Pulmonary Tuberculosis in Severely-malnourished or HIV-infected Children with Pneumonia: A Review.

Presentation of pulmonary tuberculosis (PTB) as acute pneumonia in severely-malnourished and HIVpositive children has received very little attention, although this is very important in the management of pneumonia in children living in communities where TB is highly endemic. Our aim was to identify confirmed TB in children with acute pneumonia and HIV infection and/or severe acute malnutrition (SAM) (weight-for-length/height or weight-for-age z score <-3 of the WHO median, or presence of nutritional oedema). We conducted a literature search, using PubMed and Web of Science in April 2013 for the period from January 1974 through April 2013. We included only those studies that reported confirmed TB identified by acid fast bacilli (AFB) through smear microscopy, or by culture-positive specimens from children with acute pneumonia and SAM and/or HIV infection. The specimens were collected either from induced sputum (IS), or gastric lavage (GL), or broncho-alveolar lavage (BAL), or percutaneous lung aspirates (LA). Pneumonia was defined as the radiological evidence of lobar or patchy consolidation and/or clinical evidence of severe/ very severe pneumonia according to the WHO criteria of acute respiratory infection. A total of 17 studies met our search criteria but 6 were relevant for our review. Eleven studies were excluded as those did not assess the HIV status of the children or specify the nutritional status of the children with acute pneumonia and TB. We identified only 747 under-five children from the six relevant studies that determined a tubercular aetiology of acute pneumonia in children with SAM and/or positive HIV status. Three studies were reported from South Africa and one each from the Gambia, Ethiopia, and Thailand where 610, 90, 35, and 12 children were enrolled and 64 (10%), 23 (26%), 5 (14%), and 1 (8%) children were identified with active TB respectively, with a total of 93 (12%) children with active TB. Among 610 HIV-infected children in three studies from South Africa and 137 SAM children from other studies, 64 (10%) and 29 (21%) isolates of M. tuberculosis were identified respectively. Children from South Africa were infected with HIV without specification of their nutritional status whereas children from other countries had SAM but without indication of their HIV status. Our review of the existing data suggests that pulmonary tuberculosis may be more common than it is generally suspected in children with acute pneumonia and SAM, or HIV infection. Because of the scarcity of data, there is an urgent need to investigate PTB as one of the potential aetiologies of acute pneumonia in these children in a carefully-conducted larger study, especially outside Africa.

Analysis of fecal leukocytes and erythrocytes in Shigella infections in urban Bangladesh.

We evaluated the usefulness of enumeration of fecal leukocytes and erythrocytes in making an early diagnosis of Shigella infection, where Shigella is a leading cause of invasive diarrhea. Stool specimens from 561 invasive diarrhea patients were submitted for microscopic examination. A presumptive diagnosis of shigellosis based on microscopic examination was made in 389 of them; 227 had stool cultures positive for Shigella spp (Shigella patients). One hundred sixty-two patients with no detectable Shigella infection (non-Shigella invasive diarrhea cases) served as a comparison group. Two hundred twenty-seven randomly selected Shigella patients and 227 non-Shigella infectious diarrhea cases from the surveillance system database of the hospital constituted another group for comparative evaluation. The stool specimens of the patients were examined under the microscope, and isolation, biochemical characterization and serotyping of Shigella were performed. In comparison with non-Shigella invasive diarrhea cases, the presence of >50 WBC/hpf in association with any number of RBC in the fecal sample had a modest sensitivity of 67%, specificity of 59%, positive predictive value of 70%, negative predictive value of 56%, accuracy of 64%, and positive likelihood ratio of 1.6 in predicting shigellosis. Comparison between Shigella and non-Shigella infectious diarrhea patients revealed the presence of >20 WBC/hpf was a less accurate predictor of shigellosis (sensitivity 51%, specificity 88%, positive predictive value 81%, negative predictive value 64%, accuracy 69%, and positive likelihood ratio 4.1). Direct microscopical examination of stool specimens for the presence of WBC and RBC may facilitate the early diagnosis of shigellosis, and may be a cheap alternative to stool culture in this setting.

Anthropometric characteristics of elderly people: observations at a large diarrheal hospital in Dhaka, Bangladesh.

There is a lack of evidence-based information to assist health policy makers in preparing for appropriate health, nutrition, and social-support guidelines for the elderly in Bangladesh. We examined selected indicators of the nutritional status of elderly people attending the Dhaka Hospital of ICDDR,B, Dhaka, Bangladesh. The population constituted of 1,196 individuals (718 men and 478 women), aged 60 to 106 years, who attended the hospital between 1 January 1993 and 31 December 2003. Patients were recruited from a hospital-based systematic sampling, regardless of age and gender, that presented to the facility. Men were heavier, and taller than women were (p < 0.001 for both comparisons). Using MUAC cut-off of < 22 cm for females and < 23 cm for males, at least 50% of the elderly were peripherally wasted (malnourished). Among all the study population, 40% had a BMI within the optimal range (18.5-24.9 kg/m(2)). Using the chronic energy deficiency (CED) classification, at least half of elderly (> or= 60 year) women were chronic energy deficient (BMI < 18.5). A significantly higher proportion of elderly women (7%) compared to men (2%) were overweight (BMI > or = 25, p < 0.001). Among the elderly ( > or = 60 year), males and females from a higher socioeconomic status (SES) had significantly higher BMI (p < 0.001, p = 0.001, respectively) and MUAC values (p < 0.001, p < 0.001, respectively) than their less well-off SES counterparts. We consider that, although our data were not valid for assessing the country situation, they are still useful as baseline information for longitudinal studies and for highlighting the need for studies in other geographical locations and in other population groups.

Childhood anemia and vitamin a deficiency in rural Bangladesh.

The study aimed to assess the prevalence of anemia and vitamin A deficiency in preschool children in rural Bangladesh. A cross-sectional study was done on eight randomly-selected sub-districts of rural Bangladesh. Children (n=1,302) aged 2-6 years were studied. Families of 43% of the study participants had a monthly household expenditure of US$ 60 or less. Fifty-six percent of the children were underweight, and 17% were severely underweight; 18% were wasted, and 1% were severely wasted; and 45% were stunted while 20% were severely stunted. The mean+/-SD serum retinol of the children was1.0+/-0.4 micromol/l, and 3% of them had serum retinol levels of <0.35 micromol/l, about one-fifth (20%) had a serum retinol level of <0.70 micromol/l and 55% had serum retinol levels of <1.05 pmol/l. The mean hemoglobin concentration of the children was 110+/-11 g/l, and 48% had a Hb of <11 g/l signifying anemia in this age group. Thirty-one percent (31 %) of children had low serum ferritin (<12 microg/l), and 14% had elevated CRP (> or = 15 mg/l) indicating the presence of a sub-clinical infection. Male and female children had similar nutritional status and biochemical profiles although boys tended to be heavier than girls (p=0.013). The proportion of children with anemia and iron deficiency anemia (IDA) declined significantly (p<0.001) with advancing age. Five percent of the study children had IDA and concomitant low serum retinol. The proportion of children with IDA and serum retinol also declined significantly with increasing age from 8% in children aged 35 months or younger, to 3% in children aged 60 months and more (p=0.025). Results of our study clearly demonstrated the public health importance of anemia and vitamin A deficiency among children of rural Bangladesh.