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STAGING OF HIV INFECTION, COMMON AND OPPORTUNISTIC INFECTIONS.

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Presentation on theme: "STAGING OF HIV INFECTION, COMMON AND OPPORTUNISTIC INFECTIONS."— Presentation transcript:

1 STAGING OF HIV INFECTION, COMMON AND OPPORTUNISTIC INFECTIONS

2 Key Questions 2 Why do we need to do Staging of HIV in infected children? What are the different methods of staging? What are the common opportunistic infections in HIV infected children and how do you treat them? What tool can I use to easily identify, stage and treat OI’s in HIV infected children?

3 Why do we do Staging? Provides a guide to the timing of initiation of ART Provides a guide to prognosis and interventions needed at the different stages Provides guidance in monitoring response to therapy (treatment failure or improvement).

4 How do we stage? Clinical staging: o WHO staging-commonly used  Immunological staging o CD4 count

5 How many clinical stages are in the WHO clinical staging criteria? ClassificationWHO clinical stage Asymptomatic1 Mild2 Advanced3 Severe4

6 Immunological Staging Differences in CD4 counts between adults and children – Absolute CD4 count varies with age – Absolute CD4 count is higher in healthy children than in adults.  Cut-off CD4 counts CHANGE with age in children < 5 years; CD4 percentage more constant

7 7 CD4% does NOT change with age. CD4 Pattern in Young Children CD4 counts are high in healthy young children. Decline to adult levels by 6 yrs.

8 WHO Immunological Staging Classification of HIV associated immune deficiency Age-related CD4 values ≤11 months (%) months (%) months (%) ≥5 yrs (cells/mm 3 ) Not Significant>35>30>25>500 Mild Advanced Severe<25<20<15<200 or <15% 8

9 WHO Clinical Staging Stage 1 Asymptomatic Persistent generalised lymphadenopathy (PGL) 9

10 WHO STAGE 1 Clinical diagnosis No HIV related symptoms reported and no signs on examination. Asymptomatic

11 WHO STAGE 1 Clinical signs and symptoms Swollen or enlarged lymph nodes >1 cm at two or more non- contiguous sites, without known cause Persistent generalized lymphadenopathy (PGL)

12 WHO clinical stage 2 Unexplained persistent hepatosplenomegaly Papular pruritic eruptions Fungal nail infections Angular cheilitis Lineal gingival erythema Extensive wart virus infections Extensive molluscum contagiosum infection Unexplained persistent hepatosplenomegaly Papular pruritic eruptions Fungal nail infections Angular cheilitis Lineal gingival erythema Extensive wart virus infections Extensive molluscum contagiosum infection Recurrent oral ulcerations Unexplained bilateral parotid enlargement Herpes zoster Recurrent or chronic upper respiratory infection (URI): otitis media, otorrhea, sinusitis, tonsillitis Recurrent oral ulcerations Unexplained bilateral parotid enlargement Herpes zoster Recurrent or chronic upper respiratory infection (URI): otitis media, otorrhea, sinusitis, tonsillitis 12

13 WHO clinical stage 3 Moderate Unexplained malnutrition not adequately responding to standard therapy Unexplained persistent diarrhea (14 days or more) Unexplained persistent fever (>37.5 O C, intermittent or constant >1 mo) Persistent oral candidiasis (after 6 weeks of life) Oral hairy leukoplakia Acute necrotizing ulcerative gingivitis/periodontis Moderate Unexplained malnutrition not adequately responding to standard therapy Unexplained persistent diarrhea (14 days or more) Unexplained persistent fever (>37.5 O C, intermittent or constant >1 mo) Persistent oral candidiasis (after 6 weeks of life) Oral hairy leukoplakia Acute necrotizing ulcerative gingivitis/periodontis Lymph node TB Pulmonary tuberculosis Severe recurrent bacterial pneumonia Symptomatic Lymphoid interstitial pneumonitis (LIP) Chronic HIV-associated lung disease including bronchiectasis Unexplained anemia ( 1 month. Lymph node TB Pulmonary tuberculosis Severe recurrent bacterial pneumonia Symptomatic Lymphoid interstitial pneumonitis (LIP) Chronic HIV-associated lung disease including bronchiectasis Unexplained anemia ( 1 month. 13

