Infection With The Human Immunodeficiency Virus (Hiv) Infection In Infants And Children

HIV infection is caused by the retrovirus HIV-1 (and less frequently by the related retrovirus HIV-2) gives. An infection leads to progressive destruction of the immune system and to opportunistic infections and cancers. The final stage is the acquired immunodeficiency syndrome (AIDS). The diagnosis is made in children who are older than 18 months by viral antibodies and in children under 18 months using virological Nukleidsäureamplifikationstests (such as PCR). The treatment is carried out with a combination of antiretroviral drugs.

HIV infection is caused by the retrovirus HIV-1 (and less frequently by the related retrovirus HIV-2) gives. An infection leads to progressive destruction of the immune system and to opportunistic infections and cancers. The final stage is the acquired immunodeficiency syndrome (AIDS). The diagnosis is made in children who are older than 18 months by viral antibodies and in children under 18 months using virological Nukleidsäureamplifikationstests (such as PCR). The treatment is carried out with a combination of antiretroviral drugs.

(Human immunodeficiency virus infection (HIV-infection).) The HIV-infection is caused by the retrovirus HIV-1 (and less frequently by the related retrovirus HIV-2) gives. An infection leads to progressive destruction of the immune system and to opportunistic infections and cancers. The final stage is the acquired immunodeficiency syndrome (AIDS). The diagnosis is made in children who are older than 18 months by viral antibodies and in children under 18 months using virological Nukleidsäureamplifikationstests (such as PCR). The treatment is carried out with a combination of antiretroviral drugs. The general medical history and pathophysiology of pediatric HIV infection is similar to that of adults. However, the type of infection, the clinical manifestation and the treatment differ. HIV-infected children also have important needs that affect the social integration (integration of HIV-infected children). Integration of HIV-infected children HIV infection in a child affects the entire family. Serological testing of siblings and parents are recommended. The doctor has to take in this case, educational and advisory functions. The infected child should practice methods of hygiene and behavior to reduce the risk of infection for other people. Exactly how and when the child is to learn about the disease, depends on his age and maturity. Older children and adolescents should be informed about their diagnosis and the possibility of sexual transmission and advise accordingly. Some families do not want to talk to people outside the immediate family about the diagnosis, because it could lead to social isolation. Feelings of guilt are common. Family members, including children, may be clinically depressed and need help. Since HIV infection are not acquired by the typical pathways that in children normally occur (eg., By saliva or tears), most HIV-infected children may attend school without restrictions. Similarly, there are no inherent reasons, inclusion in foster care, adoption or child care to HIV-infected to restrict. Circumstances that an increased risk of other mean (z. B. aggressive biting or the presence of exudative, oozing skin lesions that can not be covered) may require special precautions. The number of school employees who are privy to the child’s condition should be just large enough to provide adequate support is guaranteed. The family has to inform the school the right, but the people who are involved in the care and education of an infected child must respect the child’s right to protect his privacy. Any disclosure of information should only take place with the informed consent of their parents or guardians, the age-appropriate consent of the child. Epidemiology In the United States stepped HIV in children probably as early as in the adult, but was not recognized clinically for years. To the present day, about 10,000 cases in children and young adolescents were reported, equivalent to only 1% of all cases. In 2011, an estimated 192 new cases were diagnosed <13 years in children. More than 90% of children with HIV infection in the US before their infection from the mother or during birth (vertical transmission) acquired. Most other (including children with hemophilia, or other coagulation disorders) have received contaminated blood or contaminated blood products. Isolated cases are due to sexual abuse. Vertical transfers have decreased significantly in the US, about 25% in 1991 (resulting in> 1500 infected children led a year) to 1% in 2009 (which only about 150 infected children led