Pulmonary disease in children with acquired immune deficiency syndrome and AIDS-related complex

Spectrum of chest radiographic abnormalities in children with AIDS and Pneumocystis carinii pneumonia

This report aims to provide a description of the spectrum of radiographic findings in children with AIDS and Pneumocystis carinii pneumonia (PCP). The chest radiographs of all children with perinatally transmitted HIV infection who had PCP were reviewed. Thirty-eight episodes of PCP were noted in 32 children. The age range was 2-17 months. The radiographic findings were characterized as to pattern, severity, presence of pulmonary air cyst, thoracic air leak, thoracic lymphadenopathy, and pleural effusion. The initial distribution of disease was as follows: diffuse (n = 20), patchy (n = 12), focal (n = 4), normal (n = 2). In nearly one-third of children parenchymal abnormalities were mild enough that most normal lung markings were visible. During the course of the illness pneumothorax was noted in eight cases, pulmonary air cyst in five, and pneumomediastinum in one. Pleural effusions were noted in three (5%) cases. Thoracic lymphadenopathy was not observed in any case. The authors concluded that the initial chest radiographic appearance of PCP in children with AIDS is variable. The initial chest radiograph may be normal. The distribution was patchy or focal in nearly one-half of all cases with parenchymal abnormalities. Pulmonary air cysts or thoracic air leaks were noted during the course of the illness in approximately one-third of all cases.

Pulmonary pathology in AIDS: atypical Pneumocystis carinii infection and lymphoid interstitial pneumonia

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Exploration of the pulmonary circulation. Festschrift to Professor Donald Heath

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The spectrum of pathological changes in the lung in children with the acquired immunodeficiency syndrome: an autopsy study of 36 cases

We present the pulmonary findings in 36 autopsies of children affected by the acquired immunodeficiency syndrome (AIDS). Twenty-three patients were male and 13 were female, ranging in age between 3 days and 13 years. Twenty children had human immunodeficiency virus (HIV)-positive parents or parents who were at high risk of exposure (intravenous drug abusers and prostitutes), five had a history of transfusion, and one had a history of renal transplantation and blood transfusion. Clinically, the patients presented with recurrent infections, failure to thrive, hepatosplenomegaly, fever, cough, and/or hemoptysis. Histologically, specific infectious processes were the most common finding (75% of cases), with Pneumocystis carinii pneumonia being the most prevalent type of infection, followed by bacterial pneumonia. Neoplastic conditions and lymphoid interstitial pneumonia were less frequent (approximately 10% of cases). In addition, in approximately 10% of the cases the pulmonary findings were non-specific (ie, pulmonary edema and atelectasis) and probably unrelated to HIV infection. Our findings suggest that specific infectious conditions constitute the most common type of pulmonary pathology in children with AIDS. However, because there is a small percentage of children with nonspecific findings, a transbronchial biopsy is important for proper evaluation before institution of therapy.

Interstitial lung disease in children

Interstitial lung disease in children is a heterogeneous group of disorders of both known and unknown causes that share a common histologic characteristic (i.e., inflammation of the pulmonary interstitium that may resolve completely, partially, or progress to derangement of alveolar structures with varying degrees of fibrosis). The inflammatory process, evoked as a result of injury to alveolar epithelium and/or the endothelium, is responsible for alveolar wall thickening that is the histologic marker of ILD. This article extrapolates some of the known pathogenic mechanisms of ILD from adult and animal models and applies this information for a better understanding of the pathogenesis of ILD in children. The clinical manifestations vary and are often subtle and nonspecific. There is no consensus on specific criteria for the clinical diagnosis of ILD in children. There are no pathognomonic laboratory criteria for the diagnosis of ILD in children other than the characteristic findings on histologic examination of the lung. It is important to make the diagnosis early to minimize lung damage. Therapy is directed toward the reduction of the inflammatory response to minimize or prevent the progression to fibrosis. ILD suffers from lack of uniform guidelines for diagnostic evaluation, therapy, and prognostic indicators essential for critical monitoring of disease activity. No one medical center has enough cases of ILD in children to allow objective evaluation of a significant number of cases with adequate longitudinal follow-up to determine guidelines for optimal management and to identify accurate prognostic indicators. The organization of a multicenter approach will guide us towards a better understanding of ILD in children.

