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1
Respiratory Diseasesin HIV-infected Children
- Part 1- Upper Respiratory Infection
and Pneumonia
HAIVNHarvard Medical School AIDS
Initiative in Vietnam
2
Learning Objectives
By the end of this session, participants should be able to:
Identify the most common causes of respiratory disease in HIV patients
Describe how to manage ear infections Explain how to clinically diagnose and
treat:• Bacterial pneumonia• Viral pneumonia• Fungal pneumonia
What are Common Respiratory Syndromes in HIV infected Children?
Upper respiratory infections: Ear infections Sinusitis
Lower respiratory infections: Pneumocystis jiroveci
pneumonia (PCP) Bacterial pneumonia Pulmonary tuberculosis Viral pneumonia Fungal pneumonia
Infectious causes
Upper respiratory infections:•Ear infections•Sinusitis
Lower respiratory infections:•Pneumocystis jiroveci pneumonia (PCP)•Bacterial pneumonia•Pulmonary tuberculosis•Viral pneumonia•Fungal pneumonia
Non-infectious causes
Lymphocytic interstitial pneumonitis (LIP)
Bệnh cảnh nhập việnở BV Nhi Đồng 1 – khảo sát
năm 2006
71
16
17
13
8
5
0 10 20 30 40 50 60 70 80
hô hấp
suy dinh …
sốt kéo dài
Tiêu …
bệnh não
Thiếu máu
50% trẻ nhập viện vì bệnh cảnh hô hấp
n = 134
Bs. Trương Hữu Khanh NĐ1
5
Upper Respiratory Infections
Ear InfectionsSymptoms Treatment
Otitis media
• Usually begins at age 6-9 months
• Fever, pain, irritability• Tends to be recurrent• Complications:
perforated tympanic membranes common, chronic otitis media
• Acute pain, often severe
• Edema, erythema of the canal
• Thick, clumpy otorrhea
Otitis externa
Amoxicillin:80-90mg/kg/day for 10-14 days
Cipro or ofloxacin otic drops
Sinusitis (1)
Pathology:
8
Sinusitis (2) Symptoms:
• Fevers, poor feeding• Nasal congestion, purulent nasal discharge• Cough for >10-14 days, or high fever to 39oC
and purulent discharge for 3-4 days, indicate bacterial sinusitis
Treatment: Mild cases Amoxicillin 45mg/kg/day
More severe cases
Amoxicillin-clavulanate (80-90mg/kg/day)
Alternatives Azithromycin, cotrim, cefuroxime, ceftriaxone, levofloxacin
9
Pharyngitis
Usually caused by virus or Bacteria: Group A streptococcus
Symptoms: • Fever• With/without rash• Sore throat• Large tonsils and lymph node on the
neck
10
Pharyngitis
Acute pharyngitis caused by Strep.
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Lower Respiratory Infections
12
Lower Respiratory Infections
Pneumonia is the number one cause of deaths in children worldwide:• Responsible for nearly 1 in 5 deaths, for
an estimated 1.8 million deaths annually• Most cases are in Africa and South East
Asia• Incidence may be higher where there is
high prevalence of HIV• Occurs more often and more severe,
with higher mortality rates, in HIV-infected children
Pneumonia – Etiology by Age
Age Etiologies
<2 months •Gram-negative organisms•Anaerobes•and PCP
<1 year •PCP
<2 years •Viral (RSV), mixed with bacteria
<5 years •Bacterial: Streptococcus pneumoniaeHaemophilus influenzaeand Staphylococcus aureus
>5 years •Mycoplasma pneumoniae •or Chlamydophila pneumoniae
TB?
LIP?
Pneumonia – DiagnosisNon-severe pneumonia (can be managed as outpatient)
Diagnosis based on clinical presentation
Moderate to severe pneumonia(especially in inpatient setting)
Indicate:•Pulse oximetry•Microbiology:Obtaining sputum when possibleBlood culture
•Acute phase reactant (CRP, ESR)•Complete blood count•Viral specific testing•CXR
15
Bacterial Pneumonia
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Bacterial Respiratory Infections
Bacterial pneumonias were more common in HIV-infected children than HIV-uninfected:
S. pneumoniae 43x
H. Influenzae B 21x
S. aureus 49x
E. coli 98x
M. tuberculosis 23x
* Madhi SA et al, Clin Infect Dis 2000;31:170.
