When to suspect HIV When to suspect HIV in childrenin children

A clinical perspectiveA clinical perspective

16 month old boy16 month old boy

Fever, increased work of Fever, increased work of breathing, poor feeding.breathing, poor feeding.

Normal pregnancy – LSCS at term Normal pregnancy – LSCS at term Breast fedBreast fed2/12: facial swelling2/12: facial swelling11/12: severe chicken pox11/12: severe chicken poxNo developmental progress after No developmental progress after age 1 year.age 1 year.

Family historyFamily history

Parents from ZimbabweParents from ZimbabweMum nurse – in UK for 8 yearsMum nurse – in UK for 8 yearsDad student – in UK for 3 yearsDad student – in UK for 3 yearsMum reported negative HIV test Mum reported negative HIV test 3 years ago3 years ago

HIV diseaseHIV disease

Pneumocystis pneumoniaPneumocystis pneumoniaCMV pneumonitisCMV pneumonitisCMV retinitisCMV retinitisCMV/HIV encephalopathyCMV/HIV encephalopathy

SequelaeSequelae

Marrow failureMarrow failure GanciclovirGanciclovir ZidovudineZidovudine CotrimoxazoleCotrimoxazole

Pseudomonas Pseudomonas sepsissepsis

Renal failureRenal failure GanciclovirGanciclovir FoscarnetFoscarnet AminoglycosidesAminoglycosides

Where are we now?Where are we now?

HIV undetectable HIV undetectable Immune reconstitution Immune reconstitution Normal respiratory functionNormal respiratory function Marrow recovered Marrow recovered Neurodevelopmental progress but Neurodevelopmental progress but delayeddelayedBUTBUT

Chronic renal failureChronic renal failure on dialysison dialysis

Girl aged 4 months, 29 Girl aged 4 months, 29 daysdays

Persistent cough, 2-3 monthsPersistent cough, 2-3 months3 courses antibiotics3 courses antibiotics

Pale, lethargicPale, lethargicFeeding normallyFeeding normallyNormal pregnancy, deliveryNormal pregnancy, deliveryCaucasian mother, no relevant Caucasian mother, no relevant PMH PMH

Initial investigationsInitial investigations

Hb 10.6Hb 10.6 WBC 8.0WBC 8.0 Pl 316Pl 316 Bili 6Bili 6 AST 384AST 384 ALT 283ALT 283 ALP 362ALP 362 CRP <7CRP <7

No organisms No organisms identifiedidentified

CXR:CXR: hyperinflation hyperinflationdiffuse diffuse interstitial interstitial changes ? Viralchanges ? Viral

Abd US:Abd US:liver and spleen liver and spleen enlarged, normal enlarged, normal texturetexture

ProgressProgress

Increasing oxygen requirementIncreasing oxygen requirementMax 3 litresMax 3 litres

Improved with antibioticsImproved with antibioticsHome after 4 daysHome after 4 daysReadmitted 8 days laterReadmitted 8 days laterPale, lethargic, breathlessPale, lethargic, breathlessVentilatedVentilated

Further investigationsFurther investigations

WBC 5.5WBC 5.5 IgG 8.89IgG 8.89 Lymph 2.11Lymph 2.11 IgA 2.03IgA 2.03 CD3 1.22CD3 1.22 IgM 2.45IgM 2.45 CD4 0.80CD4 0.80 CD8 0.40CD8 0.40 CD19 0.38CD19 0.38 CD56 0.21CD56 0.21 Poor lymphocyte Poor lymphocyte proliferationproliferation

Normal:Normal: Sweat test Sweat test Urine and Urine and plasma amino plasma amino acids acids

Organic Organic acidsacids

Pneumocystis from BALHIV antibody and RNA positive

AIDS defining conditionsAIDS defining conditions

PneumocystisPneumocystis CMV pneumonitisCMV pneumonitis TBTB

HIV HIV encephalopathy/encephalopathy/

Meningitis/Meningitis/encephalitisencephalitis

Kaposi sarcomaKaposi sarcoma LymphomaLymphoma

Wasting syndromeWasting syndrome Persistent Persistent cryptosporidiosicryptosporidiosiss

CMV retinitisCMV retinitis Recurrent Recurrent bacterial bacterial infectioninfection

PUOPUO

Barriers to diagnosisBarriers to diagnosis

UncommonUncommonMay not present with May not present with opportunistic infectionopportunistic infection

CD4 count often in “adult” CD4 count often in “adult” normal rangenormal range

CD4:CD8 ratio can be normalCD4:CD8 ratio can be normalIssues around testingIssues around testing

Who needs to think Who needs to think about HIV?about HIV?

ENT surgeonENT surgeon

Chronic Chronic parotitisparotitis

Severe Severe chronic/recurrent chronic/recurrent otitis mediaotitis media

DentistDentist

Oral candidiasisOral candidiasis Poor dental Poor dental hygienehygiene

RespiratoryRespiratory

Lymphocytic interstitial Lymphocytic interstitial pneumonitispneumonitis

Recurrent pneumoniaRecurrent pneumoniaBronchiectasisBronchiectasis

NeurologistNeurologist

Unexplained Unexplained encephalopathy/encephalitisencephalopathy/encephalitis

Developmental delayDevelopmental delayChildhood strokeChildhood stroke

DermatologistDermatologist

Severe Severe dermatitisdermatitis

Fungal infectionFungal infection

Extensive Extensive molluscummolluscum

Extensive wartsExtensive warts

GastroenterologistGastroenterologist

Chronic Chronic diarrhoea and diarrhoea and wastingwasting

Unexplained Unexplained hepatosplenomegahepatosplenomegalyly

Haemato-oncologistHaemato-oncologist

LymphomaLymphoma ThrombocytopoeniThrombocytopoenia/a/neutropoenia/neutropoenia/lymphopoenialymphopoenia

OphthalmologistOphthalmologist

Unexplained retinopathyUnexplained retinopathy

General paediatricianGeneral paediatrician

Developmental delayDevelopmental delayFailure to thriveFailure to thrivePersistent generalised Persistent generalised lymphadenopathylymphadenopathy

Recurrent respiratory infectionRecurrent respiratory infectionRecurrent bacterial infectionRecurrent bacterial infectionMuco-cutaneous candidiasisMuco-cutaneous candidiasisRecurrent herpes zosterRecurrent herpes zosterSevere varicellaSevere varicella

GPGP

Developmental delayDevelopmental delay Failure to thriveFailure to thrive Persistent generalised Persistent generalised lymphadenopathylymphadenopathy

Recurrent respiratory infectionRecurrent respiratory infection Recurrent bacterial infectionRecurrent bacterial infection Muco-cutaneous candidiasisMuco-cutaneous candidiasis Recurrent herpes zosterRecurrent herpes zoster

The child may be completely The child may be completely well!well!

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Shared

Glasgow

Who should be Who should be thinking about HIV thinking about HIV

testing?testing?

Everybody!Everybody!