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CLINICO PATHOLOGICAL CONFERENCE  
Year : 2015  |  Volume : 58  |  Issue : 2  |  Page : 204-210
Cystic fibrosis in a retro-positive child


1 Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Paediatric Immunology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

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Date of Web Publication17-Apr-2015
 

   Abstract 

We present a rare association of cystic fibrosis and retro positivity in a grossly malnutrited child. The child had pulmonary, pancreatic and colonic manifestations with superadded herpes simplex virus interstitial pneumonia and lymphocytic meningitis.

Keywords: Cystic fibrosis, human immunodeficiency virus infection, herpes simplex pneumonitis, lymphocytic meningitis, pancreatitis, colonic mucoviscidosis

How to cite this article:
Sharma P, Arthi N, Bhattad S, Vaiphei K. Cystic fibrosis in a retro-positive child. Indian J Pathol Microbiol 2015;58:204-10

How to cite this URL:
Sharma P, Arthi N, Bhattad S, Vaiphei K. Cystic fibrosis in a retro-positive child. Indian J Pathol Microbiol [serial online] 2015 [cited 2019 Dec 11];58:204-10. Available from: http://www.ijpmonline.org/text.asp?2015/58/2/204/155316



   Clinical Protocol Top


A 2-year-old boy was admitted on 4 th June and died in the hospital on 11 th June. He had presented with a history of fever and loose stools of 25 days duration associated with difficulty in breathing for 7 days. Fever was intermittent, not associated with chills and rigor. Loose stools accounted for 8-10 episodes per day with no blood or mucus. There was also the history of vomiting for 4 days before he was admitted in the hospital. There was also another episode of diarrhea 1-month back before the present one, and he was treated with intravenous fluids, improved and discharged. No further details are available.

Clinical examination and investigations

Examination at the time of hospital admission: The child was grossly malnutrited, and his anthropometric findings are highlighted in [Table 1]. He had pallor, but no cyanosis, clubbing, edema or lymphadenopathy. Signs of micronutrient deficiency were seen in the form of sparse hypopigmented hair and cheilitis. He was also signs of dehydration as he was noted to have sunken eyes, dry skin and mucosa. He was detected to be tachypneic. Auscultation of the chest revealed crepitation's in right infra axillary and mammary areas with SpO 2 -86% at room air. The cardiovascular, central nervous system and abdominal examination were within normal limits. He had low hemoglobin, leukocytosis, lymphocytosis and gradually decreasing platelet count [Table 2] and mildly deranged coagulogram [Table 3]. He had hyporkalemia toward the terminal stage of his illness and was also detected to have hypoalbumin anemia, hyperglycemia and mildly elevated transaminases [Table 4]. He developed metabolic acidosis [Table 5]. His chest X-ray done at admission showed diffuse homogenous radio-opacity involving right mid and lower zones with obscuration of the underlying right hemi-diaphragm [Figure 1]. The radiology findings suggested consolidation with possible underlying pleural effusion. Ultrasonography of abdomen was within normal limit. He had a negative mantoux test and gastric lavage tested for tuberculosis (TB) was also negative. Routine stool examination by cultures (on 8 th and 10 th June) was sterile, there was no ova or cyst (9 th June) and hanging drop (10 th June) was also negative. Routine serology screening for human immunodeficient virus (HIV) by ELISA was found to be reactive.
Figure 1: Plain chest X-ray showing diffuse homogenous radio-opacity involving right mid and lower zones with obscuration of the underlying right hemidiaphragm


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Table 1: Anthropometry findings in the child


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Table 2: Hematological parameters


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Table 3: Coagulogram


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Table 4: Biochemical parameters


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Table 5: ABG analysis


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Course in the hospital

The child had severe electrolyte imbalance including hypokalemia and hyperglycemia and was corrected with intra-venous fluid. Pneumonia was managed with intravenous antibiotics. His response was not satisfactory, and he required ventilator support at a later stage of the hospital stay. In addition, anti-fungal medication was prescribed in suspicion of fungal sepsis. However, the child had worsening thrombocytopenia and progressive downhill course. Ultimately he developed cardiac arrhythmia and cardiac arrest, and ultimately he succumbed to his illness.

Unit's final diagnosis

A retro positive child with protein-energy malnutrition, pneumonia, and fungal sepsis. Cause of death-cardiac arrhythmia and cardiac arrest.

