Pediatric emergency medicine trisk 2346 2346
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hospitalized for close observation and further evaluation as needed. In general,
patients with PCP do not respond rapidly to antibiotic therapy. Patients intolerant
of TMP-SMZ can be treated with systemic (not aerosolized) pentamidine (4
mg/kg/day as a single daily dose) or atovaquone, but these should be considered
second-line agents. Corticosteroid therapy in children with severe PCP improves
survival and is generally recommended for patients with PaO2 less than 70 mm
Hg or an alveolar–arterial gradient of greater than 35 mm Hg. Standard
precautions are indicated.
LIP is a lymphoid hyperplastic condition associated with both HIV and EBV
infections. LIP results in a slowly progressive hypoxemic condition in children
outside infancy. The most common symptoms are chronic cough, mild
tachypnea, generalized adenopathy, marked hypoxemia, and digital clubbing.
Chest radiography reveals an interstitial nodular pattern, and bronchiectasis can
be seen on high-resolution CT of the chest. The diagnosis is confirmed via
biopsy. Fever is an unusual manifestation of LIP and should prompt evaluation
for secondary pyogenic bacterial infections. Therapy may be with antiretroviral
therapy; in acute respiratory compromise, empiric corticosteroid therapy may be
warranted. If the PaO2 is less than 65 mm Hg, LIP is treated with 1 to 2
mg/kg/day of prednisone (maximum: 60 mg/day) for 2 to 4 weeks and
subsequently tapered to maintain the PaO2 above 70 mm Hg. If the patient is
febrile, tuberculosis or MAI must be ruled out before beginning steroid therapy.
Management: Whenever a child with HIV infection presents with high-grade
fever (temperature higher than 39°C or 102.2°F), a complete blood cell count
(CBC) with differential and blood culture is recommended. If the child is still in
diapers, a urine sample should be obtained for analysis and culture. Older
children who are toilet trained usually complain of dysuria or frequency if they
have a UTI. If the child has any respiratory signs or symptoms, including
isolated tachypnea, or if the CBC has an elevated leukocyte count with a shift to
left, regardless of the presence of respiratory signs, pulse oximetry and a chest
radiograph should be ordered. The WBC count is best evaluated in relation to
baseline counts because many HIV-infected children have some degree of
leukopenia. If it is known that the child is not leukopenic or the baseline is not
available, a WBC count of 15,000/mm3 or more should be considered suggestive
of bacterial infection. If the child appears well and the evaluation has not
revealed a source for the fever that requires hospitalization, the child may be sent
home (if the child’s caregiver can be easily contacted and has the means to return
if necessary) with instructions to return if symptoms worsen or if the patient
