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Objectives: Endotoxin is a potent stimulus of proinflammatory response and systemic coagulation in patients with severe sepsis. Endotoxin is a component of Gram-negative bacteria that triggers an innate immune response through Toll-like receptor 4 signaling pathways in myeloid cells. We evaluated safety and tolerability of two dose regimens of eritoran tetrasodium (E5564), a synthetic Toll-like receptor 4 antagonist, and explored whether it decreases 28-day mortality rate in subjects with severe sepsis., Design: Prospective, randomized, double-blind, placebo-controlled, multicenter, ascending-dose phase II trial., Setting: Adult intensive care units in the United States and Canada., Patients: Three hundred adults within 12 hrs of recognition of severe sepsis, with Acute Physiology and Chronic Health Evaluation (APACHE) II-predicted risk of mortality between 20% and 80%., Interventions: Intravenous eritoran tetrasodium (total dose of either 45 mg or 105 mg) or placebo administered every 12 hrs for 6 days., Measurements and Main Results: Prevalence of adverse events was similar among subjects treated with 45 mg or 105 mg of eritoran tetrasodium or with placebo. For modified intent-to-treat subjects, 28-day all-cause mortality rates were 26.6% (eritoran tetrasodium 105 mg), 32.0% (eritoran tetrasodium 45 mg), and 33.3% in the placebo group. Mortality rate in the eritoran tetrasodium 105-mg group was not significantly different from placebo (p = .335). In prespecified subgroups, subjects at highest risk of mortality by APACHE II score quartile had a trend toward lower mortality rate in the eritoran tetrasodium 105-mg group (33.3% vs. 56.3% placebo group, p = .105). A trend toward a higher mortality rate was observed in subjects in the lowest APACHE II score quartile for the eritoran 105-mg group (12.0% vs. 0.0% placebo group, p = .083)., Conclusions: Eritoran tetrasodium treatment appears well tolerated. The observed trend toward a lower mortality rate at the 105-mg dose, in subjects with severe sepsis and high predicted risk of mortality, should be further investigated.

Purpose: To assess the relative impact of antibodies specific for HSV-1 glycoproteins on eye disease in response to HSV-1 infection, the composition of antibodies specific for 10 of the viral glycoproteins, and the effect of anti-glycoprotein (g)D and anti-gK antibodies on antibody-dependent enhancement (ADE)., Methods: In a prospective case-control study, sera from patients with a history of herpes stromal keratitis (HSK) were compared with sera from nonocular HSV-1-seropositive and HSV-seronegative control subjects. HSV-1 neutralizing antibody titer and type-specific IgG and IgM were measured. In addition, the presence of anti-HSV-1 gD and gK antibodies in the sera of all patients also was determined by ELISA using gD and gK antigens. Finally, the role of anti-gD- and gK-specific antibodies to ADE was investigated., Results: Average neutralizing antibody titers and levels of HSV-1 IgG were similar between HSK- and non-HSK-seropositive patients. However, the contribution of gD to the neutralizing antibody titer in HSK sera was significantly lower than that in non-HSK-seropositive patients, despite higher anti-gD ELISA titers. Overall, sera from patients with HSK had higher anti-gK antibody titers and induced ADE in vitro compared with non-HSK or seronegative sera. The ADE response in HSK sera was attributed to anti-gK antibody., Conclusions: These results suggest that sera from HSK patients had higher anti-gD and -gK antibody titers than sera from seropositive patients who had no history of HSK despite similar levels of neutralizing antibody titers and HSV-1 IgG, that HSK sera induced ADE whereas sera from non-HSK patients did not induce ADE, and that anti-gD antibody in sera of HSK patients contributed less to the HSV-1 neutralization antibody titer than did sera from non-HSK patients.

A live-attenuated, intranasal respiratory syncytial virus (RSV) candidate vaccine, cpts-248/404, was tested in phase 1 trials in 114 children, including 37 1-2-month-old infants-a target age for RSV vaccines. The cpts-248/404 vaccine was infectious at 104 and 105 plaque-forming units in RSV-naive children and was broadly immunogenic in children >6 months old. Serum and nasal antibody responses in 1-2 month olds were restricted to IgA, had a dominant response to RSV G protein, and had no increase in neutralizing activity. Nevertheless, there was restricted virus shedding on challenge with a second vaccine dose and preliminary evidence for protection from symptomatic disease on natural reexposure. The cpts-248/404 vaccine candidate did not cause fever or lower respiratory tract illness. In the youngest infants, however, cpts-248/404 was unacceptable because of upper respiratory tract congestion associated with peak virus recovery. A live attenuated RSV vaccine for the youngest infant will use cpts-248/404 modified by additional attenuating mutations.

