The child with hiv and gastroenteritis

Author: Andrew Riordan
Date of preparation: September 2004
Date reviewed: May 2007
Next review date: July 2010
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 Clinical history
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. Foreign travel
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 Examination
The most important points are to assess the state of DEHYDRATION, and to identify whether there is any OTHER PATHOLOGY mimicking or Dehydration
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. Other pathology
“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 Management
Admission
Severe History (eg >5 loose stools/day) Investigation
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. Treatment
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. Nutrition
“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.

Source: http://www.chiva.org.uk/files/guidelines/gastroenteritis.pdf