Acquired immunodeficiency syndrome in infants

Cutaneous manifestations of acquired immunodeficiency syndrome in children

Cutaneous disorders are among the most common manifestations of HIV infection in both children and adults. Because of the obvious visibility of the integument, these lesions are often the presenting manifestation of HIV-related disease. The cutaneous afflictions are frequently related to the sequelae of impaired immunity and include opportunistic infections and neoplasms as well as dramatic exacerbations and/or the development of rapidly progressive and severe manifestations in pre-existing, normally benign dermatoses. In many cases of AIDS, iatrogenic cutaneous disorders associated with toxic or allergic drug reactions are seen. With the increasing incidence of pediatric HIV infection and with therapeutic prolongation of survival, certain cutaneous manifestations (especially drug reactions) are likely to become more common. Kaposi sarcoma and other neoplasms may be recognized with increased frequency in HIV-infected children. New or previously unrecognized cutaneous manifestations of pediatric AIDS are likely to emerge. Familiarity with the various dermatologic presentations of pediatric AIDS can result in the earlier diagnosis and treatment of the disease and, hopefully, the prolongation of the patient's life.

Intravenous immune globulin for the prevention of bacterial infections in children with symptomatic human immunodeficiency virus infection

BACKGROUND

Serious recurrent bacterial infections are a major cause of morbidity and mortality in children infected with the human immunodeficiency virus (HIV). Because intravenous immune globulin has been shown to prevent bacterial infection in patients with primary immunodeficiency and in uncontrolled studies of HIV-infected children, we undertook a multicenter study of its safety and efficacy in children with symptomatic HIV infection.

METHODS

In a double-blind trial, 372 HIV-infected children (mean age, 40 months) with clinical or immunologic evidence of HIV disease were randomly assigned to receive either intravenous immune globulin (400 mg per kilogram of body weight) or placebo (0.1 percent albumin) every 28 days. The children were stratified into two groups according to CD4+ lymphocyte count at entry into the study and the clinical classification of the Centers for Disease Control. The median length of follow-up was 17 months.

RESULTS

For children in either group with CD4+ counts greater than or equal to 0.2 x 10(9) per liter (greater than or equal to 200 per cubic millimeter) at entry, treatment with intravenous immune globulin significantly increased the time free from serious infection; estimated infection-free rates after 24 months were 67 percent for children receiving immune globulin as compared with 48 percent for those receiving placebo (P = 0.01). In addition, immune globulin was associated with an overall reduction in the number of both serious and minor bacterial infections (relative risk, 0.68; P = 0.01) and in the number of hospitalizations for acute care (relative risk, 0.65; P = 0.03). No such benefits were seen for children with CD4+ counts below 0.2 x 10(9) per liter at entry. For group 1 overall, there was a trend toward a difference in serious bacterial infection between immune globulin and placebo (24-month infection-free survival, 31 percent for intravenous immune globulin vs. 25 percent for placebo; P = 0.10). For group 2, the estimates of survival without serious infection were 73 percent with intravenous immune globulin as compared with 53 percent with placebo (P = 0.04). There was no effect of treatment on mortality for any group or CD4+ count at entry. Adverse reactions, noted for less than 1 percent of infusions, were minor.

CONCLUSIONS

In symptomatic HIV-infected children the prophylactic use of intravenous immune globulin, is safe, and it significantly increases the time free from serious bacterial infections for those entering treatment with CD4+ lymphocyte counts greater than or equal to 0.2 x 10(9) per liter.

A rapid screening test for HIV-1 antibodies: application to biological studies on human tissue

Human umbilical cord vessels are commonly used as a source of human vascular tissue for physiological studies and as a source of endothelial and smooth muscle cells. Blood samples from 236 umbilical cords were tested for the presence of HIV-1 antibodies to access the prevalence of HIV-1 infection and to evaluate possible methods for screening umbilical cords. Ten of the 236 samples were HIV-1 antibody positive by ELISA whereas 3 were positive by Western blot and a new method, the Quick-Western blot. Two of the 3 positive samples contained antibody bands against gp160, gp120, gp41, and p24 HIV-1 proteins, and one sample had antibodies against only gp160, gp120 and gp41. The Quick-Western blot required only 45 minutes for the analysis while the ELISA and Western blot took 3 hours and 18 hours, respectively. These data indicate that HIV-1 infection in mothers may present a hazard to researchers using human umbilical cords as a source of vascular tissue. The Quick-Western blot method is a simple, portable, rapid and accurate method that may be used to screen blood. The short analysis time of the Quick-Western blot allows the identification of infected blood before the tissue deteriorates as a source of cells or vascular tissue for experimental studies.

