Pulmonary disease in children with acquired immune deficiency syndrome and AIDS-related complex

Human Herpesvirus 8 in Perinatally HIV-infected Children with Interstitial Lung Disease

INTRODUCTION

Human herpesvirus 8 (HHV-8) is associated with the pathogenesis of Kaposi Sarcoma and interstitial pneumonitis in adults. This study aims to evaluate association between HHV-8 and interstitial lung disease in HIV-infected children.

METHODS

HIV-infected children with interstitial pneumonitis underwent lung biopsies in a tertiary hospital and were investigated for HHV-8, Epstein-Barr virus (EBV) and cytomegalovirus (CMV) using polymerase chain reaction (PCR) and immunohistochemistry in lung tissue. Peripheral blood PCR was also performed for HHV-8.

RESULTS

From six patients included, PCR for HHV-8 was positive in lung samples in four children and in peripheral blood in one. PCR for EBV and CMV and immunohistochemical study for HHV-8, EBV and CMV in lung were negative in all patients.

CONCLUSION

No previous cases of HHV-8-associated interstitial pneumonitis was described in HIV-infected children. An immunological disorder and an infectious agent might influence development of the lymphoid interstitial pneumonitis. HHV-8 may be this infectious trigger.

The chest X-ray features of chronic respiratory disease in HIV-infected children--a review

Several features of human immunodeficiency virus (HIV) infection contribute to the development of chronic respiratory disease in children. These include the frequency and severity of acute chest infections, as well as the increased risk of pulmonary tuberculosis, aspiration, cardiovascular disease, lymphocytic interstitial pneumonitis or pulmonary neoplasia. The chest radiograph (CXR) remains the most accessible investigation for respiratory disease and plays an important role in the baseline assessment and follow-up. This review focuses on the CXR abnormalities of HIV-related chronic respiratory disease in children. The most commonly documented chronic CXR abnormalities are homogeneous opacification and pulmonary nodules, with pulmonary tuberculosis and lymphocytic interstitial pneumonitis the leading respective causes. Deficiencies in radiographic reporting methodology and relative paucity of radiographic data contribute to current limitations in knowledge and understanding of this field. The review highlights the need for standardised terminology and systematic reporting methodology in future studies. Prospective research on the natural history of lymphocytic interstitial pneumonitis, response to anti-tuberculous therapy, the impact of anti-retroviral therapy and HIV-associated bronchiectasis are needed.

Nail disorders as signs of pediatric systemic disease

Herein, we describe some of the more common changes in the nail unit that can be seen in systemic diseases in children. Changes that can be seen are not limited to those discussed in the following pages. The presence of changes on multiple nails is suggestive of a systemic cause in an ill child. However, multiple nails can also be affected in primary inflammatory disorders and infections of the nail unit. When evaluating a pediatric patient with a nail disorder, it is important to perform a complete physical examination of the skin and oral mucosa, as other clues to the diagnosis of the nail problem may be found. A comprehensive family history is also important to uncover possible syndromic associations with nail disease or diseases that can manifest with nail changes.

Do we need new diagnostic criteria for Sjögren's syndrome?

Diagnostic and classification criteria for Sjögren's syndrome (SS) continue to evolve as more is learned about SS and about autoimmune diseases in general. Among diagnostic or classification criteria for SS that are in current use, most include various and variable combinations of results from questions about symptoms and objective tests, many of which are not specific to SS. Given the rapid increase of genetic knowledge about other autoimmune diseases and the potential of finding and testing new biological agents to treat SS, selection of patients who have as uniform a disease process as possible becomes an important goal to better understand and treat this prevalent autoimmune disease. Such is the goal and promise of the latest entry into the SS classification criteria field.

Epstein-Barr virus (EBV) gene expression in interstitial pneumonitis in Brazilian human immunodeficiency virus-1-infected children: is EBV associated or not?

To gain further knowledge on the subject we evaluated Epstein-Barr virus (EBV) gene expression and TCD4+, TCD8+, and B lymphocyte counts in lung tissue samples from 20 human immunodeficiency virus (HIV)-infected children with chronic lung disease. Twenty HIV-1 infected children with chronic pulmonary disease underwent open lung biopsy to define the diagnosis. Histological section of this material was submitted to nonisotopic in situ hybridization (ISH) using EBV-encoded RNA (EBER) 1/2 probes and TCD4+, TCD8+, and CD20+ B-cell counts by immunohistochemistry. The histology of 16 out of the 20 children (median age 53.5 months) proved to be examples of pulmonary lymphoid hyperplasia/lymphoid interstitial pneumonitis (PLH/LIP) complex, 13 of which were EBER positive, but no significant association was found (Fisher exact test P = 0.439). Four patients had non-LIP diseases (3, nonspecific interstitial pneumonia; 1, diffuse advanced alveolar damage), two being EBER negative. Nineteen children showed a predominant T-CD8+ cell response (CD4+/CD8+ <1) in lung tissue. The mean TCD4+ and theTCD4/TCD8 ratio in lung tissue were significantly higher in the sections with PLH/LIP complex, but without significant difference between EBER positive and EBER negative samples. EBV gene expression was detected in the majority of the lung samples but without significant association with PLH/LIP complex or with TCD4+, TCD8+, B cells and the TCD4+/TCD8+ ratio. Regarding the pattern of lung disease in HIV-1 infected children, associated or not to EBV, the findings are of importance concerning the possible role of EBV in the pathogenesis of PLH/LIP.

