Cytokine Profile and Clinical Correlates in HIV-Exposed Infants with Severe (Hypoxic) Pneumonia

Introduction. Severe pneumonia in infants who are HIV-infected is a common problem in many parts of the developing world; especially sub-Saharan Africa. What has been missing from previous studies of severe pneumonia in HIV-infected infants; however; is a description of the host inflammatory response and cytokine/chemokine profile that accompanies this disease. Objective. To describe the cytokine profiles associated with severe hypoxic pneumonia in HIV-infected infants Methods. In a cohort of HIV-infected children diagnosed clinically with severe hypoxic pneumonia; paired serum and sputum cytokines were tested. A control group of HIV-infected children with bronchiectasis contributed matching controls.Results. A total of 100 infants (mean age 2.8 months) with a clinical diagnosis of severe hypoxic pneumonia were included in this study. IP-10 was markedly elevated in both sputum (mean 560.77pg/ml) and serum (mean 9091.14pg/ml); while IP-10 was elevated in serum (mean 39.55 pg/ml); with both these cytokines being significantly higher than in stable children with HIV-related bronchiectasis. Conclusion. This study of HIV-infected infants with severe hypoxic pneumonia suggests that IL-10 and IP-10 are associated with more severe lung disease. However; further investigation of this association is required

Atopy in HIV-infected children in Pretoria.

INTRODUCTION: The development or aggravation of a pre-existing atopic state in patients with human immunodeficiency virus (HIV) has not been thoroughly investigated in South Africa. HIV-infected adults have been shown to have a higher prevalence of atopy in some international studies, but this has not been documented in children. METHODS: A prospective convenience sample of 50 children aged between 3 months and 12 years attending the Tshwane District Hospital Paediatric HIV Clinic in Pretoria was recruited. Their personal and family histories of atopy, World Health Organization (WHO) HIV clinical staging and Centers for Disease Control (CDC) immunological staging with CD4 counts were documented. An age- and sex-matched control group of 50 HIV-negative children was included. Skin prick tests (SPTs) to identify common aeroallergens were conducted on all patients. RESULTS: One hundred children were enrolled, with 50 in each group. Ten per cent of the HIV-infected patients compared with 16% of controls had positive SPTs to aeroallergens. A higher percentage of the HIV-infected patients had chronic rhinitis and eczema (60% and 68%, respectively). There was no relationship between CD4 count and positive SPTs (p = 0.61), mean log CD4 count and presence of reported asthma (p = 0.71), and CD4 count and presence of reported dermatitis (p = 0.84). The CD4 count was not statistically different between children with and without a family history of atopy (p = 0.68). CONCLUSION: It appears that the stage of HIV disease does not influence the development or expression of allergy. There is a high prevalence of dermatitis and chronic rhinitis in HIV-infected children, probably not atopic in origin.

Adjunctive Corticosteroid Treatment of Clinical PCP Pneumonia in Infants Less than 18 Months of Age : a Randomized Controlled Trial

"Objectives. To determine the efficacy and safety of adjunctive corticosteroid therapy in clinical PCP pneumonia (Pneumocystis jiroveci pneumonia) in infants exposed to HIV infection. Design. Double blind randomised placebo-controlled trial. Methods: Infants with a clinical diagnosis of PCP; based on an ""atypical"" pneumonia with: 1) hypoxia out of proportion to the clinical findings on auscultation; 2) CRP less than 10 IU; 3) LDH above 500 IU; 4) compatible CXR findings and 5) positive HIV ELISA test were included in the study. Patients were randomised to receive either prednisone or placebo. The protocol provided for the addition of prednisone to the treatment at 48 hours if there was clinical deterioration or an independent indication for steroid therapy. Other treatment was carried out in accordance with established guidelines. in room air. Results. One hundred patients were included; 47 in the prednisone and 53 in the placebo group. Patients in the prednisone group had a 43 better chance of survival than the placebo group (HR 0.57; 95CI 0.30-1.07; p=0.08). No significant differences could be demonstrated between groups in respect of other parameters of recovery. Conclusions. In HIV exposed infants with clinical PCP pneumonia; adjunctive corticosteroid treatment does not appear to add benefit regarding time to recovery or oxygen independency; but early administration may improve survival. A large multi-centred trial is needed to confirm these findings.The primary study endpoint was in hospital survival. Secondary outcome was time from admission to the first day of mean oxygen saturation above 90"

