Presented ByVijayaletchumy Chandrashekaran

Ruthra Devi Narayana Samy

SupervisorDr. Rita Evalina M.Ked (Ped) Sp,A (K)

Epidemiology

Epidemiology
In 2013, 240,000 children younger than 15
years of age were newly infected with HIV
bringing the total number of children worldwide
living with HIV or acquired immune deficiency
syndrome (AIDS) to 3.2 million or approximately
9 percent of all people living with AIDS
It is estimated that 343,460 adults are in need of AntiRetroviral Therapy (ART).

Definition of HIV
HIV infection is a condition caused by
Human Immunodeficiency Virus (HIV).
This condition gradually destroys the
immune system, which makes it hard for the
body to fight infections.
It causes acquired immunodeficiency virus
(ADIS).

Etiology & structure

Causative agent: Human Immuno-deficiency

Virus

Structure of HIV virus

Enveloped RNA retrovirus

Spherical 120 nm in diameter envelope proteins make the spikes
on the
membrane.
Enveloped truncated conical capsid
Electron dense core
Two copies of the single stranded (+) RNA
Has enzymes: Reverse transcriptase, Integrase & Protease
Has gag, pol and env structural genes
Has LTR (long terminal repeats) rev and neg regulatory genes

 HIV infects CD-4 positive cells

CD4+ T-cell lymphocytes

Macrophages
Lymph node follicular dendritic cells
Langerhans cells
Binding to CD4 by gp120
Entry into cell by fusion requires gp41 and
coreceptors
CCR5 (Beta chemokine receptor)

 CXCR4 (alpha chemokine receptor)

Envelope lost and RNA uncoated

DNA made from RNA using reverse
transcriptase
DNA and Integrase migrate to nucleus forming
a provirus by integrating viral DNA to host
DNA

 Rate of viral replication regulated by the

activity of regulatory proteins (tat/rev, nef, etc)
Co-infections (e.g., mycobacterial) stimulate
the HIV-infected cells to produce more virus
Transcription and translation produces
necessary polyprotiens which are cleaved by
the HIV protease
Assembly
Maturation/release of virus

Difference between
HIV-1 & HIV-2:
HIV-2 is lower transmissibility.
HIV-2 develops more slowly.
MTCT )Mother to child transmission) is
relatively rare with HIV-2.
HIV-2 is found primarily in West Africa.
HIV-1 is more common worldwide.

The most methods of transmission

of HIV are:
Sharing needles with infected person.

Having sex with infected person.

A pregnant women can transmit the virus to her
fetus through their shared blood circulation, or a
nursing mother can pass it to her baby in her
breast milk.
HIV/AIDS cant be transmitted through:
Toilet.
Sharing Utensils.
Mosquito.

Risk factor of HIV

Have unprotected sex (do not use condoms).
Are a man who has sex with other men.
Have or have recently had a sexually transmitted
disease such as hepatitis B&C.
People who inject drugs or steroids, especially if
they share needles.
Babies who are born to mothers who are infected
with HIV.

V
I
H
f
o
s
e
g
Sta
With its
symptoms

Stage 1:
Primary HIV Infection
The first stage is called acute infection.
It is often accompanied by a short flu-like illness
It typically happens within 2 to 6 weeks after
exposure or becoming infected.
During this stage there is a large amount of HIV in
the peripheral blood and the immune system begins to
respond to the virus by producing HIV antibodies.
This process is known as (seroconversion).

The symptoms of HIV

infection for stage 1
Headache

Fatigue

Fever
vomiting

Sore throat
Diarrhea that
lasts for more
than a week

Stage 2:
Clinically Asymptomatic Stage

This stage lasts for an average of ten years

During this period without symptoms, HIV is slowly
killing the CD4 T-cells and destroying the immune
system.
Blood tests during this time can reveal the number of
these CD4 T-cells. For an HIV-infected person, the
number of CD4 T-cells steadily drops.

No clear symptoms appear *

Stage 3:
Symptomatic HIV Infection
AIDS (acquired immune deficiency
syndrome) is the advanced stage of HIV
infection. When the CD4 T-cell number drops
below 200, people are diagnosed with AIDS.

The symptoms of stage 3

Being tired all of the time.

