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Fighting AIDS

'We saw our first AIDS patient in July 1980. He was a 33-year-old homosexual, originally from West Germany, who had lived for the past three years in Haiti, where he'd worked as a chef," says Dr. Donna Mildvan, chief of infectious diseases at Beth Israel Medical Center. "He came to New York after he'd gotten sick in Haiti with weight loss and uncontrollable bloody diarrhea."

At that time, no one had heard of AIDS—acquired-immune-deficiency syndrome—and none of the clues made sense. AIDS is caused by a virus that destroys the body's immune system, leaving victims defenseless against opportunistic infections caused by ordinarily innocuous bugs (certain bacteria, parasites, viruses, fungi). The virus, previously called HTLV-III or LAV, is now called HIV—for "human immunodeficiency virus." In the United States, it has so far affected chiefly homosexual and bisexual men, intravenous-drug users, people who have received infected transfusions or blood products, female sexual partners of infected men, and people from places—such as Africa and Haiti—where AIDS is usually transmitted by heterosexual intercourse.

In the chef's stool, Dr. Mildvan's team found amoebic parasites and other intestinal bugs that travelers often pick up in other countries. Dr. Mildvan and other New York doctors had found similar intestinal infections in many homosexual men.

"We treated him for the things we found, but he didn't get better. That was extraordinary. For the next six months, he was in and out of the hospital. We'd get him a little more stabilized, he'd go home for a while, and then he'd be back. His weight loss continued, and he had intermittent diarrhea. He developed sores around the rectum, and then he began to lose vision in one eye," she says.

What was it? The team ran every test they could think of. They spent hours in the library looking up obscure diseases. Nothing fit.

Antibiotics work against diseases caused by bacteria, not against diseases caused by viruses. AIDS, the common cold, flu, cold sores, genital herpes, hepatitis B—all are viral diseases, and very few drugs can touch them. Some antibiotics work by holding bacteria in check until the patient's own immune defenses regain strength and take over. But what if the bug destroys the immune defenses?

"People who fear they're infected may want to take the blood test, but testing positive poses an enormous dilemma. The person infected may end up having no sex life or suffer discrimination."—Sheldon Landesman

These researchers did suspect that a virus might be the underlying cause of the patient's problems. But Beth Israel didn't have a virology lab. So Dr. Mildvan and Dr. Usha Mathur-Wagh took fluid from inside the patient's eye and from his rectal lesions and sent the samples to a colleague, Dr. Ilya Spigland, at Montefiore Medical Center in the Bronx, which had a clinical virology lab.

He managed to culture herpes simplex type 2 (genital herpes 2) from the rectal lesions, and cytomegalovirus (CMV) from the eye fluid six weeks later. These were extraordinary findings. Both viruses are common, but they rarely cause disease of this magnitude. In fact, CMV had never been isolated and grown from a living patient with retinitis. Sometimes CMV had been found at an autopsy of a patient whose immune system was suppressed—by leukemia, for example.

"We treated the herpes simplex 2 with vidarabine," Dr. Mildvan says, "but we had nothing for the CMV. It spread to the other eye, and he lost vision. Over the next couple of months, he deteriorated neurologically. CAT scans showed his brain had shrunk. He stopped talking to us. He curled up in a ball, staring blindly into the distance. He was incontinent. And he died. It was frightening and horrible in a 33-year-old man, and it had an unknown cause," she says. "It was clear he had herpes. It was clear he had CMV. But why?"

Dr. Mildvan realized that as early as 1978 or 1979, she had seen homosexual male patients with lymphadenopathy (enlargement of the lymph nodes that help fight infection). But the patients weren't sick. In early January 1981, exactly two weeks after the West German chef died, Dr. Mildvan saw a second patient with a similar problem. "He was a homosexual man in his thirties, a nurse with no history of travel. He was admitted with explosive Pneumocystis carinii pneumonia (PCP) and CMV infection. In ten days, he was dead," she says. Pneumocystis pneumonia is rare, usually affecting only patients whose immune systems are severely compromised.

"That's when it clicked," Dr. Mildvan says. "I said to myself, I bet lymphadenopathy is an early form of this disease. And it's a new disease. Something's going on."

The cause of the new disease turned out to be the virus now called HIV. Some patients with lymphadenopathy did develop what's usually called full-blown AIDS. Whether the other patients with lymphadenopathy will also eventually develop the disease is not clear.