Pediatric acquired immune deficiency syndrome with panhypogammaglobulinemia

Semiquantitative human immunodeficiency virus antibody tests in diagnosis of vertical infection

OBJECTIVE

This study evaluated the roles of semiquantitative anti-HIV antibody tests for early diagnosis of vertical HIV-1 infection in infants.

METHODS

The study included 0- to 18-month-old children of HIV-1-infected mothers. They were regularly followed up, and blood was obtained for semiquantitative anti-HIV tests using a particle agglutination (PA) test and a microparticle enzyme immunoassay (MEIA).

RESULTS

One hundred forty-six children of HIV-1-infected mothers, including 104 infected and 42 uninfected infants, were studied. Using anti-HIV titer of < or = 1:100 by PA and optical values of < or = -3 by MEIA for diagnosis of not being infected, approximately 69 and 53% of the uninfected cases at age 7 to 8 months, 76 and 67% at age 9 months and 100% at age 12 months could be diagnosed. By comparison with the diagnosis by qualitative tests the figures were 16%, 8 and 11%, 70 and 74% at the same ages. All asymptomatic HIV-infected cases had persistently high PA titers and MEIA values of at least 1:5000 and 6, respectively, but 7 cases with AIDS-related manifestation at the time of tests had low anti-HIV titers. One severely ill, HIV-infected infant had a transient negative anti-HIV test at the age of 7 months. Two asymptomatic infected children, who had been breast-fed, had transient decrease in anti-HIV titers after the age of 6 months, and transient seroreversion occurred in one. CONCLUSION. Semiquantitative anti-HIV tests between the age of 6 to 12 months were very useful in diagnosis of HIV-1 infection in infants born of HIV-1-infected mothers. Interpretation must be accompanied by information about AIDS-related manifestation and history of breast-feeding.

Evaluation and medical treatment of the HIV-exposed infant. American Academy of Pediatrics. Committee on Pediatric AIDS

As a result of the expanding human immunodeficiency virus (HIV) infection epidemic and recently published recommendations for routine HIV testing with consent for all pregnant women in the United States, pediatricians are becoming increasingly involved in providing care to infants born to HIV-infected women. This article provides guidelines about counseling the parent or care giver of the infant, use of antiretroviral therapy to reduce the risk of infection in the infant, medical treatment of the HIV-exposed infant, laboratory testing to determine the infection status of the infant, laboratory monitoring of hematologic and immunologic parameters, prophylaxis for Pneumocystis carinii pneumonia, and recommendations for immunizations and tuberculosis screening.

Pediatric human immunodeficiency virus infection

In the past decade, an increase in pediatric human immunodeficiency virus (HIV) infection has had a substantial impact on childhood morbidity and mortality worldwide. The vertical transmission of HIV from mother to infant accounts for the vast majority of these cases. Identification of HIV-infected pregnant women needs to be impoved so that appropriate therapy can be initiated for both mothers and infants. While recent data demonstrate a dramatic decrease in HIV transmission from a subset of women treated with zidovudine during pregnancy, further efforts at reducing transmission are desperately needed. This review focuses on vertically transmitted HIV infection in children, its epidemiology, diagnostic criteria, natural history, and clinical manifestations including infectious and noninfectious complications. An overview of the complex medical management of these children ensues, including the use of antiretroviral therapy. Opportunistic infection prophylaxis is reviewed, along with the important role of other supportive therapies.

Early diagnosis of HIV infection in infants by detection of IgA HIV antibodies

With the aim of achieving earlier diagnosis of human, immunodeficiency virus (HIV) infection in infants, IgA and IgM HIV antibodies in serum samples from babies born to seropositive mothers were assayed by immunoblot and enzyme-linked immunosorbent assay after removal of IgG with recombinant protein G. 64 samples were from 38 HIV-infected babies with Centers for Disease Control classifications of P1 or P2. Among these infected children IgA HIV antibodies were present in all 23 samples from those older than 12 months, in 12 of 18 samples from babies aged 6-12 months, in 5 of 10 samples from babies aged 3-5 months, and in 2 of 13 from babies under 3 months old. The 6 IgA-negative samples from infants over 6 months were all from infants with severe AIDS and/or hypogammaglobulinaemia. IgA HIV antibodies were present in twice as many samples as IgM HIV antibodies (66% vs 33%). No IgM or IgA HIV antibodies were detected in infants who subsequently seroreverted or in infants born to seronegative mothers. The correlation of the serological results with clinical information on each child suggests that detection of IgA HIV antibodies is an effective method for early diagnosis of HIV-infected infants without signs of infection.

