The child with hiv and gastroenteritis
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Children with HIV infection are told to come hospital if they become unwell.
This is usually either because they have a fever, vomiting and diarrhoea, or a
chest infection. These guidelines are for the child with vomiting and
Children with HIV have a considerably increased risk of bacterial infections.
General principles are: treat with antibiotics earlier, with higher doses for
Note the stage of the childʼs illness. The more severely
immunosuppressed the more likely to have minimal signs and serious
pathology. Look in notes for recent letters and CD4 count. A CD4 <
10% (or <200 in children over 5 years old) means severely
Take a good history of the acute illness and examine the child
thoroughly. Get past history from notes – parents often vague/reluctant
historians of past illness. If the child has had proven bacterial infection
before – most likely to be recurrence of that infection.
Think of serious bacterial infections eg. UTI, septicaemia
“Children with HIV are different”
The cause of endemic gastroenteritis (GE) in paediatric HIV varies around the
world. Children can have GE with pathogens that infect HIV negative children
(eg. rotavirus, adenovirus, Salmonella, Shigella, or Campylobacter in the UK).
Children with symptomatic HIV infection can also have infection with unusual
organisms (including; Cytomegalovirus, Candida, Cryptosporidium Parvum,
Isopora Belli, Microsporidia (especially Enterocytozoon bieneusi), Giardia
lamblia, Cyclosorae and Mycobacteria avium complex and Yersinia
Ask about bile-stained vomiting, blood/mucous in diarrhoea, reduced urine
output, altered level of consciousness, other affected family members, foreign
travel (see below), previous GI problems and medication already received.
Malaria must be looked for in a child recently returned from abroad with a
fever and either vomiting or diarrhoea. It is particularly important to consider
typhoid in a febrile child recently returned from abroad (see below). Other
diagnoses to consider include amoebiasis, cholera, or helminth infection (if an
The most important points are to assess the state of DEHYDRATION, and to
identify whether there is any OTHER PATHOLOGY mimicking or
This is a clinical diagnosis. A recent clinic weight and evaluating urine output
and osmolarity may be useful in assessing fluid loss. Hypernatraemic
dehydration can be very difficult to assess clinically.
Children with severe HIV infection and diarrhoea often lose a lot of
bicarbonate and develop a metabolic acidosis. These children will usually be
drowsy, but other signs of dehydration may be masked. They may need
oral/IV sodium bicarbonate supplementation.
“Not all children with d+v have gastroenteritis”
Particular care should be taken if the child is febrile and looks toxic, has
bloody diarrhoea or a tender or distended abdomen. Diagnoses to consider
include other infections (UTI, meningitis, pneumonia, septicaemia, OM) and
Severe History (eg >5 loose stools/day)
All children with HIV and diarrhoea should be investigated. If febrile they
should have blood cultures and an MSU as well as:-
Stool microscopy, especially ova, cysts and parasites
trophozoites, cysts, spores and modified ZN
E.coli, salmonella, shigella, campylobacter
1 fresh stool labelled for virology for EM and culture
It is important to write two forms and make sure two separate specimens are
sent. Write the form yourself with “Diarrhoea and decreased CD4” as clinical
Send 1 stool/day to virology and bacteriology for 3 days if diarrhoea persists.
If the diarrhoea persists, discuss with an HIV paediatrician and consider:
Blood and stool cultures for mycobacteria
Jejunal biopsy +/- colonoscopy should be considered in all culture negative
persistent diarrhoea unresponsive to medical therapy. Biopsy material should
go for histopathology (CMV IFT, fungi, AFB), microbiology (including
mycobacterial culture) and viral culture.
If the child is febrile and toxic get blood and urine cultures, then empirically
treat with IV Ceftriaxone/Cefotaxime and await culture results.
If the child is well and the diarrhoea persists over 3 days with negative stool
cultures then treat with oral Metronidazole 7.5 mg/kg/dose tds. Give at least
If the diarrhoea still persists with negative cultures, consider changing to
Ciprofloxacin. In an older child with chronic diarrhoea and HIV, use an anti
Mycobacteria - Ciprofloxacin, Rifabutin, Clarithromycin
Microsporidia - Metronidazole, Albendazole
Discuss these with an HIV paediatrician.
“it is important to return to normal diet quickly”.
It is critical to minimise the weight loss associated with acute infections.
Involve a paediatric dietician early, who can give oral supplements.
Severe weight loss can occur very quickly If diarrhoea persists over 5 days
and weight is decreasing, then consider a hydrolysed milk feed.
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