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• HIV


  Lentivirus, retrovirus with single stranded RNA transcribed to double stranded DNA by reverse transcriptase, integrates into host genome, high potential for genetic diversity, can lie dormant within a cell for many years
• HIV-1


  Causes worldwide pandemic
• HIV-2


  Isolated in West Africa, causes AIDS much more slowly than HIV-1 but otherwise clinically similar
• Worldwide in 2008, an estimated 430,000 new HIV infections occurred in infants and children, of which 90% were acquired through mother to child transmission (MTCT)
• Modes of MTCT


  • Antipartal
  • Intrapartal
  • Postpartal or breastfeeding
• Factors that increase MTCT

  • Maternal factors: High viral load, new/recently acquired infection, low CD4 count, viral/parasitic placental infections, malnutrition, breast problems
  • Infant factors: First in multiple birth, preterm/low birth weight, longer breastfeeding, mixed feeding, oral lesions
  • Obstetric/delivery factors: Prolonged rupture of membranes, invasive procedures, vaginal delivery, routine suctioning
• Virologic tests for diagnosis

  • HIV DNA PCR
  • RNA PCR
  • HIV culture
  • HIV p24 antigen
• Virologic tests done in first 48 hrs of life can detect 40% of infected infants
• Diagnosis of HIV infection requires 2 positive virologic test results from different blood samples
• Pneumocystis carinii (jiroveci) pneumonia (PCP)


  Commonest opportunistic infection in pediatrics, peak age 3-6 months, highest mortality in children <1 year
• PCP


  • Sudden onset of fever, tachypnea, dyspnea, marked hypoxemia
  • Indolent development of hypoxemia may precede other symptoms
• PCP diagnosis


  • CXR shows bilateral diffuse alveolar disease with granular pattern, progressing from perihilar to peripheral, decreased PaO2, positive staining of bronchoalveolar fluid lavage
• PCP treatment


  1. Trimethoprim-sulfamethoxazole IV until improved, then oral for 21 days

  2. Pentamidine if hypersensitive

  3. Corticosteroids for severe hypoxia
• PCP prevention


  • Supportive care: oxygen, hydration, ventilation
  • Trimethoprim-sulfamethoxazole prophylaxis
• Indications for PCP prophylaxis

  • All HIV-infected children 6 weeks to 12 months
  • All HIV-infected children 1-4 years with clinical stage 2-4 or CD4 <25%
  • All HIV-infected children >5 years with clinical stage 3-4 or CD4 <350
  • All HIV-infected children with prior PCP
  • Age <18 months with presumptive HIV disease
• Recurrent bacterial infections


  Account for 20% of HIV-defining illnesses in children, primarily encapsulated organisms due to HIV-related humoral immunity disturbance, most common are bacteremia, sepsis, pneumonia
• Other recurrent infections


  • Meningitis, UTI, abscesses, bone/joint infections
  • Milder infections like otitis media, sinusitis, skin/soft tissue
• Mycobacterium avium-intracellulare complex (MAC)

  Causes disseminated disease in severely immunosuppressed children, incidence 10% in children CD4<100 and not on ART, presents with fever, malaise, weight loss, night sweats, diarrhea, abdominal pain
• MAC diagnosis and treatment

  1. Diagnosis by isolation from blood, bone marrow, or tissue

  2. Treated with at least 2 drugs: clarithromycin or azithromycin and ethambutol
• MAC prophylaxis


  Azithromycin or clarithromycin based on CD4 count for age, lifelong after treatment
• Oral candidiasis


  Most common fungal infection, can progress to esophageal involvement with symptoms like anorexia, dysphagia, vomiting, fever
• Forms of oral candidiasis

  • Erythematous (atrophic)
  • Pseudomembranous
  • Angular cheilitis
• Treatment of oral candidiasis

  Oral nystatin, gentian violet, miconazole gel, fluconazole for recurrent/refractory cases
• Treatment of esophageal candidiasis

  Oral fluconazole 3-6 mg/kg/day for 7-14 days
• Viral infections


  HSV causes recurrent gingivostomatitis, varicella-zoster may be prolonged and complicated, disseminated CMV with severe CD4 depletion, measles may occur despite immunization
• Toxoplasma gondii infections


