Журнал «Здоровье ребенка» 1 (52) 2014

We observed the boy M., age 1 year and 10 months, a resident of the city, which is admitted to the Children's Infectious Diseases Hospital with the diagnosis of acute intestinal infection, exsicosis of II degree, aphthous stomatitis and oropharyngeal mucosal candidiasis. The mother made complaints about the fever up to 38–40 ^oC, the liquid bulky stools 5–7 times a day, weight loss, ulcers on the mucous membrane of the mouth, the white "cheesy" raid on the buccal mucosa and the tongue, cough and dyspnea.

After inspection at the reception department the child was suspected in having HIV infection that was confirmed by a rapid test. Only after that the child's mother revealed that she was HIV-infected and she has known about her status for 10 years. Nevertheless, all these years she refused the investigation and treatment out of the fear of accidentally revealing the diagnosis to family members and friends. In order to maintain this secrecy the woman was not observed during pregnancy, so the prevention of vertical transmission of her and the child was not carried out. She stayed with the relatives in the Khmelnitsky region for delivery and left the hospital without leaving any permanent address.

It was revealed from the medical history that the boy grew up and developed according  his age up to 1,5 years, when his mother first noticed the increase of the  cervical lymph nodes. Child's weight at the time was 14 kg. A month later he suffered the cough, lethargy, loss of appetite, and after 2 weeks the fever to 38–39 ^oC appeared. Antibiotic therapy conducted at home  had no effect. At the age of 1 year and 7 months watery stools up to 5–7 times a day appeared, and from that moment the child began to lose weight rapidly. After unsuccessful antibiotical treatment, at the age of 1 year and 10 months, with a weight of 10 kg, when the parents had realized that the child was on the verge of death, he was hospitalized.

An objective examination revealed that the child's condition is serious, due to extreme exhaustion and dehydration. The skin is pale with a waxy touch. The tissue turgor reduced, the skin literally sag on the thighs, buttocks and upper arms. The skin fold on the back of the hand was not unruffled for a long time. The mucosa of the mouth is dry, ulcerations on the gums and buccal mucosa, covered with a white cheesy coating observed. Palpable peripheral lymph nodes (cervical, axillary, inguinal) up to 0,5 cm in diameter. There was a dyspnoe of mixed character, respiratory rate reached 35–40 min. Saturation was at 94–95 %. At lung percussion the blunting sound over the lower parts of the lungs was noted as well as wheezing on auscultation krepitiruyuschie in the same areas. The boundaries of the heart at the age norm, auscultation –  heart sounds are muffled, rhythmic. Abdomen greatly increased in size, the edge of the liver appeared from under the costal margin at 4 cm, the edge of the spleen – at 5cm.

Laboratory examinations. Blood test: RBC – 2,6 × 10¹²/l, Hb – 68 g/l, WBC – 13,4 x 10⁹/l, young cells – 17 %, segment – 34 %, lymphocytes – 43 %,  monocytes – 6 %, PLT – 120 x 10⁹/l, erythrocyte sedimentation rate – 58 mm/hour. The microscopy of the sputum on the first day of hospitalization revealed mycelium of Aspergillus, erosions of the mucous secretions of the mouth –  the mycelium of the fungus genus Candida, stool microscopy – cryptosporidium. CT scan: in 3 and 4 segments of the left lung the infiltration of 45 x 15 mm deep in the bronchial lumen is determined. Similar infiltration is observed in the basal segment of the right lung (10^th segment).

Immunological status: the number of CD4-lymphocyte count was 0 % – 6 cells/ml, viral load (VL) – 261 260 copies/ml.

Based on the above the following diagnosis was made: HIV-infection clinical stage IV, severe immunosuppression. Invasive pulmonary aspergillosis. Cryptosporidiosis. Vasting syndrome. Oropharyngeal candidiasis. Hepatosplenomegaly. Anemia (Hb – 68 g/l).  

In the differential diagnosis, and after further investigation, tuberculosis, Pneumocystis pneumonia, cytomegalovirus infection, deep mycosis of other etiologies (cryptococcus, histoplasmosis, etc.) were excluded.

Treatment.

As the main drug for the treatment of IAL we used voriconazole, general course of 83 days, including 30 days i.v., the remaining 53 days – orally. Such duration of the course was due to the slow speed of the immune recovery. Only after 83 days the number of CD4 lymphocytes reached 116 cells (6 %). During the treatment with voriconazole there was an increase in the liver enzymes in 6–7 times. As to the hepatoprotector we used the heptral i.v. for 14 days with good effect. Because the child's parents could not provide further treatment with voriconazole due to financial reasons, for a further 30 days the child received itraconazole, and on reaching the level of CD4-lymphocyte cells 262 (9 %), and BH – 295 copies/ml, the drug was discontinued. Thus, the overall course of IAL treatment with untifungal medicine lasted for  103 days. In the control CT scan infiltrative lesions were not detected.

Simultaneously with the start of the treatment of aspergillosis, we started ART using the scheme AZT +3TC + LPV/r.  With the aim of substitution in the first 2 weeks of treatment the child received infusion of intravenous immunoglobulin (Bioven Mono). Such preparations as granulocyte or granulocyte-macrophage of colony-stimulating factors were not used.

Pathological regression of clinical symptoms occurred very slowly. After 1 month from the start of the treatment the child has returned to normal stool and in 3 months the signs of respiratory failure disappeared. Iits original weight of 14 kg  the child gained after 4,5 months. The level of hemoglobin in the blood count has come to normal after 5 months. After 6 months of therapy BH HIV in the child’s blood serum  was undetectable; CD4 lymphocyte matched the normal level only after 1 year and 3 months of treatment. At present the child is 3 years old and he looks no different from a completely healthy children.

Thus, invasive pulmonary aspergillosis should be included into the differential diagnosis at the identification of HIV-infected children with pulmonary infiltrates.