Benefits of antibiotic prophylaxis in children with chronic sinusitis: assessment of outcome predictors

Immunoglobulin Replacement Therapy Versus Antibiotic Prophylaxis as Treatment for Incomplete Primary Antibody Deficiency

Background

Patients with an IgG subclass deficiency (IgSD) ± specific polysaccharide antibody deficiency (SPAD) often present with recurrent infections. Previous retrospective studies have shown that prophylactic antibiotics (PA) and immunoglobulin replacement therapy (IRT) can both be effective in preventing these infections; however, this has not been confirmed in a prospective study.

Objective

To compare the efficacy of PA and IRT in a randomized crossover trial.

Methods

A total of 64 patients (55 adults and 9 children) were randomized (2:2) between two treatment arms. Treatment arm A began with 12 months of PA, and treatment arm B began with 12 months of IRT. After a 3-month bridging period with cotrimoxazole, the treatment was switched to 12 months of IRT and PA, respectively. The efficacy (measured by the incidence of infections) and proportion of related adverse events in the two arms were compared.

Results

The overall efficacy of the two regimens did not differ (p = 0.58, two-sided Wilcoxon signed-rank test). A smaller proportion of patients suffered a related adverse event while using PA (26.8% vs. 60.3%, p < 0.0003, chi-squared test). Patients with persistent infections while using PA suffered fewer infections per year after switching to IRT (2.63 vs. 0.64, p < 0.01).

Conclusion

We found comparable efficacy of IRT and PA in patients with IgSD ± SPAD. Patients with persistent infections during treatment with PA had less infections after switching to IRT.

Clinical Implication

Given the costs and associated side-effects of IRT, it should be reserved for patients with persistent infections despite treatment with PA.

Electronic supplementary material

The online version of this article (10.1007/s10875-020-00841-3) contains supplementary material, which is available to authorized users.

Immunohistochemical Analysis of Mononuclear Inflammatory Cells in Nasal and Sinus Epithelium in Children with Sinusitis

The etiology and pathophysiology of both recurrent acute and chronic sinusitis in children are not well understood. To investigate this problem, the nature and magnitude of the local cellular inflammatory response was evaluated in the sinus mucosa of 34 children (25 with chronic sinusitis and 9 with recurrent acute sinusitis), of which 27 are atopic and 7 are nonatopic. In addition, sinus mucosa from three patients who underwent sinus surgery for noninfectious sinus disease (two with antral choanal polyp and one with facial pain syndrome) was studied for comparison and “controls. “ Immunohistochemical methods were used to identify phenotypically distinct mononuclear cells subpopulations (B cells, T cells, macrophages, and MHC class II antigen presenting cells) in the epithelium, stroma, and periglandular compartments of the uncinate and ethmoid mucosal tissue layers. Eosinophils were assessed in the same sinus mucosal tissue compartments and in nasal secretions. For all patients, most of the inflammatory cells were found in the stroma. MHC class II positive cells and T cells were found in the epithelium of greater than 50%, and in the stroma of almost 100% of either the uncinate or ethmoid mucosa. Of interest, the local accumulation of tissue eosinophils and/or their presence in nasal smears was not closely linked to the presence of atopy. In three patients with noninfectious sinusitis, the majority of inflammatory cells had also accumulated in the stroma; the mononuclear cell subset composition in those controls was indistinguishable from the sinusitis population. No difference in the number and distribution of any inflammatory cell subset was noted with respect to clinical classification, atopy or immunocompetency profile in our patient population. These observations indicate that the mucosal surfaces studied were likely to have been immunocompetent. Taken together, the uniformly modest local inflammation and the similarity of cell subpopulations in patients with different clinical profiles suggest that local inflammatory mechanisms may not account for clinical differences in the pathophysiology of sinusitis.

