CD4 lymphopenia in very elderly people

the

hospital/general practice setting is a further cause for concern. Infected patients leave with no greater awareness than when they arrived, and with no encouragement to access convenient, confidential HIV testing. There is evidently as great a potential to discover HIV infections in this district general hospital setting as there is for discovery among heterosexual attenders at genitourinary medicine clinics in London. There are important, obvious, but overlooked implications in these data for the interruption of onward HIV transmission, and also with respect to allocation of resources to hospitals to promote voluntary HIV testing. Universal availability of confidential personal HIV testing in a high prevalence setting is preferable to selectivityunless

the

latter

is

very

well

founded.

Consensual

salivary HIV surveillance, linked to a selfcompletion behavioural/diagnostic/investigational risk factor questionnaire-as originally designed to ensure against deductive disclosure in prison settings4,5-should now be considered in hospital settings to provide the evidence on which to choose an effective hospital policy. The choice is between universal or targeted offering a voluntary HIV test in hospital. We recommend follow-up research studies of this nature as a matter of high priority. anonymous

*Sheila M Gore, A Graham Bird,

Raymond P Brettle

Medical Research Council Biostatistics Unit, Institute of Public Health, CB2 2SR, UK

1

2

3

4

5

Cambridge

Report from the Unlinked Anonymous HIV Surveys Steering Group (Chairman: Dr Eileen Rubery). Unlinked Anonymous HIV Prevalence Monitoring Programme: England and Wales (data to the end of 1993). London: Department of Health, 1995. Report from the Unlinked Anonymous HIV Surveys Steering Group (Chairman: Mr G Podger). Unlinked Anonymous HIV Prevalence Monitoring Programme: England and Wales (data to the end of 1994). London: Department of Health, 1996. Banatvala JE. Unlinked anonymous HIV screening programme in England and Wales. Provides information on where to direct preventive efforts. BMJ 1995; 310: 206-07. Bird AG, Gore SM. Inside methodology. AIDS 1994; 8: 1345-46. Gore SM, Bird AG. Cross-sectional Willing Anonymous Salivary HIV (WASH) Surveillance studies and self-completion risk factor questionnaire in establishments of the Scottish Prison Service. ANSWER 1995; Sept 29: 1-4.

peptides.’ Subtype B peptide was recognised in eight patients, seven of whom were male; whether they had had homosexual activity was unknown. Travel/residential history was available for 88 individuals. Five of eight patients with subtype B (63%) had travelled or resided in North America or Europe whereas only eight of 80 (10%) with other subtypes had travelled to these areas. Sex-adjusted odds ratio of subtype B to travel/residential history to North America or Europe was 8-6 (95% CI 1’4-52,1, p=0013). HIV-1 infection has increased alarmingly in The Gambia. The prevalence of HIV-1 in commercial sex workers has risen from 1-7% in 1986’ to 13-6% in 1992 (S Hawkes, et al, unpublished data). However, our data show that the proportion of subtype B among those with HIV-1 infection remains low: three of 42 (7%) before 1992 and three of 54 (6%) for 1992 and after. This finding together with the clear association between subtype B and travel to North America or Europe suggest that this subtype has not readily spread in The Gambia. So far no survey has reported that subtype B predominates in any part of Africa. Accumulating data indicate that other HIV-1 subtypes such as A, C, or D rather than subtype B are more prevalent in many African countries.’ These observations indicate that HIV-1 subtypes other than B are being preferentially transmitted heterosexually in Africa; they may well be of importance for the development of HIV vaccines, which are urgently needed in Africa. More research on the geographical distribution of subtypes and the cross-protection afforded against these subtypes by vaccine strains are needed before large-scale vaccine trials We thank E

undertaken in Africa.

Harding, S Jaffar,

and S

Sabally for their help.

*Koya Ariyoshi, Rachanee Cheingsong-Popov, Andrew Wilkins, Tumani Corrah, Jonathan Weber, Hilton Whittle *Medical Research Council Laboratories, Fajara, The Gambia, West Africa; and Department of GU and Communicable Diseases, St Mary’s Hospital Medical School, London, UK

1 2

3

HIV-1 subtype B in West Africa SiR-Williamson and colleagues’ showed that there was a clear link between HIV-1 subtype B and HIV-positive homosexual men in South Africa, most of whom had sexual contact in Europe and North America. In The Gambia we have noted a similar link between HIV-1 subtype B and male patients who have travelled or lived in North America or

are

4

Williamson C, Englebrecht S, Lambrick M, et al. HIV-1 subtypes in different risk groups in South Africa. Lancet 1995; 346: 782. Cheingsong-Popov R, Lister S, Callow D, et al. Serotyping HIV type 1 by antibody binding to the V3 loop: relationship to viral genotype. AIDS Res Hum Retrovir 1994; 10: 1379-86. Bobkov A, Cheingsong-Popov R, Salminen M, et al. Complex mosaic structure of the partial envelope sequence from a Gambian HIV-1 isolate. AIDS Res Hum Retrovirus 1996; 12: 169-71. Pepin J, Morgan G, Dunn D, et al. HIV-2 induced immunosuppression among asymptomatic West African prostitutes evidence that HIV-2 is pathogenic but less so than HIV-1. AIDS 1991; 5: 1165-72.

