Utility of clinically-directed selective screening to diagnose HIV infection in hospitalized children in Bombay,India

The increasing prevalence of HIV infection in urban India together with limited financial resources necessitates judicious HIV testing. This prospective study was undertaken to determine the utility of selective screening for HIV infection based on five clinical risk factors reported in African children. The study was conducted at the Departments of Paediatrics and Microbiology, LTMG Hospital, Bombay, India between September 1998 and 2000. The children were enrolled after taking informed consent from their parents. The HIV seroprevalence rate was determined in children (aged 1 month to 12 years) consecutively admitted with severe malnutrition, serious pyogenic infections (pneumonia, pyogenic meningitis, septicaemia), disseminated tuberculosis, chronic diarrhoea and oral candidiasis, present either singly or in combination. Children above 18 months of age were diagnosed as being infected with HIV if they tested positive by two different HIV enzyme-linked immunosorbent assay (ELISA) tests. In children less than 18 months of age the diagnosis of HIV infection was made if they were ELISA positive and also fulfilled the WHO criteria for symptomatic HIV infection. Of a total 204 children (110 male, 94 female) screened, 24 (11.8 per cent) were diagnosed as HIV-infected. The HIV seropositive rate was highest in children having oral candidiasis (40.6 per cent), followed by chronic diarrhoea (18.2 per cent), disseminated tuberculosis (16.2 per cent), severe malnutrition (14.4 per cent), and serious pyogenic infections (11.2 per cent). Only the presence of oral candidiasis was a significant independent risk factor for predicting HIV infection (p < 0.0001). However, as the number of risk factors concomitantly present increased, the chances of the child being infected with HIV also increased significantly (p < 0.001). Our study shows that clinically-directed selective screening does have a practical role in diagnosing HIV infection in a resource-poor setting.     

Prevalence of pediatric HIV in New Delhi

Objective: This study was carried out to determine the prevalence of HIV infection in North India, as there are scanty reports from this part of India.Methods: The prevalence of HIV infection was determined by serological tests for HIV antibodies in children born to a seropositive mother or suffering from chronic diarrhea, failure to thrive or disseminated tuberculosis.Results: One hundred and twelve children were tested of which ten were seropositive (8.9%). This included six children born to seropositive mother (22%), two with chronic diarrhea (4%), one with failure to thrive (5%) and one child with disseminated tuberculosis (6.6%).Conclusion: HIV infection is an emerging reality in New Delhi. A clinically directed screening can help detect more cases.     

Clinically directed selective screening for HIV infection in hospitalized children

BACKGROUND: As HIV infection presents with several manifestations, none of which is specific, several children are subjected to HIV testing. Very few studies have examined the issue of probability of HIV infection with a given clinical manifestation. AIM: To determine the probability of HIV infection when a child is hospitalized with at least one of the selected manifestations. MATERIAL AND METHODS: Children aged 18 mo and above, admitted to a tertiary care center in Mumbai, India with chronic diarrhea, severe malnutrition, persistent cough, generalized lymphadenopathy, oral thrush, hepatomegaly, repeated common infections, generalized dermatitis, chronic parotid swelling, recurrent bacterial infection, disseminated tuberculosis and/ or Pneumocystis carinii pneumonia were enrolled in a prospective study after obtaining informed consent. They were subjected to HIV testing using WHO-UNAIDS strategy II. The data obtained was analyzed using the Statistical Package For Social Sciences (SPSS) software program. RESULTS: Twenty-three (20 PERCENT) of the 115 children enrolled tested positive for HIV. The seropositivity rate for various features ranged from 9.1 PERCENT for chronic diarrhea to 83.3 PERCENT for chronic dermatitis. Oral thrush, generalized dermatitis and generalized lymphadenopathy were the significant independent clinical risk factors for predicting HIV seropositivity. The probability of HIV infection was higher in children who had higher number of risk factors present concomitantly CONCLUSIONS: The probability of HIV infection in a child is dependent upon the nature and number of manifestations present.     

