Comparative Study between the Use of Pigtail Catheters and Traditional Chest Tube Drain in Cases with Pneumothorax.

Background Pneumothorax is a condition in which air or other gas is present in the pleural cavity. Mainstay of management of pneumothorax is to remove the air from the pleural space usually done by chest tube insertion. There is still uncertainty whether minimal invasive management with pigtail catheter is sufficient for the management of pneumothorax. Objective To find the effectiveness, safety, tolerability, efficacy of pigtail catheters and large bore chest tubes. Method Prospective comparative study was done in Dhulikhel Hospital between August 2019 till August 2021. Chest tube insertion used to be the only available treatment modality till December 2020 (15 months). Following January 2021 after obtaining ethical clearance for use of pigtail insertion for pneumothorax, this treatment modality was done (8 months). Result Among 76 patients, 52(68.4%) underwent a large bore chest tube and 24 (34.6%) pigtail catheter patients. Mean age of the patients was 48 years (SD 18.01). Duration of hospital stay and length of hospital stay was more in large bore catheters and less in pigtail catheters. Eight hours post tube placement of the expansion of the lungs was present in pigtail and was statistically significant. Pain killer used in pigtail catheters was limited to Non-steroidal anti-inflammatory drugs, for large bore catheter opioids were added and were statistically significant. Conclusion Pigtail catheter is nearly effective as compared to traditional wide bore catheters.

Can sliding-window correlations reveal dynamic functional connectivity in resting-state fMRI?

During the last several years, the focus of research on resting-state functional magnetic resonance imaging (fMRI) has shifted from the analysis of functional connectivity averaged over the duration of scanning sessions to the analysis of changes of functional connectivity within sessions. Although several studies have reported the presence of dynamic functional connectivity (dFC), statistical assessment of the results is not always carried out in a sound way and, in some studies, is even omitted. In this study, we explain why appropriate statistical tests are needed to detect dFC, we describe how they can be carried out and how to assess the performance of dFC measures, and we illustrate the methodology using spontaneous blood-oxygen level-dependent (BOLD) fMRI recordings of macaque monkeys under general anesthesia and in human subjects under resting-state conditions. We mainly focus on sliding-window correlations since these are most widely used in assessing dFC, but also consider a recently proposed non-linear measure. The simulations and methodology, however, are general and can be applied to any measure. The results are twofold. First, through simulations, we show that in typical resting-state sessions of 10 min, it is almost impossible to detect dFC using sliding-window correlations. This prediction is validated by both the macaque and the human data: in none of the individual recording sessions was evidence for dFC found. Second, detection power can be considerably increased by session- or subject-averaging of the measures. In doing so, we found that most of the functional connections are in fact dynamic. With this study, we hope to raise awareness of the statistical pitfalls in the assessment of dFC and how they can be avoided by using appropriate statistical methods.

Physician's Perception about the Use of PPE, COVID-19 Prevention and Management in Bangladesh.

This study aims to explore physician's perceptions about the use of Personal Protective Equipment (PPE), COVID prevention, and management during the COVID pandemic since knowledge on these might explain the reason behind infection and death of physicians in Bangladesh at an unexpected rate. This cross-sectional study was conducted based on an online questionnaire on 346 physicians (n=346) by the Department of Gastroenterology of Mymensingh Medical College Hospital, Bangladesh from 15th July 2020 to 14th September 2020. Physicians of different health care facilities across Bangladesh were invited to take part. Knowledge on specific points of the questionnaire was evaluated, scored, and compared between different groups by Independent sample t-test. Mean knowledge score between the respondents working up to 8 hours and beyond 8 hours per day was 17.28±1.28, 16.90±1.40 respectively (p=0.03). Mean knowledge score observed between graduate and post-graduate physicians and work experience of 5 years and beyond 5 years were 17.26±1.36 vs. 17.16±1.27; (p=0.40), 16.87±1.75 vs. 17.27±1.21; (p=0.11) respectively. Physician's safety should be first concern that is highlighted through proper use of PPE and prevention of COVID. Patient management skills would be better if physicians are trained well on infection prevention and control which in turn will reduce infection and death of physicians.

