Bictegravir/emtricitabine/tenofovir alafenamide in paediatrics: Real-life experience from a French cohort (2019-2023)

OBJECTIVES

Although widely recommended, data on bictegravir/emtricitabine/tenofovir alafenamide (BIC/FTC/TAF) efficacy in HIV-1-infected children/adolescents are mainly extrapolated from studies in adults and one paediatric trial in which subjects have good treatment adherence. This study aimed to provide data about the risk of virological failure (VF) and acquired genotypic resistance in children and adolescents receiving BIC/FTC/TAF in a real-world setting.

METHODS

This retrospective monocentric study included 74 paediatric patients who received BIC/FTC/TAF during ≥6 months in 2019-2023. VF was defined as not achieving a plasma viral load <50 copies/mL within 6 months of BIC/FTC/TAF initiation or as experiencing virological rebound ≥50 copies/mL.

RESULTS

Most patients were antiretroviral therapy (ART)-experienced (93.2%), previously exposed to integrase inhibitors (85.1%) and displayed viral suppression at baseline (67.6%). Their median age was 11.2 years [interquartile range (IQR): 8.8-15.2]. BIC/FTC/TAF introduction reduced treatment burden in most ART-experienced subjects. Genotypic susceptibility score of BIC/FTC/TAF was ≥2 in all cases. Median follow-up was 40 months (IQR: 21-46). VF occurred in 28 people (37.8%), more frequently in the case of VF versus viral suppression at baseline (68% vs. 26%, P = 0.02). BIC/FTC/TAF was interrupted for suspected intolerance in only one case (1.4%). Nucleoside reverse transcriptase inhibitor (NRTI) mutation (T69D/N) emerged in one patient (3.6% of VF) after 47 months of continuous detectable viraemia while on ART. No acquisition of mutations in the integrase gene was observed.

CONCLUSION

Because of its high genetic barrier to resistance, BIC/FTC/TAF could be especially useful in the paediatric population, in which the risk of poor treatment adherence and VF is high.

High rates of antiretroviral coverage and virological suppression in HIV-1-infected children and adolescents

OBJECTIVES

To assess the outcome of HIV-infected individuals attending one of the largest French pediatric HIV centers in 2016-2017 and to compare the rates of antiretroviral coverage and virological suppression with the UNAIDS targets.

PATIENTS AND METHODS

The clinical and immuno-virological status of 163 HIV-1-infected children and adolescents attending Necker Hospital in Paris, France, were investigated. Virological suppression was defined as an HIV-1 viral load<50 copies/mL for at least six months. All genotypic resistance tests performed since birth were analyzed.

RESULTS

Most patients were born in Sub-Saharan African countries (41.7%) or in France (38.0%). Their median age was 14 years [IQR 7.3-17.0]. Although 33.7% of individuals had a history of AIDS-defining clinical event(s), 86.5% of children/adolescents were free from HIV-related symptoms at their most recent evaluation. Antiretroviral coverage was high (98.2%; mainly including one integrase inhibitor [42.3%] or one protease inhibitor [23.9%]). At the last visit, most patients (82.8%) had normal CD4T lymphocytes counts (≥25%). Although 61.7% of antiretroviral-experienced children had resistance to≥1 drug class and 9.2% had triple-class resistance, 80.3% of patients receiving antiretrovirals for≥6 months (126/157) were virologically suppressed. International adoptees were more frequently virologically suppressed than other patients (96.0% versus 74.6%, P=0.02).

CONCLUSIONS

Antiretroviral coverage exceeded the second UNAIDS 90 target aimed at ending the AIDS epidemic. The rate of virological suppression, one of the highest reported in children in high-income countries, is approaching the third UNAIDS 90 target and the rate observed in French HIV-infected adults on antiretrovirals.

Is the French Emergency Medical Service System duplicable in developing countries?

Issue

The management of pre-hospital emergencies is a growing issue in developing countries, particularly because of the increase of both road accidents and cardio-vascular diseases.

