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Christian Surya E.P.

PDA08 - 0810710032 KASUS 1 Seorang anak usia 8 bulan dibawa ke poli anak dengan keluhan utama sesak, yg diderita sejak 4 hari terakhir. Selain itu anak juga menderita diare berulang dan BB tidak naik malah bertambah kurus. Mulut dan lidah juga timbul bercak-bercak putih sejak usia 3 bulan yg tidak sembuh dengan obat. Riwayat keluarga: ibu saat ini sedang dirawat di RS paru-paru dan diare lama , ayah telah meninggal 3 bulan yg lalu Anak lahir ditolong bidan dengan kehamilan cukup bulan, BB lahir 2200 g, langsung menangis, anak merupakan anak pertama, ibu tidak pernah minum obat selama hamil Anak telah mendapatkan imunisasi BCG, hepatitis B, DTP 1 dan polio, stlh itu anak sering sakit shg tidak diimunisasi Riwayat nutrisi: ASI sd usia 3 bulan dan sd skrg minum susu formula dan bubur susu Pemeriksaan fisik: Anak laki2 usia 8 bln BB 4 kg, PB 54 cm Nadi 100 x/menit, tampak sesak RR 40x/menit, suhu tubuh 37C Old man face, tampak kandidosis oral dan esofageal Pembesaran KGB leher dan aksila mutipel Thorax: ronkhi (+) basah halus dan kasar, wh (-) Abdomen: Hepar 4 cm di bawah arcus costae, lien ttb, Bising usus meningkat Ekstremitas: baggy pants (+), kulit kering kehitaman 1. 2. 3. 4. Data yang perlu ditambahkan? Diagnosis kerja? Pemeriksaan penunjang utk diagnosis dan penunjang lain? Tatalaksana?

KASUS 2 Seorang anak usia 4 tahun dibawa ke poli anak dengan keluhan utama bertambah kurus, yg diderita sejak 4 bulan terakhir. Selain itu anak juga menderita diare berulang sejak 1 thn yg lalu dan sejak itu BB tidak naik malah bertambah kurus. Mulut dan lidah juga timbul bercak-bercak putih sejak 6 bln yg lalu hilang timbul yg tidak sembuh dengan obat. Riwayat keluarga: ibu telah meninggal dan ayah saat ini sedang dirawat di RS paru-paru dan diare lama Anak lahir ditolong bidan dengan kehamilan cukup bulan, BB lahir 3000 g, langsung menangis, anak merupakan anak pertama, ibu tidak pernah minum obat selama hamil Anak telah mendapatkan imunisasi BCG, hepatitis B, DTP 1 dan polio, stlh itu anak sering sakit shg tidak diimunisasi Riwayat nutrisi: ASI sd usia 1 tahun dan sd skrg minum susu formula dan makanan sehari-hari Pemeriksaan fisik: Anak laki2 usia 4 thn BB 10 kg, TB 70 cm Nadi 90 x/menit, tampak lemah RR 40x/menit, suhu tubuh 37C Old man face, tampak kandidosis oral dan esofageal Pembesaran KGB leher dan aksila mutipel Thorax: ronkhi (+) basah kasar dan kasar, wh (-) Abdomen: Hepar 4 cm di bawah arcus costae, lien ttb, Bising usus meningkat Ekstremitas: baggy pants (+), kulit kering kehitaman Data yang perlu ditambahkan? Diagnosis kerja? Pemeriksaan penunjang utk diagnosis dan penunjang lain? Tatalaksana?

1. 2. 3. 4.

Children Younger Than Age 18 Months: Definitive diagnosis: Positive results on two separate determinations on blood or tissue (excluding cord blood) for one or more of the following HIV detection tests: HIV nucleic acid detection (DNA or RNA), HIV antigen (p24), HIV culture . Presumptive clinical diagnosis (in settings lacking access to HIV virologic diagnostic tests): HIV-seropositive by repeatedly reactive enzyme-linked immunosorbent assay (ELISA) and confirmatory test. and Meets criteria for AIDS diagnosis based on the 1987 Centers for Disease Control and Prevention (CDC) AIDS surveillance case (see Table 391 and CDC case definition, MMWR Morb Mortal Wkly Rep, 1994) or has evidence of cellular and humoral immunodeficiency (without another cause) and symptoms compatible with HIV infection. Children Older Than Age 18 Months: HIV-seropositive on two separate determinations on blood by ELISA and confirmatory test. or Meets any of the criteria listed for children younger than age 18 months.