17
Bacterial Pneumonia in HIV-infected Patients
Compared to non-HIV infected: More frequent, more severe, more
likely to be fatal Caused by a wider variety of
organisms, including resistant ones More likely to be polymicrobial More often accompanied by
bacteremia
18
Bacterial Pneumonia – Clinical Presentation
Onset usually acute High fevers, rigors, chills Cough productive of sputum Tachypnea, dyspnea Chest pain May have poor feeding,
nausea/vomiting Rales often present on lung exam
19
Bacterial Pneumonia – CXR (1)
Often seen:• Lobar infiltrate• Bronchoalveolar infiltrate• Parapneumonic effusions• Pleural effusions
Bacterial Pneumonia – CXR (2)
Bacterial Pneumonia – CXR (3)
Bacterial Pneumonia – CXR (4)
Bacterial Pneumonia – CXR (5)
Bacterial Pneumonia – Treatment
Inpatient(moderate to severe pneumonia)
Outpatient(mild to moderate pneumonia)
Ampicillin +
gentamycin (WHO)
or Ceftriaxone
or cefotaxime
Azithromycin (also for atypical pneumonia)
Amoxicillin/clavulanate Use Cotrimoxazole for PCP for all
infants ≤ 1 year Vancomycin, clindamycin if suspect
MRSA Levofloxacin or ciprofloxacin if
suspect resistant S. pneumoniae and TB has been ruled out
25
Viral Respiratory Infections
26
Viral Respiratory Infections (1)
Most viral infections manifest no differently in HIV-negative children than in HIV-positive children until HIV disease is advanced• RSV, influenza, parainfluenza, coronaviruses,
rhinovirus, are similar except: Virus is excreted for longer For RSV, influenza and parainfluenza, wheezing is
less frequent
• Bacterial co-infections are more frequent• Hospitalization and mortality rates are higher
27
Viral Respiratory Infections (2)
Outcomes are worse with certain infections:• Measles, varicella, CMV, adenovirus• CMV pneumonia is present in advanced
HIV infection, usually as a co-pathogen, especially in infants and young children
28
Viral Respiratory Infections (3)
Diagnosis:• RSV: bronchiolitis• Influenza: seasonal, with local circulation• CMV: severe pneumonia. CXR with bilateral
infiltrates, CMV IgM+, PCR+ with high titer Treatment: mostly supportive
• Influenza: oseltamivir (Tamiflu), zanamivir (Relenza), peramivir (IV), amantadine, rimantadine
• CMV: gancyclovir IV
29
Fungal Pneumonia
30
Fungal Pneumonia
Difficult to diagnose clinically Diagnosis requires microbiology, specific testing
• Sputum or bronchoalveolar stain and culture, biopsy
Fungal pneumonia in the immunocompromosed patients is often part of a systemic, multi-organ infection• Cryptococcosis with meningitis• Penicillium marneffei with skin lesions,
splenomegaly CXR reveals no typical findings Treatment according to etiology
Pneumonia – IMCISeverity of Pneumonia
Definitions
Mild
Cough or difficulty breathing with age-adjusted tachypnea:
Age 0-2 months: ≥60/min Age 2-11 months: ≥50/min Age 1-5 years: ≥40/min Age > 5 years: ≥20/min
Severe
Cough or difficulty breathing plus one of the following: Lower chest indrawing Nasal flaring Or grunting
Very severe
Cough or difficulty breathing plus one of the following: Cyanosis Severe respiratory distress Inability to drink or vomiting everything Lethargy Loss of consciousness/convulsions
32
Pneumonia – Criteria for Admission
Moderate to severe pneumonia, with respiratory distress and hypoxemia (SpO2 <90%)
8 signs of respiratory distress1. Tachypnea, respiratory rate, breaths/min
Age 0–2 months: .60 Age 2–12 months: .50
2. Dyspnea3. Retractions (suprasternal, intercostals, or subcostal)4. Grunting5. Nasal flaring6. Apnea7. Altered mental status8. Pulse oximetry measurement ,90% on room air
Age 1–5 Years: .40 Age .5 Years: .20
33
Case Study
34
Linh, Girl (1)
A 17 month old girl with fever and dyspnea is transferred to your clinic
PM: 10 days prior to the admission, patient presented fever (38), productive cough, dyspnea. The fever and dyspnea went worse with time. The child had no vomiting or convulsion. The patient had been treated at provincial hospital for 4 days without improvement.
35
Linh, Girl (2)
Both parent are HIV positive, not yet on ART The child was not on PMCTC; TB vaccination at
1 months PE:
• alert, no fever, non-productive cough• Blue lips while crying, subcostal withdrawing, BR:
70 per min, Sp02 : 82% no oxygen• Lung: moist rales, sound breath decreased on the
left lung• Heart: HR: 155 per min, regular• Oral thrush• Abdomen: soft, hepatomegaly, 4cm subcostal
HIV ELISA: Positive
36
Linh, Girl (3)
What do you see on CRX?• Opaque entire left
lung, mediasternal shift
What is your clinical diagnosis:• Bacterial pneumonia• Pleural effusion• Tuberculosis• PCP
At admission
37
Linh, Girl (4)
What possible diagnostic tests are necessary?• WBC: 15 G/l• Thoracentesis: pus fluid• Pleural fluid culture: Staphyloccocus aureus, TB
PCR neagative• PCR for TB from gastric lavage: negative
What is the diagnosis?• Pneumonia and empyema
What is the best treatment plan?• Pleural drainage• Antibiotics: Vancomycin, Ceftriaxone, Amikacin
Linh, Girl (5) The patient got better after 7 days treatment (no
fever, no dyspnea) and after two weeks patient was discharged
HIV + confirmed, initiated ARV
After 7 days treatment At the timing of discharge
39
Key Points
Otitis media is common in children with HIV and should be treated with a long course of antibiotics to prevent complications
Recurrent bacterial pneumonia is common in HIV infected children
40
Thank you!
Questions?