Objective: To evaluate the safety and immunogenicity of a polyvalent (PV) HIV envelope synthetic peptide immunogen, C4-V3. The immunogen comprised four peptides containing T-helper epitopes from the fourth constant region (C4) of gp120 of HIV-1MN, and T-helper, cytotoxic T-lymphocyte HLA-B7-restricted, and B-cell neutralizing epitopes from the gp120 third variable region (V3) of four clade B HIV-1 isolates, HIV-1MN, HIV-1RF, HIV-1EV91, and HIV-1Can0A., Design: A pilot, Phase I controlled trial [Division of AIDS Treatment Research Initiative (DATRI) 010] conducted at a single center., Methods: Ten HIV-infected, HLA-B7-positive patients with CD4 cells > 500 x 10(6)/l were enrolled. Eight patients received the C4-V3 PV immunogen emulsified in incomplete Freund's adjuvant in five intramuscular injections over 24 weeks, and two controls received incomplete Freund's adjuvant alone. All subjects were followed for 52 weeks., Results: Four out of eight C4-V3 PV recipients generated at least fourfold rise in serum antibody titers to at least three immunogen peptides in contrast to none of the control subjects. Four out of eight C4-V3 PV recipients and none of the controls had an at least fourfold rise in neutralizing antibodies to either HIV-1MN, HIV-1RF, or HIV-1(4489-5) laboratory-adapted HIV isolates. 3H-Thymidine incorporation assays of peripheral blood mononuclear cells increased at least fivefold over the baseline stimulation index to at least one of the immunogen peptides in two consecutive post-immunization timepoints in five out of eight C4-V3 PV recipients versus none of the controls. CD4 cell counts and plasma HIV RNA levels did not change in patients who received either C4-V3 PV or adjuvant alone. Adverse events consisted primarily of grade 1 injection site reactions in six subjects (four C4-V3 recipients, two controls)., Conclusions: C4-V3 PV synthetic peptides demonstrated both immunogenicity and safety in HIV-infected patients.

Objective: To study the clinical course of varicella-zoster infection in children infected with human immunodeficiency virus type I., Design and Setting: A clinical and laboratory study of human immunodeficiency virus-infected children was undertaken at Cedars-Sinai Medical Center, Los Angeles., Participants: Twenty-seven human immunodeficiency virus-infected children aged 1 to 13 years who were treated between 1987 and 1992. Twenty-one children had acquired the infection through blood transfusion, 18 during the neonatal period and three during their early years of life. Six infants had acquired the infection perinatally., Results: Seventeen children have developed varicella, of whom 10 had an uncomplicated course and seven suffered from chronic, recurrent, or persistent varicella. Uncomplicated or recurrent varicella was a relatively benign illness that did not require antiviral therapy except in one child. In contrast, patients with persistent varicella required antiviral therapy as they were sicker and had a prolonged course. One had pneumonia, and another patient developed hyperkeratotic lesions that were refractory to therapy. They had lower CD4 counts (P < .01) and had a more advanced stage of the human immunodeficiency virus disease than the other children. Three patients who were receiving regular intravenous immunoglobulin developed their initial attack of varicella despite the presence of the varicella-zoster antibody. Four patients, three of whom had uncomplicated varicella, developed zoster involving one or two dermatomes. One patient developed zoster while receiving acyclovir therapy., Conclusions: Children infected with human immunodeficiency virus type 1 may suffer unusual manifestations of varicella-zoster infection. The incidence of zoster in these children is higher than in the general population and is close to that in patients with leukemia. The effectiveness of antiviral therapy in these patients was difficult to evaluate.

A newborn infant born to a mother infected with human immunodeficiency virus type 1 had acute meningoencephalitis on the second day of life. Human immunodeficiency virus type 1 was isolated from the plasma, cerebrospinal fluid, and peripheral blood mononuclear cells. Specific IgM for human immunodeficiency virus type 1 was detected by an enzyme-linked immunosorbent assay antibody-capture technique in cord blood and in serum obtained 3 weeks later. We believe that the meningoencephalitis was caused by human immunodeficiency virus type 1 acquired in utero.

