Pediatric emergency medicine trisk 2345 2345
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trimethoprim intravenously every 6 hours) should be considered if there are
respiratory symptoms, with or without a positive chest radiograph. Treatment for
suspected PCP should not be delayed because of concern of interfering with the
diagnostic workup. Fungal infections, with the exception of oral thrush, are
uncommon in HIV-infected children. However, candidal sepsis should be
considered in hospitalized patients who do not improve with antibiotics.
Chronic fever is common in HIV-infected children and has a broad differential
diagnosis. The major focus of such an evaluation in the ED is to rule out acute
bacterial infection. A careful history and physical examination should be
followed by a CBC, urinalysis, chest and sinus films, and blood, urine, and stool
cultures. Recurrent otitis media is commonly seen, and some children may have
recurrent parotitis or sinusitis. If no source is recognized on examination and the
initial testing is negative, more unusual infections need to be considered.
Tuberculosis, although common among HIV-infected adults, is uncommon in
children but may be more likely among adolescents. Mycobacterium avium
complex may cause chronic fevers in HIV-infected children. This pathogen is
often associated with anemia secondary to bone marrow infiltration and can be
cultured from blood, stool, and bone marrow. Numerous viruses can cause
chronic infections associated with fever in these children. EBV and CMV are
among the more common, with CMV often presenting with chronic hepatitis and
bloody diarrhea. It may also cause pneumonia and retinitis. A blood buffy coat
specimen can be sent for quantitative CMV-antigen detection. Most HIV-positive
children with fever of unknown origin are hospitalized to facilitate the diagnostic
process. The possibility of drug fever must also be considered.
Two OIs warrant special attention: PCP and lymphoid interstitial pneumonitis
(LIP). PCP is caused by a fungal pathogen and is the most common initial
manifestation of HIV in the perinatally infected infant. The infant or child
typically is febrile, with marked tachypnea, wheezing, rhonchi, and diminished
breath sounds. Rales are not usually part of the PCP picture, and cough may be
absent. When coughing is present, it is typically dry and nonproductive. Over
hours to days, the patient develops hypoxia and increased respiratory distress.
Initial ED evaluation should include beginning supplemental oxygen, obtaining
pulse oximetry, an arterial blood gas, a chest radiograph, and serum LDH levels.
Radiographs may show a diffuse interstitial (“ground-glass”) pattern, but infants
may develop patchy infiltrates or complete opacification of the lung fields. The
diagnosis often requires bronchoscopy with specimens sent for silver stains.
However, if the ED physician suspects PCP, it is appropriate to start IV TMPSMZ at a dosage of 5 mg/kg/dose of TMP every 6 hours. The child should be