Chest radiographic features of lymphocytic interstitial pneumonitis in HIV-infected children

AIM

To review the radiological features of biopsy-proven lymphocytic interstitial pneumonitis (LIP) in human immunodeficiency virus (HIV)-infected children and establish whether these are based on systematic radiological analysis, and to investigate whether more specific radiological diagnostic criteria can be developed.

MATERIALS AND METHODS

A Medline search of English-language articles on the radiological features of biopsy-proven LIP in HIV-infected children was conducted for the period 1982 to 2007 inclusive. Radiological findings were compared with the Centers for Disease Control and Prevention (CDC) criteria for a presumptive diagnosis of LIP.

RESULTS

Pulmonary pathology was recorded as "diffuse" and "bilateral" in 125 (97.6%) of 128 reported cases of LIP. Twenty-five different terms were used to describe the pulmonary parenchyma. In 96 (75%), the terminology was consistent with CDC diagnostic criteria. Radiological evolution was documented in 43 (33.5%). Persistent focal opacification superimposed on diffuse pulmonary nodularity was demonstrated in 10 (7.8%). The method of radiological evaluation was described in six (4.6%). In no instance was the terminology defined.

CONCLUSION

The radiological features of LIP have not been systematically analysed. However, CDC criteria remain reliable, allowing diagnosis of at least 75% of cases. The sensitivity of these criteria may be increased by including cases with persistent focal pulmonary opacification superimposed on diffuse nodularity. Longitudinal studies utilizing standardized radiographic analysis are needed to elucidate the natural history of LIP.

Clubbing: an update on diagnosis, differential diagnosis, pathophysiology, and clinical relevance

Finger clubbing can be a striking physical finding. At other times, the presence of clubbing is difficult to establish by subjective examination alone and the profile angle or distal phalangeal to interphalangeal depth ratio are needed to confirm the finding. Most microscopic and imaging studies of clubbed fingers reveal hypervascularization of the distal digits. Recent research shows that when platelet precursors fail to become fragmented into platelets within the pulmonary circulation, they are easily trapped in the peripheral vasculature, releasing platelet-derived growth factor and vascular endothelial growth factor, promoters of vascularity and, ultimately, clubbing. Clinically, clubbing is associated with a number of neoplastic, pulmonary, cardiac, gastrointestinal, infectious, endocrine, psychiatric, and multisystem diseases. In narrowing the differential diagnosis, we recommend a detailed history and physical examination accompanied by focused laboratory and imaging studies. An algorithm for the evaluation of newly diagnosed clubbing is suggested.

MALT Lymphoma in Children: Case Report and Review of the Literature

Mucosa-associated lymphoid tissue (MALT) lymphoma predominantly occurs in adults, and is rare in children. We report a case of MALT lymphoma involving minor salivary gland of the lip in an otherwise healthy 12-year-old boy. This is the second case report of MALT lymphoma of minor salivary gland in an immunocompetent child. Of 24 cases of MALT lymphomas in children reported in the English literature, parotid MALT lymphomas in human immunodeficiency virus (HIV) patients and H. pylori infection-associated gastric MALT lymphomas are the most common. As in adult cases, most MALT lymphomas in the pediatric age group are localized and follow an indolent clinical course, respond well to therapy, and have an excellent outcome.

Lymphoid tissue and emphysema in the lungs of transgenic mice inducibly expressing tumor necrosis factor-alpha

To develop a model in which the pathogenic effects of the proinflammatory cytokine tumor necrosis factor-alpha (TNF) could be investigated, transgenic mice that express TNF in the lung under the control of a doxycycline-inducible promoter were generated. TNF transgene message was expressed at a low level in the absence of doxycycline treatment and was induced in the lung by administration of the drug. Analysis of lung lavage fluid indicated increases in neutrophils and lymphocytes in doxycycline-treated transgenic mice. Histologic analysis of lungs from adult transgenic mice treated with doxycycline revealed prominent development of lymphoid tissue and increases in airspace size. Genes upregulated in TNF transgenic mice, as identified by oligonucleotide microarray analysis, included a variety of transcripts expressed in lymphoid tissues. Immunohistochemical analysis demonstrated the presence of B lymphocytes and, to a lesser extent, T lymphocytes within lymphoid aggregates in TNF transgenic mice. CD8-positive T cells were absent from lymphocytic nodules, but in the lung parenchyma were more abundant in transgenic than in nontransgenic mice. These results indicate that induction of TNF in adult lung promotes the formation of lymphoid tissue and emphysema, and provides a model in which the pathogenic effects of TNF on the lung can be investigated.

Pediatric lymphocytic interstitial pneumonitis in an HIV-negative child with pulmonary Epstein-Barr virus infection

Lymphocytic interstitial pneumonitis (LIP) in children has been most commonly associated with human immunodeficiency virus (HIV) infection. Epstein-Barr virus (EBV) associated LIP without HIV infection has been reported only in adults. EBV associated LIP has been reported in children, but only with concurrent HIV infection. We report a case of EBV associated, HIV negative LIP in a child.

