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