Symptomatic Conditions in Infants and

Children with Advancing Disease

Blok HIV-AIDS
 Anemia
 Etiologi, patogenesis, diagnosis >>> sama
dengan dewasa
 Prevention/treatment
 During the postneonatal period and in early
infancy, children with anemia due to antiretroviral
therapy (ART) seldom need cessation of treatment
and often respond to erythropoietin if needed
(Belperio & Rhew, 2004; Donato, 2005).
 Erythropoietin at a dose of 50–200 IU/kg/dose, 3
times/week is recommended. Regular transfusion
may benefit if response to erythropoietin is
unsatisfactory (DHHS, 2008).
 Nursing implications

a. Monitor lab work that is suggestive of anemia:

complete blood count (CBC), red blood cell
count (RBC), hemoglobin (Hbg), hematocrit
(Hct), and reticulocyte count.
b. Educate patients to recognize and report early
signs of anemia, such as fatigue, shortness of
breath, and amenorrhea.
c. Provide dietary counseling and nutritional
support as needed. Iron is best absorbed from
meat, fish, and poultry. Orange juice doubles the
absorption of iron from an entire meal, whereas
tea or milk reduces absorption to less than one
half.
d. Patients receiving erythropoietin therapy should
receive iron supplementation (DHHS, 2008).
 Cardiomyopathy

Etiology/epidemiology
a. The cause of cardiomyopathy is not completely
understood and may be related to primary HIV
disease, infection, or antiretroviral (ARV)
medications.
b. Cardiac dysfunction rates in children with HIV
infection have been reported to vary between 18%
and 39% (Fisher et al., 2005) with a prevalence rate
of more than 90% in pediatric patients (Dadlani &
Lipshultz, 2006).
 Pathogenesis

a. The severity of cardiac disease in children with HIV

infection may range from asymptomatic cardiac lesions to
fatal disease with severity correlated to the degree of
immune suppression (Laufer & Scott, 2000). Included are
abnormalities in left ventricular performance,
contractility, wall thickness, dilated cardiomyopathy,
rhythm disturbances, myocarditis, and pericarditis
(Dadlani & Lipshultz, 2006).
b.With increased survival of HIV-infected patients,
cardiovascular complications impact morbidity and
mortality (Dadlani & Lipshultz, 2006).
 Clinical presentation

a. Most commonly, cardiomyopathy is associated

with sinus tachycardia; however, other symptoms
including dysrhythmias and blood pressure
abnormalities may also be present.
b. Problems seen in children with HIV infection
include cardiomegaly, congestive heart failure,
nonbacterial thrombotic endocarditis, cardiac
tamponade, conductive disturbances, and sudden
death.
 Diagnosis

a. Echocardiogram is the most commonly used

diagnostic tool for detection of cardiac abnor-
malities and should be routine for all
HIVinfected children.
b. b. Routine screening should include blood
pressure, lipid panels, and blood markers of
cardiomyopathy and myocardial injury.
Prevention/treatment

Medications to improve cardiac output may be

prescribed in collaboration with a cardiac
specialist.
Nursing implications

Patient and family education focuses on the

possible cause of the abnormality and any
limitations on activity that should be undertaken
as well as monitoring needs, such as daily blood
pressures or heart rate readings.
 Dermatitis

Etiology/epidemiology
a. Dermatitis and other mucocutaneous
manifestations are commonly seen in children
with HIV infection.
b. Frequency is related to the child’s degree of
immunosuppression.
 Pathogenesis

a. Most skin lesions in HIV-infected children are the

result of secondary infections with viral,
bacterial, or fungal organisms.
b. Frequently seen noninfectious skin conditions
include seborrheic dermatitis, atopic dermatitis,
and eczema. These occur at similar rates to
immune-competent patients.
 Clinical presentation

a. Infectious skin conditions often present as more

severe forms than those seen in healthy children
and may be more recalcitrant (Blauvelt, 2006).
b. Some skin lesions may be signs of severe
systemic infection or cancer (Blauvelt, 2006).
Diagnosis
Diagnosis is commonly made by visual
inspection of the area and characteristic primary
and secondary skin changes.
Prevention/treatment
Treatment is based on etiology.
Nursing implications
Nursing care is based on etiology.
 Diarrhea Recurrent or Chronic

