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Antiretroviral Therapy for HIV Infection in Infants and Children: Towards Universal Access: Recommendations for a Public Health Approach: 2010 Revision. Geneva: World Health Organization; 2010.

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Antiretroviral Therapy for HIV Infection in Infants and Children: Towards Universal Access: Recommendations for a Public Health Approach: 2010 Revision.

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ANNEX DPRESUMPTIVE AND DEFINITIVE CRITERIA FOR RECOGNIZING HIV-RELATED CLINICAL EVENTS IN INFANTS AND CHILDREN WITH ESTABLISHED HIV INFECTION

Clinical eventClinical diagnosisDefinitive diagnosis
Stage 1
AsymptomaticNo HIV-related symptoms reported and no clinical signs on examinationNot applicable
Persistent generalized lymphadenopathy (PGL)Persistent swollen or enlarged lymph nodes >1 cm at two or more non-contiguous sites, excluding inguinal, without known causeClinical diagnosis
Stage 2
Unexplained persistent hepatosplenomegalyEnlarged liver and spleen without obvious causeClinical diagnosis
Papular pruritic eruptionsPapular pruritic vesicular lesionsClinical diagnosis
Fungal nail infectionsFungal paronychia (painful, red and swollen nail bed) or onycholysis (painless separation of the nail from the nail bed). Proximal white subungual onychomycosis is uncommon without immunodeficiency.Clinical diagnosis
Angular cheilitisSplits or cracks on the lips at the angle of the mouth with depigmentation, usually responding to antifungal treatment but may recurClinical diagnosis
Lineal gingival erythema (LGE)Erythematous band that follows the contour of the free gingival line; may be associated with spontaneous bleedingClinical diagnosis
Extensive wart virus infectionCharacteristic warty skin lesions; small fleshy grainy bumps, often rough, fat on sole of feet (plantar warts); facial, more than 5% of body area or disfiguringClinical diagnosis
Extensive molluscum contagiosum infectionCharacteristic skin lesions: small flesh-coloured, pearly or pink, dome-shaped or umbilicated growths, may be inflamed or red; facial, more than 5% of body area or disfiguring. Giant molluscum may indicate advanced immunodeficiency.Clinical diagnosis
Recurrent oral ulcerations (two or more in six months)Aphthous ulceration, typically with a halo of inflammation and yellow-grey pseudomembraneClinical diagnosis
Unexplained parotid enlargementAsymptomatic bilateral swelling that may spontaneously resolve and recur, in absence of other known cause; usually painlessClinical diagnosis
Herpes zosterPainful rash with fluid-filled blisters, dermatomal distribution, may be haemorrhagic on erythematous background, and may become large and confluent. Does not cross the midline.Clinical diagnosis
Recurrent upper respiratory tract infection (URTI)Current event with at least one episode in past six months. Symptom complex: fever with unilateral face pain and nasal discharge (sinusitis) or painful swollen eardrum (otitis media), sore throat with productive cough (bronchitis), sore throat (pharyngitis) and barking croup-like cough (laryngotracheal bronchitis [LTB]), persistent or recurrent ear dischargeClinical diagnosis
Stage 3
Unexplained moderate malnutritionWeight loss: low weight-for-age, up to -2 standard deviations (SDs), not explained by poor or inadequate feeding and/or other infections, and not adequately responding to standard managementDocumented loss of body weight of -2 SD, failure to gain weight on standard management and no other cause identified during investigation
Unexplained persistent diarrhoeaUnexplained persistent (14 days or more) diarrhoea (loose or watery stool, three or more times daily) not responding to standard treatmentStools observed and documented as unformed. Culture and microscopy reveal no pathogens.
Unexplained persistent fever (intermittent or constant for longer than one month)Reports of fever or night sweats for longer than one month, either intermittent or constant, with reported lack of response to antibiotics or antimalarials. No other obvious foci of disease reported or found on examination. Malaria must be excluded in malarious areas.Documented fever of >37.5 °C with negative blood culture, negative malaria slide and normal or unchanged CXR, and no other obvious foci of disease
Oral candidiasis (after first 6 weeks of life)Persistent or recurring creamy white, soft, small plaques which can be scraped off (pseudomembranous), or red patches on tongue, palate or lining of mouth, usually painful or tender (erythematous form)Microscopy or culture
Oral hairy leukoplakiaFine small, linear patches on lateral borders of tongue, generally bilateral, which do not scrape offClinical diagnosis
Lymph node TBNon-acute, painless “cold” enlargement of lymph nodes, usually matted, localized in one region. May have draining sinuses. Response to standard anti-TB treatment in one month.Histology or isolation of M. tuberculosis from fine needle aspirate
Pulmonary TBNon-specific symptoms, e.g. chronic cough, fever, night sweats, anorexia and weight loss. In older children, productive cough and haemoptysis as well. Abnormal CXR.Isolation of M. tuberculosis on sputum culture
Severe recurrent bacterial pneumoniaCough with fast breathing, chest indrawing, nasal flaring, wheezing and grunting. Crackles or consolidation on auscultation. Responds to course of antibiotics. Current episode plus one or more in previous six months.Isolation of bacteria from appropriate clinical specimens (induced sputum, bronchoalveolar lavage [BAL], lung aspirate)