Pulmonary manifestations of HIV infection in children

We retrospectively reviewed the spectrum, course, and outcome of pulmonary diseases in 66 children with AIDS, hospitalized between 1982 and 1988, prior to the use of zidovudine. Fifty-two of the 66 (79%) patients developed pulmonary problems. In fifty-two percent of all patients, a pulmonary problem was the first symptom of HIV infection. The most common respiratory illness requiring hospitalization was an episode of respiratory distress with normal PaO2 and unchanged X-ray with a 9.7 +/- 6.8 days mean duration of hospitalization. Bacterial pneumonia, Pneumocystis carinii pneumonia (PCP) and pulmonary lymphoid hyperplasia/lymphoid interstitial pneumonia occurred in 30%, 32% and 22% of the patients, respectively. Bacterial pneumonia and PCP were associated with a high mortality rate. Sixty-eight percent of the patients died within 24 months of the onset of pulmonary disease. In 50% of the children, pulmonary disease was a primary cause of death. The results of this study can be useful in developing prospective studies for the prevention and treatment of pulmonary complications of HIV 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.

Maternal and perinatal issues regarding HIV infection

A review of the information available regarding maternal and fetal factors involved in both protection from and infection with HIV raises more questions than answers. Although providing prevention of HIV infection in women and infants is the ultimate goal, the recent increases in HIV seroprevalence among women of childbearing age gives little hope that this approach will have an effect in the near future. Early detection of HIV infection in pregnant women may provide the opportunity to counsel, provide routine obstetric care, and consider early therapeutic intervention with antiretroviral therapy and active or passive immunotherapy. Identification of HIV-infected infants before they are symptomatic is an equally important goal, as similar therapeutic options may be used.

Subcellular localization of low-abundance human immunodeficiency virus nucleic acid sequences visualized by fluorescence in situ hybridization

Detection and subcellular localization of human immunodeficiency virus (HIV) were investigated using sensitive high-resolution in situ hybridization methodology. Lymphocytes infected with HIV in vitro or in vivo were detected by fluorescence after hybridization with either biotin or digoxigenin-labeled probes. At 12 hr after infection in vitro, a single intense signal appeared in the nuclei of individual cells. Later in infection, when cytoplasmic fluorescence became intense, multiple nuclear foci frequently appeared. The nuclear focus consisted of newly synthesized HIV RNA as shown by hybridization in the absence of denaturation and by susceptibility to RNase and actinomycin D. Virus was detected in patient lymphocytes and it was shown that a singular nuclear focus also characterizes cells infected in vivo. The cell line 8E5/LAV containing one defective integrated provirus revealed a similar focus of nuclear RNA, and the single integrated HIV genome was unequivocally visualized on a D-group chromosome. This demonstrates an extremely sensitive single-cell assay for the presence of a single site of HIV transcription in vitro and in vivo and suggests that it derives from one (or very few) viral genomes per cell. In contrast, productive Epstein-Barr virus infection exhibited many foci of nuclear RNA per cell.

HIV infection in children

Human immunodeficiency virus (HIV) infection in children has emerged as a major, rapidly growing public health problem. The majority of children become infected by perinatal transmission of the virus from an infected mother. The disease is frequently associated with progressive neurologic dysfunction and with opportunistic infections. The cutaneous manifestations of pediatric HIV infection include a wide variety of fungal, bacterial, and viral infections of the skin. These diseases tend to be less responsive to conventional therapies than in the healthy child. In addition, severe seborrheic dermatitis, vasculitis, and drug eruptions are sometimes signs of HIV infection.

