HIV diarrhea: Difference between revisions
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*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 ([[E. coli]] O157, [[campylobacter]], [[Shigella]], [[Salmonella]], Yersinia) | ***Hematochezia - Consider opportunistic pathogens, also consider classic hemorrhagic bacteria ([[E. coli]] O157, [[campylobacter]], [[Shigella]], [[Salmonella]], Yersinia) | ||
*Weight loss is concerning for infiltrative disease, opportunistic infection | *Weight loss is concerning for infiltrative disease, opportunistic infection | ||
*Receptive anal sex - consider local [[HSV]], [[Gonorrhea]], [[ | *Receptive anal sex - consider local [[HSV]], [[Gonorrhea]], [[chlamlydia]], [[entamoeba]] | ||
==Differential Diagnosis== | ==Differential Diagnosis== | ||
Line 45: | Line 45: | ||
===CD4 <50=== | ===CD4 <50=== | ||
*Mycobacterium avium complex (MAC) - infiltration of bowel | *Mycobacterium avium complex (MAC) - infiltration of bowel associated with malabsorption | ||
*CMV | *CMV | ||
{{HIV associated conditions}} | {{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. Dif toxin | *Start with stool WBCs, cultures, Ova and Parasites x3, C. Dif toxin | ||
Line 88: | Line 88: | ||
[[Category:GI]] | [[Category:GI]] | ||
[[Category:ID]] | [[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/