14 Unexplained Persistent Diarrhea: Unexplained persistent (14 days or more) diarrhea(loose or watery stool, three or more times daily) not responding to standard treatment Unexplained persistent Fever Reports of fever or night sweats for longer than one month. Intermittent or constant Reported lack of response to antibiotics or antimalarials. No other obvious foci of disease reported or found on examination. Malaria must be excluded Unexplained persistent Fever Reports of fever or night sweats for longer than one month. Intermittent or constant Reported lack of response to antibiotics or antimalarials. No other obvious foci of disease reported or found on examination. Malaria must be excluded WHO clinical Stage 3

15 Severe recurrent bacterial pneumonia Cough with fast breathing, chest in drawing, nasal flaring, wheezing and grunting. Crackles or consolidation on auscultation. Responds to course of antibiotics. Current episode plus one or more in previous six months. Pulmonary TB Non-specific symptoms, e.g. chronic cough, fever, night sweats, anorexia and weight loss. In older children, productive cough and haemoptysis as well. Abnormal CXR. Pulmonary TB Non-specific symptoms, e.g. chronic cough, fever, night sweats, anorexia and weight loss. In older children, productive cough and haemoptysis as well. Abnormal CXR. WHO clinical Stage 3

16 WHO clinical stage 4 Unexplained severe wasting, or severe malnutrition not adequately responding to standard therapy Pneumocystis pneumonia (PCP). Recurrent severe presumed bacterial infection e.g. empyema, pyomyositis, bone/joint infections, meningitis, but excluding pneumonia Chronic herpes simplex infection Unexplained severe wasting, or severe malnutrition not adequately responding to standard therapy Pneumocystis pneumonia (PCP). Recurrent severe presumed bacterial infection e.g. empyema, pyomyositis, bone/joint infections, meningitis, but excluding pneumonia Chronic herpes simplex infection Extrapulmonary tuberculosis Kaposi’s Sarcoma Esophageal candidiasis (Candida of trachea, bronchi or lungs) CNS toxoplasmosis HIV encephalopathy CMV infection, retinitis or infection affecting other organs Extrapulmonary cryptococcosis, including meningitis Extrapulmonary tuberculosis Kaposi’s Sarcoma Esophageal candidiasis (Candida of trachea, bronchi or lungs) CNS toxoplasmosis HIV encephalopathy CMV infection, retinitis or infection affecting other organs Extrapulmonary cryptococcosis, including meningitis 16

17 WHO clinical stage 4 Disseminated endemic mycosis (extra pulmonary histoplasmosis, coccidiomycosis, pennicilliosis Chronic cryptosporidiosis Chronic Isosporiasis Disseminated non- tuberculous mycobacteria infection Disseminated endemic mycosis (extra pulmonary histoplasmosis, coccidiomycosis, pennicilliosis Chronic cryptosporidiosis Chronic Isosporiasis Disseminated non- tuberculous mycobacteria infection Cerebral or B-cell non- non-Hodgkin's lymphoma Progressive multifocal leukoencephalopathy HIV associated cardiomyopathy and nephropathy Cerebral or B-cell non- non-Hodgkin's lymphoma Progressive multifocal leukoencephalopathy HIV associated cardiomyopathy and nephropathy 17

18 Types of recurrent severe bacterial infections Empyema Pyomyositis Bone or Joint infection Meningitis Excluding Pneumonia Signs and Symptoms Fever accompanied by specific symptoms or signs that localize infection. Current episode plus one or more in previous six months WHO clinical Stage 4 Recurrent severe bacterial infection Treatment Antibiotic treatment When there pus- Do I&D

19 NN is a one year old girl with multiple swellings one week prior to coming to hospital. The one on the buttock burst on the third admission day spontaneously and drained green offensive pus. Green debrie can be seen in both incised abscesses. Photo courtesy of Dr Israel Kalyesubula