Antibiotics for preventing lower respiratory tract infections in high-risk children aged 12 years and under

BACKGROUND

Lower respiratory tract infections (LRTIs) in young children account for 1.4 million deaths annually worldwide. Antibiotics could be beneficial in preventing LRTIs in high-risk children, and may also help prevent school absenteeism and work days missed by children and/or carers. While it is well documented that the efficacy of antibiotic prophylaxis for RTIs decreases over time, there are no reviews that describe the use of antibiotic prophylaxis to prevent LRTIs in high-risk children aged 12 years and under.

OBJECTIVES

To assess the effectiveness and safety of antibiotic prophylaxis in the prevention of bacterial LRTIs in high-risk children aged 12 years and under.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2015, Issue 1) and the Database of Abstracts of Reviews of Effects (DARE), MEDLINE and MEDLINE In-Process (OvidSP) (1946 to 13 February 2015), EMBASE (OvidSP) (1974 to 12 February 2015), Science Citation Index Expanded (1945 to 13 February 2015) and Conference Proceedings Citation Index-Science (Web of Science Core Collection) (1990 to 13 February 2015). We searched for ongoing studies on ClinicalTrials.gov and the World Health Organization ICTRP. We handsearched the bibliographies of retrieved full texts of relevant studies.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing oral or intravenous antibiotics versus placebo or no treatment to prevent infections in high-risk children aged 12 years and under. We used a combination of the Centers for Disease Control and Prevention (CDC), National Health Service (NHS), American Academy of Paediatrics (AAP) and National Institute for Health and Care Excellence (NICE) guidelines to define conditions at higher risk of complications. Our primary outcome was the incidence of bacterial lower respiratory infections. Secondary outcomes included clinical function, hospital admission, mortality, growth, use of secondary antibiotics, time off school or parental work, quality of life and adverse events.

DATA COLLECTION AND ANALYSIS

We extracted data using a customised data extraction sheet, assessed the risk of bias of included studies using the Cochrane 'Risk of bias' criteria, and used the GRADE criteria to rate the quality of the evidence. We used a random-effects model for meta-analysis. We presented the results narratively where we could not statistically combine data.

MAIN RESULTS

We included 10 RCTs of high-risk children using antibiotics (azithromycin, ciprofloxacin, co-trimoxazole, isoniazid, oral penicillin V or vancomycin) to prevent LRTIs. Three studies included HIV-infected children (n = 1345), four cystic fibrosis (n = 429) and one each sickle cell disease (n = 219), cancer (n = 160) and low birth weight neonates with underlying respiratory disorders (n = 40). The study duration ranged from seven days to three years. The quality of the evidence from studies including children with HIV infection, cystic fibrosis or cancer was moderate. Due to inadequate data, we were unable to rate the quality of the evidence for two studies: one in children with sickle cell disease (low risk of bias), and another in low birth weight neonates with underlying respiratory disorders (high risk of bias).In HIV-infected children receiving continuous isoniazid prophylaxis, there was no significant difference in the incidence of pulmonary tuberculosis (risk ratio (RR) 0.64, 95% confidence interval (CI) 0.32 to 1.29, I(2) statistic = 47%, P value = 0.21). There was no significant effect on mortality with co-trimoxazole or isoniazid prophylaxis (RR 0.82, 0.46 to 1.46, I(2) statistic = 76%, P value = 0.58); however, analysis of one study that used co-trimoxazole showed a significant reduction in mortality (RR 0.67, 95% CI 0.53 to 0.85, P value = 0.001). There was a significant decrease in the rates of hospital admission per child-year of follow-up with co-trimoxazole prophylaxis in one study (P value = 0.01). There was no evidence of increased adverse events due to antibiotic prophylaxis (RR 1.10, 95% CI 0.75 to 1.64, I(2) statistic = 22%, P value = 0.28); however, there was scant reporting of antibiotic resistance - the one study that did assess this found no increase.In two studies of children with cystic fibrosis receiving ciprofloxacin prophylaxis, there was no significant difference in Pseudomonas infections (RR 0.76, 0.44 to 1.31, I(2) statistic = 0%, P value = 0.33). In two studies assessing the benefit of azithromycin prophylaxis, there was a significant reduction in the frequency of pulmonary exacerbations (RR 0.60, 95% CI 0.48 to 0.76, I(2) statistic = 0%, P value < 0.0001). The effect of antibiotic prophylaxis on growth in children with cystic fibrosis was inconsistent across the studies. There was an increased risk of emergence of pathogenic strains with either azithromycin or ciprofloxacin prophylaxis in two studies reporting this outcome. There was no significant difference in the quality of life (one study). In three studies, there was no significant increase in the frequency of adverse events with prophylaxis with azithromycin (two studies) or ciprofloxacin (one study). There was no evidence of increased antibiotic resistance in two studies.In the one study of children with sickle cell disease, a significantly lesser proportion of children with pneumococcal septicaemia was reported with penicillin V prophylaxis (P value = 0.0025).In the one study of children with cancer there was a significant decrease in Pneumocystis carinii pneumonia with trimethoprim-sulfamethoxazole prophylaxis (RR 0.03, 95% CI 0.00 to 0.47, P value < 0.01). There was no significant increase in the frequency of adverse events with antibiotic prophylaxis.In low birth weight children with underlying respiratory disorders, there was no significant difference in the proportion of children with pulmonary infection with vancomycin prophylaxis (P value = 0.18).No included studies reported time off school or carer time off work.

