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ORIGINAL RESEARCH: ARTICLES
Background. Bronchiectasis (BE) in children living with HIV (CLWH) remains a signicant cause of morbidity and mortality, especially in
tuberculosis (TB)-endemic low- and middle-income countries. Treatment modalities for BE in CLWH currently focus mainly on prevention
of infections and management of symptoms, while surgical management is indicated for a select group. In contrast, surgical management
in non-cystic brosis BE is well established.
Objectives. To describe the indications for and complications of surgical resection for BE in CLWH, and to identify variables inuencing
outcome.
Methods. A retrospective medical records review was conducted of all CLWH aged ≤14 years who underwent surgical resection for
BE at Tygerberg Hospital, Cape Town, South Africa, between 1 January 2007 and 30 September 2014. e variables collected included
immune status, antiretroviral treatment (ART), previous treatment for TB, operative and postoperative complications, and postoperative
symptom relief.
Results. Twelve CLWH on ART with symptomatic BE underwent surgical resection. e mean age was 7 years and the mean CD4 count
970cells/µL. Indications for surgery included recurrent infections, chronic cough and persistent lobar collapse. e most common procedures
were le lower lobe lobectomy (42%), le pneumonectomy (17%) and right bilobectomy (17%). Complications were limited to persistent
pneumothorax aer surgery in one child. ere were no deaths. Ten children (83%) showed signicant improvement of symptoms at follow-up.
Conclusion. Surgical resection for BE in CLWH can be performed safely with a low complication rate, resulting in signicant improvement
of symptoms postoperatively.
Keywords. Bronchiectasis, childhood thoracic surgery, HIV-related chronic lung disease, lobectomy.
Afr J Thoracic Crit Care Med 2024;30(3):e1128. https://doi.org/10.7196/AJTCCM.2024.v30i3.1128
Bronchiectasis (BE) is dened as the irreversible destruction of the
bronchial wall and surrounding tissues. It is caused by an initial
infectious process that initiates a persistent inammatory response
resulting in impaired mucociliary clearance, complicated by acute or
chronic infections causing permanent damage to the bronchial wall
and subsequently to the lung parenchyma.[1,2]
HIV-related lung disease has been responsible for an increase
in chronic lung disease (CLD), including BE, especially in the
pre-antiretroviral therapy (ART) era.[1] In 2017, the prevalence
of HIV infection in South Africa (SA) was 12.6% (7 million
people),[3] while Western Cape Province had a prevalence of 6.6% in
2015/16.[4] Furthermore, SA remains among the countries with the
Surgery for bronchiectasis in children living with HIV:
Acaseseries from a low- to middle-income country
H Peens-Hough,1 MB ChB, FC Cardio (SA), MMed (orac Surg);
P Goussard,2 MB ChB, FC Paed (SA), MMed (Paed), PhD ;
D Rhode,2 MB ChB, FC Paed (SA), MMed (Paed);
L van Wyk,2 MB ChB, FC Paed (SA), MMed (Paed), BSc (Pharm) Hons, BSc Med Sci (Epidemiol), Cert Neonatology (SA), MSc (Neonatol), PhD;
J Janson,1 MB ChB, MMed (orac Surg), FCS (or) (SA), PhD
1 Division of Cardiothoracic Surgery, Department of Surgical Sciences, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital,
Cape Town, South Africa
2 Department of Paediatrics and Child Health, Faculty of Medicine and Health Sciences, Stellenbosch University and Tygerberg Hospital, Cape Town, South Africa
Corresponding author: P Goussard (pgouss@sun.ac.za)
Study synopsis
What the study adds. Bronchiectasis (BE) in children living with HIV (CLWH) is a signicant cause of morbidity and mortality. Current
treatment focuses on preventing infections and managing symptoms, while surgical management is rarely considered. A retrospective
medical records review of 12 children aged ≤14 years in South Africa found that surgical resection for BE can be performed with a low
complication rate, resulting in signicant improvement of symptoms postoperatively. Variables inuencing outcome include immune status,
antiretroviral treatment and previous treatment for tuberculosis.
