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Early and aggressive nutritional intervention may help to prevent malnutrition in HIV-infected children. This in turn may result in slower disease progression and improved quality of life. Routine nutritional monitoring and the establishment of individualized nutritional goals are necessary for effective of malnutrition and the effectiveness of various nutritional therapies will assist in the struggle to optimize the clinical care of children with HIV infection.
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PMID:Nutritional considerations and management of the child with human immunodeficiency virus infection. 764 75

We report the case of a non-HIV patient suffering from a metastatic renal adenocarcinoma who developed trichomegaly 3 months before death. The patient also developed generalized hypertrichosis of the terminal hair, a feature that has been previously described in malnutrition. Other cases of hypertrichosis, including ectopic hormone production, were excluded and the differential diagnosis with paraneoplastic acquired hypertrichosis lanuginosa is discussed. Although trichomegaly is usually considered as a cutaneous marker of AIDS, we suggest that both trichomegaly and hypertrichosis of the terminal hair were secondary to malnutrition.
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PMID:Acquired trichomegaly and hypertrichosis in metastatic adenocarcinoma. 767 21

Between 1982 and 1986 in western Zaire, a pediatrician collected data on 206 children under 5 years old presenting at the Institute Medical Evangelique, a 400-bed mission hospital (60 pediatric beds), in Kimpese with persisting fever despite chloroquine therapy for falciparum malaria, a negative or scanty positive thick film for malaria, and no clear localizing signs of infections. The pediatrician suspected that these cases had an extraintestinal Salmonella infection and took blood, synovial fluid, and/or cerebrospinal fluid samples for diagnostic analyses. Salmonella serotypes other than Salmonella typhi (non-S. typhi) were responsible for most bacteremia cases (83%). The clinical features of non-S. typhi and S. typhi infections were basically the same. The case fatality rate for non-S. typhi and S. typhi an S. typhi infections were 22.7% and 29.4%, respectively. Infants under 6 months old had a significantly higher case fatality rate than older children (relative risk [RR] = 1.7; p .0005; e.g., 66% and 100% for infants under 3 months old). Meningitis was significantly associated with increased mortality, regardless of age (RR = 4.68). Jaundice was the only clinical sign significantly linked to increased mortality (RR = 2.35), especially among children who had S. typhi infection (80%). Mortality occurred significantly more often when children fell ill with Salmonella bacteremia in the late rainy season, coinciding with the peak of malnutrition, than in the dry season (RR = 2.62). Chloramphenicol-resistant non-S. typhi isolated were significantly associated with increased mortality (RR = 3.19). Hemoglobin levels below 6 g (i.e. severe anemia) has a strong link to increased mortality (RR = 1.77). Salmonella bacteremia will become more difficult to treat as antibiotic resistance and the prevalence of HIV infection increases in African countries.
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PMID:Salmonella bacteraemia among young children at a rural hospital in western Zaire. 768 45

In patients with AIDS, short-term survival has been related to body weight, body composition, and serum nutritional parameters, but their prognostic impact at earlier stages of the HIV infection is not known. With an individual follow-up period of 1,000 days, we investigated the prognostic relevance of electrical tissue conductivity [resistance R, reactance Xc, phase angle alpha, extracellular mass (ECM), body cell mass (BCM)] measured by bioelectrical impedance analysis, of the CD4+ cell count, and of serum parameters indicating malnutrition in 75 HIV-infected male patients at Walter Reed stages 3-5. After initial recording, 29 patients (38.7%) died from AIDS during this period. Among 12 parameters estimated with a semiparametric Cox regression model adjusted for therapy (pentamidine, azidothymidine), the phase angle alpha (parameter estimate: -1.043, 95% confidence interval of -0.61 to -1.47; p < or = 0.0001), the ECM/BCM ratio, Xc, BCM, serum cholesterol, number of CD4+ cells, and serum albumin had significant prognostic influence on survival, whereas age, body weight, body mass index, resistance, serum protein, and serum triglycerides did not. In a model with four covariates (CD4+ cells, phase angle, pentamidine, azidothymidine), the prognostic impact of the CD4+ cell count (parameter estimate: -0.549) was lower compared with the phase angle alpha (parameter estimate: -0.799; p < or = 0.0001) and did not gain statistical significance (p = 0.0626). The phase angle alpha was the best single predictive factor for survival among all 12 parameters (comparison of the respective Cox models with the likelihood ratio test).(ABSTRACT TRUNCATED AT 250 WORDS)
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PMID:Bioelectrical impedance analysis as a predictor of survival in patients with human immunodeficiency virus infection. 771 30

