AIDS Attack

You AIDS is an abbreviation for acquired immunodeficiency disease and this particular problem revolves around a set of symptoms and patient complaints that were not recognized in this country before around 1979.

Dr. Mike Cohen is with the UNC School of Medicine in the Division of Infectious Diseases. He's one of many doctors across the country looking at acquired immunodeficiency syndrome. This new and fast spreading illness is a little understood and more often than not proves fatal. It was first diagnosed in homosexual men though Haitians are also contracting the sickness. It has occurred in heterosexuals and even children. I'm Famital Henderson, let's learn more. During the time between 1979 and the first reports of the disease in 1981, a variety of young people who were otherwise an excellent health and who should have remained an excellent health began to develop a set of problems early on. These problems were characterized by fevers, weight loss, some swollen glands, just general ill health that was not characteristic of one disease or another. Then subsequently these same otherwise healthy people began to develop cancers that were

reasonably unusual in nature and to develop infections, which here to for we had only seen in patients whose immune systems were suppressed by disease or physician therapy. What kinds of infections and cancers were occurring? With respect to the cancers, there are two that attract particular attention. One is lymphoma and it's not all that surprising that lymphoma should develop after a chronic period of swollen lymph nodes that didn't go away and these lymphomas however were somewhat atypical in nature and occasionally occurred in very unusual sites such as in the brain. Now that kind of cancer is less commoner, has been less common than a disease called caposi sarcoma.

Caposi sarcoma is a cancer that here to for we had generally seen in elderly men generally over 60 of Italian and Jewish extraction. These men developed bluish red tumor nodules or bumps on their skin and these nodules have a very characteristic pathological appearance on biopsy that allows them to be identified as caposi sarcoma. Generally for these elderly men the disease was reasonably benign and associated with prolonged survival. Now in this group that we're talking about who developed acquired immunodeficiency disease they tend to develop the much more aggressive type of caposi sarcoma that is to say they develop skin lesions or skin nodules but in addition they develop an invasive form of the disease which proves quite difficult to treat with cancer chemotherapy although there

is aggressive cancer chemotherapy available and the disease has a fairly high mortality in this population as high as 15 to 20 percent. Interestingly just as an aside the aggressive form of this caposi sarcoma has actually been seen in young people in a particular part of Africa and in that setting caposi sarcoma in Africans it has there have been attempts to implicate a viral illness as the cause of the disease in particular cytomegalovirus, CMV, one of the herpes viruses and we'll come back to that later to answer your question about infections well we as a species are confronted constantly with pathogens in our environment were covered or encoded with pathogens in our environment were provided with a near perfect immune system that helps us to prevent disease and occasionally a healthy adult will develop a bacterial infection and most

adults over the course of their life will have many viral infections but when you immunosuppress an adult or when an adult becomes immunosuppressed and their immune system isn't functioning properly they become susceptible to organisms which under normal circumstances have almost no potential to invade and as it turns out the same group of patients who developed acquired immunodeficiency disease developed a series of infections with low potential to invade the most important of which perhaps is pneumocystis carinii which is a protozoan with which we all become colonized or most of us become colonized or we acquired during the course of our lives which tends to produce little or no disease in less immunosuppression superveens now previously we'd seen problems with pneumocystis carinii in patients in children with childhood leukemias being vigorously

treated and in adults receiving higher doses of corticosteroid or steroid therapy. But in this new syndrome where disease we're talking about pneumocystis carinii develops superimposed on this chronic malaise like illness and superimposed on Kaposi sarcoma or other neoplasms or other cancers and under those circumstances the mortality is very high pneumocystis carinii is a disease that involves a pathogen that involves the pulmonary tree and is associated with dry hacking cough, shortness of breath and ultimately makes it quite difficult to breathe. There is treatment available for pneumocystis carinii but the therapy must be very aggressive and even in the best of circumstances there is a reasonably high mortality associated with that infection.

