Altered Mental Status Among Febrile Hospitalized HIV-Infected Children Aged 0–59 Months in Mozambique

Abstract

Background Altered mental status (AMS) is a priority presenting sign that must be assessed in HIV-infected, febrile children, yet diagnosis is difficult in areas with limited diagnostic capacity. Malaria and bacterial meningitis have been reported as the most common causes of AMS in febrile children presenting to the hospital in sub-Saharan Africa. However, in an HIV-infected child, central nervous system manifestations are diverse. Methods We conducted a clinical observational study of HIV-infected febrile children, aged 0–59 months, hospitalized in Mozambique and prospectively followed. Within this cohort, a nested study was designed to characterize children admitted with AMS and to assess factors associated with mortality. Univariate and multivariable analysis were performed comparing characteristics of the cohort by AMS status and evaluated demographic and clinical factors by in-hospital mortality outcome. Results In total, 727 children were enrolled between April 2016 and February 2019, 16% had AMS at admission. HIV-infected, febrile children, who presented with AMS and who had a diagnosis of bacteremia, had a 4-fold increased relative odds of in-hospital mortality, and children who presented with neurologic symptoms on admission had a roughly 8-fold higher odds of in-hospital mortality relative to children without presenting neurologic findings. Conclusions Mozambique has a pressing need to expand local diagnostic capacity. Our results highlight the critical need for clinicians to incorporate a broader differential into their potential causes of AMS, and to develop a Ministry of Health approved diagnostic and management algorithm, which is standardly used, to manage patients for whom reliable and relevant diagnostic services are not available.

Community-acquired bacteremia among HIV-infected and HIV-exposed uninfected children hospitalized with fever in Mozambique

“…As our blood cultures were collected at the time of hospital admission, this seems also to be plausible in our population. Mozambique is one of the high prevalence countries for HIV and tuberculosis ( Moon et al, 2013 ; Duffy et al, 2020 ; Moon et al, 2020 ). As such, the bacteria in the country are under direct pressure with a large proportion of the general population taking prophylactic cotrimoxazole.…”

“…Access to a microbiology laboratory is limited in many developing countries ( Reddy et al, 2010 ). In Mozambique, blood culture capacity is currently only available at referral hospitals or research centers with little direct impact on patient care ( Duffy et al, 2020 ; Moon et al, 2020 ; Moon et al, 2013 ). Consequently, health professionals must rely on empirical approaches oriented towards syndromic treatment, risking an unsatisfactory clinical outcome and potentially promoting antimicrobial resistance ( Reddy et al, 2010 ; Moon et al, 2013 ; Duffy et al, 2020 ; Moon et al, 2020 ).…”