BRIEF REPORTS
METHODS
IS PERTUSSIS IMMUNE GLOBULIN EFFICACIOUS
FOR THE TREATMENT OF HOSPITALIZED INFANTS
WITH PERTUSSIS?
NO ANSWER YET
Scott A. Halperin, MD,*† Wendy Vaudry, MD,‡
Francois D. Boucher, MD,§ Kate Mackintosh, BN, RN,*
Thomas B. Waggener, PhD,储 and Bruce Smith, PhD,¶ for the
Pediatric Investigators Collaborative Network on Infections in
Canada (PICNIC)
Abstract: In a multicenter, randomized, placebo-controlled clinical
trial of pertussis immune globulin, intravenous (P-IGIV), 25 infants
hospitalized with pertussis were enrolled in 24 months (15% of the
target sample size) before the study was prematurely terminated
because of expiration of the P-IGIV lots and unavailability of
additional study product. Although well tolerated, there was no
difference in the number or rate of improvement of symptoms
(paroxysmal cough, whoop, apnea, bradycardia, oxygen desatura-
tions) in P-IGIV recipients compared with placebo.
Key Words: pertussis, immunoglobulin, placebo-controlled,
randomized clinical trial
Accepted for publication September 14, 2006.
From the Departments of *Pediatrics and †Microbiology and Immunology
and ¶Mathematics and Statistics, Dalhousie University, Halifax, Nova
Scotia, Canada; the ‡Department of Pediatrics, University of Alberta,
Edmonton, Alberta, Canada; §Le Centre Hospitalier Universitaire de
Québec, CHUL, Ste-Foy, Quebec, Canada; and 㛳Physio Analytics, New-
ton, MA.
Address for correspondence: Dr Scott A. Halperin, Canadian Center for
Vaccinology, Halifax, Dalhousie University, IWK Health Centre, 5850/
5980 University Avenue, Halifax, NS B3K 6R8 Canada. E-mail:
scott.halperin@dal.ca.
Copyright © 2006 by Lippincott Williams & Wilkins
DOI: 10.1097/01.inf.0000247103.01075.cc
P ertussis (whooping cough) is an acute respiratory infection
caused by Bordetella pertussis characterized by paroxysmal
coughing, coughs ended by a whoop or vomiting, apnea and cya-
nosis. Although the epidemiology of pertussis has shifted toward
disease in adolescents and adults,1–3 most morbidity and virtually all
mortality remains in young infants, particularly those too young to
have completed their primary immunization series.4,5 Macrolide
antibiotics eradicate the bacteria from the nasopharynx but do not
modify the clinical course unless given early in the catarrhal stage of
the illness, usually before pertussis is suspected.6
Hyperimmune globulin for the treatment of pertussis predates
the antibiotic era beginning with the observation that convalescent
serum administered during the incubation period prevented or mod-
ified the subsequent disease.7 However, clinical trials with pertussis
immune globulin did not provide additional benefit compared with
antibiotics alone8 leading to the withdrawal from the market of the
only commercial intramuscular pertussis immune globulin. More
recently, with the identification of pertussis toxin (PT) as the major
virulence factor of B. pertussis9 and evidence that anti-PT antibody
was protective in an animal respiratory model of pertussis infec-
tion,10 there has been renewed interest in hyperimmune globulin. In
a phase I clinical trial, a single injection of an intravenous prepara-
tion of pertussis immune globulin (P-IGIV) was well tolerated in
young infants hospitalized with pertussis with the suggestion of a
shortened duration and rate of paroxysmal cough.11 We report a
multicenter, phase 3, randomized, placebo-controlled clinical trial to
assess the efficacy of P-IGIV.
The Pediatric Infectious Disease Journal • Volume 26, Number 1, January 2007
Products and Devices. P-IGIV is a sterile 5% solution of IgG
stabilized with 5% sucrose and 1% human albumin derived from
volunteers immunized with a tetranitromethane inactivated PT vac-
cine (Massachusetts Biologic Laboratories, Jamaica Plain, MA).
Pooled plasma was fractionated by ethanol precipitation followed by
a solvent– detergent viral inactivation process. The IgG fraction was
modified to yield a product suitable for intravenous administration.
Two lots were used; the anti-PT antibody levels were 171 and 91.2
EU/mL, respectively. The initial placebo was an identical-appearing
solution of a 1% human albumin in 5% sucrose; because of concerns
about human albumin, the placebo was changed to 0.9% sodium
chloride solution. P-IGIV (750 mg/kg) or placebo was administered
as a single infusion over approximately 3 hours; the infusion was
initially at 1.5 mL/kg per hour increasing gradually to 6.0 mL/kg per
hour. The rate was decreased if any adverse events (flushing, chills,
muscle cramps, fever, transient hypotension) were encountered. The
dose of P-IGIV used had previously been demonstrated to achieve
anti-PT antibody titers 7-fold higher than patients recovering from
natural pertussis infection.11
Subjects were monitored with a Physiac monitor (Physio
Analytics, Newton, MA) specifically designed and validated for the
study that provides continuous, high-resolution monitoring of phys-
iological variables for extended periods of time (up to 13 days). A
standard clinical monitor (Nonin 8800 CardioRespiratory Oximeter;
Nonin Medical, Inc, Plymouth, MN) serves as the patient interface
with vocal activity recorded with a microphone and audio monitor.
Analog outputs from the patient and audio monitors are sent to a
computer-based data acquisition system, digitized and stored. The
Physiac monitors respiration, heart rate, oxygen saturation and
cough and, using predefined, validated criteria, identifies paroxys-
mal coughing episodes (ⱖ8 coughs within 10 seconds).
Study Population, Randomization, and Blinding. Children ⬍5 years
of age were eligible for enrollment if they were admitted to a
participating hospital with suspected pertussis defined by paroxys-
mal cough of any duration and one or more of the following criteria:
cough ⱖ7 days, cough with whoop, posttussive vomiting, apnea,
cyanosis and elevated white blood count ⬎12.5 ⫻ 109/L and
lymphocytosis (⬎40%). For infants ⬍1 year, apnea and a positive
culture or polymerase chain reaction for B. pertussis or a household
or other close contact with laboratory-confirmed pertussis was also
sufficient for eligibility. At least 4 inhospital observed or monitored
episodes of paroxysmal coughing or oxygen desaturation ⬍90%
during a 4-hour observation period were also required. Children
were excluded if they had any allergy to immune globulin,
personal or family history of IgA deficiency, hemodynamically
significant cardiac disease, bronchopulmonary dysplasia, receipt
of systemic steroids ⬎1 mg/kg per day for 7 consecutive days
within the 3 weeks before enrollment, history of culture-con-
firmed pertussis before the current illness or intubation before
randomization (intubation after enrollment was not an exclusion
to continued participation).
After informed consent and establishment of an intravenous
line, participants underwent a 4-hour observational and monitoring
baseline. Participants were randomly allocated by a computer-
generated list in a 2:1 (P-IGIV:placebo) ratio with a balanced block
size of 6 stratified by age (⬍1 year, ⱖ1 year) and center. Study
medication was prepared by an unblind pharmacist at each site; all
investigators, study staff and participants were blind to the treatment
assignment. After the placebo was changed from albumin to saline,
blinding was maintained by covering the medication bag with an
opaque plastic bag.
Outcomes, Analysis, and Sample Size. The primary outcome mea-
sure was the rate of improvement in the number of paroxysmal
79
Halperin et al The Pediatric Infectious Disease Journal • Volume 26, Number 1, January 2007

