- Email: [email protected]
HIV-I AND HIV-II DOUBLE INFECTION IN CENTRAL AFRICAN REPUBLIC
1391 and classmate of the symptomless son of the family and a daily visitor to the household. On April 16 he had been sent to the school nursing office with bright red cheek rashes. The mother and teacher recall that the rash lasted 5 days and was unusual in that it repeatedly disappeared and reappeared. The figure shows the proposed method of spread in this family, suggesting that the incubation period was indeed 13-18 days. Anderson and colleagues’ experimental data and my epidemiological findings suggest that the incubation period of fifth disease is 13-18 days. 87 Cold
Spring Road, Syosset, NY11791, USA
PAUL R.
JOSEPH
MJ, Higgins PG, Davis LR, et al. Experimental parvoviral infection in humans. J Infect Dis 1985; 152: 257-65. 2. Joseph PR. Fifth Disease: The frequency of joint involvement in adults NY State J 1. Anderson
Med 1986; 86: 560-63.
MAGNETIC RESONANCE SPECTROSCOPY IN ISCHAEMIC FEET
SiR,—Muscle energy metabolism has been extensively studied non-invasively by 31P-magnetic resonance spectroscopy (31P-MRS). The application of this technique to the study of diseased muscle has proved very fruitful,l-4 and it has also -
demonstrated the changes associated with claudication in peripheral vascular disease.5 However, most of this work has been limited to major limb muscles (eg, flexor digitorum superficialis and gastrocnemius) and in most diseases exercise of the muscle is needed to uncover any abnormality. The need for imposition of such a stress has drawbacks: it introduces variables which may be difficult to control for, such as the relation between work load and muscle bulk; and the patient’s ability to exercise the muscle may be impaired by the disease itself. To extend our studies to patients with advanced peripheral vascular disease causing rest pain we have been using 31P-MRS to study the foot muscle extensor digitorum brevis. In healthy subjects this muscle differs significantly from more proximal limb muscles at rest with a much lower phosphocreatine:inorganic phosphate ratio (about 5 vs 9-10 in gastrocnemius and flexor digitorum superficials) and a much higher intracellular pH (7’12 vs 7-00-703 in gastrocnemius and flexor digitorum superficials).5,6 We have studied this muscle in a few patients with ischaemic rest pain due to peripheral vascular disease and all have shown marked abnormalities in spectra at rest (figure). The most consistent finding was a phosphocreatine:inorganic phosphate ratio much lower than that in control foot muscle. After surgical restoration of blood supply changes were sharply reversed. In our experience of other muscles, poor perfusion has never changed the phosphocreatine:inorganic phosphate ratio at rest. For example, it was normal in the gastrocnemius of patients with severe claudication or rest pain.5 It seems that the extensor digitorum brevis provides a more sensitive measure of disease, either because of poorer perfusion or because it is especially sensitive to the effects of ischaemia. Changes in its energy metabolism detected by 3’P-MRS may prove useful in indicating distal limb perfusion and tissue viability. CMR Facility and Nuffield Department of Surgery, John Radcliffe Hospital, Oxford OX3 9DU
L.
J. HANDS
G. S. PAYNE
P. J. BORE
Nuffield Department of Surgery, John Radcliffe Hospital, Oxford
P.
Department of Biochemistry, University of Oxford
G. K. RADDA
J. MORRIS
1. Ross BD, Radda GK, Gadian DG, Rocker DG, Esin M, Falconer-Smith J. Examination of a case of suspected McArdle’s syndrome by 31P NMR. N Engl J Med 1981; 304: 1338-42 2 Chance B, Bank W, Leigh JS, Warnell R. 31P NMR studies of control of mitochondrial function in phosphofructokinase deficient human skeletal muscle Proc Natl Acad Sci 1982; 79: 7714-18. 3. Edwards RHT, Dawson MJ, Wilkie DR, Gordon RE, Shaw D. Clinical use of NMR in the investigation of myopathy. Lancet 1982; i. 725-30 4. Amold DL, Bore PJ, Radda GK, Styles P, Taylor DJ. Excessive intracellular acidosis of skeletal muscle on exercise in a patient with post-viral exhaustion/fatigue syndrome. Lancet 1984; i: 1367-69. 5. Hands LJ, Bore PJ, Galloway G, Morris PJ, Radda GK. Muscle metabolism in patients with peripheral vascular disease investigated by 31P nuclear magnetic spectroscopy. Clin Sci 1986, 71: 283-90. 6. Taylor DJ, Crowe M, Bore PJ, Styles P, Arnold DL, Radda GK. Examination of the energetics of aging skeletal muscle using nuclear magnetic resonance. Gerontology 1984; 30: 2-7.
