Hiv In Children


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Hiv In Children

  1. 1. <ul><li>Presented by Guided by </li></ul><ul><li>Dr Harish Kumar singhal Prof Abhimanyu Kumar </li></ul><ul><li>M.D Scholar Head of Department </li></ul><ul><li>Department of Bal Roga </li></ul><ul><li>N.I.A, JAIPUR </li></ul>
  2. 2. <ul><li>AIDS stands for Acquired Immune Deficiency Syndrome: </li></ul><ul><li>* Acquired means you can get infected with it. </li></ul><ul><li>* Immune Deficiency means a weakness in the body's system that fights diseases. </li></ul><ul><li>* Syndrome means a group of health problems that make up a disease. </li></ul><ul><li>AIDS some time also called SLIM DISEASE. </li></ul>
  3. 3. <ul><li>AIDS was originally defined by CDC as “the presence of a reliably diagnosed disease that is at least moderately indicative of an underlying defect in cell mediated immunity.” </li></ul><ul><li>The current surveillance of definition categorizes HIV infected person on the basis of clinical condition associated with HIV infection & CD4 + T lymphocyte counts. </li></ul><ul><li> or </li></ul><ul><li>AIDS is a clinical entity characterized by profound loss of immune function associated with a depletion of CD4 +helper T lymphocyte. </li></ul>
  4. 4. <ul><li>AIDS has now attained a form of unique pandemic with America, Europe, Africa being most affected & Asia least affected. </li></ul><ul><li>WHO estimated that by the end of 2001,40 million people were globally living with HIV & of which 1 / 3 rd aged between 15 to 24 years. </li></ul><ul><li>95% of new infection are occurring in developing countries & almost 50% are women. </li></ul>
  5. 5. <ul><li>Pediatric AIDS contribute 2% of all HIV infected case in developed countries as compared with 15-20% in developing countries. </li></ul><ul><li>At the end of 2007, there were 2.5 million children living with HIV around the world. </li></ul><ul><li>420,000 children became newly infected with HIV in 2007. </li></ul><ul><li>Of the 2.1 million people who died of AIDS during 2007, more than one in seven were children. Every hour, around forty children die as a result of AIDS. </li></ul>
  6. 6. <ul><li>Because HIV infected mothers are likely to dies of AIDS,10 million children orphaned thus far and an estimated 20 million will be orphaned by 2010. </li></ul><ul><li>In India approximately 30000 of that 27 million deli varies occur in seropositive women & between 6000-8000 infant are thought to be perinatelly infected with HIV. </li></ul><ul><li>All above data shown that HIV infection in children progress more rapidly than in adults ,and some untreated children die with in the first 2 yr of life. </li></ul>
  7. 7. <ul><li>AIDS was first reported June 5 , 1981 , when the U.S. Centers for Disease Control and Prevention recorded a cluster of Pneumocystis carinii pneumonia (now still classified as PCP but known to be caused by Pneumocystis jirovecii ) in five homosexual men in Los Angeles . </li></ul><ul><li>Three of the earliest known instances of HIV infection are: </li></ul><ul><li>A plasma sample taken in 1959 from an adult male living in Kinshasa , today part of the Democratic Republic of the Congo. </li></ul><ul><li>HIV found in tissue samples from &quot; Robert R. &quot;, a 15 year old African-American teenager who died in St. Louis in 1969. </li></ul><ul><li>HIV found in tissue samples from Arvid Noe , a Norwegian sailor who died around 1976. </li></ul><ul><li>First pediatric case of AIDS globally was recognised in 1982. </li></ul><ul><li>In india first AIDS patient was recognised in 1986. </li></ul>
  8. 8. <ul><li>AIDS is caused by a virus called HIV, the Human Immunodeficiency Virus. </li></ul><ul><li>When HIV virus was first identified it was called “Lymphadenopathy associated virus” (LAV) by the French scientist. </li></ul><ul><li>Researcher in USA called it Human T lymphocytic virus III ( HTLV III). </li></ul><ul><li>In may 1986, the international committee on taxonomy gave it a new name HIV. </li></ul>
  9. 9. <ul><li>An enveloped virus, approximately 120 nm in diameter. </li></ul><ul><li>Sub family :- Lentivirus </li></ul><ul><li>Family:- Retrovirus </li></ul><ul><li>Two species of HIV infect humans: HIV-1 and HIV-2 . </li></ul><ul><li>HIV-1 is more virulent and more easily transmitted. </li></ul><ul><li>HIV-1 is the source of the majority of HIV infections throughout the world, while HIV-2 is not as easily transmitted and is largely confined to West Africa. Both HIV-1 and HIV-2 are of primate origin. </li></ul><ul><li>The origin of HIV-1 is the Central Common Chimpanzee ( Pan troglodytes troglodytes ) found in southern Cameroon . It is established that HIV-2 originated from the Sooty Mangabey ( Cercocebus atys ), an Old World monkey of Guinea Bissau , Gabon , and Cameroon. </li></ul><ul><li>HIV 2 has about 40% sequence homology with HIV 1. </li></ul>
