Graham, SM

Kigoro, A

Nduati, E

Sanders, EJ

Thiong'o, A

Sanders, Eduard J

Kigoro, Alex

Thiong'o, Alexander

Nduati, Eunice

Graham, Susan M

Oxford University Research Archive

736 • cid 2019:69 (15 August) • CORRESPONDENCENotePotential conflicts of interest. The author: No reported conflicts of interest. The author has submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manuscript have been disclosed.Peter BaxterChildrens Hospital, Sheffield, United KingdomReferences1. Marais  BJ, Heemskerk  AD, Marais  SS, et  al; Tuberculous Meningitis International Research Consortium. Standardized methods for enhanced quality and comparability of tuberculous menin-gitis studies. Clin Infect Dis 2017; 64:501–9.2. STREPTOMYCIN treatment of tuberculous men-ingitis. Medical Research Council Lancet 1948; 6503:582–96.3. Bang ND, Caws M, Truc TT, et al. Clinical presenta-tions, diagnosis, mortality and prognostic markers of tuberculous meningitis in Vietnamese children: a prospective descriptive study. BMC Infect Dis 2016; 16:573–582.4. Misra UK, Kalita J, Maurya PK. Stroke in tubercu-lous meningitis. J Neurol Sci 2011; 303:22–30.5. Kirkham FJ, Newton CR, Whitehouse W. Paediatric coma scales. Dev Med Child Neurol 2008; 50:267–74. Correspondence: P. Baxter, Ryegate Centre, Sheffield Childrens NHS Foundation Trust, Tapton Crescent Rd, Sheffield S10 5DD, UK (p.s.baxter@sheffield.ac.uk).Clinical Infectious Diseases®  2019;69(4):735–6© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.DOI: 10.1093/cid/ciz024Reply to BaxterTo the Editor—We thank Doctor Baxter for raising 2 important points concerning the prognosis of young children with tu-berculous meningitis (TBM). We agree that there is a discrepancy between the original British Medical Research Council (BMRC) TBM grading, which included “gross pareses” in the most severe grade, and the current, widely used, modified BMRC grading, which is primarily de-fined by coma severity. We also agree that stroke is the likely cause of gross paresis and that clinical experience suggests these children do indeed have a poor prog-nosis. However, an alternative scoring system, which accommodates paresis independently from coma, requires deri-vation from high-quality clinical data and statistical modelling if it is to represent a practice-changing advance to the empiri-cally derived BMRC grade. Unfortunately, the high-quality clinical data required to perform this task are lacking, but we hope that the standardized methodology proposed will encourage future research and enable sharing and merging of the re-quired data sets to more accurately define prognoses in all age groups.The second point raised was the need to specify that a “modified Glasgow coma scale” should be used in young children, with a clear indication of the best versions to use in relevant age groups. Various modifications to the coma score have been made to accommodate children less than 5 years of age, who are at different phases of language and motor development. Our proposed standardized methodology did not clarify which scale to use beyond in-fancy [1]. We agree with Doctor Baxter that the unified scale developed by James, together with the Grimace scale for intu-bated children, as summarized in the ar-ticle by Kirkham et  al [2], provides the most pragmatic approach to a standardized assessment for all children less than 5 years of age. In children older than 5 years of age, the standard adult Glasgow coma scale is appropriate, which implies that this stan-dardized approach can be used across the full age range. However, standardization is not easy in children, with wide variation in practice. Even for a traumatic brain injury, which is the most common cause of acute pediatric neurological impairments world-wide and for which there have been prac-tice guidelines for several years [3], there is no standardization of assessment.We hope that this clarification will im-prove the utility of our proposed stan-dardized methods and that more data will accrue over time to substantiate their value and identify the components that require further refinement.NotePotential conflicts of interest. All authors: No reported conflicts. All authors have submit-ted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manu-script have been disclosed.Ben J. Marais,1 Ronald van Toorn,2 Tony Figaji,3 and Guy E. Thwaites4,5; on behalf of the Tuberculous Meningitis International Research Consortium1Westmead Children’s Hospital and the Marie Bashir Institute for Infectious Diseases and Biosecurity, University of Sydney, Australia; 2Tygerberberg Children’s Hospital and the Stellenbosch University, Bellville, and 3Red Cross Children’s Hospital and the University of Cape Town, South Africa; 4Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam; and 5Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, University of Oxford, United KingdomReferences1. Marais  BJ, Heemskerk  AD, Marais  SS, et  al. Standardized methods for enhanced quality and comparability of tuberculous meningitis studies. Clin Infect Dis 2017; 64:501–9.2. Kirkham FJ, Newton CR, Whitehouse W. Paediatric coma scales. Dev Med Child Neurol 2008; 50:267–74.3. Kochanek  PM, Carney  N, Adelson  PD, et  al. Guidelines for the acute medical management of severe traumatic brain injury in infants, children, and adolescents-second edition. Pediatr Crit Care Med 2012; 13(Suppl 1):S1–82. Correspondence: G.  