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John Midturi Kazembe, PN., Schutze, GE., Kline, MW

Case Series of HIV-infected children with Bacillus Calmette-Guérin Vaccine Related Lymphadenopathy in Lilongwe, Malawi. John Midturi Kazembe, PN., Schutze, GE., Kline, MW. Background-Malawi. Population of 13 million HIV prevalence 14% (15-49yr) 30,000 children infected with HIV

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John Midturi Kazembe, PN., Schutze, GE., Kline, MW

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  1. Case Series of HIV-infected children with Bacillus Calmette-Guérin Vaccine Related Lymphadenopathy in Lilongwe, Malawi John Midturi Kazembe, PN., Schutze, GE., Kline, MW

  2. Background-Malawi • Population of 13 million • HIV prevalence 14% (15-49yr) • 30,000 children infected with HIV • 125,000 individuals have been started on ART (Sept 2007) • children 8%

  3. Background-Malawi (2) • BCG incorporated into EPI schedule in 1974 • Administered within 1st week of life • 99% coverage • Danish 1331

  4. Background-Baylor COE • Baylor COE- established officially in November 2006 • Provision of pediatric HIV care, treatment and training • 3612 patients • 2155 active patients • ~50% on ART • Enroll ~100 new clients/month • Average age at enrolment • 4.56 years

  5. Background-BCG vaccine • Live attenuated vaccine • Adverse reactions • Injection site ulceration • Lymphadenitis • Disseminated disease • Dependent on strain, administration method, bacillary load, host immunity, and physical-chemical property • Incidence 0-17%

  6. True Incidence, unknown: Under-reported 0% to 30% Frequency similar to uninfected population Turnbull CID 2002 HIV-negative: 2.5% vaccine site abscess & 1.7% lymphadenitis HIV-Infected: 2.7% vaccine site abscess & 0.7% lymphadenitis Adverse reactions to BCG in HIV infected infants

  7. Objective • Identify incidence of BCG Disease in children infected with HIV at Baylor COE • Determine clinical course of BCG disease

  8. Retrospective chart review July 2005 through February 28th, 2007 All children diagnosed as HIV-infected at the Baylor COE. Data gathering: Computerized medical record chart Diagnosis of axillary lymphadenopathy, axillary lymphadenitis, BCG reaction, TB lymphadenitis, or right axillary adenopathy Methods

  9. Methods • Diagnosis: • BCG disease (EPI): • ipsilateral axillary lymph node enlargement of >15x15 mm, suppurative ipsilateral axillary lymphadenitis, injection site abscess of 10 mm, or a clinically significant or non-resolving BCG papule • BCG disease IRIS: • Temporal association of ARV initiation and development of right axillary adenopathy • CD4/CD4% increase >5%

  10. 13 cases:13/958, prevalence of 1.46% in HIV-infected children 10 BCG Disease IRIS (1.04%) Age: Range 4 months to 18 months Median 9 months WHO Stage: 8 Stage III (PTB/thrush/diarrhea) 5 Stage IV (PCP/severe malnutrition) Follow-up time: Range 2 weeks to 37 weeks Median 20 weeks Results

  11. Median CD4% 13%, (2.2%-23.4%)

  12. Median 3.5 weeks, (1-11weeks)

  13. 69.2% Spontaneously ruptured Median time to rupture 9.2 weeks, (2-14 weeks)

  14. Median 3 months, (1-4 months)

  15. Management • Treatments: • 8 TB therapy, 6 started TB meds prior to BCG Disease • 6 antibiotics • All Started ART • No surgical intervention • Outcome: • 11 alive • 2 died • both had BCG disease prior to ART • 1 on TB therapy • Mortality 3.2 per 100 weeks follow-up

  16. Conclusions • Prevalence of 1.46% in our HIV-infected pediatric population • Most develop BCG Disease IRIS 3-4 weeks after ART • ~70% of them rupture 9 weeks after ART • Most cases resolved after 3 months • Most of our patients were already on TB therapy when they developed BCG Disease

  17. Future • Complete analysis of our data • Potentially will become a more significant issue with the proposed universal treatment for all HIV-positive children under 12 months of age • Prospective study: • Role of INH prophylaxis to see if it decreases incidence of BCG disease • Delaying BCG vaccination in HIV-infected infants

  18. Acknowledgments • Dr. Peter Kazembe • BIPAI • Dr. Mark Kline • Dr. Gordon Schutze • Dr. Mark Kabue • All the patients and families from the Baylor COE-Malawi

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