AGA technical review: malnutrition and cachexia, chronic diarrhea, and hepatobiliary disease in patients with human immunodeficiency virus infection

Multimethodological Approach to Gastrointestinal Microsporidiosis in HIV-Infected Patients

PURPOSE

Microsporidiosis is an opportunistic infection that produces chronic diarrhoea and cholangiopathy in patients with AIDS, mainly caused by two species of microsporidia, Enterocytozoon bieneusi and Encephalitozon intestinalis. The aim of this work was to develop an integral system for the diagnosis of microsporidiosis of the intestine and biliary tract in HIV-infected patients, comprising microscopic and molecular techniques.

METHODS

The study population comprised 143 adult patients of both sexes with diagnosis of HIV infection, with chronic diarrhoea, and with or without HIV-associated cholangiopathy. Stool studies for microsporidia identification of spores were performed on each patient. A video esofagogastroduodenoscopy with biopsy collection was also carried out for routine histology and semi-thin sections stained with Azure II. Species identification was carried out by transmission electron microscopy and/or polymerase chain reaction for the species E. bieneusi and E. intestinalis.

RESULTS

Out of the 143 patients a total of 12.6% (n = 18) were infected with microsporidia. Microsporidia species identified in most cases was E. bieneusi (16/18 cases), followed by E. intestinalis (4/18), all of these last ones in coinfection with E. bieneusi.

CONCLUSIONS

Clinical, imaging, microscopic and molecular analyses, when applied in a systematic and integrated approach, allow diagnosis and identification of microsporidia at species level in AIDS patients with chronic diarrhoea, and with or without HIV-associated cholangiopathy.

The investigation of patients with HIV infection: 10 years of progress

The past decade has seen great advances in the management of patients with HIV infection. The introduction of highly active antiretroviral therapy (HAART) has resulted in a decrease in opportunistic infections but the development of new clinical entities such as lipodystrophy and immune reconstitution illnesses. The use of investigations such as lipid profiles and dual energy X-ray absorptiometry (DEXA) scanning to assess lipodystrophy have been necessitated by these changes in the epidemic. Technological advances have resulted in new techniques such as viral resistance assays and single photon emission computed tomography (SPECT) scanning. The appropriate use of these investigations is subject to ongoing assessment.

Bacterial resistance and immunological profiles in HIV-infected and non-infected patients at Mbouda AD LUCEM Hospital in Cameroon

This study investigated the variations in some cells of the immune system, as well as the antibiotic resistance of the bacteria responsible for enteric infections among HIV+ patients compared to HIV- patients in Mbouda AD LUCEM Hospital, Cameroon. A cross-sectional study was performed from September 2014 to February 2015 in 67 human immunodeficiency virus (HIV)-seropositive (HIV+) and 37 HIV-seronegative (HIV-) patients. Blood collected from these patients was used to perform cluster of differentiation 4 (CD4) and cluster of differentiation 8 (CD8) lymphocyte blood counts and a white blood cell count, as well as to measure C-reactive protein (CRP) blood by flow cytometry and perform optical and immuno-turbidimetric detection. Enteric bacteria were isolated from the stool of patients, and their antibiotic susceptibility profiles were determined using agar diffusion methods. The results showed that Escherichia coli was the main pathogenic bacteria in the digestive tracts of HIV+ (85.3%) and HIV- (81.1%) patients, and infections with Klebsiella sp. were also predominant among HIV- patients (29.4%). Resistance of Klebsiella sp. to ceftriaxone (CRO; P=0.001), gentamicin (GEN; P=0.005), chloramphenicol (CHL; P=0.0004), ciprofloxacin (CIP; P=0.005) and doxycycline (DOX; P<0.0001) was significantly higher in HIV+ patients than in HIV- patients. Enterobacter sp. showed high resistance to GEN (P=0.009) and CIP (P=0.001) in HIV+ patients compared to HIV- patients. Citrobacter sp. was resistant to GEN (P=0.009) in HIV+ patients compared to HIV- patients. Salmonella sp. showed high resistance to CHL (P<0.0001) and DOX (P<0.0001) in HIV+ patients compared to HIV- patients. Resistance of Serratia sp. to AMO (P=0.005), AMC (P=0.005) and CHL (P=0.005) was significantly higher in HIV+ patients than in HIV- patients. Lymphopenia was higher in HIV+ patients (36.8%) than in HIV- patients (2.7%). In 45.9% of the HIV- patients, the CRP rate was higher than 6mg/L compared to 16.2% in HIV+ patients. In general, bacterial multi-drug resistance in HIV+ patients (79.4%) was significantly higher (P<0.0001) than in HIV- patients (29.7%). The present study revealed that the resistance profiles of bacteria should be considered in HIV-infected patients to improve their health care.

