Beruflich Dokumente
Kultur Dokumente
vitae
• dr
Finny
Fitry
Yani
SpA(K)
• Staf
Respirologi
Anak
FK
Unand
RS
M
Djamil
• Sp1
Anak
2004
• Fellowship
Respi
anak
FKUI
RSCM
• Konsultan
Respirologi
Anak
:
2011
• Shortcourse
Pediatric
TB
:
Capetown,
South
Africa
2011
• Organisasi
:
Komite
CPD
IDAI
Sumbar
Common Respiratory
Problems in HIV Children
Confirma=on
of
the
diagnosis
of
HIV
infec=on
should
be
sought
as
soon
as
possible.
Respiratory
Illnes
among
HIV-‐Infected
Children
according
to
WHO
Clinical
Stage
PCP,
LIP,
Unexlained
Empyema,
was=ng,
Disseminated
fever,
MAC
pulmonary
Upper
TB
,
Respiratory
pneumonia
Limfodeno
Stage
4
(severe)
Infec=on
pa=
persisten
Stage
3
(advance)
Stage 2 (mild)
Stage
1
(asymptoma=c)
7
General
CondiSons
• Lower
respiratory
tract
infecSons
are
the
most
common
recurrent
infecSons
in
PLHIV.
• They
are
usually
life-‐threatening
• PaSents
may
present
early
in
the
course
of
HIV
infecSon
with
bacterial
pneumonias,
which
respond
readily
to
anSbioScs
• PaSents
with
HIV
infecSon
appear
to
be
parScularly
prone
to
infecSons
with
encapsulated
organisms
such
as
Streptococcus
pneumoniae
and
Haemophilus
influenzae
General
CondiSons
• Later,
and
with
the
onset
of
immune
suppression,
paSents
may
develop
opportunisSc
pulmonary
infecSons,
the
most
important
of
which
is
pulmonary
TB.
• As
cell-‐mediated
immunity
deteriorates,
paSents
may
develop
life-‐threatening
opportunisSc
infecSons
such
as
PCP
and
severe
fungal
and
viral
pneumonias.
Unknown
Life
HIV
status
threatening
Asymptoma=c
Known
HIV
status
16
Bacterial
Respiratory
Infec;on
Treatment
&
PrevenSon
• According
to
treatment
bacterial
pneumonia
in
general
populaSon
• First
line
:
Ampicillin/sulbactam
or
Amoxycillin/
clavulanic
acid.
• CAP
with
co-‐morbidity:
2nd
cefalosporin
(cefuroxim),
3rd
cefalosporin
(cefotaxim/cehriaxon),
• Suspected
atypical
pneumonia:
Macrolide
• Pneumococcal
vaccina=on
is
recommended
17
Non-‐severe
pneumonia
(0–5
years)
• Oral
amoxicillin
as
first-‐line
anSbioSc.
• Oral
cotrimoxazole
is
also
recommended,
but
should
ideally
not
be
used
rouSnely
as
this
will
encourage
resistance
and
diminish
its
effecSveness
against
P.
jiroveci.
• Regular
follow-‐up
to
monitor
progress.
Severe
pneumonia
(2–11
months)
• Hospitalize
and
administer
intravenous
anSbioSc:
ampicillin/penicillin
+
gentamicin
or
oral
amoxicillin
+
gentamicin.
•
Treat
for
P.
jiroveci
with
intravenous
cotrimoxazole.
•
If
not
improving
within
72
h
change
to
second-‐line
anSbioSc:
cehriaxone.
•
Give
oxygen
if
signs
of
hypoxaemia.
Severe
pneumonia
(12–59
months)
• Hospitalize
and
administer
intravenous
anSbioSc:
• ampicillin/penicillin
þ
gentamicin
or
oral
amoxicillin
• þ
gentamicin.
•
Treat
for
P.
jiroveci
if
clinically
indicated.
If
not
improving
within
72
hr
change
to
secondline
• anSbioSc:
cehriaxone.
• Give
oxygen
if
signs
of
hypoxaemia.
Mycobacterium
tuberculosis
Clinical
ManifestaSons
• Non
specific
symptoms,
such
as
chronic
cough,
fever,
night
sweats,
anorexia
and
weight
loss.
• In
the
older
child
also
producSve
cough
and
haemoptysis.
• History
of
contact
with
adults
with
smear-‐
posiSve
pulmonary
tuberculosis.
• No
response
to
standard
broad-‐spectrum
anSbioSc
treatment
Mycobacterium
tuberculosis
Clinical
ManifestaSons
• Younger
children
progress
more
rapidly
(possibly
due
to
delayed
diagnosis)
• Extrapulmonary:
marrow,
lymph
node,
bone,
pleura,
pericardium,
peritoneal
• Pulmonary
TB
most
likely
appears
as
infiltrate
with
hilar
adenopathy
• Clinical
presentaSon
of
TB
similar
in
HIV-‐
posiSve
and
HIV-‐negaSve
children
Mycobacterium
tuberculosis
Diagnosis
• Difficult
to
diagnose;
• About
10%
of
culture-‐posiSve
children
have
negaSve
TST
• Perform
annual
TST
beginning
at
3-‐12
months
using
5
TU
PPD
intradermally
• DefiniSve
:
One
or
more
sputum
smear
posiSvef
or
acid-‐fast
bacille
and/or
radiographic
abnormaliSes
consistent
with
acSve
tuberculosis
and/or
culture-‐posiSve
for
Mycobacterium.
