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Prof ML Siddaraju Dept of Pediatrics Bangalore Medical College

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.

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Prof ML Siddaraju Dept of Pediatrics Bangalore Medical College

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  1. Opportunistic Infections Prof ML Siddaraju Dept of Pediatrics Bangalore Medical College

  2. 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.

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  4. 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

  5. CARDINAL FINDINGSAny One Pneumocystic Carnii Pneumonia. Lymphocytic Interstitial Pneumonia. Esophageal Candidiasis Persistent diarrhea.

  6. CHARACTERISTIC FINDINGSAny 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

  7. ASSOCIATED FINDINGSAny Three Oral Thrush Fever –intermittent or continuous for > 1 month Generalized Lymphadenopathy. Generalized Dermatitis.

  8. 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.

  9. DIARRHOEALevel – 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 co-trimaxazole /nalidixic acid. Patient should be daily evaluated for evidence of dehydration and other signs of improvement A: disappearanceof fever . B: decreased frequency of stools . C:increased appetite. D:wt gain . 20 gm /day for >2 days .

  10. 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.

  11. 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.

  12. Level C Stool culture Blood culture Endoscopy Are done to pinpoint exact etiopathogenesis and treated accordingly.

  13. 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.

  14. 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,.

  15. 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.

  16. Respiratory Infections • Respiratory infections are classified as per WHO/CSSM criteria • Pneumonia: RR >60/min >50/min >40/min <2mo 2mo-12mo 1yr-5yr • Severe pneumonia: 1+ lower chest indrawing or nasal flaring • Very severe pneumonia: 2+ cyanosis, inability to feed, convulsions, lethargy, unconsciousness, head nodding.

  17. Respiratory Infections • Presumptive treatment is started with cotirmoxazole in all cases of ALRI • Improvement in 3 days = bacterial inf. • No improvement • Tuberculosis • PCP • LIP • Fungal pneumonia • Viral pneumonia

  18. Respiratory Infections • Condition CD4 count • M. tuberculosis <400 • Bacterial pneumonia <250 • PCP <200 • MAC <100 • Suppurative lung disease <100 • CMV <100

  19. Mycobacterium Tuberculosis • Most common OI in our country • Extra pulmonary forms more common • Lymphadenopathy ( even in resp tract) • Miliary disease • CNS • Bone marrow • Genito urinary

  20. 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

  21. Mycobacterium Tuberculosis Treatment: • 4 drugs – 2 months • 2 drugs – 4months • Longer duration for miliary, bone/joint and CNS TB. • MDRTB more common with HIV

  22. 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

  23. 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

  24. Neurological Manifestations • Due to • Usual neuroinfections • Opportunistic infections • HIV encephalopathy • Usual infections: ABM, TBM, Cerebral malaria. • Opportunistic: cryptococcosis, toxoplasma, CMV

  25. 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.

  26. 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

  27. Cryptococcal Meningitis • Amphotericin B 0.5-1mg/kg/Q 6 H • Suppressive therapy like fluconazole 100mg/day

  28. 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

  29. CMV infection • Ganciclovir: 5 mg/kg/12hrsly 21 days • Maintenance: 5 mg/kg indefinitely

  30. Case 1 • Pravin • 8 months • 3.5 kg • Failure to thrive • Unable to sit • Reccurent fever • HSM • Harsh breathing

  31. Case 1 • CXR: patchy pneumonia\ • USG: focal necrosis in liver and spleen, free fluid • HIV +ve by ELISA 1 month back

  32. 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)

  33. Case 1 • FTT/unable to sit: • HIV disease itself • HIV encephalopathy • Repeated infections • FTT • Further Ix: CXr, Mx, Blood coutns, culteres • Rx: ATT, SMP-TMX, IV antibiotics

  34. 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

  35. 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

  36. Case 2 • Diet: • Hydration • Antimicrobial based on organism • Counseling parents regarding HIV status • No pcp px needed as CD4 is >500.

  37. Case 3 • 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

  38. 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

  39. Case 4 • 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

  40. Case 4 • 3yrs – 10 kgs • Past Hx – pneumonia • Source of inf: transfusion • CD4 = no immunosuppression • D/D: • Tuberculoma • Toxoplasmosis • Cryptococcosis • CNS lymphoma • CMV • HIV encephalopathy

  41. Case 4 • CSF analysis to rule out ABM • Rx depends on etiology

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