AUTHORS' CONCLUSIONS

There is inconclusive evidence that antibiotic prophylaxis in certain groups of high-risk children can reduce pneumonia, exacerbations, hospital admission and mortality in certain conditions. However, limitations in the evidence base mean more clinical trials assessing the effectiveness of antibiotics for preventing LRTIs in children at high risk should be conducted. Specifically, clinical trials assessing the effectiveness of antibiotics for preventing LRTIs in congenital heart disease, metabolic disease, endocrine and renal disorders, neurological disease or prematurity should be a priority.

Prospective, randomized comparison of OM-85 BV and a prophylactic antibiotic in children with recurrent infections and immunoglobulin A and/or G subclass deficiency

BACKGROUND

Patients with immunoglobulin (Ig)A and/or IgG subclass deficiency may be asymptomatic or may have recurrent, mainly respiratory infections.

OBJECTIVE

This study compared the clinical efficacy and tolerability of prophylactic therapy with either the oral immunomodulator bacterial extract OM-85 BV or benzathine penicillin G (BPG) in the prevention of recurrent infections in symptomatic patients.

METHODS

In this 26-month, prospective, randomized study conducted at the Department of Pediatric Immunology, Ege University (Izmir, Turkey), children aged 1 to 12 years with recurrent infections and IgA and/or IgG subclass deficiency were enrolled. After an initial 12-month control period, patients were randomized to receive OM-85 BV or BPG. OM-85 BV (3.5-mg capsule) was given once daily for the first 10 days of each month for the first 3 months of the study. IM injections of BPG were given at a dose of 1.2 million units (for patients with body weight > 27 kg) or at a half-dose (for patients with body weight ≤27 kg) every 3 weeks for 12 months. In nonresponders (ie, those who continued to have recurrent infections at 12-month follow-up), IV immunoglobulin (IVIG) replacement therapy at 400 mg/kg body weight was given every 4 weeks for an additional 12 months. The results of IVIG therapy were assessed by the authors using clinical observation. Adverse effects and adverse drug reactions were documented by the authors for each vaccine, prophylactic therapy, and IVIG.

