Otolaryngologic manifestations of pediatric immunodeficiency

The multidisciplinary approach to diagnosing inborn errors of immunity: a comprehensive review of discipline-based manifestations

INTRODUCTION

Congenital immunodeficiency is named primary immunodeficiency (PID), and more recently inborn errors of immunity (IEI). There are more than 485 conditions classified as IEI, with a wide spectrum of clinical and laboratory manifestations.

AREAS COVERED

Regardless of the developing knowledge of IEI, many physicians do not think of IEI when approaching the patient's complaint, which leads to delayed diagnosis, misdiagnosis, serious infectious and noninfectious complications, permanent end-organ damage, and even death. Due to the various manifestations of IEI and the wide spectrum of associated conditions, patients refer to specialists in different disciplines of medicine and undergo - mainly symptomatic - treatments, and because IEI are not included in physicians' differential diagnosis, the main disease remains undiagnosed.

EXPERT OPINION

A multidisciplinary approach may be a proper solution. Manifestations and the importance of a multidisciplinary approach in the diagnosis of main groups of IEI are discussed in this article.

Organ-based clues for diagnosis of inborn errors of immunity: A practical guide for clinicians

Inborn errors of immunity (IEI) comprise a group of about 490 genetic disorders that lead to aberrant functioning or the development of distinct immune system components. So far, a broad spectrum of IEI-related manifestations has been noted in the literature. Due to overlapping signs and symptoms of IEI, physicians face challenges in appropriately diagnosing and managing affected individuals. The last decade has witnesses improving in the molecular diagnosis of IEI patients. As a result, it can be the mainstay of diagnostic algorithms, prognosis, and possibly therapeutic interventions in patients with IEI. Furthermore, reviewing IEI clinical complications demonstrates that the manifestations and severity of the symptoms depend on the involved gene that causes the disease and its penetrance. Although several diagnostic criteria have been used for IEI, not every patient can be explored in the same way. As a result of the failure to consider IEI diagnosis and the variety of diagnostic capabilities and laboratory facilities in different regions, undiagnosed patients are increasing. On the other hand, early diagnosis is an almost essential element in improving the quality of life in IEI patients. Since there is no appropriate guideline for IEI diagnosis in different organs, focusing on the clues in the patient's chief complaint and physical exams can help physicians narrow their differential diagnosis. This article aims to provide a practical guide for IEI diagnosis based on the involved organ. We hope to assist clinicians in keeping IEI diagnosis in mind and minimizing possible related complications due to delayed diagnosis.

Neonatal Parotitis: A Case Report

Introduction

Acute suppurative parotitis is a rare finding in the neonate. It is commonly caused by Staphylococcus aureus, but other bacterial isolates may be emerging. It is a novel disease for this age group and requires unique management. Only 32 cases of neonatal suppurative parotitis have been described in the English-language literature over the last 35 years.

Case Report

We describe a case of a 14-day-old male who presented to the pediatric emergency department with a 24-hour history of swelling and redness of the right cheek. On examining him, purulent material was seen inside his oral cavity. He was subsequently hospitalized with a diagnosis of neonatal suppurative parotitis and received five days of parenteral antibiotics with improvement in swelling and redness. He was discharged home with oral antibiotics.

Conclusion

Although neonatal suppurative parotitis is rare, it should be suspected in newborns presenting with an erythematous pre-auricular mass with or without any predisposing factors. We describe a rare case of acute suppurative parotitis in a neonate and review the published literature.

Pediatric Human Immunodeficiency Virus and Otolaryngologic Manifestations: An Analysis of Hospital Admissions From 1997 to 2012

OBJECTIVES/HYPOTHESIS

Many human immunodeficiency virus (HIV)-infected pediatric patients develop otolaryngologic disease. We aimed to characterize their otolaryngologic manifestations by type and demographic variation, and model temporal trends.

STUDY DESIGN

Retrospective cohort review.

METHODS

A retrospective review utilizing the Kids' Inpatient Database (KID) was conducted. International Classification of Diseases, Ninth Revision, Clinical Modification codes for HIV and otolaryngologic diagnoses were used to query data from the triennially published KID files from 1997 to 2012. A subset analysis of infectious versus non-infectious admitting otolaryngologic diagnoses was conducted.