HIV-I AND HIV-II DOUBLE INFECTION IN CENTRAL AFRICAN REPUBLIC new retrovirus has been isolated from AIDS patients in West Africa (Cape Verde, Guinea Bissau).l It is called human immunodeficiency virus type II (HIV-II) and shares epitopes with the major core protein of HIV-1. Its morphology and biological properties (including preferential T4 lymphotropism and its cytopathic effect on T4 cells) argue for the classification of this virus in the HIV family. However, cross-reactivities with a simian retrovirus (STLV-IIIg isolated from captive macaques presenting with a disease very similar to human AIDS have been found, especially for the envelope glycoprotein.2 HIV-I is endemic in central Africa (eg, in Zaire and the Central African Republic3) but HIV-11 infection has not hitherto been described in this area. We report here evidence for HIV-11infection in the Central African Republic and suggest that double infection with HIV-I and HIV-11 is possible. HIV-I and HIV-11 antibodies were sought in sera taken in May, 1986, from 82 low-income
SIR,-A
living
3, P-MRS spectra collected from extensor digitorum brevis at rest in patient with rest pain.
(1) and (2) = spectra in patient before and after surgery, respectively. (3) = spectrum in a healthy individual. A inorganic phosphate peak, B phosphocreatine peak, C y-ATP peak, D = x-ATP peak, E = p-ATP =
=
peak.
=
1392 mothers (some of them prostitutes) of undernourished children; and in August, 1986, from 24 patients of the Bangui Hospital, including AIDS and non-AIDS patients. These sera were tested by ELISA with a negative antigen as a control for specificity (’Elavia’; Diagnostics Pasteur). The ELISA used for HIV-II antibodies was kindly provided by Diagnostics Pasteur and used the same principle as the anti-HIV-I ELISA. All sera giving a differential optical density between the positive and the negative antigens of more than 03 were confirmed by western blot. Nitrocellulose sheets containing HIV-I or HIV-11 antigens were provided by Diagnostics Pasteur. The criteria for positivity in western blot was the presence of antibodies to at least one of the envelope glycoproteins (gpll0 and gp41 for HIV-I and gpl40 for HIV-II) with or without antibodies to the internal proteins (p 18 and p25 for HIV-I; p16 and p26 for HIV-II). Sera with bands to internal proteins only were not considered true positives. By ELISA, 14 of the 82 symptomless mothers were positive for HIV-I and among them 11 were also positive by HIV-11 ELISA. All were confirmed by western blot as seropositive for HIV-1, while only 3 were found positive for HIV-II antibodies; 8 of the HIV-I positive sera cross-reacted at the p26-HIV-II level. Among the 18 suspected AIDS patients at Bangui Hospital (including Kaposi’s sarcoma) 12 were positive for HIV-I antibodies, confirmed by western blot. The 6 negative sera were from terminal AIDS cases. Of the 12 HIV-I positives 8 were ELISA HIV-11 positive also. Western blots indicated that only 3 of these 8 were true anti-HIV-II positive; the other sera cross-reacted with the major core protein of HIV-II, p26. A 26-year-old woman with suspected AIDS (loss of weight, fatigue) and antibodies to HIV-I and HIV-11 died a week after the test; her 6-year-old son was also positive for HIV-I and HIV-II antibodies. Since transmission from mother.to child is the most likely mechanism in this young child, HIV-11 may have been present in the Central African Republic 6 years ago. The third HIV-II positive patient denied contacts with men other than her husband. None of the 6 non-AIDS inpatients were positive for HIV-I or HIV-11 antibodies. These findings suggest that HIV-11 infection is present in the Central African Republic and is not localised to West Africa alone. The 6 cases described (in 5 women and in a child of 1 of them) all had double infections. Double infection with HIV types I and II in patients with AIDS is possible. ,