Description of the problem

Numerous countries have tried or are currently trying to develop emergency response systems like the French SAMU but the outcome of those actions show a lot of difficulties. It is however proved that efficient care of serious pre-hospital medical emergencies significantly improves both patients’ mortality and morbidity.

Results

AP-HP, Greater Paris University Hospitals, has a strong experience of supporting the development of this model of care in countries with limited resources. Most of last 30 years’ experiments have been reviewed to understand what the essential prerequisites to succeed in setting up an emergency response system such as SAMU are. The analysis (5 criteria evaluation: efficiency, sustainability, effectiveness, impact, relevance) of past and present experiments in 28 countries showed that main issues are political (what are the priorities?), financial and societal (what does the population expect?). The question of medical resources is also crucial as the French model introduces medical regulation at all levels. Moreover, in France, such a system is built as a health care pathway with a predetermined orientation towards the appropriate and operational structure, which unfortunately is not the case in a lot of countries. Aside from those realized in China or in some Southern American countries, most of the projects so far don’t match all the evaluation criteria, particularly sustainability, as it is based both on stable funding and a strong reactivity of local hospitals.

Lessons

Future projects will have to fit with the local context. Strong commitments from partner countries must be made on the long term to have a real impact.

Key messages

There is no universal system easily duplicable. Some major prerequisites must be identified and implemented to succeed in the set-up of an efficient and sustainable EMSS.

Developing international inter hospital cooperation to reach the SDGs

Background

The current epidemiological transition creates news issues to address (NCD as oncology, cardiovascular, diabetes, road accidents...) and causes an important increase of skills transfer needs in resource-poor/intermediate countries. Hospital cooperation is an efficient way to help the partner country/city adapt and increase their quality of care.

Objectives

The aims were multiple: set up transfer skills programs, but also understand both obstacles and success factors of such projects over the long term. AP-HP’s (Greater Paris University Hospitals) Department of International Relations, has developed 3 year-long projects (financed in majority by public funders) which link one or more hospitals of our group to a southern hospital, on a precise topic. Our multidisciplinary teams then support the local professionals either by training them or assessing their current situation and proposing an action plan.

Results

Over those last 4 years, we built more than 50 cooperations, most of them being successful and still active today. 20 of our hospitals have been involved in at least one project. In 2018, we were working with more than 30 different countries. We noticed a growing interest both from our teams and new partners, over the years. In 2018, around 150 healthcare professionals from AP-HP took part in at least one mission abroad and more than 3 000 foreign professionals have been trained in various ways (from conferences to technical surgical skill transfer), including about 50 trained on site in Paris. These trainings are intended not only to physicians but also for midwives, nurses and managers.

Conclusions

Those projects have a good efficiency in a short term. Therefore, the risk of unsustainability is quite important. For the programs to be effective in the long run, there needs to be a collective involvement both from institutions and healthcare teams in the project on both sides.

Key messages

European hospitals should develop a strong international cooperation policy. AP-HP intends to intensify its work, being an efficient way of contributing to reach both SDG 3 and 9.

Similar efficacy and safety of dolutegravir between age groups of HIV-1-infected paediatric and young adult patients aged 5 years and older

OBJECTIVES

The aim of the study was to carry out a comparison of the safety and efficacy of dolutegravir-based regimens among age groups of HIV-1-infected paediatric and young adult patients.

PATIENTS AND METHODS

This retrospective monocentric study included 109 patients infected since childhood who began receiving dolutegravir between January 2014 and December 2017. The patients were divided into three groups according to age at the time of dolutegravir initiation: 5-11, 12-17 and 18-25 years old. The primary endpoint was the proportion of patients achieving a plasma viral load (PVL) < 50 HIV-1 RNA copies/mL within 3 months of dolutegravir initiation (for patients with detectable viraemia at baseline), and maintaining virological suppression (PVL < 50 copies/mL) until the last follow-up visit (for all patients).