Etiology/epidemiology
 Infection, noninfectious inflammatory processes, and
anatomic abnormalities, as well as antiretroviral therapies,
may cause diarrheal illness in HIV-infected children.
 In children who are severely immunocompromised, causes
may include AIDS-defining illnesses, such as
Cryptosporidium, cytomegalovirus (CMV), and
mycobacterium avium complex (MAC). Others causes
include Clostridium difficile, Giardia lamblia,
Campylobacter, Salmonella, and Shigella (Winter & Moye,
2006).
 Pathogenesis

a. Diarrheal disease in children with HIV infection

may be acute, recurrent, or persistent with
persistent causes, such as infection with
cryptosporidiosis, which may be more likely to
cause severe dehydration and weight loss.
b. Diarrhea is a common clinical symptom resulting
from immune system deterioration and viral load
increase (Winter & Moye, 2006).
Clinical presentation

Abdominal pain, distention, frequent watery

bowel movements, fever, dehydration, and
weight loss may all be present in children with
diarrhea.
 Diagnosis

a. Diagnosis is made on the basis of symptoms.

b. More specific causes of diarrhea are diagnosed
with stool collection for culture and sensitivity of
suspect organisms.
c. Ongoing diarrheal illness not caused by
medications and in the absence of identified
enteric pathogenesis is presumed to be caused by
direct HIV infection and replication in the
intestinal tract.
 Prevention/treatment
a. Prevention of diarrheal illness includes good nutritional
practices, such as a healthy diet and appropriate food
preparation techniques.
b. Immunocompromised patients should also be cautioned about
the use of water supplies that may contain infectious organisms.
c. Treatment measures for diarrheal illness include treating any
identifiable underlying infectious causes with appropriate
courses of antibiotic therapy.
d. Treatment can also include bulk-forming diets, antiretroviral
(ARV) medication changes or dose adjustments, and short-term
use of antidiarrheal agents, such as loperamide.
 Nursing implications
a. Caretakers of children with HIV infection should be educated
about diarrheal illness and when to report symptoms.
b. Historical information, such as food intake and illnesses in
other members of the household or among school and social
contacts, should also be reported.
c. Parents and children should be informed to anticipate some
gastrointestinal symptoms with the initiation of or change in
ARV medications.
d. Antidiarrheal medication may be prescribed in advance when
medication regimens are changed so that it can be taken as
soon as symptoms begin.
 Hepatitis
Etiology/epidemiology
 Successful vaccination of adults and children with HIV makes infection with
hepatitis A and B rare.
 Hepatitis C is mainly acquired during childhood via true vertical transmission.
 The risk of acquiring hepatitis C is related to the presence and amount of RNA
for hepatitis C virus (HCV) in mothers at the time of birth. The infection rate
for the hepatitis C virus is higher in children from mothers who have tested
positive for HIV.
 Vertical transmission of HCV is between 5% and 20% but varies according to
the presence or absence of certain cofactors (particularly maternal coinfection
with HIV) or medical conditions, or both (Abrams, Moon, Robinson, & Van
Dyke, 2006).
 The average rate of HCV infection among infants born to women coinfected
with HCV and HIV is 15% to 22%, higher than among infants born to women
infected with HCV alone (Abrams et al., 2006)
Pathogenesis
 Data are limited on the natural history of
HCVinfection in children
Clinical presentation
 There is the absence or paucity of signs and
symptoms of this disease in children
 Diagnosis
a. There are two types of tests used in HCV infection evaluation.
i)i Tests measuring serum antibodies—an enzyme- linked immunoassay
(EIA) and an immunoblot assay obtained through genetic recombination
(RIBA)
ii) A test detecting the presence of HCV nucleic acid in plasma (PCR)
b. For the child 18 months of age or younger, the presence of maternal anti-
HCV IgG antibodies in the infant’s serum necessitates the use of tests that
detect plasma viral RNA with polymerase chain reaction (PCR)
techniques. Due to a very low sensitivity in the newborn period, PCR
should be performed after 4 to 6 weeks of age.
c. In children 18 months of age or older, these tests are diagnostic for current
or past infection with HCV, with a sensitivity of 97% and a specificity of
95%. HCV-RNA testing is necessary to confirm active infection.
 Prevention/treatment
a. Testing for hepatitis C virus during pregnancy will also identify
infants who require subsequent testing and follow-up.
b. Antiviral drugs for chronic hepatitis C are not FDA approved
for use in children under 18 years of age. Therefore, children
should be referred to a pediatric hepatologist or similar
specialist for management and for determination for eligibility
in clinical trials.
c. Children with HCV infection should be immunized for hepatitis
A and B viruses.
d. Adolescents should avoid unprotected sexual intercourse, body
piercings, and intravenous drug use (Abrams et al., 2006).
 Nursing implications