Tuberculosis is a major global public health problem with 8 million new cases of pulmonary tuberculosis in the world per year and 2.89 million deaths. In India in 1989, the approximate morbidity of tuberculosis was 2%, i.e., there were 15 million cases of pulmonary tuberculosis. Of these 25% were sputum positive, posing a serious threat of transmitting the infection to children. Of the 4 million infectious patients, over 1 million would be considered as chronic or relapsing cases who have been partially treated. The Indian National Tuberculosis Program (NTP) has now completed 25 years. Every year, 1 million new cases of adult tuberculosis are detected. 70% of these patients do not complete standard regimens and 45% do not complete short course regimens. In 1983 about 80.71 million children under 16 years old in India were infected. In a survey carried out in 1990 in urban and rural areas of Delhi, BCG vaccination coverage was 90% in the urban and 84.7% in the rural areas. Impact of BCG vaccination has demonstrated that classical or generalized tuberculosis meningitis, miliary TB, disseminated tuberculosis, and other serious complications of primary infections go on occurring in malnourished BCG-vaccinated children. The variable efficacy of the present BCG vaccine observed in different prospective human trials has shown the necessity of conducting research of immunoregulatory mechanisms, and developing newer vaccines for global control of tuberculosis. Other topics include immune responses to the present BCG vaccine (cellular immunity, macrophage, T-lymphocytes); BCG vaccination and tuberculin test; BCG vaccination by nebulization (aerosol BCG vaccine) by the respiratory route; a booster dose of BCG vaccine in the preschool period; protein energy malnutrition and delayed hypersensitivity reaction; BCG test in non-vaccinated and vaccinated children; HIV infections or their symptoms as a contraindication to BCG vaccination; and BCG lymphadenitis in children (7% in seropositive HIV children).
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PMID:BCG vaccination in India and tuberculosis in children: newer facets. 774 45

Central venous access devices have become important tools in the management of pediatric patients with malnutrition, malignancy, and infections requiring long-term antibiotic treatment. Hemophilia presents a lifetime challenge for venous access and at times can be an urgent or life-threatening situation. Since 1986, the authors have implanted 11 subcutaneous infusion ports in nine patients with hemophilia. The systems have remained in place for up to 7 years, without major complications or problems. Two catheters were replaced, after 4 and 6 years, because of skin erosion and blockage, respectively. One catheter was removed after 7 years because of blockage following local trauma and was not replaced. A recent survey through the Canadian Hemophilia Centre Directors Group obtained a further 45 subcutaneous infusion ports in other centers across Canada. The benefits of this system are overwhelming enthusiasm by the parents and children and no major complications. Some of the patients are now HIV-positive and are able to use their system for ongoing drug therapy.
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PMID:Subcutaneous infusion ports in the pediatric patient with hemophilia. 780 50

Malnutrition and wasting are common in patients with HIV infection. Nutritional needs vary with the stage of HIV disease. Severe weight loss is associated with increased mortality in patients with AIDS and is multifactorial in development. Possible causes of weight loss include decreased food intake due to oral or GI pathology or anorexia, nutrient malabsorption, and systemic infections. Severe malabsorption is limited to patients with advanced HIV disease with CD4+ cell counts < 100 and usually < 50 cells/microliters. The spectrum of GI pathogens continues to broaden. For hypermetabolic patients, evaluation for systemic infection followed by effective antiinfective treatment is critical. For nonhypermetabolic patients, a variety of metabolic and endocrinological abnormalities may be present. It is important to recognize that micronutrient deficiencies often accompany macronutrient deficits. Providing appropriate nutritional support to patients with AIDS is fundamental to optimal medical care. Overall indications for nutritional support in a patient with AIDS are the same as in any other chronic disease. Nutritional repletion is well documented, and there are a variety of approaches to achieving appropriate intake, including volitional (megestrol or dronabinol therapy) and nonvolitional (feeding tubes and total parenteral nutrition). Parenteral nutrition should not be undertaken without preset limits. The value of nutritional pharmacology with supraphysiological doses of micronutrients has not been established.
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PMID:Wasting syndrome: nutritional support in HIV infection. 781 45

