World Journal of AIDS, 2011, 1, 165-168
doi:10.4236/wja.2011.14024 Published Online December 2011 (
Copyright © 2011 SciRes. WJA
HIV-Infected Adolescent: A Case Report
Apezteguia Fernández Carolina Aurora1*, Hernández Muniesa Belén1, Vicent e S ánchez Marí a d e l P ilar1,
Álvarez García Ana2, Ruiz Jiménez Marta2, Ramos Amador José Tomás2
1Pharmacy Department, Getafe University Hospital, Getafe, Spain; 2Pediatric Infectious Diseases Unit, Getafe University Hospital,
Getafe, Spain.
E-mail: *
Received August 10th, 2011; revised October 7th, 2011; accepted October 19th, 2011.
We report the case of a Nigerian adolescent recently arrived to Spain, who presented at the emergency room with
severe respiratory distress. She had been previously diagnosed of HIV-1 discontinuing antiretroviral therapy, what was
hidden by the family. This case illustrates the difficulties in management and stigma in HIV-infected adolescents,
particularly immigrants and the need to collect all the information available before starting antiretroviral therapy.
Keywords: HIV, Adolescent, Immigrant
1. Introduction
Human Immunodeficiency Virus (HIV) infection is one
of the most important pandemic infections around the
world. Perinatal transmission remains the main cause of
HIV infection in paediatrics. The uses of highly active
antiretroviral therapy (HAART) during pregnancy, anti-
retroviral prophylaxis for newborns and administration of
intravenous zidovudine for pregnant women, have dras-
tically reduced the rate of perinatally acquired HIV in-
fection. Nevertheless, vertical transmission remains still
high, especially in developing countries. Sub-Saharan
Africa is the region most heavily affected by HIV. Al-
most 90% of HIV infected children younger than 15
years live in sub-Saharan Africa [1].
It is necessary to consider the particular features of
HIV infection in paediatrics, clinical prognosis and evo-
lution. Children have immature immune system, which
makes them highly vulnerable to infections, such as HIV.
An early diagnosis and treatment are essential to get a
better prognosis and a lower incidence of AIDS progres-
sion. HAART is scaling up, but maintenance of adher-
ence is a major barrier to complete control of viral repli-
cation. Herein, we present the case of a Nigerian girl
recently arrived to Madrid, in whom the HIV diagnosis
was not revealed and antiretroviral treatment had been
2. Case Report
A 14 year-old Nigerian girl, 72 hours after arriving in
Spain, was admitted to hospital, in September 2008, with
a 2-day history of high fever, headache, cough, tachyp-
nea and vomiting. No drug allergies were known and
immunization schedule completed. Family history re-
ferred that mother died in Nigeria 5 years before by a car
accident. HIV infection was suspected by physicians,
because she came from a country with high HIV preva-
lence. In the emergency room, antibodies against HIV
were positive. Her father and sister were unaware of her
HIV-diagnosis, but referred a past history of malaria
treated in Nigeria and some vitamines prescribed there.
Her medical history from Nigeria was obtained one week
later: in May 2007, our patient was diagnosed and classi-
fied in stage 2 of HIV infection (WHO), with 442/µL
CD4 count. A fixed-dose combination of lamivudine,
stavudine and nevirapine was started 6 months after di-
agnosis, (from December 2007 to June 2008). CD4 count
fell to 168/µL probably because of poor adherence, and
there was a disease progression until stage 3 (WHO).
At ER, physical examination revealed mild dehydra-
tion, malaise, tachycardia, tachypnea, slight drowsiness,
bilateral neck lymphadenopathy, mild hepatomegaly and
thrush. She was 148.2cm in height and 35 Kg in weight
(<P3). Other significant findings were hyponatremia (Na
= 128 meq/l), raised C-reactive protein (>250 mg/l) and
procalcitonine of 26.1 ng/ml. Immunoglobulins levels
were increased: 3310 mg/dl IgG, 214 mg/dl IgA and 568
mg/dl IgM. Cerebrospinal fluid (CSF) showed 58 cells
(99% mononuclears and 1% polinuclears), glucose 65
mg/dl, proteins 48 mg/dl and 0 red blood cells. Chest
Xray showed bilateral alveolar infiltrates and brain CT
HIV-Infected Adolescent: A Case Report
scan was normal. Eye funduscopy was also normal.
