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Case
Definition
Incidence
Aetiology
Pathophysiology
Objectives Clinical Presentation
Differential Diagnosis
Workup
Treatment
Complications
A 13 year old male student presented to the A&E with a history of cough for 3 weeks,
lethargy, tiredness intermittently, fevers, weight loss and chills.
His past medical history was unremarkable and there was not further information on
systematic enquiry.
He had been seen at the regional polyclinic on 2 occasions in 3 weeks, and treated with
Paracetamol, and Histal DM , Amoxil for 1 week and two varieties of cough syrup. His
cough did not vary from day to night.
His mother steed that the cough had worsened and that he was producing phlegm which
varied in colour from yellow to green for the past week.
Case
His family history revealed that he is the only product of his unmarried parents' union. He
attend s the St George secondary school, is in 2nd form, and comes near last in class-with
20% average.
The student was used to staying at a friend of the mother's who lived in the
neighbourhood on afternoons, during the school term, from 3pm to 6 pm until his mother
came home from work.
Examination revealed: His weight and height were on the 50th gentile. He has
clear cognitive deficits.
He was a febrile child (T-38 degrees C) with a normal blood pressure and oxygen
saturation of 85% consistently. He is RR was 45/ min and there were crepitations
scattered over the chest with vesicular breath sounds.
There was significant bilateral enlargement of inguinal lymph nodes 3 cm in
diameter, and 1cm axillary nodes.
Investigations including blood tests and radiological tests were done after
admission.
He was treated with iIV amoxicillin for 1 week and then Azithromycin, however
her remained hypoxic and symptomatic of cough.
Definition
• Presence of opportunistic or
AIDS – Acquired persistent infection or CD4+
Immunodeficiency
Syndrome lymphocyte count < 200 in
persons > 12 years of age
Definition
A patient is HIV positive when both the ELISA and Western blot tests are positive
A positive ELISA but negative Western blot = NO infection
Infants born HIV-infected mothers have positive ELISA and Western blot due to
passive transfer of maternal antibodies
This does not confirm infection
Viral-specific testing must be performed
INCIDENCE
In 2015: 150,000 children <15 years old were newly infected with HIV, bringing the
total number of children worldwide living with HIV or AIDS to 1.8 million
Approx. 2/3 reside in Sub-Saharan Africa
In Developed Countries: CDC estimates that the no. of infants born to HIV infected
mothers has decreased to 86 in 2015 (1650 in 1991)
Developing Countries: in eastern and southern Africa, mother to infant
transmission declined from 18% in 2010 to 6% in 2015
2000
After start of the Prevention of mother to child transmission
(PMTCT) program
• ~ 80% decline in vertical transmission from 27.1% to 5.5% with long course AZT
monotherapy
• 8% transmission rate with NVP regimen
2006–2012
INCIDENCE (BARBADOS)
Aetiology
• Sexual contact
• Percutaneous contact
• Mucous membrane exposure to contaminated
Modes of blood products
Transmission
Vertical transmission
• Transplacentally in utero
• During birth
• During breastfeeding
TRANSMISSION
IMMUNE
RESPONSE CD95/Fas receptor/ligand system Abnormalities:
• Anaemia
• Neutropenia
• Thrombocytopenia
HAEMATOLOGICAL
EFFECTS
Thrombotic Thrombocytopenic Purpura
Developmental delay
CLINICAL MANIFESTATIONS
Selected AIDS-defining conditions:
Pneumocystis jirovecii pneumonia (PCP)
Recurrent bacterial infections
Wasting syndrome
Esophageal candidiasis
HIV encephalopathy
Cytomegalovirus pneumonia, colitis, encephalitis, or retinitis
CLINICAL MANIFESTATIONS
Accounts for approximately 1/2 of all AIDS-defining
conditions diagnosed during the first year of life.
PNEUMOCYSTIS
JIROVECII PNEUMONIA
(PCP) Symptoms: Should be suspected in patients with
low-grade fever, tachypnea, non-productive cough,
and progressive shortness of breath.
Sinusitis
Bronchitis
RECURRENT
BACTERIAL Otitis media
INFECTIONS
Pharyngitis
WASTING
SYNDROME Downward crossing of two or more major
percentile lines on the pediatric weight-for-age
chart (eg, 95th, 75th, 50th, 25th, 5th)
<5th percentile on WFH chart on 2 consecutive
measurements 30 or more days apart, plus chronic
diarrhea or documented fever
Risk factors:
CANDIDIASIS
Receipt of antibiotics
Studies
• Complete Blood Count
• Renal Function Test
• Liver Function Test
• Quantitative immunoglobulin levels should be followed up
periodically.
Renal Imaging (US and CT Scan) in
Patients with HIV nephropathy.
Diagnosis of Lymphoid
Interstitial Pneumonitis
What are the
radiological findings?
What’s the diagnosis?
How is it diagnosed?
Management
Components of special care for these
infants include:
1. Antiretroviral prophylaxis
2. HIV diagnostic testing
Management 3. Evaluation for the need for PJP
of HIV-Exposed prophylaxis
Infants 4. Routine immunizations
5. Monitoring for manifestations of HIV
infection
6. Reinforcing education and counseling
for the mother and family
Neonatal ARV Prophylaxis
High risk newborn, born to mothers who didn’t not receive ARV during pregnancy:
Nevirapine should be given as 3 oral doses within 48 hour of birth
Adverse effects:
Zidovudine: anemia and neutropenia (most common)
HIV Virologic Testing Schedule
All infants regardless of CD4 cell count or percentage should be prescribed PJP
prophylaxis at age 6 weeks
Dose: 2.5-5 mg/kg TMP-SXM bd 3 days a week
Standard childhood immunizations are
recommended, including influenza in CD4
counts are not profoundly low
Provides opportunities to asses social support needs for mothers and families,
review results and reinforce safe feeding recommendations
Management of HIV
Infection in Infants,
Children and Adolescents
Baseline Evaluation
2 Nucleoside (or
nucleotide) reverse
Protease inhibitors
transcriptase inhibitors
(NRTIs) +
Integrase inhibitors
ART Regimens
Obstacles with Treatment
Planning treatment with the patient and family strengthens the therapeutic
relationship and promotes successful adherence and HIV control
Patients generally achieve undetectable viral load within 6 months
Failure to achieve within this time frame strongly suggest suboptimal adherence
rather viral resistance
Once controlled on a stable regimen,
most patients are seen every 3 to 4
months for routine monitoring of:
viral load
Monitoring CD4 cell response
clinical status
evaluation for potential adverse or toxic
medication effects
PJP prophylaxis with TMP-SXM