[Gastrointestinal findings in HIV infection. Clinical aspects, microbiological findings and endoscopic picture]

Among 200 hospitalized patients treated for HIV infections there were 98 with gastrointestinal symptoms, independent of the stage of the disease. Only 22 had abnormal stool findings. But histological examination and culture of endoscopically obtained biopsies revealed opportunistic infection in 62, of whom 28 had a cytomegalovirus infection. Mycobacterium avium-intracellulare was found in the gastrointestinal mucosa of 25 patients, but its clinical significance is unclear. In 33 of the 98 patients previously classified as positive for HIV or AIDS-related complex, endoscopic demonstration of an opportunistic infection required amendment of their HIV stage. In over 60% endoscopy revealed mucosal changes. A distinction from Crohn's disease or ulcerative colitis could only be made by histology or exclusion of the causative microorganism. Demonstration of the causative microorganism from the biopsy is thus essential in patients with gastrointestinal symptoms, because specific treatment is in principle possible and successful for some opportunistic infections.

[Gastroenteric pathology in AIDS. Retrospective study of a case series of 21 patients]

The clinical aspects of gastrointestinal pathologies in 21 AIDS patients are examined. The study confirms the frequency of gastroenteric alterations in AIDS.

Overview of infection with the human immunodeficiency virus: infectious complications

HIV is a retrovirus. Infection with HIV results in a progressive loss of immune function, primarily of the T-helper lymphocyte, although other arms of the immune system are secondarily affected. Patients who develop AIDS are amazingly susceptible to the development of opportunistic infections and neoplastic diseases. Common presentations include pneumonia, gastrointestinal infections, and central nervous system infections. Infections are usually due to reactivation of latent infections. These infections have a tendency to relapse and prolonged treatment appears to be necessary. HIV infection is occurring worldwide and medical personnel, especially pulmonary physicians, will be increasingly required to diagnose and treat infections occurring in these patients. The spread of HIV infection is already altering the epidemiology and clinical presentation of major infectious illnesses such as syphilis and tuberculosis.

Effect of broiler chicken age on susceptibility to experimentally induced Cryptosporidium baileyi infection

Clinical signs of respiratory tract disease were observed in chickens that were inoculated intratracheally with 1 x 10(6) oocysts of Cryptosporidium baileyi at 2 or 14 days of age (10 chickens/group), but not in chickens inoculated at 28 or 42 days of age (10 chickens/group). Orally inoculated chickens in all age groups (10 chickens/group) did not develop clinical signs of disease. Orally and intratracheally inoculated chickens in all age groups were infected, as determined by the finding of cryptosporidia in tissue sections of the trachea, bursa of Fabricius, and cloaca, and by the recovery of oocysts from their feces. Chickens inoculated at 2 and 14 days of age excreted oocysts for a longer period and had greater numbers of cryptosporidia in their tissues, compared with chickens inoculated at 28 and 42 days of age.

Spiramycin therapy for cryptosporidial diarrhoea in immunocompromised patients

Spiramycin, 3 g daily, was used to treat immunocompromised patients with chronic diarrhoea due to Cryptosporidium. Most patients treated had acquired immune deficiency syndrome. Among 37 patients evaluated, 28 had a favourable response, defined as a reduction in the daily number of bowel movements to less than 50% of baseline and fewer than five. Twelve of these individuals had Cryptosporidium oocysts eradicated from stool. Spiramycin was well tolerated. These data suggest that spiramycin is effective in alleviating cryptosporidial diarrhoea in some immunocompromised patients and may lead to eradication of cryptosporidial oocysts.

Cryptosporidial diarrhoea in AIDS and its treatment

Of 234 patients with AIDS diagnosed at St. Stephen's Hospital between January 1981 and June 1987, 26 (11%) were found to have cryptosporidiosis. Stool examination was positive in all patients, but an average of three specimens (range 1-6) were required before a positive diagnosis was made. Other methods of diagnosis included jejunal and rectal biopsy and aspiration of the duodenal contents. Twenty three (89%) lived for six months from the time of diagnosis and 16 (60%) were alive at one year. Only five patients died as a direct result of cryptosporidial infection, while 10 other patients died from another complication of AIDS. Fifteen patients were enrolled in a prospective controlled study of erythromycin or spiramycin in the treatment of cryptosporidial diarrhoea. Most patients showed a significant response to antibiotic therapy but treatment was limited because of side effects. All patients responded to antidiarrhoeal agents, particularly long acting morphine sulphate. Three of our patients recently given zidovudine (AZT) have responded with a cessation of diarrhoea and cryptosporidia are no longer isolated from the stools.

