OBSERVATIONS AND RESULTS

The present study was carried out at tertiary center in rural and tribal area in

department of Pediatrics from January 2011 to June 2012. The study population

included was patients who were already HIV positive or diagnosed later on investigation

on suspicion of the clinical features, attending OPD or IPD of Pediatric department.

There were 6732 admissions in pediatric ward during study period and 21517

cases visited OPD with a sum of 28249 during study period. Amongst those 108 were

found to be HIV reactive. Hence the prevalence of HIV infection during the study period

was 0.38%.

Out of 108 patient under study, 1 patient was found HIV II and rest were (107)

HIV I reactive.
 TABLE NO. 1

AGE/SEX DISTRIBUTION IN HIV

Sr. Cummulative
No Age group Total no
Male% Female% frequency
in months of cases
(%)

1 <18 3(2.77) 2(1.85) 5(4.62) 4.62

2 >18-36 20(18.51) 11(10.18) 31(28.70) 33.32

3 >36-60 19(17.59) 10(9.25) 29(26.85) 60.18

4 >60-120 21(19.44) 12(11.11) 33(30.55) 90.72

5 >120 6(5.55) 4(3.70) 10(9.25) 100

Total 69(63.88) 39(36.11) 108(100)

SEX DITRIBUTION
39

Male
Female

69

From table -1 it is seen that majority (60.18%) cases in this study are below 5 yrs

of age. Maximum cases were between 5-10yrs of age and 5 cases (4.62%) were below

18 months. Males 69(63.88%) outnumbered females 39(36.11%) with M: F ratio of

1.76:1.
 TABLE-2
AREA DISTRIBUTION IN HIV

RURAL N=61 URBAN N=47

MALE FEMALE TOTAL MALE FEMALE TOTAL

n=61(%) n=47(%)
<18 2 1 3 1 1 2

>18-36 12 5 17 8 6 14

>36-60 9 6 15 10 4 14

>60- 13 7 20 8 5 13
120
>120 4 2 6 2 2 4

TOTAL 40 21 61(56.48) 29 18 47(43.51)

70
60
50 21
40 18 Female
30 Male
20 40
29
10
0
RURAL URBAN

Maximum 61(56.48%) patients were from rural area with male predominance
and remaining were from urban area. (Table-2)
 TABLE-3A

SOURCE OF INFECTION

Sr.No. Mode of transmission No.of patient %

1 Perinatal (vertical) 106 98.15

2 Blood / blood Product 02 01.85

3 Others 00 00.00

SOURCE OF INFECTION
120
100
80 SOURCE OF INFECTION
60
106
40
20
0 2 0
Perinatal Blood product Others

In the present study predominant route of transmission of HIV to the child was by

perinatal (vertical) transmission (98.15%). (Table- 3A)

 TABLE-3B

MODE OF DELIVERY

Sr. no. Mode of delivery No. of patients

1 Home delivery 64(59.25%)

2 Normal 29(26.85%)
Hospital delivery LSCS/ 06(5.55%)
instrumental

3 Not known 09(8.33%)

TOTAL 108

Table-3B shows, maximum 64(59.25%) were home delivered cases followed by

29(26.85%) normal hospital delivered and 6(5.55%) LSCS / instrumental delivered

cases.
 TABLE-4

AGE OF PRESENTATION IN PERINATAL TRANSMISSION

Sr.no. Age group in months No. of patients (n=108) %

1 <18 42 38.89
2 >18-36 30 27.77
3 >36-60 23 21.29
4 >60-120 09 8.33
5 >120 04 3.07
Total 108 100

History wise, the perinatal transmission 96 (88.88%) presented below 5 years of

age for the first time. Of them, 42(38.89%) were symptomatic even before 18months of

age (Table -4). Mean age of presentation was 5.5 years. Median age of presentation

was 4.8 years and Mode is 3 years.