Swollen lymph nodes in the neck .
Fever lasting for more than 10 days.
Night sweats.
Unexplained weight loss.
Purplish spots on the skin that don't go away.
Shortness of breath.
Severe, long-lasting diarrhea.

Diagno
sis

The HIV Test:

Enzyme-linked immunosorbent assay (ELISA).
This test is usually the first one used to detect infection
with HIV. If antibodies to HIV are present (positive),
the test is usually repeated to confirm the diagnosis.

Cont ..
Western blot.
This test is more difficult than the ELISA to
perform.
Polymerase chain reaction (PCR).
This test finds either the RNA of the HIV virus
or the HIV DNA in white blood cells infected
with the virus.

If you receive a diagnosis of HIV/AIDS, several

types of tests can help your doctor determine what
stage of the disease you have. These tests include:
CD4 count.
-

CD4 cells are a type of white blood cell that's specifically targeted
and destroyed by HIV.

CD4 count vary from 500 to more than 1,000=

healthy person .

CD4 count becomes less than 200 =HIV infection

progresses to AIDS.

Viral load:

This test measures the amount of virus in your blood.

Babys investigation of
HIV after birth
Most HIV tests look for antibodies to HIV, not the
virus itself. But these tests arent very useful for babies
born to HIV-positive mothers.

WHY ?
Thats because the mothers HIV antibodies get into the
babys blood during pregnancy. If the mother is HIVpositive, the regular HIV test will show that the baby is
HIV-positive, even when that isnt true.

Treatment

Treatment
Anti-retroviral medicines work by stopping the HIV from
making copies of itself .
To strengthen the immune system.
The amount of virus in your body (viral load) is
decreased.
Allows your body to make more CD4 T cells.
Commonly three different types of medicines are taken
together. This is called combination therapy. And that helps
to prevent the virus from becoming resistant to the
medicines. These medicines are usually taken for life.

The classes of anti-HIV

drugs include:
Non-nucleoside reverse transcriptase inhibitors (NNRTIs).
It disables a protein needed by HIV to make
copies of itself.
Nucleoside reverse transcriptase inhibitors (NRTIs).
They are faulty versions of building blocks that
HIV needs to make copies of itself.
Protease inhibitors (PIs).
It disables protease, another protein that HIV
needs to make copies of itself.
Entry or fusion inhibitors.
These drugs block HIV's entry into CD4 cells.
Integrase inhibitors.
Raltegravir (Isentress) works by disabling
integrase, a protein that HIV uses to insert its

Preventi
on

How to protect your baby

from getting HIV :
Mother-to-child transmission of HIV
can be prevented by using antiretroviral drugs,
which reduce the chances of a child becoming
infected with HIV from 20% to less than 5%.

CASE REPORT
Name
: MA
Age : 6 years 6 month
Sex : Female
MR : 00.62.36.60
Date of Admission : 14th November2014
Chief Complaint: Diarrhea
History:
Since approximately 3 weeks ago, having diarrhea non-stop , 3
times in 1 day with volume aqua bottle size.
Children complain of cough (+), appetite decreased (+) and fever
(+), the child looks weak (+), chills (-), seizures (-). In addition to
fever patients do not experience red eyes (-), cough (-), cold (-),
nausea (+), vomiting (+), weight loss (+) 5kg within 3 months

 Urinary pain (-), red or murky urin (-), back pain (-), slightly
urin (-), liquid form defecation (-), hard defecation (-), black
defecation (-).
Patient was referred to the emergency room laboratories
Adam Malik Hospital, Medan. In the ER RS.H.Adam Malik,
Medan


History of previous illness : Patients were referrals from
the general hospital of Kabanjahe by pediatrics specialist
doctor with diagnosis of malnutrition and TB Primer.

History of drugs : Ceforaxime, Paracetamol and OAT

 Pregnant History
: She is third child, age of
the mother when pregnant patients is 27 years old,
maternal history of fever (-), diabetes (-), hypertension
(-), taking birth control pills (-), drinking herbs (-) and
drugs (-), and Father of child is diagnosed as TB patient
and undergoing OAT medicine.

Birth History
: Spontaneous; aterm;
attended by midwives; crying (+); history of blue (-);
BW2500 gram; BL 46 cm.

