Nutthapong Tangsinmankong

Immunogenicity of 23-valent pneumococcal polysaccharide vaccine in children with human immunodeficiency virus undergoing highly active antiretroviral therapy

BACKGROUND The 23-valent pneumococcal polysaccharide vaccine (23PSV) has been recommended for children infected with human immunodeficiency virus (HIV); however, the efficacy of this vaccination in HIV-infected children undergoing highly active antiretroviral therapy (HAART) has not been studied. OBJECTIVE To study the immunogenicity and immunologic protection of 23PSV in HIV-infected children after stable HAART. METHODS Serotype-specific IgG antibodies to 12 pneumococcal capsular polysaccharides were analyzed before and after 23PSV vaccination in 41 HIV-infected children undergoing HAART and compared with 95 HIV-negative control children. Seropositivity, clinical protection, and additional clinical protection from 23PSV were calculated based on serotype specific IgG antibody levels and on the known incidence of these serotypes for causing invasive disease. RESULTS Children with HIV infection undergoing HAART developed a significant increase in specific IgG levels to Streptococcus pneumoniae after 23PSV vaccination (0.95 vs 1.84 micro/gmL, P < .001). The HIV-infected children with CD4+ cell counts of 25% or higher at the time of vaccination developed a higher additional clinical protection gain from 23PSV vaccination than did children with a lower percentage of CD4+ cells. CONCLUSIONS HIV-infected children undergoing stable HAART develop a significant immunologic response to 23PSV, especially those with higher T-cell counts and lower viral loads at the time of vaccination.

Acrodermatitis enteropathica-like eruption and food allergy

BACKGROUND Acrodermatitis enteropathica-like eruption (AE) is a distinct rash associated with profound zinc deficiency. It is seen in a variety of conditions but has not been reported as a presentation of food allergy. OBJECTIVE To report AE as an unusual presentation of food allergy in infants. METHODS Acrodermatitis enteropathica-like eruption was diagnosed by a characteristic rash and a low serum zinc level. The diagnosis of food allergy was made by history, serum total IgE and food specific IgE levels, or oral challenge with suspected foods. RESULTS Two infants with AE, diarrhea, and low serum zinc levels were evaluated. Food allergy was found in both infants. The first infant had a serum IgE level of 4642 IU/mL. Specific IgE levels to milk, soybean, wheat, and peanut were 39.04, 10.14, 5.65, and 102.61 kU/L, respectively. Oral challenges to milk and peanut were positive and to soybean were negative. The second infant had a serum IgE level of 991 IU/mL; specific IgE levels to soybean and milk were 36.9 and 0.53 kU/L, respectively. Evaluation for other possible causes of diarrhea revealed homozygous delta F508 in the first infant, confirming the coexistence of cystic fibrosis; findings in the second infant were negative. CONCLUSIONS Undiagnosed food allergy can lead to profound zinc deficiency. Food allergy should be suspected in a child with acquired AE.

Glucocorticosteroid treatment for cerebrospinal fluid eosinophilia in a patient with ventriculoperitonial shunt

BACKGROUND Cerebrospinal fluid (CSF) eosinophilia commonly occurs in patients with ventriculoperitoneal (VP) shunts and is associated with shunt complications such as obstruction or infection. Glucocorticosteroids (GCS) are effective in reducing eosinophilia and eosinophils in skin, nasal mucosa, and airway epithelium. Effects of GCS on CSF eosinophils has not been reported. OBJECTIVE To demonstrate glucocorticosteroid effects on the CSF eosinophil levels and to propose that GCS may be used as a therapeutic agent for CSF eosinophilia. RESULT A case report of a patient with congenital hydrocephalus and a VP shunt developed CSF eosinophilia associated with latex allergy and shunt malfunction. Daily treatment with 2 mg/kg of methylprednisolone was associated with reduced peripheral eosinophilia and slightly reduced CSF eosinophil counts. Pulse methylprednisolone, 15 mg/kg, was associated with complete reduction of CSF eosinophils and prolonged VP shunt survival. CONCLUSION Systemic glucocorticosteroids effectively reduce CSF eosinophils. Glucocorticosteroids may be beneficial for treatment of CSF eosinophilia associated with VP shunt malfunction.

Different mechanisms are utilized by HIV-1 Nef and staphylococcal enterotoxin A to control and regulate interleukin-10 production.