In addition there are a whole series of other pathogens which have occurred less commonly but which have been reported, these include toxoplasmagandii which can cause whole abscesses in the brain, no cardio which can also produce abscesses in the brain and a wide variety of other unusual saprophytic pathogens. Finally in the same group a very unusual pathogens been recently reported as a source of chronic diarrhea and this is cryptosporidiosis which has for the most part been limited has been a disease of calves or cattle and now we see its surface in humans superimposed on this acquired immunodeficiency disease. These are all diseases that most of us are for most part unaware of and prefer to stay that way does AIDS make more common illnesses more likely to occur. Well insofar as bacterial infections like those that cause pneumonia or skin infections we haven't seen those in increased incidence in this population however there are certain

kinds of reasonably low grade pathogens that were exposed to that are very common but that which usually are self limited. Good examples of this are thrush such as this seen in newborn babies and causes diaper rash and with mild medication, topical therapy this kind of thrush infection can be cured. However in the AIDS patients they develop a candida, thrush of their upper airway and of their esophagus and it becomes very difficult to treat this thrush infection effectively. Another common infection is herpes simplex and more recently herpes genitalias and both of these infections in normal hosts tend to produce blistery lesions either around the mouth, fever blisters or around the genital area but they tend to be self limited. In the AIDS patients the infections these virally produced infections are not self limited.

They spread somewhat more aggressively than they would in the normal host. They tend to produce more ulceration than they would in the normal host and worst of all they tend to be quite chronic and once again very difficult to treat or to eradicate. We attribute these, once again these chronic infections to the immunosuppression which we believe is associated with the AIDS syndrome. The basic question I guess all the medical people are looking at is where it has come from anyway, why are people getting this? Well there's really two main theories which are popular presently. Now an early theory which attracted attention was that one or more of these viral infections which we're familiar with was suppressing the immune system. We know for example that cytomegal virus itself can suppress the immune system and so the idea was that these viruses were immunosuppressive per se.

Superimposed on this theory was the observation that the men in this group had a very high frequency of drug utilization and these drugs occasionally were administered by an intravenous root street drugs but in addition a drug called beetle nitrate or poppers were used in excess by this population and these drugs have a carcinogenic potential they probably can cause cancer and it became attractive to speculate that perhaps that these kinds of drugs were also immunosuppressive weight was lent to this theory by the observation that acquired immunodeficiency disease began to occur in heterosexual intravenous drug abusers above and beyond these homosexual men. Now another theory leading back towards the homosexual men is the idea that their contact with a variety of bodily secretions including sperm and prosthetic secretions would also

be immunosuppressive and these theories as I said were very popular early on until acquired immunodeficiency disease began to occur in other groups and the other groups in whom we've seen it that have attracted recent attention include Haitians and we really have no idea why these Haitians who appear to be heterosexual non-drug abusers have developed this disease. It's clear that there are many cases of Kaposi Sarcoma that cancer we talked about earlier occurring in porta-prints a central location of Haiti and it's possible that whatever is going on has been imported from Haiti but that's certainly unclear at this time and the bottom line is we don't understand the implications of the Haitians in this whole arena however more recently to unfortunate remarkable events have occurred first the acquired immunodeficiency disease as characterized by malaise and fatigue followed by superimposition of numusus dyschrionia

pneumonia has occurred in hemophiliax and the implications there I think are somewhat obvious hemophiliax are a group who require blood products constantly to avoid developing major bleeding disorders and the idea is that something in the blood products led to acquired immunodeficiency disease the CDC investigation strongly support the idea that the hemophiliax who developed this disease are heterosexuals and are not drug abusers and so the frightening idea is there's something in these blood products that cause the disease. In addition unfortunately once again a small child required a blood transfusion shortly after birth and this small child received that blood transfusion from a man who subsequently died of the acquired immunodeficiency disease subsequently or more recently that small

child has developed acquired immunodeficiency disease so what we see is epidemiological evidence leading this away from this earlier explanation that there was some sort of combination immunosuppression in this unusual and small population of homosexual men and that there is a broader message in the epidemiology of this disease and the broader message is that there's something in blood products and in addition something which can be sexually transmitted that produces acquired immunodeficiency disease either or not necessarily both of these are true clearly once again I think this area is highly speculative and it could be both that could be all of these factors I fail to mention the idea that there may be a genetic predisposition to this problem and certain kinds of genetic makeup seem to be more common among those patients who've developed acquired immunodeficiency disease so we've already talked and once again these

