1
|
Manthey CF, Epple HJ, Keller KM, Lübbert C, Posovszky C, Ramharter M, Reuken P, Suerbaum S, Vehreschild M, Weinke T, Addo MM, Stallmach A, Lohse AW. S2k-Leitlinie Gastrointestinale Infektionen der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS). ZEITSCHRIFT FUR GASTROENTEROLOGIE 2024; 62:1090-1149. [PMID: 38976986 DOI: 10.1055/a-2240-1428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/10/2024]
Affiliation(s)
- Carolin F Manthey
- I. Medizinische Klinik und Poliklinik - Schwerpunkt Gastroenterologie; Sektionen Infektions- und Tropenmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- Gemeinschaftspraxis Innere Medizin Witten, Witten, Deutschland
| | - Hans-Jörg Epple
- Antibiotic Stewardship, Vorstand Krankenversorgung, Universitätsmedizin Berlin, Berlin, Deutschland
| | - Klaus-Michael Keller
- Klinik für Kinder- und Jugendmedizin, Helios Dr. Horst Schmidt Kliniken, Klinik für Kinder- und Jugendmedizin, Wiesbaden, Deutschland
| | - Christoph Lübbert
- Bereich Infektiologie und Tropenmedizin, Medizinische Klinik I (Hämatologie, Zelltherapie, Infektiologie und Hämostaseologie), Universitätsklinikum Leipzig, Leipzig, Deutschland
| | | | - Michael Ramharter
- I. Medizinische Klinik und Poliklinik - Schwerpunkt Gastroenterologie; Sektionen Infektions- und Tropenmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Philipp Reuken
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie, Infektiologie, Zentrale Endoskopie), Universitätsklinikum Jena, Jena, Deutschland
| | - Sebastian Suerbaum
- Universität München, Max von Pettenkofer-Institut für Hygiene und Medizinische Mikrobiologie, München, Deutschland
| | - Maria Vehreschild
- Medizinische Klinik II, Universitätsklinikum Frankfurt, Frankfurt, Deutschland
| | - Thomas Weinke
- Klinik für Gastroenterologie und Infektiologie, Klinikum Ernst von Bergmann, Potsdam, Deutschland
| | - Marylyn M Addo
- I. Medizinische Klinik und Poliklinik - Schwerpunkt Gastroenterologie; Sektionen Infektions- und Tropenmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
- Institut für Infektionsforschung und Impfstoffentwicklung Sektion Infektiologie, I. Med. Klinik, Zentrum für Innere Medizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| | - Andreas Stallmach
- Klinik für Innere Medizin IV (Gastroenterologie, Hepatologie, Infektiologie, Zentrale Endoskopie), Universitätsklinikum Jena, Jena, Deutschland
| | - Ansgar W Lohse
- I. Medizinische Klinik und Poliklinik - Schwerpunkt Gastroenterologie; Sektionen Infektions- und Tropenmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Deutschland
| |
Collapse
|
2
|
Abadi T, Teklu T, Wondmagegn T, Alem M, Desalegn G. CD4 + T cell count and HIV-1 viral load dynamics positively impacted by H. pylori infection in HIV-positive patients regardless of ART status in a high-burden setting. Eur J Med Res 2024; 29:178. [PMID: 38494500 PMCID: PMC10946129 DOI: 10.1186/s40001-024-01750-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 02/26/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND There is a widespread co-infection of HIV and Helicobacter pylori (H. pylori) globally, particularly in developing countries, and it has been suggested that this co-infection may affect the course of HIV disease. However, the interplay between H. pylori infection and HIV disease progression is not fully elucidated. In this study, we investigated the effect of H. pylori co-infection on CD4+ T cell count and HIV viral load dynamics in HIV-positive individuals in a high co-endemic setting. METHODS A comparative cross-sectional study was conducted among 288 HIV-positive and 175 HIV-negative individuals, both with and without H. pylori infection. Among HIV-positive participants, 195 were on antiretroviral therapy (ART) and 93 were ART-naïve. CD4+ T cell count and HIV-1 viral load were measured and compared between H. pylori-infected and -uninfected individuals, taking into account different HIV and ART status. RESULT Our study demonstrated that individuals infected with H. pylori had a significantly higher CD4+ T cell count compared to uninfected controls among both HIV-negative and HIV-positive participants, regardless of ART therapy. Conversely, HIV/H. pylori co-infected participants had lower HIV-1 viral load than those without H. pylori infection. Linear regression analysis further confirmed a positive association between H. pylori infection, along with other clinical factors such as BMI, ART, and duration of therapy, with CD4+ T cell count while indicating an inverse relationship with HIV-1 viral load in HIV-positive patients. Additionally, factors such as khat chewing, age and WHO clinical stage of HIV were associated with reduced CD4+ T cell count and increased HIV-1 viral load. CONCLUSION Our study demonstrates that H. pylori co-infection was associated with higher CD4+ T cell count and lower HIV-1 viral load in HIV-positive patients, regardless of ART status. These findings show a positive effect of H. pylori co-infection on the dynamics of HIV-related immunological and virological parameters. Further studies are needed to elucidate the underlying mechanisms of the observed effects.
Collapse
Affiliation(s)
- Tesfay Abadi
- Department of Medical Laboratory Science, Adigrat University, Adigrat, Ethiopia
- Department of Immunology and Molecular Biology, University of Gondar, Gondar, Ethiopia
| | - Takele Teklu
- Department of Immunology and Molecular Biology, University of Gondar, Gondar, Ethiopia.
- School of Medical Laboratory Sciences, College of Health Sciences and Medicine, Wolaita Sodo University, Sodo, Ethiopia.
| | - Tadelo Wondmagegn
- Department of Immunology and Molecular Biology, University of Gondar, Gondar, Ethiopia
| | - Meseret Alem
- Department of Immunology and Molecular Biology, University of Gondar, Gondar, Ethiopia
| | - Girmay Desalegn
- Department of Medical Microbiology and Immunology, College of Health Sciences, Mekelle University, Mekelle, Ethiopia
| |
Collapse
|
3
|
Montalvo-Otivo R, Vilcapoma P, Murillo A, Mathey C, Olivera A, Veliz G, Estrella D. Evaluation of chronic diarrhea in patients newly diagnosed with HIV infection through the FilmArray® gastrointestinal panel. REVISTA DE GASTROENTEROLOGIA DE MEXICO (ENGLISH) 2024; 89:80-88. [PMID: 36890062 DOI: 10.1016/j.rgmxen.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/25/2022] [Accepted: 11/16/2022] [Indexed: 03/08/2023]
Abstract
INTRODUCTION The treatment and diagnosis of chronic diarrhea in the immunocompromised patient depends on the ability to rapidly detect the etiologic agents. AIMS Our aim was to evaluate the results of the FilmArray® gastrointestinal panel in patients newly diagnosed with HIV infection that presented with chronic diarrhea. MATERIAL AND METHODS Utilizing nonprobability consecutive convenience sampling, 24 patients were included that underwent molecular testing for the simultaneous detection of 22 pathogens. RESULTS In 24 HIV-infected patients with chronic diarrhea, enteropathogen bacteria were detected in 69% of the cases, parasites in 18%, and viruses in 13%. Enteropathogenic Escherichia coli and enteroaggregative Escherichia coli were the main bacteria identified, Giardia lamblia was found in 25%, and norovirus was the most frequent viral agent. The median number of infectious agents per patient was three (range of 0 to 7). The biologic agents not identified through the FilmArray® method were tuberculosis and fungi. CONCLUSIONS Several infectious agents were simultaneously detected through the FilmArray® gastrointestinal panel in patients with HIV infection and chronic diarrhea.
Collapse
Affiliation(s)
| | - P Vilcapoma
- Facultad de Medicina Humana, Universidad Continental, Huancayo, Peru
| | - A Murillo
- Servicio de Enfermedades Infecciosas, Hospital Daniel Alcides Carrión, Huancayo, Peru
| | - C Mathey
- Facultad de Medicina Humana, Universidad Continental, Huancayo, Peru
| | - A Olivera
- Facultad de Medicina Humana, Universidad Peruana Los Andes, Huancayo, Peru
| | - G Veliz
- Facultad de Medicina Humana, Universidad Peruana Los Andes, Huancayo, Peru
| | - D Estrella
- Servicio de Microbiología, Hospital Daniel Alcides Carrión, Huancayo, Peru
| |
Collapse
|
4
|
Montalvo-Otivo R, Vilcapoma P, Murillo A, Mathey C, Olivera A, Veliz G, Estrella D. Evaluación de la diarrea crónica en pacientes con reciente diagnóstico de infección por VIH mediante el panel gastrointestinal FilmArray®. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2023. [DOI: 10.1016/j.rgmx.2022.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
|
5
|
Verma A, Hine AM, Joelson A, Mei R, Pitts RA, Lebwohl B, Axelrad JE. The influence of hospitalization and HIV severity on gastrointestinal PCR panel evaluation of HIV-related acute diarrhea in New York City: a retrospective, cross-sectional study. Therap Adv Gastroenterol 2022; 15:17562848221092593. [PMID: 35509422 PMCID: PMC9058368 DOI: 10.1177/17562848221092593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Accepted: 03/18/2022] [Indexed: 02/04/2023] Open
Abstract
INTRODUCTION Diarrhea is common in persons living with HIV (PLWH)/AIDS. With the increasing utilization of multiplex gastrointestinal PCR panel (GI panel) testing, we aimed to characterize the roles of CD4 count and hospitalization in GI panel assessments of PLWH with acute diarrhea. METHODS We performed a cross-sectional study of adult PLWH with acute diarrhea who underwent GI panel testing at two urban academic centers. Demographic, HIV disease, GI panel result, and hospitalization data were collected, and patients were cohorted by CD4 count (CD4 < 200, CD4 200-499, CD4 > = 500). The primary outcome was enteric infection as detected by GI panel, and hospitalization. RESULTS Of 298 PLWH, 119 (39.9%) had a CD4 count below 200, 195 (65.4%) were hospitalized, and 137 (46.0%) had enteric infection. Bacterial infection correlated with higher CD4 count (41.9% (CD4 > = 500) vs 31.2% (CD4 200-499) vs 25.2% (CD4 < 200), p = 0.041). Hospitalization correlated with poorly controlled HIV and fewer enteric infections (34.4% vs 68.0%, p < 0.001). After adjusting for HIV disease severity, a negative GI panel remained independently associated with hospitalization (adjusted odds ratio (aOR) 5.32, 95% confidence interval (CI) 2.72-10.9), even in patients tested within 72 hours of hospitalization. Despite better HIV control, men who have sex with men (MSM) had more frequent infectious diarrhea, including from E. coli, giardiasis, and multiple pathogens. MSM status independently predicted enteric infection (aOR 1.93, 95% CI: 1.02-3.67). CONCLUSIONS GI panel results vary by HIV disease severity and hospitalization in PLWH. Clinicians - especially in the inpatient setting - should carefully consider these factors when interpreting GI panel results. Further characterization of diarrheal etiology in PLWH with a negative GI panel is needed. PLAIN LANGUAGE SUMMARY PCR stool test results are affected by certain factors in HIV-related diarrhea Diarrhea is common in people living with HIV (PLWH) and has a variety of causes, including infections, medications, and HIV itself. Multiplex polymerase chain reaction (PCR) stool testing simultaneously evaluates for a variety of common viral, bacterial, and parasitic infections of the gastrointestinal tract, and is increasingly being used in patients with diarrhea. However, patients with HIV and diarrheal illness may have uncommon infections not typically present in those with normal immune function - and thus not routinely evaluated for in stool testing. It is not known what factors, if any, might affect the results of PCR testing in HIV-related diarrhea.In this study, we examined all PLWH who underwent stool PCR testing for diarrhea over a 4-year period. We separated the patients into groups based on HIV disease severity as measured by CD4 T-cell count, or the count of the immune cells affected by HIV. We examined whether there were differences among groups in infection rates as detected by PCR stool testing. Separately, we studied the role of hospitalization in stool PCR test results.Of 298 PLWH who underwent stool PCR testing for diarrhea, 119 had a CD4 count less than 200 (low CD4 count), 195 were hospitalized at time of testing, and 137 had a positive stool PCR test. Compared to those with a low CD4 count, subjects with less severe HIV disease were more likely to have a bacterial infection on stool PCR testing and less likely to be hospitalized. Hospitalized patients were more likely to have a negative PCR stool test, regardless of CD4 count. Many patients with a low CD4 count had diarrheal etiologies not evaluated by multiplex stool PCR. In PLWH who experience diarrhea, stool PCR testing results vary by CD4 count and hospitalization. Providers should be mindful of these factors when interpreting stool PCR test results.