RESULTS

A total of 91 children (56 boys, 35 girls; mean [SD] age at the start of the control period, 46.4 [31.0] months) were enrolled. Of these, 44 were randomized to the OM-85 BV group and 47 to the BPG group. The year before prophylactic therapy, the mean (SD) number of reported infections was 10.7 (3.6) and the mean (SD) number of antibiotic courses was 9.7 (3.6) (OM-85 BV group: mean [SD] number of reported infections, 10.5 [3.3]; mean (SD) number of antibiotic courses, 9.3 [3.3]; BPG group: mean [SD] number of reported infections, 10.8 [3.9], mean (SD) number of antibiotic courses, 10.1 [3.9]). At 12 months, the number of infections and antibiotic courses decreased significantly in the entire study population, but the between-group difference was not significant. Five patients in each group (OM-85 BV group, 11.4%; BPG group, 10.6%) were considered nonresponders and received IVIG treatment. Compared with responders, nonresponders were significantly younger (mean [SD] age, 34.40 [21.70] months vs 52.65 [30.52] months; P = 0.036) and had lower serum IgG (P<0.001), IgG1 (P = 0.006), IgG2 (P = 0.003), IgG3 (P = 0.035), and IgM (P = 0.008) levels and antibody responses to tetanus toxoid and Haemophilus influenzae type b (Hib) vaccines (P = 0.036 and 0.013, respectively). At 12-month follow-up, a protective effect of the prophylactic IVIG therapy was seen, with a statistically significant reduction in the number of infections to 3.3 (2.4) and in the number of antibiotic courses to 2.7 (2.5) (both P = 0.005).

CONCLUSIONS

In this study population of children with recurrent infections and IgA and/or IgG subclass deficiency, prophylactic therapy with either OM-85 BV or an antibiotic significantly decreased the number of infections per year. In addition, nonresponders benefited from IVIG replacement therapy.

Evidence for the diagnosis and treatment of acute uncomplicated sinusitis in children: a systematic review

In 2001, the American Academy of Pediatrics published clinical practice guidelines for the management of acute bacterial sinusitis (ABS) in children. The technical report accompanying those guidelines included 21 studies that assessed the diagnosis and management of ABS in children. This update to that report incorporates studies of pediatric ABS that have been performed since 2001. Overall, 17 randomized controlled trials of the treatment of sinusitis in children were identified and analyzed. Four randomized, double-blind, placebo-controlled trials of antimicrobial therapy have been published. The results of these studies varied, likely due to differences in inclusion and exclusion criteria. Because of this heterogeneity, formal meta-analyses were not performed. However, qualitative analysis of these studies suggests that children with greater severity of illness at presentation are more likely to benefit from antimicrobial therapy. An additional 5 trials compared different antimicrobial therapies but did not include placebo groups. Six trials assessed a variety of ancillary treatments for ABS in children,and 3 focused on subacute sinusitis. Although the number of pediatric trials has increased since 2001, there are still limited data to guide the diagnosis and management of ABS in children. Diagnostic and treatment guidelines focusing on severity of illness at the time of presentation have the potential to identify those children most likely to benefit from antimicrobial therapy and at the same time minimize unnecessary use of antibiotics

Role of antibiotics in sinusitis

PURPOSE OF REVIEW

Sinusitis is a leading reason for outpatient antibiotic use, but symptoms are nonspecific. We review potential methods that might enhance the ability to appropriately prescribe antibiotics.

RECENT FINDINGS

The evidence base for antibiotic use in acute rhinosinusitis is strongest in studies with stringent entry criteria. In less restrictive studies antibiotics and placebo perform equally. Bacteria from nasopharyngeal swabs in adults correlate with sinus cultures. A recent study showed that antibiotics shortened the duration of acute rhinosinusitis (ARS) symptoms in children. Tellingly, over 2000 children with symptoms were screened to enroll less than 10% who fulfilled the study's stringent criteria. In chronic rhinosinusitis (CRS), two grade 1 studies on efficacy of long-term macrolide therapy showed conflicting results. Odontogenic sinusitis is underappreciated and frequently fails to grow on culture because of presumed difficulty in growing anaerobes.