Chemokine gene expression and clonal analysis of B cells in tissues involved by lymphoid interstitial pneumonitis from HIV-infected pediatric patients

Lymphoid interstitial pneumonitis (LIP), a frequent pulmonary complication in HIV-infected pediatric patients, is characterized histologically by marked infiltration of lymphoid cells. We sought to evaluate the nature and pathogenesis of the lymphoid infiltrates and to examine the relationship of LIP to pulmonary MALT lymphoma that has been described in pediatric HIV positive patients. To examine the potential contribution of chemokines and cytokines to the inflammatory cell recruitment in tissues involved by lymphoid interstitial pneumonitis from HIV-infected pediatric patients, RNA was extracted from paraffin-embedded tissues from five lung biopsies in four pediatric HIV-positive patients and from five control, normal lung biopsies in five HIV-negative patients and was analyzed by semiquantitative RT-PCR for the expression of cytokines (TNF-alpha, GM-CSF, IFN-gamma, IL-4, IL-6, IL-10, and IL-18) and chemokines (IP-10, Mig, regulated upon activation, normal T expressed and secreted [RANTES], and MIP1-alpha and beta) after normalization for G3PDH. Expression of IL-18 was increased, as well as expression of IFN-gamma-inducible chemokines IP-10 and Mig in LIP tissues compared with controls. RANTES and MIP1-alpha and -beta were also increased in pediatric LIP lesions compared with controls. In contrast, expression of TNF-alpha, GM-CSF, IL-10, and IL-6 was variable in LIP tissues and controls. In addition, clonality of the B-cell population was evaluated by VDJ-PCR. A polyclonal B-cell population was shown in all five biopsies from five patients with LIP; and in one patient with concurrent LIP and MALT lymphoma, a band of increased intensity was observed in the LIP biopsy that was identical in size to the monoclonal band in the concurrent MALT lymphoma biopsy. These results provide evidence of high-level expression of certain chemokines in lymphoid interstitial pneumonitis tissues and suggest that chemokines and cytokines may play an important role in the recruitment of inflammatory cell infiltrates into these tissues. In addition, LIP may represent an early stage of MALT lymphoma or an immunologic response to a chronic antigenic stimulus that may provide a milieu or microenvironment for the evolution of a monoclonal B-cell population.

Clinical features and T-cell subsets in HIV-infected children with and without lymphocytic interstitial pneumonitis

Lymphocytic interstitial pneumonitis (LIP) is a non-infective lung condition common in untreated older children with vertically acquired HIV infection. Little is known about the prognosis in children with LIP, and diagnosis remains a problem where lung biopsy is not feasible. Our aim was to determine which clinical features aid the diagnosis of LIP in conjunction with the typical reticulonodular radiological picture, and whether the prognosis in children with LIP is different from that in HIV-infected children of the same age without LIP. We retrospectively compared the clinical features and T-cell subsets of 49 children with LIP with those of 56 children of similar age without LIP. Diagnosis of LIP was made radiologically. All children were apyrexial at the time of X-ray and acute intercurrent infections and tuberculosis had been excluded as far as possible. Ages ranged from 24 to 112 months in the non-LIP group and from 24 to 120 months in the LIP group. Digital clubbing and reticulo-endothelial hyperplasia were significantly more common in children with LIP than in those without. Children with LIP tended to have lower CD4+ counts and CD4% and higher CD8+ counts and CD8%, which resulted in significantly lower CD4/CD8 ratios in children under 5 years with LIP. It is possible in most cases to diagnose LIP using a combination of clinical and X-ray findings, as long as every effort is made to exclude tuberculosis. Lower CD4+ counts and CD4% as well as more frequent hospital admissions suggest that LIP adversely affects prognosis in children with HIV.

Ocular manifestations of infection with the human immunodeficiency virus in an African pediatric population

PURPOSE

To describe the ocular manifestations of HIV/AIDS infection in an African pediatric population.

METHODS

From 1984 to 1990, all children with HIV infection attending the Department of Pediatrics of the 'Centre Hospitalier de Kigali', Rwanda, were referred to the Department of Ophthalmology for ophthalmic examination.

RESULTS

A total of 162 HIV-infected children were examined. The overall rate of ophthalmic involvement was 54%. The most common finding was a perivasculitis of the peripheral retinal vessels, observed in 38% of the patients. Cytomegalovirus (CMV) infection of the retina was diagnosed in three patients. Isolated cotton-wool spots of the retina were not observed. Ophthalmic herpes zoster and conjunctival xerosis responding to vitamin A administration were each seen in two patients. One third of a subset of children tested for lacrimal function had evidence of decreased tear secretion.

CONCLUSION

Our data, in agreement with other series reported in the literature, indicate that cotton-wool spots and CMV retinitis, the most common ocular manifestations of HIV/AIDS in adults, are much less prevalent in children. The high incidence of perivasculitis in the present series, not observed or only seen in a few cases in other series, suggests that this ocular sign is more prevalent in African children. Our working hypothesis is that perivasculitis of the retinal vessels, lymphoid interstitial pneumonitis, parotitis, and lacrimal gland involvement are the expression of a diffuse infiltrative lymphocytosis syndrome, similar to what has been described in adults.

