Unabated occupational risk in a patient with rheumatoid pulmonary fibrosis.

BACKGROUND: This case highlights the importance of considering hypersensitivity pneumonitis (HP) in the differential diagnosis of interstitial lung disease (ILD) and of obtaining an occupational history so that remediable risk factors may be identified and managed. AIMS: To report a case of a chicken sexer with severe rheumatoid arthritis (RA) who developed progressively worsening dyspnoea and restrictive lung disease associated with pulmonary fibrosis. METHODS: Clinical investigation included physical examination, occupational history, pulmonary function tests (PFTs), chest imaging and bronchoalveolar lavage (BAL), as well as serological tests including standard IgE bird feather mixture and local IgG precipitin preparation to chicken excrement. Lung histopathology was examined post-mortem. RESULTS: The patient had worked as a chicken sexer for 29 years with limited control of exposure to chicken bioaerosols. PFTs initially showed mild restriction with a moderate gas transfer defect and computerized tomography of the chest exhibited extensive interstitial infiltrates throughout with severe honeycombing at the bases. Cytology from a BAL revealed multinucleated giant cells (MNGs). Specific serologic tests for bird antigens were negative. Histopathology demonstrated diffuse interstitial fibrosis with honeycombing, poorly formed granulomas and MNGs. CONCLUSIONS: Findings were consistent with a diagnosis of HP with RA-associated ILD. The patient's history of severe RA biased the diagnosis to one of RA-associated ILD and her occupational risk had been less emphatically addressed. Obtaining a thorough occupational history can uncover exposures to workplace respiratory hazards and may create opportunities for intervention to limit morbidity from chronic lung disease.

Detection of salivary immunoglobulin A antibodies to HIV-1 in infants and children.

Secretory immunoglobulin A (slgA) antibodies of non-maternal origin are present in newborns and slgA to HIV-1 antigens has been detected in infected adults. In this study we investigated the presence of HIV-1-specific IgA in saliva from 41 children (aged 1 day-46 months) born to women at risk for HIV-1 infection. Saliva samples were assayed for HIV-1 antibodies with IgA-specific Western blot. The samples from 10 out of 11 children with subsequently proven infection, including one aged 6 months, demonstrated IgA antibodies to HIV-1 envelope antigens. Samples from infants under 15 months, who were born to infected mothers and subsequently shown to be uninfected, were slgA negative. Of the 12 children with continued indeterminate HIV-1 status, eight showed neither slgA nor serologic evidence of infection and four showed slgA antibodies. HIV-1-specific slgA was detectable before the age of 15 months and may prove to be valuable in the diagnosis of HIV-1 infection in infants.

Interactions of human immunodeficiency virus infection and pregnancy.

OBJECTIVE: To assess the influence of human immunodeficiency virus (HIV) infection on pregnancy outcome and the effect of pregnancy on the short-term course of HIV infection. METHODS: Pregnant women with identified risk factors for HIV infection but without AIDS were tested serologically for HIV antibodies. Seropositive women were compared to seronegative patients with similar risk factors and demographic characteristics at enrollment, at delivery, and 6-8 weeks postpartum. One hundred one seropositive and 97 seronegative subjects were evaluated for symptoms or physical manifestations of HIV infection; evidence of immune dysfunction; historical, physical, or laboratory evidence of related infections; and maternal and neonatal outcome. Both groups were compared to the entire obstetric population delivering at the University of Maryland Hospital during 1 year. RESULTS: There was a significant reduction in reported risk behaviors in both groups during pregnancy as compared to the period before pregnancy (P < .001). The majority of women in both groups were asymptomatic, but seropositive women were more likely to have a history or physical evidence of condylomata (13 versus 4%; P < .05) and higher temperatures on admission to the labor suite (98.6 +/- 1.0 versus 98.3 +/- 0.8F; P = .02). Seropositive women were not at greater risk for antepartum medical complications. Only one woman developed an AIDS-defining opportunistic infection. Although hematologic indices in seropositive women were abnormal, these did not progress over the course of pregnancy. At delivery, seropositive women were more likely to receive antibiotics (25 versus 10%; P = .006) and less likely to have an episiotomy (25 versus 40%; P = .03), but obstetric outcome was unaffected. Neonatal status was independent of antibody status. CONCLUSION: Our findings support a growing body of evidence that pregnancy has no discernible effect on the early progression of HIV disease in asymptomatic women, and infection does not influence perinatal outcome.

