Tuberculosis in children with acquired immunodeficiency syndrome

With AIDS related tuberculosis in the pediatric population on the rise, we review our experience with 14 such children. A brief review of the pertinent literature is also presented. Received: 20 March 1996 Accepted: 25 June 1996     

Respiratory failure in children with acquired immunodeficiency syndrome and acquired immunodeficiency syndrome-related complex

Acute respiratory failure has a high mortality in patients with acquired immunodeficiency syndrome (AIDS). This study was undertaken to determine the etiology of acute respiratory failure and the outcome of children with AIDS and AIDS-related complex. Records of 31 children with AIDS or AIDS-related complex admitted to the pediatric intensive care unit for acute respiratory failure throughout a 46-month period were reviewed. Acute respiratory failure was due to Pneumocystis carinii pneumonia in 13, cytomegalovirus pneumonia in six, bacterial pneumonia in five, severe bacterial sepsis in four, Candida pneumonia in two, and a giant cell pneumonia in one patient. In addition, 11/19 patients with acute respiratory failure due to P carinii pneumonia or cytomegalovirus had superinfections with bacteria or Candida. Of the total of 19 primary and secondary bacterial infections, Pseudomonas aeruginosa was responsible in ten and Klebsiella pneumoniae in three children. Five children (16%) survived until pediatric intensive care unit discharge; three died within 6 months. The causes of acute respiratory failure were not significantly different in survivor and nonsurvivor groups. It is concluded that, in addition to P carinii pneumonia and cytomegalovirus pneumonia, bacterial infections (especially due to Pseudomonas and other Gram-negative organisms) are important causes of respiratory failure. The high mortality and grim ultimate prognosis seen may have implications for pediatricians attempting to identify the proper limits of medical intervention for this group of patients.     

Extrapulmonary cryptococcosis in children with acquired immunodeficiency syndrome

There is a paucity of published information available on extrapulmonary cryptococcosis (EC) in children infected with human immunodeficiency virus, the etiologic agent of the acquired immunodeficiency syndrome. We surveyed investigators in pediatric acquired immunodeficiency syndrome around the country regarding their experience with EC. Investigators from 33 (87%) of 38 institutions responded and information on 13 patients from 11 institutions was analyzed. EC was the acquired immunodeficiency syndrome indicator disease in 9 (69%) of 13 patients. Median age was 8 years with a range of 2 to 17 years. Human immunodeficiency virus risk factors were transfusion (5 patients), hemophilia (4 patients) and perinatal exposure (4 patients). Meningitis, seen in 62% of patients, was the most common clinical manifestation. Although 2 patients with fulminant disease died before therapy was started, 10 (91%) of 11 had a clinical response to amphotericin B with or without flucytosine. Our study indicates a spectrum of EC in pediatric human immunodeficiency virus infection ranging from fulminant, fatal fungemia to chronic meningitis and fever of unknown origin. Cryptococcosis was generally not the cause of death in patients who initially responded to amphotericin B therapy. Optimal antifungal therapy, including the role of fluconazole, warrants further study.     

艾滋病2例

例1,女,5岁,因发热、腹泻、呕吐2个月入院。2个月前因发热、腹胀,在当地医院治疗,诊断为结核性腹膜炎。经异烟肼、利福平及头孢曲松钠治疗后腹水消失。体温不降,出现脓血便、呕吐。大便红细胞5~10个／HP,白细胞10~13个／HP。脑脊液细胞总数3600×106／L,中性0.86,淋巴     

Acquired circulating anticoagulants in children with acquired immunodeficiency syndrome

The mechanism underlying the prolonged activated partial thromboplastin time (APTT) seen in some pediatric patients with acquired immunodeficiency syndrome (AIDS) and opportunistic infections was studied. A circulating inhibitor of coagulation was demonstrated in three patients. The inhibitor appears to be an immunoglobulin that interferes with some of the phospolipid-dependent coagulation reactions of the intrinsic pathway. This "AIDS anticoagulant" does not predispose the patient to clinical bleeding despite its ability to cause a marked prolongation of the APTT. As such, careful laboratory diagnosis of the cause of abnormal coagulation test results is necessary for children with AIDS.     

Nontuberculous mycobacteria in children with acquired immunodeficiency syndrome.

