The differential diagnosis of AIDS in infants includes primary immunodeficiency syndromes and intrauterine infections with cytomegalovirus (CMV) and syphilis. Prominenceof individual symptoms, such as diarrhea, may suggest otheretiologies.
Management of HIV infection in children and adolescents is rapidly evolving and becoming increasingly complex. It should be directed by a specialist in the treatment of HIV infection. Therapy is initiated based on the severity of HIV disease, as indicated by AIDS-defining conditions, and the risk of disease progression, as indicated by CD4 cell count and plasma HIV RNA level (Table 125-3). Initiation of antiretroviral therapy while the patient is still asymptomatic may preserve immune function and prevent clinical progression but incurs the adverse effects of therapy and may facilitate emergence of drug-resistant virus. Because the risk of HIV progression is fourfold to sixfold greater in infants and very young children, treatment recommendations for children are more aggressive than for adults. All age groups show rapid increases in risk as CD4 cell percentage declines to less than 15%.
Initiation of therapy (see Table 125-3) is recommended for infants less than 12 months of age regardless of symptoms of HIV disease or HIV RNA level. Initiation of therapy is recommended for all children 1 to 5 years of age with AIDS or significant HIV-related symptoms or CD4 below 25% (clinical category C or most clinical category B) regardless of symptoms or HIV RNA level. For children older than 5 years with AIDS or significant HIV-related symptoms, CD4 count below 350/mm3 should be treated. Indications for treatment of adolescents and adults include CD4 cell count less than 200 to 350/mm3 or plasma HIV RNA levels above 55,000 copies/mL.
Combination therapy with highly active antiretroviral therapy (HAART) is recommended based on the risk of disease progression as determined by CD4 percentage or count and plasma HIV RNA copy number; the potential benefits
Children who have no signs or symptoms considered to be the result of HIV infection or who have only one of the conditions listed in category A
Children with two or more of the following conditions, but none of the conditions listed in categories B and C: Lymphadenopathy (nodal tissue enlargement of ≥0.5 cm palpable at more than two sites; bilateral = one site)
Recurrent or persistent upper respiratory infection, sinusitis, or
Children who have symptomatic conditions, other than those listed for category A or category C, that are attributed to HIV infection. Examples of conditions in clinical category B include, but are not limited to, the following:
Anemia (<8 g/dL), neutropenia (<1000/mm3), or thrombocytopenia (<100,000/mm3) persisting ≥30 days
Bacterial meningitis, pneumonia, or sepsis (single episode) Candidiasis, oropharyngeal (i.e., thrush) persisting for >2 months in children younger than 6 months of age
Cardiomyopathy Cytomegalovirus infection with onset before the age of 1 month Diarrhea, recurrent or chronic Hepatitis HSV stomatitis, recurrent (i.e., more than two episodes within 1
HSV bronchitis, pneumonitis, or esophagitis with onset before the age of 1 month Herpes zoster (i.e., shingles) involving at least two distinct episodes or more than one dermatome Leiomyosarcoma LIP or pulmonary lymphoid hyperplasia complex Nephropathy Nocardiosis Fever lasting >1 month Varicella, disseminated (i.e., complicated chickenpox)