Viral Oncology Unit, Institut Pasteur, 75724 Paris, France
FRANÇOISE REY
Institut Pasteur, Bangui, Central African Republic
DANIÈLE SALAUN
CHNU, Bangui
J. L. LESBORDES
Diagnostics Pasteur, Marnes-la-Coquette
STÉPHANE GADELLE
FRANÇOISE OLLIVIER-HENRY FRANÇOISE BARRE-SINOUSSI Institut Pasteur, Paris Institut Pasteur, Bangui
JEAN-CLAUDE CHERMANN ALAIN-JEAN GEORGES
1. Clavel F, Guetard D, Brun-Vezinet F, et al. Isolation of a
new human retrovirus from West African patients with AIDS. Science 1986; 233: 343-46. 2. Kanki PJ, Alroy J, Essex M, et al. Isolation of T-lymphotropic retrovirus related to HTLV III-LAV from wild caught African green monkeys. Science 1985; 228: 951-54. 3. Georges AJ, Lesbordes JL, Meunier DMY, et al. Antibodies to LAV in various groups of the CAR. Ann Virol (Inst Pasteur) 1985; 136: 323-25.
LACK OF HIV INFECTION AND CONDOM USE IN LICENSED PROSTITUTES
SIR,-Licensed prostitutes in West Germany have a human immunodeficiency virus (HIV) antibody prevalence rate of 1 % and unlicensed prostitutes have a prevalence of20%.1,2 This difference has not been explained although intravenous drug usage is more common in unlicensed prostitutes. Any data on variable rates may provide useful information to limit the spread of HIV infection.3
448 licensed female prostitutes in Nuemburg, West Germany, studied in March and April, 1986. The city has a population of about 500 000, with 25 000 US Army personnel. 1 % of US soldiers presenting to the sexually transmitted disease clinic are western blot positive and about 1-6 per 1000 US soliders are western blot were
positive. 89 % of the licensed prostitutes were tested for HIV antibody by enzyme-linked immunosorbent assay and positives were confirmed by immunofluoresence test. 50% of the prostitutes completed an anonymous questionnaire, providing demographic data and details on sexual practices. No prostitute tested was anti-HIV positive by immunofluorescence. All prostitutes were German or other Westem European. Their mean age was 30 years (range 18-62) and they had been prostitutes for 77 months on average (range 1-480). The mean number of clients was 13 per week (range 1-50). 21 % regularly had US military clients and 2 % of the prostitutes regularly had African clients. 1 was an intravenous drug user, 10 % had tattoos, and 1 ’8 % had had intimate contact with a person in an AIDS high risk group. 13 % practise open-mouth kissing with clients. 74 % occasionally to always masturbate clients, 80 % with condoms; 63% occasionally to always perform oral sex, 90 % with condoms; 92 % occasionally to always have vaginal sex with clients, 97-5% do this with condoms; and 5% occasionally to always have rectal sex, 55-5% with
condoms. This heterosexually very active group of women has remained free from HIV infection. The demographic mix of their clients, the absence of intravenous drug abuse, and the frequency with which condoms are used for all sexual practices may be protecting these prostitutes from infection. US Army Hospital, Nuernberg, West Germany, APO New York 09105-3501, USA
GREGORY L. SMITH
Yale University Medical School, New Haven, Connecticut
KEVIN F. SMITH
James JJ, Morgenstern MA, Hatten JA. HTLV-III/LAV-antibody-positive soldiers in Berlin. N Engl J Med 1986; 314: 55-56. 2. Hansfield H, Kobayashi J,Fishl M, et al. Heterosexual transmission of human 1.
