Human immunodeficiency virus type 1 antigenemia in children

Human immunodeficiency virus type 1 (HIV-1) core antigen was assayed in the plasma of children at risk for infection with HIV to determine its usefulness in the diagnosis of infection and to correlate it with the clinical stage of disease. Antigen was detected in the plasma of all children less than 15 months of age with acquired immunodeficiency syndrome (AIDS). Two thirds of children with AIDS-related illnesses and half of children with asymptomatic infection had antigen. Although 53% of plasma specimens originating from HIV-infected children younger than 6 months of age contained antigen, only 25% of plasma specimens from children younger than 6 months who had no symptoms and none of the 10 specimens from HIV-infected newborn infants contained antigen. Half of the specimens containing core antigen also contained anticore antibody. Quantitative mean antigen levels were more likely to be elevated in children with AIDS (516 pg/ml) than in children with AIDS-related illnesses (295 pg/ml) or in those who had no symptoms (70 pg/ml). Antigen levels tended to increase over time in children with advancing clinical illness, but they tended to decrease over time after a diagnosis of AIDS was made. Antigen was detected in the plasma of 4 of 14 children without symptoms who subsequently reverted to an HIV seronegative state. We conclude that the detection of core antigen occurs with high frequency in children, even young infants, with symptomatic HIV infection. Plasma core antigen was less frequent in children without symptoms and was not detected in 10 infected children when they were tested at birth.     

IgG2 deficiency in children with human immunodeficiency virus infection

Infection with the human immunodeficiency virus (HIV) induces a polyclonal B-cell activation. Despite elevated serum immunoglobulin levels, a significant deterioration of the antigen specific humoral immune response exists in most cases. We studied the influence of HIV infection on the serum levels of IgG subclasses in children. We investigated 76 children (aged 15 months to 18 years) with HIV-1-infection. Most children (88%) showed elevated serum immunoglobulin levels. IgA (87%) and IgM (74%) were more often above normal levels for age than IgG (60%). IgG subclass serum levels were significantly altered. The increase in total IgG was mainly due to a marked augmentation of the IgG1 fraction. In most cases IgG3 was simultaneously elevated. Ten children (13%) had very low IgG4 levels (<0.03 g/l). Out of 61 patients older than 2 years 8 (13%) had a profound IgG2 deficiency with normal or elevated total IgG. Four of them also had low IgG4 levels (<0.03 g/l). A correlation between IgG2 deficiency and HIV infection according to the Centres for Disease Control classification for acquired immunodeficiency syndrome could not be demonstrated (three patients with symptomatic and five with asymptomatic infection).     

Serum immunoglobulin E levels in human immunodeficiency virus‐infected children with pneumonia

Elevated serum immunoglobulin E (IgE) levels have been reported in association with human immunodeficiency virus (HIV) infection in adults, but there is little information in children. The aim of the present study was to compare serum IgE levels in HIV‐positive and ‐negative children hospitalized with pneumonia in South Africa and to investigate whether IgE may be useful as a marker of specific infections or prognosis in HIV‐infected children. History, examination, blood tests, and induced sputum or bronchoalveolar lavage were carried out. Of 122 children [45% female, median age 8 months (3–20 months)], 81 were infected with HIV. A history of allergy or asthma was present in three children (two of whom were HIV positive). Serum IgE was higher in HIV‐infected children [83 (33–147) vs. 29 (6–113) IU/l; p = 0.011] as was immunoglobulin G (IgG) [49 (37–63) vs. 27.5 (23–34) g/l; p < 0.001]. CD4 lymphocytes [600 (330–1210) vs. 1900 (1500–3030) cells/µl], percentage CD4 cells [13.6 (9.4–20.3) vs. 40.1 (31.1–44.9)] and CD4 : CD8 ratio [0.3 (0.2–0.4) vs. 2 (1.4–2.8)] were lower in HIV‐positive children (p < 0.001 for all). Bacteremia occurred in 12 (10%) children; other specific pathogens identified included Mycobacterium tuberculosis in eight (7%) and Pneumocystis carinii in nine (7%). There was no correlation with CD4 count, CD4 : CD8 ratio, or the presence of specific pathogens, and IgE level. In‐hospital mortality (11%) did not correlate with IgE levels. HIV‐infected children with pneumonia have higher serum IgE compared with seronegative patients. In HIV‐positive children, IgE levels did not correlate with the degree of immunosuppression or with outcome.     

