Letters to the Editor

Indian Pediatrics 2002; 39:597-598

HIV Wasting Syndrome

Growth failure occurs in 20-80% of symptomatic HIV-infected children who may progress to a distinct wasting syndrome, an AIDS defining illness.

We present a case of a 5½-year-old boy who presented with intermittent fever, diarrhea and weight loss since 6 months. Physical examination revealed weight of 13 kg, height of 94 cm, hepato-splenomegaly, cervical lymphadenopathy and scars of Herpes zoster involving two dermatomes on the turnk. The patient and both parents were ELISA and spot test positive. The routine investigations were normal except hemoglobin of 9.4 g/dL, ESR of 108 mm and chest X-ray showing right mid and lower zone consolidation. Mantoux text was negative and no opportunistic pathogens were seen in the stool. His mother had pulmonary tuberculosis. The patient received anti-tubercular therapy for nine months along with nutritional supplementation and Pneumocystis carinii pneumonia prophylaxis. On follow up, the pulmonary lesions cleared but intermittent diarrhea and fever was persistent with weight remaining static. After 18 months, progressive weight loss (4 kg) continued to give him severely emaciated look with loss of fat from all over the body. He suffered second episode of Herpes zoster, which was treated with intravenous Acyclovir. The child had severe immuno-suppression [CD4 = 140/µL (5%)](1). Laboratory investigations did not reveal any other pathogen or site of infection. Here, antiretroviral therapy (zidovudine + lamivudine) was started without viral load estimation. With four months of antiretroviral therapy (ART), fever subsided with no improvement in diarrhea and weight. The child died, 22 months after the diagnosis.

Wasting is due to HIV associated hypermetabolic-catabolic state and AIDS enteropathy. Anorexia, opportunistic infec-tions, and macro-and micronutrient deficiency further contribute to wasting. Hyper-metabolic-catabolic state due to cytokine production is postulated to be the cause of wasting(2). These children experience chronic diarrhea for which no etiological agent other than HIV can be identified and this is referred to as AIDS enteropathy(3).

In this patient, intermittent fever was due to hypermetabolic state while persistent diarrhea (with no pathogen identified) indicates AIDS enteropathy. Nutritional supplementation alone was in vain. Wasting, severe immuno-suppression and probably high viral load were responsible for failure of two drugs anti-retroviral therapy.

These children are likely to have low CD4 count and high viral load, so only highly active antiretroviral therapy (HAART) will produce greatest improvement in health including nutritional status. HAART includes at-least two nucleoside reverse transcriptase inhibitors and one protease inhibitor. The supportive therapy includes megestrol acetate (oral synthetic progestational agent), oxandrolone (oral anabolic agent) and nutritional supplementation.

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1. Centres for Disease Control and Prevention. 1994 Revised classification system for HIV infection in children less than 13-years of age. MMWR 1994; 43 (RR-12): 1-17.

2. Mintz M, Rapaport R, Oleske JM, Connor EM, Koenigsberger MR, Denny T, et al. Elevated serum levels of tumor necrosis factor are associated with progressive encephalopathy in children with AIDS. Am J Dis Child 1989; 143: 771-774.

3. Ullrich R, Zeitz M, Heise W, Lage M, Hoffken G, Riecken EO. Small intestinal structure and function in patients infected with HIV: Evidence for HIV-induced enteropathy. Ann Intern Med 1989; 111:15-21.