Management of Infants Born to Mothers with HIV Infection.

In the United States, approximately 5,000 women living with HIV infection give birth each year. HIV can be transmitted from a mother to her child at any time during pregnancy, labor and delivery, and breastfeeding. Because of effective preventive measures, the transmission rate from pregnant women to their children has declined significantly. Strategies to prevent mother-to-child transmission include maternal and infant antiretroviral therapy and formula-feeding instead of breastfeeding. All infants born to mothers with HIV infection should receive antiretroviral postexposure prophylaxis as soon as possible, ideally within six hours after delivery. The type of prophylaxis depends on whether the mother has achieved virologic suppression, defined by an HIV RNA load of less than 50 copies per mL, and if the infant is at high risk of vertical transmission of HIV. Risk factors for vertical transmission include maternal seroconversion during pregnancy or breastfeeding, high maternal plasma viral RNA load during pregnancy, and advanced maternal HIV disease.

Distinguishing Benign Mediastinal Masses from Malignancy in a Histoplasmosis-Endemic Region.

OBJECTIVE: To describe the characteristics of benign and malignant mediastinal masses, which may predict their etiology and facilitate the safe and timely management of patients, especially those residing in histoplasmosis-endemic regions. STUDY DESIGN: We conducted a retrospective review of the health records of 131 patients aged <19 years who were referred to 2 tertiary care children's hospitals between 2005 and 2010 for evaluation of mediastinal masses. RESULTS: Most patients (79%) had benign masses, including 98 with confirmed or suspected histoplasmosis. Overall, compared with patients with malignant masses, patients with benign masses were younger and more likely to be African American, to complain of cough, and to have pulmonary nodules by chest computed tomography. In addition, patients with malignant disease were more likely to complain of malaise and to have neck swelling, abnormal extrathoracic lymphadenopathy, lymphopenia, anterior mediastinal involvement, and/or pleural effusion. Positive histoplasmosis serologic tests were specific but insensitive for a benign etiology. No single clinical, laboratory, or radiologic feature was sufficiently sensitive and specific for distinguishing between benign and malignant masses; however, the presence of lymphopenia, anterior mediastinal involvement, or enlarged cervical lymph nodes on computed tomography had a sensitivity of 93%, specificity of 95%, positive predictive value of 86%, and negative predictive value of 97% for cancer. Sixty-four patients (49%) underwent invasive testing, including 37 (36%) of those with benign masses. CONCLUSION: Patients in this series who had involvement of the anterior mediastinum, lymphopenia, or enlarged cervical lymph nodes had a high likelihood of cancer. Expectant management of patients lacking these characteristics may be safe and reduce unnecessary invasive testing.

Relapse of Pediatric Coccidioidomycosis Tenosynovitis.

Disseminated coccidioidomycosis is a rare cause of flexor tendon tenosynovitis, particularly in the pediatric population. We present the case of a 2-month-old male infant with disseminated coccidioidomycosis of the right index finger, which was initially treated with debridement and long-term antifungal therapy. Six months after discontinuing antifungal medications and at the age of 2 years, the patient presented with relapse of coccidioidomycosis of his right index finger. Serial debridement and long-term antifungal therapy resulted in disease quiescence. The relapse of pediatric coccidioidomycosis tenosynovitis using surgical management with accompanying magnetic resonance imaging, histopathology, and intraoperative findings is described herein. Coccidioidomycosis should be considered for the differential diagnosis of pediatric patients who have traveled to or live in endemic areas and present with indolent hand infections.

Central Nervous System Coccidioidomycosis in Children: A Retrospective Case Series.

BACKGROUND: Published literature on central nervous system (CNS) coccidioidomycosis in children is limited. Here we describe a large case series of pediatric CNS coccidioidomycosis from a tertiary care center in an endemic region. METHOD: This is a retrospective case review of patients ≤21 years old with a diagnosis of CNS coccidioidomycosis from January 1, 2000, to December 31, 2018. RESULTS: Thirty patients (median age 10.8 years) were identified and most (93%) were previously healthy. Fever (90%), headache (70%), vomiting (53%), and fatigue (57%) were the most common presenting clinical manifestations, with focal neurological signs/symptoms present in 14 (47%). The initial serum Coccidioides compliment fixation (CF) titer was ≤ 1:8 in 33%. Most patients had extra-axial brain involvement (83%) and seven (23%) had associated spinal cord disease. Shunt placement was required in 70% and 62% required revision. Fluconazole was the initial treatment in 22 (73%), with treatment failure occurring in 50%. Most patients (77%) stabilized and were maintained on suppressive therapy, 4 (13%) experienced relapses and/or progressive disease, and one (3%) died, while long-term neurological complications occurred in 17%. CONCLUSIONS: CNS coccidioidomycosis is an uncommon and sometimes devastating complication of disseminated coccidioidomycosis. Many patients present with relatively low CF titers and hydrocephalus is common. Fluconazole treatment failures are common, and management remains difficult despite recent advances in therapy. Most patients do well once the disease is stabilized and require lifelong therapy. Newer therapeutic agents are needed.

