Impact of gastrointestinal endoscopy on HIV‐infected children

Objective: To evaluate the role of gastrointestinal (GI) endoscopy in human immunodeficiency virus (HIV)‐infected children with GI problems. Methods: From 1998 to 2002, we retrospectively reviewed all cases of HIV‐infected children presenting with GI problems in which an upper or lower GI endoscopy was indicated. The initial diagnostic endoscopic examination and any repeat endoscopic session leading to a new diagnosis were used in the data analysis. Tissue biopsies were obtained from all abnormal lesions and representative sites of normal‐appearancing GI mucosa. Results: Fourteen patients (median age: 22.5 months) underwent 23 sessions of GI endoscopy, including 10 esophagogastroduodenoscopy, nine colonoscopy and four flexible sigmoidoscopy. Chronic diarrhea was the most common indication, followed by lower GI bleeding, abdominal/retrosternal pain, dysphagia/odynophagia, and upper GI bleeding. Gross endoscopic abnormalities were observed in 78.3%; whereas histological inflammation and opportunistic pathogens were identified in 87% and 43.5%, respectively. Cytomegalovirus was the most common identified pathogen. Abnormal gross findings were significantly associated with histological inflammation and identification of pathogens (P = 0.006 and 0.046, respectively). Specific changes in medical management were made in 50% of cases as a result of endoscopic investigation. Conclusion: If non‐invasive investigations for HIV‐infected children with GI symptoms fail to establish a diagnosis, gastrointestinal endoscopy should be performed and often yields a positive result leading to changes in medical management.     

Emergence of rifampin-resistant Rhodococcus equi with several types of mutations in the rpoB gene among AIDS patients in northern Thailand

The antimicrobial susceptibilities of 30 Rhodococcus equi isolates obtained from 30 patients between 1993 and 2001 in northern Thailand were investigated. The MICs showed a tendency toward resistance to various antibiotics but sensitivity to imipenem, minocycline, vancomycin, and teicoplanin (MICs, /=64 micro g/ml) to rifampin. PCR amplification and DNA sequencing of the rpoB gene and molecular typing by pulsed-field gel electrophoresis (PFGE) were performed for eight R. equi isolates from eight AIDS patients with pneumonia or lung abscess caused by R. equi between 1998 and 2001, including one low- and three high-level rifampin-resistant isolates. As a result, two high-level rifampin-resistant strains with PFGE pattern A had a Ser531Trp (Escherichia coli numbering) mutation, and one high-level rifampin-resistant strain with PFGE pattern B had a His526Tyr mutation, whereas one low-level rifampin-resistant strain with PFGE pattern C had a Ser509Pro mutation. Four rifampin-susceptible strains with PFGE patterns D and E showed an absence of mutation in the rpoB region. Our results indicate the presence of several types of rifampin-resistant R. equi strains among AIDS patients in northern Thailand.     

Epidemiologic,clinical and laboratory features of scrub typhus in thirty Thai children

BACKGROUND: Scrub typhus, a potentially fatal rickettsial infection, is common in Asia. Although serologic surveys suggested that as many as one-fourth of cases of scrub typhus might be in children, very few reports of childhood scrub typhus are available in the medical literature. OBJECTIVES: To document the clinical, laboratory and epidemiologic characteristics of pediatric patients with scrub typhus. METHODS: From January 1, 2000 to December 31, 2001, all pediatric patients at Chiang Mai University Hospital who had obscure fever for >5 days were tested for indirect immunofluorescent antibody (IFA) against Orientia tsutsugamushi, the causative organism of scrub typhus. Scrub typhus was diagnosed on the basis of either a single IFA titer against O. tsutsugamushi > or =1/400 or a 4-fold or greater rise in IFA titer to at least 1/200. RESULTS: Thirty children with scrub typhus were enrolled. Most were diagnosed during the rainy months of June to November. Common physical signs included lymphadenopathy (93%), hepatomegaly (73%), eschar (68%), conjunctival hyperemia (33%), maculopapular rash (30%) and splenomegaly (23%). Eleven patients had interstitial pneumonitis and 1 patient had meningitis. All patients responded well to doxycycline or chloramphenicol. The average interval to defervescence after treatment was 29 h (range, 6 to 72). CONCLUSIONS: Clinical and epidemiologic features of 30 pediatric patients with scrub typhus are reported in a prospective study. The presence of eschar was helpful in making the diagnosis. Complications included pneumonitis and meningitis. All cases responded well to treatment with antibiotic.     