are all theories we've talked about the idea that several viral infections concominantly might be involved we've talked about the idea that there might be a new agent in the blood in blood product distribution that might be immunosuppressive and lead to AIDS syndrome and in addition there might be a genetic predisposition finally there may be things that we haven't even considered to date but in reality what we're talking about are twelve hundred cases of a disease which appears to be doubling very rapidly in 81 there were only a couple of hundred cases and now in 83 we're talking about twelve hundred cases and the reporting system is imperfect so it's likely there's even more cases than those that have been reported if any epidemic situation we only see the tip of the iceberg of an epidemic and AIDS I think clearly can be can be called an epidemic and I think it's important to emphasize this because we really don't know what's going to happen with patients who are at risk who

demonstrate some aspect that suggests that AIDS might be developing and some aspect might be swollen lymph nodes or fatigue or weight loss or low grade fever are all of these patients going to develop the full blown very severe illness that I've described or are some of them going to recover without any side effects we don't know at this point in time obviously the information available to us is limited. Suppose someone presents who is displaying some of the symptoms and you figure out that maybe this is what they have is there anything you can do for them. Well I think there's two separate issues first of all what should we do for that patient and second what should we do to try and prevent further spread of the disease and both questions are extremely difficult to answer on this date in 1983 I think several years will have much more information with respect to intervention I think that if the patient has symptoms that suggest that they are becoming immunosuppressed

we would recommend that they maintain good nutrition obviously and that they avoid any sort of drugs or other behavior which might immunosuppress them further. In addition should they develop symptoms of infection or symptoms that would suggest us the kind of cancers we've talked about we would certainly want to institute vigorous therapy at the earliest possible date which I think would be associated with improved survival. The bottom line is however that if a patient develops acquired immunodeficiency disease something is immunosuppressing that patient and we don't know how to reverse the immunosuppression that's that's the key to the disease we don't know what the agents or agents are that are immunosuppressive and we don't know how to reverse the immunosuppression all we know how to do which would by the way be preventive medicine

the goal of any physician instead all we know how to do at this point is to treat the problems as they arise with respect to prevention we are using information available to us from multiple studies with hepatitis P as best we can tell the acquired immunodeficiency disease seems to be spread somewhat akin to hepatitis B hepatitis B is spread in blood products and hepatitis B is spread by sexual transmission or intimate contact with secretions from that point of view the Center for Disease Control has recently issued a set of guidelines which are certainly not final but which are designed to try and help to prevent spread among these guidelines are first that a patient with known acquired immunodeficiency disease or who believes they're going to who has the pro-dromal the malaise the swollen glands to acquired immunodeficiency disease should be cautious in their sexual contacts and conversely

others in the community should be cautious with whom they have sex secondly the hand washing after meals stool precautions and things of that nature that we employ in control of hepatitis B should also be employed by a patient with acquired immunodeficiency disease this is obviously particularly important if such a patient comes into a hospital situation where we have to be quite rigorous in terms of how we handle their secretions and excretions next and perhaps most important is what to do about blood banking policies in this country all organized medical bodies involved with blood banking have asked that patients with acquired immunodeficiency disease or those who believe they are at risk for acquired immunodeficiency disease because they belong to a group that's at risk that such patients do not contribute blood products that's the first point these same groups and special emphasis should be given to the CDC

are looking for a screening test to apply to blood products so the blood products that might carry the agent or agents associated with acquired immunodeficiency disease can be removed from the blood pool in addition blood transfusions should be scrutinized before they're given in the sense that many patients receive blood transfusions or blood products that they don't absolutely need and those kinds of practices should be limited patients should only be transfused or given blood products when they're absolutely essential elective surgery for example can be preceded by a blood donation and so then if blood is required you can receive your own blood back because the blood product is good for some period of time generally an addition a family member can contribute blood if they're the same blood type or an acquaintance of the same blood type could contribute blood and that blood might be made available for you should you need it after surgery so there's all kinds of ways that we can cut into the blood banking practice to