Implications of the ndings. is study demonstrates that surgery for BE can be performed safely in CLWH, with signicant improvement
of respiratory symptoms postoperatively.
108 AJTCCM VOL. 30 NO. 3 2024
ORIGINAL RESEARCH: ARTICLES
highestincidence of tuberculosis (TB) (615 per 100 000 population
in 2019).[5]
BE is a common cause of morbidity and mortality in children living
with HIV (CLWH), specically those in early adolescence.[6,7]
Subsequent to the early use of ART in children, the prevalence of BE
decreased in industrialised countries, but it remains common in the
high HIV prevalence countries of sub-Saharan Africa.[2] is situation
can be explained by the late diagnosis of HIV infection in children,
poorly managed lower respiratory tract infections (LRTIs), and a high
prevalence of TB.[8] It has been reported that CLD, including BE, is
common in adolescents living with HIV (ALWH) who were only
recently diagnosed with HIV infection.[9] Even aer initiating ART in
CLWH with BE, lung function does not improve and patients remain
symptomatic.[10]
Studies conducted in Zimbabwe and Malawi among older children
and adolescents with perinatally acquired HIV showed that 50% had
chest radiographic features consistent with BE.[11,12] Two-thirds of
children in the African studies had been on ART for at least a median
duration of 20 months and had a median CD4 count >350 cells/µL.[13]
Risk factors for developing BE in CLWH are severe immunosuppression
(blood lymphocyte CD4 percentage <15%), pulmonary TB (PTB), and
persistent and/or recurrent pneumonia, mostly caused by multiple
organisms.[1,8] In CLWH, both neutrophil-driven airway inammation
and an exaggerated local and systemic immunological response to
bacterial and fungal pathogens contribute to BE.[10]
Despite HIV-associated BE being one of the most common
causes of non-cystic brosis (non-CF) BE, there are no published
guidelines on the standard of care with regard to medical and
surgical management.[14]
Reports of surgical treatment for non-CF BE in children
demonstrate that it is a safe procedure with acceptable morbidity and
negligible mortality, leading to signicant improvements in symptoms
and quality of life.[15,16] ere are only case reports of single cases of
HIV-related BE in which surgical management of BE in adults or
children has been described.[2,17,18]
e aim of this study was to report on the surgical management of
BE in a series of CLWH and to determine morbidity and mortality
following thoracic surgery in these chronically ill children.
Methods
This was a retrospective study of a case series of CLWH who
underwent surgical resection for BE between 1 January 2007 and 30
September 2014. e study was conducted at Tygerberg Hospital, a
tertiary care hospital in Western Cape Province, SA, a region with a
high prevalence of both HIV and TB.
All CLWH aged ≤14 years with surgically resectable BE were
included in the case series. Surgical resection of the BE was only
considered if the child had unilateral BE and relatively preserved
lung function and remained symptomatic aer ART and medical
management of the BE were optimised. Symptomatic was dened as
one or more of the following conditions: a chronic cough (dened
as lasting 3 - 4 weeks)[19] with copious sputum production, recurrent
pneumonia (dened as two episodes of pneumonia in 1 year or three
episodes over any time frame), or recurrent LRTI (more than eight
per year)[20] and failure to thrive. ese symptoms had to persist aer
optimising ART.
Standard medical management of BE in the paediatric pulmonology
unit includes optimising nutrition, physiotherapy, appropriate
immunisations and exclusion of PTB, in addition to the use of
macrolide antibiotics as an immune modulator. All the children in the
study were managed by a team of healthcare providers in the context
of a dedicated HIV or ARV clinic. Standard practice includes that
children are admitted preoperatively for intensive chest physiotherapy,
pulmonary hygiene and preoperative evaluation before thoracotomy.
e children were therefore carefully assessed prior to surgery.
The assessment included an immunological work-up, cardiac
echocardiography, fibreoptic bronchoscopy and chest computed
tomography (CT). e paediatric pulmonologist and cardiothoracic
surgeons discussed the children with BE to ensure that they were
optimally managed and met the inclusion criteria.
