Detection of cytomegalovirus DNA in classic and epidemic Kaposi's sarcoma by in situ hybridization

Several lines of evidence have suggested an etiologic association of cytomegalovirus (CMV) with Kaposi's sarcoma. This contention is supported by a pathoepidemiologic survey of 54 cases of acquired immunodeficiency syndrome (AIDS) at our own institution. Of the 27 patients with documented Kaposi's sarcoma, 24 (89%) showed histologic evidence of CMV infection (cytomegalic cells with viral inclusions), whereas only 9 (33%) of the patients with AIDS without Kaposi's sarcoma showed hallmarks of CMV infection. In an attempt to address this question further, we have searched for the presence of CMV nucleic acid sequences in a series of 25 patients with AIDS and Kaposi's sarcoma, using the technique of in situ DNA hybridization. The reliability of the in situ technique is demonstrated, and the technique is shown to be more sensitive than the detection of viral inclusions within Kaposi's sarcoma lesions by routine light microscopy. However, only 20% of our cases showed evidence of CMV involvement, and the CMV-positive cells within the affected Kaposi's sarcoma lesions were few and sparsely distributed. In addition, a companion series of 6 elderly patients with "classic" Kaposi's sarcoma showed no evidence of CMV infection by either conventional microscopy or in situ hybridization. These results do not support the notion of a strong association between Kaposi's sarcoma and CMV, unless the CMV sequences are present at a copy number too low for detection by these methods. The implications of these findings in light of current theories of CMV oncogenesis are discussed.     

Histology of early lesions of AIDS-associated Kaposi's sarcoma

The original cutaneous biopsy specimens of 93 patients who presented themselves to the Memorial Sloan-Kettering Cancer Center with acquired immunodeficiency syndrome (AIDS)-related Kaposi's sarcoma (KS) were systematically reviewed for 23 histologic variables. KS was the initial manifestation of AIDS in all of the patients. The vast majority of patients presented with plaque histology of KS. Early lesions of KS were characterized by the presence of dilated vascular spaces haphazardly arranged in the biopsy specimen, a sparse inflammatory cell infiltrate composed of lymphocytes (usually without plasma cells), and aggregates of cuboidal cells with the appearance of epithelioid cells. Individually necrotic tumor cells were present in nearly every case. Spindle cells arranged in fascicles or nodules were seen in a minority of cases. These data provide an overview of the different histologic patterns seen in initial lesions of AIDS-associated KS and may lead to better understanding of the pathogenesis of this tumor.     

Value of lymph node biopsy in lymphadenopathies occurring in patients at risk for AIDS

On the basis of four cases of patients with persistent lymphadenopathy and at risk for acquired immune deficiency syndrome (AIDS), (3 Haitians, one haemophiliac), histopathologic features of lymph node biopsy in AIDS are recalled. Two main types of alterations of lymph node architecture--follicular hyperplasia or lymphoid depletion--can be associated with interfollicular lesions: vascular proliferation, numerous plasma cells, epithelioid reaction that may reflect an infectious process. Alterations of T-cell subsets distribution were also analyzed using immunocytochemical labelling of frozen sections from lymph nodes. In all four cases, T4 (helper)--lymphocytes were markedly depleted, whereas they normally represent the majority of lymph node T cells. They were replaced by prominent T8 (cytotoxic, suppressor)-cells, particularly inside the follicle. T8 lymphocytes are usually rare in this latter area. The fine analysis of these abnormalities is useful in prodromal or mild forms of AIDS.     

CMV as a cofactor enhancing progression of AIDS.

BACKGROUND: Cytomegalovirus (CMV) has been proposed as a cofactor driving HIV pathogenicity since the late 1980s. Potential mechanisms which CMV could use as a cofactor have been described in vitro and potential criteria for assessing cofactor activity in vivo have been proposed. OBJECTIVE: To determine if recent publications have added new information to these in vitro or in vivo studies since the author last reviewed this subject in 1998. STUDY DESIGN: Literature survey prior to presenting an overview lecture. RESULTS: No new in vitro mechanisms have been described though several clinical cohort studies are consistent with the possibility that active CMV infection can act as a cofactor. One study published in 1999 showed that mortality in AIDS patients was driven more by CMV viral load than HIV viral load. Although highly active antiretroviral therapy (HAART) has now greatly controlled end organ disease caused by CMV, a recent study showed that CMV viraemia was still strongly associated with death in AIDS patients. CONCLUSIONS: (1) CMV remains important in the era of HAART. (2) CMV has been underestimated as an important cofactor since the beginning of the AIDS epidemic.     