Immunization History
: BCG, Hepatitis B, DPT,
Polio Vaccines were complete

PRESENS STATUS
Consciousness: Alert
Body temperature: 38,6 oC
HR : 96 bpm
RR : 24 x/i
Blood pressure : 100/60 mmHg
Body Weight : 12kg
Body Length : 102cm
Anemic (+) Icteric (-) Cyanosis (-) Edema (-)
Dyspnea (-).

LOCALIZED STATUS
Head
Eye: Isochoric pupil (3mm/3mm), light reflex (+/+), inferior palpebra conjunctiva pale
(-/-), icteric sclera (-/-).
Nose and Ear were within normal limit
Mouth: Lips mucosa pale (-).
Neck
TVJ R-2 cmH2O, Lymph node enlargement (-)
Thorax
Symmetrical fusiformis, Chest retraction(-), HR : 96 bpm, reguler, murmur (-), RR: 22
x/i, regular, rales (-/-).
Abdomen
Rapid turgor. Normoperistaltic. Liver was palpable with 2cm, spleen and renal
unpalpable
Extremities
Pulse 96 bpm, regular, adequate pressure and volume, warm acral, CRT < 3, Blood
Pressure 90/60 mmHg
Urogenital
Female , within normal limit.

Working Diagnosis:
Suspected TB milier, suspected HIV and Malnutrition

Management:
Diet F 75 130cc/2hr/with Mineral Mix 2,6cc
Rifampisin 1150mg
INH 1100mg
Pirazinamid 1150mg
Prednisolon 115mg
Vitamin A 1200mg
Asam Folat 150mg
Multivitamin without Fe 11 cth

Follow up

November 14th 2014

Diarrhea (+)

Head

Eye: Isochoric pupil (3mm/3mm), light

reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-).
Nose, Mouth and Ear were within normal
limit

Neck

TVJ difficult in value, Lymph node

Thorax

enlargement (-).
Symmetrical fusiformis, Chest retraction
(-), HR : 96 bpm, reguler, murmur (-), RR:
22 x/i, regular, rales (-/-).

Abdomen

Rapid turgor. Normoperistaltic. Liver

palpable with 2cm, spleen and renal
unpalpable.

Extremities

Pulse 96 bpm, regular, adequate pressure

Genital

and volume, warm acral,CRT < 3

Female, within normal limit

Susp. TB milier + susp. HIV

and Malnutrition

Diet F 75 130cc/2hr/with
Mineral Mix 2,6cc
Rifampisin 1150mg
INH 1100mg
Pirazinamid 1150mg
Prednisolon 115mg
Vitamin A 1200mg
Asam Folat 150mg
Multivitamin without Fe 11
cth
Diagnostic Planning :
Consul division of
respiratory and
pulmonulogy
Consul division of nutrition
and metabolic disease
Consul division of social
pediatric
Consul division of allergy
and immunology

November 15th
2014
S

Diarrhea (+), Fever (-)

Head

Eye: Isochoric pupil (3mm/3mm), light

reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-).
Nose, Mouth and Ear were within normal
limit

Neck

TVJ difficult in value, Lymph node

Thorax

enlargement (-).
Symmetrical fusiformis, Chest retraction
(-), HR : 96 bpm, reguler, murmur (-), RR:

Abdomen

22 x/i, regular, rales (-/-).

Rapid turgor. Normoperistaltic. Liver
palpable with 2cm, spleen and renal

Extremities

unpalpable.
Pulse 96 bpm, regular, adequate pressure

Genital

and volume, warm acral,CRT < 3

Female, within normal limit

Susp. TB milier +
susp. HIV and
Malnutrition

Diet F 75
130cc/2hr/with
Mineral Mix 2,6cc
Rifampisin 1150mg
INH 1100mg
Pirazinamid
1150mg
Prednisolon 115mg
Vitamin A 1200mg
Asam Folat 150mg
Multivitamin without
Fe 11 cth
Diagnostic
Planning:
Consul division of
nutrition and
metabolic disease

November 16th
2014
S

Diarrhea (+), Fever (-)

Head

Eye: Isochoric pupil (3mm/3mm), light

reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-).
Nose, Mouth and Ear were within normal
limit

Neck

TVJ difficult in value, Lymph node

Thorax

enlargement (-).
Symmetrical fusiformis, Chest retraction
(-), HR : 96 bpm, reguler, murmur (-), RR:

Abdomen

22 x/i, regular, rales (-/-).