Cells derived from Kaposi's sarcoma (KS) were propagated in vitro using conditions which resulted in elimination of contaminating fibroblasts and the emergence of homogeneous cell populations which morphologically resembled smooth muscle cells and had neoplastic characteristics. In long-term culture, they differentiated into large ribbon-like cells with longitudinal fibrillarity of their cytoplasm. These fibrils stained red by Masson trichrome staining, and were reactive with antibodies to desmin. Dense bodies typical of myoblasts were observed in some cells by electron microscopy. The cells did not form capillary structures like endothelial cells, they lacked Weible-Palade bodies, and did not express the blood-clotting Factor VIII-related antigen or receptors for the lectin Ulex europaeus agglutinin I. They did express four other antigens, however, in common with endothelial cells. The cells did not form tumors in athymic nude mice; however, they formed colonies in soft agar, manifested tumor-like growth on muscle organ cultures, and were invasive in an artificial basement membrane invasion assay. The results indicate that a component of KS is closely related to leiomyoblasts and and has neoplastic properties.

Ganciclovir and foscarnet possess substantial activity against cytomegalovirus. Both exhibit dose-limiting toxicity, which reduces their clinical usefulness. We demonstrated synergistic inhibition of cytomegalovirus replication in vitro by ganciclovir and foscarnet. Reduced-dose combination therapy may provide a means to treat patients with cytomegalovirus infection while reducing drug toxicity.

A sensitive enzyme immunoassay was developed for detecting human immunodeficiency virus (HIV) core antigen. Assay sensitivity was 3.67 pmol/L of purified HIV core protein, and 1 or 100 in-vitro infectious units/mL of HIV in purified virus preparations or cell culture supernatants, respectively. Enzyme immunoassay sensitivity exceeded that of reverse transcriptase assay by 1000-fold. Core antigen was detected in whole plasma from 41% of symptomatic subjects and 13% of asymptomatic subjects seropositive for HIV. After plasma fractionation, antigenemia was found in 60% of symptomatic subjects and in 33% of asymptomatic subjects seropositive for HIV. Fifty-seven percent of samples from which HIV could be isolated in lymphocyte culture had detectable quantities of core antigen in plasma. However, at least 87% of samples with measurable antigen in plasma had HIV isolated from lymphocyte cultures. Antigenemia was associated with reduced T-cell number and symptomatic disease, and may be a useful marker for disease progression.

Inhibition of human fibroblasts, granulocyte-monocyte progenitor cells, and lymphocytes was observed at (E)-5-(2-bromovinyl)-2'-deoxyuridine concentrations ranging from 21 to 197 micrograms/ml. These concentrations were 10- to 100-fold above usual serum concentrations after oral administration. (E)-5-(2-Bromovinyl)-2'-deoxyuridine compares favorably with currently used antivirals in terms of in vitro myelotoxicity and immunotoxicity.

Immunoglobulin A (IgA) antibodies to varicella-zoster virus (VZV) were measured in sera from subjects with acute varicella and herpes zoster, VZV-immune subjects remote from infection, and recipients of a live attenuated varicella vaccine, using a solid-phase radioimmunoassay. Primary infection with VZV was associated with early production of IgA antibodies. Among 36 subjects with varicella tested 1 to 5 days after onset, 22 had detectable IgA, and all of the negative sera were obtained before day 3 of the varicella exanthem. VZV IgA was detected in one of three sera obtained more than 60 days after onset of the illness. Four of five sera obtained from subjects within 1 week of the onset of herpes zoster had measurable levels of IgA. Between 1 and 4 weeks after onset of zoster, all 10 subjects tested had detectable IgA to VZV. VZV IgA was detected as late as 63 days after the onset of herpes zoster. Of 10 vaccine recipients, 5 developed VZV IgA which was detected as early as 4 weeks and persisted for as long as 16 weeks after vaccination. VZV IgA was not detected in sera from 42 children who had no detectable IgG antibody to VZV. VZV IgA was found on only 3 of 23 sera from adults who had varicella more than 20 years before.

