[HIV infection in children in Poland - clinical advancement at time of diagnosis]

At the end of 2006, there were about 130 children with confirmed HIV infection in Poland, 90% of them being infected vertically.

AIM

to present the causes, the diagnostic procedure of HIV infection and the assessment of clinical staging at diagnosis of vertical infection in a child.

MATERIALS AND METHODS

between 1987-2006 there were 86 HIV infected children (45 male, 41 female) treated in our Department. 78 children had been infected vertically, 8 by other route. Reasons for HIV testing in children and clinical staging at diagnosis were analysed in vertically infected children. The patients were divided into two groups: I - diagnosed because of clinical signs and symptoms, II - because of knowledge of HIV positive status in family members.

RESULTS

there were 22/79 children in group I and 56/79 in group II. Vertical HIV infection diagnosis was confirmed at the age from 1 month to 11 years, the mean age was: 26 months - in group I, 25 months - in group II. During the first year of life HIV infection was diagnosed in 36 children (33% of them having AIDS, 36% severe immunodeficiency), at the age of 12-35 months in 22 children (23% of them having AIDS, 32% severe immunodeficiency) and above 35 months in 20 children (15% of them having AIDS, 35% severe immunodeficiency), respectively. Children diagnosed because of clinical manifestations were more likely to have AIDS (p<0.01) and severe immunodeficiency (p<0.07).

CONCLUSIONS

early diagnosis in children relies on the knowledge on the mother's HIV infection positive status. In Poland vertical HIV infection diagnosis is established late (mean: above 2 years), often at the advanced stage of the disease.

Decline in mortality, AIDS, and hospital admissions in perinatally HIV-1 infected children in the United Kingdom and Ireland

OBJECTIVE

To describe changes in demographic factors, disease progression, hospital admissions, and use of antiretroviral therapy in children with HIV.

DESIGN

Active surveillance through the national study of HIV in pregnancy and childhood (NSHPC) and additional data from a subset of children in the collaborative HIV paediatric study (CHIPS).

SETTING

United Kingdom and Ireland.

PARTICIPANTS

944 children with perinatally acquired HIV-1 under clinical care.

MAIN OUTCOME MEASURES

Changes over time in progression to AIDS and death, hospital admission rates, and use of antiretroviral therapy.

RESULTS

944 children with perinatally acquired HIV were reported in the United Kingdom and Ireland by October 2002; 628 (67%) were black African, 205 (22%) were aged > or = 10 years at last follow up, 193 (20%) are known to have died. The proportion of children presenting who were born abroad increased from 20% in 1994-5 to 60% during 2000-2. Mortality was stable before 1997 at 9.3 per 100 child years at risk but fell to 2.0 in 2001-2 (trend P < 0.001). Progression to AIDS also declined (P < 0.001). From 1997 onwards the proportion of children on three or four drug antiretroviral therapy increased. Hospital admission rates declined by 80%, but with more children in follow up the absolute number of admissions fell by only 26%.

CONCLUSION

In children with HIV infection, mortality, AIDS, and hospital admission rates have declined substantially since the introduction of three or four drug antiretroviral therapy in 1997. As infected children in the United Kingdom and Ireland are living longer, there is an increasing need to address their medical, social, and psychological needs as they enter adolescence and adult life.

Height, weight, and growth in children born to mothers with HIV-1 infection in Europe

OBJECTIVES

Little is known about the independent long-term effect on growth of exposure to maternal human immunodeficiency virus (HIV) infection. Growth patterns in uninfected children who are born to infected mothers have not been described in detail previously beyond early childhood, and patterns over age for infected and uninfected children have not been based on appropriate general population standards. In vertically HIV-infected children, poor growth has been suggested to be an early marker of infection or progression of disease. However, whether growth faltering is an independent HIV-related symptom or caused indirectly by other HIV clinical symptoms requires clarification. This information is needed to inform the debate on a possible effect of antiretroviral combination therapy on the height of infected children and would provide evidence for the use of specific interventions to improve height. The objective of this study was to describe growth (height and weight) patterns in infected and uninfected children who are born to HIV-infected mothers with respect to standards from a general population and to assess age-related differences in height and weight by infection status, allowing for birth weight, gestational age, gender, HIV-related clinical status, and antiretroviral therapy (ART).

METHODS

Since 1987, children who were born to HIV-infected mothers in 11 centers in 8 European countries were enrolled at birth in the European Collaborative Study and followed prospectively according to a standard protocol. Height and weight were measured at every visit, scheduled at birth; 3 and 6 weeks; 3, 6, 9, 12, 15, 18, and 24 months; and every 6 months thereafter. Serial measurements of height and weight from birth to 10 years of age of 1403 uninfected and 184 infected children were assessed. We fitted linear mixed effects models allowing for variance changes over age and within-subject correlation using fractional polynomials and natural cubic splines. Growth patterns were compared with British 1990 growth standards and by infection status.

