Hepatobiliary complications in patients with human immunodeficiency virus infection

Hepatic Involvement in Acquired Immunodeficiency Syndrome-Associated Kaposi's Sarcoma: A Descriptive Analysis on CT, MRI, and Ultrasound

Purpose

To retrospectively analyse the different imaging manifestations of acquired immunodeficiency syndrome-associated hepatic Kaposi's sarcoma (AIDS-HKS) on CT, MRI, and Ultrasound.

Patients and Methods

Eight patients were enrolled in the study. Laboratory tests of liver function were performed. The CT, MRI, and Ultrasound manifestations were reviewed by two radiologists and two sonographers, respectively. The distribution and imaging signs of AIDS-HKS were evaluated.

Results

AIDS-HKS patients commonly presented multiple lesions, mainly distributed around the portal vein on CT, MRI, and Ultrasound. AIDS-HKS presented as ring enhancement in the arterial phase on contrast-enhanced CT and MRI scanning, and nodules gradually strengthen in the portal venous phase and the delayed phase. AIDS-HKS presented as intrahepatic bile duct dilatation and bile duct wall thickening around the lesion. Five patients (62.5%, 5/8) were followed up. After chemotherapy, the lesions were completely relieved (60.0%), or decreased (40.0%).

Conclusion

AIDS-HKS presented as multiple nodular lesions with different imaging features. The combination of different imaging methods was helpful for the imaging diagnosis of AIDS-HKS.

HIV Infection Predisposes to Increased Chances of HBV Infection: Current Understanding of the Mechanisms Favoring HBV Infection at Each Clinical Stage of HIV Infection

Human immunodeficiency virus (HIV) selectively targets and destroys the infection-fighting CD4+ T-lymphocytes of the human immune system, and has a life cycle that encompasses binding to certain cells, fusion to that cell, reverse transcription of its genome, integration of its genome into the host cell DNA, replication of the HIV genome, assembly of the HIV virion, and budding and subsequent release of free HIV virions. Once a host is infected with HIV, the host’s ability to competently orchestrate effective and efficient immune responses against various microorganisms, such as viral infections, is significantly disrupted. Without modern antiretroviral therapy (ART), HIV is likely to gradually destroy the cellular immune system, and thus the initial HIV infection will inexorably evolve into acquired immunodeficiency syndrome (AIDS). Generally, HIV infection in a patient has an acute phase, a chronic phase, and an AIDS phase. During these three clinical stages, patients are found with relatively specific levels of viral RNA, develop rather distinctive immune conditions, and display unique clinical manifestations. Convergent research evidence has shown that hepatitis B virus (HBV) co-infection, a common cause of chronic liver disease, is fairly common in HIV-infected individuals. HBV invasion of the liver can be facilitated by HIV infection at each clinical stage of the infection due to a number of contributing factors, including having identical transmission routes, immunological suppression, gut microbiota dysbiosis, poor vaccination immune response to hepatitis B immunization, and drug hepatotoxicity. However, there remains a paucity of research investigation which critically describes the influence of the different HIV clinical stages and their consequences which tend to favor HBV entrenchment in the liver. Herein, we review advances in the understanding of the mechanisms favoring HBV infection at each clinical stage of HIV infection, thus paving the way toward development of potential strategies to reduce the prevalence of HBV co-infection in the HIV-infected population.

Beyond pyogenic liver abscess: a comprehensive review of liver infections in emergency settings

Hepatobiliary infections are commonly encountered in emergency settings ranging from common pathology such as pyogenic abscess to relatively uncommon and rare etiologies. Since extensive literature is already available on imaging of more common bacterial infections, for the sake of focused discussion, this review will discuss radiological appearance of less commonly encountered hepatic infections of fungal, parasitic, viral, and tubercular etiologies. Epidemiological and clinical information remain extremely important for obtaining more accurate presumptive diagnosis. In the era of diverse population migration, a modern-era radiologist must be well versed about the imaging spectrum of liver infections.

A Case of Cryptococcal Hepatitis in an HIV Patient with a Negative Serum Cryptococcal Antigen

Infectious Cryptococcus neoformans occurs primarily in immunocompromised patients. The primary organ affected is the lungs, but the infection of the central nervous system (CNS) is also be seen. Disseminated cryptococcosis can involve any organ in the body. However, hepatic involvement is rare. Here we discuss a case of cryptococcal hepatitis in a patient who presented with persistently elevated liver enzymes. A 56-year-old Ecuadorian female with no known past medical history presented with fever, abdominal pain, nausea, unintentional weight loss, and diarrhea for two months. Her liver function tests (LFTs) revealed elevated aspartate aminotransferase (AST: 415 U/L), elevated alanine aminotransferase (ALT: 201 U/L), elevated alkaline phosphatase (ALP: 763 U/L), but normal total bilirubin (0.9 mg/dl). Her HIV antigen screening was reactive, and the absolute cluster of differentiation 4 (CD4) helper count was 22 cell/µL. Over the course of her hospital stay, the patient's liver enzymes continued to trend upward, with negative Histoplasma antibodies and negative serum cryptococcal antigen titers. During the second week of hospitalization, her liver enzymes continued to rise with an ALP of 4046 U/L, AST of 436 U/L, and ALT of 276 U/L. With a persistent elevation of the liver enzymes without any definitive cause, an ultrasound-guided biopsy was performed. Pathology revealed cryptococcal hepatitis, and the patient was started on a 15-day course of amphotericin B with an eight-week course of fluconazole 400 mg with LFTs nearly normalizing at six weeks. This case demonstrates an unusual manifestation of cryptococcosis. Our patient did not present with the typical cryptococcal pulmonary or central nervous system infection. Additionally, our patient's serum cryptococcal antigen titers were negative, but biopsy results revealed cryptococcal hepatitis, despite a very high sensitivity and specificity of the serum cryptococcal antigen test. This case demonstrates the importance of maintaining a broad differential, specifically in immunocompromised patients.

