Module8 Infant Dx Cases 2007

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Infant Diagnosis Case Studies-1

Case 1: Sam : 

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 She was not eligible for ART 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 breastfeeding without difficulty and has gained weight as expected Grace wants to know if Sam has HIV

Case 1: Sam: 

Case 1: Sam Sam’s growth parameters

Case 1: Sam : 

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?

Case 1: Sam: 

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- he has social smile Complete your physical examination which is normal You prick his heel for blood for DNA PCR, prescribe cotrimoxazole and provide counseling about infant feeding (exclusive breastfeeding)

Sam’s Growth Curve: 

Sam’s Growth Curve Weight Birth wt- 3.5kg 6 wks- 4.8kg

Sam’s Growth Curve: 

Sam’s Growth Curve Length Birth- 50cm 6 wks- 57cm

Sam’s Growth Curve: 

Sam’s Growth Curve Head Circumference Birth - 35cm 6 wks- 38cm

Case 1: Sam: 

Case 1: Sam When Sam returns at 10 weeks of age, his first virologic test is negative He is still breastfeeding and is doing well He is still taking cotrimoxazole His exam is normal You plot his growth curves and he continues to grow on the 50% percentile for weight, HC and height. His development is appropriate for age

Case 1: Sam : 

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?

Diagnostic Algorithm for Infants < 18 months of age: 

Diagnostic Algorithm for Infants < 18 months of age Infant 4-6 weeks of age Or at first health encounter HIV DNA PCR HIV DNA PCR POSITIVE HIV-INFECTED DNA PCR NEGATIVE Refer for HIV care & treatment Continue Follow-up Continue CTX Do confirmatory HIV DNA PCR Test and send results to CTC Do not WAIT. Refer for HIV care & treatment IMMEDIATELY

Case 1: Sam: 

Case 1: Sam You explain to Grace that since his first test was negative you cannot find any HIV in his blood However, since he is breastfeeding he may still get HIV so you will have to test him again after he stops breastfeeding completely You explain the importance of continued exclusive breastfeeding even with a negative initial PCR If Sam should fall sick you will repeat the virologic test Refill his cotrimoxazole prescription Schedule follow-up in a month Encourage Grace to go for follow-up CD4 testing at the CTC

Case 1: Sam: 

Case 1: Sam Grace and Sam do not return for 3 months The social worker who visits the home says Grace was admitted with a severe case of shingles one month ago. She went to her mothers village to recuperate. Her mother is helping out with Sam. The social worker manages to convince Grace to bring Sam for a check up

Case 1: Sam: 

Case 1: Sam Grace tells you Sam had two episodes of diarrhea while they were away Her mother fed Sam porridge while she was in hospital. She still breastfeeds whenever she feels well has energy Sam is now 6 months old. He has not gained any weight and is unable to sit unsupported He has some thrush when you examine him

Case 1: Sam: 

Case 1: Sam Sam’s growth parameters

Sam’s Growth Curve: 

Sam’s Growth Curve Weight Birth wt- 3.5kg 6 wks- 4.8kg 6mos-6kg

Sam’s Growth Curve: 

Sam’s Growth Curve Length Birth- 50cm 6 wks- 57cm 6mos-68cm

Sam’s Growth Curve: 

Sam’s Growth Curve Head Circumference Birth - 34cm 6 wks- 38cm 6mos-41cm

Case 1: Sam: 

Case 1: Sam Does Sam have HIV? What can you do to find out? What will you tell Grace?

Case 1: Sam: 

Case 1: Sam Because Sam has symptoms that might be related to HIV infection (growth failure, oral thrush, developmental delay, and microcephaly), the team explains to Grace that Sam requires another blood test. You prick him again and get blood for repeat DNA PCR using DBS Continue CTX Send him to be evaluated by the physician Refer him for nutritional rehabilitation

Case 1: Sam: 

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 reinforce the importance of continuing CTX and breastfeeding You send a confirmatory test and refer Sam to the pediatric HIV clinic for evaluation and treatment

Case 2: Hadiyah : 

Case 2: Hadiyah Akili just had her first child, Hadiyah Akili was diagnosed with HIV during the recent pregnancy and participated in the pMTCT program Her CD4 count was 180 so she started ART during the pregnancy She brings Hadiyah to clinic for the baby’s first visit at 1 month of age She is breastfeeding Hadiyah She complains that Hadiyah is a poor feeder. She is always hungry and sucks at the breast continuously

Case 2: Hadiyah : 

Case 2: Hadiyah How will you assess if Hadiyah is getting enough breast milk? What will you do for Hadiyah at her first postnatal visit at 1 month?