coughing events (defined as ⱖ8 coughs within 10 seconds). For each

subject, the number of events in 6-hour periods was counted and the TABLE 1. Demographics, Illness Characteristics, and
slope of the resulting plot of events versus time was estimated Measures of Efficacy
using Poisson regression. The estimated mean slopes and 95%
Pertussis
confidence intervals were calculated by treatment group and Immune
compared using t tests. Similar analyses were carried out for Placebo
Globulin,
Category Measure Intravenous
episodes of oxygen desaturation, bradycardia, apnea and whoop.
A second efficacy analysis was performed based on the number of Number reporting (%)
events per hour; medians were compared by group using Wil-
coxon tests. A P value of ⬍0.05 was considered statistically Clinical symptoms Paroxysmal cough 7 (87.5) 17 (100)
significant for all comparisons. Vomiting with cough 7 (87.5) 14 (82.4)
The sample size was calculated based on the ability to detect Whoop 3 (37.5) 10 (58.8)
Apnea 2 (28.6) 11 (64.7)
a more rapid achievement of a 50% reduction in events. A sample Cyanosis 6 (75.0) 13 (76.5)
size of 174 was sufficient to have 90% power to detect a reduction Nasal congestion 6 (75.0) 11 (64.7)
of 50% of events from 5 days in the placebo group to 2.5 days in the Efficacy
P-IGIV group. Rate of
improvement Mean Slope
Paroxysmal cough ⫺0.009 ⫺0.007
RESULTS Oxygen desaturations ⫺0.003 ⫺0.003
As a result of slower than anticipated enrollment, both P- Bradycardia ⫺0.011 ⫺0.007
Apnea ⫺0.001 ⫺0.004
IGIV lots expired before the study could be completed and no Whoop ⫺0.007 ⫺0.006
further P-IGIV was available. After 24 months of study, only 25 Frequency of
participants had been enrolled and randomized (17 P-IGIV, 8 pla- events Median Events/h
cebo); one participant randomized to saline who did not meet the Paroxysmal cough 0.851 0.492
criteria for sufficient events during the observation period was not Oxygen desaturations 0.269 1.039
infused. Bradycardia 0.633 0.740
Apnea 0.032 0.176
Demographics. The mean age was 2.3 months (range: 0.7– 6.8 Whoop 0.461 0.306
months) in the P-IGIV group and 1.9 months (range: 0.6 –5.1
months) in the placebo group; there was a female preponderance in
both groups (59% and 62.5%, respectively). None of the placebo
recipients and 4 of the P-IGIV recipients had previously received
any doses of pertussis vaccine (2 one dose, one 2 doses, and one 3 secondary efficacy outcome, there were also no differences in the
doses). median number of events per hour during the observation period
Illness Characteristics. Six (75%) placebo recipients and 12 (70.6%) (Table 1).
P-IGIV recipients had laboratory confirmation of pertussis (the
majority were culture positive); all participants were included in the DISCUSSION
analysis of safety and efficacy. Approximately half had a known The negative results of this phase 3, randomized, double-
exposure to a case of pertussis. There were no differences between blind, placebo-controlled clinical trial of P-IGIV do not support the
the groups for presence, duration or severity of pertussis symptoms initial promise of efficacy with another pertussis immune globulin12
(Table 1). and from the phase 1 study with this product.11 Although the power
Safety. P-IGIV was well tolerated by study participants. An adverse of the study was low because only 15% of the calculated sample size
event was reported by 5 (62.5%) placebo and 13 (76.5%) P-IGIV was enrolled, there were no trends suggesting a beneficial effect.
recipients. Most adverse events were attributed to the disease (par- Potential explanations for these results include the type of patients
oxysmal cough, apnea, cyanosis), another condition (gastroesopha- selected, the timing of administration, the appropriateness of the
geal reflux) or intercurrent infection days to weeks later (Clostrid- outcome measures and the presence of sufficient antibody. Although
ium difficile diarrhea, respiratory syncytial virus bronchiolitis). not required by the inclusion criteria, the patients enrolled in the trial
There were no infusion-related adverse events; no infusions were were all infants. This reflects the known epidemiology of severe
slowed or stopped as a result of an adverse event. Vital signs did not pertussis in North America with infants most likely to be hospital-
change significantly during the infusion in either group and there ized and also most likely to benefit from this type of treatment.4,5
were no differences between the groups. Subjects were enrolled shortly after admission to the hospital with
Efficacy. There were no differences in geometric mean antibody the only delay being that required to ensure that pertussis-like
titers (GMT) against the pertussis antigens PT, filamentous hemag- symptoms were present. The outcomes were specifically chosen to
glutinin, pertactin and fimbriae before P-IGIV infusion. On day 3 reflect typical pertussis symptoms that contribute to the morbidity
postinfusion, IgG GMT were higher in P-IGIV than placebo recip- and mortality and to assess both the quantity of symptoms and the
ients against all pertussis antigens (filamentous hemagglutinin GMT rapidity of improvement. Finally, the anti-PT antibody levels
of 33.3 versus 2.37 EU/mL; pertactin 23.8 versus 1.95 EU/mL; achieved by 3 days after infusion were far in excess of those
fimbriae 30.6 versus 3.72 EU/mL) with the most significant differ- achieved after active immunization of infants or adults.13
ence in anti-PT antibody (GMT of 854 versus 3.09 EU/mL); there The clinical trial was terminated early because of slow subject
were no significant differences between the 2 P-IGIV lots. The recruitment, expiration of the 2 product lots and the financial
higher titers in P-IGIV recipients persisted 1 month postinfusion (eg, investment required to manufacture additional product for this
for PT: GMT 480 EU/mL in P-IGIV recipients versus 174 EU/mL orphan indication. The economic burden to continue development of
in placebo recipients). both a vaccine for donor immunization as well as a hyperimmune
For clinical efficacy outcomes, there were no differences globulin could not be sustained by the sponsor. Unfortunately, this
between P-IGIV or placebo in the rates of improvement (as mea- study was unable to either confirm or refute the benefit of pertussis
sured by the slope of the event line) for any of the symptoms. In the immune globulin for the treatment of pertussis. In view of the trend