A Rare Case of Disseminated Mycobacterium avium-intracellulare Presenting as Proctitis

Mycobacterium avium intracellulare (MAI) infections are common in Human Immuno-deficiency Virus (HIV) positive patients. MAI infection can have localized or disseminated presentation, patients with low CD4 count presenting with disseminated infection. Fever, abdominal pain, diarrhea, and weight loss are generally the presenting symptoms of disseminated MAI. We present a rare case of a patient with HIV and low CD4 count presenting with proctitis as manifestation of disseminated MAI infection. A 25 year-old-man with HIV came to the emergency room (ER) with complaints of intermittent rectal bleeding for two months. His CD4 count was less than 20 cells/µL. He was MSM (men having sex with men) and has receptive anal intercourse with men. His stool work-up was unrevealing for infectious etiology. Swabs for gonorrhea and chlamydia were negative. Colonoscopy revealed erythematous, congested, friable rectal mucosa with two superficial ulcers. Biopsies of the ulcer were positive for acid fast staining bacteria and the culture grew MAI. His blood culture was negative for growth of acid-fast bacteria (AFB). However, liver biopsy performed for elevated alkaline phosphatase of 958 units/L revealed noncaseating granuloma. Gastro-duodenoscopy with duodenal biopsy did not reveal any mucosal abnormality. He was managed as with disseminated MAI infection using clarithromycin, ethambutol, and rifabutin in addition to HAART therapy. Interval Colonoscopy in 20 months showed resolution of rectal ulcer. The gut is often involved in patients with disseminated MAI infection, with the duodenum being the most common site. MAI infection should be suspected as possible etiology for proctitis in HIV positive patient with low CD4 count, as proctitis, though infrequent can be the sole presentation for disseminated MAI infection in patients with HIV and low CD4 count.

Human Immunodeficiency Virus Infection, Antiretroviral Therapy, and Liver Pathology

The improvement in antiretroviral therapy has significantly impacted the lives of people living with human immunodeficiency virus (HIV). In high-income countries, HIV deaths are predominated by liver disease consequent to viral hepatitis coinfection, alcohol, and nonalcoholic fatty liver disease. Published liver pathology findings have shifted from being predominated by opportunistic infections to the metabolic effects of HIV and antiretroviral therapy as well as drug-induced liver injuries. Differences remain between high-income and low-income countries, where opportunistic infections and immune reconstitution syndromes, dominate findings.

Prevalence of and progression to abnormal noninvasive markers of liver disease (aspartate aminotransferase-to-platelet ratio index and Fibrosis-4) among US HIV-infected youth

OBJECTIVE

To longitudinally characterize noninvasive markers of liver disease in HIV-infected youth.

DESIGN

HIV infection, without viral hepatitis coinfection, may contribute to liver disease. Noninvasive markers of liver disease [FIB-4 (Fibrosis-4) and APRI (aspartate aminotransferase-to-platelet ratio index)] have been evaluated in adults with concomitant HIV and hepatitis C, but are less studied in children.

METHODS

In prospective cohorts of HIV-infected and HIV-uninfected youth, we used linear regression models to compare log-transformed FIB-4 and APRI measures by HIV status based on a single visit at ages 15-20 years. We also longitudinally modeled trends in these measures in HIV-infected youth with two or more visits to compare those with behavioral vs. perinatal HIV infection (PHIV) using mixed effect linear regression, adjusting for age, sex, body mass index, and race/ethnicity.

RESULTS

Of 1785 participants, 41% were men, 57% black non-Hispanic, and 27% Hispanic. More HIV-infected than uninfected youth had an APRI score more than 0.5 (13 vs. 3%, P < 0.001). Among 1307 HIV-infected participants with longitudinal measures, FIB-4 scores increased 6% per year (P < 0.001) among all HIV-infected youth, whereas APRI scores increased 2% per year (P = 0.007) only among PHIV youth. The incidence rates (95% confidence interval) of progression of APRI to more than 0.5 and more than 1.5 were 7.5 (6.5-8.7) and 1.4 (1.0-1.9) cases per 100 person-years of follow-up, respectively. The incidence of progression of FIB-4 to more than 1.5 and more than 3.25 were 1.6 (1.2-2.2) and 0.3 (0.2-0.6) cases per 100 person-years, respectively.

CONCLUSION

APRI and FIB-4 scores were higher among HIV-infected youth. Progression to scores suggesting subclinical fibrosis or worse was common.

HIV infection of hepatocytes results in a modest increase in hepatitis C virus expression in vitro

Previous studies demonstrate that soluble HIV proteins impact both hepatocyte function and HCV replication in vitro. It has also been reported that HIV can productively infect hepatocytes. We therefore investigated the impact of HIV infection of hepatocytes on HCV expression. The Huh7.5_JFH1 cell line that constitutively expresses infectious HCV was infected with the lab-adapted strains HIV_NL4-3 or HIV_YK-JRCSF. HCV expression was quantified via HCV core antigen ELISA, Western blot, and strand-specific real-time PCR for positive-sense and negative-sense HCV RNA. After HIV_NL4-3 infection of Huh7.5_JFH1 cells, positive-sense and negative-sense HCV RNA levels were elevated compared to HIV uninfected cells. Increased HCV RNA synthesis was also observed after infection of Huh7.5_JFH1 cells with HIV_YK-JRCSF. HIV-induced HCV core production was decreased in the presence of the anti-HIV drugs AZT, T20, and raltegravir, although these medications had a minimal effect on HCV expression in the absence of HIV. HCV core, NS3, and NS5A protein expression were increased after HIV infection of Huh7.5_JFH1 cells. Chemically inactivated HIV had a minimal effect on HCV expression in Huh7.5_JFH1 cells suggesting that ongoing viral replication was critical. These data demonstrate that HIV induces HCV RNA synthesis and protein production in vitro and complement previous in vivo reports that HCV RNA levels are elevated in individuals with HIV/HCV co-infection compared to those with HCV mono-infection. These findings suggest that HIV suppression may be a critical factor in controlling liver disease, particularly if the underlying liver disease is not treated.