Tuberculosis in children--what has changed in last 20 years?

Several changes have been observed in the epidemiology, clinical manifestations, diagnostic modalities and treatment of tuberculosis. Emergence of HIV epidemic and drug resistance have posed significant challenges. With increase in number of diseased adults and spread of HIV infection, the infection rates in children are likely to increase. It is estimated that in developing countries the annual risk of tuberculosis infection in children is 2.5%. Nearly 8-20% of the deaths caused by tuberculosis occur in children. Lymph node tuberculosis has increased over last two decades. HIV infected children are at an increased risk of tuberculosis, particularly disseminated disease. In last two decades drug resistant tuberculosis has increased gradually. The rates of drug resistance to any drug varied from 20% to 80% in different geographic regions. Various diagnostic techniques such as improved culture techniques, serodiagnosis, and nucleic acid amplification have been developed and evaluated to improve diagnosis of childhood tuberculosis. Serodiagnosis is an attractive investigation but till date none of the tests have desirable sensitivity and specificity. Tests based on nucleic acid amplification are a promising advance. Relatively less experience in children, need for technical expertise and high cost are limiting factors for their use in children with tuberculosis. Short-course chemotherapy for childhood tuberculosis is well established. Treatment with intermittent regimens is comparable to daily regimens. Directly observed treatment strategy have shown encouraging result.     

Sputum induction for the diagnosis of pulmonary tuberculosis in infants and young children in an urban setting in South Africa.

BACKGROUND: Bacteriological confirmation of pulmonary tuberculosis is difficult in infants and young children. In adults and older children, sputum induction has been successfully used; this technique has not been tested in younger children. AIMS: To investigate whether sputum induction can be successfully performed in infants and young children and to determine the utility of induced sputum compared to gastric lavage (GL) for the diagnosis of pulmonary tuberculosis in HIV infected and uninfected children. SUBJECTS AND METHODS: 149 children (median age 9 months) admitted to hospital with acute pneumonia who were known to be HIV infected, suspected to have HIV infection, or required intensive care unit support. Sputum induction was performed on enrollment. Early morning GL was performed after a minimum four hour fast. Induced sputum and stomach contents were stained for acid fast bacilli and cultured for Mycobacterium tuberculosis. RESULTS: Sputum induction was successfully performed in 142 of 149 children. M tuberculosis, cultured in 16 children, grew from induced sputum in 15. GL, performed in 142 children, was positive in nine; in eight of these M tuberculosis also grew from induced sputum. The difference between yields from induced sputum compared to GL was 4.3% (p = 0.08). M tuberculosis was cultured in 10 of 100 HIV infected children compared to six of 42 HIV uninfected children (p = 0.46). CONCLUSION: Sputum induction can be safely and effectively performed in infants and young children. Induced sputum provides a satisfactory and more convenient specimen for bacteriological confirmation of pulmonary tuberculosis in HIV infected and uninfected children.     

Detection of Mycobacterium tuberculosis in gastric aspirate and sputum collected from Ethiopian HIV-positive and HIV-negative children in a mixed in- and outpatient setting

AIM: To investigate, through a prospective study, the detection rate of Mycobacterium tuberculosis in sputa and gastric aspirate from tuberculous children in a low-income country with high prevalence of tuberculosis and an increasing HIV epidemic. METHODS: Gastric aspirates and/or sputum samples were collected from 355 children with pulmonary tuberculosis as follows: from 136 children under 5 y only gastric aspirate was taken, for 159 children aged 5 to 9 y both methods were used, and for 60 children over 10 y only sputum was analysed. The diagnosis of tuberculosis was based on clinical data, tuberculin test and chest radiography. All children were tested for HIV infection. RESULTS: Direct microscopy for acid-fast bacilli was positive for 55 (15%) and mycobacterial culture for 183 (52%) children. The proportion of positive cultures was similar in all age groups. Among the 5 to 9 year-old children who could produce a sputum sample, sputum gave just as good culture yield of M. tuberculosis as gastric aspirate. Of the clinical or radiological findings only weight loss was associated with a higher yield. Repeat gastric aspirate increased the culture yield by 6%. Mycobacterial culture from HIV-positive children gave lower yield compared with HIV-negative children. CONCLUSION: Our data suggest that one gastric aspirate for children less than 6 y and three sputum samples for the older children collected at an outpatient TB clinic, is enough to provide a close to 50% yield of M. tuberculosis available for culture and further analyses. However, with an increasing prevalence of HIV, this detection rate may be reduced.     

