Kurikulum

 vitae  
•  dr  Finny  Fitry  Yani  SpA(K)  
 
•  Staf  Respirologi  Anak    
         FK  Unand  RS  M  Djamil  
•  Sp1  Anak    2004  
•  Fellowship  Respi  anak  FKUI  RSCM  
•  Konsultan  Respirologi  Anak  :  2011  
•  Shortcourse  Pediatric  TB  :  Capetown,  
South  Africa  2011  
•  Organisasi      :  Komite  CPD    IDAI  Sumbar  

 
 Common Respiratory
Problems in HIV Children

Finny  Fitry  Yani  

UKK  Respirologi  IDAI  
Sub  Bagian  Respirologi  RS  M  Djamil-­‐FK  Unand  Padang  
 Why is this topic important?

•  Worldwide, in 2011, an estimated 330 000 [280

000–380 000] new infections due to the human
immunodeficiency virus (HIV) occurred in children
WHO 2012
•  Respiratory diseases in HIV –infected children :
opportunistic infection (OI) related to
presumptive diagnosis, increase morbidity and
mortality
•  Problems : difficult to diagnose and management,
especially in developing country
  
Natural  history  of  HIV  in  ver=cally  HIV-­‐
infected  children  –  differences  from  adults  
  progression  in  some  
•   Faster  rate  of  clinical  disease  
children;  20–25%  progress  in  the  first    year    
•  Primary  disease  with  opportunisSc  infecSons  more  
common  than  re-­‐acSvaSon  
•  LymphocySc  intersSSal  pneumoniSs  (LIP)  is  common  
•  Bacterial  infecSons  are  very  common  and  occur  at  all  
stages  of  disease  
•  Growth  failure  occurs  as  well  as  weight  loss  and  
wasSn  
  Clinical  criteria  for  presump=ve  diagnosis  of  severe  HIV  disease  in  infants  
and  children  age  under  18  months  requiring  ART  in  situa=ons  where  
virological  tes=ng  is  not  available  (WHO  Guldelines  2011)  
 
A  presump=ve  diagnosis  of  severe  HIV  disease  should  be  made  if:  
§   the  infants  is  confirmed  as  being  HIV  anSbody-­‐posiSve  
     and  
§   diagnosis  of  any  AIDS-­‐indicator  condiSon(s)a  can  be  made    
     or  
§   the  infants  is  symptomaSc  with  two  or  more  of  the  following:  
                           -­‐  oral  thrush  
                           -­‐  severe  pneumonia;  
                           -­‐  severe  sepsis;  
Other  factors  that  support  the  diagnosis  of  severe  HIV  disease  in  an  HIV-­‐
seroposi=ve  infant  include:  
• Recent  HIV-­‐  related  maternal  death  or  advanced  HIV  disease  in  the  mother;  
•   CD4  <  20%  
 

Confirma=on  of  the  diagnosis  of  HIV  infec=on  should  be  sought  as  soon  as  
possible.  
Respiratory   Illnes   among   HIV-­‐Infected  
Children  according  to    WHO  Clinical  Stage  

PCP,  LIP,  
Unexlained   Empyema,  
was=ng,   Disseminated  
fever,   MAC  
pulmonary  
Upper   TB  ,  
Respiratory   pneumonia    
Limfodeno   Stage  4  (severe)  
Infec=on  
pa=  
persisten   Stage  3  (advance)  

Stage  2  (mild)  

Stage  1  
(asymptoma=c)    
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General  CondiSons  
•  Lower  respiratory  tract  infecSons  are  the  most  
common  recurrent  infecSons  in  PLHIV.  
•  They  are  usually  life-­‐threatening    
•  PaSents  may  present  early  in  the  course  of  HIV  
infecSon  with  bacterial  pneumonias,  which  
respond  readily  to  anSbioScs  
•  PaSents  with  HIV  infecSon  appear  to  be  
parScularly  prone  to  infecSons  with  
encapsulated  organisms  such  as  Streptococcus  
pneumoniae  and  Haemophilus    influenzae    
General  CondiSons  
•  Later,  and  with  the  onset  of  immune  
suppression,  paSents  may  develop  
opportunisSc  pulmonary  infecSons,  the  most  
important  of  which  is  pulmonary  TB.  
•  As  cell-­‐mediated  immunity  deteriorates,  
paSents  may  develop  life-­‐threatening  
opportunisSc  infecSons  such  as  PCP  and  
severe  fungal  and  viral  pneumonias.  
Unknown  
Life  
HIV  status  
threatening  