The immunological work-up of the children was central to
consideration for surgery. e clinical immune status, CD4 count
(percentage and absolute values) and viral load were assessed. All the
children were on ART and clinically considered t for surgery.
Chest CT ndings were used to evaluate the severity and distribution
of BE and to determine the resectability of aected lung tissue.
Bronchial blockers and selective bronchial intubation were used
during thoracotomy in cases where they were possible.
As recommended by studies in children with non-CF BE, all
aected lung tissue was resected.[16] A posterolateral thoracotomy was
performed in all children, either in the 4th or 5th intercostal space.
Anatomical pulmonary, lobar or segmental resection was done.
Intercostal drains were placed prior to closure of the chest. All resected
specimens were sent for histopathological evaluation.
Postoperatively, the children were admitted to the intensive care unit
(ICU) for optimal analgesia and monitoring. e chest drains were
monitored for drainage and air leaks and removed when indicated.
Complications were recorded during the intra- and postoperative
periods. All the children received prophylactic TB treatment with
rifampicin, isoniazid and pyrazinamide for 3 months postoperatively.
Lung tissue was sent for histological examination and reviewed by
one paediatric pathologist.
The children were subsequently reviewed at the paediatric
pulmonology outpatient clinic 6 weeks aer surgery and then as
required at monthly intervals for at least 1 year aer surgery. ey
and their caregivers were questioned regarding symptoms according
to the following categories: symptom free, improved symptoms, no
change, or worsening of symptoms. ey were asked about chronic
cough, night-time coughing, admission to hospital and oral antibiotic
use.
e patient data were collected from the medical records on a
clinical research form and transcribed to a database where all patient
identiers were removed. Ethical permission was received from the
Human Research Ethics Committee, Faculty of Medicine and Health
Sciences, Stellenbosch University (ref. no. S13/10/212).
Results
Twelve CLWH underwent surgical resection for BE during the study
period (Table1). e mean (standard deviation (SD)) age was 7 (3.3)
years, and the male-to-female ratio was 1:1. All the children were
receiving ART. e median (interquartile range) duration of ART
before surgery was 31 (12.3 - 47.8) days.
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According to World Health Organization immunological staging, the absolute CD4
count (cells/µL) was used to classify immunosuppression in children aged >5years,
while the CD4 percentage was used in children aged 0 - 59 months.[21] Seven children
had non-signicant immunosuppression, 3 had mild immunosuppression, 1 had
advanced immunosuppression, and 1 had severe immunosuppression. e viral
load was measured in 11 of the 12 children. e results showed that 7 children had
a viral load that was lower than detectable (log10 <1.3). Of the remaining children,
1 had a viral load between log10 1.3 and 2, 2 aviral load between log10 2 and 3, and
1 a viral load between log10 3 and 4.
e indications for surgery were recurrent infections in 75% (n=9), chronic
cough with sputum production in 33% (n=4), and persistent lobar collapse in
17% (n=2). More than one of the conditions was present in 3 children (Table2).
Prior to referral to our unit, 92% of the children received TB treatment, despite
the fact that TB was conrmed by Mycobacterium tuberculosis (MTB) culture in
only 17%. Seven children had negative MTB cultures prior to surgery. One child
was diagnosed with culture-proven drug-susceptible TB on bronchoalveolar
lavage (BAL) during work-up, despite receiving a four-drug anti-TB regimen
during the 6months prior to surgery.
From the BAL performed prior to surgery, the following organisms were
cultured: Haemophilus inuenzae (n=5), Streptococcus pneumoniae (n=2), beta-
haemolytic Streptococcus (n=1), MTB (n=1) and Candida species (n=1).
