Hospitalisation rates for youth living with perinatally acquired HIV in England.

INTRODUCTION: Complex challenges amongst ageing cohorts of adolescents and adults living with perinatally acquired HIV (PaHIV) may impact on hospitalisation. We report hospitalisation rates and explored predictive factors for hospitalisation in adolescents and adults (10-35 years) living with PaHIV in England. METHOD: Retrospective observational cohort study over a three-year period 2016-2019. Data collected included cause and duration of hospitalisation, HIV viral load and CD4 lymphocyte count. The primary outcome was overnight hospitalisation. Patients exited at study end/ transfer of care (TOC)/ loss to follow up (LTFU) or death. Maternity/hospital admissions at other centres were excluded. Admission rates per 100 person-years (95% CI) were calculated by age group. Negative binomial regression with generalized estimating equations was performed. RESULTS: 255 patients contributed 689 person-years of follow up. 56% were female and 83% were of a Black, Black British, Caribbean or African ethnicity. At baseline, the median age was 19 years (IQR 16-22). 36 individuals experienced a total of 62 admissions which resulted in 558 overnight stays (median stay was 5 nights). One person died (lymphoma), six had TOC and one was LTFU by the end of the three-year study period. Crude incidence of admission for the whole cohort was 9.0 per 100 PY (6.9-11.6). The respective crude incidence rates were 1.5 PY (0.0-8.2) in those aged 10-14 years and 3.5 PY (1.5-7.0) in the 15-19-year-olds. In those aged 20-24 years it was 14.5 PY (10.1-20.2) and in those >25 years the crude incidence rate was 11.7 PY (6.9-18.5). Factors significantly associated with admission were a CD4 lymphocyte count <200 cells/uL, adjusted IRR 4.0 (1.8-8.8) and a history of a CDC-C diagnosis, adjusted IRR 2.9 (1.6-5.3). 89% admissions were HIV-related: 45% new/current CDC-C diagnoses, 76% due to infection. CONCLUSIONS: Hospitalisation rates were four-fold higher in adults (>20 years of age) compared to adolescents (10-19-year-olds). The continuing challenges experienced by PaHIV youth require enhanced multidisciplinary support throughout adulthood.

Lung infections in immunocompromised children.

Pulmonary infection is the leading cause of infectious morbidity and mortality in children with immune defects. We provide a comprehensive review of lung infections in immunocompromised children, with a focus on imaging findings and imaging-based management. We include an overview of the immune defences of the respiratory tract, the aetiologies of immune defects in children, the features of specific infections and important differential diagnoses and describe diagnostic strategies using imaging and non-imaging-based techniques.

Discordant Congenital Toxoplasmosis and Cytomegalovirus Infection in Dichorionic Diamniotic Twins.

BACKGROUND: Toxoplasmosis and cytomegalovirus (CMV) congenital infection present with similar clinical pictures. Both infections have long-term sequelae that can be mitigated by early detection and treatment. Coinfection is uncommonly reported. METHODS: Dichorionic diamniotic twins born at 35 weeks of gestation were investigated for congenital infections due to abnormalities on the antenatal scan at 31 weeks of gestation. Antenatal investigations were delayed due to late booking and delay in maternal investigations. In the neonatal period, they suffered discordant symptoms and were both investigated for Toxoplasma gondii infection. This diagnosis was confirmed in twin 2 but proved difficult in twin 1 who had a weakly positive polymerase chain reaction with inconclusive serology. Twin 1 was also diagnosed with congenital CMV, further complicating the clinical picture. Toxoplasmosis can cause long-term sequelae, and definitive diagnosis requires serology at 12 months of age; in view of this, treatment for congenital toxoplasmosis was initiated in both twins. Twin 1 was also treated for congenital CMV. RESULTS: Due to limitations in serological investigations in neonates, diagnosing congenital toxoplasmosis can be challenging, and initiating treatment may be warranted in suspected cases, given the risk of infective complications. Discordant presentations between twins are known in congenital toxoplasmosis and CMV, but coinfection has rarely been reported without concurrent immunocompromise. A high index of suspicion should be maintained in the twin of an infected neonate, and the possibility of multiple infections should be considered. Multidisciplinary working is crucial in reaching a diagnosis and treating appropriately.

Haemophagocytic lymphohistiocytosis complicating visceral leishmaniasis in the UK: a case for detailed travel history, a high index of suspicion and timely diagnostics.

A 4-month-old male infant presented acutely unwell with fever. He was initially treated for sepsis but failed to improve with IV broad spectrum antibiotics. Haemophagocytic lymphohistiocytosis (HLH) was diagnosed due to his fever, pancytopenia, splenomegaly, hypertriglyceridaemia, hypofibrinogenaemia and significant hyperferritinaemia. An array of differentials for HLH including both immunological and infectious causes were considered and excluded. He had travelled to Madrid, and hence visceral leishmaniasis (VL) was suspected, but was not confirmed on the initial bone marrow aspirate (BMA) microscopy or culture. He improved with empirical treatment with dexamethasone and liposomal amphotericin B. VL was later confirmed on BMA PCR. He made a good recovery and remained well at 12 month follow-up. Non-endemic countries need rapid and sensitive VL diagnostics. A thorough travel history and high clinical index of suspicion are necessary to avoid the pitfall of treatment with intense immunosuppression recommended in treatment guidelines for HLH.