Discussion on Clinical Protocol by Aarthi N, Junior Resident, Department of Pediatric Medicine.

This was a story of a 2-year-old boy from a poor socioeconomic background who was unimmunized for age, and he was the 5 th of the sixth siblings. The parents had refused for a test for the retro virus, and both were not cooperative for any kind of further clinical examination. The child had presented with persistent diarrhea, pneumonia, failure to thrive and severe wasting. On examination, he had anemia, worsening thrombocytopenia, electrolyte disturbances in the form of hypokalemia and hyperglycemia with evidence of metabolic acidosis. HIV serology by ELISA was found to be reactive. Preterminally he developed cardiac arrhythmia and died of cardiac arrest. The cause of diarrhea in this retro-positive index child could most likely to be due to infectious pathology. [1] Acquired immunodeficient syndrome (AIDS) related diarrhea is a complex disease. The underlying etiology tends to be multifactorial with infections by common and atypical pathogenic agents. Infectious agents may include bacteria, parasites, mycobacteria and viruses, and these organisms are frequently isolated in the stools or in mucosal biopsies in this group of patients. [2] The bacteria may be  Salmonella More Details, Shigella, Campylobacter, Clostridium difficle, Mycobacterium avium complex (MAC) intracellulare or Mycobacterium tuberculosis. Common parasites are Cryptosporidium, Isospora, Enterocytozoon, Septata intestinalis, Entamoeba histolyica Giardia, Strongyloides or Cyclospora. Finally, the associated viruses may be Cytomegalovirus (CMV), Herpes group, Adenovirus, Astrovirus or Calcivirus, and HIV per se may also be responsible for diarrheal illness in HIV-infected AIDS patients. [3]

At this point, it is essential to understand the best methodology that may be employed for detection of the inciting agents in the stool specimen. Stool analyses are the initial step in evaluating HIV-related diarrhea. [1],[2],[3] Hence, multiple stool samples for routine enteric pathogen cultures should be collected, and stool analyses for ova and parasites should be performed in such patients. The most common cause of chronic debilitating diarrhea among patients with AIDS is Cryptosporidium parvum. Patients with cryptosporidiosis have profuse watery diarrhea, weight loss, paraumbilical abdominal pain, nausea, and vomiting. Acid fast stain of concentrated stool is helpful in the diagnosis. In the last 5 years as a major cause of chronic diarrhea among patients with HIV disease is Microsporidiosis, which is responsible for 15-20% of all chronic diarrheal illnesses in patients with AIDS. [4] Enteric biopsies or "fungi fluor" stain can aid in the diagnosis. CMV is responsible in 10-20% of debilitating diarrheal illness in AIDS patients, which can be diagnosed on enteric biopsies by identifying viral inclusions and by immunohistochemistry. [5]

Mycobacterium avium can be diagnosed by stool cultures and Endoscopic biopsies of thickened folds which show foamy macrophages in lamina propria, containing numerous acid-fast-positive organisms. Even after a thorough evaluation, approximately 15-20% of patients have no identifiable pathogen, but present with blunt mucosal biopsy, diarrhea, and malnutrition. This constellation of findings was labeled as AIDS enteropathy by Kotler and associates in 1984. [1],[2],[3],[4],[5]

What could be the cause of pneumonia in this child? An analysis of bacteremic pneumonia in HIV-infected children from low and middle-income countries reported that Streptococcus pneumoniae (7.4%) was the most common pathogen followed by Staphylococcus aureus (2.4%). The most common Gram-negative bacteria responsible for pneumonia were  Haemophilus influenzae Scientific Name Search .8%),  Escherichia More Details coli (0.8%) or Salmonella species (0.7%). Respiratory viral infections have been identified in HIV-infected children with severe pneumonia as much as 16-40%. Viruses most commonly identified are CMV, respiratory syncytial virus, influenza, human metapneumovirus, parainfluenza, and Adenovirus. Pneumocystis jirovecii is a commonly isolated pathogen in HIV-infected children hospitalized with severe pneumonia, resulting in severe rapidly progressive pneumonia, with a mortality rate of around 50%. It is known that children with polymicrobial pneumonia have a 10-fold greater risk of dying than children in whom only a single organism is identified. In this index child, Gram-negative bacteria, CMV, MAC/TB could be the possible culprits responsible for pneumonia. PCP is one another possibility that needs to be considered. [1],[2],[3],[4],[5] This child had severe wasting, which, according to WHO clinical staging, comes under stage 4 category. Wasting could be multifactorial, because of nutritional deficit, Infections, Diarrhea or HIV-associated endocrinopathy. [6] Arrhythmia in HIV patient could be related to drug toxicity, Myocarditis or Dyselectrolytemia. In this index child, Dyselectrolytemia or Myocarditis could be possibly response for cardiac arrest. [7]