Changing Trends in Childhood Tuberculosis

Several changes have been observed in the epidemiology, clinical manifestations, diagnostic modalities and treatment of tuberculosis. Emergence of HIV epidemic and drug resistance have posed significant challenges. With increase in the number of diseased adults and spread of HIV infection, the infection rates in children are likely to increase. It is estimated that in developing countries, the annual risk of tuberculosis infection in children is 2.5%. Nearly 8–20% of the deaths caused by tuberculosis occur in children. Extra pulmonary tuberculosis has increased over last two decades. HIV infected children are at an increased risk of tuberculosis, particularly disseminated disease. In last two decades, drug resistant tuberculosis has increased gradually with emergence of MDR and XDR-TB. The rate of drug resistance to any drug varied from 20% to 80% in different geographic regions. Significant changes have occurred in TB diagnostics. Various diagnostic techniques such as flourescence LED microscopy, improved culture techniques, antigen detection, nucleic acid amplification, line probe assays and IGRAs have been developed and evaluated to improve diagnosis of childhood tuberculosis. Serodiagnosis is an attractive investigation but till date none of the tests have desirable sensitivity and specificity. Tests based on nucleic acid amplification are a promising advance but relatively less experience in children, need for technical expertise and high cost are limiting factors for their use in children with tuberculosis. Short-course chemotherapy for childhood tuberculosis is well established. Directly observed treatment strategy (DOTS) have shown encouraging result. DOTS plus strategy has been introduced for MDR TB.     

Prevalence and risk factors for transmission of infection among children in household contact with adults having pulmonary tuberculosis.

AIMS: To study the prevalence of tuberculosis infection among children in household contact with adults having pulmonary tuberculosis, and identify the possible risk factors. METHODS: Children under the age of 5 years who were in household contact with 200 consecutive adults with pulmonary tuberculosis underwent tuberculin skin testing. Transverse induration of greater than 10 mm was defined as positive tuberculin test suggestive of tubercular infection. Infected children underwent chest radiography and analysis of gastric lavage fluid or induced sputum for detection of acid fast bacilli. RESULTS: Tuberculin test was positive in 95 of 281 contacts (33.8%), of which 65 were contacts of sputum positive patients, while 30 were contacts of sputum negative patients. Nine of these children were diagnosed as having tuberculosis based on clinical features and/or recovery of acid fast bacilli; seven were in contact with sputum positive adults. The important risk factors for transmission of infection were younger age, severe malnutrition, absence of BCG vaccination, contact with an adult who was sputum positive, and exposure to environmental tobacco smoke. CONCLUSION: The prevalence of tuberculosis infection and clinical disease among children in household contact with adult patients is higher than in the general population, and risk is significantly increased by contact with sputum positive adults.     

