Pulmonary manifestations of pediatric HIV infection

The chest X-ray features of chronic respiratory disease in HIV-infected children--a review

Several features of human immunodeficiency virus (HIV) infection contribute to the development of chronic respiratory disease in children. These include the frequency and severity of acute chest infections, as well as the increased risk of pulmonary tuberculosis, aspiration, cardiovascular disease, lymphocytic interstitial pneumonitis or pulmonary neoplasia. The chest radiograph (CXR) remains the most accessible investigation for respiratory disease and plays an important role in the baseline assessment and follow-up. This review focuses on the CXR abnormalities of HIV-related chronic respiratory disease in children. The most commonly documented chronic CXR abnormalities are homogeneous opacification and pulmonary nodules, with pulmonary tuberculosis and lymphocytic interstitial pneumonitis the leading respective causes. Deficiencies in radiographic reporting methodology and relative paucity of radiographic data contribute to current limitations in knowledge and understanding of this field. The review highlights the need for standardised terminology and systematic reporting methodology in future studies. Prospective research on the natural history of lymphocytic interstitial pneumonitis, response to anti-tuberculous therapy, the impact of anti-retroviral therapy and HIV-associated bronchiectasis are needed.

Clinical and immunological correlates of chest X-ray abnormalities in HIV-infected South African children with limited access to anti-retroviral therapy

BACKGROUND

The chest X-ray (CXR) abnormalities of human immunodeficiency virus (HIV)-infected children in low/middle income countries (LMIC's) have not been well studied.

OBJECTIVE

To describe the CXR abnormalities and associated clinical/immunological features in HIV-infected South African children.

MATERIALS AND METHODS

A prospective study of HIV-infected children who underwent baseline chest radiography and clinical and immunological HIV-staging. CXR abnormalities were stratified as grade 1 (mild) or grade 2 (moderate/severe). Univariate and multiple logistic regression analyses assessed associations between radiological severity and clinical/immunological parameters.

RESULTS

Three hundred thirty children (53% male), median age 23.8 months, were included; 303 (92%) had moderate/severe clinical disease and 225 (68%) moderate/severe immune suppression; 52 (16%) had a normal CXR; 169 (51%) had grade 2 CXR abnormalities, manifesting as: confluent opacification (n = 91, 28%), nodules (n = 37, 11%), or nodules with opacification (n = 41, 12%) Grade 2 abnormality was associated with more advanced clinical HIV disease (OR: 6.9; 95% CI: 1.9-25.6), CD4+ less than 20% (OR: 1.8; 95% CI: 1.0-3.0) and age over 24 months (OR: 4.1; 95% CI: 2.1-8.0).

CONCLUSION

CXR abnormalities are common in HIV-infected children in LMIC's. The extent of radiological abnormality correlates with age and clinical and immunological severity of HIV-disease.

Chest radiographic features of lymphocytic interstitial pneumonitis in HIV-infected children

AIM

To review the radiological features of biopsy-proven lymphocytic interstitial pneumonitis (LIP) in human immunodeficiency virus (HIV)-infected children and establish whether these are based on systematic radiological analysis, and to investigate whether more specific radiological diagnostic criteria can be developed.

MATERIALS AND METHODS

A Medline search of English-language articles on the radiological features of biopsy-proven LIP in HIV-infected children was conducted for the period 1982 to 2007 inclusive. Radiological findings were compared with the Centers for Disease Control and Prevention (CDC) criteria for a presumptive diagnosis of LIP.

RESULTS

Pulmonary pathology was recorded as "diffuse" and "bilateral" in 125 (97.6%) of 128 reported cases of LIP. Twenty-five different terms were used to describe the pulmonary parenchyma. In 96 (75%), the terminology was consistent with CDC diagnostic criteria. Radiological evolution was documented in 43 (33.5%). Persistent focal opacification superimposed on diffuse pulmonary nodularity was demonstrated in 10 (7.8%). The method of radiological evaluation was described in six (4.6%). In no instance was the terminology defined.

CONCLUSION

The radiological features of LIP have not been systematically analysed. However, CDC criteria remain reliable, allowing diagnosis of at least 75% of cases. The sensitivity of these criteria may be increased by including cases with persistent focal pulmonary opacification superimposed on diffuse nodularity. Longitudinal studies utilizing standardized radiographic analysis are needed to elucidate the natural history of LIP.

Pneumocystis carinii in children with severe pneumonia at Mulago Hospital, Uganda

The prevalence of Pneumocystis carinii pneumonia (PCP), its clinical and radiological features and the outcome in 121 children aged 2-60 months presenting with severe pneumonia over a 2-month period at Mulago Hospital, Kampala are described. Children presenting with severe pneumonia had sputum induction using 3% hypertonic saline. The sputum was stained using PCP monoclonal antibodies and viewed with fluorescent microscopy. Twenty children with confirmed PCP were compared with 101 without PCP. The prevalence of PCP was 16.5%, and 12 (60%) were < 6 months of age. Eighteen (42%) of 43 children infected with HIV had PCP and two of 78 not infected with HIV. The outcome in children with PCP was poor with a case fatality rate of 40% compared with 20% in those without HIV. Radiological findings were non-specific. Clinical features associated with PCP included: HIV-positive infants with a small head circumference, AIDS, a clear chest on auscultation and elevated LDH levels. PCP occurs in one in six children < 5 years with severe pneumonia in Mulago Hospital. In developing countries where investigations for PCP are not routinely available, infants suspected of PCP should be treated as an emergency.

The role of companion animals in the emergence of parasitic zoonoses

Pets offer individuals and the community significant benefits, however cognisance must be taken of the potential for transmission of infectious agents from these animals to humans. The prevalence of many parasites, such as Giardia and Cryptosporidium, has increased over the past few decades while others, such as Toxocara and Ancylostoma, have decreased. These changes could be real, associated with the ready availability of efficacious anthelmintic products or could be artificial due to the type of surveys conducted, the animals surveyed and the diagnostic tests used. Immunocompromised people, in particular, must be aware of the potential risk of acquiring parasitic infections from their pets. However, with the adoption of good hygiene and a thorough knowledge of the transmission of these parasites, immunocompromised people should be able to continue to enjoy the significant benefits of pet ownership. As many owners are not aware of the zoonotic parasites that could be carried by their pets or their mode of transmission, it is concluded that veterinarians need to play a greater role in the education of their clients.