Download Care of HIV-Infected Infants and Children

Common Diseases in HIVInfected Infants and Children
Learning Objectives
 Describe common clinical manifestations of HIV
disease in children
 Describe the diagnostic criteria and
management of common illness in HIV-infected
children
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Respiratory
Oral
Neurologic
Cardiac
Gastrointestinal
Dermatological
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Common Infections
 Recurrent bacterial infections
 Account for about 20% of AIDS defining illnesses in infants and
children
 Most are caused by encapsulated organisms such as S.
pnuemoniae and Salmonella, others are Staphylococcus,
Enterococcus etc
 Most common serious infections are – pneumonia, bacteremia,
sepsis and meningitis (account for more than 50% of infections
in HIV-infected children)
 Clinical features
 Similar as in HIV uninfected children, but may have protracted
fulminant course with rapid progression
 Management
 Same as in non HIV-infected children
 Occasionally may require longer duration of treatment
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Opportunistic Infections (OI)
 Generally occur with severe immune
suppression, some occur at higher CD4 counts
 Young children have primary infection rather
than reactivation
 Lack of immunity leads to more severe course
than in adults
 In children with severe immunodeficiency clinical
manifestations may vary
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Common OIs: Pneumocystis
Pneumonia (PCP)
 Parasitic infection
 Pneumocystis
jeroveci (formerly
Pneumocystis carinii)
 Diffuse and severe
pneumonia
 Peak incidence is
between the age of 3 – 6
months
 Characterized by gradual
onset of hypoxia, fever,
cough and respiratory
distress
• Normal CXR/or there may
be diffuse alveolar
disease with granular
pattern
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Common OIs: Pneumocystis
Pneumonia (PCP)
 Management
 Intravenous/oral 15 – 20
mg of the trimethoprim
and 75 – 100 mg of the
sulfamethoxazole /24hrs
given every 6 hrs for 21
days
 If there is severe hypoxia give
corticosteroids 2 mg/kg/24 hrs
for 7 – 10 days then gradual
tapering over 7 – 14 days
 Prophylaxis
 Secondary- Lifelong
after infection
 Primary-Dependent on
clinical stage and/or
immunologic
suppression
 In case of allergy to
CTX use Dapsone
 Alternative if intolerant to
TMP/SMX: Pentamidine
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Common Oral Manifestations:
Candidial Infection
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Oral candidiasis is the most
common oral condition in HIV
infected children
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Three forms
 Atrophic candidiasis
 Chronic hyperplastic candidiasis
 Angular Cheilitis
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Dysphagia and poor oral intake,
irritability indicates involvement of
the esophagus
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Management
 Oropharyngeal:
• Nystatin 100,units/ml;1-2ml
four times a day
• Oral miconazole gel 2.5 ml
twice aday.
• Fluconazole 3-6mg/kg daily
for 7-14 days
 Esophageal disease: Fluconazole
6mg/kg on day one then 3-6mg/kg
daily for minimum of 14-21 days
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Common Skin Manifestations:
Bacterial skin infections
 Folliculitis, cellulitis, skin
abscesses impetigo,
furunculosis and
paronychia may occur
with increasing frequency
 Staphylococcus aureus is
the cause in most
bacterial skin infections
 Good hand washing is
needed to prevent spread
of lesion
 Treatment: Erythormycin
or cloxacillin
Impetigo
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Common Skin Manifestations:
Molluscum contagiosum
 Common childhood viral
infection characterized
by: discrete, dome
shaped, pearly white
papules with central
umblication
 Transmitted by skin to
skin contact, self limited
in most cases
 In HIV-infected children
M.congtagiosum tends to
be extensive- covering >
5% of the body surface
area
Extensive Molluscum
 Treatment: liquid
nitrogen, curettage
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Common Skin Manifestations:
Scabies
 Pruritic papular eruptions
 In infants and children
tend to involve the sole
and the palms
 Diagnosis is made
clinically
 Norwegian Scabies:
generalized scaling and
enlarged crusted plaques
 Treatment:
Scabies lesions on mother and infant
 Benzylbenzoate lotion 25%
 10% sulfur ointment