annually). Vertical transfers were reduced by using scale serological screening and infected pregnant women treated during pregnancy and childbirth. However, the total number of HIV-infected young people in the US is rising despite the significant success in reducing perinatal HIV infection to continue. This paradoxical increase is a result of the greater chances of surviving perinatally infected children and in new cases of HIV infection acquired through sexual transmission among other young people (especially among young men who have sex with men). Reducing the transmission of HIV among young men who have sex with men, remains an important focus of the dome-Nazi HIV control efforts; This also applies to the further reduction of vertical transmission. Worldwide about 3 million children are living with HIV infection (10% of global cases). Each year, about 330,000 more children infected (13% of all new infections) and about 230,000 children die. Although these data represent an extreme disease number, have new programs that have been created to provide antiretroviral therapy (ART) to pregnant women and children, the annual number of new infections in childhood and child deaths in recent years by 10 to 15 % reduced. However, infected children are still not as common an ART as adults; only about 28% of children with indications for treatment received ART compared to 57% of adults. The interruption of vertical transmission and the provision of treatment for HIV-infected children remain the two main objectives of the global pediatric HIV medicine. The transfer risk of infection to the infant an HIV positive mother who has not received ART during pregnancy is 25% (zwichen 13% and 39%). Risk factors for vertical transfer are seroconversion during pregnancy or lactation (primary risk) High viral RNA concentrations in serum (primary risk) advanced disease Low peripheral CD4 + T cell numbers prolonged period of cracked amniotic sac In vaginal deliveries of the first-born twin has a higher risk than the second-born, though this observation does not apply to developing countries. A delivery by caesarean section before the onset of labor reduces the risk of transmission from mother to child. but it is obvious that the transmission from mother to child by treating the mother and the newborn with combination ART, usually including zidovudine (ZDV), can be significantly reduced (infection with the human immunodeficiency virus (HIV) infection in infants and children: prevention). ZDV monotherapy reduces transmission from mother to child from 25% to about 8%; with the current combination ART transmission is reduced to 1%. HIV was detected in cellular and cell-free fraction of human breast milk. The risk of transmission through breastfeeding is about 6/100 breastfed infants per year. The generally estimated risk of transmission during breastfeeding is 12-14% depending on the duration of lactation. Transmission by breastfeeding is most likely in mothers with high viral RNA concentration in plasma (z. B. women during pregnancy or during lactation have been infected) .Klassifizierung caused HIV infection a large spectrum of diseases. AIDS is doing the most severe manifestation. The established by the Centers for Disease Control and Prevention (CDC) classification defines the stages of disease progression and deterioration of the immune status. Clinical categories in children <13 years (Clinical categories for children aged <13 years with HIV infection) are defined by the presence or absence of certain common opportunistic infections or cancers. These categories are N = Not symptomatic A = weak symptomatic B = Moderately symptomatic C = Severe symptomatic Immunological categories in children <13 years (s. Immunologic categories for children <13 years with HIV infection based on age-specific CD4 + T cell counts and percentage values ??of the total number of lymphocytes) reflect the degree of immunosuppression based on the number of CD4 + T cells (absolute number and as a percentage of total lymphocyte number): 1 = No evidence of immunosuppression 2 = Moderate suppression 3 = Severe suppression a child with a B3 classification would therefore advanced clinical symptoms and a severe immune deficiency. Clinical and immunological categories form a unidirectional hierarchy; once classified at a certain level, children can not be reclassified to a less severe level, regardless of clinical or immunological improvement. These clinical and immunological categories are becoming less relevant in the era of combination ART. If this therapy is performed correctly, there is almost always a decrease in symptoms and an increase in CD4 + T-cell count. The categories are