RESULTS

Of the 1587 children enrolled, 810 were male and 777 were female; 1403 were not infected (681 boys, 722 girls), and 184 were infected (88 boys, 96 girls). Neither height nor weight was associated significantly with the main effects of HIV infection status at birth, but differences between infected and uninfected children increased with age. Uninfected children had normal growth patterns from early ages. Infected children were estimated to be significantly shorter and lighter than uninfected children with growth differences increasing with age. Differences in growth velocities between the infected and uninfected children increased after 2 years of age for height and after 4 years of age for weight and were more marked in the latter. Between 6 and 12 months, uninfected children grew an estimated 1.6% faster in height and 6.2% in weight than infected children; between ages 8 and 10 years, these figures were 16% and 44%, respectively. By 10 years, uninfected children were on average an estimated 7 kg heavier and 7.5 cm taller than infected children. Growth in uninfected children who were born before 1994, before the widespread use of ART prophylaxis to reduce vertical transmission, did not substantially differ from that of children who were born after 1994. To investigate whether the growth differences between infected and uninfected children were associated with HIV disease progression, we analyzed growth of infected children using the Centers for Disease Control and Prevention (CDC) clinical classification, in 3 groups: no symptoms, mild or moderate symptoms (A and B), and severe symptoms (C or death). Infected children with mild or serious symptoms lagged behind asymptomatic children in both height and weight, and these differences increased with age. Infected children who were born before availability of ART, before 1988, were more likely to reach a weight below the third centile for age than children who were born after 1994 when effective HIV treatment was widely available. Of the 184 infected children, 67 had been weighed and/or measured at least once while on combination (> or = 2 drugs) ART. Reflecting the longitudinal nature of the European Collaborative Study and the changing availability of HIV treatment, most of these measurements took place after 7 years of age, and therefore analyzing the possible effect of combination therapy on growth is difficult. The z scores for height and weight gain improved substantially in several children who received combination therapy regardless of their CDC clinical classification. To increase available information, we pooled all measurements according to CDC clinical classification and presence of combination therapy at the time of the observation. Weight and height significantly improved for severely ill children after combination therapy.

CONCLUSION

Using data from this large prospective European study, we investigated in comparison with general British standards growth patterns in the first 10 years of life of HIV-infected and uninfected children who were born to HIV-infected mothers. The duration of follow-up of uninfected as well as infected children makes this a unique data set. We allowed for repeated measurements for each child and the increase of variability in height and weight with age. Growth faltering may be related to the social environment, and our finding that uninfected children have normal growth, which is unaffected by exposure to maternal HIV infection, is consistent with observations that in Europe the HIV-infected population is more like the general population and less socioeconomically disadvantaged than that in the United States. However, HIV-infected children grew considerably slower, and differences between infected and uninfected children increased with age. Growth patterns in asymptomatic infected children were similar to those with only mild or moderate symptoms. However, compared with these 2 groups combined, severely ill children had poorer growth at all ages. Although limited by the small number of children who received combination therapy, severely ill children may benefit from such therapy in terms of improvements in weight and, to a smaller extent, in height. Growth faltering, particularly stunting, may adversely affect a child's quality of life, especially once they reach adolescence, and this should be taken into account when making decisions about starting and changing ART. Additional research will help to elucidate the relationship between combination therapy and improved growth, in particular regarding different regimens and the best timing of initiation for optimizing growth of infected children.

Systemic lupus erythematosus in a pediatric patient with congenital acquired immunodeficiency syndrome

The coexistence of congenital HIV infection with primary rheumatologic disease is rare. We have described a child with congenital AIDS and concurrent systemic lupus erythematosus who presented with small vessel vasculitis with no renal involvement. Oral corticosteroid therapy resulted in significant improvement in her clinical state. The child also responded strongly to potent antiretroviral therapy both virologically and immunologically.

Proposed initiatives for healthy children orphaned by AIDS

The epidemiology of AIDS has changed greatly in recent years and increasing numbers of poor, minority women with children now contract HIV/AIDS. As infected women succumb to AIDS, many of their children become orphans. The paper explores the ability and appropriateness of the current child welfare system to care for healthy children orphaned by AIDS, and the likelihood of adoption for this population. The study includes a wide-ranging literature review of information about children orphaned by AIDS, and relevant information about the child welfare system, including racial bias. To determine current support for children orphaned by AIDS, the author surveyed social service departments and private agencies in eight major cities about programs available. Based on this information, the author proposes a series of policy initiatives aimed at alleviating the flight of children orphaned because of AIDS.

Women--the missing persons in the AIDS epidemic. Part II

In the Winter 1989 issue, Anastos and Marte wrote about the neglect of women in defining and treating AIDS. Women in the AIDS epidemic, they wrote, are considered mainly as vectors of transmission to men or children, not as people who are themselves HIV-infected and victims of transmission. They are predominantly women of color who, by the dictates of poverty and racism, live in communities at high risk for HIV infection. They are subjected to demeaning attitudes, poor health care services, and tragically late diagnosis in many cases. In this article the authors examine the issues of reproductive rights and HIV testing in women hospitalized for childbirth. Wendy Chavkin continues the discussion on p. 19, focusing on the efforts of AIDS prevention programs to target women solely because of their reproductive function and on the lack of services available for women who are tested.