a. Standard precautions should be used on all patients.

b. Patients with HCV should be screened for hepatitis
A and B and immunized if indicated.
c. Treatment with INF/ribaviran (if indicated) is
associated with many adverse reactions (e.g.,
injection site reactions, anemia). Educate patients
about adverse effects and monitor patient frequently.
d. Provide patient and family teaching regarding
prevention of disease and disease management
 Hepatomegaly

Etiology/epidemiology
 A common finding in children with HIV infection
and can be related to HIV replication,
antiretroviral agents, and viral causes, such as the
hepatotrophic virus
Pathogenesis
a. Varies according to the etiology

Clinical presentation
a. Hepatomegaly typically presents with other
findings indicative of lymphoproliferation, such
as lymphadenopathy.
b. Palpation on physical examination may be the
only finding in some children.
c. In some children, abdominal distension and pain
may be significant findings.
 Diagnosis

a. Initial laboratory testing to determine the cause of

hepatomegaly includes liver function tests
(LFTs), Epstein-Barr Virus (EBV) testing, and
hepatitis panels.
b. Follow-up includes serial LFT monitoring.
Prevention/treatment
a. In general, no specific treatment is undertaken for
otherwise asymptomatic hepatomegaly.
b. Treatment may be specific to identified organism.

Nursing implications
a. Nursing interventions primarily focus on patient
and family education regarding the possible
causes of hepatomegaly and the need for ongoing
follow-up of laboratory studies, as well as drug
toxicity monitoring.
 Herpes simplex virus

Etiology/epidemiology
a. Transmission is primarily through infected virus
oral secretions in HSV-1 and through infected
genital secretions in HSV-2.
b. Children living in lower socioeconomic
conditions are at higher risk of contracting herpes
simplex virus (HSV; Rutstein & Starr, 2006).
 Pathogenesis

a. After infection, the virus becomes latent and

recurs in response to fever, menstruation, sun
exposure, or trauma.
b. Most commonly seen as herpes labialis, viremia
and disseminated disease can develop in the
severely immunosuppressed patient (Rutstein &
Starr, 2006).
Clinical presentation
a. Lesions erupt as painful vesicles evolving to crusted
ulcerations.
b. Patients experience fever, mucosal ulcerations,
drooling, pain or burning at lesion site, and anorexia.

Diagnosis
a. The diagnosis is often made on the basis of clinical
presentation.
b. The definite diagnostic test is viral isolation. Because
HSV grows rapidly, it can be detected in tissue culture
from 1 to 3 days (Rutstein & Starr, 2006).
Prevention/treatment
a. Treatment: The drug of choice is acyclovir. Oral: maximum 80
mg/kg/day in 3–5 doses; IV: 250 mg/m2 q8h
b. Secondary prophylaxis for HSV infection: oral, 80 mg/kg/day
in 3–4 divided doses
c. Topical (ointment): apply every 3 hours, 6 times/day

Nursing implications
a. Local care of mucocutaneous lesion includes keeping lesions
clean and dry by gently cleansing with mild soap and water.
b. Teach child and parent that frequent hand washing will prevent
the spread of infection to others.
c. Pain can be severe, and analgesia should be administered as
needed.
 Leiomyosarcoma

Etiology/epidemiology
a. Leiomyosarcomas are included in Category B as a
sign of a moderately symptomatic stage.
b. They are described as high aggressive neoplasms
arising from smooth muscle.
c. The number of children with HIV infection who
develop a malignancy is poorly defined.
d. Although very rare, leiomyosarcomas are the second
leading cancer of children with HIV infection
(Pollock et al., 2003)
Pathogenesis
a. There is an association with EBV in HIV disease.

