Acquired immunodeficiency syndrome in infants

Pediatric human immunodeficiency virus infection

In the past decade, an increase in pediatric human immunodeficiency virus (HIV) infection has had a substantial impact on childhood morbidity and mortality worldwide. The vertical transmission of HIV from mother to infant accounts for the vast majority of these cases. Identification of HIV-infected pregnant women needs to be impoved so that appropriate therapy can be initiated for both mothers and infants. While recent data demonstrate a dramatic decrease in HIV transmission from a subset of women treated with zidovudine during pregnancy, further efforts at reducing transmission are desperately needed. This review focuses on vertically transmitted HIV infection in children, its epidemiology, diagnostic criteria, natural history, and clinical manifestations including infectious and noninfectious complications. An overview of the complex medical management of these children ensues, including the use of antiretroviral therapy. Opportunistic infection prophylaxis is reviewed, along with the important role of other supportive therapies.

Malignant otitis externa in HIV and AIDS

Malignant otitis externa is a necrotising infection of the external ear canal which may spread to include the mastoid and petrous parts of the temporal bone, leading to skull base osteomyelitis. It is almost exclusively caused by infection with Pseudomonas aeruginosa, and usually occurs in elderly non-insulin-dependent diabetic patients. However isolated cases have been reported in a small number of non-diabetic patients, particularly in children who are immunocompromised due to malignancy, malnutrition and severe anaemia. In 1984 a case of malignant otitis externa was reported in a child with an acquired immunodeficiency syndrome (AIDS)-like illness, prior to identification of the human immunodeficiency virus (HIV). Since that time further sporadic cases of this invasive infection have been reported in HIV and AIDS. We present two further cases and also a review of the current literature.

Maternal-Fetal Transmission of Human Immunodeficiency Virus

The World Health Organization estimates that by year 2000, 10 million children will be infected with human immunodeficiency virus type 1 (HIV-1) at birth and will subsequently develop AIDS. Perinatally acquired infections account for the majority of all HIV-1 cases in children, with an estimated mother-to-infant transmission rate of more than 30%. It is not clear why more than half of the children born to HIV-1-infected mothers are uninfected. Maternal transmission of HIV-1 occurs at three levels: prepartum, intrapartum, and postpartum. Several maternal parameters including advanced clinical stages of the mother, low CD4+ lymphocyte counts, maternal immune response to HIV-1, recent infection, high level of circulating HIV-1, and maternal disease progression have been implicated in an increased risk of mother-to-infant transmission of HIV-1. Viral factors influencing mother-to-infant transmission are not known. Furthermore, several other factors such as acute infection during pregnancy, presence of other sexually transmitted diseases (STD) or other chronic infections, vaginal bleeding, disruption of placental integrity, premature rupture of membrane (PROM), and preterm PROM have been associated with mother-to-infant transmission of HIV-1. In addition, tobacco and cigarette smoking during pregnancy have been shown to triple the rate of maternal transmission of HIV-1. The AIDS Clinical Trial Group (ACTG) suggested that zidovudine (ZDV) can reduce therate of mother-to-infant transmission of HIV-1 if administered to HIV-1-infected pregnant women with CD4 counts greater than 200. Moreover, this study failed to take into consideration several factors that may influence maternal transmission of HIV-1. However, the molecular mechanisms involved in mother-to-infant transmission of HIV-1 are not understood, which makes it more difficult to define strategies for effective treatment and prevention of HIV-1 infection in children. Several groups are engaged in the understanding of the molecular and biological properties of HIV-1 influencing mother-to-infant transmission. Results from my and several other laboratories suggest that the minor genotypes, subtypes, or variants of HIV-1 found in a genetically heterogeneous virus population of infected mothers are transmitted to their infants. The minor HIV-1 genotype predominates initially as a homogeneous population in the infant and then becomes diverse as the infant matures. Furthermore, transmission of a major or multiple HIV-1 genotypes from mother to infant has been reported. Taken together, these results strongly suggest that there are differences among the molecular and biological properties of the maternal variants that are transmitted to the infants and the maternal variants that are not transmitted to the infants. The understanding of the molecular and biological properties of the transmitted viruses will enable researchers to target a particular subtype in the mothers that is transmitted to the infants. Copyright 1996 S. Karger AG, Basel

Growth of human immunodeficiency type 1-infected and uninfected children: a prospective cohort study in Kigali, Rwanda, 1988 to 1993

OBJECTIVE

To compare the anthropometric characteristics of children with and without HIV-1 infection.

METHODS

In a prospective cohort study of 218 children born to HIV-1 seropositive mothers and 218 children born to HIV-1 seronegative mothers in Kigali, Rwanda, 3 groups were compared: infected children (n = 46); uninfected children born to seropositive mothers (n = 140); and uninfected children born to seronegative mothers (n = 207). Weight, height and head circumference were measured at birth, every 3 months during the first year of life and every 6 months thereafter. The weight-for-age, height-for-age, weight-for-height and head circumference-for-age mean z scores were calculated.

