Severe BCG immune reconstitution inflammatory syndrome lymphadenitis successfully managed with pre-antiretroviral counseling and a non-surgical approach: a case report.

BACKGROUND: Bacillus Calmette-Guérin (BCG) reactions are the most common cause of immune reconstitution inflammatory syndrome (IRIS) in HIV-positive infants who initiate antiretroviral therapy (ART). There is limited evidence regarding the incidence of BCG-IRIS; however, reports from outpatient cohorts have estimated that 6-9% of infants who initiated ART developed some form of BCG-IRIS within the first 6 months. Various treatment approaches for infants with BCG-IRIS have been reported, but there is currently no widely accepted standard-of-care. CASE PRESENTATION: A 5-month-old male HIV-exposed infant BCG vaccinated at birth was admitted for refractory oral candidiasis, moderate anemia, and moderate acute malnutrition. He had a HIV DNA-PCR collected at one month of age, but the family never received the results. He was diagnosed with HIV during hospitalization with a point-of-care nucleic acid test and had severe immune suppression with a CD4 of 955 cells/µL (15%) with clinical stage III disease. During pre-ART counseling, the mother was educated on the signs and symptoms of BCG-IRIS and the importance of seeking follow-up care and remaining adherent to ART if symptoms arose. Three weeks after ART initiation, he was readmitted with intermittent subjective fevers, right axillary lymphadenopathy, and an ulcerated papule over the right deltoid region. He was subsequently discharged home with a diagnosis of local BCG-IRIS lymphadenitis. At six weeks post-ART initiation, he returned with suppurative lymphadenitis of the right axillary region that had completely eviscerated through the skin without signs of disseminated BCG disease. He was then started on an outpatient regimen of topical isoniazid, silver nitrate, and oral prednisolone. Throughout this time, the mother maintained good ART adherence despite this complication. After 2.5 months of ART and one month of specific treatment for the lymphadenitis, he had marked mass reduction, improved adenopathy, increased CD4 count, correction of anemia, and resolution of his acute malnutrition. He completely recovered and was symptom free two months after initial treatment without surgical intervention. CONCLUSIONS: This case details the successful management of severe suppurative BCG-IRIS with a non-surgical approach and underlines the importance of pre-ART counseling on BCG-IRIS for caregivers, particularly for infants who initiate ART with advanced HIV.

HIV Encephalopathy in ART-Naïve, Hospitalized Infants in Mozambique.

INTRODUCTION: The neurodevelopmental impact of HIV infection in older children has been well-described, with characterization of HIV-associated encephalopathy (HIVE) and associated cognitive defects. HIVE is relatively common in older children who were vertically infected. The sparse literature on HIVE in infants suggests that incidence may be up to 10% in the first year of life, but no studies were identified that specifically evaluated hospitalized infants. METHODS: A descriptive study of routine inpatient data from two central referral hospitals in Mozambique was conducted. Inclusion criteria were infants with confirmed HIV infection aged <12 months, not on ART, admitted between 1 January 2019 and 30 June 2019. Presumptive HIVE was defined as having delayed developmental milestones in addition to microcephaly and/or pathological reflexes. RESULTS: Seven out of 27 patients (26%) were classified as presumptive HIVE. Delayed milestones were seen in 18 patients (67%) and the prevalence was approximately two times higher in the HIVE (+) group across all milestone categories. Delayed or no maternal ART (p = 0.03) and the infant not having received postnatal nevirapine prophylaxis (p = 0.02) were significantly associated with HIVE. CONCLUSIONS: HIVE prevalence is high in ART naïve hospitalized infants, particularly in those with risk factors for in-utero transmission. Thorough neurologic and developmental assessments can help identify HIV-infected infants and can be of particular utility in pediatric wards without access to point-of-care virologic testing where presumptive HIV diagnosis is still needed. Infants with HIVE need comprehensive care that includes antiretroviral therapy and physical/occupational therapy.

Test positivity and clinical presentation of COVID-19 in Mozambican infants hospitalized during the second wave of the pandemic in 2021.