Collapse
Affiliation(s)
- Abhishek Verma
- Department of Medicine, NYU Grossman School of Medicine, New York, NY USA
| | - Ashley M. Hine
- University of Connecticut School of Medicine, University of Connecticut, Farmington, CT, USA
| | - Andrew Joelson
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | - Rena Mei
- Department of Medicine, NewYork-Presbyterian and Columbia University Irving Medical Center, New York, NY, USA
| | - Robert A. Pitts
- Division of Infectious Diseases, NYU Langone Health, New York, NY, USA
| | - Benjamin Lebwohl
- Division of Digestive and Liver Diseases, Department of Medicine, Columbia University Irving Medical Center, New York, NY, USA
| | | |
Collapse
|
6
|
Basile FW, Fedele MC, Lo Vecchio A. Gastrointestinal Diseases in Children Living with HIV. Microorganisms 2021; 9:microorganisms9081572. [PMID: 34442651 PMCID: PMC8398799 DOI: 10.3390/microorganisms9081572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2021] [Revised: 07/19/2021] [Accepted: 07/21/2021] [Indexed: 12/12/2022] Open
Abstract
Thanks to the advances in antiretroviral therapies (ART) and early diagnosis, pediatric HIV has turned into a chronic infection that requires the collaboration of all pediatric subspecialists for holistic patient management. Gastrointestinal complaints are a frequent reason for seeking access to medical care in all pediatric patients worldwide. Intestinal involvement is present in virtually all children with HIV infections. In high-prevalence settings, up to 25% of children accessing the hospital for diarrhea are diagnosed with HIV. More than half of patients with advanced disease present with gastrointestinal symptoms, from mild infectious diarrhea to severe gastrointestinal impairment, malabsorption and failure to thrive. Gastrointestinal disorders do not spare children on ART, particularly in the initial months of therapy. ART-associated pancreatitis and hepatitis are rare but potentially severe adverse events, whereas lower abdominal symptoms have been reported in more than a third of patients. The latter are usually mild and transient, but may limit ART adherence; a correct framing of the problem is necessary to minimize therapy switches while optimizing the quality of life of children on ART. This review aims to provide state-of-the-art guidance for the initial approach to gastrointestinal diseases in children living with HIV.
Collapse
Affiliation(s)
- Francesca Wanda Basile
- Baylor International Pediatric AIDS Initiative, Pediatrics, Baylor College of Medicine, 1100 Bates Street, Houston, TX 77030, USA;
| | - Maria Cristina Fedele
- Department of Woman, Child and of General and Specialized Surgery, University of Campania “Luigi Vanvitelli”, Via Luigi De Crecchio 2, 80138 Naples, Italy;
| | - Andrea Lo Vecchio
- Department of Translational Medical Science, Section of Pediatrics—University of Naples Federico II, 80131 Naples, Italy
- Correspondence: ; Tel.: +39-081-7463365; Fax: +39-081-7464232
| |
Collapse
|
7
|
Craviotto V, Furfaro F, Loy L, Zilli A, Peyrin-Biroulet L, Fiorino G, Danese S, Allocca M. Viral infections in inflammatory bowel disease: Tips and tricks for correct management. World J Gastroenterol 2021; 27:4276-4297. [PMID: 34366605 PMCID: PMC8316900 DOI: 10.3748/wjg.v27.i27.4276] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/01/2021] [Accepted: 05/15/2021] [Indexed: 02/06/2023] Open
Abstract
Over the past decades, the treatment of inflammatory bowel diseases (IBD) has become more targeted, anticipating the use of immune-modifying therapies at an earlier stage. This top-down approach has been correlated with favorable short and long-term outcomes, but it has also brought with it concerns regarding potential infectious complications. This large IBD population treated with immune-modifying therapies, especially if combined, has an increased risk of severe infections, including opportunistic infections that are sustained by viral, bacterial, parasitic, and fungal agents. Viral infections have emerged as a focal safety concern in patients with IBD, representing a challenge for the clinician: they are often difficult to diagnose and are associated with significant morbidity and mortality. The first step is to improve effective preventive strategies, such as applying vaccination protocols, adopt adequate prophylaxis and educate patients about potential risk factors. Since viral infections in immunosuppressed patients may present atypical signs and symptoms, the challenges for the gastroenterologist are to suspect, recognize and diagnose such complications. Appropriate treatment of common viral infections allows us to minimize their impact on disease outcomes and patients’ lives. This practical review supports this standard of care to improve knowledge in this subject area.
Collapse
Affiliation(s)
- Vincenzo Craviotto
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
| | - Federica Furfaro
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
| | - Laura Loy
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
| | - Alessandra Zilli
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
| | - Laurent Peyrin-Biroulet
- Department of Hepato-Gastroenterology and Inserm U954, University Hospital of Nancy, Lorraine University, Nancy 54511, France
| | - Gionata Fiorino
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milano, Italy
| | - Silvio Danese
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milano, Italy
| | - Mariangela Allocca
- Humanitas Clinical and Research Center, IRCCS, Rozzano 20089, Milano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele 20090, Milano, Italy
| |
Collapse
|
8
|
Cordie A, Gaber Y, AbdAllah M, Vergori A, Kharono B, Omran S, Afify S, Karkouri M, Chakroun M, Musa S, Moorhouse M, Esmat G. Gastrointestinal manifestations of human immunodeficiency virus and coronavirus disease 2019: Understanding the intersecting regions between the two epidemics. Arab J Gastroenterol 2021; 22:75-87. [PMID: 34120849 PMCID: PMC8149211 DOI: 10.1016/j.ajg.2021.05.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2020] [Revised: 04/07/2021] [Accepted: 05/24/2021] [Indexed: 01/08/2023]
Abstract
In March 2020, the World Health Organization declared coronavirus disease (COVID-19) a pandemic. As of February 2021, there were 107 million COVID-19 cases worldwide. As a comparison, there are approximately 38 million people living with human immunodeficiency virus (PLHIV) worldwide. The coexistence of both epidemics, and the syndemic effect of both viruses could lead to a delirious impact both at individual and community levels. Many intersecting points were found between severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), the causative agent of COVID-19, and HIV; among which, gastrointestinal (GI) manifestations are the most notable. GI manifestations represent a common clinical presentation in both HIV and SARS-CoV-2. The emergence of GI symptoms as a result of SARS-CoV-2 infection provides a new dynamic to COVID-19 diagnosis, management, and infection control measures, and adds an additional diagnostic challenge in case of coinfection with HIV. The presence of GI manifestations in PLHIV during the COVID-19 pandemic could be referred to HIV enteropathy, presence of opportunistic infection, adverse effect of antiretrovirals, or coinfection with COVID-19. Thus, it is important to exclude SARS-CoV-2 in patients who present with new-onset GI manifestations, especially in PLHIV, to avoid the risk of disease transmission during endoscopic interventions. Structural similarities between both viruses adds a valuable intersecting point, which has mutual benefits in the management of both viruses. These similarities led to the hypothesis that antiretrovirals such as lopinavir/Rironavir have a role in the management of COVID-19, which was the target of our search strategy using the available evidence. These similarities may also facilitate the development of an efficient HIV vaccine in the future using the advances in COVID-19 vaccine development.
