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Brief Reports Indian Pediatrics 1999;36: 1250-1253 |
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HIV Infection in Children: Indian Experience |
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| S.R. Daga, Bela Verma, D.V. Gosavi From the Cama and Albless Hospital, Mumbai, India. |
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| Human immunodeficiency virus (HIV) infection is
rapidly becoming a problem among children in India. One of the problems in establishing
the diagnosis in developing countries has been the lack of adequate laboratory facilities
and the fact that the clinical manifestations of HIV infection in children are often seen
in uninfected children. There are few published reports of the clinical manifestations of
pediatric HIV infection in India. This paper describes the clinical manifestations of HIV
infection in a small group of children and attempts to identify clinical features and risk
factors that may lead one to suspect HIV infection in children in India. Subjects and Methods The subjects included 28 children who were suspected to have HIV infection based on suggestive clinical presentation or risk factors for infection. The clinical manifestations leading to the suspicion of HIV infection included: 1. Severe malnutrition with (a) extensive oral candidiasis, (b) recurrent diarrhea, (c) recurrent lower respiratory tract infection (LRTI), or (d) recurrent or chronic parotitis. 2. Prolonged unexplained illness or wasting. 3. Congenital syphilis. 4. Death of a parent from a prolonged debilitating illness or confirmed tuber-culosis. 5. Parent with a positive HIV test. 6. Suggestive social history, including (a) child of a commercial sex worker (CSW), (b) parental disharmony or separation or (c) infrequent hospital visits by parent(s). The diagnosis was confirmed by positive serology beyond the age of 18 months (20 children), a positive polymerase chain reaction (PCR) test for HIV DNA at 13 and 19 weeks of age (1 patients), positive serology below 18 months of age but with clinical features strongly suggestive of HIV infection (2 infants). The remaining 5 children were siblings of HIV infected children; 4 asymptomatic and 1 symptomatic, who also had a positive serology. Serology was performed by an ELISA test (DETECT-HIV, Biochem Immunosystem, Montreal) and confirmed using a second ELISA test which used a different test principle (Immunocomb Biospot test, Organics, Yavne). The PCR test used to detect viral DNA was based on amplification of the gag gene. The clinical manifestations, nutritional status, risk factors and disease progression of these 28 children were reviewed. The children were also categorized using the World Health Organization (WHO) and Centers for Disease Control and Prevention (CDC) criteria. Results The 28 children included 18 boys and 10 girls. The mean age at presentation was 10 months (range 3 months to 96 months). The clinical manifestations of HIV infection seen in these children are shown in Table I. The most frequent manifestation seen was recurrent diarrhea. Tuberculosis was diagnosed in 8 children. The diagnosis was based on clinical criteria and radiological findings and response to anti-tuberculosis treatement: only 4 patients had a positive tuberculin test. All the children with tuberculosis had pulmonary involvement. Hepatosplenomegaly was seen in 5 of these children. However, since hepatosplenomegaly is a common manifestation in HIV infection, it is difficult to say whether this was due to HIV infection or tuberculosis since biopsies were not performed. None of the children had miliary or central nervous system tuberculosis. Table I__ Clinical Syndromes Seen in Children with HIV Infection.
Only six children fulfilled the WHO clinical case definition of pediatric AIDS(1). The classification of patients according to the CDC classification was as follows: asymptomatic-10, mildly symptomatic-1, moderately symptomatic - 6, and severely symptomatic-11. Among mildly symptomatic cases, we came across hepato-splenomegaly and parotitis. Moderately symptomatic cases presented with severe bacterial infection or candidiasis. Severely symptomatic cases had multiple infection or disseminated tuberculosis or suspected oppor-tunistic infection(2). The nutritional status was graded according to the Indian Academy of Pediatrics classifica-tion(3). Eight children had normal nutrition, 3, 8, and 9 children had grades 2,3 and 4 protein energy malnutrition, respectively. During a follow up period ranging from 10-18 months, 10 children died, 6 were lost to follow up and the remaining 12 children were alive. The children who were alive were mildly symptomatic. The median age of death was 18 months. The median age of the survivors at last follow up was 4 years. Four children died of an acute illness associated with multi-organ failure, presumbaly sepsis. Death occurred within 48 hours of admission. Four children died follow-ing protracted undiagnosed illnesses. The risk factors identified included known HIV infection in one or both parents in 7, history of a chronic debilitating history or tuberculosis in one or both parents in 9 and the mothers being a commercial worker in 5 children, respectively. We found that in 17 children the father either did not visit the child in hospital or made only very infrequent visits. In five children HIV testing was performed because of unexplained wasting or prolonged undiagnosed illness in the child, rather than a risk factor in the parents(s). Discussion Though the prevalence of HIV infection in India is rapidly increasing there is very little published data on the clinical manifestations of the infection in children in this country. This case series attempts to provide such information. One of the limitations of this study is the lack of etiological diagnosis in the patients and we have only been able to describe clinical syn-dromes rather than specific infectious complica-tions. Nevertheless, there are several important lessons to be learnt. Tuberculosis was a common problem among these children. The high prevalence of tuberculosis among HIV-infected adults leads to an increased risk of this infection among their infected children. Therefore, it is essential to monitor these children carefully and institute treatment early, since response to treatment is good. Since tuberculin test may be negative in a significant proportion of these children, one must be careful not to rely solely on this test for screening. Chest radiographs must be obtained when tuberculosis is suspected. Several studies in developing and developed countries show that mortality is highest in infancy and those who survive infancy may remain well for several years before succumb-ing(4). Our findings are on the same lines. The commonest identifiable disease result-ing in death was an acute illness with multi-organ failure. Though we were unable to prove it with cultures, we suspect that this was due to septicemia. Children with HIV infection are prone to septicemia from pneumococcus, H. influenzae and Pseudomonas. Thus, a high index of suspicion must be maintained in children with HIV infection who present with high fever without localizing signs, Early institution of parenteral antibiotics, after taking blood culture (if available), may be life saving. None of the deaths was due to acute or persistent diffuse pneumonia. Pneumocystis carinii pneu-monia has been described as a common cause of death in infants with HIV(5). Data from our study suggests otherwise. Many children with HIV infection in India present with recurrent episodes of common childhood illnesses like acute diarrhea, lower respiratory infection and otitis media. These children often do not fulfil the WHO criteria for the diagnosis of pediatric AIDS. In such children, careful history for risk factors in the parents will often help in suspecting the diagnosis of HIV infection. Though it is not conventionally considered to be a risk factor, our data suggests the failure of the father to visit the child in hospital or only make very infrequent visits may be a significant marker of the illness. However, a more systematic study is required before this hypothesis can be accepted. References 1. World Health Organization. Acquired immuno-deficiency syndrome (AIDS). WHO/CDC case definition for AIDS. Wkly Epid Rec 1986; 61: 69-76. 2. Centers for Disease Control. Revision of the case definition of acquired immunodeficiency syn-drome for national reporting, United states. MMWR 1987, 36 (Suppl 15): 3-15. 3. Nutrition sub-committee of the Indian Academy of Pediatrics. Report. Indian Pediatr 1972; 9: 360. 4. Tovo PA, de Martino M, Gabianco C, Galhi L, Cappello N, Ruga E, et al. Prognostic factors and survival in children with perinatal HIV-1 infection. Lancet 1992; 339: 1249-1253. 5. Cherian T, Ramkrishna B, George Babu P, John JT, Raghupathy P. Pneumocystis carinii pneumonia in pediatric acquired immnodefi-ciency syndrome. Indian Pediatr 1997; 34: 550-554. |
