Rash, swollen glands and fever associated with acute HIV infection in infants

Rash, swollen glands and a failure to thrive are symptoms suggestive of acute HIV infection in infants, according to a study conducted in Kenya and published in the January 15^th edition of Clinical Infectious Diseases. In addition, the study showed that acute HIV infection in infants aged over two months was associated with pneumonia, fever and dehydration.

Although symptoms during acute HIV infection were not associated with more rapid HIV disease progression, the investigators did note that viral load was higher in the long term in infants who had experienced symptoms than those who had not.

The investigators are hopeful that noticing symptoms of acute HIV infection may allow the prompt identification of HIV-infected infants. But they also note that many of the symptoms suggestive of acute HIV infection, such as fever or diarrhoea, occur frequently in infants and are not very specific to HIV.

Many HIV-infected individuals experience what is often called a seroconversion illness during the time HIV infection establishes itself and the body produces antibodies to the infection. Flu-like symptoms, sore throat, swollen glands, fever and headache are the symptoms that are often characteristic of this illness in adults.

There is some evidence that patients who experience severe symptoms during acute HIV infection experience more rapid HIV disease progression than patients without such symptoms.

But relatively little is known about the symptoms of acute HIV infection in infants. Most children who become infected with HIV acquire their infection from their mother during the first few months of life. Illnesses that cause fever are fairly common during infancy, making acute HIV infection difficult to recognise.

Although it is possible to detect HIV infection in infants soon after birth using HIV viral load tests, such tests are not widely available in countries with the highest HIV prevalence. An awareness of the symptoms suggestive of acute HIV infection would therefore help healthcare workers identify HIV-infected infants.

Investigators in Kenya therefore designed a study involving the infants of mothers known to be HIV-positive. At regular intervals over two years the infants had HIV viral load tests to detect HIV infection. They were also frequently examined by medical staff to see if they were experiencing any symptoms associated with acute HIV infection. Viral load in HIV infected infants was monitored over two years to see if an illness during acute HIV infection was associated with more rapid HIV disease progression.

None of the mothers in the study, which ran between 1992 and 1998, received antiretroviral therapy.

A total of 362 infants were included in the investigators analysis and 92 of these infants became infected with HIV. Of the HIV-infected infants, 56 were included in the investigators’ analysis. The mean age at acute HIV infection was 2.6 months and 40 infants were diagnosed aged under two months.

At least one symptom during acute HIV infection was present in 47 infants (84%). Cough, cold, rash, fever or swollen glands were each reported in at least 30% of infants. Overall, acute HIV infection was associated with rash (p = 0.02), failure to thrive (p = 0.04), swollen glands (p = 0.004), and hospitalisation (p = 0.04).

The symptom most associated with acute HIV infection during the first two months of life was swollen glands (p = 0.01). Symptoms significantly associated with acute HIV infection after two months of age were cough (p = 0.01), fever (p = 0.002), failure to thrive (p = 0.01), difficulty feeding (p = 0.001), diarrhoea (p = 0.005), pneumonia (p = 0.006) and dehydration (p = 0.02).

There was no association between maternal viral load and the presence or otherwise of symptoms associated with acute HIV infection. Mortality was very high in the cohort at 40% by month 24. But mortality did not differ over this period in the infants who experienced an acute HIV infection illness and those who did not.

However, infants with symptoms had a higher HIV viral load later in the course of infection than those who did not (p = 0.02). This remained the case when the investigators restricted their analysis to infants with at least twelve months of follow-up (p = 0.05). Although viral load fell over time in infants who did not experience symptoms suggestive of acute HIV infection (p = 0.002), no such fall was seen in the infants with such symptoms.

“In this study, we observed signs and symptoms that were significantly more prevalent at visits that occurred during acute primary HIV infection, compared with noninfection visits in the same cohort”, write the investigators.

However, none of the signs or symptoms were highly sensitive predictors of acute infection. The investigators comment, “rash was noted in 26.4% of acute infection visits, but it was also noted in 17.8% of noninfection visits.”

The investigators conclude, “with expanded HAART access, awareness of acute HIV symptoms during infancy may serve to facilitate rapid diagnosis of pediatric HIV infection and early referral for treatment.”