HIV Exposure: Neonatal Considerations
2003; Elsevier BV; Volume: 32; Issue: 1 Linguagem: Inglês
10.1177/0884217502239808
ISSN1552-6909
AutoresMarisha E. Meleski, Elizabeth G. Damato,
Tópico(s)HIV Research and Treatment
ResumoThe presence of human immunodeficiency virus (HIV) in pregnant women puts infants at risk for exposure through placental infection and contact with contaminated maternal blood and genital secretions. Efforts to combat this inevitably fatal disease continue to focus on preventing transmission of the virus from a mother who has HIV to her newborn during the prenatal, intrapartum, and postnatal periods. Prophylaxis against transmission and vigilant assessment for indicators of infection are hallmarks of appropriate health care for infants exposed to HIV. The presence of human immunodeficiency virus (HIV) in pregnant women puts infants at risk for exposure through placental infection and contact with contaminated maternal blood and genital secretions. Efforts to combat this inevitably fatal disease continue to focus on preventing transmission of the virus from a mother who has HIV to her newborn during the prenatal, intrapartum, and postnatal periods. Prophylaxis against transmission and vigilant assessment for indicators of infection are hallmarks of appropriate health care for infants exposed to HIV. Word about a new devastating disease, which would later be termed acquired immunodeficiency syndrome (AIDS), first appeared in the early 1980s. It is now known that AIDS is caused by the human immunodeficiency virus (HIV), a cytoplasmic retrovirus of the human T-cell that reproduces and infects even when antibodies against the virus are present. HIV attacks a subgroup of T-lymphocytes known as “helper” T-cells, which are important in cell-mediated immunity. HIV infection causes immunosuppression and susceptibility to opportunistic infections, and may lead to the development of unusual neoplasms ("Bailey and Toltzis, 2002Bailey J.E. Toltzis P. The immune system: Viral infections.in: Fanaroff A.A. Martin R.J. Neonatal‐perinatal medicine: Diseases of the fetus and infant. 7th ed. Mosby, St. Louis2002: 755-802Google Scholar; "Chernecky and Berger, 2001Chernecky C.C. Berger B.J. Laboratory tests and diagnostic procedures.3rd ed. Saunders, Philadelphia2001Google Scholar). Because HIV is a blood-borne pathogen and can infect the placenta, infants born to mothers infected with HIV are at risk for contracting the virus. The purpose of this article is to provide an overview of HIV infection as it relates to exposed neonates and to summarize current approaches during infancy. The vast majority of pediatric AIDS cases can be traced to maternal-infant transmission ("Connor et al., 1994Connor E.M. Sperling R.S. Gelber R. Kiselev P. Scott G. O'sullivan M.J. Reduction of maternal‐infant transmission of human immunodeficiency virus type 1 with zidovudine treatment.New England Journal of Medicine. 1994; 331: 1173-1180Crossref PubMed Scopus (3385) Google Scholar; "Luzuriaga et al., 1995Luzuriaga K. Bryson Y. Krogstad P. Robinson J. Stechenberg B. Lamson M. Combination treatment with zidovudine, didanosine, and nevirapine in infants with human immunodeficiency virus type 1 infection.New England Journal of Medicine. 1995; 336: 1343-1349Crossref Scopus (195) Google Scholar). Therefore, efforts to combat this inevitably fatal disease in pediatric populations have focused on prevention of transmission from the mother who is infected with HIV to her newborn during the perinatal period. Less than 10 years ago, as many as 15% to 40% of infants born to these women acquired HIV infection via vertical transmission ("Connor et al., 1994Connor E.M. Sperling R.S. Gelber R. Kiselev P. Scott G. O'sullivan M.J. Reduction of maternal‐infant transmission of human immunodeficiency virus type 1 with zidovudine treatment.New England Journal of Medicine. 1994; 331: 1173-1180Crossref PubMed Scopus (3385) Google Scholar). Concentrated research efforts in the past decade have led to clinical treatment approaches that markedly decreased the rate of vertical transmission. Administration of zidovudine (ZDV) to the pregnant woman and neonate reduces the perinatal transmission rate to 7% to 9% in treated women ("Connor et al., 1994Connor E.M. Sperling R.S. Gelber R. Kiselev P. Scott G. O'sullivan M.J. Reduction of maternal‐infant transmission of human immunodeficiency virus type 1 with zidovudine treatment.New England Journal of Medicine. 