Human immunodeficiency virus infection in children

Low prevalence of dental caries in children with perinatal HIV infection

AIM AND OBJECTIVE

The objective is to assess the prevalence of caries in children with perinatal human immunodeficiency virus (HIV) infection.

MATERIALS AND METHODS

Oral examination was performed on children aged 2-12 years with perinatal HIV infection who stayed at 'Calvary Chapel home of hope for special children' to assess decayed, missing, or filled primary teeth/decayed, missing, or filled permanent teeth (dmft/DMFT).

RESULTS

Prevalence of tooth decay in primary teeth (dmft) for the age group 2-6 years was 57.15% and 7-12 years was 20.0%. Prevalence of tooth decay in permanent teeth (DMFT), for the age group 7-8 years was 16.60% and 10-12 years was 21.42%. Of the 27 children examined, 59.25% were caries free, in which 40.0% were male children and 70.58% were female children.

CONCLUSION

Based on these results we can conclude that oral hygiene can be maintained with a favorable dental behavior.

The oral health of HIV-infected Brazilian children

BACKGROUND

The number of HIV-infected people has increased almost continuously. Paediatric dentists should be concerned about the oral findings in HIV-infected children and their aetiologic factors, to promote adequate treatment.

AIM

To present the oral health aspects of Brazilian HIV-infected children and to verify the aetiological factors.

DESIGN

A cross-sectional study was conducted with HIV-infected children. During the medical appointments, children were submitted to visual-tactile exams of oral soft tissues and teeth. All parents answered questions in a structured interview. Data were analysed using the SPSS, release 10.0 (Chicago, IL, USA).

RESULTS

Of the 57 children examined, 39 (69.6%) presented one or more oral soft tissue manifestations. More than a half suffered from gingivitis and only 12.5% had no visible dental biofilm. A high prevalence of dental surfaces with active carious lesions was observed; mean DMFS-m and dmfs-m scores were 5.41 ± 5.61 and 16.77 ± 19.52, respectively. Caries activity and gingivitis were correlated with the presence of mature dental biofilm.

CONCLUSIONS

Prevalence of soft tissue lesions, dental caries and gingivitis in HIV-infected children was high and correlated to lack of satisfactory oral hygiene habits, suggesting the need of therapeutic programmes that allow these children to recover their oral health.

Sensitivity of paediatric AIDS score vs. WHO case classification in Indian children--a retrospective study

This study was conducted at the Department of Paediatrics, Dr Ram Manohar Lohia Hospital, to test the statistical significance of existing World Health Organization (WHO) clinical case definition (CCD) for diagnosis of AIDS in areas where diagnostic resources are limited. A total of 360 cases between 18 months and 12 years of age satisfying WHO case definitions of AIDS were included in study group. Our study detected 16.66% (60) of HIV incidence in children visiting the paediatrics outpatient clinic. Twenty percent of cases manifested three major and two minor signs, which had sensitivity of 73.33%; specificity, 90.66% and positive predictive value (PPV), 61.11%. Stepwise logistic analysis identified weight loss, chronic fever >1 month and total lymphocyte count <1500 cells mm(-3) as important predictors. Eighty-six cases (23.89%) showed two major and two minor signs with sensitivity and specificity of 86.66 and 88.66%, respectively. Thus a CCD based on 13 clinical signs/symptoms was proposed for paediatric AIDS with better sensitivity and PPV than the WHO case definition but with almost similar specificity.

Effect of methanol intoxication on spcific immune functions of albino rats

Our previous studies revealed that methanol intoxication significantly altered the non-specific immune functions in albino rats. The present investigation focuses on the effect of methanol on certain specific immune functions of cell mediated immunity such as footpad thickness, leukocyte migration inhibition test (LMI) and antibody levels. In addition, serum interleukins (IL-2, IL-4, TNF-alpha and IFN-gamma), and splenic lymphocyte subsets were measured after an immune challenge. The specific immune function tests were carried out in three different groups of albino rats, which include control, 15 and 30 days methanol intoxication. Our study reports that animal body weight, organ weight ratio, lymphoid cell counts, footpad thickness, antibody titer, IL-2, TNF-alpha, IFN-gamma, Pan T cell, CD4, macrophages, MHC class II molecule expression, and B cell counts were significantly decreased compared to control animals nevertheless, LMI, IL-4, and DNA single strand breakage were increased significantly. Plasma corticosterone level was significantly increased in the 15 days group whereas the 30 days methanol intoxication group showed considerable decrease in corticosterone level compared with control animals. Therefore, our investigation concluded that repeated exposure of methanol profoundly suppressed the cell mediated and humoral immune functions in albino rats.