Clinical manifestations and outcome in HIV-infected young infants presenting with acute illness in Durban, South Africa.

OBJECTIVES: In young infants, early development of symptomatic HIV infection increases the risk of morbidity and mortality. A prospective study was conducted over a 1-year period in a region with a high burden of HIV in order to describe the clinical presentation of HIV infection in infants aged between 0 and 59 days on attendance at hospital and the factors associated with the need for urgent hospital management. METHODS: Sick young infants presenting to the King Edward VIII Hospital, Durban between February 2003 and January 2004 were enrolled. After systematic evaluation by a primary health worker, an experienced paediatrician determined the primary diagnosis and need for urgent hospital management. Comparisons of these assessments were stratified by HIV status. Children were classified as HIV-uninfected (HIV ELISA-negative), HIV-exposed-but-uninfected (HIV ELISA-positive and HIV RNA PCR-negative), HIV-infected (HIV ELISA-positive and HIV viral load >400 copies/ml). RESULTS: Of 925 infants enrolled, 652 (70·5%) had their HIV status determined: 70 (10·7%) were HIV-infected, 271 (41·6%) HIV-exposed-but-uninfected, and 311 (47·7%) HIV-uninfected. Factors associated with an increased probability of being HIV-infected included if the mother had children from more than one sexual partner, if the infant had had contact with a tuberculosis-infected person or if the HIV-infected mother and/or her exposed infant failed to receive nevirapine prophylaxis. Signs of severe illness were more frequently encountered in HIV-infected than in HIV-exposed-but-uninfected infants, including the prevalence of chest in-drawing (20·3% vs 8·8%, p = 0·004) and severe skin pustules (18·6% vs 8·6%, p = 0·01). Among infants requiring urgent hospital management, observed or reported feeding difficulties and severe skin pustules were more common in HIV-infected than uninfected infants. More HIV-infected infants (12·9%) required hospitalisation than those who were HIV-exposed-but-uninfected (7·7%) or uninfected (7·4%). Primary diagnoses of pneumonia, sepsis or oral thrush were more frequently seen in HIV-infected than exposed-but-uninfected or HIV-uninfected children. CONCLUSION: Early recognition and triaging of infants suspected of having HIV infection provides an opportunity for early diagnosis and treatment which could prevent the adverse impact of rapidly progressive HIV disease.

Value of Serum Adenosine Deaminase (ADA) in Distinguishing between Tuberculous and Non-tuberculous Lymphadenopathies.