  10. 10. <ul><li>HIV genome is single stranded RNA 9.8 in size. </li></ul><ul><li>Both the ends have identical regions that contain regulation & expression genes of HIV. The remainder genome has 3 major section :- </li></ul><ul><li>Gag region –encode for viral protein </li></ul><ul><li>Pol region – produce viral enzyme.ex: Reverse transcriptase,protease,integrase etc </li></ul><ul><li>Env region – encode for viral envelop protein </li></ul>
  11. 11. <ul><li>Other regulatory protein such as tat,rev,vif,vpr,hef,vpw are involved in transactivation,viral mRNA expression, viral replication, promotion of nuclear import of viral reverse transcription. </li></ul><ul><li>Complexes down regulation of cell surface receptor CD4 & class I major histocompatibility complex, proviral DNA synthesis & virus release. </li></ul><ul><li>The important one include glycoprotein gp120 which has knob like structure,inteact with protruding loop on CD4 protein forming CD+-gp120 complex,gp41(envelop protein) & p24(core protein). </li></ul>
  12. 12. <ul><li>CXCR -4 act as co receptor for HIV attachment to lymphocyte. </li></ul><ul><li>CCR-5 a beta chemokinine co receptor that facilitate HIV into macrophage. </li></ul><ul><li>HIV virus is easily killed by heat(56 C for 30 min). It is readily inactivated by ether,acetone,20%ethanol,.2%sodium hypochlorite,1%gulatealdehyde,beta propioacetone(1:400 dilution). </li></ul><ul><li>It is relatively resistant to ionizing radiation & ultra violet light. </li></ul>
  13. 13. <ul><li>HIV binds via the viral envelop protein gp120 to CD4 receptor on the target cell. </li></ul><ul><li>Virus fuses with the host cell membrane & is internalized in an endosome. </li></ul><ul><li>Viral RNA genome Double helical DNA </li></ul><ul><li>Transported to host nucleus </li></ul><ul><li>Integrated into host genome (proviral DNA) </li></ul><ul><li>Transcription </li></ul><ul><li>Viral RNA </li></ul>
  14. 14. <ul><li>Viral RNA </li></ul><ul><li>Translation </li></ul><ul><li>Protein synthesis </li></ul><ul><li>The virus are assembled at cell membrane & are release by budding. The host cell either ruptures releasing virions is attached by the immune system & continued to produce virions.the virus spread to infect other cell,most of which express the CD4 protein. </li></ul>
  15. 15. <ul><li>Unlike HBV which is highly infectious, the HIV virus has less infectivity. Probably because relatively small number of infectious particle (I.P) circulating in blood.10-50 IP/ml of HIV are present in plasma of infected person as compared to 100000000 IP/ml of HBV. </li></ul><ul><li>However, the likely hood of becoming infected with HIV after receiving an HIV +ve blood product is nearly 100%. </li></ul><ul><li>The initial outcome of HIV infection depends on host’s immune reaction to virus either through falling of the infected cells or through suppression of further HIV multiplication. </li></ul>
  16. 16. <ul><li>The viruses has been found in greatest concentration in semen, blood & CSF. </li></ul><ul><li>Lower concentration have been detected in tears,saliva,breast milk,urine,cervical & vaginal secretions. </li></ul><ul><li>HIV has also been isolated in brain tissue, lymph nodes, bone marrow cells & skin. </li></ul>
  17. 17. <ul><li>Cases & carrier are one. </li></ul><ul><li>Once a person is infected, virus remains in the body life long. since HIV infection can take years to manifest itself. The symptom less carrier can infect other people for years. </li></ul>
  18. 18. <ul><li>Persons engaging in unprotected sex </li></ul><ul><li>Sexual partners of those who participate in high-risk activities (such as anal sex) </li></ul><ul><li>Intravenous drug users who share needles </li></ul><ul><li>Infants born to mothers with HIV who don't receive HIV therapy during pregnancy </li></ul><ul><li>People who received blood transfusions or clotting products between 1977 and 1985 (prior to the beginning standard screening for the virus in the blood) </li></ul>
  19. 19. <ul><li>The causative virus is transmitted from person to person most frequently through :- </li></ul><ul><li>Sexual activity </li></ul><ul><li>Needle sticks </li></ul><ul><li>Blood & blood product </li></ul><ul><li>This horizontal transmission however accounts for only 10-15% cases of AIDS in children. </li></ul><ul><li>HIV infection are acquired from infected mother resulting in vertical transmission to her offspring. </li></ul><ul><li>Rate of vertical transmission is 13-50%. </li></ul><ul><li>HIV is transmitted to infant-during gestation( in utero 30-40%),during delivaries(intrapartum 60-70%),postpartum(through breast feeding 14%). </li></ul><ul><li>Potentially routes of infections includes admixture of maternal fetal blood or viral infection across placenta alternately or extensive mucocutaneous exposure to maternal blood & vaginal secretion intranately. </li></ul>
