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AIDS AND DRUG ADDICTS IN EUROPE
626 TABLE I-AIDS CASES REPORTED IN EUROPE* AMONG HETEROSEXUAL IVDA AND OTHER TRANSMISSION GROUPS BY AGE: MARCH
31, 1987
Ictal SPECT axial images of brain of patient with focal epilepsy.
through cerebral hemispheres showing hyperperfusion in right frontoparietal area. Right: slice through posterior fossa showing hyperperfusion in left cerebellar hemisphere. Left: slice
SPECT scanning detects y-rays emitted by a radionuclide attached to HMPAO which is distributed in brain tissue in proportion to blood-flow. HMPAO is taken up largely on first pass, and redistributed very slowly, It may be given during a seizure, but the patient need not be scanned for up to 6 h afterward, as the pattern of blood-flow at the time of injection is effectively frozen. Studies of regional cerebral blood-flow in focal epilepsy have shown hyperperfusion ictally and hypoperfusion interictally, at the site of the EEG focus,4,5 even when CT is negative. There have been no published studies of cerebellar blood flow-during seizures. While studies of cerebellar diaschisis2,3 demonstrate that an area of reduced function may produce a remote area of reduced blood-flow, our case demonstrates that an area of increased function may have the opposite effect, reflecting the interdependence of activity in different areas of the brain, and the close coupling between electrical activity and blood-flow. It may be easiest to detect in the cerebellum, as cerebellar afferents outnumber efferents by a factor of 40 to 1, reflecting the enormous extent to which incoming information is integrated and generates neural activity. The cerebellar syndrome described in poorly controlled epilepsy may not always be due to anticonvulsants, but may perhaps be the result of chronic or intermittent diaschisis. The Novo 810 SPECT
scanner was
funded
by the Wellcome Trust. RODERICK DUNCAN
Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF
1. 2.
JAMES PATTERSON IAN BONE DAVID J. WYPER
Kempinsky WH. Experimental study of distant effects of acute focal brain injury: a study of diachisis Arch Neurol Psychiatry 1958; 79: 376-89 Meneghetti G, Vorstrup S, Mickey B, Lindewald H, Lassen NA. Crossed cerebellar diaschisis in ischaemic stroke a study of regional cerebral blood flow by 133Xe inhalation and single photon emission computed tomography. J Cereb Blood Flow
*Austriat, Belgiumt, Czechoslovakia, Denmarkt, Fmland, Francet, East Germany, West Germanyt, Greecet, Hungary, Iceland, Irelandt, Israelt, Italyt, Luxemburgt, Malta, Netherlandst, Norwayt, Poland, Portugalt, Rumania, Spaint, Sweden, Switzerlandt, United Kingdomt, USSR, Yugoslavia (tcountries that have reported IVDA with AIDS).
factor and 137 cases in male homosexual drug abusers. The percentage contribution of heterosexual intravenous drug abusers (IVDA) among European AIDS cases has increased sharply from 1% in December, 1984, to 7% in December, 1985, 14% in December, 1986, and 15% in March, 1987. These cases are particularly concentrated in southern Europe, 87 % of them having been reported by Italy, Spain, or France. Heterosexual IVDA accounts for 59% and 52% of AIDS cases in Italy and Spain, respectively. However, seroepidemiological studies in other European countries show high and rapidly increasing prevalence rates of HIV infection among drug abusers in several cities.1-3 The seriousness of this situation has been frequently stressed; heterosexual IVDA is a key link for the spread of HIV in the heterosexual population (notably through prostitution), and to children through mother-to-child transmission. However, the specific contribution of HIV-infected heterosexual IVDA to the challenge of AIDS should also be emphasised. Separate analysis of AIDS surveillance data related to heterosexual IVDA may thus be useful. Three characteristics stand out: (1) Although the AIDS epidemic began in Europe in 1981, cases among heterosexual IVDA only began to appear during the second part of 1984. The continuous increase in the relative percentage of these cases indicates rapid spread of the disease in this group
(figure). (2) Heterosexual IVDA
with AIDS is reported significantly often in the clinical group with opportunistic infections (91 %) than in other AIDS patients (67%, p<0001) (table II). This difference, as observed in the USA, is related to the high frequency of Kaposi’s sarcoma in HIV infected homosexual males’ (3) The distribution of cases according to age differs remarkably between heterosexual IVDA and the others. 76% of heterosexual IVDA patients with AIDS are under 30 years of age, whereas 78 %
more
Metab 1984; 4: 235-40.
