Pediatric HIV Infection Differential Diagnoses

  • Author: Ronald A Greenfield, MD; Chief Editor: Russell W Steele, MD   more...
 
Updated: Mar 28, 2012
 
 

Diagnostic Considerations

Older children and young teenagers can have human immunodeficiency virus (HIV) infection or AIDS without a history of immunodeficiency or severe illness. Fever of unknown origin, recurrent infection, growth failure, or developmental regression without an obvious etiology should increase the index of suspicion for HIV infection.

The failure to complete neonatal testing is another pitfall. The process to verity that an at-risk neonate does not have HIV infection is complex. Too often, follow-up tests are not performed if initial results are negative.

Prenatal HIV tests are often performed, but the results may not be followed up, especially in low-risk women.

Nonopportunistic infections

Like most children, children with HIV are susceptible to common pathogens. Diseases caused by such pathogens should be high in the list of differential diagnoses for these children. Of course, the particular child's medical history guides the differential diagnosis. For example, chronic lung disease requires special consideration of atypical respiratory pathogens, such as Pseudomonas or Xanthomonas species.

One of the challenges with children who are infected with HIV is that they are more likely than others to have recurrent infections, which cause them to undergo repeat treatment with many broad-spectrum antibiotics. This antibiotic exposure increases the risk of their developing resistant pathogens. Therefore, infection with penicillin-resistant pneumococci is not uncommon in children with recurrent ear infections.

Common recurrent infections are otitis, sinusitis, and pneumonia. Recurrent otitis is observed in 55% and 35% of HIV-infected children with AIDS and those without AIDS, respectively.

Children with recurrent bacterial infections and CD4+ counts of less than 200 X 109/L may benefit from monthly IVIG.

Moderate and severe neutropenia increases the risk for bacterial infection by 2.3- and 7.9-fold, respectively. Other risk factors for bacterial infection include neutropenia within the last 3 months and central venous line access.

Differential Diagnoses

Proceed to Workup
 
 
Contributor Information and Disclosures
Author

Ronald A Greenfield, MD  Professor, Department of Internal Medicine, University of Oklahoma College of Medicine

Ronald A Greenfield, MD is a member of the following medical societies: American College of Physicians, American Federation for Medical Research, American Society for Microbiology, Central Society for Clinical Research, Infectious Diseases Society of America, Medical Mycology Society of the Americas, Phi Beta Kappa, Southern Society for Clinical Investigation, and Southwestern Association of Clinical Microbiology

Disclosure: Pfizer Honoraria Speaking and teaching; Gilead Honoraria Speaking and teaching; Ortho McNeil Honoraria Speaking and teaching; Abbott Honoraria Speaking and teaching; Astellas Honoraria Speaking and teaching; Cubist Honoraria Speaking and teaching; Forest Pharmaceuticals Speaking and teaching

Coauthor(s)

Delia M Rivera, MD  Assistant Professor, Department of Pediatrics, Division of Infectious Disease and Immunology, University of Miami Leonard M Miller School of Medicine

Delia M Rivera, MD is a member of the following medical societies: American Academy of Pediatrics, American Society for Microbiology, and Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Richard E Frye, MD, PhD  Assistant Professor, Departments of Pediatrics and Neurology, University of Texas Medical School at Houston

Richard E Frye, MD, PhD is a member of the following medical societies: American Academy of Neurology, American Academy of Pediatrics, Child Neurology Society, and International Neuropsychological Society

Disclosure: Nothing to disclose.

Chief Editor

Russell W Steele, MD  Head, Division of Pediatric Infectious Diseases, Ochsner Children's Health Center; Clinical Professor, Department of Pediatrics, Tulane University School of Medicine

Russell W Steele, MD is a member of the following medical societies: American Academy of Pediatrics, American Association of Immunologists, American Pediatric Society, American Society for Microbiology, Infectious Diseases Society of America, Louisiana State Medical Society, Pediatric Infectious Diseases Society, Society for Pediatric Research, and Southern Medical Association

Disclosure: Nothing to disclose.

Additional Contributors

Mark Abdelmalek, MD Chief, Division of Laser and Dermatologic Surgery, Assistant Professor, Department of Dermatology, Drexel University College of Medicine

Mark Abdelmalek, MD is a member of the following medical societies: American Academy of Dermatology, American College of Mohs Micrographic Surgery and Cutaneous Oncology, American Medical Association, American Society for Dermatologic Surgery, Pennsylvania Academy of Dermatology, and Pennsylvania Medical Society

Disclosure: Nothing to disclose.

David F Butler, MD Professor of Dermatology, Texas A&M University College of Medicine; Chair, Department of Dermatology, Director, Dermatology Residency Training Program, Scott and White Clinic, Northside Clinic

David F Butler, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Dermatology, American Medical Association, American Society for Dermatologic Surgery, American Society for MOHS Surgery, Association of Military Dermatologists, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Joseph Domachowske, MD Professor of Pediatrics, Microbiology and Immunology, Department of Pediatrics, Division of Infectious Diseases, State University of New York Upstate Medical University

Joseph Domachowske, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Pediatrics, American Society for Microbiology, Infectious Diseases Society of America, Pediatric Infectious Diseases Society, and Phi Beta Kappa

Disclosure: Nothing to disclose.