Rapid turgor. Normoperistaltic. Liver
palpable with 2cm, spleen and renal

Extremities

unpalpable.
Pulse 96 bpm, regular, adequate pressure

Genital

and volume, warm acral,CRT < 3

Female, within normal limit

Susp. TB milier +
susp. HIV and
Malnutrition

Diet F 75
130cc/2hr/with
Mineral Mix 2,6cc
Cotrimoxazole
1240mg
Rifampisin 1150mg
INH 1100mg
Pirazinamid 1150mg
Prednisolon 115mg
Vitamin A 1200mg
Asam Folat 150mg
Multivitamin without
Fe 11 cth

November 17th
2014
S

Diarrhea (-), Fever (-),

Cough (+)

Head

Eye: Isochoric pupil (3mm/3mm), light

reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-).
Nose, Mouth and Ear were within normal
limit

Neck

TVJ difficult in value, Lymph node

Thorax

enlargement (-).
Symmetrical fusiformis, Chest retraction
(-), HR : 96 bpm, reguler, murmur (-), RR:

Abdomen

22 x/i, regular, rales (-/-).

Rapid turgor. Normoperistaltic. Liver
palpable with 2cm, spleen and renal
unpalpable.

Extremities

Pulse 96 bpm, regular, adequate pressure

Genital

and volume, warm acral,CRT < 3

Female, within normal limit

Susp. TB milier +
Susp. HIV and
Malnutrition

Diet F 75
130cc/2hr/with
Mineral Mix 2,6cc
Cotrimoxazole
1240mg
Rifampisin 1150mg
INH 1100mg
Pirazinamid 1150mg
Prednisolon 115mg
Vitamin A 1200mg
Asam Folat 150mg
Nystatin 41 cc
Multivitamin without
Fe 11 cth

November 18th
2014 November
24th 2014
S

Diarrhea (-), Fever (-),

Cough (+)

Head

Eye: Isochoric pupil (3mm/3mm), light

reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-).
Nose, Mouth and Ear were within normal
limit

Neck

TVJ difficult in value, Lymph node

Thorax

enlargement (-).
Symmetrical fusiformis, Chest retraction
(-), HR : 96 bpm, reguler, murmur (-), RR:
22 x/i, regular, rales (-/-).

Abdomen

Rapid turgor. Normoperistaltic. Liver

palpable with 2cm, spleen and renal
unpalpable.

Extremities

Pulse 96 bpm, regular, adequate pressure

and volume, warm acral,CRT < 3

Susp. TB milier +
Susp. HIV and
Malnutrition

November 25th
2014
November29th 2014
S

Diarrhea (-), Fever (-),

Cough (+)

Head

Eye: Isochoric pupil (3mm/3mm), light

reflex (+/+), inferior palpebra
conjunctiva pale (+/+), icteric sclera (-/-).
Nose, Mouth and Ear were within normal
limit

Neck

TVJ difficult in value, Lymph node

Thorax

enlargement (-).
Symmetrical fusiformis, Chest retraction
(-), HR : 96 bpm, reguler, murmur (-), RR:

Abdomen

22 x/i, regular, rales (-/-).

Rapid turgor. Normoperistaltic. Liver
palpable with 2cm, spleen and renal

Extremities

unpalpable.
Pulse 96 bpm, regular, adequate pressure

Genital

and volume, warm acral,CRT < 3

Female, within normal limit

Susp. TB milier +
Susp. HIV and
Malnutrition

Diet MB 1500 calorie

+ F 100 /60cc/8 hours
(Mineral Mix 3,2 cc)
Cotrimoxazole
1240mg
Rifampisin 1150mg
Etambutol 2200 mg
Vitamin B6 2 10mg
Vitamin A 1200mg
Asam Folat 11 mg
Nystatin 41 cc
Dactarin Oral Gel
Lamivudin 150 mg
Stravudin 30mg
Multivitamin without
Fe 11 cth