As the number of HIV-1 infected individuals and AIDS patients continues to increase, more cases involving the genitourinary tract will be encountered. Often, genitourinary manifestations will be the initial presentation of AIDS. Proper diagnosis will require awareness and a high index of suspicion. In addition to routine cultures, opportunistic infections with unusual organisms will require staining for fungi and acid-fast bacilli. Repeat cultures of blood, urine, seminal fluid, and abscess cavities may be required to establish a diagnosis. Prolonged courses of antibiotic treatment for prophylaxis and for relapses are usually required. Clinical understaging and rapid progression of tumors distinguish HIV-1-associated malignancies involving the genitourinary tract. Treatment for these malignancies will depend on the stage of HIV-1 infection. Any concomitant drug therapy and evidence of malnutrition will be important factors in selecting the proper timing and mode of therapeutic intervention. Although AIDS predominantly affects individuals between 30 and 50 years of age, an increasing percentage of patients over 50 years of age are being diagnosed. Common risk factors for acquisition of HIV include homosexuality or bisexuality and transfusion of blood or blood products. For the urologist, it is important to recognize that older patients more frequently present with AIDS at the time of diagnosis of HIV infection. A more rapid course of deterioration and high mortality is noted in this population. Clearly, protocols including surveillance, dosing regimens, and surgical intervention will need to be established and clarified to treat an anticipated increasing number of affected patients. In addition, it appears that adequate adherence to universal precautions is far from being achieved. Close monitoring and active surveillance of infection control may be needed to improve compliance.
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PMID:Genitourinary manifestations of the acquired immunodeficiency syndrome. 781 65

All children 2 years and younger with diagnosis of gastroenteritis (diarrhea and vomiting) admitted to the Eldoret District Hospital between the February and June 1992 were enrolled. ELISA test was performed for HIV for each of the 57 children. In addition, relevant tests were carried out in all cases, such as hemogram, stool for ova and cysts, blood slide for malaria parasites, and urinalysis. The ELISA results were confirmed by the Western blot for all positive cases. A total of 57 children, 32 (56.1%) males and 25 (43.9%) females were studied. All the children were 2 years or younger, with 61.4% under 9 months old. The difference with respect to distribution of HIV positivity and negativity in those under 9 months and those above 9 months was significant (p 0.001). 29 of the 57 infants (50.9%) were ELISA and Western blot positive. Of the positive cases, 23 (79.3%) were 9 months or younger, with 6 (20.7%) between 9 months and 24 months (p 0.001). Of the 33 (58.3%) patients with diarrhea of less than 14 days' duration, 12 (36.70%) were seropositive, and of the 24 (41.7%) with diarrhea of more than 14 days, 17 (70.8%) were HIV positive. The difference in the duration of diarrhea in both the positive and negative cases in the 2 groups was significant. There were 34 patients who presented with diarrhea and vomiting alone of whom 15 (44.1%) were positive for HIV, while there were 10 who presented with diarrhea and either malnutrition or pneumonia with 8 (80%) positive for HIV. Diarrhea lasting more than 14 days was a significant parameter, as 70.8% of the patients in this category were seropositive for HIV compared to 36.7% in those with diarrhea of less than 14 days' duration (p 0.02). In addition, children 0-9 months old had a higher incidence of HIV seropositivity than the older age group, especially the age group 5-9 months, 73.6% of whom were seropositive.
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PMID:HIV seropositivity in children admitted with diarrhoea at Eldoret District Hospital, Kenya. 782 Dec 40

Salient points of AIDS control in India are summarized. An autonomous national AIDS control organization has been set up, which received a sizable loan from the World Bank. As a result, the central health budget became skewed with one-fourth of its expenditures going for AIDS and not enough spent on general health services. Among issues inadequately addressed are: 1) HIV surveillance; 2) diagnosis of AIDS; 3) appropriate and safe medical care; 4) wasteful expenditure; 5) educating health workers; and 6) blood bank services. HIV surveillance and testing centers have been attached to a few large hospitals and medical colleges, but more testing and treatment services will be needed. The World Health Organization (WHO) recommends testing only after informed consent has been obtained; however, in India this is impossible because of the high rate of illiteracy. Instead, counseling is provided by special social workers and testing is prescribed by doctors. Special AIDS clinics might be the solution, although they lead to isolation and stigmatization of patients. Doctors and nurses should be made aware about the importance of informed consent and counseling to encourage voluntary and anonymous testing. The present WHO definition of AIDS for diagnosis is too general and is based on the African experience. Its use may lead to misdiagnosis of many cases of tuberculosis, diarrhea, and malnutrition as AIDS. Clinical criteria applicable to the Indian reality need to be developed urgently. Private practitioners have also entered HIV testing, but often they rely only on the ELISA test without confirmation which might result in a high rate of false positives. General medical care of AIDS cases have to be strengthened with routine sterilization to avoid wasteful expenditures, health workers have to be reeducated, blood bank services need to be streamlined, and more AIDS-related research is also required.
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PMID:AIDS, public health and the panic reaction (Part II). 784 82


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