Curcumin and its analogues: a potential natural compound against HIV infection and AIDS

No safe and effective cure currently exists for human immunodeficiency virus (HIV). However, antiretroviral therapy can prolong the lives of HIV patients and lowers the secondary infections. Natural compounds, which are considered to be pleiotropic molecules, could be useful against HIV. Curcumin, a yellow pigment present in the spice turmeric (Curcuma longa), can be used for the treatment of several diseases including HIV-AIDS because of its antioxidant, anti-inflammatory, anticancer, antiviral, and antibacterial nature. In this review we have summarized that how curcumin and its analogues inhibit the infection and replication of viral genes and prevent multiplicity of HIV. They are inhibitors of HIV protease and integrase. Curcumin also inhibits Tat transactivation of the HIV1-LTR genome, inflammatory molecules (interleukins, TNF-α, NF-κB, COX-2) and HIV associated various kinases including tyrosine kinase, PAK1, MAPK, PKC, cdk and others. In addition, curcumin enhances the effect of conventional therapeutic drugs and minimizes their side effects.

Sexually transmitted proctitis

There are many different sexually transmitted infections that can cause proctitis. Recognition of the common symptoms with anoscopic examination is crucial in accurate diagnosis of the pathogen. Clinicians should have a high index of suspicion of more than one inciting pathogen. Treatment should be prompt and extended to sexual partners who have been exposed to the disease. Effective treatment can alleviate the discomfort and potentially serious complications associated with sexually transmitted proctitides. This article illustrates and discusses the clinical presentations, diagnostic pearls, and treatments of sexually transmitted proctitides.

Sensitization of enteric neurons to morphine by HIV-1 Tat protein

BACKGROUND

Gastrointestinal (GI) dysfunction is a major cause of morbidity in acquired immunodeficiency syndrome (AIDS). HIV-1-induced neuropathogenesis is significantly enhanced by opiate abuse, which increases proinflammatory chemokine/cytokine release, the production of reactive species, glial reactivity, and neuronal injury in the central nervous system. Despite marked interactions in the gut, little is known about the effects of HIV-1 in combination with opiate use on the enteric nervous system.

METHODS

To explore HIV-opiate interactions in myenteric neurons, the effects of Tat ± morphine (0.03, 0.3, and 3 μM) were examined in isolated neurons from doxycycline- (DOX-) inducible HIV-1 Tat(1-86) transgenic mice or following in vitro Tat 100 nM exposure (>6 h).

KEY RESULTS

Current clamp recordings demonstrated increased neuronal excitability in neurons of inducible Tat(+) mice (Tat+/DOX) compared to control Tat-/DOX mice. In neurons from Tat+/DOX, but not from Tat-/DOX mice, 0.03 μM morphine significantly reduced neuronal excitability, fast transient and late long-lasting sodium currents. There was a significant leftward shift in V(0.5) of inactivation following exposure to 0.03 μM morphine, with a 50% decrease in availability of sodium channels at -100 mV. Similar effects were noted with in vitro Tat exposure in the presence of 0.3 μM morphine. Additionally, GI motility was significantly more sensitive to morphine in Tat(+) mice than Tat(-) mice.

CONCLUSIONS & INFERENCES

Overall, these data suggest that the sensitivity of enteric neurons to morphine is enhanced in the presence of Tat. Opiates and HIV-1 may uniquely interact to exacerbate the deleterious effects of HIV-1-infection and opiate exposure on GI function.

Ethnobotanical study of indigenous knowledge on medicinal and nutritious plants used to manage opportunistic infections associated with HIV/AIDS in western Uganda

ETHNOPHARMACOLOGICAL RELEVANCE

Traditional medicine plays an important role in the daily lives of the people of Uganda to treat a wide range of health problems. Our study presents results of an ethnobotanical inventory conducted to identify and document medicinal and nutritional plants used in the management of opportunistic infections associated with human immunodeficiency virus / acquired immunodeficiency syndrome (HIV/AIDS), the plant parts used, preparation and administration methods of herbal remedies.

MATERIALS AND METHODS

We performed semi-structured interviews with 79 respondents (women 78%, men 22%), who included specialists in medicinal plants (such as traditional birth attendants and herbalists) and non specialists with general knowledge of plant use. Respondents answered a semi-structured questionnaire regarding their knowledge of plants and general treatment practices including management of HIV/AIDS opportunistic infections. The reported plants were collected and identified. Data were analyzed using factor informant consensus and fidelity level to determine homogeneity of informants׳ knowledge on medicinal and nutritional plants suitable for different ailment categories and the most preferred plant species used to treat each ailment category in the study areas.

RESULTS

The study revealed 148 plant species belonging to 54 families, most of which were herbs (50.7%). Leaves (61.6%) were the most frequently used parts in remedy preparations which were mainly administered orally (72%). The majority of plants (62%) were harvested from wild habitats. The most important species according to fidelity values are Hibiscus sabdariffa L. for anaemia, Mangifera indica L. for cough, Zehneria scabra (L. F.) Sond. for skin infections, Rhus natalensis Bernh.ex.Krauss for diarrhoea and Tarenna pavettoides (Harv.) Sim for appetite boosting. The factor informant consensus highlighted the agreement in the use of plants and showed that the respiratory infections category had the greatest agreement (0.60). Family Asteraceae accounted for 15% of the total species recorded. Sixty plant species (40%) of the plants provide nutritional support.

