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Key Features

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Essentials of Diagnosis
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  • Infants with in utero HIV infection have virus detectable in the blood at birth

  • Those infected peripartum test negative for virus at birth but have virus detected by 2–4 weeks of age

  • Infant viremia rises steeply, reaching a peak at age 1–2 months

  • Infants have a gradual decline in plasma viremia that extends to age 4–5 years

  • Up to 50% of infants will have rapid disease progression to AIDS or death by age 2 years

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General Considerations
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  • Infection results in profound effects on both humoral and cell-mediated immunity

  • In the absence of treatment, HIV infection causes generalized immune incompetence

  • Clinical diagnosis of AIDS is made when severe opportunistic illnesses develop in an HIV-infected individual, such as

    • Candidiasis of bronchi, trachea, lungs, or esophagus

    • Disseminated or extrapulmonary histoplasmosis

    • Kaposi sarcoma

    • Disseminated or extrapulmonary Mycobacterium avium complex

    • Wasting syndrome

  • In children older than 6 years, the criteria for a diagnosis of AIDS also include an absolute CD4 T-lymphocyte count of 200 cells/μL or less

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Demographics
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  • Among children younger than 15 years, there were 220,000 new infections and 150,000 deaths in 2014

  • High rates of new pediatric infections are the result of ongoing mother-to-child transmission (MTCT) in resource-limited settings where access to preventative measures is often not accessible

    • Transmission occurs in utero, at the time of labor and delivery (peripartum), or during breast-feeding (postnatal transmission)

    • However, MTCT can be reduced to less than 1–2% with prenatal, perinatal, and postnatal interventions

  • Occupational exposure resulting from accidental needle sticks or, rarely, mucosal exposure to blood may occur

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Clinical Findings

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  • Newborns with perinatal HIV infection rarely have symptoms or physical examination findings at birth, and there is no recognized primary infection syndrome in infants

  • However, symptoms develop in 30–80% of infected infants within the first year of life

  • Signs associated with slow progression include

    • Hepatomegaly

    • Splenomegaly

    • Lymphadenopathy

    • Parotitis

    • Recurrent respiratory tract infections

  • Severe bacterial infections, progressive neurologic disease, anemia, and fever are associated with rapid progression

  • Children with HIV are at increased risk of malignancy; most commonly occurring tumors are non-Hodgkin lymphomas

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Diagnosis

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Laboratory Findings
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  • Infants born to HIV-infected mothers will have transplacental maternal HIV antibody regardless of their infection status

  • The median time to seroreversion is 13.9 months and most uninfected infants become antibody negative by 18 months; in a minority of infants, however, maternal antibody is detected until age 24 months

  • The preferred test for infant diagnosis is detection of HIV nucleic acid (DNA or RNA) in blood

  • Positive HIV nucleic acid testing (NAT) at any age requires a subsequent sample for confirmation to rule out a false positive

  • The hallmark of HIV disease progression is decline in the absolute number and percentage of CD4 T lymphocytes and an increasing percentage of CD8 T lymphocytes

  • Hypergammaglobulinemia ...

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