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Clinical Considerations Clinical recognition: Initial ED recognition of children with known HIV infection should include categorizing children as likely OIs ( Table 94.24 and e-Table 94.26 ) based on their CD4+ cell count, infections caused by pathogens which also infect normal hosts, and drug toxicities from their antiretroviral regimen or from prophylactic antibiotics or antiviral medications ( e-Table 94.27 reviews antiretroviral medications and e-Table 94.28 reviews adverse events) ED clinicians should also be cognizant of the presentations of acute HIV infection ( Tables 94.24 and 94.25 ) in adolescents and of the presentations of OIs in as-yet undiagnosed children with perinatally acquired HIV infection ( e-Table 94.29 ), most of whom will become symptomatic during infancy Triage considerations: HIV-infected children should be roomed as rapidly as possible to prevent them from acquiring a nosocomial infection while in the ED Triage assessment should include obtaining pulse oximetry, as indolent hypoxemia may be the first sign of early Pneumocystis jiroveci (formerly, P carinii ) pneumonia (PJP) Triage personnel need to be cognizant that HIVinfected children are at risk for overwhelming bacterial and viral sepsis, similar to other immunocompromised children Clinical assessment: The most common clinical presentations of HIV-infected children and one diagnostic approach are reviewed in e-Table 94.30 The first branch point in decision making for the febrile HIV-infected child is whether or not they are ill appearing Most infections, even in HIV-infected children will be caused by common pathogens also seen in immunocompetent children However, it is important that providers realize that the rates of bacteremia are higher in HIV-infected children than in their immunocompetent peers It appears that serious bacterial, viral, or OIs are relatively uncommon among well-appearing HIV-positive children who present to the ED with fever TABLE 94.24 OPPORTUNISTIC INFECTIONS MOST COMMONLY SEEN IN HUMAN IMMUNODEFICIENCY VIRUS (HIV)-INFECTED CHILDREN TABLE 94.25 CLINICAL MANIFESTATIONS AND DIAGNOSIS OF ACUTE HIV INFECTION Symptoms Signs Laboratory findings Fever Pharyngitis Pyrexia Generalized lymphadenopathy Rash Maculopapular rash HIV PCR ELISA, Western blot often initially negative, convert to positive by 2–4 mo Leukopenia Myalgias Headache Nausea, vomiting Diarrhea Mucocutaneous ulcerations Hepatomegaly Splenomegaly Neurologic symptoms: aseptic meningitis, meningoencephalitis, neuropathy, radiculopathy, facial nerve palsy, Guillain– Barré syndrome, psychosis Thrombocytopenia HIV, human immunodeficiency virus; PCR, polymerase chain reaction; ELISA, enzyme-linked immunosorbent assay HIV-positive patients with fever who appear ill should be treated like other illappearing, febrile children because they are likely to be infected with the same types of organisms that infect immunocompetent children An LP is indicated for those with meningismus, change in mental status, or an underlying abnormal mental status makes assessment difficult; the clinician should consider obtaining a CT of the brain prior to LP to evaluate for a mass-occupying lesion If a child is believed to be so unstable that LP is not safe, it can be delayed In either case, the child should be started on parenteral broad-spectrum antimicrobials Ceftriaxone (100 mg/kg/day divided every 12 hours) is an appropriate choice because it covers the organisms that most commonly cause sepsis in children In areas with high rates of pneumococcal penicillin resistance, addition of vancomycin should be considered In young children, because of the possibility of PCP presenting with fever and ill appearance, TMP-SMZ (5 mg/kg/dose of