Clinical Manifestation of HIV / AIDS in Children
On history taking
- Unusually frequent and severe occurrences of common childhood bacterial infections, such as otitis media, sinusitis, and pneumonia
- Recurrent fungal infections, such as candidiasis (thrush), that do not respond to standard antifungal agents: Suggests lymphocytic dysfunction
- Recurrent or unusually severe viral infections, such as recurrent or disseminated herpes simplex or zoster infection or cytomegalovirus (CMV) retinitis; seen with moderate to severe cellular immune deficiency
- Growth failure
- Failure to thrive
- Wasting
- Failure to attain typical milestones: Suggests a developmental delay; such delays, particularly impairment in the development of expressive language, may indicate HIV encephalopathy ∙ Behavioral abnormalities (in older children), such as loss of concentration and memory, may also indicate HIV encephalopathy
During Physical examination inclusive of investigations
- Candidiasis: Most common oral and mucocutaneous presentation of HIV infection ∙ Thrush in the oral cavity and posterior pharynx: Observed in approximately 30% of HIV-infected children
- Linear gingival erythema and median rhomboid glossitis
- Parotid enlargement and recurrent aphthous ulcers
- Hepatic infection with herpes simplex virus (HSV): May manifest as herpes labialis, gingivostomatitis, esophagitis, or chronic erosive, vesicular, and vegetating skin lesions; the involved areas of the lips, mouth, tongue, and esophagus are ulcerated
- HIV dermatitis: An erythematous, papular rash; observed in about 25% of children with HIV infection
- Dermatophytosis: Manifesting as an aggressive tinea capitis, corporis, versicolor, or onychomycosis ∙ Pneumocystis jiroveci (formerly P carinii) pneumonia (PCP): Most commonly manifests as cough, dyspnea, tachypnea, and fever
- Lipodystrophy: Presentations include peripheral lipoatrophy, truncal lip hypertrophy, and combined versions of these presentations; a more severe presentation occurs at puberty ∙ Digital clubbing: As a result of chronic lung disease
- Pitting or non-pitting edema in the extremities
- Generalized cervical, axillary, or inguinal lymphadenopathy
Signs/conditions very specific to HIV infection
- Pneumocystis pneumonia
- Esophageal candidiasis
- Extrapulmonary cryptococcosis
- Invasive salmonella infection
- Lymphoid interstitial pneumonitis
- Herpes zoster (shingles) with multi-dermatomal involvement
- Kaposi’s sarcoma
- Lymphoma
- Progressive multifocal encephalopathy
Signs/conditions common in HIV-infected children and uncommon in uninfected children
- Severe bacterial infections, particularly if recurrent
- Persistent or recurrent oral thrush
- Bilateral painless parotoid enlargement
- Generalized persistent non-inguinal Lymphadenopathy
- Hepatosplenomegally (in non-malaria endemic areas)
- Persistent and recurrent fever
- Neurologic dysfunction
- Herpes zoster, single dermatome
- Persistent generalized dermatitis (unresponsive to treatment)
Conditions common in HIV-infected children but also common in ill uninfected children
- Chronic recurrent otitis with ear discharge
- Persistent or recurrent diarrhoea
- Severe pneumonia
- Tuberculosis
- Bronchiectasis
- Failure to thrive
Opportunistic Infections in Children
Common clinical conditions associated with HIV
- Babies are born with an immature and immunologically naïve immune system, predisposing them to an increased frequency of bacterial infections. The immunosuppressive effect of HIV are additive to those of immature immune system and place HIV-infected infants at high risk of invasive bacterial infections. Common childhood infections and conditions are more frequent in HIV-infected children and have a higher case fatality compared to uninfected children. These infections include:
- Diarrhea
- Acute suppurative otitis media
- Sinusitis
- Failure to thrive
- Immunization and cotrimoxazole prophylaxis significantly decreases the frequency of invasive bacterial infections in HIV-infected children.
Common Opportunistic Infections
- Cytomegalovirus: presents with encephalitis with retinitis or neuritis
- Cryptococcus: presents with fever, headache, seizures, change in mental status; focal neurological signs are uncommon
- Toxoplasmosis: most common manifestations are encephalitis, mental changes, fever, headache, and mental confusion
- Herpes simplex virus: is associated with fever, altered state of consciousness, personality changes, convulsions
- Kaposi’s sarcoma: this presents as early as the first month of life. It is associated with human herpes virus and usually presents as generalized Lymphadenopathy, black/purple mucocutaneous lesions (skin, eye, mouth)
- Bacterial pneumonia: It is the leading cause of hospital admissions and death in HIV infected children. Streptococcus pneumoniae is the most common pathogen isolated. Other organisms include: H. influenzae, staphylococcus aureus, Klebsiella.
