About Pneumonia in HIV-Infected InfantsAleix Cabrera2019-09-25T17:20:31+02:00
Pneumonia remains the main cause of death in children in the post-neonatal period, with nearly 900,000 premature deaths globally, each year. According to UNAIDS, the global number of deaths is 110,000 to 120,000 per year including 40,000 deaths due to tuberculosis. Pneumonia is also the main cause of death in HIV-infected children.
Currently, the World Health Organization (WHO) guidelines recommend treating severe pneumonia in HIV-infected infants with empirical treatment against Pneumocystis jirovecii, Streptococcus pneumoniae, and Haemophilus influenza type b. This approach has decreased mortality in this group of children. However, mortality remains unacceptably high, reaching 35%.
Cytomegalovirus and tuberculosis are other important causes of death, still heavily under-recognized, and as such undertreated in this population. Cytomegalovirus has been described as the second most important cause of death among HIV-infected infants with pneumonia under six months of age, accounting for around 10-30% of all deaths.
Although the benefit of cytomegalovirus-antivirals for patients with presumed cytomegalovirus pneumonia has been proposed to reduce mortality up to 50% in observational studies and trials in immunocompromised patients, there are not, to our knowledge, clinical trials testing this hypothesis in HIV-infected children or adults. However, some data exists describing the benefits of the use of pre-emptive anti-CMV therapy improving end-organ disease or death in HIV-infected adults with cytomegalovirus-viremia.
Prevalence of tuberculosis in acute pneumonia is 15%, and at least 75% of them are unrecognized tuberculosis. Mortality of unrecognized tuberculosis is well over 80%. According to experts, tuberculosis treatment (diagnosis-based or empirically) decision should be accelerated to reduce mortality.
Even for those children who are hospitalized, mortality is extremely high despite prompt ART initiation. The high mortality risk observed despite accelerated ART in children who presented with advanced HIV disease emphasizes the need for further strategies to improve survival. In summary, CMV and TB remain significant, but hidden and undertreated, killers of HIV-infected children presenting with pneumonia.