and reading glasses were prescribed. The corrected visual acuity of both eyes was 10. The symptoms partly diminished. No other neurological or ophthalmological deficits except for convergence insufficiency were observed. Visual evoked potentials were normal. An EEG revealed mild temporal slowing without specific changes.
have been
The CSF showed evidence of increasing immune response of the CNS and of blood-brain-barrier impairment (table). During the next 2 months the symptoms progressed, with mono-ocular polyopia and inability to read or to follow moving targets. The patient was unable to work. He had disturbed optokinetic nystagmus, progressive convergence insufficiency, abnormal and dysconjugated saccade movements, and blepharospasm. Corrected visual acuity and stereoacuity were normal. The patient was binocular. Colour vision, pupillary reactions, visual fields, and ocular fundi were normal. The third, fourth, and sixth cranial nerves were unaffected. Magnetic resonance imaging and brain auditory evoked potentials were normal. Visual evoked potentials with stimulation at the left eye revealed a low-amplitude response. The second patient was a 38-year-old male heterosexual who
Departments of Ophthalmology and Neurology, University of Helsinki, SF 00290 Helsinki, Finland; and Aurora Hospital, Helsinki
AG, Rodrigues MM, Macher AM, et al. Ophthalmic involvement in acquired immunodeficiency syndrome. J Ophthalmol 1984; 91: 1092-99 2. Jack MK, Smith T, Collier AC. Oculomotor cranial nerve palsey associated with acquired immunodeficiency syndrome. Ann Ophthalmol 1984; 16: 460-62. 1. Palestine
FALSE-POSITIVE RESULTS WITH HIV ELISA KITS
Sm,—We read with interest the evaluation of HIV ELISA kits by the Retrovirus Study Group of the French National Society of Blood Transfusion (SNTS).l Although we would agree with their estimates of sensitivity of the kits, our own experience of false-positive reactions with several of the kits is lower than that of the French group. We are using the ’Vironostika’ (Organon Teknika) screening test for blood donors. We screen approximately 15 000 blood donations per month for HIV antibodies. We find an overall repeatable false-positive rate of 0-14%and a true-positive rate of 1:46 393 (0-002° o). Marked batch-to-batch variation has been noted with this kit. We have recently assessed the Abbott and DuPont HIV ELISA kits. The DuPont kit was handled by the short-incubation method. Our results were: No of samples
Manufacturer Organon (Jan-June, 1986)
tested
Repeatable false positives
Confirmed pOSltn’e
92786 134 (O,14Ou) 2* 4289 DuPont 9 (0’ 20 u) Nil 2 (0’250 u) Abbott 800 Nil *These two samples were reactive by the DuPont, Abbott, and Wellcome HIV antibody kits.
prophylaxis
France
P. FAVET
Department of Community Medicine, University of Glasgow
L. D. GRUER
of a working party of the European Society of Cardiology. Prophylaxis of infective endocarditis for dental procedures. Eur Heart J 1985; 6: 826-28. 2. Russel C. A review. Bacteria in the human mouth. J Appl Microbiol 1978; 44: 163-81. 3. Durack DT, Kaplan EL, Bisno AL. Apparent failures of endocarditis prophylaxis. Analysis of 52 cases submitted to a national registry. JAMA 1983; 250: 2318-33. 4. Committee on rheumatic fever and infective endocarditis of the council on cardiovascular disease m the young. Prevention of bacterial endocarditis. Circulation 1984; 70: 1123A-27A. 5. Schweizerische Arbeitsgruppe fur Endokarditis Prophylaxe. Prophylaxe der bakteriellem Endokarditis. Schweiz Med Wschr 1984; 114: 1246-52. 1.