Causes of first hospitalization among 1121 HIV-infected children: comparison of the pre-Pneumocystis jiroveci pneumonia prophylaxis, pre-antiretroviral therapy and antiretroviral therapy periods

This study identified causes of first hospitalization among perinatally acquired HIV-infected children at Chiang Mai University Hospital between 1989 and 2009. Data were stratified into three seven-year time periods: pre-Pneumocystis jiroveci pneumonia (PJP) prophylaxis, pre-antiretroviral therapy (ART) and ART period. Over the 21-year study period, 1121 children were hospitalized. The mean age at admission was 2.7 years and had become older over time. Of the 1121 hospitalization causes, 50.6% were AIDS-defining illnesses (ADIs), 48.1% were non-AIDS-defining illnesses (NADIs) and 1.3% were related to immune reconstitution syndrome. Types of ADIs changed over time: PJP and recurrent Salmonella septicaemia decreased, while mycobacterial infection and systemic fungal infection increased. For NADIs, bacterial infections, viral infections and gastrointestinal problems decreased, but haematological problems increased in the third period. Decline in the number of hospitalizations and mortality rate, increase in the mean age of hospitalized children, change in the distribution of specific illnesses and appearance of immune reconstitution syndrome were observed in the ART period.     

Immune reconstitution inflammatory syndrome from Penicillium marneffei in an HIV-infected child: a case report and review of literature

Backgrounds  

Disseminated Penicillium marneffei infection is one of the most common HIV-related opportunistic infections in Southeast Asia. Immune reconstitution inflammatory syndrome (IRIS) is a complication related to antiretroviral therapy (ART)-induced immune restoration. The aim of this report is to present a case of HIV-infected child who developed an unmasking type of IRIS caused by disseminated P. marneffei infection after ART initiation.     

Identification of virulence-associated antigens and plasmids in Rhodococcus equi from patients with acquired immune deficiency syndrome and prevalence of virulent R. equi in soil collected from domestic animal farms in Chiang Mai,Thailand

The prevalence of virulent Rhodococcus equi in soil collected from 17 domestic animal farms (from 12 cattle, 1 pig, and 4 horse farms) and in 6 clinical specimens from patients with acquired immune deficiency syndrome (AIDS) in Chiang Mai, Thailand, was investigated. The isolates were tested for the presence of 15-17-kDa antigens (VapA) and a 20-kDa antigen (VapB) by immunoblotting and for the presence of virulence plasmid DNA. Rhodococcus equi was isolated from most soil samples (68 of 80) obtained from the 17 farms, with 2.0 x 10(2) to 6.0 x 10(5) colony-forming units per gram of soil. We detected VapA in none of the 537 isolates from the soil samples. In one isolate from a pig farm, both VapB and virulence plasmid DNA were detected. Of the 6 clinical isolates from patients with AIDS, however, 4 isolates contained both VapB and virulence plasmid DNA. The remaining 2 isolates were avirulent.     

Discontinuation of secondary prophylaxis against penicilliosis marneffei in AIDS patients after HAART

A retrospective cohort study was conducted to determine the relapse rate of penicilliosis marneffei after the discontinuation of itraconazole secondary prophylaxis in 33 HIV-infected patients who received HAART and had CD4 cell counts of 100 cells/mul or greater for at least 6 months. The observed incidence of relapse of penicilliosis marneffei was zero cases per 641 person-months (95% confidence interval 0-0.6 cases per person-month) after a median follow-up of 18 months (range 6-45).