HIV diarrhea: Difference between revisions

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==Background==
==Background==
*Chronic diarrhea (over 28 days); can be presenting symptom of AIDS
*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
*Acute diarrhea common with normal and low CD4
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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 copious
***May have weight loss
***May have weight loss
***Bloating, gas, cramping
***Bloating, gas, cramping
***Vit B12 deficient if terminal illeum involved
***[[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)
***[[lower GI bleeding|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]], [[chamlydia]], [[entamoeba]]
*Receptive anal sex - consider local [[HSV]], [[Gonorrhea]], [[chlamydia]], [[entamoeba]]


==Differential Diagnosis==
==Differential Diagnosis==
===CD4 200-500===
===CD4 200-500===
*Consider routine pathogens causing [[Diarrhea]]  
*Consider routine pathogens causing [[Diarrhea]]  
**Viruses (Norovirus, Rotavirus, Adenoviruses, Astrovirus, etc.)
**Viruses ([[Norovirus]], [[Rotavirus]], [[Adenovirus]], Astrovirus, etc.)
**Bacteria (Salmonella, Campylobacter, Shigella, Enterotoxigenic E. coli, C. dif, etc.)
**Bacteria ([[Salmonella]], [[Campylobacter]], [[Shigella]], Enterotoxigenic [[E. coli]], [[C. diff]], etc.)
**Protozoa (Cryptosporidium, Giardia, Cyclospora, Entamoeba, etc.)
**Protozoa ([[Cryptosporidium]], [[Giardia]], [[Cyclospora]], [[Entamoeba]], etc.)
*Side effect of nelfinavir and ritonavir
*Side effect of nelfinavir and ritonavir
*Kaposi Sarcoma
*[[Kaposi sarcoma]]
*Cryptosporidium parvum (brief course of illness) - severe watery diarrhea
*[[Cryptosporidium]] parvum (brief course of illness) - severe watery diarrhea
*C. dif if antibiotic exposed
*[[C. diff]] if antibiotic exposed


===CD4<200===
===CD4<200===
*Microsporidium
*[[Microsporidium]]
*Cryptosporidium
*[[Cryptosporidium]]
*Histoplasma
*[[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


===CD4 <100===
===CD4 <100===
*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
*Isospora


===CD4 <50===
===CD4 <50===
*Mycobacterium avium complex (MAC) - infiltration of bowel associated with malabsorption  
*[[Mycobacterium avium]] complex (MAC) - infiltration of bowel associated with malabsorption  
*CMV
*[[CMV]]


{{HIV associated conditions}}
{{HIV associated conditions}}
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**Indicated if workup is negative and severely immunocompromised  
**Indicated if workup is negative and severely immunocompromised  
**Small bowel biopsy to look for MAC, lymphoma, or Microsporidiosis
**Small bowel biopsy to look for MAC, lymphoma, or Microsporidiosis
**Guaic postive stools and weight loss: consider Kaposi Sarcoma of bowel, diagnosis with colonoscopy
**Guaiac positive 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
*[[electrolyte repletion|Electrolyte]] and [[volume repletion]]
*Early consultation of HIV service
*Early consultation of HIV service
*Nutrition replacement in chronic small bowel disease
*Nutrition replacement in chronic small bowel disease
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*Generally, avoid starting antibiotics unless have specific target
*Generally, avoid starting antibiotics unless have specific target
*Antimotility agents  
*Antimotility agents  
**loperamide
**[[Loperamide]]
**crofelemer (blocks chloride secretion and approved for HIV diarrhea) 125mg po bid
**crofelemer (blocks chloride secretion and approved for HIV diarrhea) 125mg po bid


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[[Category:GI]]
[[Category:GI]]
[[Category:ID]]
[[Category:ID]]
[[Category:Symptoms]]

Latest revision as of 21:24, 29 September 2019

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
  • Weight loss is concerning for infiltrative disease, opportunistic infection
  • Receptive anal sex - consider local HSV, Gonorrhea, chlamydia, entamoeba

Differential Diagnosis

CD4 200-500

CD4<200

CD4 <100

CD4 <50

HIV associated conditions

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
    • Guaiac positive 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 repletion
  • 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

  1. ↑ 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.
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