Fever and Rash in an 8-month-old Girl

• DOI: 10.1097/inf.0b013e31821dc794
• Publication Date: 2011-07-09T12:31:38Z
• Authors: Eric J. Stern; Gysella Muniz
• Keywords: Girl

An 8-month-old previously healthy Hispanic female was in her usual state of health until 3 weeks before admission, when she presented to a community clinic with irritability, dry cough, decreased oral intake, urine output, and fever. She diagnosed acute otitis media received 10 days amoxicillin-clavulanic acid azithromycin. The fever persisted despite antibiotic therapy, ranging from 38°C 39.4°C, developed maculopapular rash on head, face, trunk, extremities 5 admission. One day local hospital persistent morbilliform rash. ceftriaxone, prednisone, diphenhydramine transferred our for suspected measles. child's mother denied any vomiting, diarrhea, recent travel, or exposure sick contacts. Immunizations were not up date due brief febrile illness at the last scheduled 6-month checkup clinic. child lived 6 other persons, there no pets household. Her father had been deported his country origin, Honduras, months earlier. On initial examination, patient temperature 39.1°C, pulse 182 beats/min, respiratory rate 20 breaths/min, blood pressure 120/84 mm Hg. weight 7.7 kg (25th percentile); height, 66.6 cm (20th head circumference, 41 (<5th percentile). awake but very irritable. oropharynx clear, moist mucous membranes crusting lips nares. conjunctivae injected bilaterally. neck supple bilateral anterior posterior cervical lymphadenopathy. Lymph nodes mobile, nontender, without overlying erythema, measured approximately 1 diameter. abdominal examination significant massive hepatosplenomegaly liver edge palpable below right costal margin spleen 8 left margin. skin showed an erythematous, nonblanching neck, upper thorax, lower extremities, sparing palms soles. white cell count 12,000/mm3 differential 8% neutrophils, 2% bands, 77% lymphocytes, 4% monocytes, 3% eosinophils, metamyelocytes, atypical lymphocytes. hemoglobin hematocrit 10.1 g/dL 29.4%, respectively, platelet 204,000/mm3. Coagulation studies normal. C-reactive protein 3.5 mg/dL. There laboratory evidence renal hepatic dysfunction. Cytomegalovirus serologies Epstein-Barr virus (EBV) viral capsid antigen IgG negative EBV IgM positive, consistent probable infection. early nuclear antibody assays performed, plasma polymerase chain reaction obtained. measles positive negative. A chest radiograph normal mediastinal Further maternal history additional test revealed primary diagnosis. Denouement further questioning, that HIV infection load 22,500 copies/mL during third trimester pregnancy. treated highly active antiretroviral therapy zidovudine-lamivudine lopinavir-ritonavir, taken medications consistently diagnosis physicians. born full term via planned cesarean section, intrapartum prophylaxis intravenous zidovudine (azidothymidine [AZT]). baby exclusively formula fed. baby's DNA PCR assay performed 34 hours life indeterminate. AZT prescribed, did complete recommended 6-week course. have regular care physician immunizations center where medical personnel unaware perinatal exposure. admission institution, HIV-1 RNA 2,389,087 copies/mL. HIV-2 CD4 1800/mm3 CD4% 20%. regimen lamivudine, AZT, and, lopinavir-ritonavir along trimethoprim-sulfamethoxazole Pneumocystis jiroveci (carinii) prophylaxis. However, tolerate this replaced nevirapine. genotyping displayed resistance nucleoside analog reverse transcriptase inhibitor, nonnucleoside protease inhibitor classes agents. Three after presentation, 76 1871/mm3 (CD4% 45%). is presently followed Children Youth Ambulatory Services Clinic infectious diseases Georgetown University Hospital. Growth development are age, undetectable, 2183/mm3 32.1%). This case perinatally acquired woman raises several interesting clinical points serves highlight troubling issues about ongoing epidemic Washington, DC. presentation upon referral institution infection, although extent splenomegaly lymphadenopathy likely better explained by underlying In addition, could combined use amoxicillin. most frequent findings include diffuse lymphadenopathy, hepatoplenomegaly, failure thrive, chronic recurrent bacterial infections (eg, skin/soft-tissue pneumonias). Laboratory may absolute lymphopenia, anemia, thrombocytopenia, elevation transaminases. important factor indeterminate result lack appropriate follow-up evaluations, considering infant known time birth be high risk HIV. Infants HIV-positive mothers enzyme-linked immunosorbent Western Blot results passive transfer antibodies, which can persist 18 age. Therefore, confirmation requires virus-specific testing. Our patient's should triggered more visits prompt testing PCR. virologic infants 14 21 days, 2 months, 4 months. newborn ruled out definitively if ≥2 tests, one >1 month age ≥4 both >6 age.1 World Health Organization estimated 2006 between 410,000 660,000 newly infected worldwide, whereas 2007 2.2 2.6 million children younger than 15 years living HIV/AIDS, greater 90% sub-Saharan Africa.2 United States, decrease maternal-to-child transmission achievement fight against number peaked States 1650 1991 declined range 144 236 2002.3 1994, Pediatric AIDS Clinical Trials Group published recommendations reduce HIV4 2001, Centers Disease Control Prevention (CDC) routine screening pregnancy all pregnant women. These interventions led decline vertical 1995 2005, 142 (<13 years) HIV/AIDS 2005.3 CDC has adolescents adults 2006, men who sex men, blacks/African Americans, Hispanics/Latinos disproportionately affected.3,5,6 remained primarily urban disease, DC highest rates 164 new cases per 100,000 reported 2004.6 Through December 31, 2008, District Columbia Department (DCDOH) 16,513 residents 3.2% population over 12 years.6 Black/African Americans accounted 52.2% constituted 75.6% 4.7% district's black infected.6 Blacks/African make 12% US yet account nearly half infections, 15% 17% infections.5 From 1983 DCDOH reports 349 pediatric years), 331 (94.8%) 9 (2.6%) Hispanics/Latinos. Perinatal 90.8% these 2008 occurring mother-child pairs engaged multiple efforts implement recommendations, including voluntary opt-out persons 64 education social marketing providers.6 also changed its system reporting code-based 2001 confidential integrated name-based 2006. After instituting changes, 2004 137 2007, 102.8 2008.6,7 still suffers higher incidence African countries, Ethiopia, Nigeria, Rwanda.8 2009 times comparable cities such as Baltimore, Chicago, Detroit, New York City, Philadelphia.6,7 retrospective, observational cohort analysis Children's National Medical Center 2000 2005 28 (33.3%) 84 immigrant mothers.9 origin largest proportion all, 25 (29.7%) only (3.6%) Latin-American countries. significantly later similarly low among origin. At Hospital, 37 patients currently service through multidisciplinary team approach worker adolescent medicine specialists. Of patients, sexual behavior. Their ages 22 24 years, (average, 12.8 years). 23 (62.2%) females, 11 descent, (8.1%) Hispanic/Latino. countries represented Uganda, Kenya, Zambia, Malawi. described report first highlights continued importance women HIV-exposed neonates. We believe pediatricians play vital role prevention identifying newborns mothers, verifying receipt prophylaxis, ensuring at-risk receive prophylactic scheduling confirm exclude infancy. ACKNOWLEDGMENTS authors thank Charlotte Barbey-Morel, MD, Janet Osherow, MSW, their review manuscript.