Chest CT scans were done in 11 cases (92%). e results demonstrated BE in the
right lower lobe (n=1), le lower lobe (n=6), right upper lobe (n=1), and combined
right middle and lower lobe (n=2). Two patients suered total destruction of the
le lung, and 2 had bilateral BE with one lung minimally involved.
e following surgical procedures were performed: le lower lobe lobectomy
(n=5; 42%), right lower lobe lobectomy (n=1; 8%), right upper lobe lobectomy
(n=1; 8%), right bilobectomy (n=2; 17%), le lobectomy and segmentectomy
(n=1; 8%), and le pneumonectomy (n=2; 17%) (Table2). None of the health
workers involved with the surgery sustained needle-stick or splash incidents
during the surgery.
Intercostal drains were removed 2 - 6 days postoperatively (median 3.5 days).
e mean (SD) duration of ICU stay was 2.3 (0.87) days. e children were
discharged home postoperatively at a mean of 5.7 (1.92) days. e mean total
hospital stay, including the pre- and postoperative periods, was 12.6 (5.23) days
(Table3).
e intra- and postoperative morbidity rate was low, with only one child (8%)
developing a persistent pneumothorax requiring replacement of an intercostal
drain. No children had re-operations, and there was no operative mortality.
e histological reports conrmed BE in 75% (n=9) of the children. In one child
the histological features were those of CLD with extensive brosis, and in another
child reactive lymphoid hyperplasia was reported. e histology report for one
child was unavailable. ere was no histological or microbiological conrmation
of TB on the resection samples.
At follow-up, the children and their caregivers were questioned regarding
symptoms. One child was lost to follow-up. Six children (50%) were completely
symptom free, and 4 (33%) reported improved symptoms. e improved symptoms
included reduced coughing, especially night-time coughing. One child reported
no change in symptoms, and none reported worsening of symptoms. ere were
no hospital admissions for LRTIs in this cohort during the year aer surgery.
Two children received oral antibiotics for episodes of LRTI as home therapy.
Chest radiographs were available for 11 of the patients at 1 year aer surgery. In
7 cases the radiographs were normal except for the post-surgical appearance, and
4 showed volume loss with mediastinal shi to the side of the surgical resection.
e outcome of surgical management of these children shows that 83% either
had no symptoms or had improved symptoms at follow-up.
Table1. Demographics and clinical characteristics
Patient no.
1 2 3 4 5 6 7 8 9 10 11 12
Age 13y3m 5y10m 1y10m 7y2m 4y2m 7y6m 3y9m 8y2m 6y4m 11y2m 11y1m 8y7m
WHO immunological
staging[19]
Advanced Mild Severe Mild Not
signicant
Not
signicant
Mild Not
signicant
Not
signicant
Not
signicant
Not
signicant
Not
signicant
CD4 count (cells/µL) 263 378 691 422 2 362 561 996 1 471 676 648 1 434 1 748
CD4% 14 13.6 11 27.8 32.3 19 24 25.4 31.55 14.47 44.5 32.5
Viral load Unknown 1 300
copies/mL
log10 3.11
310 copies/
mL
log10 2.49
LDL LDL LDL 688 copies/
mL
log10 2.84
LDL LDL LDL LDL log10 1.89
Duration of ART 1y2m 3y5m 1y1m 7m 8m 3y 2y2m 5y8m 3y3m 10m 6y4m 7 - 8y
TB diagnosis proven No No No No Yes No Yes No No No No No
TB Rx received Yes Yes Yes Yes Yes Yes Yes No Yes Yes Yes Yes
WHO = World Health Organization; LDL = lower than detectable limit; ART = antiretroviral treatment; TB = tuberculosis; Rx = treatment.
110 AJTCCM VOL. 30 NO. 3 2024
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Discussion
The incidence of acute pulmonary
infections in patients with HIV has
been declining because of the use
of co-trimoxazole prophylaxis and
ART, but CLD remains an important
complication among older CLWH and
ALWH.[11] Adolescents with delayed
diagnosis of perinatally acquired HIV
have a particularly high burden of
chronic respiratory disease.[11-13,22]
All of the CLWH in the present
study were not diagnosed at birth,
emphasising the significance of early
ART in preventing permanent lung
damage.