80 © 2006 Lippincott Williams & Wilkins

The Pediatric Infectious Disease Journal • Volume 26, Number 1, January 2007
to replace human-derived intravenous immunoglobulin preparations
with monoclonal antibodies, the benefit of passive antibodies against
pertussis antigens for the treatment or prevention of pertussis may
need to await the development of novel antibody products.
ACKNOWLEDGMENTS
The authors thank Beth Halperin, Heather Samson, Petra
Rykers and Mary Fotheringham from the Clinical Trials Research
Center for study management, coordination, data management and
study report compilation, respectively. The authors thank Pat Roebuck
from the Orphan Products Grant Program of the U.S. Food and Drug
Administration and David Klein from the U.S. National Institute of
Allergy and Infectious Diseases for continued programmatic support.
Participating PICNIC investigators: Kathryn Edwards, MD,
Vanderbilt University, Nashville, TN; Robert Daum, MD, University
of Chicago–Wyler Children’s Hospital, Chicago, IL; H. Dele Da-
vies, MD, Alberta Children’s Hospital, Calgary, Alberta (currently
affiliated with the Michigan State School of Medicine, East Lansing,
MI); Barbara Law, MD, University of Manitoba, Winnipeg, Mani-
toba, Canada; Elaine Mills, MD, Montreal Children’s Hospital,
Montreal, Quebec, Canada (currently affiliated with Sanofi Pasteur,
Toronto, Ontario, Canada); Noni MacDonald, MD, Children’s
Hospital of Eastern Ontario, Ottawa, Ontario, Canada (currently
affiliated with Dalhousie University, Halifax, Nova Scotia, Canada);
Elaine Wang, MD, Hospital for Sick Children, Toronto, Ontario,
Canada (currently affiliated with Replidyne, Inc., Hartford, CT);
Penelope Dennehy, MD, Rhode Island Hospital, Providence, RI;
Sarah Long, MD, Saint Christopher’s Hospital, Philadelphia, PA;
and Donna Ambrosino, MD, Massachusetts Biologic Laboratories,
Jamaica Plain, MA.
This study was funded by grants from the Orphan Product
Grant Program of the U.S. Food and Drug Administration and the
U.S. National Institute of Allergy and Infectious Diseases (grant no.
FD-R-001044) and the Massachusetts Biologic Laboratories, Uni-
versity of Massachusetts Medical School.
REFERENCES
1. Galanis E, King AS, Varughese P, Halperin SA; IMPACT Investigators.
Changing epidemiology and emerging risk groups for pertussis. CMAJ.
2006;174:451– 452.
2. Skowronski DM, De Serres G, MacDonald D, et al. The changing age
and seasonal profile of pertussis in Canada. J Infect Dis. 2002;185:
1448 –1453.
3. Centers for Disease Control and Prevention (CDC). Pertussis—United
States, 2001–2003. MMWR Morb Mortal Wkly Rep. 2005;54:1283–
1286.
4. Tanaka M, Vitek CR, Pascual FB, Bisgard KM, Tate JE, Murphy TV.
Trends in pertussis among infants in the United States, 1980 –1999.
JAMA. 2003;290:2968 –2975.
5. Halperin SA, Wang EE, Law B, et al. Epidemiological features of
pertussis in hospitalized patients in Canada, 1991–1997: Report of the
Immunization Monitoring Program–Active (IMPACT). Clin Infect Dis.
1999;28:1238 –1243.
6. von König CH. Use of antibiotics in the prevention and treatment of
pertussis. Pediatr Infect Dis J. 2005;24(suppl 5):S66 – 68.
7. Bradford WL. Use of convalescent blood in whooping cough. Am J Dis
Child. 1935;50:918 –923.
8. Balagtas RC, Nelson KE, Levin S, Gotoff SP. Treatment of pertussis
with pertussis immune globulin. J Pediatr. 1971;79:203–208.
9. Pittman M. Pertussis toxin: the cause of the harmful effects and pro-
longed immunity of whooping cough. A hypothesis. Rev Infect Dis.
1979;1:401– 412.
10. Sato H, Sato Y. Protective antibodies in mice of monoclonal antibodies
against pertussis toxin. Infect Immun. 1990;58:3369 –3374.
11. Bruss J, Malley R, Halperin S, et al. Treatment of severe pertussis: a
study of the safety and pharmacology of intravenous pertussis immuno-
globulin. Pediatr Infect Dis J. 1999;18:505–511.
© 2006 Lippincott Williams & Wilkins
Pneumocystis and SIDS
12. Granstrom M, Olinder-Nielsen AM, Holmblad P, Mark A, Hanngren K.
Specific immunoglobulin for treatment of whooping cough. Lancet.
1991;338:1230 –1233.
13. Black S, Greenberg DP. A combined diphtheria, tetanus, five-component
acellular pertussis, poliovirus and Haemophilus influenzae type b vac-
cine. Expert Rev Vaccines. 2005;4:793– 805.
PNEUMOCYSTIS IS NOT A DIRECT CAUSE OF
SUDDEN INFANT DEATH SYNDROME
Sergio L. Vargas, MD,* Carolina A. Ponce, MS,*
Paula Gálvez, DVM,* Carolina Ibarra, DVM,*
Elisabeth A. Haas, MPH,† Amy E. Chadwick, BA,†
and Henry F. Krous, MD†‡
Abstract: We compared the frequency of Pneumocystis in 126
sudden infant death syndrome (SIDS) cases with a control group of
24 infants from the San Diego SIDS/SUDC Research Project who
died of accidental or inflicted injuries. Cysts were identified in 33%
of SIDS cases and 29% of controls. We conclude that Pneumocystis
is not a direct cause of SIDS.
Key Words: Pneumocystis, infants, autopsy, infanticide, accident,
SIDS, respiratory infection
Accepted for publication September 14, 2006.
From the *Programa de Microbiologı́a Instituto de Ciencias Biomédicas,
Facultad de Medicina Universidad de Chile, Santiago, Chile; the †De-
partment of Pathology, Rady Children’s Hospital–San Diego, San Diego,
CA; and the ‡University of California, San Diego School of Medicine, La
Jolla, CA
Address for correspondence: Dr Sergio L. Vargas, Instituto de Ciencias
Biomédicas, Facultad de Medicina Universidad de Chile, Casilla 215,
Correo Tajamar, Santiago, Chile. E-mail svargas@terra.cl.
DOI: 10.1097/01.inf.0000247071.40739.fd
S udden infant death syndrome (SIDS) is one of the leading
diagnoses of postneonatal death in industrialized countries.1 The
triple risk hypothesis for SIDS has achieved considerable consensus
and suggests that these deaths are a result of a triggering external
factor acting in a vulnerable infant during a critical period of
development.2
A mild infection by Pneumocystis has been identified by light
microscopy in the lungs of 35%, 14% and 13.9% of SIDS cases in
Santiago, Chile, Oxford, U.K., and Rochester, NY, and New Haven,
CT, respectively.3,4 Molecular methods increased detection rates to
51.7% in a series of 87 Chilean SIDS cases examined by nested
polymerase chain reaction of a single lung section5 and to 100%
when 4 lung sections per infant were examined in another set of
cases from the United States.6 Genotyping has demonstrated that
this organism is Pneumocystis carinii f. sp. hominis (Pneumocystis
jirovecii, human-derived Pneumocystis sp.).7
In our previous reports, Pneumocystis was found more fre-
quently in SIDS cases than in control infants whose deaths occurred
in the hospital and were not sudden.3,5 Because those control cases
were suboptimal,3 the present study was undertaken to further
explore this association by comparing the incidence of Pneumocystis
in SIDS with a control group of infants who died of either accidental
or inflicted injuries.
MATERIALS AND METHODS
Autopsy Specimens. The Rady Children’s Hospital–San Diego In-
stitutional Review Board and the University of Chile School of
Medicine Ethics Committee approved this study. The study popu-
lation comprised 130 SIDS and control infants dying suddenly and
unexpectedly who had undergone autopsy at the medical examiner’s
81
Vargas et al
office in San Diego County, California, between January 1, 1991,
and December 31, 2000, and accessioned into the San Diego
SIDS/Sudden Unexplained Death in Childhood Research Project
database. They included 106 cases who died of SIDS, 16 who died
of accidental injuries and 8 who died of inflicted injuries and were
selected on the basis of available lung slide sections at the time of
the study.
Case data were selected from the medical history, death scene
and postmortem information in the investigative and autopsy reports
and from 2 standardized data protocols for the death scene investi-
gation and autopsy. In 1989, a California statute mandated use of
standardized scene investigation and autopsy protocols (developed
by a multidisciplinary expert committee) for cases of sudden, unex-
pected infant death without external evidence of inflicted injuries.
Trained, experienced investigators from the medical examiner are
charged with collecting this information within 30 hours of an
infant’s death. The data are not complete for every case.
A diagnosis of SIDS was made when criteria from the recent
definition proposed in 2004 in San Diego were fulfilled.1 Other
diagnoses were reached after analyses of the reports of the medical
history, scene investigation and autopsy, including ancillary studies,
and review of the microscopic slides.
Detection of Pneumocystis. Blind, unstained light microscopic sec-
tions were submitted to the Pneumocystis Laboratory of the Univer-
sity of Chile School of Medicine in Santiago, Chile. The micro-
scopic sections were stained with Gomori-Grocott methenamine
silver nitrate and examined by 2 investigators (S.L.V. in all cases
and, C.A.P., P.G., or C.I.) who were blind to all demographic, scene,
postmortem, and diagnostic information. A minimum of 1 cm2 of
the lung tissue was carefully examined in all cases. All microscopic
fields were inspected. The presence of Pneumocystis was assessed as
positive or negative. Discordant results were discussed and cases
were labeled as positive only if typical Pneumocystis cysts in
clusters of 3 or more organisms were confirmed by both investiga-
tors. Pneumocystis-negative specimens were examined twice.
Statistical Analysis. Causes of death were provided on completion of
the determination of each case as Pneumocystis-positive or negative.
The STATA Ed. 9.1 statistical package was used to test the propor-
tions of Pneumocystis-positive and -negative cases for infants dying
of SIDS versus controls using Fisher exact test. Age comparisons
between Pneumocystis-positive and Pneumocystis-negative infants
within each group were analyzed using t test. A P value of ⬍0.05
was considered significant.
RESULTS
Cyst forms of Pneumocystis grouped in clusters were identi-
fied in 35 (33%) of 106 SIDS cases and in 7 (29%) of 24 control
TABLE 1. Ages and Incidence of Pneumocystis in the Lung of Sudden Infant Death Syndrome (SIDS) and Control
Infants Who Died of Accidental or Inflicted Injuries in Whom Pneumocystis was Sought by Microscopy and
Gomori-Grocott Silver Methenamine Stain
SIDS
n (%)
Mean age in days ⫾ SD (range)
106 (100%)
94 ⫾ 56 (10 –321)
Pneumocystis-positive Pneumocystis-negative
35 (33%) 71 (67%)
95 ⫾ 46 (37–321) 93 ⫾ 61 (10 –280)
Note: Age of Pneumocystis-positive SIDS cases was not different than age of Pneumocystis-negative SIDS cases (P ⫽ not significant). Pneumocystis-positive controls were younger than
Pneumocystis-negative controls (P ⫽ 0.047).
82
The Pediatric Infectious Disease Journal • Volume 26, Number 1, January 2007
cases, including 5 of 16 cases dying of accidental injuries and 2 of
8 cases dying of inflicted injuries (P ⫽ not significant) (Table 1).
SIDS cases were younger than controls (P ⬍ 0.001) as were
Pneumocystis-positive cases in comparison to Pneumocystis-nega-
tive cases in the control group (P ⫽ 0.047) (Table 1).
DISCUSSION
Our study demonstrates no significant difference in the
proportions of cases with Pneumocystis cysts identified in the
lungs of (presumably) immunocompetent SIDS and control cases.
We can, therefore, conclude that Pneumocystis infection is not a
direct cause of SIDS. This finding is in contrast to that of our
previous work in which we found Pneumocystis significantly
more prevalent in SIDS than in control cases dying within
hospitals in Chile.3,5
The control cases in the previous reports were suboptimal
given that the death in the control cases was preceded by clinical
illness and was not sudden and unexpected as occurs in SIDS.3 An
important strength of this study is the selection of SIDS and control
cases exclusively from the San Diego SIDS/SUDC Research Project
in San Diego County, CA, all of whom have undergone compre-
hensive postmortem evaluations using standardized protocols and
the most current definition for SIDS.1
The Gomori-Grocott methenamine silver nitrate stain used in
this study has limited sensitivity because it stains only the cyst form
of Pneumocystis, which represents approximately 10% of the total
number of organisms present. Furthermore, the tendency for this
organism to be distributed focally in the immunocompetent infant
enhances the difficulty of identification by light microscopy, sug-
gesting that the incidence of Pneumocystis is underrepresented in all
of the cases in this study. Our current results are therefore consistent
with our previous reports documenting that Pneumocystis is preva-
lent among young infants.3,5 More recent data show that the inci-
dence of Pneumocystis in infants regardless of autopsy diagnosis can
be as high as 100% when sensitive molecular methods such as
nested polymerase chain reaction are used in multiple lung tissue
samples.6
In our study, an indirect role of Pneumocystis as a cofactor in
SIDS may remain undetected by our use of a case– control incidence
comparison as well as the relatively small number of available cases.
Unfortunately, the large number of samples required for comparison