Effect of methanol-induced oxidative stress on the neuroimmune system of experimental rats

It is well known that the nervous system has increased susceptibility to methanol intoxication. The present study reveals the effect of methanol intoxication on antioxidant status, lipid peroxidation and DNA integrity in hypothalamic-pituitary-adrenal (HPA) axis organs and spleen. Non-specific and specific immune functions were analyzed. In addition, open field behavior, plasma corticosterone level and blood methanol level were estimated. Male Wistar albino rats were intoxicated with methanol (2.37 g/kg b.wt., i.p.) for 1 day, 15 and 30 days. Administration of methanol showed significant increase in enzymatic (superoxide dismutase, catalase, glutathione peroxidase), non-enzymatic (reduced glutathione and Vitamin C) antioxidants and lipid peroxidation (LPO) in hypothalamus and adrenal gland of day 1 group. However, decrease in enzymatic and non-enzymatic antioxidants with concomitant increase in LPO level were observed in 15 and 30 days groups. Plasma corticosterone level was significantly increased in day 1 and 15 days groups whereas, 30 days methanol intoxication group showed considerable decrease in corticosterone level compared with control animals. Cell-mediated immune response of footpad thickness was significantly decreased with an increased leukocyte migration inhibition. Humoral immune response of antibody titers was elevated in methanol-intoxicated groups. Neutrophil functions, adherence and phagocytic index (PI) were found to be significantly decreases. Furthermore, significant increase in the avidity index and nitro blue tetrozolium reduction was observed in the methanol exposed animals. Day 1 methanol exposed group showed increased PI compared to the control ones. Methanol exposure for 30 days showed an increased DNA fragmentation in the hypothalamus, adrenal glands, and spleen. In conclusion, exposure to methanol-induced oxidative stress disturbs the HPA-axis function altering the level of corticosterone, which lead to varied non-specific and specific immune response in experimental rats.

HIV and communication

The human immunodeficiency virus (HIV) continues to plague many countries across the globe, including the United States, Africa, China and India. Children and adults have been infected with HIV, and both populations can present with communication disorders that coexist with the presence of the virus. The purpose of this paper is to present an overview of HIV and a discussion of the types of conditions that impact communication in both pediatric and adult populations. Persons living with HIV may present with disorders in the areas of language, phonology, voice and swallowing. Given the advances in pharmacological management of HIV, speech-language pathologists need to be knowledgeable of how medications can impact communication and swallowing. Also, since HIV crosses the blood-brain barrier and impacts all aspects of an infected person's life, speech-language and hearing professionals need to be members of the interdisciplinary teams that assess and manage patients living with HIV. Specific information regarding communication disorders in the pediatric population and research issues that warrant continued investigation will be addressed.

LEARNING OUTCOMES

The reader will become aware of the ways in which a speech-language pathologist or audiologist may become involved with a patient infected with HIV or AIDS. The reader will learn the specific manners in which HIV and AIDS may affect the speech, language, hearing, and swallowing of pediatric and adult patients, as well as the appropriate intervention philosophies.

Neuropsychological functioning and viral load in stable antiretroviral therapy-experienced HIV-infected children

OBJECTIVE

Neuropsychological functioning and its correlation with viral load were investigated for previously treated HIV-infected children who underwent a change in treatment regimen.

METHODS

Thirteen age-appropriate measures of cognitive, neurologic, and behavioral functioning were administered to 489 HIV-infected children who were aged 4 months to 17 years and had been treated previously for at least 16 weeks with antiretroviral therapy. These clinically and immunologically stable children were randomized onto 1 of 7 drug treatment combinations, 6 of which included a protease inhibitor (PI), and evaluated prospectively for 48 weeks with respect to changes in neuropsychological performance and viral load.

RESULTS

Neuropsychological functioning was significantly poorer at baseline for the HIV-infected children as compared with established norms for their age. Children with higher viral load had poorer cognitive, both-hands fine-motor, and neurologic signs at baseline, but single-hand fine-motor and behavioral functioning were not correlated with viral load. After 48 weeks of treatment with PI-containing combination therapy, there was significant improvement in only the vocabulary score. Neuropsychological changes did not differ among the 6 PI-containing combination regimens. At week 48, even children with a viral load response below the level of detection (RNA < or =400 copies/mL) still showed poorer neuropsychological functioning compared with established norms.

CONCLUSION

Poor neuropsychological functioning was seen for HIV-infected children and was worse for children with higher viral loads. Only 1 measure of neuropsychological functioning showed improvement after treatment with PI-containing combination therapy, and the extent of that improvement was relatively minor. Treatment strategies for children with HIV disease need to be reevaluated so that they consider restoration of neuropsychological functioning in addition to lowering the viral load.

Predictors of HIV seropositivity following intrapartum voluntary counseling and testing among Rwandan women

We investigated risk factors associated with HIV infection in women who accepted voluntary counselling and testing (VCT) intrapartum. A survey questionnaire containing information on sociodemographic characteristics was administered to parturients at the Central Hospital Kigali after informed consent had been obtained. Participants were then offered VCT for HIV, and those who accepted were informed of their results. Of the 427 eligible participants, 317 accepted VCT (74.2%). The results of 312 (98.4%) of these women were obtained and 50 tested positive for HIV, yielding an HIV seroprevalence of 16.0% intrapartum. Women who had been pregnant three or more times were three times as likely to test positive for HIV in comparison to those of lower parity (OR=2.9; 95% confidence interval (CI)=1.1 - 8.0). This finding contradicts earlier studies performed antenatally among women of childbearing age and pregnant women in general. This may be attributable to some inadequacy in the existing health-care infrastructure to effectively detect HIV in multiparous women antenatally, or may represent a signal that a change in the nature of the epidemic in Rwanda is occurring.