Persistent lymphadenopathy with or without fever is often a diagnostic challenge to the physician which are usually caused by infection like tuberculosis, hematological malignancy (lymphoma, leukemia), connective tissue diseases (SLE, RA, Sjogren's syndrome etc.), sarcoidosis, storage diseases, drugs (like phenytoin) in Bangladesh. To establish the cause of lymphadenopathy, we need to do a good number of investigations including invasive tests like FNAC or histopathology of the involved lymph node. In many instances these are not possible due to unavailability or cost. But for last few years the adenosine deaminase is an enzyme involved in purine catabolism and its significance in the diagnosis of tuberculosis has been demonstrated by many studies. In addition to tuberculosis, elevated serum adenosine deaminase has also been found in lymphoma, sarcoidosis and some connective tissue diseases. The study was intended to assess if there are any significant diagnostic difference in the level of elevated adenosine deaminase between tubercular and different types of non tubercular lymphadenopathy. It included 68 patients, equally divided into two groups, tuberculous lymphadenitis and non-tuberculous lymphadenopathy. Epitheloid granuloma with caseation necrosis in biopsy or FNAC was taken as case definition of tuberculous lymphadenitis. Causes of non-tuberculous lymphadenopathy were established on the basis of clinical findings, laboratory investigations and histopathological diagnosis of biopsy or FNAc materials. This cross-sectional observational study was done in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka, Bangladesh over a period of one year and participants of 18 years and above of both genders were included as per consecutive sampling technique. Serum ADA concentrations were estimated by enzymatic method. Mean serum ADA concentration was 25.52±7.11 in tuberculous lymphadenitis and in non-tuberculous lymphadenopathy patients it was 27.29±15.91U/L with no significant difference (p=0.480). The non-tuberculous lymphadenopathy group consisted of Hodgkin disease (n=9), non-Hodgkin lymphoma (n=10), sarcoidosis (n=2), reactive lymphadenitis (n=9) and other lymphadenopathy group (n=4) (that consisted one case of each of follicular hyperplasia, adult Still disease, sinus histiocytosis and Castleman's disease). The mean ADA of these groups was 32.77±13.14U/L, 46.40±46.10U/L, 13.94±2.81U/L and 21.75±3.17U/L respectively. Tuberculous lymphadenitis patients had significantly higher serum ADA than persistent reactive lymphadenitis. On the other hand, there were statistically significant elevation of serum ADA in non-Hodgkin lymphoma and sarcoidosis than in tuberculous lymphadenitis.

Fixation of subcondylar fractures of the mandible: a randomized clinical trial comparing one trapezoidal plate with two miniplates.

Subcondylar fracture of the mandible accounts for 25-35% of all mandibular fractures. In the past, most subcondylar fractures were managed non-surgically. The traditional method of fixation for subcondylar fractures uses two miniplates; however some bench studies have reported that trapezoidal plates are superior. The aim of this study was to compare the outcomes of subcondylar fractures fixed either with two non-parallel straight miniplates or with one trapezoidal plate. A randomized clinical trial was designed and implemented. Fifty-two consecutive patients with subcondylar fractures were recruited. All patients underwent surgery via a retromandibular approach. The time taken for fixation of the plate after fracture reduction and postoperative outcomes and complications were compared between the groups. The trapezoidal plates were superior in terms of ease of adaptation and time taken for fixation (P= 0.0001). Plate fracture was observed only in the two miniplates group, in four (16%) patients. Outcomes were similar in the two groups in terms of occlusion, mouth opening, protrusion, and lateral excursion. In conclusion, both systems - two miniplates and the trapezoidal plate - provide functionally stable fixation. The outcome was significantly better for the trapezoidal plate than for two miniplates regarding the time taken for insertion and ease of adaptation, but not for other parameters.

Glycaemic Status of Asthma Patients Using Inhaled Fluticasone.

Inhaled fluticasone is used in asthma for long duration. However, it's adverse effect on glycaemia is debatable. This study observed the outcome of inhaled fluticasone in asthma patients. A cross sectional comparative study was conducted among the normoglycaemic asthma patients aged 18 years and above attending outpatient department of Internal Medicine and Respiratory Medicine department of Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh from June 2017 to May 2018. Study group were getting inhaled fluticasone for minimum three months whereas comparative group were not on any steroids. Each group had 35 eligible participants (n=70). Spirometry and plasma glucose at fasting and 2-hour after 75gm oral glucose intake were measured along with HbA1c%. Statistical analysis was done using SPSS 21.0. In study group mean plasma glucose at fasting was 5.27±0.48mmol/L, 2-hour after 75gm oral glucose was 6.04±1.21mmol/L and mean of HbA1c was 5.57±0.41% whereas in comparative group these were5.17±0.59mmol/L, 5.69±1.09mmol/L, 5.47±0.40% respectively (p=0.25, 0.20, 0.75 respectively). There was no specific co-relation between duration of use of fluticasone inhaler and glycaemic parameters like plasma glucose at fasting, 2-hour after 75gm oral glucose and HbA1c% (r=0.016, p=0.46; r=0.015, p=0.47; r=0.019, p=0.42 respectively). Use of inhaled fluticasone for 3months or more has insignificant effect on plasma glucose levels of asthma patients. Duration of use of inhaled fluticasone has no specific correlation with plasma glucose and HbA1c values.