Low-level HIV infection of hepatocytes

BACKGROUND

There are only limited data on whether HIV infection occurs within the liver; therefore, we explored early and late stages of the HIV life cycle in two hepatocyte cell lines--Huh7.5 and Huh7.5JFH1--as well as in primary human hepatocytes.

RESULTS

Integrated HIV DNA was detected in Huh7.5 and Huh7.5JFH1 cells, as well as in primary hepatocytes, and was inhibited by the integrase inhibitor raltegravir in a dose-dependent manner. HIV p24 protein was also detected in cell culture supernatants at days 1, 3, 5, and 7 post-infection and was inhibited by AZT, although levels were modest compared to those in a lymphocyte cell line. Culture supernatants from HIV-infected hepatocytes were capable of infecting a non-hepatic HIV indicator cell line.

CONCLUSIONS

These results indicating low-level HIV replication in hepatoctyes in vitro complement evidence suggesting that HIV has deleterious effects on the liver in vivo.

Cryptic parasite revealed improved prospects for treatment and control of human cryptosporidiosis through advanced technologies

Cryptosporidium is an important genus of parasitic protozoa of humans and other vertebrates and is a major cause of intestinal disease globally. Unlike many common causes of infectious enteritis, there are no widely available, effective vaccine or drug-based intervention strategies for Cryptosporidium, and control is focused mainly on prevention. This approach is particularly deficient for infections of severely immunocompromised and/or suppressed, the elderly or malnourished people. However, cryptosporidiosis also presents a significant burden on immunocompetent individuals, and can, for example have lasting effects on the physical and mental development of children infected at an early age. In the last few decades, our understanding of Cryptosporidium has expanded significantly in numerous areas, including the parasite life-cycle, the processes of excystation, cellular invasion and reproduction, and the interplay between parasite and host. Nonetheless, despite extensive research, many aspects of the biology of Cryptosporidium remain unknown, and treatment and control are challenging. Here, we review the current state of knowledge of Cryptosporidium, with a focus on major advances arising from the recently completed genome sequences of the two species of greatest relevance in humans, namely Cryptosporidium hominis and Cryptosporidium parvum. In addition, we discuss the potential of next-generation sequencing technologies, new advances in in silico analyses and progress in in vitro culturing systems to bridge these gaps and to lead toward effective treatment and control of cryptosporidiosis.

HIV variability in the liver and evidence of possible compartmentalization

There is growing evidence to suggest that HIV may interact with several hepatic cell types; however, evaluation of HIV variability in liver tissue has not been addressed to date. Among 16 HIV-positive individuals examined, nine (56%) had detectable HIV RNA in the liver. The mean CD4 cell count for these nine individuals was 337 cells/mm(3) (range: 0-601), while their mean plasma HIV RNA level was 106,974 copies/ml (range: 1200-320,740). Among individuals in this study with detectable HIV in both the plasma and the liver, the consensus gag nucleotide sequences for each tissue type were different for seven of seven (100%) individuals, while amino acid sequences were distinct for five of seven (71%). Consensus envelope (env) nucleotide and amino acid sequences were also distinct in the plasma and liver tissue for six of six (100%) individuals. Statistical evidence of compartmentalization between HIV in the plasma and in the liver was demonstrated, and multiple liver-specific amino acids were identified that may distinguish HIV variants replicating within the liver. These preliminary data demonstrate that HIV is frequently detectable in the liver of HIV-positive persons at various levels of immunosuppression. Possible compartmentalization may reflect tissue-specific selection pressures that drive viral adaptation to the liver microenvironment and may facilitate interactions with other hepatotropic viruses.

HIV mono-infection is associated with FIB-4 - A noninvasive index of liver fibrosis - in women

BACKGROUND

FIB-4 represents a noninvasive, composite index that is a validated measure of hepatic fibrosis, which is an important indicator of liver disease. To date, there are limited data regarding hepatic fibrosis in women.

METHODS

FIB-4 was evaluated in a cohort of 1227 women, and associations were evaluated in univariate and multivariate regression models among 4 groups of subjects classified by their human immunodeficiency virus (HIV) and hepatitis C virus (HCV) infection status.

RESULTS

The median FIB-4 scores were 0.60 in HIV-/HCV- women, 0.83 in HIV-/HCV+ women, 0.86 in HIV+/HCV- women, and 1.30 in HIV+/HCV+ women. In the HIV/HCV co-infected group, multivariate analysis showed that CD4(+) cell count and albumin level were negatively associated with FIB-4 (P <.0001), whereas antiretroviral therapy (ART) was positively associated with FIB-4 score (P =.0008). For the HIV mono-infected group, multivariate analysis showed that CD4(+) cell count (P <.0001) and albumin level (P =.0019) were negatively correlated with FIB-4 score, ART was positively associated with FIB-4 score (P =.0008), and plasma HIV RNA level was marginally associated with FIB-4 score (P =.080). In 72 HIV mono-infected women who were also hepatitis B surface antigen negative, ART naive, and reported no recent alcohol intake, plasma HIV RNA level was associated with increased FIB-4 score (P =.030).