Among 139 children with acquired immunodeficiency syndrome at Children's Hospital of New Jersey, 20 had positive cultures for non-tuberculous mycobacteria. Eighty-five percent had Mycobacterium avium complex isolated and 70% had definite evidence of disseminated disease. Ninety-three percent had CD4 lymphocyte counts less than 100 cells/mm3 and 95% had met acquired immunodeficiency syndrome criteria before the time of first positive culture. Clinical findings included failure to gain weight, anorexia, fever, abdominal pain/tenderness and anemia. The median age at onset of symptoms was 46 months and the median time between onset of symptoms and positive culture was 9 months. Outcome for patients with positive cultures for nontuberculous mycobacteria was poor, with 75% of the children surviving for less than or equal to 10 months. Nontuberculous mycobacteria are increasingly important causes of morbidity and indirect mortality in human immunodeficiency-infected children. Children with severe immunodeficiency are at particular risk. In addition to M. avium complex, other species of nontuberculous mycobacteria may be involved.     

Severe gastrointestinal involvement in children with the acquired immunodeficiency syndrome

Five children with the acquired immunodeficiency syndrome (AIDS) and unusual gastrointestinal disease are described. Two children presented with malnutrition, abdominal distention, and diarrhea. One was found to have moderately severe villus atrophy on jejunal biopsy and was initially thought to have celiac disease. Jejunal biopsy from the second child revealed infiltration of the mucosa with acid-fast bacilli-laden macrophages. A third child suffered recurrent abdominal pain, progressive weight loss, diarrhea, and severe gastrointestinal hemorrhage secondary to infection with cytomegalovirus. Pseudomembranous necrotizing jejunitis associated with overgrowth of Klebsiella pneumoniae in the duodenal fluid occurred in one patient. The fifth child presented in the newborn period with Serratia marcescens cholecystitis. Gastrointestinal disease in children with AIDS may be due to idiopathic villus atrophy and bacterial or opportunistic infection.     

Growth and neuroendocrine dysfunction in children with acquired immunodeficiency syndrome

To assess whether neuroendocrine dysfunction is present in children with acquired immunodeficiency syndrome (AIDS) and growth failure, we evaluated the thyroid, adrenal, and growth hormone-insulin-like growth factor I (IGF-1) axes in nine children with AIDS and failure to thrive. Basal thyroid-stimulating hormone, free thyroxine, and triiodothyronine levels were normal in eight of the nine children and indicated primary hypothyroidism in one child; thyroxine levels were elevated in four and normal in five children. Thyroxine-binding globulin levels were elevated in all children. Serial measurements of thyroid-stimulating hormone, made hourly from 2 to 6 pm and from 10 pm to 2 am, revealed a flat diurnal rhythm of thyroid-stimulating hormone in six children, which may indicate early central hypothyroidism, and a normal nocturnal rise in the remaining three children. Basal plasma corticotropin and aldosterone levels were normal in all children, plasma renin levels were normal in three and elevated in six children, and cortisol levels were normal or elevated in all children. Corticotropin-stimulated cortisol levels exceeded 500 nmol/L (18 micrograms/dl) in all children except one, who was receiving treatment with ketoconazole. Thus adrenocortical function appeared to be grossly intact. The peak growth hormone responses to provocative testing was normal (greater than 7 ng/ml) in eight children and low in one child. The plasma level of insulin-like growth factor I was normal in eight of the nine children and low in one child. We conclude that growth failure in children with AIDS does not usually result from a recognized endocrine cause and that adrenal function is usually normal. However, endocrine deficiency may contribute to morbidity in some children with AIDS.     

Cytomegalovirus and Pneumocystis carinii pneumonia in children with acquired immunodeficiency syndrome.

To ascertain the effect of cytomegalovirus (CMV) infection on the course of Pneumocystis carinii pneumonia (PCP) in children with acquired immunodeficiency syndrome (AIDS), we reviewed the charts of all children with AIDS who also had a lung biopsy specimen or a bronchoalveolar lavage specimen cultured for CMV at the time PCP was diagnosed. The data indicate that children with AIDS and PCP whose cultures are positive for CMV do not have a poorer prognosis during a first episode of PCP compared with children whose cultures are negative for CMV.     