Collapse
Affiliation(s)
- Ahmed Cordie
- Endemic Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Yasmine Gaber
- Endemic Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | - Mohamed AbdAllah
- Medical Research Division, National Research Center, Giza, Egypt
| | - Alessandra Vergori
- HIV/AIDS Unit, National Institute for Infectious Diseases L. Spallanzani, IRCCS, Rome, Italy.
| | | | - Salma Omran
- Endemic Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| | - Shimaa Afify
- National Hepatology and Tropical Medicine Research Institute, Cairo, Egypt
| | - Mehdi Karkouri
- Association de Lutte Contre le Sida/Coalition Plus, Faculté de Médecine et de Pharmacie, Université Hassan II, Casablanca, Morocco
| | - Mohamed Chakroun
- Infectious Diseases Department, University Hospital of Monastir, Tunisia
| | - Sherief Musa
- Endemic Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt.
| | | | - Gamal Esmat
- Endemic Medicine Department, Faculty of Medicine, Cairo University, Cairo, Egypt
| |
Collapse
|
9
|
Leonard MM, Lebwohl B, Rubio-Tapia A, Biagi F. AGA Clinical Practice Update on the Evaluation and Management of Seronegative Enteropathies: Expert Review. Gastroenterology 2021; 160:437-444. [PMID: 33010252 DOI: 10.1053/j.gastro.2020.08.061] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2020] [Revised: 08/25/2020] [Accepted: 08/28/2020] [Indexed: 12/22/2022]
Abstract
DESCRIPTION Our aim was to provide a consensus statement for the best approaches for diagnosis and management of patients with suspected enteropathy, but negative results from serologic tests for celiac disease (seronegative enteropathy). METHODS We collected findings from published cohort, case-control, and cross-sectional studies of diagnosis and case series and descriptive studies of management of patients believed to have celiac disease or other enteropathies unrelated to gluten, but negative results from serologic tests. BEST PRACTICE ADVICE 1: Review histologic findings with experienced pathologists who specialize in gastroenterology. BEST PRACTICE ADVICE 2: Serologic tests are essential for an accurate diagnosis of celiac disease. For patients with suspected celiac disease but negative results from serologic tests, total IgA level should be measured; patients should also be tested for anti-tissue transglutaminase, IgA against deamidated gliadin peptide, and endomysial antibody (IgA). Patients with total IgA levels below the lower limit of detection and IgG against tissue transglutaminase or deamidated gliadin peptide, or endomysial antibody, should be considered to have celiac disease with selective IgA deficiency rather than seronegative celiac disease. BEST PRACTICE ADVICE 3: Patients' diets should be carefully reviewed and duodenal biopsies should be collected and analyzed at the time of serologic testing to determine exposure to gluten and accuracy of test results. BEST PRACTICE ADVICE 4: Thorough medication histories should be collected from patients, with attention to angiotensin II receptor blockers, such as olmesartan, along with travel histories to identify potential etiologies of villous atrophy. This will guide additional testing. BEST PRACTICE ADVICE 5: Patients should be analyzed for disease-associated variants in human leukocyte antigen genes; results must be carefully interpreted. Negative results can be used to rule out celiac disease in seronegative patients. BEST PRACTICE ADVICE 6: Patients with suspected celiac disease who are seronegative but have villous atrophy and genetic risk factors for celiac disease must undergo endoscopic evaluation after 1-3 years on a gluten-free diet to evaluate improvements in villous atrophy. A diagnosis of seronegative celiac disease can then be confirmed based on clinical and histologic markers of improvement on the gluten-free diet. BEST PRACTICE ADVICE 7: Seronegative patients with an identified cause for enteropathy should be treated accordingly; a follow-up biopsy might or might not be necessary. BEST PRACTICE ADVICE 8: Patients with persistent signs and symptoms who do not respond to a gluten-free diet, and for whom no etiology of enteropathy is ultimately identified, should be treated with budesonide. CONCLUSIONS These best practice guidelines will aid in diagnosis and management of patients with suspected celiac disease, but negative results from serologic tests.
Collapse
Affiliation(s)
- Maureen M Leonard
- Center for Celiac Research and Treatment, Division of Pediatric Gastroenterology and Nutrition, MassGeneral Hospital for Children, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Benjamin Lebwohl
- Celiac Disease Center, Columbia University Irving Medical Center, New York, New York
| | - Alberto Rubio-Tapia
- Division of Gastroenterology, Hepatology, and Nutrition, Digestive Disease and Surgery Institute, Cleveland Clinic, Cleveland, Ohio
| | - Federico Biagi
- Clinical Scientific Institutes Maugeri Scientific Institute for Research, Hospitalization and Healthcare, Gastroenterology Unit of Pavia Institute, University of Pavia, Italy
| |
Collapse
|
10
|
Leishmaniasis immunopathology-impact on design and use of vaccines, diagnostics and drugs. Semin Immunopathol 2020; 42:247-264. [PMID: 32152715 DOI: 10.1007/s00281-020-00788-y] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/03/2020] [Indexed: 12/18/2022]
Abstract
Leishmaniasis is a disease complex caused by 20 species of protozoan parasites belonging to the genus Leishmania. In humans, it has two main clinical forms, visceral leishmaniasis (VL) and cutaneous or tegumentary leishmaniasis (CL), as well as several other cutaneous manifestations in a minority of cases. In the mammalian host Leishmania parasites infect different populations of macrophages where they multiply and survive in the phagolysosomal compartment. The progression of both VL and CL depends on the maintenance of a parasite-specific immunosuppressive state based around this host macrophage infection. The complexity and variation of immune responses and immunopathology in humans and the different host interactions of the different Leishmania species has an impact upon the effectiveness of vaccines, diagnostics and drugs.
Collapse
|
11
|
Multimethodological Approach to Gastrointestinal Microsporidiosis in HIV-Infected Patients. Acta Parasitol 2019; 64:658-669. [PMID: 31286356 DOI: 10.2478/s11686-019-00095-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Accepted: 06/14/2019] [Indexed: 12/24/2022]
Abstract
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.
Collapse
|
12
|
Abstract
Malabsorption syndrome refers to the small intestines' inability to absorb certain nutrients and fluids. There are several common associated disorders, which may present with subtle and/or overt symptoms. With subtle symptoms, it is difficult to determine the cause, making diagnosis difficult or even inaccurate. Malabsorption can originate from an immune response, an inflammatory process, or alternation of the small intestines by surgical methods. This article reviews common malabsorption disease processes of the small bowel and the resulting pathophysiology. Diagnostic studies, treatment, and prognosis of various conditions within the malabsorption disease state are discussed.
Collapse
|
13
|
Panarelli NC, Yantiss RK. Inflammatory and infectious manifestations of immunodeficiency in the gastrointestinal tract. Mod Pathol 2018; 31:844-861. [PMID: 29403083 DOI: 10.1038/s41379-018-0015-9] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 11/24/2017] [Accepted: 12/11/2017] [Indexed: 12/27/2022]
Abstract
Immune compromise may result from genetic abnormalities, HIV/AIDS, or consequences of therapy for neoplastic and autoimmune diseases. Many immunocompromised patients develop severe gastrointestinal symptoms, particularly diarrhea, accompanied by non-specific or mild endoscopic abnormalities; mucosal biopsy with pathologic interpretation has a major role in the diagnosis and management of these patients. Immunocompromised individuals are at risk for all the diseases that affect those with a healthy immune system, but they are also prone to other illnesses that rarely affect immunocompetent patients. This review discusses the gastrointestinal manifestations of primary and acquired immunodeficiency, chemotherapy-related injury, and infections that show a predilection for immunocompromised patients. Key histologic features and relevant differential diagnoses are emphasized.
Collapse
|
14
|
A short course of gluten free diet is effective treatment for HIV enteropathy in the elderly: A case report in the highly active antiretroviral therapy era. Eur Geriatr Med 2017. [DOI: 10.1016/j.eurger.2017.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
|
15
|
d'Ettorre G, Rossi G, Scagnolari C, Andreotti M, Giustini N, Serafino S, Schietroma I, Scheri GC, Fard SN, Trinchieri V, Mastromarino P, Selvaggi C, Scarpona S, Fanello G, Fiocca F, Ceccarelli G, Antonelli G, Brenchley JM, Vullo V. Probiotic supplementation promotes a reduction in T-cell activation, an increase in Th17 frequencies, and a recovery of intestinal epithelium integrity and mitochondrial morphology in ART-treated HIV-1-positive patients. Immun Inflamm Dis 2017; 5:244-260. [PMID: 28474815 PMCID: PMC5569369 DOI: 10.1002/iid3.160] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Revised: 01/31/2017] [Accepted: 02/16/2017] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION HIV infection is characterized by a persistent immune activation associated to a compromised gut barrier immunity and alterations in the profile of the fecal flora linked with the progression of inflammatory symptoms. The effects of high concentration multistrain probiotic (Vivomixx®, Viale del Policlinico 155, Rome, Italy in EU; Visbiome®, Dupont, Madison, Wisconsin in USA) on several aspects of intestinal immunity in ART-experienced HIV-1 patients was evaluated. METHODS A sub-study of a longitudinal pilot study was performed in HIV-1 patients who received the probiotic supplement twice a day for 6 months (T6). T-cell activation and CD4+ and CD8+ T-cell subsets expressing IFNγ (Th1, Tc1) or IL-17A (Th17, Tc17) were stained by cytoflorimetric analysis. Histological and immunohistochemical analyses were performed on intestinal biopsies while enterocytes apoptosis index was determined by TUNEL assay. RESULTS A reduction in the frequencies of CD4+ and CD8+ T-cell subsets, expressing CD38+ , HLA-DR+ , or both, and an increase in the percentage of Th17 cell subsets, especially those with central or effector memory phenotype, was recorded in the peripheral blood and in gut-associated lymphoid tissue (GALT) after probiotic intervention. Conversely, Tc1 and Tc17 levels remained substantially unchanged at T6, while Th1 cell subsets increase in the GALT. Probiotic supplementation was also associated to a recovery of the integrity of the gut epithelial barrier, a reduction of both intraepithelial lymphocytes density and enterocyte apoptosis and, an improvement of mitochondrial morphology sustained in part by a modulation of heat shock protein 60. CONCLUSIONS These findings highlight the potential beneficial effects of probiotic supplementation for the reconstitution of physical and immunological integrity of the mucosal intestinal barrier in ART-treated HIV-1-positive patients.
