Genotype-guided antiretroviral regimens in children with multidrug-resistant HIV-1 infection.

BACKGROUND: Genotyping tests were developed to attenuate the impact of viral resistance. Information about the efficacy in genotype base antiretroviral therapy in children is rare and even more in low- and middle-income countries. METHODS: Sixteen children with antiretroviral therapy (ART) failure and triple-class drug-resistant viruses were included in this study. Protease and retrotranscriptase genotypes were available for all patients. Switch of ART regimen was guided by genotyping data. The primary end point was virological suppression (<50 copies/ml) and immunological improvement after 48 wk of treatment with the new ART regimen. RESULTS: The median age of the patients was 14.5 y (interquartile range (IQR) 11-16.5). Median HIV-1 RNA viral load was 4.2 log10 (IQR: 3.4-4.8). The primary end point was found in 11 children (69%), and 13 children (81%) had an HIV-1 RNA viral load <200 copies/ml. Median (IQR) for the baseline CD4(+) cell count was 382 cells/µl (281-686 cells/µl), whereas after 48 wk of treatment with the new ART regimen, it was 640 cells/µl (361-936 cells/µl) (P < 0.001). CONCLUSION: Darunavir/ritonavir, raltegravir, and etravirine were well tolerated in the present pediatric population. These drugs provide good options for children exposed to extensive ART. Regimens guided by genotyping data were effective for children who had ART failure and multidrug-resistant HIV-1 infection.

Antibody persistence 7 years after hepatitis-A vaccine in children with human immunodeficiency virus infection.

BACKGROUND: HIV-infected children have a higher risk of presenting infections, including the hepatitis A virus (HAV). The inactivated HAV vaccine is immunogenic in immunocompetent hosts; however, there are insufficient studies on the duration of seroprotection in HIV-infected children. METHODS: An analytical cohort study was conducted. HIV-1-infected children who received the inactivated HAV vaccine (2 doses) were included. Blood samples were taken for antibody measurement, the first one 28 days after the second dose and another 7 years after the vaccination schedule. Information on viral load, immunological category, weight, height, and response to antiretroviral treatment from diagnosis to the last assessment was obtained. RESULTS: 19 patients were included, with a mean age of 12.6 years (SD ± 2.29). 58% were male. 80% of the patients presented protective immunoglobulin G antibodies against HAV 7-year post-vaccination. The antibody concentration was found to be between 13 and 80 mIU/mL (median of 80 mIU/mL). 52% showed some degree of immunosuppression. There was no statistically significant relationship between the presence of seroprotection and viral load, treatment failure, immunological category, and malnutrition. Twelve patients presented with antiretroviral treatment failure, and in 33% of them, the antibodies did not offer satisfactory seroprotection. CONCLUSION: 7-year post-vaccination, 80% of HIV-infected children maintain seroprotection titers against HAV.

INTRODUCCIÓN: Los niños infectados por el virus de la inmunodeficiencia humana (VIH) tienen mayor riesgo de presentar infecciones, incluyendo hepatitis por virus A (VHA). La vacuna inactivada contra el VHA es inmunógena en el huésped inmunocompetente. No hay estudios suficientes sobre el tiempo de seroprotección en niños infectados por el VIH. MÉTODO: Estudio de cohorte, analítico. Se incluyeron niños con infección por VIH-1 que recibieron la vacuna inactivada contra el VHA (dos dosis). Se les tomaron muestras sanguíneas para medición de anticuerpos, una 28 días después de la segunda dosis y otra 7 años después del esquema de vacunación. Se obtuvo información de carga viral, categoría inmunológica, peso y talla, y respuesta al tratamiento antirretroviral desde el diagnóstico hasta la última valoración. RESULTADOS: Se incluyeron 19 pacientes con una edad media de 12.6 años (± 2.29). El 58% fueron del sexo masculino. El 80% de los pacientes presentaron anticuerpos immunoglobulin G (IgG) contra el VHA protectores a los 7 años de la vacunación. La concentración de anticuerpos se encontró entre 13 y 80 mUI/ml (mediana: 80 mUI/ml). El 52% mostraron algún grado de inmunosupresión. No existe relación estadísticamente significativa entre la presencia de seroprotección y la carga viral, la falla al tratamiento, la categoría inmunológica ni la desnutrición. Doce pacientes presentaron falla al tratamiento antirretroviral; en el 33% de ellos los anticuerpos no ofrecían seroprotección satisfactoria. CONCLUSIONES: A 7 años posvacunación, el 80% de los niños con VIH mantienen títulos de seroprotección frente al VHA.

Fistula of the mitral-aortic intervalvular fibrosa in a patient with bacterial endocarditis: a case report and systematic literature review.

BACKGROUND: A fistulous tract in the mitro-aortic intervalvular fibrosa (MAIVF) is a rare entity, which presents as a complication of endocarditis or surgical trauma. Generally, it is associated to a pseudoaneurysm of the MAIVF (p-MAIVF) or aortic abscesses. MAIVF fistulas could potentially lead to devastating complications and a high mortality rate. This condition is managed surgically, either by a percutaneous closure or an open surgical approach. Herein we report the complex case of a patient with a MAIVF fistula secondary to bacterial endocarditis. Further clinical deterioration was caused by severe aortic valve insufficiency and hemodynamic compromise, requiring surgical intervention. CASE PRESENTATION: A 74-year-old male patient was admitted to a primary care center with complaints of malaise, asthenia, adynamia, hyporexia, and lower limb edema over the past eight days. His past medical history is positive for arterial hypertension and being monorenal. A transesophageal echocardiogram (TEE) was performed, exhibiting a 56% left ventricle ejection fraction (LVEF) and complicated aortic valve endocarditis. Surgical management through an open approach included vegetation resection, valve replacement, and closure of the MAIVF fistula. After completing antibiotic therapy, the patient was discharged without complications. During postoperative follow-up, the patient remained asymptomatic, and the control echocardiogram showed no signs of MAIVF fistula.4. CONCLUSIONS: The clinical case of a patient with a MAIVF fistula secondary to endocarditis by Streptococcus Anginous was presented. The fistulous tract was not associated to p-MAIVF or aortic abscess, findings which further deteriorate the patient's condition and increase the likelihood of fatality. This case reinforces the importance of a prompt diagnosis through cardiac imaging and timely surgical closure of the defect.