Routine immunization of the HIV-positive asymptomatic patient

Physicians should develop the habit of considering, during initial routine and subsequent examinations of persons coming under their primary care, whether a vaccine is needed to establish or maintain universally recommend immunity. Furthermore, the physician should identify specific circumstances that call for special vaccines. Age, occupation, lifestyle, environmental risks, and diseases that compromise host defenses require systematic consideration.

HIV infection and community midwives: experience and practice

To assess the effects of HIV infection on the work of community midwives, a postal survey of 1 in 5 in Scotland and England was carried out. The 907 respondents represent an 83% response rate. While only 1% of respondents had experience of patients with AIDS, 8% had been involved with known asymptomatic HIV infection and 32% had encountered those that they considered to be 'at high risk'. While the workload generated by HIV-infected patients for individual midwives at this time was small, almost all midwives themselves considered that they had a role to play in the prevention of HIV infection through health education and in counselling. While less than a quarter of those who had encountered HIV-positive patients had provided health education, more than half had done so to those worried about HIV infection and almost a quarter had counselled them. However, confidence to provide these aspects of practice was low, even among those who had received in-service education, although higher than among those who had not done so. A minority of community midwives had read policies or guidelines about aspects of practice and service provision, except for infection control where two thirds had read what they considered an adequate policy.

Serum IgE and human immunodeficiency virus (HIV) infection

Human immunodeficiency virus infection is characterized by a progressive depletion of helper T-lymphocytes and, like allergic diseases, is associated with altered T cell regulation. Total serum IgE was measured in 67 infected male subjects, 27 uninfected heterosexual male subjects, and 18 uninfected homosexual male subjects. The mean IgE level (132 IU/ml) of infected subjects with a helper T-lymphocyte number less than or equal to 200/mm3 was significantly greater than mean IgE levels of the uninfected heterosexual (38 IU/ml) and homosexual (35 IU/ml) groups. IgE levels were inversely related to both helper T cell and suppressor/cytotoxic T cell numbers but not to IgG or IgA levels. The increase in IgE was not a reflection of an increased prevalence of atopic disease (allergic asthma, allergic rhinitis, or atopic dermatitis) in the infected subjects. The elevation of IgE may be related to a difference among the groups in T cell production of IgE regulatory lymphokines.

Role of polymorphonuclear leukocytes in infection by retroviruses with emphasis on the human immunodeficiency virus

Neutrophil function is an integral part of the host defense against multiple pathogens. Through phagocytosis and production of toxic substances, these short lived cells aid in the effective elimination of invading microorganisms such as bacterial and fungal targets. Viral infections, and in particular those of the retroviral type, appear to suppress the immune response through direct cytotoxic destruction of immune cells or alteration of the biochemical interactions that are essential for eradicating the foreign agent. In this report, we describe abnormalities of neutrophil number and function consequent to HIV and other retroviral infections. A myriad of mechanisms, either alone or in concert may explain the underlying aberrations.

Skin diseases in children with HIV infection and their association with degree of immunosuppression

Since the recognition of the acquired immunodeficiency syndrome (AIDS) in 1981, several dermatologic manifestations have been associated with the syndrome, including candidiasis, dermatophyte infection, molluscum contagiosum, herpes simplex and zoster, bacterial infection, and malignancy. Skin diseases have been observed in both the adult and the pediatric human immunodeficiency virus (HIV) infection in an academic hospital setting in relationship to the current CDC classification of pediatric HIV infection. The severity of dermatologic manifestations is correlated with the immune status of the patients. The latter was determined by T4 helper cell numbers and lymphoproliferative responses to mitogens and recall antigens. More severe T helper cell depletion was associated with a wider spectrum and increased severity of dermatologic manifestations.