HIV disease in children. The many ways it differs from the disease in adults

HIV infects and affects children differently than it does adults. An understanding of the epidemiology of pediatric HIV infection may reveal opportunities to reduce and perhaps eliminate perinatal transmission. Knowledge of unique diagnostic features of HIV-exposed newborns and pathogenetic characteristics reflected in clinical manifestations helps physicians meet the management challenges presented by children with HIV and their families.

Pulmonary manifestations of pediatric HIV infection

Vertically acquired HIV infection is becoming increasingly common in India. The main clinical manifestations of HIV in childhood are growth failure, lymphadenopathy, chronic cough and fever, recurrent pulmonary infections, and persistent diarrhoea. Pulmonary disease is the major cause of morbidity and mortality in pediatric AIDS, manifesting itself in more than 80% of cases. The most common causes are Pneumocystis carinii pneumonia (PCP), lymphocytic interstitial pneumonitis (LIP), recurrent bacterial infections which include bacterial pneumonia and tuberculosis. The commonest AIDS diagnosis in infancy is PCP, presenting in infancy with tachypnea, hypoxia, and bilateral opacification on chest-X-ray (CXR). Treatment is with cotrimoxazole. LIP presents with bilateral reticulonodular shadows on CXR. It may be asymptomatic in the earlier stages, but children develop recurrent bacterial super infections, and can progress to bronchiectasis. LIP is a good prognostic sign in children with HIV infection in comparison to PCP. HIV should be considered in children with recurrent bacterial pneumonia, particularly with a prolonged or atypical course, or a recurrence after standard treatment. Pulmonary TB is common in children with HIV, but little data is available to guide treatment decisions. Much can be done to prevent PCP and bacterial infections with cotrimoxazole prophylaxis and appropriate immunisations, which may reduce hospital admissions and health care costs.

Pediatric AIDS-associated lymphocytic interstitial pneumonia and pulmonary arterio-occlusive disease: role of VCAM-1/VLA-4 adhesion pathway and human herpesviruses

Because the mechanisms of lymphocyte accumulation in the lungs of children with AIDS-associated lymphocytic interstitial pneumonia (LIP) are unknown, we studied the relative contributions of known adhesion pathways in mediating lymphocyte adherence to endothelium and the potential role of human herpesviruses in the expansion of these lesions. LIP was characterized by lymphoid hyperplasia of the bronchus-associated lymphoid tissue (BALT) and infiltration of the pulmonary interstitium with CD8(+) T lymphocytes. In some individuals there was expansion of the alveolar septae with dense aggregates of B lymphocytes, many containing the Epstein-Barr viral (EBV) genome. Patients with concurrent EBV infection also demonstrated large-vessel arteriopathy characterized by thickening of the intimae with collagen and smooth muscle. Venular endothelium from the lung of children with LIP, but not uninflamed lung from other children with AIDS or lung from children with nonspecific pneumonitis, expressed high levels of vascular cell adhesion molecule-1 (VCAM-1) protein. In turn, inflammatory cells expressing very late activation antigen-4 (VLA-4), the leukocyte ligand for VCAM-1, were the predominant perivascular infiltrate associated with vessels expressing VCAM-1. Expression of other endothelial adhesion molecules, including intracellular adhesion molecule-1 and E-selectin, was not uniformly associated with LIP. Using a tissue adhesion assay combined with immunohistochemistry for VCAM-1, we show that CD8(+) T cell clones that express VLA-4 bind preferentially to pulmonary vessels in sites of LIP: vessels that expressed high levels of VCAM-1. When tissues and cells were pretreated with antibodies to VCAM-1 or VLA-4, respectively, adhesion was inhibited by >/=80%. Thus, infiltration of alveolar septae with CD8(+) T cells was highly correlative with VCAM-1/VLA-4 adhesive interactions, and focal expansion of B cells was coincidental to co-infection with EBV.

Rhesus macaques infected with macrophage-tropic simian immunodeficiency virus (SIVmacR71/17E) exhibit extensive focal segmental and global glomerulosclerosis