RESULTS

Most of the subjects were antiretroviral-experienced (91.7%) and virologically suppressed at baseline (66.7%, 54.9% and 56.0% in the 5-11, 12-17 and 18-25 year age groups, respectively). Median follow-up was 24 months (range 6-54 months). Sustained virological success throughout follow-up was observed in 79.8% of patients, with similar rates among age groups (87.9%, 72.5% and 84.0%, respectively; P = 0.22). With reinforced measures to improve adherence, undetectable PVL was obtained at the last visit in 88.1% of patients, with similar proportions among age groups (93.9%, 84.3% and 88.0%, respectively; P = 0.51). No emergence of resistance mutations was observed in the 22 patients with virological failure. Dolutegravir was well tolerated; only one patient stopped treatment for severe drug-related side effects.

CONCLUSIONS

The virological efficacy and safety of dolutegravir were similar among the three age groups. Because of its high genetic barrier to resistance, dolutegravir could be especially useful in the paediatric population, in which the risk of poor treatment adherence is high.

Separation between HIV-positive women and their children: the French prospective study, 1986 through 1993

OBJECTIVES

We studied the risk and circumstances of separation (due to either maternal death or drug use) between women infected by human immunodeficiency virus (HIV) type 1 and their children.

METHODS

This analysis was based on the French Prospective Study of Infants Born to HIV-seropositive Women (1986 through 1993). Data recorded at each follow-up visit included the mother's effective presence with the child and the child's care after separation.

RESULTS

A child's cumulative risk of long-term or permanent separation from his or her mother was 37% at 60 months. Maternal drug use was associated with an added risk during the child's first years (adjusted relative risk [RR]=3.4, 95% confidence interval [CI]=2.3, 5.0). The risk among drug users was even higher when the mother used injection drugs during pregnancy (adjusted RR=2.9, 95% CI=1.9, 4.3). Risk of early separation related to drug use tended to diminish since survey initiation. After separation, 57% of the children were placed through child welfare services and 43% were cared for by relatives.

CONCLUSIONS

In the French Prospective Study, 2% to 3% of HIV-infected children were separated each year from their mothers as a result of the mothers death from acquired immunodeficiency syndrome (AIDS). Separations related to drug use have decreased over the years, and the family is becoming the most frequent carer after separation.

Chondrosarcoma of the larynx

A case of a low grade chondrosarcoma of the cricoid cartilage which had been diagnosed initially as a chondroma is presented. The tumour recurred twice after limited surgical resections. Total laryngectomy was inevitable due to near total involvement of the cricoid cartilage and subsequent histological examination revealed a low grade chondrosarcoma. We have discussed in brief, the diagnosis and treatment of chondrosarcomas of the larynx and support the view of conservative surgical management for low grade tumours as they are slow growing and metastases are infrequent. A total laryngectomy may be reserved for salvage or primarily when more than half of the cricoid cartilage needs to be resected. Histological grading reveals the biological behaviour of the tumour and CT scans help in planning the surgery. A regular follow-up is necessary for early detection of recurrences and metastases.

Long-term itraconazole prophylaxis against Aspergillus infections in thirty-two patients with chronic granulomatous disease

We conducted a prospective, open study of oral itraconazole therapy (5 and then 10 mg/kg per day) to assess tolerance and potential efficacy in preventing fungal infections in patients with chronic granulomatous disease. Thirty-two patients were enrolled in one center between 1985 and 1991. Tolerance was excellent in all cases. Poor compliance was suspected in three cases. Two patients were excluded from efficacy analysis because itraconazole was used as part of therapy for pulmonary aspergillosis. Of 30 patients, 3 developed a fungal (Aspergillus) lung infection, an incidence 3.4/100 patient-years versus 11.5 in a historical control group that did not receive any prophylaxis (p = 0.13) and 9.55 in a historical group of patients who received daily ketoconazole prophylaxis (p = 0.19). The percentage of patients infected with Aspergillus was significantly different: 10% in the itraconazole group versus 34.4% in the untreated group (p = 0.013). These results require further evaluation through a comparative randomized trial to assess the possible benefit of itraconazole prophylaxis in patients with chronic granulomatous disease.