Lindegaard MW, Skretting A, Hagar B, Watne K, Lindegaard K-F Cerebral and cerebellar uptake of 99mTc-(d,l)-hexamethylpropyleneamine oxime (HM-PAO) in patients with brain tumour studied by single photon emission computed tomography. Eur J Nucl Med 1986; 12: 417-20 4. Mazziotta JC, Engel J. The use and impact of positron computed tomography scanning epilepsy. Epilepsia 1984; 25 (suppl 2): S86-104. 5 Uren RF, Magistretti PL, Royal HD, et al. Single photon emission computed tomography: a method of measuring cerebral blood flow in three dimensions (preliminary results of studies in patients with epilepsy and stroke). Med J Aust 3.
1983; i: 411-13.
AIDS AND DRUG ADDICTS IN EUROPE
SIR,-Since 1983, countries belonging to the WHO’s European region have been participating in an AIDS surveillance network. National surveillance data, recorded on standard tables, are sent to our centre every three months. By March, 1987, the twenty-seven participating countries had reported 5687 AIDS cases, including 826 for which intravenous drug abuse was the only known risk
AIDS cases reported in Europe among IVDA and other transmission categories by half-year of diagnosis, to March 31, 1987.
627 TABLE II-AIDS CASES REPORTED IN EUROPE AMONG
HETEROSEXUAL IVDA AND OTHER TRANSMISSION GROUPS BY DISEASE CATEGORY: MARCH
31, 1987
of the other AIDS cases are aged 30 or over. Heterosexual IVDA accounts for 42 % of cases in the 20-29 year age group. The above characteristics will have at least two direct effects on the organisation of medical care that these patients will require. Firstly, most will be treated in infectious disease units for conditions which entail longer hospital stays (and thus higher costs) than those needed for other AIDS-related conditions.5,6 Since in some countries drug addicts are not always integrated into national social insurance systems, serious difficulties may arise. Secondly, the prospect of the large influx of IVDA with AIDS which can be expected soon should prompt infectious diseases specialists to strengthen their capability to care for the particular needs of such patients and to deal with the complex and long-term problems involved in the management of drug addicts. Exchanges of staff between infectious diseases units and centres dealing with drug abusers could be useful in this respect. Moreover, even though sexual transmission remains the main route of spread of HIV infection throughout the world, the young age of most heterosexual IVDA with AIDS means that AIDS information campaigns directed at adolescents in Europe should pay particular attention to education on drug abuse.
dose for 2 months did not cause recurrence. If psoriasis can be controlled with zidovudine, it might be the ideal therapy for AIDS-associated psoriasis. The pathogenesis of psoriasis is unknown but a viral cause in some patients has been postulated5-7 and abnormal epidermal proliferation is a key feature. Agents such as methotrexate, which affect DNA synthesis and bone marrow proliferation, are commonly used for severe psoriasis, but are contraindicated in HIV-positive patients.1,2,8 Zidovudine, by virtue of its combined DNA inhibition and antiviral and bone marrow effects, may turn out to be the treatment of choice for this condition. Zidovudine caused remissions of psoriasis in the two AIDS patients reported on here, and might also be of benefit for
HIV-negative psoriasis. Department of Dermatology, University of Texas Medical School
Institute for Immunological Disorders, Houston, Texas
ADAN RIOS GARY W. BREWTON
2. 3.
D, Blecha HG, Deinhardt F, et al. High frequency of HTLV-III antibodies among heterosexual intravenous drug abusers in the Austrian Tyrol. Lancet 1985; i:
4.
U13, Hôpital Claude Bernard, 75944 Paris, France 1. Fuchs
1506.