66例儿童艾滋病临床分析

目的：探讨儿童艾滋病临床特点。方法：66例儿童艾滋病入选该研究,男46例,女20例,平均年龄8.7岁（2～16岁）。回顾分析其人口学资料、流行病学资料、临床表现及实验室检查结果。结果：HIV感染确诊年龄2～15岁,平均7.7岁。通过母婴传播感染48例（72.7％）,通过输血或血制品感染14例（21.2％）,感染途径不明4例（6.1％）。常见的临床表现如下：体重下降43例（65.2%）、贫血 42例（63.7%）,持续或反复发热40例（60.6%）、疲乏感38例（57.6%）、皮疹31例（47.0%）、慢性或反复咳嗽28例（12.1%）、慢性腹泻24例（36.4%）、神经系统受累16例（24.2%）、鹅口疮13例（19.7%）、肝脾大12例（18.2%）。体格生长评价显示,身高和体重处于下等的分别有30例（45.4％）和26例（39.4％）。免疫功能均受抑制,重度抑制59例（89.4%）,中度抑制7例（10.6％）。结论：儿童HIV感染途径以母婴传播为主,临床表现多样,免疫系统显著受抑制。［中国当代儿科杂志,2009,11（2）：93-95］     

Primary lymphoma of the central nervous system in children with acquired immunodeficiency syndrome

Three children with acquired immunodeficiency syndrome and primary lymphoma of the CNS are described. All three children had clinical signs of focal mass lesions and progressive neurologic deficits. In one child the deterioration was extremely rapid. New lesions appeared on serial CT scans every few days, simulating an infectious process and leading to death within 3 weeks. Results of neuroradiologic studies in these patients demonstrated multicentric lesions that were often periventricular. On CT scans, the lesions were hyperdense before contrast and were enhanced with contrast medium. Double-dose delayed contrast CT scans and magnetic resonance imaging studies were more sensitive in indicating additional lesions. Histologically, all three tumors were B cell neoplasms; two lymphomas were large cell type, whereas one was small cell, noncleaved (Burkitt-like). Primary CNS lymphoma occurred with an incidence of 1/26 (4%) in our autopsy series and 3/100 (3%) of all pediatric cases of human immunodeficiency virus-type 1 infection, living and dead, that have been seen at the Children's Hospital of New Jersey. By comparison, opportunistic and reactivated latent CNS infections were less common in this same population and never appeared clinically as mass lesions. Therefore, in our experience, primary lymphoma is the most common cause of focal or multifocal mass lesions in the brains of children with acquired immunodeficiency syndrome. This tumor may be radiosensitive. In most cases, early biopsy is probably necessary to establish the diagnosis.     

小儿人类免疫缺陷病毒感染/艾滋病诊断及处理建议

艾滋病即获得性免疫缺陷综合征 (acquriedimmunodefi ciencysyndrome ,AIDS) ,是由人类免疫缺陷病毒 (humanim munodeficiencyvirus ,HIV)感染所致的一种传播迅速、病死率极高的恶性病。我国目前HIV感染人群已超过 10 0万 (2 0 0 2年 ) ,且大多数集中在生育期成人。如果控制不好 ,10年后HIV感染者可能超过 10 0 0万。HIV感染母婴传播率高达2 2 %～ 6 5 %。小儿HIV感染发生率增长较成人快、潜伏期短、疾病进展快、死亡率高。因此小儿HIV感染 /艾滋病防治已是我国儿科所面临的严峻挑战和紧迫任务。本建议适用于各级儿科医疗机构对HI…     

小儿艾滋病合并卡氏肺孢子虫肺炎48例临床诊治体会

获得性免疫缺陷综合征(AIDS)又称艾滋病,是人类免疫缺陷病毒(HIV)感染的一种表现。HIV感染和艾滋病的特点是发生各种各样严重的机会菌和非机会菌感染,卡氏肺孢子虫肺炎(PCP)是最常见的艾滋病相关性机会感染,HIV感染患儿有许多感染性和非感染性肺部合并症,但以PCP、淋巴间质性肺     

Pericardial effusion and its relationship to cardiac disease in children with acquired immunodeficiency syndrome

Over 200 children with acquired immunodeficiency syndrome (AIDS) have been followed at our institution. We retrospectively evaluated 45 children from the above group. 26 of the 45 children had a pericardial effusion documented at echocardiography and/or at post-mortem examination. This report describes the association of pericardial effusion, myocarditis, and pericarditis in children with AIDS and the implications for imaging. Half of the children with a pericardial effusion had a normal cardiac silhouette on chest radiography. 18 children with a pericardial effusion, had associated cardiac abnormalities. These abnormalities were ventricular dilatation and/or hypertrophy, myocarditis, or pericarditis. The presence of pericardial effusion also correlated highly with pleural effusion and ascites. The presence of a pleural effusion and a pericardial effusion was almost exclusively seen in the children with cardiac abnormalities. Pericardial effusion and cardiac disease should not only be suspected in any child with radiographic signs of cardiomegaly, but be strongly suspected in any child with pleural effusions or ascites, even with a normal cardiac silhouette, especially if they are not responding to conventional medical therapy and their respiratory condition is not improving.