1994; 331: 1173-1180Crossref PubMed Scopus (3385) Google Scholar; "International Perinatal HIV Group, 1999International Perinatal HIV Group The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1: A meta‐analysis of 15 prospective cohort studies.New England Journal of Medicine. 1999; 340: 977-987Crossref PubMed Scopus (693) Google Scholar; "Sperling et al., 1996Sperling R.S. Shapiro D.E. Coombs R.W. Todd J.A. Herman S.A. McSherry G.D. Maternal viral load, zidovudine treatment, and the risk of transmission of human immunodeficiency virus type 1 from mother to infant.New England Journal of Medicine. 1996; 335: 1621-1629Crossref PubMed Scopus (702) Google Scholar). Delivery by elective cesarean section (performed prior to the onset of labor and rupture of membranes) has also reduced the risk of transmission of HIV from mother to child by 50%, independent of the effects of treatment with ZDV. The risk may be further reduced to 2% when ZDV prophylaxis is combined with elective cesarean delivery ("International Perinatal HIV Group, 1999International Perinatal HIV Group The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1: A meta‐analysis of 15 prospective cohort studies.New England Journal of Medicine. 1999; 340: 977-987Crossref PubMed Scopus (693) Google Scholar). Despite the increased costs of cesarean delivery, elective cesareans are considered to be a cost-effective intervention to prevent vertical transmission of HIV ("Halpern et al., 2000Halpern M.T. Read J.S. Ganoczy D.A. Harris D.R. Cost‐effectiveness of cesarean section delivery to prevent mother‐to‐child transmission of HIV‐1.AIDS. 2000; 14: 691-700Crossref PubMed Scopus (28) Google Scholar). The most recent treatment trend has been to use combination drug therapy to decrease maternal plasma viral load and combat increasing resistance to ZDV. HIV has proven to be adept at developing resistance to ZDV, and perinatal transmission of antiretroviral-resistant strains of HIV has been reported ("McGowan et al., 1999McGowan J.P. Crane M. Wiznia A.A. Blum S. Combination antiretroviral therapy in human immunodeficiency virus‐infected pregnant women.Obstetrics & Gynecology. 1999; 94: 641-646Crossref PubMed Scopus (47) Google Scholar). If possible, ZDV is recommended to be included in the combination therapy for pregnant women because it has been most studied, is relatively well tolerated by the mother and the fetus and neonate, crosses the blood-brain barrier and the placenta, and is known to prevent vertical transmission ("Bailey and Toltzis, 2002Bailey J.E. Toltzis P. The immune system: Viral infections.in: Fanaroff A.A. Martin R.J. Neonatal‐perinatal medicine: Diseases of the fetus and infant. 7th ed. Mosby, St. Louis2002: 755-802Google Scholar; "Burpo, 2000Burpo R.H. Common antiviral agents used in women's and children's care, part 2.Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2000; 29: 191-200Abstract Full Text Full Text PDF PubMed Google Scholar; "Connor et al., 1994Connor E.M. Sperling R.S. Gelber R. Kiselev P. Scott G. O'sullivan M.J. Reduction of maternal‐infant transmission of human immunodeficiency virus type 1 with zidovudine treatment.New England Journal of Medicine. 1994; 331: 1173-1180Crossref PubMed Scopus (3385) Google Scholar). Vertical transmission of HIV from the pregnant woman to her infant is the predominant mode of pediatric infection. Approximately 95% of persons infected with HIV live in the developing world ("National Center for HIV, STD and TB Prevention, Divisions of HIV/AIDS Prevention, 2002National Center for HIV, STD and TB Prevention, Divisions of HIV/AIDS Prevention Basic statistics.http://www.cdc.gov/hiv/stats.htm#cumageDate: 2002Google Scholar). HIV has reached epidemic proportions in Africa, with overall prevalence in sub-Saharan Africa as much as 7.4%. There are 36.1 million Africans estimated to be living with HIV/AIDS. Of these, 1.4 million are children under the age of 15 years. In the year 2000 alone, 500,000 children died of AIDS (National Center for HIV, STD and TB Prevention, Divisions of National Center