HIV-infected children with TB are also more susceptible to other respiratory diseases and more likely to die despite TB treatment. An important reason for a poor response to TB treatment is that the child does not have PTB.The difficulties in diagnosing PTB in children mean that it may be confused with other causes of HIV-related lung disease (see Chapter 4). Most children who receive treatment for PTB are smear-negative cases. If they do not improve on TB treatment, consider other diagnoses, e.g. LIP or cardiac disease. In all cases, consider poor treatment adherence as a cause of poor treatment response.
Mixed respiratory infections are a particular feature of HIV-infected children. It is common for children with TB to develop bacterial pneumonia as a complication. The main bacterial pathogens are those listed above. Treatment should follow Integrated Management of Childhood Illness (IMCI) guidelines. If the child has severe pneumonia, admit to hospital and give chloramphenicol 25 mg/kg intramuscularly or intravenously three times a day (and oxygen if necessary). If the child does not improve within 48 hours, switch to gentamicin 7.5 mg/kg IM once a day and cloxacillin 50 mg/kg IM or IV every 6 hours.
HIV-infected children with presumed TB may have lymphocytic interstitial pneumonitis (LIP) either as an alternative diagnosis or occasionally as a mixed infection. LIP is also often complicated by acute bacterial pneumonia. Clinical features that suggest LIP are generalized symmetrical lymphadenopathy, non-tender parotid enlargement and finger clubbing. Typical CXR features are a bilateral reticulonodular interstitial pattern and adenopathy. If the child with LIP has persistent respiratory distress, then give prednisolone 1-2 mg/kg daily for 2-4 weeks and then reduce gradually over 2 weeks.
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