RJ, Bucknall ABV, Wiggins P. Regional variations in HIV antibody seropositivity in British intravenous drug users. Lancet 1986; i: 1435-36. 3. Brunet JB, Des Jarlais DC, Koch MA. Report on the European Community Workshop on Epidemiology of HIV Infections: Spread among intravenous drug abusers and the heterosexual population. AIDS 1987; 1: 59-61. 4 Jaffe HW, Bregman DJ, Selik RM. Acquired immune deficiency syndrome in the United States: the first 1000 cases. J Infect Dis 1983; 148: 339-45. 5. Scitovsky AA, Cline M, Lee PR. Medical care costs of patients with AIDS m San Francisco. JAMA 1986; 256: 3103-06. 6 Seage GR, Landers S, Barry A, Groopman J, Lamb GA, Epstein AM. Medical care costs of AIDS in Massachusetts. JAMA 1986; 256: 3107-09. 2. Robertson
Houston,
MADELEINE DUVIC
ROSEMARY ANCELLE-PARK JEAN-BAPTISTE BRUNET ANGELA M. DOWNS
INSERM
at
Houston, Texas 77030, USA
1.
WHO Collaborating Centre on AIDS, Institut de Médecine et
d’Epidémiologie Tropicales,
significant improvement in pruritus. Over the next 3 weeks, the psoriasis cleared completely, with normal nail regrowth at 3 months. Pruritus returned temporarily when the drug was withheld for 7 days because of anaemia. In March, 1987, zidovudine was discontinued because of PCP. Psoriasis reappeared over the next 6 weeks. Reinstitution of zidovudine at a lower dose of 400 mg daily in June resulted in improvement, but not total clearing. When the dose was raised to 200 mg four times daily in August the psoriasis again cleared almost entirely within 3 weeks. A second HIV-positive male proceeded to AIDS with PCP and cytomegalovirus and candida infection 6 months after psoriasis was diagnosed. T4 count was 14/)il. After receiving zidovudine 200 mg every 4 h for 8 weeks, his psoriasis completely cleared. Halving the
5. 6. 7.
8.
Johnson TM, Duvic M, Rapini R, Rios A. AIDS exacerbates psoriasis. N Engl JMed 1985; 313: 1415. Duvic M, Johnson TM, Rapini R, Freese T, Brewton GM, Rios A. AIDS associated psoriasis/Reiter’s syndrome. Arch Dermatol (in press). Mitsuya H, Weinhold KJ, Furman PA, et al. 3’azido-3’deoxythymidine (BW A509U): an antiviral agent that inhibits the infectivity and cytopathic effect of human
T-lymphotrophic virus type II/lymphadenopathy-associated virus in vivo. Proc Natl Acad Sci USA 1985; 82: 7096-100. Yarchoan R, Klecker RW, Weinhold KJ, et al. Administration of 3’-azido-3’deoxythymidine, an inhibitor of HTLV-III/LAV replication to patients with AIDS or AIDS-related complex. Lancet 1986; i: 575-80. Dalen AB, Hellgran L, Iversen OJ, Vincent J. A virus-like particle associated with psoriatic skin. Acta Pathol Microbiol Immunol Scand B 1983; 91: 221-29. Bjerke JR, Livden JK, Degre M, Matre R. Interferon in suction blister fluid from psonatic lesions. Br J Dermatol 1983; 108: 295-99. Dieyel W, Waschke SR, Sonnichsen N. Detection of interferon in sera of patients with psoriasis and its enhancement by PUVA treatment. Br J Dermatol 1983; 109: 549-52. Winchester R, Bernstein DH, Fischer HD, Enlow R, Solomon G. Co-occurrence of Reiter’s syndrome and acquired immunodeficiency. Ann Intern Med 1987; 106: 19-26.