免疫缺陷患儿合并结核分枝杆菌感染的临床特征分析

目的 探讨继发性免疫缺陷病（SID）及原发性免疫缺陷病（PID）患儿合并结核分枝杆菌感染的临床特征。方法 回顾性分析合并结核分枝杆菌感染的免疫缺陷患儿（SID组36例、PID组52例）及非免疫缺陷患儿（对照组108例）的临床资料。结果 PID组患儿起病年龄低于对照组和SID组（P < 0.05）,男性比例高于对照组和SID组（P < 0.05）。SID组及PID组患儿其他结核中毒症状（盗汗、消瘦、乏力、食欲下降）及PPD试验阳性率均低于对照组（P < 0.05）,且更易出现肺叶受累≥ 3叶（P < 0.05）。PID患儿更易合并多器官受累（P < 0.05）。SID组肺部粟粒影发生率高于对照组和PID组（P < 0.05）,PID组γ-干扰素释放试验阳性率低于对照组和SID组（P < 0.05）。结核分枝杆菌感染在SID组表现为潜伏结核感染（36.1%）和活动性结核病（63.9%）;在PID组以卡介苗病（90.4%）为主,有2例（3.8%）同时合并结核病。结论 免疫缺陷患儿合并结核分枝杆菌感染的临床症状不典型,易出现播散性感染,PPD试验及γ-干扰素释放试验阳性率较低,容易出现误诊及漏诊。免疫缺陷患儿应常规进行结核相关筛查,早期识别及干预以改善预后。     

Global aspects of tuberculosis in children

Tuberculosis (TB) in children reflects the prevalence of the disease in adults as well as current transmission rates. Africa and South-east Asia have the largest number of tuberculosis cases and the situation there has been worsened by the HIV epidemic. Children born to HIV-infected parents, whether infected or not, are at high risk of developing tuberculosis because of the increased risk of exposure to the disease. Tuberculosis is more common among the disadvantaged and vulnerable groups in each society and the impact of overcrowding, under-nutrition and poverty is particularly severe on children. Recent studies have documented the increase in the occurrence of tuberculosis in children, both in developed and developing countries. The peak age of notification of tuberculosis decreases as the incidence of the disease increases in the region. Tuberculosis infection can progress rapidly to disease, particularly in infancy and early childhood. Most of the morbidity occurs in the first few years after infection. Recently infected children and those with large tuberculin reaction (>18 mm) are at increased risk for progression and should be followed closely. Mortality from tuberculosis is also highest in early childhood, mainly due to disseminated forms like meningeal and miliary tuberculosis.Tuberculosis can be controlled either by preventing the infection from occurring or by treating early infection after it has occurred. An efficient tuberculosis control program with early detection of infectious adults and their cure is the best long-term approach to the reduction of TB disease in children. The DOTS strategy advocated by the WHO has the potential to have a significant impact on the epidemiology of tuberculosis by achieving high cure rates and thereby decreasing community transmission. BCG vaccination, through effective against disseminated forms of the disease in childhood, has very little impact on adult forms of the disease. Chemoprophylaxis or preventive therapy is effective, but difficult to implement on a mass scale and is only recommended for special high-risk groups in developing countries.     

Diagnosis of pulmonary tuberculosis in children in an HIV-endemic area, Malawi

The diagnosis of pulmonary tuberculosis (PTB) in young children is particularly complex in resource-poor regions where HIV infection is common. This study examines the impact of HIV infection on diagnosis in children with suspected PTB attending Queen Elizabeth Central Hospital, Blantyre. A total of 110 children (4 months-14 years) were studied over a 4-month period. Clinical data were recorded and investigations included Mantoux test, chest X-ray, HIV status (HIV-PCR when younger than 18 months) and sputum, if available. Laryngeal swabs were compared with sputa or gastric aspirates in a subgroup of 60 children. All children were commenced on anti-TB therapy and followed for treatment response. Aware of the clinical overlap between HIV and TB infection, we used more limited criteria than recommended to allocate a final diagnosis following review of all data except HIV status. Final diagnosis included confirmed PTB (n = 8), probable PTB (n = 41), lymphocytic interstitial pneumonitis (n = 10), pulmonary Kaposi sarcoma (n = 3) and bronchiectasis (n = 5). Culture rates of M. tuberculosis were: five (27.8%) of 18 sputa, three (7.1%) of 42 gastric aspirates and four (6.6%) of 60 laryngeal swabs. The HIV infection rate was 70.6% overall and 57.8% in 45 children with confirmed or probable PTB. Although a positive contact history was more common in HIV-infected children, a final diagnosis of confirmed or probable PTB was less common than in HIV-uninfected children (36% vs 63%; p = 0.02). The Mantoux test was positive in 14 (19%) of 72 HIV-infected compared with 15 (50%) of 30 HIV-uninfected children (p < 0.01). A final diagnosis could not be made in 43 (39%) of the study children with suspected PTB, the majority of whom were HIV-infected. HIV-infected children had a significantly poorer response to TB treatment and higher lost-to-follow-up rates.     