  20. 20. <ul><li>Factors which may increase rate of vertical transmission :- </li></ul><ul><li>High level of viremia </li></ul><ul><li>Maternal seroconversion just before delivery </li></ul><ul><li>Vitamin A deficiency in mother </li></ul><ul><li>>4 hr duration of PROM </li></ul><ul><li>Vaginal delivaries </li></ul><ul><li>Delivary before 34 week </li></ul><ul><li>Birth weight <2500gm </li></ul><ul><li>Detectable P24 antigen in maternal serum </li></ul><ul><li>Absence of neutralizing antibodies in maternal serum </li></ul><ul><li>Maternal CD 4 +count <700/cubic mm </li></ul><ul><li>CD4+/CD8 ratio<.6 </li></ul><ul><li>Placental membrane inflammation </li></ul><ul><li>First born twin </li></ul><ul><li>Lack of anti viral therapy to infected women </li></ul>
  21. 21. <ul><li>HIV -1 has been detected by culture & by PCR method in cellular & acellular component of breast milk. </li></ul><ul><li>The colostral viral lode appears to be particularly high. </li></ul><ul><li>Fetal gut cells are susceptible to infection with HIV-1,such a route is facilitated by the absence of an cid environment in newborn baby’s stomach that allow HIV -1 to retain its infectivity. </li></ul>
  22. 22. <ul><li>PERINATAL </li></ul><ul><li>Shorter incubation period </li></ul><ul><li>LIP is common </li></ul><ul><li>Acute HIV syndrome almost never identified. </li></ul><ul><li>*LIP- lymphocytic interstitial pneumonitis </li></ul><ul><li>TRANSFUSION ACQUIRED </li></ul><ul><li>Larger incubation period </li></ul><ul><li>LIP is rare </li></ul><ul><li>Acute HIV syndrome can be seen 4-6 week after transfusion. </li></ul>
  23. 23. <ul><li>HIV Infected :- </li></ul><ul><li>A child less than 18 months of age who is HIV seropositive or born to HIV infected mother & has seropositive results on two separate determination from one or more of the following test: </li></ul><ul><li>HIV culture </li></ul><ul><li>HIV specific PCR </li></ul><ul><li>HIV antigen </li></ul><ul><li>Clinical criteria for AIDS diagnosis </li></ul><ul><li>A child 18 month of age or older born to HIV infected mother or infected by blood,blood product or other known mode of transmission. who is HIV antibody+ve by: </li></ul><ul><li>ELISA </li></ul><ul><li>Western blot </li></ul><ul><li>Immunofluorescence assay </li></ul><ul><li>Above criteria </li></ul><ul><li>Perinatelly exposed:- </li></ul><ul><li>A child who dose not meet above criteria but who is HIV seropositive by: </li></ul><ul><li>ELISA </li></ul><ul><li>Western blot </li></ul><ul><li>Immunofluorescence assay </li></ul><ul><li>< 18 month of age at the time of testing </li></ul><ul><li>Unknown antibody status, but was born to HIV infected mother </li></ul>
  24. 24. <ul><li>Sero reverter :- </li></ul><ul><li>A child born to HIV infected mother & who has been documented as HIV antibody negative ie </li></ul><ul><li>2 or more –ve ELISA test performed at 6-18 month of age </li></ul><ul><li>One –ve ELISA test after 18 month of age </li></ul><ul><li>And has no other lab evidence of infection & has not had an AIDS defining condition. </li></ul><ul><li>INCUBATION PERIOD – </li></ul><ul><li>From a few month to 10 years or even more. </li></ul>
  25. 25. <ul><li>CLINICAL FEATURES </li></ul><ul><li>The clinical manifestation of HIV infection varies widely among infant, children & adolescents. </li></ul><ul><li>In most of infants physical examination at birth is normal. </li></ul><ul><li>INTIAL SYMPTOM- </li></ul><ul><li>Lymphadenopathy </li></ul><ul><li>Hepatosplenomegaly </li></ul><ul><li>Failure to thrive </li></ul><ul><li>Chronic or recurrent diarrhea </li></ul><ul><li>Interstitial diarrhea </li></ul><ul><li>Oral thrush </li></ul><ul><li>SYMPTOMS more commonly found in children than adults are- </li></ul><ul><li>Recurrent bacterial infection </li></ul><ul><li>Chronic parotid swelling </li></ul><ul><li>LIP </li></ul><ul><li>Early progressive neurological deterioration </li></ul><ul><li>HIV classification system is used to categorize the stage of pediatric disease by using 2 parameters- </li></ul><ul><li>(a) Clinical category-CDC pediatric classification </li></ul><ul><li>(b) Immune classification-is based on the absolute CD4 lymphocyte count </li></ul>
