Muscle metastasis in a patient with epidermoid carcinoma of the lung

Diagnosis of vertically acquired human immunodeficiency virus (HIV) infection is often difficult because of transplacentally acquired maternal antibodies. The polymerase chain reaction (PCR) test is commercially available and has high sensitivity and specificity. To evaluate the usefulness of PCR testing in the early diagnosis of perinatally acquired HIV infection, we reviewed records of 122 children having follow-up in the Northeast Florida Pediatric AIDS Program. Seventy-two children were excluded for various reasons. Of the remaining 50 children, 37 had PCR testing. In 5 children, the initial PCR test was done at > 18 months of age. Results of PCR testing were positive in 8 of 13 (62%) at birth, 12 of 18 (67%) by 1 month of age, 18 of 23 (78%) by 2 months of age, and 20 of 24 (83%) by 3 months of age. In 24 of 27 (85%), results were positive by the time the children reached 4 months of age. Our data suggest that the PCR test is a useful tool for early diagnosis of vertically transmitted HIV infection.     

Effect of motorcycle rider education on changes in risk behaviours and motorcycle-related injuries in rural Thailand

Nutrition is a final common pathway in chronic disease, and weight loss is a major manifestation of acquired immunodeficiency syndrome (AIDS). In sub-Saharan Africa, studies have shown that 25% of children with malnutrition have human immunodeficiency virus (HIV) infection, although patterns of malnutrition are indistinguishable from those who are HIV negative. Breast-feeding increases the risk of vertical transmission, and the overall risk versus benefit needs continuing careful consideration in relation to local mortality from gastroenteritis and malnutrition. Chronic diarrhea is much more common in HIV-infected children in Africa and may have a multiplicity of causes, including infection with adherent forms of Escherichia coli, protozoa, and even direct HIV infection of intestinal mucosal cells. The HIV wasting syndrome produces reduction in bioelectrical impedence, fat, lean body mass, and body cell mass, but the changes can be predicted from equations used in starvation states. Micronutrients may be important, but observed changes may be due to immune mediator activation, rather than malnutrition. Calorie supplementation is beneficial when delivered by any route, but is likely to produce the greatest positive change when CD4 counts are highest in relation to calorie intake. Paradoxically, HIV-infected children may be obese early in the disease until AIDS develops. There is an inextricable link between disease and nutritional status. In children with AIDS wasting syndrome, a low CD4 count and high viral load are likely so that effective antiviral treatment may ultimately produce the greatest improvement in health, including nutritional status.     

Cancer in human immunodeficiency virus-infected children: a case series from the Children's Cancer Group and the National Cancer Institute

PURPOSE: To describe the spectrum of malignancies in human immunodeficiency virus (HIV)-infected children and the clinical outcome of patients with these tumors. METHODS: We retrospectively surveyed the Children's Cancer Group (CCG) and the National Cancer Institute (NCI) for cases of cancer that occurred between July 1982 and February 1997 in children who were HIV seropositive before or at the time of cancer diagnosis. We used Kaplan-Meier survivorship curves, hazard function estimates, and Cox proportional hazards models to evaluate survival. RESULTS: Sixty-four children (39 boys, 25 girls) with 65 tumors were reported. Thirty-seven children (58%) acquired HIV infection vertically (median age at cancer diagnosis, 4.3 years); 22 children (34%) acquired HIV through transfusion of blood or blood products (median age at cancer diagnosis, 13.4 years). Forty-two children (65%) had non-Hodgkin's lymphoma (NHL). Eleven children (17%) had leiomyosarcomas (or leiomyomas), which are otherwise exceptionally rare in children. Other malignancies included acute leukemia (five children), Kaposi's sarcoma (KS; three children), Hodgkin's disease (two children), vaginal carcinoma in situ (one child), and tracheal neuroendocrine carcinoma (one child). Median survival after NHL diagnosis was 6 months (range, 1 day to 89 months) and after leiomyosarcoma was 12 months (range, 10 days to 19 months). The average monthly death rate after NHL diagnosis was 12% in the first 6 months, which decreased to about 2% thereafter. In contrast, the monthly death rate after leiomyosarcoma diagnosis increased from 5% in the first 6 months to about 20% thereafter. CONCLUSION: After NHL, leiomyosarcoma is the second leading cancer in children with HIV infection. Both cancers have high mortality rates; improved outcome for NHL, in particular, may depend on earlier diagnosis and therapy.     