Survival in children with perinatally acquired human immunodeficiency virus type 1 infection

We describe our experience at Jackson Memorial Hospital in Miami, Florida, with 172 children who were given diagnoses of perinatally acquired infection with human immunodeficiency virus type 1 (HIV-1). The 146 mothers of the children acquired HIV-1 through heterosexual contact (69 percent), intravenous drug use (30 percent), or blood transfusion (1 percent). The children presented with symptomatic disease at a median age of eight months; only 21 percent presented after the age of two years. The most common first manifestations of disease were lymphoid interstitial pneumonia (in 17 percent), encephalopathy (in 12 percent), recurrent bacterial infections (in 10 percent), and candida esophagitis (in 8 percent), for which the median survival times from diagnosis were 72, 11, 50, and 12 months, respectively. Nine percent of the children had Pneumocystis carinii pneumonia at a median age of five months and had a median survival of only one month. The median survival for all 172 children was 38 months from the time of diagnosis. Mortality was highest in the first year of life (17 percent), and by proportional-hazard analysis the probability of long-term survival is low. In multivariate analyses, early age at diagnosis and the first identifiable pattern of clinical disease were found to be independently related to survival. We conclude that children with perinatally acquired HIV-1 infection have a very poor prognosis and that most become symptomatic before one year of age. Early diagnosis is important, since there is only a short interval in which to initiate prophylactic or antiviral treatment before progressive disease begins.

Bronchoalveolar lavage in HIV infected patients with interstitial pneumonitis

The value of taking microbiological and cytological specimens by flexible bronchoscopy and bronchoalveolar lavage under local anaesthesia was assessed on 43 occasions in 35 HIV infected children, aged 3 months to 16 years, with interstitial pneumonitis. In acute interstitial pneumonitis (n = 22, 26 specimens from bronchoalveolar lavages) the microbiological yield was 73%, Pneumocystis carinii being the commonest infective agent (n = 14). P carinii pneumonia was found only in children with deficient antigen induced lymphocyte proliferative responses who had not been treated with long term prophylactic co-trimoxazole. In contrast, in 13 children with chronic interstitial pneumonitis that was consistent with a diagnosis of pulmonary lymphoid hyperplasia who underwent bronchoalveolar lavage on 17 occasions, there were two isolates of cytomegalovirus and one of adenovirus, but P carinii was not found. Ten of the 13 children had normal antigen induced lymphocyte proliferative responses. Useful cytological data were also gleaned from bronchoalveolar lavage specimens. Lymphocytosis was significantly higher in pulmonary lymphoid hyperplasia (36(SD 11)%) than in P carinii pneumonia (24(19)%) whereas the percentage of polymorphonuclear neutrophils was significantly lower (3(2)% compared with 12(13)%). Flexible bronchoscopy with bronchoalveolar lavage is safe even in young infants and should reduce the necessity for open lung biopsy in the management of HIV infected children with interstitial pneumonitis.

Vertical transmission of HIV: a prospective study

Forty nine infants of HIV seropositive women were followed up for a median of 24 months, together with 24 controls. The infection status of 11 index children under 18 months of age was indeterminate; 34 were presumed uninfected while four showed clinical and laboratory evidence of HIV disease. Based on current definitions of HIV infection and excluding children under 18 months old as well as those who had not been studied from birth, two out of 28 children were infected. The estimated rate of maternofetal transmission was therefore 7.1%. In children with proved infection, sequential laboratory data showed that hypergammaglobulinaemia was noted as early as 6 months and often predated clinical signs. This observation, in the presence of non-specific clinical findings, was helpful in alerting the paediatrician to a diagnosis of HIV infection.

Intravenous immunoglobulin in HIV infection: evidence for the efficacy of treatment

Eight children with symptoms of HIV infection were treated for 12-26 months (median 14 months) with infusions of intravenous immunoglobulin (200 mg/kg) every three weeks. Significant improvement was noted in all children in terms of weight gain, number of infectious episodes, and days spent in hospital. This resulted in a 49% saving in cost on treatment compared with costs accrued previously during inpatient admissions. Immunoglobulin concentrations, which were raised at the start of treatment were not altered, and T4 counts continued to decline slowly. HIV core antigen was detected in four children before treatment, but all became core antigen negative after treatment was commenced, this effect being sustained in three. Intravenous immunoglobulin therefore has major clinical benefit, and by reducing viral activity may delay disease progression.