RESULTS

The weight-for-age, height-for-age and head circumference-for-age mean z scores were lower among HIV-infected children than among uninfected ones at each time period. The reduction in the weight-for-age mean z score was the greatest between 12 and 36 months. The reduction in the height-for-age mean z score of HIV-infected children was persistently below 2 SD after 9 months of age. On the other hand the weight-for-height mean z score was not consistently lower in HIV-infected children when compared with uninfected ones. The anthropometric characteristics of uninfected children born to seropositive mothers were similar to those of children born to seronegative mothers.

CONCLUSIONS

In this study HIV-infected children were more frequently stunted (low height-for-age) than uninfected ones. Wasting (low weight-for-height) was not common among HIV-infected children.

Disease patterns and survival after acquired immunodeficiency syndrome diagnosis in human immunodeficiency virus-infected children

BACKGROUND

The clinical manifestations of HIV infection in children involve a broad spectrum of conditions ranging from mild symptoms to AIDS. Knowledge of the disease and survival patterns of these children are needed to plan for future needs and develop baseline information to evaluate newer prophylactic or therapeutic management options.

OBJECTIVES

To identify AIDS-defining conditions and estimate post-AIDS diagnosis survival among HIV-infected children.

METHODS

Disease patterns and survival after the diagnosis of AIDS-defining conditions were studied in 126 children who were identified through a multisite university-based active surveillance system in California from January, 1989, through August, 1993. Hospital medical records were periodically reviewed and data were abstracted onto standardized forms designed for pediatric HIV surveillance. We determined the length of survival between AIDS diagnosis and death and evaluated the impact of disease patterns on survival using Kaplan-Meier's product-limit method and Cox proportional hazards regression.

RESULTS

The median age at diagnosis was 13 months for children with perinatally acquired infection and 101.5 months for children infected through other routes of transmission. Pneumocystis carinii pneumonia and lymphoid interstitial pneumonia were the most common AIDS-defining conditions among perinatal cases, whereas the disease patterns observed among nonperinatal cases were more varied. The median postdiagnosis survival for the cohort was 26 months.

CONCLUSIONS

Survival time did not differ significantly by race/ethnicity, sex or route of transmission. Respiratory candidiasis and wasting syndrome had significant negative impact on survival but P. carinii pneumonia was not associated with shorter survival. Zidovudine or other antiviral therapies was associated with increased survival.

CD8+ lymphocytes in bronchoalveolar lavage and blood: in vivo indicators of lung pathology caused by maedi-visna virus

A study to determine the putative relationship between lymphocyte phenotypic alterations in bronchoalveolar lavage fluid and stage of lung pathology in maedi-visna infected sheep has been carried out. Twenty-one ewes (16 Texel and five Scottish blackface) naturally infected by maedi-visna virus and three Oxford controls were used. Animals were killed, lungs were removed, bronchoalveolar lavage was performed and pathological studies were completed. Blood samples were also obtained from 16 animals. Lymphocytes in both bronchoalveolar lavage and peripheral blood were labelled with monoclonal antibodies against the main T lymphocyte subsets (CD4, CD8, CD5 and gamma delta TCR) in order to perform flow cytometric studies. Three aspects of pathology were studied: lymphoid interstitial pneumonia, lymphoid follicular hyperplasia and smooth muscle hyperplasia. Percentages of CD4+, CD5+, gamma delta + T cells and the value for the CD4+ / CD8+ ratio in bronchoalveolar lavage of maedi-visna infected animals were significantly decreased (P < 0.05) when compared to controls, while percentages of CD8+ lymphocytes were increased in bronchoalveolar lavage of infected sheep and they were very close to being significant (P = 0.07) when compared to controls. Lesions were evaluated and simple least-squares regression tests demonstrated that there were several significant correlations between various lymphocyte subsets and pathological parameters studied in this work. However, when a multiple regression test was applied to the data, it was observed that only the CD8+ T cell subset both in bronchoalveolar lavage and in blood was significantly correlated with severity of lung pathology. It is concluded that CD8+ lymphocytes are key cells in the development of the interstitial reaction and the lymphocytic alveolitis observed in maedi-visna infected ewes and that the CD8+ alveolitis is a parallel feature to the intensity of lung lesions. It is further suggested that the percentage of CD8+ lymphocytes in bronchoalveolar lavage and in blood may act as in vivo indicators of lung pathology in maedi-visna infected sheep.