E. Thwaites, Nuffield Department of Medicine, Centre for Tropical Medicine and Global Health, Old Road Campus, Roosevelt Dr, Oxford OX3 7FZ, United Kingdom (gthwaites@oucru.org).Clinical Infectious Diseases®  2019;69(4):736© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permissions, e-mail: journals.permissions@oup.com.DOI: 10.1093/cid/ciz026applyparastyle “fig//caption/p[1]” parastyle “FigCapt”Symptom-based Scoring for Acute Human Immunodeficiency VirusTo the Editor—We read with interest the report by Lin et  al showing that a simple symptom score consisting of fever, myalgia, and weight loss accurately pre-dicted acute human immunodeficiency virus (HIV) infection (AHI) [1]. We agree with the authors that symptom-based as-sessment is less prone to limitations in-herent to risk-based scores, as “symptoms may be less subject to stigma, and there-fore individuals may be more comfortable disclosing symptoms than sexual behav-iors” [1]. Our concern is that the symptom score was developed in the United States, and therefore may not optimally identify CORRESPONDENCE • cid 2019:69 (15 August) • 737AHI in resource-limited countries, as rec-ommended by the authors.We have previously developed a symp-tom-based score with data from at-risk and general populations from Kenya, Malawi, and South Africa [2]. This score assigns 1 point each for age 18–29 years or reported fever, fatigue, body pains, diarrhea, or sore throat, and 3 points for reported genital ulcer disease; individuals scoring ≥2 should be tested for AHI [2]. We are using this score to detect AHI with the Xpert HIV-1 Qual assay (Cepheid, Sunnyvale, California) among adults aged 18–39 years seeking ur-gent care in coastal Kenya (R01AI124968, ongoing). While HIV-1 RNA testing for AHI diagnosis is not supported by policy in sub-Saharan Africa, an exclusive focus on identifying chronic HIV in seropositive adults leads to missed opportunities [3]. This is especially important as preexposure prophylaxis (PrEP) is being scaled up in African settings.The following case history from a volun-tary testing and counseling center affiliated with our research clinic in coastal Kenya illustrates this: A 24-year-old heterosexual man tested negative on 2 HIV rapid anti-body tests, whereas his female partner of 3  months tested antibody positive in the same session. He reported diarrhea and fa-tigue in the preceding 4 days, but no fever, weight loss, or myalgia. He was eligible for PrEP per Kenyan guidelines [4], as he was in a serodiscordant relationship. The patient met 3 of the criteria (young age, fatigue, and diarrhea) from our symptom-based score and was therefore tested with the Xpert HIV-1 Qual assay [2]. He tested pos-itive, as confirmed by a viral load of 5500 copies/mL by Xpert HIV-1 Quant assay. He enrolled in an AHI cohort and started anti-retroviral therapy shortly thereafter.Per Kenyan guidelines, healthcare pro-viders should assess for AHI symptoms prior to PrEP initiation when a recent high-risk exposure is reported [4]. While most front-line healthcare providers in sub-Saharan Africa received no specific training about AHI diagnosis [5, 6], PrEP guidelines offer a glimmer of hope that AHI symptoms will now be assessed in at-risk clients under evaluation for PrEP eligibility. We propose that this symptom screening should be done with our symp-tom-based score in African settings [2], as limiting AHI screening to those with fever, myalgia, and weight loss will lead to missed opportunities according to our data. As AHI testing should be targeted in resource-limited settings, we applaud the efforts of Lin and colleagues to pro-mote the concept of targeted testing and encourage further research into this important area.NotesDisclaimer. The contents of this work are the responsibility of the study authors and do not necessarily reflect the views of the US Agency for International Development (USAID), the National Institutes of Health (NIH), the United States government, or the Wellcome Trust. This report was published with permission from the Kenya Medical Research Institute (KEMRI).Financial support. This work was par-tially funded by the International AIDS Vaccine Initiative (IAVI) with the generous support of USAID and other donors; a full list of IAVI donors is available at www.iavi.org. The KEMRI–Wellcome Trust Research Programme is sup-ported by core funding from the Wellcome Trust (grant number 203077/Z/16/Z). E.  