Acute necrotizing ulcerative gingivitis or stomatitis, or acute necrotizing ulcerative periodontitisSevere pain, ulcerated gingival papillae, loosening of teeth, spontaneous bleeding, bad odour, and rapid loss of bone and/or soft tissueClinical diagnosis
Symptomatic lymphoid interstitial pneumonitis (LIP)No presumptive clinical diagnosisCXR: bilateral reticulonodular interstitial pulmonary infiltrates present for more than two months with no response to antibiotic treatment and no other pathogen found. Oxygen saturation persistently <90%. May present with cor pulmonale and may have increased exercise-induced fatigue. Characteristic histology.
Chronic HIV-associated lung disease (including bronchiectasis)History of cough productive with copious amounts of purulent sputum (bronchiectasis only), with or without clubbing, halitosis, and crepitations and/or wheeze on auscultationCXR: may show honeycomb appearance (small cysts) and/or persistent areas of opacification and/or widespread lung destruction, with fibrosis and loss of volume.
Unexplained anaemia (<8 g/dl), or neutropenia (<0.5 × 109/L) or chronic thrombocytopenia (<50 × 109/L/No presumptive clinical diagnosisLaboratory testing, not explained by other non-HIV conditions, or not responding to standard therapy with haematinics, antimalarials or anthelminthics as outlined in the IMCI.
Stage 4
Unexplained severe wasting, stunting or severe malnutrition not adequately responding to standard therapyPersistent weight loss not explained by poor or inadequate feeding or other infections and not adequately responding in two weeks to standard therapy. Characterized by: visible severe wasting of muscles, with or without oedema of both feet, and/or weight-for-height of -3 SDs, as defined by the WHO IMCI guidelinesConfirmed by documented weight loss of >-3 SD +/- oedema
Pneumocystis pneumonia (PCP)Dry cough, progressive difficulty in breathing, cyanosis, tachypnoea and fever; chest indrawing or stridor. (Severe or very severe pneumonia as in IMCI.) Usually of rapid onset especially in infants <6 months of age. Response to high-dose co-trimoxazole +/-prednisoloneConfirmed by: CXR, typical bilateral perihilar diffuse infiltrates; microscopy of induced sputum or BAL or nasopharyngeal aspirate (NPA)
Recurrent severe bacterial infection, e.g. empyema, pyomyositis, bone or joint infection, meningitis but excluding pneumoniaFever accompanied by specific symptoms or signs that localize infection. Responds to antibiotics. Current episode plus one or more in previous six months.Confirmed by culture of appropriate clinical specimen
Chronic herpes simplex infection; (orolabial or cutaneous of more than one month's duration or visceral at any site)Severe and progressive painful orolabial, genital, or anorectal lesions caused by HSV infection present for more than one monthConfirmed by culture and/or histology
Oesophageal candidiasis (or candidiasis of trachea, bronchi or lungs)Chest pain and dysphagia (difficulty in swallowing), odynophagia (pain on swallowing food and fluids) or retrosternal pain worse on swallowing (food and fluids); responds to specific treatment. In young children, suspect particularly if oral Candida observed and food refusal occurs and/or difficulties/crying when feeding.Confirmed by macroscopic appearance at endoscopy, microscopy of specimen from tissue or macroscopic appearance at bronchoscopy or histology
Extrapulmonary/disseminated TBSystemic illness usually with prolonged fever, night sweats, weight loss. Clinical features of organs involved, e.g. sterile pyuria, pericarditis, ascites, pleural effusion, meningitis, arthritis, orchitisPositive microscopy showing AFB or culture of Mycobacterium tuberculosis from blood or other relevant specimen except sputum or BAL. Biopsy and histology
Kaposi sarcomaTypical appearance in skin or oropharynx of persistent, initially flat, patches with a pink or blood-bruise colour, skin lesions that usually develop into nodulesMacroscopic appearance or by histology:
  • typical red-purple lesions seen on bronchoscopy or endoscopy;
  • dense masses in lymph nodes, viscera or lungs by palpation or radiology;
  • histology
CMV retinitis or CMV infection affecting another organ, with onset at age >1 monthRetinitis only
CMV retinitis may be diagnosed by experienced clinicians: progressive floaters in field of vision, light flashes and scotoma; typical eye lesions on serial fundoscopic examination; discrete patches of retinal whitening with distinct borders, spreading centrifugally, often following blood vessels, associated with retinal vasculitis, haemorrhage and necrosis
Definitive diagnosis required for other sites. Histology or CMV demonstrated in CSF by culture or DNA-PCR
CNS toxoplasmosis with onset at age >1 monthFever, headache, focal neurological signs, convulsions. Usually responds within 10 days to specific therapy.Postive serum Toxoplasma antibody and if available, neuroimaging showing single/multiple intracranial mass lesions
Extrapulmonary cryptococcosis including meningitisMeningitis: usually subacute, fever with increasing severe headache, meningism, confusion, behavioural changes that respond to cryptococcal therapyIsolation of Crytococcus neoformans from extrapulmonary site or positive cryptococall antigen test (CRAG) in CSF or blood.
Copyright © 2010, World Health Organization.

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Bookshelf ID: NBK138580

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