is untenable. Nevertheless, this hypothesis may be interesting to
consider given the higher frequency of Pneumocystis at an age when
SIDS deaths are more prevalent than at other ages.5 The infant
host–Pneumocystis interaction, along with the pathogenic mecha-
nisms by which Pneumocystis could be implicated in SIDS, remains
largely unexplored.
Controls
n (%) P
Mean age in days ⫾ SD (range)
24 (100%) Not applicable
170 ⫾ 105 (40 –364) ⬍0.001
Pneumocystis-positive Pneumocystis-negative
7 (29%) 17 (71%) Not significant
118 ⫾ 58 (71–232) 196 ⫾ 110 (40 –364) See note
© 2006 Lippincott Williams & Wilkins
The Pediatric Infectious Disease Journal • Volume 26, Number 1, January 2007
ACKNOWLEDGMENTS
The authors thank the staff of the Office of the Medical
Examiner of San Diego County, California, for their support.
This work was supported in Chile by the Fondo Nacional
de Desarrollo Cientı́fico y Tecnológico (FONDECYT research
grant 1011059 (S.L.V.), Santiago, Chile, and by the CJ Founda-
tion for SIDS and First Candle/SIDS Alliance in the United States
(H.F.K.).
REFERENCES
1. Krous HF, Beckwith JB, Byard RW, et al. Sudden infant death syndrome
and unclassified sudden infant deaths: A definitional and diagnostic
approach. Pediatrics. 2004;114:234 –238.
2. Filiano JJ, Kinney HC. A perspective on neuropathologic findings in
victims of the sudden infant death syndrome: The triple-risk model. Biol
Neonate. 1994;65:194 –197.
3. Vargas SL, Ponce CA, Hughes WT, et al. Association of primary
Pneumocystis carinii infection and sudden infant death syndrome. Clin
Infect Dis. 1999;29:1489 –1493.
4. Morgan DJ, Vargas SL, Reyes-Mugica M, Walterspiel JN, Carver W,
Gigliotti F. Identification of Pneumocystis carinii in the lungs of infants
dying of sudden infant death syndrome. Pediatr Infect Dis J. 2001;20:
306 –309.
5. Vargas SL, Ponce CA, Luchsinger V, et al. Detection of Pneumocystis
carinii f. sp. hominis and viruses in presumably immunocompetent infants
who died in the hospital or in the community. J Infect Dis. 2005;191:
122–126.
6. Beard CB, Fox MR, Lawrence GG, et al. Genetic differences in Pneu-
mocystis isolates recovered from immunocompetent infants and from
adults with AIDS: Epidemiological implications. J Infect Dis. 2005;192:
1815–1818.
7. Chabe M, Vargas SL, Eyzaguirre I, et al. Molecular typing of Pneumo-
cystis jirovecii found in formalin-fixed paraffin-embedded lung tissue
sections from sudden infant death victims. Microbiology. 2004;150:1167–
1172.
CEREBRAL TUBERCULOMA PRESENTING AS
FLEXION SPASMS
Cristina L. Martins, MD,* José Paulo Monteiro, MD,*
Sofia Sarafana, MD,† Gabriela Caldas, MD,†
Pedro Oliveira, MD,储 Paula Breia, MD,‡ Paula Rodeia, MD,§
and Maria José Fonseca, MD*
Abstract: A 10-month-old girl was admitted with refractory infan-
tile spasms. Video EEG demonstrated focal epileptic activity, and
MRI revealed a conglomeration of annular lesions. Surgical excision
was performed and pathology was consistent with tuberculoma.
After antituberculous therapy, the outcome was favorable.
Despite all investigations, Mycobacterium tuberculosis’s mode
of transmission was unclear, and both congenital and postnatal
acquired forms were considered.
Key Words: cerebral tuberculoma, flexion spasms, congenital
tuberculosis
Accepted for publication September 14, 2006.
From the *Neuropediatric Unit, Pediatric Department, †Pediatric Depart-
ment, ‡Neurological Department, and §Neurosurgical Department, Hos-
pital Garcia de Orta, Almada, Portugal; and the 㛳Pathology Department,
Instituto Português de Oncologia Francisco Gentil, Lisboa, Portugal.
Address for correspondence: Cristina L. Martins, MD, Unidade de Neuro-
pediatria e Desenvolvimento–Serviço de Pediatria, Hospital Garcia de
Orta, Av. Professor Torrado da Silva, 2801-951 Almada, Portugal.
E-mail: cristins@netcabo.pt.
DOI: 10.1097/01.inf.0000247135.05706.e6
© 2006 Lippincott Williams & Wilkins
Cerebral Tuberculoma
T uberculosis in children has special features of pathogenesis and
clinical presentation.1 The 2 major central nervous system forms
of tuberculosis are tuberculous meningitis, an often devastating
disease, and tuberculoma, which presents a more subtle clinical
picture.2 We report a case of central nervous system tuberculoma
manifested as flexion spasms in a 10-month-old girl.
CASE REPORT
AB is now a 4-year-old girl. She is the second child born to
nonconsanguineous, healthy parents. Her 39-year-old mother was born
in Angola but has lived in Portugal for 24 years. Complications during
pregnancy included vaginal bleeding at 18 weeks and premature rupture
of the membranes at 33 weeks. One week later, vaginal delivery
occurred. Apgar scores were 5 at 1 minute and 9 at 5 minutes. Birth
weight, length, and head circumference were in the 50th percentile.
Physical examination at birth was unremarkable. No neonatal problems
were reported. She was immunized with BCG at 15 days of age. Her
general health was good, and she grew and developed normally.
When the child was aged 8 months, her mother noticed periods
of irritability and involuntary brief, symmetric flexor contractions of her
neck, trunk, and limbs, which occurred in clusters. She did not present
postictal somnolence and quickly resumed normal activity. No other
symptoms were reported. She had no psychomotor regression. At 10
months of age, as spasms persisted and became more frequent
(20 –30/d), she was referred for assessment and admitted with the initial
working diagnosis of West syndrome, which was not confirmed by
further evolution and investigation.
Physical examination, including funduscopic examination,
was normal. Hematologic and biochemical screenings, including the
erythrocyte sedimentation rate, were normal. Serology to rule out
toxoplasmosis, echinococcosis, cysticercosis, syphilis, cytomegalo-
virus, enterovirus, herpesvirus, HIV 1 and 2, and Bartonella infec-
tion was negative. CSF analysis was normal. Stained smear and
culture for bacteria and acid-fast bacilli were sterile. EEG detected
left parietal and temporal posterior spikes, as well as spikes and
waves. MRI revealed an intracranial space-occupying lesion with
calcifications, which enhanced after contrast administration (Fig. 1).
There was no abnormality on chest roentgenogram. Abdominal
ultrasound examination revealed multiple splenic calcifications. Sei-
zures persisted after antiepileptic drug trials (vigabatrin, valproate,
topiramate). Video EEG reported focal epileptic activity with sec-
ondary generalization, with correlation with clinical seizures. As a
result, a surgical approach was chosen.
The infant underwent craniotomy, with removal of the lesion
using electrocorticography control. No additional seizures were seen
and she was discharged home 1 week later. Histopathologic exam-
ination of the excised material revealed a chronic inflammatory
granulomatous process with caseous necrosis and multinuclear giant
cells (Langhans giant cells) consistent with tuberculoma. However,
acid-fast bacilli were not identified (Ziehl-Neelsen stain and poly-
merase chain reaction 关PCR兴).
Tuberculin skin test was then performed, and it was strongly
positive (18 mm), but cultures of blood, urine, and gastric aspirate
were sterile. Placental histology (reviewed) was normal.
Investigation of household contacts was negative, except for
her mother, whose Mantoux test was positive (23 mm), although she
was asymptomatic and had a normal chest radiograph. Direct stain,
PCR, and culture of material obtained from the mother’s endome-
trium were negative for Mycobacterium tuberculosis. Triple antitu-
berculous therapy (isoniazid 10 mg/kg/d, rifampicin 15 mg/kg/d,
pyrazinamide 30 mg/kg/d) was initiated.
This child recovered well, with harmonious cognitive and
motor development. Antiepileptic drugs were well tolerated and then
suspended.
83
Lindeboom et al The Pediatric Infectious Disease Journal • Volume 26, Number 1, January 2007
FIGURE 1. T1-weighted MRI image
after gadolinium, showing irregular
but intense enhancement of the
lesion.
DISCUSSION
In this report, we emphasize a peculiar clinical presentation: a
focal lesion manifested as refractory symmetric infantile epileptic
spasms, initially considered as West syndrome. However, West syn-
drome was not confirmed either by EEG, which did not present a
hypsarrhythmia pattern, or by clinical evolution because she always
presented unremarkable psychomotor development.3 EEG showed in-
stead focal epileptic activity with secondary generalization, symptom-
atic of a tuberculoma, which was an unexpected cause, considering that
there were no other clinical manifestations or contact cases identified.
M. tuberculosis bacilli can reach the central nervous system
during hematogenous disseminated disease in various ways. Tubercu-
loma has an unspecific clinical presentation that includes fever, head-
aches and convulsions. There are no specific features on neuroimaging
studies that differentiate a tuberculoma from other space-occupying
masses, particularly neoplastic and other infectious lesions.4,5
In this case, controversy remains: should we consider this a
congenital/perinatal infection or acquired tuberculosis? If it is re-
garded as a perinatally acquired infection, was it implicated in
prematurity? When did the probable asymptomatic systemic dissem-
ination, indicated by spleen calcifications, occur?
Criteria for distinguishing congenital from postnatally ac-
quired tuberculosis were published by Beitzke in 1935 and reviewed
by Cantwell et al in 1994.6 –9 According to them, the infant must
have a proved tuberculous lesion and at least 1 of the following:
lesions in the first week of life, a primary hepatic complex or
caseating hepatic granulomas, tuberculous infection of the placenta
or the maternal genital tract, or exclusion of the possibility of
postnatal transmission by a thorough investigation of contacts,
including the infant’s hospital attendants.
Congenital tuberculosis diagnosis is difficult and, in this case,
cannot be confirmed because the neonatal period had no known
complications besides prematurity and placenta histology was un-
remarkable for tuberculous infection. The mother was also submit-
ted to a thorough general examination. Gynecologic and uterine
biopsies were normal. Investigations did not find a probable post-
natal contact with the disease, but it is virtually impossible to
guarantee that it did not occur.
The outcome of this case was excellent; the child is now 4
years old, free of all therapies, and her physical and psychomotor
development are completely normal. Brain tuberculoma has become
rare in developed countries10; nevertheless, this diagnosis should be
kept in mind.
84
REFERENCES
1. ATM. Diagnostic standards and classification of tuberculosis in adults
and children. Am J Respir Crit Care Med. 2000;161:1376 –1395.
2. Waecker NJ Jr, Connor JD. Central nervous system tuberculosis in
children: a review of 30 cases. Pediatr Infect Dis J. 1990;9:539 –543.
3. Dulac O, Tuxhorn I. Infantile spasms and West Syndrome. In: Roger J,
Bureau M, Dravet C, Genton P, Tassinari C, Wolf P, eds. Epileptic
Syndromes in Infancy, Childhood and Adolescence. 2nd ed. London,
England: John Libbey & Co; 2002:47– 63.
4. Bouchama A, al-Kawi MZ, Kanaan I, et al. Brain biopsy in tuberculoma:
the risks and benefits. Neurosurgery. 1991;28:405– 409.
5. Brutto O, Mosquera A. Brainstem tuberculoma mimicking glioma: the role
of antituberculous drugs as a diagnostic tool. Neurology. 1999;52:210.
6. Beitzke H. Uber die angeborene tuberkulose infektion. Ergeb Ges
Tuberk Forsch. 1935;7:1–30.
7. Cantwell MF, Shehab ZM, Costello AM, et al. Brief report: congenital
tuberculosis. N Engl J Med. 1994;330:1051–1054.
8. Hageman J, Shulman S, Schreiber M, Luck S, Yogev R. Congenital
tuberculosis: critical reappraisal of clinical findings and diagnostic
procedures. Pediatrics. 1980;66:980 –984.
9. Abughali N, Van der Kuyp F, Annabable W, Kumar M. Congenital
tuberculosis. Pediatr Infect Dis J. 1994;13:738 –741.
10. Hest vR, Vries G, Morbano G, Pijnenburg M, Hartwig N, Baars H.
Cavitating tuberculosis in an infant. Pediatr Infect Dis J. 2004;23:667–
670.
INGUINAL LYMPHADENITIS CAUSED BY
MYCOBACTERIUM HAEMOPHILUM IN AN
IMMUNOCOMPETENT CHILD
Jerome A. H. Lindeboom, MD, DDS, PhD,*
Caroline F. Kuijper, MD,† and Marceline van Furth, MD, PhD‡
Abstract: Infections caused by Mycobacterium haemophilum in
immunocompetent patients are unusual. M. haemophilum have been
associated with cervicofacial lymphadenitis in children, but inguinal
infections have not yet been described. We present a case of an
inguinal lymphadenitis caused by M. haemophilum in an immuno-
competent girl.
Key Words: Mycobacterium haemophilum, nontuberculous
mycobacteria, inguinal lymphadenitis
Accepted for publication September 14, 2006.
From the *Department of Oral and Maxillofacial Surgery, Academic Med-
ical Center, Amsterdam and the Academic Center for Dentistry (ACTA),
University of Amsterdam, Amsterdam, The Netherlands; the †Pediatric
Surgical Center of Amsterdam (Location Emma Children’s Hospital
© 2006 Lippincott Williams & Wilkins
The Pediatric Infectious Disease Journal • Volume 26, Number 1, January 2007 M. haemophilum Lymphadenitis