 TABLE-5

COMPLAINTS ON FIRST PRESENTATION

Sr. No of cases
Complaints Percentage (%)
No. (n=108)

1 Fever 63 58.33

2 Cough 49 45.37

3 Not gaining weight 45 41.66

4 Diarrhea 43 39.81

5 Skin rash 25 23.15

6 Ear discharge 21 19.44

7 Oral Ulcers 15 13.88

8 Parotid swelling 09 08.33

9 Bleeding tendencies 01 0.92

 COMPLAINTS ON FIRST PRE-
SENTATION
63
60 49 45 43
40 25 21
20 15 9 No of patients
1
0
r t a h e r g cy
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F co g w ai r in ch l e
Sk is a sw ten
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No Bl

Table-5 shows the symptomatology of pediatric HIV on first presentation. Majority

(58.33%) had fever as main complaint followed by cough (45.37%), not gaining weight

(41.66%), diarrhea (39.81%), skin rash (23.15%), ear discharge (19.44%), oral ulcers

(13.88%) and parotid swelling (8.33%).

 TABLE-6

PHYSICAL EXAMINATION (SIGNS)

No. of
cases Percentage
Sr.no. Signs
(%)
(n=108)

1 Severe malnutrition (Gr.III & 60 55.55

IV)

2 Pallor 58 53.70

3 Respiratory signs 51 46.78

4 Lymphadenopathy 49 45.37

5 Fever 37 34.26

6 Skin manifestations 36 31.48

7 Hepatosplenomegaly 33 30.55

8 Signs of vitamin deficiency 32 29.63

9 Hepatomegaly 26 24.07

10 CSOM 24 22.22

11 Oral Thrush 21 19.44

12 Dental Caries 19 17.59

13 Splenomegaly 9 8.33

14 Parotitis 9 8.33

15 Clubbing 7 6.48

16 CNS manifestations 6 5.55

17 Ascitis 2 1.85

18 Bleeding tendencies 1 0.92

 PHYSICAL EXAMINATION (SIGNS)
70 60
58
60 51 49
50
40 37 36 33
32
30 26 24
21 19
20
9 9 7 6 PHYSICAL EXAMINATION
10 2 1 (SIGNS)
0
)
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(G at len pa Or plen
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Se

In present study 60(55.55%) severe malnutrition (Gr.III & IV) was the most

common examination finding followed by pallor 58(53.70%), respiratory signs

51(47.22%), lymphadenopathy 49(45.37%), fever 37(34.26%), skin manifestations

36(33.33%), hepatosplenomegaly 33(30.55), signs of vitamin deficiency 32(29.63%),

hepatomegaly 26(24.07), CSOM 24(22.22%), oral thrush 21(19.44%), dental caries

19(17.59%), splenomegaly 9 (8.33%), parotitis 9(8.33%), clubbing 7(6.48%), CNS

manifestation 6(5.55%), ascitis 2(1.85%) and bleeding tendency 1(0.92%) were the

other observed signs (Table-6).

 TABLE-6A (I)
MALNUTRITION IN HIV
Sr. no. IAP grading No. of cases %

1 Normal 9 8.33

2 Gr. I 13 12.03

3 Gr. II 26 24.07

4 Gr. III 41 37.96

5 Gr. IV 19 17.59

MALNUTRITION IN HIV
41
40

30 26
19 MALNUTRITION IN HIV
20
13
9
10

0
Normal Grade I Grade II Grade Grade
III IV

As per Table-6A (I) only 9(8.33%) HIV reactive children were normal and almost 60

(55.55%) were severely malnourished (Gr. III & IV).