CONCLUSION

The study revealed that folk medicine is still widely practised. Fidelity level values indicate that these plants are the most preferred species for particular ailments. The high consensus value (0.6) indicated that there was high agreement in the use of plants for respiratory ailments among others. These preferred plant species could be prioritized for conservation and subjected to chemical screening to ascertain their pharmacological activities.

Management of chronic diarrhea in HIV-infected patients: current treatment options, challenges and future directions

Diarrhea is a common clinical manifestation of HIV infection regardless of whether the patients have AIDS. HIV and malnutrition tend to occur in the same populations, the underprivileged and resource-poor. Malnutrition increases severity and mortality of infection. Occurrence of chronic diarrhea in HIV-infected patients, gut status and pathogenic agents, nutritional status and the crucial role of nutrition are reviewed. Bovine colostrum-based food can be useful for managing chronic diarrhea in HIV-infected patients, enhancing both nutritional and immunological status.

HIV/AIDS cholangiopathy: clinical spectrum, cholangiographic features and outcome in 30 patients

BACKGROUND AND AIMS

AIDS cholangiopathy is presently considered rare and has been reported mainly from the West. With the HIV epidemic in India, we have encountered an increasing number of patients. We aimed to study these patients and determine differences from earlier experiences.

METHODS

We describe the clinical presentation, cholangiographic features, and outcome and determine differences reported in Western literature.

RESULTS

From Jan 1999 to May 2009, 30 patients (27 men) with AIDS cholangiopathy were seen. The most common mode of transmission was heterosexual (n = 28) followed by blood transfusion (n = 2). Abdominal pain (n = 20) of biliary origin, was the commonest manifestation followed by an asymptomatic group (n = 6) and a third group (n = 3) with pain due to pancreatitis. Ultrasonography of the abdomen was abnormal in all patients. Papillary stenosis (n = 23) was the most common cholangiographic feature followed by sclerosing cholangitis (n = 5). Abdominal pain resolved reliably and promptly after endoscopic sphincterotomy. Cholangiographic abnormalities regressed during follow up on antiretroviral therapy in 10 patients. Seven patients on anti retroviral therapy developed de novo cholangiopathy, with a precipitous drop in CD4 count of whom two had a worse prognosis. None had Kaposi's sarcoma.

CONCLUSIONS

In contrast to Western literature, HIV cholangiopathy was seen predominantly in patients who acquired HIV by heterosexual transmission. De novo development of cholangiopathy on antiretroviral therapy may indicate the occurrence of resistance. Papillary stenosis is the most common feature. Abdominal pain resolved with sphincterotomy. Regression of cholangiographic abnormality occurred with anti retroviral medications. Median survival following cholangiopathy diagnosis was 34 months, higher than reported in previous studies.

Micronutrients and HIV infection

The immune system requires several essential micronutrients to maintain an effective immune response. HIV infection destroys the immune system and promotes nutritional deficiencies, which further impair immunity. This article reviews the role of several micronutrients (vitamins A, C, E and D, the B vitamins, and minerals, selenium, iron and zinc) that are relevant for maintaining immune function. In addition, the deficiencies of these micronutrients have been associated with faster progression of HIV-1 disease. This review examines the evidence from observational studies of an association between micronutrient status and HIV disease, as well as the effectiveness of micronutrient supplementation on HIV-disease progression, pregnancy outcomes and nutritional status, among others, utilizing randomized clinical trials. Each micronutrient is introduced with a summary of its functions in human physiology, followed by the presentation of studies conducted in HIV-infected patients in relation to this specific micronutrient. Overall findings and recommendations are then summarized.

Treatment of HIV-associated diarrhea with curcumin

Curcumin is the organic extract of turmeric and possesses known anti-inflammatory properties. Our aim was to explore the utility of curcumin in patients with HIV-associated diarrhea. Eight patients with HIV-associated diarrhea were given a mean daily dose of 1,862 mg of curcumin and followed for a mean of 41 weeks. All had resolution of diarrhea and normalization of stool quality in a mean time of 13 +/- 9.3 days. Mean number of bowel movements per day dropped from 7 +/- 3.6 to 1.7 +/- 0.5. Seven of eight patients had considerable weight gain on curcumin (10.8 +/- 8.9 lbs). Five of six patients had resolution of bloating and abdominal pain. Patients on anti-retroviral therapy experienced no discernible drug interactions, changes in CD(4) count, or changes in HIV viral load while taking curcumin. Curcumin therapy was associated with rapid and complete resolution of diarrhea, substantial weight gain, improvement in the reduction of bloating and abdominal pain.

