Liver transient elastography values in healthy South African children

BACKGROUND

Transient elastography (TE) is a rapid noninvasive ultrasound-based technology that measures liver stiffness as a surrogate for liver fibrosis and controlled attenuation parameter (CAP) as a measure of liver steatosis. However, normal ranges in children are not well defined in all populations. The aim of this study was to determine transient elastography values in healthy South African children.

METHODS

From April 2019 to December 2021, children were recruited from the HIV negative control group of a cohort study. Only children neither overweight nor obese, without evidence of liver disease, no medical condition or medication associated with hepatic steatosis or fibrosis and normal metabolic profile were included in this cross-sectional analysis. Clinical data, anthropometry and blood samples were collected on the same day as transient elastography with controlled attenuation parameter was performed.

RESULTS

104 children (median age 12.8 years [IQR 11.4-14.8, range 7.9-17.7 years]; 59 [57%] boys) were included. Liver stiffness was positively correlated with age (Pearson's r = 0.39, p < 0.001). Median liver stiffness in boys (5.2 kPa [5th to 95th percentiles 3.6 to 6.8 kPa]) was greater than in girls (4.6 kPa [5th to 95th percentiles 3.6 to 6.1 kPa; p = 0.004]), but there was no difference by ethnicity. Median CAP was 179dB/m (5th to 95th percentiles 158 to 233dB/m). There was a positive correlation between CAP and body mass index (BMI) z-score, but no difference by age, sex, ethnicity or pubertal status.

CONCLUSION

Liver stiffness values increase with age and are higher in healthy South African boys than girls, whereas CAP values vary with BMI, but not with age or sex.

Decreased Hepatic Steatosis in South African Adolescents With Perinatal HIV Switching to Dolutegravir-containing Regimens

BACKGROUND

Although dolutegravir (DTG) has a favorable metabolic profile, it has been linked to excess weight gain. We evaluated changes in hepatic steatosis in adolescents with perinatally acquired HIV switching to DTG-containing antiretroviral therapy (ART).

METHODS

Virologically suppressed adolescents switched to dolutegravir for a minimum of 4 months or on unchanged ART (84% protease inhibitor) were assessed prospectively with anthropometry, transient elastography with controlled attenuation parameter (CAP) and fasting metabolic profiles. ART regimens were determined independently of the study.

RESULTS

In total 68 adolescents [baseline median age 13.5 years [interquartile range (IQR): 12.5-14.4 years]; 42 (62%) female] were recruited. However, 38 remained on the same regimen and were followed for a median of 98 weeks (IQR: 48-108 weeks), and 30 switched to DTG and were followed for a median of 52 weeks (IQR: 49-101). There was no baseline difference in CAP between groups. There was no significant change in body mass index z-score in either group, but the median CAP in the DTG group decreased by -40dB/m (IQR: -51 to -31 dB/m) after a median of 44 weeks (IQR: 28-50 weeks) on DTG, compared to +1dB/m (IQR: -29 to +14 dB/m) in adolescents not switched ( P < 0 .01). Cholesterol and triglycerides were lower in those switched. Whereas hepatic steatosis prevalence decreased from 17% to 3% in adolescents who switched to dolutegravir, its prevalence doubled from 8% to 16% in those not switched ( P = 0.1).

CONCLUSIONS

In this exploratory study, adolescents switched to DTG-containing regimens had reduced hepatic steatosis, cholesterol and triglycerides with no excess weight gain compared to those on unchanged ART.

Prevalence and Risk Factors for Hepatic Steatosis in Children With Perinatal HIV on Early Antiretroviral Therapy Compared to HIV-Exposed Uninfected and HIV-Unexposed Children

Objectives

We evaluated the prevalence and risk factors for hepatic steatosis in South African children with perinatally acquired HIV (PHIV) who started treatment early and remain on long-term antiretroviral therapy (ART) compared to HIV-uninfected children.

Design

A cross-sectional study from April 2019 to October 2021. PHIV, HIV-exposed uninfected (HEU) and HIV-unexposed (HU) children were enrolled from an ongoing cohort study.

Methods

All children had transient elastography (TE) with controlled attenuation parameter (CAP). Liver enzymes, lipogram, insulin and glucose were sent after an overnight fast. Multivariable linear regression analyses identified predictors of CAP. Hepatic steatosis was defined as CAP>248kPa.