Chemokine and chemokine receptor gene variants and risk of non-Hodgkin's lymphoma in human immunodeficiency virus-1-infected individuals

Normal B-lymphocyte maturation and proliferation are regulated by chemotactic cytokines (chemokines), and genetic polymorphisms in chemokines and chemokine receptors modify progression of human immunodeficiency virus-1 (HIV-1) infection. Therefore, 746 HIV-1-infected persons were examined for associations of previously described stromal cell-derived factor 1 (SDF-1) chemokine and CCR5 and CCR2 chemokine receptor gene variants with the risk of B-cell non-Hodgkin's lymphoma (NHL). The SDF1-3'A chemokine variant, which is carried by 37% of whites and 11% of blacks, was associated with approximate doubling of the NHL risk in heterozygotes and roughly a fourfold increase in homozygotes. After a median follow-up of 11.7 years, NHL developed in 6 (19%) of 30 SDF1-3'A/3'A homozygotes and 22 (10%) of 202 SDF1-+/3'A heterozygotes, compared with 24 (5%) of 514 wild-type subjects. The acquired immunodeficiency syndrome (AIDS)-protective chemokine receptor variant CCR5-triangle up32 was highly protective against NHL, whereas the AIDS-protective variant CCR2-64I had no significant effect. Racial differences in SDF1-3'A frequency may contribute to the lower risk of HIV-1-associated NHL in blacks compared with whites. SDF-1 genotyping of HIV-1-infected patients may identify subgroups warranting enhanced monitoring and targeted interventions to reduce the risk of NHL.

Prevalence of Helicobacter pylori infection detected by serology and 13C-urea breath test in HIV-1 perinatally infected children

BACKGROUND

Conflicting results have been reported in adults with human immunodeficiency virus (HIV-1) who were investigated for Helicobacter pylori infection. Most studies indicate a lower prevalence than is found in the general population. The purposes of this study were to evaluate H. pylori prevalence by noninvasive methods in a population of children perinatally infected with HIV-1 and to correlate H. pylori prevalence with HIV-1-related clinical and immunologic status.

METHODS

H. pylori infection was studied in 45 children perinatally infected with HIV-1 by performing serologic testing of anti-H. pylori immunoglobulin G antibodies and the 13C-urea breath test.

RESULTS

Eight children with HIV-1 (17.7%) were positive by serology, and nine (20%) were positive by 13C-urea breath test. No significant differences related to age, previous antibiotic treatment, immunoglobulin administration, antiretroviral treatment, abdominal pain, CD4+ cell count, number of HIV-1 RNA copies, and frequency of severe immunodepression were noted between children with positive 13C-urea breath test results and those with negative results. Children with positive results were significantly more likely to have severe clinical manifestations.

CONCLUSIONS

The results show, by both serology and 13C-urea breath test, a prevalence of H. pylori infection comparable with the prevalence in the normal population of the same age. H. pylori prevalence has probably been underestimated in patients with HIV. Results of serologic and histologic analyses for H. pylori require cautious interpretation, especially in severely immunodeficient patients.

[HIV infection in children perinatally infected]

During the period from 1987 to the middle of 1996 only 20 children were born of HIV-infected women, while during the following 1.5 years the number of such children were 59, the maximum number of seropositive children being registered in Kaliningrad and the Kaliningrad region, in the Krasnodar Territory, Stavropol and Nizhny Novgorod (altogether 46 children). Out of 79 children born of HIV-infected mothers during the whole period of the epidemic, 8 children died. Out of the children born before 1995 who remained alive, 9 children were struck off the register after 3 years of observation due to the absence of HIV infection. By the end of 1997 63 children were registered, the majority of them born in 1996-1997.

CD30-positive anaplastic large cell lymphoma (ALCL) of T-cell lineage in a 14-month-old infant with perinatally acquired HIV-1 infection

PURPOSE

CD30-positive anaplastic large cell lymphoma (ALCL) has been described in adults with HIV-1 infection but is extremely rare in HIV-1-infected infants and children.

PATIENT AND METHODS

A 14-month-old girl with congenitally acquired HIV-1 infection presented with fever and a tender, erythematous, cystic mass on the right labium majorum. The mass was biopsied. Histologic examination and immunohistochemistry were performed.

RESULTS

Histologic examination showed Touton-like giant cells resembling histiocytes and focally abundant neutrophils obscuring the lymphoid infiltrate. Immunocytochemistry revealed a CD30-positive ALCL of T-cell lineage.

CONCLUSION

Although non-Hodgkin's lymphoma is known to be associated with HIV-1 infection in children, large cell lymphomas of T-cell lineage are extremely rare in this population. Early diagnosis should be aggressively pursued in an HIV-1-infected child who presents with a fever and cutaneous mass.

HIV seronegativity in an infant with the acquired immunodeficiency syndrome

We report the case of an infant with progressive human immunodeficiency virus (HIV) infection and persistent seronegativity. The child had Pneumocystis carinii pneumonia at 4 months of age and was documented to be HIV-infected by HIV-1 deoxyribonucleic acid (DNA) polymerase chain reaction (PCR), but enzyme-linked immunosorbent assay (ELISA) and Western blot tests for HIV-1 and HIV-2 specific antibodies remained negative until the infant was 10 months old. This case should increase awareness about the possibility of seronegative HIV infection in infants and stress the fact that in questionable cases, even if the screening serology is negative, additional methods of diagnosis (ie, PCR, viral culture, and p24 antigen) should be considered.