High levels of plasma dengue viral load during defervescence in patients with dengue hemorrhagic fever: implications for pathogenesis

Studies of the pathogenesis of dengue hemorrhagic fever (DHF), a potentially life-threatening disease, have revealed the importance of initial high levels of virus replication. However, the possible involvement of virus during the transition from fever to defervescence, a critical stage in determining the severity of disease, has not been appreciated. Using quantitative reverse transcription-polymerase chain reaction, we examined the levels of plasma dengue viral load during both fever and defervescence periods in patients from a DEN-3 outbreak in southern Taiwan in 1998. Higher levels of plasma dengue viral RNA were found in DHF patients than in DF patients. During defervescence, while the level of plasma dengue viral RNA was undetectable in most DF patients, it remains high in all DHF patients. Using a modified immunoprecipitation assay, we demonstrated for the first time that the plasma dengue viruses persisting during defervescence were in the immune complexes for most DHF patients. These findings suggest that continued active viral replication or delay in the clearance of viremia contributes to the pathogenesis of DHF. Moreover, high levels of plasma dengue viral RNA during defervescence may serve as a disease marker for DHF.

Clinical implications of the oral manifestations of HIV infection in children

The authors hypothesized that patients infected with HIV at birth would be more vulnerable to oral diseases such as periodontal disease and caries because of their compromised immune system. As a result, they designed a 3-year, longitudinal, case-controlled study that examined HIV-infected children as compared with their normal noninfected household peers. Over 100 HIV-infected participants ages 2 to 15 years were examined at 6-month intervals; no differences were found with respect to caries or periodontal disease prevalence and incidence when the two groups were compared. Although the level of oral disease was similar in the two groups, both groups had more caries than the national norm. Thus, failure to use a control group would have led to the erroneous conclusion that children with HIV infection had a high level of caries. In addition, the authors discovered that tooth eruption was delayed in the HIV-infected group, suggesting some developmental impediment. The HIV-infected group also showed more oral lesions that included candidiasis, linear gingival erythema, and medial rhomboid glossitis. Overall, oral lesions were not valid predictors of the serious consequences of AIDS. The authors speculated, however, that examinations at intervals more frequent than every 6 months might be required to determine whether oral lesions can predict frank AIDS and lowered CD4 cell counts.

Dental considerations for the paediatric AIDS/HIV patient

HIV infection and AIDS are spreading rapidly among the world's children, especially among African-American and Hispanic children in the USA, and those in developing countries. Although recent research has identified several ways of preventing perinatal transmission of HIV, most of these methods are too expensive for widespread use in developing countries, where the epidemic is most severe. Oral manifestations are early and common clinical indicators of HIV infection and progression in children, as in adults, although the specific manifestations differ between adults and children. Oropharyngeal candidiasis is the most common sign of HIV infection in children and is significantly associated with markers of HIV disease progression. Other common oral manifestations in children include herpes simplex, linear gingival erythema, parotid enlargement and recurrent aphthous ulceration. Further research is needed on the ways in which oral manifestations can be used as predictors of disease progression; on the impact of the limited availability of health care for impoverished families who are disproportionately affected by HIV infection; and on supportive care and its impact on infected children's quality of life.

[Relation between biofilm, caries activity and gingivitis in HIV + children]

The utilization of medicines to treat HIV-infected children has been promoting a decrease in the prevalence of soft-tissue oral lesions, as years pass by. In contrast, it has been observed that the experience of caries and gingivitis is constant in this population, mostly because of the chronic influence of some factors involved in the HIV-infection process, such as the chronic utilization of sweetened liquid medicines and carbohydrate-enriched diet, as well as frequent episodes of hospitalization. So, the purpose of this study was to evaluate if the quality and quantity of biofilm are important factors in the activity of dental caries and gingivitis, also in this special group. After examination of the biofilm (biofilm index - Ribeiro23, 2000), the activity of caries and gingivitis was assessed in 56 children, aging from 0 to 14 years, who were patients with definitive diagnosis of HIV infection. It was observed that only 7 subjects (12.5%) did not present with clinically visible biofilm, and 33 (58.9%) presented with gingivitis, with the average of 4.44 bleeding sites. As to dental caries, 73.2% of the patients presented with active carious lesions. A strong correlation was verified between Biofilm Index, gingival status and active carious lesions (Spearman's correlation test, r s = +0.57 and r s = +0.49, respectively). It was concluded that, also in HIV-infected children, the quality and quantity of biofilm over the dental surfaces are important etiologic factors related to the activity of caries and gingivitis. Biofilm should, thus, be controlled in order to reestablish the oral health of HIV-infected children.

The relationship of maternal and child HIV infection to security of attachment among Ugandan infants

This study was designed to examine the relationship of maternal and child human immunodeficiency virus (HIV) infection to the security of attachment of Ugandan infants. The attachment patterns of two groups of Ugandan mother-infant pairs: 35 HIV-positive mothers and their infants and 25 HIV-negative mothers and their infants were compared. We tested the hypothesis that infants of HIV-positive mothers would demonstrate less secure attachment as measured by the Waters Attachment Q-set than infants of HIV-negative mothers. No differences were found in the security of attachment of infants of HIV-positive versus HIV-negative mothers. Infants of HIV-positive mothers with Acquired Immunodeficiency Syndrome (AIDS) were less securely attached than infants of mothers without AIDS. These findings underscore the relationship of infant security of attachment to maternal HIV infection in the presence of AIDS-related symptoms but not to asymptomatic maternal HIV infection.

[Intestinal absorption of D-xylose in children infected with the human immunodeficiency virus]

AIM

To evaluate the intestinal absorption in HIV-infected children children 14 months to 14 years and to investigate its relationship to diarrhea, nutritional status, immune dysfunction, classical enteric parasites and Cryptosporidium.