Collapse
Affiliation(s)
- Gabriella d'Ettorre
- Department of Public Health and Infectious DiseasesAzienda Policlinico Umberto I of RomeRomeItaly
| | - Giacomo Rossi
- School of BiosciencesVeterinary Medicine University of CamerinoMatelicaItaly
| | - Carolina Scagnolari
- Laboratory Affiliated to Istituto Pasteur Italia—Fondazione Cenci BolognettiDepartment of Molecular MedicineSapienza University of RomeRomeItaly
| | - Mauro Andreotti
- Department of Therapeutic Research and Medicines EvaluationItalian Institute of HealthRomeItaly
| | - Noemi Giustini
- Department of Public Health and Infectious DiseasesSapienza University of RomeRomeItaly
| | - Sara Serafino
- Department of Public Health and Infectious DiseasesSapienza University of RomeRomeItaly
| | - Ivan Schietroma
- Department of Public Health and Infectious DiseasesSapienza University of RomeRomeItaly
| | | | - Saeid Najafi Fard
- Department of Public Health and Infectious DiseasesSapienza University of RomeRomeItaly
| | - Vito Trinchieri
- Department of Public Health and Infectious DiseasesSapienza University of RomeRomeItaly
| | - Paola Mastromarino
- Section of MicrobiologyDepartment of Public Health and Infectious DiseasesSapienza University of RomeRomeItaly
| | - Carla Selvaggi
- Laboratory Affiliated to Istituto Pasteur Italia—Fondazione Cenci BolognettiDepartment of Molecular MedicineSapienza University of RomeRomeItaly
| | - Silvia Scarpona
- School of BiosciencesVeterinary Medicine University of CamerinoMatelicaItaly
| | - Gianfranco Fanello
- Department of Emergency Surgery—Emergency Endoscopic UnitPoliclinico Umberto ISapienza University of RomeRomeItaly
| | - Fausto Fiocca
- Department of Emergency Surgery—Emergency Endoscopic UnitPoliclinico Umberto ISapienza University of RomeRomeItaly
| | - Giancarlo Ceccarelli
- Department of Public Health and Infectious DiseasesAzienda Policlinico Umberto I of RomeRomeItaly
| | - Guido Antonelli
- Laboratory Affiliated to Istituto Pasteur Italia—Fondazione Cenci BolognettiDepartment of Molecular MedicineSapienza University of RomeRomeItaly
| | - Jason M. Brenchley
- Laboratory of Parasitic DiseasesNational Institute of Allergy and Infectious Diseases, NIHBethesdaMarylandUSA
| | - Vincenzo Vullo
- Department of Public Health and Infectious DiseasesSapienza University of RomeRomeItaly
| |
Collapse
|
16
|
Presti R, Pantaleo G. The Immunopathogenesis of HIV-1 Infection. Infect Dis (Lond) 2017. [DOI: 10.1016/b978-0-7020-6285-8.00092-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
|
17
|
Kwakye-Nuako G, Boampong JN, Dong MK, Obiri-Yeboah D, Opoku YK, Amoako-Sakyi D, Asare KK. Modulation of cyptosporidiosis by CD4 levels in chronic diarrhoea HIV/AIDS individuals visiting Tarkwa Municipal hospital, Ghana. ASIAN PACIFIC JOURNAL OF TROPICAL DISEASE 2016. [DOI: 10.1016/s2222-1808(16)61127-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
18
|
O'Neill TJ, Raboud JM, Tinmouth J, Rourke SB, Gardner S, Cooper C, Rueda S, Hart TA, Rachlis A, Burchell AN. Burden and risk factors for gastrointestinal symptom distress in HIV patients in the modern antiretroviral era. AIDS Care 2016; 29:156-167. [PMID: 27454239 DOI: 10.1080/09540121.2016.1210076] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In the modern antiretroviral (ARV) era, there is limited knowledge about the prevalence and risk factors for HIV patient-reported gastrointestinal (GI) symptoms (diarrhoea/soft stool, nausea/vomiting, bloating/painful abdomen, loss of appetite, and weight loss/wasting) and distress. We prospectively analysed data (2007-2014) on distressing GI symptoms from the Ontario HIV Treatment Network Cohort Study, which follows people attending HIV clinics. Using generalized estimating equations with a logit link, we estimated the associations of psychosocial, demographic, behavioural, and clinical factors with each GI symptoms compared to asymptomatic and non-bothersome symptoms. Among 1532 included participants, 80.4% were male, mean age was 45 years, and 64.6% reported being men who have sex with men. Most were Caucasian (56.3%), a median time since HIV diagnosis of 9.8 years (interquartile range (IQR): 4.1-16.9), and 83.1% were on ARV. More than two-thirds (68.7% (95% confidence intervals (CI): 63.1% to 69.2%)) reported one or more symptoms with a median of 1.2 (IQR: 0-1.7). The proportion remained stable over time since HIV diagnosis and ARV initiation. Risk factors varied for multivariable models. A strong association with Centre for Epidemiologic Studies Depression scale scores of ≥23 was found for all symptoms. Adjusted odds ratios (95% CI) were 1.72 (1.39-2.12), 2.95 (2.33-3.72), 2.20 (1.81-2.68), 4.97 (3.99-6.19), and 2.98 (2.52-3.82) for diarrhoea, nausea/vomiting, bloating, loss of appetite, and weight loss, respectively. With the exception of bloating, odds were significantly lower for those on ARV containing integrase inhibitors and greater for patients reporting current cannabis use. GI symptoms in the modern ARV era are highly prevalent and may arise as a common pathway of distress in response to psychosocial vulnerabilities, regardless of the stage of diagnosis. These findings support the need for integrated approaches to address psychological and physical distress in HIV disease.
Collapse
Affiliation(s)
- Tyler J O'Neill
- a Dalla Lana School of Public Health, University of Toronto , Toronto , Canada.,b Ontario HIV Treatment Network , Toronto , Canada
| | - Janet M Raboud
- a Dalla Lana School of Public Health, University of Toronto , Toronto , Canada.,c Toronto General Research Institute, University Health Network , Toronto , Canada
| | - Jill Tinmouth
- a Dalla Lana School of Public Health, University of Toronto , Toronto , Canada.,d Sunnybrook Research Institute, Sunnybrook Health Sciences Centre , Toronto , Canada.,e Department of Medicine, Sunnybrook Health Sciences Centre , Toronto , Canada
| | - Sean B Rourke
- b Ontario HIV Treatment Network , Toronto , Canada.,f Department of Psychiatry, University of Toronto , Toronto , Canada
| | - Sandra Gardner
- a Dalla Lana School of Public Health, University of Toronto , Toronto , Canada.,b Ontario HIV Treatment Network , Toronto , Canada.,g Rotman Research Institute, Baycrest , Toronto , Canada
| | - Curtis Cooper
- h Ottawa Hospital Research Institute, University of Ottawa , Ottawa , Canada
| | - Sergio Rueda
- i Department of Psychiatry, University of Toronto , Toronto , Canada.,j Institute for Mental Health Policy Research, Centre for Addiction and Mental Health , Toronto , Ontario , Canada
| | - Trevor A Hart
- a Dalla Lana School of Public Health, University of Toronto , Toronto , Canada.,k Department of Psychology , Ryerson University , Toronto , Canada
| | - Anita Rachlis
- l Sunnybrook Health Sciences Centre, University of Toronto , Toronto , Canada
| | - Ann N Burchell
- a Dalla Lana School of Public Health, University of Toronto , Toronto , Canada.,m Department of Family and Community Medicine, Faculty of Medicine , University of Toronto , Toronto , Canada.,n Centre for Urban Health Solutions , Li Ka Shing Knowledge Institute, St. Michael's Hospital , Toronto , Canada
| | | |
Collapse
|
19
|
Abstract
Small intestinal infections are extremely common worldwide. They may be bacterial, viral, or parasitic in etiology. Most are foodborne or waterborne, with specific etiologies differing by region and with diverse pathophysiologies. Very young, very old, and immune-deficient individuals are the most vulnerable to morbidity or mortality from small intestinal infections. There have been significant advances in diagnostic sophistication with the development and early application of molecular diagnostic assays, though these tests have not become mainstream. The lack of rapid diagnoses combined with the self-limited nature of small intestinal infections has hampered the development of specific and effective treatments other than oral rehydration. Antibiotics are not indicated in the absence of an etiologic diagnosis, and not at all in the case of some infections.
Collapse
Affiliation(s)
- Khushboo Munot
- Department of Medicine and Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Mount Sinai St. Luke's and Mount Sinai West Hospitals, New York, NY, USA
| | - Donald P Kotler
- Department of Medicine and Division of Gastroenterology, Icahn School of Medicine at Mount Sinai, Mount Sinai Health System, Mount Sinai St. Luke's and Mount Sinai West Hospitals, New York, NY, USA.
| |
Collapse
|
20
|
|
21
|
Abstract
Diarrhea generates a wide range of diagnostic considerations and has profound individual and public health significance. The setting and circumstances under which a patient presents with diarrhea drastically influences the concern brought to the encounter. Nausea, vomiting, and diarrhea are often provisionally labeled "gastroenteritis" with appropriate expectant management. In resource-poor countries, the significance of diarrhea is even greater. This review focuses on diarrhea and its initial evaluation and management in the emergency department.
Collapse
Affiliation(s)
- Alexa R Gale
- Department of Emergency Medicine, Medstar Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010, USA.
| | - Matthew Wilson
- Department of Emergency Medicine, Medstar Washington Hospital Center, 110 Irving Street NW, Washington, DC 20010, USA
| |
Collapse
|
22
|
McKean J, Ronan-Bentle S. Abdominal Pain in the Immunocompromised Patient-Human Immunodeficiency Virus, Transplant, Cancer. Emerg Med Clin North Am 2016; 34:377-86. [PMID: 27133250 DOI: 10.1016/j.emc.2015.12.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Patients with human immunodeficiency virus, those who are posttransplant, and those undergoing chemotherapy are populations who are immunocompromised and present to the emergency department with abdominal pain related to their disease processes, opportunistic infections, and complications of treatment. Emergency department practitioners must maintain vigilance, as the physical examination is often unreliable in these patients. Cross-sectional imaging and early treatment of symptoms with aggressive resuscitation is often required.
