Presentation on theme: "STAGING OF HIV INFECTION, COMMON AND OPPORTUNISTIC INFECTIONS"— Presentation transcript:
1 STAGING OF HIV INFECTION, COMMON AND OPPORTUNISTIC INFECTIONS
2 Key QuestionsWhy 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 ARTProvides a guide to prognosis and interventions needed at the different stagesProvides guidance in monitoring response to therapy (treatment failure or improvement).
4 How do we stage? Clinical staging: Immunological staging WHO staging-commonly usedImmunological stagingCD4 count
5 How many clinical stages are in the WHO clinical staging criteria? ClassificationWHO clinical stageAsymptomatic1Mild2Advanced3Severe4
6 Immunological Staging Differences in CD4 counts between adults and childrenAbsolute CD4 count varies with ageAbsolute CD4 count is higher in healthy children than in adults.Cut-off CD4 counts CHANGE with agein children < 5 years; CD4 percentage more constant
7 CD4% does NOT change with age. CD4 Pattern in Young ChildrenCD4 counts are high in healthy young children.Decline to adult levels by 6 yrs.CD4% does NOT change with age.
8 WHO Immunological Staging Classification of HIV associated immune deficiencyAge-related CD4 values≤11 months (%)12-35 months (%)36-59 months (%)≥5 yrs (cells/mm3)Not Significant>35>30>25>500Mild30-3525-3020 -25Advanced20-2515-20Severe<25<20<15<200 or <15%
10 No HIV related symptoms reported and no signs on examination. WHO STAGE 1AsymptomaticClinical diagnosisNo HIV related symptoms reported and no signs on examination.
11 Persistent generalized lymphadenopathy (PGL) WHO STAGE 1Persistent generalized lymphadenopathy (PGL)Clinical signs and symptomsSwollen or enlarged lymph nodes >1 cm at two or more non-contiguous sites, without known cause
13 WHO clinical stage 3Moderate Unexplained malnutrition not adequately responding to standard therapyUnexplained persistent diarrhea (14 days or more)Unexplained persistent fever (>37.5OC, intermittent or constant >1 mo)Persistent oral candidiasis (after 6 weeks of life)Oral hairy leukoplakiaAcute necrotizing ulcerative gingivitis/periodontisLymph node TBPulmonary tuberculosisSevere recurrent bacterial pneumoniaSymptomatic Lymphoid interstitial pneumonitis (LIP)Chronic HIV-associated lung disease including bronchiectasisUnexplained anemia (<8 gm/dL), neutropenia (<1,000/mm3 ), or chronic thrombocytopenia (<50,000/mm3) for >1 month.
14 Unexplained persistent Fever WHO clinical Stage 3Unexplained Persistent Diarrhea: Unexplained persistent (14 days or more) diarrhea(loose or watery stool, three or more times daily) not responding to standard treatmentUnexplained persistent FeverReports of fever or night sweats for longer than one month.Intermittent or constantReported lack of response to antibiotics or antimalarials.No other obvious foci of disease reported or found onexamination.Malaria must be excluded
15 In older children, productive cough and haemoptysis as well. WHO clinical Stage 3Severe 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 TBNon-specific symptoms, e.g. chronic cough, fever, night sweats, anorexia and weight loss.In older children, productive cough and haemoptysis aswell.Abnormal CXR.