   Final Clinical Diagnosis Top


Human immunodeficient virus stage 4 with persistent diarrhea, pneumonia, severe wasting, polymicrobial sepsis either by Gram-negative bacterial and fungal infection, disseminated CMV infection, M. avium (MAC) Intracellulare or toxoplasmosis. Cause of death: Cardiac Arrhythmia due to dyselectrolytemia or myocarditis by toxoplasmosis or CMV.

Pathology Protocol (PM 26158) by Praveen Sharma, Junior Resident, Pathology.

At the time of autopsy, the child was noted to be grossly cachectic. All the serous cavities were within normal limits.

Lungs together weighed 200 g (normal mean 145 g). Both the lungs were overweight. Pleura felt slimy, dull with fibrinous tags. Serial slicing of the lungs showed patchy areas of congestion, consolidation and foci of subpleural hemorrhages. Tracheobronchial tree was congested and showed prominent bronchial marking [Figure 2]. There was the presence of blood stained aspirated material within the bronchial tree. Bilateral hilar and carinal lymph nodes were enlarged measuring 5 to 15 mms in size, cut sections were pale brown with focal blackish discoloured areas. Multiple sections form both the lungs were studied. Sections taken from the hilum showed irregularly dilated bronchus with squamous metaplasia of the bronchial lining epithelium [Figure 2]a, and the lumen were seen to contained thick mucinous secretion mixed with fresh red blood cells. There was submucosal fibrosis, destruction of bronchial cartilage and submucosal glands. Some of the remaining submucosal glands were ectatic and filled with thick mucus secretion [Figure 2]b. There was a moderate amount of mixed neutrophils, lymphocytes, and plasma cell infiltration. Sections from the consolidated areas showed bronchiolar lumen and surrounding alveoli alveolar cavities filled with mixed inflammatory cells including many foamy histiocytes [Figure 2]c. Oil Red O stain was performed, which highlighted presence of fat droplets inside these macrophages indicating lipoid pneumonia [Figure 2]d. Section from the nonconsolidated areas showed widening of the inter-alveolar septa and infiltration by lymphocytes and scattered alveolar lining cells with enlarged and smudge nuclei with reddish intranuclear inclusions [Figure 2]e. These cells were positivity for Herpes simplex virus 1 and 2 in immunohistochemistry [Figure 2]f. There were also focal areas of intra-alveolar hemorrhages and a focus of necrotizing inflammation of a medium sized bronchus due to invasive mucormycosis [Figure 2]g. The fungal hyphae were broad, dominantly aseptate, folded upon itself.
Figure 2: Gross photograph of the lungs showing shiny pleura with fibrous tags. The cut surface of both the left lung shows prominent bronchial markings and multiple discolored areas representing the patchy consolidation. (a and b) Photomicrographs of the hilar region showing dilated bronchus with squamous metaplasia of the lining epithelium. There is submucous fibrosis with destruction of the cartilage and submucosal glands. Some of the submucosal glands were ectatic filled with secretions (H and E, ×40). (c) Photomicrograph from consolidated areas showing evidence of bronchopneumonia with spillage of the inflammatory cells into the adjacent alveoli (H and E, ×40). (d) Photomicrograph of a special stain showing red colored oil droplets within alveolar macrophages indicating lipoid pneumonia (Oil Red O stain, ×1000). (e) Photomicrograph showing prominent intra-alveolar macrophages and expanded alveolar seta along with infiltration by lymphomononuclear cells. Some of the alveolar macrophages have enlarged and smudge nuclei (H and E, ×40). (f) A representative photomicrograph of an immuhistochemistry stained section showing nuclear and cytoplasmic positive staining for Herpes simplex virus (type I and II) (peroxidase anti-peroxidase, ×1000). (g) Photomicrograph showing a dilated segmental bronchus with submucosal fibrosis, destruction of cartlage and metaplastic lining mucosa. Lumen and wall of the ecstatic bronchus show invasion by numerous fungal profiles with inflammatory cell exudate (H and E, ×40). (h) High power photomicrograph of the same area to highlight the fungal hyphae better, which are broad, aseptate and easily foldable conforming to the morphology of mucormycosis (H and E, ×400)