Mycobacterium
tuberculosis
Treatment
• Treatment
principles
similar
in
HIV-‐posiSve
and
HIV-‐negaSve
children
(3-‐4
OAT)
• IniSate
treatment
as
soon
as
possible
in
children
<4
years
old
with
suspected
TB
•
Begin
TB
treatment
4-‐8
weeks
before
ARVs
• If
already
on
ARV,
review
drug
interacSons
• Use
of
DOT
increases
adherence,
decreases
resistance,
treatment
failure,
and
relapse
Mycobacterium
tuberculosis
Preven=on
?
• Although
INH
prophylaxis
is
recommended
for
all
young
children
with
a
household
contact
with
TB
irrespecSve
of
their
HIV
status,
in
many
developing
countries
this
may
not
occur
due
to
limited
resources,
lower
priority
given
to
childhood
TB
and
quesSons
regarding
efficacy.
• Thus,
providing
INH
prophylaxis
for
HIV
infected
children
in
developing
countries
may
be
challenging.
Life
Cycle
of
PCP
Pneumocys==s
Jerovecii
Pneumonia
Clinical
Manifesta=ons
• Should
be
suspected
and
anS-‐pneumocysSs
therapy
considered
in
any
HIV-‐posiSve
infant
with
severe
pneumonia
•
Age
<12
months,
absent
or
low-‐grade
fever,
cyanosis,
hypoxia
that
is
persistent,
poor
response
to
48
h
of
first-‐line
anSbioScs
and
elevated
levels
of
LDH,
all
support
the
diagnosis.
•
PCP
is
ohen
the
first
clinical
indicator
of
HIV
infecSon.
Pneumocys==s
Jerovecii
Pneumonia
Clinical
Manifesta=ons
and
Diagnosis
•
Clinical
and
radiological
signs
are
not
diagnosSc.
• However,
a
clear
chest
or
diffuse
chest
signs
on
auscultaSon
are
typical
with
PCP
infecSon,
as
is
the
presence
of
diffuse
infiltrates
rather
than
focal
signs
on
chest
X-‐ray.
•
Induced
sputum
and
NPA
are
useful
for
obtaining
sputum
for
examinaSon
when
BAL
is
not
possible.
PCP
in
HIV
(+)
paSent
Chest
X-‐ray
32
Pneumocys=s
Jerovecii
Pneumonia
Treatment
and
Preven;on
• >2
months
15-‐20
mg/kg/day
of
TMP,
75-‐100
mg/Kg/
day
of
SMZ
intravenously
in
3-‐4
divided
doses
over
1
hour
for
21
days
(per
oral
for
mild-‐moderate)
• Steroid
can
be
use
for
moderate
-‐
severe
PCP
within
72
hours
of
diagnosis,
reduced
respiratory
failure,
venSlaSon
requirements,
and
mortality
• Lifelong
prophylaxis
indicated
(CD4
<
200)
• The
incidence
of
adverse
drug
reacSon
to
co-‐
trimoxazole
Limphoid
Inters;sial
Pneumonia
(LIP)
Clinical
ManifestaSon
• Common
in
pediatric
HIV
infecSon
(30-‐40%)
• Associated
with
autoimmune
and
lymphoproliferaSve
disorders,
human
immunodeficiency
virus
(HIV)
type
1,
Epstein-‐Barr
virus,
human
T-‐cell
leukemia
virus
(HTLV)
type
1
• CD4+
count
>
200
cells/µL
• ManifestaSon:
insidious
onset
cough,
faSgue,
dyspnea,
tachypnea,
hepatosplenomegaly,
paroSd
gland
enlargement,
hypoxemia
• PE:
crackles,
wheezing,
cyanosis,
clubbing
Limphoid
Inters;sial
Pneumonia
(LIP)
Diagnosis
and
Treatment
• Chest
X-‐ray:
diffuse
reSculonodular/alveolar
infiltrate
(lower
lobe),
pleural
effusion,
hilar
lymphadenopathy,
•
No
respon
to
anSbioSc
treatment
•
Hypoxemia
persisten
<
90%
• DefiniSve
diagnosis:
biopsy,
• Prednisone
2
mg/kg/day
2-‐4
weeks
DisconSnued:
no
response
aher
4-‐6
month
• Bronchodilator:
mild-‐moderate
disease
Chest
X-‐ray:
diffus
nodular
infiltrate
+
hilar
lymphadenopathy
36
Other
infecSons
involved
pulmonary
• Cryptococcosis
• Hystoplasmosis
• CMV
• Candida
Summary
Recurrent
Pneumonia
PCP
Tuberculosis
etc
Isoniazid
and
Health
care
Age
Cotri
acces
Prophylaxis