Sputum induction for the diagnosis of pulmonary tuberculosis in infants and young children in an urban setting in South Africa

BACKGROUND—Bacteriological confirmation of pulmonary tuberculosis is difficult in infants and young children. In adults and older children, sputum induction has been successfully used; this technique has not been tested in younger children.
AIMS—To investigate whether sputum induction can be successfully performed in infants and young children and to determine the utility of induced sputum compared to gastric lavage (GL) for the diagnosis of pulmonary tuberculosis in HIV infected and uninfected children.
SUBJECTS AND METHODS—149 children (median age 9 months) admitted to hospital with acute pneumonia who were known to be HIV infected, suspected to have HIV infection, or required intensive care unit support. Sputum induction was performed on enrolment. Early morning GL was performed after a minimum four hour fast. Induced sputum and stomach contents were stained for acid fast bacilli and cultured for Mycobacterium tuberculosis.
RESULTS—Sputum induction was successfully performed in 142 of 149 children. M tuberculosis, cultured in 16 children, grew from induced sputum in 15. GL, performed in 142 children, was positive in nine; in eight of these M tuberculosis also grew from induced sputum. The difference between yields from induced sputum compared to GL was 4.3% (p = 0.08). M tuberculosis was cultured in 10 of 100HIV infected children compared to six of 42 HIV uninfected children (p = 0.46).
CONCLUSION—Sputum induction can be safely and effectively performed in infants and young children. Induced sputum provides a satisfactory and more convenient specimen for bacteriological confirmation of pulmonary tuberculosis in HIV infected and uninfected children.

     

Diagnosed tuberculosis during the follow-up of a cohort of human immunodeficiency virus-infected children in Abidjan, Côte d'Ivoire: ANRS 1278 study

INTRODUCTION: Most data on tuberculosis in human immunodeficiency virus (HIV)-infected children in Africa come from hospital-based and cross-sectional studies. OBJECTIVES: To estimate the incidence of tuberculosis in HIV-infected children participating in an observational cohort. METHODS: HIV-infected children in Abidjan, C?te d'Ivoire, are followed in a prospective cohort. At enrollment, all children had a physical examination, CD4 lymphocyte counts, chest radiograph and a tuberculin test. Quarterly follow-up visits are organized. All patients with suspected tuberculosis undergo specific investigations including gastric aspiration and culture. All isolates are tested for susceptibility. RESULTS: From October 2000 to December 2003, 129 girls and 153 boys were recruited. Of children without a current or previous diagnosis of tuberculosis, 6.5% (13 of 199) had a tuberculin test result of >5 mm, compared with 17.5% of children (10 of 57) with current or previous tuberculosis (P < 0.02). Forty-eight children (17%) had a history of treated tuberculosis, and 27 children were being treated for tuberculosis at enrollment or during the first month of follow-up. Eleven children were diagnosed with tuberculosis after the first month of follow-up, and the diagnosis of mycobacterial infection was confirmed in 7 cases. Of 5 tested isolates of Mycobacterium tuberculosis, 3 were resistant to at least 1 antitubercular drug.Cumulative incidence of tuberculosis was 2060/100,000 at 12 months, 3390/100,000 at 2 years and 5930/100,000 at 3 years. The 3-year risk was 12,400/100,000 in immunocompromised children (CD4 <15%) and 3300/100,000 in other children (P < 0.0001). CONCLUSION: The risk of tuberculosis among HIV-infected children in C?te d'Ivoire is strongly associated with the degree of immunodeficiency in HIV infection.     