particularly useful in clinical research and to describe the severity of the disease at diagnosis. The classification system for young people> 13 years old and adults has been revised and now simply contains the CD4 + T cell counts as a major component of the gradation unless AIDS-defining findings (z. B. opportunistic infections) exist (Clinical categories for children aged < 13 years with HIV infection). Clinical categories for children aged <13 years with HIV infection Category N: Not symptomatic Children who have no or only have such symptoms that may be associated with HIV infection or children who are only one of the conditions of the category A are category A: slightly symptomatic children with ? 2 of the conditions listed below, but none of the conditions of the category B or C: dermatitis Hepatomegaly, lymphadenopathy (? 0.5 cm to> 2 points; bilateral = 1 page) Parotitis Recurrent or persistent infections of the upper respiratory tract, sinusitis, otitis media or splenomegaly Category B: Moderately symptomatic children with symptomatic conditions that are caused by HIV infection, which go beyond those listed for category A symptoms, but have any of the symptoms listed under category C; Terms of Category B include the following symptoms, but are not limited to: anemia (Hb <8 g / dL), neutropenia (<1000 / ul) or thrombocytopenia (<100,000 / ul) persistent ? 30 days Bacterial meningitis, pneumonia or sepsis (single episode) candidiasis, oropharyngeal (thrush), persisting (> 2 mo) in children> 6 months old cardiomyopathy cytomegalovirus infection with onset before 1 month of age diarrhea, as derkehrend or chronic hepatitis herpes zoster (shingles) with ? 2 different sequences or> 1 dermatome HSV stomatitis, recurrent (> 2 episodes within 1 year) HSV bronchitis, pneumonia or esophagitis, inserting before 1 month of age Leiomyosarcoma Lymphoid interstitial pneumonia or pulmonary lymphoid hyperplasia complex Nephro pathy Nokardiose Persistent fever (duration> 1 month) Toxoplasmosis with onset before 1 month of age Varicella, disseminated (chickenpox complications) Category C: Strong symptomatic children with ? 1 of the following conditions: (multiple or recurrent severe bacterial infections d. H. a combination of ? 2 culture infection confirmed within a 2-year period) of the following types: sepsis, pneumonia, meningitis, bone or joint infection or abscess of an internal organ or body cavity (not otitis media, superficial skin or mucosal abscesses and permanent catheter infections) candidiasis, esophageal or lung (bronchi, trachea, lung) coccidioidomycosis disseminated, (persist at a different location than or in addition to lungs or cervical or hilar lymph nodes) cryptococcosis, extrapulmonary Cryptosporidiosis or isosporiasis with diarrhea d for> 1 month Zytomegaloviruserkrankung with onset of symptoms at age> 1 month (at a site other than the liver, spleen or lymph nodes) encephalopathy (presence of ? 1 of the following progressive findings on ? 2 months under absence of other concurrent disease except HIV infection that could explain the findings): non-achievement or loss of developmental milestones or loss of intellectual ability, verified by standard developmental scale or neuropsychological tests Impaired brain growth or acquired microcephaly demonstrated by measurements of head circumference or by the presence of brain atrophy in the computed tomography or magnetic resonance imaging (for Children <2 years is a serial imaging required) acquired symmetric motor deficit, which is manifested by ? 2 of the following symptoms: paralysis, pathologic reflexes, ataxia, or gait disturbance Histoplasmosis, disseminated (at a different location or in addition to lungs and throat or hilar lymph nodes) HSV infection causing a mucocutaneous ulcer that persists for> 1 month or HSV bronchitis, pneumonitis or esophagitis in a child> 1 month Kaposi’s sarcoma, lymphoma, primary, in brain Lymphomas: small, non-cleaved cell lymphomas (Burkitt’s lymphoma) or immunoblastic or lymphoma of the large cells of the B-cell or an unknown immunological phenotype Mycobacterium tuberculosis, disseminated or extrapulmonary Mycobacterium, other types or unknown species, disseminated (at a different location, or in addition to the lung, skin, cervical or hilar lymph nodes) Pneumocystis jirovecii pneumonia Progressive multifocal leukoencephalopathy Salmonella septicemia, not type hos, recurrent Toxoplasmosis of the brain with onset> 1 month of age Wasting syndrome in the absence of concomitant disease (except HIV infection) that could explain one of the following three findings: Persistent weight loss> 10% of baseline undershoot ? 