Prevalence of metabolic syndrome (METS) using IDF 2005 guidelines in a semi urban south Indian (Boloor Diabetes Study) population of Mangalore.

OBJECTIVE: To identify metabolic syndrome (MetS) prevalence using International Diabetes Federation (IDF) 2005 guidelines in a semi urban south Indian (Boloor Diabetes Study) population of Mangalore. METHODS: Population of randomly selected adults > or =20 years living in Boloor locality who were available for the house to house survey were assessed for the following: anthropometric variables; blood pressure; fasting blood glucose and lipid profile. Among 800 responders; 300 men, 500 women, 551 were examined (68.8%). Fasting plasma glucose as well fasting lipid profile could be done for 451 (147 men, 304 women) 81.85%; Data was analysed for prevalence of MetS and its individual components. Diagnosis of MetS was based on IDF 2005 criteria for Asian men and women. Intergroup comparisons were performed using student 't' test and Chi-square test. RESULTS: MetS was prevalent in 134 of 451 (29.7%); men 39 (26.5%) and women 95 (31.2%). Prevalence of individual components of MetS were as follows: increased waist circumference, (common component) present in all; elevated TG in 38.8%; low HDL-C in 59.7%; increased FPG in 57.4%; elevated SBP in 80.5% and DBP in 56.7%; body mass index (BMI) > or =25 kg/sq.m (obesity) in 58.9% Barring increased waist circumference which is the essential criteria for diagnosis of Mets, Systolic hypertension emerged as the most frequent component in the population followed by low HDL-C and elevated FPG. Elevated TG was less prevalent in this population. CONCLUSION: Prevalence of MetS in this semi urban population (Boloor) of Mangalore compares with MetS prevalence identified in cross sectional studies in India. Prevention and treatment of the predictive factors: dyslipidemias, hyperglycaemia, hypertension, together with enhanced physical activity may together reduce the prevalence of MetS.

Toxoplasmosis Presenting as Nonhealing Cutaneous Ulcer.

INTRODUCTION: Systemic manifestation of toxoplasmosis is commonly seen in immune-compromised individuals. Skin manifestations are seen commonly in conjunction with systemic features. Isolated cutaneous toxoplasmosis is extraordinarily rare in immunocompetent patients. Case Description. A 64-year-old female presented to the Dermatology Outpatient Department (OPD), with a nonhealing ulcer over dorsum of the left hand for one year. The patient did not have any systemic diseases. Serology tests were negative. An incisional biopsy of the lesion revealed dense inflammatory cell infiltrates comprising predominantly of plasma cells and lymphocytes, multinucleated giant cells, and focal abscess formation in the dermis. Periodic Acid Schiff (PAS) stain showed organisms in the dermis with morphological resemblance to tachyzoites of Toxoplasma gondii. CONCLUSION: Though rare, a possibility of primary cutaneous toxoplasmosis should always be considered and looked for, even in immunocompetent patients presenting with chronic nonhealing ulcers.

A Rare Case of Fibrous Hamartoma of Infancy: A Clinicopathological Diagnosis at a Tertiary Hospital, Eastern Nepal.

BACKGROUND: Fibrous hamartoma of infancy is a rare soft tissue lesion of infants and young children with characteristic triphasic morphology. CASE DESCRIPTION: An 18-month-old female child was presented with complaints of swelling over right leg shin since birth. On examination, a lump of size 7x3 cm was identified which was mobile and nontender. Local excision was performed and tissue sent for histopathological examination. On gross examination, a globular, capsulated, firm to hard tissue had cut section revealing solid grey-white to grey-brown lesion with myxoid areas identified. Microscopic examination revealed a poorly circumscribed lesion comprising intersecting trabeculae of fibrous tissue, areas of immature oval and stellate cell within myxoid matrix, and varying amounts of interspersed mature fat cells. CONCLUSION: Even though fibrous hamartoma of infancy is a rare benign entity with limited clinical knowledge, proper diagnosis is mandatory as its prognosis is excellent.

