corrections

1
682 were done with novel samples in PBLs from distinct seronegative healthy donors; the cocultivation of a second sample on Feb 17, 1992, at Institut Pasteur and of a third sample on March 23, provided identical evidence for virus isolation. Both plasma and PBLs from the March 23 sample were culture-positive. Virus indicators (ie, p24 antigen and RT) were serially propagated within a week in PBLs by either cells or filtered (0-22 1ill1) medium from primary cocultures, and the appearance of both signals was inhibited by 2 umol/1 zidovudine. In infected cell cultures, electron microscopy revealed mature viral particles with the cone-shaped core typical of lentiviruses and immature particles budding from the cell surface (figure, A and B respectively). However, numerous particles were elongated (C), which broadly differs from those usually observed for HIV-1 and HIV-2 virions. In addition, when the DNA from either the patient’s PBLs or serially infected PBLs underwent PCR, no amplified product was detected with a wide set of primers bordering selected gag, pol, env, tat, vif, and nef regions of the HIV-1 genome. Results remained negative with two pairs of HIV-2-specific gag primers. For the detection of amplified products, hybridisation was done with both oligomers and large sub-genomic probes matching the regions submitted to amplification to exclude false negatives due to oligomer mismatch. Positive DNA controls reproducibly provided detectable amplified products when tested in the same PCR runs. Lack of PCR reactivity has been described with genetically distinct HIV-1 isolates from Africa3,4 but a failure of amplification with 14 different combinations of primer pairs is intriguing, especially for a European isolate. Together with the atypical serological response in our patient and the abnormalities of virus morphology, this finding suggests a high genetic divergence of this AIDS virus compared with HIV-1 and HIV-2 prototypes. We are now doing a precise molecular characterisation. Virology Laboratory, H&ocirc;pital de la Piti&eacute;-Salp&ecirc;tri&eacute;re, 75013 Paris, France H. AGUT B. RABANEL D. CANDOTTI J.-M. HURAUX Department of Internal Medicine and Microbiology Laboratory, H&ocirc;pital Robert Debr&eacute;, Reims G. REMY T. TABARY D. INGRAND C. CHIPPAUX Viral Oncology Unit, Institut Pasteur, Paris S. CHAMARET C. DAUGUET D. GUETARD L. MONTAGNIER 1. Huet T, Dazza MC, Brun-V&eacute;zinet F, Roelants GE, Wain-Hobson S A highly defective HIV-1 strain isolated from a healthy Gabonese individual presenting an atypical western blot. AIDS 1989; 3: 707-15. 2. De Leys R, Venderborght B, Vanden Haesevelde M, et al. Isolation and partial characterisation of an unusual human immunodeficiency retrovirus from two persons of West-Central African origin J Virol 1990; 64: 1207-16. 3 Candotti D, Jung M, K&eacute;roudean D, et al Genetic variability affects the detection of HIV by polymerase chain reaction. AIDS 1991; 5: 1003-07. 4 Ayehunie S, Sonnerborg A, Johansson B, et al. Differences in PCR reactivity between HIV proviruses from individuals in Ethiopia and Sweden J Acquir Immune Defic Syndr 1990; 3: 975-80. Transmission of HIV-associated tuberculosis to health-care workers SiR,&mdash;HIV-infected subjects are vulnerable to tuberculosis because of downgrading of cell-mediated immune function.1 Little is known about the infectiousness of subjects with active tuberculosis who are also infected with HIV. Patients with HIV have more viable bacilli and a weaker tissue reaction.Z3 Such a "lepromatous-like" pattern seems to be compatible with the dissemination of large inocula by deeply immunosuppressed patients with HIV. Standaert et al in Burundi,4 found that household members of HIV-infected patients with tuberculosis were at greater risk of developing tuberculosis than contacts of HIV-negative patients with tuberculosis. We have retrospectively reviewed the occupational risk of tuberculosis in health-care workers (HCWs) taking care of HIV positive or negative patients with active tuberculosis. In Italy, patients with tuberculosis are admitted to different wards depending on HIV status. Tuberculosis-related hospital activity 1986-91 was reviewed in three divisions of infectious diseases (Verona, Mantova, and Brescia) where only HIV-positive patients with tuberculosis are admitted, and in the division of pneumology of Verona as well as in the tuberculosis clinic of Arco di Trento, where only HIV-negative patients are admitted. 