Intravenous immunoglobulin in HIV infection: evidence for the efficacy of treatment

Eight children with symptoms of HIV infection were treated for 12-26 months (median 14 months) with infusions of intravenous immunoglobulin (200 mg/kg) every three weeks. Significant improvement was noted in all children in terms of weight gain, number of infectious episodes, and days spent in hospital. This resulted in a 49% saving in cost on treatment compared with costs accrued previously during inpatient admissions. Immunoglobulin concentrations, which were raised at the start of treatment were not altered, and T4 counts continued to decline slowly. HIV core antigen was detected in four children before treatment, but all became core antigen negative after treatment was commenced, this effect being sustained in three. Intravenous immunoglobulin therefore has major clinical benefit, and by reducing viral activity may delay disease progression.

Effect of continuous intravenous infusion of zidovudine (AZT) in children with symptomatic HIV infection

To produce concentrations of zidovudine (AZT) in plasma and cerebrospinal fluid that would provide constant inhibition of the replication of human immunodeficiency virus (HIV), we gave AZT by continuous intravenous infusion to 21 children ranging in age from 14 months to 12 years who had acquired HIV infection through transfusions or perinatally. All patients were symptomatic before AZT treatment (Class P2 of the Centers for Disease Control); 13 (62 percent) had evidence of neurodevelopmental abnormalities. The mean CD4/CD8 ratio was 0.18; 11 patients had CD4 counts below 0.2 x 10(9) per liter. We administered AZT at four dose levels: 0.5, 0.9, 1.4, and 1.8 mg per kilogram of body weight per hour. The plasma drug concentrations achieved at the respective dose levels were 1.9 +/- 0.3, 2.8 +/- 1.4, 3.1 +/- 1.1, and 4.5 +/- 1.0 microM. The steady-state cerebrospinal fluid:plasma ratio was 0.24 +/- 0.07. The only evidence of toxicity was bone marrow suppression. Transfusion was required in 14 patients because of low levels of hemoglobin (5 mmol per liter [less than 8 g per deciliter]). Dose-limiting neutropenia (less than 0.5 x 10(9) polymorphonuclear leukocytes per cubic millimeter) occurred in most patients who received doses of 1.4 mg per kilogram per hour or more. Improvement in neurodevelopmental abnormalities occurred in all 13 children who had presented with encephalopathy before treatment. Serial measurements of IQ before therapy and after three and six months of continuous therapy with AZT showed that IQ scores, including those for verbal and performance IQ, rose in these 13 patients and in 5 other children who had no detectable evidence of encephalopathy before treatment. Most patients also had increased appetite and weight, decreased lymphadenopathy and hepatosplenomegaly, decreased immunoglobulin levels, and increased numbers of CD4 cells. In some patients the improvement in the features of encephalopathy occurred despite the absence of immunologic improvement. We conclude that AZT is beneficial in children with symptomatic HIV infection, especially those with encephalopathy (which may be subclinical), and that the optimal continuous intravenous dose of AZT in children is between 0.9 and 1.4 mg per kilogram per hour.

Human-immunodeficiency-virus infections in infants negative for anti-HIV by enzyme-linked immunoassay

Of 85 children with human-immuno-deficiency-virus (HIV) infection based on clinical (opportunistic infection), epidemiological (mother a drug addict or known to be HIV infected), and immunological (helper-T-cell deficiency and impaired proliferative response to pokeweed mitogen) features, 9 were found to lack antibody to HIV as measured by a commercial enzyme-linked immunoassay (ELISA). All 9 children had detectable levels of HIV antigen in simultaneous plasma specimens, measured by a sensitive antigen-capture ELISA. The use of the western blot assay and an ELISA with recombinant HIV antigens was able to identify HIV infection in 4 of the 9 children.