HIV/AIDS in Children

Case Report
Nenden
Ismawaty

Introduction
UNAIDS
In 2004:
2.2 million children <15 yr of age HIV (+)
640,000 newly infected
510,000 die of AIDS

Asia
At the end of 2001:
200,000 children <15 yr of age HIV (+)
68,000 newly infected
>40,000 die of AIDS

The prevalence of AIDS

Indonesia (September 2004) 2,682 cases

West Java (1989 June 2005) 268 cases
perinatal: 5 cases
Cipto Mangunkusumo Hospital (AIDS in Children):
1996 & 2000 1 case
2003 17 cases
2004 44 cases
Hasan Sadikin Hospital:
4 cases HIV/AIDS in children
1 case die of AIDS

Case 1
V, 3 y.o. girl, BW: 9 kg, H: 82 cm, BW/H: 78%
1 month ago
Mother: die of AIDS
Father: HIV (+), history of
drug abuse (+)

Born at term to gravida 1

BW: 2,700 gr
Breast fed until 2 years of age

13 June 05

14 July 05
Cough >>

HIV (+)?

Hospitalized

13 June 2005
Physical Examination
Oral thrush (+)
Lymphadenopaty colli (+)
Hepatomegaly (+)
Paronychia ulcer on the right thumb (+)

Laboratory findings

Hb: 8.9 gr/dL

Leucocyte: 10,200/mm3
PCV: 29%
Thrombocyte: 500,000/mm3
Differential Count: 1/4/-/48/40/7
AST: 28 U/L
ALT: 10 U/L
Ureum: 19 mg/dl
Creatinine: 0.21 mg/dl
CD4: 3%
CD4(Absolut): 55 sel/l.

Chest x-ray: suspected tuberculosis

Mantoux test: (-)
Therapy:
Isoniazid 1 x 75 mg p.o.
Rifampisin 1 x 100 mg p.o.
Pirazinamid 1 x 150 mg p.o.
Zidovudin 2 x 75 mg p.o.
Lamivudine 2 x 40 mg p.o.
Nevirapin 2 x 50 mg p.o.
Roborantia 1 x 1 cth
Nystatin 4 x 0.5 cc

14 28 July 2005 (Hospitalization)

Laboratory findings (reassessment)
Hb: 9.4 gr/dL
Leucocyte: 10,100/mm3
PCV: 29%
Thrombocyte: 620,000/mm3
Differential Count: -/20/-/48/31/1
AST: 52 U/L
ALT: 11 U/L
Ureum: 20 mg/dl
Creatinine: 0.35 mg/dl
CD4: 4%
CD4(Absolut): 110 sel/l

Therapy:
Cefotaxime 3 x 375 mg i.v.
anti tuberculosis
antiretroviral (ART)
Kandistatin 4 x 0.5 cc p.o.
Cotrimoxazole 2 x 1 cth

Case 2
F, 2 y.o. boy, BW: 12 kg, H: 84 cm, BW/H: 105%
6 months ago

5 months ago
Father die of AIDS

3 weeks ago
Cough (+)

20 June 05

Parents: HIV (+), history

of drug abuse (+)

Born pre term to gravida 1

BW: 2,200 gr
Breast fed until 10 months of age

HIV (+)
CD4: 24.54%
(1666 cells/L)

20 June 2005
Physical Examination
Oral thrush (-)
Lymphadenopaty colli (+)
Hepatomegaly (-)

Laboratory findings

Hb: 10.9 gr/dL

Leucocyte: 13,200/mm3
PCV: 35%
Thrombocyte: 146,000/mm3
Differential Count: -/1/-/26/65/8
AST: 66 U/L
ALT: 56 U/L

Chest x-ray: suspected tuberculosis

Mantoux test: (+)
Therapy:
Isoniazide 1 x 100 mg p.o.
Rifampicin 1 x 150 mg p.o.
Pyrazinamide 1 x 200 mg p.o.
roborantia 1 x 1 cth

22 July 2005
Laboratory findings (reassessment)
Hb: 10.6 gr/dL
L: 10,600/mm3
PCV: 26%
T: 80,000/mm3
AST: 68 U/L
ALT: 36 U/L
Therapy: continued

Discussion
Problems:
Diagnose
Classification
Management

Vertical transmission >>

Risk of MTCT: 15-40%
The use of prophylaxis 2%
Vertical transmission disease more
dynamic
HIV (+)

