Infant Diagnosis Cases

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Infant Diagnosis Cases
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Case 1 Sam

• Grace is an 18 year-old woman who was diagnosed
  with HIV during her first pregnancy
• She enrolled in the pMTCT program and took
  nevirapine at the onset of labor. Her baby, Sam
  received nevirapine at birth
• When Grace and Sam return for their first
  post-partum check at 6 weeks, both are doing well
  
• Sam is breast feeding without difficulty and has
  gained weight as expected
• Grace wants to know if Sam has HIV

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Case 1 Sam

• What do you tell her?
• What test should be used?
• What other interventions should be performed?
• When should Grace bring Sam back to clinic for
  his next appointment?

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Case 1 Sam

• You tell Grace that you will do the first test to
  check for HIV today.
• You weigh Sam, measure his length, and head
  circumference, and plot them on the growth chart.
• You check his development and complete your
  physical examination.
• You prick his heel for blood for DNA PCR,
  prescribe cotrimoxazole and provide counseling
  about infant feeding (exclusive breast feeding).

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Case 1 Sam

• When Sam returns at 10 weeks of age, his first
  virologic test is negative
• He is still breast feeding and is doing well
• He is still taking cotrimoxazole
• His exam is normal

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Case 1 Sam

• What will you tell Grace about this test?
• What else will you do for Sam
• When should Grace and Sam return for their next
  appointment?

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Diagnostic Algorithm for Infants lt 18 months of
age
Infant 6-8 weeks of age
First Clinic Visit
HIV DNA PCR
HIV DNA PCR POSITIVE HIV-INFECTED
DNA PCR NEGATIVE
Refer for HIV care treatment
Continue Follow-up Continue CTX
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Case 1 Sam

• You explain to Grace that since his first test
  was negative you can find any HIV in his blood.
• However since he is breast feeding he may still
  get HIV so you will have to test him again after
  he stops breast feeding completely.
• If Sam should fall sick you will repeat the
  virologic test
• Refill his cotrimoxazole prescription
• Schedule follow-up in a month

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Case 1 Sam

• Grace and Sam do not return for 3 months
• The social worker who visits the home says Grace
  has gone to the village to help her ailing mother
• Grace tells you Sam had two episodes of diarrhea
  while they were away
• Sam has lost weight and is now below the 3rd
  percentile for weight
• He has some thrush and diffuse lymphadenopathy

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Case 1 Sam

• Does Sam have HIV?
• What can you do to find out?
• What will you tell Grace?

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Case 1 Sam

• Because Sam has symptoms that might be related to
  HIV infection (growth failure, oral thrush, and
  generalized lymphadenopathy), the team explains
  to Grace that Sam requires another blood test.
• You prick him again and get blood for DNA PCR
  using DBS.

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Case 1 Sam

• The DNA PCR test is positive
• You explain to Grace that Sam has HIV infection.
• Although she is extremely upset, Grace finds
  hope in the fact that Sam will continue to
  receive care and treatment
• You send another test and refer Sam to the
  pediatric HIV clinic for evaluation and treatment.

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Diagnostic Algorithm for Infants lt 18 months of
age
Infant 6-8 weeks of age
HIV DNA PCR
First Clinic Visit
HIV DNA PCR POSITIVE HIV-INFECTED
DNA PCR NEGATIVE
Refer for HIV care treatment
ILL Infant
Repeat DNA PCR
HIV DNA PCR NEGATIVE
HIV DNA PCR POSITIVE HIV-INFECTED
Refer for HIV care treatment
Refer for consultation
HIV Rapid Antibody gt6-12 weeks post weaning
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Case 2 Hadiyah

• Akili just had her first daughter, Hadiyah.
• Akili was diagnosed with HIV during the recent
  pregnancy and participated in the pMTCT program.
• She brings Hadiyah to clinic for the babys
  first visit.
• She is breast feeding Hadiyah.

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Case 2 Hadiyah

• What will you do for Hadiyah at her first
  postnatal visit at 6 weeks?

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Case 2 Hadiyah

• Growth monitoring (measure and plot weight ,
  length, and head circumference)
• Developmental assessment
• Physical examination
• Get blood for DBS DNA PCR
• Prescribe cotrimoxazole
• Counsel Alik about the benefits of exclusive
  breast feeding

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Case 2 Hadiyah

• Hadiyah returns to the clinic when she is 10
  weeks old
• Her virologic HIV test is positive
• Her clinical status is unremarkable. She has
  good growth and a normal exam.

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Case 2 Hadiyah

• Does Hadiyah have HIV?
• Does she require additional testing?
• If so which type of test should be performed and
  when should it be done?
• What should the team tell Akili?
• What other interventions should be performed?

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Case 2 Hadiyah

• The team explains to Akili that Hadiyahs first
  test was positive and that this means that she is
  presumed to have HIV-infection
• A second confirmatory virologic test is sent
  immediately
• Cotrimoxazole is continued
• The team provides counseling, patient education,
  and psychosocial support to Akili and her husband
• Akili is referred to the District Hospital to the
  pediatric HIV program.

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Case 2 Hadiyah

• The DNA PCR result is sent back to the clinic 3
  weeks later. The second virologic test is also
  positive.
• Alik did not come back for her next visit at the
  clinic. However, when the outreach worker went to
  her home they found that Hadiyah was already
  being seen at the district hospital. Mom
  reported that the baby may need medications to
  fight the HIV infection.