Culture-positive tuberculosis in human immunodeficiency virus type 1-infected children

BACKGROUND: Adults infected by HIV have increased susceptibility to Mycobacterium tuberculosis and progress more rapidly to disease. HIV and tuberculosis (TB) coinfection in children has been reported but often lacks bacterial confirmation. We report on the clinical picture, special investigations, clinical course and outcome of 14 children with HIV infection and culture-confirmed TB from a developing country. METHODS: The clinical records of all children, from 1992 to 1997, with HIV infection and culture-proved TB were reviewed. RESULTS: Fourteen (10.4%) of 135 children with vertically transmitted HIV infection, 93% <2 years of age, fit the criteria. Nonresolving pneumonia (4) and otorrhoea (6) were common complaints. A Mantoux test was positive (> or =15 mm) in 6 of 11 children. Extrapulmonary TB was present in 5 cases. Ear swabs were the source of M. tuberculosis culture in 3. Chest radiographs were abnormal in all with hilar and paratracheal lymphadenopathy present in 7. A source case with pulmonary TB was identified for 10. Susceptibility tests were done on 9 strains of which 1 was drug-resistant. Four children were culture-positive 4 to 10 months after initiation of TB treatment. Mortality was 21% and 3 were lost to follow-up. CONCLUSIONS: In HIV-infected children the Mantoux skin test remains useful and culture specimens should be obtained from all sources. Response to treatment is unpredictable, and for this reason repeated cultures should be taken during treatment and a 9-month course of treatment considered.     

Management of HIV infection. A 1995-96 overview for the clinician

Although the challenges of HIV/AIDS care may seem overwhelming, we are better able than ever to positively affect the course of HIV for each individual patient. Treatment goals involve three areas: 1) Antiretroviral drugs aimed at retarding the rate of HIV replication, thus reducing the rate of damage to the immune system; 2) drugs used to treat or prevent opportunistic infections seen in the context of HIV-related immune deficiency; and 3) drugs used to treat symptoms or syndromes commonly seen in these patients (including dementia and wasting syndrome). The multitude of clinical problems seen in advanced HIV disease leads to significant polypharmacy and costs resulting in a very complex and confusing situation. I recommend that physicians with little HIV experience link up with an HIV specialist when caring for HIV-infected patients to optimize access to the best therapies or research studies currently available. With no cure in sight, physicians need to focus on educating the public and patients about how to avoid HIV infection and to identify persons who are infected to minimize spread.     

Benign and malignant smooth muscle tumors containing Epstein-Barr virus in children with AIDS

Smooth muscle tumors (leiomyosarcomas) are the second most prevalent malignancy of children with the acquired immunodeficiency syndrome (AIDS). We have investigated the tumors, plasma, and peripheral white blood cells of eight children with AIDS with smooth muscle tumors for evidence of tumor association with human immunodeficiency virus (HIV) and Epstein-Barr virus (EBV). Very low levels of HIV were found in the tumors of the AIDS patients, probably resulting from blood-borne carriage of virus. These smooth muscle tumors had very high quantities of EBV in all the tumor cells by in situ hybridization, with an average of 4.5 EBV genomes per cell by quantitative polymerase chain reaction amplification. Increased amounts of EBV were found in the peripheral blood cells of two AIDS patients before the time of tumor diagnosis. EBV clonality studies demonstrated different monoclonal EBV infection of two separate colonic tumors from one patient, and dual or mixed monoclonal EBV infection in another patient. The muscle cells of leiomyomas and leiomyosarcomas of patients with AIDS demonstrated prominent staining with antibodies to the EBV receptor. The uniform distribution and striking amount of EBV in the tumor cells demonstrates that EBV is capable of infecting smooth muscle cells and that these cells support EBV replication. Clonal EBV proliferation suggests that EBV infection occurs at an early stage of tumor development. These findings indicate that EBV has a causal role in the oncogenesis of leiomyosarcomas of patients with AIDS.     

