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HIV infection in paediatric practice

Nia Kurniati
Department of Child Health-Cipto Mangunkusumo Hospital in affiliation with Faculty of Medicine, University of Indonesia

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Paediatric patients with human immunodeficiency virus (HIV) infection may present in many ways. Appropriate treatment of children with HIV infection requires identification as soon as possible to prevent aggressive disease progression.

in cases of unexplained fever, recurrent middle ear infection, or persistent oral thrush in an older child (Figure 11.1). A key piece of history is parental HIV status. However, families may be reluctant to disclose this information due to fears of stigma and discrimination. It may be helpful to first obtain clues about potential HIV risks through asking about a history of maternal health problems (e.g. frequent infections, weight loss), illicit drug use by either parent, transfusions to child or parents, and sex-related risks (e.g. multiple or new partners). HIV infection should be suspected in the following clinical situations: Recurrent oral thrush after 6 months of age Poor growth (e.g. unexplained reduced weight gain or weight loss) Severe or frequent infections (e.g. pneumonia, sepsis, otitis media, zoster Figure 11.2) Developmental delay (e.g. failure to attain, or loss of, common milestones).

Introduction
HIV infection in Asian children is primarily transmitted through perinatal infection. Most Asian countries except Thailand and India are at an early stage of their local epidemics. Guidelines usually focus on how to diagnose HIV-exposed children, protocols for prophylaxis of opportunistic infections, and management of antiretroviral treatment. It can be difficult for health care workers to decide whether and when they should consider HIV infection in a paediatric patient. However, as children progress more rapidly to acquired immunodeficiency syndrome (AIDS) than adults,1,2 it is essential to identify and test HIV-exposed infants and children and refer them into HIV care as soon as possible. In addition, children may be the first members of their family to present with acute symptoms of HIV and can lead to opportunities to test and treat their parents. This chapter is intended to deal with clinical situations commonly found in children with HIV infection and how to interpret these situations to rule-in or rule-out HIV.

When should you suspect HIV infection?


Paediatric patients with HIV infection may present in many ways. Early symptoms may be interpreted as routine childhood illnesses rather than as possible signs of immune compromise. For example, health care workers may not think of HIV

Figure 11.1: Oral thrush in a 6 year-old boy with HIV. Late-stage conditions, such as fungal sepsis, viral pneumonia, chronic diarrhoea, and wasting can occur when immune deficiency is severe.

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Health care workers should consider obtaining an HIV test whenever there are clinical signs and symptoms (Table 11.1), and suspicion or confirmation of parental HIV. In children with evidence of severe immunosuppression or life-threatening conditions, the absence of parental risk factors should not discourage HIV testing.

Figure 11.2: Varicella-zoster infection

Table 11.1: Selected clinical criteria and diagnostic clues to HIV in children with correlating WHO HIV staging* Clinical category General: Clinical finding - Failure to thrive: severe wasting or malnutrition - Chronic diarrhoea due to parasitic infection - Hepatosplenomegaly - Persistent respiratory distress - Hypoxia not related to respiratory distress - Unexplained digital clubbing - Pulmonary tuberculosis - Unexplained microcephaly - Chronic stomatitis secondary to herpes virus - Oral thrush unresponsive to therapy or in children > 6 weeks - Persistent or recurrent parotid swelling - Severe otitis media or sinusitis - Extensive wart virus infection - Extensive molluscum contagiosum - Recurrent folliculitis - Severe eczematous or seborrhoeic dermatitis - Papular pruritic rashes - Unexplained developmental delay or loss of milestones - Unexplained spasticity WHO stage 4 4 2 4 3 3 3 4 4 3 2 2 2 2 2 2 2 4 4

Pulmonary:

Head and neck:

Skin:

Neurological:

* Source: WHO. Antiretroviral therapy of HIV infection in infants and children in resource-limited settings: Towards universal access. Recommendations for a public-health approach. 2006. Available at: http://www.who.int/hiv/pub/guidelines/art/en/index.html. Cited 26 April 2008

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HIV testing
HIV testing should take age and breastfeeding practices into consideration. Although standard HIV antibody tests (i.e. EIA/ELISA) are reliable in children over 18 months of age, World Health Organization (WHO) guidelines encourage virological testing to determine HIV status in younger infants and children.2 However, if virological testing is not available, HIV exposure can be determined through antibody testing of the mother or infant. This will provide a basis for presumptive clinical diagnosis before confirmatory testing can be done after 18 months of age.

Investigations relevant for suspected pulmonary tuberculosis and suspected extrapulmonary tuberculosis. Routine HIV testing in high-prevalence areas.

The presence of the following should strongly suggest the diagnosis of tuberculosis.3,4 Chronic symptoms and signs suggestive of tuberculosis (subacute onset, fever, weight loss, chronic cough). A positive tuberculin skin test (diameter of induration > 5 mm). Chest x-ray suggestive of tuberculosis.