Primary results of antiretroviral treatment among HIV/AIDS infected children in Lomé (Togo)]

Since 2004 in Togo HIV/AIDS infected children have, free of charge, access to antiretroviral drugs according to the national program. The aim of this study was to investigate the clinical, biological and prognosis aspects of anti-retroviral treatment on HIV/AIDS infected children. PATIENTS AND METHOD: We conducted a cross sectional study on 72 HIV/AIDS infected children with anti-retroviral treatment, under the supervision of clinicians within 3 associations specialized in the management of subjects infected by HIV/SIDA at Lomé (Togo). RESULTS: The average age of children was 6 years 9 months. The middle age to HIV screening was 4 years 2 months. The sex ratio was 1.05. The majority of these children (79.2%) were orphans of at least 1 of their parents. All the children were stemmed from families with modest income. The transmission mother to child was the way of HIV contamination found among all the children. To a certain extent, all the children were infected by the HIV 1. Most of the children (66.7%) receiving an antiretroviral treatment for at least 6 months were asymptomatic and had no more immunodeficiency. After 15 months, the children have gained 464 CD4/mm(3). The initial protocols antiretroviral prescribed among children were: zidovudine-lamivudine-abacavir (36.1%), lamivudine-didanosine-nevirapine (30.5%), lamivudine-stavudine-nevirapine (29.2%), zidovudine-lamivudine-didanosine (4.2%). The digestive disorders have been the first side effects (83.4%). The rate of good observance was middle (51%) and lowered with the increased age of children, and the period of the anti-retroviral treatment. CONCLUSIONS: Antiretroviral treatment among HIV/AIDS infected children is giving good results in Togo. But many efforts remain to increase the number of beneficiaries.     

Mass needle stick injury in children from the Western cape

Illegal dumping of contaminated medical waste occurs commonly in South Africa. There is little information on the management and outcome of the children exposed to and injured by medical waste. On 15 September 1999, 54 children where involved in a mass exposure incident. 44 presented the same evening and 10 following day. Used needles and syringes were discarded on their soccer field. Children gave one another injections and played darts with the discarded needles. Parents were counselled and blood was drawn for HIV and Hepatitis B virus (HBV) serology. All were given HBV vaccination (HBVV). Stat doses of zidovudine (ZDV) and lamivudine (LMV) were given to all with visible wounds or history of percutaneous injury. Younger children were given prophylaxis as we considered their histories unreliable. Further visits were conducted at the community clinic for patient convenience. Children were reviewed at weeks 1 and 3 for drug adherence and side effects. At week 4, the second HBVV was given. At 3 months and 6 months HIV and HBV serology were repeated. 18/44 (40 per cent) had entry wounds. 44/54 (81 per cent) were given antiretroviral treatment (ART). Initial screening for HIV was negative in all, 6 had antibodies to HBV surface antigen, and 2 were HBV surface antigen positive. At week 1 all patients on ART were seen but at week 3 only 30 (55 per cent) attended. 41 (75 per cent) attended at 4 weeks, 8 non-attendees being located by primary healthcare workers. At 3 months, none of the 35 (64 per cent) children had seroconverted for either virus. 44 (81 per cent) attended at 6 months and all serology was negative. All were also Hepatitis C negative. The exposure incident sensitized the community to HIV. Follow up of patients after mass exposure is difficult and time-consuming. Adherence to ART was poor and should be carefully monitored. ZDV was probably adequate for this incident. In a non-mobile community a 3 month visit unnecessary.     

