Human immunodeficiency virus serology in a

CASE REPORT
Human immunodeficiency virus serology in a pediatric
emergency department: reasons for ordering tests and
the characteristics of positive cases
VANESA FERNÁNDEZ DÍAZ1, JUAN DARÍO ORTIGOZA ESCOBAR1, ANTONI NOGUERA JULIÁN2,
CLÀUDIA FORTUNY GUASCH2, VICTORIA TRENCHS SAINZ DE LA MAZA1,
YOLANDA FERNÁNDEZ SANTERVÁS1
Servicio de Urgencias, 2Unidad de Infectología, Servicio de Pediatría, Hospital Sant Joan de Déu, Universitat
de Barcelona, Esplugues de Llobregat, Barcelona, Spain.
1
CORRESPONDENCE:
Yolanda Fernández Santervás
C/ Passeig Sant Joan de Déu, 2
08950 Esplugues de Llobregat
Barcelona, Spain
E-mail:
[email protected]
RECEIVED:
20-10-2011
ACCEPTED:
5-3-2012
CONFLICT OF INTEREST:
The authors declare no conflict
of interest in relation with the
present article.
This study aimed to determine the most common reasons for ordering human
immunodeficiency virus (HIV) serology in a pediatric emergency department and to
describe the characteristics of HIV-positive cases. In 11 years, 933 HIV serologies were
ordered in the department. The most common reasons were protocols at the onset of
cancer or blood disease (40.1%), accidental puncture (17.8%), and high-risk sexual
intercourse (14.3%). The serology was positive in 4 cases (prevalence, 0.4%; 95% CI,
0.1%-1.1%). Three of the positive results were for children with a family history of HIV;
in the fourth positive case the patient had a mononucleosis-like syndrome and had had
high-risk sexual intercourse. Thus, most HIV serologies are performed to follow hospital
protocol rather than because there is clinical suspicion of HIV infection. The very few
patients who are diagnosed as HIV-positive in the pediatric emergency department have
family histories of seropositivity or have had high-risk intercourse. [Emergencias
2013;25:289-291]
Keywords: Children. Emergency department. Human immunodeficiency virus.
Introduction
The overall rate of newly diagnosed human
immunodeficiency virus (HIV) infection in Spain is
similar to that of neighboring countries such as
France (7.9 and 7.6/100,000 population in 2009).
Despite a decline in recent years, it remains higher than the rate for all EU countries (5.7/100,000
in 2009)1,2.
In pediatrics, the main route of HIV transmission is from mother to child3,4. Recent years have
seen a drastic decrease in the incidence of HIV infection in children, and a reduction in vertical
transmission to below 1%, due to the application
of different prevention measures for infected
pregnant women and their newborns4-6.
In Spain, HIV testing is free and confidential.
However, 50% of those diagnosed with HIV in
2009 showed signs of late diagnosis1. There are
different situations and medical conditions where
Emergencias 2013; 25: 289-291
serology must be used because of increased risk
of infection and because a positive result leads to
a change in the therapeutic approach of the underlying disease. The present study aimed to determine the most common reasons for requesting
HIV serology in a pediatric emergency department
(PED) and describe the characteristics of positive
cases.
Method
The study was carried out in an urban, tertiary
mother-child hospital – the reference center for
some 1,800,000 inhabitants – with an average
280 visits per day. We retrospectively reviewed
the discharge reports of patients under 18 years
for whom HIV serology had been requested by
the PED between 2000 and 31 December 2010.
The variables studied were age, gender, reason for
289
V. Fernández Díaz et al.
requesting HIV serology and the result. The characteristics of positive cases were then analyzed.
As per PED protocol, HIV serology is requested
for all patients with discarded needle puncture,
risky sexual intercourse, and those diagnosed with
hematological malignancy debut who will receive
blood transfusion, as well as any patients with a
clinical picture suggesting infection by this virus.
Occasionally, at the discretion of the attending
pediatrician, HIV serology is requested in cases of
recent adoption if there is some reason to justify
the test and there is great family distress about it.
In our center, the HIV detection method is an
immunoassay (ELISA) of chemiluminescent microparticles using an Architect i2000 ® analyzer
with Architect HIV Ag/AB® reagent from Abbott
with subsequent confirmation of positive results
by Innolia of INNOGENETICS® (Western blot) immunoassay. In patients younger than 18 months,
the detection method is polymerase chain reaction technique (CA HIV Monitor®, Roche, Basel,
Switzerland ; limit < 50 copies/ml).
Quantitative variables are expressed as mean
and standard deviation or as median and percentiles and qualitative variables as proportions.