T-lymphotrophic
virus type
III/lymphadenopathy-associated
virus. MMWR
1985; 34: 561-63. 3. Papaevangelou G, Roumeliotou-Karayannis A, Kallinikos G, et al. LAV/HTLV-III infection in female prostitutes. Lancet 1985; ii: 1018.
AZIDOTHYMIDINE NEUROTOXICITY
SIR,-Azidothymidine (AZT) is being used in the United States for the treatment of patients with AIDS who have recovered from Pneumocystis carinii pneumonia. Side-effects include anaemia, rashes, pruritus, nausea, and headache and mild confusion.1,2 We report a case of central nervous system toxicity contributing to death in an AIDS patient treated with AZT. In October, 1985, a 41-year-old homosexual man was successfully treated for P carinii pneumonia with pentamidine. He was put on prophylactic co-trimoxazole. Subsequently, extensive cutaneous Kaposi’s sarcoma developed, treated with chemotherapy and whole body electron beam radiation; cytomegalovirus retinitis and hepatitis responded well to and remained in remission on 9-[2-hydroxy-l-(hydroxymethyl) ethoxymethyl]guanine, (BWB759U). In July, 1986, Mycobacterium avium-intracellulare complex grew from blood cultures, and he was started on ansamycin, clofazimine, and ethambutol. In September, 1986, invasive oesophageal candidiasis unresponsive to ketoconazole 400 mg daily required amphotericin B 15 mg intravenously daily for control of symptoms. M avium-intraaellulare and cytomegalovirus blood cultures continued positive despite therapy. In October, 1986, he was accepted in the AZT protocol. At that time, his white blood cell count was 2600/[tl (77 % polymorphs, 4% lymphocytes). His haemoglobin was 9-0 g/dl, SGOT 76 (normal below 30), SGPT 43 (normal below 35),
serum
creatinine 14
mg/dl. The intravenous amphotericin B, BW-B759U, oral cotrimoxazole, clofazimime, ansamycin, and ethambutol were
stopped. On the same day he was put on oral AZT 200 mg every 4 h. He complained of severe headache 48 h after the institution of AZT and was found unresponsive on the floor of his house later that
Spring Road, Syosset, NY11791, USA
PAUL R.
JOSEPH
MJ, Higgins PG, Davis LR, et al. Experimental parvoviral infection in humans. J Infect Dis 1985; 152: 257-65. 2. Joseph PR. Fifth Disease: The frequency of joint involvement in adults NY State J 1. Anderson
Med 1986; 86: 560-63.
MAGNETIC RESONANCE SPECTROSCOPY IN ISCHAEMIC FEET
SiR,—Muscle energy metabolism has been extensively studied non-invasively by 31P-magnetic resonance spectroscopy (31P-MRS). The application of this technique to the study of diseased muscle has proved very fruitful,l-4 and it has also -
demonstrated the changes associated with claudication in peripheral vascular disease.5 However, most of this work has been limited to major limb muscles (eg, flexor digitorum superficialis and gastrocnemius) and in most diseases exercise of the muscle is needed to uncover any abnormality. The need for imposition of such a stress has drawbacks: it introduces variables which may be difficult to control for, such as the relation between work load and muscle bulk; and the patient’s ability to exercise the muscle may be impaired by the disease itself. To extend our studies to patients with advanced peripheral vascular disease causing rest pain we have been using 31P-MRS to study the foot muscle extensor digitorum brevis. In healthy subjects this muscle differs significantly from more proximal limb muscles at rest with a much lower phosphocreatine:inorganic phosphate ratio (about 5 vs 9-10 in gastrocnemius and flexor digitorum superficials) and a much higher intracellular pH (7’12 vs 7-00-703 in gastrocnemius and flexor digitorum superficials).5,6 We have studied this muscle in a few patients with ischaemic rest pain due to peripheral vascular disease and all have shown marked abnormalities in spectra at rest (figure). The most consistent finding was a phosphocreatine:inorganic phosphate ratio much lower than that in control foot muscle. After surgical restoration of blood supply changes were sharply reversed. In our experience of other muscles, poor perfusion has never changed the phosphocreatine:inorganic phosphate ratio at rest. For example, it was normal in the gastrocnemius of patients with severe claudication or rest pain.5 It seems that the extensor digitorum brevis provides a more sensitive measure of disease, either because of poorer perfusion or because it is especially sensitive to the effects of ischaemia. Changes in its energy metabolism detected by 3’P-MRS may prove useful in indicating distal limb perfusion and tissue viability. CMR Facility and Nuffield Department of Surgery, John Radcliffe Hospital, Oxford OX3 9DU
L.