for HIV, STD and TB Prevention, Divisions of HIV/AIDS Prevention, 2002National Center for HIV, STD and TB Prevention, Divisions of HIV/AIDS Prevention Basic statistics.http://www.cdc.gov/hiv/stats.htm#cumageDate: 2002Google Scholar). By December 2000, 774,467 cumulative AIDS cases in the United States were reported to the Centers for Disease Control and Prevention (CDC) (National Center for HIV, STD and TB Prevention, Divisions of HIV/AIDS Prevention, 2002National Center for HIV, STD and TB Prevention, Divisions of HIV/AIDS Prevention Basic statistics.http://www.cdc.gov/hiv/stats.htm#cumageDate: 2002Google Scholar). Of these, 8,908 were in children under the age of 13 years. Children under the age of 15 accounted for 5,178 AIDS-related deaths. In the United States, HIV infection was the 6th leading cause of death in children between the ages of 1 and 4 from 1993 to 1995; by 2001, it was reported as being the 11th leading cause of death in this age group ("Langston et al., 2001Langston C. Cooper E.R. Goldfarb J. Easley K.A. Husak S. Sunkle S. Human immunodeficiency virus‐related mortality in infants and children: Data from the pediatric pulmonary and cardiovascular complications of vertically transmitted HIV (P2C2) study.Pediatrics. 2001; 107: 328-338Crossref PubMed Scopus (41) Google Scholar). It does, however, remain the 7th leading cause of death among African American children and the 10th most common among Hispanic children ("Langston et al., 2001Langston C. Cooper E.R. Goldfarb J. Easley K.A. Husak S. Sunkle S. Human immunodeficiency virus‐related mortality in infants and children: Data from the pediatric pulmonary and cardiovascular complications of vertically transmitted HIV (P2C2) study.Pediatrics. 2001; 107: 328-338Crossref PubMed Scopus (41) Google Scholar). The rise in HIV incidence across all continents has implications for the increasing numbers of children who will be exposed to HIV during the perinatal period. In infants and children, HIV appears to invade the central nervous system early in the disease process, even before development of full-blown AIDS ("Gay et al., 1995Gay C.L. Armstrong F.D. Cohen D. Lai S. Hardy M.D. Swales T.P. The effects of HIV on cognitive and motor development in children born to HIV‐seropositive women with no reported drug use: Birth to 24 months.Pediatrics. 1995; 96: 1078-1082PubMed Google Scholar). Pediatric HIV infection has been associated with encephalopathy (either the slowing or cessation of developmental progress or the loss of previously acquired developmental milestones), microcephaly (possibly due to cortical atrophy and calcification in the basal ganglia and frontal cortex white matter), and altered nervous system myelination ("Gay et al., 1995Gay C.L. Armstrong F.D. Cohen D. Lai S. Hardy M.D. Swales T.P. The effects of HIV on cognitive and motor development in children born to HIV‐seropositive women with no reported drug use: Birth to 24 months.Pediatrics. 1995; 96: 1078-1082PubMed Google Scholar). In most reports, a small proportion (approximately 20% to 30%) of infants have been termed “rapid progressors.” This group includes those infected at birth, who had viral loads often 2 to 3 times higher than other infants, whose disease progressed rapidly, and who died in infancy. A larger proportion were thought to have a slower progression of the disease, with some children remaining asymptomatic beyond the preschool years ("Bailey and Toltzis, 2002Bailey J.E. Toltzis P. The immune system: Viral infections.in: Fanaroff A.A. Martin R.J. Neonatal‐perinatal medicine: Diseases of the fetus and infant. 7th ed. Mosby, St. Louis2002: 755-802Google Scholar; "De Rossi et al., 1996De Rossi A. Masiero S. Giaquinto C. Ruga E. Comar M. Giacca M. Dynamics of viral replication in infants with vertically acquired human immunodeficiency virus type 1 infection.Journal of Clinical Investigation. 1996; 97: 323-330Crossref PubMed Scopus (107) Google Scholar). However, a recently reported multicenter study of 816 children infected with HIV found that equal proportions of children were dying at each year of age, although the cause of death varied by age ("Langston et al., 2001Langston C. Cooper E.R. Goldfarb J. Easley K.A. Husak S. Sunkle S. Human immunodeficiency virus‐related mortality in infants and children: Data from the pediatric pulmonary and cardiovascular complications of vertically transmitted HIV (P2C2) study.Pediatrics. 