J. S.  receives research funding from IAVI, the NIH (grant R01AI124968), and the Wellcome Trust. S.  M. G. and E. J. S. were supported by the NIH (grant number R01AI124968). This work was also supported through the Sub-Saharan African Network for TB/HIV Research Excellence, a DELTAS Africa Initiative (grant number DEL-15-006). Potential conflicts of interest. All authors: No reported conflicts. All authors have submit-ted the ICMJE Form for Disclosure of Potential Conflicts of Interest. Conflicts that the editors consider relevant to the content of the manu-script have been disclosed.Eduard J. Sanders,1,2,  Alex Kigoro,1 Alexander Thiong’o,1 Eunice Nduati,1 and Susan M. Graham1,31Kenya Medical Research Institute–Wellcome Trust Research Programme, Kilifi; 2Nuffield Department of Medicine, University of Oxford, United Kingdom; and 3University of Washington, SeattleReferences1. Lin  TC, Gianella  S, Tenenbaum  T, Little  SJ, Hoenigl  M. A simple symptom score for acute human immunodeficiency virus infection in a San Diego community-based screening program. Clin Infect Dis 2018; 67:105–11.2. Sanders EJ, Wahome E, Powers KA, et al. Targeted screening of at-risk adults for acute HIV-1 infec-tion in sub-Saharan Africa. AIDS 2015; 29(Suppl 3):S221–30.3. Sanders EJ, Chirro O, Oduor C, et al. Point-of-care HIV RNA testing and immediate ART initiation in young adults seeking out-patient care in Kenya. AIDS 2019. In press.4. National AIDS & STI Control Programme (NASCOP). Guidelines on use of antiretroviral drugs for treating and prevention HIV infection in Kenya. Nairobi, Kenya: NASCOP, 2018.5. Rafferty H, Chirro O, Oduor C, et al. Pilot testing of an online training module about screening for acute HIV infection in adult patients seeking ur-gent healthcare. Int Health 2018. doi:10.1093/inthealth/ihy077.6. Prins  HA, Mugo  P, Wahome  E, et  al. Diagnosing acute and prevalent HIV-1 infection in young African adults seeking care for fever: a systematic review and audit of current practice. Int Health 2014; 6:82–92. Correspondence: E.  J. Sanders, Kenya Medical Research Institute–Wellcome Trust Research Programme, Kilifi, Kenya (esanders@kemri-wellcome.org).Clinical Infectious Diseases®  2019;69(4):736–7© The Author(s) 2019. Published by Oxford University Press for the Infectious Diseases Society of America. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creative-commons.org/licenses/by/4.0/), which permits unrestricted reuse, distribution, and reproduction in any medium, provided the original work is properly cited.DOI: 10.1093/cid/ciz059SubSubBList2=SubBList=SubSubBList=SubBListSubBList2=BList=SubBList=BListHeadB/HeadA=HeadC=HeadB/HeadA=HeadC/HeadBHeadC/HeadB=HeadD=HeadC/HeadB=HeadC/HeadBHeadC=NList_dot_numeric1=HeadC=NList_dot_numericHeadC/HeadB=NList_dot_numeric1=HeadC/HeadB=NList_dot_numericHeadD=NList_dot_numeric1=HeadD=NList_dot_numericHeadD/HeadC=NList_dot_numeric1=HeadD/HeadC=NList_dot_numericSubBList2=NList_dot_numeric2=SubBList=NList_dot_numeric2SubBList2=NList_dot_numeric=SubBList=NList_dot_numericNList_dot_numeric2=HeadB=NList_dot_numeric=HeadBNList_dot_numeric3=HeadB=NList_dot_numeric=HeadBNList_dot_numeric2=SubBList1=NList_dot_numeric=SubBList1NList_dot_numeric3=SubBList1=NList_dot_numeric=SubBList1SubBList3=HeadD=SubBList_Before_Head=HeadDSubBList2=HeadD=SubBList_Before_Head=HeadDSubBList2=HeadB=SubBList=HeadBSubBList3=HeadB=SubBList=HeadBHeadC=NList_dot_numeric1(2Digit)=HeadC=NList_dot_numeric(2Digit)HeadC/HeadB=NList_dot_numeric1(2Digit)=HeadC/HeadB=NList_dot_numeric(2Digit)HeadD=NList_dot_numeric1(2Digit)=HeadD=NList_dot_numeric(2Digit)HeadD/HeadC=NList_dot_numeric1(2Digit)=HeadD/HeadC=NList_dot_numeric(2Digit)SubBList2(2Digit)=NList_dot_numeric2(2Digit)=SubBList(2Digit)=NList_dot_numeric2(2Digit)SubBList2(2Digit)=NList_dot_numeric(2Digit)=SubBList(2Digit)=NList_dot_numeric(2Digit)NList_dot_numeric2(2Digit)=HeadB=NList_dot_numeric(2Digit)=HeadBNList_dot_numeric3(2Digit)=HeadB=NList_dot_numeric(2Digit)=HeadBNList_dot_numeric2(2Digit)=SubBList1(2Digit)=NList_dot_numeric(2Digit)=SubBList1(2Digit)NList_dot_numeric3(2Digit)=SubBList1(2Digit)=NList_dot_numeric(2Digit)=SubBList1(2Digit)SubBList3(2Digit)=HeadD=SubBList(2Digit)=HeadDSubBList2(2Digit)=HeadD=SubBList(2Digit)=HeadDSubBList2(2Digit)=HeadB=SubBList(2Digit)=HeadBSubBList3(2Digit)=HeadB=SubBList(2Digit)=HeadBExtract3=BList3=Extract1=BList3BList3=Extract3=BList3=Extract3_0

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Symptom-based scoring for acute human immunodeficiency virus

Symptom-based scoring for acute human immunodeficiency virus

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