Echocardiogram revealed dilated myocardiopathy with
preserved ejection fraction. HIV was confirmed by
ELISA test and Western Blot (viral load: 133.000 cop-
ies/ml and CD4 count: 157 cel/µL). HIV infection and
bilateral pneumonia with alveolar pattern were the main
Microbiological findings showed the following results:
blood thick smear and urine antigen test for malaria were
negative. PCR blood for malaria was positive and in
blood culture grew Streptococcus pneumoniae. Pneumo-
nia by Streptococcus pneumoniae was confirmed and
cefotaxime was continued for 10 days, remitting fever and
dyspnea. She also received intravenous trimethoprim/
sulfamethoxazole for covering Pneumocystis jiroveci (PJ)
pneumonia and Atovaquona-proguanile (Malarone®) for
Plasmodium falciparum malaria. Bronchoalveolar lavage
showed negative results for Pneumocystis jiroveci, so
intravenous trimethoprim/sulfamethoxazole was discon-
tinued and switched to oral prophylactic doses. Parasite
tests made for Cryptosporidium and Schistosoma were
negative. Mantoux, gastric washing for culture and PCR
for mycobacterium were also negative. Blood PCR for
criptococcus and cerebrospinal fluid (CSF) PCR for
pneumococcus and mycobaterium showed negative re-
sults. In the absence of microbiologial diagnosis, the in-
crease of CSF cellularity was interpreted as possibly re-
lated to HIV-infection.
Infection symptoms improved and HAART was de-
cided to start one week later, when genotypic resistance
testing was available and patient and family were pre-
pared to start treatment. HLA-B*5701 test showed nega-
tive result. The subtype of HIV-1 was G and the stage of
infection was determined to be B3. All mutations de-
tected (L10:I, V82:I, L89:M. V179:I) not conferred re-
sistance to protease (PIs) and retrotranscriptase (RT) in-
hibitors. It was decided to use 3 new drugs in the new
regimen: ddI qd +ABC qd+ lopinavir/ritonavir bid after
getting genotypic resistance testing and considering the
previous history on antiretrovirals, because of the likeli-
hood of selecting for resistance due to previous exposure.
The patient was discharged from hospital two weeks
after admission, with antiretroviral treatment and oral
prophylaxis against PJ. Clinical evolution and adherence
follow-up was carried out by a multidisciplinary team
(physician, psychologist and pharmacist). She had an
excellent adherence and response to AR. The viral load
became undetectable and the CD4 increased up to 617
(17%) at 6 months of therapy. PCP prophylaxis was then
discontinued. Twelve months after the initation of
HAART, in the routine trimestral visit, the viral load
went up to 2811 cop/ml (3.45 log) and CD4 count was
622 (19%). In the hospital pharmacy, adherence was
calculated through two indirect methods: dispensing re-
cord and valid questionnaire. Our patient referred having
some difficulties taking lopinavir/ritonavir bid, but she
did not recognize missing any dose. This medication-
related problem was detected by compliance question-
naire and a simultaneously increase of viral load oc-
curred (Figure 1). When adherence was improved and
the viral load returned to <50 copies/ml, lopinavir/ri-
tonavir was switched to atazanavir/ritonavir qd with good
adherence and tolerance and good control of viral repli-
cation. 12 months after switching, she had undetectable
viral load and CD4 > 500. Last CD4 was 953 (32%)
Figure 1. Clinical parameters evoluti o n.