AMC), Amsterdam, The Netherlands; and the ‡Department of Paediat-

rics, Free University Medical Center, Amsterdam, The Netherlands.
Address for correspondence: Dr Jerome A. H. Lindeboom, Department of Oral
and Maxillofacial Surgery, Academic Medical Center and Academic Center
for Dentistry (ACTA), University of Amsterdam, Meibergdreef 9, 1105 AZ
Amsterdam, The Netherlands. E-mail: j.a.lindeboom@amc.uva.nl.
DOI: 10.1097/01.inf.0000247134.58134.7d

H ead and neck lymphadenitis originating from nontuberculous

mycobacterial infections in children is well documented. In
most cases, Mycobacterium avium is the causative microorganism,1
but infections caused by Mycobacterium haemophilum in immuno-
competent children have been described in the cervicofacial re-
gion.2–7 Inguinal lymphadenitis caused by M. haemophilum has not
been previously described.

CASE REPORT
A 5-year-old girl with a previous state of good health pre-
sented with fever of 1 week’s duration and an enlarged, painful
lymph node in the left groin. She had a small indolent wound on the
dorsum of her left foot for 2 weeks. There was no history of trauma.
Treatment with amoxicillin– clavulanate acid for bacterial lymphad-
enitis was ineffective. Because the wound on her foot would not
heal, surgical exploration looking for a foreign body was performed.
At the same time, fine needle biopsy of the inguinal lymph node was
done for bacterial cultures and pathologic examination. Histopatho-
logic analysis revealed lymphadenitis with granulomatous inflam-
mation, whereas the Ziehl-Neelsen stain demonstrated acid-fast
bacilli. Standard mycobacterial culturing was performed at 35°C in
liquid MGIT medium and on solid Löwenstein-Jensen medium. M.
haemophilum-specific culturing was performed at 30°C with added
iron citrate and in MGIT with X-factor strip added. After 2 weeks,
M. haemophilum was cultured. Considering the various treatment
options, the parents decided to choose conservative treatment with
antimycobacterial therapy consisting of clarithromycin and rifabutin
for 12 weeks. The drugs were well tolerated by the child and only a
slight yellowish skin discoloration was noted as a side effect of
rifabutin. Laboratory examination revealed no abnormalities. During
antimycobacterial therapy, the inguinal lymph node started suppu-
rating, and after 12 weeks of treatment, complete necrosis of the
lymph node was visible (Fig. 1). The parents and the pediatric
surgeon agreed on surgical excision of the affected inguinal lymph
nodes. At operation, superficial and deep lymph nodes were affected
and excised. No short-term postoperative complications were noted,
but 6 months after surgery, lymphedema of the dorsum of the left
foot developed. Compression treatment with a class 2 elastic stock-
ing for 3 months was successful.
DISCUSSION
Mycobacterium haemophilum is an uncommon pathogen in
humans and mainly causes infections in immunocompromised pa-
tients. Cutaneous lesions, osteomyelitis, disseminated infection with
lymphadenopathy and are principal manifestations of M. hae-
mophilum infections.8 Since the first case report of a cervicofa-
cial lymphadenitis in an immunocompetent child in 1981,2 only
7 additional children with head and neck lymphadenitis have been
added to the literature.3– 6 Recently, we described a larger series of
immunocompetent children with cervicofacial lymphadenitis caused
by M. haemophilum.7 Inguinal lymphadenitis caused by M. avium
and Mycobacterium scrofulaceum have been reported,9 but no pre-
vious reports on inguinal lymphadenitis caused by M. haemophilum
have been described. In our patient, diagnosis was established by
culture. M. haemophilum infection can often be undetected because
routine microbiologic techniques (ie, mycobacterial culture on stan-
FIGURE 1. Inguinal lymphadenitis due to M. haemophilum
infection prior to operation.
dard culture media such as Loewenstein-Jensen media incubated at
37°C) are insufficient. M. haemophilum grows only selectively on
ferric ion supplemented culture media and requires incubation at a
temperature of 30°C.10 Recently, we reported the application of a
Mycobacterium genus-specific real-time polymerase chain reaction
in combination with amplicon sequencing and M. haemophilum-
specific polymerase chain reaction to diagnose M. haemophilum
cervicofacial lymphadenitis.10 Antimycobacterial therapy consisting
of clarithromycin and rifabutin for a period of 12 weeks was used to
treat the M. haemophilum inguinal lymphadenitis in our patient.
Like many other nontuberculous mycobacteria, M. haemophilum
does not respond to treatment with isoniazid or pyrazinamide, but it
may respond to quinolones, the macrolides and the rifamycins.8 In
our patient, complete resolution of M. haemophilum infection was
achieved after surgical removal of the affected lymph nodes. Sur-
gery is considered to be the treatment of choice in selected cases for
nontuberculous cervicofacial lymphadenitis.1 Conservative treat-
ment with or without antibiotics is sometimes used as an alternative
in the head and neck region to prevent the risk of facial nerve
dysfunctions and to avoid facial scarring. Surgical excision of the
affected inguinal lymph nodes could have been the preferred pri-
mary management in the presented case.
REFERENCES
1. Albright JT, Pransky S. Nontuberculous mycobacterial infections of the
head and neck. Pediatr Clin N Am. 2003;50:503–514.
2. Dawson DJ, Blacklock ZM, Kane DW. Mycobacterium haemophilum
causing lymphadenitis in an otherwise healthy child. Med J Aust.
1981;2:289 –290.
3. Saubolle MA, Kiehn TE, White MH, Rudinsky MF, Armstrong D.
Mycobacterium haemophilum: Microbiology and expanding clinical and
geographic spectra of disease in humans. Clin Microbiol Rev. 1996;9:435–
447.
4. Thilbert L, Lebel F, Martineau B. Two cases of Mycobacterium hae-
mophilum infection in Canada. J Clin Microbiol. 1990;28:621– 623.
5. Armstrong KL, James RW, Dawson DJ, Francis PW, Masters B.