Pathogenesis of ovine lentivirus-induced arthritis: phenotypic evaluation of T lymphocytes in synovial fluid, synovium, and peripheral circulation

Sheep and goats develop a chronic, progressive arthritis reminiscent of rheumatoid arthritis, but caused by lentiviruses related to human immunodeficiency virus. The distribution of T lymphocytes in peripheral circulation of two infected sheep with arthritis, one infected sheep with interstitial pneumonia, three asymptomatic sheep, and three uninfected sheep was evaluated. Sheep with clinical disease have depressed ratios of CD4/CD8 lymphocytes in peripheral circulation compared to asymptomatic and uninfected animals. In one sheep, the depressed ratio was due to an absolute increase in CD8-positive lymphocytes. The predominant lymphocyte populations in both synovial fluid and synovium from this animal were also CD8 positive. Macrophages were the other predominant cell population in synovial fluid and were infected with lentivirus. Little cell-free virus was detected in the synovial fluid, although 1 in 400 cells was infected as determined by infectious center assays. Infected cells in the synovial fluid had a reduction in virus gene expression compared to infected cells in peripheral circulation. This reduction in virus gene expression may be due to the presence of interferon-like activity in the synovial fluid.

Clinical course of primary HIV infection: consequences for subsequent course of infection

OBJECTIVE

To investigate the impact of the clinical course of the primary HIV infection on the subsequent course of the infection.

DESIGN

Prospective documenting of seroconversion, follow up at six month intervals, and analysis of disease progression by life tables.

PATIENTS

86 Men in whom seroconversion occurred within 12 months.

PRIMARY OUTCOME MEASURE

Progression of HIV infection, defined as CD4 lymphocyte count less than 0.5 X 10(9)/l, recurrence of HIV antigenaemia, or progression to Centers for Disease Control group IV.

MAIN RESULTS

Median follow up was 670 (range 45-1506) days. An acute illness like glandular fever occurred in 46 (53%) subjects. Three year progression rates to Centers for Disease Control group IV was 78% at three years for those who had longlasting illnesses (duration greater than or equal to 14 days) during seroconversion as compared with 10% for those who were free of symptoms or had mild illness. All six patients who developed AIDS had had longlasting primary illnesses. Three year progression rates to a CD4 lymphocyte count less than 0.5 X 10(9)/l and to recurrence of HIV antigenaemia were significantly higher for those who had longlasting primary illnesses than those who had no symptoms or mild illness (75% v 42% and 55% v 14%, respectively).

CONCLUSION

The course of primary infection may determine the subsequent course of the infection.

Sero survey of human immunodeficiency virus infection in women at a family planning clinic: absence of infection in an indigent population in San Francisco

To determine the seroprevalence of human immunodeficiency virus (HIV) in contracepting women, 1,308 consecutive attendees at an inner-city family planning clinic completed a risk factor questionnaire and were then asked to have an HIV test. None of the 1,000 women tested was seropositive. Preventive efforts in family planning clinics are likely to be productive because few contraceptors, including those with risk factors, are already infected. The factors which determine differences in HIV positivity between childbearing and contracepting women, who are similar in demographic and HIV risk characteristics, warrant further investigation.

Perinatal transmission of the human immunodeficiency virus type 1 to infants of seropositive women in Zaire

To examine perinatal transmission of the human immunodeficiency virus type 1 (HIV-1) in Zaire, we screened 8108 women who gave birth at one of two Kinshasa hospitals that serve populations of markedly different socioeconomic status. For up to one year, we followed the 475 infants of the 466 seropositive women (5.8 percent of those screened) and the 616 infants of 606 seronegative women matched for age, parity, and hospital. On the basis of clinical criteria, 85 of the seropositive women (18 percent) had the acquired immunodeficiency syndrome (AIDS). The infants of seropositive mothers, as compared with those of seronegative mothers, were more frequently premature, had lower birth weights, and had a higher death rate in the first 28 days (6.2 vs. 1.2 percent; P less than 0.0001). The patterns were similar at the two hospitals. Twenty-one percent of the cultures for HIV-1 of 92 randomly selected cord-blood samples from infants of seropositive women were positive. T4-cell counts were performed in 37 seropositive women, and cord blood from their infants was cultured. The cultures were positive in the infants of 6 of the 18 women with antepartum T4 counts of 400 or fewer cells per cubic millimeter, as compared with none of the infants of the 19 women with more than 400 T4 cells per cubic millimeter (P = 0.02). One year later, 21 percent of the infants of the seropositive mothers had died as compared with 3.8 percent of the control infants (P less than 0.001), and 7.9 percent of their surviving infants had AIDS. We conclude that the mortality rates among children of seropositive mothers are high regardless of socioeconomic status, and that perinatal transmission of HIV-1 has a major adverse effect on infant survival in Kinshasa.