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Liver weighed 400 g (normal mean 390 g) and mildly enlarged, pale in color. Grossly, there was no significant pathology identified. Microscopy: Sections showed extensive micro and macrovesicular steatosis. There was centri-zonal sinusoidal dilation and congestion possibly related to terminal shock. Portal tracts were within normal limits [Figure 3]a and b.
Figure 3: (a) Gross photograph of organ complex comprising of slice of liver, gall bladder, c-loop of duodenum, bisected pancreas and slice of spleen. All the organs are pale. Liver is greasy to touch, no focal lesion. Pancreas was felt firm. (b) Low power photomicrograph of the liver to show diffuse micro and macrovescicular fatty changes with relatively normal looking portal tracts and central veins, and centri-zonal sinusoidal dilation and congestion (H and E, ×40)


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Pancreas grossly felt firm in consistency [Figure 3]a. Microscopy: There was the interlobular and intralobular fibrosis with mild to moderate amount of chronic inflammatory cell infiltration. There was dilation of the intralobular and interlobular ducts with periductal fibrosis and inflammation. There was destruction of the periductal mucous glands, the remaining ones showing dilatation [Figure 4]a. The pancreatic acini were dilated the lumen of which were filled with thick pinkish inspissated secretion [Figure 4]b.
Figure 4: (a) Section from pancreas showing periductal, inter and the intralobular fibrosis with moderately heavy inflammatory cell infiltration. There was dilation of the intralobular and interlobular ducts. The glands underlying the ducts were ecstatic with patchy areas of atrophy. In addition, there was focal destruction of the pancreatic acini (H and E, ×200). (b) Higher magnification showing the inflammatory cells which were predominatly composed of lymphocytes and acinar ectasia (H and E, ×400)


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Intestine were pale, otherwise there was no focal lesion. Terminal part of the ileum showed prominent Peyer's patches which were also seen microscopically as well [Figure 5]a. Large intestine was nondescriptive grossly. Sections studied however showed slightly elongated crypts, and the depth of the crypts were filled with thick mucus which was better highlighted better by periodic acid Schiff staining [Figure 5]b and c. The findings in the colon were consistent with mucoviscidosis.
Figure 5: (a) Low power photomicrograph of the terminal ileum to show the hyperplastic Peyer's patch (H and E, ×10). (b and c) Representative photomicrograph of colonic mucosa in H and E and Periodic acid-Schiff (PAS) stained section to show slightly hypeprlastic and dilated colonic crypts which are filled with PAS positive thick mucus (H and E and PAS, ×20)


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Spleen weighed 60 g (mean normal 33 g), mildly enlarged and congested [Figure 3]a. Microscopy: Depletion of the white pulp, congestion of the red pulp with extra-medullary hematopoietic cells. Areas of hemorrhage were seen on gross examination, which were confirmed microscopically. In addition, there was congestion of the red pulp with relative depletion of the white pulp.

Lymph nodes: Different groups were enlarged including the mesenteric lymph nodes measuring form few mm to more than 1 cm [Figure 6]a. Cut sections were homogenous pale brown. Microscopy: Showd reactive lymphoid tissue [Figure 6]b.
Figure 6: (a) Gross picture showing collections of enlarged mesenteric lymph nodes. (b) Low poer photomicrograph of a reactive lymph node to show cortical and paracortical expansion (H and E, ×10)


