HIV-Infected Adolescent: A Case Report

doi:10.4236/wja.2011.14024

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World Journal of AIDS, 2011, 1, 165-168

doi:10.4236/wja.2011.14024 Published Online December 2011 (http://www.SciRP.org/journal/wja)

165

HIV-Infected Adolescent: A Case Report

Apezteguia Fernández Carolina Aurora1*, Hernández Muniesa Belén1, Vicent e S ánchez Marí a d e l P ilar1,

Álvarez García Ana2, Ruiz Jiménez Marta2, Ramos Amador José Tomás2

1Pharmacy Department, Getafe University Hospital, Getafe, Spain; 2Pediatric Infectious Diseases Unit, Getafe University Hospital,

Getafe, Spain.

E-mail: *[email protected]

Received August 10th, 2011; revised October 7th, 2011; accepted October 19th, 2011.

ABSTRACT

We report the case of a Nigerian adolescent recently arrived to Spain, who presented at the emergency room with

severe respiratory distress. She had been previously diagnosed of HIV-1 discontinuing antiretroviral therapy, what was

hidden by the family. This case illustrates the difficulties in management and stigma in HIV-infected adolescents,

particularly immigrants and the need to collect all the information available before starting antiretroviral therapy.

Keywords: HIV, Adolescent, Immigrant

1. Introduction

Human Immunodeficiency Virus (HIV) infection is one

of the most important pandemic infections around the

world. Perinatal transmission remains the main cause of

HIV infection in paediatrics. The uses of highly active

antiretroviral therapy (HAART) during pregnancy, anti-

retroviral prophylaxis for newborns and administration of

intravenous zidovudine for pregnant women, have dras-

tically reduced the rate of perinatally acquired HIV in-

fection. Nevertheless, vertical transmission remains still

high, especially in developing countries. Sub-Saharan

Africa is the region most heavily affected by HIV. Al-

most 90% of HIV infected children younger than 15

years live in sub-Saharan Africa [1].

It is necessary to consider the particular features of

HIV infection in paediatrics, clinical prognosis and evo-

lution. Children have immature immune system, which

makes them highly vulnerable to infections, such as HIV.

An early diagnosis and treatment are essential to get a

better prognosis and a lower incidence of AIDS progres-

sion. HAART is scaling up, but maintenance of adher-

ence is a major barrier to complete control of viral repli-

cation. Herein, we present the case of a Nigerian girl

recently arrived to Madrid, in whom the HIV diagnosis

was not revealed and antiretroviral treatment had been

discontinued.

2. Case Report

A 14 year-old Nigerian girl, 72 hours after arriving in

Spain, was admitted to hospital, in September 2008, with

a 2-day history of high fever, headache, cough, tachyp-

nea and vomiting. No drug allergies were known and

immunization schedule completed. Family history re-

ferred that mother died in Nigeria 5 years before by a car

accident. HIV infection was suspected by physicians,

because she came from a country with high HIV preva-

lence. In the emergency room, antibodies against HIV

were positive. Her father and sister were unaware of her

HIV-diagnosis, but referred a past history of malaria

treated in Nigeria and some vitamines prescribed there.

Her medical history from Nigeria was obtained one week

later: in May 2007, our patient was diagnosed and classi-

fied in stage 2 of HIV infection (WHO), with 442/µL

CD4 count. A fixed-dose combination of lamivudine,

stavudine and nevirapine was started 6 months after di-

agnosis, (from December 2007 to June 2008). CD4 count

fell to 168/µL probably because of poor adherence, and

there was a disease progression until stage 3 (WHO).

At ER, physical examination revealed mild dehydra-

tion, malaise, tachycardia, tachypnea, slight drowsiness,

bilateral neck lymphadenopathy, mild hepatomegaly and

thrush. She was 148.2cm in height and 35 Kg in weight

(<P3). Other significant findings were hyponatremia (Na

= 128 meq/l), raised C-reactive protein (>250 mg/l) and

procalcitonine of 26.1 ng/ml. Immunoglobulins levels

were increased: 3310 mg/dl IgG, 214 mg/dl IgA and 568

mg/dl IgM. Cerebrospinal fluid (CSF) showed 58 cells

(99% mononuclears and 1% polinuclears), glucose 65

mg/dl, proteins 48 mg/dl and 0 red blood cells. Chest

Xray showed bilateral alveolar infiltrates and brain CT

HIV-Infected Adolescent: A Case Report

166

scan was normal. Eye funduscopy was also normal.