[Perinatal infection with the human immunodeficiency virus]

INTRODUCTION

HIV infection, eventually resulting in AIDS, represents an important problem of the present days, whereas statistical parameters corresponding with the incidence of its manifestations and lethal outcome deserve great attention and cause anxieity of both general population and medical workers of all profiles. The problem is particularly complicated in the HIV-infected pregnant women. The aim of this paper is to examine epidemiology of HIV and AIDS, influence of HIV infection on the course and outcome of pregnancy, ways of transmission of HIV infection from mother to child, possible effects of progression of HIV infection and medical procedures and approaches in HIV-infected pregnant women.

CLINICAL MANIFESTATIONS AND OPINIONS

Some studies from North America and Europe demonstrated an adverse effect of HIV-1 infection on pregnancy outcome, others failed to confirm these findings. Most studies from Africa describe an untoward effect of HIV-1 infection on pregnancy outcome, including fetal wastage, prematurity, low birth weight, stillbirth and neonatal death, but not in terms of embryopathy or congenital abnormalities. The incidence of perinatal transmission varies from 13% and 48%, 13% to 32% for the developed world and 25% to 48% for developing countries. Transmission can take place antepartum, during delivery and postpartum by breastfeeding. Transmission during the first trimester may take place but current data suggest that a substantial proportion of perinatal HIV-1 transmissions take place rather late in pregnancy or during delivery. The apparent absence of viral genome from fetal tissue, presence of a normal immune system at birth, absence of neonatal morbidity and reports of differential viral transmission in twins are arguments in favour of late transmission. One of the greatest concerns for both women and their physicians is the possibility that pregnancy may accelerate the onset of AIDS in mother. Pregnancy itself can be immunosupressive and some investigators have hypothesized that the cumulative immunosupressive effect of HIV-1 infection and pregnancy may accelerate the course of HIV-1 infection in pregnant women. Counselling of HIV-positive women worldwide in regard to their HIV serological status has not proved to influence most women's attitudes towards their subsequent reproductive behaviour.

MANAGEMENT AND PREVENTION

HIV-infected women should be offered a possibility of an abortion. Ongoing pregnancies should be carefully monitored and CD4 lymphocyte subsets examined at booking. If the CD4 count is below 200 cells/mm, prophylaxis Pneumocystis carinii and Zidovudine therapy should be initiated. Prevention includes changes of behaviour such as reduction of the number of partners, condom use and early and appropriate treatment of sexually transmitted diseases. Antiviral therapy at birth may prevent this type of HIV-transmission. Also vaginal lavage with virus inactivating products such as chlorhexidine has to be assessed as a possible intervention. Prevention of phase 3 transmission (by breast milk) primarily involves recommendation for seropositive mothers not to breats feed their children. Contraceptives should be strongly advocated as soon as possible after giving birth.

CONCLUSION

HIV infection, reproduction and motherhood jeopardize millions of women worldwide. The most appropriate approach in preventing perinatal transmission involves preventing HIV-1 infection in women of childbearing age, including sexual education nd condom promotion at a very young age.

Promoting HIV testing proves to be a challenging subject

BGM, a Los Angeles-based advertising agency, has created a campaign for the Pediatrics AIDS Foundation to promote awareness of the importance of HIV testing of all pregnant women. The agency is taking a personal stake in the campaign by offering its services pro bono.

Airway resistance and spirometry in children with perinatally acquired human immunodeficiency virus-type 1 infection

Airway resistance was measured by the interrupter technique in 54 children [aged 63.8 months (range: 9.1-131.6 months)], with perinatal human immunodeficiency virus-type 1 (HIV-1) infection and in a control group of 315 gender, height, and race-matched healthy children. In addition, 14 HIV-infected children, aged 75-131 months, had spirometry performed. Resistance was significantly higher in infected children than in controls (0.84 +/- 0.3 vs 0.64 +/- 0.08 kPa x l(-1) x s; t = 9.991; P < 0.0001). Resistance decreased with age in controls (r = -0.95; P < 0.001), but not in infected children (r= -0.22; P = 0.105). Resistance did not correlate with mothers' intravenous drug addiction, perinatal data, T-cell subset numbers, treatment, clinical course, or presence of respiratory complications. Resistance was higher (t = 3.103; P < 0.003) in p24 antigen-positive than in negative children. Thirty-nine children underwent a second evaluation 12.3 months (range 11.1-14 months) after the first. Resistance was higher (t = 3.960; P < 0.0001) at the second evaluation compared to the first. Eight of 14 children had abnormal spirometric measurements. We conclude that perinatal HIV-1 infection is associated with increased airway resistance and often abnormal spirometry. The degree of abnormalities in resistance depends on the duration of the infection rather than on HIV-1-related respiratory complications.

Growth failure as a prognostic indicator of mortality in pediatric HIV infection

OBJECTIVE

To study the effect of perinatally acquired human immunodeficiency virus (HIV) on somatic growth and examine the relationship of nutritional status to mortality in HIV-infected infants.

METHOD

Pregnant women attending the antenatal clinic at Mulago hospital in Kampala, Uganda, were enrolled. All live-born babies born to HIV-1 seropositive (HIV+) women, and to every fourth age-matched HIV-1 seronegative (HIV-) woman, were followed for 25 months.

RESULTS

The mean weight-for-age and length-for-age curves of HIV+ children were significantly lower than those of HIV- controls and seroeverters. Forty-five (54%) of the 84 HIV+ infants died before their second birthday, as compared with a 1.6% and 5.6% mortality in HIV- and seroeverters. HIV+ infants with an average weight-for-age Z-score below -1.5 in the first year of life have a nearly fivefold risk of dying before 25 months of age compared with noninfected controls.