Impact of the learning environment on career intentions of paediatric interns.

BACKGROUND: High childhood disease burdens in South Africa (SA) prioritise the need for careers in paediatrics. Experiences of junior doctors during internship may influence career trajectories in a direction that is discordant with national health priorities. OBJECTIVE: To explore the influence of the learning environment and demography on career intentions of SA paediatric interns. METHODS: This cross-sectional study involved sampling intern groups at the start and completion of internship in paediatrics to determine their career intentions. A validated version of the Postgraduate Hospital Educational Environmental Measure was used to measure perceptions of the learning environment (LE) in the post-paediatric internship cohort. Measures of the LE in combination with demographic factors were compared with career intentions. Associations were determined by t-tests or analysis of variance and χ2 tests. RESULTS: A total sample size of 422 was obtained from two separate cohorts, which were demographically similar except for age. Most interns (88.4%) intended to remain in SA, with 72.6% indicating an intention to practise in the public healthcare sector. There was a high intention to specialise (85.9%), and 60.2% were keen on a career that involved children. Previous educational exposure and demographic factors other than gender did not significantly influence career intentions. Perceptions of the LE significantly influenced decisions to stay in SA's public sector and to care for children. The decision to specialise, however, was not influenced by demographic variables or perceptions of the LE. CONCLUSIONS: Paediatric interns from diverse sociocultural and educational backgrounds had similar career intentions. Most interns were keen to work with children in SA's public sector. However, learning experiences during internship significantly influence these intentions and have the potential to drive young doctors away from SA, its public health service and paediatric care. Ensuring that training and support of interns are optimised is essential if SA is to align its healthcare needs with the aspirations of its future healthcare workers.

The significance of cytomegalovirus in children with pneumonia admitted for mechanical ventilation.

BACKGROUND: The pathogenic role of cytomegalovirus (CMV) among children with pneumonia is not clear. OBJECTIVES AND DESIGN: We describe the outcome of children on mechanical ventilation with 'probable' CMV-related pneumonitis (CMV DNA polymerase chain reaction [PCR] positive as well as clinical and imaging features of CMV on ganciclovir) and children with pneumonia and CMV infection (CMV DNA PCR-positive without clinical and imaging features of CMV and not on ganciclovir therapy) at a paediatric intensive care unit in South Africa between 2011 and 2013. CMV viral loads were measured in non-bronchoscopic bronchoalveolar lavage fluid (NBBALF), plasma and whole-blood samples. RESULTS: Of the 97 children enrolled, 38 had CMV-related pneumonitis, 27 had pneumonia and CMV infection and 32 had pneumonia without CMV infection (negative CMV DNA PCR). Survival in the three groups was respectively 73.7% (P < 0.05), 92.6% (P < 0.05) and 88.0%. The difference in outcome could be accounted for by variance in the prevalence of human immunodeficiency virus (HIV) infection (respectively 60.5% and 29.6%, P < 0.05). A higher CMV viral load in NBBALF and plasma was seen in cases of CMV-related pneumonitis than in pneumonia with CMV infection: respectively log 5.20 vs. log 4.10 (P < 0.05) and 4.56 vs. 3.47 (P < 0.05). CONCLUSIONS: HIV-infected children on mechanical ventilation with CMV-related pneumonitis on ganciclovir have poor outcomes. Randomised placebo-controlled studies on ganciclovir are required.

The HIV-1 exposed neonate: outcome of intensive care management in the first week of life.

