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Gastrointestinal illnesses, especially diarrhea, are a major problem for HIV-infected patients. Salmonella can be a persistent problem, particularly in patients with blood or mucus in the stool. Severe or prolonged diarrhea in pediatric AIDS patients also occurs with parasitic enteric pathogens, most notably Glardia Lamblia, and cryptosporidium. In some instances, even after extensive evaluation, no specific etiology can be found to account for the diarrhea.
Clinical Evaluation and Ancillary data
Use an aggressive diagnostic approach, because many of the acute illnesses are treatable. For example, a child with HIV infection who presents with fever is quite likely to have a bacterial infection: obtain a complete blood count (CBC), blood culture, urinalysis, and chest X-ray if there is no obvious source of fever on examination, other imaging studies such as sinus films may be indicated. If the child has a history of neutrophil count may be depressed, which would influence therapeutic decisions. The new onset of pulmonary symptoms requires a thorough evaluation. Although many of these patients may not have an easily treated form of pulmonary disease, early therapy is important, Because it is difficult to differentiate clinically the common forms of pneumonia in pediatric, AIDS patients, hospitalization is often required. In such patients, the initial diagnostic tests include Chest X-ray, WBC count, blood culture, and, in the appropriate epidemiologic setting, nasopharyngeal swabs for immunofluorescence or culture.
Weight loss and diarrhea may be acute or chronic and are often quite severe. In addition to routine bacterial culture, obtain stool for ova and parasites. Assess the patient's state of hydration clinically and measure serum electrolytes, blood urea nitrogen, and creatinine, since enormous fluid losses and profound electrolyte imbalances are sometimes present. CNS symptoms and physical signs will determine whether lumbar puncture or scanning is appropriate. If a spinal tap is performed, obtain more fluid than necessary to diagnose bacterial meningitis, because additional tests are often indicated, such as a culture for acid-fast organisms, viral culture and cryptococcal antigen. If focal neurologic signs are present, arrange for a CT scan to evaluate for lymphoma or toxoplasmosis.
Treatment and disposition
The treatment plan and the decision to hospitalize the patient must be made in conjunction with the family; many families want aggressive diagnostic and therapeutic plans, while others may prefer to keep medical intervention limited, with the goal of making the patient comfortable.
Consider hospitalizing HIV-infected patients with fever without a focus of infection, recent onset of pulmonary or CNS manifestations, or severe failure to thrive or diarrheal disease. Patients who are not acutely ill and do not require hospitalization may require antibiotic therapy. If a focal infection is identified, such a sinusitis or otitis media, and there is no evidence of bacteremia, the patient can ordinarily be managed as an out patient. However, a longer duration of therapy is required, for example, treat sinusitis for a minimum of 3 weeks.
In cases of possible bacteremia, the antimicrobials must be effective against the encapsulated organisms and the enteric gram-negative rods. For any HIV-infected patient who does not require problem with the primary physician and make appropriate referrals for long-term management. Because of the chronic and complex nature of pediatric HIV infection, non-urgent problems are best handled in the calmer, more familiar outpatient office or clinic, not the ED. Isolation techniques are based upon the mode of transmission of the disease.
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