Clinical Characteristics and Lung Function in Older Children Vertically Infected With Human Immunodeficiency Virus in Malawi

Abstract

BackgroundAntiretroviral therapy (ART) has led to increased survival of children with vertically acquired human immunodeficiency virus infection. Significant morbidity arises from respiratory symptoms, but aetiology and pulmonary function abnormalities have not been systematically studied.MethodsHuman immunodeficiency virus-positive children aged 8–16 years were systematically recruited within clinics in Blantyre, Malawi. Clinical review, quality of life assessment, spirometry, and chest radiography were performed.ResultsOne hundred sixty participants had a mean of age 11.1 (range, 8–16) years and 50.0% were female. Cough was present in 60 (37.5%) participants, and 55 (34.4%) had moderate or severe dyspnoea. Thirty-four (22.1%) participants had digital clubbing. Thirty-three (20.6%) participants were hypoxic at rest. One hundred eighteen (73.8%) of the children were receiving ART; median CD4 count was 698 cells/µL in these compared with 406 cells/µL in ART-naive individuals (P < .001). From 145 spirometry traces (90.6%), mean forced expiratory volume in 1 second (FEV1) and forced vital capacity (FVC) were 1.06 and 0.89 standard deviations below predicted mean, respectively. Twenty-one (14.5%) traces demonstrated obstructive defects and 26 (17.9%) reduced FVC. Lung function abnormality was not associated with any clinical findings. Of the 51 individuals with abnormal lung function, the mean increase in FEV1 after salbutamol was 3.8% (95% confidence interval, 0.02–7.53). “Tramlines” and ring shadows were seen on chest radiographs in over half of cases.ConclusionsSymptoms of chronic lung disease were highly prevalent with 2 main clinical phenotypes: “cough” and “hypoxia”. Lung function abnormalities are common, poorly responsive to bronchodilators, and apparent throughout the age range of our cohort. Pathological causes remain to be elucidated. Cough and hypoxic phenotypes could be a useful part of diagnostic algorithms if further validated.

Chronic lung disease in HIV-infected children established on antiretroviral therapy

“…However, in resource-limited settings, no longitudinal studies have been conducted to define how such abnormalities change over time or how they respond to ART. Interestingly, in our current study, obstructive lung disease was less common than in a study conducted in Malawi (4 vs 26%) [4]. In the Malawi study, however, 31% of individuals were ART-naive or had been taking ART for a relatively shorter duration (median 20 months) [2].…”

“…Respiratory disease is the most common manifestation of HIV/AIDS among children, accounting for more than 50% of HIV-associated mortality [1–4]. The use of antiretroviral therapy (ART) and co-trimoxazole prophylaxis has contributed to a reduction in the rate of acute respiratory tract infections and mortality among HIV-infected children in both high-resource and low-resource settings [5].…”

“…Nevertheless, recent studies in Southern Africa have demonstrated that about 30% of African HIV-infected older children have chronic respiratory symptoms, classically a chronic cough [often leading to presumptive treatment for tuberculosis (TB)] and reduced exercise tolerance [3,4]. In these studies, even participants with pronounced respiratory impairment looked well at rest, not all had cough, and plain radiological abnormalities were subtle and not consistent with LIP [9].…”

Risk Factors for Hypoxia and Tachypnea Among Adolescents With Vertically-acquired HIV in Nairobi

“…In a study of HIV-infected adolescents in Malawi, chronic lung disease phenotypes were characterized as hypoxia- or cough-predominant. 7 Although pathologic correlates were not available in that study or in ours, specific combinations of routinely ascertained signs and symptoms may contribute to future clinical algorithms for identifying adolescents with chronic lung diseases in resource-limited settings. Most risk factors identified in our study are modifiable and may be amenable targets for mitigating the burden of chronic lung diseases.…”

“…Respiratory abnormalities, such as hypoxia and tachypnea, are often manifestations of lung disease, 5–7 and their presence may aid in identifying HIV-infected adolescents with chronic lung diseases. Among adolescents with vertically-acquired HIV in Zimbabwe who had no acute respiratory symptoms, 13% had hypoxia at rest and 28% were tachypneic.…”