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References
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2. Chanock RM, Parrott RH: Acute respiratory disease in infancy and childhood: present understanding and prospects for prevention. Pediatrics (1965) 36:21-39
3. Lipson SM, Krilov LR: Comparison of the rapid second generation directigenR EIA with cell culture and immuno- fluorescence for the detection of respiratory syncytial virus in nasopharyngeat aspirates. Clinical and Diagnostic Virology (1994) 2:105-112
4. Ray CG, Minnich LL: Efficiency of immunofluorescence for rapid detection of common respiratory viruses. Journal of Clinical Microbiology (1987) 25:355-357
5. Rothbarth Phil, Hermus M-C, Schrijnemakers P: Reliability of two new test kits for rapid diagnosis of respiratory syncy- tial virus infection. Journal of Clinical Microbiology (1991) 29 : 824-826
6. Krilov LR, Lipson SM, Barone SR, Kaplan MH, Ciamician Z, Harkness SH: Evaluation of a rapid diagnostic test for respi- ratory syncytial virus (RSV): potential for bedside diagnosis. Pediatrics (1994) 93:903-906
7. Swierkosz EM, Flanders R, Melvin L, Miller JD, Kline MW: Evaluation of the Abbott TESTPACK RSV enzyme immu- noassay for detection of respiratory syncytial virus in naso- pharyngeal swab specimens. Journal of Clinical Microbiology (1989) 27:1151-1154
8. Thomas EE, Book L: Comparison of two rapid methods for detection of respiratory syncytial virus (RSV) (TestPack RSV and Ortho RSV ELISA) with direct immunofluorescence and virus isolation for the diagnosis of pediatric RSV infection. Journal of Clinical Microbiology (1991) 291632-635
9. Dominguez EA, Taber LH, Couch RB: Comparison of rapid diagnostic techniques for respiratory syncytial virus and influenza A virus respiratory infections in young children. Journal of Clinical Microbiology (1993) 31:2286-2290 I0. Wren CG, Bate B J, Masters HB, Lauer BA: Detection of
respiratory syncytial virus antigen in nasal washings by Abbott TestPack enzyme immunoassay. Journal of Clinical Microbiology (1990) 28 : 1395-1397
Relationship between Erythema of
the Proximal Nailfold in
HIV-Infected Patients and Hepatitis
C Virus Infection
S. Courvoisier, H. Grob, M. Weisser, P.H. Itin, M. Battegay
Periungual e r y t h e m a was first described in HIV- infected patients in 1995 by our group [1]. In 1996 P e c h e r e et al. [2] presented nine patients with periun- gual erythema, all of w h o m were serologically positive
S. Courvoisier, H. Grob, P.H. Itin
Department of Dermatology, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
M. Weisser, M. Battegay (IE~)
Outpatient Department of Internal Medicine, University Hospital Basel, Petersgraben 4, CH-4031 Basel, Switzerland
for hepatitis C virus ( H C V ) antibodies. All had active viral hepatitis, and in six patients hepatitis C - R N A was found. In the nine patients we reported, only four had a serological test positive for H C V [3]. However. the percentage of H C V infections may have been underes- timated, as serological tests for H C V were not p e r f o r m e d in all patients who had no signs of chronic liver disease. T o give a description of the course of disease and a possible relationship with HCV. we present an overview of 21 patients, eight of whom have b e e n presented earlier [3, 4].
T h r o u g h 30 June 1997. we d o c u m e n t e d periungual e r y t h e m a in 22 of 540 (4.1%) HIV-infected patients. HIV-infected persons were examined routinely every 6 months by a dermatologist. Demographic. clinical, and laboratory data of the 21 patients we analysed are shown in Table 1. Asymptomatic e r y t h e m a was restricted to the distal part of the fingers in nine patients and to the distal part of the toes m 10 patients and was found in both sites in two patients. Some patients had telangiectases. M a r k e d palmar e r y t h e m a was observed in nine patients. Periungual e r y t h e m a was d o c u m e n t e d at two consecutive consultations or repeatedly in nine patients: in four of these patients. the e r y t h e m a disappeared.
