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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

Opportunistic Infections

Prof ML Siddaraju

Dept of Pediatrics

Bangalore Medical College

introduction

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.

recognition of symptoms of hiv infection

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

CARDINAL FINDINGSAny One

Pneumocystic Carnii Pneumonia.

Lymphocytic Interstitial Pneumonia.

Esophageal Candidiasis

Persistent diarrhea.

characteristic findings any two

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

associated findings any three

ASSOCIATED FINDINGSAny Three

Oral Thrush

Fever –intermittent or continuous for

> 1 month

Generalized Lymphadenopathy.

Generalized Dermatitis.

epidemiological risk factors

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

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 .

diarrhoea level a1

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

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

Level C

Stool culture

Blood culture

Endoscopy

Are done to pinpoint exact etiopathogenesis and treated accordingly.

persistent diarrhoea

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

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

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
  • 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.
respiratory infections1
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
respiratory infections2
Respiratory Infections
  • Condition CD4 count
  • M. tuberculosis <400
  • Bacterial pneumonia <250
  • PCP <200
  • MAC <100
  • Suppurative lung disease <100
  • CMV <100
mycobacterium tuberculosis
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
mycobacterium tuberculosis1
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 tuberculosis2
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
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 thrush1
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
Neurological Manifestations
  • Due to
    • Usual neuroinfections
    • Opportunistic infections
    • HIV encephalopathy
  • Usual infections: ABM, TBM, Cerebral malaria.
  • Opportunistic: cryptococcosis, toxoplasma, CMV
neurological manifestations1
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 manifestations2
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
Cryptococcal Meningitis
  • Amphotericin B 0.5-1mg/kg/Q 6 H
  • Suppressive therapy like fluconazole 100mg/day
toxoplasmosis
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
CMV infection
  • Ganciclovir: 5 mg/kg/12hrsly 21 days
  • Maintenance: 5 mg/kg indefinitely
case 1
Case 1
  • Pravin
  • 8 months
  • 3.5 kg
  • Failure to thrive
  • Unable to sit
  • Reccurent fever
  • HSM
  • Harsh breathing
case 11
Case 1
  • CXR: patchy pneumonia\
  • USG: focal necrosis in liver and spleen, free fluid
  • HIV +ve by ELISA 1 month back
case 12
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 13
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
case 2
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 21
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 22
Case 2
  • Diet:
  • Hydration
  • Antimicrobial based on organism
  • Counseling parents regarding HIV status
  • No pcp px needed as CD4 is >500.
case 3
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
case 31
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
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
case 41
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
case 42
Case 4
  • CSF analysis to rule out ABM
  • Rx depends on etiology