Neurocognitive Lag in School-Aged Children Living With HIV in India and Its Relevance.

Objective Objective assessment of neurocognitive lags in pediatric HIV patients and its correlation with various clinical, social and familial factors. Methods Ninety-eight school-aged children living with HIV (CLHIV) (age 7-18 years) attending regional pediatric HIV clinic were observed for neurocognitive lag using Raven's Standard Progressive Matrices by the same trained instructor. Sociodemographic data, mode of transmission, clinical staging, CD4 count, highly active antiretroviral therapy (HAART) duration were recorded and analyzed in the well-performing group and under-performing group. Results 29.6% of children had definitive neurocognitive lag. The proportion of older children (11-18 years) in the under-performing group was significantly high (P = 0.007). The mean CD4 counts were low in the under-performing group (P = 0.001). Other socioeconomic factors could not be specifically correlated with neurocognitive lag in either of the groups. Conclusion CLHIV has a significant neurocognitive lag, which is accentuated in the upper age group. Findings point toward declining intellectual gains with increasing age in CLHIV.

Psychiatric Problems Amongst Adolescents Living With HIV at a Tertiary Care Centre in India.

OBJECTIVE: To assess the prevalence of psychiatric problems among adolescents living with HIV (ALHIV). METHODS: Questionnaire-based cross-sectional study conducted at pediatric HIV clinic of a tertiary care hospital. Participants: 101 ALHIV between 10-18 years of age. RESULTS: Of the 101 ALHIV, 12 (11.88%) met criteria for psychiatric disorders, of which dysthymi (5,41.6%) and oppositional defiant disorder (6,50%) were the commonest. Father of 7 (58.34%) and mother of 8 (66.6%) screen positive patients were dead as compared to 22 (24.7%) and 13 (14.6%) of screen negative patients (P=0.016 and P=0.0003, respectively). CONCLUSION: Psychiatric problems are common in ALHIV in the age group more than 15 years.

Factors affecting adherence to treatment in children living with HIV.

BACKGROUND: With the successful introduction of ART, the life expectancy of children living with HIV (CLHIV) is substantially increased. However, strict compliance is a necessary step to begin with as noncompliance is again associated with its own demerits of incomplete suppression and decreasing the overall survival of the patients. AIMS: The aim of this study was to measure factors associated with adherence to ART among CLHIV. MATERIALS AND METHODS: This is a 1-year follow-up study conducted from November 2012 to December 2013. A total of 171 children between 18 months and 15 years living with HIV and on ART attending the two ART centers of Delhi were enrolled in the study. Adherence and factors affecting adherence were obtained from the study participants using a semi-structured interview schedule. STATISTICAL ANALYSIS USED: Collected data were transformed into variables and analyzed into SPSS. All observations were in terms of mean, median, standard deviations, percentages, and proportions. Tests of significance such as Chi-square test and t-test were applied wherever required. RESULTS: In nearly 89% of the study participants, adherence to ART was ≥95% at the end of the study. The most common reason for nonadherence was forgetfulness (59%), and 57% of the parents/caretakers were facing monetary problems. Long distance, greater duration to reach center, and unavailability of the parents/caretakers were also quoted as problems. CONCLUSION: Adherence is genesis to successful treatment outcome and is strongly associated with availability of support by their parents/caretakers. Professional help along with guidance and encouragement is required not only at the caretaker level but also to the family as a whole.

Acute lymphoblastic leukemia presenting as nephromegaly in a child: A rare case report.

