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close this bookNational Guidelines for the Clinical Management of HIV/AIDS - Tanzania (NACP; 2005; 131 pages)
View the documentLIST OF ABBREVIATIONS
View the documentACKNOWLEDGEMENTS
View the documentFOREWORD
Open this folder and view contentsCHAPTER 1: INTRODUCTION
Open this folder and view contentsCHAPTER 2: ORGANIZATION OF HIV/AIDS CARE AND TREATMENT
Open this folder and view contentsCHAPTER 3: HIV/AIDS PREVENTION
Open this folder and view contentsCHAPTER 4: PROTECTIVE MEASURES AGAINST HIV TRANSMISSION
Open this folder and view contentsCHAPTER 5: LABORATORY TESTS IN HIV/AIDS
Open this folder and view contentsCHAPTER 6: HIV/AIDS AND PREGNANCY
close this folderCHAPTER 7: PEDIATRIC HIV/AIDS AND RELATED CONDITIONS
View the document7.1 Introduction
View the document7.2 HIV/AIDS Manifestations in Children
View the document7.3 Diagnosis of HIV infection in infants
View the document7.4 Management of infants born to HIV positive women
View the document7.5Care of HIV infected Children
close this folder7.6 Clinical manifestations of paediatric HIV infection
View the document7.6.1 Respiratory conditions in children with HIV infection
View the document7.6.2 Oro-pharyngeal candidiasis in children with HIV infection
View the document7.6.3 Neurologic problems in children with HIV infection
View the document7.6.4 Persistent generalised lymphadenopathy (PGL) in children
View the document7.6.5 Chronic parotitis
View the document7.6.6 Chronic Ear Infection
View the document7.6.7 Persistent or recurrent fever in children
View the document7.6.8 Persistent Diarrhoea
View the document7.6.9 Impaired growth in children with HIV infection
View the document7.6.10 Supportive therapy
View the document7.6.11 Pain control in terminally ill children
Open this folder and view contentsCHAPTER 8: COMMUNITY AND HOME BASED CARE FOR PEOPLE LIVING WITH HIV/AIDS (PLHA)
Open this folder and view contentsCHAPTER 9: COUNSELLING RELATED TO HIV-TESTING AND TREATMENT ADHERENCE
Open this folder and view contentsCHAPTER 10: MANAGEMENT OF COMMON SYMPTOMS AND OPPORTUNISTIC INFECTIONS IN HIV/AIDS
Open this folder and view contentsCHAPTER 11: MANAGEMENT OF MENTAL HEALTH PROBLEMS IN HIV/AIDS
Open this folder and view contentsCHAPTER 12: MANAGEMENT OF HIV INFECTED PATIENTS USING ANTIRETROVIRAL DRUGS
Open this folder and view contentsCHAPTER 13: ARV THERAPY IN INFANTS AND CHILDREN
Open this folder and view contentsCHAPTER 14: USE OF ARVS IN SPECIAL CIRCUMSTANCES
Open this folder and view contentsCHAPTER 15: HIV/AIDS AND NUTRITION
Open this folder and view contentsCHAPTER 16: MANAGEMENT OF ANTIRETROVIRAL MEDICINES
Open this folder and view contentsCHAPTER 17: CERTIFICATION OF HEALTHCARE FACILITIES AS CARE AND TREATMENT SITES
 

7.6.1 Respiratory conditions in children with HIV infection

Lower respiratory tract infections (pneumonias) occur commonly in children with HIV infection and are the commonest cause of death in immuno-suppressed children. Lower respiratory tract infections may be:

7.6.1.1 Bacterial pneumonias

Caused by Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, and gram negative bacteria such as Klebsiella pneumoniae

Clinical Presentation

Children present with history of fever, cough and fast breathing (tachypnoea) with or without signs of severe pneumonia (chest in drawing, cyanosis & lethargy). On auscultation of the chest one hears unilateral or bilateral crepitations (crackles), decreased breath sounds or bronchial breathing (lobar pneumonia). When pulse oximetry is available it will demonstrate hypoxia (O2 saturation less than 95%)