Etiological agents of diarrhea in patients infected by the human immunodeficiency virus-1: a review

Despite the importance of understanding the epidemiology of agents responsible for infectious diarrhea in human immunodeficiency virus (HIV)/acquired immunodeficiency syndrome (AIDS) population, the number of articles about this subject is relatively few. The current article summarizes published data on bacterial, fungal, viral and parasitic enteropathogens in the HIV/AIDS seropositive subjects in different countries, regions and localities. In general, there is a great difference in the frequencies of etiological agents due to factors which include immune status, geographical location, climate and socioeconomic conditions. It is important to stress that a great prevalence of infection by emergent agents has been reported in the more advanced stages of AIDS. Therefore, to establish specific treatment depends directly on knowledge of these agents and risk factors associated to their distribution. Moreover, the colonization by potential pathogenic agents verified in these individuals is high thus implicating that they act as carriers. Finally, public health measures of control and prevention must take into consideration the regional previously identified enteropathogens, especially in areas where HIV prevalence is high.

Gastrointestinal opportunistic infections in human immunodeficiency virus disease

Gastrointestinal (GI) opportunistic infections (OIs) are commonly encountered at various stages of human immunodeficiency virus (HIV) disease. In view of the suppressive nature of the virus and the direct contact with the environment, the GI tract is readily accessible and is a common site for clinical expression of HIV. The subject is presented based on information obtained by electronic searches of peer-reviewed articles in medical journals, Cochrane reviews and PubMed sources. The spectrum of GI OIs ranges from oral lesions of Candidiasis, various lesions of viral infections, hepatobiliary lesions, pancreatitis and anorectal lesions. The manifestations of the disease depend on the level of immunosuppression, as determined by the CD4 counts. The advent of highly active antiretroviral therapy has altered the pattern of presentation, resorting mainly to features of antimicrobial-associated colitis and side effects of antiretroviral drugs. The diagnosis of GI OIs in HIV/acquired immunodeficiency syndrome patients is usually straightforward. However, subtle presentations require that the physicians should have a high index of suspicion when given the setting of HIV infection.

ColoPlus, a new product based on bovine colostrum, alleviates HIV-associated diarrhoea

OBJECTIVE

HIV-associated diarrhoea occurs in nearly all patients with acquired immunodeficiency syndrome (AIDS) in the developing countries. Diarrhoea is caused by the HIV-related immune dysfunction and is pivotal in the decrease of the helper T-cell (CD4 + ) population. Enteric pathogens in HIV-associated diarrhoea are, for example, Cryptosporidium, Amoeba and Campylobacter species. Bovine colostrum is the first milk the suckling calf receives from the cow. It is rich in immunoglobulins, growth factors, antibacterial peptides and nutrients. It supplies the calf with a passive immunity before its own active immunity is established. ColoPlus is a product based on bovine colostrum and is designed for slow passage through the gastrointestinal tract, as well as having a high nutritional value. The aim of the study was to investigate whether ColoPlus given orally can influence the severe diarrhoea associated with HIV infection.

MATERIAL AND METHODS

The study was carried out at Braithwaite Memorial Specialist Hospital, Port Harcourt, Nigeria. Thirty patients with HIV-associated diarrhoea were included in the study. The patients were treated with ColoPlus for 4 weeks in an open-labelled non-randomized study, after an observational period of one week. After a post-treatment period of another two weeks, treatment with anti-HIV drugs was started, if deemed appropriate. The effects on the frequency of stool evacuations per day, on body-weight, fatigue, haemoglobin levels and CD4+ counts before (week 1) and after treatment with ColoPlus (week 7) were measured.

RESULTS

There was a dramatic decrease in stool evacuations per day from 7.0+/-2.7 to 1.3+/-0.5 (+/-SD), a substantial decrease in self-estimated fatigue of 81%, an increase in body-weight of 7.3 kg per patient and an increase in CD4+ count by 125%.

CONCLUSION

ColoPlus may be an important alternative or additional treatment in HIV-associated diarrhoea.