CONCLUSIONS

HIV RNA level was associated with increased FIB-4 score in the absence of hepatitis B, hepatitis C, ART, or alcohol use, suggesting a potential relationship between HIV infection and hepatic fibrosis in vivo. A better understanding of the various demographic and virologic variables that contribute to hepatic fibrosis may lead to more effective treatment of HIV infection and its co-morbid conditions.

[Intraabdominal infection in inmunodepressed patients]

Diseases of the gastrointestinal system frequently complicate immunosuppressed patients. Endogenous flora is the principal source of infection in humans, especially in patients with dysfunction of the digestive epithelial barrier due to various factors. Bacterial translocation, traumatisms, ischemia and surgery are frequent events in the general population. In addition, important risk factors for abdominal infections in specific patients include tumoral infiltration, mucositis complicating chemotherapy and/or radiotherapy, hypoproteinemia, neutropenia and lymphocyte deficiency. Clinical pictures vary according to patients' baseline condition and the environmental setting, including nosocomial infections. The differential clinical characteristics of abdominal infections observed in distinct types of immunosuppressed patients are reviewed.

Liver disease in the HIV-infected individual

Since the advent of effective antiretroviral therapy (ART) for human immunodeficiency virus-1 (HIV), there has been a substantial decrease in deaths related to acquired immunodeficiency syndrome (AIDS). However, in the ART era, liver disease is now the most common non-AIDS-related cause of death among HIV-infected patients, accounting for 14%-18% of all deaths in this population and almost half of deaths among hospitalized HIV-infected patients. Just as the burden of non-AIDS morbidity and mortality has changed in the ART era, the types of liver disease the clinician is likely to encounter among these patients have changed as well. This review will discuss the causes of liver disease in the HIV-infected population in the ART era, including chronic hepatitis C virus, chronic hepatitis B virus, medication-related hepatotoxicity, alcohol abuse, nonalcoholic fatty liver disease, and AIDS-related liver diseases.

Prevalence and factors associated with liver test abnormalities among human immunodeficiency virus-infected persons

BACKGROUND & AIMS

Liver disease is a major cause of morbidity and mortality among human immunodeficiency virus (HIV)-infected persons. We evaluated the prevalence, etiology, and factors associated with liver dysfunction in patients during the highly active antiretroviral therapy era.

METHODS

We performed liver tests (baseline and after a 6-month follow-up period) in HIV-infected patients treated at a large clinic. Comprehensive laboratory and ultrasound analyses were performed. Factors associated with liver test abnormalities were assessed using multivariate logistic regression models.

RESULTS

Eighty of 299 HIV-positive patients (27%) had abnormal liver test results during the 6-month study period. The majority of abnormalities were grade 1. Of those with liver test abnormalities, the most common diagnosis was nonalcoholic fatty liver disease (30%), followed by excessive alcohol use (13%), chronic hepatitis B (9%), chronic active hepatitis C (5%), and other (hemochromatosis and autoimmune hepatitis, 2%); 8 participants (10%) had more than 1 diagnosis. In total, 39 HIV patients with abnormal liver test results (49%) had a defined underlying liver disease. Despite laboratory tests and ultrasound examination, 41 abnormal liver test results (51%) were unexplained. Multivariate analyses of this group found that increased total cholesterol levels (odds ratio, 1.6 per 40-mg/dL increase; P = .01) were associated with liver abnormalities.

CONCLUSIONS

Liver test abnormalities are common among HIV patients during the highly active antiretroviral therapy era. The most common diagnosis was nonalcoholic fatty liver disease. Despite laboratory and radiologic investigations into the cause of liver dysfunction, 51% were unexplained, but might be related to unrecognized fatty liver disease.

Clinical significance of enteric protozoa in the immunosuppressed human population

Globally, the number of immunosuppressed people increases each year, with the human immunodeficiency virus (HIV) pandemic continuing to spread unabated in many parts of the world. Immunosuppression may also occur in malnourished persons, patients undergoing chemotherapy for malignancy, and those receiving immunosuppressive therapy. Components of the immune system can be functionally or genetically abnormal as a result of acquired (e.g., caused by HIV infection, lymphoma, or high-dose steroids or other immunosuppressive medications) or congenital illnesses, with more than 120 congenital immunodeficiencies described to date that either affect humoral immunity or compromise T-cell function. All individuals affected by immunosuppression are at risk of infection by opportunistic parasites (such as the microsporidia) as well as those more commonly associated with gastrointestinal disease (such as Giardia). The outcome of infection by enteric protozoan parasites is dependent on absolute CD4(+) cell counts, with lower counts being associated with more severe disease, more atypical disease, and a greater risk of disseminated disease. This review summarizes our current state of knowledge on the significance of enteric parasitic protozoa as a cause of disease in immunosuppressed persons and also provides guidance on recent advances in diagnosis and therapy for the control of these important parasites.

Minireview: clinical cryptosporidiosis

Cryptosporidium has emerged as an important cause of diarrhoeal illness worldwide, especially amongst young children and patients with immune deficiencies. Usually presenting as a gastro-enteritis-like syndrome, disease ranges in seriousness from mild to severe and signs and symptoms depend on the site of infection, nutritional and immune status of the host, and parasite-related factors. Sources and routes of transmission are multiple, involving both zoonotic and anthroponotic spread, and facilitated by the resistance of the parasite to many commonly used disinfectants. Prevention and control measures are important for the protection of vulnerable groups since treatment options are limited. This review covers the life cycle, pathogenesis, clinical presentations, diagnosis, prevention and management of cryptosporidiosis in humans.