Viral diagnostic testing should be performed within the 1st 48 hr of life. Almost 40% of HIVinfected children can be identified at this time. It seems that many of these children have a more rapid progression of their disease and deserve more aggressive therapy. In exposed children with negative virologic testing at 2 days of life, additional testing should be done at 1 2 mo of age and at 46 mo of age; some also favor testing at age 14 days to maximize early detection of infected infants, if initiation of anti-retroviral therapy is desired. A positive virologic

assay (i.e., detection of HIV by PCR, culture, or p24 antigen) suggests HIV infection and should be confirmed by a repeat test on a 2nd specimen as soon as possible. A diagnosis of HIV infection can be made with 2 positive virologic test results obtained from different blood samples. Although the perinatal use of prophylactic zidovudine to prevent vertical transmission has not affected the predictive value of viral diagnostic testing, the effect of more intensive antiviral combinations (protease inhibitors) in pregnant women on the accuracy of the infant's viral tests is unknown. HIV infection can be reasonably excluded if an infant has had at least 2 negative virologic test results with at least 1 test performed at 4 mo of age. In some parts of the world where non-subtype B (the predominant type in the United States) are common, interpretation of a negative PCR test result should be done cautiously because the assay may not detect the particular subtype (group O). Close clinical monitoring with serologic testing (by 18 mo of age) or culture (if possible) is recommended. In older infants, 2 or more negative HIV antibody tests performed at least 1 mo apart past 6 mo of age in the absence of hypogammaglobulinemia or clinical evidence of HIV disease can reasonably exclude HIV infection. The infection can be excluded definitively if the same parameters are met when the infant is at least 18 mo of age. Infants born to HIV-infected mothers should be prescribed zidovudine (ZDV) prophylaxis. A complete blood count, differential leukocyte count, and platelet count should be performed at 4 wk of age to monitor ZDV toxicity. If the child is found to be HIV-infected or if the HIV status is not clear, these tests should be continued every 13 mo to assess the hematologic effect of the disease or its treatment (prophylactic TMP-SMZ and anti-retroviral therapy). If the child is found to be HIV infected, CD4 and CD8 lymphocyte counts should be performed at 1 and 3 mo of age and repeated every 3 mo. The frequency of the test should be increased (every 46 wk) if the CD4 lymphocyte count or percentage declines rapidly.

Imaging Cerebral imaging can demonstrate atrophy and calcification in the basal ganglia and frontal lobes in patients with encephalopathy. Chest radiographs of children with lymphoid interstitial pneumonitis show diffuse interstitial reticulonodular infiltrates, occasionally with hilar adenopathy. The chest radiograph in P jiroveci pneumonia typically demonstrates perihilar infiltrates progressing to bilateral diffuse alveolar disease.

General Measures Immunizations Combined diphtheria-tetanus-acellular pertussis, inactivated poliovirus, conjugated Haemophilus influenzae type b, conjugated Streptococcus pneumoniae, hepatitis B, and hepatitis A vaccines should be given as recommended for healthy children. (See Chapter 9.) The conjugated meningococcal vaccine and human papillomavirus vaccine are also recommended. Studies evaluating the immunogenicity of these vaccines in HIV-infected children are underway. A dose of 23-valent polysaccharide vaccine at age 2 years and a booster after 35 years is recommended in addition to the conjugated pneumococcal vaccine series given in infancy. Infected children and their household contacts should receive inactivated influenza vaccine annually after age 6 months. In general, live virus vaccines should be avoided. However, the risk of measles is considered greater than the potential risk of the vaccine in asymptomatic children; thus measles-mumps-rubella vaccine should be given at age 12 months, with the second dose given 1 month later, provided the child does not have evidence of severe immunosuppression (category C or category 3). Varicella vaccine, also a live virus, should be considered after the potential risks and benefits are weighed, for asymptomatic or mildly symptomatic HIV-infected children older than age 12 months with CD4 T-lymphocyte levels of 15% or more. HIV-infected children receive two doses of varicella vaccine administered 3 months apart. Because antibody titers to vaccines decline with time and with progression of immune deficiency, prophylaxis with immune globulin for measles exposure and tetanus immune globulin for tetanus-prone wounds should be given regardless of immunization status. Prophylaxis for Infections Children with suppressed CD4 lymphocyte numbers benefit from prophylactic treatment to prevent opportunistic infections. Children who have had their CD4 counts restored to category