Diagnoses unveiled by early bronchoscopy in children with leukemia and pulmonary infiltrates.

Pulmonary complications in children with leukemia often display nonspecific clinical and radiologic manifestations that lead to a delay in diagnosis. The role of fiberoptic bronchoscopy (FOB) and the proper time for its performance are controversial. The aim of our study was to evaluate the frequency and nature of specific diagnoses revealed by FOB. Children with leukemia submitted to FOB because of suspicion of pulmonary involvement (mainly pneumonia) were retrospectively analyzed. A total of 33 FOB procedures performed in 31 patients (20 males) with an average age of 9.4 years (range, 3.5 to 15 y) were evaluated. Microorganisms isolated from 21 (63.6%) bronchoalveolar lavage samples were mainly fungi including Candida in 13 cases (39.4%) and Aspergillus in 3 cases (9.1%). Isolation rate in 10 procedures performed within the first 3 days was 90%. Tracheobronchitis was present in > 50% of patients, pulmonary hemorrhage was seen in 7 (21.0%) patients, and leukemic infiltration was demonstrated in 2 patients (6.1%), among other conditions visualized by FOB. Complications of FOB were minimal and transient. Our study suggests that FOB is a useful and safe procedure in patients with leukemia and pulmonary infiltrates. The earlier the FOB was performed, the higher the isolation rate of causative agents. In addition, this procedure allowed the identification of noninfectious airway comorbidities. Further studies in regard to this issue are warranted.

Enterocolitis necrosante; escala de valoración clínico radiológica para su diagnóstico y manejo; parte I / Necrotizing enterocolitis; clinico-radiological evaluation scale for its diagnosis and management; part I

Se revisaron 102 expedientes clínicos y radiológicos de pacientes con diagnóstico de enterocolitis necrosante (ECN) manejados en el servicio de Terapia Intensiva del Instituto Nacional de Pediatría, con objeto de encontrar los signos clínicos y radiográficos más frecuentes o significativos relacionados con esta patología. La ECN en nuestro medio, a diferencia de lo descrito en la literatura de países principalmente desarrollados, fue más frecuente en los lactantes de 1 a 12 meses de edad (56 pacientes), con antecedentes de infección gastrointestinal y desnutrición. En el grupo de recién nacidos (38 pacientes) los antecedentes más importantes fueron prematurez, parto distócico e insuficiencia respiratoria. Los signos clínicos más frecuentes fueron: Rechazo al alimento (86%), vómito (79,4%), deshidratación (77%), resistencia muscular y dolor a la palpación de abdomen en un 75% y 58% respectivamente; y evacuaciones con moco y sangre macroscópica, en un 39%. Los hallazgos radiológicos fueron: Edema de asas (97%); neumatosis intestinal (68%); asa fija (47%); dilatación de asas (45%); neumoperitoneo (39%); niveles hidroaéreos (13%). La neumatosis hepática y/o líquido libre en la cavidad abdominal ("abdomen blanco") se vieron en un 15 y 12% respectivamente. A pesar de su baja frecuencia, siempre ocurrieron en etapas de evolución avanzadas del padecimiento y tuvieron mayor mortalidad, la cual, en forma global y A pesar del manejo, fue muy elevada (72%)

Infection of pregnant women with hepatitis B and C viruses and risks for vertical transmission

Pregnant women infected with hepatitis B and C viruses pose a risk for infecting their newborn infants by vertical transmission. We studied 6,253 pregnant women aged 12-49 years for infection with hepatitis b (HBV) and C (HCV) viruses. Infection was diagnosed by measuring IgC antibodies against HBC, HBs, HBe, as well as IgM-HBc and HCV viral antigens with commercially avalible immunoassay kits. HBV infection was detected in 113 cases (1.8 percent), and prevalence was signficantly higher (2.4 percent) in a group of women with a high-risk pregnancy who were attending a perinatology hospital than in healthy pregnant women (1.67 percent, p<0.05). Infection with HBV was significantly higher in women older than 30 years old (p<0.05). HBsAg was found in blood, colostrum and vaginal exudate of two pregnant women; HBsAg was detected in the gastric aspirate but not in the blood of the two newborn infants. HBeAg and IgM-HBc were not detected in any of the smples. DNA-HBV was detected in serum of seven women, and DNA-HBV was detected in the gastric aspiratwe of only one of the newborns. HCV infection was diagnosed in three out of 111 women with markers for HBV infection (2.7 percent), and in 6 out of 1,000 women without these markers (0.6 percent). Anti-HCV antibodies were found in the serum of six of their infants during up to six months of age. Infants were monitored for one year and none of them developed any sign of hepatic disease. These results ksuggest that special attention should be paid to women older than 30 years and with a high-risk pregnanacy, as they are at a higher risk of HBV and HCB infections