Immune reconstitution inflammatory syndrome from Penicillium marneffei in an HIV-infected child: a case report and review of literature

<p>Abstract</p> <p>Backgrounds</p> <p>Disseminated <it>Penicillium marneffei </it>infection is one of the most common HIV-related opportunistic infections in Southeast Asia. Immune reconstitution inflammatory syndrome (IRIS) is a complication related to antiretroviral therapy (ART)-induced immune restoration. The aim of this report is to present a case of HIV-infected child who developed an unmasking type of IRIS caused by disseminated <it>P. marneffei </it>infection after ART initiation.</p> <p>Case presentation</p> <p>A 14-year-old Thai HIV-infected girl presented with high-grade fever, multiple painful ulcerated oral lesions, generalized non-pruritic erythrematous skin papules and nodules with central umbilication, and multiple swollen, warm, and tender joints 8 weeks after ART initiation. At that time, her CD4⁺cell count was 7.2% or 39 cells/mm³. On admission, her repeated CD4⁺cell count was 11% or 51 cells/mm³and her plasma HIV-RNA level was < 50 copies/mL. Her skin biopsy showed necrotizing histiocytic granuloma formation with neutrophilic infiltration in the upper and reticular dermis. Tissue sections stained with hematoxylin and eosin (H&E), periodic acid-Schiff (PAS), and Grocott methenamine silver (GMS) stain revealed numerous intracellular and extracellular, round to oval, elongated, thin-walled yeast cells with central septation. The hemoculture, bone marrow culture, and skin culture revealed no growth of fungus or bacteria. Our patient responded well to intravenous amphotericin B followed by oral itraconazole. She fully recovered after 4-month antifungal treatment without evidence of recurrence of disease.</p> <p>Conclusions</p> <p>IRIS from <it>P. marneffei </it>in HIV-infected people is rare. Appropriate recognition and properly treatment is important for a good prognosis.</p

Successful treatment of a child with vascular pythiosis

<p>Abstract</p> <p>Background</p> <p>Human pythiosis is an emerging and life-threatening infectious disease caused by <it>Pythium insidiosum</it>. It occurs primarily in tropical, subtropical and temperate areas of the world, including Thailand. The aim of this report is to present the first pediatric case of typical vascular pythiosis.</p> <p>Case Presentation</p> <p>A 10-year-old boy with underlying β-thalassemia presented with gangrenous ulcers and claudication of the right leg which were unresponsive to antibiotic therapy for 6 weeks. Computerized tomography angiography indicated chronic arterial occlusion involving the right distal external iliac artery and its branches. High-above-knee amputation was urgently done to remove infected arteries and tissues, and to stop disease progression. Antibody to <it>P. insidiosum </it>was detected in a serum sample by the immunoblot and the immunochromatography tests. Fungal culture followed by nucleic sequence analysis was positive for <it>P. insidiosum </it>in the resected iliac arterial tissue. Immunotherapeutic vaccine and antifungal agents were administered. The patient remained well and was discharged after 2 months hospitalization without recurrence of the disease. At the time of this communication he has been symptom-free for 2 years.</p> <p>Conclusions</p> <p>The child presented with the classical manifestations of vascular pythiosis as seen in adult cases. However, because pediatricians were unfamiliar with the disease, diagnosis and surgical treatment were delayed. Both early diagnosis and appropriate surgical and medical treatments are crucial for good prognosis.</p

Family Functioning in Adolescents with Perinatal HIV Infection

This study aimed to assess family functioning in adolescents with perinatal HIV infection receiving antiretroviral therapy compared with healthy controls. Correlations between self-reported and caregiver-reported family functions were also evaluated. A sample of 195 participants including 65 perinatally HIV-infected adolescents and 130 healthy controls were enrolled. The total family functioning score in HIV-infected adolescents was significantly lower than that in healthy controls by self-report (105.86 vs 115.41; P ≤ .001). Caregivers of HIV-infected adolescents also reported lower scores of family functioning than those of controls (109.91 vs 114.98; P ≤ .001). Among the HIV-infected group, there was no or minimal correlation between the self-reported and caregiver-reported total scores of family functioning. However, there were moderate correlations between self-reported and caregiver-reported family functioning total scores in the control group. Overall, HIV-infected adolescents reported lower family functioning than healthy controls. Improved functioning in the family may help with better adjustment in perinatally HIV-infected adolescents

Poor Cognitive Functioning of School-Aged Children in Thailand with Perinatally Acquired HIV Infection Taking Antiretroviral Therapy