Collapse
Affiliation(s)
- Jonathan McKean
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0769, Cincinnati, OH 45267-0769, USA
| | - Sarah Ronan-Bentle
- Department of Emergency Medicine, University of Cincinnati College of Medicine, 231 Albert Sabin Way, ML0769, Cincinnati, OH 45267-0769, USA.
| |
Collapse
|
23
|
Yang L, Poles MA, Fisch GS, Ma Y, Nossa C, Phelan JA, Pei Z. HIV-induced immunosuppression is associated with colonization of the proximal gut by environmental bacteria. AIDS 2016; 30:19-29. [PMID: 26731752 DOI: 10.1097/qad.0000000000000935] [Citation(s) in RCA: 50] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVES To evaluate the impact of HIV infection on colonization resistance in the proximal gut. DESIGN It was a case-control study. METHODS We contrasted microbiota composition between eight HIV-1-infected patients and eight HIV-negative controls to characterize community alteration and detect exogenous bacteria in the esophagus, stomach, and duodenum, as well as the mouth using a universal 16s ribosomal RNA gene survey and correlated the findings with HIV serostatus and peripheral blood T-cell counts. RESULTS HIV infection was associated with an enrichment of Proteobacteria (P=0.020) and depletion of Firmicutes (P = 0.005) in the proximal gut. In particular, environmental species Burkholderia fungorum and Bradyrhizobium pachyrhizi colonized the duodenum of HIV patients who had abnormal blood CD4 T-cell counts but were absent in HIV-negative controls or HIV patients whose CD4 cell counts were normal. The two species coexisted and exhibited a decreasing trend proximally toward the stomach and esophagus and were virtually absent in the mouth. B. fungorum always outnumbered B. pachyrhizi in a ratio of approximately 15 to 1 regardless of the body sites (P < 0.0001, r = 0.965). Their abundance was inversely correlated with CD4 cell counts (P = 0.004) but not viral load. Overgrowth of potential opportunistic pathogens for example, Prevotella, Fusobacterium, and Ralstonia and depletion of beneficial bacteria, for example, Lactobacillus was also observed in HIV patients. CONCLUSIONS The colonization of the duodenum by environmental bacteria reflects loss of colonization resistance in HIV infection. Their correlation with CD4 cell counts suggests that compromised immunity could be responsible for the observed invasion by exogenous microbes.
Collapse
|
24
|
HIV enteropathy and aging: gastrointestinal immunity, mucosal epithelial barrier, and microbial translocation. Curr Opin HIV AIDS 2015; 9:309-16. [PMID: 24871087 DOI: 10.1097/coh.0000000000000066] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Despite decreases in morbidity and mortality as a result of antiretroviral therapy, gastrointestinal dysfunction remains common in HIV infection. Treated patients are at risk for complications of 'premature' aging, such as cardiovascular disease, osteopenia, neurocognitive decline, malignancies, and frailty. This review summarizes recent observations in this field. RECENT FINDINGS Mucosal CD4 lymphocytes, especially Th17 cells, are depleted in acute HIV and simian immune deficiency virus (SIV) infections, although other cell types also are affected. Reconstitution during therapy often is incomplete, especially in mucosa. Mucosal barrier function is affected by both HIV infection and aging and includes paracellular transport via tight junctions and uptake through areas of apoptosis; other factors may affect systemic antigen exposure. The resultant microbial translocation is associated with systemic immune activation in HIV and SIV infections. There is evidence of immune activation and microbial translocation in the elderly. The immune phenotypes of immunosenescence in HIV infection and aging appear similar. There are several targets for intervention; blockage of residual mucosal virus replication, preventing antigen uptake, modulating the microbiome, improving T cell recovery, combining therapies aimed at mucosal integrity, augmenting mucosal immunity, and managing traditional risk factors for premature aging in the general population. SUMMARY Aging may interact with HIV enteropathy to enhance microbial translocation and immune activation.
Collapse
|
25
|
Dikman AE, Schonfeld E, Srisarajivakul NC, Poles MA. Human Immunodeficiency Virus-Associated Diarrhea: Still an Issue in the Era of Antiretroviral Therapy. Dig Dis Sci 2015; 60:2236-45. [PMID: 25772777 PMCID: PMC4499110 DOI: 10.1007/s10620-015-3615-y] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Accepted: 02/27/2015] [Indexed: 12/14/2022]
Abstract
Over half of patients with human immunodeficiency virus (HIV) experience diarrhea that contributes negatively to quality of life and adherence to antiretroviral therapy (ART). Opportunistic infectious agents that cause diarrhea in patients with HIV span the array of protozoa, fungi, viruses, and bacteria. With global use of ART, the incidence of diarrhea because of opportunistic infections has decreased; however, the incidence of noninfectious diarrhea has increased. The etiology of noninfectious diarrhea in patients with HIV is multifactorial and includes ART-associated diarrhea and gastrointestinal damage related to HIV infection (i.e., HIV enteropathy). A basic algorithm for the diagnosis of diarrhea in patients with HIV includes physical examination, a review of medical history, assessment of HIV viral load and CD4+ T cell count, stool microbiologic assessment, and endoscopic evaluation, if needed. For patients with negative diagnostic results, the diagnosis of noninfectious diarrhea may be considered. Pharmacologic options for the treatment of noninfectious diarrhea are primarily supportive; however, the use of many unapproved agents is based on unstudied and anecdotal information. In addition, these agents can be associated with treatment-limiting adverse events (AEs), such as drug-drug interactions with ART regimens, abuse liability, and additional gastrointestinal AEs. Currently, crofelemer, an antisecretory agent, is the only therapy approved in the USA for the symptomatic relief of noninfectious diarrhea in patients with HIV on ART.
Collapse
Affiliation(s)
- Andrew E. Dikman
- Division of Gastroenterology, Department of Medicine, NYU School of Medicine, Veterans Affairs New York Harbor Healthcare System, 423 East 23rd Street, Room 11097, New York, NY 10010 USA
| | - Emily Schonfeld
- Division of Gastroenterology, Department of Medicine, NYU School of Medicine, Veterans Affairs New York Harbor Healthcare System, 423 East 23rd Street, Room 11097, New York, NY 10010 USA
| | | | - Michael A. Poles
- Division of Gastroenterology, Department of Medicine, NYU School of Medicine, Veterans Affairs New York Harbor Healthcare System, 423 East 23rd Street, Room 11097, New York, NY 10010 USA ,NYU Langone Medical Center, New York, NY USA
| |
Collapse
|
26
|
Beshoy Y, Nneji J, Buxbaum J. A case of the hiccups in the setting of colonic ulcers. Gastroenterology 2015; 148:e8-9. [PMID: 25450078 DOI: 10.1053/j.gastro.2014.07.036] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Revised: 06/06/2014] [Accepted: 07/14/2014] [Indexed: 12/02/2022]
Affiliation(s)
- Yanny Beshoy
- Division of Gastroenterology and Liver Diseases, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - Jackie Nneji
- Division of Gastroenterology and Liver Diseases, University of Southern California, Keck School of Medicine, Los Angeles, California
| | - James Buxbaum
- Division of Gastroenterology and Liver Diseases, University of Southern California, Keck School of Medicine, Los Angeles, California
| |
Collapse
|
27
|
Wanyiri JW, Kanyi H, Maina S, Wang DE, Ngugi P, O'Connor R, Kamau T, Waithera T, Kimani G, Wamae CN, Mwamburi M, Ward HD. Infectious diarrhoea in antiretroviral therapy-naive HIV/AIDS patients in Kenya. Trans R Soc Trop Med Hyg 2014; 107:631-8. [PMID: 24026463 DOI: 10.1093/trstmh/trt078] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Diarrhoea is a significant cause of morbidity and mortality in immunocompromised patients. The objectives of this study were to investigate the aetiological agents, risk factors and clinical features associated with diarrhoea in HIV/AIDS patients in Kenya. METHODS Sociodemographic, epidemiological and clinical data were obtained for 164 HIV/AIDS patients (70 with and 94 without diarrhoea) recruited from Kenyatta National Hospital, Kenya. Stool samples were examined for enteric pathogens by microscopy and bacteriology. RESULTS Intestinal protozoa and fungi were identified in 70% of patients, more frequently in those with diarrhoea (p<0.001). Helminths were detected in 25.6% of patients overall, and bacterial pathogens were identified in 51% of patients with diarrhoea. Polyparasitism was more common in patients with diarrhoea than those without (p<0.0001). Higher CD4(+) T-cell count (OR = 0.995, 95% CI 0.992-0.998) and water treatment (OR = 0.231, 95% CI 0.126-0.830) were associated with a lower risk of diarrhoea, while close contact with cows (OR = 3.200, 95% CI 1.26-8.13) or pigs (OR = 11.176, 95% CI 3.76-43.56) were associated with a higher risk of diarrhoea. CONCLUSIONS Multiple enteric pathogens that are causative agents of diarrhoea were isolated from stools of antiretroviral therapy-naïve HIV/AIDS patients, indicating a need for surveillance, treatment and promotion of hygienic practices.
Collapse
Affiliation(s)
- Jane W Wanyiri
- Division of Geographic Medicine and Infectious Diseases, Tufts Medical Center, 800 Washington Street, Boston, MA 02111, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
HIV protease inhibitors in gut barrier dysfunction and liver injury. Curr Opin Pharmacol 2014; 19:61-6. [PMID: 25105480 DOI: 10.1016/j.coph.2014.07.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2014] [Revised: 07/12/2014] [Accepted: 07/18/2014] [Indexed: 12/14/2022]
Abstract
The development of HIV protease inhibitors (HIV PIs) has been one of the most significant advances of the past two decades in controlling HIV infection. HIV PIs have been used successfully in highly active anti-retroviral therapy (HAART) for HIV infection, which is currently the most effective treatment available. Incorporation of HIV PIs in HAART causes profound and sustained suppression of viral replication, significantly reduces the morbidity and mortality of HIV infection, and prolongs the lifespan of HIV patients. However, in the era of HAART, drug-induced gastrointestinal (GI) side effects and hepatotoxicity have emerged as important potential complications of HIV therapy, particularly those regimens containing HIV PIs. In this mini-review, we highlight the current understanding of the mechanisms of HIV PI-associated GI and liver injury.