Prevention of hepatitis B infection in newborns through mass screening and delayed vaccination of all infants of mothers with hepatitis B surface antigen

Beginning in 1982 all pregnant women undergoing prenatal routine blood analysis in three large city hospitals and one large rural area were tested for hepatitis B surface antigen (HBsAg). Infants of all HBsAg-positive mothers received hepatitis B immunoglobulin (HBIg), 0.5 mL/kg of body weight within two hours of birth and, after randomization, 10 micrograms of hepatitis B vaccine either at 0, 1, 2, and 11 months of age (schedule A) or at 3, 4, 5, and 11 months of age (schedule B). A second injection of HBIg (1 mL) was given to infants on schedule B at 3 months of age. Blood samples were obtained at 3, 6, 11, 12, 24, and 36 months. In a two-year period, 28,412 pregnant women were tested for HBsAg; screening efficiency varied between 85% and 98%. The overall prevalence of HBsAg was 0.8%, with a marked variation between urban centers (2.2%) and the rural area (0.3%). Vaccinations were received by 180 of 193 infants of HBsAg-positive mothers (90 on schedule A and 90 on schedule B). Concentrations of hepatitis B surface antibody less than 10 IU/L were observed in nine instances in five children from group A and in seven instances in six children from group B. Four hepatitis B viral infections (two HBsAg carriers, two who underwent antihepatitis B core seroconversions) were recorded in group A v one infection (antihepatitis B core seroconversion) in group B. The protective efficacy of the program (screening plus passive immunization and delayed vaccination) was 94%. The estimated cost of preventing one cae of hepatitis B infection in neonates was $3,000 (US currency).(ABSTRACT TRUNCATED AT 250 WORDS)     

儿童人类免疫缺陷病毒相关性血小板减少性紫癜—附2例报告

目的通过两例人类免疫缺陷病毒相关免疫性血小板减少性紫癜(HIV-ITP)特点的临床总结及相关文献复习,提高对本病的认识。方法临床病历分析及文献复习。结果2例儿童分别经输血感染HIV后5年和7年后出现血小板减少性紫癜(ITP)的症状,经相关检测确诊为HIV-ITP,经丙球冲击及激素治疗好转,但很快复发。结论ITP是HIV病人常见的血液系统表现,也常是HIV的首发症状之一,抗ITP治疗短期有效,长期疗效不佳,彻底治愈困难。     

HIV infection in the child after materno-fetal transmission: early treatment with azidothymidine and prevention of secondary infectious complications]

Twenty-four perinatally HIV infected children received early treatment as soon as the diagnosis of viral contamination was established. In 13 cases (group 1), this diagnosis was based on a viremia and/or antigenemia during the first 6 months of life. In 11 cases (group 2), children were more than 15 months-old and had a positive HIV antibody test. Therapy included azidothymidine (AZT, 400 mg/m2/d) and the prevention of secondary infectious complications with intravenous immunoglobulin and cotrimoxazole. With a median follow-up of 26 months, we reported no case of severe secondary infection and no case of encephalopathy. Hematological side effects of AZT were rarely observed. Only one patient developed anemia. In all other cases, the only hematological abnormality was macrocytosis of red blood cells. Before treatment, the mean value of T4 cells age-adjusted count was 96, 86 and 91%, respectively, for groups 1, 2 and the entire study group. At the time of analysis, these values were 64, 62 and 63% respectively. This decrease was statistically significant for group 1 and for the entire study group, but did not reach statistical significance for group 2. These data show that AZT is probably insufficient as a long-term therapy for HIV infected children. Other therapeutic approaches need to be developed in the future, notably the combination of anti-retroviral drugs.     

Anti-CD20 monoclonal antibody (Rituximab) treatment for Epstein-Barr virus-associated, B-cell lymphoproliferative disease in pediatric liver transplant recipients

OBJECTIVES: Anti-B-cell immunotherapy has been used with success in adults with posttransplant B-cell lymphoproliferative disease (PTLD), but such treatment has rarely been reported in children. We report the outcome of anti-CD20 antibody (rituximab) therapy for Epstein-Barr virus (EBV)-associated PTLD in six pediatric liver transplant recipients. METHODS: In these six patients, PTLD was diagnosed within 2 to 4 months after transplantation. The tumors were classified as monomorphic or polymorphic B-cell infiltrate expressing CD20 antigen and EBV genome. Anti-CD20 therapy was associated with withdrawal of tacrolimus or ciclosporine therapy in all patients. Intravenous rituximab was administered at 375 mg/m2 once a week for 3 to 4 consecutive weeks. RESULTS: Rituximab treatment was associated with decreased EBV load, disappearance of abnormal serum immunoglobulin concentration, and disappearance of tumoral masses, which occurred 1 to 2.5 months after treatment onset. Despite rituximab therapy, one patient was diagnosed subsequently with a cerebral tumor. Five patients experienced acute liver graft rejection episodes within 10 days to 2.5 months after beginning treatment. In these patients, immunosuppression was reintroduced, but three children experienced fatal chronic rejection, whereas two experienced complete tumor remission. Three children are alive and in complete remission, with normal liver tests, 15 months to 3 years after PTLD onset. CONCLUSIONS: Rituximab therapy is an interesting approach for children with early EBV-associated PTLD after liver transplantation. It does not prevent cerebral localization, and rapid resumption of immunosuppression may be advisable to prevent lethal chronic liver graft rejection.     