Cryptosporidium parvum-associated sclerosing cholangitis in a liver transplant patient

Cryptosporidium parvum causes severe long-standing diarrhea in immunocompromised patients. Sclerosing cholangitis caused by C. parvum is a rare complication in transplant recipients. We report herein the presentation of Cryptosporidium-associated cholangitis in an adult liver transplant patient diagnosed by liver biopsy. The patient improved on treatment with azithromycin and paromomycin.

Hemobilia caused by cytomegalovirus cholangiopathy

A 57-yr-old male on long-term steroid therapy presented with hematemesis, fever, and a retroperitoneal fluid collection. Hemobilia was diagnosed, but the cause was not identified by ERCP, computed tomography, or angiography. Peroral cholangioscopy revealed multiple biliary ulcers. Cholangioscopic biopsies diagnosed cytomegalovirus (CMV) infection. Intravenous ganciclovir therapy was initiated, and was associated with cessation of bleeding. Biliary CMV disease is rare in HIV-negative persons, but should be considered in a patient with unexplained hemobilia. Cholangioscopy may be useful for diagnosis.

[Secondary sclerosing cholangitis in a patient with acquired immunodeficiency syndrome treated by common hepatic duct plasty by the laparoscopic route]

We report the case of a patient with obstructive jaundice caused by sclerosing cholangitis secondary to acquired immunodeficiency syndrome. In acquired immunodeficiency syndrome-related cholangiopathy, patients present with right upper quadrant or epigastric pain, fever, diarrhea and characteristic biliary alterations. The patient was submitted to transverse plasty of the common hepatic duct by laparoscopic route.

Factors that complicate the treatment of tuberculosis in HIV-infected patients

Treatment of tuberculosis (TB) in persons coinfected with HIV has become increasingly complex during the past decade. We describe the factors that complicate anti-TB therapy in a large observational cohort of HIV-infected persons in the United States. Among 367 HIV-infected patients with 372 episodes of culture-confirmed TB, 44.1% had injection drug use as a mode of HIV transmission. Hepatic disease was present at the time of TB diagnosis or during anti-TB therapy for 91 episodes (24.5%). Elevation at least twice the upper limits of normal of aminotransaminases was observed during the first month of anti-TB therapy in 116 (31.2%) of the episodes. The most commonly reported adverse effects occurring during therapy were rash (27.8%), nausea (26.2%), leukopenia or neutropenia (20.2%), diarrhea (19.3%), vomiting (18.5%), and elevated temperature (>101.5 degrees F [38.6 degrees C], 16.9%). Prescription of a rifamycin and a medication known to interact with rifamycins occurred during 270 (72.6%) episodes. Because HIV-infected patients with TB often have underlying complicating conditions, such as hepatic disease, and are treated with medications that may have toxicities and cause drug-drug interactions, we recommend that clinicians pay careful attention to these factors when treating coinfected patients.

Hepatopulmonary Syndrome in HIV--Hepatitis C Virus Coinfection: A Case Report and Review of the Literature

A wide array of diagnoses must be considered when a patient with advanced liver disease and human immunodeficiency virus (HIV) infection presents with hypoxemia. It is important to entertain the possibility of hepatopulmonary syndrome (HPS) in such patients, a diagnosis that must be confirmed with a contrast-enhanced echocardiogram (bubble study). We describe a case of HPS diagnosed in a patient with HIV infection and chronic liver disease and review the literature on HPS.

AIDS cholangiopathy

AIDS is an advanced disease with systemic and infectious complications that can be fatal. When a patient with AIDS presents with right upper quadrant or midepigastric pain, cholestasis, and symptoms of cholangitis, AIDS cholangiopathy should be suspected and appropriate diagnostic and therapeutic interventions should be initiated. Opportunistic infections such as Cryptosporidium and cytomegalovirus are the most common cause of AIDS cholangiopathy. Four distinct cholangiographic abnormalities have been demonstrated by endoscopic retrograde cholangiopancreatography, the most common being papillary stenosis with sclerosing cholangitis. Antimicrobial therapy is often ineffective. Highly active antiretroviral therapy may enhance immune function and offers the best medical therapy to clear the opportunistic infections. Ursodeoxycholic acid has a limited benefit in patients with sclerosing cholangitis and cholestasis. Endoscopic sphincterotomy has been shown to relieve pain and biliary obstruction in patients with papillary stenosis. Balloon dilation of strictures and stent placement decompress the biliary system and may be helpful. Cholecystectomy is recommended to treat acalculous cholecystitis, and celiac plexus block may be offered to patients with terminal disease and intractable abdominal pain.

Cholestasis in HIV-infected patients

Cholestasis is frequently observed in the HIV-infected population and can be caused by drugs, such as highly active antiretroviral therapy (HAART) and antimicrobial agents, and by opportunistic infections of the liver. Less common causes such as HIV-related malignancies or biliary tract disease are also encountered. Most disorders respond to medical management, but patient outcome was often dictated by the stage of the HIV infection and concomitant illnesses in the pre-HAART era. Prompt recognition and specific treatment may improve the outcome for these patients in the HAART era.

Ultrasonography

Diagnostic sonography is experiencing a breath-taking period of technological advancement. Ultrasound contrast agents, new imaging techniques, and handheld instruments will play a role in facilitating more diagnostic power in high-end imaging and insuring more widespread use of diagnostic sonography in medicine in general.

