When to suspect HIV in children A clinical perspective

16 month old boy Fever, increased work of breathing, poor feeding. Fever, increased work of breathing, poor feeding. Normal pregnancy – LSCS at term Normal pregnancy – LSCS at term Breast fed Breast fed 2/12: facial swelling 2/12: facial swelling 11/12: severe chicken pox 11/12: severe chicken pox No developmental progress after age 1 year. No developmental progress after age 1 year.

Family history Parents from Zimbabwe Parents from Zimbabwe Mum nurse – in UK for 8 years Mum nurse – in UK for 8 years Dad student – in UK for 3 years Dad student – in UK for 3 years Mum reported negative HIV test 3 years ago Mum reported negative HIV test 3 years ago

HIV disease Pneumocystis pneumonia Pneumocystis pneumonia CMV pneumonitis CMV pneumonitis CMV retinitis CMV retinitis CMV/HIV encephalopathy CMV/HIV encephalopathy

Sequelae Marrow failure Ganciclovir Ganciclovir Zidovudine Zidovudine Cotrimoxazole Cotrimoxazole Pseudomonas sepsis Pseudomonas sepsis Renal failure Ganciclovir Ganciclovir Foscarnet Foscarnet Aminoglycosides Aminoglycosides

Where are we now? HIV undetectable HIV undetectable Immune reconstitution Immune reconstitution Normal respiratory function Normal respiratory function Marrow recovered Marrow recovered Neurodevelopmental progress but delayed Neurodevelopmental progress but delayedBUT Chronic renal failure on dialysis Chronic renal failure on dialysis

Girl aged 4 months, 29 days Persistent cough, 2-3 months Persistent cough, 2-3 months 3 courses antibiotics 3 courses antibiotics Pale, lethargic Pale, lethargic Feeding normally Feeding normally Normal pregnancy, delivery Normal pregnancy, delivery Caucasian mother, no relevant PMH Caucasian mother, no relevant PMH

Initial investigations Hb 10.6 Hb 10.6 WBC 8.0 WBC 8.0 Pl 316 Pl 316 Bili 6 Bili 6 AST 384 AST 384 ALT 283 ALT 283 ALP 362 ALP 362 CRP <7 No organisms identified CRP <7 No organisms identified CXR: hyperinflation diffuse interstitial changes ? Viral CXR: hyperinflation diffuse interstitial changes ? Viral Abd US: liver and spleen enlarged, normal texture Abd US: liver and spleen enlarged, normal texture

Progress Increasing oxygen requirement Increasing oxygen requirement Max 3 litres Max 3 litres Improved with antibiotics Improved with antibiotics Home after 4 days Home after 4 days Readmitted 8 days later Readmitted 8 days later Pale, lethargic, breathless Pale, lethargic, breathless Ventilated Ventilated

Further investigations WBC 5.5IgG 8.89 WBC 5.5IgG 8.89 Lymph 2.11IgA 2.03 Lymph 2.11IgA 2.03 CD3 1.22IgM 2.45 CD3 1.22IgM 2.45 CD CD CD CD CD CD CD CD Poor lymphocyte proliferation Poor lymphocyte proliferation Normal: Sweat test Sweat test Urine and plasma amino acids Urine and plasma amino acids Organic acids Organic acids Pneumocystis from BAL HIV antibody and RNA positive

AIDS defining conditions Pneumocystis Pneumocystis CMV pneumonitis CMV pneumonitis TB TB HIV encephalopathy/ HIV encephalopathy/Meningitis/encephalitis Kaposi sarcoma Kaposi sarcoma Lymphoma Lymphoma Wasting syndrome Wasting syndrome Persistent cryptosporidiosis Persistent cryptosporidiosis CMV retinitis CMV retinitis Recurrent bacterial infection Recurrent bacterial infection PUO PUO

Barriers to diagnosis Uncommon Uncommon May not present with opportunistic infection May not present with opportunistic infection CD4 count often in “adult” normal range CD4 count often in “adult” normal range CD4:CD8 ratio can be normal CD4:CD8 ratio can be normal Issues around testing Issues around testing

Who needs to think about HIV?

ENT surgeon Chronic parotitis Chronic parotitis Severe chronic/recurrent otitis media Severe chronic/recurrent otitis media

Dentist Oral candidiasis Oral candidiasis Poor dental hygiene Poor dental hygiene

Respiratory Lymphocytic interstitial pneumonitis Lymphocytic interstitial pneumonitis Recurrent pneumonia Recurrent pneumonia Bronchiectasis Bronchiectasis

Neurologist Unexplained encephalopathy/encephalitis Unexplained encephalopathy/encephalitis Developmental delay Developmental delay Childhood stroke Childhood stroke

Dermatologist Severe dermatitis Severe dermatitis Fungal infection Fungal infection Extensive molluscum Extensive molluscum Extensive warts Extensive warts

Gastroenterologist Chronic diarrhoea and wasting Chronic diarrhoea and wasting Unexplained hepatosplenomegaly Unexplained hepatosplenomegaly

Haemato-oncologist Lymphoma Lymphoma Thrombocytopoenia/ neutropoenia/ lymphopoenia Thrombocytopoenia/ neutropoenia/ lymphopoenia

Ophthalmologist Unexplained retinopathy Unexplained retinopathy

General paediatrician Developmental delay Developmental delay Failure to thrive Failure to thrive Persistent generalised lymphadenopathy Persistent generalised lymphadenopathy Recurrent respiratory infection Recurrent respiratory infection Recurrent bacterial infection Recurrent bacterial infection Muco-cutaneous candidiasis Muco-cutaneous candidiasis Recurrent herpes zoster Recurrent herpes zoster Severe varicella Severe varicella

GP Developmental delay Developmental delay Failure to thrive Failure to thrive Persistent generalised lymphadenopathy Persistent generalised lymphadenopathy Recurrent respiratory infection Recurrent respiratory infection Recurrent bacterial infection Recurrent bacterial infection Muco-cutaneous candidiasis Muco-cutaneous candidiasis Recurrent herpes zoster Recurrent herpes zoster

The child may be completely well!

Who should be thinking about HIV testing?

Everybody!