Management of gastrointestinal disorders in children with HIV infection

A double scenario characterizes the epidemiology of HIV infection in children. In countries where highly active antiretroviral therapy (HAART) is available, the pattern of HIV infection is evolving into that of a chronic disease, for which control strictly depends on patients' adherence to treatment. In developing countries with no or limited access to HAART, AIDS is rapidly expanding and is loaded with a high fatality ratio, due to the combined effects of malnutrition and opportunistic infections. The digestive tract is a target of the disease in both settings. Opportunistic infections play a major role in children with severe immune impairment, with Cryptosporidium parvum being the leading agent of severe diarrhea. Several therapeutic approaches are effective in reducing fecal output, but the eradication of the parasite is rarely obtained. Other opportunistic infections may induce severe and protracted diarrhea, including atypical mycobacteria and cytomegalovirus. Diagnosis of diarrhea should be individually tailored based on presenting symptoms and risk factors. A stepwise approach is effective in limiting patient discomfort and minimizing the costs of investigations, starting with microbiologic investigation and proceeding with endoscopy and histology. Aggressive treatment of infectious diarrhea is required in severely immunocompromised children. However, antiretroviral therapy prevents the development of severe cryptosporidiosis. The liver and pancreas are also target organs in HIV infection, although functional failure is rare. The digestive-absorptive functions are impaired, with steatorrhea, nutrient malabsorption, and increased permeability occurring in 20-70% of children. Intestinal dysfunction contributes to growth failure and further immune derangement, leading to wasting, the terminal stage of AIDS. Nutritional management is crucial in HIV-infected children and is based on aggressive nutritional rehabilitation through enteral or parenteral routes and micronutrient supplementation.HIV may play a direct enteropathogenic role and is implicated in both diarrhea and intestinal dysfunction. This explains the efficacy of antiretroviral therapy in inducing remission of diarrhea and restoring intestinal function. Gastrointestinal side effects of antiretroviral drugs are increasingly observed; they are often mild and transient. Severe reactions are rare but require the withdrawal of drugs. In conclusion, severe enteric infections and intestinal dysfunction characterize the intestinal involvement of HIV infection. This is more common in, but not limited to, children who do not receive effective antiretroviral therapy. Diagnostic approaches include microbiologic and morphologic examinations and assessment of digestive processes, but immunologic and virologic data should be also carefully considered. Treatment is based upon specific anti-infectious drugs, antiretroviral therapy, and nutritional rehabilitation.

Increased risk of wasting syndrome in HIV-infected travellers: prospective multicentre study

HIV-infected patients from moderate regions who travel in tropical countries may experience clinical disease progression due to exposure to bacteria (including mycobacteria), fungi and parasites. In the Swiss HIV Cohort Study we examined the hypothesis that travelling increases the risk of tuberculosis, wasting syndrome, cryptosporidiosis, isosporiasis, cryptococcosis, coccidiomycosis, histoplasmosis and Salmonella septicaemia. A total of 4549 participants were included (in 1988-98) of whom 596 (13.1%) travelled at least once. During 16,800 person-years of follow-up 231 patients developed at least 1 of the diseases of interest. Wasting syndrome was the only diagnosis significantly associated with travelling (hazard ratio 2.16, 95% confidence interval 1.09 to 4.30). The risk of wasting syndrome ('slim disease') should be taken into account when counselling HIV-infected patients intending to travel in tropical regions.

Infectious diarrhea in human immunodeficiency virus

Chronic HIV-associated diarrhea is currently a field in flux. Improved noninvasive diagnostic tests, improved pathogen-specific regimens, and better empiric therapies may change some of the assumptions used to select algorithms for diagnostic evaluation and management. Any shift in the cause of diarrhea from pathogen-associated to idiopathic or a reduction in the overall incidence of diarrhea would have considerable impact. It is unclear how significant the problem of pathogen relapse in previous responders will become. Existing studies reviewed in this article show that the high diagnostic yield of endoscopy when stool tests are negative, coupled with significantly better outcomes when pathogens are identified, support the current practice of routine endoscopic evaluation. There currently are scant data on the economic impact of HIV-associated diarrhea as it relates to pathogen-specific and empiric therapy in the era of protease inhibitors. Such data would be integral to future evaluation of the impact of diagnostic and therapeutic strategies.

Small Intestinal Infections

The differential diagnosis of small intestinal infections is broad, making the identification and management of these disorders challenging. The majority of cases of acute diarrhea are self-limited and do not require diagnostic evaluation or treatment. Most patients do not require specific therapy, and treatment should focus on fluid and electrolyte replacement. In patients with severe, persistent, or chronic diarrhea, a careful medical history and routine stool testing are helpful in determining the cause. Pathogen-specific therapy should be given in patients in whom a pathogen is identified. In those without an identifiable pathogen, antidiarrheal agents are helpful in reducing the number of bowel movements and preventing further dehydration. Endoscopy may be helpful in patients with severe diarrhea and a negative stool evaluation, particularly in HIV-infected patients with chronic diarrhea. Surgery has a limited role in the management of small intestinal infections, but may be lifesaving in patients with intestinal perforation or small bowel obstruction.

The changing etiology of chronic diarrhea in HIV-infected patients with CD4 cell counts less than 200 cells/mm3

PURPOSE

The purpose of this study was to evaluate the incidence and causes of chronic diarrhea in patients with AIDS over a period of time that included the pre-HAART (highly active antiretroviral therapy) era and the introduction of HAART.

METHODS

The study cohort was comprised of patients receiving primary care at a university-associated outpatient HIV clinic from January 1, 1995 to December 31, 1997. Patients were identified retrospectively through a clinical database and were included in the study if their diarrhea had persisted for longer than two weeks and their CD4 cell count at time of symptoms was <200 cells/mm3. Further data were obtained by chart review.

RESULTS

Over the 36-month period, the occurrence of chronic diarrhea did not change significantly, ranging from 8 to 10.5% per year in patients with CD4 cell counts <200 cells/mm3. The percentage of patients diagnosed with opportunistic infectious etiologies decreased over the three-year period from 53% (1995) to 13% (1997). The percentage of patients diagnosed with noninfectious causes increased from 32% to 70% over this same time period.

