HIV-1 infection and the acquired immunodeficiency syndrome in children

Acquired Nonneoplastic Neonatal and Pediatric Diseases

The lung biopsy is an established procedure to procure a pathologic diagnosis in a child with a suspected pneumonic process of undetermined etiology. Improvements in pediatric anesthesia and surgery have reduced the operative complications to a minimum. A biopsy can usually be taken through a small intercostal incision when localization is not especially important in a patient with diffuse changes (see Chapter 1). The alternative method for tissue sampling is the endoscopic transbronchial biopsy. There is less risk to the patient, but the specimen is smaller and crush artifacts from the instrument are more common.

Impact of highly active antiretroviral therapy on the morbidity and mortality in Spanish human immunodeficiency virus-infected children

BACKGROUND

Highly active antiretroviral therapy (HAART) slows the progression of HIV disease and lowers mortality and morbidity in adults. The impact on the disease course in children has not been still completely elucidated. Furthermore the effect of HAART on organ-specific complications of HIV is unknown.

OBJECTIVES

To assess the effect of HAART on the progression of HIV infection, mortality, organ-specific complications, number of infections and hospitalizations in HIV-1-infected children.

PATIENTS AND METHODS

Records of HIV-1-infected children were reviewed in a large referral pediatric hospital. Patients were divided into three groups: children who did not receive antiretroviral therapy (Group 1); children who received mono- or bitherapy (Group 2); and patients who received HAART (Group 3). Endpoints analyzed were progression to AIDS and mortality among AIDS patients and overall.

RESULTS

One hundred seven children have been evaluated. Actuarial survival at 5 years of age was 33% in Groups 1 and 2 compared with 100% in Group 3 (P < 0.01). At 5 years of age, the proportion of children progressing to AIDS was 76% in Groups 1 and 2, compared with 26% in Group 3 (P < 0.01). At 5 years of follow-up, there were 45 cases of organ-specific complications in patients without HAART. No children without organ-specific complications when HAART was started have developed them after 5 years (P < 0.01). In patients without HAART there were 9 cases of lymphoid interstitial pneumonia, and there was none in Group 3 (P < 0.01). The incidence rates of infections and hospitalizations were 2.83 and 0.52 per patient-year, respectively, in children who did not receive HAART and 0.75 and 0.17 when they were managed with HAART (relative risk, 0.26 and 0.32).

CONCLUSIONS

HAART is associated with a marked decline in the progression to AIDS, improved survival in HIV-1-infected children, reduced incidence of infections and hospitalizations and decreased incidence of some organ-specific complications of HIV.

Impact of human immunodeficiency virus type 1 infection on the epidemiology and outcome of bacterial meningitis in South African children

OBJECTIVE

To define the impact that the human immunodeficiency virus type 1 (HIV-1) epidemic has had on the burden and outcome of bacterial meningitis in an area with a high prevalence of pediatric HIV-1 infection.

METHODS

Children less than 12 years of age with proven or suspected bacterial meningitis were enrolled in this study between March 1997 and February 1999, and their hospital records were retrospectively reviewed for clinical data.

RESULTS

Sixty-two (42.2%) of the 147 children tested for HIV-1 infection were infected. Streptococcus pneumoniae (Pnc) exceeded Haemophilus influenzae type b (Hib) as the most important cause of meningitis in HIV-1-infected (74.2% vs. 12.9%, respectively) compared with uninfected children (29.4% vs. 42.3%, respectively, P less than 10(-5)). The estimated relative risk of Pnc meningitis was greater in HIV-1-infected than in uninfected children under 2 years of age (relative risk [RR] = 40.4; 95% confidence intervals [CI] = 17.7-92.2). Overall, HIV-1-infected children had a higher rate of mortality than uninfected children (30.6% vs. 11.8%, respectively, P = 0.01), and in particular, HIV-1-infected children with Pnc meningitis (60.8% vs. 36.0%, respectively, P = 0.04) had a poorer outcome.

CONCLUSIONS

Streptococcus pneumoniae has exceeded Hib as the most important pathogen causing bacterial meningitis in HIV-1-infected compared with uninfected children. Effective vaccination against Hib and Pnc should be evaluated to reduce the overall burden of bacterial meningitis in HIV-1-infected children.

Resolution of organ-specific complications of human immunodeficiency virus infection in children with use of highly active antiretroviral therapy

Opportunistic infections are a major source of morbidity and mortality in children and adults infected with human immunodeficiency virus (HIV). In addition, organ-specific complications of HIV infection, such as cardiomyopathy, nephropathy, encephalopathy, and others, contribute substantially to the morbidity and mortality associated with HIV infection. Highly active antiretroviral therapy (HAART) has produced a dramatic decline in the incidence of opportunistic infections among patients with HIV infection. Nevertheless, there is very little information concerning the value of HAART for organ-specific complications of HIV infection. In this report, we describe 3 children with HIV infection in whom the dominant clinical manifestations were cardiomyopathy, red cell aplasia, and nephropathy. HAART produced a decrease in the HIV ribonucleic acid level, an increase in the CD4 cell count, and resolution of the organ-specific complications in all patients. These cases add to our knowledge concerning the benefits of HAART for children with HIV infection.

Immune functions in splenectomized thalassaemic children

A prospective study to assess the immune functions in splenectomized thalassaemic children. Children were those registered in the Thalassemia major. There were 10 splenectomized children (Group 1), 10 non-splenectomized children and 6 age-matched control (Group 3). All children were shown to be HIV seronegative. The mean concentrations of serum IgG and IgA were higher in Group 1 as compared to Groups 2 and 3 but the differences were not statistically significant. Nitroblue tetrazolium (NBT) dye reduction by stimulated polymorphonuclear leukocytes was normal in both study and control groups and the differences were not statistically significant. However, NBT reduction in the unstimulated state was much higher in Group 2 as compared to Groups 1 and 3. Phytohaemagglutinin induced mitogen proliferation was normal in all 3 groups. Children in Group 1 not only had a significantly higher absolute lymphocyte count but also had a lower CD4/CD8 ratio as compared to Groups 2 and 3. Splenectomy does appear to alter the immune status of thalassemic children but the exact mechanism by which this occurrence is not clear.

Stroke and seizures as the presenting signs of pediatric HIV infection

The authors report two pediatric patients with definite human immunodeficiency virus infection whose initial presentation was stroke and seizure. The first patient was a 3-year-old female who developed acute hemiparesis as the first manifestation. The other, a 2-month-old infant, had focal seizures secondary to cerebral infarction. Investigations revealed ischemic infarction of the thalamus, hypothalamus, and internal capsule in the first patient and cerebral cortex in the second. Further investigations failed to demonstrate any other causes of these cerebral infarctions. Opportunistic infection of the central nervous system was not documented. The authors emphasize that cerebrovascular accident may be the initial presentation in human immunodeficiency virus infection in children. Human immunodeficiency virus infection must be included in the differential diagnosis, and testing for the disease is mandatory in the investigation of stroke in any child who is at risk of having this infection.

Progress in the understanding of HIV infection: an overview

The worldwide epidemic of human immunodeficiency virus (HIV) infection will likely be considered the most important public health event of the twentieth century. During the past 15 years, a wealth of information relating to the epidemiology, diagnosis, natural history, and treatment of HIV infection has accumulated. This article details the recent progress in each of these areas.