Kaposi sarcoma in a Thai boy with acquired immunodeficiency syndrome

Kaposi sarcoma is rare in children with acquired immunodeficiency syndrome (AIDS). We report a 3-year-old boy with AIDS and Kaposi sarcoma of the skin and lymph node. This patient is the only one with this disease among 278 children with AIDS who have been seen at Chiang Mai University Hospital. He responded well to intravenous vincristine.

Infections in children with human immunodeficiency virus/acquired immunodeficiency syndrome: an autopsy study of 30 cases in south Florida, 1990-1993

Thirty autopsies performed on infants and children with HIV infection and/or AIDS were reviewed for the presence and type of infection. Twenty-six (87%) demonstrated evidence of infection in addition to HIV at the time of postmortem examination. Pathogenic bacterial infectious were the most frequently encountered, seen in 15 of the cases. Nine of the 15 (60%) were due to gram-negative rods, most commonly Pseudomonas aeruginosa. Infections with gram-negative organisms often involved multiple organ systems and were frequently undiagnosed both pre- and postmortem because of variability in culture results and difficulties in identification both clinically and in tissue sections. Discussion is presented of unusual staining characteristics and filamentous morphology found with these pathogens. Other pathogenic bacteria encountered were Klebsiella pneumoniae, Escherichia coli, Enterobacter sp., and Staphylococcus. Fungal infections due to Candida species were present in nine cases (31%) but were invasive in only two of these. One instance of Aspergillus meningo-encephalitis was noted. Proven viral infections were present in five children (three cytomegalovirus, one herpes simplex, and one adenovirus). Pneumocystis carinii pneumonia was diagnosed in five of the patients (17%), and one instance of disseminated Mycobacterium avium-intracellulare was encountered.

Malignant Otitis Externa in AIDS Patients: Case Report and Review of the Literature

Malignant otitis externa is a necrotizing infection of the external ear canal and surrounding soft tissue and bone, usually caused by Pseudomonas aeruginosa. The infection classically occurs in diabetic patients, however recently, several patients with the acquired immunodeficiency syndrome (AIDS) have been reported to have malignant otitis externa. A patient with AIDS who had malignant otitis externa with skull base osteomyelitis is presented and reported cases in patients with AIDS are reviewed. Predisposing factors include immunologic abnormalities (notably neutropenia), dermatitis, medications, neoplasm, and iatrogenic procedures, e.g., ear lavage. Treatment of malignant otitis externa has traditionally included anti-pseudomonal cephalosporins/penicillins and aminoglycosides for prolonged durations. Recently, ciprofloxacin has been shown to be effective as an oral regimen.

With the increasing number of patients with AIDS being seen in the outpatient clinics, the diagnosis of malignant otitis externa should be considered in any patient with persistent ear pain or otorrhea who does not respond to conventional treatment for external otitis.

Pulmonary pathology in AIDS: atypical Pneumocystis carinii infection and lymphoid interstitial pneumonia

Images

Early impairment of gut mucosal immunity in HIV-1-infected children

This study was performed in 27 HIV-1+ children to characterize the IgA hyperglobulinaemia observed in the serum during the course of HIV-1 infection. By contrast with serum IgG, which increased very early, IgA elevation was related to the decrease of CD4+ cell percentage. It was demonstrated that IgA1 subclass increased selectively. Secretory IgA (SIgA) and IgA and IgG activity to gliadin, bovine serum albumin (BSA) and at a lower level to casein could be detected in the serum at the early stages of HIV infection, but SIgA levels and IgA activity to gliadin further increased during the course of immunodeficiency. By contrast, IgA and IgG activity to tetanus toxoid did not change. These data demonstrate that the hyper IgA, closely related to the degree of immunodeficiency, could be due in part to a disturbance of the gut mucosal immune system. Moreover, impaired intestinal immunity seems to appear very early, and to progress during the course of paediatric HIV-1 infection.

Exploration of the pulmonary circulation. Festschrift to Professor Donald Heath

Images

The spectrum of pathological changes in the lung in children with the acquired immunodeficiency syndrome: an autopsy study of 36 cases

We present the pulmonary findings in 36 autopsies of children affected by the acquired immunodeficiency syndrome (AIDS). Twenty-three patients were male and 13 were female, ranging in age between 3 days and 13 years. Twenty children had human immunodeficiency virus (HIV)-positive parents or parents who were at high risk of exposure (intravenous drug abusers and prostitutes), five had a history of transfusion, and one had a history of renal transplantation and blood transfusion. Clinically, the patients presented with recurrent infections, failure to thrive, hepatosplenomegaly, fever, cough, and/or hemoptysis. Histologically, specific infectious processes were the most common finding (75% of cases), with Pneumocystis carinii pneumonia being the most prevalent type of infection, followed by bacterial pneumonia. Neoplastic conditions and lymphoid interstitial pneumonia were less frequent (approximately 10% of cases). In addition, in approximately 10% of the cases the pulmonary findings were non-specific (ie, pulmonary edema and atelectasis) and probably unrelated to HIV infection. Our findings suggest that specific infectious conditions constitute the most common type of pulmonary pathology in children with AIDS. However, because there is a small percentage of children with nonspecific findings, a transbronchial biopsy is important for proper evaluation before institution of therapy.