SUMMARY

There is currently no grade 1 evidence to support antibiotic use in CRS; however, studies to date have not been conducted in patients with isolated purulent sinusitis. Future use of cultures to direct antibiotic therapy, such as nasopharyngeal swabs in adults with ARS or endoscopically guided cultures, may aid in targeting antibiotic therapy more effectively.

Rhinosinusitis diagnosis and management for the clinician: a synopsis of recent consensus guidelines

Rhinosinusitis (RS) affects approximately 1 in 7 adults in the United States, and its effect on quality of life, productivity, and finances is substantial. During the past 10 years, several expert panels from authoritative bodies have published evidence-based guidelines for the diagnosis and management of RS and its subtypes, including acute viral RS, acute bacterial RS, chronic RS (CRS) without nasal polyposis, CRS with nasal polyposis, and allergic fungal RS. This review examines and compares the recommendations of the Rhinosinusitis Initiative, the Joint Task Force on Practice Parameters, the Clinical Practice Guideline: Adult Sinusitis, the European Position Paper on Rhinosinusitis and Nasal Polyps 2007, and the British Society for Allergy and Clinical Immunology. Points of consensus and divergent opinions expressed in these guidelines regarding classification, diagnosis, and management of adults with acute RS (ARS) and CRS and their various subtypes are highlighted for the practicing clinician. Key points of agreement regarding therapy in the guidelines for ARS include the efficacy of symptomatic treatment, such as intranasal corticosteroids, and the importance of reducing the unnecessary use of antibiotics in ARS; however, guidelines do not agree precisely regarding when antibiotics should be considered as a reasonable treatment strategy. Although the guidelines diverge markedly on the management of CRS, the diagnostic utility of nasal airway examination is acknowledged by all. Important and relevant data from MEDLINE-indexed articles published since the most recent guidelines were issued are also considered, and needs for future research are discussed.

Controversies in the treatment of chronic rhinosinusitis

Chronic rhinosinusitis (CRS) including nasal polyps is a chronic inflammatory disease involving the mucosa of the nose and one or more paranasal sinuses. Despite differing hypotheses, the cause remains poorly understood. The key issue is the maintaining of ostial patency. CRS with nasal polyps is considered to be a subgroup of CRS. Major symptoms are nasal congestion or blockage, loss of smell, rhinorrhea, post-nasal drip, and facial pain or pressure. CRS is associated with lower airway disease such asthma, chronic obstructive pulmonary disease and bronchiectasis. In CRS with and without nasal polyps, medical treatment, including nasal and oral corticosteroids, is the first therapeutic option. The treatment of CRS still remains an unmet need. Corticosteroids are the mainstay of treatment and are the most effective drugs for treating airway inflammatory diseases such as asthma, allergic rhinitis and CRS. Endoscopic sinus surgery is only recommended when medical treatment fails. After surgery, medical treatment, including nasal and oral corticosteroids, is recommended.

Expression profiling of inflammatory mediators in pediatric sinus mucosa

OBJECTIVE

To evaluate gene expression by microarray analyses of inflammatory mediators in the sinus mucosa of children with and without chronic rhinosinusitis (CRS).

DESIGN

Prospective molecular genetics analysis.

SETTING

Children's National Medical Center, Washington, DC.

SUBJECTS

Eleven patients with CRS who underwent endoscopic sinus surgery and 10 control children who underwent craniofacial resection or neurosurgical procedures.

MAIN OUTCOME MEASURES

Gene expression levels of sinus tissue from 6 patients with CRS and 6 controls and messenger RNA expression levels of upregulated inflammatory/immune response genes, as well as cytokines of interest, determined by quantitative reverse transcription-polymerase chain reaction.

RESULTS

Gene expression using the Plier algorithm yielded the most consistent grouping of samples: 96 genes were significantly upregulated more than 2-fold, and 123 genes were downregulated by at least 50% in the CRS sinus tissues compared with controls (P < .05). GeneSpring analysis demonstrated significant changes in several ontology categories in the CRS samples, including inflammatory/immune response genes. The chemokines CXCL13 and CXCL5, serum amyloid A, serpin B4, and defensin beta1 were highly upregulated (> or =5-fold). Increased expression of these genes was validated by quantitative reverse transcription-polymerase chain reaction in an independent set of tissues. Expression levels of interleukins 5, 6, and 8 were similar in both cohorts; these results were validated by reverse transcription-polymerase chain reaction.

