- Immunodeficiency should be suspected in individuals with recurrent bacterial infections, especially invasive infections such as bacteremia, meningitis, and pneumonia, and in those with unusual infections, such as those caused by the Mycobacterium avium complex (MAC).
- Children with HIV infection often present with the common bacterial infections of childhood (eg, otitis media, sinusitis, pneumonia), which can be more frequent and more severe than similar infections in immunologically healthy children.
- Recurrent fungal infections, such as candidiasis (ie, thrush), that do not respond to standard antifungal agents suggest lymphocytic dysfunction.
- Recurrent or unusually severe viral infections, such as recurrent or disseminated herpes simplex or zoster infection or cytomegalovirus (CMV) retinitis, are seen with moderate-to-severe cellular immune deficiency.
- Growth failure, failure to thrive, or wasting in the child may indicate HIV infection if other common metabolic and endocrine disorders do not appear to be the etiology.
- Growth failure, failure to thrive, or wasting in the patient with HIV infection may signify disease progression or underlying malnutrition.
- The failure to attain typical milestones signifies a developmental delay. Such developmental delays, particularly impairment in the development of expressive language, may indicate HIV encephalopathy.
- The loss of previously attained milestones may signify a CNS insult due to progressive HIV encephalopathy or opportunistic infection.
- In older children, behavioral abnormalities, such as the loss of concentration and memory, may indicate HIV encephalopathy
Physical: Few physical findings are specific to HIV infection, and many of the physical findings are caused by opportunistic infections. Lymphadenopathy, hepatomegaly, and splenomegaly are fairly common in HIV infection. Other findings may include the following:
- Monitoring the patient’s growth is one of the most important portions of the physical examination, and anthropometric measurements should be obtained at each visit.
- Delayed growth in the head circumference is correlated with the development of underlying encephalopathy. Normal head growth, however, does not rule out encephalopathy, and many patients with a normal head circumference may have radiographic or psychometric findings consistent with encephalopathy.
- Head, eyes, ears, nose, and throat (HEENT)
- Parotid enlargement is observed in 30% of children with category C disease and in 15% of children with disease in other categories.
- Tonsillar hypertrophy may be observed.
- Aphthous ulcers may be observed.
- Thrush in the oral cavity and posterior pharynx is observed in approximately 30% of children infected with HIV. In children with AIDS, the prevalence of thrush is correlated with a low CD4 count. Thrush in the posterior pharynx may signify candidal esophagitis, especially in patients with feeding difficulties or retrosternal pain.
- CMV retinitis occurs in 3.4% of children with CD4 counts less than 50 X 109/L.
- Cardiomyopathy may be present.
- Congestive heart failure may be present.
- Lung examination is important, and good documentation of findings is required at each visit.
- Chronic lung disease may produce baseline findings of crackles and decreased regional breath sounds.
- Changes in the lung findings are important to note because pneumonia is common in children with HIV infection. Pneumonia may not be obvious during the examination, and many children have few symptoms. For example, Mycoplasma infection may not cause a high fever, and Pneumocystis carinii infection may cause only tachypnea, fever, and hypoxemia.
- Changing findings at lung examination may also signify worsening of chronic lung disease, lymphoid interstitial pneumonitis, or tuberculosis (TB).
- Hepatomegaly is observed in 70% and 45% of children with AIDS and children without AIDS, respectively.
- Splenomegaly is observed in about 35% of children with HIV infection.
- Generalized cervical, axillary, or inguinal lymphadenopathy is common and may be the first sign of initial infection during the asymptomatic phase of the disease. Generalized lymphadenopathy may not be present with well-controlled disease or end-stage AIDS. New shotty nodes may indicate that the disease has again progressed and that treatment failure has occurred.
- A large single node may indicate lymphoma, and it may need to be examined with biopsy.
- Motor delay, hypotonia, hypertonia, and/or pyramidal tract signs may indicate progressive HIV encephalopathy or opportunist infection of the CNS.
- Spastic diplegia and oral motor dysfunction are early signs of encephalopathy.
- Acquired microcephaly with accompanying cerebral atrophy is a poor prognostic sign.
- Subacute combined degeneration of the spinal cord with higher cortical dysfunctions occurs in vitamin B-12 deficiency.
- HIV dermatitis causes an erythematous papular rash and is observed in about 25% of children with HIV infection.
- Vesicular lesions in a unilateral dermatomal distribution or in the oral, genital, or anal area may represent reactivation of herpes zoster.
- Erythematous candidal dermatitis that does not respond to standard therapy may be present.
- Bleeding or bruising of the mucous membranes and skin may be observed in children with HIV and immune thrombocytopenic purpura, although this is not a common finding.
- Digital clubbing may be observed as a result of chronic lung disease.
- Nonpitting edema may result from hypoalbuminemia caused by HIV nephropathy or malnutrition.
- Pitting edema may develop as a result of congestive heart failure.
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