Arora SK, Swarnim S, Hemal A, Bidhuri N. Acute lymphoblastic leukemia presenting as nephromegaly in a child: A rare case report. Turk J Pediatr 2019; 61: 97-101. Acute leukemia is the commonest pediatric malignancy with acute lymphoblastic leukemia (ALL) constituting about 75% of all leukemias. ALL commonly presents as fever, bleeding, bone pains, anemia, lymphadenopathy and hepatosplenomegaly. The liver, spleen or lymph nodes are the most common sites of extramedullary involvement in ALL, with renal involvement being relatively uncommon. The usual differential diagnosis of acquired massive bilateral nephromegaly in children includes pyelonephritis, obstructive uropathy, infections such as HIV nephropathy, mucormycosis, glycogen storage diseases, myelofibrosis with extramedullary hematopoiesis, kidney tumors and rarely hematological malignancies like ALL. Here we report a 2 years old child who presented with abdominal distention, low grade fever and constipation. Clinical examination revealed massive bilateral nephromegaly. Preliminary investigations showed severe anemia and slightly elevated WBC counts with presence of reactive changes in lymphocytes along with few atypical cells (9%). Abdominal ultrasonography revealed bilaterally enlarged kidneys which was later confirmed by CT abdomen. He was eventually diagnosed with CALLA positive B cell ALL for which treatment was started in accordance with the International network for cancer treatment and research (INCTR) protocol 02 04. At present, he is on maintenance phase and responding well to the treatment with regression of kidney size to normal on follow up ultrasonogram. Thus, leukemia should be considered in a child presenting with bilateral nephromegaly after exclusion of above mentioned differential diagnosis. Bone marrow aspiration must be done before doing a more invasive investigation like renal biopsy.

Pediatric HIV Disclosure in Northern India: Evaluation of Its Prevalence, Perceptions amongst Caregivers, and Its Impact on CLHIV.

BACKGROUND: With improving standards of care of children living with HIV (CLHIV), pediatric HIV related mortality rates are declining. New challenges like HIV status disclosure are emerging which need to be addressed to ensure their smooth transition into adulthood. Poor disease disclosure rates are observed in CLHIV globally. AIMS: This study was done to assess the prevalence of HIV disclosure in North Indian CLHIV, know the perceptions of caregivers regarding disclosure, and evaluate the impact of disclosure on CLHIV. METHODS: It was a questionnaire based cross-sectional study carried out amongst 144 caregivers of CLHIV aged 6-16 years attending the pediatric HIV clinic of a tertiary care teaching hospital. RESULTS: Though the majority (93.8%) caregivers felt that it is important to disclose but only 33% of the children were actually disclosed. Eighty five percent felt that disclosure must be done by one of the family members and correspondingly 73% of the disclosed children were actually disclosed by their parents. Forty seven percent believed that the most appropriate age for disclosure is 10-12 years. The mean age at which disclosure was actually done was 11.06 ± 1.62 years. Comparison of the disclosed and undisclosed CLHIV revealed that the disclosed group had significantly higher age, longer duration of taking ART, and higher proportion of paternal orphans. Age of the CLHIV was the only significant factor for disclosure. Several reasons were cited by the caregivers for nondisclosure. The caregivers observed improved drug adherence in 47.9% of the children following disclosure. CONCLUSIONS: There is a need to develop region specific pediatric HIV disclosure guidelines keeping in mind the caregivers' perceptions. The guidelines must be age appropriate, systematic, and socioculturally acceptable. The most suitable age for disclosure appears to be 10-12 years. Involvement of caregivers and health care providers in the process is a must.

Proteinuria in HIV-infected Indian children.

Chronic kidney disease (CKD) is a major cause of morbidity and mortality among individuals with HIV infection. Screening for proteinuria in HIV-infected children will help in early detection and treatment, and thus prevention and progression to CKD to end-stage kidney disease (ESRD). We screened 139 HIV-infected children aged 18 months to 18 years for proteinuria by urinary dipstick and confirmed by spot urine protein-to-creatinine ratio. If proteinuria was absent by the above methods, patients were screened for microalbuminuria by urinary albumin to creatinine ratio. We found proteinuria in 11.5% and microalbuminuria in 10.6% of our study population. The prevalence of proteinuria was higher in the advanced stages; 8.05% in stage 1, 12.12% in stage 2 and 26.32% in stages 3 + 4.

A prospective study of haematological changes after switching from stavudine to zidovudine-based antiretroviral treatment in HIV-infected children.

Long-term use of stavudine is associated with a high incidence of lipodystrophy, warranting its substitution with zidovudine in first-line antiretroviral therapy (ART) regimens. In a prospective observational study, we determined the spectrum and severity of haematological changes after switching from stavudine- to zidovudine-based ART in Indian children aged 2-18 years who had received a stavudine-based ART regimen for at least 48 weeks. They were followed for 48 weeks for changes in haematological parameters and CD4 cell counts after switching to zidovudine. Of the 60 children analysed, 45 (75%) showed a significant fall in Hb (>1 g/dl). A majority developed grade 1 anaemia (14 [31%]) while only three (6%) developed grade 4 anaemia. The lowest Hb was recorded between 12 and 16 weeks with spontaneous improvement noticed after 28 weeks. A significant drop in absolute neutrophil count (5067 cells/mm3 to 3625 cells/mm3; p = 0.004) was also observed but none developed severe neutropenia. No significant changes were observed in platelet and CD4 cell counts. Since the incidence of severe drug toxicity was low with zidovudine and the majority of children recovered without intervention, drug toxicity should not preclude its routine use in poor countries.

Comparison of Bone Mineral Density in Thalassemia Major Patients with Healthy Controls.

Chronic hemoglobinopathies like thalassemia are associated with many osteopathies like osteoporosis. Methods. This observational study was carried out to compare the bone mineral density (BMD) in transfusion dependent thalassemics with that of healthy controls. Thirty-two thalassemia patients, aged 2-18 years, and 32 age and sex matched controls were studied. The bone mineral concentration (BMC) and BMD were assessed at lumbar spine, distal radius, and neck of femur. Biochemical parameters like serum calcium and vitamin D levels were also assessed. Results. The BMC of neck of femur was significantly low in cases in comparison to controls. We also observed significantly lower BMD at the lumbar spine in cases in comparison to controls. A significantly positive correlation was observed between serum calcium levels and BMD at neck of femur. Conclusion. Hence, low serum calcium may be used as a predictor of low BMD especially in populations where incidence of hypovitaminosis D is very high.

Cardiac manifestations in HIV infected children.

OBJECTIVE: To determine the occurrence of cardiac involvement in HIV infected children and describe its spectrum using non-invasive tests like ECG and 2-Dimensional Echocardiography (2-D ECHO). METHODS: A cross sectional observational study was carried out on 100 HIV infected children between 1 and 18 y of age. The various cardiac manifestations were determined clinically, by electrocardiogram (ECG) and 2-D echocardiography. RESULTS: Seventy four percent of the patients were males with a mean age of 9.62 ± 3.62 y. Seventy seven percent children were in WHO stage I. Sixty five percent did not have significant immune suppression. Eighty six percent children were on HAART (mean duration- 35.12 ± 29.48 mo). Fifty nine percent of children were symptomatic and only nine patients were clinically suspected to have cardiac involvement. ECG abnormalities were found in 14 % cases. The most common abnormal echocardiographic finding was left ventricular diastolic dysfunction by tissue Doppler (E/E') observed in 64 % cases followed by systolic dysfunction (37 %), abnormal left ventricular mass (29 %), pericardial effusion (2 %) and dilated cardiomyopathy (2 %); 64.2 % cases with left ventricular systolic dysfunction (LVSD) were in WHO stage III. CONCLUSIONS: Involvement of heart in HIV/AIDS is mostly subclinical. HIV myocarditis produces systolic as well as diastolic dysfunction. At present, echocardiography remains the only tool for identifying heart involvement in HIV-infected children. Early diagnosis and intervention may halt the progression of the disease, thereby preventing morbidity and mortality.

Lipodystrophy syndrome among HIV infected children on highly active antiretroviral therapy in northern India.