Gastroenteritis in young children

Acute diarrhoea is due to intestinal infection. The patient ingests the pathogen which has contaminated water; food; drink; toys or anything that can be placed in the mouth. An inadequate and unsafe water supply; and poor application and practice of hygiene leads to faecal contamination. The most important complication is dehydration; with a poor correlation between the clinical features and actual dehydration. The management of the dehydrated patient depends on a careful assessment of the state of the circulation and the need for resuscitation. In most instances; oral rehydration is appropriate and fully effective if the solution is offered in small quantities at a time. Normally nourished infants do not require modi fication of their feeds beyond adapting the quantity offered as tolerated; but if diarrhoea persists; there is a risk of intestinal mucosal damage with malabsorption and nutritional consequences

Screening for childhood anaemia using copper sulphate densitometry.

OBJECTIVE: To evaluate copper sulphate densitometry to screen for childhood anaemia in a primary care setting, with a view to identifying children requiring definitive diagnostic testing and treatment. DESIGN: A cross-sectional screening study. Results of densitometry with a copper sulphate solution of specific gravity (SG) 1.048, corresponding to a haemoglobin (Hb) concentration of 10 g/dl, were compared with laboratory Hb determination. SETTING: Outpatient department of Pretoria Academic Hospital (73 children) and a local crèche (27 children). SUBJECTS: One hundred consecutive children, aged between 6 months and 6 years, with informed written consent by parents. OUTCOME MEASURE(S): Accuracy of copper sulphate densitometry in screening for Hb concentration below 10 g/dl in terms of sensitivity, specificity, positive and negative predictive values, as well as likelihood ratio. RESULTS: The prevalence of anaemia (Hb < 10 g/dl) was 17% (95% confidence interval (CI) 10.2; 25.8). Copper sulphate densitometry had a sensitivity of 88.2% (95% CI 62.3; 97.9), a specificity of 89.2% (95% CI 79.9; 94.6), a positive predictive value of 62.5% (95% CI 40.8; 80.5) and a negative predictive value of 97.4% (95% CI 90.0; 99.5) in screening for anaemia. The likelihood ratio of a positive screening test was 8.17. CONCLUSIONS: Copper sulphate densitometry was accurate in screening for childhood anaemia.

Epidemic Shigella dysenteriae type 1 in Natal.

Since its first isolation in South Africa in 1994, Shigella dysenteriae type 1 has now spread to cause an epidemic outbreak in Natal Kwazulu, resulting in a steep rise in admissions for dysentery and the haemolytic uraemic syndrome in children. We report on the epidemic as it has evolved so far. A large outbreak is to be expected in South Africa in view of large scale poverty, lack of housing, and adequate water and sanitation, unless urgent public health measures are taken.

Paediatric diarrhoea--rehydration therapy revisited.

Acute infective diarrhoea remains one of the most common causes of morbidity and mortality in children under 5 years of age. This paper reports on a 7-year experience of management of paediatric diarrhoea at King Edward VIII Hospital, Durban, in which an inpatient case-fatality rate of nearly 25% was reduced to less than 7%, and the admission rate was reduced by 60% by a cumulative effect of the following measures: one of four paediatric wards was converted into a diarrhoea ward; improved attention to protocol resulted in a rapid reduction in the inpatient case-fatality rate, but further improvement resulted from a strong commitment to an efficient outpatient oral rehydration protocol to reduce the pressure on inpatient beds, as well as a simplified approach to fluid therapy; and a formula was developed based on units of 5 ml/kg/h, and applicable to both oral and intravenous routes. The most important assessment of dehydrated patients is determination of a need for resuscitation. In less severely ill patients it is not necessary to calculate rehydration fluid requirements by a 'percent dehydration' formula.

Racial differences in the seroprevalence of hepatitis A virus infection in Natal/KwaZulu, South Africa.

The age- and race-specific seroprevalence of hepatitis A virus (HAV) infection was determined by radioimmunoassay (RIA) in 786 subjects between the ages of 6 months to 60 years. More than 50% of African children were seropositive by the age of 5 years. In blood donors (17-60 years), 50% (93/187) of Whites, 67% (110/163) of Indians, 85% (117/137) of Coloureds, and 91% (115/127) of Africans were seropositive. There was a significant difference in the seroprevalence of HAV infection between White blood donors and blood donors from the other three racial groups [Coloureds (P < 0.0001), Africans (P < 0.0001), and Indians (P < 0.001)] and between Indians and Coloureds (P < 0.0001) and Indians and Africans (P < 0.0001). There was no significance difference in HAV infection between Coloureds and Africans (P < 0.200). Eighty-seven per cent (32/37) of rural Africans had previous infection. In the African population HAV infection is acquired in childhood. There are significant racial differences in the seroprevalence of HAV infection. The surveillance of HAV infection may be used as a valuable yardstick to monitor the changing standards of hygiene and socioeconomic conditions of a community in transition in South Africa and to make rational public health decisions regarding a hepatitis A vaccination policy.