[Acquired and constitutional neutropenia in children]

The evaluation of a neutropenia first must document its etiology. Besides the particular etiological aspects in the newborn, neutropenia in a child may be 1) acquired, 2) constitutional, part of a complex genetic disease, 3) constitutional, isolated. Primary acquired neutropenia, also called benign chronic neutropenia, is the most frequent cause of chronic neutropenia in children; it is usually well tolerated and has a frequent favorable outcome in 12-14 months. Many complex genetic diseases include a neutropenia, among which several immunologic disorders that must be ruled out before considering the diagnosis of isolated constitutional neutropenia. Infantile agranulocytosis is the main primary constitutional neutropenia. It may be sporadic or hereditary (autosomal recessive or dominant inheritance) and is present at birth. It is profound, usually < 0.5 G/l (< 500/mm3) and exposes to severe pyogenic and fungal infections. In the neonatal period neutropenia must primarily suggest a bacterial infection, although other etiologies have to be known, particularly neonatal neutropenia caused by passive transfer of maternal antibodies and neutropenia related to gravidic maternal hypertension. The treatment of severe chronic neutropenia is directed towards the prevention of infections. It includes prophylactic antibiotherapy, the most commonly used one being the trimetroprim-sulfamethoxazole association, and granulocyte colony stimulating factor (G-CSF). G-CSF has considerably improved the condition of patients; it is usually well tolerated, but secondary effects have been reported (hypersplenism, glomerulonephritis, osteoporosis, vasculitis), and a potential leukemogenic risk has been evoked.

Bacillus Calmette-Guérin infection after vaccination of human immunodeficiency virus-infected children

The use of Mycobacterium bovis/Bacillus Calmette-Guérin (BCG) to vaccinate against tuberculosis remains controversial. The development of tuberculosis in human immunodeficiency virus (HIV)-infected children demands specific evaluation of the risk/benefit ratio of BCG vaccination in this situation. In our institution 9 of 68 HIV-infected children vaccinated with BCG before the diagnosis of HIV infection was suspected developed vaccine-related complications: 7 of these children had a large satellite adenopathy with or without skin fistulae, whereas the other 2 had disseminated BCG infection beyond the satellite ganglion (involvement of the spleen and mesenteric and mediastinal lymph nodes in one case and the liver and lungs in the other). The children were vaccinated soon after birth; no particular problems were observed at that time, but complications appeared 3 to 35 months later. All but one of these children had a rapidly progressive form of HIV disease. The possibility of delayed local or disseminated BCG infection must be considered in analysis of the risk/benefit ratio of vaccination of HIV-infected children. The prognosis of HIV infection must be taken into account, even if the child is asymptomatic when vaccination is being considered.

Autoimmune hepatitis associated with anti-actin antibodies in children and adolescents

The clinical, biochemical, morphological, and evolutive features of autoimmune hepatitis associated with serum smooth muscle antibodies of anti-actin specificity were retrospectively analyzed in 31 children and adolescents. Cirrhosis was present at diagnosis in all but six patients, including nine of the 12 diagnosed within 6 months from the onset. In 15 children, one or more associated diseases of an immune-mediated mechanism were present, including chronic arthritis, sclerosing cholangitis, inflammatory bowel disease, and cutaneous vasculitis. All patients were treated with prednisone and azathioprine with normalization or improvement of liver function tests: 28 children are currently alive after a mean follow-up of 4 years, 10 months. Treatment was interrupted in four patients only. Two patients died of liver failure in spite of immunosuppressive therapy before the era of liver transplantation. In spite of prolonged therapy, five other patients ultimately required liver transplantation during adolescence or early adulthood. These results (a) further define a group of autoimmune hepatitis in children characterized by the presence of serum anti-actin antibodies; (b) indicate that immunosuppressive therapy improves liver function, although in most cases it must be continued for a long period to maintain remission; and (c) suggest that progressive liver failure may occur in early adulthood and may require liver transplantation.