Impact of HIV-1 status on the radiological presentation and clinical outcome of children with WHO defined community-acquired severe pneumonia.

AIMS: We compared the radiological features and outcome of WHO defined severe pneumonia among HIV infected and exposed uninfected children randomised to receive penicillin or oral amoxicillin in Durban, South Africa. METHODS: Of 425 children aged between 3 and 59 months with WHO defined severe pneumonia, 366 had anonymous HIV testing performed. Outcome was assessed by failure to improve at 48 h after enrolment or deterioration within 14 days. Chest radiographs were evaluated according to WHO defined radiological criteria for pneumonia and internationally standardised radiological criteria. Findings were stratified for HIV status. RESULTS: 82 (22.4%) children were HIV infected, 40 (10.9%) were HIV exposed and 244 (66.7%) were HIV uninfected. The day 14 outcome in children <12 months of age was significantly worse in HIV-1 infected than HIV uninfected children (OR 2.8 (95% CI 1.35 to 3.5), p = 0.002), while HIV-1 infected and uninfected children aged > or =12 months had equivalent outcomes. Parental penicillin and oral amoxicillin had equivalent response rates in all HIV groups. According to the WHO radiological classification, children who failed WHO standard antimicrobial treatment had significantly higher "other consolidates/infiltrates" than "endpoints for consolidation" in the HIV infected group (OR 5.45 (95% CI 1.58 to 21.38), p<0.002), while the reverse was true for HIV exposed uninfected children (OR 4.13 (95% CI 0.88 to 20.57), p<0.036). CONCLUSIONS: The WHO standard treatment guideline for severe pneumonia is inadequate for HIV-1 infected infants. The increased prevalence of "other consolidates/infiltrates" among HIV-1 infected children who failed standard treatment supports the addition of co-trimoxazole to WHO standard treatment.     

Response to influenza virus vaccination in vertical HIV infection

OBJECTIVE: To assess the antibody response to influenza vaccine of children vertically infected with HIV. DESIGN: Prospective study in HIV infected children vaccinated during the winter of 1994-5. SETTING: Family HIV clinic at St Mary's Hospital, Paddington. SUBJECTS: 25 children, aged 1-11 years, vertically infected with HIV. MAIN OUTCOME MEASURES: Responses to influenza antigens (H1N1-A/Taiwan/1/86, H3N2-A/Shandong/9/93, B/Panama/45/ 90) were tested by haemagglutination inhibition. Antibody responses were assessed according to clinical symptoms and immune function, stratified according to the 1994 revised classification for HIV infection in children. RESULTS: 23 children (92%) had either very low or no detectable antibody before vaccination. New protective antibody responses were made by 10 children (40%): in seven to a single antigen, in two to two antigens, and in one to all three antigens. For each antigen there was an overall small increase in the mean geometric titre of antibody produced, but this only reached a protective level for antigen H1N1 and for children with minimal symptoms. Less symptomatic children were significantly more likely to produce a protective antibody response to influenza vaccination. No association was found between immune function, as measured by CD4 count, and vaccine response. CONCLUSIONS: Only vaccination of the least symptomatic HIV infected children against influenza is likely to be effective. This will not only protect them against influenza, but will also protect other more immunosuppressed and vulnerable members of their families.     