Prevalence of lymphopenia in children with AIDS

Hematologic abnormalities, such as anemia, neutropenia, lymphopenia, and thrombocytopenia, are frequently observed in patients with acquired immunodeficiency syndrome (AIDS). While lymphopenia has been noted in up to 80% of adults, only 50% of children with AIDS are reported to be lymphopenic. We reviewed the blood counts of hospitalized children with AIDS to determine the frequency of lymphopenia and other hematologic abnormalities. Seventy-four children with AIDS (ages 4 months to 9.5 years) were admitted to Kings County Hospital Center (Brooklyn, New York) from January 1990 to March 1991; data consisted of 709 CBCs (range one to 39, median 11) from 176 admissions (range one to 15). In some patients admitted during the study period, charts from previous admissions were reviewed. Anemia (Hb less than than third percentile for age) was noted in 68 of 74 (92%) patients. Leukopenia (WBC less than 4000/mm3) was noted in 32 of 74 (43%) patients. Lymphopenia (lymphocyte counts below normal for age) was seen in 59 of 74 (78%) patients; of these, more than half (31 of 59) had persistently low absolute lymphocyte counts. Thrombocytopenia (platelet count less than 150,000/mm3) was seen in 20 of 74 (27%) and was found in four of eight patients who expired. Pancytopenia was seen in nine of 74 (12%) patients. Progression of hematologic abnormalities with anemia followed by lymphopenia, thrombocytopenia, and finally leukopenia was demonstrated in 22 patients. This review shows a prevalence of hematologic abnormalities that is similar to those of previous reports in children except for a considerably higher prevalence of lymphopenia. As expected, lymphopenia was a marker for disease progression.

Neonatal disease induced by SIV infection of the rhesus monkey (Macaca mulatta)

Seven 72-hr-old Indian origin rhesus monkeys (Macaca mulatta) were inoculated with 10 animal ID50 of SIV/DeltaB670. Nine age-matched animals were used as uninoculated controls. All seven inoculated animals became infected as verified by viral isolation and SIV p26 antigenemia. Five of seven infected animals died within a mean of 31 days (range, 26-41 days), with high levels of antigenemia beginning 1-2 weeks postinoculation (PI) that persisted until death. Absolute lymphocyte numbers were within normal limits in all animals in both groups throughout the study. Inoculated animals that died within a mean of 31 days (short-term survivors) had significantly lower numbers of CD4+CD29+ (helper/inducer) lymphocytes than did long-term surviving inoculated animals through 3 weeks PI. Numbers of CD4+ lymphocytes were no different when controls were compared to all inoculated animals through 4-5 weeks PI. The two inoculated animals surviving 216 and 423 days PI (long-term survivors) did demonstrate declining CD4+ cells, but only late in disease. CD8+ lymphocytes were significantly lower in short-term survivors when compared to long-term survivors through 5 weeks PI. Antibody production against SIV viral proteins was detected only in the long-term survivors and was similar to results from past studies in juveniles. Clinical signs in the inoculated group were consistent with those seen in past studies on older animals. Persistent bacterial infections, primarily of the GI and respiratory tracts, were seen in the infected group. Aside from the lack of some opportunistic infections such as cytomegalovirus (CMV) and Pneumocystis carinii, necropsy findings were not different when compared to past studies on juvenile animals.(ABSTRACT TRUNCATED AT 250 WORDS)

Assessing neurobehavioral changes in HIV+ infants and children. A methodological approach

The rationale and development of a developmental approach to assessing neurobehavioral changes in infants and children exposed to or infected with the HIV-1 virus is presented. Methodological problems in earlier approaches to assessment are reviewed. Among these are measures employed, impact of different treatments on measures of outcome, multicultural differences between samples, and analytic approaches to developmental data. The assessment protocol developed by the Pediatric Neurobehavioral Study Group of NIMH/NICHD/NIAID is described.

