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Articles tagged with: HIV

May28

Sometimes history makes itself known when you least expect it

Thursday, 28 May 2015 Written by // Bob Leahy - Editor Categories // Gay Men, Health, International , Living with HIV, Population Specific , Bob Leahy

Bob Leahy on the early CDC document that reported the first cases of AIDS in the United States some 34 years ago that, although seldom seen, has become part of our history

Sometimes history makes itself known when you least expect it

In the course of preparing our May 27 article on National HIV/AIDS Long Terms Survivors Day, I came across a link to an important document I’d heard about but never actually seen. In fact I’d wager many of us have heard about it but never seen. But it’s fascinating and dreadful, all at the same time. It dates from June 1981. 

In June 1981 I had been with my current boyfriend for just a few months. We had met while on vacation in San Juan, Puerto Rico, both living in Toronto at the time, and connected again on our return. That June we were in the process of buying our first house together, a modest home in the east end of Toronto.

At the exact same time a storm was quietly gathering on the other side of the continent

On June 5, 1981 the CDC issued a bulletin alerting medical professionals to five unusual cases of  Pneumocystis carinii pneumonia (PCP), a rare opportunistic infection that was known to occur in people with very compromised immune systems.  The cases involved five gay men in three different hospitals in Los Angeles, California. The underlying cause was unknown but, the CDC reported in its conclusions at the time “the observations suggest the possibility of a cellular-immune dysfunction related to a common exposure that predisposes individuals to opportunistic infections such as pneumocystosis (PCP) and candidiasis (thrush).”

The document, which I am reproducing below, marks the first time AIDS, although not so named, was clinically observed in the United States. By September 1982 the CDC started referring to the disease as AIDS.

The rest is history.

The document is full of medical jargon, but I found it chilling reading nevertheless. I’ve provided common names for some of the disease and infections in brackets. They are what defined the epidemic in those very early days.

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From the CDC Archives - Epidemiologic Notes and Reports – June 5, 1981

Pneumocystis Pneumonia --- Los Angeles

In the period October 1980-May 1981, five young men, all active homosexuals, were treated for biopsy-confirmed Pneumocystis carinii pneumonia (PCP) at three different hospitals in Los Angeles, California. Two of the patients died. All five patients had laboratory-confirmed previous or current cytomegalovirus (CMV) infection and candidal mucosal (yhrush) infection. Case reports of these patients follow.

Patient 1: A previously healthy 33-year-old man developed P. carinii pneumonia (PCP) and oral mucosal candidiasis (thrush) in March 1981 after a two-month history of fever associated with elevated liver enzymes, leukopenia (reduction in white blood cells), and CMV viruria. The serum complement-fixation CMV titer in October 1980 was 256; in May 1981 it was 32.* The patient's condition deteriorated despite courses of treatment with trimethoprim-sulfamethoxazole (TMP/SMX), pentamidine, and acyclovir. He died May 3, and postmortem examination showed residual P. carinii (PCP) and CMV pneumonia, but no evidence of neoplasia (tumours).

Patient 2: A previously healthy 30-year-old man developed p. carinii pneumonia (PCP) in April 1981 after a five-month history of fever each day and of elevated liver-function tests, CMV viruria, and documented seroconversion to CMV, i.e., an acute-phase titer of 16 and a convalescent-phase titer of 28* in anticomplement immunofluorescence tests. Other features of his illness included leukopenia (reduction in white blood cells) and mucosal candidiasis (thrush). His pneumonia responded to a course of intravenous TMP/.SMX, but, as of the latest reports, he continues to have a fever each day.

Patient 3: A 30-year-old man was well until January 1981 when he developed esophageal and oral candidiasis (thrush) that responded to Amphotericin B treatment. He was hospitalized in February 1981 for P. carinii pneumonia (PCP) that responded to TMP/SMX. His esophageal candidiasis (thrush) recurred after the pneumonia was diagnosed, and he was again given Amphotericin B. The CMV complement-fixation titer in March 1981 was 8. Material from an esophageal biopsy was positive for CMV.

Patient 4: A 29-year-old man developed P. carinii pneumonia (PCP) in February 1981. He had had Hodgkins disease three years earlier, but had been successfully treated with radiation therapy alone. He did not improve after being given intravenous TMP/SMX and corticosteroids and died in March. Postmortem examination showed no evidence of Hodgkins disease, but P. carinii (PCP) and CMV were found in lung tissue.

Patient 5: A previously healthy 36-year-old man with clinically diagnosed CMV infection in September 1980 was seen in April 1981 because of a four-month history of fever, dyspnea (shortness of breath), and cough. On admission he was found to have P. carinii pneumonia (PCP), oral candidiasis (thrush), and CMV retinitis. A complement-fixation CMV titer in April 1981 was 128. The patient has been treated with two short courses of TMP/SMX that have been limited because of a sulfa-induced neutropenia (low white blood cells). He is being treated for candidiasis (thrush) with topical nystatin.

“The fact that these patients were all homosexuals suggests an association between some aspect of a homosexual lifestyle or disease acquired through sexual contact and Pneumocystis pneumonia in this population”

The diagnosis of Pneumocystis pneumonia (PCOwas confirmed for all five patients antemortem by closed or open lung biopsy. The patients did not know each other and had no known common contacts or knowledge of sexual partners who had had similar illnesses. Two of the five reported having frequent homosexual contacts with various partners. All five reported using inhalant drugs, and one reported parenteral drug abuse. Three patients had profoundly depressed in vitro proliferative responses to mitogens and antigens. Lymphocyte (lymph gland) studies were not performed on the other two patients.

Editorial Note: Pneumocystis pneumonia (PCP) in the United States is almost exclusively limited to severely immunosuppressed patients. The occurrence of pneumocystosis in these five previously healthy individuals without a clinically apparent underlying immunodeficiency is unusual. The fact that these patients were all homosexuals suggests an association between some aspect of a homosexual lifestyle or disease acquired through sexual contact and Pneumocystis pneumonia in this population. All five patients described in this report had laboratory-confirmed CMV disease or virus shedding within five months of the diagnosis of Pneumocystis pneumonia (PCP). CMV infection has been shown to induce transient abnormalities of in vitro cellular-immune function in otherwise healthy human hosts. Although all three patients tested had abnormal cellular-immune function, no definitive conclusion regarding the role of CMV infection in these five cases can be reached because of the lack of published data on cellular-immune function in healthy homosexual males with and without CMV antibody. In one report, 7 (3.6%) of 194 patients with pneumocystosis also had CMV infection' 40 (21%) of the same group had at least one other major concurrent infection. A high prevalence of CMV infections among homosexual males was recently reported: 179 (94%) had CMV viruria; rates for 101 controls of similar age who were reported to be exclusively heterosexual were 54% for seropositivity and zero for viruria. In another study of 64 males, four (6.3%) had positive tests for CMV in semen, but none had CMV recovered from urine. Two of the four reported recent homosexual contacts. These findings suggest not only that virus shedding may be more readily detected in seminal fluid than urine, but also that seminal fluid may be an important vehicle of CMV transmission.

All the above observations suggest the possibility of a cellular-immune dysfunction related to a common exposure that predisposes individuals to opportunistic infections such as pneumocystosis (PCP) and candidiasis (thrush). Although the role of CMV infection in the pathogenesis of pneumocystosis (PCP) remains unknown, the possibility of P. carinii infection must be carefully considered in a differential diagnosis for previously healthy homosexual males with dyspnea (reduced while blood cells) and pneumonia. 

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NBC's earliest report on AIDS was in 1982. See the video below.

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