- Pneumocystis pneumonia (PCP): PCV is caused by a fungus called Pneumocystis jiroveci(formally known as pneumocystis carnii). It is a major cause of severe pneumonia and death in HIV-infected infants.
- Tuberculosis: Tuberculosis and HIV-co-infection; The HIV pandemic has led to the resurgence of tuberculosis in both adults and children. Children are at increased risk of developing primary progressive tuberculosis because of the associated severe immune suppression resulting from their young age and HIV. There is a high fatality rate for children who are co-infected with tuberculosis and HIV.
- Lymphoid interstitial pneumonia (LIP): LIP is common in children (occurs in about 40% of children with perinatal HIV) and usually occurs in children more than 2 years of age.
- Viral pneumonitis: It develops due to a number of viruses, including respiratory syncytial virus, para-influenza virus, influenza virus, adenovirus, varicella, measles and Cytomegalovirus (CMV).
Examples of Opportunistic infections
Bacterial OIs
- ∙ Pneumococcal pneumonia
- ∙ Pulmonary tuberculosis
- ∙ Salmonellosis
- ∙ Extra-pulmonary tuberculosis
Viral OIs
- ∙ Herpes zoster
- ∙ Recurrent/disseminated viral herpes simplex
Parasitic OIs
- ∙ Pneumocystis cariini pneumonia
- ∙ Toxoplasmosis
Fungal OIs
- ∙ Cryptosporidium
- ∙ Oro-pharyngeal candida
- ∙ Candida Esophagitis
- ∙ Histoplasmosis
- ∙ Coccidioidomycosis,
- ∙ Cryptococcal meningitis
Opportunistic cancers
- ∙ Invasive cervical cancer (caused by human papilloma virus)
- ∙ Kaposi sarcoma (caused by human herpes virus 8 HHV-8)
- ∙ Non Hodgkin lymphoma
Causes of opportunistic infections in HIV/AIDS children
- ∙ Poor adherence to treatment
- ∙ Presence of other diseases e.g. juvenile diabetes mellitus
- ∙ Delay in identification of the Infection
- ∙ High viral load
- ∙ Poor nutrition
- ∙ Exposure to opportunistic infectious agents
- ∙ Ingestion of substances contaminated with opportunistic infectious agents ∙ Missing out immunization programs
- ∙ Poor hygiene of the child
- ∙ Poor sanitation
- ∙ Poor ventilation
Prevention of opportunistic infections
- ∙ Avoidance of contact with the disease agents
- ∙ Proper treatment of other underlying diseases
- ∙ Adherence on HIV drug treatment
- ∙ Immunization of children against killer diseases
- ∙ Ensuring that children eat well cooked food and boiled water
- ∙ Early identification and treatment of the opportunistic diseases ∙
- ∙ Health education of the family and infected child about opportunistic infection
General management of opportunistic infections
- Assessment of the child
⇒ History taking from the mother/caregiver and the child if he/she is verbal ∙ Physical examination
⇒ Vital observations
⇒ Head to toe examinations
⇒ Investigations e.g. blood microscopy e.t.c
- Provision of treatment
No. | Type of infections | Drugs of choice |
1. | Fungal infections | Anti – fungals |
2. | Bacterial infections | Anti – bacterials |
3. | Viral infections | Anti – virals |
4. | Parasitic | Anti – protozoa |
5. | Cancers | Cytotoxic drugs |
|
WHO CLINICAL STAGING OF HIV
Staging HIV infection and disease in children
Staging is a standardized method for assessing disease stage/progression and for making treatment decision. Clinical and laboratory parameters are used to stage HIV disease.
WHO staging for HIV infection and disease in children above 10 years
Clinical Stage I:
- Asymptomatic
- Persistent generalized lymphadenopathy
Clinical Stage II:
- Moderate weight loss (less than 10% of presumed or measured body weight)
- Minor muco-cutaneous manifestations (seborrhoeic dermatitis, prurigo, fungal nail infections, recurrent oral ulcerations, angular stomatitis)
- Herpes zoster within the last five years
- Recurrent upper respiratory tract infections, e.g., bacterial sinusitis, tonsillitis, otitis media and pharyngitis
Clinical Stage III:
- Severe weight loss (more than 10% of presumed or measured body weight)
- Unexplained chronic diarrhea for more than one month
- Unexplained prolonged fever, intermittent or constant, for more than one month 4. Oral candidiasis
- Oral hairy leukoplakia
- Pulmonary tuberculosis (current)
- Severe bacterial infections such as pneumonia, pyomyositis, empyema, bacteremia or meningitis 8. Acute necrotizing ulcerative stomatitis, gingivitis or periodontitis.