The H I V viral load at the time of diagnosis was avail- able for 19 patients; it showed no correlation with the presence of periungual e r y t h e m a (Table 1)i Serological data regarding H C V infection was at least partly avail- able for 20 patients. Serological tests for H C V (second- generation EIA; Abbott, U S A ) were confirmed as positive in 12 patients and were negative in five patients, in one patient the confirmatory test (Dediscan; Sanofi, France) for H C V was questionaNe. This patient also had cryogtobulinemia, a complication that can occur during H C V infection [5]. In three patients serological testing for H C V was either n o t done or was not available. Chronic h e p a t o p a t h y docu- m e n t e d by elevated liver enzymes was seen in seven patients. No patient tested positive for hepatitis B surface antigen, which indicates that all were free of acute or chronic hepatitis B infection.
In our series of 21 patients, 12 had d o c u m e n t e d H C V infection. In one other patient, H C V infection was highly probable. In five patients serological testing for H C V was negative. T h e r e f o r e , it is possible that condi- tions other than H C V may also contribute to erythema. One patient (no. 11) who tested negative serologically for H C V and H B V but who was a known alcohol abuser with elevated liver enzyme values had periun- gual and palmar erythema. A n o t h e r patient (no. 15) with a history of alcohol abuse and recurrent pancrea- titis had no signs of chronic liver disease. In the remaining three patients with negative H C V serological tests, no sign of chronic h e p a t o p a t h y was found. In
Eur J Clin Microbiol Infect Dis, Volume 17, 1998 597
Table 1 Clinical and labora-
tory findings in patients with HIV infection and periungual erythema
Patient Age in Focus of > l x * Mode of CDC C D 4 + T HIV viral HCV no. years/sex infection transmission classi- cell count load anti-
fication in I*1 (copies/ml) bodies 1 36/m F/T/P yes iv C3 160 23993 pos 2 40/m T no iv B1 608 3847 pos 3 35/f T no iv B3 190 793404 pos 4 32/m T/P no iv/msm C3 100 413 pos 5 31/f F/P yes iv C3 157 750000 pos 6 30/f T/P yes iv B2 374 766 pos 7 38/m F yes iv B3 260 < 244 pos 8 33/m F no msm A2 370 38515 neg 9 39/m T no iv B3 45 122085 nd 10 38/f F yes iv C3 57 15474 prob 11 58/m T/P no bi C3 5 169254 neg 12 33/m T no iv C3 30 40271 pos 13 34/m F no iv C2 260 < 274 pos 14 31/m T/P yes iv B3 119 < 418 pos 15 35/m T yes hetero B3 170 206167 ueg 16 29/f F/P yes iv B2 310 na na 17 56/m F no msm B2 270 nd neg 18 57/m T no msm C3 20 45060 neg 19 28/f F no iv A1 851 1329 pos 20 33/m F/P no iv C3 135 165616 na 21 36/f F/T/P yes iv C3 95 4467 pos * Diagnosis was established in more than one consultation
bi, bisexual; CDC, Centers for Disease Control; F, fingers; HCV, hepatitis C virus; hetero, hetero- sexual intercourse; iv, intravenous drug abuse; msm, men having sex with men; na, not available; nd, not done; neg, negative; P, palmar erythema; pos, positive; prob, probable; T, toes