Varicella is a serious infection in the immunocompromised patient. Prophylaxis with varicella zoster immune globulin is known to decrease the incidence of severe varicella infection. The titers of antibody to varicella zoster virus were compared in patients who received either varicella zoster immune globulin or intravenous immune globulin, 4 ml or 6 ml/kg per dose. The titers of antibody to varicella zoster virus were comparable in each group.

The varicella-zoster virus-infected cell proteins (VZV-ICPs) against which IgG, IgM and IgA antibodies were made in the course of primary varicella-zoster virus (VZV) infection were analysed by the immune transfer method. IgG antibodies were made against one or more of 18 VZV-ICPs by patients with varicella. IgM antibodies were produced which reacted with 21 VZV-ICPs. The spectrum of IgG antibody production during the first week after the onset of infection was limited to an average of three VZV-ICPs while IgM antibodies which reacted with an average of seven VZV-ICPs were detectable in the acute phase of varicella. Equivalent VZV IgG or IgM antibody titres by radioimmunoassay did not correlate with a similar pattern of antibody specificity for VZV-ICPs by immune transfer. A detectable immune response to all VZV-ICPs was not required for the recovery of individual patients from primary VZV infection.

In 414 pregnant women with a history of recurrent genital herpes simplex infection, we studied the correlation between asymptomatic viral shedding in late pregnancy and at the time of delivery. Antepartum cultures for asymptomatic reactivation of herpes simplex virus were positive in 17 of the 414 women (4.1 percent). None of these women had positive cultures at the time of delivery. Cultures of specimens obtained at delivery from 5 of 354 asymptomatic mother-infant pairs (1.4 percent) were positive for asymptomatic excretion of herpes simplex virus. None of these women had had antepartum cultures that documented asymptomatic excretion of herpes simplex virus, despite the fact that culturing was repeatedly performed during the four weeks before delivery. Asymptomatic shedding of herpes simplex virus occurred with the same frequency at delivery, whether or not any episodes of symptomatic recurrence were noted during the pregnancy (1.4 vs. 1.3 percent). We conclude that antepartum maternal cultures do not predict the infant's risk of exposure to herpes simplex virus at delivery.

Humoral and cellular immunity against two major glycoproteins (gp) of varicella-zoster virus (VZV), gp I (gp 90/58) and gp III (gp 118), and against a nonglycosylated phosphoprotein (p 170) was demonstrated in human subjects. Primary VZV infection was accompanied by the development of IgG to gp I (mean titer 1:200), gp III (mean titer 1:132), and p 170 (mean titer 1:331). Increased IgG antibody production to each of the VZV proteins occurred during recurrent VZV infection with mean titers to gp I of 1:29512, to gp III of 1:15848, and to p 170 of 1:15848. Persistent high titers to gp III (mean titer 1:891) and to p 170 (mean titer 1:2238) were observed in 75% and 88% of VZV-immune subjects, respectively. T lymphocytes which proliferated on stimulation with gp I, gp III, and p 170 developed with primary VZV infection. VZV-immune subjects had mean transformation indices of 4.2 +/- 0.70 SE to gp I, 4.7 +/- 1 SE to gp III, and 3 +/- 0.39 SE to p 170. Among individual subjects, humoral and cellular immunity was not always detected to all three of the VZV proteins. Resolution of primary VZV infection and maintenance of VZV latency did not require a host response to each of these major viral proteins.

Asymptomatic shedding of herpes simplex virus (HSV) was detected in 0.83% of 955 cultures obtained from pregnant women with culture-proved recurrent genital HSV infections during pregnancy; seven (2.3%) of 299 women had asymptomatic shedding. In addition, one (2.3%) of 42 pregnant women with recurrent genital infection in the past but no attacks during pregnancy shed HSV when asymptomatic. Shedding occurred more frequently from the usual lesion site than from the cervix. The virus was not isolated at delivery from women with asymptomatic antepartum shedding. When an active lesion was present, concomitant shedding of HSV from the cervix occurred in seven (3.6%) of 193 pregnant women with vulvar lesions and in one (2.1%) of 47 women with lesions remote from the vulva. Ninety-two percent of the latter lesions were caused by type 2 HSV. In women who have had recurrent genital HSV infections in the past, asymptomatic shedding occurs in those with active attacks during pregnancy as well as in those asymptomatic throughout pregnancy; however, asymptomatic shedding during the antepartum period does not predict asymptomatic shedding at delivery.