CONCLUSION

Perinatally acquired HIV infection is associated with early and progressive growth failure. The severity of growth failure is associated with an increased risk of mortality. The effect of early, aggressive nutritional intervention in delaying HIV progression and mortality should be evaluated by controlled intervention studies.

Microencephaly in children congenitally infected with human immunodeficiency virus--a gross-anatomical morphometric study

A quantitative technique involving serial sectioning and semiautomatic morphometric analysis was used to assess the severity of the reduction in size of the major brain structures in cerebral hemispheres of children congenitally infected with HIV-1. Cerebral hemispheres from 12 children (18-48 months of age) who died of AIDS were sectioned into 5-mm-thick serial slabs and photographed. The cross-sectional areas of grossly recognizable brain structures were digitized, and the volumes were calculated according to Cavalieri's principle. The results were compared with those of an identically processed group of control brains from non-AIDS children. Analysis of the brain weight showed that there was a significant reduction in supratentorial and infratentorial weight in the AIDS group. The results of the morphometric study revealed that the loss in brain mass was associated with a statistically significant reduction in the total volume of both hemispheres, the entire cortex, white matter, and basal ganglia. Detailed analysis of individual brain structures also showed a significant reduction in volume of all cortical regions and most of the subcortical gray matter (e.g., caudate nucleus, putamen, globus pallidus, claustrum, and thalamus). It appears that in the microencephaly observed as a frequent sequel in pediatric AIDS, the loss of brain tissue is global and includes an almost proportional loss of cortex, subcortical gray matter and white matter.

Viewing AIDS from a glycobiological perspective: potential linkages to the human fetoembryonic defence system hypothesis

The primary molecular changes that lead to development of acquired immunodeficiency syndrome (AIDS) are very poorly understood, as are the mechanisms underlying the protection of the developing human from the maternal immune response. Recent data that the human immunodeficiency virus (HIV) may be using the glycosylation system of the T lymphocytes to acquire glycans for its glycoproteins that enable it to disrupt carbohydrate dependent immune cell interactions or induce aberrant immune reactions. Consistent with this hypothesis, gp120 from HIV infected human H9 lymphoblastoid cells expresses biantennary N-linked glycans with a bisecting GlcNAc sequence on 11% of their total oligosaccharides. This specific carbohydrate sequence has recently been shown to protect K562 erythroleukemic cells from natural killer (NK) cell responses when presented on the cell surface. We have recently demonstrated that bisecting biantennary type N-linked glycans are also expressed on the human zona pellucida (ZP); previous lectin binding studies indicate that is also expressed on human spermatozoa. Thus both the human gametes and HIV produced by H9 cells carry this same protective carbohydrate epitope on their outer surfaces. Human alpha-fetoprotein expressed in the developing human also carries the bisecting GlcNAc sequence, indicating that it may be suppressing the emerging fetal immune response by using its carbohydrate sequence as a functional group. We have suggested that the developing human and the gametes are also protected by soluble immunosuppressive glycoproteins found in the amniotic fluid and seminal plasma known as glycodelin-A (GdA) and glycodelin-S (GdS) respectively. Structural analysis of their N-linked oligosaccharides combined with other functional studies suggest that GdA and GdS employ their very unusual carbohydrate sequences as functional groups that enable them to manifest their immunosuppressive activities. GdA and GdS are significant components of our recently proposed model for the protection of the developing human and gametes designated the human fetoembryonic defence system hypothesis. A striking relationship now emerging is that the same unusual carbohydrate sequences associated with these immunosuppressive glycodelins are also specifically expressed on intravascular helminthic parasites, Helicobacter pylori, human tumour cells, and HIV infected T lymphocytes. The information presented in this review suggests that two new corollaries should be added to our recently proposed defence system hypothesis: (i) mimicry or acquisition of glycans that are used in this protective system by pathogens or tumour cells may enable them to either subvert or misdirect the human immune response, thereby greatly increasing their pathogenicity; and (ii) expression of glycoproteins used in this system by normal cells and tissues outside the reproductive system may protect them from immune responses, especially in those cases where major histocompatibility recognition is either absent or minimal. A better understanding of this hypothesis and its corollaries may enable us to address the molecular mechanisms underlying not only AIDS but also a host of other very serious pathological conditions in the human.

Leiomyomas of the gallbladder and splenic calcifications in an HIV-infected child

Smooth muscle neoplasms seem to be particularly frequent in children with AIDS, and several cases of such lesions, both benign and malignant (leiomyomas and leiomyosarcomas), have recently been reported in the literature. We describe here the imaging findings in a boy with AIDS who developed two leiomyomas of the gallbladder wall as well as calcification of the intraparenchymal splenic arteries.