t h e s e t h r e e p a t i e n t s p e r i u n g u a l e r y t h e m a was s e e n o n l y o n c e , a n d in t w o o f t h e m it d i s a p p e a r e d b e f o r e t h e n e x t f o l l o w - u p visit. H o w e v e r , it is also p o s s i b l e t h a t t h e s e r o l o g i c a l t e s t f o r H C V w a s f a l s e l y n e g a t i v e [6]. A l l p a t i e n t s d e s c r i b e d b y P e c h 6 r e et al. [2] w e r e i n t r a v e - n o u s d r u g u s e r s o r a l c o h o l a b u s e r s . I n t e r e s t i n g l y , all o f o u r p a t i e n t s w h o w e r e i n t r a v e n o u s d r u g u s e r s h a d p o s i - t i v e s e r o l o g i c a l t e s t s f o r H C V . T h e r e w a s n o c o r r e l a - t i o n b e t w e e n d i a g n o s i s o f t h e p e r i u n g u a l e r y t h e m a a n d t h e a c t i v i t y o f t h e H I V i n f e c t i o n e x p r e s s e d b y t h e a c t u a l v i r a l l o a d . W e c o n c l u d e t h a t p e r i u n g u a l e r y t h e m a in H I V - i n f e c t e d p a t i e n t s is m o s t o f t e n a s s o c i a t e d w i t h H C V i n f e c t i o n w i t h o r w i t h o u t c o n c o m i t a n t a c t i v i t y a n d n o n - v i r u s - i n d u c e d c h r o n i c l i v e r d i s e a s e . O t h e r a s s o c i a t i o n s a r e s u g g e s t e d , e s p e c i a l l y in t r a n s i e n t p e r i u n g u a l e r y t h e m a . P o s s i b l y , n o n - o r g a n - s p e c i f i c a u t o a n t i b o d i e s in H I V i n f e c t i o n [7] p l a y a r o l e in t h e p a t h o g e n e s i s o f p e r i u n - g u a l e r y t h e m a , r e f l e c t i n g t h e l a r g e s p e c t r u m o f a n t i - b o d i e s f o u n d in H I V - i n f e c t e d p a t i e n t s .
4. Itin PH, Gilli L, Ntiesch R, Courvoisier S, Battegay M, Rufli T, Gasser P: Erythema of the proximal nail fold in HIV-infected patients. Journal of the American Academy of Dermatology (1996) 35:631-633
5. Levey JM, Bjornsson B, Banner B, Kuhns M, Malhotra R, Whitman N, Romain PL, Cropley TG, Bonkovsky HL: Mixed cryoglobulinemia in chronic hepatitis C infection. Medicine (1994) 73:53-67
6. Sugitani M, Inchauspe G, Shindo M, Prince AM: Sensitivity of serological assays to identify blood donors with hepatitis C viraemia. Lancet (1992) 339:1018-1019
7. Muller S, Richalet P, Laurent-Crawford A, Barakat S, Riviere Y, Porrot F, Chamaret S, Briand JP, Montagnier L, Hovanes- sian A: Autoantibodies typical of non-organ-specific autoim- mune diseases in HIV-seropositive patients. AIDS (1992) 6: 933-942
Intrauterine Rubella Virus Infection
Despite Expected Maternal
Immunity
W . B o s s a r t , D. N a d a l
R e f e r e n c e s
1. Itin PH, Gilli L, NiJesch R, Courvoisier S, Battegay M, Rufli T, Gasser P: Erythema of the proximal nail fold a further cuta- neous clue to HIV infection? Dermatology (1995) 191:176 2. Pech~re M, Krischer J, Rosay A, Hirschel B, Saurat JH: Red
fingers syndrome in patients with HIV and hepatitis C infec- tion. Lancet (1996) 348:196-197
3. Battegay M, Itin PH: Red fingers syndrome in HIV patients. Lancet (1996) 348:763
S c r e e n i n g f o r i m m u n i t y a g a i n s t t h e r u b e l l a v i r u s is an e s s e n t i a l p a r t o f t h e p r e n a t a l c a r e o f p r e g n a n t w o m e n . W. Bossart (1E)
Institute of Medical Virology, University of Zurich, Gloriastrasse 30, CH-8028 Zurich, Switzerland D. Nadal
University Children's Hospital, Infectious Disease Unit, University of Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland