HIV MEETING The 4th International Workshop on HIV Pediatrics (http://www.virology-education.com/index.cfm/t/4th_International_Workshop_on_HIV_Pediatrics/vid/E567967E-C8A8-59D1-07BD0428AF19651F) took place on July 20-21, 2012, in Washington, DC, immediately before the 2012 International AIDS Conference. This meeting attracted almost 300 participants to present and discuss the latest developments and controversies in maternal and pediatric HIV. Major themes included HIV prevention and management in adolescents, framework for advancing toward the cure of HIV infection in children, strategies and barriers in the WHO goal of perinatal HIV transmission elimination by 2015, and emerging long-term complications of perinatal HIV infection. Two controversial areas were presented using a debate-style format: use of treatment interruption in children as an alternative to continuous antiretroviral therapy and whether isoniazid preventive therapy is warranted for all HIV-infected children in TB endemic settings. Twenty-three oral abstracts and 118 poster presentations rounded out the intensive two days of meetings. All abstracts and most of the presentations can be accessed through the meeting website. The next conference will precede the International AIDS Society (IAS) Meeting in Kuala Lumpur in 2013
AMEBIC MENINGITIS A 9-year-old previously healthy male presented to a local emergency department for evaluation of fatigue, persistent headache, fever, emesis and altered mental status. Five days before presentation he had been swimming with his family at a river in south Oklahoma. Because of the concern for meningitis he was transferred to Children’s Medical Center, Dallas. At presentation here he was combative and unresponsive to commands. Cranial tomography of the head showed mild paucity of sulci over the superior convexities, indicative of mild increase intracranial pressure. The CSF was cloudy with 133 red blood cells, and 9442 white blood cells with 85% polymorphonuclear cells. The CSF glucose was 12 mg/dL and protein, 462 mg/dL. Opening pressure was > 55 cm water. No bacteria were seen on Gram stained smear, but careful examination of a Wright’s stained centrifuged CSF specimen revealed trophozoites and was positive by PCR for Naegleria fowleri. The patient was admitted to the ICU, intubated to protect his airway and given amphotericin B liposomal, fluconazole and rifampin, plus dexamethasone, mannitol, and hypertonic saline. An extraventricular drain (EVD) was placed as a result of increasing cerebral edema visualized on CT scan. After initial improvement but continued presence of trophzoites in ventricular fluid, 0.1 mg amphotericin was instilled through the EVD on day 3. Several hours later, ICP increased markedly and CT of the head showed loss of supratentorial and infratentorial gray-white differentiation and effacement of the sulci and basilar cisterns consistent with cerebral edema, increased intracranial pressure and ischemia. Because of refractory intracranial hypertension, increased evidence of cerebral ischemia and absent brainstem reflexes management was withdrawn and he died on hospital day 4. This boy had primary amebic meningoencephalitis caused by Naegleria fowleri that is commonly found in warm fresh water, proliferates during the increased ambient temperatures of southern summers, and is the only species of Naegleria known to infect people. Trophozoites penetrate nasal mucosa and migrate to the brain via the olfactory bulbs causing meningitis (http://www.cdc.gov/parasites/naegleria/). Sharon Roy, MD, MPH, Division of Foodborne, Waterborne, and Environmental Diseases, Centers for Disease Control and Prevention, Atlanta, GA was consulted and advised treatment with amphotericin B (IV +/- IT), rifampin (PO), azithromycin (IV) and either fluconazole (IV or PO) or miconazole (IV). Miltefosine was considered because of invitro activity against various species of Leishmania and such protozoan parasites as Entamoeba histolytica and Acanthamoeba, but it could not be obtained in time. According to Dr. Roy there has only been 1 survivor in the U.S. out of >130 known cases. The CDC would like to be informed about all cases of PAM in the United States and to offer assistance (http://www.bt.cdc.gov/emcontact/) when possible (Drs. Jane Siegel and Claudia Gaviria contributed to this item).
BABESIOSIS SURVEILLANCE When was the last time you thought of babesiosis in a child with fever, flu-like symptoms and hemolytic anemia? Never? To refresh your memory: Babesia are protozoan parasites transmitted by tick bites except for rare instances of congenital or blood transfusion transmission. In January 2011 the CDC began surveillance for babesiosis in 18 states where the disease had previously been reported. During the first year the CDC was notified of 1124 cases (MMWR 2012; 61: 505). That means babesiosis is not a rare disease. Seven states (Connecticut, Massachusetts, Minnesota, New Jersey, New York, Rhode Island and Wisconsin) accounted for 97% of cases. Of the total cases, 847 were confirmed and 277 were probable. Confirmation of diagnosis was by blood smear microscopy, PCR or antibody studies. The male:female ratio was 63:34 (sex unknown in 3%). There was one case of congenital transmission. All cases were caused by one species, B. microti. Treatment is with either atovaquone plus azithromycin or clindamycin plus quinine given for 7-10 days or longer. Exchange blood transfusion has been used in some cases of severe hemolytic anemia. These numbers are large enough to justify consideration of the possibility of babesiosis in a suspicious clinical and epidemiologic setting.
ZINC FOR ACUTE INFECTIONS In the 1960s the American Medical Association organized a medical education program in Saigon (now Ho Chi Minh City) that was funded by the U. S. Agency for International Development. The pediatric portion of the program was headed by the late Heinz F. Eichenwald, who was at the time Chairman of Pediatrics at the University of Texas Southwestern Medical Center, Dallas. Bright young Vietnamese doctors who had completed the pediatrics program at Nhi Dong, their children’s hospital, were recruited into the program for training with U. S. pediatricians of many subspecialty areas who volunteered their teaching skills for 2 month stints in Saigon. Two American pediatricians, JoAnne Whitaker and JoAnn Cornet, were full-time on-site to supervise the program. After 2 years of training in Saigon, the Vietnamese doctors took fellowships in the U. S. The concept was to train a new generation of Vietnamese faculty for the medical school in Saigon. One of us had the unforgettable, interesting experience of serving twice in Saigon in 1971 and 1973. This was brought to mind by a recent publication from New Delhi, India in The Lancet (2012;doi:10.1016/S01406736(12)60477-2) reporting the beneficial effect of oral zinc supplementation (10 mg daily) in infants less than 120 days of age with clinically diagnosed serious probable bacterial infections. This was a randomized, placebo controlled study. Treatment failure was 40% less in the zinc supplementation group. Similar improvement has been previously reported with vitamin A in infants from low income populations where nutritional deficiency is common. The reason that the zinc study stimulated reminiscences of the Saigon program is that Dr. Eichenwald was a strong proponent of zinc supplementation for poorly nourished infants and children with acute infection and advocated its use in the Saigon program. We do not know the basis of his thinking, but we are sure that he would have been pleased to see that advocacy supported by this well-performed study from India. It would be interesting to learn whether the zinc and vitamin A supplementation data have relevance to other populations.