reduce the risk for those who receive blood products with regards to hemophiliax who are absolutely in need of blood products it's a much more difficult question and many different groups are working to resolve an optimal solution for that group doctor Cohen points out data indicates that homosexuals who contacted AIDS had a large number of partners over their lifetimes he recommends limiting sexual activity to those familiar and who will be healthy he further explains partners of heterosexuals who acquired AIDS had also gotten the disease as well as children and households where AIDS is present AIDS has been identified in 34 states and 15 countries it is more likely to occur in metropolitan areas like New York or San Francisco though five to 10 cases have been reported at medical schools in North Carolina under 10 hemophiliax in the country have acquired AIDS most in metropolitan areas

nonetheless Dr. Campbell McMillan acting director of North Carolina Memorial Hospitals Hemophilia Center is taking precautions we're looking at this problem and trying to deal with it in a variety of ways one way is that we are staying in very close contact with other hemophilia centers of which we are one of a network we're also staying in close close touch with developments at the centers for disease control in Atlanta which is heading up the very very intensive investigation that's going on to look for the cause of AIDS we hope you know at the first sign of any breakthrough in discovery of the cause of this to make appropriate adjustments to that information secondly we're staying in very close touch with all of our hemophilia patients they're all alerted

at this point to reporting any suspicious illness that they may have and we see them instantly if there are any questions like that so far there have been no problems we have not found a case of AIDS anywhere in the state up to the present time and we hope that will continue to be true of course when we see and third when we see our patients for a regular check up every six months to a year in a clinic that's held every week we are carrying out certain tests to look at abnormalities that might suggest that their immune system is not working properly we've just started in this evaluation and we're not results of two preliminary to report anything definite but certainly we found no problems up to the present time and fourth we are beginning dialogue with personnel and the director of our blood bank in order to be prepared to make appropriate

adjustments in the way our patients are treated so at the moment we are not seeing any major problems and any of our patients and we certainly hope that this will continue to be the case but we are working along the four lines that I have mentioned first close communication with other hemophilia centers and the centers for disease control for developments that may occur second keeping in close touch with our patients by telephone and other means of communication in order to check out right away any unusual or suspicious illness that any of them might have third carrying out laboratory tests when patients come to our hemophilia center in our weekly clinic to look for any evidence of breakdown in immune function

and fourth we are looking very closely at the possible need to change our approach to treatment of our patients as far as blood products are concerned doctor McMillan believes North Carolina's low density population is an advantage but reminds that Haiti is a low density area that is having problems with AIDS does that mean every member of an at-risk population should seek medical attention doctor Cohen some of some of the groups at risk are under the care physician on a regular basis anyhow this especially the hemophilia x are seen quite frequently in reasonably large medical centers and they're under great scrutiny right now with respect to other patients at risk those with homosexual lifestyle those who fit into some other risk group I don't think they need to seek any attention in particular unless they develop some set of symptoms that are new those we talked about swollen glands fatigue weight loss or new skin lesions etc. now with respect to predicting who is going to get the acquired immunodeficiency disease

that is absolutely impossible today we do use certain blood tests as markers of immunosuppression and these blood tests tend to be correlated with the acquired immunodeficiency disease but in those patients in whom we make these observations these blood tests observation those patients are generally already ill enough to have sought the attention of a physician so they're not walking in off the street saying test my blood tell me if I'm going to develop AIDS they're they're ill at the time their blood is evaluated so we don't have a screening test and I think it should also once again be emphasized we've only seen in the entire country 1200 cases of the disease at this point in time so it's a reasonably uncommon problem and what attracts so much attention is that it's new that it's associated with a very high mortality and morbidity as of last month about 60% of the patients who had developed the disease had died so very high mortality and it's unknown many aspects of it are unknown but right now it's reasonably confined

and I think that unless a person developed a new set of problems they don't need to seek medical attention because of their lifestyle or their risk there's a lot going on to understand acquired immunodeficiency disease though a cure seems no closer than when it first appeared some medical practices even refuse to treat those suffering from this puzzling sickness Dr. Cohen points out the AIDS incubation period is from a few months to two years so we may be hearing a lot more from AIDS in years to come let's help the research can provide some answers by then I'm Faye Mitchell-Henderson for WUNC