e lungs are particularly susceptible
to infection in individuals living
with HIV, leading to recurring and
severe LRTIs, an elevated risk of
TB, susceptibility to opportunistic
organisms, and immune dysregulation
by HIV, resulting in inammation and
a modied lung microbiome.[23] All of
the patients in this cohort had a history
of recurrent infections for which ART
only started later in life, which would
have increased their risk of developing
BE. These factors serve as potential
precursors to BE.[6,24-27] Among older
children and adolescents in Zimbabwe
with perinatally acquired HIV, CLD was
prevalent (86%), and high-resolution
CT scans conrmed bronchiectasis in
33% (n=28/84) to 43% (n=24/56) of
cases.[28] Additionally, a history of severe
LRTIs and PTB was linked to a 4 - 5-fold
increased risk of bronchiectasis in this
well-controlled group receiving ART.[29]
e results of the present study conrm
that surgical removal of bronchiectatic
lobes and lungs in CLWH established
on ART can be performed safely
without short- or long-term morbidity
or mortality, provided the children are
carefully evaluated preoperatively. e
surgery resulted in an improvement in
the chronic symptoms associated with
BE in 83% of these CLWH, with only
2 of the 12 children (17%) unable to
report an improvement of symptoms.
In our series, 7 of the children
(58%) had an undetectable viral
load with immune reconstitution
preoperatively. This is likely to be why
the findings of this study differ from
Table2. Bronchiectasis and surgical interventions
Patient no.
1 2 3 4 5 6 7 8 9 10 11 12
Aected
segments
RLL LLL LLL RUL LLL RML, RLL LLL,
lingula
LLL LLL RML, RLL Le lung Le lung
Indications
for surgery
Recurrent
infections
Recurrent
infections
Recurrent
infections
Recurrent
infections
Persistent
LLL
collapse
Persistent
RLL collapse
Symptoms,
recurrent
infections
Symptoms,
recurrent
infections
Symptoms,
recurrent
infections
Symptoms Recurrent
infections
Recurrent
infections and
FTT
Resection RLL
lobectomy
LLL
lobectomy
LLL
lobectomy
RUL
lobectomy
LLL
lobectomy
Bilobectomy,
RML and
RLL
LLL and
lingula
LLL
lobectomy
LLL
lobectomy
Bilobectomy,
RML and
RLL
L
pneumonectomy
L
pneumonectomy
ICU stay
(days)
3 2 2 4 1 2 2 1 2 3 3 2
Hospital stay
(days)
26 12 14 15 14 14 7 8 15 10 9 7
Discharged
aer surgery
(days)
8 10 4 6 3 5 5 7 4 6 5 5
Operative
morbidity
None None None None None None Additional
ICD
None None None None None
Operative
mortality
No No No No No No No No No No No No
Histology BE Report
lost
Follicular
BE
CLD with
extensive
brosis
Reactive
lymphoid
hyperplasia
Follicular BE BE of LLL
and lingula
BE BE BE BE and
aspergilloma
BE
Follow-up
symptoms
Improved
symptoms
No
symptoms
No
change in
symptoms
Improved
symptoms
No
symptoms
Lost to
follow-up
Improved
symptoms
Improved
symptoms
No
symptoms
No
symptoms
No symptoms No symptoms
RLL = right lower lobe; LLL = le lower lobe; RUL = right upper lobe; RML = right middle lobe; FTT = failure to thrive; L = le; ICU = intensive care unit; ICD = intercostal drain; BE = bronchiectasis; CLD = chronic lung disease.
AJTCCM VOL. 30 NO. 3 2024 111
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other studies that reported higher morbidity and mortality rates in
CLWH requiring general surgery when compared with HIV-uninfected
children.[30] Karpelowsky etal.[30] reported on 84 CLWH, among whom
postoperative complications occurred in 38% and were associated with
young age (odds ratio (OR) 4.3; 95% condence interval (CI) 1.6 - 11.9)
and a major surgical procedure (OR 6.8; 95% CI 1.6-31.4), but not
with malnutrition or degree of immunosuppression. e same group
reported that children who were born to HIV-infected mothers but
were not themselves infected (HIV-exposed children) also had an
increased risk of developing postoperative complications.[31] e risk
of complications was, however, lower than the complication rate in
CLWH. In our study, the children had all received ART, allowing for
reconstitution of their immune systems, which was probably the reason
why few had infection-related complications. ere are no known case
series of CLWH who were established on ART and required thoracic
surgery for comparison.