Malignancies in UK children with HIV infection acquired from mother to child transmission

By April 1995, 302 cases of vertically acquired HIV infection had been reported through the British Paediatric Association Surveillance Unit. Over 50% of these children had developed an AIDS indicator disease, including nine malignancies (seven cases of non-Hodgkin's lymphoma (NHL) and two of Kaposi's sarcoma). There were two other malignancies that were not AIDS indicator diseases. In children less than 5 years of age the incidence of NHL was approximately 2500 times greater than expected in the UK child population. Three children presented with NHL as their AIDS indicator disease and four developed NHL at a median of 14 (range 10-19) months after the initial diagnosis of AIDS. Six of the seven children died at a median of 6.5 (range 2-14) months after the diagnosis of NHL. The seventh child responded to treatment and is alive nearly four years later. Histology was available in five cases, of which four were of B cell and one of T cell origin. Epstein-Barr virus was detected in all three patients with NHL where it was sought; all had B cell lymphomas. Although comparatively rare, malignancies occur in children infected with HIV and may be the presenting illness. Paediatricians now need to consider HIV infection as a predisposing cause of childhood cancer, especially NHL.     

Impact of CD4 T cell count on the outcome of planned treatment interruptions in early-treated human immunodeficiency virus-infected children

Early highly active antiretroviral therapy is recommended in all vertically human immunodeficiency virus (HIV)-infected infants. We describe the long-term immunologic outcome after planned treatment interruption (PTI) in 7 children diagnosed and treated during acute HIV infection (age <12 weeks). Children had remained a median of 57 months off treatment, 3 of them indefinitely. The 2 patients with the lowest nadir CD4% reinitiated highly active antiretroviral therapy because of a CD4 cell decline of <20%; 2 children resumed treatment because of clinical progression and parents' wishes. All patients experienced a decrease in CD4% after PTI, which particularly affected the naive subpopulation. The interferon-γ response against HIV-p24 antigen directly correlated with nadir CD4%. Our results suggest that early treatment in HIV-infected infants increases their potential to safely control viral replication after PTI for long periods.     

Paediatric HIV infection in a rural South African district hospital

The objective of this study was to determine the prevalence, clinical spectrum, and outcome of paediatric HIV infection in 281 consecutive children admitted to hospital in rural South Africa between October 1996 and January 1997. HIV infection was defined as two positive ELISAs in those aged > 12 months; a positive ELISA plus a positive IgG3 in those aged 6-12 months; and a positive ELISA plus positive p24 antigen or PCR in those aged 0-5 months. In all, 72 (26 per cent) children were HIV infected. Age-specific HIV prevalence was at least 25 per cent in all 1-5 year age groups. HIV-infected children were more likely to have been previously admitted (46 per cent vs. 23 per cent; p = 0.0002), and were more likely to have severe malnutrition (52 per cent vs. 17 per cent; p < 0.0001). Both HIV-infected and HIV-uninfected most frequently presented with diarrhoeal disease (51 per cent vs. 32 per cent), acute respiratory infection (13 per cent vs. 23 per cent), and malnutrition (18 per cent vs. 11 per cent). Satisfactory response to antibiotic therapy was less likely among the HIV-infected (56 per cent vs. 73 per cent; p = 0.02), and mortality was higher among the HIV-infected (21 per cent vs. 7 per cent; p = 0.005). It is concluded that HIV-infected children present with disease syndromes common to this setting, but do so more frequently and with worse outcome than their uninfected counterparts. The high burden of paediatric HIV disease in this setting poses a substantial challenge for health resources.     

Cutaneous hypersensitivity reactions due to thiacetazone in the treatment of tuberculosis in Zambian children infected with HIV-I.