20 Pneumocystis Pneumonia Caused by Pneumocystis Jiroveci (fungus) Major cause of mortality and morbidity in HIV infected children Clinical presentation: Usually less than 1 year Cough Fast breathing Difficulty in breathing Low grade fever or afebrile Hypoxemia (paO 2 < 90%) WHO clinical Stage 4

21 Management Supportive – Oxygen/ventilatory support – Maintain and monitor hydration – Nutritional support – Continue therapy for bacterial pneumonia IV Cotrimoxazole Trimethoprim (TMP): mg/kg/day 6-8 hourly Sulphamethoxazole (SMX): mg Oral Cotrimoxazole TMP: 20 mg/kg/day 6-8 hourly SMX: 100mg OR 1.IV Pentamidine 4mg/kg/day OD 2.Dapsone 2mg/kg/OD Course: 2-3 weeks Add prednisone 2 mg/kg for 7-14 days in severely ill children 21 WHO clinical Stage 4

22 PCP Prophylaxis Who Should Receive Prophylaxis? 22 All HIV exposed and HIV infected infants should receive cotrimoxazole prophylaxis from 6 weeks of age Dose: 10 mg/kg daily or Dapsone 2mg/kg daily

23 Esophageal Candidiasis Causes painful swallowing Results in inadequate oral intake with consequences of: – Dehydration, malnutrition and death Treatment: – Local treatments (Nystatin, GV) – Fluconazole 3-6 mg/kg/OD for 2-3 wks. – Ketoconazole 5-10mg/kg/in 1or 2 divided dose 23 WHO clinical Stage 4

24 Cryptococcal Meningitis Less common in children than adults usually sub acute, fever with increasing severe headache. meningism, confusion, behavioral changes. Seizures 24 WHO clinical Stage 4 Diagnosis Do LP and Indian ink stain of CSF Cryptococcal antigen test on CSF.

25 Cryptococcal Meningitis Treatment Initial treatment Amphotericin B 0.7-1mg/kg for 14 days then Fluconazole 3-6mg/kg OD X 8 weeks May need to do therapeutic LP’s to relieve headache Maintenance treatment (secondary prophylaxis) Fluconazole 3 mg/kg OD for life 25 WHO clinical Stage 4

26 Toxoplasmosis Presents in 2 forms Congenital Toxoplasmosis- Diffuse disease Acquired CNS Toxoplasmosis 26 WHO clinical Stage 4 Congenital Toxoplasmosis Hepatosplenomegaly Fever Chorioretinitis Seizures Periventricular calcifications Hypodense lesions with ring enhancement

27 CNS Toxoplasmosis Fever Headache, Focal neurological signs Convulsions. 27 WHO clinical Stage 4 Diagnosis Toxoplasma antibodies (IgM) CNS Imaging (Ring enhancing lesions on MRI) Response to empiric treatment most practical means of making a diagnosis

28 Toxoplasmosis 28 Cranial CT showing ring-enhancing lesion in the brain WHO clinical Stage 4

29 Toxoplasmosis - Treatment Preferred regimen Pyrimethamine 2mg/Kg/day for 3 days maximum 25mg, then 1mg/kg/day for 6weeks Sulphadiazine mg/kg/dose QID for 6 weeks Plus – Folinic acid 5-20 mg 3 times weekly Alternative regimens Cotrimoxazole (15-20mg/kg Trimethoprim plus 100mg Sulfamethoxazole) IV or Oral BD Clindamycin (5 – 7mg/kg QID orally) plus Pyrimethamine and Folinic acid CNS Toxoplasmosis-Treatment WHO clinical Stage 4 Prophylaxis –Cotrimoxazole prophylaxis

30 Cryptosporidiosis and Isosporiasis Usually present with chronic diarrhoea in advanced HIV infection Diagnosis is by stool analysis: modified ZN staining, PCR Treatment: Paromomycin, Cotrimoxazole Prevention: Cotrimoxazole WHO clinical Stage 4

31 Case Study Practice: Staging & Managing OIs 31

32 Case 1 A 3 year old HIV infected girl presents with a 1 week’s history of cough. For the last 2 days she has had a high grade fever and difficulty in breathing. On examination temperature is 38.4 degrees C, the respiratory rate is 60bpm, She looks very sick. The chest has bilateral coarse crepitations. This is her 2 nd episode of this illness in 6 months Qn 1: What is the possible diagnosis in this child? Qn 2: What WHO clinical stage is this? Qn 3: How would you treat this child? 32 Recurrent Broncho Pneumonia Stage 3 Admit, Parenteral Antibiotics, Start ARV’s as soon as possible.