We previously showed that inoculation of rhesus macaques with molecularly cloned lymphocytetropic simian immunodeficiency virus (SIVmac239) results in SIV-associated nephropathy (SIVAN) and that the glomerulosclerotic lesions were associated with the selection of macrophagetropic (M-tropic) variants (V. H. Gattone et al., AIDS Res. Hum. Retroviruses 14:1163-1180, 1998). In the present study, seven rhesus macaques were inoculated with M-tropic SIVmacR71/17E, and the renal pathology was examined at necropsy. All SIVmacR71/17E-infected macaques developed AIDS, and most developed other systemic complications, including SIV-induced encephalitis and lentivirus interstitial pneumonia. There was no correlation between the length of infection (42 to 97 days), circulating CD4(+) T-cell counts, and renal disease. Of the seven macaques inoculated with SIVmacR71/17E, five developed significant mesangial hyperplasia and expansion of matrix and four were clearly azotemic (serum urea nitrogen concentration of 40 to 112 mg/dl). These same five macaques developed focal segmental to global glomerulosclerotic lesions. Increased numbers of glomerular CD68(+) cells (monocytes/macrophages) were found in glomeruli but not the tubulointerstitium of the macaques inoculated with SIVmacR71/17E. All macaques had glomerular deposits of immunoglobulin G (IgG), IgM, and tubuloreticular inclusions, and six of seven had IgA deposition. However, there was no correlation between the presence of circulating anti-SIVmac antibodies, immunoglobulin deposition, and glomerular disease. Tubulointerstitial infiltrates were mild, with little or no correlation to azotemia, while microcystic tubules were evident in those with glomerulosclerosis or azotemia. The four most severely affected macaques were positive for diffuse glomerular immunostaining for viral core p27 antigen, and there was intense staining in the glomeruli of the two macaques with the most severe glomerulosclerosis. Viral sequences were isolated from glomerular and tubulointerstitial fractions from macaques with severe glomerulosclerosis but only from the tubulointerstitial compartment of those that did not develop glomerulosclerosis. Interviral recombinant viruses generated with env sequences isolated from glomeruli confirmed the M-tropic nature of the virus found in the glomeruli. The correlation between the increased number of CD68(+) cells (monocytes/macrophages) in the glomeruli, the localization of p27 antigen in the glomeruli, and the glomerular pathology confirms and extends our previous observations of an association between glomerular infection and infiltration by M-tropic virus and SIVAN.

Characteristics of acute pneumonia in human immunodeficiency virus-infected children and association with long term mortality risk. National Institute of Child Health and Human Development Intravenous Immunoglobulin Clinical Trial Study Group

OBJECTIVE

To describe the epidemiologic, clinical, radiologic, laboratory and treatment characteristics of acute pneumonia and its association with mortality in HIV-infected children.

METHODS

Data were collected during a trial of intravenous immunoglobulin (IVIG) for infection prophylaxis (1988 to 1991); CD4+ percentage was measured and HIV RNA was assessed on stored sera collected at baseline and every 3 months. Mortality was recorded during the trial and updated through 1996. All reported physician-diagnosed pneumonia episodes underwent blinded review for trial endpoint classification as acute (new radiologic findings and presence of clinical symptoms) or nonacute.

RESULTS

On blinded clinical trial endpoint review of all reported pneumonia episodes (n = 281), only 47% were classified as acute. One hundred thirty-one episodes of acute pneumonia were reported in 93 children (47 in 31 IVIG and 84 in 62 placebo patients, P < 0.01). The incidence of acute pneumonia was 24 episodes per 100 patient years. Findings associated with an acute bacterial process were uncommon (leukocytosis > or =15000/mm3 in 21% and fever > or =103 degrees F in 32% of episodes). Multiple acute episodes occurred in 34% of the children and were associated with increased risk of mortality in a univariate analysis (risk ratio, 2.1; 95% confidence interval, 1.3 to 3.4, P = 0.002), but in a multivariate model only baseline HIV RNA copy number and CD4+ percentage remained independently associated with mortality (relative risk, 2.0 and 1.4, respectively, P < 0.001).

CONCLUSION

Acute pneumonia was a common occurrence in HIV-infected children and was associated with long term mortality risk. Multiple episodes of acute pneumonia likely represent a marker of progressive disease and immunologic dysfunction rather than being causally associated with increased long term mortality.

SIV-associated nephropathy in rhesus macaques infected with lymphocyte-tropic SIVmac239

We examined the renal pathology and viral genetic changes following inoculation of six rhesus macaques with lymphocyte-tropic SIVmac239. Portions of the renal cortex were sieved into glomerular and tubulointerstitial (TI) fractions and examined for SIVmac sequences by PCR and for p27 core antigen. SIVmac sequences were detected in renal tissue from five of six macaques (three of five glomerular and five of five TI fractions were positive for SIV by PCR). Glomerulosclerosis (segmental and global) was evident in two macaques that were positive for env sequences in the glomerular fractions. Diffuse mesangial hyperplasia and matrix expansion were present in all three animals with glomerular SIV, as was an increase in glomerular collagen I and collagen IV. Tubulointerstitial inflammation was evident in all virus-inoculated macaques. The TI infiltration of CD68+ cells was most pronounced in the animals with SIVmac present in the glomerulus. All SIVmac-infected macaques exhibited increased glomerular deposition of IgM and to a lesser extent IgG, but no C3 or IgA was evident. Sequence analyses of the viral env gene (gp120) isolated from the glomerular and TI fractions of a macaque that developed glomerulopathy revealed the presence of specific viral variants in glomerular and TI fractions. In addition, chimeric viruses constructed with glomerular but not tubulointerstitial gp120 sequences were converted to a macrophage-tropic phenotype. These results indicate that infection by lymphocyte-tropic SIVmac239 is primarily associated with immunoglobulin deposition in the glomerulus and suggests that when glomerulosclerosis develops there is selection of viral variants that are macrophage tropic in nature.

