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Vaccination with MV1-F4 induces strong F4- and MV-specific T cell responses in mice

The immunogenicity of MV1-F4 recombinant vaccine was first evaluated in genetically modified CD46-IFNAR mice susceptible to MV infection. Intracellular cytokine staining was detected by flow cytometry following in vitro stimulation of freshly extracted splenocytes with HIV-1 F4 peptide pools (Figure 1A and B) and empty MV (Figure 1C and D). Intracellular cytokine staining for IFNγ and IL-2 was observed in both CD4+ and CD8+ T cells from immunised animals, as compared with non-immunised control mice. The intensity of response, expressed as the percentage of single or double cytokine-positive CD4+ and CD8+ cells, was dependent on the inoculated dose with a marked increase with the highest dose (107 TCID50), resulting in strong HIV and MV responses. Single and double cytokine staining for IFNγ and IL-2 was observed in both HIV F4- and MV-specific CD4+ and CD8+ T cells. However, IFNγ was produced in a much higher amount than IL-2. The percentages of CD4+ T cell cytokine responses were at least 2 times higher than CD8+, both for HIV and MV. Altogether, this analysis shows that MV1-F4 is strongly immunogenic and elicits a high level of CD4+ and CD8+ T cell responses in CD46-IFNAR mice, supporting its further evaluation in non-human primates.


Vaccination with MV1-F4 induces polyfunctional T cell responses to HIV in macaques

Polyfunctional CD4+ and CD8+ T cell cytokine responses were detected by flow cytometry following in vitro stimulation of PBMC with HIV-1 F4 peptide pools (Figure 2). Single, dual and triple cytokine staining for TNFα, IL-2 and IFNγ by CD4+ and CD8+ T cells was observed (Figure 2A–D). The activation marker CD154, also known as CD40 ligand, was co-expressed by cytokine positive CD4+ T cells (Figure 2A and B).


Following vaccination, potent CD4+ T cell cytokine responses against HIV-1 F4 insert peptide pools were detected in macaques F52 and F53 from group A and macaques F56 and F57 from group B (Figure 3A and B). By contrast, macaques F51 and F54 from group A and F55 and F58 from group B did not demonstrate significant CD4+ T cell cytokine responses (Figure 3A and B). The CD4+ T cell response of macaque F55 was ambiguous as it was low and occurred only at a single, late time point (Figure 3B). Only one animal in group A, F52, showed any sign of a boosted CD4+ and CD8+ T cell response against F4 peptides after a second vaccination. The CD4 responses of F53 were already high and continuing to rise at the time of boosting peaking on day 42. Responses in both groups declined sharply at day 84 and could not be detected in lymphoid tissues taken at termination (Figure 3A and B). Significant CD8+ T cell cytokine responses against HIV-1 F4 insert peptide pools were detected in all animals (Figure 3C and D). However, compared with the CD4+ T cell responses against HIV-1 F4 peptides, the magnitude of CD8+ T cell responses was moderate. CD8+ T cell cytokine responses were overall greater and appeared earlier in group B than in group A, but peripheral responses in both groups declined sharply at day 84. Nonetheless, significant HIV-1 F4-specific CD8+ T cell responses could still be detected in spleen cells collected over 3 months after the last immunisation, from all macaques except F51 and F53 (Figure 3C and D).


Vaccination with MV1-F4 induces humoral responses to HIV in macaques

Macaques F51, F52, F53, F54 and F57 developed binding antibodies against HIV-1 F4 antigen as soon as 14 days after immunisation with MV1-F4 (Figure 5A). A very low F4-specific binding antibody response was detected in the F55 animal only at day 14. Seroconversion of macaque F51 was only detected after a second immunisation (Figure 5A). Titres of anti-F4 binding antibodies in macaques F52, F53 and F54 were boosted after a second immunisation, while the anti-F4 humoral responses in the F57 animal waned at day 56. Macaques F56 and F58 did not seroconvert to the F4 antigen (Figure 5A).



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Several therapeutic approaches are being considered to control or eliminate the HIV latent reservoir. These involve either a complete elimination of all persistent HIV (sterilizing cure) or the immunological control of persistent HIV (functional cure). The “shock and kill” approach is the main focus of current research efforts for a sterilizing cure. In this approach, small molecules that activate HIV transcription would be used to force the reactivation of latent HIV in memory CD4+ T cells under the cover of ART. Subsequently, reactivation of HIV expression would induce viral cytopathic effects, immune clearance, and cell death, thereby purging latently infected cells while uninfected cells are protected by ART (4). Challenges to this approach involve the heterogeneity of latent HIV and the lack of evidence that lymphocytes, in which HIV is reactivated, are eliminated from the latent pool (reviewed in 5–7). Recent studies have also illustrated that different latent viruses might become differentially reactivated in response to different drugs (8–10), and that HIV-latency reactivation might behave in a stochastic rather than deterministic manner when challenged by small molecules (10). Additionally, many of the non-reactivated proviruses appear to be replication competent, indicating that the latent reservoir may be up to 60-fold larger than previously estimated (10).