Table 1. Reasons for requesting HIV serology in the Pediatric
ED (n = 933)
n (%)
Hematological malignancy
Accidental puncture
Suspected sexual abuse
Prolonged febrile syndrome
Immigrant patient
Multiple adenopathy
Risky sexual behavior
Liver Disease
Skin lesions
Renal transplantation protocol
Other
324 (35)
165 (18)
98 (11)
87 (9)
75 (8)
37 (4)
34 (4)
33 (3)
29 (3)
13 (1)
38 (4)
– Case 3: 4 year-old girl born in Andalusia to a
HIV-positive mother with uncontrolled and risky
behavior. The child was referred to our center
with the diagnosis of pneumonia and positive
blood culture for Pneumocystis carinii; HIV infection was classified as stage C2.
– Case 4: 13 year old boy who consulted for
persistent fever, generalized adenopathic reaction,
asthenia and disseminated macula-papular rash.
The boy had had unprotected sex; HIV infection
was classified as stage A2 at diagnosis.
Discussion
Results
During the study period, HIV serology was requested from the ED for 933 patients who constituted the study sample. Of these, 473 (52.4%)
were male, median age 6.3 years (P25-P75 from
2.7 to 13.3 years).
The most common reasons for requesting HIV
serology were: hematologic cancer debut in 324
patients (35%), accidental needle puncture in 165
(18%) and suspected sexual abuse in 98 (11%)
patients (Table 1).
Of 933 determinations, 6 were ELISA positive
(0.4% of all HIV serology tests requested; 95% CI
0.2 to 1.1%) and 4 of these were confirmed as
positive by Westerm blot.
– Case 1: 6-year-old child immigrant from
Thailand, HIV positive serology in her country of
origin. At 72 hours of arrival in Spain she presented fever and cough. On PED arrival she was provisionally diagnosed with probable pulmonary tuberculosis and HIV serology was requested; HIV
infection was classified as stage B2.
– Case 2: 11-month girl from Ethiopia after
adoption; her biological parents were HIV positive
but the child’s HIV status was unknown and for
this reason her adopted parents took her to the
PED; HIV infection was classified as stage N1.
290
The number of patients diagnosed with HIV infection in our PED is very low: 0.4% of all HIV
serology tests requested. This low rate is related
with the reasons for requesting HIV serology in
our PED with two main groups of patients: those
diagnosed with hematological malignancy who
will receive a blood transfusion (patients with no
personal or familial history of HIV) and the those
with accidental needlestick puncture, although
there is only a theoretical risk of HIV transmission
and no cases of new infection by this route7-9.
In our study, patients with HIV-positive serology had a familial history of known HIV infection
or risky sexual behavior favoring transmission. According to Oliva et al.10, delayed diagnosis is observed in up to 22.2% of documented cases of
HIV infection in the pediatric population up to 19
years of age in Spain. Correct history taking is
therefore essential in both the patient and family
members, to detect possible risky behaviors and,
secondarily, to avoid delayed diagnoses which
worsens prognosis.
The study presents the limitations of a retrospective study in which there may be undetected
cases or data not collected. However, the sample
size is large and very representative of patients
seen in our PED in the last 11 years with respect
Emergencias 2013; 25: 289-291
HUMAN IMMUNODEFICIENCY VIRUS SEROLOGY IN A PEDIATRIC EMERGENCY DEPARTMENT
to HIV serology solicited. In conclusion, most
were in compliance with the protocol for hematological malignancy or accidental needlestick puncture and not on suspicion of HIV infection, which
makes overall diagnostic yield very low. However,
it is important to maintain a high index of suspicion in cases with personal or family history at risk
to avoid delay in diagnosis.
References
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Motivos de solicitud de la serología frente al virus de la inmunodeficiencia humana
en un servicio de urgencias pediátrico. ¿Cuándo resulta positiva?
Fernández Díaz V, Ortigoza Escobar JD, Noguera Julián A, Fortuny Guasch C, Trenchs Sainz de la Maza V,
Fernández Santervás Y
En el presente estudio se pretende determinar los motivos más frecuentes por los que se solicitan serologías para el virus de la inmunodeficiencia humana (VIH) en un servicio de urgencias (SU) pediátrico, así como describir las características de los casos en que resultan positivas. En 11 años se solicitaron 933 determinaciones de VIH en el SU. Los motivos de solicitud más frecuentes fueron por protocolo debut de patología hematooncológica (40,1%), pinchazo
accidental (17,8%) y relación sexual de riesgo (14,3%). Resultaron positivas 4 determinaciones (prevalencia 0,4%;
IC95% 0,1-1,1%); 3 en pacientes con antecedentes familiares de VIH y 1 en un paciente con síndrome mononucleosiforme y relaciones sexuales de riesgo. Por tanto, la mayoría de serologías de VIH se realizaron por protocolo hospitalario y no por sospecha clínica de infección VIH. El número de pacientes diagnosticados de VIH en urgencias pediátricas
es pequeño y éstos tienen antecedentes familiares o presentan conductas de riesgo. [Emergencias 2013;25:289-291]
Palabras clave: Niños. Servicio de urgencias. Virus de la Inmunodeficiencia humana.
Emergencias 2013; 25: 289-291
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