Risk factors for human immunodeficiency virus infection in Ethiopian children with tuberculosis.

BACKGROUND: Separate risk factors for HIV infection and for tuberculosis (TB) are well-studied, but it is unclear whether these risk factors still apply in the new epidemiologic situation of dual infection. This study examines risk factors associated with seropositivity for HIV in Ethiopian children with clinical TB. METHODS: A prospective, controlled study of children with TB diagnosed in Addis Ababa from December 11, 1995, to January 28, 1997, in which HIV-positive children were compared with HIV-negative children with regard to sociodemographic background, previous medical history and vaccination. RESULTS: HIV prevalence among children with clinical TB was 11.2%. High educational status of mothers, low age, loss of one or two parents and earlier Calmette-Guérin bacillus (BCG) vaccination of the child were factors independently related to HIV infection. CONCLUSION: Factors associated with HIV infection among children with clinical TB include higher education of parents, higher income and better living conditions. The HIV epidemic might thus modify traditional risk factors for tuberculosis. It might also decrease the overall effect of BCG vaccination given that BCG did not provide protection in children infected with HIV. An expected increase of dually infected children who are younger, more in need of hospitalization and often lacking one or both parents will put an additional burden on the Ethiopian health care system.     

Endocarditis as the first presentation of AIDS in infancy

A two month old Ugandan boy underwent surgery for an obstructive right ventricular vegetation associated with disseminated Staphylococcus aureus infection. Both the child and his mother subsequently tested positive for HIV infection. Very little is know about the incidence of endocarditis in paediatric patients with AIDS. To our knowledge this is the first case reported of disseminated S aureus infection associated with endocarditis and an obstructing vegetation in an HIV positive infant with a structurally normal heart. The initial signs and symptoms for endocarditis were atypical, a reflection of the overwhelming infection in an immunocompromised patient. Severe infections may have an atypical presentation in immunosuppressed patients. AIDS needs to be considered in these patients, especially if they come from populations with endemic HIV infection.

     

Clinical profile of HIV infection

OBJECTIVE: To study the clinical profile of human immunodeficiency virus (HIV) infection in children. DESIGN: Prospective. SETTING: HIV clinic at a pediatric tertiary care center in an urban metropolis. METHODS: From August 1994 onwards, 285 HIV positive children were referred to the HIV clinic. These included those intramural deliveries born to HIV positive mothers, those referred from other centers with a positive HIV ELISA (enzyme-linked immunosorbent assay) test and those screened routinely at our center in view of transfusion dependence and found to be HIV positive. After informed consent from either parent, the HIV status of all referred patients was retested by ELISA. RESULTS: Two hundred and thirteen (74.73%) patients were below the age of five years. Vertical transmission as the route of infection was documented in 247 (86.66%), 33 (11.57%) were infected through blood and in 5 (1.75%), the mode of transmission could not be ascertained. The clinical features noted were protein energy malnutrition in 127 (44.56%), pulmonary and extrapulmonary tuberculosis in 84 (29.47%), hepatosplenomegaly in 82 (28.77%), persistent generalized lymphadenopathy in 67 (23.50%), skin lesions in 63 (22.10%), chronic diarrhea in 43 (15.08%), oral thrush in 42 (14.73%), pyrexia of unknown origin in 36 (12.63%), chronic lung disease in 32 (11.22%), chronic hypertrophic parotitis in 27 (9.47%), chronic ottorrhea in 26 (9.12%), recurrent lower respiratory tract infection in 24 (8.42%), neurological manifestations of non-tuberculous origin in 13 (4.56%) and Pneumocystis carinii pneumonia in 11(3.88%). Forty-eight (16.84%) were asymptomatic, 30 (10.52%) died of AIDS during the study period and 39 (13.68%) have been lost to follow up. CONCLUSION: Vertical transmission was the commonest mode of infection. Perinatally infected children become symptomatic by five years of age. Protein energy malnutrition, hepatosplenomegaly and persistent generalized lymphadenopathy were common presenting features. Tuberculosis was the major co-infection. Chronic hypertrophic parotitis and chronic lung disease were distinguishing features of this study. Encephalopathy was associated with poor outcome.     

