Transient elastography (TE) is a rapid noninvasive ultrasound-based technology that measures liver stiffness as a surrogate for liver fibrosis and controlled attenuation parameter (CAP) as a measure ...of liver steatosis. However, normal ranges in children are not well defined in all populations. The aim of this study was to determine transient elastography values in healthy South African children.
From April 2019 to December 2021, children were recruited from the HIV negative control group of a cohort study. Only children neither overweight nor obese, without evidence of liver disease, no medical condition or medication associated with hepatic steatosis or fibrosis and normal metabolic profile were included in this cross-sectional analysis. Clinical data, anthropometry and blood samples were collected on the same day as transient elastography with controlled attenuation parameter was performed.
104 children (median age 12.8 years IQR 11.4-14.8, range 7.9-17.7 years; 59 57% boys) were included. Liver stiffness was positively correlated with age (Pearson's r = 0.39, p < 0.001). Median liver stiffness in boys (5.2 kPa 5th to 95th percentiles 3.6 to 6.8 kPa) was greater than in girls (4.6 kPa 5th to 95th percentiles 3.6 to 6.1 kPa; p = 0.004), but there was no difference by ethnicity. Median CAP was 179dB/m (5th to 95th percentiles 158 to 233dB/m). There was a positive correlation between CAP and body mass index (BMI) z-score, but no difference by age, sex, ethnicity or pubertal status.
Liver stiffness values increase with age and are higher in healthy South African boys than girls, whereas CAP values vary with BMI, but not with age or sex.
BACKGROUND:Abdominal tuberculosis (TB) in children is poorly described and often poses a diagnostic challenge. We evaluated abdominal involvement in children presenting with bacteriologically ...confirmed TB.
METHODS:We undertook a retrospective study at Tygerberg Hospital, Cape Town, from January 1, 2014, through December 31, 2018, of all children (<13 years) diagnosed with bacteriologically confirmed TB, in whom abdominal involvement was found. Demographic and clinical data were collected through folder review, laboratory records and imaging reports.
RESULTS:Of 966 children with bacteriologically confirmed TB, 111 (11.5%) had abdominal involvement; 16 (14.4%) were excluded from further analysis because of lack of clinical data. The median age of the remaining 95 children was 43 months (interquartile range 20–94); 26 (27%) were HIV positive. The main gastrointestinal symptoms/signs were weight loss (84.2%), abdominal distention (54.7%), hepatomegaly (60.0%) and abdominal pain (26.3%). The main pathologic types were intra-abdominal lymph nodes (68.4%), solid organ involvement (54.7%), peritoneal type (23.2%) and intestinal type (10.5%). Splenic abscesses and solid organ involvement on ultrasonography were more common in HIV-positive children (P < 0.001 and P = 0.008, respectively). Liver abscesses were associated with age less than 5 years (P = 0.03), while abdominal lymphadenopathy on ultrasonography was more common in children older than 5 years (P = 0.038). Abdominal specimens were collected in an attempt to identify Mycobacterium tuberculosis in 15 of 95 (15.8%) patients and were positive in 13 of 15 (86.7%).
CONCLUSIONS:Over 10% of children with confirmed TB had abdominal involvement. Abdominal TB should be considered in any pediatric TB case with abdominal symptoms, and ultrasonography should be the radiologic study of choice.
We evaluated the prevalence and risk factors for hepatic steatosis in South African children with perinatally acquired HIV (PHIV) who started treatment early and remain on long-term antiretroviral ...therapy (ART) compared to HIV-uninfected children.
A cross-sectional study from April 2019 to October 2021. PHIV, HIV-exposed uninfected (HEU) and HIV-unexposed (HU) children were enrolled from an ongoing cohort study.
All children had transient elastography (TE) with controlled attenuation parameter (CAP). Liver enzymes, lipogram, insulin and glucose were sent after an overnight fast. Multivariable linear regression analyses identified predictors of CAP. Hepatic steatosis was defined as CAP>248kPa.