Centers for Disease Control and Prevention (CDC). AIDS among children--United States, 1996

As of September 30, 1996, a total of 566,002 acquired immunodeficiency syndrome (AIDS) cases, including 7472 cases among children ages < 13 years (1%), had been reported to CDC by state and territorial health departments. Most children reported with AIDS acquired human immunodeficiency virus (HIV) infection perinatally from their mothers. During 1988-1993, an estimated 6000-7000 children were born each year to HIV-infected women; an estimated 1000-2000 of these children were infected annually. In 1994, results of clinical trials demonstrating effective therapy for reducing perinatal HIV transmission indicated a two-thirds decrease in such transmission associated with zidovudine (ZDV) therapy for HIV-infected pregnant women and their newborns. The Public Health Service (PHS) issued recommendations in 1994 for ZDV treatment to reduce perinatal HIV transmission, and in 1995 for routine HIV counseling and voluntary testing for all pregnant women in the United States. This report summarizes the epidemiology of AIDS in children in the United States reported cumulatively from 1982 through September 1996, presents rates for 1995 (the most recent year for which census estimates are available), and describes a recent decrease in the rate of perinatally acquired AIDS.

Darren's case: narrative ethics in Perri Klass's Other Women's Children

During the past fifteen years, the relationship between literature and medical ethics has evolved from the occasional use of stories as a substitute for the traditional case study in medical ethics to the emergence of a narrative approach to ethical analysis and decision making. Thus far, literary theory has been more important to narrative medical ethics than have works of literature themselves. Perri Klass's novel Other Women's Children deserves special scrutiny, however, because an analysis of it demonstrates ways that a narrative approach could enhance traditional philosophical and legal approaches to resolving ethical dilemmas in medicine.

Natural history of human immunodeficiency virus disease in perinatally infected children: an analysis from the Pediatric Spectrum of Disease Project

OBJECTIVE

To describe the progression of human immunodeficiency virus (HIV) disease through clinical stages from birth to death among a large number of perinatally infected children.

METHODS

The Pediatric Spectrum of Disease (PSD) project, coordinated by the Centers for Disease Control and Prevention (CDC), has conducted active surveillance for HIV disease since 1988 in seven geographic regions. PSD data are collected from medical and social service records every 6 months through practitioners at each participating hospital clinic. We analyzed data from perinatally HIV-infected children born between 1982 and 1993. The natural history of HIV disease was divided into five progressive stages using the clinical categories in the CDC 1994 pediatric HIV classification system: stage N, no signs or symptoms; stage A, mild signs or symptoms; stage B, moderate signs or symptoms; stage C, severe signs or symptoms; and stage D, death. A five-stage Markov model was fitted to the PSD data. To compare the estimates from the PSD project with the published estimates, we also fitted an alternative Markov model using acquired immunodeficiency syndrome (AIDS; 1987 case definition) in place of stage C and also calculated standard Kaplan-Meier estimates.

RESULTS

A total of 2148 perinatally HIV-infected children were included in the analysis. The estimated mean times spent in each stage were: N, 10 months; A, 4 months; B, 65 months; and C, 34 months. We estimated that a child born with HIV infection has a 50% (95% confidence interval [CI], 40%-60%) chance of severe signs or symptoms developing by 5 years of age and a 75% (95% CI, 68%-82%) chance of surviving to 5 years of age. For a child in stage B, there is a 60% (95% CI, 49%-71%) chance of severe signs or symptoms developing within the next 5 years and a 65% (95% CI, 56%-73%) chance of surviving 5 more years. The estimated mean time from birth to stage C was 6.6 (95% CI, 5.7-7.5) years, and the estimated mean survival time from birth was 9.4 (95% CI, 8.1-10.7) years. From the alternative Markov model, the estimated mean time from birth to AIDS was 4.8 (95% CI, 4.5-5.2) years.

CONCLUSION

Markov modeling using the revised pediatric classification system allowed us to describe the natural history of HIV disease in children before diagnosis of AIDS. On average, children progress to moderate symptoms in the second year of life and then remain moderately symptomatic for more than half of their expected lives, underscoring their need for clinical care before the onset of AIDS. The results from the Markov model are useful in family counseling, health care planning, and clinical trial designs.

Extensive vascular calcification in a patient with perinatally acquired AIDS

Extensive vascular calcification in an 8-year-old girl with perinatally acquired AIDS is reported. Complicating factors included cardiomyopathy, chronic lung disease, disseminated Mycobacterium avium complex (MAC), and wasting syndrome with total nutrition dependence. Plain abdominal films and CT of the abdomen immediately prior to her death revealed dense calcification of major vessels. Autopsy revealed calcification in the media of most major vessels typical of HIV arteriopathy. A review of the literature failed to reveal a description of similar vascular calcifications in pediatric AIDS.

Therapy of pediatric AIDS

Therapy of pediatric AIDS utilizes antiretroviral compounds; antibiotic, antifungal, and antiparasitic agents; and both active and passive immunization in a multifactorial approach. Currently, newly diagnosed pediatric AIDS cases are acquired predominantly through vertical transmission from HIV-infected mothers. Pediatric AIDS research is focused on strategies to prevent vertical transmission of HIV infection as well as therapy against opportunistic and progressive HIV disease. Zidovudine remains first-choice therapy for HIV infection and can reduce the rate of vertical transmission of HIV. Didanosine is also approved to treat HIV infection in pediatric AIDS. Other reverse transcriptase inhibitors are under investigation as alternative or combination therapies because of HIV resistance to zidovudine and didanosine. Alternative therapies for opportunistic infections are being investigated. Passive immunity with intravenous immunoglobulin is being reevaluated to determine efficacy in combination with other therapies. Finally, vaccination against usual childhood diseases with standard immunization schedules produces limited immunity, and alternative vaccination protocols warrant further investigation.