Asymptoma=c  
Known    
HIV  status  

How    respiratory   Low  CD4    

related  HIV  can  be  
High  CD4  
find?  
 Ini=al  Inves=ga=on  
   
•  Evidence  of  advanced  immune  deficiency  state  e.g.  
oral  thrush  etc.  according  to  WHO  clinical  stage    
•  If  the  CD4  count  is  available,  it  is  useful  to  consider  
the  aeSological  differenSal  diagnosis    
•  Evidence  of  prophylaxis  therapy  e.g:  Cotrimoxazol,  
Isoniazid,  include  duraSon  
•  PaSents  with  a  history  of  tuberculosis  should  have  a  
chestX-­‐ray  once  a  year.  
Symptoms that might be related to
Respiratory Illness

•  Dyspnoea: Pneumocystis jirovecii pneumonia

(PCP), TB, pneumonia;

•  Cough: PCP, TB, pneumonia;

•  Bloody sputum :TB, pneumonia;

•  Weightloss, fever, nightsweats:

TB, atypical TB, lymphoma
Summary  for  CD4  correlates  with  respiratory  diseases  
CD4  count/μL   Respiratory  disease  
Any  CD4  count   •   Upper  Respiratory  Infec=on  
•   Bacterial  penumonia  
•   TB  
•   Non-­‐spesific  inters==al  pneumonias  

CD4  count  <200   •   PCP  

•   TB  but  oden  disseminated  
•   Cryptococcus  pneumonia  
•   Bacterial  pneumonia  oden  with  bacteraemia    
     or  sepsis  
CD4  count  <100   •   Bacterial  pneumonia  due  to    Pseudomonas    
     aeruginosa  
•   Toxoplasmosis  
•   Kaposi  
CD4  <50   •   MAC  
•   CMV  
•   Fungal  infec=ons  
Recurrent    or  chronic    
upper    respiratory    tract    infec;on.  
•  Current    event      with    at    least  one      episode      in  
the  past  six    months.    
•  Symptom    complex;  fever    with    unilateral    face  
pain  and  nasal  discharge    (sinusiSs)  or    painful  
swollen  ear  drum  (oSSs  media),  sorethroat  with  
producSve    cough  (bronchiSs),    sorethroat  
(pharyngiSs)  and  barking    croup-­‐like  cough  
(laryngotrachealbronchiSs).  
•  Persistent  or  recurrent  ear  discharge  
Bacterial  Respiratory  Infec;on  
Clinical  Manifesta=ons  
•   Bacterial  lower  respiratory  tract  infecSons  are  
common  in  the  general  populaSon,  but  they  are  more  
frequent  and  more  severe  in  immunosuppressed    
persons    with    HIV    infecSon.  
•  S.  pneumoniae  is  the  most  common  lower  respiratory  
tract  pathogen.  
•  PaSents  with  bacterial  pneumonia  present  with  cough  
and  fever    and    oden    have    chest    pain,    difficulty  
inbreathing  and    tachypnoea.  
•  Chest  X-­‐rays  may  show  classic  lobar  pneumonia,  
bronchopneumonia  or  atypical  (or  absent)  infiltrates.  
Chest  X-­‐ray:  

16  
Bacterial  Respiratory  Infec;on  
Treatment  &  PrevenSon  
•  According  to  treatment  bacterial  pneumonia  in  general  
populaSon    
•  First  line  :  Ampicillin/sulbactam  or    Amoxycillin/  
clavulanic  acid.  
•  CAP  with  co-­‐morbidity:  2nd  cefalosporin  (cefuroxim),    
         3rd  cefalosporin  (cefotaxim/cehriaxon),    
•  Suspected  atypical  pneumonia:  Macrolide  
•  Pneumococcal  vaccina=on  is  recommended  

17  
 Non-­‐severe  pneumonia  (0–5  years)  
•  Oral  amoxicillin  as  first-­‐line  anSbioSc.    
•  Oral  cotrimoxazole  is  also  recommended,  but  
should  ideally  not  be  used  rouSnely  as  this  will  
encourage  resistance  and  diminish  its  
effecSveness  against  P.  jiroveci.  
•  Regular  follow-­‐up  to  monitor  progress.  
  