Human immunodeficiency virus infection in pregnancy

Human immunodeficiency virus (HIV) infection in women is an increasing problem. World wide, at least 25% of all infections occur in adolescent or adult women, most of whom are of child-bearing age. The commonest modes of acquisition of HIV infection are sexual contact with an HIV-infected male and sharing needles during injecting drug use. Vertical transmission is the major route of HIV infection in infants and children and can occur in utero, intrapartum, through exposure to infected blood or secretions, or post partum, via breast milk. HIV infection has not been demonstrated to affect fertility, or to influence the outcome of pregnancy unless there is evidence of significant immune dysfunction, with CD4 counts below 400/mm3. Though data are limited, pregnancy does not appear to affect the course of HIV infection. Low CD4 counts predispose women to the opportunistic infectious complications of HIV. Pathogens include Candida sp., Mycobacterium tuberculosis, Pneumocystis carinii, Toxoplasma gondii, Cryptococcus neoformans and Cryptosporidium. These pathogens require early recognition and diagnosis if optimal treatment and outcome are to be attained. Treatment with zidovudine and prophylaxis against Pneumocystis carinii are appropriate when CD4 counts are less than 200/mm3, though the safety of zidovudine in early pregnancy is not known. Similarly it is not known whether zidovudine treatment of the mother prevents transmission of HIV infection to her baby. Caesarean section does not prevent peripartum transmission of HIV and should be undertaken only for other appropriate indications. The utility of antenatal screening for HIV depends upon the seroprevalence in the population. Such programmes must be supported by comprehensive clinical care as well as sensitive and non-judgemental counselling.

Phenotypic analysis of cells in bronchoalveolar lavage fluid and peripheral blood of maedi visna-infected sheep

A phenotypic analysis of bronchoalveolar lavage fluid (BALF) and peripheral blood (PB) cells in maedi visna virus (MVV)-infected sheep has been performed. The differential cell count in BALF from MVV-infected animals was characterized by a significant increase (P < 0.05) in lymphocytes and neutrophils. Lymphocyte phenotyping in BALF from MVV-infected sheep showed a significant decrease (P < 0.05) of CD4+ cells, a significant increase (P < 0.05) of CD8+ cells and a significant inversion (P < 0.001) of the CD4+/CD8+ ratio. CD5+ lymphocytes were also significantly decreased (P < 0.05). Gamma delta T cells and B cells did not differ significantly when compared with the controls. No correlation was observed between BALF and PB lymphocyte phenotypes. BALF macrophages from MVV-infected animals showed increased MHC class II expression and BALF lymphocytes from the same animals demonstrated up-regulation of LFA-1 and LFA-3 expression. These findings and their relationship with lentiviral pathogenesis are discussed.

Aspergillosis in children with acquired immune deficiency

Two children are presented with AIDS and aspergillosis. One child had pulmonary involvement while the other had invasion of the skull and brain. The rarity of aspergillosis in AIDS patients is discussed as well.

Multiple viral infections in HIV-infected children with chronically-evolving hepatitis

Hepatic involvement was investigated in 31 children with perinatal HIV-1 infection, who were followed for 2-82 months (mean 30.5). Liver disease, as revealed by increased aminotransferase levels, liver biopsy or necroscopy, was diagnosed in 18 children (58%), of which 7 (22.5%) had acute hepatitis and 11 (35.5%) showed chronic liver disease. Overall, 40 persistently active or recurrent viral infections, as demonstrated by positive culture and/or detection of serum DNA, specific IgM, IgA and high levels of IgG, were revealed in the children with liver disease, while 12 similar infections were detected in 13 children without liver disease (p < 0.001). In particular, the children with liver disease showed a significantly (p < 0.002) higher incidence of cytomegalovirus (CMV) infections than children without liver disease (13 versus 3). Moreover, hepatitis C and B virus infections were revealed only in children with liver disease (5 and 1 patients, respectively). Clinical outcome showed a significantly (p < 0.001) higher mean survival in the children without liver disease than those with liver disease (47.5 versus 18.2 months). In fact, nine of the children with liver disease (50%) died, as opposed to only one of the children without liver disease (7.7%; p = 0.01). Based on these findings, liver disease is indicative of a poor prognosis in children with HIV infection, being related to the presence of multiple active viral infections.

Modification of resistance to Streptococcus pneumoniae by dietary ethanol, immunization, and murine retroviral infection

Hallmarks of the acquired immune deficiency syndrome (AIDS) are immunologic alterations, frequently associated with opportunistic infections. To study such associations, LP-BM5 murine retrovirus infection was used as a murine model of AIDS. Retrovirally infected and uninfected mice were fed a 5% (v/v) ethanol diet for 55 days and then fed a 7% v/v ethanol diet for the final 7 days to assert the role of ethanol as a cofactor in development of murine AIDS. There was a reduction in polymorphonuclear neutrophils count in ethanol-fed groups. Neutrophils increased in retrovirus-infected groups, except those vaccinated 10 days before challenge with live bacteria. The percentage of splenic lymphocytes in the retrovirus-infected group was reduced in comparison with controls. Survival of the mice challenged intraperitoneally with Streptococcus pneumoniae was increased by vaccination and suppressed by dietary alcohol. Retrovirus infection caused a much faster death rate after bacterial challenge than nonretrovirus infected controls. Vaccination played an important role in delaying the death rate in all treated groups. Transferring spleen cells from healthy, unimmunized mice also enabled the retrovirally infected mice to survive the bacterial infection longer. Enhancement of resistance to S. pneumoniae by vaccination and transfer of immunocompetent cells to mice immunosuppressed by retroviral infection show the potential to use immunomodulation to affect disease resistance in AIDS.