Pediatric Laryngeal Coccidioidomycosis: A Case Series in an Endemic Region.

BACKGROUND: Laryngeal coccidioidomycosis is a rare but life-threatening manifestation of coccidioidomycosis. Data in children are sparse and limited to case reports. We conducted this study to review the characteristics of laryngeal coccidioidomycosis in children. METHODS: We performed a retrospective review of patients ≤21 years of age with laryngeal coccidioidomycosis who were treated from January 2010 to December 2017. We collected demographic data, clinical and laboratory studies and patient outcomes. RESULTS: Five cases of pediatric laryngeal coccidioidomycosis were reviewed. All children were Hispanic and 3 were female. The median age was 1.8 years and the median duration of symptoms before diagnosis was 24 days. The most common symptoms included fever (100%), stridor (60%), cough (100%) and vocal changes (40%). Airway obstruction requiring tracheostomy and/or intubation for airway management was present in 80%. The most frequent location of lesions was the subglottic area. Coccidioidomycosis complement fixation titers were frequently low and culture/histopathology of laryngeal tissue was necessary to make a definitive diagnosis. All patients required surgical debridement and were treated with antifungal agents. None of the patients had recurrence during the follow-up period. CONCLUSIONS: This study suggests that laryngeal coccidioidomycosis in children presents with refractory stridor or dysphonia and severe airway obstruction. Favorable outcomes can be achieved with a comprehensive diagnostic work-up and aggressive surgical and medical management. With the rise in cases of coccidioidomycosis, physicians should have a heightened awareness regarding the possibility of laryngeal coccidioidomycosis when encountering children who have visited or reside in endemic areas with stridor or dysphonia.

An Enigmatic Case of a Febrile Infant With Seizures.

Herpes simplex virus (HSV) encephalitis is one of the most common viral infections in infants associated with high morbidity and mortality rates despite available antiviral therapy. For symptomatic infants, starting empiric therapy with acyclovir can prevent serious neurological sequelae while awaiting results from diagnostic studies. The gold standard of diagnosis remains to be the detection of HSV DNA via polymerase chain reaction (PCR) from cerebrospinal fluid (CSF). However, due to the low viral load in the initial stages of infection, even the gold standard test may not detect active infection. We present a case of an eight-month-old child who presented with fever and seizures and had negative HSV DNA PCR from initial CSF studies. Ongoing fever and recurrent seizures prompted an MRI which was suggestive of meningoencephalitis, HSV DNA PCR from repeat CSF sample resulted positive. This case emphasizes the importance of keen clinical judgment and the caution required when deciding to stop empiric therapy when the clinical suspicion for HSV encephalitis remains high.

Neonatal Coccidioidomycosis: A Single-center Experience and Review of the Literature.

BACKGROUND: Coccidioidomycosis is common in adult and pediatric populations living in endemic areas of the United States but has rarely been reported in neonates. We reviewed recent cases of neonatal coccidioidomycosis treated at a tertiary care children's hospital in an endemic area and compared them with previously reported cases in the literature. METHODS: We performed a retrospective chart review of infants 1 month old or less hospitalized with a diagnosis of coccidioidomycosis from January 1, 2014, to December 31, 2019. Additionally, we performed a literature review of all reported cases of neonatal coccidioidomycosis over the past 7 decades through PubMed. Infants born to mothers with confirmed or suspected active coccidioidomycosis were excluded. RESULTS: Three cases of neonatal coccidioidomycosis were identified at our institution. Each presented in a unique manner and had an alternative diagnosis at the time of initial presentation. Two patients had negative coccidioidal screening tests upon admission but later seroconverted. All patients had extrapulmonary involvement, and all recovered after appropriate treatment. A review of the literature reveals that the presentations and outcomes of neonatal coccidioidomycosis vary widely. CONCLUSIONS: There is significant variability in the presentation of coccidioidomycosis in the neonatal period, and diagnosis may be challenging. In endemic regions, healthcare providers should consider coccidioidomycosis in their differential diagnoses of ill-appearing neonates that do not respond to treatment.