CONCLUSIONS

Over the three years of the study, the incidence of chronic diarrhea in AIDS patients in our clinic did not change. The etiologies of diarrhea did change significantly, with an increased incidence of noninfectious causes and a decreased incidence of opportunistic infectious causes. This shift in etiologies coincides with the introduction and increased use of HAART in our clinic population (1996).

Outcome of AIDS-associated cytomegalovirus colitis in the era of potent antiretroviral therapy

The effect of protease inhibitors (PIs) on the outcome of AIDS-associated cytomegalovirus (CMV) colitis is unknown. The aim of this study was to determine the impact of PIs on the recurrence of CMV disease and long-term survival in a large cohort of acquired immunodeficiency syndrome (AIDS) patients with CMV colitis. We reviewed the medical records of 252 AIDS patients who were diagnosed with CMV colitis by colonoscopy between January 1992 and January 1997 at Bellevue Hospital (New York, NY, U.S.A.). Follow-up data were obtained from chart review and direct telephone contact. A complete response to ganciclovir and/or foscarnet therapy was seen in 87.0% of the patients. Recurrence of CMV colitis occurred in 53.1% of patients and was significantly less common in those who received maintenance therapy (36.1% vs. 56.7%; p = 0.03) and in those who were treated with PIs (22.8% vs. 71.9%; p < 0.001). During follow-up. 69.3% of patients died. Multivariate analysis using Cox regression showed that mortality was increased in patients with recurrent CMV colitis (relative risk [RR] of death, 1.7: 95% CI, 1.1-2.6; p = 0.02) and comorbid disease (RR, 1.5: 95% CI, 1.1-2.2; p = 0.02), and decreased in those who were treated with PIs (RR, 0.42; 95% CI, 0.3-0.7; p = 0.001). The median survival was 71 weeks and was significantly longer in patients who were treated with PIs than in those who did not receive these potent anti-retroviral medications (99 vs. 51 weeks; p < 0.001). PIs significantly improve the outcome of AIDS-associated CMV colitis.

Use of a chinese herbal medicine for treatment of hiv-associated pathogen-negative diarrhea

Background: Diarrhea is a frequent problem among persons with advanced HIV disease. In the absence of treatable pathogens, symptomatic relief is all that is available for current therapy. As a result, many patients with HIV and chronic diarrhea have turned to herbal formulas for treatment. We assessed the effectiveness and safety of a Chinese herbal formulation (Source Qi) in reducing the number of stools per day related to HIV-associated, pathogen-negative diarrhea. Methods: Sixteen male patients received treatment with Source Qi in an 8-week, open-label study. Patients tested negative for cryptosporidium and other gastrointestinal pathogens, and had chronic diarrhea, defined as having three or more loose stools/day for >/=14 days (and no other treatable causes for diarrhea). Measurements of diarrhea included numbers of bowel movements/day, abnormal bowel movements/day, and liquid bowel movements/day. Subjects completed daily stool diaries an average of 2 weeks before and up to 8 weeks after starting Source Qi. Paired Wilcoxon tests compared the last week before treatment with each week of treatment. Results: There was a reduction in average number of stools/day in each week of treatment (-0.2 to -0.8), except week 1 (+0.1), with improvements in weeks 2-6 approaching or reaching statistical significance. Conclusions: A modest but sustained decrease in average number of stools/day was observed in patients with HIV-associated, pathogen-negative diarrhea. The entry criteria, 2-week run-in period, lack of benefit in week 1, and sustained benefit thereafter all suggest that the improvement was not due to bias.

Impact of protease inhibitors on the outcome of human immunodeficiency virus-infected patients with chronic diarrhea

OBJECTIVE

The effect of protease inhibitors on the outcome of chronic HIV-related diarrhea is unknown. The aim of this study was to compare the response to treatment of chronic HIV-related diarrhea, recurrence of diarrhea, and survival in a large cohort of individuals taking protease inhibitors to the outcome in similar patients not receiving protease inhibitors.

METHODS

We reviewed the medical records of all patients referred between October 1993 and October 1996 at Bellevue Hospital for endoscopic evaluation of chronic HIV-related diarrhea after negative stool examination. Only patients presenting after December 1995 received protease inhibitor therapy. Follow-up data were obtained from chart review and direct telephone contact. The success of antidiarrheal therapy was compared between protease inhibitor and nonprotease inhibitor groups for patients receiving pathogen-specific therapy and for those with no pathogens found on endoscopy.

RESULTS

Two hundred eighty-two of 307 patients evaluated for chronic diarrhea were followed for a mean of 69.9+/-34.1 weeks. Patients receiving protease inhibitors had a significantly higher rate of successful response to antidiarrheal therapy (62.0% vs 33.5%, p < 0.001). Protease inhibitors were associated with a significant decrease in stool frequency (4.8+/-4.5 vs 3.4+/-4.6 bowel movements per day, p = 0.01), an increase in weight (2.4+/-5.9 vs -1.6+/-6.2 kg, p < 0.001), a decrease in recurrence of diarrhea (34.8% vs 15.3%, p = 0.02), and a longer mean survival (148 vs 118 weeks, p = 0.002).