1st year: 23%

5 years of age: 40%

AIDS
1st year: 10%
5 years of age: 21%

First observable symptoms: >> non specific

Delayed diagnosis
At early stages:
Febrile states
Generalized lymphadenopaty
Hepato- and splenomegaly
Parotitis
Dermatitis
Persistent diarrheas
Bacterial infection of the upper respiratory tract

As the disease progresses

Anemia (Hb<8 g/dl)
Thrombocytopenia (<100.000/mm3)
Chronic or persistent diarrhea
Cerebrospinal meningitis
Bacterial pneumonia
Sepsis
GIT candidiasis
Recurrent viral infections caused by Herpes simplex
and Varicella zoster
Lymphocytic intersititial pneumonia (LIP)
Cardiomyopathy
Nephropathy

In full-blown AIDS:
HIV-encephalopathy
Cachexia
Recurrent bacterial infections
Opportunistic infections with predominant
mycoses

The onset of clinical manifestations of

perinatally acquired AIDS 4 months (3
weeks 21 months)
The risk of transmission 30%
breastfeeding infants
The reliable test of HIV Ab after the age
of 15-18 months

CDC Pediatric HIV Classification

Clinical Categories
Immune
Categories

N-No
Signs/Symptoms

A-Mild
Signs/Symptoms

B-Moderate
Signs/Symptoms

C-Severe
Signs/Symptoms

1. No evidence
of suppression

N1

A1

B1

C1

2. Evidence of
moderate
suppression

N2

A2

B2

C2

3. Severe
suppression

N3

A3

B3

C3

CDC Revised Pediatric HIV Classification: Immune Categories

Based on CD4 count or CD4 Percentage
<12 Months

1-5 Years

>6 Years

Immune
Categories

Cells/L

Cells/L

Cells/L

1. No
evidence of
suppression

>1500

>25

>1000

>25

>500

>25

2. Evidence
of moderate
suppression

750-1499

15-24

500-999

15-24

200-499

15-24

3. Severe
suppression

<750

<15

<500

<15

<200

<15

Children with pulmonary TB might have

little or symptoms nonspecific (e.g.,
weight loss, fever, and failure to thrive)

Children with HIV infection high risk for

TB annual Mantoux tuberculin skin
testing (age 312 months)

A definitive diagnosis of TB disease requires

isolation M. tuberculosis from expectorated
sputum, BAL fluid, aspirated gastric fluid,
biopsied peripheral lymph node or other
tissue, or mycobacterial blood culture

The currently available therapy does not

eradicate the virus and cure the patient
suppresses the virus for extended periods
of time
changes the course of the disease to a
chronic process
Decisions about ART are based on:
The magnitude of viral replication
CD4 lymphocyte count or percentage
Clinical condition

Indications for Initiation of Antiretroviral Therapy in

Children >1 Year of age Infected with Human
Immunodeficiency Virus (HIV)

In the setting of antiretroviral nave HIVinfected children, treatment of TB should be

initiated 48 weeks before initiating
antiretroviral medications to improve
adherence and better differentiate potential
side effects

For children already receiving antiretroviral

therapy who have had TB diagnosed, the
childs antiretroviral regimen should be
reviewed and altered, if needed, to ensure
optimal treatment for both TB and HIV and
to minimize potential toxicities and drugdrug interactions

Rifampin induces hepatic cytochrome

P450 enzymes and can accelerate
clearance of drugs metabolized by the
liver e.g., protease inhibitors and nonnucleoside reverse transcriptase
inhibitors)subtherapeutic levels of the
drug

Rifampin- and nevirapine-containing

regimens should be used only when no
other options are available and close
clinical and virologic monitoring can be
performed

Cotrimoxazole prophylaxis
the incidence and severity of PCP
Protection against common bacterial
infections, toxoplasmosis, and malaria

the frequency of episodes of

increased HIV viral load associated
with acute illness improved longterm CD4-cell response

Who needs PCP prophylaxis?

All infants born to an HIV-infected mother irrespective of

any ARV during pregnancy and labour
All infants identified as HIV infected during the first year
of life by a PCR test or by a clinical diagnosis of HIV
infection and a positive antibody test
Children >12 months, with symptomatic HIV disease or
an AIDS-defining illness or with CD4 <15% or TLC
1500/mm3
Any child with a history of PCR, should continue with
secondary prophylaxis (daily CTZ) for life