EIJMRMS ISSN: 2750-8587
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CLINICAL FEATURES OF ACUTE DIARRHEA IN CHILDREN WITH HIV INFECTION
Bolunts Evgeniya Andronikovna
Student of Tashkent Medical Academy, Tashkent Medical Academy, Tashkent, Uzbekistan
Shakhnoza Bakhadirovna Rakhmatullaeva
Scientific supervisor, Doctor of Medical Sciences, Associate Professor of the Department of Infectious and
Children's Infectious Diseases, Tashkent Medical Academy, Uzbekistan
AB O U T ART I CL E
Key words:
Human immunodeficiency virus
(HIV), children, undetectable viral load level
(UVL), Acute diarrhea, clinical features,
dehydration.
Received:
05.08.2024
Accepted
: 10.08.2024
Published
: 15.08.2024
Abstract:
The article is devoted to the study of
clinical features of acute diarrhea in children with
HIV infection. A comparative study of 261 children
with HIV and 247 children without HIV was
conducted. The results showed that children with
HIV have a more severe course of diarrhea with
frequent and prolonged episodes, marked
dehydration, blood, and pus in the stool. These
findings highlight the need for differential
diagnosis and increased monitoring of children
with HIV in acute diarrhea.
INTRODUCTION
Acute diarrhea affects up to 1.4 billion children under 5 years of age worldwide each year, of whom 123
million require emergency care, 9 million require hospital treatment and 1.8 million die from
dehydration. Diarrhea in children can be watery (acute gastroenteritis, as defined by ESPGHAN) and
mucous-bloody (colitis, enterocolitis). The incidence of acute infectious diarrhea in children of the first
3 years of age in European countries is 0.5-1.9 episodes per year [1, 2].
To date, the spectrum of infectious diarrhea pathogens has been established and sufficiently
characterized, which can be caused by many viral (rotaviruses, noroviruses, adenoviruses, etc.),
bacterial (shigella, salmonella, E. coli, St. aureus, etc.) and parasitic agents (Cryptosporidium parvum,
Cystoisospora belli, etc.) [3-1 2].
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In HIV-infected patients, the mucosa of the gastrointestinal tract is both the entry gate and the site of
clinical manifestations of many opportunistic and non-opportunistic infections and tumors. The leading
symptom in this form of AIDS is persistent or recurrent diarrhea with progressive weight loss,
dehydration, and intoxication [7, 9, 11]. It occurs in 30-50% of patients from developed countries and
in 90% of patients from developing countries. The mechanism of diarrhoea development in AIDS
patients is associated with atrophy of intestinal mucosal villi and increased permeability of the
intestinal wall. Increased permeability of the intestinal wall leads to penetration of antigens through it
and increased release of various inflammatory mediators. These abnormalities may be related to
immunological changes in lamina propria lymphocytes caused by HIV or may develop during an
infectious process in the intestine.
All young children are vulnerable to acute intestinal infections, but children living with HIV are more
affected by diarrhea because they are infected with a wider range of pathogens and have more severe
manifestations of infection [7, 9, 13]. Diarrhea is a major predictor of HIV in children. The severity of
diarrhea varies widely according to fluid losses, of particular importance is the accuracy of assessing
the degree of dehydration in a child. The presence of blood in the stool is also among the indicators of
diarrheal disease severity.
Our study aimed
to compare the clinic and course of acute diarrhea in children with HIV infection.
METHODS
During the study, children under 18 years of age were divided into two groups: the main group
consisted of 261 HIV-infected children with acute diarrhea, and the comparison group consisted of 247
children without HIV infection with infectious diarrhea only. The clinical stage of HIV infection in
children was established by the classification of HIV infection according to the National Clinical Protocol
‘National clinica
l report on the organization and implementation of medical care for persons with
confirmed HIV status’ № 206 dated 19.08.2021 of the Ministry of Health of the Republic of Uzbekistan,
the stage and phase of the disease is established only based on clinical manifestations - by the presence
and significance of secondary diseases. The level of viral load (VL) or CD4 is not a criterion for
determining the clinical stage or phase of the disease. The diagnosis of ‘Acute diarrhea’ was made based
on the existing ord
er No. 122 of 25.03.2015. Ministry of Health of the Republic of Uzbekistan “On
improvement of measures to control typhoid, paratyphoid, salmonellosis, and acute intestinal
diseases”.