5

Janssens W, Heyndrickx L, vande Peer Y,

et al. Molecular phylogeny of part of the env gene of HIV-1 strains isolated in Cote d’Ivoire. AIDS 1994; 8: 21-26.

Europe. Serum samples from 48 male and 48 female HIV-1 seropositive Gambians who presented to the Medical Research Council clinic between 1988 and 1993 were tested in an ELISA assay with V3 loop peptides derived from subtype A, B, C, D, E, and F consensus sequences.2 Briefly, in 100 dilution were incubated in serum samples at 1 peptide-coated plates for 1 h at 37°C. After washing the plate, antihuman IgG peroxidase conjugate was added; bound antibody was then detected by orthophenylediamine tetrahydrocholoride substrate. The ratio of the optical density (OD) at 492 nm in the sample well to the cutoff value for each peptide was measured. The highest OD ratio to a particular peptide determined the HIV-1 subtype. However, because of the diverse antibody reactivity of serotype A samples to C peptide or vice versa, HIV-1 serotype A and C were grouped together. The results showed that there were at least five district HIV-1 subtypes; A or C (57%), B (8%), D (7%), and F (2%), and 26% of samples were not reactive to the panel of 328

CD4

lymphopenia in very elderly people

SIR-As part of a study into ageing,’1 physically well, mentally competent elderly people who lived independently at home and took no medication known to affect immune function were recruited. 209 were recruited (table). Whole blood, labelled with fluorochrome-conjugated monoclonal antibodies, was analysed by an EPICS 541 flow cytometer. 19 people had CD4 counts less than 0-4X10"/L and 9 had counts of less than 0-3X 109/L (table). The CD4 count was correlated with body-mass index (BMI) (r=0-364; p=0002), weight (r=0-167, p=004), albumin (r=0-222; p=001), and cholesterol (r=0-195; p=0-05). The relatively high incidence of low CD4 counts in elderly people living at home was unexpected. Although HIV infection is usually associated with low CD4 counts, other causes include infections,

systemic lupus erythematosis, lymphoma, sarcoidosis, or idiopathic CD4 lymphopenia.2,3 These elderly people were

Total number shown in

parentheses. Table: Individuals with CD4 lymphopenia according to age, and total number of people in each age group

well, and HIV infection is unlikely since HIV positivity in Northern Ireland is low (139 cases of HIV positivity since 1986) and 75% of cases relate to drug abuse, homosexuality, or haemophilia. The term idiopathic CD4 lymphopenia, which describes people with CD4 counts of less than 0’3X10"/L but no HIV-related disease, is a possible

diagnosis, although the criteria cannot be fully met.2 The CD4 lymphocyte count was associated with BMI, albumin, and cholesterol, which are recognised nutritional markers. Protein energy malnutrition causes secondary immune deficiency in childrenand nutritional supplementation has improved immune status in older subjects." The association of CD4 lymphopenia in elderly people with simple anthropometric and biochemical markers suggests aetiological factors related to nutrition and may be amenable

to treatment.

We thank the elderly people, general practitioner colleagues, and the Blood Transfusion Service, and we acknowledge funding from the DHSS(NI). Part of this work was presented at the Ninth International Conference on Immunology July, 1995.

*I M Rae, H D Alexander, A D Crockard, T C M Morris *Department of Geriatric Medicine, The Queen’s University of Belfast, Department of Haematology, Belfast City Hospital; and Regional Immunology Laboratory, Royal Victorial Hospital, Belfast 1 Rae IM, Middleton D. Is the phenotypic combination A1B8Cw7DR3 a marker for male longevity? J Am Geriatr Soc 1994; 42: 978-83. 2 Piketty C, Weiss L, Kazatchkine M. Idiopathic CD4 lymphocytopenia. Press Med 1994; 23: 1374-75. 3 Rezza G, Pezzotti F, Aiuti F. Acquired immunodeficiency without HIV infection: epidemiology and clinical outcomes in Italy. Br Med J 1995; 311: 785-86. 4 Ozkan H, Olgun N, Sasmaz E, Abacioglu H, Okuyan M, Cevik N. Nutrition, immunity and infections: T lymphocyte subpopulations in protein-energy malnutrition. J Trop Pediatr 1993; 39: 257-60. 5 Roebothan BV, Chandra RK. Relationship between nutritional status and immune function in elderly people. Age Ageing 1994; 23: 49-53.