The practical significance of lactose maldigestion in institutionalised black children.

A study was carried out to determine the practical significance of a high prevalence of lactose maldigestion in institutionalised children whose diet included 500 ml milk daily. Thirty of 34 children at a child welfare home were found to be lactose maldigesters as judged by a 2-hour rise in breath hydrogen of 20 parts per million or more after an oral load of lactose. Breath hydrogen tests were also performed on the same group of children, before and up to 150 minutes after the routine mid-morning cup of milk. Sixteen of the 30 lactose-maldigesting children did not show increased breath hydrogen up to 2.5 hours after milk. No children were clinically intolerant of either the lactose or the milk. In these children the degree of lactose digestion was much improved in the non-fasting state when measured by the breath hydrogen response to milk lactose. Lactose maldigestion per se is not a contraindication to institutional feeding routines, including regular moderate milk intake.

Lactose maldigestion: increased age-related prevalence in institutionalized children.

A study was performed to determine whether the age-related prevalence of lactose maldigestion is increased in healthy institutionalized children. Previous malnutrition did not exclude children from study. The control children had no prior history of malnutrition or hospital admissions for diarrhea. The anthropometric comparison showed the institutionalized children to be shorter and lighter than the controls, but they were of normal weight by stature, suggesting a normal recent nutritional state. Fasting breath hydrogen tests were performed following an oral dose of lactose 1 g/kg, given as a 10% solution. A rise of breath hydrogen of greater than or equal to 20 ppm was considered to indicate lactose maldigestion. Twenty-two of 44 controls and 39 of 49 study children were lactose maldigesters (p less than 0.01). The control children showed an age-related increase in the prevalence of lactose maldigestion, from 31.6% at age less than 5 years to 75% at age greater than 9 years. The institutionalized children, by comparison had an increased prevalence of 78.8% in the group under 5 years of age (p = 0.002). Equally high prevalence rates were found at all ages tested. At follow-up, lactose maldigestion was persistent in the majority of the study children. This had no nutritional impact despite a regular milk intake. The distinction between acquired and primary lactose maldigestion is of no practical significance in these children.

Lactose maldigestion--age-specific prevalence in black and Indian children.

A study was performed to determine the prevalence and age of onset of primary lactose maldigestion in healthy black and Indian children, and to determine whether this was of clinical significance. More black (22 of 44-50%) than Indian children (10 of 45-22.2%) had lactose maldigestion (P less than 0.02), the development of which was age-related and occurred earlier in blacks than in Indians; 6 of 19 black children less than 5 years old (31.6%) were lactose maldigesters, compared with 8 of 10 (80%) over 10 years old, while only 1 of 16 Indian children aged under 8 years (6.3%) were maldigesters, compared with 5 of 13 (38.5%) aged over 10 years. Most children had a very low intake of milk and lactose maldigestion was of no clinical significance to them.

Diarrhoea is a nutritional disease.

More hospitalised patients with diarrhoea than patients without diarrhoea were underweight for age. In a retrospective survey of patients hospitalised more than once with either diarrhoea or bronchopneumonia, the patients with diarrhoea were found to have a greater decrease in weight for age at the time of the second admission than the patients with bronchopneumonia. The malnutrition associated with diarrhoea is due to a number of factors, including decreased intake, extra losses and malabsorption of nutrients. Patients on marginal food intakes may be unable to make up lost ground after diarrhoeal episodes and become malnourished. A brief survey of health professionals' attitudes suggested a tendency to overlook the nutritional component in the management of diarrhoea. Nutritional rehabilitation during and after episodes of diarrhoea ought to receive more emphasis in teaching and practice.

Hypogonadotrophic variant of Klinefelter's syndrome. A case report.

A 16-year-old boy with 47,XXY chromosomal complement (Klinefelter's syndrome) presented with delayed puberty and apparent gonadotrophin deficiency. Despite an inadequate growth hormone response to insulin-induced hypoglycaemia and to L-dopa administration, his somatic growth was appropriate for his delay in pubertal development, increasing markedly on testosterone treatment. Patients with Klinefelter's syndrome may have abnormalities of neuro-endocrine regulation.