Interleukin-10 (IL-10) plays an important immunopathogenic role in immunologic diseases, especially in HIV infection and atopic dermatitis. The control and regulatory mechanisms of IL-10 production have not been described in these diseases. Recently, we demonstrated that HIV-1 Nef induces IL-10 production in monocytes and that staphylococcal enterotoxin A (SEA) induces IL-10 production in T-lymphocytes. Here we show that Nef-induced IL-10 production and mRNA expression are strongly blocked by rapamycin, but are not blocked by cyclosporin (CsA) or FK506. Conversely, we show that CsA and FK506 completely inhibit SEA-induced IL-10 protein production and mRNA expression. The results of this study demonstrate that IL-10 production by Nef and SEA is controlled and regulated by different mechanisms.

Profound reduction of invariant natural killer T cells in the peripheral blood of a patient with interleukin-1 receptor-associated kinase 4 deficiency.

We previously described a patient with a history of frequent life-threatening pneumonias, infections with bacterial pathogens, interleukin 1 receptor-associated kinase 4 deficiency, and failure to maintain antibody titers to polysaccharide antigens or to a neoantigen bacteriophage. In the present study, we show that the patients peripheral blood mononuclear cells have a profound deficiency of invariant natural killer T cells.

Effect of influenza virus vaccine on the expression of human immunodeficiency virus co-receptor CCR5

BACKGROUND Administration of influenza vaccine to human immunodeficiency virus (HIV)-infected children can lead to increased viral load. CCR5 and CXCR4 are known to play an important role in HIV cell entry and viral replication. OBJECTIVE To determine the effects of influenza vaccine on chemokine receptors and on viral load in HIV-infected children. METHODS Eight HIV-infected children receiving stable therapy and 11 healthy adults were enrolled. Chemokine expression and immune activation were determined before and 48 hours after influenza vaccination. CCR5 and beta-chemokine gene expression were analyzed using real-time polymerase chain reaction. Viral load was measured at baseline, 48 hours, and 6 to 12 weeks. RESULTS Forty-eight hours after influenza vaccination, mean CCR5 expression was significantly decreased on the CD3 (21.1% vs 11.3% in HIV-infected children; P = .02; and 18.3% vs 10.7% in controls; P = .008) and CD4 (13.0% vs 3.6% in the HIV group; P = .04; and 13.6% vs 6.5% in controls; P = .02) lymphocytes. This was observed in conjunction with an increase in HLA-DR expression on T lymphocytes in HIV-infected children (P = .046). No significant changes were observed in HIV viral load, CD3 and CD8 lymphocyte counts, expression of interleukin 2 receptor and CXCR4, or gene expression of CCR5 and beta-chemokines 48 hours after vaccination. CONCLUSIONS Influenza virus vaccine markedly decreased chemokine receptor CCR5 expression on CD4 T lymphocytes. However, this immunomodulatory effect does not seem to affect overall viral replication in HIV-infected children who received highly active antiretroviral therapy.

Improving care of HIV-infected patients in the outpatient setting with patient data flow sheets.

Medical management of pediatric/adolescent HIV has become increasingly complex, requiring a multidisciplinary approach to care. Close clinical monitoring is needed to minimize opportunistic infections, initiate appropriate antiretroviral therapy, and ensure optimal health care to the patient. Monitoring should include evaluation of efficacy and side effects of therapy, early detection and treatment of HIV-associated complications, and maintenance of current immunizations. Tracking clinical data in chronically ill patients is a difficult task without an effective monitoring system. A patient data flow sheet was created to assist in planning care and monitoring disease progression by consolidating clinical information into an organized, one-page summary for each patient. One year after the patient data flow sheets were instituted, there was a significant improvement in the consistency of obtaining and monitoring routine HIV labs as well as serologies, and other recommended tests. The flow sheets have increased effectiveness of patient care and have been used to assist with quality assurance monitoring and quality improvement in the clinic setting.

Osteoporosis for the allergist

OBJECTIVE This review is intended to be an authoritative summary of the pathogenesis of osteoporosis, a problem that may be encountered in allergy practice. It also provides an outline for identification of subjects at high risk and directions for their appropriate evaluation, management, and prevention of the disease. DATA SOURCES References were obtained through a MEDLINE literature search as well as from previous reviews. Relevant articles were critically reviewed and their conclusions were included. RESULTS Osteoporosis is a relatively common disease that is associated with significant morbidity and mortality. The management and prevention of osteoporosis have been improved by an increased awareness of the magnitude of the problem, a better understanding of the pathogenesis, development of a better technique for assessment of bone mineral density, and the availability of specific medications. With the increase in human life-span and the increasing use of glucocorticosteroids for a wide variety of diseases, the incidence of osteoporosis has been on the rise. CONCLUSION Glucocorticosteroids are the most common medications that cause or contribute to the pathogenesis of osteoporosis and have been widely used in allergy practice. It is important for physicians to appreciate the current basic understanding of osteoporosis and to be able to identify patients at high risk for this serious disorder, and to initiate appropriate intervention at a sufficiently early time to be effective. Medications for treatment and prevention of osteoporosis include: calcium, vitamin D, estrogen, bisphosphonates, calcitonin, and others are reviewed in this article.

