Intracardiac thrombi in pediatric patients: presentation profiles and clinical outcomes.

We document the presentation profiles, treatment strategies, and clinical outcomes in a relatively large cohort of pediatric patients with intracardiac thrombi (ICT). We performed a retrospective review of patients diagnosed with ICT by echocardiography at a tertiary pediatric hospital during a 10-year period. These patients received medical therapy or thrombectomy. We provided echocardiographic descriptions of the ICT-size, chamber location, and mobility/morphology. The outcome measures were ICT (persistence, resolution, or embolization), effectiveness of therapy, and patient morbidity and mortality. There were 40 ICT diagnosed in 31 patients (22 males and 9 females). Mean age at diagnosis was 8.8 years (range, 15 days to 18 years). Overall mortality was 12/31 patients (39%); only one death was attributed to ICT embolization. Embolic events occurred in 4/31 patients (13%). The most common initial therapies included heparin infusion (n = 15), warfarin (n = 7), and aspirin (n = 7). The ICT resolved with medical therapy alone in 19/30 patients (63%). One patient required surgical thrombectomy. The cohort was divided into group 1 (dilated cardiomyopathy), group 2 (status post Fontan operation), and group 3 (other diagnoses). In group 1 (n = 11), there were 8 deaths. Embolization occurred in 2/5 large ICT, resulting in cerebral infarction and death (n = 1) and renal infarction (n = 1). The most common ICT location was the left ventricle (n = 10). Severe ventricular systolic dysfunction was present in 10/11 patients (91%). In group 2 (n = 9), there was 1 death. Embolization occurred in 1/7 large ICT, resulting in seizures and temporary paresis. All ICT were located in the Fontan pathway. Severe ventricular systolic dysfunction was present in 2/9 patients (22%). In group 3 (n = 11), there were 3 deaths. Embolization occurred in 1/9 small ICT, resulting in coronary emboli. ICT are most commonly diagnosed in pediatric patients with dilated cardiomyopathy or patients status post Fontan operation. The majority of ICT resolve with medical therapy. Larger ICT tend to embolize more frequently, and the morbidity secondary to embolization is significant. Rarely is mortality due to ICT embolization. The prognosis is poor for patients with left ventricular ICT or ICT in the presence of ventricular systolic dysfunction.

HLA-restricted CD8+ cytotoxic T lymphocyte, interferon-gamma, and interleukin-4 responses to respiratory syncytial virus infection in infants and children.

CD8+ cytotoxic T lymphocyte (CTL) activity, interferon (IFN)-gamma, and interleukin (IL)-4 production were evaluated in a blinded manner among respiratory syncytial virus (RSV)-infected newborns and their mothers for 3 epidemic seasons. Most mothers (80%) exhibited RSV-specific CD8+ CTL activity. Twenty (80%) of the 26 infants exhibited significant RSV-specific CTL activity during or after their first RSV season. CTL frequency increased with RSV infection rate, reaching 75% by the end of the third season. Most infants who shed virus (75%) had a medically attended lower respiratory tract disease (LRD). In the first year, RSV-infected infants (virus culture and antibody increase) were more likely to develop CTL activity (10 of 13) than were uninfected infants (1 of 5; P=.02). Infants with CTL activity in the first year were less likely to have an LRD in the second year. CD8+ CTL levels correlated positively with IFN-gamma (P<.001) and inversely with IL-4 (P=.03). Contribution of CD8+ CTL and IFN-gamma in the control of RSV disease in infants and children is implicated.

Comparison of blood-culture contamination rates in a pediatric emergency room: newly inserted intravenous catheters versus venipuncture.

We compared contamination rates of blood cultures obtained either from newly inserted intravenous catheters or via venipuncture. Of 2,431 blood cultures, the overall contamination rate was 2.7% (intravenous catheter, 3.4%; venipuncture, 2.0%; P=.043). The site of lowest contamination was the antecubital fossa, making this the optimal choice for blood-culture sampling.

Dental caries in HIV-infected children: a longitudinal study.

PURPOSE: The purpose of this descriptive longitudinal clinical study was to determine primary and permanent dentition caries status in HIV-infected children, and to compare caries status with the CD4 percentage (CD4%) and immune suppression category. MATERIALS AND METHODS: 73 children up to 9 years of age with vertical HIV transmission were evaluated for caries in the primary dentition at baseline and at 6 month intervals over a 30 month period; while 19 HIV-infected children between 5 and 11 years of age had their permanent dentition evaluated for caries at baseline and at 6 month intervals over a 24 month period. Caries status was also compared with CDC CD4 percentage (> 25%, 15-24%, < 15%), and CDC immune suppression categories (immune suppression: none, moderate, severe). With primary dentition caries, comparisons were made among all children (2-9 yr-olds, N = 73), < 2 yr-olds (N = 28), 2 to 4 yr-olds (N = 20), and 5 to 9 yr-olds (N = 25), and compared with NHANES III data. Caries-free status was also determined. RESULTS: During the 30-month period, there was an almost two-fold increase in primary tooth surface caries for the 2 to 9 year-olds. Caries-free status in the primary dentition declined from 60% at baseline to 37% at the 30-month period. With 5 to 11 years-olds, DMFS and DMFT remained relatively stable, while the proportion of caries-free individuals declined from 72% at baseline to 50% at 18 months. Caries in the primary dentition was increased substantially for those in the low CDC CD4 percentage categories and CDC moderate to severe immune suppression categories. CONCLUSION: Primary dentition caries status in HIV-infected children is considerably greater than that for the US pediatric population, and increases with decreasing CD4 percentage and moderate to severe immune suppression. HIV-infected children with caries-free primary dentitions are less frequent than in the US pediatric population, and caries-free status decreases with age, lower CD4 percentage and moderate to severe immune suppression.