Clinical presentation
b. The clinical presentation varies according to the
location of the tumor. Unusual localizations, such as
spleen, pleural space, adrenal glands, and lungs,
have been described, although they present most
commonly in the gastrointestinal tract.
b. May be characterized by fever, abdominal pain or
obstruction, bloody diarrhea, and pulmonary
infection
Diagnosis
a. The method of diagnosis varies according to the site of tumor.

Prevention/treatment
a. Smooth muscle tumors are in general not very sensitive to
chemotherapy or radiotherapy; local excision, if feasible, is
the first line of therapy.
b. The course of the disease is highly variable, with indolent
tumors (more likely leiomyomas) that probably do not
necessitate intervention in some children, and very
aggressive, disseminated tumors in other children.
c. Intensive and prolonged chemotherapy as used in noninfected
patients is undefined (Little, 2006).
 Nursing implications

a. Provide education about the disease, specific

therapies, and potential side effects and their
management.
b. Emphasize the importance of adequate rest and
nutrition. In all diseased states, the body requires
adequate rest and nutrition to heal.
c. A diagnosis of cancer can be distressing to the family
and child. Provide emotional support for the patient
and the family and significant others. Assess the
need for palliative care and hospice.
 Lymphadenopathy

Etiology/epidemiology
a. High levels of viral replication in the lymphoid
tissue associated with perinatally acquired HIV
infection makes lymphadenopathy a common
finding among children with HIV disease.
b. Lymphadenopathy is typically a direct result of
HIV replication but may also be caused by Epstein-
Barr virus (EBV), cytomegalovirus (CMV), or
mycobacterial infections, as well as malignancies.
Pathogenesis
a. Varies according to the etiology

Clinical presentation
a. There are a large number of diseases with which
lymphadenopathy can be present; therefore, the
detection of lymphadenopathy is common.
b. Nodes less than 0.5 cm generally are not cause for
concern.
c. If nodes have grown rapidly and are suspiciously large
(2–3 cm), mildly painful, or fixed, they should be
investigated further. Bilateral findings count as one site.
Diagnosis
a. Biopsy is the most definitive test to determine the etiology
of enlarged lymph nodes.

Prevention/treatment
a. Meticulous physical examination to detect abnormal lymph
nodes is essential.
b. Treatment varies according to the etiology of enlarged
nodes.

Nursing implications
a. See specific implications according to etiology of enlarged
nodes.
 Lymphoid Interstitial Pneumonia
(LIP)
Etiology/epidemiology
a. LIP is considered an AIDS-defining condition, but
because it is associated with a relatively benign course,
favorable prognosis, and long-term survival, it has been
placed in the B category of the Centers for Disease
Control and Prevention’s (CDC) classification system.
b. LIP is more commonly seen in children with HIV
infection than in adults and has been found in
approximately 30%–40% of these children with
pulmonary disease (Wood, 2006).
Pathogenesis
a. LIP is a chronic lymphocytic infiltrative disease of the lung,
and the cause is poorly understood.
b. Non-infectious

Clinical presentation
a. LIP is often seen in combination with other signs of
lymphoproliferation, such as parotitis and hepatomegaly.
b. It is characterized by its insidious onset, often with persistent
cough, wheezing, and tachypnea that over time progresses to
dyspnea and hypoxia with resultant finger clubbing.
c. The clinical course is generally benign but can be highly
variable (Wood, 2006).
 Diagnosis