2 of the following percentile lines (on the standard growth curve z. B. 95th, 75th, 50th 25th, 5th) in a child ? 1 year <5th percentile on standard growth curve on 2 consecutive measurements at a distance of ? 30 days also one of the following symptoms: Chronic diarrhea (ie ? 2 thin stools daily for ? 30 days) Documented fever (? about 30 days intermittent or constant) HSV = herpes simplex virus. Adapted from: Centers for Disease Control and Prevention, Revised surveillance case definitions for HIV infection among adults, adolescents, and children aged <18 months and for HIV infection and AIDS among children aged 18 months to <13 years of age-United States, 2008 . Morbidity and Mortality Weekly Report 57 (RR-10): 1-13, 2008. Immunological categories for children <13 years with HIV infection based on age-specific CD4 + T cell counts and percentages of the total number of lymphocytes Immunologic category <12 months 1-5 years 6-12 years cell n / ul% cells / mm% cells / mm% 1: No evidence of suppression ? 1500 ? 25 ? 1000 ? 25 ? 500 ? 25 2 Detection of moderate suppression 750-1499 500-999 15-24 15-24 200 499 15-24 3: Heavy suppression <750 <15 <500 <15 <200 <15 Adapted from: Centers for Disease Control and Prevention: Revised surveillance case definitions for HIV infection among adults, adolescents, and children aged <18 months and for HIV infection and AIDS among children aged 18 months to <13 years of age-United States, 2008. Morbidity and Mortality Weekly Report 57 (RR-10): 1-13 of 2008. Symptoms and discomfort Natural development in untreated children Perinatal infected children are asymptomatic, even if no combination ART was started usually during the first months of life. Although the average age is the onset of symptoms in three years, a large number of children remain asymptomatic away over the age of 5 years. With an adequate ART survive into adulthood. Before the era before ART 10-15% of children had a rapid progression of the disease. The first symptoms occurred during the first year and led with 18-36 months to death. It is believed that these children were already infected in utero with HIV. but most children become infected just before or at birth and have a slower disease progression (survival over 5 years, there were even before ART). Among the most common manifestations of HIV infection in children who do not receive ART, include generalized lymphadenopathy, hepatomegaly, splenomegaly, failure to thrive, oral candidiasis, CNS diseases (progressive developmental delays), interstitial, lymphatic pneumonitis, frequent bacteremia, opportunistic infections, frequent diarrhea , cardiomyopathy, hepatitis, nephropathy Krebserkrankungen.Komplikationen If complications occur, they typically include opportunistic infections (and rarely cancer). The combination ART has made such infections rarely occur now and especially in undiagnosed children who have not yet received any ART, or in children who do not adhere to the ART. If opportunistic infections occur Pneumocystis jirovecii pneumonia is the most common and schwerwigendste infection that has the highest mortality. Pneumocystis pneumonia can in the 4th-6th Week of life occur, but most often occurs in infants aged 3-6 months who were infected before or during birth. Infants and older children with Pneumocystis pneumonia typically develop a subacute diffuse pneumonitis with dyspnea at rest, tachypnea, decreased O2 saturation, non productive cough and fever (as opposed to non-infected with HIV, immunocompromised infants and young children, often a have high acute and fulminant beginning). Other opportunistic infections in immunocompromised children include Candida esophagitis, disseminated cytomegalovirus infection, chronic or disseminated herpes simplex infection varicella virus infection (rare) infection with Mycobacterium tuberculosis and M. avium complex, chronic enteritis caused by the Cryptosporidium and other organisms and CNS infections caused by cryptococcal or Toxoplasma gondii one. Cancers are relatively rare in children with HIV infection, but leiomyosarcomas and certain lymphomas, including CNS lymphomas and non-Hodgkin's B-cell lymphomas (Burkitt type) are more common than in immunocompetent children. Kaposi's sarcoma occurs in HIV-infected children rarely vor.Kinder who are receiving antiretroviral combination therapy, the combination ART has changed the clinical symptoms of pediatric HIV infection. Although bacterial pneumonia and other bacterial infections (eg. As bacteremia, recurrent otitis media) are more common in HIV-infected children, opportunistic infections and growth disorders are much less frequent than in the pre-ART. Of new problems such. B. Changes in serum lipids, hyperglycemia, maldistribution