CLWH with CLD are at high risk for MTB infection, especially in
TB-endemic countries. Eleven of the children in our study received TB
treatment prior to referral to the paediatric pulmonology unit, despite
the fact that only 2 children had conrmation of TB with culture.
Empirical TB treatment remains common practice in low- and
middle-income settings where there is a high incidence of PTB. Clinical
and radiological signs, together with a high index of suspicion, oen
result in initiation of empirical anti-TB treatment in CLWH. ere is
considerable overlap in the symptoms caused by PTB and those caused
by HIV-related lung disease, especially BE,[7] resulting in overdiagnosis
of PTB, as can be seen in this case series, where 92% of the children were
treated for TB while the diagnosis was only proven in 16%. Ascribing
a cause to the BE can therefore be complicated. In a study reporting on
pneumonectomy in children, TB was present in 13%.[32] In our study,
we cultured MTB in 16%. It is for this reason that all children received
3 months’ standard anti-TB treatment postoperatively to prevent
activation of latent TB.
Postoperative anti-TB treatment depends on the bacillus status of the
patient at the time of surgery. Previously susceptible bacteria need 3 - 4
months, and drug-resistant bacteria require 6 - 8 months. An 18-month
window seems to be needed following the conversion. Double-blind
randomised multicentre trials are not the exclusive sources of reasonable
knowledge in the vast eld of TB, especially as the outcomes are also
deeply inuenced by non-medical factors.[33,34]
e use of anti-TB treatment aer BE in CLWH needs to be studied,
as routine anti-TB treatment in children with normal immunity is not
advocated. Our cohort was a select cohort, but none of the patients had
histological evidence of current or previous TB.
Although surgical resection of diseased lung has been done in children
of all ages without an increased risk of morbidity and mortality,
an increased risk of complications has been reported in children
undergoing pneumonectomy.[32] ese authors recommend careful
assessment of these patients prior to surgery. In the present study we
followed this recommendation, but in addition ensured that ART had
been established, to reduce postoperative complications and to reduce
the risk of accidental transmission of HIV to the surgeon.
e main limitation of this retrospective study is the small number
of children included, although the study was conducted in an area
with a high HIV prevalence. As HIV care for mothers and their
infants improves, fewer children are becoming HIV infected, making
it less likely to nd children with HIV-related lung disease. Objective
evidence of the degree of improvement, especially in the absence of
lung function testing during follow-up, further limits the study.
Conclusion
is study showed that the ultimate goal of a symptom-free child with
a decreased risk of LRTI can be achieved with very low morbidity
and mortality in symptomatic CLWH by selective resection
of bronchiectatic lung. Surgical management requires special
preoperative care, with treatment of immunosuppression, including
ART, diagnosis and management of associated infections, and
meticulous perioperative care.
Declaration. PG is a member of the editorial board. e research for this
study was done in partial fullment of the requirements for HP-H’s MMed
(orac Surg) degree at Stellenbosch University.
Acknowledgements. None.
Author contributions. is was a joint work by all the listed authors.
Data availability. e data that support the ndings of this study are
available on request from the corresponding author (PG). e data are
not publicly available owing to privacy or ethical restrictions.
Funding.None.
Conicts of interest.None.
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Table3. Summary of patient data
Age (years), mean (SD) 7.488 (3.340)
CD4 count (cells/µL), mean (SD) 970 (646)
CD4%, mean (SD) 17 (5.72)
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ICU stay (days), mean (SD) 2.3 (0.87)
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SD = standard deviation; ARVs = antiretrovirals.
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Received 4 September 2023. Accepted 14 June 2024. Published 11 October 2024.