a. Though the diagnosis is initially made clinically,

serial chest X-rays or chest CT scan, or both,
showing a reticulonodular pattern or interstitial
infiltrates is used to confirm the diagnosis.
b. Chest CT is used to confirm X-ray findings and
monitor disease severity and extent. Biopsy is
rarely used in diagnosis (Wood, 2006).
Prevention/treatment
a. Prevention of LIP is dependent on controlling HIV
replication through the use of HAART.
b. Treatment of symptomatic LIP with hypoxia
includes the use of prednisone at 2 mg/kg/day for 2–
4 weeks on a tapering schedule, then continuing at 1
mg/kg/day until oxygen saturation improves.
Complete weaning can be undertaken when a
satisfactory response is observed. Repeated courses
of steroids may be necessary.
c. Bronchodilators, chest physical therapy, and, in
some cases, diuretics may be useful.
 Nursing Implication

a. Nursing interventions are supportive depending

on the severity of the disease.
b. Patient and family education as to the chronic
and persistent nature of LIP and its associated
symptoms is essential.
 Nephropathy

Etiology/epidemiology
a. The incidence of glomerular disease in
HIVinfected children is unknown
(Tanawattanacharoen & Kopp, 2006), but
virusassociated nephropathy (HIVAN) has
become a common disease among those who are
HIV infected (Herman & Klotman, 2003).
 Pathogenesis

a. The pathogenesis of HIV-associated nephropathy

is a focal segmental glomerulosclerosis and is a
result of viral replication within renal cells
causing proliferation and apoptosis (Herman &
Klotman, 2003).
b. HIV nephropathy is typically associated with a
higher degree of immune suppression and a
higher mortality rate.
Clinical presentation
a. May range from an asymptomatic proteinuria to
symptomatic renal tubular acidosis, hematuria,
and acute renal failure (Herman & Klotman,
2003).

Diagnosis
a. In children, diagnosis is made by using the ratio
of urine creatinine to protein. A creatinine–
protein ratio of more than 0.2 is consistent with
nephropathy.
Prevention/treatment
a. Routine urinalysis
b. Alkalinizing agents, such as sodium or potassium citrate, in
addition to other mineral supplements, may be used to
correct renal tubular acidosis.
c. In severe cases, dialysis may be considered.

Nursing implications
a. Dose adjustments on antiretroviral therapy (ART) and
other drugs used to treat HIV associated diseases are often
necessary.
b. Nursing interventions focus on supportive care and
education.
 Neutropenia
Etiology/epidemiology
a. In some children, neutropenia represents manifestations of
HIV disease and may improve with enhanced suppression of
HIV with antiretroviral therapy (ART).

Pathogenesis
a. Impaired myelopoieses due to HIV infection of accessory
cells in the bone marrow
b. Myelosuppression related to drugs, opportunistic infections,
nutritional deficiencies, andmmalignancies
c. Peripheral destruction of neutrophils due to
hypersplenismand infection (Owen &Werner, 2006).
Clinical presentation
a. Respiratory tract symptoms, such as cough and sputum
production
b. Urinary tract infection symptoms: frequency, urgency, burning
c. Fever
d. Adenopathy
e. Organomegaly

Diagnosis
a. Complete blood count (CBC) with differential reveals
decreases in white blood cells (WBCs), including neutrophils,
lymphocytes, and sometimes monocytes. Atypical
lymphocytes may be seen.
 Prevention/treatment
a. If a child is clinically stable, but there is a significant and
persistent absolute neutropenia, supportive treatment with
granulocyte colony stimulating factor (G-CSF) or filgastrim
should be initiated before modifying ART. The dosage for
children is 5–10 mcg/kg/day (IV/SC): single daily dose for up
to 14 days, then titrated to maintain ANC > 1000–2000/mm3.
b. If neutropenia does not improve within 1 week of initiating G-
CSF, the dose can be increased.
c. When no alternative etiology is identified and the response to
G-CSF is not adequate, then interruption of ART should be
considered but only for as brief a period of time as possible
(American Academy of Pediatrics, 1998).
Nursing implications

Few HIV-infected children suffer infectious

complications of neutropenia. Severe and
prolonged fever is suggestive of an infectious
complication, thus teach the patient and family to
report high and prolonged fevers immediately.
When children are present in clinical settings,
staff should use neutropenic precautions
 Otitis Media Akut dan Recurrent