Case 2: Hadiyah : 

Case 2: Hadiyah You obtain a complete history – prenatal, birth, and psychosocial history and intercurrent history-Hadiyah has been well since birth You ask about Akili’s health, she is still taking her ARVs and feels well You ask about number of diapers changed each day -5-6/day You obtain a feeding history- Hadiyah feeds on each breast for about 15 minutes, she does not empty each breast You inspect Akili's breast to check for inverted nipples, cracks or evidence of mastitis. Her breasts are healthy You observe Akili breastfeeding Hadiyah and notice she does not latch on properly You plot Hadiyah’s growth curve

Hadiyah’s growth curve: 

Hadiyah’s growth curve Weight Birth: 4 kg 1mo: 4.6 kg

Hadiyah’s growth curve: 

Hadiyah’s growth curve Length Birth-53cm 1mo-57cm

Hadiyah’s growth curve: 

Hadiyah’s growth curve Head circumference Birth- 35cm 1mo-37cm

Case 2: Hadiyah: 

Case 2: Hadiyah You teach Akili how to make sure Hadiyah has latched to the breast properly Infants chin is touching the breast and mouth is wide open Lower lip is turned outward More areola is above than below the mouth Infant is taking long slow sucks Infant looks like he is sucking from a straw Mouth does not cover the areola

Case 2: Hadiyah: 

Case 2: Hadiyah You educate Akilli about the need for close growth monitoring (measure and plot weight, length, and head circumference), developmental assessment, and physical examination. You do all of these at the visit. You get blood for DBS DNA PCR You prescribe cotrimoxazole You counsel Akili about the benefits of exclusive breastfeeding

Case 2: Hadiyah : 

Case 2: Hadiyah Hadiyah returns to the clinic when she is 2 months old Her virologic HIV test is positive Her clinical status is unremarkable Her weight is 5.7kg, height-61cm and HC-38cm Her clinical exam is normal exam She is able to hold her head and lift her head of the table

Hadiyah’s growth curve: 

Hadiyah’s growth curve Weight Birth: 4 kg 1mo: 4.6 kg 2mos: 5.7 kg

Hadiyah’s growth curve: 

Hadiyah’s growth curve Height Birth-53cm 1mo-57cm 2mo-61cm

Hadiyah’s growth curve: 

Hadiyah’s growth curve Head circumference Birth- 35cm 1mo-37cm 2mo-38m

Case 2: Hadiyah : 

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?

Case 2: Hadiyah : 

Case 2: Hadiyah The team explains to Akili that Hadiyah’s 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 You counsel Akili on the importance of continued EBF 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.

Case 2: Hadiyah : 

Case 2: Hadiyah The DNA PCR result is sent back to the clinic 3 weeks later. The second virologic test is also positive. Akili 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.

Case 3:Patrick: 

Case 3:Patrick Denise was diagnosed with HIV during the second trimester Her CD4 was 450, she received AZT and NVP for PMTCT She enrolled in the clinic immediately post partum Her son Patrick is 8 weeks old and mom has brought him back because his initial DNA PCR test done at 6 weeks is positive Patrick is breastfeeding and growing well He is developmentally appropriate for age and his clinical exam is also normal He is taking CTX

Case 3:Patrick: 

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?

Diagnostic Algorithm for Infants < 18 months of age: 

Diagnostic Algorithm for Infants < 18 months of age Infant 4-6 weeks of age* or at first health encounter HIV DNA PCR HIV DNA PCR POSITIVE HIV-INFECTED *Infant born to HIV-infected mother or infant known to be antibody positive # Confirm HIV exposure with Rapid Antibody test if > 9 months of age. If antibody negative, and infant is still breastfeeding, repeat Rapid Antibody test >6 weeks after complete cessation of breast feeding. Do confirmatory HIV DNA PCR Test and send results to CTC Do not WAIT. Refer for HIV care & treatment IMMEDIATELY

Case 3:Patrick : 

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 baby’s status You send a confirmatory repeat DNA PCR You refill her cotrimoxazole prescription You refer her to the pediatric CTC at the district hospital

Case 3:Patrick : 

Case 3:Patrick Since it is Thursday you can send a CD4 count for the baby to the district laboratory in addition to the repeat DNA PCR You schedule Patrick’s next immunization visit in a month Because the pediatric CTC is 4 hours away from home, Denise decides to wait until her husband gets back from the city so he can accompany her to the CTC

Case 3:Patrick : 

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

Case 3:Patrick : 

Case 3:Patrick What should you say to mother? Should further testing be done?

Case 3:Patrick : 

Case 3:Patrick Since the baby is doing WELL and mom is breastfeeding, the team decides to consult with the HIV specialist at the District Hospital. They’ve had a number of recent test results that didn’t make sense lately. They are not sure that Patrick’s tests are accurate. 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.

Case 3:Patrick : 

Case 3:Patrick Patrick returns at 4 months of age and then again at 6 months. He does well. He is weaned at 12 months of age. Since the team still does not have access to reliable PCR testing, they decide to wait a little longer. At 14 months they test Patrick with a rapid HIV antibody.

Case 3:Patrick : 

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.

Case 4: Malaika: 

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 breastfeed Malaika

Case 4: Malaika : 

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?

Case 4: Malaika : 

Case 4: Malaika At 6 weeks of age, Malaika weighs 4.2kg (50%) 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

Case 4: Malaika : 

Case 4: Malaika When she returns at the 10 week visit, Halima learns that the result is negative

Case 4: Malaika : 

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?

Case 4: Malaika : 

Case 4: Malaika The team explains to Halima that Malaika’s DNA PCR is NEGATIVE, this means she is presumed not to have HIV-infection However, since she is not breastfeeding, the test generally means that the baby does not have HIV infection

Case 4: Malaika : 

Case 4: Malaika The team meets to discuss Malaika’s 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

Case 4: Malaika : 

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

Case 4: Malaika : 

Case 4: Malaika What test should be done?

Case 4: Malaika : 

Case 4: Malaika A Rapid HIV antibody test is done The result is negative

Case 4: Malaika : 

Case 4: Malaika Does Malaika have HIV infection? Does she require further testing? Should she continue follow-up at the clinic?

Case 4: Malaika : 

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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