Introduction: during the second wave of the COVID-19 pandemic in Mozambique, there was a surge in pediatric hospitalizations at a time when there was relatively little evidence, but significant concern about clinical outcomes in African children, particularly in higher-risk infants requiring, and health system capacity to respond. Methods: a retrospective cohort study was conducted for patients 1-12 months of age admitted to the Breastfeeding ward at Hospital Central de Maputo from January-February 2021. All had routine SARS-CoV-2 PCR testing performed. For patients with positive results, hospital charts were retrospectively reviewed. Descriptive analyses were performed. Results: of 209 patients that had SARS-CoV-2 PCR testing performed, 102 (48.8%) received results, of which 37 (36.3%) were positive. Positive results were received prior to discharge for 14 patients (37.8%). Median duration of hospitalization was 3 days. There were two deaths in COVID-positive patients (5.4%), both with complex comorbidities. For the 35 COVID-19 positive patients whose charts were located, the principal admission diagnosis was respiratory for 22 (62.9%), and 14 (40.0%) had oxygen saturation <94% at admission. The white blood cell count was >12.0 x 103cells/mL in 10 patients (28.6%) and the most common abnormal finding on chest radiograph was peribronchial thickening (38.5% of patients with results). Oxygen therapy was needed for 20 patients (57.1%). Conclusion: the majority of infants with COVID-19 had a mild, short-duration respiratory illness that did not exceed ward capacity for care, including oxygen treatment. Laboratory capacity for PCR testing was overwhelmed, delaying the return of results and complicating inpatient infection control measures.

Rapid neurodevelopmental recovery after ART initiation in an infant with HIV encephalopathy.

While there is ample evidence that antiretroviral therapy (ART) can improve cognitive outcomes in older children living with HIV, encephalopathy in infants has historically been considered an advanced disease presentation with less likelihood of neurodevelopmental recovery on treatment. More recent studies suggest that timely ART can halt encephalopathic disease progression and even lead to symptom resolution. Here we present a case of an HIV-positive infant diagnosed with encephalopathy who experienced impressive and rapid improvement with a multi-disciplinary care approach that included physical and occupational therapy and ART.

Negative Rapid Serological Tests in an HIV-Infected Infant: A Call for Improved Inpatient Provider-Initiated Testing and Counseling Beginning With Breastfeeding Mothers.

Rapid serological tests are unreliable for the diagnosis of HIV exposure and infection in infants. This case reports an HIV-infected infant with a delayed diagnosis due to multiple negative serological tests, highlighting the importance of maternal testing for provider-initiated testing and counseling in hospitalized infants.

Spinal Tuberculosis in Young HIV-exposed Infants: Two Cases of Probable Congenital Transmission.

The presentation of congenital tuberculosis (TB) is varied, with frequent extrapulmonary disease, but congenital spinal TB has been rarely reported. We present 2 cases of spinal TB (1 confirmed, 1 clinical diagnosis) in HIV-exposed infants with likely congenital transmission. Increased vigilance for congenital TB, including uncommon presentations, is needed, particularly in countries with high HIV and TB prevalence.

Test positivity and clinical presentation of COVID-19 in Mozambican infants hospitalized during the second wave of the pandemic in 2021

Introduction: during the second wave of the COVID-19 pandemic in Mozambique, there was a surge in pediatric hospitalizations at a time when there was relatively little evidence, but significant concern about clinical outcomes in African children, particularly in higher-risk infants requiring, and health system capacity to respond. Methods: a retrospective cohort study was conducted for patients 1-12 months of age admitted to the Breastfeeding ward at Hospital Central de Maputo from January-February 2021. All had routine SARS-CoV-2 PCR testing performed. For patients with positive results, hospital charts were retrospectively reviewed. Descriptive analyses were performed. Results: of 209 patients that had SARS-CoV-2 PCR testing performed, 102 (48.8%) received results, of which 37 (36.3%) were positive. Positive results were received prior to discharge for 14 patients (37.8%). Median duration of hospitalization was 3 days. There were two deaths in COVID-positive patients (5.4%), both with complex comorbidities. For the 35 COVID-19 positive patients whose charts were located, the principal admission diagnosis was respiratory for 22 (62.9%), and 14 (40.0%) had oxygen saturation <94% at admission. The white blood cell count was >12.0 x 103cells/mL in 10 patients (28.6%) and the most common abnormal finding on chest radiograph was peribronchial thickening (38.5% of patients with results). Oxygen therapy was needed for 20 patients (57.1%). Conclusion: the majority of infants with COVID-19 had a mild, short-duration respiratory illness that did not exceed ward capacity for care, including oxygen treatment. Laboratory capacity for PCR testing was overwhelmed, delaying the return of results and complicating inpatient infection control measures.