RESULTS

A total of 11,150 cases met the inclusion criteria. Of these cases, 21.8% were admitted for otolaryngologic manifestations, with 18.0% presenting with infectious symptomatology, 4.8% with noninfectious disease, and 1.0% with both. On average, patients presenting with infectious disease were younger (8.17 years vs. 9.65 years, P < .001). Patients in the South were significantly more likely to be admitted for infection (54.8% vs. 42.0%, P < .001), with non-infectious predominance in the Northeast and West. HIV-infected children in 1997 were more likely to present with infectious otolaryngologic disease (56.3% vs. 45.8%, P < .001); however, there has been a decrease in the prevalence of infectious head and neck presentations (46.5%, 19.9%, 11.5%, 6.7%, 3.7%, and 1.9% from 1997 to 2012), and a gradual shift toward noninfectious manifestation with notable differences in 2000 and 2012 (19.9% vs. 25.2%; P = .017; and 1.9% vs. 4.8%, P < .001, respectively).

CONCLUSIONS

Otolaryngologic disease accounts for nearly one-fifth of hospitalizations in HIV-infected children; however, rates of hospitalization as well as otolaryngologic manifestations have progressively decreased over time. HIV-infected children nowadays are more likely to present with noninfectious rather than infectious disease.

LEVEL OF EVIDENCE

NA Laryngoscope, 129:E377-E382, 2019.

Prevalence of chronic ear disease among HIV+ children in Sub-Saharan Africa

OBJECTIVES

To determine the prevalence of chronic ear disease in HIV+, highly active anti-retroviral therapy (HAART)-treated children and compare this to the prevalence in healthy children of similar age living in a similar setting.

INTRODUCTION

From previous clinical work in Ethiopia, we suspected that chronic middle ear disease was common both in the general pediatric population and especially among children with HIV/AIDS. Few studies have examined the prevalence of chronic ear disease in HIV + children, particularly in those treated with HAART.

METHODS

Full examination of the head and neck was performed by otolaryngologists. This including cleaning of cerumen, otoscopy and microscopic otoscopy when needed. Patient's medical records were reviewed. Presence or absence of tympanic membrane (TM) perforation (unilateral or bilateral), tympanosclerosis, TM atrophy, otorrhea and/or cholesteatoma was documented.

RESULTS

112 HIV+ and 162 healthy (HIVU) children were included. Prevalence of TM perforations was 17% in the HIV + infected versus 3% in the HIVU (Fisher's-Exact-Test; OR: 7.2, 95% CI 2.5-20, p-value <0.0001). Presence of unilateral TM perforations was 12% in the HIV + population and 2% in the HIVU population (Fisher's-Exact-Test; OR: 6.8, 95% CI 2.0-22, p-value 0.002). The presence of bilateral perforations was 4% in the HIV + population and 1% in the HIVU population (Fisher's-Exact-Test; OR: 6.8, 95% CI 1.1-42, p-value 0.088). In the HIV + cohort, 2% were diagnosed with cholesteatoma compared to 0% in the HIVU population (95% CI HIV+ 0.002-0.06; HIVU 0.0-0.02) and 8% of HIV + subjects had active middle ear discharge, compared to 0% in the HIVU population (95% CI HIV+ 0.04-0.1; HIVU 0.0-0.02). Neither tympanosclerosis nor tympanic membrane atrophy was more frequent in the HIV + population compared to the HIVU population. Persistent or recurrent TM perforation was not more frequent in children with prior tympanoplasty in the HIV + population compared to the HIVU population.

CONCLUSION

TM perforations are significantly more common in HAART-treated HIV + children than in healthy, age-matched HIVU population. Otorrhea and cholesteatoma were found only in the HIV + cohort.

Pediatric inflammatory adenopathy

The differential diagnosis in pediatric lymphadenopathy includes bacterial, viral, fungal, and idiopathic causes. A systematic approach to patient evaluation is necessary because the differential diagnosis, presentation, and work up must consider infectious, immunologic, neoplastic, and idiopathic disorders. A thorough history and examination are vital to determining the diagnosis and ruling out a malignant process.