Polymerase chain reaction of cerebrospinal fluid to diagnose Whipple’s disease SiR-Whipple’s disease is generally a malabsorption syndrome, with occasional other systemic manifestations, thought to result from infection by Tropheryma whippelii., Rarely Whipple’s disease presents as an isolated central nervous system disorder; positive diagnosis can only be established by periodic acid-Schiff (PAS) staining of the macrophages on brain biopsy or necropsy. We report a diagnosis confirmed by polymerase chain reaction (PCR) to amplify bacterial ribosomal RNA in the cerebrospinal fluid (CSF). A 60-year-old man presented with gait and oculomotor disorders, which had increased progressively over a few

weeks. He had no significant medical history, except that, for about 3 months, he had felt tired and sometimes feverish in the evening, and had lost about 4 kg in weight. He also complained of constipation. There was a severe, predominantly static, cerebellar syndrome, and bilateral internuclear ophthalmoplegia with horizontal and vertical nystagmus. Magnetic resonance imaging (MRI) showed an area of spotty high-signal intensity occupying most of the pons, as well as a few small hemispheric high-signal foci. Blood cell count, sedimentation rate, coagulation, and liver and kidney function tests, were normal. Serum electrophoresis and immunoelectrophoresis, tests for antinuclear and antiphospholipid antibodies, rheumatoid factor, cryoglobulin, angiotensin-conversion enzyme, antiHu-Yo and -Ri antibodies, and tumoral markers, were normal. Tests for HIV, cytomegalovirus, Epstein-Barr virus, herpes simplex, Lyme disease, Coxiella burnetti, Rickettsia, and Candida albicans, Mycoplasma pneumoniae,

Mycobacterium tuberculosis, Legionella, Brucella, were negative. Abdominal and thoracic computed tomography scans, and endoscopy of the colon and proximal intestine were normal. Jejunal biopsy showed no indication of Whipple’s disease. CSF examination revealed an increased cell count (9 lymphocytes/ fLL), without any PAS-positive cells, and an increased protein (1-58 g/L), with normal electrophoresis. Genomic DNA was extracted from CSF cells. A first amplification specific for gram-positive bacteria subdivision was done, followed by a second amplification with T whippelii-specific primers. T whippelii-amplified product was checked by restriction with Ava II, Stu I, and Pst I endonucleases. Nested PCR on the 910-bp amplicon obtained with T whippelii-specific primers generated a 650 bp fragment for the clinical sample and for the positive control containing T whippelii DNA. No amplification was obtained for the negative controls (an extraction control without DNA and an amplification control without the target DNA) or for a positive control with Micrococcus luteus DNA. Before the results of the PCR were available, the patient was treated with co-trimoxazole, first intravenously for 15 days (480+2400 mg/day), and then orally (320+1600 mg/day). Symptoms began to improve during the 3rd week of treatment. After 7 weeks of treatment neurological status was normal. MRI revealed a pronounced improvement in the abnormal brainstem and hemispheric high-signal areas. Although ophthalmoplegia and cerebellar syndrome are among the most common neurological deficits associated with Whipple’s disease, the present case illustrates the difficulty of diagnosing a disease that may lead to death in case of delayed treatment. The PCR technique, which has recently proved instrumental in diagnosing purely ocular3or cardiac4 forms of Whipple’s disease, can facilitate the identification of purely neurological forms, while avoiding the risks inherent to brain biopsy. Antibiotic treatment should be given whenever such a diagnosis is considered, especially when PCR is unavailable. *L Cohen, K Berthet, C Dauga, L Thivart, C Pierrot-Deseilligny Neurologie, Hôpital de la Salpêtrière, 75651 Paris, France

Service de

1 2

3

4

Dobbins WO III. The diagnosis of Whipple’s disease. N Engl J Med 1995; 332: 390-92. Adams M, Rhyner PA, Day J, et al. Whipple’s disease confined to the central nervous system. Ann Neurol 1987; 21: 104-08. Rickman LS, Freeman WR, Green WR, et al. Uveitis caused by Tropheryma whippelii (Whipple’s bacillus). N Engl J Med 1995; 332: 362-66. Wendler D, Mendoza A, Schleiffer T, et al. Tropheryma whippelii endocarditis confirmed by polymerase chain reaction. Eur Heart J

1995;

16: 424-25.

329