Kathleen B Elmer, MD Consulting Staff, Department of Dermatology, First Medical Group, Langley Air Force Base

Disclosure: Nothing to disclose.

Dirk M Elston, MD Director, Ackerman Academy of Dermatopathology, New York

Dirk M Elston, MD is a member of the following medical societies: American Academy of Dermatology

Disclosure: Nothing to disclose.

Warren R Heymann, MD Head, Division of Dermatology, Professor, Department of Internal Medicine, University of Medicine and Dentistry of New Jersey-New Jersey Medical School

Warren R Heymann, MD is a member of the following medical societies: American Academy of Dermatology, American Society of Dermatopathology, and Society for Investigative Dermatology

Disclosure: Nothing to disclose.

William D James, MD Paul R Gross Professor of Dermatology, Vice-Chairman, Residency Program Director, Department of Dermatology, University of Pennsylvania School of Medicine

William D James, MD is a member of the following medical societies: American Academy of Dermatology and Society for Investigative Dermatology

Disclosure: Elsevier Royalty Other

Michael Loosemore, MD Fellow in Dermatological Surgery, The Methodist Hospital

Michael Loosemore, MD is a member of the following medical societies: American Academy of Dermatology, Massachusetts Medical Society, and Pennsylvania Academy of Dermatology

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

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Genome layout of human immunodeficiency virus (HIV)–1 and HIV-2.
Table 1. CDC Immunologic Categories for HIV-Infection in Children Based on Absolute CD4+ Counts
Category
< 1 y1-5 y6-12 y
1 - No suppression≥1500 (>25)≥1000 (>25)≥500 (>25)
2 - Moderate suppression750-1499 (15-24)500-999 (15-24)200-499 (15-24)
3 - Severe suppression< 750 (< 15)< 500 (< 15)< 200 (< 15)
Table 2. Antibiotics for Primary and Secondary Prophylaxis of Opportunistic Infections
Infection Indication First-Line Regimen Alternative Regimen
TBPPD test result >5 mmIsoniazid and pyridoxine qd for 9 moRifampin for 4 mo
ExposureIsoniazid and pyridoxine 3 times/wk for 9 mo, rifampin and pyrazinamide qd for 2 moConsult an infectious diseases specialist if the pathogen is multidrug resistant
PCPCD4+ finding*Trimethoprim-sulfamethoxazole qdTrimethoprim-sulfamethoxazole 3 times/wk
Fever of unknown origin for 2 wk, history of infectionDapsone, pyrimethamine, and leucovorinDapsone or aerosolized pentamidine in children >5 y
---AtovaquoneAtovaquone
ToxoplasmosisCD4+ count < 100 cells/mLTrimethoprim-sulfamethoxazole qdDapsone, pyrimethamine, and leucovorin
Positive immunoglobulin G findingNoneAtovaquone
Previous infectionSulfadiazine, pyrimethamine, and leucovorinClindamycin, pyrimethamine, and leucovorin
MAC infectionCD4+ finding**Azithromycin qwkRifabutin qd or clarithromycin bid
Previous infectionClarithromycin or azithromycin qd and ethambutolClarithromycin or azithromycin qd and ethambutol
Abbreviations: bid = twice daily; PPD = purified protein derivative; qd = every day; qwk = every week.



* See Table 4



**See Table 5



Table 3. Drugs and Doses for Prophylaxis of Opportunistic Infections
Drug Dose
Azithromycin20 mg/kg/dose (1.2 g maximum) PO qwk or



5 mg/kg/dose (250 mg maximum) PO qd



Clarithromycin7.5 mg/kg/dose (500 mg maximum) PO bid
Clindamycin20-30 mg/kg/d PO qid
Dapsone1-2 mg/kg/d (100 mg maximum) PO qd
Ethambutol15 mg/kg/dose (900 mg maximum) PO qd
Isoniazid10-15 mg/kg/dose (300 mg maximum) PO/IM qd
Leucovorin5 mg PO 3 times/wk
Pentamidine4 mg/kg/dose monthly
Pyrimethamine15 mg/m2/dose (25 mg maximum) PO qd
Rifabutin5 mg/kg/dose (300 mg maximum) PO qd
Rifampin10-20 mg/kg (600 mg maximum) PO/IV qd
Sulfadiazine85-120 mg/kg/d PO bid
Trimethoprim-sulfamethoxazole150/750 mg/m2/d PO bid
Abbreviations: bid = twice daily; PO = by mouth; qd = every day; qwk = every week.
Table 4. CD4+ -Based Indications for Starting PCP Prophylaxis
Age or Status CD4+ Count, cells/mL CD4+ Percentage
6 wk to 1 yAnyAny
1-2 y< 750< 15
2-5 y< 500< 15
>5 y< 200< 15
Previous PCP infectionAnyAny
Table 5. CD4+ -Based Indications for MAC Prophylaxis
Age or Status CD4+ Count, Cells/mL
< 1y< 750
1-2 y< 500
2-6 y< 75
> 6 y< 50
Previous infectionAny
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