16 WHO clinical stage 4Unexplained severe wasting, or severe malnutrition not adequately responding to standard therapyPneumocystis pneumonia (PCP).Recurrent severe presumed bacterial infection e.g. empyema, pyomyositis, bone/joint infections, meningitis, but excluding pneumoniaChronic herpes simplex infectionExtrapulmonary tuberculosisKaposi’s SarcomaEsophageal candidiasis (Candida of trachea, bronchi or lungs)CNS toxoplasmosisHIV encephalopathyCMV infection, retinitis or infection affecting other organsExtrapulmonary cryptococcosis, including meningitis
17 WHO clinical stage 4Disseminated endemic mycosis (extra pulmonary histoplasmosis, coccidiomycosis, pennicilliosisChronic cryptosporidiosisChronic IsosporiasisDisseminated non-tuberculous mycobacteria infectionCerebral or B-cell non-non-Hodgkin's lymphomaProgressive multifocal leukoencephalopathyHIV associated cardiomyopathy and nephropathy
18 Recurrent severe bacterial infection WHO clinical Stage 4Recurrent severe bacterial infectionTypes of recurrent severebacterial infectionsEmpyemaPyomyositisBone or Joint infectionMeningitisExcluding PneumoniaSigns and SymptomsFever accompanied by specific symptoms or signs that localizeinfection.Current episode plus one or more in previous six monthsTreatmentAntibiotic treatmentWhen there pus- Do I&D
19 Photo courtesy of Dr Israel Kalyesubula 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 WHO clinical Stage 4Pneumocystis PneumoniaCaused by Pneumocystis Jiroveci (fungus)Major cause of mortality and morbidity in HIV infected childrenClinical presentation:Usually less than 1 yearCoughFast breathingDifficulty in breathingLow grade fever or afebrileHypoxemia (paO2 < 90%)
21 Management Supportive IV Cotrimoxazole Oxygen/ventilatory support WHO clinical Stage 4ManagementSupportiveOxygen/ventilatory supportMaintain and monitor hydrationNutritional supportContinue therapy for bacterial pneumoniaIV CotrimoxazoleTrimethoprim (TMP): mg/kg/day6-8 hourlySulphamethoxazole (SMX): mgOral CotrimoxazoleTMP: 20 mg/kg/day 6-8 hourlySMX: 100mgORIV Pentamidine 4mg/kg/day ODDapsone 2mg/kg/ODCourse: 2-3 weeksAdd prednisone 2 mg/kg for 7-14 days in severely ill children2121
22 PCP Prophylaxis Who Should Receive Prophylaxis? All HIV exposed and HIV infected infants should receive cotrimoxazole prophylaxis from 6 weeks of ageDose: 10 mg/kg daily or Dapsone 2mg/kg daily2222
23 Esophageal Candidiasis WHO clinical Stage 4Esophageal CandidiasisCauses painful swallowingResults in inadequate oral intake with consequences of:Dehydration, malnutrition and deathTreatment:Local treatments (Nystatin, GV)Fluconazole 3-6 mg/kg/OD for 2-3 wks.Ketoconazole 5-10mg/kg/in 1or 2 divided dose2323
24 Cryptococcal Meningitis WHO clinical Stage 4Cryptococcal MeningitisLess common in children than adultsusually sub acute, fever with increasing severe headache.meningism, confusion, behavioral changes.SeizuresDiagnosisDo LP and Indian ink stain of CSFCryptococcal antigen test on CSF.2424
25 Cryptococcal Meningitis WHO clinical Stage 4Cryptococcal MeningitisTreatmentInitial treatmentAmphotericin B 0.7-1mg/kg for 14 days then Fluconazole 3-6mg/kg OD X 8 weeksMay need to do therapeutic LP’s to relieve headacheMaintenance treatment (secondary prophylaxis)Fluconazole 3 mg/kg OD for life2525
26 Toxoplasmosis Hepatosplenomegaly Fever Chorioretinitis Seizures WHO clinical Stage 4ToxoplasmosisCongenital ToxoplasmosisHepatosplenomegalyFeverChorioretinitisSeizuresPeriventricular calcificationsHypodense lesions with ring enhancementPresents in 2 formsCongenital Toxoplasmosis- Diffuse diseaseAcquired CNS Toxoplasmosis2626