Severe cystic pulmonary disease associated with chronic Pneumocystis carinii infection in a child with AIDS

A 3-year-old HIV-positive boy developed Pneumocystis carinii pneumonia (PCP) resulting in chronic interstitial pulmonary disease, which persisted for the following 3 years; he was essentially asymptomatic and the lung findings had therefore been attributed to lymphocytic interstitial pneumonia (LIP). He subsequently developed extensive cystic pulmonary disease, documented by CT, leading to recurrent pneumothorax and severe pulmonary insufficiency. Lung biopsy revealed chronic PCP infection associated with extensive pulmonary fibrosis and calcification. This case suggests that Pneumocystis carinii may cause chronic progressive pulmonary fibrosis with cyst formation and respiratory failure.

Sialectasis and HIV infection

The sialographic findings of the parotid gland of an HIV-positive patient are presented. Multiple areas of sialectasia were noted and their similarity to Sjögren's syndrome is discussed.

Primary Sjögren's syndrome

Significant abnormalities in pulmonary function are encountered in about 24% of patients with primary Sjögren's syndrome. The most common cause of dyspnoea is interstitial fibrosis, with a prevalence of around 8%, but a number of other pathologies may be encountered in the lungs of these patients (Table 1). Lymphoproliferative disorders are relatively uncommon, but these apparently benign lesions may harbour malignant potential. Interstitial fibrosis and the lymphoproliferative disorders may be responsive to corticosteroids or cytotoxic agents, and it is therefore important to establish an accurate diagnosis at an early stage. On the basis of our experience we would recommend the investigative strategy outlined below. Patients should be screened for significant lung disease by taking a careful history of respiratory symptoms followed by standard pulmonary function testing (including measurement of carbon monoxide diffusing capacity) and chest radiography. High resolution computed tomography is a non-invasive technique that should prove superior to chest radiography in the detection of early cases of interstitial fibrosis. When the disease is patchy it may be useful in identifying areas of maximal involvement for subsequent biopsy. Bronchoalveolar lavage is a sensitive tool in the non-smoker, but lacks the specificity to command a significant role in the investigation of pulmonary pathology in these patients. One exception to this may be in the investigation of the clonality of lymphocytes which may allow early and specific diagnosis of lymphomatous proliferation. The application of techniques such as the polymerase chain reaction may assist in the investigation of the role of the Epstein-Barr virus in the causation of lymphoproliferative lesions. In most patients with significant symptoms and abnormalities of pulmonary function a tissue diagnosis will be required, either by transbronchial biopsy or by open lung biopsy. Both bronchial and interstitial lung tissue should be obtained where possible. Histological confirmation is probably mandatory when there is a recent history of parotid enlargement, weight loss or the appearance of a monoclonal gammopathy. Advances in our understanding of the mechanisms of the MALT system may provide the key to unlocking some of the mysteries of 'autoimmune' diseases such as Sjögren's syndrome. The response of lymphoproliferative disorders to immunosuppressive therapy provides hope that if the diagnosis of sicca syndrome can be made earlier lymphocyte induced tissue damage may be halted or reversed.

Comparison of polymerase chain reaction and standard Southern blotting for the detection of Epstein-Barr virus DNA in various biopsy specimens

The sensitivity of the polymerase chain reaction (PCR) assay was compared to that of standard Southern blotting (SB) hybridization for detecting the presence of Epstein-Barr virus (EBV) genomes in biopsy samples from 43 patients with a variety of lymphoproliferative disorders. Two pairs of oligonucleotide primers from the first BamHI M and R leftward reading frames (BMLF1 and BRLF1) of EBV were chosen to amplify DNA. The resulting PCR products were analyzed by gel electrophoresis, transfer and hybridization. Restriction enzyme digestion was used to confirm the specificity of the amplified fragment. EBV DNA was found in 38 of 43 patients, as compared with 9 of 43 patients with the Southern technique. No amplified product was detected with other viruses from the Herpes family, nor with human genomic DNA from healthy adults using the same two sets of primers. These results indicate that EBV can be detected in a greater number of lymphoproliferative lesions than previously appreciated. The implications of these findings are discussed.