Surgical intervention in children with human immunodeficiency virus infection.

Twenty-one children with human immunodeficiency virus (HIV) infection required surgical intervention during the course of their disease. There were 11 females and 10 males (age range, 3 months to 6 years). The children underwent 54 operative procedures after diagnosis of their disease. These included placement of central venous catheter (23 patients), open lung biopsy (11), incision and drainage of perirectal abscess (4), incision and drainage of soft tissue abscess (5), myringotomy (2), diverting colostomy (3), Nissen fundoplication (1), and other (5). All 21 patients had clinical AIDS by the Centers for Disease Control CDC classification. To date, there have been 12 deaths in the 21 patients (57%) due to progressive deterioration with the patient's disease. Most procedures were adjuncts for diagnostic and therapeutic intervention in a population of children with a uniformly fatal disease. The knowledge of various high risk groups for AIDS must heighten the surgeon's awareness to the growing and significant pediatric segment of the HIV population, the complications of their disease, and the surgeon's limited role in treating these problems.

Primary care for HIV-exposed and infected children: translating progress into practice.

Recent advances have changed the guidelines for diagnosing and managing pediatric human immunodeficiency virus (HIV) infection. HIV-exposed and HIV-infected children should be evaluated by, or in consultation with, pediatric HIV specialists. Primary care practitioners play a vital role in identification of infants and children at risk for HIV infection and can work collaboratively with pediatric HIV specialists to provide state-of-the-art care. With the use of perinatal zidovudine, perinatal transmission rates have been reduced to 3% to 4%, and they may be reduced even further by the use of combination antiretroviral therapy during pregnancy, viral load monitoring, and obstetric interventions. Diagnosis of HIV infection can be determined in all perinatally infected infants by 6 months of age. Combination antiretroviral therapy is the standard of care for HIV-infected children. It has become increasingly effective, but complex. Families living with HIV are affected by a number of psychosocial issues. Disclosure of HIV diagnosis to a child is an important clinical issue. As HIV-infected children grow older, medical and psychosocial issues may impact school performance. The plan of care to address specific needs of HIV-infected children should be a collaborative effort between the children, their families, the primary care team, and the multidisciplinary pediatric HIV specialty team.

Vertical transmission of human immunodeficiency virus from seronegative or indeterminate mothers.

UNLABELLED: OBJECTIVE--To describe the identification of human immunodeficiency virus (HIV)-infected infants born to women who were seronegative or indeterminate during pregnancy. RESEARCH DESIGN--Longitudinal cohort study. SETTING--Inner-city medical center. PARTICIPANTS: A series of children born to women with histories of risk factors for HIV infection were followed up for studies of the natural history of HIV-infected infants. These children were identified through risk factor assessment of pregnant women presenting for obstetric care. INTERVENTIONS--Counseling and testing to detect HIV. RESULTS--Three women were retrospectively identified who were infected with HIV during pregnancy but whose test results showed them to be either seronegative or indeterminate. Two of these women transmitted HIV infection to their children. Subsequently, all three women were confirmed to be infected. CONCLUSIONS--Standard serologic testing to detect HIV infection will not identify all infected pregnant women. Perinatal transmission of HIV can occur in women with negative results of enzyme-linked immunosorbent assay or indeterminate results of Western blot analysis during pregnancy.

Alcohol increases commission error rates for a continuous performance test.