METHODS

Intestinal absorption was investigated by measuring serum D-xylose. Fecal samples were investigated for classical pathogens and Cryptosporidium. The sample size was calculated considering a 30% prevalence of altered D-xylose absorption in HIV-infected children with a 5% accuracy. Statistical procedures used were: descriptive measurements, multiple correspondence analysis and logistic regression.

RESULTS

D-xylose absorption was altered in only 8 out of 104 (7.7%) and Cryptosporidium was positive in 33 out of 104 (31.73%) HIV-infected children. The multiple correspondence analysis suggested an association between an altered D-xylose test and Cryptosporidium. D-xylose malabsorption was not associated with diarrhea, nutritional status, immune disfunction and classic enteric parasites.

CONCLUSIONS

Intestinal malabsorption evaluated through the D-xylose test was an uncommon finding in HIV-infected children. Intestinal dysfunction when present seems to be related to Cryptosporidium, but not to diarrhea, nutritional status, immune disfunction and classic enteric parasites.

Chemokine gene expression and clonal analysis of B cells in tissues involved by lymphoid interstitial pneumonitis from HIV-infected pediatric patients

Lymphoid interstitial pneumonitis (LIP), a frequent pulmonary complication in HIV-infected pediatric patients, is characterized histologically by marked infiltration of lymphoid cells. We sought to evaluate the nature and pathogenesis of the lymphoid infiltrates and to examine the relationship of LIP to pulmonary MALT lymphoma that has been described in pediatric HIV positive patients. To examine the potential contribution of chemokines and cytokines to the inflammatory cell recruitment in tissues involved by lymphoid interstitial pneumonitis from HIV-infected pediatric patients, RNA was extracted from paraffin-embedded tissues from five lung biopsies in four pediatric HIV-positive patients and from five control, normal lung biopsies in five HIV-negative patients and was analyzed by semiquantitative RT-PCR for the expression of cytokines (TNF-alpha, GM-CSF, IFN-gamma, IL-4, IL-6, IL-10, and IL-18) and chemokines (IP-10, Mig, regulated upon activation, normal T expressed and secreted [RANTES], and MIP1-alpha and beta) after normalization for G3PDH. Expression of IL-18 was increased, as well as expression of IFN-gamma-inducible chemokines IP-10 and Mig in LIP tissues compared with controls. RANTES and MIP1-alpha and -beta were also increased in pediatric LIP lesions compared with controls. In contrast, expression of TNF-alpha, GM-CSF, IL-10, and IL-6 was variable in LIP tissues and controls. In addition, clonality of the B-cell population was evaluated by VDJ-PCR. A polyclonal B-cell population was shown in all five biopsies from five patients with LIP; and in one patient with concurrent LIP and MALT lymphoma, a band of increased intensity was observed in the LIP biopsy that was identical in size to the monoclonal band in the concurrent MALT lymphoma biopsy. These results provide evidence of high-level expression of certain chemokines in lymphoid interstitial pneumonitis tissues and suggest that chemokines and cytokines may play an important role in the recruitment of inflammatory cell infiltrates into these tissues. In addition, LIP may represent an early stage of MALT lymphoma or an immunologic response to a chronic antigenic stimulus that may provide a milieu or microenvironment for the evolution of a monoclonal B-cell population.

Ocular manifestations of infection with the human immunodeficiency virus in an African pediatric population

PURPOSE

To describe the ocular manifestations of HIV/AIDS infection in an African pediatric population.

METHODS

From 1984 to 1990, all children with HIV infection attending the Department of Pediatrics of the 'Centre Hospitalier de Kigali', Rwanda, were referred to the Department of Ophthalmology for ophthalmic examination.

RESULTS

A total of 162 HIV-infected children were examined. The overall rate of ophthalmic involvement was 54%. The most common finding was a perivasculitis of the peripheral retinal vessels, observed in 38% of the patients. Cytomegalovirus (CMV) infection of the retina was diagnosed in three patients. Isolated cotton-wool spots of the retina were not observed. Ophthalmic herpes zoster and conjunctival xerosis responding to vitamin A administration were each seen in two patients. One third of a subset of children tested for lacrimal function had evidence of decreased tear secretion.

CONCLUSION

Our data, in agreement with other series reported in the literature, indicate that cotton-wool spots and CMV retinitis, the most common ocular manifestations of HIV/AIDS in adults, are much less prevalent in children. The high incidence of perivasculitis in the present series, not observed or only seen in a few cases in other series, suggests that this ocular sign is more prevalent in African children. Our working hypothesis is that perivasculitis of the retinal vessels, lymphoid interstitial pneumonitis, parotitis, and lacrimal gland involvement are the expression of a diffuse infiltrative lymphocytosis syndrome, similar to what has been described in adults.

Prospective cohort study of children born to human immunodeficiency virus-infected mothers, 1985 through 1997: trends in the risk of vertical transmission, mortality and acquired immunodeficiency syndrome indicator diseases in the era before highly active antiretroviral therapy

OBJECTIVES

To assess changes in the risk of vertical transmission of HIV and changes in both mortality and morbidity among children in southern Connecticut with HIV infection after the introduction of treatment of HIV-infected pregnant women with antiretroviral drugs and of regimens to prevent or to treat AIDS indicator diseases in infected children.