Clinical spectrum of chronic interstitial lung disease in children

To describe the clinical spectrum of interstitial lung disease in children, we reviewed our experience with 48 patients during a 12-year period. Most patients initially had typical findings of restrictive lung disease and hypoxemia. Growth failure or pulmonary hypertension or both were found in more than one third. Specific diagnosis, made in 35 patients (70%), most often required invasive studies, particularly open lung biopsy. Although the diagnostic yield from open lung biopsy was high, the diagnosis of many patients remained uncertain. Many different disorders were encountered. The response to corticosteroids, bronchodilators, and chloroquine was inconsistent. Six patients died, five within 1 year after the initial evaluation. The spectrum of pediatric interstitial lung disease includes a large, heterogeneous group of rare disorders associated with high morbidity and mortality rates.

Defining the population of human immunodeficiency virus-infected children at risk for Mycobacterium avium-intracellulare infection

We reviewed the 22 cases of Mycobacterium avium-intracellulare (MAI) infection that occurred among 196 human immunodeficiency virus-infected children seen at the National Cancer Institute Pediatric Branch from December 1986 through April 1991, and an additional 65 charts from children with cultures negative for MAI. All patients with proven MAI were receiving antiretroviral therapy with zidovudine, dideoxyinosine, or a combination of zidovudine and dideoxycytidine. All patients had disseminated MAI infection, except one adolescent who had only evidence of localized lymphadenitis. All cases of MAI but one were diagnosed before death. The overall incidence of MAI was 11% in our patients but increased to 24% in patients whose absolute CD4 cell counts were < 100 cells/mm3. Symptoms most commonly associated with MAI infection included recurrent fever (86% of patients), weight loss or failure to thrive (64%), neutropenia (55%), night sweats (32%), and abdominal pain (27%). Children infected with MAI had a mean CD4 percentage of 2% (range, 0% to 7%) and a mean absolute CD4 count of 12 cells/mm3 (range, 0 to 48 cells/mm3), significantly lower than in the remainder of the clinic population or the group of children with cultures negative for MAI. Of 20 patients with MAI infection who were tested, 10 had measurable p24 antigen with a mean value 939 pg/ml (range, 77 to 3270 pg/ml) compared with 19 of 59 patients without MAI infection in whom the mean positive value was 413 pg/ml. There was no difference in survival time between those children with documented MAI infection (median survival time, 45.5 weeks) and those with similarly low CD4 counts and cultures negative for MAI (median survival time, 50.4 weeks). Future improvements in therapeutic options may make screening of pediatric human immunodeficiency virus-infected patients with low CD4 counts a reasonable plan.

Natural history of HIV-associated salivary gland disease

To describe the natural history of HIV-associated salivary gland disease, which is characterized by enlarged major salivary glands and/or xerostomia in HIV-infected persons, we assessed 22 patients at an initial and follow-up examinations (median span of examinations, 15 months). Sixteen patients (73%) had bilateral parotid gland enlargement, 17 had symptoms of dry mouth, and 11 had both conditions. Parotid gland enlargement remained unchanged in 10 patients, it progressed in 2, and it regressed in 4 during treatment with zidovudine or steroids. Those patients with parotid gland enlargement had a significantly lower mean stimulated parotid flow rate (0.27 ml/min/per gland) than a control group of HIV+ persons without salivary gland disease (0.48 ml/min/per gland) (p less than 0.05), whereas the mean unstimulated whole salivary flow rates did not did not differ significantly between the two groups. The mean salivary flow rate of the study group did not change during the observation period. When HIV-associated salivary gland disease was diagnosed, 5 patients (23%) had AIDS, and at follow-up 10 (46%) had AIDS. Seven of these had Kaposi's sarcoma. The mean peripheral blood CD4 cell count was 280 and 225 per mm3 at the initial and follow-up examinations, respectively. The corresponding CD8 counts were 1138 and 900. The pathogenesis of HIV-associated salivary gland disease may include hyperplasia of intra-parotid lymphoid tissue. Because HIV-associated salivary gland disease can clinically resemble Sjögren's syndrome, the differential diagnosis of bilateral parotid enlargement should include HIV infection.