Human immunodeficiency virus replication: modulation by cellular levels of cAMP

HIV infection is associated with qualitative and functional immune deficiencies. It has been shown that the in vitro infection of CD4+ cells with HIV was associated with sustained elevation of cAMP and cGMP. In the present report the role of cAMP on HIV replication in MT-4 cells was investigated. The MT-4 cells were infected with HIV (strain 3b), in the presence or absence of agents that increase intracellular levels of cAMP, through different mechanisms. At selected times postinfection, HIV replication was measured by reverse transcriptase activity or HIV P24Ag in culture supernatants. Forskolin (FK, an activator of adenylate cyclase 1-100 microM), Isobutyl-methylxanthine (IBMX, a phosphodiesterase inhibitor, which indirectly increases intracellular levels of cAMP, 30-100 microM) and dibutyryl (db) cAMP (0.1-10 microM) enhanced HIV replication, in a dose-dependent manner. FK, IBMX, and db cAMP enhanced HIV replication by 2- to 10-fold, 4- to 7-fold, and 2- to 6-fold, respectively. Intracellular levels of cAMP were measured by radioimmunoassay and were also enhanced. Since cAMP exerts its catalytic effects through activation of protein kinase (PK) A the effect of H-8 (a specific inhibitor of the cAMP dependent PK A) on HIV replication was simultaneously examined. The H8 at doses of 0.1 to 10 microns inhibited HIV replication by 25 to 99.9%. Moreover H9 inhibited HIV replication in peripheral blood mononuclear cells by more than 90%. The replication of HIV appears to be a cAMP-dependent event, and PK A could possibly be a target for the development of anti-HIV therapies.

Laboratory methods for early detection of human immunodeficiency virus type 1 in newborns and infants

Cumulative data on serological testing of newborns and infants have shown that (i) maternal and newborn anti-HIV-1 IgG titers are high at delivery, which may explain the persistence of antibody in the infants of seropositive mothers; (ii) in some situations, serial HIV-1 antibody testing may identify infected infants; and (iii) detection of anti-HIV-1 IgA or IgM is specific for infection but the sensitivity of this assay may be compromised in certain situations, such as when infected infants are hypogammaglobulinemic or when the rise and fall of HIV-1-specific IgM synthesis following acute infection has been completed before delivery of the infant. Cumulative data on PCR, viral culture, and tests for antigen in newborns and infants have shown that (i) among all age groups, viral culture is probably the most specific test available for detection of HIV-1, as PCR and the p24 antigen test may (though rarely) give false-positive results; (ii) the sensitivity of these tests increases in the order of antigen, culture, and PCR, with relatively insensitive results in the first 3 months of life for all of these tests; (iii) the sensitivity of all of these tests improves and approximates 90 to 100% when infants over 6 months of age are tested; and (iv) data regarding the sensitivity, specificity, and usefulness of these virological assays in infants under 3 months of age are very scant and inconclusive.

Longitudinal study of parotid saliva in HIV-1 infection

Parotid flow rate and chemistry of 78 HIV + gay/bisexual men and 27 HIV-gay/bisexual controls were compared on a longitudinal basis at 4-month intervals over a 1 yr period for changes indicative of inflammatory or autoimmune diseases of the salivary glands, or reduced protective capacity toward oral opportunistic infection. Parotid saliva was examined for concentrations of sodium, chloride, phosphate, total protein, lysozyme, lactoferrin, secretory IgA, salivary peroxidase, histatin and albumin. Chloride, lysozyme and peroxidase were significantly higher in HIV + at all 3 examinations and increased in concentration over time. Although mean values for stimulated flow rate were not significantly different in the two groups over the year, there was a significant increase in the number of HIV + with reduced flow over time. In 6% of HIV + there was a marked reduction in flow rate and Sjögren's syndrome-like elevations in parotid chemistry but no enlargement. At all examinations low flow rate was significantly related to oral candidiasis; T4 levels were inversely related to oral candidiasis, but not to concentration of salivary components or flow rate; nor was AZT use. As a group the HIV + patients maintained normal flow rate and secreted normal or elevated concentrations of protective proteins. A subgroup, however, exhibited diminished flow over time and an increasing tendency to oral candidiasis and a diminution in output of histatins.