Collapse
|
29
|
Abstract
While celiac disease is the most common cause of villous remodeling and intraepithelial lymphocytosis in the proximal small bowel, there are many entities that can mimic its histologic appearance. The purpose of this review is to discuss normal small bowel histology and the differential diagnosis of celiac disease. Approaches to evaluate increased intraepithelial lymphocytes are presented, followed by a detailed discussion of the pathology of celiac disease. Particular emphasis is given to those conditions that cause intraepithelial lymphocytosis in the setting of preserved villous architecture, although other important entities, such as peptic injury, idiopathic inflammatory bowel disease, medication injury, eosinophilic (allergic) gastroenteritis, autoimmune enteropathy, common variable immunodeficiency, and infections are also reviewed.
Collapse
Affiliation(s)
- Rish K Pai
- Department of Anatomic Pathology, Robert J Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio 44195.
| |
Collapse
|
30
|
Chordia P, MacArthur RD. Crofelemer, a novel agent for treatment of non-infectious diarrhea in HIV-infected persons. Expert Rev Gastroenterol Hepatol 2013; 7:591-600. [PMID: 24070150 DOI: 10.1586/17474124.2013.832493] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
Crofelemer is the first US FDA-approved drug for symptomatic relief in HIV-infected persons on antiretroviral therapy (ART) who have non-infectious diarrhea. With the availability of ART, there is increased survival and decrease in gastrointestinal opportunistic infections. However, diarrhea secondary to ART and HIV enteropathy is common in HIV-infected persons. Crofelemer is manufactured from the red latex sap of the Croton lechleri tree in South America. It has a unique mechanism leading to inhibition of chloride ion secretion by blocking chloride channels in the gastrointestinal lumen. This reduces efflux of sodium and water, which in turn reduces the frequency and consistency of diarrhea. Crofelemer is well tolerated due to minimal systemic absorption and has a good safety profile. The availability of crofelemer will likely have a positive impact on the quality of life in HIV-infected persons and also increase compliance to ART.
Collapse
Affiliation(s)
- Poorvi Chordia
- Department of Infectious Diseases, Wayne State University, Detroit, MI, USA
| | | |
Collapse
|
31
|
Ayinmode AB, Zhang H, Dada-Adegbola HO, Xiao L. Cryptosporidium hominis subtypes and Enterocytozoon bieneusi genotypes in HIV-infected persons in Ibadan, Nigeria. Zoonoses Public Health 2013; 61:297-303. [PMID: 23870732 DOI: 10.1111/zph.12072] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Indexed: 11/30/2022]
Abstract
Cryptosporidium and Enterocytozoon are common opportunistic pathogens in HIV+ patients in developing countries, especially those do not have access to antiretroviral therapy. To determine the distribution of genotypes/subtypes of Cryptosporidium and Enterocytozoon bieneusi, faecal specimens were collected from 132 HIV+ persons attending a tertiary hospital in Ibadan, Nigeria. By polymerase chain reaction, eight and ten patients were identified as positive for Cryptosporidium spp. and E. bieneusi, respectively. Seven of the Cryptosporidium specimens were identified as C. hominis, while the remaining one as the new species C. viatorum recently identified in the United Kingdom. DNA sequencing of the 60-kDa glycoprotein gene showed that the C. hominis belonged to three common subtype families: Ia (in three patients), Ib (in one patient) and Ie (in one patient). In contrast, DNA sequencing of the E. bieneusi internal transcribed spacer products showed the occurrence of genotypes associated with both humans (Peru 8 in one patient, Nig2 in two patients and a new genotype in one patient) and animals (D in one patient and Type IV in five patients). Low CD4+ cell count was identified as a risk factor for both cryptosporidiosis and microsporidiosis.
Collapse
Affiliation(s)
- A B Ayinmode
- Department of Veterinary Microbiology and Parasitology, Faculty of Veterinary Medicine, University of Ibadan, Ibadan, Nigeria
| | | | | | | |
Collapse
|
32
|
Ahmed AS, McGaw LJ, Eloff JN. Evaluation of pharmacological activities, cytotoxicity and phenolic composition of four Maytenus species used in southern African traditional medicine to treat intestinal infections and diarrhoeal diseases. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2013; 13:100. [PMID: 23663902 PMCID: PMC3726504 DOI: 10.1186/1472-6882-13-100] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/10/2012] [Accepted: 05/10/2013] [Indexed: 12/16/2022]
Abstract
BACKGROUND Microbial infections and resulting inflammation and oxidative stress are common pathogenesis of gastrointestinal tract (GIT) disorders. In South Africa, several species of the genus Maytenus are used in traditional medicine to treat various infectious diseases. Most of the previous work on this genus was focused on nonpolar extracts from the root and bark. In this study, leaf extracts of polar extracts of Maytenus peduncularis, Maytenus procumbens, Maytenus senegalensis and Maytenus undata were evaluated for antimicrobial, anti-inflammatory and antioxidant activities to determine their efficacy as therapeutic agents in GIT disorders. METHODS Phenolic-enriched leaf extracts and fractions were prepared by extracting with acidified 70% methanol and solvent-solvent fractionation. The activities of the fractions against Staphylococcus aureus, Pseudomonas aeruginosa, Escherichia coli and Enterococcus faecalis as well as clinical isolates of Aspergillus fumigatus, Candida albicans and Cryptococcus neoformans were determined using a serial microplate dilution method. Antioxidant activities were determined using 1,1-diphenyl-2-picrylhydrazyl (DPPH), 2,2'-azinobis(3-ethylbenzthiazoline-6-sulphonic acid) (ABTS), hydroxyl (OH) radical scavenging and linoleic acid peroxidation inhibitory assays. The phenolic composition as well as the cytotoxicity against Vero cell lines of the crude extracts was evaluated using various standard protocols. RESULTS The antimicrobial activities were concentrated in the non-polar fractions of hexane, dichloromethane and ethyl acetate (MICs 19-312 μg/ml). The crude extracts and polar fractions (butanol and water) had moderate to poor antimicrobial activity (MICs 312 to above 2500 μg/ml). The crude extracts and polar fractions had good antioxidant activity (EC50 values varied from 1.22 to 607 μg/ml, 1.71 to 312 μg/ml and 23 to 284 μg/ml for DPPH, ABTS and OH respectively. Linoleic acid peroxidation inhibition EC50 values of the crude extracts ranged between 27 and 39 μg/ml with relatively low toxicity against Vero cell lines (IC50 values 87 to 187 μg/ml). Fractionation of a crude extract with low activity could lead to fractions with more potent activity. CONCLUSION This study justifies the traditional use of leaf crude extracts and fractions from these four plants to remedy gastrointestinal disorders resulting from infection, inflammation and oxidative stress complications. The study also provides rationale for the use of leaf extracts with same beneficial effects in place of unsustainable root and bark harvest.
Collapse
Affiliation(s)
- Aroke Shahid Ahmed
- Phytomedicine Programme, Department of Paraclinical Sciences, Faculty of Veterinary Science, University of Pretoria, Private Bag X04, Onderstepoort 0110, South Africa
- Permanent address: Federal Institute of Industrial Research, Oshodi, P.M.B 21023, Ikeja, Lagos, Nigeria
| | - Lyndy J McGaw
- Phytomedicine Programme, Department of Paraclinical Sciences, Faculty of Veterinary Science, University of Pretoria, Private Bag X04, Onderstepoort 0110, South Africa
| | - Jacobus N Eloff
- Phytomedicine Programme, Department of Paraclinical Sciences, Faculty of Veterinary Science, University of Pretoria, Private Bag X04, Onderstepoort 0110, South Africa
| |
Collapse
|
33
|
Mohan M, Kaushal D, Aye PP, Alvarez X, Veazey RS, Lackner AA. Focused examination of the intestinal epithelium reveals transcriptional signatures consistent with disturbances in enterocyte maturation and differentiation during the course of SIV infection. PLoS One 2013; 8:e60122. [PMID: 23593167 PMCID: PMC3621888 DOI: 10.1371/journal.pone.0060122] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Accepted: 02/21/2013] [Indexed: 12/29/2022] Open
Abstract
The Gastrointestinal (GI) tract plays a pivotal role in AIDS pathogenesis as it is the primary site for viral transmission, replication and CD4+ T cell destruction. Accordingly, GI disease (enteropathy) has become a well-known complication and a driver of AIDS progression. To better understand the molecular mechanisms underlying GI disease we analyzed global gene expression profiles sequentially in the intestinal epithelium of the same animals before SIV infection and at 21 and 90 days post infection (DPI). More importantly we obtained sequential excisional intestinal biopsies and examined distinct mucosal components (epithelium. intraepithelial lymphocytes, lamina propria lymphocytes, fibrovascular stroma) separately. Here we report data pertaining to the epithelium. Overall genes associated with epithelial cell renewal/proliferation/differentiation, permeability and adhesion were significantly down regulated (<1.5–7 fold) at 21 and 90DPI. Genes regulating focal adhesions (n = 6), gap junctions (n = 3), ErbB (n = 3) and Wnt signaling (n = 4) were markedly down at 21DPI and the number of genes in each of these groups that were down regulated doubled between 21 and 90DPI. Notable genes included FAK, ITGA6, PDGF, TGFβ3, Ezrin, FZD6, WNT10A, and TCF7L2. In addition, at 90DPI genes regulating ECM-receptor interactions (laminins and ITGB1), epithelial cell gene expression (PDX1, KLF6), polarity/tight junction formation (PARD3B&6B) and histone demethylase (JMJD3) were also down regulated. In contrast, expression of NOTCH3, notch target genes (HES4, HES7) and EZH2 (histone methyltransferase) were significantly increased at 90DPI. The altered expression of genes linked to Wnt signaling together with decreased expression of PDX1, PARD3B, PARD6B and SDK1 suggests marked perturbations in intestinal epithelial function and homeostasis leading to breakdown of the mucosal barrier. More importantly, the divergent expression patterns of EZH2 and JMJD3 suggests that an epigenetic mechanism involving histone modifications may contribute to the massive decrease in gene expression at 90DPI leading to defects in enterocyte maturation and differentiation.