Some aspects of protozoan infections in immunocompromised patients- a review

Protozoa are among the most important pathogens that can cause infections in immunocompromised hosts. These microorganisms particularly infect individuals with impaired cellular immunity, such as those with hematological neoplasias, renal or heart transplant patients, patients using high doses of corticosteroids, and patients with acquired immunodeficiency syndrome. The protozoa that most frequently cause disease in immunocompromised patients are Toxoplasma gondii, Trypanosoma cruzi, different Leishmania species, and Cryptosporidium parvum; the first two species cause severe acute meningoencephalitis and acute myocarditis, Leishmania sp. causes mucocutaneous or visceral disease, and Cryptosporidium can lead to chronic diarrhea with hepatobiliary involvement. Various serological, parasitological, histological and molecular methods for the diagnosis of these infections are currently available and early institution of specific therapy for each of these organisms is a basic measure to reduce the morbidity and mortality associated with these infections.

Biliary giardiasis in a patient with human immunodeficiency virus

A 41-year-old man with human immunodeficiency virus (HIV) (CD4 count, 446/mm3) developed a protracted course of abdominal pain, weight loss, and increasing liver function tests after undergoing a metronidazole treatment regimen for Giardia enteritis. Three months later, endoscopic retrograde cholangiography (ERCP) showed dilated common and intrahepatic bile ducts and luminal irregularities of the common bile duct. Seven months after the onset of his acute diarrhea, a repeat ERCP with aspiration demonstrated many Giardia trophozoites and cysts in the bile and continued structural abnormalities consistent with cholangiopathy. A 10-day course of high-dose intravenous metronidazole did not resolve these signs or symptoms. A gallbladder ultrasound showed a thickened wall. Laparoscopic cholecystectomy led to resolution of abdominal pain and normalization of serum alkaline phosphatase over an 8-month period. Gallbladder histopathology revealed chronic cholecystitis, but no parasites were seen on hematoxylin and eosin staining or with Giardia antigen enzyme immunoassay testing of the gallbladder. The patient refused to undergo a follow-up ERCP, but a right upper quadrant ultrasound and computed tomography of the abdomen were normal.

Jaundice and hepatocellular damage associated with nevirapine therapy

OBJECTIVE

Nevirapine is a nonnucleoside reverse transcription inhibitor that is used as part of highly active antiretroviral therapeutic combinations. Nevirapine has been associated with a skin rash in 32 to 48% of patients. Recent reports indicate that hepatic toxicity also occurs.

METHODS

We describe four instances of reversible hepatocellular damage associated with the use of nevirapine in patients with HIV infection. Two of the four patients were also coinfected with the hepatitis C virus.

RESULTS

Evidence of malaise, skin rash, and icteric hepatitis with pruritus occurred 4-6 wk after the beginning of nevirapine therapy. No evidence of metabolic acidosis was present in any of our patients. In all cases, liver test results declined to normal or near normal levels, and pruritus disappeared 4-6 wk after discontinuation of the medication. No patient was rechallenged with the drug.

CONCLUSION

Nevirapine can be associated with icteric hepatitis, which appears to be reversible after withdrawal of the drug.

Infections of the liver in HIV-infected patients

The liver is a common site of pathology in HIV-infected patients. In patients with controlled HIV and minimal immunosuppression, infection with hepatitis viruses is common owing to the risk factors of sexual transmission or parenteral drug use. In patients with AIDS, the liver is a common site of lymphohematogenous dissemination of several infectious pathogens. A thorough diagnostic approach leads to a diagnosis of most hepatobiliary processes. The therapeutic nihilism that has surrounded hepatic disease, including viral hepatitis, is unwarranted, because treatment of the underlying HIV and the hepatic process may improve the quality of life and longevity of these patients.

Mortality for liver disease in patients with HIV infection: a cohort study

We undertook this study to assess the association between the various potential causes of liver disease in HIV-seropositive patients and mortality due to liver failure. Three hundred and eight in-hospital deaths were observed from 1987 to December 1995 in a prospectively followed cohort of 1894 HIV-seropositive patients. For each study subject, clinical data were evaluated to assess whether liver failure had substantially contributed to mortality. A case control study nested in the cohort was then performed, which compared demographic and clinical variables observed at enrollment and during follow-up between patients who died for liver disease as the main or concurrent cause of death (cases) and those who died as a result of illness related to AIDS or other causes (controls). Among 308 in-hospital deaths, liver failure was found the cause of death in 35 patients (12%); in 16 cases, it was the primary cause and in 19 cases it was concurrent. Multivariate analysis showed that in-hospital liver-disease-related mortality was independently associated with hepatitis B surface antigen reactivity (odds ratio [OR], 9; 95% confidence interval [CI], 3.8-21.7) and history of alcohol abuse (OR, 2.3; 95% CI, 1-5.2). Prevention and treatment of hepatitis B virus infection and alcohol intake are management priorities in HIV-seropositive patients.

Postoperative jaundice

Postoperative jaundice is often multifactorial (Fig. 2). A precipitating or causative factor may be identified but seldom can a specific therapy be offered. A systematic approach will help eliminate a hepatotoxic drug or identify a biliary tract problem. Treatment involves discontinuation of an offending drug; however, the drug, such as an anesthetic agent, may not be in use when the jaundice is detected. Recognition of an anesthetic-induced injury would certainly warn the physician not to repeat its use in future surgery for that patient. Hyperalimentation may contribute to jaundice, but patients developing postoperative jaundice are generally very ill and require nutrition. Extrahepatic biliary tract disease should be readily recognized and treated. The physician should be alert to the possibility of acalculous cholecystitis so that it can be appropriately diagnosed and treated.

