Kathleen Walker

Neurologic and Neurobehavioral Sequelae in Children With Human Immunodeficiency Virus (HIV-1) Infection

The range and extent of neurologic and neurobehavioral complications of human immunodeficiency virus (HIV-1) infection in children are under-described. Seventy-eight children with HIV-1 infection (32 females) were assessed for neurologic complications. Forty-six children had abnormal neurology examinations. Thirty-three children had global pyramidal tract signs, 5 had a hemiparesis, 4 had peripheral neuropathy, 18 had visual impairment, and 5 had hearing impairment. Thirty-nine of 63 children over 1 year of age had neurobehavioral problems. Of 24 children with HIV encephalopathy, 74% had severe immunosuppression and 45% were not receiving antiretroviral therapy. Twelve children had prior opportunistic central nervous system infections, and 9 had epilepsy. Diverse neurologic and neurobehavioral deficits are common in children with HIV-1 infection. Children with severe immunosuppression, who were not receiving antiretroviral therapy, were growth impaired and less than 1 year of age, were at greatest risk for developing neurologic complications.

Treatment of sydenham chorea with intravenous immunoglobulin.

Sydenham chorea is a post-streptococcal, autoimmune, neuropsychiatric, movement disorder. There is no effective treatment. In a randomized study, comparison was made of the outcomes of 10 children treated with standard management alone compared to 10 who received additional intravenous immunoglobulin. The outcomes were assessed using a clinical rating scale, brain single-photon emission computed tomography, and the duration of symptomatic treatment. All three outcome measurement tools found improved outcomes in the group that received intravenous immunoglobulin.

HIV Encephalopathy: pediatric case series description and insights from the clinic coalface

BackgroundThe Human Immune Deficiency Virus (HIV) can manifest neurologically in both adults and children. Early invasion of the central nervous system by the virus, affecting the developing brain, is believed to result in the most common primary HIV-related neurological complication, HIV Encephalopathy (HIVE). In countries such as South Africa where many children have not been initiated on antiretroviral treatment early, HIVE remains a significant clinical problem.MethodsChildren were selected from a clinic for children with neurologic complications of HIV, located at the Red Cross War Memorial Children’s Hospital, South Africa 2008–2012. Eligible subjects fulfilled the following inclusion criteria: aged 6 months-13 years; positive diagnosis of HIV infection, vertically infected and HIVE as defined by CDC criteria. Each participant was prospectively assessed by a Pediatric Neurologist using a standardized proforma which collated relevant details of background, clinical and immunological status.Results The median age of the 87 children was 64 months (interquartile range 27–95 months). All except one child were on antiretroviral treatment, 45% had commenced treatment <12 months of age. Delayed early motor milestones were reported in 80% and delayed early speech in 75% of children in whom we had the information. Twenty percent had a history of one or more seizures and 41% had a history of behavior problems. Forty-eight percent had microcephaly and 63% a spastic diplegia. CD4 percentages followed a normal distribution with mean of 30.3% (SD 8.69). Viral loads were undetectable (<log 1.6) in 70% of the children. Brain imaging was performed on 56% with 71% of those imaged demonstrating at least one abnormality, most commonly white matter volume loss or signal abnormality. ConclusionsAmongst the cohort of children referred to this clinic, the diagnosis of HIVE was unrecognized in the general medical services, even in its most severe form. Developmental delay and school failure were major presenting problems. Co-morbidities are a frequent finding and should be sought actively in order to optimize management and promote best possible outcomes for this vulnerable group of children.

Prevalence of Seizures in Children Infected With Human Immunodeficiency Virus

A retrospective study of 354 human immunodeficiency virus (HIV)–infected patients identified a subgroup of 27 children with seizures (7.6%, 95% confidence interval: 5.1%-10.9%). Of the total group, 13% (n = 46) had identifiable neurologic deficits and 30% (n = 107) had developmental delay. Both observations were significantly more frequent in the subgroup of patients with seizures (P < .001). The median age of patients with seizures was 20 months (range, 8-87 months) and the median baseline CD4 percentage was 13.5% (interquartile range, 8%-23%). Seizures were treated with sodium valproate (n = 11), phenobarbital (n = 3), diazepam (n = 2), lamotrigine (n = 1), and carbamazepine (n = 1). Combination therapy was required for 5 children. Suboptimal valproic acid levels were recorded for 3 patients. When resources are available, antiepileptic drug level monitoring is advised for children who require both antiepileptic and antiretroviral medications to facilitate optimal seizure management.

