Faculty Bibliography

The long term clinical outcome for infants and children with the pediatric acquired immunodeficiency syndrome-related complex is unknown. This report describes our experience with 14 patients with acquired immunodeficiency syndrome-related complex who have been followed for 11 to 71 months since the onset of their symptoms. The most frequent clinical features at presentation were persistent generalized lymphadenopathy (14 of 14), hepatosplenomegaly (11 of 14) and a history of recurrent otitis media (7 of 14). Except for hypergammaglobulinemia (14 of 14) and reversed T4/T8 ratios (9 of 14), immunologic analyses, including in vitro responses to mitogens and antibody responses following immunization, revealed no consistent abnormalities. Over the course of follow-up, none of the patients have developed serious or opportunistic infections and 12 of 14 have shown catch up or age-appropriate growth. The T4/T8 ratios have remained stable in 8 of 11 and improved in 2 of 11 patients. Gradual regression of hepatosplenomegaly and lymphadenopathy has been noted patients. Although follow-up studies over a longer period are needed to confirm our observations to date, acquired immunodeficiency syndrome-related complex may represent a prolonged plateau in the course of human immunodeficiency virus infection in many infected children. Detailed immunologic evaluation of these patients may help to identify a subset of children that could benefit from periodic gamma-globulin or chronic antibiotic therapy.

We prospectively evaluated three enzyme immunoassays (EIAs) and a direct fluorescent-antibody (DFA) test for respiratory syncytial virus detection. Of 90 specimens, 79% gave the same results in all four tests (30 positive and 41 negative) and 97% were in agreement in three of the four assays. The agreement between the direct fluorescent-antibody test and each enzyme immunoassay was greater than or equal to 86%.

The ability of respiratory syncytial virus (RSV) and parainfluenza virus type 3 (PIV3) to replicate in peripheral blood monocytes cultured in vitro for 1, 2, 4 or 7 days prior to infection was investigated. Inoculation of 1-day old monocytes produced at least tenfold less new virus than infection of the older, more macrophage-like cells for both viruses. PIV3 induced extensive syncytium formation, whereas RSV caused a cytopathic effect manifest by increased rounding of the cells with minimal syncytium formation. Supernatants of infected monocytes were assayed for human interferon-alpha (HuIFN-alpha) in an attempt to explain the restricted viral replication in the youngest monocytes. In PIV3-infected cells, HuIFN-alpha production was inversely correlated with new virus formation. Monocytes infected after 1 day in culture produced 800 IU/ml of HuIFN-alpha; the older cells produced 100 to 200 IU/ml. In contrast, monocytes infected on day 1 with RSV produced minimal amounts (1.5 IU/ml) of HuIFN-alpha. Increasing amounts of HuIFN-alpha were detected in cells infected with RSV after 2, 4 or 7 days in culture, reaching a maximum of 400 IU/ml on day 7. Further investigation of the apparent restriction of replication in young monocyte cultures may be helpful in understanding the pathogenesis of these respiratory infections.

A questionnaire based on a hypothetical 6-day-old infant exposed to a sibling with varicella was mailed to 316 Pediatric Infectious Diseases Society members to determine their recommendations for administration of varicella zoster immunoglobulin (VZIG). Of the 137 faculty members who responded 20% would recommend VZIG for the infant described (13% were undecided). When further information including a negative maternal history for varicella, prematurity or maternal varicella infection occurring 1 week after delivery was considered, the numbers who recommended VZIG (43, 46 and 52%, respectively) rose significantly (P less than 0.01). Twenty-two physicians had knowledge of a severe case of varicella following postnatal exposure. Only 33% of faculty members surveyed feel there are no indications for VZIG in infants exposed after 48 hours of age.

Nineteen patients with pulmonary exacerbations of cystic fibrosis due to Pseudomonas aeruginosa were given imipenem/cilastatin for six to 10 days at dosages of 30-90 mg/kg per day. Mean Shwachman scores rose from 46.6 to 50.3 (P less than .001), clinical efficacy scores from 34.3 to 43.3 (P less than .001), vital capacity from 53.7% to 58.5% of the predicted value (P less than .01), forced expiratory volume in 1 sec from 39.5% to 42.6%, and partial pressure of oxygen in arterial blood from 68.2 mm Hg to 72.6 mm Hg. Treatment failed in only two instances. The concentration of P. aeruginosa in the sputum decreased to a modest extent (8.5 log10 cfu/ml on day 1, 8.1 log10 cfu/ml on day 10; P greater than .1). Four patients had imipenem-resistant strains of P. aeruginosa at the start of therapy, and 11 additional patients developed resistant strains during treatment; in eight patients greater than 90% of all Pseudomonas organisms in the sputum were resistant at the end of therapy. Six patients acquired Candida in their sputum. There was no correlation between bacteriologic improvement or the development of resistance to imipenem and either clinical outcome or improvement in pulmonary function. In summary, imipenem/cilastatin therapy is associated with a good clinical outcome in patients with cystic fibrosis, but resistance emerges rapidly.