METHODS

The risk of vertical transmission of HIV, the rates of death and of AIDS indicator diseases and temporal trends in each were determined for children born in the first 5 years of a prospective, longitudinal cohort study (Period 1: December 1, 1985, through November 30, 1990) compared with those for children born during the latter 7 years of the study (Period 2: December 1, 1990, through November 30, 1997).

RESULTS

Of 347 infants enrolled, HIV infection status could be determined for 341; 44 (12.9%) were infected. The risk of vertical transmission declined from 20.7% among children born in Period 1 to 6.5% among children born in period 2 (rate ratio, 3.2; 95% confidence interval, 1.7 to 6.0; P = 0.0001). Of the 21 infected children who died, 11(52%) were < or =18 months of age and 18 (86%) were < or =36 months of age at the times of death. Approximately one-fourth of infected children born during each period died at < or =18 months of age. Among those < or =36 months of age, 15 deaths occurred during 878 person months of observation for those born in Period 1 compared with 3 deaths that occurred during 334 person months for those born in Period 2 (rate ratio, 1.9; 95% confidence interval, 0.5 to 10.3; P = 0.45). Of the 44 children infected with HIV, 32 had one or more AIDS indicator diseases (a total of 67 episodes), 73% of which occurred when the children were < or =36 months of age. Among children born in Period 2, none developed Pneumocystis carinii pneumonia and the rates of Mycobacterium avium complex disease and of wasting syndrome declined, but the differences in rates of disease were not statistically significant.

CONCLUSION

A substantial and statistically significant decline in the risk of vertical transmission of HIV-1 occurred during the 12-year study period. In contrast although there was a trend toward a decrease in mortality among HIV-infected children < or =36 months of age and changes in the overall rates of AIDS indicator diseases among children born in Period 1 compared with Period 2, the differences were not statistically significant.

Invasive pneumococcal disease in the immunocompromised host

A normal constituent of the human upper respiratory flora, Streptococcus pneumoniae also produces respiratory tract infections that progress to invasive disease at high rates in specific risk groups. The individual factors that contribute to the development of invasive pneumococcal disease in this distinct minority of persons, include immune (both specific and innate), genetic, and environmental elements. Specific defects in host responses may involve age, deficiencies in levels of antibodies and complement factors, and splenic dysfunction. Combinations of these immune defects contribute to the increased rates of invasive pneumococcal disease in patients with sickle cell disease, nephrotic syndrome, neoplasms, and underlying medical conditions such as diabetes and alcoholic liver disease. The number of risk factors are greatest and the rates of invasive disease are highest in patients with HIV-1 infection, which has emerged as a major risk factor for serious S. pneumoniae infection worldwide.

Nutrition in paediatric human immunodeficiency virus infection

The nutritional condition of children with human immunodeficiency virus (HIV) infection continues to be a problem both in developed and developing countries. HIV-infected children grow below normal standards in both height and weight when compared with HIV-exposed non-infected children. These patterns persist over time. It is possible that acute infectious episodes and increased HIV viral burden contribute to decrements in all growth variables. Potential aetiologies for abnormal growth include inadequate dietary intake, gastrointestinal malabsorption, increased energy utilization and psycho-social problems. It is likely that all these factors contribute to the growth problems of these children to some extent. With the development of protease inhibitor anti-retroviral therapy and highly-active anti-retroviral treatment regimens, children with HIV infection in developed countries are living longer with a chronic illness. New nutritional problems have arisen with the development of the fat redistribution syndrome or lipodystrophy. Emerging problems are now being recognized, with the development of insulin resistance and truncal obesity which may potentially lead to premature cardiovascular disease.

Are there clinical and laboratory predictors of 5-year mortality in HIV-infected children and adolescents with hemophilia?

To determine factors associated with survival in a cohort of HIV-infected children and adolescents with hemophilia, an analysis of the 5-year mortality data for 207 HIV-infected young men was performed to examine the effect of selected clinical covariates on survival. The subjects were enrolled into the Hemophilia Growth and Development Study cohort from 1989 to 1990. Estimated mean time since infection at baseline was 6.7 years and mean estimated age at infection was 6.5 years. The baseline characteristics examined for their association with the hazard of death over the 5-year follow-up period were the following: absolute CD4+ cell count, hemoglobin status, skin test anergy, results of brain magnetic resonance imaging, non-hemophilia-related muscle atrophy (NHRMA), height for age, and impaired neuropsychological functioning as measured by the Vineland Adaptive Behavior and the Pediatric Behavior Scales. In all, 66 deaths occurred over the 5-year follow-up, 62 of whom met the 1987 (n = 56) or 1993 (n = 6) U.S. Centers for Disease Control and Prevention (CDC) definition of AIDS. Although each of the characteristics listed previously significantly increased the hazard of death by Cox proportional hazard regression models, only NHRMA remained a significant predictor of AIDS-related death when added to models that included each of the other cited baseline covariates.