Diagnosis

Where complete blood counts can be done a raised WBC with a neutrophilia suggests a bacterial pneumonia. In malaria endemic areas remember to do a malarial smear and treat for malaria if indicated. Where blood cultures can be done they may assist in identifying the causative agent

CXR is not necessary but may be useful in ruling out complications or other pulmonary conditions

If the patient is not improving after 1st line antibiotics sputum induction and nasopharyngeal aspirate may assist in the diagnosis of PCP or TB

Management

Outpatient:

Oral amoxycillin, or penicillin is adequate

Where the child is already on Cotrimoxazole prophylaxis CTX should not be used to treat pneumonia unless PCP is suspected. If PCP is suspected then high dose CTX should be used

If the child is under one year of age the risk of PCP is very high and should be considered

Give paracetamol for fever

Management of Severe Pneumonia:

Severe pneumonia should be managed in hospital

Supportive Care - a Pulse oximeter is critical for assessment of 02 saturation and need for supplemental oxygen where the child presents with chest in drawing, cyanosis, hypoxia

Ensure adequate hydration and monitor- IV or oral depending on the severity

Remember to give paracetamol for fever and pain

Specific therapy:

Use Chloramphenicol or Ceftriaxone/Cefotaxime (3rd generation) if available

Alternatives include of Ampicillin/Cloxacillin and Gentamicin

Remember antibiotic therapy for HIV infected children needs to be longer 7-14 days

Hospital management of Pneumonia

If the child is under one year PCP must be considered as a possible diagnosis and treatment with high dose cotrimoxazole and steriods prescribed

If an infant presents with severe pneumonia they should be treated for both bacterial pneumonia and PCP and investigated for possible HIV

Children treated for PCP should continue on PCP prophylaxis until the diagnosis of HIV exposure or infection has been excluded

If Staph pneumonia suspected add Cloxacillin or Vancomycin, skin lesions, CXR - pneumatoceles, positive blood culture, poor response to 1st line drugs, post measles

7.6.1.2 Lymphocytic Interstitial Pneumonitis

Clinical symptoms include cough, difficulty in breathing and terminally hypoxia, Associated parotitis, generalised L’adenopathy, and hepatosplenomegaly. Poor response to TB therapy

Radiological picture reveals Diffuse bilateral reticulonodular infiltrates may appear similar to miliary TB; May develop consolidation, cystic lesions; bilateral hilar or mediastinal lymph node enlargement; Particularly difficult to differentiate from TB

Management

Steroids are needed when children with LIP have significant respiratory distress

Prednisone 2 mg/kg/day - initially for 4 weeks daily and then an alternate day maintenance for 2-3 months and review.

Oxygen therapy during episodes of hypoxia

Bronchodilators like salbutamol where wheezing is a problem

Antibiotics are needed during episodes of concurrent superinfection with pneumonia

Chest physiotherapy and postural drainage if there is secondary bronchiectasis

Supportive care includes correction of anemia especially iron supplemenatation

Antiretroviral therapy is the specific therapy

Refer for specialist care if resistant to therapy.

7.6.1.3. Pneumocystis carinii Pneumonia (PCP)

Clinical features of PCP

Usually under 1 year of age

No fever or low grade

Marked resp distress (chest indrawing, cyanosis)

Auscultation: clear chest or diffuse fine crepitations

Poor response to standard antibiotic treatment

Pulse oximetry: severe persistent hypoxia (paO2 < 90%)

They may have other stigmata of HIV: splenomegaly, oral thrush, lymphadenopathy, weight loss

Investigations

Even where investigations are not available and there is a high index of suspicion therapy should be initiated promptly along with treatment for bacterial pneumonia

CXR - hyperinflation, diffuse infiltrates or normal

Sputum induction with nasopharyngeal aspirate

Sputum stained with Giemsa or Silver stain

Bronchoalveolar lavage where available can also be used to produce a specimen for staining

Management of PCP

Supportive:

Oxygen therapy

Maintain and monitor hydration

Paracetamol for pain

Continue therapy for bacterial pneumonia

Specific:

High dose Cotrimoxazole (CTX) I.V 20mg/kg TMP/day given every 6 hours for 21 days

Oral CTX may also be used if IV not available

Prednisone at 2mg/kg/day for 7-14 day (taper if > 7dys)

Remember to provide secondary prophylaxis using cotrimoxazole after an acute episode of PCP

7.6.1.4. TB in children

Diagnosis

Diagnosis of TB in children is difficult because of the non-specific clinical presentation and lack of sputum especially in the younger age group

HIV infected children are often exposed to adult with HIV & TB. A high index of suspicion must be maintained especially since many other chronic lung diseases may mask TB.