  26. 26. <ul><li>The 1987 system defined the spectrum of disease & include illness that specific to children. According to it: </li></ul><ul><li>P0-an infant born to HIV seropositive women, whose immune status are not known </li></ul><ul><li>P1-children with documented HIV infection who are clinically asymptomatic. </li></ul><ul><li>P2- this category was classified into P-2A,P-2B,P-2C,P-2D1,P-2d2,P-2D3,P-2E1,P-2E2,P-2F & described the spectrum of symptomatic clinical disease, from non-specific s/s to opportunistic infection. </li></ul><ul><li>In 1994 CDC,ATLANTA revised the classification. </li></ul>
  27. 27. Immunological Categories CD4 + Lymphocyte count Clinical categories No sign / symptom (N) Mild sign/ symptom (A) Moderate sign/ symptom (B) Severe sign/ symptom (C) No evidence of suppression Normal >25% N1 A1 B1 C1 Evidence of moderate suppression Moderate reduction (15-24%) N2 A2 B2 C2 Severe suppression Severe reduction (<15%) N3 A3 B3 C3
  28. 28. Category A Category B Category C <ul><li>Lymphadenopathy </li></ul><ul><li>Anemia (Hb<8g/dl) or </li></ul><ul><li>Neutropenia (<1000/mm3) or </li></ul><ul><li>Thrombocytopenia(<1000000/mm3)persisting for >30days </li></ul><ul><li>Recurrent serious bacterial infection(meningitis,sepsis,pneumonia) </li></ul><ul><li>Parotitis </li></ul><ul><li>Bacterial meningitis,sepsis,pneumonia </li></ul><ul><li>Pulmonary or esophageal canadiasis </li></ul><ul><li>Hepatomegaly </li></ul><ul><li>Oropharyngeal canadiasis >2 month </li></ul><ul><li>Disseminated coccidiomycosis </li></ul><ul><li>Splenomegaly </li></ul><ul><li>Cadiomyopathy </li></ul><ul><li>Extra pulmonary cryptococcosis </li></ul><ul><li>Dermatitis </li></ul><ul><li>Cytomegalo virus </li></ul><ul><li>Cryptosporidiosis or isopsoriasis with diarrhea for >1 month </li></ul><ul><li>Recurrent or persisent sinusitis or </li></ul><ul><li>AOM </li></ul><ul><li>Persisentor recurrent diarrhea </li></ul><ul><li>Encephalopathy </li></ul>
  29. 29. <ul><li>Hepatitis </li></ul><ul><li>HSV infection >1 month </li></ul><ul><li>Recurrent HSV stomatitis(>2 incident in 1 yr) </li></ul><ul><li>Disseminated histoplasmosis </li></ul><ul><li>HSV bronchitis,pneumonitis,esophagitis with onset <1 month of age </li></ul><ul><li>Kaposi sarcoma </li></ul><ul><li>Recurrent herpis zoster </li></ul><ul><li>Primary lymphoma in brain </li></ul><ul><li>Leiomyosarcoma </li></ul><ul><li>Burkitt lymphoma </li></ul><ul><li>LIP or pulmonary lymphoid hyperplasia complex </li></ul><ul><li>Disseminated TB </li></ul><ul><li>Nocardosis </li></ul><ul><li>Pneumocystitis carini pneumonia </li></ul><ul><li>Persistent fever >1 month </li></ul><ul><li>Recurrent salmonella septicemia </li></ul><ul><li>Toxoplasmosis onset before 1 month of age </li></ul><ul><li>Toxoplasmosis of brain onset at>1 month age </li></ul><ul><li>Disseminated varicella </li></ul><ul><li>Wasting syndrome </li></ul><ul><li>Severe weight loss </li></ul>* Category N - Asymptomatic
  30. 30. <ul><li>Use of CD4 counts to asses HIV associated immunosuppresion in children are not free from problems, since: </li></ul><ul><li>Normal CD4 counts are higher in infants & younger children & decline over the first few year of life. </li></ul><ul><li>Children may develop opportunistic infection at higher level than adults. </li></ul><ul><li>Nevertheless, CD4 levels are apparently useful to asses the immunological status of HIV infected children. </li></ul>
  31. 31. Immunological Categories Age of child Cells/micro liter <12 month 1-5 years 6-12 years No evidence of suppression >1500 >1000 >500 Evidence of moderate suppression 750-1499 500-999 200-499 Severe suppression <750 <500 <200
  32. 32. <ul><li>Causative organism- </li></ul><ul><li>Streptococcus pneumonia </li></ul><ul><li>Salmonella </li></ul><ul><li>Staphylococcus </li></ul><ul><li>Enterococcus </li></ul><ul><li>Pseudomonas aeruginosa </li></ul><ul><li>Haemophilus influenzae </li></ul><ul><li>Most common serious infection is - </li></ul><ul><ul><li>Bacterimia </li></ul></ul><ul><ul><li>Pneumonia 5o% </li></ul></ul><ul><ul><li>Meningitis </li></ul></ul><ul><ul><li>UTI </li></ul></ul><ul><ul><li>Deep seated abscess </li></ul></ul><ul><ul><li>Bone & joint infection –less frequently </li></ul></ul><ul><li>OPPURTUNISTIC INFECTION -These infection are generally seen in children with severe decrease CD4 count </li></ul>