Reduction of graft failure by a monoclonal antibody (anti-LFA-1 CD11a) after HLA nonidentical bone marrow transplantation in children with immunodeficiencies, osteopetrosis, and Fanconi's anemia: a European Group for Immunodeficiency/European Group for Bone Marrow Transplantation report

Forty-six infants and children suffering from either inherited immunodeficiency disorders (Wiskott-Aldrich syndrome, functional T-cell immunodeficiency with or without HLA class II expression deficiency), malignant osteopetrosis, or Fanconi's anemia received HLA-nonidentical bone marrow transplantation (BMT) from related donors. Bone marrow was T-cell depleted to reduce the risk of graft-versus-host disease (GVHD). To prevent graft failure, a mouse monoclonal antibody specific for the CD11a-lymphocyte function-associated antigen 1 (LFA-1) molecule was infused into the patients. Eleven patients received five infusions of 0.1 mg/kg every other day from day -3 to +5. Thirty-five patients received 0.2 mg/kg daily from day -3 to +6. The overall sustained engraftment rate was 72% instead of 26.1% in a historical control group of 24 patients similarly treated except for the infusion of the anti-LFA-1 antibody. No late rejection occurred. The T-cell depletion method (E-rosetting or Campath IM plus complement) resulted in different rate of engraftment (83.3% v 57.9%, respectively, P = .05). Engraftment rate was slightly but not significantly influenced by the degree of HLA incompatibility between donor and recipient. Acute GVHD of grade II or more occurred in 35.5% of the patients and the rate of chronic GVHD was 12.9%. The overall actuarial survival rate with a functional graft is 47.3% with a mean follow-up of 28.0 months for patients with immunodeficiency and osteopetrosis, while none of the four patients with Fanconi's anemia survived. The development of full T-cell functions took on the average 6 months and of full B-cell functions 10 months. Significant infectious problems developed in the majority of the patients during the posttransplant course. Epstein-Barr virus-induced B-cell proliferative syndromes were observed in seven patients, six of whom had Wiskott-Aldrich syndrome. Correction of immunodeficiency was comparable in terms of kinetics and quality with that observed in patients with severe combined immunodeficiency undergoing HLA-nonidentical BMT. Correction of osteopetrosis appears not to be different from what has been observed after HLA-identical BMT. The in vivo use of an anti-CD11a-LFA-1 antibody as an additional immunosuppressive therapy in HLA-nonidentical BMT may thus promote engraftment and survival with correction of the primary disease in a significant number of patients with life-threatening immunodeficiency and osteopetrosis, but not with Fanconi's anemia.

Altered expression of neutrophil peripheral benzodiazepine receptor in X-linked chronic granulomatous disease

This study was aimed at determining whether the peripheral benzodiazepine receptor (PBZDR), which is abundantly expressed on mononuclear phagocytes, is involved in host defense mechanisms depending on phagocyte membrane-associated NADPH-oxidase complex. Analysis by reversible and covalent binding of PBZDR expression on human neutrophils shows that it is modulated during NADPH-oxidase activation with phorbol 12-myristate 13-acetate. Based on a series of 17 patients with chronic granulomatous disease (CGD), results show that PBZDR expression is dramatically impaired in X-linked CGD, an inherited disorder due to a mutation on the gene coding for cytochrome b558 NADPH-oxidase component, whereas it is unaffected in autosomal recessive CGD where cytochrome b558 is normally expressed, suggesting a link between PBZDR and cytochrome b558 expressions. PBZDR can be assigned by covalent binding to an 18-Kd membrane protein. These results suggest that the neutrophil PBZDR, which can accommodate the widely prescribed anxiolytic drug Valium (diazepam), is involved in host defense against pathogens, a function that could be affected by neuroimmune interactions.