BACKGROUND: Studying the effects of alcohol on Continuous Performance Test (CPT) performance was of interest for two reasons, i.e., (1) perhaps because of the ease of the task used in previous experiments, alcohol has not been found to impair performance, and (2) CPT commission errors (described below) have been related to impulsive behavior. METHODS: In this study, the CPT featured both an Immediate Memory Task (IMT) and a more difficult Delayed Memory Task (DMT). We compared the performance of 18 subjects under both alcohol and placebo conditions, using a within-subject design. Both the IMT (0.5-sec delay) and the DMT (3.5-sec delay, with distracter stimuli at 0.5-sec intervals) required the subject to respond if a briefly displayed number was identical to the one presented before it. Stimuli included target (identical match), catch (4 of 5 digits matched), and novel (random number) stimuli. On 2 separate days, subjects performed between administrations of three hourly placebo drinks or three hourly drinks containing 0.20 g/kg of alcohol (producing peak breath alcohol concentrations of approximately 0.035%). RESULTS: The main finding was that alcohol consumption increased responses to catch stimuli (i.e., commission errors) in the DMT. In contrast, performance in the IMT (the easier task) was unaffected by alcohol. Commission errors measured during peak breath alcohol concentrations were significantly correlated with scores on the Barratt Impulsivity Scale for both the IMT and DMT. Discriminability (A') between target and catch stimuli was reduced by alcohol for the DMT only. CONCLUSIONS: These data indicate that even small amounts of alcohol can produce measurable changes in CPT performance parameters if the task is of sufficient difficulty and that commission errors can be increased by alcohol consumption.

Invasive pneumococcal disease among infected and uninfected children of mothers with human immunodeficiency virus infection.

OBJECTIVE: To describe the incidence and clinical presentation of invasive pneumococcal disease in a cohort of children infected with human immunodeficiency virus (HIV) who were prospectively followed from birth, in comparison with uninfected children born to HIV-infected mothers and control children. DESIGN: Prospective follow-up of a cohort recruited at birth and born to mothers with known HIV status. The person-years analysis method used the occurrence of invasive pneumococcal disease as the end point. SETTING: Hospital-based clinic specializing in care of HIV-at-risk and HIV-infected children in Baltimore, Md. PARTICIPANTS: Forty-one vertically HIV-infected children, 128 uninfected children born to HIV-infected mothers, and 71 control children born to mothers with negative findings for HIV but with HIV risk factors. RESULTS: Among HIV-infected children, 10 episodes of invasive pneumococcal disease occurred during the first 36 months of life compared with 4 episodes among uninfected children and 1 episode among control subjects. The relative risk for HIV-infected children versus the combined uninfected and control groups was 12.6 with a 95% confidence interval (5.4, 28.8) and a p value for difference between groups of < 0.001. The incidence rate per 100 child-years of observation during the first 36 months of life was 11.3 for HIV-infected, 1.1 for uninfected, and 0.5 for control children. Clinical and laboratory variables were not useful in identifying HIV-infected children at risk for pneumococcal disease. CONCLUSION: Practical strategies to prevent pneumococcal disease among HIV-infected children need to be developed.

Natural history and serologic diagnosis of infants born to human immunodeficiency virus-infected women.

Perinatal transmission of human immunodeficiency virus is thought to occur in 25% to 50% of the offspring of infected women. Standard diagnostic methods do not permit identification of the infected newborns. To assess diagnostic methods and document the natural history of perinatal human immunodeficiency virus infection, 20 children born to human immunodeficiency virus-infected women were followed prospectively for 18 months by measuring antibody titer, Western blot profiles, and antigenemia, and the results were compared with clinical outcome. Endogenous synthesis of anti-human immunodeficiency virus IgG was demonstrated in 6 of the 8 infected children. Four children synthesized IgM against human immunodeficiency virus. Five had demonstrable p24 antigenemia. No significant differences between infected and noninfected children were noted at birth except drug withdrawal, which occurred more frequently in noninfected infants. The incidence of adenopathy, hepatomegaly, and neurologic and immunologic abnormalities in the infected children were compared with noninfected children. The distinguishing illnesses were the opportunistic infections, lobar pneumonia, and failure to thrive. Seven of the 8 infected children had human immunodeficiency virus-mediated disease by 1 year of age (Centers for Disease Control [Atlanta, Ga] P2 classification), and four had acquired immunodeficiency syndrome (Centers for Disease Control P2D). These studies offer an approach to diagnosis of human immunodeficiency virus infection in infants and document the natural history and possible outcomes of infected children.