Medicine Pediatrics 08.12.2011

8/4/2019 Medicine Pediatrics 08.12.2011

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MedPeds Morning ReportMedPeds Morning ReportTiffany Milner, MD

August 12, 2011


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HPIHPIPrincess Marina Hospital - Gaborone,

Botswana

n 5 year old male who presents to the A&Ewith facial puffiness, tachypnea, andbilateral lower extremity edema. Momhas noted the edema for a few weeks, andit has been getting worse. He is less

active than usual, seems tired, and is notinterested in eating. He has not had anyrecent fevers or night sweats. He coughsoccasionally, but this is no different fromusual. No recent viral infections, no GIcomplaints, no bleeding or bruising.


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Further HPIFurther HPIn PMH:

- Pulmonary TB, currently on continuationphase- Frequent AOM and URIs

n Medications:- Isoniazid- Rifampin

n Allergies: none

n Family Hx: no heart, liver, or kidney disease

n Social Hx: Lives with mother, grandmother,and 2 sisters in Moshupa, 61km from

Gaborone.n


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Physical ExamPhysical Examn Vitals: T 37, HR 115, BP 80/40, RR 35, SpO2 87%

n Wt 17.5kg (15%), Ht 103 cm (2.4%)

n HEENT: facial puffiness, numerous dental caries, scarredTMs bilaterally

n Neck: Bilateral anterior cervical LAD, +JVD

n CV: tachycardic, hyperdynamic precordium, PMIdisplaced inferiorly and laterally

n Resp: tachypneic, occasional cough, crackles bilaterally

n Abd: hepatomegaly at 4 cm below RCM, splenomegalyat 3 cm below LCM, soft, nontender, nondistended,no ascites

n Ext: 2+ pitting edema in bilateral lower extremities upto the thigh

n


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What are youWhat are you

thinking?thinking? Heart failure

n What is the most common cause of heart

failure in children?

Congenital malformations

n What about a 77 year old man?

Ischemic heart disease

n What is the most likely cause of new onsetHF in a 7 year old boy in Botswana, who iscurrently being treated for TB?


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Etiologies of HeartEtiologies of Heart

FailureFailuren Structural defects: VSD, PDA, AVSD, AR, MR,

tricuspid atresia, inflow obstruction, outflowobstruction

n Cardiomyopathy: dilated, hypertrophic, restrictive

n Myocarditis: viral (adenovirus, coxsackie B,influenza, HIV), Chagas, Mycoplasma, etc

n HTN systemic or pulmonary HTN

n

Hypermetabolic states anemia, sepsis,hyperthyroidism

n Fluid overload liver failure, renal failure, iatrogenic

n Vitamin deficiencies/Toxins

n Coronary artery disease, dysrhythmias, autoimmunedisease


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CardiovascularCardiovascular

diseasesdiseasesn Dilated Cardiomyopathy

n Lymphocytic Interstitial Myocarditis

n Pericardial Effusion

n Infective Endocarditis

n Malignancy (myocardial Kaposi sarcoma and

B-cell immunoblastic lymphoma)n Vasculitis

n Accelerated Atherosclerosis

n


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TestingTestingn CXR


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TestingTestingn HIV test positive

n CBC microcytic anemia, leukopenia

n BUN/Cr, AST, ALT within normal limits

n Abdominal ultrasound hepatomegaly,splenomegaly, para-aorticlymphadenopathy

n Echocardiogram RV dilatation withincreased RA and PA pressure,significantly decreased LV function

n


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In the hospitalIn the hospitaln Started on diuretic therapy (lasix and

spironolactone) and afterload reduction(ACE-inhibitor)

n Continued on anti-TB therapy

n Started on cotrimoxazole

n Once clinically stable, he was discharged tohome, with follow up at the Botswana-Baylor Childrens Center of ClinicalExcellence


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o swana- ay oro swana- ay orChildrens Center forChildrens Center for

Clinical ExcellenceClinical Excellence


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HPI - In ClinicHPI - In Clinicn 5 year old HIV positive male who just

completed 6 months of anti-TB therapy,recently admitted to the hospital and newly

diagnosed with HIV-associatedcardiomyopathy who presents with hismother for hospital follow up and initiation ofHAART.