© 2006 Lippincott Williams & Wilkins 85

Plipat et al The Pediatric Infectious Disease Journal • Volume 26, Number 1, January 2007
Mycobacterium haemophilum causing perihilar or cervical lymphadeni-
tis in healthy children. J Pediatr. 1992;121:202–205.
6. Griendt van de EJ, Rietra PJ, Andel van RN. Mycobacterium haemophi-
lum as the cause of lymphadenitis in the neck in an otherwise healthy
boy. Ned Tijdschr Geneesk. 2003;147:1367–1369.
7. Lindeboom JA, Prins JM, Bruijnesteijn van Coppenraet ES, Lindeboom
R, Kuijper EJ. Cervicofacial lymphadenitis in children caused by My-
cobacterium haemophilum. Clin Infect Dis. 2005;41:1569 –1575.
8. Shah MK, Sebti A, Kiehn TE, Massarella SA, Sepkowitz KA.
Mycobacterium haemophilum in immunocompromised patients. Clin
Infect Dis. 2001;33:330 –337.
9. Holland AJA, Holland HCO, Cummins G, Cooke-Yarborough C, Cass
DT. Noncervicofacial atypical mycobacterial lymphadenitis in child-
hood. J Pediatr Surg. 2001;36:1337–1340.
10. Bruijnesteijn van Coppenraet ES, Kuijper EJ, Lindeboom JA, Prins JM,
Claas EC. Mycobacterium haemophilum and lymphadenitis in children.
Emerg Infect Dis. 2005;11:62– 68.
EFFICACY AND PLASMA CONCENTRATIONS OF
INDINAVIR WHEN BOOSTED WITH RITONAVIR IN
HUMAN IMMUNODEFICIENCY VIRUS–INFECTED
THAI CHILDREN
Nottasorn Plipat, MD, MS,* Tim R. Cressey, PhD,†
Nirun Vanprapar, MD, MSc,* and Kulkanya Chokephaibulkit, MD*
Abstract: We evaluated 19 children using 220 –300 mg/m2 of
indinavir (IDV) boosted with 100 mg ritonavir (RTV) (n ⫽ 12) or
full-dose RTV (n ⫽ 7). Geometric mean (GM) (90% confidence
interval, CI) of IDV Ctrough in children who took IDV with 100 mg
RTV (n ⫽ 12) was 0.17 (0.06 – 0.50) mg/L. For children who took
IDV with full-dosage RTV, GM (90% CI) was 0.40 (0.10 –1.61)
mg/L. C2hours were less than 10 mg/L in all subjects. Eighteen
children had good virologic response. This report demonstrates that
smaller IDV dosages given with RTV provide efficacious plasma
concentrations and can be safely used.
Key Words: indinavir, pharmacokinetics, children, drug levels,
Thailand
Accepted for publication September 14, 2006.
From the *Division of Pediatric Infectious Diseases, Department of Pediatrics,
Siriraj Hospital, Mahidol University, Bangkok, Thailand; and †PHPT–
Harvard School of Public Health, Harvard University, Boston, MA.
Address for correspondence: Nottasorn Plipat, MD, MS, Division of Infec-
tious Diseases, Department of Pediatrics, Siriraj Hospital, Mahidol Uni-
versity, 2 Prannok Road, Bangkoknoi, Bangkok 10700 Thailand. E-mail
nplipat@msn.com.
DOI: 10.1097/01.inf.0000247140.94669.1b
U se of indinavir (IDV) as a component of highly active antiret-
roviral therapies (HAART) in developed countries has de-
creased, primarily because of its disadvantageous pharmacologic
and tolerability profiles, but IDV-containing regimens remain an
important part of salvage therapy in resource-limited countries.
In adults, the dosage of IDV boosted with ritonavir (IDV/r)
800/100 mg has been recommended. Reduced doses of IDV/r
(600/100 and 400/100 mg) twice daily in Thai adults provide
adequate IDV plasma concentrations and viral suppression.1,2 For
children, IDV/r pharmacokinetic data and dosage recommendations
are limited. A pharmacokinetic study in children using 400/125
mg/m2 of IDV/r produced a drug exposure similar to those found in
adults using IDV/r 800/100 mg.3 A lower dosage of IDV 350 mg/m2
with ritonavir (RTV) 125 mg/m2 attains sufficient IDV drug expo-
sure, but the authors concluded that pill burden and palatability
remained an obstacle.4 The lower 400/100 mg IDV/r dose in Thai
adults was approximately equivalent to 220 –285 mg/m2 and had
86
better tolerability, suggesting that IDV/r dosing in children in this
range might also be warranted.
This report describes the results of HIV-infected children
using an IDV-based HAART regimen with an IDV dosage between
220 and 300 mg/m2 and either a “boosted” RTV (100 mg) dosage
(IDV/r) or full RTV dosage (IDV/RTV).
PATIENTS AND METHODS
Nineteen HIV-infected children (14 boys and 5 girls) receiv-
ing IDV-containing HAART at the Pediatric Infectious Diseases
Clinic at Siriraj Hospital, Bangkok, were assessed. The study was
approved by the Siriraj Ethics Committee. All children received
their antiretroviral through the National Antiretroviral Access Pro-
gram for People Living with HIV/AIDS. Due to lack of pediatric
formulation, exact dosage was difficult to achieve. IDV (Crixivan)
200 or 400 mg capsules and RTV (Norvir) 100 mg capsules were
available. Children who weighed between 14 and 35 kg received
200/100 mg of IDV/r, and children more than 35 kg received
400/100 mg. Children would be given 100 mg RTV as a booster
unless multiple NRTI and NNRTI resistance had been reported; in
such cases, a full RTV dose would be given.
CD4 lymphocytes were measured at HAART initiation and
every 6 months thereafter. Plasma HIV-1 RNA was measured using
Roche Amplicor HIV-1 Monitor version 1.5 (Cobas; Roche), with a
limit of detection of 400 copies/mL. Virologic success was defined
as either undetectable virus or a decrease of viral load of more than
1 log10.5 To verify appropriate IDV dosage, IDV and RTV drug
plasma concentrations were assessed. All children had received
IDV/r for at least 2 months before the analysis. Antiretroviral
adherence was assessed by pill counts and physician prediction
using a visual analog scale.6 Full adherence (100%) 3 days before
blood draws was assured using adherence questionnaires. Nephro-
toxicity was evaluated by recording patient history of any flank or
abdominal pain, changes of urination, and urinalysis every 6 months.
For assessment of IDV and RTV plasma drug concentrations,
blood samples were taken at predose (Ctrough) and 2 hours postdose
(C2hours). All medications were taken on an empty stomach, fol-
lowed by breakfast. All blood samples were centrifuged; plasma was
separated, aliquoted, and stored at ⫺20°C until analysis. Before
analysis, the median (interquartile range, IQR) sample storage time
was 85 (64 –106) days. IDV and RTV plasma drug concentrations
were measured by high-performance liquid chromatography at the
Faculty of Associated Medical Sciences, Chiang Mai University.7
The lower limit of assay quantification was 0.05 mg/L. The labora-
tory participates in the AIDS Clinical Trial Group (ACTG), Phar-
macology External Quality Control Program.
RESULTS
Patient baseline characteristics and ARV drug regimens are
described in Table 1. After a median (IQR) duration of 12 (6 –17)
months of treatment, median CD4% increase was 13.7% (6.30 –17.03),
and the median CD4 cell count increase was 446 (248 – 656) cells/mm3.
Currently, HIV-1 RNA PCR monitoring is not part of the routine care
in Thailand; therefore, not all of the subjects had this test performed at
every time point. Of 19 patients, 17 patients achieved an undetectable
viral load within 17 months’ follow-up (11 patients at 6 months, 5
patients at 11 months, and 1 patient at 17 months).
Figure 1 (Online only) shows the IDV Ctrough and C2hours
observed in our clinic and the Cmin and Cmax data in the recent 400/125
mg/m2 pediatric data.3 The median postdose times for Ctrough and
C2hours blood samples were 12.17 (11.52–12.50) and 2.02 (1.52–2.10)
hours, respectively. Indinavir plasma levels in children using either
boosted RTV or full-dose RTV. A, Indinavir Ctrough and C2hours plasma
levels when boosted with 100 mg ritonavir. B, Indinavir Ctrough and
© 2006 Lippincott Williams & Wilkins
The Pediatric Infectious Disease Journal • Volume 26, Number 1, January 2007 Indinavir Efficacy

TABLE 1. Clinical Characteristics, ARV Drug Regimens, and ARV Plasma Drug Concentrations
of Children Initiating an IDV-Based HAART Regimen With Either Boosted RTV (100 mg) Dosage
(IDV/r) or Full RTV Dosage (IDV/RTV)

Reduced RTV Dose (n ⫽ 12) Full RTV Dose (n ⫽ 7)

Baseline Characteristics
Median IQR Median IQR

Age, yr 9.7 (8.2–12.4) 11.3 (6.3–12.0)

CD4, % 3.3 (1.3–5.2) 3.4 (1.3–11.9)
CD4 count, cells/mm3 70 (29.3–275) 108 (38 –180)
HIV viral load, log10 copies/mL 4.8 (4.4 –5.4) 5.1 (4.4 –5.7)
Previous ARV regimen, n
Dual NRTI 2 0
2 ⫻ NRTI ⫹ NNRTI 8 7
IDV dose (mg/m2) 233.9 (215.6 –286.3) 298.5 (217.4 –341.9)
RTV dose (mg/m2) 111.8 (91.4 –123.2) 298.5 (256.4 –380.6)
ARV regimens
Duration IDV/RTV regimen, mo 9.3 (5.1–18.5) 6.3 (4.6 –13.1)
Cumulative ARV exposure, mo
NRTI 60 (54.3– 83.5) 52 (26 – 82)
NNRTI 15.5 (8 –25.5) 20 (16 –24)
Other ARVs used with IDV/RTV, n
2⫻ NRTI 5 0
2⫻ NRTI ⫹ NNRTI 5 0
1⫻ NRTI ⫹ NNRTI 2 0
1⫻ NRTI 0 7
Plasma drug concentrations: geometric mean
(90% confidence interval, mg/L)
IDV Ctrough 0.17 (0.06 – 0.49) 0.40 (0.10 –1.60)
IDV C2hours 2.79 (1.18 – 6.61) 3.25 (0.73–14.35)
RTV Ctrough 0.47 (0.15–1.47) 3.58 (0.83–15.33)
RTV C2hours 2.13 (1.08 – 4.21) 6.05 (1.93–18.91)
IQR indicates interquartile range.

C2hours plasma levels with full-dose ritonavir. C, Indinavir Cmin and
Cmax plasma levels with IDV/r 400/125 mg/m2.3 Short solid lines in the
online figure represent the median plasma levels within each group.
Dashed lines represent recommended therapeutic efficacy and toxicity
thresholds: Cmin (0.1 mg/L) and Cmax (10 mg/L).8 Indinavir (IDV),
ritonavir (RTV), and indinavir boosted with ritonavir (IDV/r).
IDV and RTV Ctrough and C2hours plasma drug concentrations
are described in Table 1. Despite the fact that IDV drug concentra-
tions appeared to be higher in the full-dosage RTV group, this was
not statistically significant for Ctrough (P ⫽ 0.056) or C2hours (P ⫽
0.43). Two patients had Ctrough less than the recommended threshold
of 0.10 mg/L, but after an IDV dosage increase from 250 to 500
mg/m2 and 200 to 400 mg/m2, Ctrough levels were adequate. No
patients had an IDV C2hours higher than the maximum recommended
threshold of 10.0 mg/L.
olemia (cholesterol ⬎200 mg/L) and hypertriglyceridemia (triglyc-
eridemia ⬎200 mg/L) were significantly higher in the RTV full-dose
group compared with the RTV reduced-dose group.
In conclusion, we believe that reduced dosages of IDV
(220 –300 mg/m2), when boosted with either 100 mg or with full
RTV dosages, provide adequate IDV therapeutic concentrations in
most patients and can be safely used as salvage therapy. Long-term
efficacy data at this dosage are needed.
ACKNOWLEDGMENTS
The authors would like to thank Dr. D. Burger for sharing the
IDV plasma drug levels data for comparison in Figure 1. We also
would like to thank Dr. C. Komontri for the statistical analysis
assistance.

