Pediatric emergency medicine trisk 2341 2341
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Clinical Considerations
Clinical recognition: Initial ED recognition of children with known HIV
infection should include categorizing children as likely OIs ( Table 94.24 and
e-Table 94.26 ) based on their CD4+ cell count, infections caused by pathogens
which also infect normal hosts, and drug toxicities from their antiretroviral
regimen or from prophylactic antibiotics or antiviral medications ( e-Table
94.27 reviews antiretroviral medications and
e-Table 94.28 reviews adverse
events). ED clinicians should also be cognizant of the presentations of acute HIV
infection ( Tables 94.24 and 94.25 ) in adolescents and of the presentations of
OIs in as-yet undiagnosed children with perinatally acquired HIV infection (
e-Table 94.29 ), most of whom will become symptomatic during infancy.
Triage considerations: HIV-infected children should be roomed as rapidly as
possible to prevent them from acquiring a nosocomial infection while in the ED.
Triage assessment should include obtaining pulse oximetry, as indolent
hypoxemia may be the first sign of early Pneumocystis jiroveci (formerly, P.
carinii ) pneumonia (PJP). Triage personnel need to be cognizant that HIVinfected children are at risk for overwhelming bacterial and viral sepsis, similar
to other immunocompromised children.
Clinical assessment: The most common clinical presentations of HIV-infected
children and one diagnostic approach are reviewed in
e-Table 94.30 . The
first branch point in decision making for the febrile HIV-infected child is
whether or not they are ill appearing. Most infections, even in HIV-infected
children will be caused by common pathogens also seen in immunocompetent
children. However, it is important that providers realize that the rates of
bacteremia are higher in HIV-infected children than in their immunocompetent
peers. It appears that serious bacterial, viral, or OIs are relatively uncommon
among well-appearing HIV-positive children who present to the ED with fever.