The value of classifying interstitial pneumonitis in childhood according to defined histological patterns

AIMS

Interstitial pneumonitis in children is very rare and most cases have been classified according to their counterparts in adults, although the term 'chronic pneumonitis of infancy' has recently been proposed for a particular pattern of interstitial lung disease in infants. We reviewed our paediatric cases of interstitial pneumonitis, first, to look at the spectrum of histological patterns found in this age group and, second, to determine whether the classification of such cases in childhood is both appropriate and worthwhile.

METHODS AND RESULTS

Twenty-five of 38 open lung biopsies showed an overlapping spectrum of interstitial pneumonitis, including three cases that fulfilled the histological criteria for chronic pneumonitis of infancy. There were 11 cases of reactive pulmonary lymphoid hyperplasia (either lymphoid interstitial pneumonitis or follicular bronchiolitis), five of which were associated with abnormalities of the immune system. Four cases were classified as desquamative interstitial pneumonitis and the remaining seven cases were classified as nonspecific interstitial pneumonitis. There were no cases with the histological features of usual interstitial pneumonitis. Most patients responded to steroids but tended to have a residual deficit in lung function. Mortality appeared to be associated with presentation at a young age.

CONCLUSION

Classification of interstitial pneumonitis according to their adult counterparts is appropriate for this younger age group and can provide valuable information for the clinician. The term 'chronic pneumonitis of infancy' refers to a specific histological pattern, but whether it represents a separate disease or a reflection of pulmonary immaturity remains to be proven.

Persistent and chronic lung disease in HIV-1 infected and uninfected African children

OBJECTIVE

The causes of persistent lung disease (PLD) and chronic lung disease (CLD) are unknown in HIV-infected children in developing countries. We describe the causes and course of PLD and CLD in HIV-infected and uninfected children.

METHOD

Of 194 children with lung disease persisting for at least 1 month who were seen at the paediatric respiratory clinic over a 2-year period, 42 underwent invasive investigations after failed initial management over 3 months. PLD was defined as the presence of clinical and radiological features of lung disease for more than 1 month, and CLD as these features for more than 3 months.

RESULTS

One hundred and thirty-eight (71%) of the 194 children with PLD were HIV-infected, 52 (27%) were not infected and four (2%) were of undetermined HIV status. Forty-eight per cent of the HIV-infected children and 52% of the HIV-uninfected children responded to initial treatment over 3 months; the presumptive diagnoses in these were tuberculosis, interstitial pneumonitis, bronchiectasis and post-ventilation lung syndrome. Of the 28 HIV-infected children with CLD who underwent invasive investigations 16 (57%) had lymphoid interstitial pneumonitis, eight (29%) had tuberculosis and four (14%) had non-specific interstitial pneumonitis. Of the 14 HIV-uninfected children with CLD who had invasive testing there were four cases (29%) each of tuberculosis and interstitial pneumonitis, three (22%) cases of bronchiectasis and one case of each of extrinsic allergic alveolitis, crytogenic fibrosing alveolitis and non-Hodgkin's lymphoma.

CONCLUSION

This is the first set of data on the causes of CLD in HIV-infected children in a developing country. Every effort should be made to identify the infectious agent, whether M. tuberculosis or a secondary bacterial infection in LIP, in order to treat most appropriately these children with lung disease.

Bronchiectasis in pediatric AIDS

OBJECTIVES

There are several reports of the pulmonary findings in children with HIV disease; however, the occurrence of bronchiectasis rarely has been noted. We evaluated occurrence of bronchiectasis in a large group of children referred to us with AIDS pneumopathy.

METHODS

From January 1984 to April 1996, 203 children with AIDS and respiratory problems were referred to the pediatric pulmonary division at Children's Medical Center of Brooklyn. Medical records for 164 of these children were available and retrospectively reviewed.

RESULTS

Uncomplicated pneumonia was present in 75, 24 had recurrent pneumonia, and 18 had unresolved pneumonia; lymphocytic interstitial pneumonitis (LIP) was diagnosed in 47 patients, worsening with time in all patients. Bronchiectasis was observed in 26 patients (26/164, 15.8%), diagnosed by chest radiograph in 26 (26/26, 100%), confirmed by CT scan of chest in 10 (10/26, 38.4%), and by histology in three (3/26, 11.5%). Median age at time of diagnosis of bronchiectasis was 7.5 years (range, 1 to 16 years). Sixteen children with LIP developed bronchiectasis (16/47, 34.0%). Three patients with recurrent pneumonia (3/24, 12.5%) developed bronchiectasis. Five patients with unresolved pneumonia (5/18, 27.7%) developed bronchiectasis. One infant developed bronchiectasis after Pneumocystis carinii pneumonia; another child developed bronchiectasis after P. carinii and Mycobacterium tuberculosis pneumonia. The CD4+ T-cell counts measured within 6 months of diagnosis of bronchiectasis were available in 23/26 patients and, all were < 100 cells per cubic millimeter.

CONCLUSION

We conclude, from our experience, that there is a significant occurrence of bronchiectasis in children with AIDS and pulmonary disease, especially in children developing LIP, recurrent pneumonia and unresolved pneumonia, and CD4+ T-cell counts < 100 cells per cubic millimeter.