DISCUSSION
The IDV predose levels in this report were similar to previous
reports using 600/100 and 400/100 mg of IDV/r in Thai adults1,2;
however, when compared with the pediatric study using the higher
dose of 400/125 mg/m2 of IDV/r,3 IDV Ctrough levels in our patients
were slightly lower, but none had too high a level (⬎10 mg/L), as
seen in some subjects that received higher IDV dosage. A limitation
of this report is that only 2 IDV plasma time points were determined
and IDV drug exposure (ie, AUC) was not available, but the predose
and C2hours time points provided sufficient data to make compari-
sons with published studies.
No nephrotoxicity was reported, which could be attributed to
the lower IDV dosage in comparison to other studies.9 Dyslipide-
mia, when defined according to the National Cholesterol Educa-
tional Program, was found in 14 (64%) of 18 children, which is
consistent with previous studies.10,11 Interestingly, hypercholester-
REFERENCES
1. Cressey TR, Leenasirimakul P, Jourdain G, et al. Low-doses of
indinavir boosted with ritonavir in HIV-infected Thai patients: phar-
macokinetics, efficacy and tolerability. J Antimicrob Chemother.
2005;55:1041–1044.
2. Boyd M, Mootsikapun P, Burger D, et al. Pharmacokinetics of reduced-
dose indinavir/ritonavir 400/100 mg twice daily in HIV-1-infected Thai
patients. Antivir Ther. 2005;10:301–307.
3. Bergshoeff AS, Fraaij PL, van Rossum AM, et al. Pharmacokinetics of
indinavir combined with low-dose ritonavir in human immunodeficiency
virus type 1-infected children. Antimicrob Agents Chemother. 2004;48:
1904 –1907.
4. Chadwick EG, Rodman JH, Samson P, et al. Antiviral activity, tolerance
and pharmacokinetics of indinavir with two doses of ritonavir as salvage
therapy in children 关abstract兴. 10th Conf Retrovir Opportunistic Infect.
2003;abstr 875.
5. Working Group on Antiretroviral Therapy and Medical Management of
HIV-Infected Children. Guideline for the use of antiretroviral agents in

© 2006 Lippincott Williams & Wilkins 87

Vandenberg et al The Pediatric Infectious Disease Journal • Volume 26, Number 1, January 2007
pediatric HIV infection 关Centers for Disease Control and Prevention web
site兴. Available at: http://aidsinfo.nih.gov/guidelines/pediatric/PED_032405.
pdf. Accessed October 19, 2005.
6. Giordano TP, Guzman D, Clark R, Charlebois ED, Bangsberg DR.
Measuring adherence to antiretroviral therapy in a diverse population
using a visual analog scale. HIV Clin Trials. 2004;5:74 –79.
7. Droste JA, Verweij-Van Wissen CP, Burger DM. Simultaneous deter-
mination of the HIV drugs indinavir, amprenavir, saquinavir, ritonavir,
lopinavir, nelfinavir, the nelfinavir hydroxymetabolite M8, and nevirap-
ine in human plasma by reversed-phase high-performance liquid chro-
matography. Ther Drug Monit. 2003;25:393–399.
8. Burger DM, Hoetelmans RM, Hugen PW, et al. Low plasma concen-
trations of indinavir are related to virological treatment failure in
HIV-1-infected patients on indinavir-containing triple therapy. Antivir
Ther. 1998;3:215–220.
9. Burger D, Boyd M, Duncombe C, et al. Pharmacokinetics and
pharmacodynamics of indinavir with or without low-dose ritonavir in
HIV-infected Thai patients. J Antimicrob Chemother. 2003;51:1231–
1238.
10. Executive Summary: Executive summary of the third report of the
National Cholesterol Education Program (NCEP) Expert Panel on
Detection, Evaluation, and Treatment of High Blood Cholesterol in
Adults (Adult Treatment Panel II). JAMA. 2001;285:2486 –2513.
11. Lapphra K, Vanprapar N, Phongsamart W, Chearskul P, Chokephaibulkit
K. Dyslipidemia and lipodystrophy in HIV-infected Thai children on highly
active antiretroviral therapy (HAART). J Med Assoc Thai. 2005;88:
956 –966.
TREATMENT OF DIENTAMOEBA FRAGILIS INFECTION
WITH PAROMOMYCIN
Olivier Vandenberg, MD, PhD,*† Hichem Souayah, MD,‡
Françoise Mouchet, MD,‡ Anne Dediste, MD,*
and Tom van Gool, MD, PhD§储
Abstract: Treatment with paromomycin (25–35 mg/kg/d for 7 days)
was evaluated prospectively in 15 children with Dientamoeba fra-
gilis infection after 1-month follow-up. At the end of the study,
parasitologic effectiveness and clinical improvement were observed
in 12/15 (80%) and 13/15 (87%) patients, respectively. Paromomy-
cin appears to be an effective drug for treatment of D. fragilis
infection in children.
Key Words: Dientamoeba fragilis, treatment, paromomycin,
children, triple feces test
Accepted for publication September 14, 2006.
From the *Department of Microbiology, Saint-Pierre University Hospital,
Brussels, Belgium; †Infectious Diseases Epidemiological Unit, Public
Health School, Free University of Brussels, Brussels, Belgium; ‡Depart-
ment of Pediatrics, Saint-Pierre University Hospital, Brussels, Belgium;
§Section Parasitology, Department of Medical Microbiology, Academic
Medical, Amsterdam, The Netherlands; and the 㛳Department of Parasi-
tology, Harbour Hospital, Rotterdam, The Netherlands.
Address for correspondence: Olivier Vandenberg, MD, PhD, Department of
Microbiology, Saint-Pierre University Hospital, Rue Haute 322, B-1000
Brussels, Belgium. E-mail olivier.vandenberg@ulb.ac.be.
DOI: 10.1097/01.inf.0000247139.89191.91
D ientamoeba fragilis is a frequent intestinal protozoan parasite in
humans. Gastrointestinal symptoms are observed in up to 25%
of infected individuals.1,2 Both acute watery diarrhea and a chronic
recurrent abdominal syndrome have been associated with D. fragilis
in children, as well as in adults.3 In routine clinical practice, D.
fragilis infection is probably underreported because of difficulties
with diagnosis. Only with examination of multiple stools, preferen-
tially fixed, can D. fragilis be properly diagnosed.4
Specific treatment is indicated in symptomatic patients with
D. fragilis when no other pathogenic organisms are present.3 Several
88
drugs have been reported to be effective for D. fragilis, ie, iodoqui-
nol, clioquinol, paromomycin and metronidazole.5,6 However, few
studies with these drugs have been performed in children.6 In
addition, many of these studies lacked extended parasitologic fol-
low-up after completion of treatment. As a result, there is no
consensus about the drug of choice for treatment of D. fragilis
infection or whether treatment is necessary for all cases.
Iodoquinol (30 – 40 mg/kg/d ⫻ 20 days) is the first line
treatment of D. fragilis infection in the United States.5 Although well
tolerated in most patients, iodoquinol treatment has been associated
with seizures and encephalopathy.7 Paromomycin is reported as the
second line treatment of D. fragilis infection, although the drug is still
considered investigational by the Food and Drug Administration for this
indication.5,6 To our knowledge, there is only 1 study in which
paromomycin was evaluated for treatment of D. fragilis infection.8
In the present study, parasitologic and clinical effectiveness
of paromomycin treatment was investigated in 15 children with D.
fragilis infection.
MATERIALS AND METHODS
All outpatients attending the Department of Pediatrics of the
Saint-Pierre University Hospital, Brussels, Belgium, that were clin-
ically suspected of having gastrointestinal infection caused by par-
asites were examined according to our triple feces test (TFT).4 In
this test, 3 stool samples are collected on 3 consecutive days (2 with
SAF preservative and 1 fresh specimen) and are examined with an
ethyl-acetate concentration technique and Chlorazol Black E perma-
nent staining for vegetative and cyst stages of protozoa and cysts and
larvae of helminths. On the fresh specimen, in addition, a rhoda-
mine-auramine O staining for Cryptosporidium is performed, with
confirmation with Kinyoun carbolfuchsin acid-fast staining. To
further eliminate possibility of coinfection with Cryptosporidium
and Giardia, the ImmunoCard STAT! Cryptosporidium/Giardia
rapid assay (Meridian Bioscience, Inc.) was systematically per-
formed on unpreserved stool specimens. Coinfection with common
bacterial pathogens was excluded with our specific culture protocol.9
Stool samples of patients younger than 2 years were evaluated for
the presence of rotavirus and enteric adenovirus by rapid immuno-
chromatographic assay. Only patients with pure D. fragilis infec-
tions were enrolled in the study.
A structured, close-ended questionnaire was then used to
collect the patient’s history, age, sex and history of international
travel. The clinical history included diarrhea within the preceding 3
months, nature of the diarrhea, abdominal pains, intensity of fever,
nausea or vomiting, anorexia and weight loss. Diarrhea was defined
as at least 3 unformed or liquid stools per day for at least 3 days.
Duration of diarrhea was classified as acute (duration ⬍30 days) or
persistent (duration ⬎30 days). Abdominal pain lasting more than 3
months was classified as chronic abdominal pain.
The dosage of paromomycin was at 25–35 mg/d, divided in 3
equal doses, for 7 days. With day 0 being the start of treatment,
clinical and microbiologic responses to the drug were evaluated on
days 14, 21 and 28. Clinical follow-up was evaluated as cure,
improvement or relapse of symptoms. Side effects were assessed
with a specific questionnaire on each follow-up visit.
Microbiologic follow-up after treatment was performed on
days 14, 21, and 28 after treatment. Stools for the TFT protocol were
collected on days 14 –16, 21–23, and 28 –30 for examination of D.
fragilis and other intestinal parasites. The ImmunoCard STAT!
Cryptosporidium/Giardia rapid assay (Meridian Bioscience, Inc.)
was performed on the nonfixed stools, as were bacterial and viral
examinations. Parents of the children were informed about the study,
and written consent was obtained. This study was approved by the
ethics committee of the Saint-Pierre University Hospital.
© 2006 Lippincott Williams & Wilkins
The Pediatric Infectious Disease Journal • Volume 26, Number 1, January 2007 Dientamoeba Infection