2001; 107: 328-338Crossref PubMed Scopus (41) Google Scholar). Infection was the most prevalent cause of HIV-related death for children under age 6, with 32.3% caused by pulmonary infection, specifically Pneumocystis carinii pneumonia (PCP), and another 16.9% caused by nonpulmonary infection, such as sepsis without organism identification or disseminated cytomegalovirus infection (CMV). The frequency of death caused by pulmonary disease decreased as the child’s age increased. The frequency of death caused by chronic cardiac disease (congestive heart failure, cardiomyopathy) increased with age, as did frequency of death from wasting syndrome, encephalopathy, and Mycobacterium avium complex. Except for pulmonary disease or infection, all of these causes were more likely in children over age 10 ("Langston et al., 2001Langston C. Cooper E.R. Goldfarb J. Easley K.A. Husak S. Sunkle S. Human immunodeficiency virus‐related mortality in infants and children: Data from the pediatric pulmonary and cardiovascular complications of vertically transmitted HIV (P2C2) study.Pediatrics. 2001; 107: 328-338Crossref PubMed Scopus (41) Google Scholar). HIV has been directly isolated from the placenta, amniotic fluid, and early products of conception ("Bailey and Toltzis, 2002Bailey J.E. Toltzis P. The immune system: Viral infections.in: Fanaroff A.A. Martin R.J. Neonatal‐perinatal medicine: Diseases of the fetus and infant. 7th ed. Mosby, St. Louis2002: 755-802Google Scholar). The mechanism of transplacental transfer of HIV remains unknown, but HIV can infect both the trophoblast and placental macrophage cell lines ("Burchett et al., 1998Burchett S.K. Viral infections.in: Cloherty J.P. Stark A.R. Manual of neonatal care. 4th ed. Lippincott, Philadelphia1998: 239-271Google Scholar). HIV is a retrovirus, meaning that it converts its RNA to DNA via enzyme reverse transcriptase, allowing the DNA to be incorporated in the cell’s chromosomes ("Burpo, 2000Burpo R.H. Common antiviral agents used in women's and children's care, part 2.Journal of Obstetric, Gynecologic, and Neonatal Nursing. 2000; 29: 191-200Abstract Full Text Full Text PDF PubMed Google Scholar). It infects cells that have the CD4+ surface molecule, primarily helper T-cell lymphocytes and macrophages, which weakens the immune system ("Bailey and Toltzis, 2002Bailey J.E. Toltzis P. The immune system: Viral infections.in: Fanaroff A.A. Martin R.J. Neonatal‐perinatal medicine: Diseases of the fetus and infant. 7th ed. Mosby, St. Louis2002: 755-802Google Scholar). Transmission from woman to infant may occur in utero, during delivery, or from breastfeeding ("Luzuriaga et al., 1995Luzuriaga K. Bryson Y. Krogstad P. Robinson J. Stechenberg B. Lamson M. Combination treatment with zidovudine, didanosine, and nevirapine in infants with human immunodeficiency virus type 1 infection.New England Journal of Medicine. 1995; 336: 1343-1349Crossref Scopus (195) Google Scholar). Possible mechanisms of vertical transmission may include transfusion of blood from the mother to the fetus during labor contractions, infection after membranes rupture, and/or fetal contact with secretions or blood from the maternal genital tract ("International Perinatal HIV Group, 1999International Perinatal HIV Group The mode of delivery and the risk of vertical transmission of human immunodeficiency virus type 1: A meta‐analysis of 15 prospective cohort studies.New England Journal of Medicine. 1999; 340: 977-987Crossref PubMed Scopus (693) Google Scholar). There is also evidence that infection may occur from the newborn’s oral exposure to HIV-tainted maternal genital secretions in the birth canal ("Gaillard et al., 2000Gaillard P. Verhofstede C. Mwanyumba F. Claeys P. Chohan V. Mandaliya K. Exposure to HIV‐1 during delivery and mother‐to‐child transmission.AIDS. 2000; 14: 2341-2348Crossref PubMed Scopus (47) Google Scholar; "Mandelbrot et al., 1999Mandelbrot L. Burgard M. Telglas J.P. Benifla J.L. Khan C. Blot P. Frequent detection of HIV‐1 in the gastric aspirates of neonates born to HIV‐infected mothers.AIDS. 1999; 13: 2143-2149Crossref PubMed Scopus (49) Google Scholar). Issues related to HIV transmission from ingestion of infected breast milk are discussed in a companion article in this issue. Women with HIV were originally thought to give birth to infants who showed evidence of growth restriction, were low birth weight, or were more likely to be preterm. However, other factors frequently found in women infected with HIV also may be responsible for smaller babies. They include malnutrition; coexisting infection; and illicit drug, tobacco, or alcohol use ("Bailey and Toltzis, 2002Bailey J.E. Toltzis P. The immune system: Viral infections.in: Fanaroff A.A. Martin R.J. Neonatal‐perinatal medicine: Diseases of the fetus and infant. 7th ed. Mosby, St. Louis2002: 755-802Google Scholar; "Keesler et al., 2001Keesler M.J. Fisher S.D. Lipshultz S.E. Cardiac manifestations of HIV infection in infants and children.Annals of the New York Academy of Sciences. 2001; 946: 169-178Crossref PubMed Scopus (33) Google Scholar). In fact, recent studies have found the risk factors of preterm birth, low birth weight, and intrauterine growth retardation to be no higher in pregnant women with HIV who are treated with ZDV, possibly reflecting the positive impact of prenatal care and antiretroviral treatment ("European Collaborative Study, 1998European Collaborative Study Is zidovudine therapy in pregnant HIV‐infected women associated with gestational age and birthweight.AIDS. 1998; 13: 119-124Google Scholar; "Lambert et al., 2000Lambert J.S. Watts D.H. Mofenson L. Stiehm E.R. Harris D.R. Bethel J. Risk factors for preterm birth, low birth weight, and intrauterine growth retardation in infants born to HIV‐infected pregnant women receiving zidovudine. Pediatric AIDS Clinical Trial Group 185 Team.AIDS. 2000; 14: 1389-1399Crossref PubMed Scopus (71) Google Scholar). Fetal echocardiography has suggested that fetuses of mothers who are HIV-positive have increased right and left ventricular wall thickness, irrespective of the HIV status of the fetus ("Hornberger et al., 2000Hornberger L.K. Lipshultz S.E. Easley K.A. Colan S.D. Schwartz M. Kaplan S. Cardiac structure and function in fetuses of mothers infected with HIV: The prospective P2C2 HIV multicenter study.American Heart Journal. 2000; 140: 575-584Abstract Full Text PDF PubMed Scopus (38) Google Scholar). The incidence of septal defects and valvular malformations does not appear to be more than that in the general population, although this finding may be confounded by the various maternal factors previously mentioned ("Lai et al., 1998Lai W.W. Lipshultz S.E. Easley K.A. Starc T.J. Drant S.E. Bricker T. Prevalence of congenital cardiovascular malformations in children of human immunodeficiency virus‐infected women: The prospective P2C2 multicenter study.Journal of the American College of Cardiology. 1998; 32: 1749-1755Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar). A small number of newborns with HIV may present with lymphadenopathy and/or hepatosplenomegaly, but generally symptoms do not appear in the first 2 weeks of life ("Burchett et al., 1998Burchett S.K. Viral infections.in: Cloherty J.P. Stark A.R. Manual of neonatal care. 4th ed. Lippincott, Philadelphia1998: 239-271Google Scholar). Altered growth and failure to thrive are seen in infants infected with HIV. Poor weight gain may occur early in infancy ("Burchett et al., 1998Burchett S.K. Viral infections.in: Cloherty J.P. Stark A.R. Manual of neonatal care. 4th ed. Lippincott, Philadelphia1998: 239-271Google Scholar; "Miller et al., 2001Miller T.L. Easley K.A. Zhang W. Orav E.J. Bier D.M. Luder E. Maternal and infant factors associated with failure to thrive in children with vertically transmitted human immunodeficiency virus‐1 infection: The prospective, P2C2 human immunodeficiency virus multicenter study.Pediatrics. 2001; 108: 1287-1296Crossref PubMed Scopus (46) Google Scholar). Linear growth is also compromised ("Arpadi et al., 2000Arpadi S.M. Cuff P.A. Kotler D.P. Wang J. Bamji M. Lange M. Growth velocity, fat‐free mass and energy intake are inversely related to viral load in HIV‐infected children.Journal of Nutrition. 2000; 130: 2498-2502PubMed Scopus (54) Google Scholar; "Pollack et al., 1996Pollack H. Kuchuk A. Cowan L. Hacimamutoglu S. Glasberg H. David R. Neurodevelopment, growth, and viral load in HIV‐infected infants.Brain, Behavior, and Immunity. 