A prospective study was carried out to determine if the outcome in HIV-exposed neonates requiring intensive care (n=30) is different from that in HIV-unexposed neonates (n=40) requiring intensive care in the first week of postnatal life. It was noted that the outcome in terms of incidence of death and intensive care stay do not differ significantly in these two groups although some hematological parameters may be significantly different. Considering the fact that the outcome is not worse in HIV-exposed babies and that most of these babies ultimately turn out to be HIV-uninfected, these babies should not be deprived of intensive care, whenever necessary.

Status Epilepticus in Children.

Status epilepticus (SE) is a life-threatening emergency that requires prompt treatment, including basic neuroresuscitation principles (the ABCs), antiepileptic drugs to stop the seizure and identification of etiology. It results from an inability to normally abort an isolated seizure either due to ineffective inhibition, or due to abnormally persistent excessive excitation. Symptomatic SE is more common in younger children and the likely etiology depends on the age of the child. Treating the precipitating cause may prevent ongoing neurologic injury and facilitates seizure control. Benzodiapenes, phenytoin and phenobarbital form the mainstay of treatment. A systematic treatment regimen, planned in advance, is needed, including one for refractory status epilepticus (RSE). Patient education and home management of seizures is important to reduce the morbidity and mortality associated with SE.

The research component of specialist registration--a question of alligators and swamps? A personal view.

The recent implementation of the research requirement for specialist registration presents difficulties with regard to the provision of research supervision, particularly in those medical schools that previously followed the path of qualification via the Colleges of Medicine of South Africa examinations. The differences between the requirements for research supervision as stated in the Health Professions Council of South Africa memorandum and those of the Committee for Higher Education are causing disparities between medical schools similar to those that led to the memorandum in the first place. While the research component of specialist training can only improve the quality of both patient care and academic endeavour, it requires an enormous investment of time on the part of both the specialist trainees and their supervisors. In order to deal with this, specific issues outlined in the article need to be addressed.

Perinatal tuberculosis and HIV-1: considerations for resource-limited settings.

Tuberculosis is the commonest HIV-1-related disease and the most frequent cause of mortality in young women in endemic regions. Tuberculosis and HIV-1 are independent risk factors for maternal mortality and adverse perinatal outcomes, and in combination have a greater impact on these parameters than their individual effects. In referral health centres in southern Africa around one-sixth of all maternal deaths are due to tuberculosis/HIV-1 coinfection. One-third (37%) of HIV-1-infected mothers with tuberculosis are severely immunocompromised, with CD4 counts of fewer than 200 cells/microL compared with 14-19% in mothers recruited into major mother-to-child intervention trials in Europe. Babies born to mothers with tuberculosis/HIV-1 also have higher rates of prematurity, low birthweight, and intrauterine growth restriction. Transmission rates of HIV-1 from mother to infant are around 25-45% in resource-limited settings, while that for mother-to-child-transmission of tuberculosis is 15% within 3 weeks of birth. We highlight this emergent problem, and discuss the dilemmas associated with diagnosis and management of pregnant HIV-1-infected mothers with tuberculosis, and their newborn babies.

Characterization of proteinuria in asymptomatic family members and household contacts of children with hepatitis B virus-associated membranous nephropathy.

The biosocial background in which the hepatitis B virus (HBV) carrier state with membranous nephropathy (MN) develops was studied by evaluating HBV carriage and proteinuria among 195 family members and household contacts of 31 index HBV carrier children with MN. Unrelated individuals from the communities of these index cases who were negative for HBV served as controls (n = 123). HBV was determined by using third-generation enzyme-linked immunosorbent assay, slot-blot hybridization, and nested polymerase chain reaction. Patterns of proteinuria were determined by using sodium dodecyl sulfate-polyacrylamide gel electrophoresis; immunoglobulin G and haptoglobulin were suggestive of MN. Seventy-two members (36.9%) of the study group (n = 195) were HBV carriers; 21 of these carriers (29.2%) had proteinuria. Twenty-eight members (41.2%) of the study group who were HBV negative (n = 68) and 26.8% of the controls showed proteinuria. This lack of association between HBV carriage and proteinuria remained when controlled for sex and family relationship. HBV was not protective against the development of proteinuria. Proteinuria suggestive of MN was strongly associated with an abnormal protein-creatinine ratio (P: = 0.001), but was not significantly different between subjects and controls (8.7% versus 6.5%; P: = 0.5). Genetic influences or environmental exposures in these subjects may be responsible for the proteinuria, suggesting underlying glomerular basement membrane damage. Discordance between the HBV carrier state and patterns of proteinuria in the study group suggest that HBV and MN may not be causally related or may reflect exceptional interaction between specifically vulnerable individuals and HBV.