The radiology of the thoracic manifestations of AIDS

The thoracic manifestations of AIDS have undergone a gradual metamorphosis, partly due to more awareness about the disease leading to earlier diagnoses and partly due to the fact that research has produced more effective prophylaxis as well as treatment for these patients. Many patients now demonstrate partial or complete clinical response which prolongs the length and quality of life of individuals positive for the Human Immunodeficiency Virus (HIV+). Also, with the large number of infected individuals coming to medical attention, and the years of experience in diagnosing and treating these AIDS patients, we now recognize not only the usual but also less usual manifestations of thoracic illnesses in AIDS, including infections, non-infectious diseases such as HIV associated Lymphocytic Interstitial Pneumonia and the neoplasms associated with AIDS. A section will be devoted to HIV infection in children. We will finish the article with a discussion of the current role of Nuclear Medicine in the diagnosis of HIV associated thoracic diseases. These topics are the subject of this article.     

Vertical transmission of human immunodeficiency virus: six years of development 1987-1992)

BACKGROUND: According to World Health Organization estimates, from the beginning of the epidemics to the end of 1994, the number of children infected by human immunodeficiency virus (HIV) was 1.5 million. This paper describes the evolution of some clinical and epidemiologic characteristics of vertically transmitted HIV infection. PATIENTS AND METHODS: All children born to HIV-infected mothers who delivered at a university hospital in Barcelona, Spain, between 1987 and 1992, were included in the study. Rates of HIV vertical transmission, HIV infection incidence and mortality due to HIV were estimated, and trends for the study period analyzed. Odds ratios were used to assess associations between variables. RESULTS: 192 newborns were identified and allocated, with respect to the year of birth, in three cohorts of 71, 58 and 63 children. Overall HIV vertical transmission rate was 16.5% and did not differ between cohorts. Infection incidence density rates increased over time (0.2, 4.9 and 8.1 cases/100 child-years, respectively; p = 0.016), while incubation periods decreased significantly (248, 103 and 114 days; p = 0.0004). There were no changes in mortality density rates (2.2 deaths/100 child-years). Regarding mothers' characteristics, a significant temporal trend (p < 0.001) for being older at delivery, belonging to the heterosexual transmission group and having symptomatic infection was observed over time. CONCLUSIONS: Certain clinical and epidemiologic aspects of HIV vertical transmission have changed over time, however the number of new cases has remained fairly constant. In our setting, both early diagnosis and clinical management of these children have improved, but primary prevention for HIV vertical transmission has not been effective. Better counselling for HIV-infected women of childbearing age is needed.     

Clinical manifestations of human immunodeficiency virus infection in Haitian children

OBJECTIVE: This study was designed to describe the characteristics of HIV-1 infection in children in Haiti and to assess its impact on morbidity and mortality. BACKGROUND: Throughout the developing world the female-to-male ratio of HIV-1 infection approaches 1:1, leading to a tremendous burden of vertically transmitted HIV-1 infection. The frequency of transmission, progression of disease and AIDS-defining clinical illnesses are not as well-described in this setting as in the industrial world. METHODS: Children were identified as being HIV-1-seropositive from case findings among family members of individuals presenting for screening at the GHESKIO Centers in Port-au-Prince, Haiti. Children who were seronegative from the same population were also enrolled and both groups were followed at regular intervals. The clinical course and illnesses associated with HIV infection were documented. RESULTS: Rapid progression to symptomatic disease and death was seen and a battery of physical findings enabled a clinician over time to assign with high sensitivity and specificity the diagnosis of AIDS to a child. Although many findings are similar, the presentation of HIV-1 infection in Haiti differed in significant ways from observations in the industrial world. In particular signs of malnutrition, failure to thrive and tuberculosis were more common in the Haitian population. CONCLUSION: Pediatric HIV-1 infection in Haiti differs significantly from the illness in the industrial world. Early mortality poses a particular difficulty in diagnosing and ascribing mortality to HIV-1 infection.     