Infection and diarrhea caused by Cryptosporidium sp. among Guatemalan infants

During July 1985 to June 1986, fecal excretion of Cryptosporidium oocysts was determined prospectively in a cohort of 130 infants, aged 0 to 11 months, living in a marginal urban area of Guatemala City, Guatemala. A total of 1,280 stool specimens were examined; 158 of them were collected during episodes of diarrhea, and 1,122 were collected during symptom-free periods, every 2 to 3 weeks, from every child. Of the children, 20 (15.4%) excreted Cryptosporidium oocysts during the observation period. Of the diarrheal episodes, 13 (8.3%) were associated with Cryptosporidium sp. Of the control specimens, seven (0.6%) were positive for oocysts. Most of the infections were documented during the months of February to May, at the end of the dry season. Cryptosporidium infections are very common among Guatemalan infants and are an important cause of diarrhea and weight loss. The introduction of liquid or solid foods in the diets of the children, the presence of domestic animals (dogs, cats, or poultry), and the absence of toilet facilities in the house seem to be important risk factors for infection; also, deficient nutritional status may predispose the infected child to Cryptosporidium-associated illness.

The pathology of AIDS

The acquired immunodeficiency syndrome (AIDS) is a devastating new disease caused by the human immunodeficiency virus (HIV). This retrovirus causes profound immunoincompetence in its infected hosts, who are thereafter susceptible to develop myriad severe and relapsing protozoal, fungal, bacterial, viral, and arthropodal opportunistic infections, as well as unusual malignancies. The more than 50,000 patients who have developed AIDS in the United States have produced a sudden unexpected deluge of diagnostic dilemmas that are stressing laboratories of pathology everywhere. This paper describes the gross and microscopic pathology of the numerous complications in patients infected by HIV: (a) the prodromal AIDS-related complex with persistent generalized lymphadenopathy, (b) lymphoid infiltration of salivary gland and lung, including the complex of lymphoid interstitial pneumonitis-pulmonary lymphoid hyperplasia, (c) extranodal non-Hodgkin's lymphomas, (d) multifocal mucocutaneous and visceral Kaposi's sarcoma, (e) small cell undifferentiated (oat cell) carcinomas, (f) protozoal infections caused by Pneumocystis carinii, Toxoplasma gondii, Acanthamoeba, Cryptosporidium species (sp.), and Isospora belli, (g) the causes of chronic enteritis, (h) mycotic infections caused by Candida sp., Cryptococcus neoformans, Histoplasma capsulatum, Coccidioides immitis, and Sporothrix schenckii, (i) bacterial infections caused by Mycobacterium avium-intracellulare, M. tuberculosis, M. kansasii, Nocardia sp., Listeria monocytogenes, Legionella sp., Treponema pallidum, and others, (j) viral infections caused by cytomegalovirus, herpes simplex and zoster, polyomavirus (progressive multifocal leukoencephalopathy), hepatitis B, molluscum contagiosum, and papillomavirus, (k) oral hairy leukoplakia, (l) subacute encephalopathy, and (m) Norwegian scabies.

Cryptosporidiosis associated with immunosuppression attributable to distemper in a pup

Cryptosporidiosis, giardiasis, trichomoniasis, and distemper were diagnosed in a 6-month-old female Siberian Husky pup. Poor growth rate, mucopurulent ocular and nasal discharges, and diarrhea were observed. Results of immunologic studies revealed decreased serum IgG concentration and undetectable serum IgA concentration. Cultured lymphocytes yielded a less-than-adequate response to mitogen stimulation. The serum also contained a factor that suppressed mitogen stimulation in control cultured lymphocytes.