CONCLUSIONS

Microarray analyses of sinus mucosa in children with CRS showed an increased expression of inflammatory genes involved in innate and adaptive immune systems. This technology can be successfully used to identify genes implicated in the pathogenesis of pediatric CRS.

Localization and expression of MUC5B and MUC7 mucins in pediatric sinus mucosa

OBJECTIVES

The purpose of this study was to analyze the secretory cell population and distribution of MUC5B and MUC7 mucins in the sinus mucosa of pediatric patients with and without chronic rhinosinusitis (CRS).

METHODS

Sinus mucosal specimens were collected at surgery in a pediatric tertiary care facility. Histologic, immunohistochemical, and morphometric analyses were performed on sinus mucosa of 20 children with CRS and 7 children without CRS.

RESULTS

A significant increase in the area of submucosal glands was evident in the sinus mucosa of children with CRS as compared to controls. MUC5B and MUC7 mucins were expressed in the submucosal glands, as well as in goblet cells, in the sinus mucosa of both populations. No differences in MUC5B or MUC7 expression were observed when mucin expression was normalized to glandular area.

CONCLUSIONS

Children with CRS have an increased number of submucosal glands, indicating that glandular mucins contribute to mucus overproduction in CRS. MUC5B and MUC7 mucins, which have previously been considered only glandular mucins, are also expressed in goblet cells in the sinus mucosa.

Immunohistochemical analyses of MUC5AC mucin expression in sinus mucosa of children with sinusitis and controls

OBJECTIVES

The purpose of this study was to analyze MUC5AC protein expression in sinus mucosal specimens of children with and without chronic sinusitis.

METHODS

Morphometric, histologic, and immunohistochemical analyses were carried out on sinus mucosa of 7 children with chronic sinusitis and 6 children without sinusitis.

RESULTS

MUC5AC protein was expressed in a subset of goblet cells in the surface epithelium, but not in the submucosal glands in either pediatric population. The number of goblet cells that expressed MUC5AC mucin was not significantly different in patients with and without chronic sinusitis. All specimens had similar numbers of goblet cells in the surface epithelium.

CONCLUSIONS

The data demonstrate that neither goblet cell hyperplasia nor increased MUC5AC expression occurs in the sinus mucosa of children with chronic sinusitis. This suggests that in contrast to asthma, in which goblet cell hyperplasia is present in the lower respiratory tract, mucus hypersecretion in pediatric chronic sinusitis may involve other secretory cells, eg, submucosal glandular cells, and mucins secreted by these glandular cells.

Maximal medical therapy for chronic rhinosinusitis

Chronic rhinosinusitis (CRS) is widely recognized as one of the most common, if not the most common, chronic disease entities. This article discusses CRS without nasal polyposis. The discussion of maximal medical therapy concentrates on the best available evidence from published clinical trials.

Primary immunodeficiency disorders: antibody deficiency

As a group, antibody deficiencies represent the most common types of primary immune deficiencies in human subjects. Often symptoms do not appear until the latter part of the first year of life, as passively acquired IgG from the mother decreases to below protective levels. As with the T-cell immune deficiencies, the spectrum of antibody deficiencies is broad, ranging from the most severe type of antibody deficiency with totally absent B cells and serum Igs to patients who have a selective antibody deficiency with normal serum Ig. In addition to the increased susceptibility to infections, a number of other disease processes (eg, autoimmunity and malignancies) can be involved in the clinical presentation. Fortunately, the availability of intravenous immune serum globulin has made the management of these patients more complete. Recently, molecular immunology has led to identification of the gene or genes involved in many of these antibody deficiencies. As discussed in this review, this has led to a better elucidation of the B-cell development and differentiation pathways and a more complete understanding of the pathogenesis of many of these antibody deficiencies.

