Wasting Syndrome and Prolonged Fever in HIV-Infected Children - PowerPoint Presentation

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Wasting Syndrome and Prolonged Fever in HIV-Infected Children

HAIVNHarvard Medical School AIDS Initiative in Vietnam

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 syndromeDefine prolonged fever and list common etiologies in HIV-infected childrenReview algorithmic approach to prolonged feverLearning Objectives

Wasting syndrome

http://www.siddhaquest.com/images/web_buttons/Wasting_Syndrome_1.jpg

http://www1.lf1.cuni.cz/~hrozs/hiveng1.htm

In the absence of concurrent illness other than HIVRecognized AIDS-defining conditionCan severely impact normal growth and developmentAssociated with high risk for HIV disease progression and short-term mortality

Wasting

Weight loss of more than 10% of body weight or body mass index (BMI) <18.5

PLUSProlonged & unexplained diarrhea (>2 loose stools /day for more than 1 month)ORProlonged & unexplained fever (T> 37.5⁰C for more than 1 month)

HIV Wasting Syndrome:

Clinical Diagnosis

Documented weight loss (>10% of body weight

)PLUSTwo or more unformed stools negative for pathogensORDocumented T > 37.5⁰C with no other cause of disease HIV Wasting Syndrome –

Definitive Diagnosis

Clinical Staging

MalnutritionInadequate 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)DiarrheaHIVDepression Common Etiologies - Wasting

Severity of weight lossSymptoms/signs of occult infectionPresence or history of diarrhea or vomiting

Feeding practicesSocial or other factors affecting feeding/access to nutritious foodsMedication history including any taste disturbances, reactions interfering with intakeReview of nutritional intakeMedical History

Record / trend weight and height

Thorough exam of systems for any signs of overt or occult infection(s)Focus exam based on symptoms reported

Physical Examination

http://pediatrics.about.com/cs/growthcharts2/l/blboystwo.htm

Algorithmic approach to management of Wasting / failure to thrive

Assessment

: Take detailed history

and perform thorough exam

Initial support

: Hydration and nutritional support. Begin evaluation for ARV if the child is eligible.

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.

- Consider hospitalization for dietary support.

- Re-evaluate for occult infection.

- Consider ARV treatment if eligible

Causes found?

Hospitalize to give nutritional support, fluid replacement, vitamins and minerals

Give feeding trial for 7 days with increased caloric and vitamin supplementation

Treat for candida or HSV (if ulcers)

No improvement

Child critically malnourished or dehydrated?

History of inadequate caloric intake?

History of thrush or oral ulcers?

History of fever or diarrhea?

No

Treat for causes

Yes

If improved,

continue treatment with close monitoring

Management of Wasting

Adapted from

Viet Nam MOH Guidelines

Prolonged fever

T > 37.5⁰C for more than 14 daysCommon etiologiesInfectious: bacterial (salmonellosis, bacteremia, TB, MAC), fungal (

cryptococcosis/meningitis, penicilliosis), viral (CMV, HSV/meningitis), malaria, etc.HIV related neoplasms (e.g. lymphoma)HIV itselfDrug fever (hypersensitivity to drugs such as CTX or ARVs)Prolonged Fever

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

Source: www.Uptodate.com

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?

Medical History

Perform detailed physical exam looking for signs of:General conditions: weight loss, skin or mucosal lesions, lymphadenopathyRespiratory complications: dyspnea, cyanosis, crackles, fremitus, digital clubbing

Other: mental-physical underdevelopment, immunodeficiency (e.g. oral thrush, cachexia)Focus exam from history taking/ symptomsPhysical Examination

8-year-old boy presenting with prolonged fever and skin lesions

Source: www.med.cmu.ac.th

Algorithmic approach to management of prolonged fever

Suggestive causes of fever:

Respiratory findings: TB, PCP, bacterial pneumonia

Neurologic findings: Bacterial, TB, cryptococcal meningitis, Toxoplasma encephalitis, malaria

Skin lesions: Penicilliosi

s, Crypt

ococcosis

Lymphadenopathy: TB, MAC, fungal septicemia

Diarrhea: Salmonellosis, TB enteritis, MAC

Anemia: TB, MAC, fungal septicemia

History with medication: allergy

Etc....

Diagnosis not confirmed by investigations, the child does not respond to empiric

al

treatment

Empiric

al

treatment

:

Septicemia: appropriate antimicrobials

Penicilliosis: itraconazole

PCP: co-trimoxazole

TB: Anti-TB drugs

Bacterial or cryptococcal meningitis: proper antimicrobials

Toxoplasma encephalitis: co-trimoxazole

Etc...

Diagnosis confirm

ed

by investigations,

and/or

t

he child responds to empiric

al

therapy

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...

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

Prolonged fever

Take history

Examine physicall

y

Give

antipyretics

, rehydration, good nutrition

Continue and complete treatment.

Maintenance treatment if indicated

Adapted from

Viet Nam MOH Guidelines

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 daysA thorough medical history and physical examination should be performed to diagnose and address any treatable causes of prolonged feverHealth 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

Key points

Thank you!

Questions?