Results

215 children (111 [52%] male; median age 14.1 years; IQR 12.7-14.9) participated in the study, 110 PHIV, 105 HIV-uninfected (36 HEU, 69 HU). PHIV initiated ART at a median age of 2.7 months (IQR 1.8-8.5). Hepatic steatosis prevalence was 9% in PHIV, 3% in HEU and 1% in HU children (p = 0.08). However, 8% of lean (body mass index z-score ≤ +1) PHIV had hepatic steatosis compared to zero lean HEU or HU children (p = 0.03). In multivariable linear regression analysis of all PHIV, body mass index (BMI) z-score was positively associated with CAP (p = 0.001) while CD4 count (p = 0.02) and duration of suppression of HIV viraemia (p = 0.009) were negatively associated with CAP, adjusting for age, sex and ethnicity.

Conclusions

Hepatic steatosis prevalence was higher in lean PHIV than lean HIV-uninfected South African children. Longer suppression of HIV viraemia and higher CD4 count were associated with lower CAP and might be protective factors for hepatic steatosis in PHIV children.

Paediatric admissions to a TB hospital: reasons for admission, clinical profile and outcomes

BACKGROUND: Brooklyn Chest Hospital (BCH) is a specialised TB hospital in Cape Town, South Africa. We describe reasons for admission, patient profiles and hospital-discharge outcomes in children admitted to BCH. This was compared to a previous study (2000-2001).METHODS: This retrospective, descriptive study included all children (0-14 years) admitted to BCH from January 2016 to December 2017. Data collected from patient folders and a laboratory database included demographic data, reasons for admission, clinical data and hospital outcomes.RESULTS: Of 263 children admitted, 133 (50.6%) were male. The median age was 32 months (IQR 15-75); 48 (18.3%) were HIV-positive and 150 (57.0%) had bacteriologically confirmed TB. Reasons for admission included social/caregiver-related (n = 119, 45.2%), drug-resistant TB (n = 114, 43.3%), TB meningitis (n = 86, 32.7%) and other severe types of TB (n = 63, 24.0%); 110 (41.8%) children had >1 reason for admission. TB meningitis admissions decreased (P = 0.014) and those for drug-resistant TB increased (P < 0.001) compared to 2000-2001. Pulmonary TB was diagnosed in 234 (89.0%), extrapulmonary TB in 149 (56.7%) and 126 (47.9%) had both. At discharge, 73 (27.8%) had completed treatment, 182 (69.2%) were transferred out to complete treatment at community clinics, and 6 (2.3%) died.CONCLUSIONS: Although most children were admitted for clinical reasons, social/caregiver-related reasons were also important.

A novel approach for eliciting adolescent MDR-TB treatment tolerability: qualitative data from South Africa

SETTING: Treatment tolerability among adolescents diagnosed with multidrug-resistant tuberculosis (MDR-TB) is underexplored. We present qualitative study data from adolescents participating in an observational cohort in the Western Cape, South Africa.OBJECTIVE: To elicit adolescent experiences of MDR-TB diagnosis and treatment with qualitative body-mapping activities and discussions.DESIGN: Adolescents in an observational MDR-TB cohort received routine toxicity and audiology screenings from clinicians. We enrolled eight participants (age 10-16 years) to participate in additional body-mapping activities and in-depth interviews. A thematic deductive analysis was conducted. We present a comparison of the clinical assessments and qualitative discussions.RESULTS: Adolescent participants reported few adverse effects on standard toxicity and audiology reports. Only nausea and vomiting were reported in >10% of cases, all of which were grade 1 (causing no/minimal interference) adverse effects (AEs). However, when comparing toxicity reports with qualitative body-mapping activities and interviews, we found previously unreported AEs (neurosensory alteration, neuromuscular weakness, pain); underestimated severity of AEs (nausea, itching); and missed psychosocial symptoms (signs of depression).CONCLUSION: Adolescents receiving treatment for MDR-TB experienced treatment-related AEs that were not reported during routine clinical assessments. Psychosocial experiences of adolescents are not taken into account. More research is needed to understand the experiences of this vulnerable group. We recommend that drug safety monitoring be adapted to include more creative and patient-driven reporting mechanisms for vulnerable groups, including children.