7 HCWs in the infectious diseases units developed active tuberculosis after occupational contacts with a cumulative total of 85 HIV-infected patients with newly diagnosed tuberculosis, while only 2 HCWs had tuberculosis after looking after 1079 HIV- negative patients with newly diagnosed tuberculosis over the same period: Tuberculosis patients Tuberculosis Patients admitted in HCW HIV-positive Verona 35 3 Mantova 26 3 Bresina 24 1 Total 85 7 HIV-negative Verona 158 0 Arco di Trento 921 2 Total 1079 2 Statistical analysis by separate consideration of units where HIV positive and negative patients were admitted The incidence of occupational tuberculosis among HCWs was thus 8-235 per year per 100 admitted tuberculosis patients in those who cared for patients with HIV infection and 0 185 per year per 100 for those who cared for HIV-negative patients. The relative risk is 44.4 (95% CI 8-5-438). The mean duration of hospital stay was 2-2 and 2-5 months for HIV positive and negative patients with tuberculosis, respectively. The number of HCWs per 100 beds was similar in the five units investigated. Such a difference in occupational risk is even more striking if we consider that facial masks were worn routinely only in the units of infectious diseases. These and other anecdotal findings5,6 indicate that immunosuppressed patients with HIV may contribute to the worldwide resurgence of tuberculosis, not only as new vulnerable subjects but also as unexpectedly powerful sources of dissemination of tuberculosis. Besides the preventable risk of acquiring HIV infection, tuberculosis is the major threat for hospital workers assisting AIDS patients. Institute of Immunology and Infectious Diseases. University of Verona, 37126 Verona; Mantua Hospital, University of Brescia, Civil Hospital of Verona, Armanni Hospital of Arco di Trento; Institute of Statistics, University of Trento; and University of Genova, Italy GIOVANNI DI PERRI GIAN PIETRO CADEO FRANCESCO CASTELLI ANGELO CAZZADORI SERGIO BASSETTI FRANCO RUBINI Rocco MICCIOLO ERCOLE CONCIA DANTE BASSETTI 1. Jereb JA, Kelly GD, Dooley SW, et al. Tuberculosis morbidity m the United States final data, 1990. MMWR 1992; 40 (SS-3): 23-27. 2. Prego V, Glatt AE, Roy V, et al. Comparative yield of blood culture for fungi and mycobactena, liver biopsy and bone marrow biopsy in the diagnosis of fever of undetermined origin in human immunodeficiency virus-infected patients Arch Intern Med 1990; 150: 333-36. 3. Orenstem MS, Tavitian A, Yonk B, et al. Granulomatous involvement of the liver in patients with AIDS. Gut 1985; 26: 1220-25 4. Standaert B, Niragira F, Kadenda P, Piot P. The association of tuberculosis and HIV infection in Burundi. AIDS Res Hum Retrov 1989; 5: 247-51. 5. Anon Nosocomial transmission of multidrug-resistant tuberculosis to health-care workers in HIV-infected patients in an urban hospital-Florida MMWR 1990; 39: 718-22. 6. Pierce JR, Sims SL, Holman GH Transmission of tuberculosis to hospital workers by a patient with AIDS. Chest 1992; 101: 581-82. CORRECTIONS Thromboembolism during angiography.-In this editorial (June 27, p 1576), the discussion of Gasperetti et al’s data should have read "In a series of 124 consecutive patients undergoing coronary angioplasty, 57 received an ionic agent and 67 a non-ionic agent. A new thrombus developed in 4% of the first group vs 18% of the second (p < 002) during the procedure". Bleeding oesophageal varices: lST, EVL, or TIPS.-In this editorial (Aug 29, p 515), the second sentence of paragraph two should have read: "Thus, 30% of patients require more than one injection and in 5-10% of patients bleeding is not controlled by IST."

