Association Between Finger Clubbing And Chronic Lung Disease In Hiv Infected Children At Kenyatta National Hospital
Odionyi, Justine Jelagat
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Background: Finger clubbing in HIV infected children is associated with pulmonary diseases like bronchiectasis, TB, and LIP. Pulmonary involvement is responsible for great morbidity and mortality in HIV infected children. Finger clubbing is a clinical sign that is easy and quick to detect without sophisticated equipment. Therefore, finger clubbing could provide simple screening tool to identify children for further evaluation for chronic lung disease and hence timely intervention which may result in lower morbidity and mortality. Objective: To determine the association of finger clubbing and chronic lung diseases in HIV infected children. Secondary objective was to determine clinical correlates (in terms of WHO clinical staging, CD4 counts/ percentage, antiretroviral therapy duration and pulmonary hypertension) of finger clubbing among HIV infected children. Methodology: Hospital based prospective case control study was conducted at KNH Paediatric wards and CCC. Cases were 60 HIV positive children with finger clubbing and controls were 60 HIV infected children without finger clubbing. A total of 120 HIV infected children upto 18 years whose parents gave consent were recruited into the study between February 2012 and January 2013. Baseline characteristics and physical examination, laboratory tests, chest radiographs and echocardiography were undertaken and recorded in questionnaires. Diagnosis of presence or absence of chronic lung disease was then made. Data was recorded daily in questionnaires by the investigator. The obtained data was entered into the Statistical Package Social Sciences (SPSS) data entry programme and analyzed using SPSS/PC+ version 9 programme. The data was then summarized in frequency tables. The differences between cases and controls were determined using Chi square test for categorical variables. Continuous variables was analyzed and presented as medians with interquartile ranges (IQR) then compared between cases and controls using Mann Whitney U test. Odds ratios were calculated for categorical data to estimate the magnitude of risk among the cases. All the statistical tests were performed at 95% confidence interval (5% level of significance). 2 Results: Diagnosis of chronic lung disease was six times more common among the finger clubbed, 33 (55%) than the non finger clubbed patient, 10 (16.7%), OR 6.1 [95% CI 2.6- 14.3], p<0.001. Finger clubbed patients had 2.6 times risk of being diagnosed with hypoxemia, 28 (46.7%), OR 2.6 (95% CI 1.2-5.7), p=0.013, and 4.4 times risk of pulmonary hypertension, 28 (46.7%), OR 4.4 (95% CI 1.9-10.2), p=0.001 as compared to the controls. Those with finger clubbing had advanced disease in WHO stage III/ IV (91.7%) compared to non finger clubbed patients (68.3%), OR 6.4 [95% CI 2.0-20.2], p<0.001. Patients with finger clubbing had lower CD4 cells count and percent (median 369cells, 13%) compared to non clubbed patients (median 861cells, 28%), p<0.001. Duration of ART use was shorter in the finger clubbed patients (5.5 months) compared to non finger clubbed patients (median 40 months) p<0.001. Conclusion: The diagnosis of chronic lung disease was more common in patients with finger clubbing than those without it and the presence of finger clubbing in HIV infected children was associated with advanced WHO stage III or IV, lower CD4 counts and percentage and shorter duration of ART use. There is a higher risk of developing pulmonary hypertension in HIV infected children with finger clubbing. Recommendations: All HIV infected children should be examined for the presence of finger clubbing and those found with it should have pulse oximetry, chest radiolograph and echocardiography to assess for the presence of chronic lung disease and its complications.