J. HANDS
G. S. PAYNE
P. J. BORE
Nuffield Department of Surgery, John Radcliffe Hospital, Oxford
P.
Department of Biochemistry, University of Oxford
G. K. RADDA
J. MORRIS
1. Ross BD, Radda GK, Gadian DG, Rocker DG, Esin M, Falconer-Smith J. Examination of a case of suspected McArdle’s syndrome by 31P NMR. N Engl J Med 1981; 304: 1338-42 2 Chance B, Bank W, Leigh JS, Warnell R. 31P NMR studies of control of mitochondrial function in phosphofructokinase deficient human skeletal muscle Proc Natl Acad Sci 1982; 79: 7714-18. 3. Edwards RHT, Dawson MJ, Wilkie DR, Gordon RE, Shaw D. Clinical use of NMR in the investigation of myopathy. Lancet 1982; i. 725-30 4. Amold DL, Bore PJ, Radda GK, Styles P, Taylor DJ. Excessive intracellular acidosis of skeletal muscle on exercise in a patient with post-viral exhaustion/fatigue syndrome. Lancet 1984; i: 1367-69. 5. Hands LJ, Bore PJ, Galloway G, Morris PJ, Radda GK. Muscle metabolism in patients with peripheral vascular disease investigated by 31P nuclear magnetic spectroscopy. Clin Sci 1986, 71: 283-90. 6. Taylor DJ, Crowe M, Bore PJ, Styles P, Arnold DL, Radda GK. Examination of the energetics of aging skeletal muscle using nuclear magnetic resonance. Gerontology 1984; 30: 2-7.
HIV-I AND HIV-II DOUBLE INFECTION IN CENTRAL AFRICAN REPUBLIC new retrovirus has been isolated from AIDS patients in West Africa (Cape Verde, Guinea Bissau).l It is called human immunodeficiency virus type II (HIV-II) and shares epitopes with the major core protein of HIV-1. Its morphology and biological properties (including preferential T4 lymphotropism and its cytopathic effect on T4 cells) argue for the classification of this virus in the HIV family. However, cross-reactivities with a simian retrovirus (STLV-IIIg isolated from captive macaques presenting with a disease very similar to human AIDS have been found, especially for the envelope glycoprotein.2 HIV-I is endemic in central Africa (eg, in Zaire and the Central African Republic3) but HIV-11 infection has not hitherto been described in this area. We report here evidence for HIV-11infection in the Central African Republic and suggest that double infection with HIV-I and HIV-11 is possible. HIV-I and HIV-11 antibodies were sought in sera taken in May, 1986, from 82 low-income
SIR,-A
living
3, P-MRS spectra collected from extensor digitorum brevis at rest in patient with rest pain.
(1) and (2) = spectra in patient before and after surgery, respectively. (3) = spectrum in a healthy individual. A inorganic phosphate peak, B phosphocreatine peak, C y-ATP peak, D = x-ATP peak, E = p-ATP =
=
peak.