Lymphoid pneumonitis in 50 adult patients infected with the human immunodeficiency virus: lymphocytic interstitial pneumonitis versus nonspecific interstitial pneumonitis

Lymphocytic interstitial pneumonitis (LIP) and nonspecific interstitial pneumonitis (NIP) are pulmonary complications of human immunodeficiency virus (HIV) infection that occur in the absence of a detectable opportunistic infection or neoplasm. We reviewed lung biopsy specimens from 50 adult HIV-infected patients, of whom four had LIP and 46 had NIP. The majority (47 of 50) of specimens from patients with NIP showed mild chronic interstitial pneumonitis (CIP/NIP), with three showing features of diffuse alveolar damage, organizing phase. In contrast to CIP/NIP, the five specimens from four patients with LIP demonstrated more extensive lymphocytic interstitial infiltrates that extended into the alveolar septal interstitium. The majority of the interstitial lymphocytes in both NIP and LIP were of T-cell origin and stained for UCHL-1. The etiologies of NIP and LIP remain unknown. Since the common opportunistic infections were excluded by routine methods, we sought, with special techniques, to investigate whether HIV, Epstein-Barr virus (EBV), or cytomegalovirus (CMV) could be identified in lung biopsy specimens from these patients. By in situ hybridization, we found one LIP specimen with expression of large amounts of HIV RNA primarily within macrophages in germinal centers; in the remaining specimens, occasional cells expressing HIV RNA were found (two LIP and four NIP). Neither CMV nor EBV was found by in situ hybridization in seven specimens; in these same specimens EBV was detected using the polymerase chain reaction in only one case of NIP, similar to results in control specimens. These results, together with the knowledge that lymphocytic pulmonary lesions may be caused by lentiviruses in humans and animals, suggest that HIV plays a significant role in the pathogenesis of both NIP and LIP in adult HIV-infected patients; in contrast, our data do not demonstrate a direct role for either EBV or CMV.

Radiology of AIDS in the pediatric patient

The Acquired Immunodeficiency Syndrome (AIDS) has involved the pediatric age group and is especially prevalent in babies born of mothers who are intravenous drug abusers or prostitutes. Approximately 30% of children born to mothers who are seropositive for the human immunodeficiency virus (HIV) will develop HIV infection. There are several important differences in children and adults with AIDS. The incubation period of the disease is shorter, and initial clinical manifestations occur earlier in children. In addition, certain infections are more common in children, and the different types of malignancy, especially Kaposi's sarcoma, are unusual in the pediatric age group. The altered immune system involves both T cells and humoral immunity and increases susceptibility to a variety of infections, particularly opportunistic organisms. In this publication the complications of pediatric AIDS involving the lungs, cardiovascular system, gastrointestinal tract, genitourinary system, and neurological system are described. The most common pulmonary complications in our experience are Pneumocystis carinii pneumonia and pulmonary lymphoid hyperplasia. The spectrum of cardiovascular involvement in pediatric AIDS includes myocarditis, pericarditis, and infectious endocarditis. Gastrointestinal tract involvement is usually due to opportunistic organisms that produce esophagitis, gastritis, and colitis. Abdominal lymphadenopathy is a common finding either due to disseminating Mycobacterium avium-intracellulare infection or nonspecific lymphadenopathy. Although cholangitis is more commonly seen in adults, it may occur in children with AIDS and, in most cases, is due to related opportunistic infections. Genitourinary infections may be the first evidence of HIV disease. Cystitis, pyelonephritis, renal abscesses, and nephropathy with renal insufficiency are complications of pediatric AIDS. A variety of neurological abnormalities may occur in pediatric AIDS. The most common cause of neurological dysfunction in children with AIDS is HIV neuropathy. We present the many complications of AIDS in children demonstrated by a variety of imaging modalities, emphasizing the importance of diagnostic imaging in children with this disease.

Cellular interstitial pneumonitis in infants. A clinicopathologic study

Five infants had interstitial pneumonitis with constant histologic findings, which was different from that previously described in children. All the infants presented with tachypnea at birth and persistent disease, both clinically and radiographically, despite treatment. Open-lung biopsy in each case showed a diffuse interstitial thickening due to pale oval and spindle-shaped histiocytes without scarring. This neonatal cellular interstitial pneumonitis differs both clinically and histologically from the usual interstitial pneumonitis, lymphocytic interstitial pneumonitis and desquamative interstitial pneumonitis observed in adults and children. The etiology of this cellular interstitial pneumonitis in neonates is unknown.