REMISSION OF AIDS-ASSOCIATED PSORIASIS WITH ZIDOVUDINE
ATOPIC ECZEMA IN HIV-SEROPOSITIVE HAEMOPHILIACS
SIR,-Since noting that psoriasis/Reiter’s syndrome may be precipitated or exacerbated by AIDS,1 we have managed thirteen patients with HIV-associated psoriasis.2 Therapy was difficult. Methotrexate caused leucopenia in three and precipitated HIV encephalopathy in one. Ultraviolet light exacerbated or coincided with Kaposi’s sarcoma in five. Etretinate was helpful in three but had side-effects.2 Only three patients presented with AIDS, but the total with AIDS subsequently rose to eleven, and nine have died. The average lifespan after the development of AIDS-associated psoriasis has been 12 months (range 4-24 months), which suggests that psoriasis may be a grave prognostic finding in HIV-positive individuals. Zidovudine (azidothymidine) has prolonged lifespan and reduced infections in AIDS patients.3A We report here on two patients with AIDS whose psoriasis cleared on zidovudine. A 27-year-old bisexual developed psoriasis and AIDS-related complex in January, 1986. As his T4 count fell to 14/)il over 8 months, the psoriasis spread to affect 60 % of his body, including all nails and digits. In November, 1986, AIDS developed, with Pneumocystis carinii pneumonia (PCP) and oesophageal candidiasis. He was put on zidovudine 800 mg daily and noted immediate
SiR,—To date, there are nine HIV seropositive patients out of forty-eight registered haemophiliacs aged less than 15 years at the Hospital for Sick Children, London. Of these nine, three had either atopic eczema for the first time or had a recurrence of previously quiescent eczema soon after recorded seroconversion. A 4-year-old with haemophilia known since birth was noted to be HIV seropositive in November, 1985. Atopic eczema began 1 month later and has been severe and difficult to manage. A 12-year-old with haemophilia known for 11years had mild eczema in early infancy which cleared completely. In August 1985, he was noted to be seropositive and just before this he had had a recurrence of widespread eczema which has persisted. A 9/2-year-old with haemophilia known for 9 years had mild eczema as an infant. In February, 1985, he was noted to be HIV seropositive. His eczema recurred at that time with worsening during the past 6 months. Loss of hepatitis B immunity was noted in March, 1987, despite completion of his immunisations 6 months previously with an initial satisfactory antibody response. He has no detectable antibody response against hepatitis B, as well as measles, herpes simplex, varicella-zoster, and cytomegalovirus.
31, 1987
Ictal SPECT axial images of brain of patient with focal epilepsy.
through cerebral hemispheres showing hyperperfusion in right frontoparietal area. Right: slice through posterior fossa showing hyperperfusion in left cerebellar hemisphere. Left: slice
SPECT scanning detects y-rays emitted by a radionuclide attached to HMPAO which is distributed in brain tissue in proportion to blood-flow. HMPAO is taken up largely on first pass, and redistributed very slowly, It may be given during a seizure, but the patient need not be scanned for up to 6 h afterward, as the pattern of blood-flow at the time of injection is effectively frozen. Studies of regional cerebral blood-flow in focal epilepsy have shown hyperperfusion ictally and hypoperfusion interictally, at the site of the EEG focus,4,5 even when CT is negative. There have been no published studies of cerebellar blood flow-during seizures. While studies of cerebellar diaschisis2,3 demonstrate that an area of reduced function may produce a remote area of reduced blood-flow, our case demonstrates that an area of increased function may have the opposite effect, reflecting the interdependence of activity in different areas of the brain, and the close coupling between electrical activity and blood-flow. It may be easiest to detect in the cerebellum, as cerebellar afferents outnumber efferents by a factor of 40 to 1, reflecting the enormous extent to which incoming information is integrated and generates neural activity. The cerebellar syndrome described in poorly controlled epilepsy may not always be due to anticonvulsants, but may perhaps be the result of chronic or intermittent diaschisis. The Novo 810 SPECT
scanner was
funded
by the Wellcome Trust. RODERICK DUNCAN
Institute of Neurological Sciences, Southern General Hospital, Glasgow G51 4TF
1. 2.