Oral manifestations of pediatric vertical HIV infection.

To assess the prevalence and prognostic significance of the history of oral manifestations in children with human immunodeficiency virus infection (HIV), a cohort study of 73 children with vertical HIV infection was conducted. The study subjects were examined every 6 months for oral manifestations. The period prevalence of oral manifestations ranged from a low of 1% for submandibular enlargement and 3% for hairy leukoplakia to a high of 36% for xerostomia and 51% for cervical lymphadenopathy. The occurrence of oral manifestations did not change significantly over time from 1995 to 1998. Finally, the odds of occurrence of cervical lymphadenopathy, xerostomia, and oral candidiasis were greater among children in whom these manifestations had been diagnosed in the preceding 6-18 months than in children without prior diagnosis. Oral manifestations are significant clinical outcomes in pediatric vertical HIV infection, particularly for children diagnosed previously with an oral manifestation.

Saliva collection technique for cytologic, microbiologic and viral evaluation in pediatric HIV infection.

Acquisition of saliva for biologic, immunologic and chemical analyses has been extremely difficult in infants and young children due to lack of cooperation and motor skills necessary for expectorating adequately. The purpose of this study was to investigate a technique for obtaining satisfactory quantities of whole, unstimulated saliva in the typical dental operatory setting for cytologic, microbiologic and viral evaluation, while requiring minimal cooperation and motor skills from pediatric patients. A low vacuum-assisted aspiration device was utilized to obtain samples from infants and children who were at risk for vertically acquired HIV-infection (age-range 6 mos to 8 yrs). Adequate saliva samples were collected in 175 of 196 (89 percent) attempts in 88 of 89 (99 percent) children (2.3 samples/child). Saliva was not obtained in twenty-one attempts primarily due to xerostomia (62.5 percent). Saliva sample volume obtained was variable, ranging from 1.2 to 3.6 mls with a collection time of approximately three to five minutes. Cell block preparations were made from the saliva, which allowed for cytologic evaluation of sloughed superficial squamous cells, evaluation of oral flora, and detection of yeast and hyphal fungal forms. Adequate volumes of supernate were also available for microbiologic and viral cultures, immunologic studies and PCR study for various viral agents shed in the saliva. Use of a vacuum-assisted collection device for whole unstimulated saliva in infants and young children in the dental operatory setting provides adequate saliva for multiple analyses, which may provide information regarding HIV disease status and early diagnosis of opportunistic infections.

Isolation of Lautropia mirabilis from oral cavities of human immunodeficiency virus-infected children.

Lautropia mirabilis, a pleomorphic, motile, gram-negative coccus, has been isolated from the oral cavities of 32 of 60 (53.3%) children infected with human immunodeficiency virus (HIV) and 3 of 25 (12.0%) HIV-uninfected controls; the association of L. mirabilis isolation with HIV infection is significant (P < 0.001). All children in the study, both HIV-infected children and controls, were born to HIV-infected mothers. The presence of this bacterium was not associated with clinical disease in these children. The HIV-infected children with L. mirabilis did not differ from the HIV-infected children without L. mirabilis in immunological status, clinical status, or systemic medications. The role of HIV infection itself or concomitant factors in the establishment of L. mirabilis in the oral cavity remains to be elucidated.

Detection of fungal organisms in saliva from HIV-infected children: a preliminary cytologic analysis.

PURPOSE: Fungal infections in HIV-infected individuals are associated with advancement of disease. In pediatric HIV infection, symptomatic children have a significantly higher incidence of clinical candidiasis and persistent drug-resistant candidiasis than do asymptomatic HIV-infected children. The purpose of this preliminary cytologic study was to determine the prevalence of fungal organisms in whole unstimulated saliva from children with vertically acquired HIV infection. METHODS: The subjects included 27 HIV-infected and 11 HIV-exposed, but uninfected, children. Whole unstimulated saliva was obtained for cytologic evaluation (hematoxylin and eosin, silver stains) with selected samples evaluated by electron microscopy. RESULTS: Yeast and hyphae were identified cytologically in 19% of HIV-infected (22% symptomatic HIV-infected, 11% asymptomatic HIV-infected) and 9% of HIV-exposed, but uninfected, children. Fungal organisms were found more frequently in HIV-infected with moderate (18%) and severe (27%) suppression. Fungi were more frequent with antiretroviral therapy (22%) vs no antiretroviral therapy (0%) and no antifungal therapy (20%) vs. antifungal therapy (7%). Yeast and hyphal fungal forms are more prevalent in symptomatic HIV-infection with moderate and severe suppression, and those receiving antiretroviral agents, but no antifungal medications. CONCLUSION: Fungal organisms in the saliva may reflect oral carriage or mucosal colonization, which may influence the development of clinically significant candidiasis in these immunocompromised children.