Clinical manifestations, management and therapy of HIV infection in children

Perinatal infection accounts for the majority of cases of HIV infection in children both in developed and developing countries. Transmission may occur in utero, intrapartum or postpartum as a result of breast-feeding. The actual risk of transmission through breast-feeding is unknown. The majority of infants reported to be infected through breast milk have been infected as a result of a recently acquired HIV infection in the mother. Infants with HIV infection frequently present with clinical symptoms early in life. There is a broad spectrum of clinical findings in paediatric HIV infection, with opportunistic infections and multiorgan system involvement being common. The management of infants born to seropositive mothers includes routine paediatric care as well as careful clinical and laboratory monitoring for evidence of HIV infection. Infants who are seronegative with normal clinical and immunological findings at 18 months of age are considered uninfected. The prognosis and outcome of infants with HIV infection have improved considerably with earlier diagnosis and the availability of specific antiviral therapy. Modalities of therapy include frequent medical evaluation, aggressive diagnosis and treatment of infection, prophylaxis for Pneumocystis carinii infection, the use of intravenous gamma-globulin and specific antiviral therapy, such as zidovudine, didanosine or other drugs in development through clinical trials. HIV infection in children is a chronic illness and requires a comprehensive, family-oriented approach to care. With longer survival, children require support systems and an atmosphere of care and understanding to give them a good quality of life as well as prolonged survival.

HIV-associated salivary gland disease: a review

Human immunodeficiency virus-associated salivary gland disease (HIV-SGD) is defined as the presence of xerostomia and/or swelling of the major salivary glands. It is common among children but uncommon among adults. HIV-SGD includes lymphoepithelial lesions and cysts involving the salivary gland tissue and/or intraglandular lymph nodes, and Sjögren's syndrome-like conditions, diffuse interstitial lymphocytosis syndrome, and other reported lesions of the major salivary glands. This article reviews the terminology, prevalence, symptoms, clinical features, diagnostic procedures, histopathology, serology, natural history, treatment, and pathogenesis of HIV-SGD.

Bronchiectasis in children with lymphocytic interstitial pneumonia and acquired immune deficiency syndrome. Plain film and CT observations

In a review of 77 HIV positive children seen between 1981 and 1990, 32 were diagnosed as having lymphocytic interstitial pneumonitis). Four of the LIP group developed bronchiectasis, a finding not previously reported. The precise factors leading to the bronchiectasis are unclear. All patients had chronically consolidated lung with volume loss. A history of recurrent bacterial superinfection was not noted in any of the cases. With more cases of HIV positive children living longer, bronchiectasis, long known to occur in primary immunologic disorders, will probably be more frequently noted.

Virus infections of the respiratory tract in HIV-infected children

In order to determine whether the rates of respiratory viral infection and the severity of respiratory symptoms in HIV-infected children were higher than those in noninfected children, nose and throat swabs for viral isolation were taken at 3-month intervals during the first 2 years of life from 50 children born to HIV-infected women. Similar samples were obtained during the first year of life from 19 control children born to HIV seronegative mothers. Of the 50 children, five proved to be HIV-infected while 45 were presumed to be uninfected. HIV-infected children had significantly more respiratory symptoms and a higher proportion of samples from which viruses were isolated than the non-HIV-infected children. Also, more infected episodes required admission to hospital in the HIV-infected group. There was no such difference between the non-HIV-infected and the control children. Three HIV-infected children received intravenous immunoglobulin therapy. Among these the proportion of positive samples for viral isolation was greater before than after treatment began. These results suggest that HIV-infected children are more susceptible to recurrent viral infection and that passive immunotherapy may be of benefit to such children.

Chronic cough in children

Chronic cough in children is a frequent complaint seen by the primary health care provider. Although many of these coughs spontaneously resolve, some are caused by a more serious process and require further attention. Selecting those patients who will benefit from a more extensive evaluation can be a difficult challenge. An overview is provided that emphasizes a systematic approach to the diagnosis and management of chronic cough.

Lymphocytic interstitial pneumonia

Lymphocytic interstitial pneumonia is at present a pathologic diagnosis. In the setting of a chronic interstitial pneumonia in a child with lymphocytosis, hyperglobulinemia, and lymphadenopathy or parotid enlargement, the diagnosis is often clinically presumed. At present the diagnosis can be established firmly only by lung biopsy. Models of pathogenesis include nonspecific stimulation of the immune system, HIV-specific stimulation, or synergy between EBV and HIV. Treatment includes oxygen and bronchodilators as needed. The role of zidovudine and of steroids in the management of LIP remains to be determined.

Pneumocystis carinii infections in HIV-infected children

Since 1981, 1200 children with acquired immunodeficiency syndrome have been reported to the Centers for Disease Control. Among these children, Pneumocystis carinii has been the leading cause of serious morbidity and mortality. This review discusses the epidemiology, diagnosis, and treatment of P. carinii.