Norwegian scabies
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Source: Common Skin Diseases In Africa, Colette van Hees & Ben Haafs
Common Skin Manifestations:
Seborrheic Dermatitis/eczema
 Extensive and an early
non specific sign of HIV
infection in infants
 Thick yellow scales on
the scalp but thin scales
over the rest of the body
 High recurrence
 Treatment
Seborrheic dermatitis of the axilla
 Topical steroids
Source: Common Skin Diseases In
Africa, Colette van Hees & Ben Haafs
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Common Skin Manifestations:
Pruritic Papular Eruptions (PPE)
 Chronic papular lesion
 Etiology unknown
 Evenly distributed over
the trunk and extremities
 A marker of worsening
immunosuppression and
may be stigmatizing
 Risk of secondary
bacterial infection
 Treatment:
Papular Pruritic Eruptions
 Antihistamines and steroids
Source: Common Skin Diseases In Africa, Colette van Hees & Ben Haafs
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Common Skin Manifestations: Viral
Infections
 Herpes Zoster
 Recurrent, atypical and
chronic, multidermatomal and
may need use of acyclovir
 Chickenpox
 May be prolonged and
complicated by bacterial
infection or visceral
dissemination or pneumonitis
Source: Common Skin Diseases In Africa, Colette van Hees & Ben Haafs
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Common CNS Manifestations
 Occurs in 50 – 90% of perinatally infected children in
developing countries
 Most common form is progressive encephalopathy
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Loss or plateau of developmental milestones
Cognitive deterioration
Impaired brain growth resulting in acquired microcephaly
Apathy, spasticity, hyperreflexia and gait disturbances and loss
of language and other motor skills
 CT shows cerebral atrophy in 85% of children
 Focal neurologic signs and seizure may occur with
 CNS lymphoma, toxoplasmosis, tuberculoma, stroke
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Common Cardiovascular
Manifestations
 Dilated cardiomyopathy, persistent tachycardia
and left ventricular hypertrophy are common
 With advanced disease high frequency of
autonomic instability leads to rhythm abnormality
 Gallop rhythm, tachypnea, Hepatosplenomegaly
indicates CHF
 Anticongestive therapy is effective
 Cardiac complications are associated with poor
prognosis
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Common GI Manifestations
 Most frequent GI symptoms: persistent or recurrent
diarrhea with malabsorption, abdominal pain, dysphagia
and failure to thrive
 A variety of pathogens cause GI symptoms:
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Bacteria (salmonella, campylobacter, MAC)
Protozoa (Giardia, cryptosporidium, Isosporia, microsporida)
Viruses (CMV, HSV, Rotavirus)
Fungi (Candida)
 MAC and protozoal infections are severe and protracted
 Other GI manifestations are
 Chronic liver inflammation with or without jaundice
 Pancreatitis with or without abdominal pain
 Chronic cholecystitis
 Management depends on underlying pathology
 Diarrheal illnesses are manages as per the IMCI
guideline
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Common Hematologic
Manifestations
 Unexplained Anemia:
 Leukopenia:
 20– 70% of HIV-infected
 Up to 1/3 of infected children
children
 ANC < 1000/mm3
 Hb < 8g/dL
 Other causes: drugs, OI like
 Causes: chronic infection,
CMV, MAC
poor nutrition, autoimmune
factors, virus associated
conditions (Parvovirus B19)  Thrombocytopenia:
and drugs
 10– 20% of infected children
 Platelet count < 50,00/mm3
 Causes: drugs, autoimmune,
OIs, ARV drugs
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Common Malignant Diseases
 Generally less frequent compared to adults and
represent less than 2% of AIDS defining
illnesses in children
 Most frequent:
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Non Hodgkins lymphoma
Primary CNS lymphoma
Leiomyosarcoma
Actue lymphoblastic leukemia
 Epstein-Barr virus is associated with most cases
of lymphomas and all cases of leiomyosarcoma
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Common Malignant Diseases- KS
 Kaposi sarcoma due
to human herpes
virus 8 occurs less
frequently than in the
adults
 Vascular tumor that
presents on the skin
and internal organs
 Treatment
 Optimize ART
 Chemotherapy
Source: Common Skin Diseases In Africa, Colette van Hees & Ben Haafs
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