1. Wasting Syndrome and Prolonged Fever in HIV-Infected Children
HAIVN
Harvard Medical School AIDS Initiative in Vietnam

2. Learning Objectives
By the end of this session, participants should be able to:
Define wasting syndrome and list common etiologies in HIV-infected children
Review algorithmic approach to wasting syndrome
Define prolonged fever and list common etiologies in HIV-infected children
Review algorithmic approach to prolonged fever

3. Wasting syndrome

4. Wasting In the absence of concurrent illness other than HIV
Recognized AIDS-defining condition
Can severely impact normal growth and development
Associated with high risk for HIV disease progression and short-term mortality
Tovo PA, de Martino M, Gabiano C, et al. Prognostic factors and survival in children with perinatal HIV-1 infection. The Italian Register for HIV Infections in Children. Lancet 1992; 339:1249.

5. HIV Wasting Syndrome: Clinical Diagnosis
Weight loss of more than 10% of body weight or body mass index (BMI) <18.5
PLUS
Prolonged & unexplained diarrhea
(>2 loose stools /day for more than 1 month) OR
Prolonged & unexplained fever
(T> 37.5⁰C for more than 1 month)

6. HIV Wasting Syndrome – Definitive Diagnosis
Documented weight loss
(>10% of body weight)
PLUS
Two or more unformed stools negative for pathogens OR
Documented T > 37.5⁰C with no other cause of disease
-Temp: negative blood culture, negative malaria slide and normal or unchanged CXR

7. Clinical Staging -First box is definition of HIV wasting syndrome
-Emphasize these children are in CS 3 or 4 so advanced disease

8. Common Etiologies - Wasting
Malnutrition
Inadequate intake due to factors such as drug side effects (e.g., taste disturbances)
Infection(s) or illness, including recurrent / occult including resulting conditions such as malabsorption
Oral or esophageal candidiasis (odynophagia)
Opportunistic infections (OIs)
Diarrhea
HIV
Depression

9. Medical History Severity of weight loss
Symptoms/signs of occult infection
Presence or history of diarrhea or vomiting
Feeding practices
Social or other factors affecting feeding/access to nutritious foods
Medication history including any taste disturbances, reactions interfering with intake
Review of nutritional intake

10. Physical Examination Record / trend weight and height
Thorough exam of systems for any signs of overt or occult infection(s)
Focus exam based on symptoms reported

11. Algorithmic approach to management of Wasting / failure to thrive

12. Management of Wasting
Assessment: Take detailed history and perform thorough exam
Initial support: Hydration and nutritional support. Begin evaluation for ARV if the child is eligible.
History of inadequate caloric intake?
History of thrush or oral ulcers?
Child critically malnourished or dehydrated?
History of fever or diarrhea?
Give feeding trial for 7 days with increased caloric and vitamin supplementation
Treat for candida or HSV (if ulcers)
Hospitalize to give nutritional support, fluid replacement, vitamins and minerals
If improved, continue treatment with close monitoring
Perform complete blood count with differential WBC, albumin, blood cultures, CXR, rule out TB, stool studies for bacteria, ova and parasites. Evaluate as for patients with diarrhea, fever. Abdominal ultrasound may reveal enlarged liver and spleen.
No improvement
- Consider hospitalization for dietary support.
- Re-evaluate for occult infection.
- Consider ARV treatment if eligible
Treat for causes No
Causes found?
Yes
Adapted from Viet Nam MOH Guidelines

13. Prolonged fever

14. Prolonged Fever T > 37.5⁰C for more than 14 days Common etiologies
Infectious: bacterial (salmonellosis, bacteremia, TB, MAC), fungal (cryptococcosis/meningitis, penicilliosis), viral (CMV, HSV/meningitis), malaria, etc.
HIV related neoplasms (e.g. lymphoma)
HIV itself
Drug fever (hypersensitivity to drugs such as CTX or ARVs)

15. TB Pneumonia in a 2-year-old who presented with fever, cough, weight loss
Source:

16. Medical History Take a thorough history including:
Was the onset acute or subacute?
How long has the fever/ illness lasted?
Is it associated with any signs/ symptoms (thorough review of symptoms by system, e.g., productive or dry cough, difficulty breathing, shortness of breath, skin or mucosal lesions, night sweats, chills, weight loss, mental status changes, joint pains)?
Has anyone in patient’s family or close contacts been diagnosed with / is currently being treated for TB or other infectious diseases?
Medication history including ARVs, CTX, allergies
History of OIs or other HIV-related conditions?

17. Physical Examination
Perform detailed physical exam looking for signs of:
General conditions: weight loss, skin or mucosal lesions, lymphadenopathy
Respiratory complications: dyspnea, cyanosis, crackles, fremitus, digital clubbing
Other: mental-physical underdevelopment, immunodeficiency (e.g. oral thrush, cachexia)
Focus exam from history taking/ symptoms

18. 8-year-old boy presenting with prolonged fever and skin lesions
Source:

19. Algorithmic approach to management of prolonged fever

20. Give antipyretics, rehydration, good nutrition
Prolonged fever
Give antipyretics, rehydration, good nutrition
Take history
Examine physically
Routine and cause-guiding investigations:
CBC, CD4 (if available)
Respiratory findings: CXR, sputum for AFB
Neurologic findings: PL
Septicemia, penicilliosis: blood culture
Lymphadenopathy: aspiration
Abdomen ultrasound, etc...
Suggestive causes of fever:
Lymphadenopathy: TB, MAC, fungal septicemia
Respiratory findings: TB, PCP, bacterial pneumonia
Diarrhea: Salmonellosis, TB enteritis, MAC
Neurologic findings: Bacterial, TB, cryptococcal meningitis, Toxoplasma encephalitis, malaria
Anemia: TB, MAC, fungal septicemia
History with medication: allergy
Skin lesions: Penicilliosis, Cryptococcosis
Etc....
Empirical treatment:
Bacterial or cryptococcal meningitis: proper antimicrobials
Septicemia: appropriate antimicrobials
Toxoplasma encephalitis: co-trimoxazole
Penicilliosis: itraconazole
PCP: co-trimoxazole
Etc...
TB: Anti-TB drugs
Diagnosis confirmed by investigations, and/or the child responds to empirical therapy
Diagnosis not confirmed by investigations, the child does not respond to empirical treatment
Continue and complete treatment.
Maintenance treatment if indicated
Re-evaluate clinically, consider other causes, especially TB, MAC or fever due to HIV itself
Do corresponding lab tests and investigations; consider lymphnode biopsy, bone marrow analysis and biopsy...
Treat presumptively for TB; MAC
Consider ARV treatment
Adapted from Viet Nam MOH Guidelines

21. Key points
HIV wasting syndrome is defined either clinically by patient/ caregiver report or definitively through documentation of weight loss and prolonged diarrhea or fever
A thorough medical history and physical examination should be performed to rule out and / or address any treatable causes of wasting
Prolonged fever is diagnosed when the child has T>37.5⁰C for >14 days
A thorough medical history and physical examination should be performed to diagnose and address any treatable causes of prolonged fever
Health care providers can refer to the algorithms adapted from the Viet Nam Ministry of Health for further guidance on how to manage wasting syndrome and/ or prolonged fever

22. Thank you!
Questions?