Cholangiopathy in HIV-infected patients

HIV cholangiopathy is a disease of advanced-stage AIDS that presents with biliary symptoms and anicteric cholestasis. An abnormal ultrasound examination in a patient with low CD4 count is evaluated by endoscopic retrograde cholangiopancreatography, which demonstrates the characteristic cholangiographic abnormalities. Besides being the gold standard for diagnosis, it offers therapeutic intervention and possible pain relief in the presence of papillary stenosis. An infectious pathogen is identifiable in a majority of patients, suggesting infection-related damage to the biliary tree. Anti-infective therapy, however, usually is ineffective, and prognosis is related to the underlying stage of AIDS.

Gastrointestinal complications in the intensive care unit

Pathologic conditions affecting the abdomen are a significant cause of morbidity and mortality in the intensive care unit, but their importance is not widely recognized. This article presents several aspects of abdominal pathology that can occur in intensive care unit patients. This pathology may have a considerable impact on the prognosis and survival of the critically ill patient. The diagnostic contribution of laboratory tests and imaging is discussed. Conditions such as the abdominal compartment syndrome, acute mesenteric ischemia, gastrointestinal bleeding, diarrhea, abdominal sepsis, complications of entereal and parenteral nutrition, and ileus in critically ill patients are also reviewed.

Biliary Problems in People with HIV Disease

Acute cholecystitis in a patient with HIV infection represents a difficult diagnostic problem. With improved antiretroviral therapy, many of the biliary problems we have seen in these patients are identical to those in nonimmunosuppressed patients (ie, they are largely caused by gallstones). The indication for cholecystectomy is usually right upper quadrant abdominal pain that has been persistent for weeks to months. Although cholecystectomy will result in pain relief in many patients, the presence of coexisting HIV cholangiopathy in about half these patients increases the likelihood of ongoing symptoms. Patients should be counseled that postoperative endoscopic retrograde cholangiopancreatography (ERCP) may be necessary and that some of the variants of HIV cholangiopathy do not respond to endoscopic therapy. The high perioperative mortality in these patients is not related to biliary tract disease but is rather a manifestation of severe underlying disease associated with advanced HIV infection. HIV cholangiopathy represents a complication of severe immunosuppression. Patients are generally in poor condition and often have coexisting infections or malignancies. The decision regarding how aggressively to approach a patient with suspected HIV cholangiopathy, a nonfatal condition, is best made with consideration of the degree of pain being reported. All patients should undergo an abdominal ultrasound, with ERCP being offered to those with severe or debilitating pain and who are found to have dilated bile ducts suggesting papillary stenosis. Should this finding be confirmed at cholangiography, sphincterotomy is effective palliation for abdominal pain in most cases. ERCP is considerably less useful in patients who have elevated liver enzyme levels without symptoms; there is only a small likelihood of identifying an infection not previously recognized or better diagnosed noninvasively. These patients do not generally benefit from sphincterotomy. The regular use of ERCP in patients with HIV for the evaluation of elevated liver enzyme levels is to be discouraged, because the very limited potential benefit of the procedure does not outweigh the risks.

Diagnostic usefulness of percutaneous liver biopsy in HIV-infected patients with fever of unknown origin

OBJECTIVES

to determine the value of percutaneous liver biopsy (PLB) in the diagnosis of fever of unknown origin (FUO) in HIV-infected patients and establish a prediction model for its usefulness to enable diagnosis of FUO in these patients to be standardized.

METHODS

a total of 58 HIV-infected patients who underwent PLB for the evaluation of FUO were studied at 'Carlos Haya' Hospital in Malaga, Spain. The patients were classified into three groups, according to the results of the PLB: (a) diagnostic PLB (when a definitive diagnosis was obtained); (b) helpful PLB (the tissue sample showed suggestive, but not definitive, findings); and (c) normal or non-specific PLB (no contribution to diagnosis, the findings being normal or irrelevant). Multivariate analysis was made to establish a prediction model for the diagnostic usefulness of PLB, calculating the positive (PPV) and negative (NPV) predictive values.

RESULTS

PLB was carried out in 58 HIV-infected patients during diagnosis of FUO. Risk factors for HIV infection included intravenous drug use (72.4%), homosexual or bisexual activities (12.1%), and heterosexual transmission (15.5%). Fifty-two out of 58 patients (89.6%) had previous AIDS-defining illnesses. The mean CD4 lymphocyte count +/-SD was 56.4+/-80.9/mm3. The mean duration of fever was 43 days. Diagnosis could be established in 51 (87.9%) patients, with tuberculosis (50%) and leishmaniasis (20.7%) being the most common. The PLB was diagnostic in 25 cases (43.1%), helpful in 13 (22.4%), and normal or non-specific in the remaining 20 (34.5%). Biopsy-associated complications occurred in two cases. The presence of hepatomegaly or splenomegaly were the most useful factors in predicting the usefulness of the PLB, with a PPV of 86.1% and NPV of 68.2%. In patients with tuberculosis, an increased alkaline phosphatase and hepatomegaly had a PPV of 86.4% and a NPV of 71.4%.

CONCLUSIONS

PLB is a useful technique for the diagnosis of FUO in HIV-infected persons. Early PLB should be considered in those patients with hepatosplenomegaly and increased alkaline phosphatase levels.

Findings and benefit of liver biopsies in 46 patients infected with human immunodeficiency virus

AIMS

The aim of this work is to evaluate the role of liver biopsy and to determine the histological findings in patients infected with the human immunodeficiency virus (HIV) who have abnormal liver function tests (LFT).

METHODS

We performed a percutaneous liver biopsy in 46 HIV-seropositive patients with abnormal LFT. Parts of biopsied tissue were used for bacterial and fungal culture and the rest was processed for histological examination including special staining.