RESULTS
Seventeen children presenting pure D. fragilis infection were
eligible for the study. Of these, 15 were enrolled in the study (Table
1), one being not treated and another lost for follow-up after
completion of treatment. Age distribution of children was 1–15
years (mean and median ages of 7.7 and 7 years, respectively). Most
frequent symptoms associated with D. fragilis infection were ab-
dominal pain (12/15) and diarrhea (7/15) (Table 1). Two patients
reported recent international travel in overseas countries, and none
of them had an underlying disease. All patients received 7 days’
treatment with paromomycin.
At the last follow-up, 28 days after start of treatment, 12/15
(80%) patients were parasitologically negative and 2/15 (13.3%)
were still symptomatic. All patients with parasitologic cure at day 28
also reported clinical cure. No side effects of paromomycin treat-
ment were reported. No bacterial, viral pathogens, or pathogenic
parasites, except D. fragilis in some cases, were isolated during the
3 microbiologic follow-ups.
At the first follow-up, 14 days after start of treatment, 13/14
(92.9%) patients were parasitologically cured. All patients present-
ing parasitologic cure also reported resolution of symptoms, whereas
a patient (no. 1) with persistent D. fragilis infection continued to be
symptomatic. This patient received a second course of treatment
with paromomycin, which resulted in negative stool tests at day 21.
However, clinically there was no response, and at day 28 D. fragilis
also reoccurred on parasitologic stool examination. At the second
follow-up at day 21, 2 additional patients (no. 4 and 13) relapsed
parasitologically, but only 1 (no. 13) had clinical symptoms. In this
case, a second course of treatment with paromomycin was both
clinically and parasitologically ineffective at day 28.
DISCUSSION
In this study, treatment with paromomycin was effective for
D. fragilis infection in children with parasitologic and clinical cure
in 80% and in 87% of patients, respectively, at the end of the study.
We are aware of only 1 study, by Simon et al,8 where paromo-
mycin was used for treatment of D. fragilis infection. In this study,
paromomycin treatment was reported parasitologically effective in 21
patients with D. fragilis infection who received a treatment course of
1.75 g/d for 4 or 5 days. However, no details about the age of the
patients were provided in this study, and based on the prescribed dosage
(1.75 g/d) it is assumed that only adults were treated. Our study, to our
knowledge, is the first in which paromomycin was evaluated in children
for treatment of D. fragilis infection.
In the study by Simon et al,8 parasitologic examinations
during the follow-up were done on single purged stool at days 10,

TABLE 1. Clinical Features and Responses of Children With Pure Dientamoeba fragilis Infection Treated With
Paromomycin

Follow-up Day 14 Follow-up Day 21 Follow-up Day 28

Patients No./Sex/
Clinical History Microbiologic Clinical Microbiologic Clinical Microbiologic Clinical
Age (yr)
Results Evaluation Results Evaluation Results Evaluation

01/F/02 Chronic abdominal D. fragilis No improvement (RT) — No improvement D. fragilis No improvement

pain*
02/M/01 Chronic abdominal — Recovered — Recovered — Recovered
pain
03/M/03 Acute watery diarrhea, — Recovered — Recovered — Recovered
abdominal pain,
nausea or vomiting
and fever
04/F/04 Chronic abdominal — Recovered D. fragilis Recovered D. fragilis Recovered
pain, nausea or
vomiting and fever
05/F/05 Acute watery diarrhea, — Recovered — Recovered — Recovered
abdominal pain,
nausea or vomiting
06/M/07 Persistent watery — Recovered — Recovered — Recovered
diarrhea
07/M/07 Persistent abdominal — Recovered — Recovered — Recovered
pain
08/F/07 Persistent watery — Recovered — Recovered — Recovered
diarrhea
09/M/10 Chronic abdominal — Recovered — Recovered — Recovered
pain
10/F/11 Chronic abdominal — Recovered — Recovered — Recovered
pain
11/F/11 Persistent diarrhea — Recovered — Recovered — Recovered
and abdominal pain
12/M/15 Chronic abdominal ND ND — Recovered — Recovered
pain
13/M/16 Chronic abdominal — Recovered D. fragilis Relapse (RT) D. fragilis Relapse
pain
14/F/10 Abdominal pain and — Recovered ND ND — Recovered
acute watery
diarrhea
15/F/7 Persistent watery — Recovered — Recovered — Recovered
diarrhea
Overall efficacy (%) 13/14 (92.9) 13/14 (92.9) 12/14 (85.7) 12/14 (85.7) 12/15 (80.0) 13/15 (86.7)
ND indicates not done (patients no. 12 and 14 were absent at day 14 and 21 follow-ups, respectively); RT, retreatment with paromomycin; —, no D. fragilis or other enteric pathogens
observed.
*Chronic abdominal pain was classified as abdominal pain lasting ⬎3 mo. Duration of the diarrhea was classified as acute (⬍30 d) or persistent (⬎30 d).

© 2006 Lippincott Williams & Wilkins 89

Vandenberg et al The Pediatric Infectious Disease Journal • Volume 26, Number 1, January 2007
28, and 66 after the completion of treatment. With the TFT used in
this study, multiple (3) stool samples are examined in each test. For
correct diagnosis of D. fragilis and other intestinal parasites, this is
important because intermittent shedding of parasites can result in
false-negative results when single-stool specimen are examined.4 As
a consequence, real effectiveness of the 4- to 5-day treatment in the
study by Simon et al8 remains unknown and possibly is lower than
initially claimed. According to recent recommendations, we pre-
scribed paromomycin at 25–35 mg/kg/d for 7 days.5
Parasitologic failure was observed in our study in 1 patient
after 1 week and in 2 other patients after 2 weeks after treatment.
The patient with failure at the first follow-up (no. 1) weighed 13 kg.
Based on the prescribed dosage of 35 mg/kg/d, this patient received
455 mg/d, with a total dose of 3.2 g for 7 days of treatment. This
represents only 26% of the total dosage adults receive in a 7-day
treatment course. Within dose-finding studies with paromomycin,
Simon et al8 observed that short courses (2– 4 days) were ineffective
to eradicate D. fragilis. Because paromomycin is not adsorbed from
the intestine, it is possible that, with smaller children, the prescribed
dosage of 25–35 mg/kg is inadequate to eradicate infection and that
higher dosages are needed.
After an initial clearance, reoccurrence of D. fragilis was
observed in 2 patients at day 21. This could be due to ineffective
treatment in the first round or reinfection. In children, the risk of
reinfection is probably large due to poor feco-oral hygiene and the
higher prevalence of Enterobius vermicularis, a factor suggested to
be involved in transmission.2 Because E. vermicularis infection had
not been noticed in the patients of the study group, specific treatment
of this infection was not installed. In one patient (no. 4) clinical cure
was obtained during the whole follow-up period despite reoccurrence of
D. fragilis in stools after 21 and 28 days. Because of the nonblinded
nature of the study, a placebo effect could be involved, which under-
scores the need for further placebo-controlled randomized trials to
define efficacy of paromomycin therapy for D. fragilis infection.
Side effects due to paromomycin were not observed in this
study, which is in accordance with the literature where only few and
mild side effects are reported with this drug regimen.5
Apart from paromomycin, other drugs could be used for treat-
ment of D. fragilis infection in children. Treatment with metronidazole,
used in different studies with various dosages and duration of treatment,
had an overall efficacy of about 70%.9 One prospective study with
secnidazole, a long-acting 5-nitroimidazole, resulted in parasitologic
and clinical effectiveness in 16 of 18 children with pure D. fragilis
infection.10 Most of these earlier studies did, however, lack appropriate
parasitologic evaluations, with examination of multiple fixed stool
specimens after end of therapy, possibly underestimating the persis-
tence of D. fragilis after treatment.
90
With overall parasitologic and clinical effectiveness in be-
tween 80% and 87%, few side effects, short duration of treatment,
and wide availability of the drug, paromomycin appears to be an
effective treatment of D. fragilis infection in children. Our findings
call for additional placebo-controlled studies to further evaluate
efficacy of paromomycin treatment of D. fragilis infection. As was
the case in this study, highly sensitive diagnostic tests for diagnosis
and follow-up should be employed.
ACKNOWLEDGMENTS
The authors thank the patients and their families for their
participation in this study. The authors are grateful to Patricia
Retore, Souad Mohamed, and Catherine Moens for their daily
skilled technical assistance. We also thank Urielle Ullmann for her
critical comments. There are no commercial or other associations
that might pose a conflict of interest.
This work was supported in part by the Foundation Vesale
Research fellowship (Foundation for Medical Research).
REFERENCES
1. Johnson EH, Windsor JJ, Clark CG. Emerging from obscurity: biolog-
ical, clinical, and diagnostic aspects of Dientamoeba fragilis. Clin
Microbiol Rev. 2004;17:553–570.
2. Stark DJ, Beebe N, Marriott D, Ellis JT, Harkness J. Dientamoebiasis:
clinical importance and recent advances. Trends Parasitol. 2006;22:92–96.
3. Bosman DK, Benninga MA, van de Berg P, Kooijman GC, van Gool T.
Dientamoeba fragilis: possibly an important cause of persistent abdom-
inal pain in children. Ned Tijdschr Geneeskd. 2004;148:575–579.
4. van Gool T, Weijts R, Lommerse E, Mank TG. Triple faeces test: an
effective tool for detection of intestinal parasites in routine clinical
practice. Eur J Clin Microbiol Infect Dis. 2003;22:284 –290.
5. The Medical Letter on Drugs and Therapeutics. Drugs for parasitic
infections. Med Lett Drugs Ther. 2004:1–12.
6. Frenkel LM. Dientamoeba fragilis infection. In: Feigin RD, Cherry JD,
eds. Textbook of Pediatric Infectious Diseases. 4th ed. Philadelphia, Pa:
Lippincott Williams & Wilkins; 1998:2403–2406.
7. Fisher AK, Walter FG, Szabo S. Iodoquinol associated seizures and
radiopacity. J Toxicol Clin Toxicol. 1993;31:113–120.
8. Simon M, Shookhoff HB, Terner H, Weingarten B, Parker JG.
Paromomycin in the treatment of intestinal amebiasis: a short course of
therapy. Am J Gastroenterol. 1967;48:504 –511.
9. Vandenberg O, Peek R, Souayah H, et al. Clinical and microbiological
features of dientamoebiasis in patients suspected of suffering from a
parasitic gastrointestinal illness: a comparison of Dientamoeba fragilis
and Giardia lamblia infections. Int J Infect Dis. 2006;10:255–261.
10. Girginkardesler N, Coskun S, Cuneyt Balcioglu I, Ertan P, Ok UK.
Dientamoeba fragilis, a neglected cause of diarrhea, successfully treated
with secnidazole. Clin Microbiol Infect. 2003;9:110 –113.
© 2006 Lippincott Williams & Wilkins