Lipodystrophy in HIV-infected children is associated with high viral load and low CD4+ -lymphocyte count and CD4+ -lymphocyte percentage at baseline and use of protease inhibitors and stavudine

Alterations in regional fat, often associated with abnormalities in lipid and insulin metabolism, have been reported in HIV-infected adults. To determine whether similar abnormalities occur in children with HIV, patterns of change in regional body fat distribution were determined by dual energy x-ray absorptiometry in 28 prepubertal HIV-infected children. Eight (29%) children experienced lipodystrophy (LD), defined as extremity lipoatrophy together with trunk fat accumulation. Despite a mean body weight increase of 2.9 +/- 2.4 kg, children with LD experienced a mean loss of total fat in contrast to children without LD who increased total fat (-0.151 +/- 0.324 versus 0.981 +/- 1.041 kg; p <.01). Children with LD had significantly higher levels of HIV RNA and lower CD4 count and percentage at baseline. LD was associated with use of protease inhibitors or stavudine, (odds ratio [OR], 7.0, 95% confidence interval [CI], 1.1-45.2, p =.04; OR, 9.0, 95% CI, 1.4-59.8, p =.03, respectively). This observational study suggests that during a time in childhood when accumulation of extremity and trunk fat is expected, some HIV-infected children experience changes in fat distribution that are similar to HIV-associated LD reported in adults. Studies to determine whether HIV-infected children with changes in regional fat also experience increases in "atherogenic" lipids and insulin resistance as described in adults with HIV-associated LD are warranted.

Brief report: effects of pediatric HIV infection on mental and psychomotor development

OBJECTIVE

To examine the effect of HIV status on infants' mental and psychomotor functioning, controlling for confounding factors such as prenatal drug exposure and birth conditions.

METHODS

Twenty HIV-infected and 25 seroreverted infants (ages 3-30 months old) were administered the Bayley Scales of Infant Development (BSID) and a neurological examination at two time points, 4 to 12 months apart. The majority were from ethnic minority, socioeconomically disadvantaged families; 67% of the infants were prenatally drug-exposed.

RESULTS

HIV-infected infants had significantly lower scores on the BSID at baseline (mental development) and follow-up (motor development) compared to seroreverters. When HIV and neurological deficits were considered together, HIV+ children with neurological deficits scored significantly lower than HIV+ children without neurological deficits and seroreverters, with and without neurological diagnoses. Prenatal drug exposure was not associated with performance on the BSID.

CONCLUSIONS

These data suggest that CNS involvement is a critical pathway by which HIV affects infants' neurodevelopment.

Growth velocity, fat-free mass and energy intake are inversely related to viral load in HIV-infected children

The study objectives were to assess the relationships among human immunodeficiency virus (HIV) replication, energy balance, body composition and growth in children with HIV-associated growth failure (GF). Energy intake and expenditure, body composition and level of HIV RNA were measured in 16 HIV-infected children with growth failure (HIV+/GF+), defined as a 12-mo height velocity </= 5th percentile for age, and 26 HIV-infected children with normal rates of growth (HIV+/GF-). Energy intake was measured by repeated 24-h dietary recall, resting energy expenditure (REE) by indirect calorimetry and total energy expenditure (TEE) by the doubly labeled water method. Fat-free mass (FFM) was determined by dual X-ray energy absorptiometry and plasma HIV RNA by the polymerase chain reaction method. The mean plasma HIV RNA content among the HIV+/GF+ group was nearly 1.5 log higher than that of the HIV+/GF- group (4. 89 +/- 1.08 vs. 3.43 +/- 1.64 x10(2) copies/L, P: = 0.009). The mean daily energy intake, and age-adjusted REE and TEE were lower in HIV+/GF+ children (P: = 0.003, 0.06 and 0.16, respectively). HIV+/GF+ children had a mean daily energy deficit of 674 +/- 732 kJ/d compared with HIV+/GF- children who had a mean energy surplus of 1448 +/- 515 kJ/d (P: = 0.030). There were no differences in REE after adjustment for differences in FFM and age using multiple regression analysis (P: = 0.88). There was a significant inverse relationship between FFM and plasma HIV RNA [R:(2) = 0.64, standard error of the estimate (SEE) = 3.23] and between viral load and 12-mo growth velocity (R:(2) = 0.61, SE = 1.51). Viral load and energy intake were also inversely related (R(2) = 0.17, SEE = 573.2, P: = 0. 0125). In HIV-infected children, rate of growth, quantity of FFM and energy intake are closely related to the level of HIV replication. The energy intake of children with HIV-associated GF may not be adequate for supporting normal development of FFM and growth, despite possible decreases in total energy expenditure.