RESULTS

Of these 46 patients, 41 patients were males and five were females. The median age was 31+/-6 years. Mycobacterium tuberculosis was the most common histological finding (15 cases). Of 15 tuberculosis patients, 11 (73.3%) had lymphadenopathy and positive acid-fast bacilli (AFB) in node aspiration or biopsy. The other findings included AFB-negative granuloma (eight cases), histoplasmosis (six cases), cryptococcosis (six cases), penicillosis (four cases), viral hepatitis: hepatitis C virus (HCV; one case), hepatitis B virus and HCV infection (one case), fatty liver (two cases), drug-induced hepatitis (one case) and non-specific changes (five cases). There were double infections in three patients. We were able to demonstrate opportunistic infections in 41 cases (89.3%).

CONCLUSIONS

Mycobacterium tuberculosis was the most common histological finding in HIV patients with abnormal LFT in Thailand. Liver biopsy was a useful procedure in evaluating abnormal LFT in HIV patients.

Clinical utility of liver biopsy in children with acquired immunodeficiency syndrome

BACKGROUND

Little is known about hepatic histology in children with AIDS, although the liver is frequently involved in the course of HIV infection. The clinical utility of liver biopsy in these patients is not well-defined. We reviewed retrospectively the results of this procedure in a group of infected children better to delineate its indications.

PATIENTS AND METHODS

Eighteen children with AIDS underwent liver biopsy in our institution. The indications were unexplained fever in eight children, six of whom had an elevated erythrocyte sedimentation rate and clinical suspicion of mycobacterial infection; jaundice in four; suspicion of drug toxicity (dideoxyinosine) in two; discussion of treatment for chronic hepatitis B in three; suspicion of cytomegalovirus infection in one who had also AIDS cholangiopathy.

RESULTS

Of the six children thought to have mycobacterial infection, two had the disease on biopsy, both of whom had abnormal liver enzymes. The children with unexplained fever had nonspecific findings, except for one with lymphoid interstitial pneumonitis who had a dense lymphoid infiltrate. Of the four with jaundice two had extensive necrosis caused by adenovirus infection in one and suspected herpes simplex infection in the other. The other two with jaundice had unexplained findings, severe necrosis and fibrosis in one case and hemophagocytosis in the other one; both improved clinically. Both children with suspected dideoxyinosine hepatotoxicity had nonspecific findings. The three children with chronic hepatitis B had mild lesions that were not an indication for treatment.

CONCLUSIONS

Liver biopsy appeared to be useful in two groups of selected children with AIDS: when there is strong clinical suspicion of mycobacterial infection; and when the child is jaundiced.

Clinical correlates of human immunodeficiency virus (HIV)-related immunosuppression

Opportunistic infections and cancers, collectively referred to as opportunistic diseases (OD), occur with increasing frequency as HIV-related immunosuppression advances. Knowledge of an individual's degree of immunosuppression, as measured by his or her CD4 cell count, will assist a clinician in constructing a differential diagnosis to account for a given clinical presentation. Likewise, the correlation of an individual's immunosuppression with their symptoms will enable a radiologist to assist a clinician in determining which radiological studies are most likely to lead to a diagnosis.

Acalculous cholecystitis and septicemia caused by non-O1 Vibrio cholerae: first reported case and review of biliary infections with Vibrio cholerae

The first case of septicemic acute acalculous cholecystitis caused by non-O1 Vibrio cholerae is described in a healthy traveler, and biliary tract infections from V. cholerae are reviewed. Immediately after a vacation in Cancun, Mexico, a 55-year-old man developed acute cholecystitis. Blood and bile cultures grew non-O1 V. cholerae. At surgery, the gallbladder was acalculous, inflamed, distended, and nearly ruptured. Pathogenetic factors may have included diarrhea prophylaxis with bismuth subsalicylate, distension of the gallbladder from illness-induced fasting, and bacterial toxins in the gallbladder. The patient received i.v. cephapirin, followed by oral cephradine for a total of 10 days, and he made a quick and complete recovery. V. cholerae should be considered in the differential diagnosis of persons from endemic areas who present with cholecystitis or acute jaundice.

Fever of unknown origin in the HIV-infected patient: new scenario for an old problem

Many conditions may present as fever of unknown origin in the HIV-infected patient, and their relative frequency is influenced by multiple factors. The history and physical examination may provide some useful clues for the diagnosis. Haematological, biochemical, and conventional radiological tests are rarely diagnostic; even serological and/or microbiological tests have some limitations in these patients. The geographical setting and the local prevalence of diseases are of the utmost importance. Infections that have a world-wide distribution, such as tuberculosis, should be intensively searched for, particularly in areas of high prevalence. The measurement of the CD4+ cell count is essential, as there is a strong association between this count and certain opportunistic diseases that may manifest as fever of unknown origin. Imaging procedures, such as CT and radionuclide scans, are useful for the location of inflammatory and neoplastic lesions. Liver and bone marrow biopsies are helpful in certain subsets of patients and the efficacy of empirical treatments has been clearly documented in certain infections. Some HIV-infected patients with fever of unknown origin remain undiagnosed after a thorough investigation; these individuals should be managed conservatively. Finally, symptomatic treatment is the best option for terminally ill patients in whom benefit from a detailed investigation of the cause of fever is not expected.

Diagnosis and treatment of hepatic disease in patients with HIV

Liver involvement with opportunistic infections and neoplasms is a well-recognized component of AIDS, affecting most patients. The cause of hepatic disease in these patients may be divided into hepatitis, granulomatous disease, mass lesions, vascular lesions, hepatotoxic drugs, and nonspecific findings. With a rational approach, most patients with AIDS and liver disease can be diagnosed and treated in a cost-effective manner with low morbidity.