Infant Diagnosis Case Studies

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Infant Diagnosis Case Studies
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Case 1 Ayana

• Ayana is an HIV-exposed 6 week old baby girl who
  has come for her intake visit
• Birth History
• Weight- 3 kg
• Child received SD-NVP
• Baby has been exclusively breastfed
• Physical Exam
• Height 53 cm Weight 4 kg Head- 38.5 cm
• Oral thrush

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Ayanas Growth Chart
Birth- 3 kg 6 wks -4 kg
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Case 1 Ayana

• What should be done at this visit?

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Case 1 Ayana

• Normal exam and good growth
• Nystatin Suspension for thrush
• Start Cotrimoxazole Prophylaxis
• Give routine vaccines
• Send DBS DNA PCR
• Counseling on exclusive breast feeding
• Follow-Up in 1 month

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Case 1 Ayana

• Ayana returns at 10 weeks, her DNA PCR test is
  negative
• She continues to breast feed, and is gaining
  weight
• Thrush has cleared and she is tolerating the
  cotrimoxazole

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Case 1 Ayana

• Does Ayana have HIV?
• Does she require further testing?
• If so when should she have her next test and what
  type of test should it be?
• What will you tell her mother?

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Case 1 Ayana

• The team explains to her mother that Ayanas test
  is negative, she is doesnt have HIV infection
• However she may still get HIV infection since
  she is breast feeding
• If she continues to do well she will have her
  next HIV test gt 6-12 weeks after breast feeding
  is discontinued

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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 staging, care, and treatment
ILL Infant
WELL Infant
HIV Rapid Antibody Test gt6-12 weeks after weaning
Repeat HIV DNA PCR
HIV DNA PCR POSITIVE HIV-INFECTED
HIV DNA PCR NEGATIVE
Refer for staging, care, and treatment
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Case 1 Ayana

• Ayana returns for her vaccine visits
• She is well, has gained weight and is compliant
  with cotrimoxazole
• At her 6 month visit, her mother tells you she
  stopped breast feeding 3 weeks ago
• She is still taking cotrimoxazole
• Her mother is anxious to know if she can stop
  giving the medication since Ayana is doing very
  well

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Case 1 Ayana

• What will you tell the mother?
• When can she have her next HIV test, and what
  test will you use?
• When should she return for her next follow up
  appointment?

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Case 1 Ayana

• You explain to Ayanas mother that she must
  continue cotrimoxazole until you have definitely
  excluded HIV infection
• Although her first test at 6 weeks was negative
  she still needs another test. She may have been
  gotten HIV during through breast milk.
• You will test her again at least 6 weeks after
  she stopped breast feeding
• You refill her cotrimoxazole and schedule follow
  up in 2 months
• Advise her to come back to the clinic if Ayana
  should fall sick before then

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Case 1 Ayana

• What test will you do when she comes back to
  clinic?

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Case 1 Ayana

• Ayana is 9 months old when she comes back for HIV
  testing.
• Do choose to do a rapid antibody test and the
  result is negative.
• You discontinue cotrimoxazole and the tell mom
  that the baby is fine and no more testing is
  necessary.

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Case 2 Hakeem

• Hakeem is a 5 month old male who presents for his
  check up
• He has been followed in the clinic since 6 weeks
  of age
• His first DNA PCR at 6 weeks was negative
• He is breast feeding at night, but is fed
  porridge and water during the day by Grandma who
  does not know of moms status
• Lately, Hakeem has been feeding poorly and has
  had diarrhea for the past 6 days

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Case 2 Hakeem

• Hakeem receives cotrimoxazole, but sometimes he
  misses a dose when Grandma is caring for him,
  since she does not know that he needs this
  medicine.
• Today he weighs 6kg
• Physical exam is significant for
• Mild dehydration
• Diarrhea x 2 during the exam

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Hakeems Growth Chart
97th 85th 50th 15th 3rd
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Case 2 Hakeem

• Is there evidence of HIV infection?
• Does he require further tests to determine
  whether he has HIV infection?
• Are there other problems or concerns?
• What should be done at this visit?

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Case 2 Hakeem

• His growth is poor. You find that he used to
  grow along the 15th percentile for age to the
  3rd percentile (diarrhea could explain the
  weight loss)
• Since hes not very sick you decide to give him
  some ORS
• Continue cotrimoxazole and stress the importance
  of adherence
• Psychosocial support including counseling around
  disclosure to other caretakers
• Follow up in 1 month

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Case 2 Hakeem

• Hakeem returns after a month
• His mother says the diarrhea has subsided
• When you examine him he still has not gained any
  weight
• His weight is now below the 3rd percentile
• He has some thrush and bilateral enlarged
  axillary adenopathy

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Hakeems Growth chart
97th 85th 50th 15th 3rd
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Case 2 Hakeem

• Is there evidence of HIV infection?
• What should be done at this visit?
• What will you tell the mother?

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Case 2 Hakeem

• You are concerned he may have HIV because of poor
  growth and generalized lymphadenopathy
• What should you do?

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Case 2 Hakeem

• You send another DBS DNA-PCR
• Review cotrimoxazole prophylaxis and importance
  of adherence
• You evaluate his diet, provide nutritional
  counseling and help mom obtain food supplements
  for the family
• Schedule follow-up in 2 weeks

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Case 2 Hakeem

• Hakeem returns for follow-up visit
• The DNA PCR test is positive
• He is still not gaining weight and is not looking
  very well.

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Case 2 Hakeem

• Does Hakeem have HIV?
• What will you tell the mother?
• What should be done at this visit?

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Case 2 Hakeem

• You explain to his mother that Hakeem has HIV
  infection
• You send a repeat DNA PCR to confirm the
  diagnosis
• You counsel the mother, and refer Hakeem for HIV
  care and treatment at the HIV Care and Treatment
  Center. One of the outreach workers takes mom to
  the pediatric clinic at the medical center where
  the baby gets an appointment for the following
  day.