27 CNS Toxoplasmosis Diagnosis Toxoplasma antibodies (IgM) WHO clinical Stage 4CNS ToxoplasmosisDiagnosisToxoplasma antibodies (IgM)CNS Imaging (Ring enhancing lesions on MRI)Response to empiric treatment most practical means of making a diagnosisFeverHeadache,Focal neurological signsConvulsions.2727
28 Toxoplasmosis WHO clinical Stage 4 Cranial CT showing ring-enhancing lesion in the brain2828
29 Toxoplasmosis - Treatment WHO clinical Stage 4CNS Toxoplasmosis-TreatmentToxoplasmosis - TreatmentPreferred regimenPyrimethamine 2mg/Kg/day for 3 days maximum 25mg, then 1mg/kg/day for 6weeksSulphadiazine mg/kg/dose QID for 6 weeksPlusFolinic acid 5-20 mg 3 times weeklyAlternative regimensCotrimoxazole (15-20mg/kg Trimethoprim plus 100mg Sulfamethoxazole) IV or Oral BDClindamycin (5 – 7mg/kg QID orally) plus Pyrimethamine and Folinic acidProphylaxis –Cotrimoxazole prophylaxis
30 Cryptosporidiosis and Isosporiasis WHO clinical Stage 4Cryptosporidiosis and IsosporiasisUsually present with chronic diarrhoea in advanced HIV infectionDiagnosis is by stool analysis: modified ZN staining, PCRTreatment: Paromomycin, CotrimoxazolePrevention: Cotrimoxazole
32 Recurrent Broncho Pneumonia Case 1A 3 year old HIV infected girl presents with a 1 week’s history ofcough. For the last 2 days she has had a high grade fever anddifficulty in breathing. On examination temperature is 38.4degrees C, the respiratory rate is 60bpm, She looks very sick. Thechest has bilateral coarse crepitations. This is her 2nd episode ofthis illness in 6 monthsQn 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?Recurrent Broncho PneumoniaStage 3Admit, Parenteral Antibiotics, Start ARV’s as soon as possible.
33 Pneumocystis Jiroveci Pneumonia Case 2Opio, a 9 month old baby with sudden onset of cough anddifficulty in breathing. On examination, temperature 37.5degrees C,Respiratory rate 90 bpm, chest in-drawing andthe 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?Pneumocystis Jiroveci PneumoniaStage 4Admit, 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?Herpes simplex, Stage 2Acyclovir cream, analgesia, add antibiotics if there is bacterial infectionPhotograph courtesy of Dr Israel Kalyesubula
35 Case 4: Question 1: What is the diagnosis? Question 2: Kaposi sarcoma How would you confirm the diagnosis?Question 3: What clinical stage is this child in?Kaposi sarcomaBiopsyStage 4Photograph courtesy of Dr Israel Kalyesubula
36 Nystatin, Ketoconazole Case 5Question 1: What is the diagnosis?Question 2: In what clinical stage is this child?Question 3: What is the treatment of this condition?Oral CandidiasisStage 3Nystatin, KetoconazolePhotograph courtesy of Dr Israel Kalyesubula
37 Serum Toxo titers, Brain CT scan Case 6Racheal, an HIV infected 16 year old girl presents withseizures and weakness of the right side of the body. HerCD4 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?ToxoplasmosisSerum Toxo titers, Brain CT scanStage 4
38 Case 7Namubiru, 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 4Serum Crag, Lumbar Puncture, CSF Indian stainAdmit, 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 serologyCryptosporidium parvum, isospora belli
40 Lymphoid Interstitial Pneumonitis (LIP) Case 9Waiswa, 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?Lymphoid Interstitial Pneumonitis (LIP)Stage 3Antibiotics, ARVs
41 Case 10Amoding, 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 11A 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 heWhat is the clinical stage?How would you treat this child?Stage 4Ketocanazole, 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?Herpes ZosterStage 2Photograph courtesy of Dr Israel KalyesubulaAcyclovir
44 Acknowledge Dr Israel Kalyesubula for all the photographs.