=
1392 mothers (some of them prostitutes) of undernourished children; and in August, 1986, from 24 patients of the Bangui Hospital, including AIDS and non-AIDS patients. These sera were tested by ELISA with a negative antigen as a control for specificity (’Elavia’; Diagnostics Pasteur). The ELISA used for HIV-II antibodies was kindly provided by Diagnostics Pasteur and used the same principle as the anti-HIV-I ELISA. All sera giving a differential optical density between the positive and the negative antigens of more than 03 were confirmed by western blot. Nitrocellulose sheets containing HIV-I or HIV-11 antigens were provided by Diagnostics Pasteur. The criteria for positivity in western blot was the presence of antibodies to at least one of the envelope glycoproteins (gpll0 and gp41 for HIV-I and gpl40 for HIV-II) with or without antibodies to the internal proteins (p 18 and p25 for HIV-I; p16 and p26 for HIV-II). Sera with bands to internal proteins only were not considered true positives. By ELISA, 14 of the 82 symptomless mothers were positive for HIV-I and among them 11 were also positive by HIV-11 ELISA. All were confirmed by western blot as seropositive for HIV-1, while only 3 were found positive for HIV-II antibodies; 8 of the HIV-I positive sera cross-reacted at the p26-HIV-II level. Among the 18 suspected AIDS patients at Bangui Hospital (including Kaposi’s sarcoma) 12 were positive for HIV-I antibodies, confirmed by western blot. The 6 negative sera were from terminal AIDS cases. Of the 12 HIV-I positives 8 were ELISA HIV-11 positive also. Western blots indicated that only 3 of these 8 were true anti-HIV-II positive; the other sera cross-reacted with the major core protein of HIV-II, p26. A 26-year-old woman with suspected AIDS (loss of weight, fatigue) and antibodies to HIV-I and HIV-11 died a week after the test; her 6-year-old son was also positive for HIV-I and HIV-II antibodies. Since transmission from mother.to child is the most likely mechanism in this young child, HIV-11 may have been present in the Central African Republic 6 years ago. The third HIV-II positive patient denied contacts with men other than her husband. None of the 6 non-AIDS inpatients were positive for HIV-I or HIV-11 antibodies. These findings suggest that HIV-11 infection is present in the Central African Republic and is not localised to West Africa alone. The 6 cases described (in 5 women and in a child of 1 of them) all had double infections. Double infection with HIV types I and II in patients with AIDS is possible. ,
Viral Oncology Unit, Institut Pasteur, 75724 Paris, France
FRANÇOISE REY
Institut Pasteur, Bangui, Central African Republic
DANIÈLE SALAUN
CHNU, Bangui
J. L. LESBORDES
Diagnostics Pasteur, Marnes-la-Coquette
STÉPHANE GADELLE
FRANÇOISE OLLIVIER-HENRY FRANÇOISE BARRE-SINOUSSI Institut Pasteur, Paris Institut Pasteur, Bangui
JEAN-CLAUDE CHERMANN ALAIN-JEAN GEORGES
1. Clavel F, Guetard D, Brun-Vezinet F, et al. Isolation of a
new human retrovirus from West African patients with AIDS. Science 1986; 233: 343-46. 2. Kanki PJ, Alroy J, Essex M, et al. Isolation of T-lymphotropic retrovirus related to HTLV III-LAV from wild caught African green monkeys. Science 1985; 228: 951-54. 3. Georges AJ, Lesbordes JL, Meunier DMY, et al. Antibodies to LAV in various groups of the CAR. Ann Virol (Inst Pasteur) 1985; 136: 323-25.