Disseminated extraintestinal isosporiasis in a patient with acquired immune deficiency syndrome

This report describes a 38-year-old male homosexual with acquired immune deficiency syndrome (AIDS) and a history of Isospora belli infestation treated with trimethoprim-sulfamethoxazole. At autopsy, intracellular and extracellular I. belli organisms were identified in the mucosa and lamina propria of small and large intestine as well as in mesenteric and tracheobronchial lymph nodes, where an associated granulomatous reaction was also present. Until now, Isosporiasis has been observed as intracellular parasites restricted to the columnar cells of the intestinal mucosa in humans hosts. This is, to the authors' knowledge, the first time that this protozoa has been observed invading beyond the intestinal wall. This patient's autopsy also demonstrated intestinal ulcerations proven microscopically to be caused by cytomegalovirus (CMV). In patients with AIDS and CMV enterocolitis, the authors have observed an unusual frequency of extraintestinal disseminated disease by microorganisms heretofore typically restricted to the intestinal mucosa (i.e., bacteremias resulting from Shigella species). The authors propose that, in AIDS patients, the profound immunodeficient state, possibly in conjunction with CMV-induced intestinal mucosal ulcerations, promotes access of other intestinal microorganisms, including I. belli, into lymphatic and vascular spaces, culminating in lymphohematogenous dissemination of their intestinal infestations.     

Human herpesvirus 8 in Kaposi's sarcoma and Kaposi's sarcoma-mimicking vascular tumors.

Kaposi''s sarcoma (KS) had been a rare and unusual vascular tumor until a recent epidemic of a disseminated and fulminant form of KS in AIDS patients. Infectious agents have been suspected of causing KS, and recently partial genomic DNA sequences of human herpesvirus 8 (HHV8) have been identified in AIDS-associated KS lesions. Since then, genomic DNA sequences of HHV8 have been isolated in other forms of KS. Although the partial genomic DNA sequence of HHV8 was reported to be, if rare, identified in vascular tumors other than Kaposi''s sarcoma (KS), the presence of HHV8 in a very large fraction of KS indicates that detection of HHV8 by PCR is a useful auxiliary tool in differentiating KS from other KS-mimicking vascular tumors. We examined whether the 233-bp segment of the viral DNA was detected in Korean patients with KS and other KS-mimicking vascular tumors. HHV8 sequences were identified in all of nine classic type of KS but not in three epithelioid hemangioendotheliomas and seven angiosarcomas. Our results confirm the relatively restricted distribution of HHV8 and also argue against the likelihood of secondary colonization of KS cells by HHV8.     

The adrenal gland in AIDS

The adrenal gland has been known to be a common site of opportunistic infections and tumors that define the acquired immunodeficiency syndrome (AIDS) ever since the first autopsy data were published. We have examined the adrenal glands of 66 AIDS patients autopsied in New York City and tabulated and graded the findings in an attempt to estimate the likelihood of adrenal insufficiency developing on the basis of these lesions. AIDSdefining conditions were found in the adrenal glands of 56% of patients, primarily opportunistic infections (53%) and much less frequently neoplasms (3%). Cytomegaloviral (CMV) infection was by far the most common type (42%), followed by mycobacterial (8%) and fungal infections (3%). There was one case eachof Kaposi’s sarcoma and lymphoma. Total necrosis of adrenal cortex was restricted to 2 cases of tuberculosis. CMV adrenalitis, although the most common infection and often associated with necrosis, never resulted in more than 30% destruction of the cortex. We conclude that although histopathological evidence of adrenal disease is common in AIDS, most such lesions are not sufficiently extensive to result in adrenal insufficiency. In contrast to previous reports stressing the importance of CMV adrenalitis as a possible cause of adrenocortical insufficiency, we now find tuberculosis the more likely cause of total cortical destruction.     

Angiomatöse Skelettläsionen im Kindesalter

Currently, vascular lesions are being classified either as tumors with inherent proliferative potential or as vascular malformations with early manifestation and growth commensurate with the growth of the child. This new classification is also applicable to skeletal vascular lesions. 30% of all skeletal vascular lesions manifest in the first two decades of life, with a preponderance of malformations. They are attributed to disturbances in the complex cascade of angiogenesis and a minority may be hereditary. Multiple cutaneous vascular malformations are associated with mutations of the TIE2- and Glomulin-Genes. Vascular malformations with involvement of multiple skeletal elements may pursue an aggressive course and manifest as massive osteolysis. Among the epithelioid vascular tumours of bone, also in young patients, benign epithelioid hemangioma can be distinguished on a morphological basis from epithelioid hemangioendothelioma as an entity with low malignant potential.     