Pulmonary diseases in children with severe combined immune deficiency and DiGeorge syndrome

Pulmonary disease is a common presenting feature and complication of T-cell immunodeficiency. We retrospectively reviewed 15 children with severe combined immune deficiency (SCID) and 19 children with DiGeorge syndrome at the time of their first presentation to the Royal Children's Hospital in the 15-year period from 1981 to 1995. In children with SCID, pulmonary disease was a common (67%) presenting feature and the organisms identified were Pneumocystis carinii (PCP) (n = 7), bacteria (n = 4), viruses (n = 3), and a fungus (n = 1). Late pulmonary complications included lower respiratory tract infections, bronchiolitis obliterans, and lymphointerstitial pneumonitis. Pulmonary infections were common (17 occasions) and the organisms identified were bacteria (n = 7), viruses (n = 6), fungi (n = 3), and Mycobacterium tuberculosis (n = 1). Pulmonary complications were responsible for 5 of 9 deaths. PCP was not identified as a late complication in any child, presumably as a result of effective prophylactic therapy. Although pulmonary disease was not a major presenting feature in children with DiGeorge syndrome, pulmonary complications were common. These included recurrent bacterial and viral infections and bronchomalacia, which complicated management and predisposed to morbidity and mortality, even in those without a T-cell defect. We conclude that pulmonary disease is a common manifestation in children with SCID and DiGeorge syndrome.

Less common oral lesions associated with HIV infection: prevalence and classification

This paper deals with a number of group II and III lesions, ie lesions definitely but less commonly, and lesions possibly associated with HIV infection, respectively. Salivary gland disease includes dry mouth and/or swelling of major salivary glands, often as a part of CD8-lymphocytosis syndrome. Xerostomia occurs commonly (2-10%) in HIV-infected individuals. Enlargement of the major salivary glands occurs frequently (19%) among HIV-infected children, but rarely among adults (0.8%). The major salivary glands show lymphoepithelial lesions or cysts histopathologically. Hyperpigmentation of the oral mucosa was found in 2.2% of 1710 HIV+ individuals in seven studies. The hyperpigmentation has been ascribed to a number of medicaments, and possibly to HIV. The prevalence of pigmentation is not significantly higher among HIV+ than HIV- individuals. Thrombocytopenia frequently occurs in HIV infection. Oral petechiae were reported in 2% of 1121 HIV+ in five studies. Human papilloma virus (HPV) infection occurred in 1.1% of 989 HIV+ in seven studies. Drug reactions (white lichenoid lesions, ulceration, toxic epidermal necrolysis) have been reported in a number of cases, not allowing prevalence figures. However certain drugs, notably Foscarnet, Interferon and 2,3-dideoxycytidine, may frequently cause oral ulcerations. Oral neurologic manifestations such as peripheral facial paralysis and sensory neuropathy have been reported in a few cases or series only.

Pulmonary manifestations in HIV seropositivity and malnutrition in Zimbabwe

Over a 10 month period 184 children, aged 5 years or less, who died at home had their nutritional status and HIV serostatus established; necropsies were also carried out. The HIV antibody test was positive in 122/184 (66%). Of the HIV seropositive children Pneumocystis carinii pneumonia was present in 19 (16%), cytomegalovirus pneumonia in nine (7%), and lymphoid interstitial pneumonitis in 11 (9%). Opportunistic infection was therefore seen in 28/122 (23%) of the seropositive cases but in none of the seronegative cases. Tuberculosis was present in 8/184 (4%): 6/122 (5%) in HIV seropositive and 2/62 (3%) in seronegative children. Lung aspirate showed positive bacterial isolates in 106/ 122 (86%) of HIV seropositive and 46/62 (74%) of seronegative children with Gram negative organisms predominating in both groups. Malnutrition was common and affected 106/184 (58%); positive growth was obtained in 98 (92%) of the malnourished children irrespective of their HIV serostatus. Malnutrition was significantly associated with bacterial lung infection after adjustment for the confounding effect of HIV status. No association was found between HIV serostatus and bacterial lung infection that could not be attributed to malnutrition at the time of death. The importance of adequate nutrition in reducing the risk of bacterial infection in HIV infected children is apparent.

HIV in children

Because children acquire HIV infection differently than adults, this article begins with a discussion of the epidemiology of AIDS in children. This is followed by a discussion of factors related to progression of the disease and survival in pediatric AIDS. A discussion of the pulmonary manifestations in children is followed by a suggested approach to the HIV-infected child with respiratory symptoms.

Lymphocytic interstitial pneumonitis and nonspecific interstitial pneumonitis

Nonspecific interstitial pneumonitis (NIP) and lymphocytic interstitial pneumonitis (LIP), with or without lymphocytic alveolitis, are poorly understood pulmonary complications of HIV infection. These disorders probably represent a spectrum of lymphoproliferative processes that overlap, rather than distinct illnesses. The clinical presentation, radiographic findings, and physiologic abnormalities in NIP and LIP are not specific and therefore require a biopsy for definitive diagnosis. The clinical course of these illnesses is generally favorable, even without specific treatment.