LACK OF HIV INFECTION AND CONDOM USE IN LICENSED PROSTITUTES
SIR,-Licensed prostitutes in West Germany have a human immunodeficiency virus (HIV) antibody prevalence rate of 1 % and unlicensed prostitutes have a prevalence of20%.1,2 This difference has not been explained although intravenous drug usage is more common in unlicensed prostitutes. Any data on variable rates may provide useful information to limit the spread of HIV infection.3
448 licensed female prostitutes in Nuemburg, West Germany, studied in March and April, 1986. The city has a population of about 500 000, with 25 000 US Army personnel. 1 % of US soldiers presenting to the sexually transmitted disease clinic are western blot positive and about 1-6 per 1000 US soliders are western blot were
positive. 89 % of the licensed prostitutes were tested for HIV antibody by enzyme-linked immunosorbent assay and positives were confirmed by immunofluoresence test. 50% of the prostitutes completed an anonymous questionnaire, providing demographic data and details on sexual practices. No prostitute tested was anti-HIV positive by immunofluorescence. All prostitutes were German or other Westem European. Their mean age was 30 years (range 18-62) and they had been prostitutes for 77 months on average (range 1-480). The mean number of clients was 13 per week (range 1-50). 21 % regularly had US military clients and 2 % of the prostitutes regularly had African clients. 1 was an intravenous drug user, 10 % had tattoos, and 1 ’8 % had had intimate contact with a person in an AIDS high risk group. 13 % practise open-mouth kissing with clients. 74 % occasionally to always masturbate clients, 80 % with condoms; 63% occasionally to always perform oral sex, 90 % with condoms; 92 % occasionally to always have vaginal sex with clients, 97-5% do this with condoms; and 5% occasionally to always have rectal sex, 55-5% with
condoms. This heterosexually very active group of women has remained free from HIV infection. The demographic mix of their clients, the absence of intravenous drug abuse, and the frequency with which condoms are used for all sexual practices may be protecting these prostitutes from infection. US Army Hospital, Nuernberg, West Germany, APO New York 09105-3501, USA
GREGORY L. SMITH
Yale University Medical School, New Haven, Connecticut
KEVIN F. SMITH
James JJ, Morgenstern MA, Hatten JA. HTLV-III/LAV-antibody-positive soldiers in Berlin. N Engl J Med 1986; 314: 55-56. 2. Hansfield H, Kobayashi J,Fishl M, et al. Heterosexual transmission of human 1.
T-lymphotrophic
virus type
III/lymphadenopathy-associated
virus. MMWR
1985; 34: 561-63. 3. Papaevangelou G, Roumeliotou-Karayannis A, Kallinikos G, et al. LAV/HTLV-III infection in female prostitutes. Lancet 1985; ii: 1018.
AZIDOTHYMIDINE NEUROTOXICITY
SIR,-Azidothymidine (AZT) is being used in the United States for the treatment of patients with AIDS who have recovered from Pneumocystis carinii pneumonia. Side-effects include anaemia, rashes, pruritus, nausea, and headache and mild confusion.1,2 We report a case of central nervous system toxicity contributing to death in an AIDS patient treated with AZT. In October, 1985, a 41-year-old homosexual man was successfully treated for P carinii pneumonia with pentamidine. He was put on prophylactic co-trimoxazole. Subsequently, extensive cutaneous Kaposi’s sarcoma developed, treated with chemotherapy and whole body electron beam radiation; cytomegalovirus retinitis and hepatitis responded well to and remained in remission on 9-[2-hydroxy-l-(hydroxymethyl) ethoxymethyl]guanine, (BWB759U). In July, 1986, Mycobacterium avium-intracellulare complex grew from blood cultures, and he was started on ansamycin, clofazimine, and ethambutol. In September, 1986, invasive oesophageal candidiasis unresponsive to ketoconazole 400 mg daily required amphotericin B 15 mg intravenously daily for control of symptoms. M avium-intraaellulare and cytomegalovirus blood cultures continued positive despite therapy. In October, 1986, he was accepted in the AZT protocol. At that time, his white blood cell count was 2600/[tl (77 % polymorphs, 4% lymphocytes). His haemoglobin was 9-0 g/dl, SGOT 76 (normal below 30), SGPT 43 (normal below 35),
serum
creatinine 14
mg/dl. The intravenous amphotericin B, BW-B759U, oral cotrimoxazole, clofazimime, ansamycin, and ethambutol were
stopped. On the same day he was put on oral AZT 200 mg every 4 h. He complained of severe headache 48 h after the institution of AZT and was found unresponsive on the floor of his house later that