JAMES PATTERSON IAN BONE DAVID J. WYPER
Kempinsky WH. Experimental study of distant effects of acute focal brain injury: a study of diachisis Arch Neurol Psychiatry 1958; 79: 376-89 Meneghetti G, Vorstrup S, Mickey B, Lindewald H, Lassen NA. Crossed cerebellar diaschisis in ischaemic stroke a study of regional cerebral blood flow by 133Xe inhalation and single photon emission computed tomography. J Cereb Blood Flow
*Austriat, Belgiumt, Czechoslovakia, Denmarkt, Fmland, Francet, East Germany, West Germanyt, Greecet, Hungary, Iceland, Irelandt, Israelt, Italyt, Luxemburgt, Malta, Netherlandst, Norwayt, Poland, Portugalt, Rumania, Spaint, Sweden, Switzerlandt, United Kingdomt, USSR, Yugoslavia (tcountries that have reported IVDA with AIDS).
factor and 137 cases in male homosexual drug abusers. The percentage contribution of heterosexual intravenous drug abusers (IVDA) among European AIDS cases has increased sharply from 1% in December, 1984, to 7% in December, 1985, 14% in December, 1986, and 15% in March, 1987. These cases are particularly concentrated in southern Europe, 87 % of them having been reported by Italy, Spain, or France. Heterosexual IVDA accounts for 59% and 52% of AIDS cases in Italy and Spain, respectively. However, seroepidemiological studies in other European countries show high and rapidly increasing prevalence rates of HIV infection among drug abusers in several cities.1-3 The seriousness of this situation has been frequently stressed; heterosexual IVDA is a key link for the spread of HIV in the heterosexual population (notably through prostitution), and to children through mother-to-child transmission. However, the specific contribution of HIV-infected heterosexual IVDA to the challenge of AIDS should also be emphasised. Separate analysis of AIDS surveillance data related to heterosexual IVDA may thus be useful. Three characteristics stand out: (1) Although the AIDS epidemic began in Europe in 1981, cases among heterosexual IVDA only began to appear during the second part of 1984. The continuous increase in the relative percentage of these cases indicates rapid spread of the disease in this group
(figure). (2) Heterosexual IVDA
with AIDS is reported significantly often in the clinical group with opportunistic infections (91 %) than in other AIDS patients (67%, p<0001) (table II). This difference, as observed in the USA, is related to the high frequency of Kaposi’s sarcoma in HIV infected homosexual males’ (3) The distribution of cases according to age differs remarkably between heterosexual IVDA and the others. 76% of heterosexual IVDA patients with AIDS are under 30 years of age, whereas 78 %
more
Metab 1984; 4: 235-40.
Lindegaard MW, Skretting A, Hagar B, Watne K, Lindegaard K-F Cerebral and cerebellar uptake of 99mTc-(d,l)-hexamethylpropyleneamine oxime (HM-PAO) in patients with brain tumour studied by single photon emission computed tomography. Eur J Nucl Med 1986; 12: 417-20 4. Mazziotta JC, Engel J. The use and impact of positron computed tomography scanning epilepsy. Epilepsia 1984; 25 (suppl 2): S86-104. 5 Uren RF, Magistretti PL, Royal HD, et al. Single photon emission computed tomography: a method of measuring cerebral blood flow in three dimensions (preliminary results of studies in patients with epilepsy and stroke). Med J Aust 3.
1983; i: 411-13.
AIDS AND DRUG ADDICTS IN EUROPE
SIR,-Since 1983, countries belonging to the WHO’s European region have been participating in an AIDS surveillance network. National surveillance data, recorded on standard tables, are sent to our centre every three months. By March, 1987, the twenty-seven participating countries had reported 5687 AIDS cases, including 826 for which intravenous drug abuse was the only known risk
AIDS cases reported in Europe among IVDA and other transmission categories by half-year of diagnosis, to March 31, 1987.