33 Case 2 Opio, a 9 month old baby with sudden onset of cough and difficulty in breathing. On examination, temperature 37.5 degrees C,Respiratory rate 90 bpm, chest in-drawing and the chest is clear on auscultation. Question 1: What is the most likely diagnosis? Question 2: What is the WHO clinical stage? Question 3: What is the treatment of this condition? 33 Pneumocystis Jiroveci Pneumonia Stage 4 Admit, Oxygen, IV Septrin, Steroids, ARV’s as soon as possible

34 Case 3 Question 1: What is the diagnosis and WHO clinical stage? Question 2: What is the treatment of this condition? 34 Photograph courtesy of Dr Israel Kalyesubula Herpes simplex, Stage 2 Acyclovir cream, analgesia, add antibiotics if there is bacterial infection

35 Case 4: Question 1: What is the diagnosis? Question 2: How would you confirm the diagnosis? Question 3: What clinical stage is this child in? 35 Photograph courtesy of Dr Israel Kalyesubula Kaposi sarcoma Biopsy Stage 4

36 Case 5 Question 1: What is the diagnosis? Question 2: In what clinical stage is this child? Question 3: What is the treatment of this condition? 36 Photograph courtesy of Dr Israel Kalyesubula Oral Candidiasis Stage 3 Nystatin, Ketoconazole

37 Case 6 Racheal, an HIV infected 16 year old girl presents with seizures and weakness of the right side of the body. Her CD4 count is 86 cells/uL. Question 1: What would you suspect in this patient? Question 2: How would you investigate this patient? Question 3: What is the clinical stage? 37 Toxoplasmosis Serum Toxo titers, Brain CT scan Stage 4

38 Case 7 Namubiru, an 11 year old HIV infected girl who has never had any symptoms has CD4 count 60cells/uL. She presents today with 2 days history of severe headache and photophobia. Question 1: What is the likely diagnosis and WHO stage? Question 2: How would you diagnose this condition? Question 3: How would you treat this condition? Cryptococcal meningitis, Stage 4 Serum Crag, Lumbar Puncture, CSF Indian stain Admit, IV Amphotericin B, ARVs as soon as possible

39 Case 8 Okello, a 15 year old boy presents with a 3 week history of profuse diarrhea. Question 1: How would you investigate this patient? Question 2: What possible agents could cause this diarrhea? Modified ZN on stool, HIV serology Cryptosporidium parvum, isospora belli

40 Case 9 Waiswa, a 9 year old boy presents with a 2 year history of on and off cough. He has received 2 full courses of TB drugs. On examination he is in fair general condition, has bilateral parotid enlargement, digital clubbing and hepatosplenomegaly. – Question 1: What is the likely diagnosis? – Qn2: what is the WHO clinical stage? – Question 2: How would you manage this patient? 40 Lymphoid Interstitial Pneumonitis (LIP) Stage 3 Antibiotics, ARVs

41 Case 10 Amoding, a 6 year old HIV infected girl presents to the clinic with severe malnutrition non responding to standard therapy and persistent diarrhea. Question 3: In what clinical stage would you place this child? Why? Stage 4

42 Case 11 A 3year old boy is HIV positive and he is unable to walk on his own, can only say “mama” in his vocabulary. In addition he is suffering from oral thrush and recurrent fevers. In what WHO clinical stage is he What is the clinical stage? How would you treat this child? Stage 4 Ketocanazole, ARVs

43 Case 12 Question 1: What is the diagnosis? Question 2: What is WHO clinical Stage? Question 3: What is the treatment of this condition? 43 Photograph courtesy of Dr Israel Kalyesubula Herpes Zoster Stage 2 Acyclovir

44 Acknowledge Dr Israel Kalyesubula for all the photographs.


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