  33. 33. <ul><li>originally known as Pneumocystis carinii pneumonia, and still abbreviated as PCP, which now stands for P neumo c ystis p neumonia) is relatively rare in healthy, immunocompetent people, but common among HIV-infected individuals. It is caused by Pneumocystis jirovecii . </li></ul><ul><li>Incidence- occur at age of 3-6 month with highest mortality rate in children <1yr of age. </li></ul><ul><li>C / F- </li></ul><ul><li>Acute onset of fever </li></ul><ul><li>Tachypnea </li></ul><ul><li>Dyspnea </li></ul><ul><li>Marked hypoxemia </li></ul><ul><li>X-ray-There is increased white (opacity) in the lower lungs on both sides. </li></ul><ul><li>Diagnosis- Demonstration of P.Carini in the bronchoalveolar lavage. </li></ul><ul><li>Lung biopsy </li></ul><ul><li>Treatment –initially TMP 15-20mg/kg+SMZ 75-100mg/kg QID IV </li></ul><ul><li>on improvement therapy continue for next 21 days. </li></ul><ul><li>Alternative regime- </li></ul><ul><li>Pentamidine 4mg/kg/24hr </li></ul><ul><li>TMP + Dapsone </li></ul><ul><li>Clindamycin + Primaquin </li></ul>Major pulmonary illnesses
  34. 34. <ul><li>MAC ( Mycobacterium avium intracellular complex ) </li></ul><ul><li>Causative organism – Mycobacterium avium </li></ul><ul><li>It causes disseminated disease in HIV infected children who are severely immunosupressed. </li></ul><ul><li>Incidence in children with <100 CD4 cells/cubic mm- 10% </li></ul><ul><li>Symptom - fever, malaise, weight loss, night sweats, diarrhea, abdominal pain, rarely perforation or jaundice (due to biliary tract obstruction by Lymphadenopathy. </li></ul><ul><li>Diagnosis- Isolation of AC from blood, bone marrow. (Isolation of MAC from stool is not diagnostics) </li></ul><ul><li>Treatment- </li></ul><ul><li>Clarithromycin /Azithromyccin +Ethambutol </li></ul><ul><li>Rifabutin,(Rifampicin –in resistant case )+ ciprofloxacin </li></ul>
  35. 35. <ul><li>Fungal infection </li></ul><ul><li>Oral canadidiasis is most common fungal infection in HIV infected children. </li></ul><ul><li>Treatment – </li></ul><ul><li>Oral Nystatin susp 2-5 ml QID </li></ul><ul><li>In resistant case oral Amphotercine susp. </li></ul><ul><li>Flucanozole 4-6 mg/kg/24 hr for 14 days in case of esophageal canadidiasis. </li></ul><ul><li>Disseminated histoplasmosis,coccidiomycosis,cryptococcosis are rarely seen in pediatric patient. </li></ul>
  36. 36. Viral infection
  37. 37. <ul><li>CNS involvement in perinatelly infected children is 50-90% in developing countries but lower in developed countries with a median onset 19 month of age. </li></ul><ul><li>Most common presentation is progressive encephalopathy. It may result of severe immune suppression. </li></ul><ul><li>With progression of encephalopathy marked apathy,spasiticity,hyperreflexia,gait disturbances may occur, as well as loss of language, fine & gross motor skill. </li></ul><ul><li>Older children show behavioral disorder & learning disabilities. </li></ul><ul><li>Diagnosis – CT Scan shows –cerebral atrophy 85%,increased ventricle size & basal ganglia calcification. </li></ul><ul><li>CNS Lymphoma </li></ul><ul><ul><li>Symptom-Headache, seizure, mental status changes </li></ul></ul><ul><ul><li>CT scan – hyper dense or isodense mass </li></ul></ul><ul><li>CNS Toxoplasmosis is rare in young infant but may occur in HIV infected adolescent. </li></ul>
  38. 38. <ul><li>Recurrent URTI such as otitis media, sinusitis or pharyngitis are very common. </li></ul><ul><li>LIP (Lymphocytic interstitial pneumonia )- </li></ul><ul><li>Most common chronic LRTI </li></ul><ul><li>Incidence -25% </li></ul><ul><li>Etiology – yet not proven but some studies shows EBV is the cause. </li></ul><ul><li>Pathogenesis – chronic process with nodular lymphocytic hyperplasia in bronchus & bronchiolar epithelium leading into alveolar capillary block over month to years. </li></ul><ul><li>Symptom- insidious onset of tachypnea,cough,mild to moderate hypoxemia, Fine crepts. </li></ul><ul><li>In later stage-digital clubbing, symptomatic hypoxemia. </li></ul><ul><li>CXR- chronic diffuse reticulonodular pattern </li></ul><ul><li>Infection with respiratory viruses including RSV, Para influenza virus, adenovirus may occur simultaneously & have a protracted course & period of viral shedding from respiratory tract. </li></ul><ul><li>Pulmonary & extra pulmonary TB has been reported with increasing frequency in HIV infected children while it is more common </li></ul>
  39. 39. <ul><li>Dilated cardiomyopathy </li></ul><ul><li>LVH </li></ul><ul><li>CHF -5% </li></ul><ul><li>Sinus tachycardia 64% </li></ul><ul><li>Sinus arrhythmia 17% </li></ul><ul><li>Gallop rhythm with Tachypnea & Hepatosplenomegaly appear to be the best clinical indicator of CHF in HIV infected children. </li></ul>