Human immunodeficiency virus type 1 antigenaemia is enhanced in patients with disseminated cytomegalovirus infection and deficient T lymphocytes.

We have studied 61 patients with the acquired immunodeficiency syndrome (AIDS) regarding the relationships between disseminated cytomegalovirus (CMV) infection with CMV retinitis, HIV1 antigenaemia and CD4+ and CD8+ T-cell deficiency. HIV1 p24 antigenaemia was present in all patients with CMV retinitis (at a high concentration), but in only 28% of patients without retinitis (at a low concentration). Compared to patients without retinitis, those patients who developed retinitis had lower CD4+ and CD8+ prior to and during AIDS. CMV may contribute to deficiencies of T lymphocytes in patients with AIDS.     

Vascular proliferations of the breast

Vascular proliferations of the breast are uncommon but potentially diagnostically challenging lesions. Clinically apparent processes are more likely to be malignant; however, a range of benign entities which must be differentiated from angiosarcoma also exists. This review discusses first, breast lesions of apparent vascular origin, then benign and histologically bland perilobular, cavernous and capillary haemangiomas. Subsequently, more diagnostically challenging, atypical haemangiomas, papillary endothelial hyperplasia, angiomatosis and angiolymphoid hyperplasia with eosinophilia (epithelioid haemangioma) are considered. In addition, lesions with low-grade malignant potential such as haemangiopericytomas and epithelioid haemangioendotheliomas may rarely present in the breast. However, primary angiosarcomas and radiation-associated vascular lesions are reviewed in depth, as these entities are of greatest clinical and pathological significance.     

Cytomegalovirus infection of the central nervous system

Studies report that 40-100% of the general population are infected with cytomegalovirus (CMV), a virus associated with severe neurological conditions, such as CMV encephalitis, and which may have a role in some cases of Guillain-Barre syndrome. CMV infection is a particular concern among individuals with HIV, as almost all are co-infected with it. The introduction of highly active antiretroviral therapy (HAART) has provided a means of reconstituting the immune system of those with HIV/AIDS in such a way as to allow CMV infection to be controlled. In doing so, HAART has done much to reduce the mortality rate associated with CMV disease in such patients. Despite this, response to treatment in these patients remains suboptimal and many do not have access to such therapy, so, efforts to improve the treatment of CMV have been a priority. The International Herpes Management Forum (IHMF) has developed management guidelines to promote the improved diagnosis and treatment of CMV disease of the central nervous system (CNS). It is recommended that polymerase chain reaction (PCR) for viral DNA should be performed on CSF as a means of diagnosing CMV infection of the CNS. As CMV disease is always preceded by viraemia, treatment should be directed toward the prevention of CMV disease. However, if CMV disease develops, ganciclovir is recommended as therapy and continued in a maintenance fashion, which can be discontinued should CD4 count remain above 100 cells/mm3 for 6 months. In many circumstances, valganciclovir may be preferred, depending on the level of function in the patient, their ability to take oral therapy and the severity of disease. Use of foscarnet should be limited to ganciclovir-resistant cases due to the high level of toxicity associated with the drug and its intravenous mode of administration.     

The genetics of vascular tumours: an update

Recent molecular advances have shed significant light on the classification of vascular tumours. Except for haemangiomas, vascular lesions remain difficult to diagnose, owing to their rarity and overlapping clinical, radiographic and histological features across malignancies. In particular, challenges still remain in the differential diagnosis of epithelioid vascular tumours, including epithelioid haemangioma and epithelioid haemangioendothelioma at the benign/low-grade end of the spectrum, and epithelioid angiosarcoma at the high-grade end. Historically, the classification of vascular tumours has been heavily dependent on the clinical setting and histological features, as traditional immunohistochemical markers across the group have often been non-discriminatory. The increased application of next-generation sequencing in clinical practice, in particular targeted RNA sequencing (such as Archer, Illumina), has led to numerous novel discoveries, mainly recurrent gene fusions (e.g. those involving FOS, FOSB, YAP1, and WWTR1), which have resulted in refined tumour classification and improved diagnostic reproducibility for vascular tumours. However, other molecular alterations besides fusions have been discovered in vascular tumours, including somatic mutations (e.g. involving GNA family and IDH genes) in a variety of haemangiomas, as well as copy number alterations in high-grade angiosarcomas (e.g. MYC amplifications). Moreover, the translation of these novel molecular abnormalities into diagnostic ancillary markers, either fluorescence in-situ hybridisation probes or surrogate immunohistochemical markers (FOSB, CAMTA1, YAP1, and MYC), has been remarkable. This review will focus on the latest molecular discoveries covering both benign and malignant vascular tumours, and will provide practical diagnostic algorithms, highlighting frequently encountered pitfalls and challenges in the diagnosis of vascular lesions.     