Pediatric Musculoskeletal Coccidioidomycosis in Central California: A Single Center Experience.

BACKGROUND: Published literature on musculoskeletal coccidioidomycosis is sparse and limited to case reports and case series. This is one of the largest case series to describe the clinical presentation, diagnosis, medical and surgical management and outcomes of pediatric musculoskeletal coccidioidomycosis at a tertiary care hospital. METHOD: A retrospective case review was performed on patients ≤ 21 years old who were followed at a tertiary care center with a diagnosis of musculoskeletal coccidioidomycosis from January 1, 2007, to December 31, 2020. Descriptive data are expressed as medians and interquartile range (IQR) for continuous variables or as frequency and percentage for categorical variables. Categorical values were compared using the χ2 test. RESULTS: Forty-one patients were identified. The median age was 12.8 years, and most were male (71%), Latinx (66%) and healthy (71%). Limb swelling (66%), bone pain (54%) and joint pain (46%) were the most common presenting symptoms. Multiple bone involvement was present in 29% while 12% had the joint disease, and craniofacial (n = 10) and metacarpal/metatarsal bones (n=9) were the most commonly involved sites. Elevated Coccidioides complement fixation (CF) titers ≥1:32 were seen in 90% of the patients. Thirty-three patients (81%) required surgical interventions and of these 16 (48%) required additional surgical procedures. Eleven patients (27%) had disease relapse. Children >13 years of age were more likely to have > 1 organ involvement (16 vs. 7, P = 0.04), multiple bone involvement (10 vs. 2, P = 0.004) and maximum Coccidioides CF titers >1:128 (13 vs. 6, P = 0.02). CONCLUSIONS: In endemic areas, musculoskeletal coccidioidomycosis causes a substantial disease burden in children and should be considered in the differential diagnosis of those presenting with bone and joint pain or swelling. Early diagnosis and treatment are essential to minimize long-term morbidity and mortality.

Disseminated Coccidioidomycosis in an Adolescent With Crohn's Disease.

Coccidioidomycosis is a systemic mycosis caused by Coccidioides immitis/posadasii. This dimorphic fungus is endemic to the Southwestern United States, particularly in California and Arizona. Most infections are asymptomatic or mild, but around 5% of patients develop complicated pulmonary infection, and approximately 1% may progress to disseminated disease. We present the case of an adolescent male with Crohn's disease who received the integrin inhibitor, vedolizumab, and developed disseminated coccidioidomycosis. This case underscores the importance of considering severe and/or disseminated coccidioidomycosis in immunosuppressed children. In our case, clinical suspicion and bronchoscopy helped confirm the diagnosis and facilitate appropriate evaluation and treatment.

Congenital Coccidioidomycosis: A Case Report and Review of the Literature.

Coccidioidomycosis in neonates is rare and the acquisition of disease in this age group is not well understood. Congenital coccidioidomycosis is very rare, usually associated with coccidioidal placentitis. Only a handful of cases of congenital coccidioidomycosis have been described in the literature. We describe an infant with congenital coccidioidomycosis delivered by cesarean section to a mother who was diagnosed with disseminated disease in the second trimester and summarize the available literature on congenital coccidioidomycosis.

Decreasing Unnecessary Antibiotic Usage in Patients Admitted With Bronchiolitis.

BACKGROUND AND OBJECTIVES: Bronchiolitis is a viral syndrome that occurs in children aged <2 years and is a common reason for admission to children's hospitals. The American Academy of Pediatrics bronchiolitis guideline discourages routine antibiotic therapy for bronchiolitis. Despite this, there is high use of antibiotics in this patient population. METHODS: We performed a retrospective chart review of all patients aged ≤2 years admitted to our tertiary care center with bronchiolitis during 2 subsequent respiratory seasons. Between the 2 seasons, we provided an intervention to our hospital medicine group, which included a didactic review of American Academy of Pediatrics bronchiolitis guideline followed by subsequent, ongoing reinforcement from antibiotic stewardship weekday rounds. RESULTS: We were able to achieve a 40% decrease in overall antibiotic use between the 2 study periods (25% vs 15%, P < .001). CONCLUSIONS: Provider education, along with focused antibiotic stewardship audits with real-time feedback, resulted in decreased use of antibiotics in patients admitted with bronchiolitis.

Isavuconazole as Salvage Therapy for Refractory Pediatric Coccidioidal Meningitis.

