First case reports of acquired immunodeficiency appeared in 1981 from Los Angeles. The patients were at late stages of the disease that we now know as AIDS and suffered from multiple opportunistic infections. In this paper, Dr. Michael Gottlieb and coauthors described the first case reports of acquired immunodeficiency in gay men and correctly identified deficiency of CD4 lymphocytes as an important factor linking these cases together.
Pneumocystis carinii pneumonia and mucosal candidiasis in previously healthy homosexual men: Evidence of a new acquired cellular immunodeficiency
N Engl J Med. 1981 Dec 10;305(24):1425-31
Gottlieb, M., Schroff, R., Schanker, H., Weisman, J., Fan, P., Wolf, R., Saxon, A.
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Commentary by Michael Gottlieb
In this paper, my co-authors and I from UCLA made the first detailed case reports of the acquired immune deficiency syndrome with opportunistic infections and Kaposi’s sarcoma. We also described the immunologic findings in these patients including the Leu-3 (CD-4) cell deficiency that is a central feature of HIV- 1 infection. Six months earlier we briefly described these same four cases in a series of five with pneumocystis pneumonia (Pneumocystis pneumonia-Los Angeles, Morbid. Mortal. Weekly Rep. 30:250-2, 1981.) The date of that report, June 5, 1981, is considered the anniversary of the beginning of the HIV/AIDS epidemic.
The same issue of the Journal contained two other articles from New York City hospitals reporting slightly different clinical presentations of the syndrome. One by Frederick Siegal et al described severe perianal herpes simplex in homosexual men. The other by Henry Masur et al reported community-acquired pneumocystis pneumonia including cases among both homosexual men and intravenous drug users. I believe that our paper was selected as the lead article because of the previously published brief report, and the identification of the CD-4 T cell lesion. We were fortunate to have had access to cutting edge technology for quantifying T cell subsets in John Fahey’s laboratory at UCLA. It was readily apparent that the immune deficiency in our patients was acquired, as the patients had no history of prior infections. In early 1982 the CDC officially named the syndrome acquired immune deficiency syndrome (AIDS).
Because of the striking epidemiology (all of our patients were homosexual men), and based on the precedent of immune dysfunction caused by other viruses, we focused on a viral etiology and suggested that the condition might represent a “transmissible immune deficiency.” We erred in proposing cytomegalovirus (CMV) as the etiologic agent, although we did acknowledge the possibility that the immune deficiency was the result of exposure to an “undetected microorganism, drug, or toxin.” Two years later, Françoise Barré-Sinoussi, Jean-Claude Chermann, and Luc Montagnier described that previously undetected microorganism, LAV (HIV-1), using human CD-4 cells as a culture medium.
In the same issue of the Journal, David Durack wrote an editorial in which he correctly doubted that CMV was causal, but in fact the omnipresence of active CMV in our patients was a consequence rather than a cause of the profound CD-4 lymphopenia. In addition to the CD-4 depletion and reversed Leu-3/Leu2 (CD-4/CD-8) ratio in our patients, we reported an increased percentage of activated (OKT-10) T cells, designated CD-38 in current terminology. Others have generously cited this as a seminal observation of the generalized immune activation associated with HIV. However in my view, the activated T cells in these advanced patients could well have been secondary to multiple active opportunistic infections.
Today, thirty years later, I can visualize those first patients in greater detail than patients I saw yesterday. They could see that their doctors were baffled as to why they were immune deficient, but they were unaware that their underlying illness was a new disease that would quickly prove fatal; all died within the first year after their pneumocystis diagnosis.
Back then I had a feeling that our description of AIDS as a new disease was going to be a big medical story. I could not have imagined that our few patients would be the first recorded cases in a tragic, global epidemic that would cause 30 million deaths, leave 33 million infected, and after 30 years would still have no end in sight.
About the Author: Michael S. Gottlieb, M.D. is an Associate Clinical Professor of Medicine, UCLA David Geffen School of Medicine in Los Angeles, CA
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