Spectrum of chest radiographic abnormalities in children with AIDS and Pneumocystis carinii pneumonia

This report aims to provide a description of the spectrum of radiographic findings in children with AIDS and Pneumocystis carinii pneumonia (PCP). The chest radiographs of all children with perinatally transmitted HIV infection who had PCP were reviewed. Thirty-eight episodes of PCP were noted in 32 children. The age range was 2-17 months. The radiographic findings were characterized as to pattern, severity, presence of pulmonary air cyst, thoracic air leak, thoracic lymphadenopathy, and pleural effusion. The initial distribution of disease was as follows: diffuse (n = 20), patchy (n = 12), focal (n = 4), normal (n = 2). In nearly one-third of children parenchymal abnormalities were mild enough that most normal lung markings were visible. During the course of the illness pneumothorax was noted in eight cases, pulmonary air cyst in five, and pneumomediastinum in one. Pleural effusions were noted in three (5%) cases. Thoracic lymphadenopathy was not observed in any case. The authors concluded that the initial chest radiographic appearance of PCP in children with AIDS is variable. The initial chest radiograph may be normal. The distribution was patchy or focal in nearly one-half of all cases with parenchymal abnormalities. Pulmonary air cysts or thoracic air leaks were noted during the course of the illness in approximately one-third of all cases.

Effect of perinatally acquired human immunodeficiency virus infection on neurodevelopment in children during the first two years of life

OBJECTIVE

To determine the timing, extent, and magnitude of neurodevelopmental problems in children with perinatal HIV infection compared to similar uninfected children of HIV-infected women and controls.

METHODS

Neurodevelopmental assessments during the first 24 months of life for 21 HIV-infected children born to HIV-infected mothers, 65 seroreverted children born to HIV-infected mothers, and 95 non-HIV-infected children born to non-HIV-infected mothers were analyzed. Neurodevelopment was assessed by using the Bayley Scales of Infant Development beginning at 3 months of age. Kent Scoring Adaptation was also utilized. A two-stage Hierarchical Linear Model was used for analysis of neurodevelopmental scores.

RESULTS

In the initial comparison of these three groups, infected children had significantly lower scores on the Mental Development Index (MDI) and Psychomotor Development Index (PDI) than the other two groups. The HIV-infected children were further classified into HIV-infected without Centers for Disease Control-defined AIDS, those with lymphoid interstitial pneumonitis (LIP) only as their AIDS-defining illness, and children with an AIDS-defining diagnosis other than LIP in the first 24 months. The children with LIP-only AIDS and the infected children without AIDS on average were not significantly different from the seroreverters or the controls on MDI or PDI, while the children with non-LIP AIDS had significantly lower scores after 3 months of age. Analysis of the Kent scores indicated that the decrement in the non-LIP AIDS children was seen in all five functional domains.

CONCLUSION

Children with serious HIV symptomatology appear to be at very high risk for serious developmental impairments, HIV-infected children not highly symptomatic have relatively normal neurodevelopment, and uninfected children of HIV-infected mothers do not appear to be adversely affected by the mother's HIV infection.

Management strategies for infectious diseases in pregnancy

This review presented the clinical manifestations, diagnostic and therapeutic options, and preventive strategies for several congenital infections. The infections discussed show the spectrum of modes of vertical transmission and severity of fetal disease encountered, in addition to the successes and limitations of the current medical interventions. Further improvements in diagnostic techniques and therapies for managing the infected fetus are likely to occur during the next decade. Similarly, the widespread adaptation of new and sensitive diagnostic assays, such as the polymerase chain reaction, is likely to further improve our ability to identify infectious agents as the primary cause of certain abnormal fetal conditions. Where specific diagnostic tests and therapies have proven successful in preventing or treating fetal infections, universal screening programs should be given serious consideration. Of paramount importance, however, is the active research on the development of preventive interventions designed to prevent maternal infections and vertical transmission. Although specific immunotherapies, vaccines, and drug therapies hold great promise for controlling the spread of some infections, it cannot be overemphasized that some serious infectious complications of pregnancy may be avoided by simple preconception or early antenatal maternal counseling.

Maternal vitamin A deficiency and mother-to-child transmission of HIV-1

Studies show that around 10-40% HIV-positive women will give birth to children who are also infected. However, the risk factors for transmission from mother to child are not well understood and the effects of maternal nutritional status are unknown. We conducted a study of vitamin A status in pregnant women as a risk factor for mother-to-child transmission of HIV in Malawi. Serum vitamin A, height, weight, CD4 T-cell counts, and duration of breastfeeding were measured in 338 HIV-positive mothers whose infant's HIV serostatus was known. Mother-to-child transmission of HIV was 21.9% among mothers whose infants survived to 12 months of age. Mean vitamin A concentration in 74 mothers who transmitted HIV to their infants was lower than that in 264 mothers who did not transmit HIV to their infants (0.86 [0.03] vs 1.07 [0.02], p < 0.0001). We divided HIV positive mothers to 4 groups, those with vitamin A concentrations of less than 0.70, between 0.70 and 1.05, between 1.05 and 1.40, and greater than or equal to 1.40 mumol/L. The mother-to-child transmission rates for each group were 32.4%, 26.2%, 16.0%, and 7.2%, respectively (p < 0.0001). Maternal CD4 cell counts, CD4%, and CD4/CD8 ratio were also associated with increased mother-to-child transmission of HIV. Maternal age, body-mass index, and breastfeeding practices were not significantly associated with higher mother-to-child transmission. Our study suggests that maternal vitamin A deficiency contributes to mother-to-child transmission of HIV.