The pediatric pulmonary and cardiovascular complications of vertically transmitted human immunodeficiency virus (P2C2 HIV) infection study: design and methods. The P2C2 HIV Study Group

The P2C2 HIV Study is a prospective natural history study initiated by the National Heart, Lung, and Blood Institute in order to describe the types and incidence of cardiovascular and pulmonary disorders that occur in children with vertically transmitted HIV infection (i.e., transmitted from mother to child in utero or perinatally). This article describes the study design and methods. Patients were recruited from five clinical centers in the United States. The cohort is composed of 205 infants and children enrolled after 28 days of age (Group I) and 612 fetuses and infants of HIV-infected mothers, enrolled prenatally (73%) or postnatally at age < 28 days (Group II). The maternal-to-infant transmission rate in Group II was 17%. The HIV-negative infants in Group II (Group IIb) serves as a control group for the HIV-infected children (Group IIa). The cohort is followed at specified intervals for clinical examination, cardiac, pulmonary, immunologic, and infectious studies and for intercurrent illnesses. In Group IIa, the cumulative loss-to-follow-up rate at 3 years was 10.5%, and the 3-year cumulative mortality rate was 24.9%. The findings will be relevant to clinical and epidemiologic aspects of HIV infection in children.

Role of tissue diagnosis in pulmonary involvement in pediatric human immunodeficiency virus infection

BACKGROUND

Pulmonary complications occur commonly during HIV infection. The aim of this study was to evaluate the clinical value of lung tissue examination in the diagnosis and treatment of pulmonary disorders in children with HIV infection.

METHODS

The medical records of 347 children enrolled between January, 1990, and April, 1994, into various antiretroviral therapy protocols were reviewed to identify patients who underwent a lung biopsy.

RESULTS

Fourteen patients underwent diagnostic lung biopsies on 16 separate occasions. The most common radiologic findings were nodular infiltrates which were localized in 7 patients and diffuse in 6. Eight patients presented with fever and progressive respiratory distress unresponsive to empiric therapy, whereas the rest had progressive nodular infiltrates. The pathologic diagnoses included opportunistic infection in 7 patients, lymphocytic interstitial pneumonitis in 5, non-Hodgkin's lymphoma in 3 and interstitial fibrosis in 1. The biopsy led to a major change in the treatment of 7 patients which resulted in a significant improvement of the pulmonary process in all of them. In an additional patient the excisional biopsy proved curative.

CONCLUSIONS

When patients are selected appropriately, lung biopsy might have a significant impact on therapy and outcome in HIV-infected children with pulmonary infiltrates.

Interstitial pneumonitis in patients infected with the human immunodeficiency virus

BACKGROUND

A study was performed to identify the clinical, radiographic, and histopathological features of interstitial pneumonitis in patients infected with the human immunodeficiency virus.

METHODS

A retrospective review was made of the case notes, chest radiographs, and histopathological results of seven HIV-1 antibody positive patients with symptomatic diffuse pulmonary disease and a pathological diagnosis of non-specific interstitial pneumonitis.

RESULTS

All patients had dyspnoea, with or without cough, and chest radiographs showing diffuse infiltrates. The arterial oxygen tension ranged widely from 5.9 to 13.1 kPa. The initial clinical diagnosis was Pneumocystis carinii pneumonia in most cases. The pathological diagnosis was made by transbronchial biopsy in one case and by open lung biopsy in six cases. The interstitial pneumonitis consisted of a patchy lymphocytic infiltrate composed of B cells in focal aggregates and T cells in a more diffuse distribution. The T cell population was a mixture of CD4+ and CD8+ cells. The histological findings contrast with the more extensive infiltrate of predominantly CD8+ lymphocytes seen in HIV-associated lymphocytic interstitial pneumonitis which occurs mainly in children. The condition ran a subacute course. Three patients spontaneously improved and three improved with steroid therapy. Long term survival was less than three years, the prognosis being determined by other infective or neoplastic complications.

CONCLUSIONS

Non-specific interstitial pneumonitis usually presents with an illness resembling Pneumocystis carinii pneumonia but occurs when the CD4 and total lymphocyte counts are still preserved. The pneumonitis resolves spontaneously or responds to steroids, and does not itself lead directly to the patient's death. It does, however, appear to mark a downturn in the course of HIV infection.

Spontaneous pneumothorax in children with AIDS

The incidence of pneumothorax in HIV-infected children has not been reported. In adults with AIDS, pneumothorax has been described exclusively in association with Pneumocystis carinii pneumonia (PCP). We report the cases of three children with AIDS, one with lymphoid interstitial pneumonitis (LIP) without evidence of PCP and two with PCP, all of whom developed spontaneous pneumothorax (SP). On presentation, none of the children had any risk factors for the development of pneumothorax, but all had radiographic evidence of subpleural cystic lesions and bilateral pleural adhesions. None of the patients responded to conservative medical management, which included chest tube thoracostomy and chemical pleurodesis. Two patients underwent pleurectomy that resulted in resolution of the pneumothorax. Both patients with PCP who developed pneumothorax died, but the patient with LIP and SP has had no recurrences of any serious respiratory problems 3 years after pleurectomy and excision of the intrathoracic cysts.