[The accelerated phase of Chediak-Higashi syndrome]

We have retrospectively analysed the clinical and biological features as well as the outcome of 18 accelerated phases having occurred in 11 patients with the Chediak-Higashi syndrome. This complication is very frequent and is characterized by a multi-visceral lymphohistiocytic infiltration with hemophagocytosis leading to pancytopenia, a bleeding disorder secondary to low fibrinogen level, hypertriglyceridemia and hemodilution. The accelerated phase of the Chediak-Higashi syndrome is identical to the manifestations of familial erythrophagocytic lymphohistiocytosis and of the viral-associated hemophagocytic syndrome. The outcome was invariably fatal before the use of etoposide (VP 16) in association with steroids and intrathecal methotrexate. Complete remission with this management regimen was observed in 7/7 cases. However, remissions were only transient. HLA identical bone marrow transplantation appeared to be the only therapeutic strategy capable of curing the disease (3/3 patients). Non transplanted patients relapsed and died as well as one patient who received a HLA non identical bone marrow transplantation. Due to the frequency and the severity of the accelerated phase of the Chediak-Higashi syndrome, HLA identical bone marrow transplantation should be proposed as early as possible after the onset of the accelerated phase.

A prospective study of infants born to women seropositive for human immunodeficiency virus type 1. HIV Infection in Newborns French Collaborative Study Group

Assessment of the risks of transmission of infection with human immunodeficiency virus type 1 (HIV-1) from mother to newborn is difficult, partly because of the persistence for up to a year of maternal antibodies transmitted passively to the infant. To determine the frequency of perinatal transmission of HIV infection, we studied from birth 308 infants born to seropositive women, 62 percent of whom were intravenous drug abusers. Of 117 infants evaluated 18 months after birth, 32 (27 percent) were seropositive for HIV or had died of the acquired immunodeficiency syndrome (AIDS) (n = 6); of the 32, only 2 remained asymptomatic. Another 76 infants (65 percent) were seronegative and free of symptoms, whereas 9 (8 percent) were seronegative but had symptoms suggestive of HIV-1 infection. The infants infected with HIV-1 did not differ from the others at birth with respect to weight, height, head circumference, or rate of malformations, but as compared with newborns who were seronegative at 18 months, their serum IgM levels were higher (78 +/- 81 mg per deciliter vs. 38 +/- 39 mg per deciliter; P less than 0.03) and their CD4 lymphocyte counts were lower (2054 +/- 1221 per cubic millimeter vs. 2901 +/- 1195 per cubic millimeter; P less than 0.006). Neither maternal risk factors nor the route of delivery was a predictor of seropositivity at 18 months; however, 5 of the 6 infants who were breast-fed became seropositive, as compared with 25 of 99 who were not (P less than 0.01). We conclude that approximately one third of the infants born to seropositive mothers will have evidence of HIV-1 infection or of AIDS by the age of 18 months, and that about one fifth of this group will have died.

[Neutropenias in children]

Whereas the clinical expression of childhood neutropenias is fairly uniform, consisting mainly in infections, a wide variety of etiologies may be involved. Pathophysiologic mechanisms have not all been completely elucidated. We review the different etiologies of neutropenia in children using the classification that we believe is the most helpful to clinicians. The clinical features and management of primary chronic neutropenias are described in detail. On the basis of our experience we suggest a practical diagnostic strategy for investigating children with neutropenia.

Detection of HIV1 DNA in infants and children by means of the polymerase chain reaction

The polymerase chain reaction (PCR) assay was used to investigate the possibility of HIV1 DNA detection in uncultured peripheral blood mononuclear cells from newborn infants and children of HIV-infected mothers. HIV1 DNA sequences were detected in mononuclear cells of six of fourteen symptom-free newborn infants of seropositive mothers. Only one of these infants had detectable HIV antigenaemia. In addition, HIV1 DNA was identified in the mononuclear cells of five of ten children (2-5 years old) of infected mothers who had become seronegative 12-15 months after birth; among these, four children had only mild clinical features related to HIV infection, while the other had none. HIV1 DNA was shown in all of eight seropositive children with HIV infection and none of fifteen normal seronegative controls. The PCR assay thus provides an early and direct identification of HIV infection in newborn infants and seronegative children born to infected mothers.