Tuberculosis and HIV


Case study 11.1 In tuberculosis -endemic countries, it is common for individuals with HIV infection to develop tuberculosis at some stage, especially before antiretroviral therapy is started. The diagnosis of tuberculosis in children with HIV is difficult since tuberculosis can mimic a number of other infections. There are several studies describing diagnostic approaches for tuberculosis, mostly using algorithms, diagnostic classifications and point scoring systems. The approach to diagnosing tuberculosis in children with HIV is generally similar as for children without HIV (Table 11.2). . A 2-year-old boy was brought to the outpatient clinic with suspected pneumonia for the third time in 12 months. His mother passed away due to suspected brain tumour at the age of 23 years. The primary caregiver was his grandmother. His fathers whereabouts and health status were unknown. A chest x-ray showed a right-sided white out, inconsistent with his symptoms and clinical examination (Figures 11.3 and 11.4). The child had a normal white blood cell count with relative lymphocytosis, elevated erythrocyte sedimentation rate (ESR), and a negative tuberculin skin testing (TST). The HIV antibody test was positive with very low CD4 percentage (7% or 384 cells/L). On further questioning, it was found that the mother was taking tuberculosis drugs prior to her death. Pulmonary tuberculosis was suspected in the child, who was immediately started on anti-tuberculosis drugs. After 2 months of directly observed tuberculosis treatment (DOTS), repeated chest x-ray revealed dramatic improvement, and antiretroviral therapy (zidovudine-lamivudinenevirapine) was then initiated with the help of the local adherence team and the continued support of the tuberculosis DOTS program.
Continued over page

Table 11.2: WHO-recommended approach to diagnosing tuberculosis4 Careful history taking, including history of tuberculosis contacts and symptoms consistent with tuberculosis. Clinical examination including growth assessment. Tuberculin skin testing. Mycobacteriological examinations of sputum, gastric wash specimens, or tissue, whenever possible.

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Case study 11.1 (Continued)

Organisms such as non-pathogenic Escherichia . coli or Blastocystis hominis can be causes of diarrhoea in these children and should generally be treated.

Malnutrition
The following indicators of growth failure, malnutrition and failure to thrive should be included during routine nutritional assessments and can be indicators of progressive HIV disease: 5-7 Weight loss of up to -2 standard deviations (SD), not explained by inadequate feeding or concurrent infections, and not responding to nutritional supplementation. Single measurement of weight for length (or height) < 70% or -3 SD (protein-energy malnutrition, marasmus) without or with oedema of both feet (protein-energy malnutrition, kwashiorkor or marasmic kwashiorkor). Middle upper arm circumference for age < -3 standard deviations (SD) in children aged 6 months 5 years. Figures 11.3 and 11.4: A chest x-ray showed a right-sided white out After initial evaluation, whether in inpatient or outpatient settings, it is important to examine specific causes of malnutrition in order to address them, including: 8 Poor access to food inability of the family to provide adequate or appropriate food for a childs level of physical development. Inadequate food intake inability of the child to eat enough to keep up with the higher daily energy requirements of children with HIV due to oral disease (e.g. aphthous or herpetic ulcers), encephalopathy or other conditions. Malabsorption inability of the child to absorb nutrients due to chronic diarrhoea or vitamin/mineral deficiencies. HIV should be considered when there is a discrepancy between access to food and growth and development status. Nutrition management is crucial and growth recovery may be slow when malnutrition is seen in combination with opportunistic infections. In cases of severe malnutrition and wasting, hospitalisation may be necessary in order to provide an opportunity to address multiple organ systems, and antiretroviral therapy can be considered for initiation during the hospitalisation period.

Chronic diarrhoea
Diarrhoea is a common clinical manifestation in HIV infection that can progress in severity as the immune status deteriorates. There are several potential aetiologies, including infectious pathogens (e.g. bacteria, mycobacteria and viruses), HIV itself and malabsorption. In cases of acute diarrhoea, HIV may not be included in the initial differential diagnosis. However, the presence of unusual pathogens or progression to chronic diarrhoea is an indicator that the child may have HIV and should be tested. In known children with HIV infection, chronic diarrhoea is also a clinical marker of disease progression. Specific diagnostic testing should be obtained to evaluate for parasites (e.g. Giardia, Cryptosporidium) and less common pathogens (e.g. Candida, mycobacteria) to facilitate specific treatment.

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References
1. Zeichner SL, Read JS, editors. Handbook of Pediatric HIV Care. 1st edition. Cambridge University Press, 2006. 2. World Health Organization (WHO). Antiretroviral therapy of HIV infection in infants and children in resource-limited settings: Towards universal access. Recommendations for a public-health approach. 2006. Available at: http://www.who.int/hiv/pub/guidelines/art/en/index.html (Cited 26 April 2008) 3. Hesseling AC, Schaaf HS, Gie RP, Starke JR, Beyers N. A critical review of diagnostic approaches used in the diagnosis of childhood tuberculosis. Int J Tuberc Lung Dis 2002;6:1038-45. 4. World Health Organization (WHO). Guidance for National Tuberculosis Programmes on the management of tuberculosis in children. WHO/HTM/TB/2006.371. Geneva, Switzerland: WHO,2006. 5. World Health Organization (WHO). Pocket Book of Hospital Care for Children: guidelines for the management of common illnesses with limited resources. 2005. Available at: http://whqlibdoc.who.int/publications/2005/9241546700.pdf (Cited 30 April 2008). 6. Myatt M, Kara T, Collin S. A review of methods to detect cases of severely malnourished children in the community for their admission into community-based therapeutic care program. Food Nutr Bull. 2006;27(3):S7-S23. 7. Mei Z, Grummer-Strawn LM, de Onis M, Yip R. Teh development of MUAC-for-height reference, including a comparison to other nutritional status screening indicators. Bull World Health Org 1997:75:333-41. 8. WHO SEARO. Management of HIV Infection and Antiretroviral Therapy in Infants and Children, A Clinical Manual, 2006. Available at: http://www.searo.who.int/en/Section10/Section18/Section356_12675 .htm (Cited 26 April 2008) Is it HIV? a handbook for health care providers

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