215 children (111 52% male; median age 14.1 years; IQR 12.7-14.9) participated in the study, 110 PHIV, 105 HIV-uninfected (36 HEU, 69 HU). PHIV initiated ART at a median age of 2.7 months (IQR 1.8-8.5). Hepatic steatosis prevalence was 9% in PHIV, 3% in HEU and 1% in HU children (
= 0.08). However, 8% of lean (body mass index
-score ≤ +1) PHIV had hepatic steatosis compared to zero lean HEU or HU children (
= 0.03). In multivariable linear regression analysis of all PHIV, body mass index (BMI) z-score was positively associated with CAP (
= 0.001) while CD4 count (
= 0.02) and duration of suppression of HIV viraemia (
= 0.009) were negatively associated with CAP, adjusting for age, sex and ethnicity.
Hepatic steatosis prevalence was higher in lean PHIV than lean HIV-uninfected South African children. Longer suppression of HIV viraemia and higher CD4 count were associated with lower CAP and might be protective factors for hepatic steatosis in PHIV children.
Swallowing disorders, well recognised in adults, contribute to HIV-infection morbidity. Little data however is available for HIV-infected children. The purpose of this study is to describe swallowing ...disorders in a group of HIV-infected children in Africa after the introduction of combined anti-retroviral therapy.
We describe 25 HIV-infected children referred for possible swallowing disorders. Clinical and videofluoroscopic assessment of swallowing (VFSS), HIV stage, and respiratory and neurological examination were recorded.
Median age was 8 months (range 2.8-92) and 15 (60%) were male. Fifteen (60%) were referred for recurrent respiratory complaints, 4 (16%) for poor growth, 4 (16%) for poor feeding and 2 (8%) patients for respiratory complaints and either poor growth or feeding. Twenty patients (80%) had clinical evidence of swallowing abnormalities: 11 (44%) in the oral phase, 4 (16%) in the pharyngeal phase, and 5 (25%) in both the oral and pharyngeal phases. Thirteen patients had a videofluoroscopic assessment of which 6 (46%) where abnormal. Abnormalities were detected in the oral phase in 2, in the pharyngeal phase in 3, and in the oral and pharyngeal phase in 1; all of these patients also had evidence of respiratory involvement. Abnormal swallowing occurred in 85% of children with central nervous system disease. CNS disease was due to HIV encephalopathy (8) and miscellaneous central nervous system diseases (5). Three of 4 (75%) patients with thrush had an abnormal oral phase on assessment. No abnormalities of the oesophagus were found.
This report highlights the importance of swallowing disorders in HIV infected children. Most patients have functional rather than structural or mucosal abnormalities. VFSS makes an important contribution to the diagnosis and management of these patients.
The diagnosis of abdominal tuberculosis (TB) is challenging, and the prevalence of abdominal TB in children is likely underestimated. It may present with nonspecific abdominal symptoms and signs, but ...children who present with pulmonary TB may have additional abdominal subclinical involvement. Diagnosis is specifically challenging because none of the available diagnostic tools provide adequate sensitivity and specificity. In this review, we summarize the best available evidence on abdominal TB in children, covering the epidemiology, pathogenesis, clinical presentation, diagnosis, and treatment. We propose a diagnostic approach that could be followed for symptomatic children. We believe that a combination of investigations could be useful to both aid diagnosis and define the extent of the disease, and we propose that abdominal ultrasound should be used more frequently in children with possible TB and any abdominal symptoms. This neglected disease has received little attention to date, and further research is warranted.
This retrospective study describes 63 patients <18 years of age presenting with cryptosporidial diarrhea to Tygerberg Children's' Hospital, a referral centre in the Western Cape, South Africa, from ...June 2004 through May 2005. Their mean age was 18.7 months (SD 17 months). Of the patients, 39 (62%) were male and 13 (20.6%) were HIV infected. Most children (57%) presented during the hot dry months of the year (December to March) and the majority (75%) of them required hospitalization. HIV-infected children were hospitalized for longer duration (median 18 days) than HIV-uninfected children (median 8.5 days). Four HIV-infected children (30.7%) died vs. four who were either HIV uninfected or of unknown status (p = 0.049). Seven of the children who died were malnourished. The CD4 count of HIV-infected children who died was 416 × 109 l−1 compared with 1269 × 109 l−1 (p = 0.1) for uninfected children. Cryptosporidium is an important cause of diarrhea among younger children in the Western Cape, which occurs more frequently during the dry months of the year and has a worse outcome in HIV-infected children.