Manifestations of pediatric AIDS: proposed mechanisms of transmission

Pediatric Acquired Immunodeficiency Syndrome (AIDS) is expected to increase by greater than 75% by 1993. Most of these infants will become infected with the Human Immunodeficiency Virus (HIV) through the mother. It is unclear exactly how the virus is passed from mother to child. The nature of HIV infection is described in this paper, and several mechanisms relevant to its transfer are proposed.

Clinical manifestations, management and therapy of HIV infection in children

Perinatal infection accounts for the majority of cases of HIV infection in children both in developed and developing countries. Transmission may occur in utero, intrapartum or postpartum as a result of breast-feeding. The actual risk of transmission through breast-feeding is unknown. The majority of infants reported to be infected through breast milk have been infected as a result of a recently acquired HIV infection in the mother. Infants with HIV infection frequently present with clinical symptoms early in life. There is a broad spectrum of clinical findings in paediatric HIV infection, with opportunistic infections and multiorgan system involvement being common. The management of infants born to seropositive mothers includes routine paediatric care as well as careful clinical and laboratory monitoring for evidence of HIV infection. Infants who are seronegative with normal clinical and immunological findings at 18 months of age are considered uninfected. The prognosis and outcome of infants with HIV infection have improved considerably with earlier diagnosis and the availability of specific antiviral therapy. Modalities of therapy include frequent medical evaluation, aggressive diagnosis and treatment of infection, prophylaxis for Pneumocystis carinii infection, the use of intravenous gamma-globulin and specific antiviral therapy, such as zidovudine, didanosine or other drugs in development through clinical trials. HIV infection in children is a chronic illness and requires a comprehensive, family-oriented approach to care. With longer survival, children require support systems and an atmosphere of care and understanding to give them a good quality of life as well as prolonged survival.

Antibody production in infants born to HIV-1-infected mothers

Naturally occurring antibodies to polysaccharide antigens of pathogens commonly isolated from HIV-1-infected subjects were analyzed in serially collected sera of children born to seropositive mothers. Purified polysaccharides from type 14 Streptococcus pneumoniae, group C Neisseria meningitidis, type b Haemophilus influenzae, glucomannoprotein from Candida albicans and diphtheria toxoid antigens were used in an ELISA test to assess antibody levels. A significant rise of anti-pneumococcus antibody titres was noticed both in HIV-1-infected and in non-HIV-1-infected children aged 18 months or more. Anti-C. albicans and anti-group C N. meningitidis antibodies were elevated only in HIV-1-infected children older than 12 months. Anti-type b H. influenzae antibodies remained at low titres in both groups. Anti-diphtheria toxoid antibodies, analyzed as a model of humoral response to a protein antigen, were similar in both groups of HIV-1-infected and noninfected children.

Viral infections of the head and neck among HIV-seropositive patients

Many viruses cause opportunistic infections in HIV-positive patients. Those that cause oral lesions include herpes simplex, varicella zoster, Epstein-Barr virus, cytomegalovirus, and papillomavirus. Importantly, many of the herpes-group viruses are able to augment immunosuppression and some actually transactivate HIV replication-inducing genetic sequences. This article reviews the role of viral agents in the activation of HIV replication and details the features of the reported oral lesions that represent viral opportunistic infections.

Pulmonary hypertension and human immunodeficiency virus infection. Two reports and a review of the literature

Pulmonary hypertension may be primary (idiopathic) or secondary. While the etiologies for secondary pulmonary hypertension are diverse, infection with the human immunodeficiency virus (HIV) has not been included. To date there have been 16 reported cases of pulmonary hypertension in the HIV-infected population. Plexogenic arteriopathy was the most common pathologic finding. We report two HIV-infected patients who were concomitantly found to have pulmonary hypertension with plexogenic arteriopathy. One patient had lymphocytic interstitial pneumonitis, an entity not previously associated with pulmonary hypertension. We review the 16 previous cases of pulmonary hypertension and HIV infection and discuss this association.

Acute hepatitis in childhood: virological, immunological and clinical aspects

Virological, immunological and clinical findings in 7 previously healthy children, aged 18 months to 11 years, with viral hepatitis are reported. Asymptomatic and fully recovering, although protracted, hepatitis B was diagnosed by chance in a 1 1/2 year-old boy. Anicteric and short-term hepatitis occurred in three children with Epstein-Barr virus infection, concomitantly with typical mononucleosis syndrome. On the contrary, cytomegalovirus (CMV)-associated hepatitis was severe and protracted in two children, and fatal in a 4-year-old girl, whose main autoptic finding was submassive hepatic necrosis. Therefore, our study showed that acute viral hepatitis in non-immunocompromised children is generally self-limited and that CMV hepatitis is more frequent and severe than commonly believed.