  40. 40. <ul><li>Oral manifestation </li></ul><ul><li>Erythromastous or pseudo membranous canadidiasis </li></ul><ul><li>Periodontal disease </li></ul><ul><li>Paroditis </li></ul><ul><li>Xerotomia </li></ul><ul><li>Systemic Manifestation </li></ul><ul><li>Cause – </li></ul><ul><li>Bacterial – Salmonella,Campylobacter,MAC </li></ul><ul><li>Protozoal – Giardia,Cryptosporidium </li></ul><ul><li>Viruses – HSV,CMV, Rotavirus </li></ul><ul><li>Funus – candidiasis </li></ul><ul><li>C/F </li></ul><ul><li>Chronic or recurrent diarrhea with malabsorption </li></ul><ul><li>Abdominal pain </li></ul><ul><li>Failure to thrive </li></ul><ul><li>Weight loss & linear growth impairment is often related with the level of HIV viremia. </li></ul><ul><li>T reatment -supplemental entral feeding either by mouth or NG </li></ul><ul><li>AIDS entropathy & wasting syndrome is not common in pediatric patient. </li></ul><ul><li>Cryptococcal cholecystitis is associated with abdominal pain & increased gamma growth hormone </li></ul>
  41. 41. <ul><li>Nephropthy </li></ul><ul><li>Nephrotic syndrome </li></ul><ul><li>Focal glomerulosclerosis </li></ul><ul><li>Mesenglial hyperplasia </li></ul><ul><li>Segmental necrotizing glomerulonephritis </li></ul>
  42. 42. <ul><li>Anemi a -20 -70% of HIV infected children. </li></ul><ul><li>Cause – </li></ul><ul><li>*Chronic infection </li></ul><ul><li>*Poor nutrition </li></ul><ul><li>*Autoimmune factor </li></ul><ul><li>*Adverse effect of drugs </li></ul><ul><li>Leucopenia occurs in 1/3rd of HIV infected children. </li></ul><ul><li>T hrombocytopenia </li></ul><ul><ul><li>10-20% </li></ul></ul><ul><ul><li>Etiology may be immunogenic & drug toxicity. </li></ul></ul><ul><ul><li>Treatment – IV immunologlobin </li></ul></ul><ul><ul><li>*In resistant case high dose of corticosteroids (30-40 mg/kg/day) </li></ul></ul><ul><li>*Antiretroviral therapy may be reversing it </li></ul>
  43. 43. <ul><li>Non Hodgkins lymphoma,primary CNS lymphoma,leiomyosarcoma are most commonly reported neoplasm among HIV infected children. </li></ul><ul><li>Kaposi sarcoma which is caused by human herpes virus 8 occur frequently among HIV infected adult but is uncommon among children. </li></ul>
  44. 44. <ul><li>Clinical diagnosis </li></ul><ul><li>WHO case definition for AIDS is fulfilled if at least 2 major & 2 minor sign are present (if there is no other known cause of immunosuppresion.) </li></ul><ul><li>Major signs- </li></ul><ul><li>Weight loss & abnormally slow growth </li></ul><ul><li>Chronic diarrhea for >1 month </li></ul><ul><li>Prolonged fever for >1 month </li></ul><ul><li>Minor signs- </li></ul><ul><li>Gernalised lymph node enlargement </li></ul><ul><li>Oropharengeal canadidiasis </li></ul><ul><li>Recurrent common infection ex- AOM,Pharngitis </li></ul><ul><li>Persistent cough </li></ul><ul><li>Generalized rashes </li></ul>
  45. 45. <ul><li>HIV infection is diagnosed by the detection of anti HAV IgG in children > than 12 month of age via ELISA test. </li></ul><ul><li>Test for anti HAV IgG by ELISA </li></ul><ul><li>ELISA +ve </li></ul><ul><li>Confirm by WESTERN BLOT </li></ul><ul><li>+VE </li></ul><ul><li>HIV infection confirmed. </li></ul>
  46. 46. <ul><li>HIV DNA PCR </li></ul><ul><li>Preferred virological assay in developed countries </li></ul><ul><li>Almost 40% of infected newborns have +ve test in first two days of life. </li></ul><ul><li>>90% testing +ve by 2 week of age </li></ul><ul><li>PLASMA HIV RNA ASSAY </li></ul><ul><li>It detect viral replication </li></ul><ul><li>More sensitive than HIV DNA PCR </li></ul>
  47. 47. <ul><li>HIV CULTURE </li></ul><ul><li>Similar sensitivity to HIV DNA PCR </li></ul><ul><li>The major disadvantage of this is technically more complex & expensive. </li></ul><ul><li>Results are often not available for 2-4 weeks as compared to 2-3days with PCR. </li></ul><ul><li>P24 ANTIGEN ASSAY </li></ul><ul><li>It is cheaper, highly sensitive & easy to perform. </li></ul><ul><li>It is not recommended in infant < 1 month of age. </li></ul><ul><li>ICD P24 </li></ul><ul><li>It is used for older infant, if result are positive ,it dose not rule out infection. </li></ul>
  48. 48. <ul><li>The current available therapy dose not eradicate the virus & cure the patients. </li></ul><ul><li>It only suppress the virus for extended period of time & changes the course of disease to a chronic process. </li></ul><ul><li>Early specific diagnosis & aggressive antimicrobial treatment of intercurrent infections prolong the life of patient. </li></ul><ul><li>A combination of retroviral therapy is preferred over monotherapy. </li></ul>
  49. 49. Drugs Pediatric Dosage Nucleoside Reverse transcriptase inhibitor Zidovudine ZDV,AZT 90-180 mg/kg6-8hrly Didanosine ddI 90-150 mg/kg12hrly Lamivudine 3TC 4 mg/kg BD Stavudine d4T 1 mg/kg BD Abacavir ABC 8 mg/kg BD Zalcitabine ddc .005-.01 mg/kg 8hrly Non Nucleoside Reverse transcriptase inhibitor Nevi rapine NVP 120-200 mg/kg12 hrly Efavirenz EFV 200-600mg/kg6hrly Delaviridin DLV 400mg TDS