Treatment of cryptosporidiosis with spiramycin in AIDS. An "N of 1" trial

We describe a randomized, double-blind, placebo-controlled, crossover trial with spiramycin in a single patient with acquired immune deficiency syndrome (AIDS) and a severe secretory diarrhea caused by cryptosporidium. Spiramycin, a potentially harmful antibiotic, had no clinical or microbiological effect in this patient. The application of the single patient (N of 1) trial to common clinical problems is a simple way to analyze the value of different therapeutic approaches. The time-consuming, expensive, multi-patient trial with ultimate extrapolation to the individual patient can be avoided. Single-patient trials can influence management and improve patient care and have potentially wide use in patients with gastrointestinal disease.

Isospora belli and Cryptosporidium sp. from a patient not suspected of having acquired immunodeficiency syndrome

Several protozoa including Cryptosporidium sp. and Isospora belli were found in a stool specimen from a patient not suspected of having Acquired Immunodeficiency Syndrome (AIDS). As a result of the parasitologic findings, serologic tests were ordered that verified the diagnosis of AIDS. All stool specimens are routinely tested for presence of acid fast organisms with a modified acid fast technique.

Cryptosporidiosis in a feline leukemia virus-positive cat

A 4-year-old FeLV-positive cat with a 1-year history of intermittent diarrhea and subsequent anorexia, depression, and weight loss had enteric cryptosporidiosis at necropsy. Cryptosporidium sp is an important cause of gastroenteritis and diarrhea in various species, including human beings with acquired immunodeficiency syndrome. A major determinant of the severity of the disease caused by Cryptosporidium sp is the immunologic status of the affected animal. Cryptosporidiosis should be included in the differential diagnosis of protracted diarrhea in FeLV-positive cats. Because cryptosporidiosis now is recognized as a zoonosis, cats with this disease should be considered a potential source of human infection.

Treatment of cryptosporidiosis with oral bovine transfer factor

Cryptosporidia are intestinal protozoans long known to cause diarrhea in humans, especially those with acquired immune deficiency syndrome (AIDS). When transfer factor prepared from calves which possessed delayed-type hypersensitivity to Eimeria bovis was given to nonimmune calves and mice it conferred protection against clinical infection (coccidiosis). Recent studies with oral bovine transfer factor have shown that it can confer cell-mediated immunity to humans. Based on these findings we decided to treat eight AIDS patients suffering from Cryptosporidium-associated diarrhea with transfer factor prepared from calves immune to Cryptosporidium. Prior to treatment with transfer factor, three patients had been treated with spiramycin, one patient with alpha-difluoromethylornithine (DFMO), and one patient with furazolidone for greater than 1 month without clinical or laboratory improvement. Following administration of transfer factor, five or eight patients exhibited a decrease in the number of bowel movements and the development of formed stools. Cryptosporidium was eradicated from the stools of four patients but two of these patients subsequently relapsed and one patient continued to have diarrhea despite the absence of Cryptosporidium in the stool. One patient has been free of diarrhea and Cryptosporidium for 2 years after discontinuation of transfer factor therapy.

Postoperative enteral hyperalimentation for cryptosporidial acute cholecystitis associated with AIDS and enteritis

A homosexual youth presented with undiagnosed acute cryptosporidial cholecystitis, a fever of 102.8 degrees F and a WBC of 3500/mm3. This was preceded by several months of watery diarrhea and 20% weight loss. Following cholecystectomy, G-I function was maintained by efficient esophageal aspiration of swallowed air, with simultaneous immediate duodenal feeding of elemental diet. He absorbed 160 g amino acids and 4200 kcal, and was safely self-sufficient when discharged 26 hours postoperatively. Reappearance of the persistent cryptosporidial enteritis was followed by diagnoses of the offending organism and the associated AIDS. He failed to respond to specific spiramycin therapy, and 8 months after cholecystectomy he succumbed to pneumocystis carinii pneumonia. For this malnourished and particularly vulnerable patient, preservation of postoperative G-I function and its exploitation for enteral support may have been essential to enhance "immune competence" and lead to a remarkably smooth and rapid recovery.