1996; 10: 298-312Crossref PubMed Scopus (39) Google Scholar). Body composition is altered, as evidenced by a decrease in lean body mass ("Arpadi et al., 2000Arpadi S.M. Cuff P.A. Kotler D.P. Wang J. Bamji M. Lange M. Growth velocity, fat‐free mass and energy intake are inversely related to viral load in HIV‐infected children.Journal of Nutrition. 2000; 130: 2498-2502PubMed Scopus (54) Google Scholar). The etiology of growth failure may have many explanations: HIV replication may increase the basal metabolic rate and calorie expenditure, making the infant unable to also meet metabolic demands for growth; gastrointestinal dysfunction as evidenced by diarrhea may prohibit optimal absorption; and chronic comorbidities and infections can increase energy expenditure ("Miller et al., 2001Miller T.L. Easley K.A. Zhang W. Orav E.J. Bier D.M. Luder E. Maternal and infant factors associated with failure to thrive in children with vertically transmitted human immunodeficiency virus‐1 infection: The prospective, P2C2 human immunodeficiency virus multicenter study.Pediatrics. 2001; 108: 1287-1296Crossref PubMed Scopus (46) Google Scholar). Other theorized causes of altered growth in infants with HIV include decreased peripheral sensitivity to growth hormone; decreased levels of insulin-like growth factors; and the release of cytokines, which may decrease the effectiveness of growth hormone ("Pollack et al., 1996Pollack H. Kuchuk A. Cowan L. Hacimamutoglu S. Glasberg H. David R. Neurodevelopment, growth, and viral load in HIV‐infected infants.Brain, Behavior, and Immunity. 1996; 10: 298-312Crossref PubMed Scopus (39) Google Scholar). In addition, adequate nutritional intake may not be readily available to children with HIV living with ill parents, who may have limited social services and support or who have problems with substance abuse ("Williams et al., 2001Williams A.J. Duong T. McNally L.M. Tookey P.A. Masters J. Miller R. Pneumocystis carinii pneumonia and cytomegalovirus infection in children with vertically acquired HIV infection.AIDS. 2001; 15: 335-339Crossref PubMed Scopus (50) Google Scholar). Infants with HIV may have delays in linear growth within the first 6 months of life, but neurodevelopmental delays may not be apparent until 12 months of age. There appears to be a positive association between the degree of linear growth failure and the extent of cognitive and motor delays ("Pollack et al., 1996Pollack H. Kuchuk A. Cowan L. Hacimamutoglu S. Glasberg H. David R. Neurodevelopment, growth, and viral load in HIV‐infected infants.Brain, Behavior, and Immunity. 1996; 10: 298-312Crossref PubMed Scopus (39) Google Scholar). The risk of delayed linear growth and neurodevelopmental delay is especially high in infants who continue to display a high viral load at 6 months of age ("Pollack et al., 1996Pollack H. Kuchuk A. Cowan L. Hacimamutoglu S. Glasberg H. David R. Neurodevelopment, growth, and viral load in HIV‐infected infants.Brain, Behavior, and Immunity. 1996; 10: 298-312Crossref PubMed Scopus (39) Google Scholar). Neurotoxins, cytokines, and altered cortisol secretion have been implicated as possible causative or associated agents of neurodevelopmental abnormalities ("Pollack et al., 1996Pollack H. Kuchuk A. Cowan L. Hacimamutoglu S. Glasberg H. David R. Neurodevelopment, growth, and viral load in HIV‐infected infants.Brain, Behavior, and Immunity. 1996; 10: 298-312Crossref PubMed Scopus (39) Google Scholar). Pneumocystis carinii pneumonia is the AIDS-defining illness in 37% of pediatric patients, with a peak incidence at the age of 4 months ("Burchett et al., 1998Burchett S.K. Viral infections.in: Cloherty J.P. Stark A.R. Manual of neonatal care. 4th ed. Lippincott, Philadelphia1998: 239-271Google Scholar; "Merenstein et al., 1998Merenstein G.B. Adams K. Weisman L.E. Infection in the neonate.in: Merenstein G.B. Gardner S.L. Handbook of neonatal intensive care. 4th ed. Mosby, St. Louis1998: 413-436Google Scholar). In infants, PCP is characterized by an interstitial pneumonia without auscultatory findings, low-grade fever, tachypnea, and tachycardia. Lymphoid interstitial pneumonia, a condition also seen in pediatric