- Unexplained anemia (<8gm/dl), neutropenia (<0.5× 109 per liter), or chronic thrombocytopenia (<50× 109 per liter)
And/or Performance Scale 3: Bed-ridden for less than 50% of the day during the last month
Clinical Stage IV:
- HIV wasting syndrome – weight loss of more than 10%, and either unexplained chronic diarrhea for more than one month or chronic weakness or unexplained prolonged fever for more than one month
- Pneumocystis pneumonia (PCP)
- Recurrent severe bacterial pneumonia
- Toxoplasmosis of the brain
- Cryptosporidiosis with diarrhea for more than one month
- Chronic isosporiasis
- Extra-pulmonary cryptococcosis including meningitis
- Cytomegalovirus infection (retinitis or infection of other organs)
- Herpes simplex virus (HSV) infection, mucocutaneous for more than one month, or visceral at any site
- Progressive multifocal leukoencephalopathy (PML)
- Any disseminated endemic mycosis such as histoplasmosis, coccidioidomycosis
- Candidiasis of the oesophagus, trachea, bronchi or lungs
- Atypical mycobacteriosis, disseminated
- Recurrent non-typhoid salmonella septicemia
- Extra-pulmonary tuberculosis
- Lymphoma
- Invasive cancer of the cervix
- Kaposi’s sarcoma
- HIV encephalopathy – disabling cognitive and/or motor dysfunction interfering with activities of daily living, progressing slowly over weeks or months, in the absence of concurrent illness or condition other than HIV infection that could account for the findings.
- Atypical disseminated leishmaniasis
- Symptomatic HIV-associated nephropathy or symptomatic HIV-associated cardiomyopathy And/or Performance Scale 4: Bed-ridden for more than 50% of the day during the last month
WHO staging for HIV infection and disease in infants and children
Clinical Stage I:
- Asymptomatic
- Persistent generalized lymphadenopathy
Clinical Stage II:
- Unexplained persistent hepatosplenomegaly
- Papular pruritic eruptions
- Extensive wart virus infection
- Extensive molluscum contagiosum
- Recurrent oral ulcerations
- Unexplained persistent parotid enlargement
- Linear gingival erythema
- Herpes zoster
- Recurrent or chronic upper respiratory tract infections (otitis media, otorrhoea, sinusitis, tonsillitis)
- Fungal nail infections
Clinical Stage III:
- Unexplained moderate malnutrition not adequately responding to standard therapy
- Unexplained persistent diarrhea (14 days or more)
- Unexplained persistent fever (above 37.5 ºC, intermittent or constant, for longer than one month)
- Persistent oral candidiasis (after first six weeks of life)
- Oral hairy leukoplakia
- Acute necrotizing ulcerative gingivitis/periodontitis
- Lymph node Tuberculosis
- Pulmonary Tuberculosis
- Severe recurrent bacterial pneumonia
- Symptomatic lymphoid interstitial pneumonitis
- Chronic HIV-associated lung disease including bronchiectasis
- Unexplained anaemia (<8.0 g/dl), neutropenia (<0.5 x 109/L3) or chronic thrombocytopenia (<50 x 109/ L3)
Clinical Stage IV:
- Unexplained severe wasting, stunting or severe malnutrition not responding to standard therapy
- Pneumocystis pneumonia (PCP)
- Severe recurrent bacterial infections (e.g. empyema, pyomyositis, bone or joint infection, meningitis, but excluding pneumonia)
- Chronic herpes simplex infection; (oro labial or cutaneous of more than one month’s duration, or visceral at any
- site)
- Extra-pulmonary Tuberculosis
- Kaposi’s sarcoma
- Oesophageal candidiasis (or Candida of trachea, bronchi or lungs)
- Toxoplasmosis of the brain (after the neonatal period)
- HIV encephalopathy
- Cytomegalovirus (CMV) infection (retinitis or infection of other organs) with onset at age over one month
- Extra-pulmonary cryptococcosis (including meningitis)
- Disseminated endemic mycosis (extra-pulmonary histoplasmosis, coccidiomycosis)
- Chronic cryptosporidiosis (with diarrhea )
- Chronic isosporiasis
- Disseminated non-tuberculous mycobacteria infection
- Cerebral or B-cell non-Hodgkin lymphoma
- Progressive multifocal leukoencephalopathy
- HIV-associated cardiomyopathy or nephropathy