clinical implications of a HIV-infection

The secondary infections developing at late stages of a HIV - of an infection against an immunodeficiency at children, especially early age, meet less often, than at adults. According to the literature at sick HIV - an infection of children characteristic are the infections caused by viruses of simple herpes (HSV), a cytomegalovirus (CMV), Epstein Barr's virus (EBV).

As has shown our analysis (table 6.4, a drawing 6.2), frequency of the secondary diseases accompanying a HIV-infection at children of patients tuberkuleyozom, has made 60,8 %, the last were clinical markers of late stages of a HIV-infection - in 82,2 % of cases. In structure of secondary infections at children with a tuberculosis, sochetannym with a HIV-infection, the leading part was played by mycoses (53,5 %). Among mycoses diagnosed a candidiasis (27,7 %) including a candidiasis mucous oral cavities in 23,8 % (for three children in the form of a stomacace), lesions of a gastroenteric tract (visyotseralnyj a candidiasis) - in 3,9 % of cases more often.

On a share of dermal lesions 21,8 % of cases, others miyokozov - 4 % were necessary. In 5 cases (4,9 %) the dermatitis became complicated a pyoderma. The seborrhea of a pilar part of a head is noted at 3 patients. In a course of disease porayozhenija a skin and mucosas regressed, sometimes appeared again, were replaced by one others, gave various combinations. At 3 children otmeyochalos a serious current of a visceral candidiasis with a lesion of an esophagus, a stomach, an intestine.

Table 6.4

Structure of secondary diseases of a HIV-infection at children sick of a tuberculosis

Along with mycoses often enough in structure of secondary infections there were virus infections - in 37,6 % of cases. On diseases, vyzvanyonye HSV in structure of all infections 6,9 %, on diseases, etioyologicheski bound to a virus herpes Zoster - 3,9 % are necessary, a CMV-infection sostavyoljala 10,9 %, but clinical implications of this infection have made only 2,0 %, subclinical forms of illness - 8,9 % of cases. To group gerpesvirus -

nyh (the virus of herpes of the person of 4th type) concerns lymphoid interstitsiyoalnaja a pneumonia which etiological factor is the Epyoshtejn-bar virus which share has made 1,0 % though in structure on a share of a virus Epstein-bar was necessary 13,9 % of cases. In 1,2 % of cases are taped vyrazhenyonye clinical implications of a contagious molluscum.

Fig. 6.2. A share of the basic infections in structure of secondary diseases at children sick of a tuberculosis and a HIV-infection

The protozoal infection (parasitogenic diseases) in structure vtoyorichnyh infections has made 7,9 % and has been presented by a toxoplasmosis and a pneumocystosis. At patients in our observation the toxoplasmosis proceeded mainly in the form of the latent form (4,9 %), clinical implications in the form of a cerebral toxoplasmosis in a combination with mikobakteriozom diagnoyostirovany at one patient (the child has died of advance of a HIV - of an infection). pnevmotsistnaja the pneumonia and a pneumocystosis in structure infekyotsy made 2 %.

Least in structure of diseases at children, sick HIV - an infection, occupy oncologic diseases. In our research only at one child it is diagnosed limfoma (nehodzhkinskaja), etioloyogicheski bound to a virus Epstein-bar (in a consequence the child has died, hoyotja against antituberculous therapy dynamics of tubercular process became perceptible good polozhitelyonaja).

As a whole, at the moment of revealing of a tuberculosis at children with a HIV-infection other secondary diseases were available for 42,2 % of patients (at 70 of 166). And as has shown the analysis of structure of secondary diseases of a HIV-infection, tuberkuyoleznyj process proceeded against a fungally-virus - protozoal infection which in most cases defined kliniyocheskuju a picture sochetannoj pathologies, gravity of a current and an outcome of the disease more often.

On the first place on frequency of occurrence noted fungoid porayozhenija mucosas and integuments, in peer shares at patients taped herpes-virus, tsitomegalovirusnuju infections, is more rare - toksoyoplazmoz and a pneumocystosis (fig. 6.3)

Fig. 6.3. A share of patients with most often registered secondary diseases at revealing of a tuberculosis among all children with sochetanyonoj a pathology (n=166)

Most often secondary diseases at sick HIV-infections of children before tuberculosis revealing diagnosed in the first 2 years of a current of a HIV-infection - more, than for third (35,7 %), at a quarter of children secondary inyofektsija is taped on 3-4th year of a life and then again share augmentation vtoyorichnyh diseases at the age of 7 years and is more senior (fig. 6.4).

Fig. 6.4. Frequency of revealing of secondary infections on years at children with a tuberculosis, sochetannym with a HIV-infection

As a whole, to 5 summer age almost 2/3 children (58,5 %) already pereneyosli those or other diseases concerning secondary infections.