Growth failure in children with HIV infection

Poor growth is reported in as many as 50% of HIV-infected children. HIV infection adversely affects pregnancy outcome; infants born to HIV-infected women have significantly lower mean birth weight and length, regardless of the infants' HIV status, compared with infants born to uninfected women. Pediatric HIV further reduces birth weight. Progressive stunting, that is, proportionately decreased linear and ponderal growth, appears to be the most common abnormality in perinatally infected children and is accompanied by preferential decreases of fat-free or lean body mass. Although data are inconsistent, deficiencies of several micronutrients with the potential to affect growth adversely have been identified, including that of vitamin A. Neuroendocrine abnormalities also occur, including abnormal thyroid, growth hormone/ insulinlike growth factor-1, and adrenal function; however, no consistent endocrine abnormality is observed in HIV-associated growth failure. Infections of the gastrointestinal tract and malabsorption of carbohydrates, fat, and protein are common, but no relationship between these disorders and poor growth has been demonstrated. Despite normal rates of resting and total energy expenditures, the mean daily dietary intake of children with growth failure (GF) appears to be inadequate. Inadequate dietary intake is not the sole cause of GF; dietary supplementation improves weight but does not correct deficits in lean tissue or height. Levels of HIV RNA are greater in children with poor growth compared with infected children with normal rates of growth. How HIV replication impedes growth has not been established but suppression of HIV appears to have a favorable effect on ponderal and linear growth. Further investigations are necessary to evaluate the potential role of anabolic agents for the management of HIV-associated growth failure.

A pediatric AIDS patient with superior mesenteric artery syndrome

Superior mesenteric artery (SMA) syndrome is a unique type of small bowel obstruction resulting from the compression of the duodenum by the SMA. This is a case of SMA syndrome in a cachectic 6-year-old boy with AIDS who presented after a 2.3-kg weight loss in the preceding month. Unfamiliarity with this condition coupled with its intermittent, nonspecific symptomatology probably results in underdiagnosis of SMA syndrome. The presentation, predisposing and associated factors, and methods of diagnosis and treatment of SMA syndrome are all discussed.

Body composition in prepubertal children with human immunodeficiency virus type 1 infection

OBJECTIVE

To characterize the body composition of human immunodeficiency virus (HIV)-infected children, especially those with growth failure (GF), using laboratory-based methods.

DESIGN

A cross-sectional study of body composition measurements.

SETTING

Urban, hospital-based body composition laboratory.

PARTICIPANTS

Thirty-four prepubertal children with HIV infection, aged 4 to 11 years, recruited from a pediatric HIV clinic. Eighteen HIV-infected children with GF, 16 HIV-infected children with normal rates of growth, and 52 healthy children were studied.

MAIN OUTCOME MEASUREMENTS

Anthropometrics, body cell mass (BCM) by total body potassium counting, body fat percent, fat mass, and fat-free mass (FFM) by dual-energy x-ray absorptiometry were determined.

RESULTS

Both groups of boys with HIV infection had significantly lower FFM/height ratios compared with healthy boys. The mean BCM/height ratio was also lower in HIV-infected boys with GF compared with healthy boys. Measures of fat of the HIV-infected boys with GF did not differ from healthy controls, but a statistical trend suggesting decreased body fat percent and fat mass/height ratio was observed in HIV-infected boys without GF (P=.06 and .07, respectively). Mean height-for-age, weight-for-age, and weight-for-height percentiles were significantly decreased in HIV-infected boys regardless of growth status as compared with healthy boys. The mean FFM/ height and BCM/height ratios were decreased in HIV-infected girls with GF compared with healthy girls. Body fat percentage and fat mass/height ratio did not differ among the 3 groups of girls. The mean weight-for-height percentiles were not different among the 3 groups of girls. The HIV-infected girls with GF had significantly lower mean height-for-age and weight-for-age percentiles than HIV-infected girls without GF and healthy girls. The mean height-for-age percentiles of the HIV-infected girls with GF did not differ from the healthy girls.

CONCLUSIONS

Boys and girls with HIV-associated GF had diminished FFM and BCM. The decrease in FFM and BCM was in striking contrast to the fat compartment, which was normal. Decreased FFM was also detected in boys with HIV infection and normal growth but not in girls with HIV infection and normal growth, suggesting that HIV infection may affect boys differently than girls. The preferential decrease in FFM and BCM over fat observed in these children is similar to findings reported in adults with acquired immunodeficiency syndrome wasting.

Streptococcus pneumoniae bacteremia in children infected with HIV: presentation, course, and outcome

OBJECTIVE

To examine the presentation, course, and outcome of pneumococcal bacteremia in children infected with human immunodeficiency virus (HIV).

METHODS

A retrospective series of HIV-infected children less than 18 years of age with Streptococcus pneumoniae bacteremia from four urban, tertiary care hospitals was evaluated. The main outcome measures included persistent bacteremia, the development of a focal infection, and death.