HIV in the neonate

Mother-to-infant transmission of human immunodeficiency virus (HIV) is a worldwide problem. Between 7 and 40% of infants born to HIV-positive mothers become infected. The prognosis of these infants is poor, with most developing early and rapidly progressive disease. A number of advances in diagnosis and therapy offer opportunities to reduce the rate of vertical transmission and to improve the outlook of infected infants. Antiretroviral therapy during pregnancy and the neonatal period can markedly reduce the risk of mother-to-infant transmission. Recognition that 50% or more of infections are transmitted peripartum offers scope to further reduce the rate of transmission. However there is currently no consensus on the optimal management of pregnancy in HIV-infected women, and there is an urgent need for large randomized controlled trials. The development of polymerase chain reaction and p24 antigen assays has greatly facilitated the diagnosis of neonatal HIV infection, thereby enabling earlier supportive and anti-retroviral therapy. The place of zidovudine in paediatric HIV infection is now well-established, but the future will undoubtedly bring combination anti-retroviral therapy. Optimism about the prospects for developments in the prevention and treatment of paediatric acquired immunodeficiency syndrome must be tempered by the fact that the majority of cases occur in countries where patients have little or no access to medical care.

Diagnostic value of multimodal evoked potentials in HIV-1 infected children

Evoked potentials (EP) help guide the diagnosis of central nervous system involvement in demyelinating pathologies regarding both children and adults, and in human immunodeficiency virus-1 (HIV-1) correlated pathologies only in regard to adult patients. EP have been shown to be useful in highlighting early signs of the disease. We therefore studied EP in HIV-1 infected children with the aim of verifying the association of results with disease progression, clinical signs and electroencephalogram, and individualizing the most reliable test. Thirty-six patients (20 male and 16 female subjects, age range: 10 months to 12 years) belonging to a group of 45 symptomatic subjects seen at the Pediatric Department were included into the study from November 1991 to December 1994. Ten presented with neurological signs as of disease onset, eight others developed encephalopathy during the follow-up. One hundred seventeen EP, i.e., 27 pattern visual, 64 flash visual and 26 brain stem auditory EP, were recorded. Univariate statistical analysis using the Wilcoxon-Mann-Whitney U test and Student's t test was done. As a whole, we found 22.5% of abnormal EP in subjects without neurological signs and 28.3% in subjects with neurological signs. Results that were obtained suggested a close relationship between both the pattern of visual and brain stem auditory EP exams and disease progression.

Multilocular thymic cysts in children with human immunodeficiency virus infection: clinical and pathologic aspects

BACKGROUND

Children with human immunodeficiency virus (HIV) infection have an increased susceptibility to severe and unusual infections, malignancies, and disorders characterized by abnormal lymphoproliferation (e.g., lymphoid interstitial pneumonitis). We report a novel disease entity associated with pediatric HIV infection that is characterized by massive enlargement of the thymus as a result of lymphoid hyperplasia and multicystic changes.

METHODS

Eight patients with HIV infection and cystic enlargement of the thymus are subject of this report. The status of their HIV disease and its clinical and radiologic manifestations at the time of diagnosis of the mediastinal mass are described. Tissue specimens were obtained from six patients and examined by microscopy and immunohistochemistry. The specimens were also evaluated for the evidence of HIV and Epstein-Barr virus by in situ hybridization.

RESULTS

Patients were between 2.1 and 12.1 years of age, with CD4+ cell counts between 102 and 733 cells/mm3. In all eight cases an anterior mediastinal mass was discovered incidentally on radiography of the chest, and computed tomography of the chest revealed a multicystic appearance. Histologic examination demonstrated distortion of the thymic architecture by focal cystic changes, lymphoid follicular hyperplasia, diffuse plasmacytosis, and multinucleated giant cells. In situ hybridization revealed HIV particles on the surface of follicular dendritic cells. Further, results of in situ hybridization for EBV were positive in lymphoid cells from biopsy samples of four patients. The patients were followed between 8 months and 4.8 years. In five patients the mass either decreased in size or resolved completely.

CONCLUSIONS

We describe a series of children with HIV infection and multilocular thymic cysts. We hypothesize that aberrant immunoregulation in these HIV-infected children leads to follicular hyperplasia and multicystic changes in the thymus, causing massive enlargement. EBV infection might also contribute to the pathogenesis of this process. Because none of our patients had symptoms from the mass, and there was no evidence of malignancy in the examined biopsy samples, it seems prudent to manage such children with careful follow-up examinations.

Neurodevelopmental outcomes of Ugandan infants with human immunodeficiency virus type 1 infection

BACKGROUND

The neurodevelopmental outcomes of human immunodeficiency virus type 1 (HIV-1)-infected Ugandan infants of nondrug-using mothers were studied using controlled, prospective methodology.

METHOD

The sample of 436 full-term infants included 79 HIV-infected infants of HIV-1-infected mothers, 241 uninfected infants of HIV-1-infected mothers (seroreverters), and 116 uninfected infants born to HIV-negative mothers. Neurologic status, information processing ability, and motor and mental development were assessed from 6 to 24 months of age. Observations of caretaker-child interaction and home environments were made at 6 and 12 months. All evaluators were blinded to the HIV status of the child and family.

RESULTS

Compared with seroreverters and uninfected infants, HIV-infected infants demonstrated greater deficits in motor development and neurologic status, and more frequent and earlier onset of motor and neurologic abnormalities. Compared with controls, HIV-infected infants had more abnormalities in mental development at 6 and 18 months and an earlier onset of abnormalities. By 12 months, 30% of HIV-infected infants demonstrated motor abnormalities and 26% cognitive abnormalities as compared with 11% and 6% among seroreverters and 5% and 6% among seronegative infants. HIV-infected infants (62%) demonstrated a higher probability of developing an abnormal neurologic examination by 12 months, compared with seroreverters (17%) or seronegative infants (15%). Information-processing abilities did not differ as a function of HIV infection. Home environments and infants' interactions with caretakers were similar across groups.