Acquired Immunodeficiency Syndrome in Infants, Children, and Adolescents

The acquired immunodeficiency syndrome (AIDS) was first described as a disease of homosexual men. The first cases of AIDS in children were reported in 1982 and involved a transfusion recipient and four infants born to women at increased risk for AIDS. Infants may acquire their infection perinatally or possibly postnatally through infected breast milk. Parenterally acquired infection, through transfusion of blood or blood products, occurs in infants, children, and adolescents. Adolescents are also at risk for infection through sexual transmission and through shared needles among intravenous drug users. By January 1987, 1.4% of the AIDS cases were in children less than 13 years old, and 0.4% were in adolescents 13 to 19 years old. Additionally, 4.4% of the total AIDS cases were reported in 20 to 24 year olds, which most likely reflects infection which occured during adolescence. In children less than 13 years old, infection occurred primarily thorugh perinatal transmission from mothers who were intravenous drug users or sexual partners of intravenous drug users. Adolescent cases of AIDS have followed adult patterns of transmission with most cases resulting from sexual transmission. As the prevalence of infection with the human immunodeficiency virus increases, increases in drug-use-associated transmission in women followed by perinatal transmission to infants and sexual transmission in adolescents seems likely to occur. To prevent further spread, health agencies must develop and target extensive AIDS prevention campaigns at adolescents, young adults, and sexually active women.

Outcome of mechanical ventilation in children with acquired immunodeficiency syndrome

We retrospectively reviewed the records of 18 children with acquired immunodeficiency syndrome (AIDS) who required mechanical ventilation for respiratory failure. These patients represented 35% of the patients seen with pulmonary disease and AIDS. The most common causes of respiratory failure were Pnuemocystis carinii pneumonia (77%) and bacterial pneumonia (33%). Bronchial lavage by fiberoptic bronchoscopy or endotracheal tube suctioning in mechanically ventilated children with AIDS had a high yield for P. carinii. Eight of 18 (44%) children survived the episode of respiratory failure and were weaned from the ventilator. However, four of eight survivors died within 6 months. Arterial oxygen tension on admission and maximum peak inspiratory pressure on the ventilator did not differ between survivors and nonsurvivors. We conclude that children with AIDS who are mechanically ventilated can be weaned from the respirator but that the subsequent course remains poor.

Lymphadenopathic Kaposi's sarcoma in a pediatric patient with acquired immune deficiency syndrome

A six-year-old Hispanic female with acquired immune deficiency syndrome (AIDS) and multiple opportunistic infections was found to have disseminated lymphadenopathic Kaposi's sarcoma at autopsy. She was presumed to have been infected via maternal transmission, although both HIV antibody positive parents were asymptomatic. Kaposi's sarcoma is rarely reported in pediatric AIDS, and children may not have the typical aggressive cutaneous lesions found in adults with AIDS-associated Kaposi's sarcoma.

Neurodevelopmental delay and focal seizures as presenting symptoms of human immunodeficiency virus I infection

Three children presenting with neurological symptoms were subsequently diagnosed as being infected with the human immunodeficiency virus I (HIV). All children showed normal development for about 12-18 months of age but later developed psychomotor and developmental regression. One child presented with generalised hypotonia, another with focal seizures, and the third with spastic quadriplegia. Two of the children showed areas of abnormal brain density on computed tomography and in one case there was calcification of the basal ganglia. In two of the children cerebrospinal fluid contained reduced amounts of total folate and elevated concentrations of neopterin. The possibility of a link between the deranged folate metabolism and the neurological symptoms in HIV infection is discussed.