RESULTS

Seventy-two episodes of pneumococcal bacteremia were identified in 59 patients. Fifty-four first episodes were included; 26/54 were occult. Mean temperature was 39.8 degrees C. In patients with bacteremia, white blood cells (WBCs) > or = 15,000 and > or = 10,000 had sensitivities of 40% and 75%, respectively. At the time of bacteremia, age >3 years old was associated with a lower mean WBC count compared with episodes occurring in patients <3 years old (11.2 vs 16.1, P < 0.05). Patients with occult bacteremia who were discharged with antibiotics (12 i.m., 7 p.o.) were less likely than patients without antibiotic treatment to have persistent bacteremia at a return visit within 72 hours (0/19 vs 2/5, P < 0.05). No patient with occult bacteremia died, progressed to clinical meningitis, or had other sequelae. Two of fifty-four patients died as a result of their first episode of invasive pneumococcal disease. Both patients who died had meningitis and appeared ill on initial presentation.

CONCLUSIONS

Neither a WBC count > or = 15,000 nor > or = 10,000 is a sensitive indicator of pneumococcal bacteremia in HIV-infected children. Empiric antibiotics are useful to decrease the risk of persistent bacteremia. Children infected with HIV who have occult pneumococcal bacteremia appear to do well with appropriate antibiotics. Patients who are afebrile and well appearing on reevaluation may be safely treated as outpatients.

Application of bioimpedance analysis for estimating body composition in prepubertal children infected with human immunodeficiency virus type 1

The purpose of this study was to evaluate the performance of bioimpedance analysis (BIA) in the prediction of total body water and fat free mass with the use of standard equations in assessing 20 prepubertal children infected with human immunodeficiency virus (HIV). Total body water was measured by means of deuterium oxide dilution, fat free mass by means of total body dual X-ray absorptiometry, and BIA with a bioelectrical impedance analyzer. The use of standard prediction equations resulted in substantial error. Regression equations using height and BIA resistance for estimating total body water and fat free mass were developed and appear to improve accuracy for prediction. This study suggests that total body water and fat free mass can be estimated in children with HIV by means of BIA equations specifically developed for use with this group of children.

Measles antibody in vaccinated human immunodeficiency virus type 1-infected children

OBJECTIVES

The goals of this study were to evaluate the proportion of previously vaccinated human immunodeficiency virus (HIV) type 1-infected children with detectable postvaccination measles antibody; to assess risk factors for vaccine failure; and to evaluate the response to reimmunization.

METHODS

A total of 81 perinatally HIV-infected children receiving medical care in the Bronx, New York who had previously received measles vaccine were enrolled. The Centers for Disease Control and Prevention (CDC) HIV class, lymphocyte subsets, and measles antibody were determined upon enrollment. Additional data abstracted from medical records included dates and number of prior measles vaccinations and CDC HIV class at the time of vaccination. Measles antibody was determined by microneutralization enzyme-linked immunosorbent assay (ELISA).

RESULTS

The median age at time of study was 42 months (range, 9 to 168 months). Overall, 58 (72%) subjects had detectable measles antibody (microneutralization ELISA titer > 1:5). Children studied within 1 year of vaccination were more likely to have detectable measles antibody than children evaluated more than 1 year after vaccination (83% vs 52%, P < .01). The proportion of children with detectable measles antibody was higher among children with no or moderate immunosuppression compared to those with severe immunosuppression when immune status was based on CD4%. Children vaccinated at 6 to 11 months of age appeared to have a higher proportion of detectable measles antibody than those who received a first measles vaccination after age 1. Only 1 (14%) of 7 previously vaccinated children who were seronegative or had very low titers experienced a four-fold rise in measles antibody when reimmunized.

CONCLUSION

These results support current recommendations to vaccinate HIV-infected children against measles. The proportion of children with detectable measles antibody among vaccinated HIV-infected children is considerably lower than in vaccinated healthy children. HIV-infected children may respond better to measles vaccine when it is administered before the first birthday. From our limited data it appears that reimmunization of previously vaccinated HIV-infected children with moderate to severe immunosuppression does not result in an antibody recall response.

Antibodies to pneumococcal capsular polysaccharides in children with human immunodeficiency virus infection given polyvalent pneumococcal vaccine

Antibody to 7 common pneumococcal capsular polysaccharides was measured in 11 children with human immunodeficiency virus (HIV) infection who had been previously vaccinated with 23-valent polysaccharide pneumococcal vaccine, 11 unvaccinated children with HIV infection, and 11 healthy subjects. No differences in capsule-specific IgG levels against serotypes 4, 6B, 8, 12F, 14, 19A, and 19F were observed among the vaccinees with HIV infection compared with unvaccinated children with HIV infection and age-matched control children.