 TABLE –6A (II)

AGE AND SEVERE MALNUTRITION IN HIV

Age PEM Gr.III PEM Gr. IV Total

Sr.No.
group (%) (%) (%)
1 <18 1(0.92) 02(1.85) 03(2.77)
2 >18-36 12(11.11) 03(2.77) 15(13.88)
3 >36-60 15(13.88) 07(6.48) 22(20.37)
4 >60-120 10(9.25) 06(5.55) 16(14.81)
5 >120 03(2.77) 01(0.92) 04(3.70)
Total 41(37.96) 19(17.59) 60(55.55)

Amongst those who had severe malnutrition 40/60 (66.66%) were below 5 years

of age. (Table 6AII)

TABLE 6A (III)

WHO STAGING AND ANTHROPOMETRIC CORRELATION

WHO staging
Sr. no. PEM grading (%)
I II III IV
1 Normal 2(1.85) 1(0.92) 5(4.62) 1(0.92)
2 Mild (I&II) 5(4.63) 9(8.33) 21(19.44) 4(3.70)
3 Severe (III&IV) 3(2.77) 12(11.11) 29(26.85) 16(14.81)
4 Total 10(9.25) 22(20.37) 55(50.92) 21(19.44)

Table-6(III) shows in this series 76(70.37%) were in stage III and IV of WHO

clinical staging, suggesting that PEM staging worsens as the WHO staging increases.
 TABLE-6B

LYMPHADENOPATHY IN HIV

Type of No. of cases

Sr.no. Percentage (%)
lymphadenopathy (n=49)
1 Generalized 25 51.02
2 Cervical 11 22.44
3 Axillary 07 14.28
4 Inguinal 06 12.24

Generalized lymphadenopathy was seen in 51.02% followed by cervical

lymphadenopathy (Table -6B).

TYPES OF LYMPHADENOPATHY
6
7
Generalized
Cervical
25 Axillary
Inguinal

11
 TABLE-6C

VITAMIN DEFICIENCIES

Sr. no. Vitamin deficiency No. of Percentage (%)

cases(n=32)
1 A 07 21.87
2 B 20 62.50
3 C 03 09.37
4 D 02 06.25

Table- 6C shows vitamin B deficiency was commonest followed by vitamin A, C

and D respectively.

VITAMIN DEFICIENCIES
3 7
2
VIT.A
VIT. B
VIT. C
VIT. D

20
 TABLE-7

CLINICAL SYMPTOMS ON FOLLOW UP

Sr. no. Complaints on follow up No. of follow up Percentage (%)

N=250
1 Recurrent URI/LRTI 58 23.20
2 Fever 44 17.60
3 Not gaining weight 34 13.60
4 Recurrent GE 33 13.20
5 Skin rash 22 08.80
6 Ear discharge 19 07.60
7 Asymptomatic 18 07.20
8 Oral thrush 15 06.00
9 Parotid swelling 07 02.80

According to table-7, of the total 108 cases enrolled in the study, 75 cases had

regular follow up for 250 times and 33 cases did not follow up. Majority of follow ups

were for respiratory complaints (23.20%) and fever (17.60%). Only 7.20% patients

came for follow up were asymptomatic. Most of the follow up were for OI’s.
 TABLE-8

OPPORTUNISTIC INFECTIONS (OI’s)

Sr. Opportunistic infections No. of Percentage (%)

no. cases Prevalence(n=108)
(n=108)
1 Tuberculosis* 46 42.39
2 Recurrent diarrhoea* 38 35.18
3 Recurrent pneumonia 31 28.70
4 Oral candidiasis 26 24.07
5 Disseminated scabies 16 14.81
6 Recurrent otits media 14 12.96
7 Sepsis 08 07.40
8 Herpes zoster 06 05.55
9 Fungal infection of skin 06 05.55
10 Warts 04 03.70
11 Lymphoid interstitial 04 03.70
pneumonitis(LIP)
12 Pneumocystitis carinii 04 03.70
(jiroveci) pneumonia
13 HIV encephalopathy 03 02.77
14 Recurrent pyoderma 02 01.85
15 Molluscum contagiosum 02 01.85
16 CMV Chorio-retinitis 02 01.85
* Described in details in further tables.

In this study, 108 cases of the study group visited 250 times in our hospital . Out

of these 90 cases had 212 episodes of OI’s and 18 cases had no evidence of OI’s.