of fat (lipodystrophy and lipoatrophy), nephropathy and osteonecrosis have been reported, though with less Inzidienz than in HIV-infected adults. Although the combination ART improves neurological outcome significantly, there seems to be an increased rate of behavioral, developmental, and cognitive problems in treated HIV-infected children. It is unclear whether these problems are caused by the HIV infection itself, therapeutic drugs or other psychosocial factors in HIV-infected children. It is not known whether additional effects of HIV infection or ART will manifest in critical periods of growth and development phases later in life when the first cohort of perinatally infected children only now reached adulthood. To such side effects can be seen, treated HIV-infected children have to watch over some period of time. Diagnostic serum antibody tests Virological Nukleidsäuretests (NATs, including HIV, DNA, PCR, or HIV-RNA assays) HIV-specific tests is> 18 months with children the diagnosis (by a serum antibody test, for example., Enzyme immunoassay [ EIA] and Western blot) made as in adults. Recently, a new diagnostic algorithm of an HIV-1/2 antigen / antibody combination immunoassays of the 4th generation, followed by HIV-1/2 antibody differentiation test of the 2nd generation, and if necessary, a qualitative assay of HIV -1 RNA used in adults and is likely to come soon for use in children. Only very rarely has an older HIV-infected child because of a severe hypogammaglobulinemia no HIV antibodies. Children <18 months have maternal antibodies (EIA) may occur so that false positive results with enzyme immunoassay and the diagnosis by HIV assays and qualitative RNA assays (eg. As transcription-mediated amplification of RNA) or DNA-PCR assays (collectively referred to as NATs) must be submitted. This test is positive in 30% of children at birth and almost 100% of children aged 4-6 months. HIV cultures are indeed sufficiently sensitive and specific, but very expensive and dangerous and were replaced in most laboratories by NATs. Another type of NAT, the quantitative HIV-RNA assay (i. E. The viral load tests are used to monitor the effectiveness of treatment), is increasingly used in the diagnosis of infants. Quantitative RNA assays are as sensitive as DNA-PCR in infants who did not receive ART, and cheaper and more widespread than the other NATs. However, it must be observed when using RNA assays in the diagnosis of infants that test specificity at very low concentrations RNA is uncertain (<5,000 copies / ml), and the sensitivity in infants of mothers with at term completed drug treatments for viral suppression unknown is. The modified p24 antigen assay is less sensitive than HIV DNA or RNA NATs and should no longer be used for the diagnostic testing of infants in the United States. Ein virologischer Test (ein NAT) sollte zuerst in den ersten 2 Lebenswochen, dann mit 1 Monat und erneut zwischen 4–6 Monaten durchgeführt werden. Positive Ergebnisse sollten sofort mit demselben Test oder einer anderen virologischen Kultur bestätigt werden. Sind die seriellen virologischen HIV-Tests ? 2 Wochen und ? 4 Wochen negativ, kann der Säugling mit einer > 95%igen Wahrscheinlichkeit (bei Fehlen jeglicher Krankheitsanzeichen von AIDS) als nicht infiziert betrachtet werden. Sind die virologischen HIV-Tests ? 4 Wochen und ? 4 Monaten auch negativ, kann der Säugling mit einer etwa 100%igen Wahrscheinlichkeit (bei Fehlen jeglicher Krankheitsanzeichen von AIDS) als nicht infiziert betrachtet werden. Trotzdem empfehlen viele Experten weiterhin, dass Antikörpertests (1 Enzymimmunoassay [EIA] mit > 18 Monaten oder 2 EIA zwischen dem 6. und 18. Monat) folgen sollten, um eine HIV-Infektion definitiv auszuschließen und eine Serokonversion (Verlust der passiv erworbenen Antikörper) zu bestätigen. Falls ein Kind < 18 Monate mit einem positiven Antikörpertest, aber negativem virologischem Nachweis eine AIDS-definierende Krankheit (Kategorie C; Klinische Kategorien für Kinder im Alter von < 13 Jahren mit HIV-Infektion) entwickelt, wird eine HIV-Infektion diagnostiziert. Schnelltests auf HIV-Antikörper-Tests wurden aus den EIA-Tests entwickelt und zeigen bereits innerhalb von Minuten bis Stunden Resultate. Sie sind einfach mit Mundsekret, Vollblut oder Serum durchzuführen. Diese Tests haben sich in den USA in Geburtskliniken sehr bewährt, um Frauen mit einem unbekannten HIV-Status zu testen, anschließend zu beraten, eine ART einzuleiten, eine Übertragung von Mutter zu Kund zu verhindern und das Kind bei der Geburt zu testen. Als ebenso vorteilhaft haben sich die Tests auch in Notfallambulanzen, in der J

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