Download Common Clinical Syndromes: Diarrhea

Digestive Tract Diseases
in HIV-infected Children
HAIVN
Harvard Medical School AIDS
Initiative in Vietnam
1
Learning Objectives
By the end of this session, participants should
be able to:
 Diagnosis and treatment of oral candidiasis
 Describe the most common causative
pathogens of diarrhea in HIV-infected
children
 Describe clinical manifestations and
diagnosis of diarrhea
 Develop a treatment plan for diarrhea in an
HIV-infected child
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Oral Candidiasis
3
Oral Candidiasis



Common seen in severe stage of
immunodeficiency
Usually persistent and refractory
Form:
• multiple white
• easily removable patches
• pseudomembranous plaques

Place
•
•
•
•
Tongue
Gums
Buccal and pharyngeal mucosa
Esophagus
4
Oral Candidiasis

Diagnosis:
• Clinically
• Eosophagos
copy
• Microscopic
exam
• Culture
5
Esophageal Candidiasis
Dysphagia/
painful swallowing
 Post chest pain
 Nausea,
vomiting
 Fever

Spsuedomembrane
plaques on eosopaheal
wall
6
Treatment

Topical:
• Clotrimazole (Dartarin cream)
• Ketoconazole
• Nystatin

Systemic:
Medication
Duration
Oral candidiasis:
7-10 days
•Fluconazole: 3-6mg/kg BID
•Itraconazole:3-6 mg/kgBID Esophageal candidiasis:
2 weeks
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Source: National guidelines 3003, 2009
Overview of Diarrhea
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Definition
Diarrhea is defined as having loose or
watery stool at least 3 times per day,
or more frequently than normal
Acute diarrhea
Persistent diarrhea
or
Chronic diarrhea
< 14 days
>14 days
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WHO 2009. Diarrhea: why children are still dying and what can be done
Epidemiology


Diarrhea is the second leading cause
of death among children less than 5
years old
Diarrhea occurs more frequently in
HIV-infected children than in HIVnegative children, with more severe
and persistent episodes
WHO 2009. Diarrhea: why children are still dying and what can be done
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Prevalence of Diarrhea in
HIV-infected Children
23.5-100%
Thailand
(52.7% average)
Nigeria
75%
Children’s
Hospital 1
Vietnam
Hospital of
tropical diseases
9%
60% (2003)
33-49% (2006)
Etiology (1)

The most common diarrheal pathogens
in children include:
• Rotavirus
• Bacterial agents

In addition, HIV-infected children are
susceptible to other less common
pathogens:
• Protozoans
• Parasites
• Mycobacteria
WHO 2009. Diarrhea: why children are still dying and what can be done
12
Etiology (2)
HIV-associated Pathogens: occurs in
severely immunosuppressed children
 Cryptosporidium infection
 MAC infection
 Abdominal TB lymph node infection
 Cytomegalovirus (CMV)
• CMV-associated Colitis
13
Etiology (3)

Other causes are noninfectious etiologies:
• HIV-associated
malabsorption
• Lactose intolerance
• Medication side effects:


Didanosine (ddI), buffer
form
Protease inhibitors (PI):
• Lopinavir/ritonavir
• Ritonavir
14
Pathogenesis (1)

Factors that contribute to
susceptibility to diarrhea in HIVinfected children:
•
•
•
•
young age
malnutrition
undernourishment
immunocompromised status
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Pathogenesis (2)


Micronutrient deficiency increases
risk of mortality several fold
Diarrhea is transmitted through:
• Fecal-oral route
• Contaminated food and water
• Person-to-person
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How Do You Diagnose
Diarrhea?
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Diagnosis: Overview



Recognize diarrhea is important as
delayed diagnosis and treatment
would result in patient mortality
Focus on history can classify the
diarrhea, its severity, and its possible
causes
Physical exams are also important to
assess illness severity
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Diagnosis: Overview (2)
In children
<2
• acute watery, non-bloody
diarrhea with vomiting is
usually due to viral pathogens
In older
children
• viral diarrhea is still common
• bacterial diarrhea should also
be considered
In immunosuppressed
children
• diarrhea may be due to HIVassociated pathogens
19
Diagnosis: History (1)




Onset: acute, subacute
Duration: how long
Number of bowel movements a day
Stool characteristics
• Profuse
• Watery
• Semi-form
• Mucous
• Bloody
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Diagnosis: History (2)

Associated symptoms:
• Fever, vomiting, abdominal pain.
• Other household members with diarrhea

Other history:
• Medications (ARVs, other drugs)
• Food/water intake
• Other OI that may cause diarrhea
21
Assessing:
Level of Dehydration
Action
A
Look at:
•Condition Well alert
B
C
Restless,
irritable
Lethargic,
unconscious
•Eyes
Normal
Sunken
Sunken
•Thirst
Normal drink,
no thirsty
Thirsty, drink
eagerly
Drinks poorly or
unable to drink
Feel:
Goes back
skin pinch quickly
Goes back
slowly (<2 s)
Goes back very
slowly (>2 s)
Decide
If there are ≥ 2
signs: some
dehydration
If there are ≥ 2
signs: severe
dehydration
No
dehydration
Symptoms/Signs Associated with
Dehydration






