When to suspect HIV in children

1. When to suspect HIV in children A clinical perspective

2. 16 month old boy • Fever, increased work of breathing, poor feeding. • Normal pregnancy – LSCS at term • Breast fed • 2/12: facial swelling • 11/12: severe chicken pox • No developmental progress after age 1 year.

3. Family history • Parents from Zimbabwe • Mum nurse – in UK for 8 years • Dad student – in UK for 3 years • Mum reported negative HIV test 3 years ago

4. HIV disease • Pneumocystis pneumonia • CMV pneumonitis • CMV retinitis • CMV/HIV encephalopathy

5. Marrow failure Ganciclovir Zidovudine Cotrimoxazole Pseudomonas sepsis Renal failure Ganciclovir Foscarnet Aminoglycosides Sequelae

6. Where are we now? • HIV undetectable • Immune reconstitution • Normal respiratory function • Marrow recovered • Neurodevelopmental progress but delayed BUT • Chronic renal failureon dialysis

7. Girl aged 4 months, 29 days • Persistent cough, 2-3 months • 3 courses antibiotics • Pale, lethargic • Feeding normally • Normal pregnancy, delivery • Caucasian mother, no relevant PMH

8. Hb 10.6 WBC 8.0 Pl 316 Bili 6 AST 384 ALT 283 ALP 362 CRP <7No organisms identified CXR: hyperinflationdiffuse interstitial changes ? Viral Abd US:liver and spleen enlarged, normal texture Initial investigations

9. Progress • Increasing oxygen requirement • Max 3 litres • Improved with antibiotics • Home after 4 days • Readmitted 8 days later • Pale, lethargic, breathless • Ventilated

10. WBC 5.5 IgG 8.89 Lymph 2.11 IgA 2.03 CD3 1.22 IgM 2.45 CD4 0.80 CD8 0.40 CD19 0.38 CD56 0.21 Poor lymphocyte proliferation Normal: Sweat test Urine and plasma amino acids Organic acids Further investigations Pneumocystis from BAL HIV antibody and RNA positive

11. Pneumocystis CMV pneumonitis TB HIV encephalopathy/ Meningitis/encephalitis Kaposi sarcoma Lymphoma Wasting syndrome Persistent cryptosporidiosis CMV retinitis Recurrent bacterial infection PUO AIDS defining conditions

12. Barriers to diagnosis • Uncommon • May not present with opportunistic infection • CD4 count often in “adult” normal range • CD4:CD8 ratio can be normal • Issues around testing

13. Who needs to think about HIV?

14. Chronic parotitis Severe chronic/recurrent otitis media ENT surgeon

15. Oral candidiasis Poor dental hygiene Dentist

16. Respiratory • Lymphocytic interstitial pneumonitis • Recurrent pneumonia • Bronchiectasis

17. Neurologist • Unexplained encephalopathy/encephalitis • Developmental delay • Childhood stroke

18. Severe dermatitis Fungal infection Extensive molluscum Extensive warts Dermatologist

19. Chronic diarrhoea and wasting Unexplained hepatosplenomegaly Gastroenterologist

20. Lymphoma Thrombocytopoenia/neutropoenia/lymphopoenia Haemato-oncologist

21. Ophthalmologist • Unexplained retinopathy

22. General paediatrician • Developmental delay • Failure to thrive • Persistent generalised lymphadenopathy • Recurrent respiratory infection • Recurrent bacterial infection • Muco-cutaneous candidiasis • Recurrent herpes zoster • Severe varicella

23. GP • Developmental delay • Failure to thrive • Persistent generalised lymphadenopathy • Recurrent respiratory infection • Recurrent bacterial infection • Muco-cutaneous candidiasis • Recurrent herpes zoster

24. The child may be completely well!

26. Who should be thinking about HIV testing?

27. Everybody!