Besides secondary diseases at the patients who have entered into ours issleyodovanie, various clinical syndromes and symptoms of a HIV - of an infection, bacteriemic infections of a nasopharynx and bronholegochnoj systems, congenital diseases (table 6.5) were observed

Table 6.5

Structure of accompanying diseases and symptoms of a HIV-infection at children sick of a tuberculosis, sochetannym with a HIV-infection (n=166)

The persistent generalised lymphadenopathy (79,5 %), morfoloyogicheski characterised by a hyperplasia of follicles of peripheric lymph nodes was the most frequent symptom at sick of a tuberculosis and a HIV-infection. PGL develops already at early stages of disease (31,8 %), and at children of the first year of a life it was taped in 88,9 % of cases. The lymph nodes located in forward and back cervical areas, and also in axillary and submandibular areas were more often enlarged, is more rare in inguinal areas. At 4 children (2,4 %) at late stages of a HIV-infection an immunodeficiency background (at children 4, 7, 8 and 11 years) it was observed paro - tit, etiologicheski bound to a HIV-infection. The parotitis current in all cases was fixing, without the expressed symptoms of an intoxication and lihoyoradki, process slowly regressed against treatment (during neskolyokih months).

The immunodeficiency raises a susceptibility of a children's organism to various infections, therefore at children sick of a tuberculosis and HIV - in the anamnesis are noted by an infection frequent ORVI, almost at every second reyobenka (45,2 %) - a relapsing bronchitis, purulent otites and sinusitises, konjuktivity, is more rare than a pneumonia. At 2 children a purulent chronic otitis with -

186 provozhdalsja a partial hearing loss. Bacteriemic infections more often otmeyochali at late stages of a HIV-infection (68 % and 32 %; ОШ=1,59; ДИ:0,9-3,6).

Frequent enough syndrome in HIV-infection clinic was porayozhenie TSNS. As all children observed by us are born about sick HIV-infections of women, the HIV very often leads to disturbance formiyorovanija a foetus, and subsequently to a delay of psychomotor development, istoshcheyoniju nervous system. From the anamnesis at every third child (30,7 %) otyomechena perinatalnaja an encephalopathy, a delay of psychomotor development. At children is more senior 3th years at late stages of a HIV-infection are noted projavleyonija in the form of an astheno-neurotic and tserebro-asthenic syndrome. Orgayonichesky lesions TSNS noted at 5 children: in one case - mikrotsefayolija and a partial atrophy of an optic nerve, in other - a syndrome gidrotseyofalii and a mental retardation, at 4 children - to nurseries a cerebral paralysis (DTSP).

Deficiency of mass of a body was characteristic a symptom of late stages of a HIV-infection (HIV-infection advance) at children with sochetannoj payotologiej (77,3 % and 22,7 %; ОШ=12,5; Dee 10,3-14,7). At 3 children at a stage 4В the cachexia (deficiency of mass of a body exceeded 20 % from age norm) has been noted.

Lesions of a gastroenteric tract were (gastrointestinal tract observed more often in the form of an intestine dysbacteriosis (instability of a chair, a delay stuyola or augmentation of its frequency rate). At 3 children against a HIV-infection in moyoment tuberculosis revealings the diarrhoeia became perceptible; at 4 children was diagnostiyorovan a gastritis, in one case - erosive. Lesion symptoms GASTROINTESTINAL TRACT nayobljudalis more often at late stages of a HIV-infection, than at early stages (76,0 % and 24,0 %; ОШ=10,5; Dee 8,3-13,2). Gepatosplenomegaliju observed at a quarter sick (22,9 %), in third cases already at early stages of a HIV - infektsiii.

The carriage of antibodies to a virus hepatitis In and With at children from a HIV - an infection above (according to the literature), than in population also is caused

187 similar ways of transfer of hepatitises and an infection HIV-. Chronic gepayotity In and With at sick of a tuberculosis and a HIV-infection are found out in 6 % of cases. However clinical implications of a hepatitis With (giperfermentemija, high enough virus load) were observed at 2 patients.

The hematological syndrome was frequent: the expressed anaemia otmechayolas at 40 sick (24,1 %) and a thrombocytopenia - at 13 (7,8 %), including at 2­х children - a Werlhof's disease

At 9 children (5,4 %) diseases bound to developmental anomalies and a genetic predisposition have been taped: a congenital heart disease at 4 children (2,4 %), at 5 (3,0 %) - a Gee's disease (genetically determinirovanyonoe the disease of a small bowel bound to one of fractions of vegetative fiber gljutena and shown by symptoms of damage mucous oboyolochki of a small bowel).

As a whole at the moment of revealing of a tuberculosis 6 from 10 sick HIV - an infection (in 63,3 % of cases) had clinical implications of a HIV-infection in the form of secondary diseases, the bacteriemic infections expressed simyoptomov and syndromes (are excluded PGL as met almost at all children, congenital diseases), very often there was their combination at the same patient. The children, the more often at them vyjavljayolis clinical implications of a HIV-infection (fig. 6.5) were more senior.

Fig. 6.5. Frequency of clinical implications of a HIV-infection at children with tuyoberkulezom depending on age

So clinical implications of a HIV-infection among children at the age of 0-2 years are noted in 54,4 % of cases, at the age of 3-6 years - in 60 % and at the age of 7-14 years - in 89,7 % of cases (ОШ=1,4; Dee: 0,85-2,7 p> 0,05; ОШ=8,0 Dee: 6,8-9,3 p