  CNS toxoplasmosis rare in young infants but may occur in HIV-infected adolescents, severe congenital toxoplasmosis more common in HIV
• CNS toxoplasmosis


  • Presents with headache, fever, altered mental status, cognitive impairment, seizures, focal neurologic deficits
  • Diagnosis by clinical presentation, IgM antibodies, imaging showing multiple ring-enhancing lesions
• Treatment of CNS toxoplasmosis

  Pyrimethamine plus sulphadiazine with folinic acid, continued after clinical response
• r with severe CD4 depletion (<50 CD4 cells/mm3)


  • Involve single or multiple organs
  • Retinitis, pneumonitis, esophagitis, gastritis with pyloric obstruction, hepatitis, colitis, and encephalitis
• Measles may occur despite immunization and may present without the typical rash
• Toxoplasma gondii infections


  • CNS toxoplasmosis is exceedingly rare in young infants, but may occur in HIV-infected adolescents
  • Severe congenital toxoplasmosis relatively more common in patients with HIV infection
• CNS infection


  1. Headache, fever, altered mental status, cognitive impairment, seizures, and focal neurologic defects( hemiparesis, ataxia, visual field loss, cranial nerve palsies)

  2. Clinical presentation, presence of IgM antibodies and imaging of CNS xic finding multiple ring enhancing lesions on the frontal lobe, basal ganglia or parietal lobe

  3. Response to treatment is confirmatory for diagnosis
• Treatment


  1. Pyrimethamine plus sulphadiazine with folinic acid treatment is continued after clinical resolution till CD4 >200cell/μl for 4-6mo

  2. Cotrimoxaxol prophylaxis for PCP prevents toxoplasmosis
• HIV encephalopathy


  • CNS involvement in perinatally infected children is 50–90% in developing countries with a median onset at 19 mo of age
  • At least 1 of the following progressive findings present for at least 2 mo in the absence of a concurrent illness other than HIV infection that could explain the findings: Failure to attain or loss of developmental milestones or loss of intellectual ability, Impaired brain growth or acquired microcephaly, Acquired symmetric motor deficit
• Lymphoid interstitial pneumonia(LIP)

  • Most common chronic lower RT abnormality (25% of HIV-infected children)
  • Chronic diffuse reticulonodular pattern on chest radiography rarely accompanied by hilar LAP
  • Insidious onset of tachypnea, cough, and mild to moderate hypoxemia with normal auscultatory findings
  • Progressive disease digital clubbing and symptomatic hypoxemia
  • Therapy with oral corticosteroid
  • Associated with primary Epstein-Barr virus infection
• Wasting syndrome

  • Persistent weight loss >10% of baseline
  • Downward crossing of at least 2 percentile lines on the wt/age chart in a child ≥1 yr OR <5th percentile on Wt/HT chart on 2 consecutive measurements,≥30 days apart
  • Chronic diarrhea (at least 2 loose stools per day for >30 days) OR documented fever (for >30 days, intermittent or constant)
• Other manifestations

  • Lymphadenopathy
  • Hepatosplenomegaly
  • Parotitis
  • Seborrheic dermatitis or eczema
  • Viral infections like HSV, herpes zoster, molluscum contagiosum, flat warts, anogenital warts, and candidal infections are recurrent and chronic
• Gastrointestinal and hepatobilary tract manifestations

  • Periodontal disease (ulcerative gingivitis or periodontitis)
  • Salivary gland disease (swelling, xerostomia)
  • Oral hairy leukoplakia and ulcerations
  • Chronic or recurrent diarrhea due to HIV associated enteropathy
  • Viruses- CMV, HSV and rotavirus
  • Bacterias - Salmonella, Campylobacter, MAC
  • Protozoa -Giardia, Cryptosporidium, Isospora, microsporidia
• Hematology and Malignacy

  • Anemia (hemoglobin <8 g/dL)
  • Neutropenia (white blood cell count <1,000/ìL), and/or Thrombocytopenia (platelet count <100 × 103/ìL) that persist for ≥30 days
  • NHL, primary CNS lymphoma, and leiomyosarcoma are the most commonly reported neoplasms
• Cardiovascular system

  • Cardiomyopathy