Clinical Manifestations of HIV Infection : Bacterial,Viral Infections

4th Pediatric Infectious Diseases Conference

ISSN 0973 - 0958

Infectious Diseases in Children

HIV Infection Clinical Manifestations

Infectious Diseases in Children

HIV Infection

Malaria In Children

Tropical Splenomegaly Syndrome

Pneumonias In Children

Chickenpox

Varicella Zoster Virus

Clinical Manifestations Of Congenital Syphilis

H.influenzae - B Prevention Enteric Fever

Hand, Foot and Mouth Disease

Dengue and Dengue Hemorrhagic

H1N1 Influenza Epidemic

Varicella Infection in Pregnancy

Chikungunya - Indian Prespective

Enteric Fever

Otitis Media In Children

Utility of PCR Tests for Diagnosis of HIV in Infants Exposed to HIV Virus

Nonsurgical Treatment of Cystic Echinococcosis

Drug Resistant Tuberculosis in Children in India

Role of Quantiferon Gold Test (Interferon gamma release assay) for Diagnosis of Tuberculosis in Children

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HIV INFECTION AND CLINICAL MANIFESTATIONS

Clinical Manifestations

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Introduction and Statistics

Dr. Nitin Shah
Hon. Pediatrician- UHC, LTMG Hospital, Mumbai.
Treasurer, Indian Academy of Pediatrics, 1998-2001

Clinical manifestations of HIV can be grossly divided into two types:

Infections
Organ specific diseases.

HIV and Infections: Various types of infections are seen in HIV patients including bacterial, viral, fungal and parasitic infections. As the HIV patient becomes immunodeficient, the infections tend to be severe, widespread, chronic, indolent, recurrent, atypical and difficult to treat and eradicate.

Bacterial infections :

Pyogenic Bacterial infections: Unlike in adults, severe bacterial infections are taken as AIDS defining criteria especially when recurrent. Immunonaive child suffers more recurrent and severe bacterial infections then an adult with HIV does.

Commonly, patient with HIV develops invasive disease due to capsulated organisms leading to bacteremia, cellulitis, septic arthritis, meningitis, internal organ abscess etc. Other infections seen include middle ear infections, skin & soft tissue infections, urinary tract infections, GI infections etc. Of late there is an increase in Pseudomonal infection in HIV patients.

It is estimated that pediatric HIV patients suffer from an average of two episodes of diarrhea every year. 30% of them are due to bacterial causes like Salmonella infections, which in HIV patients can present as diarrhea, bacteremia, LRTI or endocarditis. They can also develop hospital acquired nosocomial infections twice as common as a non - HIV patient can. They are likely to be drug resistant.
Mycobacterial infections: HIV epidemic has led to reversal of declining trends of tuberculosis in West and increase in already existing large number of cases of tuberculosis in developing countries. Classical tuberculosis caused by M. tuberculosis and M. bovis, and atypical mycobacterial avium intracellulare are the main mycobacterial infections, which occur in HIV patients. 20 - 30% of adult patients with tuberculosis have been reported to be HIV positive in India and 70 - 80% of HIV patients suffer from tuberculosis at sometime during their life.

Due to immunodeficiency, there occurs uncontrolled replication of tuberculous bacillus with increased chances of systemic spread. In fact, extra - pulmonary tuberculosis is taken as an AIDS defining criterion. When patient develops primary complex, it presents as uncontrolled disease with progression and lymphohematogenous spread. In older patient, reactivation of tuberculosis presents with atypical manifestations like less of cavitation and more of localized or diffuse and multiple infiltrates with hilar lymphadenopathy. 40 - 50% of HIV children develop extra - pulmonary tuberculosis like disseminated tuberculosis, abdominal Kochs, CNS tuberculosis or other organ involvement.

Viral infections :

Herpes group of viruses: It includes Herpes Simplex type 1 and 2, CMV, Varicella Zoster virus, Epstein Barr virus and the newly diagnosed HHV6 and 7.
HSV infections: Primary infection tends to be severe and chronic persisting for 4 - 6 weeks. It can spread to adjacent areas of skin and leads to ulceration that heals by scarring and hyperkeratosis. It can spread and lead to viral oesophagitis which presents with dysphagia and retrosternal pain. It can also spread systemically and lead to pneumonitis, encephalitis, DIC, hemorrhage etc. Patient can develop reactivation and recurrences, which tends to be severe.

Varicella Zoster Virus (VZV): Primary infection with VZV leads to severe chickenpox in HIV patients. Patient presents with prolonged and high fever and develops rash with > 400 vesicles/sq. metre body area. The rash tends to be chronic, indolent, hemorrhagic, necrotic and hyperkeratotic. The whole illness can last for 3 - 4 weeks. It tends to spread systemically more often than in normal individuals leading to pneumonitis, encephalitis, DIC, hemorrhage etc. These complications are seen in > 50% of HIV patients. Mortality due to varicella in HIV patients is 50% in adults and 7-10% in children.

Reactivation leads to herpes zoster that tends to occur within weeks to months instead of years after primary infection. It is severe, chronic, indolent and generalized involving multiple dermatomes which sometimes makes it difficult to ascertain whether it is chicken pox or zoster. It is more painful and tends to be recurrent. Herpes zoster occurring in very young individuals should arouse the suspicion of HIV infection

CMV: 25-55 % of HIV patients develop CMV infection. In many it is asymptomatic. 25% of HIV patients have life threatening CMV, 10% develop chorioretinitis and 5-10% develop infection of lungs, GI tract and rarely involvement of CNS, gall bladder, adrenals, liver, myocardium, nerves etc.
Respiratory viral infection: Respiratory syncytial virus leads to severe bronchiolitis with prolonged viremia. Clinically wheezing may be paradoxically absent or minimum with more chances of giant cell pneumonia developing in HIV patients. Parainfluenzae viruses also tend to be more severe in HIV patients leading to bronchiolitis, pneumonitis, cough and URTI. Adenovirus can lead to severe conjunctivitis, meningitis, encephalitis and pneumonitis in HIV patients. Lastly measles also tends to be severe especially as it depends on cell mediated immunity to recover after disease, which is lacking in HIV patients. HIV patients develop atypical measles with rash, which may be absent, delayed or atypical. Patient can develop giant cell pneumonia and mortality is 25 - 30 %.