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Case 3 John

• John is a 9 month old male brought to the
  vaccination clinic by his maternal grandmother
  for his measles immunization
• According to his grandmother, he has always been
  sick since his mother passed away 2 months ago
• He was hospitalized with diarrhea and pneumonia
  one month ago, and was treated with intravenous
  antibiotics

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Case 3 John

• Wt- 7.8kg (lt 3 ), length-66cm (10), and HC-45cm
  (10)
• When you examine him he looks small for his age
• He has thrush
• His development is appropriate for his age

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Case 3 John

• What else will you like to know?
• What will you do for John today?
• When should John return to the clinic?

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Case 3 John

• Grandmother does not know the cause of death of
  Johns mother, she was never tested for HIV
• You decide to send a rapid HIV antibody test
• The HIV antibody is positive

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Case3John

• What will you tell Johns grandmother?
• What will you do for John today?
• When should John return to the clinic?

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Case3John

• You explain to grandmother that John is
  HIV-exposed, he may have HIV infection which will
  explain why he is always ill
• You give John his measles immunization
• You prescribe cotrimoxazole and send a DNA PCR
• Nutritional counseling and advice and have John
  return in a month for results

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Case 3 John

• John returns when he is 10 months old. He has
  gained a little bit of weight but still seems
  sickly.
• His DNA PCR is positive
• You tell the grandmother that John is
  HIV-infected
• You send a repeat test to confirm and refer him
  to the care and treatment center

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Case 4 Edward

• Nigist, Edwards mom, tested positive for HIV
  last year at a local VCT site.
• As soon as she knew she was pregnant, Nigist
  presented for ANC and explained that she was
  HIV-positive.
• When repeat testing confirmed that Nigist had
  HIV, she was enrolled at the clinic in her 28th
  week of pregnancy.
• After counseling and patient education, Nigist
  was started on cotrimoxazole and antiretroviral
  therapy in week 32 of her pregnancy.

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Case 4 Edward

• Nigists pregnancy was uncomplicated, and her
  first child, Edward, was born eight weeks later.
• At her first post-partum check, at 4 weeks,
  Nigist asks if Edward has HIV.

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Case 4 Edward

• What do you tell her?
• When should Edward be tested for HIV?
• What test should be used?
• What other interventions should be performed?
• When should Nigist bring Edward back to clinic
  for his next appointment?

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Case 4 Edward

• Edward will have his first virologic test between
  6-8 weeks of age
• Edward need growth monitoring, developmental
  assessment and physical exam
• Edward should start cotrimoxazole prophylactic
  therapy today
• He should come back monthly until six months of
  age

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Case 4 Edward

• When Edward is eight weeks old, a DNA PCR test is
  sent to test him for HIV infection and the result
  is negative.

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Case 4 Edward

• How will you explain the results to Nigist
• Does Edward need further testing? If so, when
  should he be tested and which test should be
  used?
• When should Nigist bring Edward back to the
  clinic for his next appointment

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Case 4 Edward

• The team explains to Nigist that Edwards HIV
  test is negative
• This means that HIV cannot be detected in his
  blood and he presumed NOT to be HIV infected.
• If he continues to feel well the next test will
  take place at least 6-12 weeks after weaning

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Case 4 Edward

• Edward returns to the clinic for monthly visits,
  which are often on the same day as Nigists
  appointments.
• On Edwards 3- and 4-month visits, the team
  notices that he has not gained weight as expected
• According to Nigist, Edward has not had any
  diarrhea or difficulty eating his appetite is
  good
• Apart from his weight, Edwards physical
  examination is normal

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Edwards Growth Chart
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Case 4 Edward

• The team is concerned that failure-to-thrive may
  be a sign of HIV infection, and repeat Edwards
  DNA PCR test for HIV.

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Case 4 Edward

• At 4 months, Edward's virologic test is negative
• He continues to be underweight, but two tests
  were negative
• Edward is developing appropriately
• Nigist says Edward has a good appetite and eats
  well
• He is still breast feeding

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Case 4 Edward

• Does Edward have HIV?
• What else might be causing failure to thrive?
• What should the team do now?

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Case 4 Edward

• The team discusses Edwards case at an
  interdisciplinary meeting.
• The counselor mentions that Nigist has recently
  missed an appointment.
• Nigists clinician mentions that Nigist has lost
  7 kgs over the past two months, although her CD4
  count is now 400.
• The outreach worker reports that Nigist was not
  at home at the time of the last scheduled home
  visit.

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Case 4 Edward

• What are some possible explanations for Nigists
  weight loss and Edwards failure to thrive

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Case 4 Edward

• With Nigists permission, another home visit is
  scheduled
• Nigists favorite nurse goes along with the
  outreach worker
• During the visit, the outreach worker notices
  that there is no food in the cupboards
• When she asks Nigist about this change, Nigist
  starts to cry

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Case 4 Edward

• With the support of the nurse and outreach
  worker, Nigist tells her story
• Her husband is away from home, working on a farm
• Although he had previously sent home money, he
  has not done so for many months
• Nigist is worried that her husband has abandoned
  her and Edward, and ashamed that she has no money
  with which to buy food

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Case 4 Edward

• The team arranges an emergency conference about
  Nigist and Edward
• Nigist is referred to a nearby food pantry, and
  to a local support organization
• She is able to earn some money by sewing dresses,
  and receives food for herself and the baby

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Case 4 Edward

• Nigist and Edward both begin to gain weight
• Several months later, Nigists husband returns
  with additional funds
• Edward is weaned at 15 months of age. An HIV
  antibody test is is done 2 months later and it
  is negative.

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