Prevalence of gallstones in the neonatal period]

The prevalence of infection with Mycobacterium avium complex (MAC) has increased since the outbreak of the HIV pandemic. This complex comprises two organisms: M. avium (mostly) and M. intracellulare (rarely). The source of MAC infection is not known. The principal risk factors for disseminated MAC infection in a patient with HIV infection are a low CD4 count and a previous opportunistic infection. The symptoms of disseminated MAC infection resemble those of HIV wasting; a positive culture of normally sterile tissue confirms a MAC infection. There is reserve with regard to routine prophylaxis in HIV-infected persons because of the possible development of resistance, interaction with other drugs used in AIDS, toxicity and possible absorption disorders which might cause prophylaxis to fail. For the treatment of disseminated MAC infection, a combination of at least two medicaments (macrolides and ethambutol) is recommended.     

Disease status in African American single mothers with HIV: The role of depressive symptoms.

The association between depressive symptoms and 2 measures of HIV disease status in 73 African American single mothers was examined. Hierarchical multiple regression analyses revealed that clinician-rated depressive symptoms predicted subjective, but not objective, parameters of disease status 12 to 14 months later. More symptoms of depression at the first assessment predicted an increase in physical complaints over the course of the study. Results suggest that researchers and clinicians interested in enhancing quality of life among African American single mothers with HIV infection, an understudied population within the HIV–AIDS literature, should consider both subjective and objective measures of the disease. (PsycINFO Database Record (c) 2010 APA, all rights reserved)     

Case managed residential care for homeless addicted veterans. Results of a true experiment

There is an interesting relationship between the HIV virus, the health of the gastrointestinal tract, and AIDS wasting syndrome, involving Tumor Necrosis Factor alpha (TNF alpha), specific and non-specific immunity in the gut, gut permeability, and oxidative stress. It is hypothesized that the progression of HIV to full-blown AIDS may be impacted by maintaining a healthy gut. A therapeutic protocol which decreases oxidative stress, inhibits TNF alpha, enhances phase I and II liver detoxification, and improves specific and non-specific immunity in the gut should be part of a therapeutic protocol for HIV-infected individuals. Through a better understanding of the pathophysiology of HIV advancing to AIDS, the practitioner can develop a treatment strategy of nutritional and lifestyle changes which could theoretically prevent an HIV infection from advancing to full-blown AIDS.     