Thus prevalance of OI’s in HIV was 83.33%.

 CMV chorioretinitis
250
Molluscum contagiosum
Recurrent pyoderma
200 HIV encephalopathy
PCP
LIP
150 Warts
Fungal infection of skin
Herpes zoster
100 Sepsis
Recurrent otitis media
Disseminated scabies
50 Oral candiasis
Recurrent pneumonia
Recurrent diarrhea
0
Tuberculosis
No of cases (N=108) Percentages(%)
Prevalance(n=108)

Among the opportunistic infections majority of cases had tuberculosis

46(42.39%). This was followed by recurrent diarrhoea 38(35.18%), recurrent

pneumonia 31(28.70%), oral candidiasis 26(24.07%).

Table – 8A

TUBERCULOSIS AS OI

Sr.no. Types of Tuberculosis No. of Percentage (%)

cases(n=46)
1 Pulmonary 27 58.69
2 Extra- pulmonary 19 41.30

Among tuberculosis cases as most common opportunistic infection found in our

study, pulmonary tuberculosis is found in majority of tuberculosis patient 27(58.69%)

followed by extra-pulmonary tuberculosis 19(41.30%)(Table -8A).

 TABLE-8B

DIARRHEA AS OI

Sr. No. of Percentage

Causative agent
No. cases(n=38) (%)

Cryptosporidium 06 15.79
1
Fungal Candida 02 05.26

Salmonella 04 10.52

2 Bacterial E.Coli 03 07.89

Shigella 01 02.63

Intestinal 02 05.26
3 Isospora
Sporozoite

4 Others 20 52.63

According to table-8B, amongst 38 cases of recurrent diarrhea, the majority of

cases 20(52.63%) the cause could not be found out. But cryptosporidium was the most

common single causative agent in rest of the cases where organisms were either

cultured or found under microscopy.

 TABLE -8C

SKIN MANIFESTATIONS AS OI

Number of cases Percentage

Sr. No. Skin Manifestation
(n=36) (%)

1 Disseminated Scabies 16 14.81

2 Herpes 06 05.55

3 Fungal infection 06 05.55

4 Wart 04 03.70

5 Pyoderma 02 01.85

Molluscum
6 Contagiosum 02 01.85

The table- 8C shows out of 108 cases, 36 cases had skin manifestations in the

form of disseminated scabies 14.81%, herpes 05.55%, fungal infections 05.55 % wart

03.70%, pyoderma 01.85%, molluscum contagiosum 01.85% cases.

 TABLE-9
DISTRIBUTION OF OI’s IN OUTDOOR AND INDOOR PATIENTS

On 1st
On follow up Prevalance
presentation
Gran
Sr. O.I. Incidence d
No. (%)
O.P.D. I.P.D. Total O.P.D. I.P.D. Total (%) Total
n=108
n=75

1 TB Pulm. 6 3 9 13 5 18 24 27 25

N=46 Exta 17.59

2 2 4 11 4 15 20 19
pulm.

2 Recurrent diarrhoea 3 6 9 14 15 29 38.66 38 35.18

3 Recurrent
2 3 5 11 15 26 34.66 31 28.70
pneumonia

4 Oral candidiasis 2 2 4 8 14 22 29.33 26 24.07

5 Scabies 4 0 4 10 2 12 16 16 14.81

6 Otitis media 3 1 4 7 3 10 13.33 14 12.96

7 Sepsis 0 1 1 0 7 7 9.33 08 07.40

8 Herpes zoster 3 0 3 3 0 3 4 06 05.55

9 Fungal infection 1 1 2 4 0 4 5.33 06 05.55

10 Wart 0 0 0 3 1 4 5.33 04 03.70

11 L.I.P. 0 1 1 0 3 3 4 04 03.70

12 P.C.P. 0 0 0 0 4 4 5.33 04 03.70

13 HIV encephalopathy 0 0 0 0 3 3 4 03 02.77

14 Recurrent pyoderma 0 0 0 2 0 2 2.66 02 01.85

15 Moluscum
0 0 0 1 1 2 2.66 02 01.85
contagiosum

16 C.M.V. retinitis 0 0 0 1 1 2 2.66 02 01.85

Total 26 20 46 88 78 166 212

 Table-9 shows the episodes of OI’s. Out of total 212 episodes of OI’s,

46(21.69%) of OI’s were detected on 1 st presentation. Of them, 26(56.52%) were

diagnosed on OPD basis and 20(46.98%) were diagnosed on IPD basis.