Echocardiogram revealed dilated myocardiopathy with

preserved ejection fraction. HIV was confirmed by

ELISA test and Western Blot (viral load: 133.000 cop-

ies/ml and CD4 count: 157 cel/µL). HIV infection and

bilateral pneumonia with alveolar pattern were the main

diagnosis.

Microbiological findings showed the following results:

blood thick smear and urine antigen test for malaria were

negative. PCR blood for malaria was positive and in

blood culture grew Streptococcus pneumoniae. Pneumo-

nia by Streptococcus pneumoniae was confirmed and

cefotaxime was continued for 10 days, remitting fever and

dyspnea. She also received intravenous trimethoprim/

sulfamethoxazole for covering Pneumocystis jiroveci (PJ)

pneumonia and Atovaquona-proguanile (Malarone®) for

Plasmodium falciparum malaria. Bronchoalveolar lavage

showed negative results for Pneumocystis jiroveci, so

intravenous trimethoprim/sulfamethoxazole was discon-

tinued and switched to oral prophylactic doses. Parasite

tests made for Cryptosporidium and Schistosoma were

negative. Mantoux, gastric washing for culture and PCR

for mycobacterium were also negative. Blood PCR for

criptococcus and cerebrospinal fluid (CSF) PCR for

pneumococcus and mycobaterium showed negative re-

sults. In the absence of microbiologial diagnosis, the in-

crease of CSF cellularity was interpreted as possibly re-

lated to HIV-infection.

Infection symptoms improved and HAART was de-

cided to start one week later, when genotypic resistance

testing was available and patient and family were pre-

pared to start treatment. HLA-B*5701 test showed nega-

tive result. The subtype of HIV-1 was G and the stage of

infection was determined to be B3. All mutations de-

tected (L10:I, V82:I, L89:M. V179:I) not conferred re-

sistance to protease (PIs) and retrotranscriptase (RT) in-

hibitors. It was decided to use 3 new drugs in the new

regimen: ddI qd +ABC qd+ lopinavir/ritonavir bid after

getting genotypic resistance testing and considering the

previous history on antiretrovirals, because of the likeli-

hood of selecting for resistance due to previous exposure.

The patient was discharged from hospital two weeks

after admission, with antiretroviral treatment and oral

prophylaxis against PJ. Clinical evolution and adherence

follow-up was carried out by a multidisciplinary team

(physician, psychologist and pharmacist). She had an

excellent adherence and response to AR. The viral load

became undetectable and the CD4 increased up to 617

(17%) at 6 months of therapy. PCP prophylaxis was then

discontinued. Twelve months after the initation of

HAART, in the routine trimestral visit, the viral load

went up to 2811 cop/ml (3.45 log) and CD4 count was

622 (19%). In the hospital pharmacy, adherence was

calculated through two indirect methods: dispensing re-

cord and valid questionnaire. Our patient referred having

some difficulties taking lopinavir/ritonavir bid, but she

did not recognize missing any dose. This medication-

related problem was detected by compliance question-

naire and a simultaneously increase of viral load oc-

curred (Figure 1). When adherence was improved and

the viral load returned to <50 copies/ml, lopinavir/ri-

tonavir was switched to atazanavir/ritonavir qd with good

adherence and tolerance and good control of viral repli-

cation. 12 months after switching, she had undetectable

viral load and CD4 > 500. Last CD4 was 953 (32%)

cells/μl.

Figure 1. Clinical parameters evoluti o n.