Polypoid mucosa with eosinophilia and glandular hyperplasia in chronic sinusitis: a histopathological and immunohistochemical study

OBJECTIVE

To evaluate the histopathological and immunohistochemical characteristics of chronic sinusitis, with reference to the extent of sinus involvement.

STUDY DESIGN

A nonrandomized, retrospective, controlled qualitative and quantitative study.

METHODS

Twenty-nine adults with refractory chronic sinusitis underwent functional endoscopic sinus surgery. The score of computed tomography scans was used to determine the extent of disease. Six patients with normal sinus mucosae served as control subjects. Specimens underwent routine histological processing and hematoxylin-eosin and periodic acid-Schiff staining. Immunohistochemistry for T and B lymphocytes was applied. Low-magnification microscopy was designed to yield typical pathological features, and high magnification to count various inflammatory cells.

RESULTS

Patients were divided into two groups according to their dominant pathological features: 16 had polypoid mucosa and eosinophilia, and 13 had glandular hyperplasia. The number of eosinophils, T and B lymphocytes in the lamina propria was significantly higher in patients with polypoid mucosa and eosinophilia, compared with those with glandular hyperplasia and with normal control subjects, whereas the difference between patients with glandular hyperplasia and control subjects was insignificant. Although the overall inflammatory reaction was relatively modest, nasal polyposis was more prevalent in patients with polypoid mucosa and eosinophilia; likewise, computed tomography revealed a significantly more extensive disease in these patients compared with the patients with glandular hyperplasia.

CONCLUSION

Two pathophysiological pathways, inducing prolonged obstruction to the outflow of sinus secretion and ultimately causing chronic inflammation, are suggested: 1) swollen polypoid mucosa with activation of eosinophils that damage the epithelium and 2) continued increased mucus secretion originated from hyperplastic submucosal seromucous glands.

Follow-up of pediatric patients with recurrent infection and mild serologic immune abnormalities

BACKGROUND

Children with recurrent infections significant enough to warrant referral to an immunologist frequently have mild abnormalities of the humoral immune system. Parents of these children are generally reassured that their child will outgrow the clinical problems that prompted their referral.

OBJECTIVE

This is a retrospective study with the objective being to evaluate changes in immune measurements and clinical status of children with recurrent infections followed in an immunology clinic.

METHODS

Forty-two patients (mean age 60 months) previously evaluated for recurrent infections were re-evaluated after at least 12 months (mean 37 months). Initial evaluation studies included quantitative immunoglobulins in all patients and IgG subclass determinations and pre- and postvaccination pneumococcal polysaccharide antibody titers in a subpopulation of patients.

RESULTS

Patients were assigned to one of two categories: those with initial laboratory abnormalities (27 patients) and those with normal initial studies (15 patients). Among the patients with initial abnormalities, partial IgA deficiency was most commonly seen (20/27). It persisted in 15. Only 6/27 patients had studies that were completely normal on follow-up. Among patients with no initial abnormality, 9/15 developed a partial deficiency of at least one immunoglobulin isotype or IgG subclass. Eighty-six percent of the patients were clinically improved at the time of their last follow-up visit regardless of their laboratory values.

CONCLUSIONS

A high proportion of children with recurrent infection have persistent, partial immunoglobulin deficiencies lasting in some cases for years. Despite this finding almost all patients demonstrate clinical improvement with time.

Open trial of intravenous immune serum globulin for chronic sinusitis in children

BACKGROUND

Chronic sinusitis in children is a complex clinical problem. Some patients do not improve with medical therapy and some fail surgery as well.

OBJECTIVE

A therapeutic trial of intravenous immune serum globulin (IVIG) was given to children whose sinus disease was recalcitrant to the usual therapeutic modalities. The objective of IVIG administration was to modulate the inflammatory process contributing to the chronicity of the sinusitis.