Sydenham's chorea - clinical and therapeutic update 320 years down the line

Rheumatic fever is currently the major cause of acquired heart disease among children in South Africa.1 The incidence of acute rheumatic fever (ARF) and rheumatic heart disease (RHD) is not declining. Recent figures quote the incidence of rheumatic fever as 0.6 0.7/1 000 population in the USA and Japan compared with 15 21/1 000 population in Asia and Africa.2 In a study conducted in 1975 in Soweto, South Africa, 12 050 schoolchildren were examined and 19.2/1 000 had rheumatic heart disease.3 A 2002 report from a cardiology workshop highlighted the belief among clinicians that South Africa is currently in the midst of a rheumatic fever epidemic.4,5 Sydenham’s chorea (SC) is a major manifestation of ARF. Accordingly, in the South African context when PNMs are diagnosed, treatment strategies must always include the prevention of RHD.

The Effect of Carbamazepine and Sodium Valproate on the Blood and Serum Values of Children From a Third-World Environment

In third-world countries many children with epilepsy also suffer from malnutrition, anemia, liver disease, and immunosuppression. Doctors might have reservations about the use of anticonvulsants that could aggravate these disorders. The purpose of this study was to establish the prevalence of abnormal blood and serum values in children receiving carbamazepine or sodium valproate as monotherapy who attended a child neurology clinic serving a third-world community in Cape Town, South Africa. Blood samples were taken at routine follow-up visits from 104 children who had been on carbamazepine or sodium valproate monotherapy for at least 6 months. Hematology, serum chemistry, immunoglobulins, and anticonvulsant levels were measured by standard laboratory procedures. Very few subjects had any values outside accepted normal ranges. When clinically indicated and available, carbamazepine and sodium valproate can be prescribed for children from a third-world environment. Frequent blood and serum testing is not necessary in asymptomatic individuals. (J Child Neurol 1999;14:751-753).

Sydenham Chorea and PANDAS in South Africa: Review of Evidence and Recommendations for Management in Resource-Poor Countries.

In South Africa, and worldwide, rheumatic fever represents a public health problem. Improved diagnosis and management of Sydenham chorea, a major manifestation of acute rheumatic fever is key to prevention of rheumatic heart disease. This article reviews Sydenham chorea from its original description to current opinions. Recommendations are founded on expert opinion as class 1 data is lacking. This South African perspective is relevant to resource-poor settings globally insofar as it provides diagnosis and management recommendations for primary- and secondary-level healthcare professionals who care for patients in such environments. Four basic tenets of care are recommended, namely, elimination of the streptococcal infection, symptomatic treatment, immunological treatment, and nonpharmacologic interventions. A user-friendly outcome measurement tool, viable for use in low-resource settings is presented. Introduction of this tool may lead to increased awareness of the neuropsychiatric manifestations of poststreptococcal movement disorders in Africa, where reports are limited.

Markers of susceptibility to acute rheumatic fever: the B-cell antigen D8/17 is not robust as a marker in South Africa

BACKGROUND Acute rheumatic fever and its chronic sequelae, rheumatic cardiac disease, and neuropsychiatric movement disorders, remain major public health problems in South Africa. Early identification and treatment of streptococcal pharyngitis in susceptible individuals would prevent rheumatic cardiac disease. The B-cell antigen D8/17 is a marker of susceptibility to rheumatic fever in some populations. METHODS AND RESULTS We assessed the significance of the D8/17 marker in a group of South Africans. Blood was collected from 107 individuals; 40 patients had previous confirmed rheumatic fever, 20 were first-degree relatives, and 47 were controls. The expression of D8/17 in each sample was analysed by flow cytometry. The mean proportion of B-cells that were D8/17 positive was 0.5% in the index cases, 0.47% in their relatives, and 0.27% in the controls. There was a significant difference between the index cases and the controls, p = 0.03, but the mean percentage positive in each group was very low. CONCLUSIONS Patients with a history of rheumatic fever had statistically increased expression of the D8/17 marker. However, the actual percentages in this observational study were markedly lower than in other populations, ranging from 0.14%-1.53% compared to 11.6%-39.3%. The D8/17 marker would be an impractical screening tool in the South African population.