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682

were done with novel samples in PBLs from distinct seronegativehealthy donors; the cocultivation of a second sample on Feb 17,1992, at Institut Pasteur and of a third sample on March 23,provided identical evidence for virus isolation. Both plasma andPBLs from the March 23 sample were culture-positive.

Virus indicators (ie, p24 antigen and RT) were seriallypropagated within a week in PBLs by either cells or filtered

(0-22 1ill1) medium from primary cocultures, and the appearance ofboth signals was inhibited by 2 umol/1 zidovudine. In infected cellcultures, electron microscopy revealed mature viral particles withthe cone-shaped core typical of lentiviruses and immature particlesbudding from the cell surface (figure, A and B respectively).However, numerous particles were elongated (C), which broadlydiffers from those usually observed for HIV-1 and HIV-2 virions.In addition, when the DNA from either the patient’s PBLs orserially infected PBLs underwent PCR, no amplified product wasdetected with a wide set of primers bordering selected gag, pol, env,tat, vif, and nef regions of the HIV-1 genome. Results remainednegative with two pairs of HIV-2-specific gag primers. For thedetection of amplified products, hybridisation was done with botholigomers and large sub-genomic probes matching the regionssubmitted to amplification to exclude false negatives due to

oligomer mismatch. Positive DNA controls reproducibly provideddetectable amplified products when tested in the same PCR runs.Lack of PCR reactivity has been described with genetically

distinct HIV-1 isolates from Africa3,4 but a failure of amplificationwith 14 different combinations of primer pairs is intriguing,especially for a European isolate. Together with the atypicalserological response in our patient and the abnormalities of virusmorphology, this finding suggests a high genetic divergence of thisAIDS virus compared with HIV-1 and HIV-2 prototypes. We arenow doing a precise molecular characterisation.

Virology Laboratory,H&ocirc;pital de la Piti&eacute;-Salp&ecirc;tri&eacute;re,75013 Paris, France

H. AGUTB. RABANEL

D. CANDOTTI

J.-M. HURAUX

Department of Internal Medicineand Microbiology Laboratory,

H&ocirc;pital Robert Debr&eacute;,Reims

G. REMYT. TABARY

D. INGRANDC. CHIPPAUX

Viral Oncology Unit,Institut Pasteur,Paris

S. CHAMARETC. DAUGUET

D. GUETARDL. MONTAGNIER

1. Huet T, Dazza MC, Brun-V&eacute;zinet F, Roelants GE, Wain-Hobson S A highlydefective HIV-1 strain isolated from a healthy Gabonese individual presenting an

atypical western blot. AIDS 1989; 3: 707-15.2. De Leys R, Venderborght B, Vanden Haesevelde M, et al. Isolation and partial

characterisation of an unusual human immunodeficiency retrovirus from twopersons of West-Central African origin J Virol 1990; 64: 1207-16.

3 Candotti D, Jung M, K&eacute;roudean D, et al Genetic variability affects the detection ofHIV by polymerase chain reaction. AIDS 1991; 5: 1003-07.

4 Ayehunie S, Sonnerborg A, Johansson B, et al. Differences in PCR reactivity betweenHIV proviruses from individuals in Ethiopia and Sweden J Acquir Immune DeficSyndr 1990; 3: 975-80.

Transmission of HIV-associated tuberculosisto health-care workers

SiR,&mdash;HIV-infected subjects are vulnerable to tuberculosisbecause of downgrading of cell-mediated immune function.1 Littleis known about the infectiousness of subjects with activetuberculosis who are also infected with HIV. Patients with HIVhave more viable bacilli and a weaker tissue reaction.Z3 Such a

"lepromatous-like" pattern seems to be compatible with thedissemination of large inocula by deeply immunosuppressedpatients with HIV. Standaert et al in Burundi,4 found thathousehold members of HIV-infected patients with tuberculosiswere at greater risk of developing tuberculosis than contacts ofHIV-negative patients with tuberculosis. We have retrospectivelyreviewed the occupational risk of tuberculosis in health-careworkers (HCWs) taking care of HIV positive or negative patientswith active tuberculosis.