  50. 50. Rifonavir RTV 400-450 mg/kg 12hrly Nefinavir NFV 30mg/kg 8hrly Amprenavir 20mg/kg QID
  51. 51. <ul><li>It consists of a combination of 2 NRTI & 1 Protease inhibitor. </li></ul><ul><li>Dural NRTI- </li></ul><ul><li>ZDV + ddI </li></ul><ul><li>ZDV + 3 TC </li></ul><ul><li>D4t + ddI </li></ul><ul><li>D4t + 3 TC </li></ul><ul><li>Third drug- </li></ul><ul><li>RTV / NFV in liquid formulation </li></ul><ul><li>NFV / IDV in capsules /tablets </li></ul><ul><li>Response to therapy is monitered byHIV copy number & CD4 lymphocyte count. </li></ul><ul><li>Maximum response occur in 12-16 weeks. </li></ul>
  52. 52. <ul><li>Growth failure is a prominent feature of untreated HIV infection. </li></ul><ul><li>Stunting, or low height for age, is more prominent than wasting. </li></ul><ul><li>Growth velocity clearly increases with effective antiretroviral therapy but often does not return to normal. </li></ul><ul><li>Nutritional assessment is important in all infected children to maximize growth. It is particularly important in children with advanced disease who may suffer poor appetite, nausea, gastro paresis, increased metabolic demands, diarrhea, or malabsorption. </li></ul><ul><li>Comprehensive nutritional assessment is useful for all HIV-infected children. Growth hormone has been used to treat persistent growth failure in some children </li></ul>
  53. 53. <ul><li>Vertical transmission can be prevented by </li></ul><ul><li>Elective caesarian section </li></ul><ul><li>Antiretroviral therapy </li></ul><ul><li>Avoidance of breastfeeding </li></ul><ul><li>Avoid Amniocenteses </li></ul><ul><li>Adequate treatment of any STD in mother </li></ul><ul><li>AZT given orally during II & III trimester of pregnancy in a dose of 100 mg 5 times in day, during labour & delivary 2mg/kg IV over 1 hrly followed by continued infusion of 1 mg/kg/hr until delivary,& postnatally 2-3 mg/kg/dose 6hrly for 6 weeks results dramatically 2/3 rd reduction in risk of perinatal transmission. </li></ul><ul><li>Recent trails with one dose of 200mg of Nevirapine administer intrapartum & 2 mg/kg single oral dose to newborn baby decrease transmission by 50%. </li></ul><ul><li>Horizontal transmission can be prevented by use disposable syringes and needles. Ensure you get blood that is screened and certified as HIV-free. Better still, get blood from close family members rather than professional donors whose medical antecedents are nebulous. </li></ul>
  54. 54. <ul><li>All HIV infected children should receive standard pediatrics Vaccination. However OPV,BCG in symptomatic children need to be with held. </li></ul>
  55. 55. <ul><li>At the present time, there is no cure for AIDS. It is always fatal if no treatment is provided. In the U.S., most patients survive many years following diagnosis because of the availability of HAART. </li></ul><ul><li>HAART has dramatically increased the time from diagnosis to death, and research continues in the areas of drug treatments and vaccine development. </li></ul><ul><li>Unfortunately, HIV medications are not always available in the developing world, where the bulk of the epidemic is raging, due to socioeconomic reasons. </li></ul>
  56. 56. <ul><li>HIV Vaccine- </li></ul><ul><li>Several vaccine are under study keeping in mind the objective for the control of AIDS. </li></ul><ul><li>Preventive vaccine </li></ul><ul><li>Therapeutic vaccine </li></ul><ul><li>Perinatal vaccine </li></ul><ul><li>Type of vaccines- </li></ul><ul><li>Whole virus vaccine –live attenuated & inactivated </li></ul><ul><li>Subunit virus vaccine-envelop protein & core protein </li></ul><ul><li>Live virus vector of HIV gene with vaccinia virus recombinants & adeno virus recombinants </li></ul><ul><li>Anti idiotype HIV vaccine. </li></ul><ul><li>some of these vaccine have completed phase I (safety) phase II (immunogenicity) human trail but phase III (efficacy) among HIV infected are being under trial. </li></ul>
  57. 57. <ul><li>This therapy required the introduction of anti HIV gene into the cells to prevent or inhibit HIV 1 viral gene expression of function & consequently to limit HIV replication & AIDS pathogenesis. </li></ul><ul><li>Gene also down regulate HIV in contrast to conventional drug thearpy. </li></ul>
  58. 58. <ul><li>To improve treatment with effective chemotherapeutics or antiretroviral agents or drug combinations. </li></ul><ul><li>Implement steps to prevent perinatal transmission with maternal screening. </li></ul><ul><li>Prevention of adolescents HIV infection with sex education, safe sex with use of condom, campaign against drugs & health education are some of the ways to curb transmission of HIV . </li></ul>
