Pediatric HIV Infection Differential Diagnoses
- Author: Delia M Rivera, MD; Chief Editor: Russell W Steele, MD more...
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.
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.
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- Table 1. CDC Immunologic Categories for HIV-Infection in Children Based on Absolute CD4+ Counts
- Table 2. Antibiotics for Primary and Secondary Prophylaxis of Opportunistic Infections
- Table 3. Drugs and Doses for Prophylaxis of Opportunistic Infections
- Table 4. CD4+ -Based Indications for Starting PCP Prophylaxis
- Table 5. CD4+ -Based Indications for MAC Prophylaxis
- Table 6. Risk Factors for Vertical Transmission
|< 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)|
|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|
|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
|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.|
|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|
|Age or Status||CD4+ Count, Cells/mL|
|< 1y||< 750|
|1-2 y||< 500|
|2-6 y||< 75|
|> 6 y||< 50|
|Period||Factors That Increase Risk||Factors That Decrease Risk|
|Prenatal||Acute HIV infection
Viral load >10,000
Illicit IV drug use
|Viral load < 1000
|Perinatal||Rupture of membranes for >4 h
Emergency cesarean delivery
Use of scalp electrodes
|Elective cesarean delivery with zidovudine treatment|
Low birth weight