n Mom attended adherence classes this morning

n

Current medications:- just finished INH and rifampin- cotrimoxazole daily- lasix 20mg BID- spironolactone 5mg twice daily- captopril 6.25mg TID

n CD4 count not back yet


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Physical Exam in clinicPhysical Exam in clinic

n Ht 103 cm (2%), Wt 16.9kg (10%)

n T 37, HR 103, BP 100/70, RR 28, SpO2 N/A

n General: small, thin, edematous, no acute distress

n HEENT: facial puffiness, extensive dental caries, naresclear

n Neck: supple, bilateral submandibular and cervical LAD

n CV: hyperactive precordium with displacement of PMI

n Resp: occasional cough, few adventitious soundsthroughout, no wheezing

n Abd: hepatomegaly at 3cm below RCM, splenomegaly at2cm below LCM

n Ext: 1+ bilateral lower extremity edema


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What AIDS-definingWhat AIDS-defining

illnesses does he have?illnesses does he have?n Tuberculosis (just finished treatment)

- WHO clinical stage 3

n Moderate malnutrition (wasting syndrome)- WHO clinical stage 3

n HIV-associated cardiomyopathy- WHO clinical stage 4

n


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AIDS defining illnessesAIDS defining illnessesn Bacterial pneumonia, recurrent

n Candidiasis of the bronchi, trachea, or lungs

n Candidiasis, esophageal

n Cervical carcinoma, invasive, confirmed by biopsy

n Coccidioidomycosis, disseminated or extrapulmonary

n Cryptococcosis, extrapulmonary

n Cryptosporidiosis, chronic intestinal

n Cytomegalovirus disease

n Encephalopathy, HIV-related

n Herpes simplex: chronic ulcers or bronchitis, pneumonitis, or esophagitis

n Histoplasmosis, disseminated or extrapulmonary

n Isosporiasis, chronic intestinal


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Impression and PlanImpression and Plan5 year old boy with AIDS, WHO Clinical Stage 4

due to HIV associated cardiomyopathy, whohas moderate malnutrition and clinical

evidence of heart failure.n Initiate HAART discuss side effects and IRIS

- Abacavir (NRTI)- Lamivudine (NRTI)- Efavirenz (NNRTI)

n

Continue cotrimoxazolen Continue lasix, spironolactone, captopril

n Referral to nutrition for education andsupplements

n Check weight and renal function in 2 weeks atfollow up


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6 months later6 months latern Repeat echocardiogram EF 64%, normal

intracardiac anatomy with good LVfunction, but moderate biventriculardilatation

n CXR persistent cardiomegaly

n CD4 140/7%

n Viral load undetectable

n Off captopril, and now beginning to weandiuretics


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2 years on HAART2 years on HAARTn 7 year old male, WHO Clinical Stage 4,

Treatment Stage 1, clinically well.

n

Wt 20.2kg (7.7%), Ht 116cm (5.5%)n Physical exam: dental caries, lungs clear, PMI

at 5th intercostal space, lateral to mid-clavicular line, liver 2cm below RCM, spleennot palpable

n

CD4 917/30%, viral load < 400, Hgb 11.5n Medications:

Abacavir (ABC)Lamivudine (3TC)Efavirenz (EFV)


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A few learning pointsA few learning pointsn What do you worry about with abacavir (NRTI)?

Hypersensitivity (check HLA-B*5701)

n What do you worry about with efavirenz(NNRTI)?

Nightmares, psychiatric problems, difficultywith school

n Why not use zidovudine (NRTI) as first line inthis patient?

It is associated with cardiomyopathy

n


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Cardiac Disease in HIVCardiac Disease in HIVn 25% of deaths > 10 years old were due to cardiac

disease

n 51% of children with HIV-related deaths had chronic

cardiac disease prior to death

n 28% of children had serious cardiac events after AIDSdiagnosis

n 35% of patients who died during the study had cardiacdysfunction

n Risk factors: Encephalopathy, wasting, low CD4, priorhistory of serious cardiac event

n No statistical difference in congenital cardiovascularmalformations

n Left ventricular dysfunction is a frequent manifestation

From the Pe diatric Pulm ona ry an d Cardiac Com plica tions of Ve rtically Tra ns m itte d HIV Infe ction Stu dy

Group


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Cardiac disease as a cause ofCardiac disease as a cause ofdeath increases with increasingdeath increases with increasing

ageage

Line a r ag e t re nds fo r the und e r ly ing cau se o f de a th in

93 HIV-relate d d e a th s


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p em o ogy -p em o ogy -20092009

n 33.3 million people were living with HIV

n 2.5 million children were living with HIV

n 2.3 million of those children live in sub-Saharan Africa

n 53% of women living with HIV in low- and middle-incomecountries received ARV to prevent vertical transmission ofthe virus

n 7000 new HIV infections each day- 1000 children < 15 years old- 2460 15-24 years old

n The number of children receiving ART has increased from75,000 in 2005 to 360,000 in 2009

n The fastest growing population of HIV-positive patients are ages15-24

n


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Global prevalence of HIVGlobal prevalence of HIV