Because of concern about the safety of immune globulins prepared for injection, we studied the effects of ethanol fractionation of human plasma on human lymphotropic virus, type III, (HTLV-III) by spiking the products of various fractionation steps with HTLV-III. Tests of inactivation and removal indicated that the ratio of residual live virus in plasma fractions/live virus in starting plasma was about 1 X 10(-15) for precipitate II from which immune globulin for injection is manufactured. The results are reassuring regarding the potential safety of immune globulin.

Hybridomas secreting human monoclonal antibodies to varicella-zoster virus were produced by fusing B cells of a patient recovering from acute varicella infection with a human-mouse cell line. Two hybrid lines have continued to secrete IgG1, one with kappa and the other with lambda chains, for at least 12 months. Each antibody neutralizes virus infectivity between 1-5 micrograms of partially purified immunoglobulin/ml, each shows a different pattern of immunofluorescent staining of virus-infected cells, and one identifies three viral proteins with molecular weights of 60,000, 95,000, and 97,000.

We compared the VZV IgG antibody titers after administration of varicella zoster immune globulin and serum immune globulin intravenously (IGIV) in VZV seronegative pediatric patients with cancer. Four patients received VZIG at standard doses; four received IGIV at 4 ml/kg every 4 weeks for four doses; and five received IGIV at 6 ml/kg every 6 weeks for two to four doses. VZV antibody titers were measured by radiommunoassay (RIA), enzyme-linked immunosorbent assay (ELISA), indirect fluorescent antibody assay (IFA), and neutralizing antibody assay. The mean peak and trough VZV titers by RIA were comparable in all three groups: 1:724 at 4 weeks after VZIG, 1:2048 at 4 weeks after 4 ml/kg IGIV, and 1:776 at 6 weeks after 6 ml/kg IGIV. The titers measured by ELISA, IFA, and neutralizing antibody were comparable after VZIG or IGIV. The VZV titers by RIA were maintained at greater than or equal to 1:1024 after subsequent doses of 4 ml/kg IGIV, and at greater than or equal to 1:256 after subsequent doses of 6 ml/kg IGIV. Adverse effects were rare. The VZV antibody titers assessed 4 to 6 weeks after IGIV administration were equivalent to the titers measured 4 weeks after administration of VZIG.

Serum samples from 28 children with symptomatic human immunodeficiency virus (HIV) infection were studied for the presence of HIV antigen. Their humoral immune response profile, including anti-HIV specific isotypic responses and neutralizing titers, was characterized. Additionally, serum specimens from 12 of these children were tested for their ability to mediate antibody-dependent cellular cytotoxicity (ADCC) against HIV envelope antigens. Analysis of our results showed that children with acquired immunodeficiency syndrome (AIDS) were much more likely to have serum antigenemia and an absence of anti-p24 antibodies than those with AIDS-related complex (ARC). A significant association was also noted between a more stable clinical status and a strong anti-p24 antibody response with detectable antibodies to other HIV antigens in multiple antibody subclasses. This suggests that the longitudinal evaluation of antigen/antibody profiles may aid in the assessment of prognosis for children with HIV infection. Sera from 6/6 patients with ARC and 4/6 patients with AIDS were able to mediate ADCC. No correlation was found between clinical status and the titers of neutralizing antibodies.

Resistance to reinfection with varicella-zoster virus (VZV) was evaluated in immune adults who had household exposure to varicella. Sixty-four percent of 25 adults exposed to varicella had a fourfold or greater rise in IgG antibody to VZV or had a high initial IgG antibody titer to VZV that declined by fourfold. IgM antibody was detected in only 12% of 25 VZV-immune subjects. Seventy percent of 23 subjects exposed to varicella had IgA antibody to VZV compared with 13% of 23 subjects with antibody to VZV who had no recent exposure (P less than 0.001, chi 2 test). Enhanced cellular immunity was documented by an increase in lymphocyte transformation to VZV antigen from a mean +/- SE index of 7.8 +/- 1.30 to 15.3 +/- 2.56 (P = 0.01, paired t-test). The increase in immunity to VZV in many immune subjects exposed to VZV suggests the occurrence of subclinical reinfection.