HIV diarrhea: Difference between revisions
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==Background== | ==Background== | ||
*Chronic diarrhea (over 28 days) | *Chronic diarrhea (over 28 days); can be presenting symptom of AIDS | ||
*Less common after introduction of HAART | *Less common after introduction of HAART | ||
*Acute diarrhea common with normal and low CD4 | |||
==Clinical | {{HIV CD4 Chart}} | ||
==Clinical Features== | |||
*Ascertain whether small bowel vs large bowel diarrhea | *Ascertain whether small bowel vs large bowel diarrhea | ||
**Small Bowel | **Small Bowel | ||
***Diarrhea watery and copius | ***[[Diarrhea]] watery and copius | ||
***May have weight loss | ***May have weight loss | ||
***Bloating, gas, cramping | ***Bloating, gas, cramping | ||
*** | ***[[Vitamin B12 deficiency]] if terminal illeum involved | ||
**Large Bowel | **Large Bowel | ||
***Frequent small volume, possibly painful stools | ***Frequent small volume, possibly painful stools | ||
***Hematochezia - Consider opportunistic pathogens, also consider classic hemorrhagic bacteria ( | ***Hematochezia - Consider opportunistic pathogens, also consider classic hemorrhagic bacteria ([[E. coli]] O157, [[campylobacter]], [[Shigella]], [[Salmonella]], Yersinia) | ||
*Weight loss is concerning for infiltrative disease, opportunistic | *Weight loss is concerning for infiltrative disease, opportunistic infection | ||
*Receptive anal sex - consider local HSV | *Receptive anal sex - consider local [[HSV]], [[Gonorrhea]], [[chlamlydia]], [[entamoeba]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
===CD4 | ===CD4 200-500=== | ||
* Consider routine pathogens causing [[Diarrhea]] | *Consider routine pathogens causing [[Diarrhea]] | ||
**Viruses ( | **Viruses (Norovirus, Rotavirus, Adenoviruses, Astrovirus, etc.) | ||
**Bacteria ( | **Bacteria (Salmonella, Campylobacter, Shigella, Enterotoxigenic E. coli, C. dif, etc.) | ||
**Protozoa ( | **Protozoa (Cryptosporidium, Giardia, Cyclospora, Entamoeba, etc.) | ||
*Side effect of nelfinavir and ritonavir | *Side effect of nelfinavir and ritonavir | ||
*Kaposi Sarcoma | |||
*Cryptosporidium parvum (brief course of illness) - severe watery diarrhea | *Cryptosporidium parvum (brief course of illness) - severe watery diarrhea | ||
*C. | *C. dif if antibiotic exposed | ||
===CD4<200=== | ===CD4<200=== | ||
*Microsporidium | |||
*Cryptosporidium | |||
*Histoplasma | |||
*Lymphoma | *Lymphoma | ||
*Enteroaggregative Escherichia coli (EAEC) (can also affect immunocompetent children) | *Enteroaggregative Escherichia coli (EAEC) (can also affect immunocompetent children) | ||
*HIV can directly infiltrate bowel wall leading to diarrhea | *HIV can directly infiltrate bowel wall leading to diarrhea | ||
| Line 36: | Line 41: | ||
*Cryptosporidium parvum (chronic course of illness) | *Cryptosporidium parvum (chronic course of illness) | ||
*M. tuberculosis (disseminated disease increasingly likely <100) | *M. tuberculosis (disseminated disease increasingly likely <100) | ||
*Cryptococcus | *Cryptococcus | ||
*Isospora | |||
===CD4 <50=== | |||
*Mycobacterium avium complex (MAC) - infiltration of bowel associated with malabsorption | |||
*CMV | *CMV | ||
== | {{HIV associated conditions}} | ||
==Evaluation== | |||
*Many workups will be non diagnostic | *Many workups will be non diagnostic | ||
*Start with stool WBCs, cultures, Ova and Parasites x3, C. | *Start with stool WBCs, cultures, Ova and Parasites x3, C. Dif toxin | ||
*Acid fast smear to assess for Cryptosporidium, Isospora, and Cyclospora | *Acid fast smear to assess for Cryptosporidium, Isospora, and Cyclospora | ||
*CD4<100 - Microsporidium more likely, test with Trichrome staining | *CD4<100 - Microsporidium more likely, test with Trichrome staining | ||
*Blood cultures with fungal / acid fast if disseminated disease a concern | *Blood cultures with fungal/acid fast if disseminated disease a concern | ||
*Endoscopy | *Endoscopy | ||
**Indicated if | **Indicated if workup is negative and severely immunocompromised | ||
**Small bowel | **Small bowel biopsy to look for MAC, lymphoma, or Microsporidiosis | ||
**Guaic postive stools and weight loss | **Guaic postive stools and weight loss: consider Kaposi Sarcoma of bowel, diagnosis with colonoscopy | ||
*Imaging | *Imaging | ||
**Generally not helpful, but could be indicated if severe tenderness, peritonitis, concern for biliary pathology, obstructing lesions. | **Generally not helpful, but could be indicated if severe tenderness, peritonitis, concern for biliary pathology, obstructing lesions. | ||
==Management== | ==Management== | ||
*Electrolyte and volume replacement | |||
*Early consultation of HIV service | |||
*Nutrition replacement in chronic small bowel disease | |||
*HAART | |||
*Generally, avoid starting antibiotics unless have specific target | |||
*Antimotility agents | |||
**loperamide | |||
**crofelemer (blocks chloride secretion and approved for HIV diarrhea) 125mg po bid | |||
==Disposition== | ==Disposition== | ||