Tuberculosis is one of the most common infections in Zambian adults and children infected with HIV. In Africa, cutaneous hypersensitivity reactions attributed to thiacetazone during treatment of tuberculosis in adults infected with HIV-I have been well documented. This study monitored adverse drug reactions during treatment for tuberculosis over an 18 month period (1 April 1990 to 31 October 1991) in 237 children with a clinical diagnosis of tuberculosis (125 boys and 112 girls; 88/237 (37%) infected with HIV-I) and 242 control children (149 boys and 93 girls; 26/242 (11%) infected with HIV-I). Twenty two (9%) of the 237 children with tuberculosis developed hypersensitivity skin reactions during the course of treatment. Adverse skin reactions were seen more often in children infected with HIV than in those who were not (odds ratio 11.65, 95% confidence interval 3.07 to 34.88). These represented 19 (21%) of 88 children infected with HIV and three (2%) of 149 children not infected with HIV. These skin reactions occurred after a period of treatment ranging between two and four weeks among 14 children receiving the HST (isoniazid, streptomycin, thiacetazone) regimen and eight children receiving the HSTR (isoniazid, streptomycin, thiacetazone, rifampicin) regimen. Twelve (55%) of the 22 children who reacted adversely to treatment developed the Stevens-Johnson syndrome. All 12 of these children with the Stevens-Johnson syndrome were infected with HIV. The mortality among these children who developed the Stevens-Johnson syndrome was 91% (11 of 12 died within three days of the onset of the reaction). No further reactions were observed in the 11 children who recovered from the cutaneous hypersensitivity reactions after thiacetazone was discontinued over a period of six months of further treatment of tuberculosis. The results of this study were in part responsible for the recommendations put forward by the World Health Organization to avoid the use of thiacetazone in the treatment of tuberculosis in children infected with HIV.     

Malignancies in UK children with HIV infection acquired from mother to child transmission

Accepted 19 November 1996By April 1995, 302 cases of vertically acquired HIV infection had been reported through the British Paediatric Association Surveillance Unit. Over 50% of these children had developed an AIDS indicator disease, including nine malignancies (seven cases of non-Hodgkin''s lymphoma (NHL) and two of Kaposi''s sarcoma). There were two other malignancies that were not AIDS indicator diseases. In children less than 5 years of age the incidence of NHL was approximately 2500 times greater than expected in the UK child population. Three children presented with NHL as their AIDS indicator disease and four developed NHL at a median of 14(range 10-19) months after the initial diagnosis of AIDS. Six of the seven children died at a median of 6.5 (range 2-14) months after the diagnosis of NHL. The seventh child responded to treatment and is alive nearly four years later. Histology was available in five cases, of which four were of B cell and one of T cell origin. Epstein-Barr virus was detected in all three patients with NHL where it was sought; all had B cell lymphomas. Although comparatively rare, malignancies occur in children infected with HIV and may be the presenting illness. Paediatricians now need to consider HIV infection as a predisposing cause of childhood cancer, especially NHL.     

Combined therapy in human immunodeficiency virus-infected children —a 4-year experience

From 1988 to 1991 the long-term efficacy of a combined therapy with a polyvalent immunoglobulin/cytomegalovirus (CMV) hyperimmunoglobulin, oral low dose zidovudine, oral cotrimoxazole or inhaled pentamidine was investigated in three groups of human immunodeficiency virus (HIV)-infected children. Group 1A consisted of three perinatally infected children with a CD4 cell decrease of >400, cells/l per year. Group 1B were 17 perinatally infected children with a CD4 cell decrease of <400 cells/l per year. Group 2 comprised eight haemophilic children infected by clotting factors. Despite combined therapy none of group 1A survived longer than 12 months showing a rapid loss of CD4 cell counts, progressive encephalopathy, wasting syndrome and severe bacterial, fungal and CMV reactivation. Under pure intravenous immunoglobulin (IVIG) therapy severe bacterial infections were seen in 1 of 12 children in group 1B. The majority of these patients showed increases or stabilisation of length and weight percentiles. In this group low dose zidovudine therapy was of benefit in HIV-associated neurological symptoms. Nevertheless combined therapy could not prevent further deterioration of CD4 cell counts. In group 2 severe bacterial infections were not seen under IVIG therapy. In this group a temporary increase (6 months) of CD4 cell counts under IVIG/zidovudine combined therapy occurred.Pneumocystis carinii pneumonia (PCP) prophylaxis with oral cotrimoxazole or inhaled pentamidine successfully prevented PCP in all three groups. Under CMV hyperimmunoglobulins (n=22), ten out of ten patients did not acquire primary CMV infection, whereas CMV reactivations mainly located in the CNS could not be prevented in 5 of 12 patients. Our findings indicate that this combined therapy showed remarkable differences in therapeutic efficacy in children with different modes of HIV progression. These modes must be considered for correct timing, dosage and evaluation of therapeutic measures.     