627 TABLE II-AIDS CASES REPORTED IN EUROPE AMONG
HETEROSEXUAL IVDA AND OTHER TRANSMISSION GROUPS BY DISEASE CATEGORY: MARCH
31, 1987
of the other AIDS cases are aged 30 or over. Heterosexual IVDA accounts for 42 % of cases in the 20-29 year age group. The above characteristics will have at least two direct effects on the organisation of medical care that these patients will require. Firstly, most will be treated in infectious disease units for conditions which entail longer hospital stays (and thus higher costs) than those needed for other AIDS-related conditions.5,6 Since in some countries drug addicts are not always integrated into national social insurance systems, serious difficulties may arise. Secondly, the prospect of the large influx of IVDA with AIDS which can be expected soon should prompt infectious diseases specialists to strengthen their capability to care for the particular needs of such patients and to deal with the complex and long-term problems involved in the management of drug addicts. Exchanges of staff between infectious diseases units and centres dealing with drug abusers could be useful in this respect. Moreover, even though sexual transmission remains the main route of spread of HIV infection throughout the world, the young age of most heterosexual IVDA with AIDS means that AIDS information campaigns directed at adolescents in Europe should pay particular attention to education on drug abuse.
dose for 2 months did not cause recurrence. If psoriasis can be controlled with zidovudine, it might be the ideal therapy for AIDS-associated psoriasis. The pathogenesis of psoriasis is unknown but a viral cause in some patients has been postulated5-7 and abnormal epidermal proliferation is a key feature. Agents such as methotrexate, which affect DNA synthesis and bone marrow proliferation, are commonly used for severe psoriasis, but are contraindicated in HIV-positive patients.1,2,8 Zidovudine, by virtue of its combined DNA inhibition and antiviral and bone marrow effects, may turn out to be the treatment of choice for this condition. Zidovudine caused remissions of psoriasis in the two AIDS patients reported on here, and might also be of benefit for
HIV-negative psoriasis. Department of Dermatology, University of Texas Medical School
Institute for Immunological Disorders, Houston, Texas
ADAN RIOS GARY W. BREWTON
2. 3.
D, Blecha HG, Deinhardt F, et al. High frequency of HTLV-III antibodies among heterosexual intravenous drug abusers in the Austrian Tyrol. Lancet 1985; i:
4.
U13, Hôpital Claude Bernard, 75944 Paris, France 1. Fuchs
1506.
RJ, Bucknall ABV, Wiggins P. Regional variations in HIV antibody seropositivity in British intravenous drug users. Lancet 1986; i: 1435-36. 3. Brunet JB, Des Jarlais DC, Koch MA. Report on the European Community Workshop on Epidemiology of HIV Infections: Spread among intravenous drug abusers and the heterosexual population. AIDS 1987; 1: 59-61. 4 Jaffe HW, Bregman DJ, Selik RM. Acquired immune deficiency syndrome in the United States: the first 1000 cases. J Infect Dis 1983; 148: 339-45. 5. Scitovsky AA, Cline M, Lee PR. Medical care costs of patients with AIDS m San Francisco. JAMA 1986; 256: 3103-06. 6 Seage GR, Landers S, Barry A, Groopman J, Lamb GA, Epstein AM. Medical care costs of AIDS in Massachusetts. JAMA 1986; 256: 3107-09. 2. Robertson
Houston,
MADELEINE DUVIC
ROSEMARY ANCELLE-PARK JEAN-BAPTISTE BRUNET ANGELA M. DOWNS
INSERM
at
Houston, Texas 77030, USA
1.
WHO Collaborating Centre on AIDS, Institut de Médecine et
d’Epidémiologie Tropicales,
significant improvement in pruritus. Over the next 3 weeks, the psoriasis cleared completely, with normal nail regrowth at 3 months. Pruritus returned temporarily when the drug was withheld for 7 days because of anaemia. In March, 1987, zidovudine was discontinued because of PCP. Psoriasis reappeared over the next 6 weeks. Reinstitution of zidovudine at a lower dose of 400 mg daily in June resulted in improvement, but not total clearing. When the dose was raised to 200 mg four times daily in August the psoriasis again cleared almost entirely within 3 weeks. A second HIV-positive male proceeded to AIDS with PCP and cytomegalovirus and candida infection 6 months after psoriasis was diagnosed. T4 count was 14/)il. After receiving zidovudine 200 mg every 4 h for 8 weeks, his psoriasis completely cleared. Halving the
5. 6. 7.
8.