Medical care of the HIV-infected child

Familiarity with the demographics of pediatric HIV disease and recognition of common and uncommon presentations of infection are keys to diagnosing the HIV-infected child. Subsequent management entails preventative care, including immunizations and nutritional support, as well as management of HIV-related complications.

Pulmonary manifestations of HIV infection in children

We retrospectively reviewed the spectrum, course, and outcome of pulmonary diseases in 66 children with AIDS, hospitalized between 1982 and 1988, prior to the use of zidovudine. Fifty-two of the 66 (79%) patients developed pulmonary problems. In fifty-two percent of all patients, a pulmonary problem was the first symptom of HIV infection. The most common respiratory illness requiring hospitalization was an episode of respiratory distress with normal PaO2 and unchanged X-ray with a 9.7 +/- 6.8 days mean duration of hospitalization. Bacterial pneumonia, Pneumocystis carinii pneumonia (PCP) and pulmonary lymphoid hyperplasia/lymphoid interstitial pneumonia occurred in 30%, 32% and 22% of the patients, respectively. Bacterial pneumonia and PCP were associated with a high mortality rate. Sixty-eight percent of the patients died within 24 months of the onset of pulmonary disease. In 50% of the children, pulmonary disease was a primary cause of death. The results of this study can be useful in developing prospective studies for the prevention and treatment of pulmonary complications of HIV infection.

Pulmonary disease in AIDS patients

Pulmonary disease remains a major complication of the human immunodeficiency virus (HIV). Over the past decade several changes in the pattern of disease have occurred. Pneumocystis carinii pneumonia (PCP) remains the most common opportunistic pathogen in AIDS patients, though its incidence on bronchoscopy has declined and empiric therapy often occurs without a specific diagnosis. Changes in the management of patients with PCP have included different dosages and routes of administration for chemotherapy, improved overall survival, and a recent increase in the number of patients surviving episodes of respiratory failure. In addition, infection with mycobacteria tuberculosis (M.Tb.) has emerged as a major public health problem. The pattern of M.Tb. is distinct from non-immunocompromised patients though response to therapy usually occurs.

HIV infection in children

Human immunodeficiency virus (HIV) infection in children has emerged as a major, rapidly growing public health problem. The majority of children become infected by perinatal transmission of the virus from an infected mother. The disease is frequently associated with progressive neurologic dysfunction and with opportunistic infections. The cutaneous manifestations of pediatric HIV infection include a wide variety of fungal, bacterial, and viral infections of the skin. These diseases tend to be less responsive to conventional therapies than in the healthy child. In addition, severe seborrheic dermatitis, vasculitis, and drug eruptions are sometimes signs of HIV infection.

Parotid gland abnormality found in children seropositive for the human immunodeficiency virus (HIV)

Out of our series of 24 children seropositive for the Human Immunodeficiency Virus (HIV), parotid gland enlargement was noted in 4 children with AIDS-related complex (ARC) presenting also a Lymphocytic Interstitial Pneumonitis (LIP) on their chest radiographs. The ultrasound (US) aspect of the parotid gland suggests acinar enlargement (suggesting the presence of lymphocytic infiltration). The aspect displayed in the parotid mirrors the process developing in other areas (lungs, liver, spleen, lymph-nodes), i.e. a syndrome of lymphocytic (CD8) proliferation present at the stage of ARC.

Pneumocystis carinii pneumonia in young children with AIDS

We present our experience with 54 episodes of Pneumocystis carinii pneumonia in 50 young children with AIDS, all but one representing congenitally acquired infection. Findings at history and physical examination are not helpful in suggesting the diagnosis. The diagnosis is suggested by marked hypoxemia, diffuse disease on chest radiograph, and elevated serum LDH level. Because important aspects of the history may be withheld, a high index of suspicion may be necessary for the correct diagnosis. The mortality rate for ventilated patients was 50%.

Diagnostic flexible bronchoscopy in human immunodeficiency virus (HIV)-positive children

Twelve children with laboratory evidence of human immunodeficiency virus (HIV) infection underwent diagnostic flexible bronchoscopy with washings or bronchoalveolar lavage at Bellevue Hospital Center from October 1987 to April 1989. The patients included 7 boys and 5 girls ranging from age 3.5 months to 10 years 5 months. Indications for bronchoscopy included respiratory distress with or without focal changes on chest radiograph in 11 patients, and persistent but asymptomatic right middle lobe collapse in one child. The etiology of pneumonia was diagnosed in 7 children and included Pneumocystis carinii, (PCP) (17%), Streptococcus viridans (17%), mechanical obstruction (17%) and cytomegalovirus (CMV) (8%). Bronchoscopy was non-diagnostic in 5 cases. Techniques for maximal yield of information using flexible bronchoscopy in HIV-positive children are discussed.