Mental status
Thirst
Heart rate
Quality of pulses
Breathing
Eyes






Tears
Mouth and tongue
Skinfold
Capillary refill
Extremities
Urine output
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Common Diseases
Shigellosis
• Fever, abdominal pain, scraping
• Bloody mucous stool, frequent
bowel movement
• Stool microscopic observation:
erythrocytes, leucocytes
• High, prolonged fever, pulse-tem
discordance, may presented as
sepsis
Salmonellosis
• Watery stool, bloody stained stool
• Culture: stool/blood
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Common Diseases
HIV-associated
•
Cryptosporidia
Microsporida
Isospora
Infection
•
•
•
CMV colonitis
•
•
•
Watery, frequent stools, no
blood, large volume
Rapid weight loss, commonly no
fever
Vomiting, nausea, abdominal
pain
Stool microscopic stain:
Fever, Abdominal pain
Bloody stools
May have CMV infection in other
organs (esophagus, lungs, liver)
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CMV-associated Colitis

Sigmoidoscopy:
disseminated
unspecific rash, submucous bleeding
and ulcer
• Histology: inclusion
body in
intracytoplasma
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Common diseases
HIV-associated
• Persistent or recurrent fever
• Persistent or recurrent diarrhea
Disseminated
MAC
Infection/
Abdominal
Lymphnode TB
• Abdominal pain
• Weight loss or no weight gain
• Fatigue, sweats
• Anemia, leukopenia, low platelet
• TB: ultrasound image, may have
pulmonary TB
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Laboratory Tests
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Overview


In general, most diarrheal illness
does not require laboratory testing
However, in cases of severe or
persistent diarrhea, the following
tests may be useful:
•
•
•
•
CBC
Electrolytes
Renal functions
Blood culture
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Stool Study



Stool microscopic exam: WBC, RBC,
O&P
Stain: AFB, Modified AFB
Antigen detection:
• Rotavirus antigen
• C. difficile toxin

Stool culture:
• Bacteria
• Mycobacterium species
Chronic diarrhea not responsive to usual therapy:
Sigmoidoscopy, Colonoscopy 30
Treatment
Fluid replacement
and feeding!!!
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Fluid Replacement
Action
A
Condition
Well alert
Eyes
Thirst
Normal
Normal drink, no
thirsty
Feel:
skin pinch
Decide
Treatment
B
C
Restless,
irritable
Sunken
Thirsty, drink
eagerly
Lethargic,
unconscious
Sunken
Drinks poorly or
unable to drink
Goes back quickly
Goes back
slowly (<2 s)
Goes back very
slowly (>2 s)
No dehydration
If there are ≥ 2 If there are ≥ 2
signs: some
signs: severe
dehydration
dehydration
Can be treated at
home
Hospitalized
necessary
Hospitalized
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necessary
Treatment at Home

Give the child more fluid than usual
• Fluid replacement: low osmolality oral rehydration
solution (ORS) or home made solution



<2 years old: 50-100 ml after each watery stool
Older child: 100-200 ml
Zinc supplement:
• younger than 6 months: 10mg daily;
• 6 months and older: 20 mg daily for 2 weeks

Continue feeding:
• Breast feeding: continue and more frequently
• Formula feeding: every 3 hours
• Soft food: continue with addition of milk
33
Treatment at Home

When to return
•
•
•
•
•
•
•
Begins passing frequent, watery stools
Has repeated vomiting
Becomes very thirsty
Is eating or drinking poorly
Develops a fever
Has blood in the stool
Does not get better in 3 days
34
Inpatient Treatment (1)
For mild and moderate dehydrated cases,
admission to the hospital is necessary
 Oral rehydration: 75 ml/kg for 4 hours
• Monitor if the ORS given appropriately
• Assess during and after 4 hours, if any sign of
severe dehydration detected, IV replacement is
needed


Zinc supplement: after first 4 hours as
treatment at home
Feeding:
• encourage breast feeding whenever possible
• Other: as treatment at home
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Inpatient Treatment (2)
For severe dehydrated
 IV rehydration with lactate ringer/normal
saline solution
 If IV not available: nasogastric tube can
be used to give ORS
 Oral rehydration in addition
 Correction of acidosis, electrolyte repletion
 Zinc supplement and feeding when
possible
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Pathogenic Treatment
37
Shigellosis
Salmonellosis (bloody stool)



Ciprofloxacin: 15 mg/kg/day BID x 5
days
Norfloxacin: 15 mg/kg/day BID x 5
days
Cephalosporin 3th gen
• Ceftriaxone: 50 mg/kg IV x 5 days

For H.histolytica:
• Metronidazole: 50 mg/kg/day TID x 5
days
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HIV-associated Pathogens
ARV is the common treatment
Cryptosporidia •Azitromycin: 10 mg/kg/day x 10 days
•Plus Paromomycin: 25-35 mg/kg/day
Microspora
•Albendazole 10 mg/kg/day x 3 days
Isospora
CMV colitis
•Gancyclovir IV 10 mg/kg x 14-21 days
then 5 mg/kg/day x 5-7 weeks
Disseminated •Clarithromycin: 7.5-15 mg/kg twice
MAC
daily Plus
•Ethambutol 15-25 mg/kg daily Plus
•Rifampicin 10-20 mg/kg daily
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TB
•TB therapy
Case Study






A 2-year-old child comes to your OPC for
follow-up
His mother mentions to you that he has
been having diarrhea for the last 2 days
He has 5-6 stools per day. The stool is
watery, non-bloody, without mucous
The mother thinks he also runs a fever
because his forehead feels hot to the
touch
His most recent CD4: 25%, 500cps/ml
He’s not yet on ARV
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Key Points



Diarrhea is common in HIV-infected
children and needs aggressive
treatment
Most common pathogens are viruses,
bacteria and local circulating agents
OIs causing diarrhea include TB,
MAC, cryptosporidia and CMV
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Thank you!
Questions?
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