AIDS, is a chronic pulmonary disease characterized by a diffuse lymphocytic and plasma cell infiltrate that leads to tachypnea, retractions, wheezing, and hypoxemia. Epstein-Barr virus may also be associated with this type of pneumonia ("Burchett et al., 1998Burchett S.K. Viral infections.in: Cloherty J.P. Stark A.R. Manual of neonatal care. 4th ed. Lippincott, Philadelphia1998: 239-271Google Scholar; "Merenstein et al., 1998Merenstein G.B. Adams K. Weisman L.E. Infection in the neonate.in: Merenstein G.B. Gardner S.L. Handbook of neonatal intensive care. 4th ed. Mosby, St. Louis1998: 413-436Google Scholar). Infants with concomitant PCP and CMV infections have an especially poor prognosis ("Williams et al., 2001Williams A.J. Duong T. McNally L.M. Tookey P.A. Masters J. Miller R. Pneumocystis carinii pneumonia and cytomegalovirus infection in children with vertically acquired HIV infection.AIDS. 2001; 15: 335-339Crossref PubMed Scopus (50) Google Scholar). Recurrent infections are a frequent feature of pediatric AIDS. Examples include chronic otitis media, parotitis (mumps), and persistent candidal infection (thrush and/or diaper rash) ("Kenner et al., 1998Kenner C. Neonatal acquired immunodeficiency syndrome: Human immunodeficiency virus.in: Kenner C. Lott J.W. Flandermeyer A.A. Comprehensive neonatal nursing: A physiologic perspective. 2nd ed. Saunders, Philadelphia1998: 815-837Google Scholar; "Merenstein et al., 1998Merenstein G.B. Adams K. Weisman L.E. Infection in the neonate.in: Merenstein G.B. Gardner S.L. Handbook of neonatal intensive care. 4th ed. Mosby, St. Louis1998: 413-436Google Scholar). Commonly seen causative organisms include Streptococcus pneumonia, Haemophilis influenzae, and several species of Salmonella ("Burchett et al., 1998Burchett S.K. Viral infections.in: Cloherty J.P. Stark A.R. Manual of neonatal care. 4th ed. Lippincott, Philadelphia1998: 239-271Google Scholar). Left ventricular dysfunction is frequently seen in children with HIV and can occur as early as the neonatal period ("Keesler et al., 2001Keesler M.J. Fisher S.D. Lipshultz S.E. Cardiac manifestations of HIV infection in infants and children.Annals of the New York Academy of Sciences. 2001; 946: 169-178Crossref PubMed Scopus (33) Google Scholar; "Miller et al., 1997Miller T.L. Orav E.J. Colan S.D. Lipshultz S.E. Nutritional status and cardiac mass and function in children infected with human immunodeficiency virus.American Journal of Clinical Nutrition. 1997; 66: 660-664PubMed Scopus (38) Google Scholar). Children with thickened ventricular walls, increased heart rate or blood pressure, or myocarditis and cardiomyopathy (commonly caused by adenovirus and CMV) have higher mortality rates. Cardiac rhythm disturbances are also common, including tachycardia, sinus arrhythmia, atrial ectopy, and ventricular arrhythmia ("Keesler et al., 2001Keesler M.J. Fisher S.D. Lipshultz S.E. Cardiac manifestations of HIV infection in infants and children.Annals of the New York Academy of Sciences. 2001; 946: 169-178Crossref PubMed Scopus (33) Google Scholar). No single test has been developed that confirms HIV infection. The typical AIDS battery consists of blood and body fluid cultures, antigen detection by serology (e.g., p24 antigen testing), antibody screening (e.g., ELISA or enzyme-linked immunosorbent assay), confirmatory antibody detection methods (e.g., Western blot), and tests for immunologic status evaluation (e.g., CD4+ and CD8 levels) ("Chernecky and Berger, 2001Chernecky C.C. Berger B.J. Laboratory tests and diagnostic procedures.3rd ed. Saunders, Philadelphia2001Google Scholar). Because the maternal IgG antibody against HIV crosses the placenta and may be present in infants until 18 months of age ("Burchett et al., 1998Burchett S.K. Viral infections.in: Cloherty J.P. Stark A.R. Manual of neonatal care. 4th ed. Lippincott, Philadelphia1998: 239-271Google Scholar; "Chernecky and Berger, 2001Chernecky C.C. Berger B.J. Laboratory tests and diagnostic procedures.3rd ed. Saunders, Philadelphia2001Google Scholar), interpretation of an infant’s results using ELISA (which screens for antibodies against HIV) or Western blot (which confirms HIV antibody presence) may be further complic
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