pediatrics
Human Immunodeficiency Virus (HIV) Infection in Infants and Children
Symptoms and Signs of HIV Infection in Infants and Children
Combination ART has significantly changed the clinical manifestations of pediatric HIV infection. Although bacterial pneumonia and other bacterial infections (eg, bacteremia, recurrent otitis media) still occur more often in children with HIV infection, opportunistic infections and growth failure are much less frequent than in the pre-ART era. New problems, such as alterations in serum lipids, hyperglycemia, fat maldistribution (lipodystrophy and lipoatrophy), nephropathy, and osteonecrosis, are reported; however, the incidence is lower in children than in adults with HIV infection. Although combination ART clearly improves neurodevelopmental outcome, there seems to be an increased rate of behavioral, developmental, and cognitive problems in treated children with HIV infection. It is unclear whether these problems are caused by HIV infection itself, medications, or other biopsychosocial factors that occur among children with HIV infection. It is unknown whether any additional effects of HIV infection or ART during critical periods of growth and development will manifest later in life. However, no such effects have been noted in perinatally infected children who were treated with ART and are now young adults. To detect such adverse effects, providers will need to monitor children with HIV infection over time. Infants infected perinatally usually are asymptomatic during the first few months of life, even if no combination ART is begun. Although the median age at symptom onset is about 3 years, some children remain asymptomatic for>5 years and, with appropriate ART, are expected to survive to adulthood. In the pre-ART era, about 10 to 15% of children had rapid disease progression, with symptoms occurring in the first year of life and death occurring by 18 to 36 months; these children were thought to have acquired HIV infection earlier in utero. However, most children likely acquire infection at or near birth and have slower disease progression (surviving beyond 5 years even before ART was used routinely). In infants who are not receiving ART, disease manifestations include failure to thrive, neurologic problems (eg, loss or delay in motor skills, irritability, poor head growth), failure to thrive, andPneumocystispneumonia. Older children who are not receiving ART frequently have recurrent otitis media, sinusitis, bacterial pneumonia, bacteremia, herpes zoster, and lymphoid interstitial pneumonitis. Older children and adolescents whose disease manifests late in childhood (called slow progressors or nonprogressors) may present with persistent generalized lymphadenopathy, esophageal candidiasis, and lymphoma of the brain or other sites, which is similar to manifestations in adults who are not receiving ART. All of these manifestations, including opportunistic infections, occur only rarely in people who are receiving combination ART. When complications occur, they typically involve opportunistic infections (and rarely cancer). Combination ART has made such infections uncommon, and they now occur mainly in undiagnosed children who have not yet received ART or in children who are not adherent to ART. When opportunistic infections occur, Pneumocystis jirovecii Pneumonia is the most common and serious and has high mortality. Other opportunistic infections in immunosuppressed children include Candida esophagitis , disseminated Cancers in immunocompromised children with HIV infection are relatively uncommon, but leiomyosarcomas and certain lymphomas, including CNS lymphomas and non-Hodgkin B-cell lymphomas (Burkitt type), occur much more often than in immunocompetent children. Kaposi sarcoma is very rare in children with HIV infection. (See Cancers Common in Patients with HIV Infection .) 