Etiology/epidemiology
 This is a common finding in children with
symptomatic HIV infection especially during first
2 years of life and recurs more often in this group
(Wald & Dashefsky, 2006).
 Acute otitis media (AOM) is much more
common in the pediatric HIV-infected patient
when compared with noninfected patients.
 Pathogenesis

a. Frequency of infections may be related to

immunological deficiencies or eustachian tube
dysfunction resulting from lymphoproliferation.
b. The pathogens encountered in recurrent otitis
media do not differ from the general population.
Streptococcus pneumoniae, Haemophilus
influenzae, and Moraxella catarrhalis
predominate.
 Clinical presentation

a. Fever and ear pain are the most common

presenting symptoms.
b. Examination of the ear demonstrates marked
redness or distinct fullness or bulging of
thetympanic membrane.
c. Hearing loss may be present.
 Diagnosis

a. Made on the basis of history and physical

examination, including assessment of tympanic
mobility
b. Selected use of tympanocentesis under following
conditions: previous treatment failure;
suppurative complications; suspicion of unusual
pathogen; seriously ill patients with otitis media;
and relief of severe pain (Wald & Dashefsky,
2006)
 Prevention/treatment
a. Treatment is dependent on suspected or cultured organism and
may be highly individualized based on history.
b. Chemoprophylaxis is recommended when there are three or
more well-documented cases of AOM within 4 months or four
cases within 12 months.
c. Myringotomy and tube placement are recommended for patients
when chemoprophylaxis does not reduce the incidence of
disease or when there is significant hearing loss due to chronic
middle ear effusion.
d. Children younger than 2 years of age may be immunized with
pneumococcal conjugate vaccine (PCV7;Wald & Dashefsky,
2006).
Nursing implications

Families should be educated about the frequency

of otitis media in children with HIV infection.
Symptoms should be reported promptly, and
adherence to antimicrobials is essential to
minimize the chance of developing resistant
organisms.
 Parotitis

Etiology/epidemiology
a. Prevalence rate in controlled studies is 2–14%
(Atkinson & O’Connell, 2006).
b. Although it is the least-reported Category A
event, parotitis can be difficult to treat and may
be associated with life-threatening illnesse
 Pathogenesis

a. Swelling of the parotid gland is generally a benign

process associated with lymphoepithelial lesions, but it
may also be the result of bacterial infections, malignant
processes, or mumps.
b. Staphylococcus aureus is the most common bacterial
cause of acute suppurative parotitis and has been cultured
in 50% to 90% of cases. Streptococcal species, including
Streptococcus pneumoniae and Streptococcus pyogenes
(betahemolytic streptococcus), as well as Haemophilus
influenzae, have been recognized as common causes.
 Clinical presentation

a. Sudden onset of parotid pain and swelling.

b. Symptoms may be exacerbated by meals.

Prevention/treatment
Antimicrobial therapy initially is directed toward
the gram-positive and anaerobic organisms
identified as common causes
 Diagnosis

a. Physical examination reveals induration, erythema,

edema, and extreme tenderness over the cheek and
angle of the mandible.
b.With parotid swelling, the clinician should be suspicious
for mumps, and HIV-infected children should be
evaluated at appropriate ages (12 months, 4–6 years) for
MMR (measles, mumps, rubella) immunization.
c. Malignancy, especially lymphoma, should be
considered in the differential diagnosis of rapid,
progressive parotid swelling.
 Nursing implications

a. Attempts must be made to reverse salivary stasis

and stimulate salivary flow by application of
warm compresses, maximization of oral hygiene
and mouth irrigations, and administration of
sialogogues, such as lemon drops or orange juice.
b. External or bimanual massage of the gland both
intraorally and externally should be employed if
the patient can tolerate these measures.
 Sinusitis, recurrent

Etiology/epidemiology
a. Occurs more frequently in immunocomprorecurrent mised
children as compared to their immunocompetent children,
as high as 39% in one study (Wald & Dashefsky, 2006).

Pathogenesis
a. Most infections caused by organisms commonly
associated with sinusitis in immune competent hosts.
Obstruction of sinus ostia caused by mucositis
production.