Erythema elevatum diutinum and hypothyroidism: coincidence or causal relationship?

Erythema elevatum diutinum is a rare chronic leukocytoclastic vasculitis of unknown etiology. It is believed to be due to deposition of immune complexes in the vessels. Clinically it is manifested as erythematous violaceous papules and nodules, isolated or confluent with hardened consistency, symmetrical, usually located on the extensor surface of the extremities, particularly over the joints. Diagnosis is based on clinical and histological findings. We report the case of a woman, 71 years old, with erythematous violaceous nodules on the hands, elbows, back and legs, beginning two years ago, with pain and itching. Histopathological analysis revealed leukocytoclastic vasculitis, confirming the clinical suspicion. Laboratory tests revealed hypothyroidism. We report the case because of its rarity, with subsequent review of the literature.

Enxerto por raspagem epidérmica no vitiligo estável: uma opção terapêutica / Grafting by epidermal scraping in stable vitiligo: a therapeutic option

O vitiligo é despigmentação adquirida caracterizada pela perda parcial ou total dos melanócitos da epiderme. Inúmeras modalidades terapêuticas foram propostas para seu tratamento. Nos casos de vitiligo estável os tratamentos cirúrgicos são a preferência. O enxerto por raspagem epidérmica é uma variante da técnica de microenxertos por punch. Constitui técnica nova, simples e de baixo custo, com altas taxas de repigmentação. O objetivo deste relato é demonstrar a experiência dos autores com essa técnica e discutir os resultados obtidos numa série inicial de dois casos (três lesões).

Vitiligo is an acquired depigmentation characterized by partial or total loss of epidermal melanocytes. Many therapeutic modalities have been proposed for its treatment. In cases of stable vitiligo surgical treatments are preferred. Grafting by epidermal scraping is a variant of micrografts by punch technique. It is a new, simple and low cost technique, with high rates of repigmentation. The objective of this report is to demonstrate the authors' experience with this technique and discuss the results in an initial series of two cases (three lesions).

Erythema elevatum diutinum and hypothyroidism: coincidence or causal relationship?

AbstractErythema elevatum diutinum is a rare chronic leukocytoclastic vasculitis of unknown etiology. It is believed to be due to deposition of immune complexes in the vessels. Clinically it is manifested as erythematous violaceous papules and nodules, isolated or confluent with hardened consistency, symmetrical, usually located on the extensor surface of the extremities, particularly over the joints. Diagnosis is based on clinical and histological findings. We report the case of a woman, 71 years old, with erythematous violaceous nodules on the hands, elbows, back and legs, beginning two years ago, with pain and itching. Histopathological analysis revealed leukocytoclastic vasculitis, confirming the clinical suspicion. Laboratory tests revealed hypothyroidism. We report the case because of its rarity, with subsequent review of the literature.

HIV Encephalopathy in ART-Naïve, Hospitalized Infants in Mozambique

Introduction: The neurodevelopmental impact of HIV infection in older children has been welldescribed, with characterization of HIV-associated encephalopathy (HIVE) and associated cognitive defects. HIVE is relatively common in older children who were vertically infected. The sparse literature on HIVE in infants suggests that incidence may be up to 10% in the first year of life, but no studies were identified that specifically evaluated hospitalized infants. Methods: A descriptive study of routine inpatient data from two central referral hospitals in Mozambique was conducted. Inclusion criteria were infants with confirmed HIV infection aged <12 months, not on ART, admitted between 1 January 2019 and 30 June 2019. Presumptive HIVE was defined as having delayed developmental milestones in addition to microcephaly and/or pathological reflexes. Results: Seven out of 27 patients (26%) were classified as presumptive HIVE. Delayed milestones were seen in 18 patients (67%) and the prevalence was approximately two times higher in the HIVE (þ) group across all milestone categories. Delayed or no maternal ART (p » 0.03) and the infant not having received postnatal nevirapine prophylaxis (p » 0.02) were significantly associated with HIVE. Conclusions: HIVE prevalence is high in ART nai¨ve hospitalized infants, particularly in those with risk factors for in-utero transmission. Thorough neurologic and developmental assessments can help identify HIV-infected infants and can be of particular utility in pediatric wards without access to point-of-care virologic testing where presumptive HIV diagnosis is still needed. Infants with HIVE need comprehensive care that includes antiretroviral therapy and physical/occupational therapy