20092009


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challenge for our 7challenge for our 7

year old patient?year old patient?Disclosure of diagnosis

Adolescence and difficulties with adherence

n Lack of family support

n Depression, low self-esteem

n Sexual activity, substance abuse

n Denial and misinformation about HIV


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DisclosureDisclosure


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Optimizing adherenceOptimizing adherencen Establish trust with patient and family

n Problem solve with patient and family ie:

financial troubles, school troubles,medication side effects, food insecurity,etc

n Peer Support Groups ie: Teen Club

n Reminders pill boxes, watches, cell phones

n Frequent, regular follow up

n Simplify medication regimen when possible

n


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What happens whenWhat happens when

he turns 18?he turns 18?n In Botswana, he would just walk down a

different hall in the same clinic

n In Salt Lake, he would go over to UniversityHospital and be seen by our adult IDdoctors

n Report from Dr. Pavia:- almost 30 children with HIV in SLC- 1/3 are adolescents- 2 recently transitioned over to clinic 1A- some go off to college- some are lost to follow up


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Is he at higher risk forIs he at higher risk for

cardiac disease?cardiac disease?n Accelerated atherosclerosis has been

observed in young HIV-infected adults andchildren without traditional risk factors

n Cardiotoxicity is associated with zidovudineuse (NRTI)

n Protease inhibitors are known to have sideeffects of lipodystrophy, atherosclerosis,dyslipidemia, and insulin resistance


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Transitions of Care Transitions of Care

Known BarriersKnown Barriersn Delay in establishing care with an adult

provider

n Lack of insurance coverage

n Limited knowledge and experience withpediatric-onset chronic conditions

n Limited communication between pediatric

and adult providersn Pediatrics family-centered approach vs the

more independent adult approach

n Reluctance to leave familiar and trustedproviders


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Suggestions forSuggestions for

improvementimprovementn Begin transitions early and in a

developmentally appropriate way

n Communication between pediatric and adultproviders

n Transition clinics giving teenagers theopportunity to practice independentdisease management

n Extra training for adult providers on theadult sequelae of pediatric-onset chronicconditions


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ReferencesReferencesn http://cardiophile.org/2009/08/pulmonary-edema-seen-on-chest-x-ray-supine-view.html

n Barbaro, et al. Incidence of Dilated Cardiomyopathy and detection of HIV in myocardial cells of HIV-positivepatients NEJM 2002;347(2):140.

n Keesler, Marcie, Cardiac Manifestations of HIV Infection in Infants and Children Annals of the New York

Academy of Sciences, 946: 169-178.

n Madriago, Erin, Heart Failure in Infants and Children Pediatrics in Review 2010;31;4.

n Melvin, Cheitlin, Cardiac involvement in HIV-infected patients Uptodate 2010.

n Reiss, John, Health Care Transition: Youth, Family, and Provider Perspectives Pediatrics 2005;115;112.

n Simpkins, Evelyn, Thinking about HIV infection Pediatrics in Review 2009;30;337

n

Panel on Antiretroviral Therapy and Medical Management of HIV-Infected Children. Guidelines for the Use ofAntiretroviral Agents in Pediatric HIV Infection. August 16, 2010; pp 1-219.

n UNAIDS Report on the Global AIDS Epidemic 2010.

n www.cdc.gov/hiv

n www.aidsinfo.nih.gov

n

n
http://cardiophile.org/2009/08/pulmonary-edema-seen-on-chest-x-ray-supine-view.htmlhttp://www.cdc.gov/hivhttp://www.aidsinfo.nih.gov/http://www.aidsinfo.nih.gov/http://www.cdc.gov/hivhttp://cardiophile.org/2009/08/pulmonary-edema-seen-on-chest-x-ray-supine-view.html


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When to start HAARTWhen to start HAARTDefinitive:

n All children < 12 months of age

Recommended:

n > 12 months, and CDC Clinical Category B or Cdisease

n > 12 months and < 5 years, and CD4 < 25%

n

> 5 years and CD4 < 350n > 12 months with viral load > 100,000

Consider

n Asymptomatic or mild symptoms


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What drugs to startWhat drugs to startn Triple therapy, from at least 2 different

classes

n Usually 2 NRTIs + PI (zidovudine,lamivudine, lopinavir/ritonavir)

n Or 2 NRTIs + NNRTI (zidovudine,lamivudine, nevirapine)

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Medicine Pediatrics 08.12.2011