*If near normal CD4 and symptoms consistent with small bowel disease ( | *If near normal CD4 and symptoms consistent with small bowel disease (copious, watery), may be managed as outpatient if no other admission indication | ||
*Severe dehydration, electrolyte abnormalities, malnutrition, fever, and hemorrhagic diarrhea all may require admission or at minimum very close HIV follow up | |||
==See Also== | ==See Also== | ||
*[[HIV - AIDS (Main)]] | |||
*[[Diarrhea]] | |||
==References== | ==References== | ||
<references/> | <references/> | ||
*UpToDate: "Evaluation of the HIV-infected patient with diarrhea" | |||
*https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/ | |||
[[Category:GI]] | |||
[[Category:ID]] | |||
[[Category:Symptoms]] | |||
Revision as of 23:24, 22 December 2016
Background
- Chronic diarrhea (over 28 days); can be presenting symptom of AIDS
- Less common after introduction of HAART
- Acute diarrhea common with normal and low CD4
HIV Associated Diseases by CD4 Level
| CD4 Count | Stage | Diseases |
| >500 | Early disease | Similar to non-immunocompromised patients (Consider HAART medication side-effects) |
| 200-500 | Intermediate disease | Kaposi's sarcoma, Candida, bacterial respiratory infections |
| <200 | Late disease | PCP, central line infection, MAC, TB, CMV, drug fever, sinusitis, endocarditis, lymphoma, histoplasmosis, cryptococcus, PML |
| <100 | Very late disease | Cryptococcus, Cryptosporidium, Toxoplasmosis |
| <50 | Final Stage | CMV retinitis, MAC |
Clinical Features
- Ascertain whether small bowel vs large bowel diarrhea
- Small Bowel
- Diarrhea watery and copius
- May have weight loss
- Bloating, gas, cramping
- Vitamin B12 deficiency if terminal illeum involved
- Large Bowel
- Frequent small volume, possibly painful stools
- Hematochezia - Consider opportunistic pathogens, also consider classic hemorrhagic bacteria (E. coli O157, campylobacter, Shigella, Salmonella, Yersinia)
- Small Bowel
- Weight loss is concerning for infiltrative disease, opportunistic infection
- Receptive anal sex - consider local HSV, Gonorrhea, chlamlydia, entamoeba
Differential Diagnosis
CD4 200-500
- Consider routine pathogens causing Diarrhea
- Viruses (Norovirus, Rotavirus, Adenoviruses, Astrovirus, etc.)
- Bacteria (Salmonella, Campylobacter, Shigella, Enterotoxigenic E. coli, C. dif, etc.)
- Protozoa (Cryptosporidium, Giardia, Cyclospora, Entamoeba, etc.)
- Side effect of nelfinavir and ritonavir
- Kaposi Sarcoma
- Cryptosporidium parvum (brief course of illness) - severe watery diarrhea
- C. dif if antibiotic exposed
CD4<200
- Microsporidium
- Cryptosporidium
- Histoplasma
- Lymphoma
- Enteroaggregative Escherichia coli (EAEC) (can also affect immunocompetent children)
- HIV can directly infiltrate bowel wall leading to diarrhea
CD4 <100
- Cryptosporidium parvum (chronic course of illness)
- M. tuberculosis (disseminated disease increasingly likely <100)
- Cryptococcus
- Isospora
CD4 <50
- Mycobacterium avium complex (MAC) - infiltration of bowel associated with malabsorption
- CMV
HIV associated conditions
- HIV neurologic complications
- HIV pulmonary complications
- Ophthalmologic complications
- Other
- HAART medication side effects[1]
- HAART-induced lactic acidosis
- Neuropyschiatric effects
- Hepatic toxicity
- Renal toxicity
- Steven-Johnson's
- Cytopenias
- GI symptoms
- Endocrine abnormalities
Evaluation
- Many workups will be non diagnostic
- Start with stool WBCs, cultures, Ova and Parasites x3, C. Dif toxin
- Acid fast smear to assess for Cryptosporidium, Isospora, and Cyclospora
- CD4<100 - Microsporidium more likely, test with Trichrome staining
- Blood cultures with fungal/acid fast if disseminated disease a concern
- Endoscopy
- Indicated if workup is negative and severely immunocompromised
- Small bowel biopsy to look for MAC, lymphoma, or Microsporidiosis
- Guaic postive stools and weight loss: consider Kaposi Sarcoma of bowel, diagnosis with colonoscopy
- Imaging
- Generally not helpful, but could be indicated if severe tenderness, peritonitis, concern for biliary pathology, obstructing lesions.
Management
- Electrolyte and volume replacement
- Early consultation of HIV service
- Nutrition replacement in chronic small bowel disease
- HAART
- Generally, avoid starting antibiotics unless have specific target
- Antimotility agents
- loperamide
- crofelemer (blocks chloride secretion and approved for HIV diarrhea) 125mg po bid
Disposition
- If near normal CD4 and symptoms consistent with small bowel disease (copious, watery), may be managed as outpatient if no other admission indication
- Severe dehydration, electrolyte abnormalities, malnutrition, fever, and hemorrhagic diarrhea all may require admission or at minimum very close HIV follow up
See Also
References
- ↑ Gutteridge, David L MD, MPH, Egan, Daniel J. MD. The HIV-Infected Adult Patient in The Emergency Department: The Changing Landscape of the Disease. Emergency Medicine Practice: An Evidence-Based Approach to Emergency Medicine. Vol 18, Num 2. Feb 2016.
- UpToDate: "Evaluation of the HIV-infected patient with diarrhea"
- https://www.aids.gov/hiv-aids-basics/staying-healthy-with-hiv-aids/potential-related-health-problems/opportunistic-infections/