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Neck Masses Hoarseness Diarrhea Arthritis Fever and Rash Lymphadenopathy Anemia Petechiae/Purpura Failure to Thrive
In adolescents and adults, primary infection results in the acute retroviral syndrome that develops after an incubation period of 2 to 6 weeks and consists of fever, malaise, weight loss, pharyngitis, lymphadenopathy, and often a maculopapular rash. The risk of opportunistic infections and other AIDS-defining conditions is related to the depletion of CD4 T cells. A combination of CD4 cell count and percentage and clinical manifestations is used to classify HIV infection in children (Tables 125-1 and 125-2).
Initial symptoms with vertical transmission vary and may include failure to thrive, neurodevelopmental delay, lymphadenopathy, hepatosplenomegaly, chronic or recurrent diarrhea, interstitial pneumonia, or oral thrush. These findings may be subtle and remarkable only by their persistence.
From Centers for Disease Control and Prevention: 1994 revised classification system for human immunodeficiency virus infection in children less than 13 years of age,
MMWR 43(RR-12):1–10, 1994.
Manifestations that are more common in children than adults with HIV infection include recurrent bacterial infections, lymphoid hyperplasia, chronic parotid swelling, lymphocytic interstitial pneumonitis, and earlier onset of progressive neurologic deterioration. Pulmonary manifestations of HIV infection are common and include Pneumocystis jirovecipneumonia, which can present early in infancy as a primary pneumonia characterized by hypoxia, tachypnea, retractions, elevated serum lactate dehydrogenase, and fever.
In the United States, most pregnant women are screened and, if indicated, treated for HIV infection. Infants born to HIV-infected mothers receive prophylaxis and are prospectively tested for infection. The diagnosis of HIV infection in most infants born in the United States is confirmed before development of clinical signs of infection.
HIV infection can be diagnosed definitively by 1 month of age and in virtually all infected infants by 6 months of age using viral diagnostic assays (RNA polymerase chain reaction [PCR], DNA PCR, or virus culture). Maternal antibodies may be detectable until 12 to 15 months of age, and a positive serologic test is not considered diagnostic until 18 months of age.
HIV DNA PCR is the preferred virologic method for diagnosing HIV infection during infancy and identifies 38% of infected infants at 48 hours and 96% at 28 days. Diagnostic viral testing should be performed by 48 hours of age, at 1 to 2 months of age, and at 3 to 6 months of age. An additional test at 14 days of age is often performed because the diagnostic sensitivity increases rapidly by 2 weeks of age. HIV RNA PCR has 25% to 40% sensitivity during the first weeks of life, increasing to 90% to 100% by 2 to 3 months of age. However a negative HIV RNA PCR cannot be used to exclude infection and, thus, is not recommended as first-line testing.
HIV infection of an exposed infant is confirmed if virologic tests are positive on two separate occasions. HIV infection can be reasonably excluded in nonbreastfed infants with at least two virologic tests performed at older than 1 month of age, with one test being performed after 4 months of age, or at least two negative antibody tests performed after 6 months of age, with an interval of at least 1 month between the tests. Loss of HIV antibody combined with negative HIV DNA PCR confirms absence of HIV infection. Persistence of a positive HIV antibody test after 18 months of age indicates HIV infection.