Completeness and accuracy of electronic recording of paediatric drug-resistant tuberculosis in Cape Town, South Africa

SETTING

Cape Town, South Africa.

OBJECTIVE

To assess the completeness and accuracy of electronic recording of drug-resistant tuberculosis (DR-TB) in children.

DESIGN

Retrospective cohort study. All children aged <15 years treated for DR-TB during 2012 were included, with clinical data collected from routine health services. Matching was performed between clinical data and an extracted data set from an electronic register for DR-TB (EDR.web), and data sources were compared.

RESULTS

Seventy-seven children were identified clinically, of whom only 49 (64%) were found in EDR.web. Most data in EDR.web were complete and accurate, but there were some internal inconsistencies for confirmed TB. Only 4.4% of all EDR.web entries were children.

CONCLUSION

Only two thirds of children clinically treated for DR-TB were recorded in the electronic reporting system, suggesting under-reporting. We also found a lower than expected prevalence of childhood DR-TB, probably suggesting both under-diagnosis and under-recording of DR-TB in children. Clinicians at facility level should be able to access the electronic reporting system, and data transfer between clinical paper-based and electronic sources should be simplified. Cross-linking between electronic registers for drug-susceptible and DR-TB or consolidation of registers could improve the accuracy of recording. Improved recording and reporting of DR-TB in children is needed.

Linezolid-containing regimens for the treatment of drug-resistant tuberculosis in South African children

BACKGROUND

Treatment options for drug-resistant tuberculosis (DR-TB) are limited. Linezolid has been successfully used to treat DR-TB in adults, but there are few case reports of its use in children for TB. The reported rate of adverse events in adults is high.

METHODS

We conducted a retrospective review of children with DR-TB treated with linezolid-containing regimens from February 2007 to March 2012 at two South African hospitals.

RESULTS

Seven children (three human immunodeficiency virus [HIV] infected) received a linezolid-containing regimen. All had culture-confirmed DR-TB; five had previously failed second-line anti-tuberculosis treatment. Four children were cured and three were still receiving anti-tuberculosis treatment, but had culture converted. None of the non-HIV-infected children experienced adverse events while receiving linezolid. Three HIV-infected children had adverse events, one of which was life-threatening; linezolid was permanently discontinued in this case. Adverse events included lactic acidosis (n = 1), pancreatitis (n = 2), peripheral neuropathy (n = 1) and asymptomatic bone marrow hypoplasia (n = 1).

CONCLUSION

Linezolid-containing regimens can be effective in treating children with DR-TB even after failing second-line treatment. Adverse events should be monitored, especially in combination with medications that have similar adverse effects. Linezolid remains costly, and a reduced dosage and duration may result in fewer adverse events and lower cost.

Value of bone marrow biopsy in children with suspected disseminated mycobacterial disease

BACKGROUND

Disseminated tuberculosis (TB) is a severe form of disease that can be difficult to diagnose or exclude. The diagnostic role of bone marrow biopsy and culture in children with suspected disseminated TB is not clearly defined.

METHODOLOGY

In a prospective hospital-based study conducted from November 2007 to October 2008, bone marrow biopsy and culture were performed in all children referred with possible disseminated TB; relevant clinical and laboratory data were reviewed.

RESULTS

Thirty-five children were included in the study. An alternative diagnosis was established in 10 (29%) and mycobacterial disease confirmed or probable in 25 (71%). Among those with mycobacterial disease, multiple respiratory specimens provided the best yield (17/25; 68%). Bone marrow histology and/or culture were positive in 5/25 (20%), but were frequently collected after initiation of TB treatment. Blood cultures were positive in only one patient. Mycobacterium tuberculosis accounted for 16/19 (84%) confirmed cases, M.bovis bacille Calmette-Guérin for one, M. avium complex for one, and one was culture-negative. Histology results were available within 24 hours; TB was confirmed exclusively by bone marrow in two cases.

CONCLUSION

Bone marrow biopsy is a valuable diagnostic procedure in children with suspected disseminated mycobacterial disease. Ideally, patients should be referred prior to treatment initiation.