Severe  pneumonia  (2–11  months)  
 
•  Hospitalize  and  administer  intravenous  anSbioSc:  
         ampicillin/penicillin  +  gentamicin  or  
         oral    amoxicillin  +  gentamicin.  
•   Treat  for  P.  jiroveci  with  intravenous  cotrimoxazole.  
•   If  not  improving  within  72  h  change  to  second-­‐line  
anSbioSc:  cehriaxone.  
•   Give  oxygen  if  signs  of  hypoxaemia.  
  
Severe  pneumonia  (12–59  months)  
 
•  Hospitalize  and  administer  intravenous  anSbioSc:  
•  ampicillin/penicillin  þ  gentamicin  or  oral  
amoxicillin  
•  þ  gentamicin.  
•   Treat  for  P.  jiroveci  if  clinically  indicated.  If  not  
improving  within  72  hr  change  to  secondline  
•  anSbioSc:  cehriaxone.  
•  Give  oxygen  if  signs  of  hypoxaemia.  
Mycobacterium  tuberculosis  
Clinical  ManifestaSons  
•  Non  specific  symptoms,  such  as  chronic  
cough,  fever,  night  sweats,    anorexia      and    
weight  loss.  
•  In    the    older    child  also    producSve      cough  
and  haemoptysis.  
•  History  of      contact    with    adults        with    smear-­‐
posiSve    pulmonary  tuberculosis.  
•  No    response    to    standard    broad-­‐spectrum    
anSbioSc    treatment  
 Mycobacterium  tuberculosis  
Clinical  ManifestaSons  
•  Younger  children  progress  more  rapidly  
(possibly  due  to  delayed  diagnosis)  
•  Extrapulmonary:  marrow,  lymph  node,  bone,  
pleura,  pericardium,  peritoneal  
•  Pulmonary  TB  most  likely  appears  as  infiltrate  
with  hilar  adenopathy  
•  Clinical  presentaSon  of  TB  similar  in  HIV-­‐
posiSve  and  HIV-­‐negaSve  children  
 Mycobacterium  tuberculosis  
Diagnosis  
•  Difficult  to  diagnose;    
•  About  10%  of  culture-­‐posiSve  children  have  
negaSve  TST  
•  Perform  annual  TST  beginning  at  3-­‐12  months  
using  5  TU  PPD  intradermally  
•  DefiniSve  :  One    or      more    sputum    smear  
posiSvef    or    acid-­‐fast  bacille  and/or  radiographic  
abnormaliSes  consistent  with    acSve  tuberculosis  
and/or  culture-­‐posiSve  for  Mycobacterium.  
Mycobacterium  tuberculosis  
Treatment  
•  Treatment  principles  similar  in  HIV-­‐posiSve  
and  HIV-­‐negaSve  children  (3-­‐4  OAT)  
•  IniSate  treatment  as  soon  as  possible  in  
children  <4  years  old  with  suspected  TB  
•   Begin  TB  treatment  4-­‐8  weeks  before  ARVs  
•  If  already  on  ARV,  review  drug  interacSons  
•  Use  of  DOT  increases  adherence,  decreases  
resistance,  treatment  failure,  and  relapse  
 Mycobacterium  tuberculosis  
Preven=on  ?  
•  Although  INH  prophylaxis  is  recommended  for  all  
young  children  with  a  household  contact  with  TB  
irrespecSve  of  their    HIV  status,  in  many  
developing  countries  this  may    not  occur  due  to  
limited  resources,  lower  priority    given  to  
childhood  TB  and  quesSons  regarding  efficacy.  
•  Thus,  providing  INH  prophylaxis  for  HIV  infected  
children  in  developing  countries  may  be  
challenging.  
Life  Cycle  of    PCP  
Pneumocys==s  Jerovecii  Pneumonia    
Clinical  Manifesta=ons  
•  Should  be  suspected  and  anS-­‐pneumocysSs  therapy  
considered  in  any    HIV-­‐posiSve  infant  with  severe  
pneumonia    
•   Age  <12  months,  absent  or  low-­‐grade  fever,  
cyanosis,  hypoxia  that  is  persistent,  poor  response    
to  48  h  of  first-­‐line  anSbioScs  and  elevated  levels  of  
LDH,  all  support  the  diagnosis.  
•   PCP  is  ohen  the  first  clinical  indicator  of  HIV    
infecSon.  
 
