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Wasting Syndrome and Prolonged Fever in HIV-Infected

Children

HAIVNHarvard Medical School AIDS

Initiative in Vietnam

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By the end of this session, participants should be able to: Define wasting syndrome and list common

etiologies in HIV-infected children Review algorithmic approach to wasting

syndrome Define prolonged fever and list common

etiologies in HIV-infected children Review algorithmic approach to prolonged

fever

Learning Objectives

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Wasting syndrome

http://www.siddhaquest.com/images/web_buttons/Wasting_Syndrome_1.jpg

http://www1.lf1.cuni.cz/~hrozs/hiveng1.htm

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In the absence of concurrent illness other than HIV

Recognized AIDS-defining condition Can severely impact normal growth

and development Associated with high risk for HIV

disease progression and short-term mortality

Wasting

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Weight loss of more than 10% of body weight or body mass index (BMI) <18.5

PLUS Prolonged & unexplained diarrhea (>2 loose stools /day for more than 1

month)OR

Prolonged & unexplained fever (T> 37.5⁰C for more than 1 month)

HIV Wasting Syndrome: Clinical Diagnosis

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Documented weight loss (>10% of body weight)

PLUS Two or more unformed stools

negative for pathogensOR

Documented T > 37.5⁰C with no other cause of disease

HIV Wasting Syndrome – Definitive Diagnosis

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Clinical Staging

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Malnutrition Inadequate intake due to factors such as

drug side effects (e.g., taste disturbances) Infection(s) or illness, including recurrent /

occult including resulting conditions such as malabsorption • Oral or esophageal candidiasis (odynophagia)• Opportunistic infections (OIs)• Diarrhea• HIV

Depression

Common Etiologies - Wasting

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Severity of weight loss Symptoms/signs of occult infection Presence or history of diarrhea or vomiting Feeding practices Social or other factors affecting

feeding/access to nutritious foods Medication history including any taste

disturbances, reactions interfering with intake

Review of nutritional intake

Medical History

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Record / trend weight and height Thorough exam of systems for any

signs of overt or occult infection(s) Focus exam based on symptoms

reported

Physical Examination

http://pediatrics.about.com/cs/growthcharts2/l/blboystwo.htm

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Algorithmic approach to management of Wasting / failure to thrive

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Assessment: Take detailed history and perform thorough examInitial support: Hydration and nutritional support. Begin evaluation for ARV if the child is eligible.

Perform complete blood count with differential WBC, albumin, blood cultures, CXR, rule out TB, stool studies for bacteria, ova and parasites. Evaluate as for patients with diarrhea, fever. Abdominal ultrasound may reveal enlarged liver and spleen.- Consider hospitalization for dietary

support.- Re-evaluate for occult infection.- Consider ARV treatment if eligible

Causes found?

Hospitalize to give nutritional support, fluid replacement,

vitamins and minerals

Give feeding trial for 7 days with increased

caloric and vitamin supplementation

Treat for candida or HSV (if ulcers)

No improvement

Child critically malnourished or

dehydrated?

History of inadequate caloric

intake?

History of thrush or oral ulcers?

History of fever or diarrhea?

NoTreat for causesYes

If improved, continue treatment with close monitoring

Management of Wasting

Adapted from Viet Nam MOH Guidelines

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Prolonged fever

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T > 37.5⁰C for more than 14 days Common etiologies

• Infectious: bacterial (salmonellosis, bacteremia, TB, MAC), fungal (cryptococcosis/meningitis, penicilliosis), viral (CMV, HSV/meningitis), malaria, etc.

• HIV related neoplasms (e.g. lymphoma)• HIV itself• Drug fever (hypersensitivity to drugs

such as CTX or ARVs)

Prolonged Fever

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TB Pneumonia in a 2-year-old who presented with fever, cough, weight lossSource: www.Uptodate.com

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Take a thorough history including:• Was the onset acute or subacute?• How long has the fever/ illness lasted?• Is it associated with any signs/ symptoms (thorough

review of symptoms by system, e.g., productive or dry cough, difficulty breathing, shortness of breath, skin or mucosal lesions, night sweats, chills, weight loss, mental status changes, joint pains)?

• Has anyone in patient’s family or close contacts been diagnosed with / is currently being treated for TB or other infectious diseases?

• Medication history including ARVs, CTX, allergies • History of OIs or other HIV-related conditions?

Medical History

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Perform detailed physical exam looking for signs of:• General conditions: weight loss, skin or

mucosal lesions, lymphadenopathy• Respiratory complications: dyspnea,

cyanosis, crackles, fremitus, digital clubbing• Other: mental-physical underdevelopment,

immunodeficiency (e.g. oral thrush, cachexia)

Focus exam from history taking/ symptoms

Physical Examination

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8-year-old boy presenting with prolonged fever and skin lesionsSource: www.med.cmu.ac.th

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Algorithmic approach to management of prolonged fever

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Suggestive causes of fever:•Respiratory findings: TB, PCP, bacterial pneumonia•Neurologic findings: Bacterial, TB, cryptococcal meningitis, Toxoplasma encephalitis, malaria•Skin lesions: Penicilliosis, Cryptococcosis

•Lymphadenopathy: TB, MAC, fungal septicemia •Diarrhea: Salmonellosis, TB enteritis, MAC•Anemia: TB, MAC, fungal septicemia•History with medication: allergy•Etc....

Diagnosis not confirmed by investigations, the child does not respond to empirical treatment

Empirical treatment:•Septicemia: appropriate antimicrobials•Penicilliosis: itraconazole•PCP: co-trimoxazole•TB: Anti-TB drugs

•Bacterial or cryptococcal meningitis: proper antimicrobials•Toxoplasma encephalitis: co-trimoxazole•Etc...

Diagnosis confirmed by investigations, and/or the child responds to empirical therapy

Routine and cause-guiding investigations:•CBC, CD4 (if available)•Respiratory findings: CXR, sputum for AFB •Neurologic findings: PL•Septicemia, penicilliosis: blood culture•Lymphadenopathy: aspiration•Abdomen ultrasound, etc...

•Re-evaluate clinically, consider other causes, especially TB, MAC or fever due to HIV itself•Do corresponding lab tests and investigations; consider lymphnode biopsy, bone marrow analysis and biopsy...•Treat presumptively for TB; MAC•Consider ARV treatment

Prolonged fever

•Take history •Examine physically

Give antipyretics, rehydration, good nutrition

•Continue and complete treatment. •Maintenance treatment if indicated

Adapted from Viet Nam MOH Guidelines

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HIV wasting syndrome is defined either clinically by patient/ caregiver report or definitively through documentation of weight loss and prolonged diarrhea or fever

A thorough medical history and physical examination should be performed to rule out and / or address any treatable causes of wasting

Prolonged fever is diagnosed when the child has T>37.5⁰C for >14 days

A thorough medical history and physical examination should be performed to diagnose and address any treatable causes of prolonged fever

Health care providers can refer to the algorithms adapted from the Viet Nam Ministry of Health for further guidance on how to manage wasting syndrome and/ or prolonged fever

Key points

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Thank you!

Questions?