Cryptosporidiosis in well-nourished and malnourished children

During a 5-month period, 513 stool samples submitted to the enteric laboratory at the University Hospital of the West Indies were examined for Cryptosporidium. Oocysts were detected in 4.9% of all stools, 7.3% of diarrhoeal stools, 19.5% of stools from malnourished children and 23.7% of stools from malnourished children with diarrhoea. Cryptosporidium was the sole pathogen detected in all 25 positive stools, and was the second most frequent enteric isolate. All cases of cryptosporidiosis occurred in children less than 2.5 years of age. All 15 malnourished children were admitted to hospital where they presented with dehydration (87%), vomiting (93%), fever (100%) and diarrhoea which lasted an average of 15.3 days. Two of these children died. In contrast, dehydration (20%), vomiting (40%) and fever (50%) were less common and diarrhoea less protracted in well-nourished children, four of whom were admitted to hospital. This preliminary report suggests that cryptosporidial gastroenteritis presents with increased frequency and severity in malnourished compared with well-nourished Jamaican children.

[Cryptosporidium infections in AIDS]

Investigations for cryptosporidia were carried out on 250 fecal samples from 131 HIV-positive patients between December 1985 and July 1986 with kinyoun carbolfuchsin staining. Cryptosporidial oocysts could be detected in six homosexual men. All of the cryptosporidia excretors had symptoms of enteritis. The clinical course and the prognosis depended on the immunological resistance of the host. Five patients with pronounced immune defect had therapy-resistant chronic diarrhea. In one patient with a slight immune defect, the cryptosporidial infection cured spontaneously. A spacial separation of cryptosporidia excretors and patients with weakened resistance is to be considered in view of the possible severe progress form with low tendency to cure and the still lacking specific chemotherapy.

Cryptosporidiosis in Haitian children

We used a modified acid-fast stain to detect Cryptosporidium oocysts in unconcentrated stools from 824 Haitian children less than 2 years of age with acute diarrhea. Oocysts were identified in stools from 17.5% of 291 children seen at a rural dispensary and in 16.3% of stools from 533 children in an urban hospital. Children with cryptosporidiosis were identified throughout a 22-month period from October 1982 to July 1984, without seasonal predilection. Cryptosporidiosis was twice as common in infants greater than 6 months of age than in younger infants. Cryptosporidium oocysts were rarely found in stools of infants receiving only breast milk. The clinical presentation of children with cryptosporidiosis was similar to other patients with diarrhea who did not have cryptosporidiosis. No asymptomatic Cryptosporidium infections were detected among 71 family members of 31 children with cryptosporidiosis. Three of the 71 family members less than 3 years of age were found to have diarrhea and Cryptosporidium oocysts. In follow-up studies of 31 patients, oocysts persisted in stools for a mean of 14 days (range 5-31 days). Duration of oocyst excretion was directly correlated with duration of diarrhea. These findings suggest that Cryptosporidium is an important cause of acute self-limited diarrheal illness to Haitian children.

[Cryptosporidiosis in grafting of allogeneic bone marrow]

Cryptosporidiosis may cause diarrhea after a conditioning regimen for allogeneic bone marrow transplantation. The case reported here suggests resurgence of latent cryptosporidiosis in early post-graft period, since other causes of immunosuppression such as graft-versus-host disease or transfusional LAV/HTLV III retroviral infection, were absent. The diagnosis was confirmed by rectal biopsy and ultrastructural analysis. Good response to spiramycin was obtained.

Biliary tract obstruction in the acquired immunodeficiency syndrome

Three patients with the acquired immunodeficiency syndrome had biliary obstruction resulting from benign strictures of the biliary tract. Stenosis of the distal common bile duct with differing degrees of irregularity of the smaller intrahepatic and extrahepatic ducts was seen in association with either cryptosporidial or cytomegaloviral infection of the biliary tree. We review cytomegaloviral and cryptosporidial infections of the biliary system, as well as possible relationships with idiopathic primary sclerosing cholangitis. Stenotic biliary tract disease appears to be yet another complication of the acquired immunodeficiency syndrome.

[Intestinal parasitoses]

While intestinal parasites are infrequent causes of acute diarrhea, investigations in travellers, children, homosexuals and immunocompromised persons who have had diarrhea for more than 2-4 weeks should include stool analyses for intestinal parasites. Intestinal helminthiases are treated with pyrantel pamoate, mebendazole, thiabendazole, albendazole, praziquantel or niclosamide. For treatment of intestinal protozoa, ornidazole (or other benzimidazoles), diloxanide furoate and co-trimoxazole are drugs of first choice; at present spiramycin is recommended for treatment of cryptosporidiosis in AIDS patients. When infections or symptoms persist after treatment, re-infection or immunodeficiency should be considered.