On follow up 166 episodes (78.3%) of OI’s were diagnosed, amogst which

88(53.01%) were OPD and 78 (53.8%) were IPD diagnosed.

It is seen from the table that the rate of diagnosis in all OI’s increased by almost
2-3 times on follow up.

TABLE -10A

WHO CLINICAL STAGING

Number Percentage

Stage (n=108) (%)

I 10 9.72

II 22 20.37

III 55 50.92

IV 21 19.44

Total 108 100

Table- 10A shows majority of the cases 55(50.92%) were from WHO stage III

followed by stage II, IV, and I respectively.

 TABLE -10B
WHO CLINICAL STAGING
60 IMMUNOLOGICAL
50 CATEGORIES

40

30 Cases(n=10 Percentage
Sr. No. Immunological Category
20 8) (%)

10 1 Mild Immunosuppression 13 12.03

0 Moderate
2
STAGE I STAGE III STAGE III 53
STAGE IV 49.07
Immunosuppression

Severe
3 42 38.88
Immunosuppression

Total 108 100

This table-10B shows majority 53(49.07%) patients were with moderate

immnunosuppression followed by 42(38.88%) with severe Immunosuppression.

IMMUNOLOGICAL CATEGORY
60
50
40
30
20
10
0 IMMUNOLOGICAL CATEGORY
n n n
ssio ssio ssio
re re re
sup sup sup
o o o
un un un
m m m
Im m m
ild eI eI
at ve
r
M er Se
od
M
 TABLE-11

DISTRIBUTION OF OI’s AS PER IMMUNOLOGICAL AND WHO CLINICAL STAGING

Sr. O.I. No. of Immunological stage (%) WHO Clinical staging (%)
no. patients
I II III I II III IV
1 Present 90 2 49 39 0 17 53 20
(1.85) (45.37) (36.11) (0.0) (15.74) (49.07) (18.51)
2 Absent 18 11 4 3 10 5 2 1
(10.18) (3.70) (2.77) (9.25) (4.62) (1.85) (0.92)
3 Total 108 13 53 42 10 22 55 21
(12.03) (49.07) (38.88) (9.25) (20.37) (50.92) (19.44)

Table-11 shows 90/108 cases had various OI’s and the maximum OI’s (87.95%)

were in the stage II & III of immunological staging and 71.29% in stage II & III of clinical

staging respectively.

Out of 108 cases 18 had no episode of OI’s and maximum amongst them were

in stage I immunologically as well as clinically.

Of the 108 cases 64 cases were put on ART and all patients tolerated ART

without any toxicity.

OI’s were treated as per the protocol. All cases were put on cotrimoxazole

prophylaxis.
 Table-12A

Immunological Category versus Death

Sr. no. Immunological Category No. of death %

1 Mild 0 0
2 Moderate 2 40
3 Severe 3 60

Table-12A shows maximum deaths were in stage II & III of immunological stage

with 2(40%) and 3(60%) deaths respectively.

TABLE -12B

CAUSITIVE AGENT versus DEATH

Sr. no Cause of death Age in months %

1 PCP 3
2 PCP 6 40%
3 Septicaemia 2
4 Septicaemia 4 40%
5 AIDS( candidemia, 36 20%
tuberculosis and
cryptosporidiosis)

In the study series there were total 5 deaths (4.62%), out of which 40% was due

to PCP, 40% due to septicaemia and 20% was due to AIDS (Table-12B).