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Pediatric HIV Infection Differential Diagnoses

  • Author: Delia M Rivera, MD; Chief Editor: Russell W Steele, MD  more...
 
Updated: Apr 07, 2016
 
 

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

 
 
Contributor Information and Disclosures
Author

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, Pediatric Infectious Diseases Society

Disclosure: Nothing to disclose.

Coauthor(s)

Richard E Frye, MD, PhD Associate Professor, Department of Pediatrics, University of Arkansas for Medical Sciences

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

Disclosure: Nothing to disclose.

Specialty Editor Board

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.

Chief Editor

Russell W Steele, MD Clinical Professor, Tulane University School of Medicine; Staff Physician, Ochsner Clinic Foundation

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, Southern Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

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 y 1-5 y 6-12 y
1 - No suppression ≥1500 (>25) ≥1000 (>25) ≥500 (>25)
2 - Moderate suppression 750-1499 (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
TB PPD test result >5 mm Isoniazid and pyridoxine qd for 9 mo Rifampin for 4 mo
Exposure Isoniazid and pyridoxine 3 times/wk for 9 mo, rifampin and pyrazinamide qd for 2 mo Consult an infectious diseases specialist if the pathogen is multidrug resistant
PCP CD4+ finding* Trimethoprim-sulfamethoxazole qd Trimethoprim-sulfamethoxazole 3 times/wk
Fever of unknown origin for 2 wk, history of infection Dapsone, pyrimethamine, and leucovorin Dapsone or aerosolized pentamidine in children >5 y
--- Atovaquone Atovaquone
Toxoplasmosis CD4+ count < 100 cells/mL Trimethoprim-sulfamethoxazole qd Dapsone, pyrimethamine, and leucovorin
Positive immunoglobulin G finding None Atovaquone
Previous infection Sulfadiazine, pyrimethamine, and leucovorin Clindamycin, pyrimethamine, and leucovorin
MAC infection CD4+ finding** Azithromycin qwk Rifabutin qd or clarithromycin bid
Previous infection Clarithromycin or azithromycin qd and ethambutol Clarithromycin 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
Azithromycin 20 mg/kg/dose (1.2 g maximum) PO qwk or



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



Clarithromycin 7.5 mg/kg/dose (500 mg maximum) PO bid
Clindamycin 20-30 mg/kg/d PO qid
Dapsone 1-2 mg/kg/d (100 mg maximum) PO qd
Ethambutol 15 mg/kg/dose (900 mg maximum) PO qd
Isoniazid 10-15 mg/kg/dose (300 mg maximum) PO/IM qd
Leucovorin 5 mg PO 3 times/wk
Pentamidine 4 mg/kg/dose monthly
Pyrimethamine 15 mg/m2/dose (25 mg maximum) PO qd
Rifabutin 5 mg/kg/dose (300 mg maximum) PO qd
Rifampin 10-20 mg/kg (600 mg maximum) PO/IV qd
Sulfadiazine 85-120 mg/kg/d PO bid
Trimethoprim-sulfamethoxazole 150/750 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 y Any Any
1-2 y < 750 < 15
2-5 y < 500 < 15
>5 y < 200 < 15
Previous PCP infection Any Any
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 infection Any
Table 6. Risk Factors for Vertical Transmission
Period Factors That Increase Risk Factors That Decrease Risk
Prenatal Acute HIV infection



Viral load >10,000



Cigarette smoking



Illicit IV drug use



Viral load < 1000



Zidovudine treatment



Neutralizing antibodies



Perinatal Rupture of membranes for >4 h



Chorioamnionitis



Emergency cesarean delivery



Surgical delivery



Episiotomy



Use of scalp electrodes



Elective cesarean delivery with zidovudine treatment
Neonatal Prematurity



Low birth weight



First-born twin



Full-term



Second-born twin



Postdelivery Breastfeeding ART
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