1. Pediatric Case Presentation BOGNON TANGUY Care Unit Children Exposed or Infected by HIV/AIDS Military Teaching Hospital - Cotonou - BENIN

2. History of present illness Date of presentation: December 27 th 2002 5 and 1/2 months old girl (born july 10 th 2002) Presented with: –Impaired development, anormal behaviors –Cutaneous lesions –Anorexia No cough, no fever Benn unwell since 2 months old

3. Past Medical History Mother 42 years, HIV +ve, seeking children since 15 years Received NVP for PMTCT Birth weigh: 2040 g Baby admitted more than 10 times for various medical conditions and has been given: Nystatine, Cotrimaxozole, Amoxicillin, Vitamins, First child Father HIV status not known

4. Physical examination at entry Weigh: 2220g; height: 57 cm; CP: 34 cm; BP: 5.7 cm Very sick looking Oral and cutaneous thrush Encephalopathy Bilateral keratitis and dry eye (seen by ophtalmologist) PGL and hepatomegaly CBC: HB=5.7 g/dl CXR normal, No LP, EEG and RMI

5. Diagnosis 5 ½ month baby with perinatal HIV infection IO: esophageal candidiasis, Anemia Encephalopathy Severely immunocompromised - CD4<15% Stage 4 WHO, Stage C CDC classification

6. Child management 1 st week Medications –Cotrimoxazole high dose 15 days followed by prophylaxis –Fluconazole 14 days, consolidation nystatine 2 months –Ocular topics (antibiotics and others) for 3 weeks Enteral nutrition by nasogastric sonde(tube) for 10 days Blood transfusion: 2 times during the first week

7. Child Management cont’d 2 nd Week (6 months old) CD4: 799 ; 12% Hb: 8 g/dl Started HAART: D4T+3TC+NFV –Giving during first day by nasogastric tube –Well tolerated Medications: iron, folates, Nutritional assistance: advice, nutritional supplements, polyvitamins Appointment for Psychosocial care

8. Follow up 1 month 3 weeks ART - 7 months old No thrush, better looking Oral nutrition was perfect Weight: 2550 g Neurological examination –Encephalopathy slightly improved Beginning of functional reeducation Exit with follow up visit plan –Every week for 2 weeks –Every 2 weeks for a month –Visit at 6 months, and every 3 months

9. Follow up 7 months 6 months ART - 1 years old Better looking Weight: 4750 g Height: 72 cm; CP: 42 cm; BP: 12.5 cm Neurologic examination: better, able to pursue vision, hold head, normal tone of arms and legs CD4: 19% (985), Hb: 10.2 g/dl RX: change D4T to AZT (stock rupture) Medications are adapted to weight

10. Follow up 1 year and later 18 months Improvement of psychomotor development: –Can Walk Weight: 11 kg seen 13/06/05 (3 years, 2yrs and half of ART) Weight: 15 kg Cd4: 1795 (26%) Hb: 12 g/dl

11. The well being January 3rd, 2005 –Weight 16,3 kg –Excellent conditions –Good adherence –Lab test for ART long-term toxicity was ok –Entered school: Kindergarten Good mark for the first quarter Last seen -Weight 26 kgs, Height 134cm -HB 12g/dl, CD4 654(30%), VL 2442 Schooling; 3 rd level at primary school

12. About the mother Psychosocial care from the beginning Appointment with adult physician when baby has 6 months follow up –CD4: 280 –Cotrimoxazole Started HAART one year ago Father still not coming Mothers concerns: –school, disclosing status to teacher, and fertility, …. Last seen October 2008:going well on HAART

13. What do we learn We can do some things for babies infected from mothers –Improvement of follow up after birth –In an area viral load or PCR DNA not available: CD4 when available is useful when symptoms appear This baby’s care involved –Pediatrician, ophthalmologist, psychologist and social worker, and kinesitherapist

14. Questions about this case Even though, successful case Compliance with school Long term ART toxicity ……

15. Thanks for attention