Transcript Opportunistic Infections

Prof ML Siddaraju
Dept of Pediatrics
Bangalore Medical College
INTRODUCTION
Opportunistic infections occur in HIV infected
child due to waning immunity.
It may be a presenting symptom in many children
who on investigation would turn out to be HIV
infected.
It develops faster in children below one and half
year than older children.
Prevalence of OI depends on prevalence of
infection in family and in community.
4
Percentage
Oppurtunistic Infection in HIV
(n=6452)
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
DIARRHEA
TB
Candidiasis
Cryptosporidi
osis
H. zoster
Toxo
Bact. Infe.
PCP
Infections
1
Crypto
meningitis
Kaposi
Sarcoma
Others
RECOGNITION OF SYMPTOMS OF
HIV INFECTION.
RULE OF FOUR
Aim
To help the health care providers recognize the
patient with symptomatic HIV infection as an
aid to clinical management
CARDINAL FINDINGS
Any One
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Pneumocystic Carnii Pneumonia.
Lymphocytic Interstitial Pneumonia.
Esophageal Candidiasis
Persistent diarrhea.
CHARACTERISTIC FINDINGS
Any Two
Recurrent bacterial and or viral infections.
Miliary ,extrapulmonary or noncavitatory TB
Herpes zoster-present or past,
multidermatomal
CMV –systemic infection
Neurological Dysfunction ,Progressive
neurological disease, microcephaly, loss of
developmental milestones
ASSOCIATED FINDINGS
Any Three
Oral Thrush
Fever –intermittent or continuous for
> 1 month
Generalized Lymphadenopathy.
Generalized Dermatitis.
EPIDEMIOLOGICAL RISK
FACTORS
 Maternal HIV seropositivity.
 H/O blood /blood product transfusion
before 1985 or screened blood from an area
with high HIV prevalence
 Sexual abuse.
 Use of contaminated syringes /needle
scarification/ear piercing /circumcision
/tattooing using unsterile instruments.
DIARRHOEA
Level – A
 If there is fever – other possible causes should
be ruled out and treated accordingly.
 Blood /mucus in the stools – indicate possibly
shigella dysentery .Empirically treat with cotrimaxazole /nalidixic acid.
 Patient should be daily evaluated for evidence
of dehydration and other signs of improvement
A: disappearance of fever .
B: decreased frequency of stools .
C:increased appetite.
D:wt gain . 20 gm /day for >2 days .
DIARRHOEA
Level – A
 Nutritional aspect has to bet taken care of :
A: if exclusively breast fed continue.
B: In tothers ,animal milk is as far as possible is
avoided / reduced or else given in the form of
curds or mixed with cereal.
C: If non vegetarian- chicken/fish/egg can be included.
D: vegetable oils are added to increase the calories .
 If no improvement is noticed after 2 days child
may be refered to a higher center.
Level – B
 Microscopic examination of stools is done
to identify the causative agent –giardia /
entamoeba/helminthic ova & cysts.
 In the stool smear , evidence of blood &
WBC’s should be looked in suggestive of
bacterial infection and treated accordingly.
Level C
Stool culture
Blood culture
Endoscopy
Are done to pinpoint exact etiopathogenesis
and treated accordingly.
PERSISTENT DIARRHOEA
Criteria
1.Diarrhoea > 14 Days
2.Chronic /Recurrent diarrhea.
In 1/3rd of cases etiology is cryptosporiodisis.
Majority of the cases – no specific enteric pathogen is
isolated
Possible pathogenesis
 Unrepaired mucosal damage
 Episodes of acute diarrhoea to start with.
Management principles
 HIV + pts with persistent diarrhea with
dehydration and malnutrition should be
hospitalized and managed accordingly.
 Assessment of dehydration – manage
accordingly.
 Exclusive breast feeding – inspite of risk.
 Later Childs nutritional requirement should
be properly met with,.
Nutrition
 Animal milk should be fermented – curds
 Curds and cereals can be mixed together
 Cooked cereal with poultry products or sea food is
liberally used depending upon the local
availability.
 Vegetable oil should also be included.
 Vitamins and minerals may be supplemented.
Respiratory Infections
•
Respiratory infections are classified as per
WHO/CSSM criteria
1. Pneumonia: RR
>60/min
>50/min
>40/min
<2mo
2mo-12mo
1yr-5yr
2. Severe pneumonia: 1+ lower chest indrawing or
nasal flaring
3. Very severe pneumonia: 2+ cyanosis, inability to
feed, convulsions, lethargy, unconsciousness, head
nodding.
Respiratory Infections
• Presumptive treatment is started with
cotirmoxazole in all cases of ALRI
• Improvement in 3 days = bacterial inf.
• No improvement
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Tuberculosis
PCP
LIP
Fungal pneumonia
Viral pneumonia
Respiratory Infections
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Condition
M. tuberculosis
Bacterial pneumonia
PCP
MAC
Suppurative lung disease
CMV
CD4 count
<400
<250
<200
<100
<100
<100
Mycobacterium Tuberculosis
• Most common OI in our country
• Extra pulmonary forms more common
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Lymphadenopathy ( even in resp tract)
Miliary disease
CNS
Bone marrow
Genito urinary
Mycobacterium Tuberculosis
• Presents a diagnostic dilemma
• MX usually –ve if>5mm taken as positive.