Cytomegalovirus retinitis in patients with AIDS in Europe

The incidence of cytomegalovirus (CMV) retinitis and risk factors associated with the condition were studied in patients with the acquired immune deficiency syndrome (AIDS) in a multicenter retrospective cohort study of 6458 patients from 52 centers in 17 countries in Europe. Cytomegalovirus retinitis was diagnosed in 154 patients (2.4%) at the time of AIDS diagnosis, the probability of this diagnosis being significantly higher for those with CD4+ cell counts of <100/mm³ (3.4%) than with counts of 100–200/mm³ (1.3%) or >200/mm³ (0.8%). The rate of developing CMV retinitis after AIDS diagnosis was 9.4 per 100 patient years of follow-up. Multivariate analysis showed that risk behavior was significantly associated with the risk of developing CMV retinitis: lower for intravenous drug users [relative risk (RR) 0.47] and those engaged in other risk behavior (RR 0.58) than for homosexual men. The risk of developing CMV retinitis after AIDS diagnosis was significantly associated with CD4+ cell count at the time of AIDS diagnosis: for counts <100/mm³ (RR 2.90) and from 100 to 200/mm³ (RR 2.13), there was a higher risk than for counts > 200/mm³. Patients withPneumocystis carinii pneumonia, toxoplasmosis, or extraocular CMV infection at time of AIDS diagnosis exhibited an increased risk of developing CMV retinitis. Patients treated with zidovudine exhibited an increased rate of CMV retinitis: RR was 1.75 during and 2.87 after the second year of treatment as compared to those who had not received zidovudine. Median survival after CMV retinitis at time of AIDS diagnosis was eight months.     

Diabetic mastopathy: a distinctive clinicopathologic entity.

Insulin-dependent diabetics may manifest evidence of autoimmune diseases involving endocrine or other organs. Rare cases of a peculiar fibrous and inflammatory lesion of the breast in diabetic patients have been previously described; however, the pathologic and clinical features that uniquely characterize these cases have not been defined or distinguished from other chronic inflammatory and fibrosing conditions in the breast. We studied eight patients with breast masses and longstanding insulin-dependent diabetes and compared them with 36 nondiabetic or short-duration diabetic patients with fibrosis and chronic mastitis. The longstanding diabetic patients presented with clinical breast masses ranging in size from 2 to 6 cm. Six of the eight patients had documented diabetic nephropathy, retinopathy, or neuropathy. Pathologically, these lesions showed lymphocytic lobulitis and ductitis, lymphocytic vasculitis (predominantly B cell), and dense keloid-like fibrosis that in many cases (six of eight) contained peculiar epithelioid cells embedded in dense fibrous stroma. We have provisionally labeled these cells "epithelioid fibroblasts" (EFBs). Although the features of lymphocytic lobulitis, ductitis, and/or vasculitis may occasionally be encountered in nondiabetic breast biopsies, EFBs appear to be unique to the diabetic condition. Control cases of chronic mastitis in nondiabetic or short-duration diabetes patients failed to show the complete constellation of lymphocytic lobulitis and ductitis, vasculitis, keloidal fibrosis, and EFBs. Diabetic mastopathy may represent an immune reaction to abnormal matrix accumulation. A hypothesis is presented.     

Epithelioid angiomatosis in the acquired immunodeficiency syndrome: morphology and differential diagnosis

A rare vascular proliferation found as a skin lesion in patients suffering from the acquired immunodeficiency syndrome and sometimes referred to as epithelioid angiomatosis is believed to be a manifestation of infection by the cat scratch bacillus or a related organism. We describe the histological findings from eight lesions seen in two cases. In all cases the diagnosis could be confirmed by demonstration within the lesions of groups of gram-negative rod-shaped organisms staining positively with the Warthin-Starry stain. This condition needs to be distinguished from a variety of reactive and neoplastic vascular proliferations.     

