Opportunistic Infections in Pediatric HIVAIDS

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Opportunistic Infections in Pediatric HIV/AIDS

• Katherine Knapp, MD
• St. Jude Childrens Research Hospital
• Memphis, Tennessee, USA
• December 2, 2003

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1994 Revised CDC Classification for Pediatric HIV
Infection - Immunologic
MMWR, 1994 43 (No. RR-12) p.1-10
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1994 Revised CDC Classification for Pediatric HIV
Infection - Clinical
MMWR, 1994 43 (No. RR-12) p.1-10
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N Not Symptomatic

• No signs or symptoms of HIV infection, or
• Only one of the conditions listed in Category A

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A Mildly Symptomatic(2 or more, none of
Category B or C)

• Lymphadenopathy ( 0.5 cm at gt 2 sites or
  bilateral at 1 site)
• Hepatomegaly
• Splenomegaly
• Dermatitis
• Parotitis
• Recurrent or persistent upper respiratory
  infection, sinusitis or otitis media

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B Moderately Symptomatic

• Several diagnoses in this category some
  examples
• Single episode of bacterial meningitis, pneumonia
  or sepsis
• Thrush persisting gt 2 months in children over 6
  months of age
• Recurrent or chronic diarrhea
• Recurrent HSV stomatitis (gt 2 episodes within 1
  year)

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B Moderately Symptomatic (continued)

• More examples
• Herpes zoster (shingles) 2 distinct episodes or
  gt 1 dermatome
• Leiomyosarcoma
• Lymphoid interstitial pneumonia (LIP) or
  pulmonary lymphoid hyperplasia (PLH)
• Persistent fever (gt 1 month)
• Varicella, disseminated (complicated chickenpox)

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C Severely Symptomatic

• Some examples
• 2 or more culture-confirmed serious bacterial
  infections over a 2 year period
• Esophageal or pulmonary candidiasis
• Extrapulmonary cryptococcosis
• Disseminated histoplasmosis or coccidioidomycosis
• Pneumocystis pneumonia
• Progressive multifocal leukoencephalopathy
• Tuberculosis

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OIs in Children Compared to Adults

• Less common in children
• Cryptococcosis
• Toxoplasmosis
• Cancers, e.g., Kaposis sarcoma
• Different for children
• Primary infection with pneumocystis
• LIP/PLH
• Leiomyosarcomas

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Pneumocystis Pneumonia (PCP)

• Cause recently identified as Pneumocystis
  jiroveci (not P. carinii, as previously thought)
• Peak age of onset 3 6 months
• Acute onset fever, tachypnea, rib retractions,
  hypoxemia
• Chest x-ray normal to bilateral interstitial
  and alveolar infiltrates
• Higher fatality in infants than in adults

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Prophylaxis

• Preferred Trimethoprim-sulfamethoxazole
  (TMP-SMX)
• Alternatives
• Dapsone ( 1month)
• Aerosolized pentamidine ( 5 years)
• Atovaquone

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PCP Prophylaxis

• Continue for first year of life in all infected
  infants
• 1-5 years if CD4 count lt 500 or lt 15
• 6 years if CD4 count lt 200 or lt 15
• The safety of discontinuing (primary or
  secondary) prophylaxis in children has not been
  studied extensively

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Mycobacterium avium Complex

• Prophylaxis indicated for the following
• lt 12 mos CD4 lt 750
• 1 2 years CD4 lt 500
• 2 6 years CD4 lt 75
• gt 6 years CD4 lt 50
• Clarithromycin or azithromycin
• The safety of discontinuing prophylaxis has not
  been studied in children.

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Recurrent Bacterial Infections

• Immunization
• Antibiotic Prophylaxis?
• IVIG
• In children with hypogammaglobulinemia (IgG lt 400
  mg/dL)
• Consider for children with recurrent severe
  bacterial infections despite daily TMP-SMX or
  other antibiotic

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Secondary Prophylaxis for Life

• PCP
• Toxoplasma encephalitis
• Mycobacterium avium complex disease
• Cryptococcosis
• Disseminated histoplasmosis or coccidioidomycosis
• CMV end-organ disease (e.g., retinitis)

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Lymphoid Interstitial Pneumonia

• Diffuse lymphocytic infiltrate (PLH is focal)
• May see chest x-ray findings first
• Chronic cough, progressive hypoxemia, clubbing of
  the fingers
• Associated with EBV
• May respond to steroids
• Tend to be older, less ill appearing than infants
  with PCP

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Leiomyosarcoma

• Smooth muscle tumors specifically associated with
  HIV infection in children
• Associated with EBV in children with HIV (but not
  leiomyosarcomas in non-infected persons)

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Immunization of the HIV-Infected Child

• All routine childhood immunizations except
  live-virus vaccines
• MMR may be given if patient not severely
  immuncompromised (category 3), may give 2nd dose
  4 weeks later
• Consider varicella vaccine for class N1 or A1
• Passive immunization measles, tetanus
• Yearly influenza vaccine
• Consider Hepatitis A vaccine
• Also, yearly TB skin test