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Respiratory Diseasesin HIV-infected Children

- Part 1- Upper Respiratory Infection

and Pneumonia

HAIVNHarvard Medical School AIDS

Initiative in Vietnam

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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

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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

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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:

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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

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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

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Pharyngitis

Acute pharyngitis caused by Strep.

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Lower Respiratory Infections

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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

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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.

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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

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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

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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

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Viral Respiratory Infections

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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

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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

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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

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Fungal Pneumonia

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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

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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

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Case Study

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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.

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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

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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

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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

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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

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Thank you!

Questions?