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Brain weighed 1005 g (mean normal 970 g). Meningeal surface was clear; there were no basal exudates or no cerebral edema. Serial slices were within normal limit. Microscopy of the standard sections showed lymphocytic meningitis along the convex surface [Figure 7]a. Microscopy foci of infarcts were identified within grey matter and grey, white junction. There was a loss of neuron and myelin [Figure 7]b, edema and collections of macrophages [Figure 7]c and d.
Figure 7: Panel of photomicrographs of brain. (a) Low power photomicrograph of cortical surface to show the lymphomononuclear inflammatory cell infiltration of the leptomeninges (H and E, ×10). (b) A microscopic focus of pale infarct with an artefactual separation of the soften brain parenchyma (H and E, ×10). (c) Higher power photomicrograph of the pale area to show the collections of bloated up macrophages and loss of myelin (H and E, ×20). (d) Photomicrograph of the area shown in (c) in immunohistochemistry staining for macrophage using CD68 primary anti-body (peroxidase anti-peroxidase, ×20)


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Heart weighed 80 g (mean normal of 60 g). Grossly the heart was pale in color. On cutting open the heart, there was biventricular hypertrophy with dilation of the cavities and the right ventricular cavity contained mural thrombus [Figure 8]a. There was discoloration of the myocardium along the posterior wall of the left ventricle and inter-ventricular septum [Figure 8]a and b. All the valves were within normal limits. Right, auricle showed mural fresh thrombus [Figure 8]c. There was also the dilatation of the roots pulmonary artery and aorta. Microscopy: There were changes of early ischemia corresponding to the discolored area in the wall of left ventricle and inter-ventricular septum in the form of hyper eosinophilia, interstitial edema and loss of cellular detail and nuclei [Figure 8]d.
Figure 8: The photographs in the panel includes, (a) a gross picture of the apical slice of the heart to show the biventricular dilation, and also to be noted is the presence of thrombi within the right ventricular cavity and myocardial discoloration involving the inter-ventricular septum (black colored circle). (b) Picture showing the cut open left ventricle outflow tract to show the normal aortic valve dilated outflow tract and the discolored myocardium along the posterior wall of left ventricle (black colored cycle). (c) Gross photograph taken from the anterior aspect to sho the dull looking pericardium which was slimy and grossly discolored right auricle by mural thrombus. (d) Low power photomicrogrpah of the left ventricular myocardium to show the early myocardial infarct (H and E, ×20)


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Kidneys weighed 120 g (normal mean of 100 g). They were pale, otherwise no gross abnormality. The ureters and the urinary bladder were within normal limit. Abdominal aorta was also within normal limit [Figure 9]a. Cut sections showed the medullary congestion with distinct corticomedullary junction [Figure 9]b. Microscopy: Glomeruli were showing mesangiolysis with dilation of the capillary loops. There were tubular dilation and some of the tubules containing pinkish hyaline cast [Figure 9]c.
Figure 9: (a) Gross photograph of organ complex comprising of pale kidneys, ureters, bladder and part of abdominal aorta. (b) Close up photograph of the cut section of kidney to show medullary congestion with distinct cortico-medullary junction. (c) Medium power photomicrograph of the kidney showing mesangiolysis with dilation of the capillary loops with dilated tubules, and some of the tubules containing pinkish hyaline cast (H and E, ×10)


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Bone marrow: It was moderatly hypocellular for the age of the child with erythroid cell hyperplasia. Megarkaryocytes showed dysplasia in the form of nuclear lobe separation and hyperlobation [Figure 10]a. There was evidence of the increase in histiocytes within the marrow spaces with increased amount of storage iron [Figure 10]b.
Figure 10: (a) Low power photomicrograph showing a moderately hypocellular marrow with erythroid cell hyperplasia, scattered macrophages and dysplastic megarkaryocytes (H and E, ×10). (b) Higher power photomicrograph showing increase in histiocytes and storage iron (Perls, ×20)


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   Final Autopsy Diagnosis Top


In a retro positive grossly malnutrited child with

  • Morphological changes in lungs, pancreas and colon consistent with cystic fibrosis (CF).
  • Lungs - Herpes virus related interstitial pneumonitis, patchy bronchopneumonia with superadded mucormycosis and endogenous lipoid pneumonia.
  • Heart - biventricular dilatation with fresh ischemia in left ventricle and thromboemboli in right auricle and right ventricle.
  • Brain - lymphocytic meningitis with recent cortical infarcts.
  • Kidneys - mesangiolysis with early acute tubular necrosis.