  59. 61. S No Disease Described symptom Srotas References 1 Abhinayas jawar Hattojas Ras vaha S u 39/43-45 2 Pandu Ojagunakshaya Ras vaha C c 16/4 3 Raj yakshma Kinchit oja kalapatae Ras vaha C c 8/41 4 Sosha Sosha Ras vaha S u 41 5 Premha Ojakshaya Medo vaha C n 4/37 6 Unmad Oja sanjhyetae Mano vaha C n 7/11 7 Madatya ojanaas Mano vaha C c 24/79 8 Avarita vaat Vaat vaha C c 28/208
  60. 62. <ul><li>The disease is caused by the dominant kapha dosha along with the other doshas tends to block the path for the flow of rasadi dhatus in their respective locations thus resulting in the deterioration of saptha dhatu Rasa(plasma), Rakta (blood cells),Mansa ( muscular tissue), Meda (adipose tissue), Asthi (bony tissue), Majja (bone marrow) and the Shukra (reproductive tissue). thus resulting into the disease. </li></ul>
  61. 63. <ul><li>Dietary factors (c s 17/76-77) </li></ul><ul><li>Behavioral factors </li></ul><ul><li>Periodical factors </li></ul><ul><li>Psychological factors </li></ul><ul><li>Emotional factors (s s 15/22) </li></ul><ul><li>Traumatic factors (s s 15/22) </li></ul><ul><li>Others </li></ul>
  62. 64. <ul><li>Bhayabhita </li></ul><ul><li>Excessive anxious </li></ul><ul><li>Mano daurbalaya (Psychological distress) </li></ul><ul><li>Deha daurbalaya (Immunological derangements & deficiency) </li></ul><ul><li>Lusterless body </li></ul><ul><li>(C su 17/73) </li></ul>
  63. 65. <ul><li>Use of etiological factor of Ojakshaya </li></ul><ul><li>Ojakshaya </li></ul><ul><li>Mano Daurbalaya Sharir Daurbalaya </li></ul><ul><li>(Psychological distress (Immunological derangements </li></ul><ul><li>& derangements) & deficiency) </li></ul>
  64. 66. Oja Kshaya Visaransa Vyapada Kshaya
  65. 67. <ul><li>Dosh Prakopak Nidan Sevana Sharir </li></ul><ul><li>Ojo Virrudha Nidan Sevana Appar Ojas </li></ul><ul><li>Mano Gat & Sarvdahik Lakhshana (Psycho Immunological Derangements ) </li></ul>V P K OJO VIKRTI VISRANAS VAYAPAF KSHAYA
  66. 68. <ul><ul><li>Dosh : Tridosha </li></ul></ul><ul><ul><li>Dusaya : Sapta dhatu </li></ul></ul><ul><ul><li>Srotas : Sarv srotas ( especially Ras vaha) </li></ul></ul><ul><ul><li>Dhamanay :Ojovah damani </li></ul></ul><ul><ul><li>Adhistan : Heart & whole body) </li></ul></ul><ul><ul><li>Vyadhi : Ojokshaya </li></ul></ul>
  67. 69. <ul><li>The first step to stem the disease is to ensure a good and healthy atmosphere for the patient. He should be surrounded by well meaning friends and relatives who must affirm that the disease state is totally curable. Nothing negative should be discussed before the patient. </li></ul><ul><li>The patient should be given nourishing food which is easily digestible. </li></ul><ul><li>He should be encouraged to do easy exercise which does not strain his fragile health. He should be kept engaged in fruitful activities which strengthen the good tendencies inherent in him. </li></ul><ul><li>Initially, the patient is given tonics and rejuvenators (Rasayanas) to boost immunity levels and to strengthen the system and stimulate appetite. </li></ul><ul><li>After gaining some strength, shodhana (elimination) techniques are used to expel toxins from the body through enemas, purgation and emesis. The medications administered at this stage are not hard or drastic, but soft, ghee-based so that the patient withstands them with ease. </li></ul><ul><li>Secondly the blood is purified with appropriate medications. Liver corrective measures also play an important role. </li></ul>
  68. 70. <ul><li>A strengthening diet along with medicated ghee preparations and soups is recommended. But spicy, oily and acidic foods are to be avoided. </li></ul><ul><li>A little alcohol is recommended as anupana (carrier) to aid the digestive process, and also remove blockages in the flow of Rasadi dhatus, i.e. srothorodha. </li></ul><ul><li>Patient is advised to do regular exercise. If the patient is incapable of exercising or running due to weakness, then steaming (swedanam) is also recommended. reason behind this is 'Heated blood is said to weaken, and even destroy, the virus in some cases'. </li></ul><ul><li>Experience has shown that certain herbo-mineral compounds prepared as per the formulae prescribed by sages like Agasthya, Charaka, Sarangadhara and others for the treatment of Kshaya have brought about significant results in improving the condition of AIDS patients. The Rasayana and Vajikara effects of the these medicines are good for the patients. </li></ul><ul><li>Some of the propritery ayurvedic medicines achieving good improvement in the quality of life of patients include 'Chyavanprash', 'Raktavardhak' for Immunity building and 'Sookshma triphla tabs' to keep away the infection. </li></ul>
  69. 71. THANKS