Johnson TM, Duvic M, Rapini R, Rios A. AIDS exacerbates psoriasis. N Engl JMed 1985; 313: 1415. Duvic M, Johnson TM, Rapini R, Freese T, Brewton GM, Rios A. AIDS associated psoriasis/Reiter’s syndrome. Arch Dermatol (in press). Mitsuya H, Weinhold KJ, Furman PA, et al. 3’azido-3’deoxythymidine (BW A509U): an antiviral agent that inhibits the infectivity and cytopathic effect of human
T-lymphotrophic virus type II/lymphadenopathy-associated virus in vivo. Proc Natl Acad Sci USA 1985; 82: 7096-100. Yarchoan R, Klecker RW, Weinhold KJ, et al. Administration of 3’-azido-3’deoxythymidine, an inhibitor of HTLV-III/LAV replication to patients with AIDS or AIDS-related complex. Lancet 1986; i: 575-80. Dalen AB, Hellgran L, Iversen OJ, Vincent J. A virus-like particle associated with psoriatic skin. Acta Pathol Microbiol Immunol Scand B 1983; 91: 221-29. Bjerke JR, Livden JK, Degre M, Matre R. Interferon in suction blister fluid from psonatic lesions. Br J Dermatol 1983; 108: 295-99. Dieyel W, Waschke SR, Sonnichsen N. Detection of interferon in sera of patients with psoriasis and its enhancement by PUVA treatment. Br J Dermatol 1983; 109: 549-52. Winchester R, Bernstein DH, Fischer HD, Enlow R, Solomon G. Co-occurrence of Reiter’s syndrome and acquired immunodeficiency. Ann Intern Med 1987; 106: 19-26.
REMISSION OF AIDS-ASSOCIATED PSORIASIS WITH ZIDOVUDINE
ATOPIC ECZEMA IN HIV-SEROPOSITIVE HAEMOPHILIACS
SIR,-Since noting that psoriasis/Reiter’s syndrome may be precipitated or exacerbated by AIDS,1 we have managed thirteen patients with HIV-associated psoriasis.2 Therapy was difficult. Methotrexate caused leucopenia in three and precipitated HIV encephalopathy in one. Ultraviolet light exacerbated or coincided with Kaposi’s sarcoma in five. Etretinate was helpful in three but had side-effects.2 Only three patients presented with AIDS, but the total with AIDS subsequently rose to eleven, and nine have died. The average lifespan after the development of AIDS-associated psoriasis has been 12 months (range 4-24 months), which suggests that psoriasis may be a grave prognostic finding in HIV-positive individuals. Zidovudine (azidothymidine) has prolonged lifespan and reduced infections in AIDS patients.3A We report here on two patients with AIDS whose psoriasis cleared on zidovudine. A 27-year-old bisexual developed psoriasis and AIDS-related complex in January, 1986. As his T4 count fell to 14/)il over 8 months, the psoriasis spread to affect 60 % of his body, including all nails and digits. In November, 1986, AIDS developed, with Pneumocystis carinii pneumonia (PCP) and oesophageal candidiasis. He was put on zidovudine 800 mg daily and noted immediate
SiR,—To date, there are nine HIV seropositive patients out of forty-eight registered haemophiliacs aged less than 15 years at the Hospital for Sick Children, London. Of these nine, three had either atopic eczema for the first time or had a recurrence of previously quiescent eczema soon after recorded seroconversion. A 4-year-old with haemophilia known since birth was noted to be HIV seropositive in November, 1985. Atopic eczema began 1 month later and has been severe and difficult to manage. A 12-year-old with haemophilia known for 11years had mild eczema in early infancy which cleared completely. In August 1985, he was noted to be seropositive and just before this he had had a recurrence of widespread eczema which has persisted. A 9/2-year-old with haemophilia known for 9 years had mild eczema as an infant. In February, 1985, he was noted to be HIV seropositive. His eczema recurred at that time with worsening during the past 6 months. Loss of hepatitis B immunity was noted in March, 1987, despite completion of his immunisations 6 months previously with an initial satisfactory antibody response. He has no detectable antibody response against hepatitis B, as well as measles, herpes simplex, varicella-zoster, and cytomegalovirus.