Collapse
Affiliation(s)
- Mahesh Mohan
- Division of Comparative Pathology, Tulane National Primate Research Center, Covington, Louisiana, United States of America
| | - Deepak Kaushal
- Division of Bacteriology and Parasitology, Tulane National Primate Research Center, Covington, Louisiana, United States of America
| | - Pyone P. Aye
- Division of Comparative Pathology, Tulane National Primate Research Center, Covington, Louisiana, United States of America
| | - Xavier Alvarez
- Division of Comparative Pathology, Tulane National Primate Research Center, Covington, Louisiana, United States of America
| | - Ronald S. Veazey
- Division of Comparative Pathology, Tulane National Primate Research Center, Covington, Louisiana, United States of America
| | - Andrew A. Lackner
- Division of Comparative Pathology, Tulane National Primate Research Center, Covington, Louisiana, United States of America
- * E-mail:
| |
Collapse
|
34
|
|
35
|
Murray JA, Rubio-Tapia A. Diarrhoea due to small bowel diseases. Best Pract Res Clin Gastroenterol 2012; 26:581-600. [PMID: 23384804 PMCID: PMC3621726 DOI: 10.1016/j.bpg.2012.11.013] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Accepted: 11/14/2012] [Indexed: 01/31/2023]
Abstract
Small intestinal diseases are a common, though often overlooked cause of diarrhoeal illness. Fully 1% of the Caucasian population are affected by coeliac disease and a substantial portion of children living in poverty in the developing world are affected by environmental enteropathy. These are but two examples of the many diseases that cause mucosal injury to the primary digestive and absorptive organ in our body. While diarrhoea may be a common, though not universally seen symptom of small bowel mucosal disease, the consequent malabsorption can lead to substantial malnutrition and nutrient deficiencies. The small intestine, unlike the colon, has been relatively inaccessible, and systematic evaluation is often necessary to identify and treat small intestinal mucosal diseases that lead to diarrhoea. Immunodeficiency states, including HIV enteropathy, adult autoimmune enteropathy, drug-associated enteropathy, and tropical sprue continue to occur and require specific therapy. All patients with severe diarrhoea or diarrhoea associated with features suggestive of malabsorption may have a disease of the small intestinal mucosa that requires careful evaluation and targeted management.
Collapse
Affiliation(s)
- Joseph A. Murray
- Corresponding author. Tel.: +1 507 255 5713; fax: +1 507 255 6318.
| | | |
Collapse
|
36
|
Abstract
Diarrhea is a common problem in patients with immunocompromising conditions. The etiologic spectrum differs from patients with diarrhea who have a normal immune system. This article reviews the most important causes of diarrhea in immunocompromised patients, ranging from infectious causes to noninfectious causes of diarrhea in the setting of HIV infection as a model for other conditions of immunosuppression. It also deals with diarrhea in specific situations, eg, after hematopoietic stem cell or solid organ transplantation, diarrhea induced by immunosuppressive drugs, and diarrhea in congenital immunodeficiency syndromes.
Collapse
Affiliation(s)
- Elisabeth Krones
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | | |
Collapse
|
37
|
Kawazoe A, Nagata N. Intestinal tuberculosis in an HIV-infected patient with advanced immunosuppression. Clin Gastroenterol Hepatol 2012; 10:A24. [PMID: 22469991 DOI: 10.1016/j.cgh.2012.03.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2012] [Revised: 03/19/2012] [Accepted: 03/21/2012] [Indexed: 02/07/2023]
Affiliation(s)
- Akihito Kawazoe
- Department of Gastroenterology and Hepatology, National Center for Global Health and Medicine, Tokyo, Japan
| | | |
Collapse
|
38
|
Thomson ABR, Chopra A, Clandinin MT, Freeman H. Recent advances in small bowel diseases: Part I. World J Gastroenterol 2012; 18:3336-52. [PMID: 22807604 PMCID: PMC3396187 DOI: 10.3748/wjg.v18.i26.3336] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2011] [Revised: 04/05/2012] [Accepted: 04/13/2012] [Indexed: 02/06/2023] Open
Abstract
As is the case in all parts of gastroenterology and hepatology, there have been many advances in our knowledge and understanding of small intestinal diseases. Over 1000 publications were reviewed for 2008 and 2009, and the important advances in basic science as well as clinical applications were considered. In Part I of this Editorial Review, seven topics are considered: intestinal development; proliferation and repair; intestinal permeability; microbiotica, infectious diarrhea and probiotics; diarrhea; salt and water absorption; necrotizing enterocolitis; and immunology/allergy. These topics were chosen because of their importance to the practicing physician.
Collapse
|
39
|
van de Ven AAJM, Hoytema van Konijnenburg DP, Wensing AMJ, van Montfrans JM. The role of prolonged viral gastrointestinal infections in the development of immunodeficiency-related enteropathy. Clin Rev Allergy Immunol 2012; 42:79-91. [PMID: 22116710 DOI: 10.1007/s12016-011-8292-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Patients with primary immunodeficiencies are prone to develop enteropathy of unknown pathogenesis. We hypothesize that ineffective clearance of gastrointestinal pathogens, particularly viruses, in combination with defective immune regulation may cause inflammatory enteropathy in certain immunodeficient hosts. We reviewed publications related to prolonged enteric viral infection, immunodeficiency, and the subsequent development of inflammatory enteropathy. Prolonged infection with especially enteroviral infections was reported more often in immunocompromised hosts than in healthy individuals. Protracted enteric viral shedding was not always associated with the presence or duration of gastrointestinal symptoms. The development of immunodeficiency-associated enteropathy after prolonged viral infections was described in sporadic cases. Clinical consequences of viral gut infections in immunocompromised hosts comprise isolation issues and supportive care. Prospective studies in cohorts of immunodeficient patients are required to study the impact of prolonged enteric viral replication with respect to the pathogenesis of non-infectious enteropathy.
Collapse
Affiliation(s)
- Annick A J M van de Ven
- Department of Pediatric Immunology and Infectious Diseases, University Medical Center Utrecht/Wilhelmina Children's Hospital, Utrecht, the Netherlands
| | | | | | | |
Collapse
|
40
|
MacArthur RD, DuPont HL. Etiology and pharmacologic management of noninfectious diarrhea in HIV-infected individuals in the highly active antiretroviral therapy era. Clin Infect Dis 2012; 55:860-7. [PMID: 22700829 DOI: 10.1093/cid/cis544] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Diarrhea remains a common problem for patients with human immunodeficiency virus (HIV) infection despite highly active antiretroviral therapies (HAART) and can negatively affect patient quality of life and lead to discontinuation or switching of HAART regimens. In the era of HAART, diarrhea from opportunistic infections is uncommon, and HIV-associated diarrhea often has noninfectious causes, including HAART-related adverse events and HIV enteropathy. Diarrhea associated with HAART is typically caused by protease inhibitors (eg, ritonavir), which may damage the intestinal epithelial barrier (leaky-flux diarrhea) and/or alter chloride ion secretion (secretory diarrhea). HIV enteropathy may result from direct effects of HIV on gastrointestinal tract cells and on the gastrointestinal immune system and gut-associated lymphoid tissue, which may be active sites of HIV infection and ongoing inflammation and mucosal damage. New therapies targeting the pathogenic mechanisms of noninfectious diarrheas are needed.
Collapse
Affiliation(s)
- Rodger D MacArthur
- Division of Infectious Diseases, Wayne State University, Detroit, Michigan 48201, USA.
| | | |
Collapse
|
41
|
Abstract
OBJECTIVES Calprotectin is a calcium- and zinc-binding protein and a marker in faeces of gastrointestinal inflammation. Reference values have been established in children older than 4 years. The aim of the present study was to determine the concentration of faecal calprotectin (FC) in human immunodeficiency virus (HIV)-infected, highly active antiretroviral therapy-naïve Ugandan children and compare it with the reference value. METHODS We tested 193 HIV-infected children ages 0 to 12 years in a hospital-based survey for FC. A standardised interview with sociodemographic information and medical history was used to assess risk factors. A cluster of differentiation 4 (CD4) cell percentage was prevalent in all of the children. RESULTS The median FC concentrations decreased with increasing age, as in healthy children. The median concentration was 208 mg/kg in infants 0 to 1 year, 171 mg/kg among toddlers 1 to 4 years, and 62 mg/kg for children 4 to 12 years. Children with advanced disease and a low CD4 cell percentage had significantly higher FC concentrations than those with a high CD4 cell percentage. Children older than 4 years with diarrhoea had significantly higher FC concentrations compared with those without diarrhoea. CONCLUSIONS HIV-infected children older than 4 years had a median FC concentration above the reference value, and gut inflammation in the children with elevated values is likely. Children with more advanced disease had increased FC concentrations regardless of age.
Collapse
|
42
|
Mohan M, Kaushal D, Aye PP, Alvarez X, Veazey RS, Lackner AA. Focused examination of the intestinal lamina propria yields greater molecular insight into mechanisms underlying SIV induced immune dysfunction. PLoS One 2012; 7:e34561. [PMID: 22511950 PMCID: PMC3325268 DOI: 10.1371/journal.pone.0034561] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 03/05/2012] [Indexed: 12/12/2022] Open
Abstract
Background The Gastrointestinal (GI) tract is critical to AIDS pathogenesis as it is the primary site for viral transmission and a major site of viral replication and CD4+ T cell destruction. Consequently GI disease, a major complication of HIV/SIV infection can facilitate translocation of lumenal bacterial products causing localized/systemic immune activation leading to AIDS progression. Methodology/Principal Findings To better understand the molecular mechanisms underlying GI disease we analyzed global gene expression profiles sequentially in the intestine of the same animals prior to and at 21 and 90d post SIV infection (PI). More importantly we maximized information gathering by examining distinct mucosal components (intraepithelial lymphocytes, lamina propria leukocytes [LPL], epithelium and fibrovascular stroma) separately. The use of sequential intestinal resections combined with focused examination of distinct mucosal compartments represents novel approaches not previously attempted. Here we report data pertaining to the LPL. A significant increase (±1.7-fold) in immune defense/inflammation, cell adhesion/migration, cell signaling, transcription and cell division/differentiation genes were observed at 21 and 90d PI. Genes associated with the JAK-STAT pathway (IL21, IL12R, STAT5A, IL10, SOCS1) and T-cell activation (NFATc1, CDK6, Gelsolin, Moesin) were notably upregulated at 21d PI. Markedly downregulated genes at 21d PI included IL17D/IL27 and IL28B/IFNγ3 (anti-HIV/viral), activation induced cytidine deaminase (B-cell function) and approximately 57 genes regulating oxidative phosphorylation, a critical metabolic shift associated with T-cell activation. The 90d transcriptome revealed further augmentation of inflammation (CXCL11, chitinase-1, JNK3), immune activation (CD38, semaphorin7A, CD109), B-cell dysfunction (CD70), intestinal microbial translocation (Lipopolysaccharide binding protein) and mitochondrial antiviral signaling (NLRX1) genes. Reduced expression of CD28, CD4, CD86, CD93, NFATc1 (T-cells), TLR8, IL8, CCL18, DECTIN1 (macrophages), HLA-DOA and GPR183 (B-cells) at 90d PI suggests further deterioration of overall immune function. Conclusions/Significance The reported transcriptional signatures provide significant new details on the molecular pathology of HIV/SIV induced GI disease and provide new opportunity for future investigation.