Pneumocys==s  Jerovecii  Pneumonia  
Clinical  Manifesta=ons  and  Diagnosis  
•   Clinical  and  radiological  signs  are  not  
diagnosSc.  
•  However,  a  clear  chest    or  diffuse  chest  signs  
on  auscultaSon  are  typical  with  PCP  infecSon,  
as  is  the  presence  of  diffuse  infiltrates  rather  
than  focal  signs  on  chest  X-­‐ray.  
•   Induced  sputum  and  NPA  are  useful  for  
obtaining  sputum  for  examinaSon  when  BAL  is  
not  possible.  
 PCP  in  HIV  (+)  paSent  
Chest  X-­‐ray  

32  
Pneumocys=s  Jerovecii  Pneumonia  
Treatment  and  Preven;on  
 
•  >2  months  15-­‐20  mg/kg/day  of  TMP,  75-­‐100  mg/Kg/
day  of  SMZ  intravenously  in  3-­‐4  divided  doses  over  1  
hour  for  21  days  (per  oral  for  mild-­‐moderate)  
•  Steroid    can  be  use  for  moderate  -­‐  severe  PCP  within  
72  hours  of  diagnosis,  reduced  respiratory  failure,    
venSlaSon  requirements,  and  mortality    
•  Lifelong  prophylaxis  indicated  (CD4  <  200)  
•  The  incidence  of  adverse  drug  reacSon  to  co-­‐
trimoxazole    
Limphoid  Inters;sial  Pneumonia  (LIP)  
Clinical  ManifestaSon  
•  Common  in  pediatric  HIV  infecSon  (30-­‐40%)  
•  Associated  with  autoimmune  and  
lymphoproliferaSve  disorders,  human  
immunodeficiency  virus  (HIV)  type  1,  Epstein-­‐Barr  
virus,  human  T-­‐cell  leukemia  virus  (HTLV)  type  1  
•  CD4+  count  >  200  cells/µL  
•  ManifestaSon:  insidious  onset  cough,  faSgue,  
dyspnea,  tachypnea,  hepatosplenomegaly,  
paroSd  gland  enlargement,  hypoxemia  
•  PE:  crackles,  wheezing,  cyanosis,  clubbing  
Limphoid  Inters;sial  Pneumonia  (LIP)  
Diagnosis  and  Treatment  
•  Chest  X-­‐ray:  diffuse  reSculonodular/alveolar  
infiltrate  (lower  lobe),  pleural  effusion,  hilar  
lymphadenopathy,  
•   No  respon  to  anSbioSc  treatment  
•   Hypoxemia  persisten  <  90%  
•  DefiniSve  diagnosis:  biopsy,    
•  Prednisone  2  mg/kg/day  2-­‐4  weeks    
         DisconSnued:  no  response  aher  4-­‐6  month  
•  Bronchodilator:  mild-­‐moderate  disease  
Chest  X-­‐ray:  diffus  nodular  infiltrate  +    
hilar  lymphadenopathy    

36  
 Other  infecSons  involved  pulmonary  
•  Cryptococcosis  
•  Hystoplasmosis  
•  CMV  
•  Candida  
Summary  
Recurrent  
Pneumonia   PCP   Tuberculosis   etc  

Natural  disease  of  children  HIV    infected  Clinical  

Stage  

Isoniazid  and  
   Health  care  
Age   Cotri  
acces  
Prophylaxis