During a 16-month period children presenting to a pediatric outpatient facility from an area with a high tuberculosis incidence (> 400/100 000) and suspected of having respiratory tuberculosis (TB) ...were evaluated for close contact with adult pulmonary tuberculosis, weight loss, symptom duration, respiratory signs, lymphadenopathy and hepatosplenomegaly and by chest radiography and tuberculin testing (Mantoux or tine). Probable tuberculosis was diagnosed in 258 children and was confirmed in 109 (42%) patients with a mean age of 31 months by culture of Mycobacterium tuberculosis from gastric aspirate or another source. Eleven children with confirmed TB had a normal chest radiograph. After review of special investigations, clinical course and follow-up of the remaining 149 children, 86 children (58%) with a mean age of 32.4 months were considered to have probable TB and 63 (42%) with a mean age of 27 months not to have TB. Significantly fewer children in the “not TB” group than in the confirmed and probable TB groups had a close adult pulmonary tuberculosis contact (13 (21%) and 95 (49%), respectively; P < 0.01). There was no difference between the “not TB” group and the confirmed and probable TB groups in the proportion presenting with weight loss, cough or other respiratory symptoms, a symptom duration >2 weeks, the presence of bronchial breathing, wheeze, hepatomegaly or splenomegaly or peripheral lymphadenopathy. Final diagnoses in the “not TB” group included bacterial or viral pneumonia or bron-chopneumonia in 37, asthma often accompanied by segmental collapse in 9 and cavitating pneumonia in 3 children. On the one hand children in whom there were sufficient criteria to be considered probable cases of TB were subsequently thought not to have TB; on the other hand 11 (10%) of children with TB confirmed by culture of Mycobacterium tuberculosis from gastric aspirate had a normal chest radiograph.
Gastro-oesophageal reflux is a normal physiological phenomenon that is frequently associated with regurgitation in infants. In general, it resolves by the age of one year. Some children are more ...likely to have persistent symptoms and develop complications, e.g. children with congenital abnormalities of the oesophagus, neurological impairment, and a family history of gastro-oesophageal reflux disease (GORD). Preliminary evidence suggests that GORD in infancy and childhood may be a precursor to adult GORD. GORD is reflux that is associated with troublesome symptoms or complications. These complications are categorised into oesophageal and extra-oesophageal difficulties. Diagnosis in most patients relies on a thorough history and physical examination. However, the symptoms in infants and young children are often atypical. Patients with significant symptoms require more extensive diagnostic assessment, such as contrast radiography, oesophagoscopy and oesophageal pH-metry. In most cases, parental reassurance and advice on feeding are sufficient. Thickened feeds reduce the frequency of regurgitation. Patients with complications require potent acid inhibition and occasionally anti-reflux surgery. PUBLICATION ABSTRACT
Introduction. Hepatitis A is a vaccine-preventable infection, common in children in the Western Cape. Objectives. To describe childhood hepatitis A morbidity and mortality at Tygerberg Children's ...Hospital, a level two and three referral hospital in the Western Cape, South Africa. Methods. Serological tests with positive hepatitis A IgM were identified from the Tygerberg Hospital virology laboratory database from 2001 to 2004. Medical records were reviewed if identified sera came from children younger than 13 years. The cases were cross-referenced with the paediatric gastroenterology database. Data collected included demographics, clinical and laboratory information, outcome, notification and primary prophylaxis. Results. 184 subjects were identified, comprising 117 males and 67 females with a median age of 69 (range 5 - 152) months. Two patients had hepatic failure and both died. Ten (5%) had known hepatitis A contacts but received no post-exposure prophylaxis, and only 31 (17%) were notified. A small percentage of patients were also positive for hepatitis B, hepatitis C and HIV. The median population incidence of serologically proven hepatitis A infection was 45.4/100 000/year, higher than the 20/100 000 advocated as a threshold for introducing vaccination into the immunisation schedule. Limitations. Incidence data calculated from prospective studies are usually more reliable than those from retrospective studies. Conclusions. This study confirms that hepatitis A is a serious risk to young children in the Western Cape, with significant morbidity and mortality. In addition, a sizeable number of cases were preventable. In order to determine the burden of disease and make recommendations about vaccination, the national incidence of hepatitis A must be assessed.
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