Pediatric emergency medicine trisk 586

Clinical Considerations
Clinical recognition: Initial ED recognition of children with known HIV
infection should include categorizing children as likely OIs ( Table 94.24 and
e-Table 94.26 ) based on their CD4+ cell count, infections caused by pathogens
which also infect normal hosts, and drug toxicities from their antiretroviral
regimen or from prophylactic antibiotics or antiviral medications ( e-Table
94.27 reviews antiretroviral medications and
e-Table 94.28 reviews adverse
events). ED clinicians should also be cognizant of the presentations of acute HIV
infection ( Tables 94.24 and 94.25 ) in adolescents and of the presentations of
OIs in as-yet undiagnosed children with perinatally acquired HIV infection (
e-Table 94.29 ), most of whom will become symptomatic during infancy.
Triage considerations: HIV-infected children should be roomed as rapidly as
possible to prevent them from acquiring a nosocomial infection while in the ED.
Triage assessment should include obtaining pulse oximetry, as indolent
hypoxemia may be the first sign of early Pneumocystis jiroveci (formerly, P.
carinii ) pneumonia (PJP). Triage personnel need to be cognizant that HIVinfected children are at risk for overwhelming bacterial and viral sepsis, similar
to other immunocompromised children.
Clinical assessment: The most common clinical presentations of HIV-infected
children and one diagnostic approach are reviewed in
e-Table 94.30 . The
first branch point in decision making for the febrile HIV-infected child is
whether or not they are ill appearing. Most infections, even in HIV-infected
children will be caused by common pathogens also seen in immunocompetent
children. However, it is important that providers realize that the rates of
bacteremia are higher in HIV-infected children than in their immunocompetent
peers. It appears that serious bacterial, viral, or OIs are relatively uncommon
among well-appearing HIV-positive children who present to the ED with fever.


TABLE 94.24

OPPORTUNISTIC INFECTIONS MOST COMMONLY SEEN IN
HUMAN IMMUNODEFICIENCY VIRUS (HIV)-INFECTED
CHILDREN



TABLE 94.25
CLINICAL MANIFESTATIONS AND DIAGNOSIS OF ACUTE HIV
INFECTION
Symptoms

Signs

Laboratory findings

Fever
Pharyngitis

Pyrexia
Generalized lymphadenopathy

Rash

Maculopapular rash

HIV PCR
ELISA, Western blot
often initially
negative, convert to
positive by 2–4 mo

Leukopenia

Myalgias
Headache
Nausea, vomiting
Diarrhea

Mucocutaneous ulcerations
Hepatomegaly
Splenomegaly
Neurologic symptoms: aseptic
meningitis,
meningoencephalitis,
neuropathy, radiculopathy,
facial nerve palsy, Guillain–
Barré syndrome, psychosis

Thrombocytopenia

HIV, human immunodeficiency virus; PCR, polymerase chain reaction; ELISA, enzyme-linked
immunosorbent assay.

HIV-positive patients with fever who appear ill should be treated like other illappearing, febrile children because they are likely to be infected with the same
types of organisms that infect immunocompetent children. An LP is indicated for
those with meningismus, change in mental status, or an underlying abnormal
mental status makes assessment difficult; the clinician should consider obtaining
a CT of the brain prior to LP to evaluate for a mass-occupying lesion. If a child
is believed to be so unstable that LP is not safe, it can be delayed. In either case,
the child should be started on parenteral broad-spectrum antimicrobials.
Ceftriaxone (100 mg/kg/day divided every 12 hours) is an appropriate choice

because it covers the organisms that most commonly cause sepsis in children. In
areas with high rates of pneumococcal penicillin resistance, addition of
vancomycin should be considered. In young children, because of the possibility
of PCP presenting with fever and ill appearance, TMP-SMZ (5 mg/kg/dose of