Clue to fine-needle aspiration diagnosis of pleural pneumocystoma: neovascularization and Langhans' giant cell reaction

Pneumocystis pneumonia is a common component of the acquired immunodeficiency syndrome (AIDS) in the United States. Extrapulmonary pneumocystosis, however, is much less common. Rare cases have been reported in lymph nodes, bone marrow, spleen, pleura, gastrointestinal tract, liver, common bile duct, pancreas, skin, thyroid, and eye. A 39-yr-old man with history of chest wall injuries from gunshot and stabbing presented with multiple pleural masses clinically suspicious of metastatic deposits from an unknown primary. Fine-needle aspiration biopsy of the largest pleural mass revealed extrapulmonary pneumocystis, which led to the diagnosis of AIDS. Similar to the previous reports of pneumocystis mass lesions in extrapulmonary sites, the current case is associated with exuberant vascular proliferation and Langhans' giant cell reaction. Neovascularization and histiocytic influx from the newly formed blood vessels and Langhans' giant cell reaction seem to be a common tissue reaction to the massive deposition of pneumocystis organisms in extrapulmonary sites in patients with AIDS.     

Activation of cytomegalovirus infection in immunosuppressed cynomolgus monkeys inoculated with varicella-zoster virus

A systemic activated cytomegalovirus (CMV) infection was fortuitously detected in almost all monkeys which had been immunosuppressed with antithymocyte globulin (ATG), cyclophosphamide (CY), and cortisone acetate (CS) before and after experimental inoculation with varicella-zoster virus (VZV). They developed exudative pneumonia, and the lesions in visceral organs and tissues contained cytomegalic cells with intranuclear inclusion bodies, in which viral antigens, specific for CMV, but not inoculated VZV, were detected by immunofluorescence. Serological study of paired sera from these monkeys ascertained preexisting CMV infection. Under the present experimental conditions, this infection was highly reproducible and always occurred within three, but not two, weeks of immunosuppression in monkeys inoculated with VZV. We therefore examined the host factors involved in activation of latent CMV. The immunocompetence of the host was destroyed almost completely with treatment of ATG, CY, and CS, but not with combinations of two of these agents, revealing the systemic depletion of lymphoid cells in tissues including the thymus medulla. Although the role of VZV in the induction of CMV remains uncertain, the heterologous VZV inoculum may have produced some effects equivalent to the allogeneic reaction to release latent CMV. These monkeys may represent an animal model of "opportunistic" CMV infection in immunocompromised and/or allografted humans.     

Race and the treatment of cytomegalovirus retinitis in a cohort of patients with acquired immunodeficiency syndrome.

This historical cohort study assessed the impact of race on critical factors in the diagnosis and drug treatment of cytomegalovirus (CMV) retinitis in acquired immunodeficiency syndrome (AIDS) patients over a 7-year period. The study subjects included 194 adult patients with a history of AIDS who were treated for CMV retinitis between September 1987 and September 1994. Abstracted inpatient hospital medical records and a statewide automated AIDS database were the primary sources of data. Patients were assessed for severity of CMV retinitis at diagnosis, time from initial CMV retinitis diagnosis to first treatment, survival from diagnosis of AIDS, and initiation of drug treatment for CMV retinitis. Results indicated a significant difference in the severity of CMV retinitis at diagnosis by race. Patients diagnosed with early disease were more likely to be white, whereas patients diagnosed with severe disease were more likely to be black. There was no difference in the type of CMV retinitis treatment or patient survival time after diagnosis, nor time to treatment once diagnosed by race. These results suggest that differences in survival may not be the result of discrimination against black patients and may be due more likely to practices associated with accessing medical treatment.     

Cytomegalovirus and human herpesvirus 8 DNA detection in peripheral blood monocytic cells of AIDS patients: correlations with the presence of Kaposi's sarcoma and CMV disease

To establish the effect of the presence in blood cells of cytomegalovirus (CMV) and human herpesvirus 8 (HHV8) DNA, two herpesviruses that are activated frequently in AIDS patients, were selected from the Amsterdam Cohort Studies on HIV/AIDS 181 PBMC samples from patients with and without Kaposi's sarcoma (KS), and with and without CMV-related disease. The viral loads of both HHV8 and CMV were determined by real-time PCR at the time of diagnosis of AIDS. There was no significant difference in prevalence and load for CMV between the KS and non-KS patients. The variable related most strongly to KS was the presence of HHV8 DNA in PBMCs, whilst CMV DNA was related to the development of CMV disease and shortened survival. The frequency of detection of HHV8 increased when the patient presented with more severe KS symptoms at diagnosis, but detection of HHV8 DNA did not influence survival. Therefore, HHV8 and CMV DNA measured in the blood of AIDS patients, are each related mainly to the associated disease, and have no additional predictive value in these patients.