Tuberculosis in the newborn: an emerging disease.

BACKGROUND: In spite of the global increase in tuberculosis, which is in part fueled by the HIV pandemic, tuberculosis in the perinatal period is rare, and to date it has not been directly associated with maternal or neonatal HIV infection. OBJECTIVES: To detect tuberculosis in newborns from a province with epidemics of both tuberculosis and HIV infection and to analyze the profile of tuberculosis in their mothers. METHODS: At King Edward VIII Hospital, in KwaZulu Natal, South Africa, during a 1-year period all neonates at the neonatal unit in whom a differential diagnosis of tuberculosis was considered were investigated. The clinical profiles, short term outcome and relationship to maternal tuberculosis and HIV infection were determined for those neonates in whom the diagnosis of tuberculosis was confirmed. RESULTS: From the investigation of 77 neonates 11 with culture confirmed perinatal tuberculosis were identified. Six of these infants were born to mothers who had HIV and tuberculosis coinfection. Six of the 11 neonates could be classified as congenital tuberculosis. The predominant clinical findings were progressive pneumonia (9 of 11), pyrexia (9 of 11), growth retardation (7 of 11), hepatomegaly (6 of 11), splenomegaly (4 of 11) and meningitis (2 of 11). Seven of their mothers had evidence of current or past tuberculosis or had close contact with a tuberculosis case. One neonate and two mothers died within the first 3 months. CONCLUSIONS: This is the first report of perinatal tuberculosis in association with maternal HIV and tuberculosis coinfection.

Severe, rapidly progressive human immunodeficiency virus type 1 disease in newborns with coinfections.

AIM: To describe a severe form of rapidly progressive HIV-1 infection manifesting in the neonatal period. METHOD: Prospective cohort study, King Edward VIII Hospital, Durban, South Africa. HIV-1-exposed neonates with hepatosplenomegaly, lymphadenopathy or persistent pneumonia within the first 28 days of life were investigated for perinatal infections. Confirmation of neonatal HIV-1 infection, HIV-1 subtype and clinical outcomes were studied. RESULTS: Twenty-three (72%) of 32 symptomatic HIV-1-exposed neonates recruited at a mean of 15.2 days were HIV-1-infected. HIV-1 infection was detected in 5 patients who were tested within 48 h of birth, confirming congenital infection. Congenital infection was not excluded in any case. Median neonatal viral load at recruitment was 471,932 copies/ml and median CD4 was 777 cells/mm3. The predominant clinical presentation was growth retardation and prematurity. Perinatal infections detected included: tuberculosis (8), syphilis (6) and cytomegalovirus (10). All of the neonates with perinatal tuberculosis were HIV-1-coinfected. Maternal and neonatal viral load and CD4 at recruitment were not statistically different between the groups with tuberculosis vs. other coinfections. Gag gene sequence analysis confirmed closely aligned HIV-1 subtype C in mothers and neonates. Nineteen (83%) died by 9 months, with a mean age at death of 3.5 months. CONCLUSIONS: A distinct group of HIV-1-infected babies may clinically manifest in the neonatal period with perinatal coinfections, subsequent rapidly progressive HIV-1 and early death.