CONCLUSIONS

Protease inhibitors significantly improve the outcome of antidiarrheal therapy and survival in patients with chronic HIV-associated diarrhea.

Acute diarrhea: a practical review

This review provides a practical, simple, and logical approach to the diagnosis and management of patients with acute infectious diarrhea, one of the most common diagnoses in clinical practice. Diarrhea in the immunocompromised host, traveler's diarrhea, and diarrhea in the hospitalized patient are also discussed. Most episodes of acute diarrhea are self-limited, and investigations should be performed only if the results will influence management and outcome. After an adequate history and physical examination, the clinician should be able to classify the acute diarrheal illness, assess the severity, and determine whether investigations are needed. Most patients do not require specific therapy. Therapy should mainly be directed at preventing dehydration. Various home remedies frequently suffice in mild, self-limited diarrhea. However, in large-volume, dehydrating diarrhea, oral rehydration solutions should be used, as they are formulated to stimulate sodium and water absorption. Antidiarrheal agents can be useful in reducing the number of bowel movements and diminishing the magnitude of fluid loss. The most useful agents are opiate derivatives and bismuth subsalicylate. Antibiotic therapy is not required in most patients with acute diarrheal disorders. Guidelines for their use are presented.

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.

Diagnostic yield and cost-effectiveness of endoscopy in chronic human immunodeficiency virus-related diarrhea

BACKGROUND

Endoscopy is commonly performed in patients with chronic human immunodeficiency virus (HIV)-related diarrhea after negative stool studies. The aim of this study was to determine the diagnostic yield and cost-effectiveness of endoscopy in this setting.

METHODS

Consecutive HIV-infected patients with chronic unexplained diarrhea who were referred for diagnostic endoscopy were identified. Patient charts, pathology reports, and endoscopy records were reviewed.

RESULTS

A total of 479 endoscopic procedures were performed in 307 patients. A pathogen was identified in 147 patients (47.9%); cytomegalovirus was the most frequent organism found (21.5%). The average cost of identifying a pathogen by endoscopy was $3822.94. Colonoscopy had a greater diagnostic yield than flexible sigmoidoscopy (38.7% vs. 22.4%, p = 0.009) and was more cost-effective. The yield of upper endoscopy was 29.6%. In patients with a CD4 count of less than 100/mm3, endoscopy had a higher diagnostic yield (62.8% vs. 8.3%, p < 0.0001) and a lower cost of identifying a pathogen ($2943.92 vs. $21,583.51) than in those with higher CD4 counts.

CONCLUSIONS

Endoscopy frequently identifies a pathogen in HIV-related chronic diarrhea. Colonoscopy is the most cost-effective procedure. Endoscopic evaluation has a significantly higher diagnostic yield and is considerably more cost-effective in patients with a CD4 count of less than 100/mm3 than in those with higher CD4 counts.

Comparison of duodenal with jejunal biopsy and aspirate in chronic human immunodeficiency virus-related diarrhea

OBJECTIVES

In human immunodeficiency virus (HIV)-infected patients with chronic unexplained diarrhea, upper endoscopy with small bowel biopsy and aspirate is often performed to identify treatable pathogens. The purpose of this study was to compare the diagnostic yield of duodenal with jejunal biopsy and aspirate.

METHODS

All HIV-infected patients with chronic unexplained diarrhea who were evaluated by upper endoscopy at Bellevue Hospital Center between January 1992 and January 1997 were identified. Data were collected by reviewing patient charts, endoscopy reports, and pathology records.

RESULTS

During the 5-yr study period, 442 patients underwent upper endoscopy with sampling of the duodenum (N=173) or jejunum (N=269). A pathogen was identified in 123 patients (27.8%). Microsporidia was the most common organism detected (12.2%). The diagnostic yield of jejunal biopsy and aspirate was significantly higher than that obtained from the duodenum (32.3% vs 20.8%, p=0.009). Small bowel aspirates detected a pathogen in only 1.8% of patients evaluated, and there was no difference in the yield of duodenal and jejunal aspirates (1.3% vs 2.1%, p=0.7). Patients with a CD4 count of < 100 cells/mm3 were significantly more likely to have a pathogen identified than those with higher CD4 counts (38.8% vs 7.1%,p < 0.0001).

CONCLUSIONS

Upper endoscopy with small bowel biopsy and aspirate identifies a pathogen in 27.8% of individuals with HIV-related chronic unexplained diarrhea. In this patient population, jejunal biopsies acquired by enteroscopy are superior to those obtained from the duodenum. Small bowel aspirates are of little value in the workup of chronic HIV-related diarrhea.