Bronchoalveolar lavage in HIV infected patients with interstitial pneumonitis

The value of taking microbiological and cytological specimens by flexible bronchoscopy and bronchoalveolar lavage under local anaesthesia was assessed on 43 occasions in 35 HIV infected children, aged 3 months to 16 years, with interstitial pneumonitis. In acute interstitial pneumonitis (n = 22, 26 specimens from bronchoalveolar lavages) the microbiological yield was 73%, Pneumocystis carinii being the commonest infective agent (n = 14). P carinii pneumonia was found only in children with deficient antigen induced lymphocyte proliferative responses who had not been treated with long term prophylactic co-trimoxazole. In contrast, in 13 children with chronic interstitial pneumonitis that was consistent with a diagnosis of pulmonary lymphoid hyperplasia who underwent bronchoalveolar lavage on 17 occasions, there were two isolates of cytomegalovirus and one of adenovirus, but P carinii was not found. Ten of the 13 children had normal antigen induced lymphocyte proliferative responses. Useful cytological data were also gleaned from bronchoalveolar lavage specimens. Lymphocytosis was significantly higher in pulmonary lymphoid hyperplasia (36(SD 11)%) than in P carinii pneumonia (24(19)%) whereas the percentage of polymorphonuclear neutrophils was significantly lower (3(2)% compared with 12(13)%). Flexible bronchoscopy with bronchoalveolar lavage is safe even in young infants and should reduce the necessity for open lung biopsy in the management of HIV infected children with interstitial pneumonitis.

Parotid gland enlargement and xerostomia associated with labial sialadenitis in HIV-infected patients

Infection with human immunodeficiency virus (HIV) may be associated with enlargement of the major salivary glands or symptoms of dry mouth. We term this condition HIV-associated salivary gland disease (HIV-SGD). In this report we describe 12 patients with HIV-SGD. Nine patients (one child, eight adults) had enlargement of the parotid glands, and three had xerostomia alone. Symptoms of dry mouth, dry eyes or arthralgia occurred in 11, five and five patients, respectively. Salivary flow rates were normal or slightly reduced in seven patients and severely reduced in five. Labial salivary gland (LSG) biopsy specimens from patients contained lymphocytic infiltrates in focal and other patterns, whereas specimens from three HIV-infected patients without salivary gland symptoms did not. The inflammatory infiltrates in LSG specimens showed a preponderance of T8-positive cells and a tissue T4/T8 average ratio of 0.66. The mean T4/T8 ratio of peripheral blood lymphocytes was 0.4. Serum antinuclear antibodies were present in one patient, but rheumatoid factor, SS-A, and SS-B antibodies were absent in all. Search for Epstein-Barr virus and cytomegalovirus in the LSG tissue of the six patients tested did not reveal evidence of antigens or DNA. HIV-SGD patients show a number of similarities to and differences from patients with Sjögren's syndrome (SS). The similarities include the oral and salivary features, histopathology and possibly changes in other organs. The differences include the lower salivary gland T4/T8 ratio and the absence of autoantibodies in serum. The causes of HIV-SGD as well as of Sjögren's syndrome are unknown.

Outcome of mechanical ventilation in children with acquired immunodeficiency syndrome

We retrospectively reviewed the records of 18 children with acquired immunodeficiency syndrome (AIDS) who required mechanical ventilation for respiratory failure. These patients represented 35% of the patients seen with pulmonary disease and AIDS. The most common causes of respiratory failure were Pnuemocystis carinii pneumonia (77%) and bacterial pneumonia (33%). Bronchial lavage by fiberoptic bronchoscopy or endotracheal tube suctioning in mechanically ventilated children with AIDS had a high yield for P. carinii. Eight of 18 (44%) children survived the episode of respiratory failure and were weaned from the ventilator. However, four of eight survivors died within 6 months. Arterial oxygen tension on admission and maximum peak inspiratory pressure on the ventilator did not differ between survivors and nonsurvivors. We conclude that children with AIDS who are mechanically ventilated can be weaned from the respirator but that the subsequent course remains poor.