BACKGROUND: It is estimated that about 2.5 million people are living with HIV infection in India. Although antiretroviral drugs have been able to reduce the mortality, these drugs have serious side effects one of which is lipodystrophy syndrome. Most of the drugs used in HAART viz, protease inhibitors, stavudine and nevirapine are associated with lipodystrophy. Hence we conducted this study to assess the prevalence of lipodystrophy in HIV infected children on HAART and its associated risk factors. MATERIALS AND METHODS: A cross sectional study was conducted on 80 HIV infected children aged 2-18 years of age who were on stavudine based HAART for ≥ 2 years. These children were assessed for presence of lipodystrophy, its metabolic complications and associated risk factors. RESULTS: Lipodystrophy was observed in 33.7% of children with lipoatrophy being the commonest subtype followed by lipohypertrophy. Older age, increased duration of treatment and dyslipidaemia were found to be associated in patients with lipodystrophy than those without. On further multivariate analysis of independent risk factors only increased duration of treatment was significantly associated with lipodystrophy. No association was found with insulin resistance. CONCLUSION: We observed that lipodystrophy is a common finding in HIV patients treated with HAART for long duration.

Inferior vena caval and right atrial thrombosis: complicating pyogenic liver abscess.

Vascular complication of liver abscess are rare but life-threatening. We herein report a 2 year 9 month boy with pyogenic hepatic abscess complicated by inferior vena cava thrombus extending to right atrium. Early clinical suspicion aided by ultrasonography and echocardiography confirmed the diagnosis. The child was treated successfully with timely medical and surgical intervention.

Simultaneous HAART improves survival in children coinfected with HIV and TB.

OBJECTIVES: This study assesses the outcome of current treatment guidelines and the effect of highly active antiretroviral therapy (HAART) on survival of HIV/TB-coinfected patients in a resource-limited setting. METHODS: Observational cohort study at the pediatric HIV Clinic, RML Hospital, Delhi. All HIV-infected patients who visited the clinic for the diagnosis of TB between 2002 and 2006 were observed until 31 March 2010. TB was diagnosed either at the time of enrolment or during follow-up visits. Clinical and epidemiological data were registered. We compared children who were given HAART with TB treatment at time of diagnosis [simultaneous therapy (ST)] and children who received delayed HAART. Survival was assessed by Kaplan-Meier method and Cox regression model. RESULTS: Among the 298 children, 126 (42.2%) had TB, including 96 who received ST (76% of 126) and 30 who did not. There were no differences between the two groups except for a lower CD4 count in patients undergoing ST. ST was associated with improved survival [hazard ratio (HR), 0.35; 95% CI, 0.20-0.74; P = 0.002] and so were year of TB diagnosis and other AIDS-defining conditions. Multivariate analysis revealed that ST was a powerful predictor of survival (HR, 0.30; 95% CI, 0.14-0.68; P = 0.003). After adjusting for other prognostic variables such as age, gender, CD4 count at time of TB diagnosis, by Cox multivariate analysis, ST remained robustly associated with improved survival (HR, 0.32; 95% CI, 0.17-0.71; P = 0.001). CONCLUSIONS: Starting HAART during tuberculosis therapy significantly improves survival and provides further impetus for the integration of TB and HIV services.

Febrile seizures.

Febrile seizures are the most common form of childhood seizures occurring in 2 to 5% of children in the United States. Most febrile seizures are considered simple, although those with focal onset, prolonged duration or that occur more than once within the same febrile illness are considered complex. Risk factors for a first febrile seizure, recurrence of febrile seizures and development of future epilepsy are identifiable and varied. Children with febrile seizures encounter little risk of mortality and morbidity and have no association with any detectable brain damage. Recurrence is possible, but only a small minority will go on to develop epilepsy. Although anti-epileptic drugs can prevent recurrent febrile seizures, they do not alter the risk of subsequent epilepsy. This has led to a changing view of how we approach the treatment of these common and largely benign seizures.