Subclinical tuberculosis and adverse infant outcomes in pregnant women with HIV

BACKGROUND: Tuberculosis (TB) in pregnant women with HIV is associated with adverse maternal and infant outcomes. Previous studies have described a substantial prevalence of subclinical TB in this group, but little is known about the impact of subclinical TB on maternal and pediatric outcomes.METHODS: The Tshepiso Study recruited 235 HIV-infected pregnant women with TB (and matched HIV-positive, TB-negative pregnant controls), in Soweto, South Africa, from 2011 to 2014. During enrolment screening, some women initially recruited as controls were subsequently diagnosed with prevalent TB. We therefore assessed the prevalence of subclinical TB, associated participant characteristics and outcomes.RESULTS: Of 162 women initially recruited as TB-negative controls, seven (4.3%) were found to have TB on sputum culture. All seven had negative WHO symptom screens, and six (86%) were smear-negative. Of their seven infants, one was diagnosed with TB, and three (43%) experienced complications compared to zero infants with TB and 11% experiencing complications in the control group of TB-negative mothers (P = 0.045).CONCLUSION: We discovered an appreciable prevalence of subclinical TB in HIV-infected pregnant women in Soweto, which had not been detected by screening algorithms based solely on symptoms. Infants of HIV-infected mothers with subclinical TB appear to have a higher risk of adverse outcomes than those of TB-negative mothers.

Outcomes of Kasai hepatoportoenterostomy in children with biliary atresia in Johannesburg, South Africa

BACKGROUND

Without timely surgical intervention, most children with biliary atresia (BA) are not expected to live beyond 2 years of age. The initial intervention, the Kasai hepatoportoenterostomy (KPE), aims to achieve biliary drainage. Liver transplantation (LT) is performed if jaundice fails to clear or when biliary cirrhosis occurs. In under-resourced South African (SA) academic state hospitals, KPE procedures are the standard of care for the majority of children with BA, but LT is becoming more routinely available.

OBJECTIVES

To describe the outcomes of children with BA undergoing KPE, and to identify presenting clinical, laboratory and histological features that were associated with a more favourable outcome.

METHODS

All children with BA who underwent KPE between January 2009 and June 2012 at the Johannesburg academic-hospital complex were included. Clinical and laboratory parameters, including paediatric end-stage liver disease (PELD) score at the time of KPE, liver histology fibrosis score, clearance of jaundice at 6 months and 24-month survival were determined.

RESULTS

Of 70 children with BA diagnosed during the study period, 43 (61.4%) underwent KPE, but only 12 (27.9%) achieved early resolution of jaundice. By 24 months, 14 (32.6%) of 43 children undergoing KPE were alive with their native liver, and 2 (4.7%) other children underwent LT. PELD score <15 and early resolution of jaundice, but not age at surgery or histological fibrosis score, predicted a favourable outcome.

CONCLUSION

Children with BA undergoing KPE in SA state hospitals have a poor prognosis. The PELD score at the time of KPE best predicts 24-month survival.

Paediatric liver transplantation for children treated at public health facilities in South Africa: time for change

Paediatric liver transplantation (PLT) is the only therapeutic option for many children with end-stage chronic liver disease or irreversible fulminant hepatic failure, and is routinely considered as a therapy by paediatric gastroenterologists and surgeons working in developed countries. In South Africa (SA), a PLT programme has been available at Red Cross War Memorial Children's Hospital in Cape Town since November 1991, and another has rapidly developed at the Wits Donald Gordon Medical Centre in Johannesburg over the past decade. However, for most children with progressive chronic liver disease who are reliant on the services provided at state facilities in SA, PLT is not an option because of a lack of resources in a mismanaged public health system. This article briefly outlines the services offered at Chris Hani Baragwanath Academic Hospital--which is typical of state facilities in SA--and proposes that resources be allocated to establish an innovative, nationally funded centre that would enable greater numbers of children access to a PLT programme.