Neurological Problems Common In Children

Developmental delay or even developmental regression are the most common neurological problems. Developmental delay is common in any child who is chronically ill and malnourished, both common in HIV-infected children with TB. HIV can also infect the brain.This may lead to a variety of neurological problems including developmental regression, behaviour change, confusion and seizure disorders.

Much of the same applies for children as for adults (see above). It is important to consider other diagnoses such as cerebral malaria or meningitis. Cryptococcal meningitis does occur in HIV-infected children but bacterial meningitis is more common. Occasionally very wasted HIV-infected children have an acute psychotic reaction with confusion, aggressive behaviour and hallucinations one to two weeks after starting TB treatment. It is likely that this is due to isoniazid and treatment is to withhold isoniazid and give pyridoxine.The condition usually settles over a week and then isoniazid can be reintroduced.

T2.9M FEVER

12.9.1 ] Approach to management

Fever usually settles within 2-3 weeks of starting anti-TB treatment. Further fever may signal a drug reaction or a disseminated infection.The table below shows the approach to management of further or persistent fever.

Features accompanying Likely cause fever

Action rash drug reaction Stop anti-TB drugs weight loss progressive anaemia or pancytopenia disseminated infection

Examine patient Investigations: ° blood film for malaria ° blood film for trypanosomes ° blood cultures ° consider lumbar puncture Consider empirical treatment for malaria-if no response start antibiotics for suspected septicaemia

12.9.2 Disseminated infection

Disseminated infection carries a high mortality. The table below shows the wide variety of pathogens that can cause disseminated infection in TB/HIV patients.

Pathogens causing disseminated infection in TB/HIV patients

Bacteria

Mycobacteria

Viruses

Others

Non-typhoidal Salmonella

M. tuberculosis

Cytomegalovirus

Cryptococcus

Streptococcus pneumonia

M. avium complex (MAC)

Histoplasma

Pseudomonas aeruginosa

Leishmania

Staphylococcus aureus

Penicillium marneffei

Other

Gram-negative bacteria

Non-typhoidal Salmonella such as S. typhimurium or S. enteritidis and Pneumococcus are the commonest identified causes of septicaemia in HIV-positive adults and children in sub-Saharan Africa. Many strains of S. typhimurium are resistant to several antibiotics. If you suspect septicaemia, treat the patient with chloramphenicol or ampicillin and gentamicin.

Disseminated M. avium complex (MAC)

MAC is less frequent in AIDS patients in sub-Saharan Africa than elsewhere. Diagnostic facilities and treatment (e.g. clarithromycin + ethambutol + rifabutin) are generally not available in district hospitals and many central hospitals.

I?i0| OTHER HIV-RELATED PROBLEMS

Tumours

Kaposi sarcoma (KS)

KS can affect many parts of the body, but usually the skin and mouth, and sometimes the lung and pleura, gastrointestinal tract, and pericardium. The clinical appearance is usually distinctive.There is often oedema with KS on the face and legs. Diagnostic confusion can arise with keloids, leprosy, sarcoidosis, melanoma and bacillary angiomatosis due to Bertonella henselae. In case of doubt, particularly with bacillary angiomatosis which is treatable with erythromycin or doxycycline (see section 12.4 on skin problems), a biopsy is diagnostic. Histology shows typical proliferation of spindle cells and small blood vessels.

In a TB/HIV patient with KS, development of a pleural effusion or progressive lung infiltrations during anti-TB treatment is probably due to KS.

Many countries have limited resources for treating KS. Treatment is often unsatisfactory. Nonsteroidal anti-inflammatory drugs (NSAIDs) may help relieve pain. Cytotoxic chemotherapy (e.g. vincristine) and radiotherapy may be available in some central hospitals but treatment response is unsatisfactory.

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