Clinical features of tuberculosis associated with HIV infection in Taiwan

To understand the clinical characteristics and outcome of tuberculosis (TB) in patients with acquired immunodeficiency syndrome (AIDS) in Taiwan, we reviewed the medical records of 118 adult AIDS patients who were hospitalized at National Taiwan University Hospital between January 1988 and September 1995. Among them, 29 (24.6%) had TB. The mean age of the AIDS patients with TB was 37 years (range, 25-66 yr). Most patients were in the advanced stages of AIDS when human immunodeficiency virus (HIV) infection and/or TB were first diagnosed. The mean CD4+ lymphocyte count was 0.037 x 10(9)/L (range, 0-0.152 x 10(9)/L) at the time TB was diagnosed. There was no statistically significant difference in the mean CD4+ lymphocyte count between patients with isolated pulmonary TB and those with extrapulmonary involvement. Twenty-two patients (75.8%) had extrapulmonary TB with the most common site being the lymph nodes (72.7%). Clinical symptoms were nonspecific, and the chest physical examination was not helpful in the diagnosis. Acid-fast bacilli were detected in sputum smears from eight patients (36.4%). A primary tuberculosis pattern (hilar adenopathy, pleural effusion, middle or lower lobe infiltrates) in the chest radiographs was the most common radiologic finding (36.4%) in patients with pulmonary TB. The reactivation pattern (predominant upper-lobe infiltrates with or without cavitation) could only be found in cases of pulmonary TB without extrapulmonary involvement. Atypical patterns (diffuse interstitial infiltrates mimicking Pneumocystis carinii pneumonia or other patterns) and normal chest radiographs were noted in nearly one-third of the patients with pulmonary TB. A good response to antituberculosis drugs and a favorable outcome were demonstrated in the patients, except for two with drug-resistant Mycobacterium tuberculosis infection. Early identification of TB in HIV-infected patients requires clinical awareness of the unusual clinical presentations, especially among patients in the advanced stages of AIDS.     

High-dose intravenous immunoglobulins in the treatment of adolescent and adult HIV-infected hemophiliacs

In children infected with human immunodeficiency virus (HIV) placebo-controlled trials with intravenous immunoglobulins have resulted in a significant reduction in morbidity; however, the results of small trials in adolescents and adults have been inconsistent. In this study 17 HIV-infected hemophiliacs aged 9-30 years were treated with monthly intravenous immunoglobulins for an average of 32 months. At the end of the study, 8 years after the HIV infection, three patients (18%) had progressed to the acquired immunodeficiency syndrome (AIDS), and the average decrease in CD4 cells was 81 cells/microliter per year. The natural history of HIV infection in hemophiliacs in this age group shows a manifestation rate of AIDS between 11% and 26% 6-8 years after seroconversion and an average yearly decrease in CD4 lymphocytes of 68-110 cells/microliters. In conclusion, we observed no difference either in the manifestation rate of AIDS or in prognostic markers in this small cohort of HIV-infected hemophiliacs treated for more than 30% of their latency period with intravenous immunoglobulins compared to the well-documented natural history of HIV-infected hemophiliacs. However, none of the patients developed severe bacterial infections during the study period.     

Ocular and sinus microsporidial infection cured with systemic albendazole

PURPOSE: To report treatment of a patient with acquired immunodeficiency syndrome (AIDS) and ocular and paranasal sinus microsporidial infection. METHOD: Case report. RESULTS: A patient with AIDS and ocular microsporidial infection experienced resolution of ocular symptoms with topical fumagillin, but symptoms recurred upon cessation of therapy. Paranasal sinus microsporidial infection was diagnosed. The patient received sequential systemic treatment with itraconazole followed by albendazole. Sinus symptoms resolved with albendazole. He remained symptom-free with a normal examination 17 months after concluding therapy. CONCLUSIONS: Although fumagillin and itraconazole may have played a role, systemic albendazole appears to be responsible for clinical resolution of microsporidial infection.     

A noncompliant patient with fluctuating capacity

Poor sleep, daytime fatigue, and loss of cognitive ability exist during all stages of HIV infection, worsening with disease progression. These symptoms contribute to disability and poor quality of life. Data from several research groups support a role of somnogenic inflammatory process peptides elevated in HIV infection, e.g. TNF alpha. Though the literature is in conflict regarding an effect of HIV infection on growth hormone (GH) secretion, GH axis dysregulation and treatment with GH may be important in HIV infection, e.g. in the wasting syndrome. It has long been known that GH varies with changes in sleep. The hypothesis tested in the current study was that the relationship between delta frequency (0.5-4.0 Hz) sleep EEG amplitude (square root of power from frequency analysis) and GH secretion would differ between HIV positive (HIV+) and HIV negative (HIV-) subjects. In 14 subjects (6 HIV+ and 8 HIV-, none with current or past AIDS-defining illness) a linear relationship change across the night's sleep was found in the coupling between delta frequency sleep EEG amplitude and GH secretion. The phase coupling change was in opposite directions in HIV+ versus HIV- subjects. This difference supports the hypothesis that the brain-based coordination of sleep and sleep-related physiology deteriorates early in HIV infection, and that GH dysregulation may contribute to this sleep pathology.     

