Transcript Case Presentation - International AIDS Society

Pediatric Case Presentation
BOGNON TANGUY
Care Unit Children Exposed or Infected by HIV/AIDS
Military Teaching Hospital - Cotonou - BENIN
History of present illness
• Date of presentation: December 27th 2002
• 5 and 1/2 months old girl (born july 10th 2002)
• Presented with:
– Impaired development, anormal behaviors
– Cutaneous lesions
– Anorexia
• No cough, no fever
• Benn unwell since 2 months old
Past Medical History
• Mother 42 years, HIV +ve, seeking children
since 15 years
• Received NVP for PMTCT
• Birth weigh: 2040 g
• Baby admitted more than 10 times for various
medical conditions and has been given:
Nystatine, Cotrimaxozole, Amoxicillin, Vitamins,
• First child
• Father HIV status not known
Physical examination at entry
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Weigh: 2220g; height: 57 cm; CP: 34 cm; BP: 5.7 cm
Very sick looking
Oral and cutaneous thrush
Encephalopathy
Bilateral keratitis and dry eye (seen by ophtalmologist)
PGL and hepatomegaly
CBC: HB=5.7 g/dl
CXR normal,
No LP, EEG and RMI
Diagnosis
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5 ½ month baby with perinatal HIV infection
IO: esophageal candidiasis,
Anemia
Encephalopathy
Severely immunocompromised - CD4<15%
Stage 4 WHO, Stage C CDC classification
Child management
1st week
• Medications
– Cotrimoxazole high dose 15 days followed by
prophylaxis
– Fluconazole 14 days, consolidation nystatine 2
months
– Ocular topics (antibiotics and others) for 3 weeks
• Enteral nutrition by nasogastric sonde(tube) for 10 days
• Blood transfusion: 2 times during the first week
Child Management cont’d
2nd Week (6 months old)
• CD4: 799 ; 12%
• Hb: 8 g/dl
• Started HAART: D4T+3TC+NFV
– Giving during first day by nasogastric tube
– Well tolerated
• Medications: iron, folates,
• Nutritional assistance: advice, nutritional supplements,
polyvitamins
• Appointment for Psychosocial care
Follow up 1 month
3 weeks ART - 7 months old
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No thrush, better looking
Oral nutrition was perfect
Weight: 2550 g
Neurological examination
– Encephalopathy slightly improved
• Beginning of functional reeducation
• Exit with follow up visit plan
– Every week for 2 weeks
– Every 2 weeks for a month
– Visit at 6 months, and every 3 months
Follow up 7 months
6 months ART - 1 years old
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Better looking
Weight: 4750 g
Height: 72 cm; CP: 42 cm; BP: 12.5 cm
Neurologic examination: better, able to pursue vision,
hold head, normal tone of arms and legs
• CD4: 19% (985), Hb: 10.2 g/dl
• RX: change D4T to AZT (stock rupture)
• Medications are adapted to weight
Follow up 1 year and later
• 18 months
• Improvement of psychomotor development:
– Can Walk
• Weight: 11 kg
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seen 13/06/05 (3 years, 2yrs and half of ART)
Weight: 15 kg
Cd4: 1795 (26%)
Hb: 12 g/dl
The well being
• January 3rd, 2005
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Weight 16,3 kg
Excellent conditions
Good adherence
Lab test for ART long-term toxicity was ok
Entered school: Kindergarten
• Good mark for the first quarter
• Last seen
-Weight 26 kgs , Height 134cm
-HB 12g/dl, CD4 654(30%), VL 2442
• Schooling; 3rd level at primary school
About the mother
• Psychosocial care from the beginning
• Appointment with adult physician when baby has
6 months follow up
– CD4: 280
– Cotrimoxazole
• Started HAART one year ago
• Father still not coming
• Mothers concerns:
– school, disclosing status to teacher, and fertility, ….
• Last seen October 2008:going well on HAART
What do we learn
• We can do some things for babies infected from
mothers
– Improvement of follow up after birth
– In an area viral load or PCR DNA not available: CD4
when available is useful when symptoms appear
• This baby’s care involved
– Pediatrician, ophthalmologist, psychologist and social
worker, and kinesitherapist
Questions about this case
• Even though, successful case
• Compliance with school
• Long term ART toxicity
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Thanks for attention