Polymerase chain reaction and HIV

In this article, the synergistic progress for both polymerase chain reaction (PCR) technology and HIV-1 is reviewed. The latest developments in standard PCR technology for the detection and quantitation of HIV-1 DNA molecules are summarized. In addition, examples of applications selected from the fields of HIV-1 diagnosis, epidemiology, pathogenesis, and therapy monitoring are presented. Finally, the limitations of standard PCR procedures in HIV-1 research and clinical settings are discussed.

Human immunodeficiency virus infection/AIDS in children: the next decade

The next decade of HIV/AIDS must resolve critical issues. It will be necessary to probe deeply to examine what is currently known, identify what needs to be known, and find ways to solve the issues that must be confronted. How to best achieve solutions in a timely manner must also be determined. Seven priorities of major importance have been identified. There are others, and there will be new ones. Each issue is complex, but each one must be faced with the hope that solutions will be found. After 10 years, HIV infection is at risk of becoming institutionalized, bringing with it an acceptance of the issues as inherent to the disease. Patients look to the medical profession and scientific community to provide hope. But there are also significant educational, psychological, social, and public health issues that must be resolved. The first decade of AIDS consisted of recognition, diagnosis, and early treatment. If hope is to be brought to our children and their parents, the next decade must consist of the prevention and therapeutic control of HIV and its complications.

An update on the epidemiology of AIDS in Missouri

It has been 13 years since the initial report from the Centers for Disease Control and Prevention (CDC) describing the condition that came to be known as the acquired immunodeficiency syndrome (AIDS). Because of the public health significance of the AIDS epidemic, an elaborate national surveillance system, involving CDC along with state and local health departments, came to be established. The surveillance system now provides detailed information about the epidemiology of AIDS in this country. At the national level, through September 1993, 339,250 cases of AIDS have been reported to CDC; 204,390 of these individuals have died, for a case-fatality rate of 60.2%. Human immunodeficiency virus (HIV) infection/AIDS is now the leading cause of death in American men aged 25-44, and the fourth leading cause of death for women in this age group. The AIDS epidemic continues to disproportionately affect minorities. For blacks, the cumulative incidence rate is approximately 3.7 times that of whites; for Hispanics it is approximately 2.7 times that of whites. The majority of AIDS cases nationally are attributable to transmission of HIV among men who have sex with other men. However, the annual incidence of AIDS is currently rising faster among women than among men, and AIDS incidence is increasing more rapidly among persons who are reported to have acquired their infection through heterosexual contact than among persons in other exposure categories. Along with the increase in the number of cases in women, there has been a corresponding increase in the number of pre- or perinatally-acquired cases in children.(ABSTRACT TRUNCATED AT 250 WORDS)

[Estimation of the rate of mother-to-child HIV transmission: methodological problems and current estimates. Report of 2 study workshops (Ghent, Belgium, 17-20 February 1992 and 3-5 September 1993).The International Study Group on mother-child transmission of HIV]

In the last eight years, numerous cohort studies have been conducted to estimate the rate of mother-to-child (MTC) transmission of HIV. Many of these have faced problems in data collection and analysis. This made it difficult to compare transmission rates (TRs) between studies. Two workshops on methodological aspects of the study of MTC transmission of HIV-1 were held in Ghent (Belgium) in February 1992 and September 1993. Fourteen teams of investigators participated, representing studies from Central (5) and Eastern Africa (3), Europe (2), Haiti (1) and the USA (3). A critical evaluation of the projects was carried out, under four headings: 1) enrollment and follow-up procedures, 2) diagnostic criteria and case definitions, 3) measurement and comparison of MTC TRs and 4) determinants of transmission. Reported TRs ranged from 13 to 32% in industrialized countries and from 25 to 48% in developing countries. However, no direct comparisons could be made because methods of calculation differed from study to study. Based on this review, a common methodology was developed during the 1992 workshop. Agreement was reached on definitions of HIV-related signs/symptoms, paediatric Aids and HIV-related deaths. A classification system of children born to HIV-1 infected mothers according to their probable HIV infection status during the first 15 months of life allowed the elaboration of a direct method of computation of the TR and of an indirect method for studies with a comparison group of children born to HIV-seronegative mothers. This standardized approach was subsequently applied to selected data sets to update previous estimates and provide a comparison of the MTC TRs of HIV-1 in 13 different settings. TRs were calculated during the 1993 workshop by the participating teams, using the direct and indirect methods. TRs based on the intermediate estimate obtained with the direct method ranged between 12.7 and 42.1%. Estimates of TRs obtained with the indirect method ranged from 20.7 to 42.8%. TRs observed in developed countries ranged from 14 to 25% with the direct method. In the developing world, these rates ranged from 13 to 42% with the direct method, from 21 to 43% with the indirect method and most of the studies reported a TR in the range of 25 to 30%. In general, both methods provide a reasonable estimate of the true TR. The risk of MTC transmission of HIV-1 tends to be higher in children born to HIV-seropositive mothers in Africa than in Europe.(ABSTRACT TRUNCATED AT 400 WORDS)