HIV myelopathy as the presenting symptom of acquired immunodeficiency syndrome

INTRODUCTION: Spinal lesions in the acquired immunodeficiency syndrome (AIDS) occur in 22% of all neurological complications, although their occurrence as the first sign of the disease is very uncommon. First place amongst the myelopathies described as associated with HIV is taken by vacuolar myelopathy, followed by the myelites. CLINICAL CASE: We studied a 65 year old homosexual man who had previously been free of symptoms and signs of HIV infection. He was seen for progressive paraparesia which had begun some days previously, followed by altered sense of position and of vibration. Complementary tests showed that the patient was a carrier of HIV antibodies in high titre (P-24) with a high viral load of 907 x 1,000 copies RNA/ml. Testing with evoked potentials showed changes compatible with involvement of the sensory pathways of the spinal cord. After treatment with dexamethasone there was obvious improvement with partial recovery of his symptoms. CONCLUSIONS: The neurological condition described was compatible with vacuolar type myelopathy due to HIV, appearing in the initial stages of the illness and coinciding with a marked increase in the viraemia. Although necropsy is necessary for confirmation of the diagnosis, more and more evidence is being found on which to base clinical suspicion. We discuss various hypotheses regarding possible pathogenic mechanisms arising in these circumstances.     

EEG diagnostic and predictive value on HIV infection in childhood

This prospective study evaluated the electroencephalographic (EEG) diagnostic and prognostic value in childhood HIV infection. It was carried out on 125 subjects and included all Piemonte's seropositive children. The EEG was repeated every three months during the first 15 months of life, and then, at least, annually in the P1 and P2 group. Data of group P2 was compared blindly to that of the seroconverted control group of the same age and risk. EEG results were normal in P0, P1 and control patients. In group P2, EEG was abnormal in 35.5% of subjects, of these 54.6% developed an encephalopathy with a delay of 2.5 months to 2 years 11 months. EEG is therefore useful to evaluate early CNS damage and to identify onset features and evolution of encephalopathy in P2 patients.     

Cerebral aneurysmal arteriopathy in childhood AIDS

OBJECTIVE: To identify cerebral aneurysmal arteriopathy in children with longstanding AIDS. BACKGROUND: Five cases are described from the authors' experience, and eight additional cases are reviewed from the literature. Details are presented in regard to the clinical picture as well as brain imaging with cerebral angiography and magnetic resonance angiography in some cases. Autopsy information is available in four cases, including one of the authors' patients. RESULTS: Seven patients acquired HIV infection perinatally, five patients were infected by blood transfusions, and one patient had both risk factors. In the four postmortem patients, the vascular pathology was similar, showing ectasia and aneurysmal dilatation confined to the large arteries of the circle of Willis. Medial fibrosis and loss of muscularis with destruction of the internal elastic lamina and intimal hyperplasia was common. The latency period following infection varied from 2 to 11 years. Once a diagnosis of aneurysmal arteriopathy was made, the patients deteriorated rapidly, with death occurring in less than 6 months. CONCLUSIONS: The development of cerebral aneurysmal arteriopathy in childhood AIDS tends to occur after a prolonged delay and is usually followed by death in a short period of time. The etiology for the vasculitis is unknown. Varicella zoster virus may be the etiology in some of the cases because of its potential to cause this pathology and the striking unilateral arterial involvement found in Case 5. HIV vasculitis is also a possibility, as suggested by the detection of HIV protein or genomic material in two of the four autopsy cases.