The complex mechanisms of HIV transcriptional regulation, as well as HIV latency, have been recently summarized in a number of excellent reviews (5–7, 11). In this review, we highlight the core principles that regulate HIV transcription and then focus on two broad mechanisms that control HIV latency: (a) cis-acting mechanisms, dependent on the site of integration of the virus into the genome and the local chromatin environment at that site, and (b) trans-acting mechanisms, including basal and activated transcription factors, their regulation by the state of activation of T cells, and the environmental cues that these cells receive.




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GBM is the most common primary brain tumor occurring in the United States, accounting for an estimated 13,000 deaths each year (5). GBM is morphologically heterogenous with the histological hallmarks of extensive microvascular proliferation, prominent necrosis, and frequent mitoses. As an astrocytic neoplasm, GBM typically stains positively for GFAP and S-100 protein. In addition to the classic form of glioblastoma, 2 histological variants and several other patterns have been defined including gliosarcoma, giant cell GBM, glioblastoma with lipidized cells, small cell glioblastoma, glioblastoma with oligodendroglioma component, and glioblastoma with heterologous differentiation (1).

Gangliogliomas are typically well-differentiated neoplasms containing both neuronal and glial components. Though rare, several reports have described the malignant transformation of well-differentiated gangliogliomas into a GBM, with tumor microscopy revealing extensive astrocytic proliferation, high mitotic activity, endothelial proliferation, and cellular pleomorphism with multinucleated cells (2, 4). Both p53 mutations and inactivation of p16 have been implicated in the malignant transformation of gangliogliomas (2, 4).

No published reports have described a primary brain neoplasm exhibiting features of both glioblastoma as well as multiple regions of extensive neuronal differentiation. The documented experiences have been limited to case reports involving children and adolescents with malignant conversion of a known, well-differentiated ganglioglioma into GBM, as well as small case series of malignant glioneural tumors (2, 3). The diagnosis of malignant glioneural tumors is dependent on antibody positivity for neurofilament protein, NeuN, synaptophysin, and chromogranin, in addition to frequent mitoses (6). Such tumors pose unique questions regarding their biology and whether the two components reflect a "collision" between two separate neoplastic processes, or if the neuronal component arose from pluripotent precursor cells within the tumor.

In our patient, there was no indication of malignant conversion from ganglioglioma, and negative immunostaining for neurofilament protein and NeuN is inconsistent with the diagnosis of malignant glioneural tumor. The numerous areas of positive staining for synaptophysin or Tuj1 suggested extensive neuronal differentiation within the GBM. As such, following gross total resection, the patient was started on temozolomide followed by focal irradiation and erlotinib. He survived 257 days (8 months, 15 days) after diagnosis.





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Neither the heroin metabolite 6-acetylmorphine nor heroin was detected. However, patient had a known history of heroine abuse. The main metabolites of heroin are 6-acetylmorphine and morphine, leaving open the possibility that heroin was consumed but not detected due to metabolism. Codeine is commonly found in heroin sold on the street. In the synthesis of heroin from opium (which contains morphine and codeine), codeine is often not completely removed in the purification and acetylation of morphine to produce heroin. Another interpretation of the test results for the case is that the patient overdosed on codeine +/- morphine.

Figure 2 demonstrates that an additional drug, xylazine, was identified by GC-MS in this patient's urine. Xylazine is an analgesic, sedative, and muscle relaxant used in the veterinary setting prior to surgical procedures. The drug is not approved for use in humans by the FDA. The drug is similar in its pharmacology to the phenothiazines and clonidine. The drug acts as a central alpha-2 agonist and may cause bradycardia and hypotension. Post-mortem examination of the urine and/or blood of drug-related deaths increased awareness of xylazine as a potential contaminant in recreational drug preparations or as a drug intentionally abused (e.g., by someone who gets access to veterinary medicine stocks). However, as in the case, it is not possible to determine the exact contribution of each compound found in a drug preparation to a patient's death.

Few reports regarding the effects of xylazine use in humans are available. One case report described a veterinary surgeon's wife with repeated bouts of tiredness, faintness, blurred vision, and sinus bradycardia who eventually admitted to taking xylazine for pain.

Another case report describes a patient who self-administered a large dose of xylazine and was subsequently found collapsed and stopped breathing. The patient apparently was on a respirator for some 60 hours until recovery.

We hope that this web case illustrates the utility of GC-MS in identifying illicit drugs which may not be picked up on initial screening. It also highlights the complex nature of interpreting the cause of death in drug overdose-related deaths.



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