1 or 2 for over 24 months can be taken off prophylactic treatments. Antibiotic prophylaxis for P jiroveci pneumonia has been extremely effective. Because this infection has its highest incidence during the first year of life, P jiroveci pneumonia prophylaxis is given to all infants born to HIV-infected mothers beginning at age 46 weeks. When tests for HIV DNA or RNA are demonstrated negative at age 34 months, prophylaxis may be discontinued. HIV-infected infants should continue on prophylactic drugs until age 12 months, when further treatment is based on assessment of symptoms and age-adjusted CD4 lymphocyte counts every 3 months. Published guidelines from the CDC for P jiroveci pneumonia prophylaxis are summarized in Tables 394 and 395.

Formerly Pneumocystis carinii.

Among children who have had two or more negative HIV cultures or PCR tests, at least one of which is performed after age 1 month and one of which is performed at age 24 months or older.
c

Prophylaxis should be considered on a case-by-case basis for children who might otherwise be at risk for Pneumocystis pneumonia, such as those with rapidly declining CD4 counts or percentages or children with category C conditions.

Children with hypogammaglobulinemia or a history of serious or multiple bacterial infections may benefit from monthly intravenous immune globulin if they are not receiving trimethoprim sulfamethoxazole and have not responded well to antiretroviral therapy. Clarithromycin or azithromycin reduces the frequency of disseminated MAC with a survival benefit for children with very low CD4 counts. Recurrent mucocutaneous candidiasis can be prevented with nystatin, clotrimazole, or fluconazole. Oral antiviral prophylaxis (acyclovir, valacyclovir, or famciclovir) is effective for recurrent severe herpes simplex or VZV infections.

HIV-infected children have a higher risk of progressive M tuberculosis infections. Because the child's infection is usually acquired from adult household contacts, the child and other household members should be skin-tested for tuberculosis yearly if they belong to a population with substantial risk for exposure to M tuberculosis. Infections and Other Conditions Rates of bacteremia, especially pneumococcal bacteremia, and shingles, are higher among HIV-infected children, even in the absence of severe suppression of CD4 counts. Shingles occurs 10 times more frequently among HIV infected children compared with age-matched healthy children. VZV and herpes simplex virus infections are treated with acyclovir, because symptoms may be prolonged in children with HIV. Short courses of valacyclovir or famciclovir drugs with good bioavailabilityare also effective, although not approved for children. Aphthous ulcers also occur in children, even when on suppressive antiretroviral drug therapy. Symptomatic CMV infection is treated with ganciclovir or foscarnet and requires ongoing secondary prophylaxis if CD4 lymphocyte counts remain low. MAC requires treatment with a multidrug regimen to delay the emergence of resistance. Lymphoid interstitial pneumonitis may respond to corticosteroid therapy. Chronic parvovirus as a cause of anemia should be investigated and can be treated with intravenous immune globulin. Anemia and granulocytopenia, whether drug-induced or HIV-induced, may respond to epoetin alfa (erythropoietin) and filgrastim (granulocyte colony-stimulating factor, G-CSF), respectively. Rarely transfusions are needed; CMV-seronegative blood should be used. General Support Growth failure (weight and height) is one of the earliest and most sensitive markers of disease progression. The cause is a combination of increased metabolic needs related to chronic infection and decreased caloric intake. Supplemental nutrition in the form of oral supplements may be required. Some antiretroviral drugs cause elevated cholesterol and triglycerides. A cross-sectional study found elevated serum cholesterol in 13% of children with HIV compared with 5% of uninfected pediatric controls. Although the long-term consequences of drug-induced hyperlipidemia in HIV-infected children are unknown, diet modification and exercise are recommended. Nutritional evaluation and counseling should be a part of early care and continue throughout the child's care. Evaluation and support for psychosocial needs of HIV-affected families is imperative. As with other chronic illnesses, HIV infection affects all family members, and it also carries an additional social stigma. Emotional concerns and financial needs are more prominent than medical needs at many stages of the disease process and influence the family's ability to comply with a medical treatment regimen. HIV-infected children often have comorbid mental health conditions. Rates of attention-deficit/hyperactivity disorder range from 2050% in various studies. Hospital admissions for mental health disorders are more frequent among HIVinfected children. In one study dual diagnosis of HIV and a mental health disorder occurred in 85% of adolescents who acquired HIV infection through high-risk behaviors. Ideally, care should be coordinated by a team of caregivers that is familiar with this disease and the newest therapies, and that has access to community resources.