In Italy, patients with tuberculosis are admitted to differentwards depending on HIV status. Tuberculosis-related hospitalactivity 1986-91 was reviewed in three divisions of infectiousdiseases (Verona, Mantova, and Brescia) where only HIV-positive

patients with tuberculosis are admitted, and in the division ofpneumology of Verona as well as in the tuberculosis clinic of Arco diTrento, where only HIV-negative patients are admitted.

7 HCWs in the infectious diseases units developed activetuberculosis after occupational contacts with a cumulative total of 85HIV-infected patients with newly diagnosed tuberculosis, whileonly 2 HCWs had tuberculosis after looking after 1079 HIV-negative patients with newly diagnosed tuberculosis over the sameperiod:

Tuberculosis patients TuberculosisPatients admitted in HCW

HIV-positiveVerona 35 3Mantova 26 3Bresina 24 1

Total 85 7

HIV-negativeVerona 158 0

Arco di Trento 921 2

Total 1079 2Statistical analysis by separate consideration of units where HIV positiveand negative patients were admitted

The incidence of occupational tuberculosis among HCWs was thus8-235 per year per 100 admitted tuberculosis patients in those whocared for patients with HIV infection and 0 185 per year per 100 forthose who cared for HIV-negative patients. The relative risk is 44.4 (95% CI 8-5-438).The mean duration of hospital stay was 2-2 and 2-5 months for

HIV positive and negative patients with tuberculosis, respectively.The number of HCWs per 100 beds was similar in the five units

investigated. Such a difference in occupational risk is even morestriking if we consider that facial masks were worn routinely only inthe units of infectious diseases.These and other anecdotal findings5,6 indicate that

immunosuppressed patients with HIV may contribute to theworldwide resurgence of tuberculosis, not only as new vulnerablesubjects but also as unexpectedly powerful sources of disseminationof tuberculosis. Besides the preventable risk of acquiring HIVinfection, tuberculosis is the major threat for hospital workersassisting AIDS patients.

Institute of Immunology and Infectious Diseases.University of Verona,37126 Verona;Mantua Hospital,University of Brescia,Civil Hospital of Verona,Armanni Hospital of Arco di Trento;Institute of Statistics,University of Trento;and University of Genova, Italy

GIOVANNI DI PERRIGIAN PIETRO CADEOFRANCESCO CASTELLIANGELO CAZZADORISERGIO BASSETTIFRANCO RUBINIRocco MICCIOLOERCOLE CONCIADANTE BASSETTI

1. Jereb JA, Kelly GD, Dooley SW, et al. Tuberculosis morbidity m the United Statesfinal data, 1990. MMWR 1992; 40 (SS-3): 23-27.

2. Prego V, Glatt AE, Roy V, et al. Comparative yield of blood culture for fungi andmycobactena, liver biopsy and bone marrow biopsy in the diagnosis of fever ofundetermined origin in human immunodeficiency virus-infected patients ArchIntern Med 1990; 150: 333-36.

3. Orenstem MS, Tavitian A, Yonk B, et al. Granulomatous involvement of the liver inpatients with AIDS. Gut 1985; 26: 1220-25

4. Standaert B, Niragira F, Kadenda P, Piot P. The association of tuberculosis and HIVinfection in Burundi. AIDS Res Hum Retrov 1989; 5: 247-51.

5. Anon Nosocomial transmission of multidrug-resistant tuberculosis to health-careworkers in HIV-infected patients in an urban hospital-Florida MMWR 1990; 39:718-22.

6. Pierce JR, Sims SL, Holman GH Transmission of tuberculosis to hospital workers bya patient with AIDS. Chest 1992; 101: 581-82.

CORRECTIONS

Thromboembolism during angiography.-In this editorial (June 27,p 1576), the discussion of Gasperetti et al’s data should have read "In a seriesof 124 consecutive patients undergoing coronary angioplasty, 57 received anionic agent and 67 a non-ionic agent. A new thrombus developed in 4% of thefirst group vs 18% of the second (p < 002) during the procedure".

Bleeding oesophageal varices: lST, EVL, or TIPS.-In this editorial(Aug 29, p 515), the second sentence of paragraph two should have read:"Thus, 30% of patients require more than one injection and in 5-10% ofpatients bleeding is not controlled by IST."