CONCLUSION

We conclude that HIV infection results in more frequent and earlier abnormalities in infants' neurologic status and motor development that are not attributable to other biological and environmental risk factors. More frequent mental developmental abnormalities were evident at several ages. However, information-processing abilities, such as recognition memory, may be spared from HIV-related deficits.

Epidemiologic principles in studies of infectious disease outcomes: pediatric HIV as a model

Epidemiologic principles have been employed in the investigation of AIDS since the early 1980s. Although such principles have demonstrated the difficulties in reporting the everchanging rates of incidence and prevalence, in addition to distributions of children with HIV, they have also established specific pieces of a multifaceted puzzle. Professionals interested in examining only a piece of the puzzle, such as a particular communication disorder, often are unable to see how it fits into the complete puzzle. This article presents several epidemiologic findings of pediatric HIV, including population distributions, a summary of modes of transmission, occurrence of opportunistic infections, and manifestations of the disease in child populations. It also discusses HIV-related speech, language, swallowing, and voice disorders, examining the complexities of quantification of risk for each piece within the pediatric HIV puzzle. The purpose is to broaden the perspective of professionals concerned with how these disorders fit within the overall puzzle of immunocompromised populations of children.

Oral aspects of HIV infection in children

Most infants with congenital HIV infection appear normal at birth. Clinical difficulties usually begin as the first year proceeds, and in about half of the children oral manifestations are the first signs. Oral manifestations are commonly found in HIV-positive asymptomatic and pediatric AIDS patients, they are the earliest clinical signs of HIV infection and disease progression in children, and may be used as diagnostic markers, especially in developing countries. Studies have established an accurate association between oral manifestations and progression of HIV disease in children. Since the mouth is easily accessed for clinical examination, the important oral signs should be utilized in the diagnosis and early intervention of AIDS in these vulnerable populations.

HIV in children

Because children acquire HIV infection differently than adults, this article begins with a discussion of the epidemiology of AIDS in children. This is followed by a discussion of factors related to progression of the disease and survival in pediatric AIDS. A discussion of the pulmonary manifestations in children is followed by a suggested approach to the HIV-infected child with respiratory symptoms.

Clinical and laboratory characteristics of a large cohort of symptomatic, human immunodeficiency virus-infected infants and children. AIDS Clinical Trials Group Protocol 152 Study Team

BACKGROUND

A large cohort of antiretroviral therapy-naive, symptomatic, HIV-infected children were enrolled into a controlled therapeutic trial (AIDS Clinical Trials Group Protocol 152), providing an opportunity to describe their clinical and laboratory characteristics and determine age-related distinctions.

METHODS

Study entry evaluations for 838 of 839 enrolled children were analyzed. Weight, head circumference (if < 30 months of age), neuroradiologic imaging of the head, developmental or cognitive status and neurologic examination were assessed. Laboratory studies included hemoglobin, absolute neutrophil count, CD4 cell count, serum amylase, alanine aminotransaminase, p24 antigen and HIV blood culture. Data were categorized by age (3 to < 12 months, 12 to < 30 months, 30 months to 6 years and > or = 6 years).

RESULTS

Younger children had significantly higher rates of abnormalities before antiretroviral therapy, especially factors relating to growth and neurologic or cognitive function. Lower CD4+ cell counts and percentages as well as a positive serum p24 antigen correlated with lower weight-for-age Z scores and developmental indices.

CONCLUSIONS

These data provide a description of the clinical characteristics of HIV-infected US children at the time antiretroviral therapy is initiated for HIV-related symptoms. The high rate of abnormalities of growth, development and cognitive ability that were observed in children < 30 months of age demonstrates that treatment strategies should be developed for earlier intervention.

Iron deficiency and intestinal malabsorption in HIV disease

Children with human immunodeficiency virus (HIV) infection have a higher prevalence of intestinal malabsorption. Anemia is also a common feature in these children. The aims of this work were (a) to establish the prevalence of iron deficiency in HIV-infected children, (b) to test the hypothesis that iron deficiency is related to intestinal malabsorption, (c) to see whether it may contribute to anemia, and (d) to evaluate the sensitivity of oral iron load in the investigation of intestinal function. To accomplish these goals, 71 HIV-infected symptomatic children were enrolled. Iron serum values were determined before and after oral load with ferrous sulfate. The correlation between basal and post-load iron levels was evaluated by linear regression. Xylose level after oral load, fecal fat, and fecal alpha 1-antitrypsin concentration were also determined. Iron deficiency was detected in 48% of patients, and it was significantly associated with intestinal iron malabsorption. Sugar malabsorption, steatorrhea, and fecal protein loss were detected in 26, 36, and 17% of patients, respectively. Low hemoglobin levels were detected in 66% of patients. The majority of children with iron deficiency also had anemia. Preliminary data showed that oral iron administration was sufficient for raising hemoglobin in children with normal iron absorption, whereas parenteral administration was required in those with iron malabsorption. We conclude that (a) iron deficiency is a major feature of pediatric HIV infection, (b) it is related to intestinal malabsorption, and (c) it contributes to anemia. Finally, oral iron load is a sensitive test for investigating intestinal function.