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To determine the severity and severity of acute infectious diarrhea in children, the degree of
dehydration (WHO criteria), the daily amount and duration of diarrhea, as well as the shape,
consistency, odor, stool color, and the presence of pathological impurities were assessed. The diagnosis
was established based on patient complaints, and clinical, anthropometric, serological, bacteriological,
immunological, virological, and instrumental studies.
Preparation for statistical analysis included studying the types of variables to be analyzed (accounting
attributes), the type of distribution of each attribute, and the formulation of the problem. In the second
stage, a specific statistical method was selected depending on the three main factors studied at the first
stage: the type of accounting characteristics analyzed; the nature of the distribution of the analyzed
characteristics; and the number and type of samples studied (dependent or independent). The analysis
of the type of distribution of the attribute was carried out using the Microsoft Excel program. The
criteria of normal distribution were the following parameters: the mean, mode, and median of the trait
are approximately equal; about 68% of the trait values are in the interval M ± a, 95% in the interval M
± 2a, 99% in the interval M ± 3a. The normal distribution of the trait is symmetrical concerning its value.
Since more than 80% of the analyzed quantitative signs were normally distributed, the statistical
analysis was based on the methods of parametric statistics.
The data obtained in the study were subjected to statistical processing on a Pentium-IV personal
computer using Microsoft Office Excel-2012 software package, including the use of built-in functions of
statistical processing. The methods of variation parametric and nonparametric statistics with the
calculation of arithmetic mean of the studied index (M), mean square deviation (a), standard error of
the mean (m), and relative values (frequency, %) were used. The statistical significance of the obtained
measurements when comparing mean values was determined by Student's criterion (t) with the
calculation of the probability of error (P) when checking the normality of distribution (by the kurtosis
criterion) and equality of general dispersions (F - Fisher's criterion). To assess the statistical
significance of the calculated criteria, indicators and tables of critical values for acceptable significance
levels (P) were used. Four main levels of significance were taken as statistically significant changes:
high - P < 0.001, medium - P < 0.010, low (marginal) - P < 0.050, insignificant (unreliable) - P > 0.050.
RESULTS AND DISCUSSION
Among 261 HIV-infected children, 7 (2.7%) were diagnosed with stage I HIV infection, 104 (39.8%)
children with stage II, 122 (46.7%) children with stage III and 28 (10.7%) children with stage IV, i.e. the
majority of children (86.5%) had stage II or III HIV infection. The age distribution of HIV-infected
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children was as follows: children under 1 year of age - 22 (8.2%), 1-3 years - 38 (14.6%), 3-7 years - 60
(23.0%), 7-14 years - 83 (31.8%) and aged 14-18 years - 58 (22.2%), i.e. the majority of observed
children (77%) with HIV infection were over 3 years of age. The age distribution of children in the
comparison group was as follows: children under 1 year - 71 (28.7%), 1-3 years - 62 (25.1%), 3-7 years
- 53 (21.5%), 7-14 years - 35 (14.2%) and aged 14- 18 years - 26 (10.5%), i.e. more than half of the
children (53.8%) were under 3 years of age.
Signs of dehydration were noted in 70.5% of patients in the main group versus 50.6% in the comparison
group. The absence of signs of dehydration in the comparison group was observed 1.7 times more often
than in the main group (49.4% and 29.5% of cases, respectively, P < 0.05).
Table 1.
Degree of dehydration in acute infectious diarrhea in children with HIV infection
Degree of
dehydration
Main group, n = 261
Control group, n = 247
P
Abs
%
Abs
%
No signs of
dehydration
77
29,5
122
49,4
< 0,05
Moderate
dehydration
135
51,7
107
43,3
> 0.05
Severe
dehydration
49
18.8
18
7.3
< 0,05
Moderate dehydration was more common in the main group of patients, but no significant differences
with the comparison group were found (P > 0.05). On the contrary, severe dehydration was 2.6 times
more frequent in the main group of patients than in the comparison group (18.8% and 7.3% of cases,
respectively, P < 0.05) (Table 1).
Diarrhea with a frequency of up to 10 times a day was registered 3.1 times more often in the comparison
group (32.8% and 10.7% of cases, respectively, P < 0.05). Almost half of the patients in both groups had
daily episodes of diarrhea 10-15 times (51.3% and 49.8%, respectively). However, diarrhea with a
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frequency of more than 15 times per day was detected in the main group 2.2 times more often than in
the comparison group (37.9% and 17.4% of cases, respectively, P < 0.05).