Copyright © 2011 SciRes. WJA
HIV-Infected Adolescent: A Case Report167
3. Discussion
Currently, paediatric HIV infection has become a chronic
disease with an excellent long term prognosis [2]. Ad-
herence is critical in determining the degree of viral sup-
pression achieved in response to antiretroviral therapy
[3-5]. It is reported to be suboptimal among children and
even worse among adolescents [6]. Suboptimal adher-
ence can lead to subtherapeutic levels of antiretrovirals
with both risk of development of drug resistence and
virologic failure [4,6]. Factors, such as medication for-
mulation, frequency of dosing, child age and psychoso-
cial characteristics, have been associated with treatment
compliance [7]. Monitoring adherence by questionnaires
and counselling by a multidisciplinary team improve
compliance and is helpful to detect and solve medica-
tion-related problems.
There is an additional problem among immigrant
groups. It is needed to consider the social and cultural
determinants of immigrant adolescents in the context of
their cultural and social norms and the role of family
relationships. All the cultural and social inhibitions may
make the management difficult and knowledge of HIV
and illustrate the difficulty of maintaining an optimal
adherence [8]. In this case, our patient referred some dif-
ficulties taking lopinavir/ritonavir. It was detected by
compliance questionnaire despite not recognizing miss-
ing any dose. Detecting such medication-related problem
is especially difficult between immigrants and may be
responsible of failure therapy and resistance. Antiretro-
viral drug resistance testing is recommended to be in-
corporated into patient management to help the choice of
new regimens and considering the possibility of prior
HAART in adolescent recently arrived to European
countries hampering new treatment options. The choice
of the antiretroviral regimen was difficult in this case.
First her family did not recognise HIV-diagnosis. Start-
ing new medications in unwell patients without full in-
formation (previous antiretroviral agents prescribed, re-
sistance testing, TB diagnosis excluded and potential
adverse drug effects) is risky. HIV infection, previous
exposure to HAART and the likelihood of developing
resistance due to prior therapy must be considered by
physicians in every adolescent or child who come from
an endemic HIV area. In our case, considering the pre-
vious history on antiretrovirals, it was decided to use ddI
+ ABC + lopinavir/ritonavir in order to introduce as
many new antiretrovirals as possible [3,4]. The optimal
moment and type of antiretrovirals to start therapy are
critical and a complete information is crucial. Depending
on previous exposure to antiretroviral drugs there must
be an increased risk of therapy failure. That is why all the
pharmacotherapy history must be collected before start-
ing HAART even if there is no resistance at all.
It is also essential to consider that HIV-infected pa-
tients are susceptible for developing opportunistic infec-
tions and the additional risk for coming from an endemic
region for malaria and TB. In Africa, TB is the most
common pulmonary complication of HIV. It is very im-
portant to do a differential diagnosis between TB and
other types of pneumonia. The CD4 count can provide
information about the type of pulmonary disease to
which the patient is susceptible [9]. Malaria and HIV
infections often coexist in areas of the world where these
diseases have the largest burden, particularly in sub-Sa-
haran Africa [10]. HIV status and immunosuppression
may be associated with an increased risk of susceptibility
to malaria infection. Conversely, malaria increases HIV
replication and declines in CD4 cell counts [11]. HIV
and malaria should be considered together as a part of
healthcare programs for both diseases in countries where
their copresence favors an interaction with important
consequences [12].
This case illustrates several aspects: the stigma and
secrecy in HIV-infected patients, particularly immigrants.
In this population, maintaining an optimal adherence
may be difficult due to cultural and social inhibitions.
HAART failure depends on adherence patient and com-
pliance therapy is reported to be suboptimal among chil-
dren and even worse among adolescents. The possibility
of HIV infection, previous exposure to HAART and the
likelihood of developing resistance due to prior therapy
must be considered by physicians in every child who
comes from a high prevalence HIV area. The need to
collect all the information available before starting anti-
retroviral therapy and genotyping testing is critical, be-
cause there must be an increased risk of therapy failure
when there was previous exposure to antiretroviral drugs,
even if there is no genotypic drug resistance. Improving
patient’s knowledge about HIV-infection and HAART
therapy, a close follow-up and detecting medication-
related-problems, might also be important tools to in-
crease medication compliance and achieve complete viral-
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