Abnormal airway function in individuals with the acquired immunodeficiency syndrome

Pulmonary function test results of individuals with the acquired immunodeficiency syndrome (AIDS) were analyzed to determine the prevalence of abnormally low forced expiratory flow rates and bronchial hyperreactivity. Of 99 individuals with AIDS, a total of 44 (44 percent) had either low forced expiratory flow rates or a significant response to inhaled bronchodilator. Thirty-one (31 percent) individuals exhibited significant improvement in airflow rates after bronchodilator inhalation, while 33 (33 percent) had low flow rates. Twenty (20 percent) individuals had both low flow rates and a significant response to bronchodilator. In 83 percent of symptomatic individuals treated with bronchodilators there was clinical improvement. Thus, we conclude that abnormally low forced expiratory flow rate with or without bronchial hyperreactivity is a common and treatable complication of AIDS.

What is the occupational risk to emergency care providers from the human immunodeficiency virus?

The risk to health care providers of acquiring human immunodeficiency virus (HIV) infection through occupational exposure is very low, but the consequences of becoming infected are obviously severe. The magnitude of this risk has been debated extensively in the medical literature, but the majority of these discussions have focused on providers of surgical, orthopedic, and obstetric care, none of whom have ever been documented to have become infected with HIV through occupational exposure. In contrast, there has been very little information published regarding the degree of risk to emergency care providers, several of whom have been confirmed as having acquired HIV infection through occupational exposures. This report addresses the extent and nature of risk of HIV infection to emergency care providers and reviews the current management of significant exposures.

Acquired immunodeficiency syndrome-associated renal disease in children

Five children with acquired immunodeficiency syndrome (AIDS) and clinically significant renal disease had detailed pathologic examination of renal tissue (biopsy specimens, autopsy specimens, or both). All patients had proteinuria, hypoalbuminemia, and edema; one patient had persistent azotemia. In two cases, renal disease was the first manifestation of human immunodeficiency virus (HIV) infection. All patients had progressive renal disease, and four of the five died. Pathologic studies revealed focal glomerulosclerosis and mesangial proliferative glomerulonephritis with deposits of immunoglobulins and complement demonstrated by immunofluorescence and electron microscopy. Characteristic tubuloreticular structures were also demonstrated in the glomerular endothelial or epithelial cells in two cases. Renal disease is part of the multisystem involvement in children with AIDS. The pathogenesis of renal disease is not known, but circulating immune complexes are known to occur in children with HIV infection and may be involved.

False negative HIV serology in a case of congenital/perinatal AIDS

A case of congenital or perinatal Acquired Immunodeficiency Syndrome (AIDS), the first recognized case of mother to child human immunodeficiency virus (HIV) infection resulting in the full-blown syndrome in Australia, is reported. The baby who died in November 1985 was diagnosed retrospectively after the child's father had presented with Category A disease (Pneumocystis carinii pneumonia) in May 1987. This case illustrates some of the difficulties that may be experienced in the serological diagnosis of HIV in young children and foreshadows the effects of spread of HIV in the heterosexual community.

Human immunodeficiency virus recovery from bronchoalveolar lavage fluid in patients with AIDS

We cultured bronchoalveolar lavage fluid for the human immunodeficiency virus (HIV) from 23 consecutive patients with acquired immunodeficiency syndrome (AIDS) and pulmonary symptoms. We also included a nonconsecutive AIDS patient with recent worsening of respiratory symptoms who had had lymphocytic interstitial pneumonitis (LIP) diagnosed six months earlier. Infectious HIV was present in the cellular fraction from two of the 23 consecutive patients and in the patient with LIP. No virus was isolated from the cell-free portion of the centrifuged fluids. The patients from whom HIV was cultured were not distinguishable from other patients by clinical, radiographic, or laboratory data, and their subsequent course did not appear to differ. One patient with a positive HIV culture had organizing pneumonia without evidence of LIP at autopsy three weeks after lavage. This study demonstrates that HIV can be cultured from cells obtained by bronchoalveolar lavage and suggests that its presence is not associated with a single specific pulmonary histologic pattern.

Cutaneous manifestations of the acquired immunodeficiency syndrome in children

The acquired immunodeficiency syndrome (AIDS) in children is now known to be a clinical entity separate and distinct from AIDS in adults. In this article we present a review of the recent literature describing the history, definitions, epidemiology, differential diagnosis, and immunologic and clinical features of pediatric AIDS. Special emphasis is placed on the cutaneous manifestations of human immunodeficiency virus infection in children, which, to date, have not been the subject of a comprehensive review.