Collapse
Affiliation(s)
- Mahesh Mohan
- Division of Comparative Pathology, Tulane National Primate Research Center, Covington, Louisiana, United States of America
| | - Deepak Kaushal
- Division of Bacteriology and Parasitology, Tulane National Primate Research Center, Covington, Louisiana, United States of America
| | - Pyone P. Aye
- Division of Comparative Pathology, Tulane National Primate Research Center, Covington, Louisiana, United States of America
| | - Xavier Alvarez
- Division of Comparative Pathology, Tulane National Primate Research Center, Covington, Louisiana, United States of America
| | - Ronald S. Veazey
- Division of Comparative Pathology, Tulane National Primate Research Center, Covington, Louisiana, United States of America
| | - Andrew A. Lackner
- Division of Comparative Pathology, Tulane National Primate Research Center, Covington, Louisiana, United States of America
- * E-mail:
| |
Collapse
|
43
|
False-positive tissue transglutaminase antibody levels occur in HIV-positive patients: HLA typing is essential. J Clin Gastroenterol 2012; 46:346. [PMID: 22064557 DOI: 10.1097/mcg.0b013e31823b3baf] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
|
44
|
Buccigrossi V, Laudiero G, Nicastro E, Miele E, Esposito F, Guarino A. The HIV-1 transactivator factor (Tat) induces enterocyte apoptosis through a redox-mediated mechanism. PLoS One 2011; 6:e29436. [PMID: 22216281 PMCID: PMC3246489 DOI: 10.1371/journal.pone.0029436] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2011] [Accepted: 11/28/2011] [Indexed: 12/23/2022] Open
Abstract
The intestinal mucosa is an important target of human immunodeficiency virus (HIV) infection. HIV virus induces CD4+ T cell loss and epithelial damage which results in increased intestinal permeability. The mechanisms involved in nutrient malabsorption and alterations of intestinal mucosal architecture are unknown. We previously demonstrated that HIV-1 transactivator factor (Tat) induces an enterotoxic effect on intestinal epithelial cells that could be responsible for HIV-associated diarrhea. Since oxidative stress is implicated in the pathogenesis and morbidity of HIV infection, we evaluated whether Tat induces apoptosis of human enterocytes through oxidative stress, and whether the antioxidant N-acetylcysteine (NAC) could prevent it. Caco-2 and HT29 cells or human intestinal mucosa specimens were exposed to Tat alone or combined with NAC. In an in-vitro cell model, Tat increased the generation of reactive oxygen species and decreased antioxidant defenses as judged by a reduction in catalase activity and a reduced (GSH)/oxidized (GSSG) glutathione ratio. Tat also induced cytochrome c release from mitochondria to cytosol, and caspase-3 activation. Rectal dialysis samples from HIV-infected patients were positive for the oxidative stress marker 8-hydroxy-2'-deoxyguanosine. GSH/GSSG imbalance and apoptosis occurred in jejunal specimens from HIV-positive patients at baseline and from HIV-negative specimens exposed to Tat. Experiments with neutralizing anti-Tat antibodies showed that these effects were direct and specific. Pre-treatment with NAC prevented Tat-induced apoptosis and restored the glutathione balance in both the in-vitro and the ex-vivo model. These findings indicate that oxidative stress is one of the mechanism involved in HIV-intestinal disease.
Collapse
Affiliation(s)
| | - Gabriella Laudiero
- Department of Paediatrics, University of Naples “Federico II,” Naples, Italy
| | - Emanuele Nicastro
- Department of Paediatrics, University of Naples “Federico II,” Naples, Italy
| | - Erasmo Miele
- Department of Paediatrics, University of Naples “Federico II,” Naples, Italy
| | - Franca Esposito
- Department of Biochemistry and Medical Biotechnology, University of Naples “Federico II,” Naples, Italy
| | - Alfredo Guarino
- Department of Paediatrics, University of Naples “Federico II,” Naples, Italy
| |
Collapse
|
45
|
Feasey NA, Healey P, Gordon MA. Review article: the aetiology, investigation and management of diarrhoea in the HIV-positive patient. Aliment Pharmacol Ther 2011; 34:587-603. [PMID: 21777262 DOI: 10.1111/j.1365-2036.2011.04781.x] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Diarrhoea is a common presentation throughout the course of HIV disease. AIM To review the literature relating to aetiology, investigation and management of diarrhoea in the HIV-infected adult. METHODS The PubMed database was searched using major subject headings 'AIDS' or 'HIV' and 'diarrhoea' or 'intestinal parasite'. The search was limited to adults and to studies with >10 patients. RESULTS Diarrhoea affects 40-80% of HIV-infected adults untreated with antiretroviral therapy (ART). First-line investigation is by stool microbiology. Reported yield varies with geography and methodology. Molecular and immunological methods and special stains have improved diagnostic yield. Endoscopy is diagnostic in 30-70% of cases of pathogen-negative diarrhoea and evidence supports flexible sigmoidoscopy as a first line screening procedure (80-95% sensitive for CMV colitis), followed by colonoscopy and terminal ileoscopy. Radiology is useful to assess severity, distribution, complications and to diagnose HIV-related malignancies. Side effects and compliance with ART are important considerations in assessment. There is a good evidence base for many specific therapies, but optimal treatment of cryptosporidiosis is unclear and only limited data support symptomatic treatments. CONCLUSIONS The immunological response to HIV infection and Antiretroviral therapy remains incompletely understood. Antiretroviral therapy regimens need to be optimised to suppress HIV while minimising side effects. Effective agents for management of cryptosporidiosis are lacking. There is an urgent need for enhanced regional diagnostic facilities in countries with a high prevalence of HIV. The ongoing roll-out of Antiretroviral therapy in low-resource settings will continue to change the aetiology and management of this problem, necessitating ongoing surveillance and study.
Collapse
Affiliation(s)
- N A Feasey
- Department of Gastroenterology, University of Liverpool, Liverpool, UK
| | | | | |
Collapse
|
46
|
Nagata N, Honda M, Kobayakawa M, Maeda S, Sakurai T, Akiyama J, Gotoda T, Oka S, Uemura N. Mycobacterium lentiflavum ileitis using aspirated intestinal fluid during endoscopy in HIV-infected patient. Dig Endosc 2011; 23:271-2. [PMID: 21699576 DOI: 10.1111/j.1443-1661.2010.01091.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
|
47
|
Plasmacytoid dendritic cells are recruited to the colorectum and contribute to immune activation during pathogenic SIV infection in rhesus macaques. Blood 2011; 118:2763-73. [PMID: 21693759 DOI: 10.1182/blood-2011-02-339515] [Citation(s) in RCA: 86] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
In SIV/HIV infection, the gastrointestinal tissue dominates as an important site because of the impact of massive mucosal CD4 depletion and immune activation-induced tissue pathology. Unlike AIDS-susceptible rhesus macaques, natural hosts do not progress to AIDS and resolve immune activation earlier. Here, we examine the role of dendritic cells (DCs) in mediating immune activation and disease progression. We demonstrate that plasmacytoid DCs (pDCs) in the blood up-regulate β7-integrin and are rapidly recruited to the colorectum after a pathogenic SIV infection in rhesus macaques. These pDCs were capable of producing proinflammatory cytokines and primed a T cytotoxic 1 response in vitro. Consistent with the up-regulation of β7-integrin on pDCs, in vivo blockade of α4β7-integrin dampened pDC recruitment to the colorectum and resulted in reduced immune activation. The up-regulation of β7-integrin expression on pDCs in the blood also was observed in HIV-infected humans but not in chronically SIV-infected sooty mangabeys that show low levels of immune activation. Our results uncover a new mechanism by which pDCs influence immune activation in colorectal tissue after pathogenic immunodeficiency virus infections.
Collapse
|
48
|
|
49
|
Ogoina D, Obiako RO, Muktar HM. HIV Wasting Syndrome in a Nigerian Failing Antiretroviral Therapy: A Case Report and Review of the Literature. Case Rep Med 2010; 2010:192060. [PMID: 21209738 PMCID: PMC3014846 DOI: 10.1155/2010/192060] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2010] [Accepted: 12/03/2010] [Indexed: 11/17/2022] Open
Abstract
The HIV wasting syndrome represented the face of HIV/AIDS before the advent of highly active antiretroviral therapy (HAART). Although the incidence of wasting has declined since the introduction of HAART, weight loss remains common in patients receiving HAART, especially in the setting of a failing HAART regimen. As we are not aware of any previous reports from Nigeria, we report a case of the classical wasting syndrome in a Nigerian female who had both virological and immunological HAART failure due to poor adherence. The influence of a failing HAART regimen, socioeconomic status, and other clinical variables in the wasting syndrome are discussed.
Collapse
Affiliation(s)
- Dimie Ogoina
- Department of Medicine, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria
| | - Reginald O. Obiako
- Department of Medicine, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria
| | - Haruna M. Muktar
- Department of Haematology, Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria
| |
Collapse
|
50
|
Stensvold CR, Nielsen SD, Badsberg JH, Engberg J, Friis-Møller N, Nielsen SS, Nielsen HV, Friis-Møller A. The prevalence and clinical significance of intestinal parasites in HIV-infected patients in Denmark. ACTA ACUST UNITED AC 2010; 43:129-35. [DOI: 10.3109/00365548.2010.524659] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
|