Neurocognitive outcome is an essential aspect of treatment for HIV-infected children. This study is aimed at assessing cognitive functioning in school-aged HIV-infected children and the change after receiving antiretroviral therapy (ART). We conducted a prospective cohort study of HIV-infected Thai children from 6–12 years of age compared with HIV-affected (children of HIV-positive mothers who were not infected with HIV), and normal control groups. Wechsler Intelligence Scale for Children-III (WISC-III) was administered at enrollment and 30 months of follow-up. Semistructured interviews of primary caregivers were performed. From April to October 2003, 121 children were enrolled; 39 HIV-infected, 40 HIV-affected, and 42 control children with a median age of 9.3 years. The HIV-infected group had a mean (standard deviation [SD]) CD4 percentage of 13.8% (5.3), 87% of whom had been receiving ART for a median of 35 weeks. At the first cognitive assessment, the mean (SD) of full-scale intelligence quotient (FSIQ) was 79 (13) and 88 (10) among HIV-infected and HIV-affected children, which was statistically lower than that of the control group at 96 (13; p < 0.01). The proportion of children with average intelligence level (FSIQ > 90) among 3 groups were 21%, 49%, and 76%, respectively (p < 0.01). At 30 months of follow-up, the HIV-infected group had a mean (SD) CD4 percentage of 25.6% (5.6); 77% had undetectable viral load. The mean (SD) FSIQ of children among three groups were 75 (12), 85 (12), and 91 (12), respectively. Compared with the baseline assessment, the verbal scale score significantly decreased in all groups, including the controls, whereas the performance scales did not change. In conclusion, school-aged HIV-infected children have lower cognitive function than HIV-affected and normal children. Cognitive function was not improved after receiving ART. Further study to address whether early ART can preserve cognitive functioning among HIV-infected children should be explored

High virologic response rate after second-line boosted protease inhibitor-based antiretroviral therapy regimens in children from a resource limited setting

Background: Limited data exist for the efficacy of second-line antiretroviral therapy among children in resource limited settings. We assessed the virologic response to protease inhibitor-based ART after failing first-line non-nucleoside reverse transcriptase inhibitor (NNRTI)-based regimens. Methods: A retrospective chart review was conducted at 8 Thai sites of children who switched to PI-based regimens due to failure of NNRTI-based regimens. Primary endpoints were HIV RNA < 400 copies/ml and CD4 change over 48 weeks. Results: Data from 241 children with median baseline values before starting PI-based regimens of 9.1 years for age, 10% for CD4%, and 4.8 log(10) copies/ml for HIV RNA were included; 104 (41%) received a single ritonavir-boosted PI (sbPI) with 2 NRTIs and 137 (59%) received double-boosted PI (dbPI) with/without NRTIs based on physician discretion. SbPI children had higher baseline CD4 (17% vs. 6%, p < 0.001), lower HIV RNA (4.5 vs. 4.9 log(10) copies/ml, p < 0.001), and less frequent high grade multi-NRTI resistance (12.4% vs 60.5%, p < 0.001) than the dbPI children. At week 48, 81% had HIV RNA < 400 copies/ml (sbPI 83.1% vs. dbPI 79.8%, p = 0.61) with a median CD4 rise of 9% (+7% vs. + 10%, p < 0.005). However, only 63% had HIV RNA < 50 copies/ml, with better viral suppression seen in sbPI (76.6% vs. 51.4%, p 0.002). Conclusion: Second-line PI therapy was effective for children failing first line NNRTI in a resource-limited setting. DbPI were used in patients with extensive drug resistance due to limited treatment options. Better access to antiretroviral drugs is needed

Incidence and predictors of severe anemia in Asian HIV-infected children using first-line antiretroviral therapy

There are limited data on treatment-related anemia in Asian HIV-infected children. Data from Asian HIV-infected children aged <18 years on first-line highly active antiretroviral therapy (HAART) were used. Children who had pre-existing severe anemia at baseline were excluded. Anemia was graded using the United States Division of AIDS (DAIDS) 2004 table. Potential risk factors for severe anemia were assessed by logistic regression. Data from 1648 children (51.9% female, 62.8% World Health Organization (WHO) stage 3/4) were analyzed. Median (interquartile range) age was 6.8 (3.7-9.6) years, CD4% was 9 (3-16)%, and plasma HIV-RNA was 5.2 (4.7-5.6) log10 copies/ml at HAART initiation in those with available testing. The most common regimens were stavudine/lamivudine/nevirapine (42%) and zidovudine/lamivudine/nevirapine (25%). Severe anemia was identified in 47 (2.9%) children after a median time of 6 months after HAART initiation, with an incidence rate of 5.4 per 100 child-years. Mild anemia or moderate anemia at baseline (p = 0.024 and p = 0.005, respectively), previous or current use of zidovudine (p <0.0001 and p = 0.013, respectively), and male sex (p = 0.008) were associated with severe anemia. Higher weight-for-age z-score (p = 0.004) was protective. The incidence of severe anemia in Asian HIV-infected children after HAART initiation was low and mainly occurred during the first few months after HAART initiation. Mild to moderate anemia at baseline and using zidovudine were independent risk factors for the development of severe anemi