Faculty Bibliography

The aim of this study was to evaluate the usefulness of thin-section low-dose computed tomography (TSCT) in the management of children with AIDS, as chest radiographs (CXR) often fail to adequately explain the patients' clinical status. We performed 54 noncontrast TSCTs on 32 children. The patients aged from 3 months to 14.6 years, were diagnosed as having bacterial pneumonia, lumphocytic interstitial pneumonitis (LIP), Pneumocystis carinii pneumonia (PCP), or Mycobacterium avium-intracellulare infection (MAI). The scans were correlated with the clinical diagnosis, T-lymphocyte-subset percentages, and p24-antigen levels. Subsegmental consolidations were seen in patients with LIP, PCP, and MAI, and as an isolated finding in those with only bacterial pneumonia. Ground-glass haziness was seen exclusively with acute PCP. Reticulonodular thickening was identified only in patients with LIP. Mosaic perfusion was seen with MAI, LIP, and pneumonia. The presence of adenopathy correlated with CD4+ T-cell subset percentages. The greatest value of CT in this study was in detecting new disease when chest films failed to correlate with a patient's clinical state, and in demonstrating acute/subacute disease in patients with severe baseline chest-film changes. Recurrent pneumonias may represent progression of 'smoldering' disease, rather than true recurrent disease following complete clearing. Adenopathy with low CD4+ levels should suggest lymphoma or infection with MAI

Objective: To study the survival and identify prognostic laboratory indicators for HIV-1 infected children with severe immunodeficiency (CD4 less than 15%). Methods: Kaplan-Meier product-limit analysis, from the time of severe immunodeficiency (i.e. presentation with CD4 less than 15% or persistent levels of CD4 less than 15%), was performed on HIV-1 infected children. Plasma p24 antigen and serial hemoglobin concentrations were reviewed as possible prognostic indicators of survival. Results: (Table: see text.) The presence of plasma p24 antigen at presentation did not appear to affect survival in children with CD4 between 10-15%, however the absence of detectable plasma p24 antigen was associated with increased survival in those with CD4 of less than 10% at presentation (50% survival 4.5y and 3.4y for children with CD4 5-9% and 0-4% respectively). A 15% reduction in serum hemoglobin concentration, was associated with decreased 50% survival only in children with CD4 less than 10% (6.2y vs 2.3y). Conclusions: Children with 9 greater than CD4% less than 15% are considered to be severely immunodeficient by the CDC, yet their 50% survival is significantly better than children who present with CD4 less than 10%. The absence of detectable p24 antigenemia at presentation appeared to be associated with improved survival only in children with CD4 T cells less than 10%, whereas a 15% decrease in serum hemoglobin concentration was associated with lower survival only in those with greater than 10% CD4 T cells

Objective: To compare survival and CD4+ T cell % (CD4%) in infants with early versus late HIV viremia. Methods: HIV viremia was measured by HIV culture. PCR or P24 ag assay of peripheral blood. Three groups were identified: infants testing positive within the first week of life (X), infants testing negative in the first week and positive within two months (Y), infants tested after the first week but positive within two months (Z). Initial CD4% for all infants in the three groups were compared using the t test. CD4% attrition in the three groups was compared using linear regressions of the last CD4% measured in each infant. Survival times were evaluated by Kaplan-Meier product-limit analyses and compared by log-rank tests. Results: There were nine infants in group X, 12 in group Y, and 20 in group Z. There were no differences in CD4% at birth among these groups. Decline of CD4% in groups X, Y and Z was -0.30, -0.18 and -3.0% per month respectively. These were not significantly different. Survival in the three groups (X vs Y, log-rank p=0.24; Y vs Z, log-rank p=0.42; X vs Z, log-rank p=0.65) was not significantly different. Conclusions: The data suggest that early HIV-1 viremia in perinatal infection is not associated with more rapid decline of CD4% and decreased survival in this small sample. Further studies must be done to determine whether early HIV viremia in perinatal HIV-1 infection can serve as a prognostic indicator