Disease patterns and survival after acquired immunodeficiency syndrome diagnosis in human immunodeficiency virus-infected children

BACKGROUND

The clinical manifestations of HIV infection in children involve a broad spectrum of conditions ranging from mild symptoms to AIDS. Knowledge of the disease and survival patterns of these children are needed to plan for future needs and develop baseline information to evaluate newer prophylactic or therapeutic management options.

OBJECTIVES

To identify AIDS-defining conditions and estimate post-AIDS diagnosis survival among HIV-infected children.

METHODS

Disease patterns and survival after the diagnosis of AIDS-defining conditions were studied in 126 children who were identified through a multisite university-based active surveillance system in California from January, 1989, through August, 1993. Hospital medical records were periodically reviewed and data were abstracted onto standardized forms designed for pediatric HIV surveillance. We determined the length of survival between AIDS diagnosis and death and evaluated the impact of disease patterns on survival using Kaplan-Meier's product-limit method and Cox proportional hazards regression.

RESULTS

The median age at diagnosis was 13 months for children with perinatally acquired infection and 101.5 months for children infected through other routes of transmission. Pneumocystis carinii pneumonia and lymphoid interstitial pneumonia were the most common AIDS-defining conditions among perinatal cases, whereas the disease patterns observed among nonperinatal cases were more varied. The median postdiagnosis survival for the cohort was 26 months.

CONCLUSIONS

Survival time did not differ significantly by race/ethnicity, sex or route of transmission. Respiratory candidiasis and wasting syndrome had significant negative impact on survival but P. carinii pneumonia was not associated with shorter survival. Zidovudine or other antiviral therapies was associated with increased survival.

The diagnosis of congenital infections: contemporary strategies

Congenital infections remain an important source of neurologic, ophthalmologic, and audiologic disability for thousands of children throughout the world. This review summarizes the clinical features and describes contemporary approaches to the microbiologic diagnosis of congenital infections. In particular, this review emphasizes the important roles that molecular methods, especially the polymerase chain reaction, have in detecting the many infectious agents capable of damaging the developing nervous system.

Broadly neutralizing, MN-like PND-directed antibodies in Rwandan children with long-term HIV1 infection

Sera from 11 perinatally HIV1-infected Rwandan children with prolonged survival were tested in vitro for the presence of neutralizing antibodies against different HIV1 strains. These 11 sera from long survivor (LS) children were compared with 16 sera from Rwandan children with AIDS. Sera from HIV1-infected children exhibited the greatest neutralizing activity against HIV1MN cell-free infection. They also inhibited HIV1RII and HIV1LAI cell-free infection with lower titres. Higher neutralization titres were observed in sera from LS compared to the AIDS group, with a significant difference for HIV1MN and HIV1LAI strains. Sera from LS children also inhibited syncytium formation induced by HIV1MN-infected cells with higher titres than AIDS children. Sera from the HIV1-infected children showed reactivity to the HIV1MN V3 peptide, as well as to both the US/European and the African consensus V3 peptides. Higher reactivity was observed in sera from LS than from AIDS children, and the difference was significant toward the African consensus peptide. The LS children also had significantly higher V3MN IgG avidity than the AIDS children. These data support the notion that the humoral response to the V3 domain, associated with a broadly neutralizing activity, may be an important factor in the prolonged survival of these children. The specificity against HIV1MN also suggests that an antigenically MN-related strain may be prevalent in Rwanda, and that an MN-related principal neutralizing domain sequence could be an important determinant for candidate vaccines in this part of Africa.

Mother-to-infant HIV transmission: timing, risk factors and prevention

Identifying when--during pregnancy, delivery or the postnatal period--transmission of human immunodeficiency virus (HIV) from mother to infant usually takes place is critical to the development of methods to prevent maternal-infant transmission. Evidence is reviewed in this paper as to whether transmission occurs prepartum (early or late in gestation), intrapartum, or postpartum with breast feeding. Evidence in support of the notion of prepartum transmission has come from isolation of HIV from aborted fetal organs, comparison of maternal-child viral genotypes and study of neonatal cell-mediated immune responses. Evidence against prepartum transmission is that fewer than half of the children later known to be HIV-infected can be identified by virological tests carried out close to birth. A reduced rate of transmission in infants delivered by Caesarean section, and a reduced risk of transmission to second-born twins delivered vaginally, offers support to the view that intrapartum factors influence the risk of HIV transmission. Transmission through breast feeding can occur if a mother is infected postpartum and seems to pose some additional risk if she is already infected at parturition. The risk of infection increases with the stage of maternal HIV disease, but specific immunological, clinical and viral characteristics need to be investigated further. A clinical trial of zidovudine, used during late pregnancy and delivery and given to the infant at birth, has reported a significant reduction in transmission. Primary prevention of HIV infection in women remains a principal priority.

Assessment and psychotherapeutic intervention for an HIV-infected preschool child

Pediatric acquired immunodeficiency syndrome (AIDS) is becoming more common. Moreover, human immunodeficiency virus (HIV) positive status in multiple family members is common and complicates disease management. Practitioners treating these children are often unaware of the effect of the virus on the child's psychological, cognitive, and emotional functioning. In addition, children with AIDS frequently come from families facing pressing social problems, including homelessness, poverty, and drug addiction. HIV-positive children thus confront such diverse issues as the deterioration of developmental skills, social ostracism, and the possibility of imminent death, placing them in a socioemotional crisis. This paper presents a comprehensive psychotherapeutic intervention for such children.