Cryptosporidium spp., a frequent cause of diarrhea in Liberian children

This report presents results from a sample survey designed to investigate the possible role of Cryptosporidium spp. in childhood diarrhea in a developing country, Liberia, West Africa. During the four months of January to April 1983, a house-to-house study was carried out in two geographically and socially different communities--an urban slum and three rural villages. Stool samples from 374 children, aged 6 to 59 months, were tested for Cryptosporidium spp. Among the children with diarrhea 8.4% were Cryptosporidium spp. positive compared with a prevalence rate of 5.9% in asymptomatic children. Of the children living in a household with a Cryptosporidium spp.-positive index child, 8.6% had a positive stool sample. Of all children attending a clinic because of diarrhea, 14.6% were Cryptosporidium spp. positive. Cryptosporidiosis was more frequent in younger children; 24 of the total of 29 positive cases (83%) were below 2.5 years old. Actual or previous bottle feeding (formula) was a risk factor, particularly in children below 18 months old. Of the bottle-fed children, 28% were Cryptosporidium spp. positive versus 9.1% of children never bottle fed. Crowding is another possible risk factor. The prevalence of cryptosporidiosis was 13.5% in big urban households with more than 10 children, whereas the prevalence in the small urban households was 6.1%. Ethnic and religious differences were particularly evident in the rural area. No Muslim households had cryptosporidiosis, whereas the prevalence in non-Muslim tribes was 9%. The general belief that cryptosporidiosis is primarily a zoonosis is questioned in this study, partly because many carriers and asymptomatic household contacts were found.

Cryptosporidiosis. Case report in a health team worker

Cryptosporidium is a coccidial protozoan of the intestinal tract; cryptosporidiosis in veterinarians has been reported as a cause of diarrhea. It has also been reported as a cause of diarrhea in marrow transplant recipients. Cryptosporidiosis has gained attention recently because of its occurrence in patients with the acquired immune deficiency syndrome (AIDS). A healthy intensive care unit nurse who acquired cryptosporidiosis from a bone marrow transplant recipient with diarrhea caused by cryptosporidiosis is described. Results of laboratory examination, including T lymphocyte subsets, were normal. She was treated with bed rest and a liquid diet and her symptoms completely resolved after 15 days. Health care workers should be aware that cryptosporidiosis can be transmitted to them from patients and should follow precautions to avoid acquiring the disease.

Cryptosporidium plus Campylobacter: an outbreak in a semi-rural population

An outbreak of cryptosporidiosis in a circumscribed semi-rural population is described; some cases were infected concurrently with campylobacter. The results of a detailed case-control study and environmental surveillance are discussed.

Acquired immune deficiency syndrome. A perspective for the medical practitioner

AIDS is a new disease process with complications and management problems unlike anything ever seen before. An attempt has been made to summarize the available information about its various clinical presentations and how to manage them. Subjects covered will include associated malignancies, infections, transmissibility, prodromal states, and infection control issues.

Cryptosporidium enterocolitis in homosexual men with AIDS

Two homosexual Danish men with the acquired immunodeficiency syndrome (AIDS) contracted cryptosporidium enterocolitis. One patient died in another opportunistic infection, the other developed severe chronic enterocolitis with malabsorption. The cryptosporidia escape detection on routine stool examination, but are easily demonstrated by a modified Ziehl-Neelsen stain. It is suggested that this procedure should be applied when persons from AIDS high risk groups or patients with other forms of immunological incompetence develop prolonged diarrhoea.

AIDS and the gut

The epidemiological, immunological and early virological observations on the acquired immune deficiency syndrome (AIDS) suggested that an agent was involved which was sexually, parenterally and perinatally transmitted and perhaps tropic for T helper lymphocytes. A new subgroup of human T lymphotropic retroviruses have been identified ans seroepidemiological studies suggest that they are aetiologically related to AIDS. The syndrome is characterised by the development of tumors: such as Kaposi's sarcoma and non-Hodgkins lymphoma, with an aggressive clinical course and infection by a wide spectrum of opportunistic organisms. Both the tumours and the infections commonly involve the gut.