HIV infected children have lower sensitivity and specificity on diagnostic tests used for TB when compared to uninfected children

Extrapulmonary TB more common and must be considered in HIV infected children

Clinical Diagnosis

History of contact with an adult Tb in the family

History of fever & cough >1 month

Failure to thrive, weight loss or wasting

Associated extrapulmonary Tb: glands, meninges, abdomen

ESR is often elevated but it is not specific as HIV itself can cause an elevated ESR

Mantoux Test using PPD may be useful when positive (>5mm)

Prior BCG immunisation should not prevent the use of the TB skin test for assisting in the diagnosis of TB in children

CXR is sensitive but not specific

Multiple clinical scoring systems for childhood TB have been developed and can be used for the HIV infected child, but none of them are very sensitive. The WHO Scoring systems is shown as an example

WHO TB Clinical Scoring System

Impact of HIV infection on the Value of features commonly used by Clinical Scoring Systems (Graham et al)

Diagnostic Feature of PTB

Impact of HIV

Chronic symptoms > 1month

Less specific

Smear positive contact

Less specific

Malnutrition

Less specific

Positive Mantoux

Less sensitive

Characteristic CXR

Less specific

Response to treatment

Less sensitive

TB diagnosis (Others)

Chest X-ray findings are similar regardless of the HIV status of the child. The main findings include bilateral infiltrates with hilar adenopathy and or mediastinal widening. Others CXR findings include lobar opacity, pleural effusion, miliary TB and cavities which are rare in younger children.

Gastric aspirates X3 and/or induced Sputum for ZN stain should be done whenever possible.

Sensitivity may be increased to 40% when fluorescent stain (stain) and mycobacterial culture are done

Diagnosis

When appropriate, biopsy or fine needle lymph node aspirate may be diagnostic

Body fluids - ascitic, pleural or cerebrospinal - can also be sent for ZN stain and culture but the yield is poor. Bone marrow aspirate and culture may be diagnostic in disseminated TB with persistent fever and wasting.

Ultrasound can help differentiate loculated fluid and consolidation and a CT scan may assist in the diagnosis of abdominal, pulmonary and CNS disease

Treatment of TB in children

In treating children that are co-infected with HIV and TB, national guidelines should be used.

The dosing schedule is as shown below:

Rifampicin -

10-15 mg/kg

Isoniazid -

5-10 mg/kg

Pyrazinamide -

25-30mg/kg

Ethambutol -

12-18mg/kg

Streptomycin -

12-18mg/kg.

Adjuncts to Therapy:

Multivitamins: if malnourished give pyridoxine (B6)

High protein diet

Steroids (eg. Prednisolone 4mg/kg OD for six weeks) are recommended in Tuberclous Meningitis, endobronchial TB, miliary TB, massive pleural effusion and TB pericarditis

It is also important to be aware of the important drug/drug interactions such as that of Antiretrovirals - (NNRTIs & PI’s) with Rifampicin as well as drug toxicities. Most anti TB drugs are hepatotoxic as is NVP; INH, d4T, ddI may cause peripheral neuropathy; Pyrazinamide may cause increased uric acid and painful joints; Ethambutol may cause optic neuritis leading to colour blindness; Streptomycin may cause renal toxicity

TB prophylaxis - Indications

INH for 9 -12 months - 5mg/kg/day QD

This should be according to national guidelines, remembering that HIV infected children are vulnerable to develop progressive primary disease.

Higher risk

HIV infected child exposed to a Sputum positive adult in the household

Infant born to mother with TB

Other conditions which may affect the lungs in HIV infected children are cardiac conditions (e.g. cardiac failure due to cardiomyopathy,) as well as neoplastic conditions (e.g. non-Hodgkins lymphoma and Kaposi sarcoma).

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