To evaluate the efficacy of primary chemoprophylaxis in preventing Pneumocystis carinii pneumonia (PCP) in infants with perinatal human immunodeficiency virus-1 infection during the first year of life, we conducted a retrospective chart review of infants with human immunodeficiency virus-1 infection born at New York University Medical Center-Bellevue Hospital Center, in New York. Between March 1989 and March 1993, 24 infants received primary chemoprophylaxis with trimethoprim-sulfamethoxazole in the first year of life and 24 infants did not receive primary prophylaxis. The CD4+ T-lymphocyte counts in the two groups did not differ during the first year of life. The median age at the time of initiation of prophylaxis was 3 months, and the average duration of prophylaxis was 5.5 months. Among the infants who had not received prophylaxis, five cases of PCP were diagnosed at a median age of 5 months; in contrast, no cases of PCP were observed in the infants receiving prophylaxis (log-rank test, p = 0.017). The probability of surviving after 1 year of age was 92% for the children who received prophylaxis and 74% for those who did not (log-rank test, p = 0.035). These data indicate that chemoprophylaxis is highly effective in preventing primary PCP and improving survival time in infants with human immunodeficiency virus-1 infection

The purpose of this study was to characterize systemic Streptococcus pneumoniae disease in human immunodeficiency virus type 1 (HIV-1)-infected children. All cases of bacteremia and meningitis caused by S. pneumoniae among children less than 18 years old were collected by review of the Microbiology Laboratory records at the Bellevue Hospital Center during the period August 1, 1978, through July 31, 1993. There were 31 bouts of systemic S. pneumoniae disease in 19 of 235 HIV-1-infected children cared for by the Pediatric Infectious Disease staff and 116 bouts in 113 children not known to be HIV-1-infected. Four of the 19 HIV-1-infected children had multiple episodes of S. pneumoniae bacteremia as compared with 3 of 113 in the general population (P = 0.008). The frequency of serotypes and distribution of infections by season of the year did not differ between the 2 groups. The median ages at the time of the S. pneumoniae infection were 1.8 and 1.1 years for the HIV-1-infected children and the general population of children, respectively, when those children with multiple episodes were included for their initial episode only (P = 0.06). In the HIV-1-infected patients, 10 episodes were associated with pneumonia, 5 with pneumonia and otitis media, 5 with otitis media only, 1 with pneumonia and meningitis, 1 with meningitis only and 1 with periorbital cellulitis; 5 had no apparent focus of infection. One episode of pneumonia was complicated by lung abscess and there were 2 deaths. Most HIV-1-infected patients recovered without significant sequelae, and the clinical course of their systemic infections did not appear to be markedly different than that of healthy children

This analysis sought to identify characteristics of pregnant human immunodeficiency virus type 1 (HIV-1)-infected women that predict mother-to-child HIV-1 transmission. Pregnant and immediately postpartum women at risk for HIV were enrolled at obstetric and pediatric care settings in New York City from 1986 to 1992. Demographic and behavioral characteristics, clinical illness, T lymphocyte subsets, immunoglobulin concentration and syphilis serology were collected on the women. Infants were followed to determine HIV infection classification according to Centers for Disease Control and Prevention criteria for HIV-1 in children. Transmission rates were calculated for women who gave birth more than 15 months before the analysis. Of 172 HIV-1-infected women with known outcome 49 (28%) had infected infants. The transmission rate (TR) was significantly higher among women with < 280 CD4+ cells/microliters (lowest CD4+ quartile) than with CD4+ counts > 280 (48% vs. 22%; P = 0.004; odds ratio, 3.4; 95% confidence interval (1.5, 7.8)); a similar trend was seen by CD4+% quartile. No difference in TR was seen comparing women by CD8+ count quartile but marginally higher TR was seen among women with CD8+% > or = 51% than with CD8+% < 51% (TR = 41% vs. 24%; P = 0.076; odds ratio, 2.2; confidence interval (1.0, 5.1)). The highest TR, 62% was seen in women with both CD8+ count above the median and CD4+ count in the lowest quartile. No significant difference in TR was seen between women with and without HIV-related illness, although the TR was 53% among women hospitalized in the previous year for pneumonia compared with 25% in others (P = 0.03). TR was somewhat lower in women who delivered by cesarean section than vaginally (entire cohort: 18% vs. 32%, P = 0.11; prenatal enrollees only, 17% vs. 38%, P = 0.045). No factor or combination of factors was both highly sensitive and specific for predicting mother-to-child HIV transmission. A possible relationship between transmission and mode of delivery deserves further investigation