Report
CSF FINDINGS IN FIRST PATIENT WITH OCULAR MOTILITY ABNORMALITIES
became infected in Africa, probably in 1982. His HIV infection was at the stage of AIDS when confirmed in April, 1985. Ocular fundi, eye movements, and visual acuity were normal at that time. Slowly progressing dementia and polyneuropathy were observed in the summer of 1985. In December he complained of inability to see downwards. Visual acuity was normal 10 (20/20). Horizontal movements were nearly normal. A few cottonwool spots were observed in both ocular fundi. The CSF total protein and IgG levels were slightly raised (557 and 44 mg/1, respectively). The CSF cell count and albumin concentration were normal but the serum/CSF HIV antibody ratio was 25, indicating virus-specific antibody synthesis within the CNS. Magnetic resonance imaging (MRI) revealed diffuse white-matter changes consistent with HIV encephalopathy bilaterally in central areas and basal ganglia. Atrophy progressed in the temporal and occipital lobes within 3 months as shown by two subsequent MRI examinations. A week before his death in June, 1986, the patient could not produce any voluntary eye movements. There was no convergence. Both patients had severe ocular motility disorders probably due to HIV-induced subacute encephalopathy. Ocular motility disorders of brain origin may appear together with CSF changes and before macroscopic morphological changes of the brain are neuroradiologically demonstrable. In HIV-infected patients ocular motility should be evaluated. TIMO TERVO IRINA ELOVAARA HILLEVI KARLI SIRKKA-LIISA VALLE JUKKA SUNI JUHANI LÄHDEVIRTA MATTI IIVANAINEN
ABNORMAL OCULAR MOTILITY AS EARLY SIGN OF CNS INVOLVEMENT IN HIV INFECTION
SIR,-Several ocular manifestationsl have been described in HIV (human immunodeficiency virus) infected patients. Cranial nerve palsies affecting eye movement2 have also been reported. We
following up HIV patients both neurologically and ophthalmologically and so far have seen one patient with AID Srelated complex (ARC) and four AIDS patients with ocular motility disorders of brain origin but not cranial nerve palsy. Two of these patients are reported here in detail. A 39-year-old male homosexual diagnosed as having ARC in January, 1985, complained in December, 1985, of impaired visual acuity, near-vision problems, intermittent polyopia, and mild photophopia. His refraction was checked and new spectacles and reading glasses were prescribed. The corrected visual acuity of both eyes was 10. The symptoms partly diminished. No other neurological or ophthalmological deficits except for convergence insufficiency were observed. Visual evoked potentials were normal. An EEG revealed mild temporal slowing without specific changes.
have been
The CSF showed evidence of increasing immune response of the CNS and of blood-brain-barrier impairment (table). During the next 2 months the symptoms progressed, with mono-ocular polyopia and inability to read or to follow moving targets. The patient was unable to work. He had disturbed optokinetic nystagmus, progressive convergence insufficiency, abnormal and dysconjugated saccade movements, and blepharospasm. Corrected visual acuity and stereoacuity were normal. The patient was binocular. Colour vision, pupillary reactions, visual fields, and ocular fundi were normal. The third, fourth, and sixth cranial nerves were unaffected. Magnetic resonance imaging and brain auditory evoked potentials were normal. Visual evoked potentials with stimulation at the left eye revealed a low-amplitude response. The second patient was a 38-year-old male heterosexual who
Departments of Ophthalmology and Neurology, University of Helsinki, SF 00290 Helsinki, Finland; and Aurora Hospital, Helsinki
AG, Rodrigues MM, Macher AM, et al. Ophthalmic involvement in acquired immunodeficiency syndrome. J Ophthalmol 1984; 91: 1092-99 2. Jack MK, Smith T, Collier AC. Oculomotor cranial nerve palsey associated with acquired immunodeficiency syndrome. Ann Ophthalmol 1984; 16: 460-62. 1. Palestine
FALSE-POSITIVE RESULTS WITH HIV ELISA KITS
Sm,—We read with interest the evaluation of HIV ELISA kits by the Retrovirus Study Group of the French National Society of Blood Transfusion (SNTS).l Although we would agree with their estimates of sensitivity of the kits, our own experience of false-positive reactions with several of the kits is lower than that of the French group. We are using the ’Vironostika’ (Organon Teknika) screening test for blood donors. We screen approximately 15 000 blood donations per month for HIV antibodies. We find an overall repeatable false-positive rate of 0-14%and a true-positive rate of 1:46 393 (0-002° o). Marked batch-to-batch variation has been noted with this kit. We have recently assessed the Abbott and DuPont HIV ELISA kits. The DuPont kit was handled by the short-incubation method. Our results were: No of samples
Manufacturer Organon (Jan-June, 1986)
tested
Repeatable false positives
Confirmed pOSltn’e
92786 134 (O,14Ou) 2* 4289 DuPont 9 (0’ 20 u) Nil 2 (0’250 u) Abbott 800 Nil *These two samples were reactive by the DuPont, Abbott, and Wellcome HIV antibody kits.