Transcript Session 3 - Teaching Slides

Clinical and Immunological
Staging in HIV-infected
Children
HAIVN
Harvard Medical School AIDS
Initiative in Vietnam
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Learning Objectives
By the end of this session, participants
should be able to:
 Explain the purposes of clinical and
immunological staging, and their
applications
 Determine the clinical stage of an HIV
patient
 Identify the severely
immunosuppressed category for each
age group
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Clinical Staging
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Clinical Staging


Based on classification developed by WHO
Purposes:
• To determine severity of clinical disease
• To determine when to start antiretroviral
therapy
• After ART started, to monitor for response to
treatment

Clinical staging ranges from stage 1
(mildest), to stage 4 (most severe)
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Application of Clinical Staging
in Relation to ARV Treatment
Before ARV:
 Identify highest
clinical stage
patient has
reached
 Purpose:
Determine
eligibility for ARV
treatment
After Starting ARV:
 Re-evaluate
current clinical
status of patient
 Purpose: Assess
clinical
improvement in
response to ARV
treatment
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Remember



The purpose of giving the highest
clinical stage is to ensure patient
receives ART timely
The purpose of clinical staging after
ART is to monitor for treatment
response
All of HIV-infected children should
have clinical stage identified at every
visit
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WHO Pediatric Stages: Stage 1


Asymptomatic
Persistent generalized
lymphadenopathy
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WHO Pediatric Stages: Stage 2
Most frequently seen:
 Hepatosplenomegaly
 Papular pruritic eruption
 Recurrent or chronic upper
respiratory tract infections
 Herpes zoster (zona)
 Angular cheilitis
 Recurrent oral ulceration
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Stage 2 Diseases (1)
Linear gingival erythema
Zona
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Stage 2 Diseases (2)

Herpes varicella
zoster (zona)
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Stage 2 Diseases (3)
PPE: lower arms and legs, leaves scars after resolution
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Stage 2 Diseases (4)
Bilateral parotid enlargement
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WHO Pediatric Stages: Stage 3
Most frequently seen:
 Moderate malnutrition or wasting
 Diarrhea >14 days
 Fever for >1 month
 Oral candidiasis
 Pulmonary, lymph node TB
 Severe recurrent bacterial pneumonia
 Anemia, neutropenia or chronic
thrombocytopenia
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Stage 3 Diseases (3)
Lymphocytic interstitial pneumonitis:
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Typical nodular infiltrates mainly at the hilar areas
WHO Pediatric Stages: Stage 4
Most frequently seen:
 Severe wasting/malnutrition
 PCP (pneumocystis pneumonia)
 Recurrent severe bacterial infection*
 Extrapulmonary TB (except lymph node TB)
 Systemic fungal infections
 CMV
 Herpes simplex infections > 1 month
 HIV encephalopathy
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Stage 4 Diseases (1)
Herpes Simplex chronic infection (>1 month)
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Stage 4 Diseases (2)
Penicillium Marneffei skin lesions:
Flesh-color, umbilicated papules concentrated mainly on
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face, back, arms, and legs
Case Study
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Case Study: Binh (1)



Binh is a five-month
old baby, presented
with severe wasting,
pulmonary TB, and
oral thrush. He is also
anemic with HgB of
6.5g/dL.
List his clinical
conditions and assign
staging
What stage is Binh at
now?
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Case Study: Binh (2)



Binh was treated
for TB and placed
on ART.
6 months later,
had significant
weight gain,
asymptomatic,
tolerated ARV well.
What stage is Binh
at now?
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Case Study: Tin




Tin, a 9-month old infant was recently
diagnosed with HIV. On questioning about
past medical history, you found that he
has had multiple admissions for
pneumonia
On exam he had small (<1cm) lymph
nodes on his neck, axilla, and inguinal
areas, and splenomegaly
List his clinical conditions and assign
staging
What stage is Tin at now?
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Immunological Staging
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CD4 Percentage/Count
Children •Absolute CD4 count is generally not
<5
used due to:
high fluctuation between measurements
age-related decline
•CD4 percentage (%) is preferred
because it is more constant
Children •CD4 count is used because its pattern
>5
is similar to that of adults
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Immunological Staging (1)


CD4 percentage and CD4 count reflect the
severity of immunosuppression in the HIVinfected patient
Purpose of immunological staging is to:
•
•
•
•
•
•
Classify severity of disease
Anticipate what OI’s are most likely
Know when to start prophylactic therapy
Know when to start ART
Monitor for immune recovery on treatment
Prognosticate
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Immunological Staging (2)
<11
months
12-35
months
36-59
months
≥ 5 yrs
Not
> 35%
significant
> 30%
> 25%
> 500
cells
Mild
25 – 30% 20 – 25% 350−499
cells
20−24% 15−20% 200−349
cells
30 – 35%
Advanced 25 – 29%
Severe
<25%
<20%
<1500 cells <750
cells
<15%
<350
cells
<15%
<200 cells
Key Points


WHO clinical staging classifies patient
into 4 categories based on clinical
manifestations
Both clinical staging and CD4
count/percentage are used to:
• determine eligibility for OI prophylaxis and
ART
• assess patient’s response to ART
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Thank you!
Questions?
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