   Brief Comment on Cystic Fibrosis Top


Cystic fibrosis, an autosomal recessive genetic disorder, is due to mutations in the gene on chromosome 7 that encodes an amino acidic polypeptide named CF transmembrane regulator (CFTR). [8] Despite great heterogeneity in clinical manifestations, the vast majority of persons with CF are diagnosed through classic signs and symptoms of the disease and corroborative laboratory results. However, the diagnosis is not as clear-cut in approximately 5-10% of individuals with CF. [8] Even though the sweat chloride test remains the gold standard for the diagnosis of CF, a clear answer is not always possible. Genotype analysis also does not always provide clarity as more than 1500 mutations have been identified in the CFTR gene, not all of which result in CF. The disease affects many organs, but the most notable are lungs, reproductive tracts, pancreas, intestine, and liver. [9] It is still a matter of controversy regarding the role of virus in initiating or promoting lung damage in CF patients. However, 50 and 60% of patients have been observed to be positive for fungi like Aspergillus fumigatus in their sputum. An equal proportion of the CF patients may develop fungal precipitating precipitins in their serum. Extensive lung damage and a long-term antibiotic therapy possibly predisposes to pulmonary fungal colonization usually within airways but occasionally as an intra-cavitatory fungal ball formation. [10] Although much of the pathology described is well characterized, the extent and patterns of pathological findings in CF will most likely change with time. And the life expectancy is gradually increasing with awareness and improved therapy. Potential new treatment modalities both at pharmacological and genetic levels are continually undergoing aggressive clinical trials. [11]

 
   References Top

1.
Cohen J, West AB, Bini EJ. Infectious diarrhea in human immunodeficiency virus. Gastroenterol Clin North Am 2001;30:637-64.  Back to cited text no. 1
    
2.
Raini S, Nyangao J, Kombich J, Sang C, Gikonyo J, Ongus J, et al. Human rotavirus group a serotypes causing gastroenteritis in children less than 5 years and HIV-Infected Adults in Viwandani Slum, Nairobi. Ethiop J Health Sci 2015;25:39-46.  Back to cited text no. 2
    
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Agholi M, Hatam GR, Motazedian MH. HIV/AIDS-associated opportunistic protozoal diarrhea. AIDS Res Hum Retroviruses 2013;29:35-41.  Back to cited text no. 3
    
4.
Calder D, Qazi S. Evidence behind the WHO guidelines: Hospital care for children: What is the aetiology of pneumonia in HIV-infected children in developing countries? J Trop Pediatr 2009;55:219-24.  Back to cited text no. 4
    
5.
McNally LM, Jeena PM, Gajee K, Thula SA, Sturm AW, Cassol S, et al. Effect of age, polymicrobial disease, and maternal HIV status on treatment response and cause of severe pneumonia in South African children: A prospective descriptive study. Lancet 2007;369:1440-51.  Back to cited text no. 5
    
6.
Sinha U, Sengupta N, Mukhopadhyay P, Roy KS. Human immunodeficiency virus endocrinopathy. Indian J Endocrinol Metab 2011;15:251-60.  Back to cited text no. 6
    
7.
Barbaro G, Barbarini G. Human immunodeficiency virus & cardiovascular risk. Indian J Med Res 2011;134:898-903.  Back to cited text no. 7
[PUBMED]  Medknow Journal  
8.
Colombo C, Battezzati PM. Liver involvement in cystic fibrosis: Primary organ damage or innocent bystander? J Hepatol 2004;41:1041-4.  Back to cited text no. 8
[PUBMED]    
9.
Farrell PM, Rosenstein BJ, White TB, Accurso FJ, Castellani C, Cutting GR, et al. Guidelines for diagnosis of cystic fibrosis in newborns through older adults: Cystic Fibrosis Foundation consensus report. J Pediatr 2008;153:S4-14.  Back to cited text no. 9
[PUBMED]    
10.
Maguire CP, Hayes JP, Hayes M, Masterson J, FitzGerald MX. Three cases of pulmonary aspergilloma in adult patients with cystic fibrosis. Thorax 1995;50:805-6.  Back to cited text no. 10
    
11.
Sheppard MN, Nicholson AG. The pathology of cystic fibrosis. Curr Diagn Pathol 2002;8:50-9.  Back to cited text no. 11
    

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Correspondence Address:
Dr. Kim Vaiphei
Department of Histopathology, Room No. 505, 5th Floor, Post Graduate Institute of Medical Education and Research, Chandigarh - 160 012
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0377-4929.155316

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    Figures

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