Coccidioidal meningitis remains difficult to treat. The newer triazole, isavuconazole, has demonstrated efficacy in invasive fungal disease with less side effects than other azoles. We describe a case of refractory pediatric coccidioidal meningitis with disease stabilization and improvement on isavuconazole after failing treatment with other antifungal agents.

Extrapulmonary Coccidioidomycosis Among Children in Central California: A Retrospective Review.

BACKGROUND: The literature on pediatric extrapulmonary coccidioidomycosis is limited. We reviewed the clinical course, diagnostic studies, treatment and outcomes of children with extrapulmonary coccidioidomycosis followed at a tertiary care center in central California. METHODS: Retrospective study of 78 patients ≤21 years old with extrapulmonary coccidioidomycosis diagnosed over 10 years (1/1/07-12/31/16). RESULTS: The median age was 9.7 years (interquartile range, 4.5-14.8). The majority of patients were males (55%), Hispanic (65%) and without comorbid conditions (85%). Over two-thirds (68%) had concurrent pulmonary disease. Organ involvements included bones and joints (33%), mediastinum (19%), central nervous system (19%), cervical lymph nodes (15%), larynx (6%) and skin (5%). Most cases (84%) resolved and/or became stable on maintenance therapy, 14% experienced relapse and/or progressive disease, and 2% were fatal. Children ≥10 years of age tended to have >1 site of involvement (47% vs. 25%, P = 0.06), and more relapsed/progressive/fatal disease (21% vs. 5%, P = 0.06) compared with those <10 years. They also required longer durations of treatment (median, 611 vs. 349 days, P = 0.02). Non-Hispanics were more likely to require >1 drug therapy (85% vs. 70%, P = 0.04) and tended to have Coccidioides complement fixation titers ≥1:32 (89% vs. 72%, P = 0.04) compared with Hispanics. CONCLUSIONS: Extrapulmonary coccidioidomycosis in children can be severe and spread to multiple sites and requires prolonged treatment. Non-Hispanics and those ≥10 years of age are more likely to experience severe disease, suggesting a need for early recognition and intervention in these populations.

Pediatric Coccidioidomycosis: Case Series From a California Pediatric Infectious Diseases Clinic.

BACKGROUND: Coccidioidomycosis is not as well described in the pediatric population as it is in the adult population. We describe clinical findings, diagnosis and management of coccidioidomycosis in 108 pediatric patients seen in an outpatient clinic in the California Central Valley, an area endemic for coccidioidomycosis. METHODS: We reviewed medical records of a convenience sample of pediatric patients (≤17 years of age) diagnosed with coccidioidomycosis who visited an infectious diseases clinic in Madera, CA, during January 1 to October 1, 2012. We described demographic characteristics, symptoms, diagnostic testing, extent of infection (acute/pulmonary or disseminated), treatment and management. RESULTS: Of 108 patients, 90 (83%) had acute/pulmonary coccidioidomycosis and 18 (17%) had disseminated disease. The median age at diagnosis was 9 years (range, 5 months to 17 years). Only 3 (3%) patients were immunocompromised. Before coccidioidomycosis diagnosis, 72 (82%) patients received antibiotics, and 31 (29%) had at least 1 negative coccidioidomycosis serology at the time of or before diagnosis. Coccidioidomycosis was diagnosed significantly later after symptom onset among patients with disseminated (median, 57 days) than with acute/pulmonary (median, 16 days) disease (p < 0.01). A total of 104 (96%) patients received antifungal therapy, 51 (47%) visited an emergency room and 59 (55%) were hospitalized with a median stay of 44 days (range, 1-272 days). CONCLUSIONS: Substantial acute/pulmonary and disseminated coccidioidomycosis was seen among pediatric patients at this infectious disease clinic in California. In endemic areas, increased coccidioidomycosis awareness and vigilance among families and providers is necessary to facilitate early diagnosis and appropriate management.

Pediatric Coccidioidomycosis Patients: Perceptions, Quality of Life and Psychosocial Factors.

Research investigating the effects of coccidioidomycosis (valley fever) on children and the psychosocial implications of this disease in general is lacking. This study reviews what is known about pediatric coccidioidomycosis patients. It documents the psychological functioning, quality of life, and illness perceptions of a sample of coccidioidomycosis patient families. Primary caregivers of pediatric patients and patients from a major hospital in the San Joaquin Valley of California were interviewed regarding their perceptions of disease detection, access to care and the patient/family experience.