[Infection of the newborn infant by the human immunodeficiency virus]

HIV infection of the newborn is now known to result mostly from mother-to-foetus transmission. The risk of transmission is at least 40 p. 100. However, the circumstances of passage are little known, and there is no maternal virological parameter capable of evaluating individual risks. The disease is more severe in children than in adults. Rare are the children who remain asymptomatic for more than 15 months; one out of three of them develop severe acquired immunodeficiency syndrome and die within the first 2 or 3 years of life. A specific encephalopathy is observed in about 30 p. 100 of the infected children. Kaposi's sarcoma is exceptional. Since there is no contagion between children, those who are in fairly good clinical condition should have a family and school life as normal as possible.

Treatment of severe Epstein-Barr virus-induced polyclonal B-lymphocyte proliferation by anti-B-cell monoclonal antibodies. Two cases after HLA-mismatched bone marrow transplantation

We treated two children who developed Epstein-Barr virus-induced polyclonal B-cell proliferation after HLA-mismatched bone marrow transplantation for congenital immunodeficiency with two monoclonal anti-B-cell antibodies. Lymphoproliferative syndrome occurred between 50 and 60 days after bone marrow infusion, and was diagnosed by the presence of spontaneously growing B cells containing Epstein-Barr-nuclear antigen in the blood and bone marrow. The mouse monoclonal anti-B-cell antibodies used were a CD21-specific antibody recognizing the CR2 receptor on B cells (BL13, IgG1) and a CD24-specific antibody binding B cells at all steps of differentiation (ALB9 IgG1). Both antibodies were given intravenously (0.2 mg/kg/body weight.d for 10 days). All clinical and biological manifestations resolved within 3 weeks of treatment. Recurrence was not seen at 18- and 15-month follow-ups. T-cell function developed normally; B-cell function remained partially deficient in one patient 21 months after bone marrow transplantation. These results suggest that monoclonal anti-B-cell antibodies could be useful in controlling severe polyclonal lymphoproliferative syndrome in profoundly immunodeficient patients after bone marrow transplantation.

Granulopoietic differentiation in long-term bone marrow cultures from children with congenital neutropenia

The capacity of granulopoietic precursor cells (CFU-GM) to differentiate in vitro was evaluated in five children with congenital neutropenia using short-term colony assays and long-term marrow cultures. In all five children, methylcellulose assays revealed normal numbers of CFU-GM, which displayed an appropriate response to various sources of GM-CSF and differentiated up to the polymorphonuclear leukocyte state (PMN). In contrast, neutrophil PMN were not observed in long-term bone marrow cultures from three patients, despite a normal production of CFU-GM, myeloblasts, and promyelocytes during the 5-6 week culture period. Thus, in these patients, the characteristic "block" in granulocytic maturation observed in vivo was reproduced in vitro in long-term cultures. Granulocytic differentiation proceeded normally in long-term cultures from the two other patients, thus indicating heterogeneity in the expression of the defect. These results might indicate abnormal interactions between stromal and hematopoietic cells in long-term marrow cultures from some patients with congenital neutropenia. Furthermore, our results showed some correlation between the granulocytic defect in vitro and the clinical outcome in vivo.

[Nervous system involvement in HIV1 infections in infants]

A prospective survey of 38 HIV1-infected infants has been performed. Thirty-four percent of the patients expressed neurological abnormalities. Three main clinical entities of various intensity have been defined: 8 patients had severe intellectual and motor dysfunctions associated with a bucco-lingual dyspraxia; in 4 patients, the intellectual and motor alterations were less intense but were associated with a severe bucco-lingual dyspraxia; finally one patient had no clinical symptomatology but a chronic lymphocytic meningitis. No opportunistic infection of the CNS was observed. The neurological alterations were correlated in intensity with the immunological dysfunction. CT scans were normal or showed cerebral atrophy in most cases. CSF were normal in 12 cases and a pleiocytosis was observed in one case. However, in 4 of the 6 tested cases, anti-HIV antibodies were detected in CSF.