• CXR: lymphadenopathy, pleural effusion,
upper zone infiltrates, cavitation, miliary
pattern.
• FNAC: AFB in lymph nodes
Mycobacterium Tuberculosis
Treatment:
• 4 drugs – 2 months
• 2 drugs – 4months
• Longer duration for miliary, bone/joint and
CNS TB.
• MDRTB more common with HIV
Oral Thrush
• Presumptive: Presence of a punctate or
diffuse erythema, white-beige
pseudomembraneous plaques on oral
mucosa
• May be confluent and extensive
• Plaques can be removed with difficulty and
reveal a granular base which bleeds easily
Oral Thrush
• Definitive:
Microscopic demonstration of
pseudohyphae and or blastopores of
candida albicans from mouth scraping or
biopsy.
• Rx:
– Local application of Nystatin QID,
– Oral ketoconazole 5mg/kg/day
Neurological Manifestations
• Due to
– Usual neuroinfections
– Opportunistic infections
– HIV encephalopathy
• Usual infections: ABM, TBM, Cerebral
malaria.
• Opportunistic: cryptococcosis, toxoplasma,
CMV
Neurological Manifestations
• HIV encephalopathy:
• Progressive: Progressive decline in motor,
cognitive and language delay in
development mile stones – hither to normal
and unexplained.
• Static : Absence of alternative explanation
for developmental delay.
Neurological Manifestations
• Acute Encephalopathy
– Acute onset of seizures with focal neurological
deficits due to infections or drug adverse
effects.
• HIV encephalopathy if HIV antigen
antibody in blood and CSF, HIV culture
from CSF positive.
– Treatment is supportive
Cryptococcal Meningitis
• Amphotericin B 0.5-1mg/kg/Q 6 H
• Suppressive therapy like fluconazole
100mg/day
Toxoplasmosis
• Pyrimethamine loading dose: 2mg/kg –
2days; 1mg/kg – 6 weeks
• Sulfadiazine: 40 mg/kg 12 hrly – 6 weeks
• Supplementation of folinic acid once in 3
days
CMV infection
• Ganciclovir: 5 mg/kg/12hrsly 21 days
• Maintenance: 5 mg/kg indefinitely
Case 1
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Pravin
8 months
3.5 kg
Failure to thrive
Unable to sit
Reccurent fever
HSM
Harsh breathing
Case 1
• CXR: patchy pneumonia\
• USG: focal necrosis in liver and spleen, free
fluid
• HIV +ve by ELISA 1 month back
Case 1
• Elisa+Ve in 7 mo old:
– May be flase +ve
• But as child is symptomatic may be HIV infected
• Rec fever/HSM/Patchy pneumonia/FTT/unable to
sit:
– PCP per se
– TB per se
– Both + bacterial pneumonia (spleen/liver necrosis)
Case 1
• FTT/unable to sit:
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HIV disease itself
HIV encephalopathy
Repeated infections
FTT
• Further Ix: CXr, Mx, Blood coutns, culteres
• Rx: ATT, SMP-TMX, IV antibiotics
Case 2
• Leela 4yr old charming girl
• First child
• Past 6 mo: adimitted 3 times for GE &
dehydration
• Has lost 2 kg in last 6 mo
• Seropositve
• Both parents +ve
• CD4: 800/mm3
Case 2
• CD4 – moderate immunosuppression
• Causes for rec. diarrhea:
• Protozoa: Isospora, cryptospridium,
microsporia, entamoeba, giardia
• Bacteria: Slamonella, campylobacter,
shigella, clostridium, MAC
• Viruses: CMV, adeno, HIV, HSV, rota
• Fungi: Histoplasoma
Case 2
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Diet:
Hydration
Antimicrobial based on organism
Counseling parents regarding HIV status
No pcp px needed as CD4 is >500.
Case 3
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Susheela
8 yrs
Resides in a slum with parents
Vesicular eruptions – rt cheek and chest
wall
• Mild fever\
• Mother had similar complaints in the past
Case 3
• Multidermatomal involvement:
– HIV testing to be done
– If +Ve =
– D/D: Drug eruptions, Zoster, molluscum,
furunculosis, impetigo, follculitis, scabies
• Rx: Herpes : Acyclovir: 15-30 mg/kg –
7days
Case 4
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Rekha
3yrs
10 kg
Pneumonia 6 mo back
Admitted with convulsions
CSF and CT: SOL, diffuse margins, dilated
ventricles, mild hydrocephalus
HIV +ve
Both parents –ve
Born preterm: Exchange transfusion for jaundice
CD4 1000/mm3
Case 4
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3yrs – 10 kgs
Past Hx – pneumonia
Source of inf: transfusion
CD4 = no immunosuppression
D/D:
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Tuberculoma
Toxoplasmosis
Cryptococcosis
CNS lymphoma
CMV
HIV encephalopathy
Case 4
• CSF analysis to rule out ABM
• Rx depends on etiology