Evaluation of young children in household contact with adult multidrug-resistant pulmonary tuberculosis cases.

BACKGROUND: The prevention and management of multidrug-resistant (MDR) tuberculosis has received much attention, but little attention has been given to children with MDR tuberculosis or children in contact with adults with MDR tuberculosis. The aim of this study was to determine the prevalence of tuberculous infection and disease in childhood contacts of adults with MDR pulmonary tuberculosis. METHOD: All children <5 years of age in household contact with 75 recently diagnosed adults with MDR pulmonary tuberculosis were evaluated. Evaluation included clinical examination, tuberculin skin test, chest radiography and culture for Mycobacterium tuberculosis from gastric aspirates. RESULTS: One hundred twenty-eight children, median age 27 months, were evaluated. Fifty children had recent contact with other adult tuberculosis cases. Sixty-six children previously had chemoprophylaxis or treatment of whom 36 defaulted treatment or received insufficient chemoprophylaxis. One child had HIV infection. Forty-seven children were classified as noninfected, 66 were considered infected only (Mantoux test, > or = 15 mm) and 15 had disease. Three children, who had not previously received antituberculosis drugs, had positive cultures for M. tuberculosis; all were multidrug-resistant. CONCLUSION: This study documents the transmission of multidrug-resistant M. tuberculosis to childhood contacts, the development of disease in these contacts and the importance of knowing the index case's M. tuberculosis susceptibility pattern in choosing a proper treatment regimen for the childhood contact.     

Pulmonary manifestations in HIV seropositivity and malnutrition in Zimbabwe

Over a 10 month period 184 children, aged 5 years or less, who died at home had their nutritional status and HIV serostatus established; necropsies were also carried out. The HIV antibody test was positive in 122/184 (66%). Of the HIV seropositive children Pneumocystis carinii pneumonia was present in 19 (16%), cytomegalovirus pneumonia in nine (7%), and lymphoid interstitial pneumonitis in 11 (9%). Opportunistic infection was therefore seen in 28/122 (23%) of the seropositive cases but in none of the seronegative cases. Tuberculosis was present in 8/184 (4%): 6/122 (5%) in HIV seropositive and 2/62 (3%) in seronegative children. Lung aspirate showed positive bacterial isolates in 106/ 122 (86%) of HIV seropositive and 46/62 (74%) of seronegative children with Gram negative organisms predominating in both groups. Malnutrition was common and affected 106/184 (58%); positive growth was obtained in 98 (92%) of the malnourished children irrespective of their HIV serostatus. Malnutrition was significantly associated with bacterial lung infection after adjustment for the confounding effect of HIV status. No association was found between HIV serostatus and bacterial lung infection that could not be attributed to malnutrition at the time of death. The importance of adequate nutrition in reducing the risk of bacterial infection in HIV infected children is apparent.     

The impact of human immunodeficency virus 1 on largyngeal airway obstruction in children

Children with laryngeal airway obstruction (LAO) require admission to the intensive care unit (ICU). The unresolved ethical dilemma of ICU access for HIV infected children in resource poor settings requires further scientific data to help guide triaging. Of 38 children with LAO, 19 had HIV infection. The mortality, need for supportive management, duration of intubation, intermittent positive pressure ventilation, and ICU and hospitalisation stay were similar in the HIV infected group compared to the HIV uninfected group. Episodes of laryngotracheobronchitis were equally distributed between both groups (31.6% v 31.3%), while oropharyngeal/laryngeal candidiasis (26.3%), tuberculosis (15.8%), and benign lymphoid hyperplasia (15.8%) were commonly seen in the HIV infected group.