Dr Ira Shah
M.D, DNB, DCH(Gold Medalist), FCPS

A 4 month old male child presented with fever and cough since 2 months, diarrhea and generalized tonic clonic convulsion 2 days back. He was admitted twice for a lower respiratory tract infection at age of 2 months and 3 months. On examination, he had generalized (cervical, axillary, inguinal) lymphadenopathy with otorrhoea and hepatosplenomegaly. His weight was 5.25 kg. His milestones were delayed and he had only achieved social smile. In view of the above clinical features, an immunodeficiency was suspected. His mother's HIV ELISA test was positive. His HIV DNA PCR was positive and HIV viral load was 40,000 copies/ml with CD4 count of 792 cells/cumm and CD4% of 13.9% suggestive of immune category III. Thus, he was diagnosed as a perinatally acquired HIV infected child. His X-Ray chest revealed a right basal pneumonia. His mantoux test was negative and was treated with IV Antibiotics for 10 days. A CSF examination revealed normal picture [7 cells - 1 polymorph, 7 lymphocytes, sugar = 75 mg/dl, proteins = 81 mg%] and TORCH titres were negative. He was started on 3 drug Antiretroviral therapy (Zidovudine/Lamivudine/Nevirapine). However, even after a month the fever persisted. A mantoux test was repeated which was now positive and X-Ray chest was suggestive of primary complex thus signifying an immune reconstitution. He was treated with Antituberculous therapy for same for 9 months. At the age of 8 months, his lymphnodes and hepatomegaly had regressed and his weight was 8 kg and milestones were normal. At the age of 16 months, his HIV viral load was less than 20 copies and CD4 count was 2679 copies/ml with CD4% of 37% and weight of 12 kg with height of 80 cms. At 18 months, his HIV ELISA was done which was positive reconfirming the HIV status though clinically the child was asymptomatic.

Thus, this is a child who had repeated opportunistic infections, delayed milestones, failure to thrive due to HIV infection and with implementation of antiretroviral therapy in him, all the HIV related problems have resolved.

The availability of an increasing number of antiretroviral agents have lead to improvement in quality of life, reduction of HIV-related morbidity and mortality with restoration and preservation of immunologic functions.

Antiretroviral regimens are complex, have serious side effects, post difficulty with adherence and carry serious potential consequences from the development of viral resistance because of non-adherance to the drug or sub-optimal levels of antiretroviral agents. Patient education and involvement in therapeutic decisions is critical.

Antiretroviral therapy in children is recommended in patients who are in CDC class B or C with severe immuno suppression. Treatment goal should be maximal and durable suppression of viral load with improved quality of life as was seen in our patient.

Thus, one has to weigh the pros and cons and decide whether a particular child needs to be started on ART now or later and which combination of drugs to offer him. Remember a minimum of 3 drug combination is recommended and a backbone of 2 nucleoside reverse transcriptase inhibitors (NRTI) is mandatory.

Last Updated on 1-10-2004 Vol 1 Issue 7 Art # 27