Primary hepatic leiomyosarcoma in a child with the acquired immunodeficiency syndrome

We report the first case of acquired immunodeficiency syndrome (AIDS)-related primary hepatic leiomyosarcoma in a 9-year-old girl. The pathologic diagnosis was made on a partial hepatectomy specimen and was confirmed by immunohistochemistry and electron microscopy. No human immunodeficiency virus-related nucleic acid was identified in tumor cells by in situ hybridization. Review of the AIDS-related literature reveals a rising incidence of tumors of smooth muscle origin in human immunodeficiency virus-infected patients. This case study details the eighth pediatric AIDS patient with a tumor of smooth muscle origin and represents the 20th and the youngest patient with primary hepatic leiomyosarcoma to be reported in the world literature.

Infection of cord blood monocyte-derived macrophages with human immunodeficiency virus type 1

We have investigated the susceptibility of cord blood monocyte-derived macrophages to human immunodeficiency virus type 1 (HIV-1) infection in vitro. Cord blood monocytes were maintained in vitro for 10 to 15 days and then infected with HIV-1. Syncytia were observed 14 days after infection by light microscopy. Viral proteins were detected by immunofluorescence assay. Electron microscopic examination demonstrated typical lentivirus particles within cytoplasmic vacuoles. The supernatants from the HIV-1-infected cultures also contained significant reverse transcriptase activity and p24 antigen. Like adult monocyte/macrophages, cord-derived monocyte/macrophages expressed the CD4 receptor molecule. Pretreatment with blocking antibody prior to infection with HIV-1 Bal significantly reduced or blocked infection of cord monocyte/macrophages. When cord and adult monocyte/macrophages were infected with HIV-1 Bal or Ada-M and directly compared, higher reverse transcriptase activities and p24 antigen expression were obtained with cord monocyte/macrophages. However, no significant difference was found between adult and cord monocyte/macrophages infected with HIV-1 IIIB. These observations suggest that cord monocyte-derived macrophages may be important in the pathogenesis of pediatric AIDS and that the increased susceptibility of cord monocyte/macrophages to HIV-1 infection in vitro may be relevant to the enhanced susceptibility of neonates to HIV-1 diseases in vivo.

Virus infections of the respiratory tract in HIV-infected children

In order to determine whether the rates of respiratory viral infection and the severity of respiratory symptoms in HIV-infected children were higher than those in noninfected children, nose and throat swabs for viral isolation were taken at 3-month intervals during the first 2 years of life from 50 children born to HIV-infected women. Similar samples were obtained during the first year of life from 19 control children born to HIV seronegative mothers. Of the 50 children, five proved to be HIV-infected while 45 were presumed to be uninfected. HIV-infected children had significantly more respiratory symptoms and a higher proportion of samples from which viruses were isolated than the non-HIV-infected children. Also, more infected episodes required admission to hospital in the HIV-infected group. There was no such difference between the non-HIV-infected and the control children. Three HIV-infected children received intravenous immunoglobulin therapy. Among these the proportion of positive samples for viral isolation was greater before than after treatment began. These results suggest that HIV-infected children are more susceptible to recurrent viral infection and that passive immunotherapy may be of benefit to such children.

Lentivirus-induced pulmonary lesions in rhesus monkeys (Macaca mulatta) infected with simian immunodeficiency virus

Necropsy reports from 28 rhesus monkeys that had been experimentally infected with simian immunodeficiency virus (SIV) and that were free of cytomegalovirus were reviewed. Lung sections from 24 of these monkeys that had no etiologic agent other than SIV detected in the lung were studied in detail by histopathologic, immunohistochemical, and electron microscopic examination and by in situ hybridization. Fourteen of the monkeys were part of a serial euthanasia study, while others were euthanatized after they became moribund. The following lesions were detected: perivascular inflammation, vasculitis, interstitial pneumonia, syncytial cells, hemorrhage, fibrin exudation, and pleural fibrosis. Perivascular inflammation was the most frequent lesion and occurred as early as 2 weeks after inoculation. Severe pneumonia and numerous syncytial cells were seen only in animals euthanatized because they had become moribund. The lesions appeared to be directly due to SIV infection. SIV antigens, RNA, and virions were detected in syncytial cells and macrophages by immunohistochemical examination, in situ hybridization, and transmission electron microscopic examination, respectively. The amount of virus present was correlated with the severity of the lesions. The SIV-induced lesions were different from those of the lymphocytic interstitial pneumonia, which occurs in human immunodeficiency virus-infected children and in ovine lentivirus-infected sheep and goats.

Mucocutaneous disease in pediatric human immunodeficiency virus infection

Children with HIV infection may develop a wide variety of infectious and inflammatory diseases of the skin. These disorders are often more severe and more difficult to treat than in the healthy child. In some cases, disorders of the skin or mucous membranes may provide an early clue to the presence of pediatric HIV infection.