Children with HIV/AIDS

Chapter 8

Case study: Thomas

Thomas, 8-month old boy was brought to hospital with history of fever for eight days. He looked small for his age and unwell. He had not been able to eat or drink much for 2 days because of sores in his mouth. His weight at triage was 6.4 kg

What are the stages in the management of and sick child?

Stages in the management of a sick child

1. Triage

(Ref. Chart 1, p. xxii)

Emergency treatment, if required

2.
3. 4. 5. 6. 7.

History and examination

Laboratory investigations, if required

Differential diagnoses
Main diagnosis

Treatment Supportive care Monitoring Plan discharge

Follow-up, if required

What emergency and priority signs have you noticed?

Triage
Emergency signs (Ref. p. 2, 6) Obstructed breathing Severe respiratory distress Central cyanosis Signs of shock Coma Convulsions Severe dehydration Priority signs (Ref. p. 6) Tiny baby Temperature Trauma Pallor Poisoning Pain (severe) Respiratory distress Restless, irritable, lethargic Referral Malnutrition Oedema of both feet Burns

What emergency treatment does Thomas need?

Emergency treatment

History
Thomas was well until 5 months of age. Since then he had two episodes of pneumonia that needed several days of hospital treatment with intravenous antibiotics. Since the first admission he had had poor weight gain. He has not been able to eat or drink much in the last week because of mouth sores, which had been there for 4 weeks

History (continued)
Thomas had had frequent episodes of watery diarrhoea since he was 5 months old. Each episode of diarrhoea lasted for 10-14 days, mostly watery diarrhoea with some mucus in the stool.

Nutrition history
Thomas is still breastfed. He was exclusively breastfed till 5

months of age and then weaning food was introduced. The weaning food mainly contained rice, vegetables, and occasionally meat. Not feeding well in last week because of mouth sores

Family history
Thomas is the second child of his parents. His father is 24 years old and is a truck driver. His mother is 20 years old and she is a housewife. His 18 month-old sister is healthy. They live in a small rented room.

Examination
Thomas was alert and active but miserable. He was a little pale and had muscle wasting, but was not cyanosed or jaundiced. He had bilateral enlarged inguinal, axillary and submandibular nontender lymph nodes, all measuring 1-1.5cm. Vital signs: temperature: 38.50C, pulse: 120/min, RR: 40/min, Weight: 6.4 kg Ear-Nose-Throat: white plaques over the buccal mucosa, gums and posterior oropharynx Skin: dry, flaky skin Chest: no respiratory distress, clear to auscultation Cardiovascular: both heart sounds were audible and there was no murmur Abdominal examination: liver was palpable 3 cm below the right costal margin and spleen was enlarged 5 cm below the left costal margin Neurology: conscious; no neck stiffness

Differential diagnoses
List possible causes of the illness Main diagnosis Secondary diagnoses Use references to confirm

Differential diagnoses
Recurrent infections Oral thrush due to antibiotics HIV Congenital immune deficiency

Primary malnutrition accompanied by various infections

Further examination based on differential diagnoses

Look for:

Recurrent infections

(Ref. p. 226-227)

Oral thrush without antibiotic treatment, or lasting over 30 days despite treatment Chronic parotitis Lymphadenopathy and hepatomegaly Persistent and/or recurrent fever Herpes zoster Dermatitis Chronic suppurative lung disease Malnutrition Persistent diarrhoea

What investigations you would like to do?

Investigations
FBE Ulcer swab HIV antibody test After counseling the parents and seeking consent Interpretation of a positive test Effect of age (antibody and viral particle assay) Need for repeat test for confirmation

Investigations (continued)
Full blood count: - Haemoglobin: - Platelets: - WCC: - Neutrophils: - Lymphocytes: - Monocytes: 8.9 g/l (105-135) 255 x 109/l (150 400) 14.6 x 109/l (6 18.0) 12.2 x 109/l (1.0 8.5) 1.4 x 109/l (4.0 10.0) 1.0 x 109/l (0.1 1.0)

Investigations (continued)
Thomas, his parents and his elder sisters (Rachel) HIV status were tested after the obligation to maintain confidentiality was assured. (Ref. p. 228).

The parents were encouraged to have a HIV test and the implications of the diagnosis were explained to them.
Thomas, his mother and father had positive HIV antibody test by ELISA assay. Rachel had a negative HIV antibody test.

Diagnosis
Summary of findings: History: persistent diarrhoea Examination: recurrent infection, oral thrush, generalised lymphadenopathy, hepatosplenomegaly Blood examination shows mild anaemia, lymphopenia Chest X-ray: bilateral lymphadenopathy HIV antibody test by ELISA assay: positive

What stage of the disease is Thomas at? see Table 22, p. 231

How would you treat Thomas and his family?

Antiretroviral treatment
There are three main classes (Ref. p. 234): Nucleoside reverse transcriptase inhibitors AZT (zidovudine), lamivudine, stavudine, didanosine, abacavir Non-nucleoside reverse transcriptase inhibitors Nevirapine, efavirenz Protease inhibitors: Nelfinavir, lopinavir/ritonavir, saquinavir
Usually two NRTIs plus one NNRTI

Antiretroviral treatment (continued)

Consider: Resistance to single or dual agents is quick to emerge, at least 3 drugs are the recommended minimum standard for all settings Fixed dose combination therapy now used: e.g.

Trimmune

Access to treatment needs to be ensured for other family members as well High level of compliance and close follow-up are necessary

Antiretroviral treatment (continued)

Who needs the treatment? Age and certainty of diagnosis Clinical stages 4 Presumptive stage 4 3 1 and 2

(Ref. p. 235)
ART Treat Treat Treat

Treat only where CD4 available and child: <18 month and CD4 <25% 18-59months and CD4 <15% >5 years and CD4<10%

Treatment (continued)
Oral thrush
Nystatin / ketaconazole (gentian violet) (Ref. p. 246)

Treatment of persistent or bloody diarrhoea

Albendazole, tinidazole, azithromycin (cryptosporidium) and zinc

What supportive care is required?

Supportive care
Nutrition:
Nasogastric feeds with breast milk Multivitamins, vitamin A, zinc

Immunization:
Asymptomatic HIV infection: give all vaccines Symptomatic HIV infection (clinical AIDS): give all vaccines except BCG, measles and yellow fever (Ref. p. 240)

Prophylaxis:

Cotrimoxazole
Consider isoniazid

Supportive care (continued)

Palliative care:
Pain control Antiemetics Mouth care Prevention of pressure areas

Care, kindness and consideration

Psychological and social support

Follow-up
HIV-infected children should, when not ill, attend MCH clinics like other children. In addition they need regular clinical follow-up at first-level facilities several times a year to monitor: Clinical condition Neurological development Growth and nutrition Immunization status Social support for the family Psychological well being

Summary
The management of children with HIV infection is mostly similar to that of other sick children
Antiretroviral treatment has improved the lives of many HIV affected children Cotrimoxazole prophylaxis is indicated at all ages Consider INAH prophylaxis

Quality and duration of life can be improved with prompt treatment of inter-current infections and nutrition support
Effective and inexpensive prevention of parent-tochild transmission is available

Prevention
Prevention of Parent-to-child-transmission (PPTCT): Pre-test counseling Screening at antenatal care

Post-test counseling
Effective drug regimens (evolving) Breast feeding counseling

Contraception