Short duration of diarrhea up to 5 days was almost 2 times more common in patients of the comparison
group (61.5% and 31.8% of cases, respectively, P < 0.05).
In contrast, longer diarrhea was significantly more frequent in children of the main group (6-9 days - in
56.3% and 32.8% of cases, respectively, 1.7 times more frequent, P < 0.05; 10-14 days - in 1 1.9% and
5.7% of cases, respectively, 2 times more frequent, P < 0.05).
In 82.4% of children in the main group and 66.8% of children in the comparison group, stools were
abundant (P > 0.05). A small amount of feces was observed 1.9 times more often in the comparison
group (33.2% and 17.6% of cases, respectively, P < 0.05).
Pathological impurities in feces in the form of mucus were detected in all cases in children of the main
group and 95.5% of the comparison group (P > 0.05). Blood impurity in feces was detected significantly
more often in children of the main group - 3.0 times more often than in the comparison group (37.5%
and 12.6% of cases, respectively, P < 0.05), and detection of pus - 2.6 times more often (59.8% and
23.1% of cases, respectively, P < 0.05) (Table 4). Children in the main group had feces with a greenish
tinge 1.6 times more often than in the comparison group (58.6% and 37.2% of cases, respectively, P <
0.05), and golden-yellow stool coloring, on the contrary, was 2.8 times less common in the main group
(17.2% and 47.8% of cases, respectively, P < 0.05).
Watery stools were 1.5 times more frequent in children of the main group than in the comparison group
(39.5% and 25.9% of cases, respectively, P < 0.05), and, in contrast, ca-lumpy stools were 2.0 times less
frequent in children of the main group (17.6% and 34.8% of cases, respectively, P < 0.05).
Stinky stool odor was 1.5 times more frequent in children of the main group (45.2% and 29.1% of cases,
respectively, P < 0.05), and odorless stool, on the contrary, was 2.7 times more frequent in the
comparison group (38.1% and 14.2% of cases, respectively, P < 0.05). Differences between the
frequency of sour stool odor in the groups were not significant (P > 0.05).
CONCLUSION
Thus, we analyzed the clinical features of acute infectious diarrhea in a group of patients with HIV
infection compared to a group of patients with acute diarrhea without HIV infection. It became evident
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that there is no single ‘most important’ symptom, but it is possible to identify a combination of several
features.
The majority of observed children (77%) with HIV infection were older than 3 years of age, and in the
comparison group, more than half of the children (53.8%) were under 3 years of age, which is consistent
with literature data that acute intestinal infections are more common at this age [2, 10]. In 86.5% of
cases, there was stage II or III HIV infection.
In children of the main group with HIV infection diarrhea runs longer and more severe. In 70.5% of
cases in children of the main group and 50.6% of children of the comparison group, signs of dehydration
were detected, but the severe degree of dehydration was 2.6 times more frequent in children of the
main group with HIV infection (18.8% and 7.3% of cases, respectively, P < 0.05). The degree of
dehydration was influenced by the number of diarrhea episodes per day and its duration. More
prolonged diarrhea was significantly more frequent in children of the main group, with a duration of 6-
9 days 1.7 times more frequent (56.3% and 32.8% of cases, respectively, P < 0.05), and 10-14 days more
frequent (11.9% and 5.7% of cases, respectively, P < 0.05). Diarrhea with a frequency of more than 15
times per day was 2.2 times more frequent in the main group than in the comparison group (37.9% and
17.4% of cases, respectively, P < 0.05). Children in the main group were 1.5 times more likely than in
the comparison group to have watery stools (39.5% and 25.9% of cases, respectively, P < 0.05),
malodorous stool odor (45.2% and 29.1% of cases, respectively, P < 0.05) and greenish tint (58.6% and
37.2% of cases, respectively, P < 0.05).
Pathological inflammatory impurities in feces in the form of blood - 3.0 times more often than in the
comparison group (37.5% and 12.6% of cases, respectively, P < 0.05), and pus - 2.6 times more often
(59.8% and 23.1% of cases, respectively, P < 0.05) were detected in children of the main group.
Thus, we found significant differences in diarrhea in children with HIV infection in terms of the
following characteristics: the presence of dehydration and its severity, the frequency of diarrhea
episodes per day of more than 15 times and its duration of more than 6 days, the watery nature of stools,
the foul smell of stools, the green color and the presence of pathological impurities in the form of blood
and pus.
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