Hepatobiliary and pancreatic infections in AIDS: Part II

In the first part of our review, we discussed the general evaluation and clinical presentation of the various hepatic infections occurring in patients with AIDS. In addition, we focused on specific hepatic parenchymal infections. In this article, we will discuss the major clinical syndromes arising from opportunistic infections affecting the gallbladder (acalculous cholecystitis), biliary tree (AIDS-cholangiopathy), and pancreas (pancreatitis). Acalculous cholecystitis can develop in patients with AIDS who have not experienced the severe precipitating physiologic stresses normally required in patients without AIDS. The most common presentation is with right upper quadrant (RUQ) pain and tenderness. The diagnosis is a clinical one since there is no standard test, other than surgery. Cholecystectomy is the treatment of choice. The most common AIDS-associated infective complication of the biliary tree is AIDS-cholangiopathy. This is best viewed as a form of secondary sclerosing cholangitis resulting from a variety of opportunistic infections within the biliary tree. Affected persons present with RUQ pain and have marked elevations in the canalicular enzymes, alkaline phosphatase, and gamma-glutamyl transferase. Morphologic abnormalities are identified by endoscopic retrograde cholangiopancreatography. These include stricturing, dilatation, and beading of the biliary tract. Endoscopic sphincterotomy of the papilla of Vater may provide symptomatic relief for patients with papillary stenosis. Opportunistic infections within the pancreas gland have been documented in both pre- and postmortem studies. However, the true incidence of pancreatitis related to infections is unknown. The presentation is similar to that of pancreatitis from other causes. A computerized tomogram of the abdomen is the investigation of choice. Tissue aspiration or biopsy of the pancreas is required to demonstrate the presence of an opportunistic infection. The management is usually supportive, as it is rare that a specific infection is identified and treated.

A randomized controlled trial evaluating nutrition counseling with or without oral supplementation in malnourished HIV-infected patients

OBJECTIVE

To evaluate the effects of nutrition counseling with or without oral supplementation in malnourished patients infected with the human immunodeficiency virus (HIV).

DESIGN

Randomized controlled trial.

SUBJECTS

HIV-infected men (n=118) who were less than 90% of usual weight for height or who had lost more than 10% of body weight.

INTERVENTION

Nutrition counseling alone (control group) vs nutrition counseling plus enteral supplementation (supplement group) for 6 weeks. All patients were instructed to consume a diet that exceeded estimated total energy expenditure by 960 kcal/day.

MAIN OUTCOME MEASURES

Weight, skinfold thickness, fat-free mass, grip strength, quality of life, and cognitive function (Buschke test).

STATISTICAL ANALYSES

Differences in baseline variables and outcomes were evaluated using analysis of variance or the Wilcoxon rank sum test.

RESULTS

Ninety-nine men completed at least 4 weeks of treatment, 49 in the supplement group and 50 in the control group. Half the patients in each treatment group achieved at least 80% of their energy target. No differences in weight, skinfold thickness measurements, or quality of life were observed. Compared with the control group, the supplement group had larger increases in fat-free mass and grip strength, although the differences did not reach statistical significance.

APPLICATIONS

In the short term, nutrition counseling with or without oral supplementation can achieve a substantial increase in energy intake in about 50% of malnourished HIV-infected patients. Although further study is needed to evaluate long-term effects, these findings suggest that nutrition counseling has an important role in the management of malnourished HIV-infected patients.

Endoscopic evaluation of chronic human immunodeficiency virus-related diarrhea: is colonoscopy superior to flexible sigmoidoscopy?

OBJECTIVES

In patients with chronic human immunodeficiency virus (HIV)-related diarrhea undergoing lower endoscopy, the decision to perform flexible sigmoidoscopy or colonoscopy is controversial. The purpose of this study is twofold: 1) to evaluate the diagnostic yield of colonoscopy in a large group of patients with chronic HIV-related diarrhea and negative stool studies, and 2) to determine whether colonoscopy is superior to flexible sigmoidoscopy in this setting.

METHODS

All HIV-infected patients with chronic diarrhea who were referred for diagnostic colonoscopy at Bellevue Hospital Center between January 1992 and December 1996 were identified. Patient charts, pathology reports, and endoscopy records were reviewed.

RESULTS

During the 5-yr study period, 317 consecutive patients with chronic unexplained diarrhea undergoing colonoscopy were identified. A potential cause of diarrhea was found in 116 patients (36.6%). Cytomegalovirus was the most common pathogen detected (24%). The yield of colonoscopy was significantly higher in patients with a CD4 count of <100 cells/mm3 than in those with higher CD4 counts (44.8% vs 6.4%, p < 0.0001). Thirty percent of pathogens and 75% of lymphomas were identified only on biopsies taken from the proximal colon, well beyond the reach of the flexible sigmoidoscope. Importantly, 94% of the pathogens that were found only in the proximal colon were organisms for which effective therapy is currently available.

CONCLUSIONS

Colonoscopy is superior to flexible sigmoidoscopy in HIV-infected patients with chronic unexplained diarrhea. If flexible sigmoidoscopy had been performed instead of colonoscopy, 30% of pathogens would have been missed and 75% of lymphomas would have escaped detection.