Longitudinal study of 18 children with perinatal LAV/HTLV III infection: attempt at prognostic evaluation

We performed a longitudinal study (mean follow-up 19.5 months, range 3 to 42 months) in 18 consecutive children with clinical symptoms of LAV/HTLV III infection. Twelve patients were born to mothers infected with LAV/HTLV III, and six were infected by blood products administered during the first weeks of life. Immunologic studies included lymphocyte markers, in vitro responses to mitogens and antigens with corresponding skin tests, and antibody response with isoagglutinins, post-vaccination antibodies, and Candida. A serologic profile of antibody to GP110, P18, and P25 LAV/HTLV III antigens by radioimmunoprecipitation assay was also performed. The antigen-induced proliferative responses were normal in 10 patients who had a stable course, but were profoundly impaired in eight others who died or had poor condition with opportunistic infections. These in vitro measurements were well correlated with antigen skin tests. An abnormal antibody response to antigens, a low level of isoagglutinins, and a peculiar profile of LAV/HTLV III antibodies were also frequently observed in these eight patients. These measurements appear to be of prognostic value because they were noticed soon after onset of clinical symptoms.

Prevention of graft failure by an anti-HLFA-1 monoclonal antibody in HLA-mismatched bone-marrow transplantation

Seven patients with immunodeficiencies (Wiskott-Aldrich syndrome, combined immunodeficiency, and osteopetrosis) were given a mouse monoclonal antibody against the alpha subunit of human leucocyte functional antigen (HLFA-1; CD18) to facilitate the engraftment of mismatched haploidentical related-donor bone marrow. Other conditioning included busulphan, cyclophosphamide, and antilymphocyte globulin. To prevent graft-versus-host disease the bone-marrow T cells were depleted with sheep erythrocyte rosetting and cyclosporin therapy was given. HLFA-1 antibody injections were well tolerated without side-effects except slight, transient fever (38-40 degrees) after the first injection. Engraftment was rapid in all seven patients. The regenerating leucocytes were of donor origin in all cases, and two patients have a mixed chimera. Two patients died from infections. The others are alive and well 60-395 days after transplantation. In a historical control group given the same treatment without anti-HLFA-1 infusion, only one of seven transplants partially engrafted; only two patients remain alive with autologous reconstitution but with uncorrected immunodeficiency.

[Metastatic cervical adenopathies appearing as primary. A propos of 124 cases]

The authors are defining the significance of a metastatic neck node from an occult carcinoma and review all the necessary investigations including surgical neck exploration and frozen section to establish the diagnosis. In such a case a radical neck dissection is carried out without delay and postoperative radiotherapy is applied on the neck with special portals focused on the pharyngo-larynx area where any possible infraclinic tumor might be located. The occult primary may become clinically detectable after a variable time interval, this occurrence is rather rare and becomes exceptional when irradiation has been delivered on the neck after surgical exploration. A high incidence of distant metastases is noticed during the follow-up period. The long term prognosis of metastatic cervical lymph node is rather poor and depends in particular of the size of the involved node.

[Mandibular reconstruction by composite musculocutaneous flap in glossopelvimandibular excisions]

Results of 14 mandibular reconstruction by a composite muscular flap of the pectoralis major and trapezium muscles during widespread glossopelvimandibular excisions are described. The technique employed is outlined, emphasis being placed on the need to observe strict precautions during removal and application of the bone component, to avoid accidental avulsion during reconstruction which could compromise the musculoperiosteal vascularization of the graft. Results are sufficiently encouraging for this type of reconstructive surgery to be proposed in all cases where mandibular repair is necessary after interruption of continuity.

[Five cases of pharyngeal tuberculosis seen over a period of one year (author's transl)]

The authors report five cases of pharyngeal tuberculosis seen over a period of one year and which were all, with one exception, surprise histological findings. Such histological findings were not always completely specific and the diagnosis was confirmed by a strongly positive tuberculin skin reaction, pulmonary disease and, above all, the elimination of symptoms and physical signs in less than 3 weeks under the influence of specific antituberculous therapy.

[Medical treatment of laryngotracheal stenosis (author's transl)]

The authors review the various types of treatment involving drugs and physical agents used for the non-surgical therapy of laryngotracheal stenosis. They emphasize three interesting propositions: the use of zinc sulphate, of lathyrogens and muscle relaxants, an extensive experimental study of which would be worthwhile in the particular context of laryngotracheal stenosis.