Endoscopy in acquired immunodeficiency syndrome patients with diarrhea and negative stool studies

Cytomegaloviral colitis in HIV positive patients: endoscopic findings

BACKGROUND

Diarrhea in seropositive human immunodeficiency virus patients is one of the most important and disabling symptoms, and often decreases their quality of life. Cytomegalovirus colitis is among the principal causes of this symptom and colonoscopy is the gold standard examination to diagnose it.

AIM

To define the main endoscopic findings in seropositive human immunodeficiency virus patients with cytomegalovirus colitis.

METHODS

Two hundred and forty-three colonoscopies were performed in 200 seropositive human immunodeficiency virus patients with diarrhea associated or not to abdominal pain or gastrointestinal bleeding, over 10-year period, whom 51 patients were diagnosed with cytomegalovirus colitis. Full length colonoscopy with ileum intubation was always tried and multiple biopsies of all segments examined, including endoscopically normal segments, were attempted. All diagnoses were confirmed by histologic and immunohistochemical studies.

RESULTS

Total colonoscopy was possible in 98.03% and ileum intubation in 88.23% of these cytomegalovirus colitis patients. At colonoscopy, a heterogeneous ulcerative pattern was presented in 72.54%, an inflammatory process of the mucosa in 21.56% and 5.88% of the patients mucosa was endoscopically normal.

CONCLUSION

Full length colonoscopy with ileum intubation and multiples biopsies of all segments, even when they are endoscopically normal, have always to be attempted in cases of seropositive human immunodeficiency virus patient with diarrhea.

Prevalence of Intestinal Infection due to Cryptosporidium Species Among Taiwanese Patients with Human Immunodeficiency Virus Infection

BACKGROUND/PURPOSE

Cryptosporidiosis causes significant morbidity and mortality in human immunodeficiency virus (HIV)-infected patients who do not receive highly active antiretroviral therapy. Related data on cryptosporidiosis in Taiwanese HIV-infected patients are very limited. This study assessed the prevalence of intestinal infection due to Cryptosporidium spp. among Taiwanese patients with HIV infection.

METHODS

This retrospective review included 1044 patients with HIV infection treated between June 1994 and June 2004. Intestinal colonization due to Cryptosporidium spp. was identified by polymerase chain reaction and restriction fragment length polymorphism of stool specimens collected from 332 of the HIV-infected patients without gastrointestinal symptoms, 90% of whom were receiving highly active antiretroviral therapy.

RESULTS

Five out of 1044 (0.5%) HIV-infected patients had a diagnosis of intestinal cryptosporidiosis by endoscopic biopsy or examinations of stool specimens. Intestinal colonization due to Cryptosporidium spp. was found in four of 332 (1.2%) asymptomatic HIV-infected patients between 2001 and 2003; two were due to C. hominis, and one each were due to C. felis and C. meleagridis.

CONCLUSION

Our findings indicate that the prevalence of intestinal colonization due to Cryptosporidium is low among HIV-infected patients in Taiwan.

A case of systemic lupus erythematosus complicated by alveolar hemorrhage and cytomegalovirus colitis

We report a rare case of systemic lupus erythematosus (SLE) complicated by alveolar hemorrhage and cytomegalovirus (CMV) colitis. Despite the successful treatment of lupus nephritis by steroid pulse therapy, the patient developed an acute alveolar hemorrhage 2 months later. Cyclophosphamide pulse therapy ameliorated the hemorrhage. One month later, she suddenly developed melena secondary to CMV colitis. Antiviral therapy was successful. We emphasize the importance of timely and precise differential diagnosis for successful management of complicated SLE.

Segmental coecal cytomegalovirus colitis during fludarabine, cytarabine and mitoxantrone induction chemotherapy for myelodysplastic syndrome

We report the case of a 59-year-old woman treated for a refractory anemia with excess blasts (RAEB) who developed cytomegalovirus (CMV) colitis during induction therapy combining fludarabine, cytarabine and mitoxantrone. CMV infection occurred rarely during cytarabine and anthracyclin based induction therapy for acute myelogenous leukemia or RAEB. CMV infection is usually observed in immunocompromised patients but some cases have been recently observed in patients after autologous stem-cell transplantation with or without CD34 + stem-cell selection. We discuss this case and issues arising from it in relation to the use of combination of high-dose cytarabine and fludarabine.

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.

Gastrointestinal infections in the immunocompromised host

The gastrointestinal tract is a common site of infection in the opportunistic host. Pathogens range from highly virulent organisms, which infect people with well functioning immune systems as well as people with poorly functioning immune systems, to opportunistic organisms, which infect only those with impaired immune systems. Viruses, bacteria, fungi, and protozoa lead to disease that can be especially severe, debilitating, and difficult to treat in the immunocompromised host. Yet in this era of highly active antiretroviral therapy for HIV-infected patients and strategies to reduce immunosuppression in transplant and oncology patients, appropriate diagnostic tests and treatment can both improve the quality of life and decrease mortality. In this article, I review the changing pathogenesis, epidemiology, clinical presentation, diagnosis, and treatment of gastrointestinal infections in the immunocompromised host.