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Case 3 Patrick

• Denise enrolled in the clinic immediately post
  partum
• Her son Patrick is 10 weeks old and mom has
  brought him for his immunizations visit
• DNA-PCR was done at 6 weeks and the baby tested
  positive
• Patrick is growing well and is developmentally
  appropriate for age. His exam is also normal.

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Case 3 Patrick

• What do you tell Denise ?
• Is there any additional testing to do today?
• When should the baby be brought back for a visit?

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Diagnostic Algorithm for Infants lt 18 months of
age
Infant 6-8 weeks of age
First Clinic Visit
HIV DNA PCR
HIV DNA PCR POSITIVE HIV-INFECTED
Refer for HIV care treatment
Infant born to HIV-infected mother or infant
known to be antibody positive Confirm HIV
exposure with Rapid Antibody test if gt 6 months
of age. If antibody negative, and infant is still
breastfeeding, repeat Rapid Antibody test gt6-12
weeks after complete cessation of breast feeding.
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Case 3 Patrick

• Denise is distraught when she is told Patrick
  seems to have HIV infection. She weeps, crying
  that the baby will die because of HIV
• Mom as well as dad meet with the counselor and
  talk about the babys status
• You sent a confirmatory repeat DNA PCR
• You refill her cotrimoxazole prescription.

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Case 3 Patrick

• The HIV clinic is 4 hours away from home. Since
  the baby is well you decide to check the results
  of the second test before referring Patrick.
  Since it is Thursday you can send a CD4 count for
  the baby to the district laboratory.
• Schedule her next immunization visit in a month

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Case 3 Patrick

• When the repeat laboratory result return the
  following week, the second DNA PCR test is
  negative. The CD4 count is also normal for his
  age.
• In the meantime, the baby does well at home and
  is brought back at 14 weeks of age.
• He has gained weight and has not had any
  illnesses since the last visit .
• His clinical exam and growth parameters are all
  normal for his age.

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Case 3 Patrick

• What should you say to mother?
• Should further testing be done?

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Case 3 Patrick

• Since the baby is doing WELL and mom is breast
  feeding, the team decides to consult with the HIV
  specialist at the District Hospital. Theyve had
  a number of recent test results that didnt make
  sense lately. They are not sure that Patricks
  tests are good.
• In consultation with the specialist they decide
  to keep the baby in care and wait until the lab
  is more reliable.
• If the baby becomes SICK another test can be done
  immediately.
• Mom is very anxious but agrees to wait for the
  next test.

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Case 3 Patrick

• Patrick returns at 4 months of age and then
  again at six months. He does well. He is weaned
  at 8 months of age.
• Since the team still does not have access to
  reliable PCR testing, they decide to wait a
  little longer. At 10 months they test Patrick
  with a rapid HIV antibody.

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Case 3 Patrick

• The rapid HIV antibody test is negative. The test
  is repeated a second time and it is negative.
• You tell mom that the baby is does not have HIV
  infection.
• You discontinue CTX.
• Patrick should come back to clinic for his
  routine immunizations.

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Case 4 Malaika

• Halima is a 22 year-old diagnosed with HIV during
  her most recent pregnancy.
• Her pregnancy was uncomplicated, and she took
  nevirapine at the onset of labor as instructed.
  Her baby, Malaika, did not receive nevirapine at
  birth.
• Halima can afford infant formula, has access to
  clean water, and her family knows of her HIV
  status.
• She has decided not to breast feed Malaika.

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Case 4 Malaika

• When should Malaika have her first HIV test?
• What test should be used?
• When should Halima return for the results?
• What other interventions should be performed?

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Case 4 Malaika

• At 6 weeks of age, Malaika weighs 4.2kg.
• Her physical examination is unremarkable, she is
  growing well, and her development is appropriate
  for her age.
• She gets her immunizations and is started on
  cotrimoxazole .
• She has a virologic test done.
• Follow-up is scheduled for 4 weeks later.

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Case 4 Malaika

• When she returns at the 10 week visit, Halima
  learns that the result is negative.

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Case 4 Malaika

• Does Malaika have HIV?
• Does she require further testing?
• If so, when should she have her next test and
  what type of test should it be?

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Case 4 Malaika

• The team explains to Halima that Malaikas DNA
  PCR is NEGATIVE, this means she is presumed not
  to have HIV-infection
• However, since she is not breast feeding, the
  test generally means that the baby does not have
  HIV infection

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Case 4 Malaika

• The team meets to discuss Malaikas care.
• Since Halima is feeding her formula, she is
  generally doing well, and she has had a negative
  virologic test, the team decides that
• Malaika can get her immunizations and well baby
  checks closer to home.
• She should continue cotrimoxazole.
• Come back to the clinic for an HIV antibody test
  when she is 12 months old

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Case 4 Malaika

• Halima brings Malaika for her 12-month visit, she
  continues to do well.
• She is gaining weight as expected and has had no
  symptoms of illness since her last appointment.

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Case 4 Malaika

• What test should be done?

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Case 4 Malaika

• A Rapid HIV antibody test is done
• The result is negative

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Case 4 Malaika

• Does Malaika have HIV infection?
• Does she require further testing?
• Should she continue follow-up at the clinic?

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Case 4 Malaika

• Malaika is NOT infected.
• She does not need further testing.
• She can stop taking cotrimoxazole.
• She can be discontinued from the program.

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