HIV-Infected Adolescent: A Case Report167

3. Discussion

Currently, paediatric HIV infection has become a chronic

disease with an excellent long term prognosis [2]. Ad-

herence is critical in determining the degree of viral sup-

pression achieved in response to antiretroviral therapy

[3-5]. It is reported to be suboptimal among children and

even worse among adolescents [6]. Suboptimal adher-

ence can lead to subtherapeutic levels of antiretrovirals

with both risk of development of drug resistence and

virologic failure [4,6]. Factors, such as medication for-

mulation, frequency of dosing, child age and psychoso-

cial characteristics, have been associated with treatment

compliance [7]. Monitoring adherence by questionnaires

and counselling by a multidisciplinary team improve

compliance and is helpful to detect and solve medica-

tion-related problems.

There is an additional problem among immigrant

groups. It is needed to consider the social and cultural

determinants of immigrant adolescents in the context of

their cultural and social norms and the role of family

relationships. All the cultural and social inhibitions may

make the management difficult and knowledge of HIV

and illustrate the difficulty of maintaining an optimal

adherence [8]. In this case, our patient referred some dif-

ficulties taking lopinavir/ritonavir. It was detected by

compliance questionnaire despite not recognizing miss-

ing any dose. Detecting such medication-related problem

is especially difficult between immigrants and may be

responsible of failure therapy and resistance. Antiretro-

viral drug resistance testing is recommended to be in-

corporated into patient management to help the choice of

new regimens and considering the possibility of prior

HAART in adolescent recently arrived to European

countries hampering new treatment options. The choice

of the antiretroviral regimen was difficult in this case.

First her family did not recognise HIV-diagnosis. Start-

ing new medications in unwell patients without full in-

formation (previous antiretroviral agents prescribed, re-

sistance testing, TB diagnosis excluded and potential

adverse drug effects) is risky. HIV infection, previous

exposure to HAART and the likelihood of developing

resistance due to prior therapy must be considered by

physicians in every adolescent or child who come from

an endemic HIV area. In our case, considering the pre-

vious history on antiretrovirals, it was decided to use ddI

+ ABC + lopinavir/ritonavir in order to introduce as

many new antiretrovirals as possible [3,4]. The optimal

moment and type of antiretrovirals to start therapy are

critical and a complete information is crucial. Depending

on previous exposure to antiretroviral drugs there must

be an increased risk of therapy failure. That is why all the

pharmacotherapy history must be collected before start-

ing HAART even if there is no resistance at all.

It is also essential to consider that HIV-infected pa-

tients are susceptible for developing opportunistic infec-

tions and the additional risk for coming from an endemic

region for malaria and TB. In Africa, TB is the most

common pulmonary complication of HIV. It is very im-

portant to do a differential diagnosis between TB and

other types of pneumonia. The CD4 count can provide

information about the type of pulmonary disease to

which the patient is susceptible [9]. Malaria and HIV

infections often coexist in areas of the world where these

diseases have the largest burden, particularly in sub-Sa-

haran Africa [10]. HIV status and immunosuppression

may be associated with an increased risk of susceptibility

to malaria infection. Conversely, malaria increases HIV

replication and declines in CD4 cell counts [11]. HIV

and malaria should be considered together as a part of

healthcare programs for both diseases in countries where

their copresence favors an interaction with important

consequences [12].

This case illustrates several aspects: the stigma and

secrecy in HIV-infected patients, particularly immigrants.

In this population, maintaining an optimal adherence

may be difficult due to cultural and social inhibitions.

HAART failure depends on adherence patient and com-

pliance therapy is reported to be suboptimal among chil-

dren and even worse among adolescents. The possibility

of HIV infection, previous exposure to HAART and the

likelihood of developing resistance due to prior therapy

must be considered by physicians in every child who

comes from a high prevalence HIV area. The need to

collect all the information available before starting anti-

retroviral therapy and genotyping testing is critical, be-

cause there must be an increased risk of therapy failure

when there was previous exposure to antiretroviral drugs,

even if there is no genotypic drug resistance. Improving

patient’s knowledge about HIV-infection and HAART

therapy, a close follow-up and detecting medication-

related-problems, might also be important tools to in-

crease medication compliance and achieve complete viral-

suppression.

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