METHODS

Six patients were given a 12-month trial of monthly (400 mg/kg) IVIG infusions. Entry criteria included persistence of sinusitis after 3 months of full course antibiotics, or two episodes of sinusitis within a 3-month period while on prophylactic antibiotics. All patients had abnormal sinus CT (computerized tomography) scans at entry. Three of the six patients remained symptomatic despite prior sinus surgery. Patients with primary immune deficiencies were excluded. Each patient served as his own control based on their previous 12-month history and clinical course. Four of the 6 patients were atopic as demonstrated by prick skin testing; however, all patients had nasal eosinophilia.

RESULTS

Full course antibiotic use decreased in five of the six patients (183 to 84 days); correspondingly, the episodes of sinusitis decreased (average 9 to 4 per year). In addition, sinus CT scans showed significant improvement.

CONCLUSION

This preliminary open-trial of IVIG suggests its usefulness as adjunct therapy to medical management in selected patients with chronic sinus disease. The mechanism(s) by which IVIG may be helpful is probably not based on the concept of replacement therapy, but more likely as an immune or inflammatory modulating agent.

Clinical classification as a guide to treatment of sinusitis in children

Evaluation of all 153 children undergoing CT scan of the paranasal sinuses for recalcitrant sinusitis symptoms between January 1988 and July 1992 was performed. Clinical categorization into groups of patients presenting with chronic sinusitis (CS) and recurrent acute sinusitis (RAS) was based upon pattern of disease and presentation. Clinical symptoms and signs, radiological examination, treatment, and outcome were compared between these distinct clinical groups. Eighty-two (55%) children were categorized as RAS and 68 (45%) as CS. Children with CS presented more frequently with a persistent cough, purulent nasal discharge, immune deficiency, and more severe mucosal disease on CT than children with RAS. Medical therapy successfully controlled the symptoms of sinusitis in 79 (96%) with RAS versus 27 (40%) with CS. Surgery was performed in 44 children: 3 (3.6%) with RAS versus 41 (60%) with CS, p < 0.01. At a mean follow-up of 2.0 years, >80% of all the children were either asymptomatic or improved regardless of treatment modality. These data support the use of clinical classification as a guide to medical versus surgical therapy in children with sinusitis.

Sinusitis in childhood

There is much to be learned about sinusitis in children. The appropriate choice and timing of diagnostic tests, correct type and duration of antibiotic treatment, role of allergy management and adjuvant drugs, and indications for and limits of endoscopic sinus surgery remain to be defined. Technological advances have been introduced and accepted as standard with little validation. Well-thought-out, controlled studies of diagnostic and treatment modalities are needed to address these issues and to better understand the function of the sinuses in health and illness.

Cell-mediated immune status of children with recurrent infection

OBJECTIVE

To evaluate the cell-mediated immune status of children with recurrent respiratory tract infections.

DESIGN

We evaluated the cell-mediated immune status of 76 patients referred because of recurrent infection. Patients were divided into those with serologic abnormalities and those without such findings. Twenty-three healthy children served as control subjects. Studies of lymphocyte phenotype included CD4+ CD29+ cells (an immunologically mature phenotype), lymphocyte proliferation studies, cytokine production including interleukin-2 (IL-2), IL-4, IL-6, and interferon gamma), and measurement of in vitro IgM and IgG synthesis.

RESULTS

Lymphocyte proliferation and T-cell phenotype were similar in both patient groups as well as in control subjects. The proportions of CD4+ CD29+ cells at different ages were similar in all groups. Patients with serologic abnormalities (e.g., partial IgA deficiency, partial IgG subclass deficiency) produced more IL-2 and IL-4 than did other patients. The control population had greater spontaneous IgM and IgG synthesis than the patient groups.

CONCLUSION

Routine studies of T-cell function of patients with recurrent infection provide little information useful in making clinical decisions.