Recurrent infections in a nine-month-old male infant.

A 9-month-old male infant presented with respiratory distress; three weeks before, he had been hospitalized for lobar pneumonia of undetermined etiology. In the hospital, he was treated with intravenous antibiotics for three days and discharged receiving oral amoxicillin/clavulanic acid. One week before the visit, the fever recurred and oral antibiotics were switched to clarithromycin. At examination, he was found to be tachypneic and hypoxic with 91% oxygen saturation while breathing room air. He was rehospitalized for further evaluation and management. Past medical history included a generalized erythematous maculopapular rash at birth with low-grade fever. The rash was spontaneously resolved in one week without specific diagnosis. He developed pneumococcal sepsis at 2 months, pneumonia at 4 months, and facial cellulitis at 6 months of age. These infections were eventually resolved with intravenous antibiotics. The patient had several episodes of otitis media in between these infections and intermittent oral thrush during antibiotic treatment. Usual bowel habits consisted of three to four mucousy, foul-smelling stools per day despite various formula changes in an attempt to improve stool pattern. At 6 months of age, nocturnal wheezing occurred but was being controlled with inhaled fluticasone (220 lg) twice a day. His development was appropriate for his age. He received three sets of diphtheria-tetanus-pertussis, inactivated polio, hepatitis B, and conjugated pneumococcal vaccines without serious adverse reaction. Family history was negative for consanguinity, cystic fibrosis, recurrent infections, or unexplained neonatal deaths. The patient never attended daycare. There was no exposure to smoking. There were no pets in the home. On admission, the patient appeared drowsy but easily aroused. It was noted that he appeared ‘‘somewhat fatigued’’ and unwilling to engage. He was afebrile, pulse was 120 beats per minute, and the respirations were 30 breaths per minute. Blood pressure was 90/40 mmHg. His weight was 7.9 kg (10th percentile for age) with no weight gain in the last two months; his length was 70.3 cm (50th percentile), and his head circumference was 45 cm (50th percentile). Tympanic membranes appeared normal. There was minimal clear nasal drainage present. The oropharynx demonstrated diffuse thrush on the buccal mucosa and tongue. No tonsillar tissue was noted. Lymphadenopathy was not appreciated. Chest examination revealed scattered crackles without wheezing. The abdomen was full with liver edge palpated 6 centimeters below the right costal margin. The spleen was not palpated. Neurologic examination revealed no focal deficit. Skin turgor was normal.

Fever, abdominal pain, and interstitial pneumonia in a 13-year-old female.

CASE PRESENTATION The patient is a 13-year-old female who presented with a 4-week history of fever, 3 days of abdominal pain, and 1 day of vomiting. Fever was intermittent, low grade, lasting for a few hours daily, and associated with generalized myalgia. One week before evaluation, fever was persistent and up to 40° C. She had daily abdominal pain, lasting for hours, located in the right upper quadrant and epigastrium, dull and mild in intensity with no aggravating or relieving factor identified. She was admitted to All Children’s Hospital, St. Petersburg, FL for further evaluation and care. Past medical history was significant for congenital hydrocephalus of unidentified etiology. Several ventriculo-peritoneal shunt revisions had been performed in the past, with the last revision 6 months before her visit. She had a history of asthma, currently in remission, with no bronchodilator use in the past 2 years. Review of systems revealed an eight-pound weight loss over a 6-month period with increasing tiredness. There were no night sweats, nasal symptoms, cough, dyspnea, chest pain, diarrhea, or urinary tract symptoms. She was not on any medication. There was no history of environmental, insect, or medication allergies. The travel history included visits to Washington DC and Maryland 4 months before admission, and Tennessee 2 months before admission. There was exposure to goats and deer but no history of tick bite during these visits. There was no history of tuberculosis exposure, nor family history of allergic or autoimmune disease. Social history was non-contributory. Physical examination revealed a thin girl in no apparent distress. Temperature was 38.8° C, pulse 120 beats/minute, respiratory rate 28 breaths/minute, blood pressure 90/60 mm Hg. Pertinent findings included palpable bilateral non-tender cervical lymph nodes, 1.5 1.5 cm in diameter. Chest was clear to auscultation, without any wheezing or crepitation. Abdomen was soft, non-tender nor distended, liver was palpable 3 cm below right costal margin with mild tenderness.