Transcript Slide 1

Chapter 8
Children with HIV/AIDS
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
(Ref. Chart 1, p. xxii)
1.
Triage
•
2.
History and examination
•
3.
Emergency treatment, if required
Laboratory investigations, if required
Differential diagnoses
•
Main diagnosis
4.
Treatment
5.
Supportive care
6.
Monitoring
7.
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:
8.9 g/l
(105-135)
- Platelets:
255 x 109/l (150 – 400)
- WCC:
14.6 x 109/l (6 – 18.0)
- Neutrophils:
12.2 x 109/l (1.0 – 8.5)
- Lymphocytes:
1.4 x 109/l (4.0 – 10.0)
- Monocytes:
1.0 x 109/l (0.1 – 1.0)
Investigations (continued)
•
Thomas, his parents and his elder sister’s (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
(Ref. p. 235)
Clinical stages
ART
4
Treat
Presumptive stage 4
Treat
3
Treat
1 and 2
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