Safety and efficacy of alemtuzumab in the treatment of late acute renal allograft rejection

Safety and efficacy of alemtuzumab in the treatment of AR in children after renal transplantation is unknown. Five episodes of refractory late AR in three children (three episodes in patient 1 and a single episode in patients 2 and 3 occurring after 7-23 months of transplantation) were treated with one dose of alemtuzumab as a rescue therapy. Four episodes (Banff IA-IB) in patients 1 and 2 reversed fully or partially with alemtuzumab, whereas patient 3 with Banff IB-IIA AR failed to respond. Patient 1 had recurrent AR 5, 13, and 15 months later; first two episodes responded to retreatment with alemtuzumab, and the last episode was not treated causing allograft failure. Patient 2 had steroid-responsive AR after two months and had a functioning allograft 25 months later. A transient reduction in all lymphocyte subsets except natural killer cells occurred in all patients. Patient 3 (treated with steroids, Thymoglobulin(R) , intravenous immunoglobulin, and rituximab prior to alemtuzumab) suffered many bacterial infections during one-yr period after therapy. However, symptomatic viral infections were not observed in any of the children. Treatment with alemtuzumab may prolong allograft survival in multidrug-resistant AR but may not prevent recurrent AR in non-adherent children.     

Fulminant hepatitis in children in Taiwan: the important role of hepatitis B virus

In a recent period of 64 months, fulminant hepatitis was diagnosed in 17 children at National Taiwan University Hospital. Eleven patients were younger than 12 months of age. Hepatitis A IgM antibody and delta-antibody were negative in all 17. Eleven (65%) patients had hepatitis B core IgM antibody, fulminant hepatitis B. Two to 5 months before onset of hepatitis. Five of the 11 children had received blood transfusions. Three of the five donors had hepatitis B e antibody (anti-HBe) and were hepatitis B virus DNA-negative hepatitis B surface antigen (HBsAg) carriers; another two were HBsAg negative, screened by a less sensitive reverse passive hemagglutination method. The mothers of all six infants younger than 6 months of age had HBsAg. HBe antigen and antibody were studied in five of these six mothers; all five had anti-HBe. We conclude that hepatitis B virus is the most important cause of fulminant hepatitis in children in Taiwan.     

儿童非人类免疫缺陷病毒感染重症耶氏肺孢子菌肺炎七例并文献复习

目的总结儿童非人类免疫缺陷病毒(HIV)感染的耶氏肺孢子菌肺炎(PCP)的临床特征及治疗情况。方法回顾性分析2015年5月1日至2021年5月1日在香港大学深圳医院PICU和咸阳彩虹医院PICU住院的7例非HIV感染的重症PCP患儿病例,观察其高危因素、临床表现、实验室检测指标、肺部影像学特征、治疗及转归等。结果7例PCP患儿,男4例,女3例,年龄13~85个月,平均(42.4±26.8)个月,均存在基础疾病,以血液系统恶性肿瘤最为多见;6例患儿有应用复方磺胺甲口,恶唑(TMP-SMX)预防PCP治疗史,其中4例自行停药2~4周发生PCP。7例患儿均存在低氧性呼吸衰竭,氧合指数(OI)30.6±3.4;临床表现为发热、干咳、进行性呼吸困难,早期肺部均未闻及湿啰音,乳酸脱氢酶[(745.7±317.0)U/L]和β-D-葡聚糖[(513.8±225.0)pg/mL]均升高,胸部CT显示双肺弥漫性间质性改变伴肺内多发性渗出。7例患儿均在入院3 d内开始抗耶氏肺孢子菌治疗,其中5例采用静脉TMP-SMX,2例口服TMP-SMX+卡泊芬净,疗程21 d,抗耶氏肺孢子菌同时应用糖皮质激素治疗;2例患儿在PCP治疗3 d后出现病情加重,其中1例死亡,另1例继续用药6 d后开始临床好转,其余5例在治疗3~7 d后开始出现临床好转,最终6例治愈,1例死亡。结论非HIV感染的PCP患儿均存在免疫受损的高危因素,TMP-SMX可有效预防PCP的发生;对于重症PCP患儿,尽早静脉应用TMP-SMX联合糖皮质激素治疗可降低病死率,在无静脉TMP-SMX情况下,也可口服TMP-SMX+卡泊芬净替代。