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Chadwick DR, Sutherland RK, Raffe S, Pool E, Beadsworth M. British HIV Association guidelines on the management of opportunistic infection in people living with HIV: the clinical management of gastrointestinal opportunistic infections 2020. HIV Med 2020; 21 Suppl 5:1-19. [PMID: 33271637 DOI: 10.1111/hiv.13004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- D R Chadwick
- Centre for Clinical Infection, James Cook University Hospital, Middlesbrough, UK
| | - R K Sutherland
- Regional Infectious Diseases Unit, NHS Lothian, Edinburgh, UK
| | - S Raffe
- Brighton and Sussex University Hospitals NHS Trust, Brighton, UK
| | - Erm Pool
- Mortimer Market Centre, Central and North West London NHS Foundation Trust, London, UK
| | - Mbj Beadsworth
- Tropical and Infectious Disease Unit, Royal Liverpool University Hospital (Liverpool University Hospitals Foundation Trust), Liverpool, UK
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Cimolai N. Features of enteric disease from human coronaviruses: Implications for COVID-19. J Med Virol 2020; 92:1834-1844. [PMID: 32462689 PMCID: PMC7283829 DOI: 10.1002/jmv.26066] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 05/25/2020] [Indexed: 01/19/2023]
Abstract
Coronaviruses have long been studied in both human and veterinary fields. Whereas the initial detection of endemic human respiratory coronaviruses was problematic, detection of these and newly discovered human coronaviruses has been greatly facilitated with major advances in the laboratory. Nevertheless, technological factors can affect the accuracy and timeliness of virus detection. Many human coronaviruses can be variably found in stool samples. All human coronaviruses have been variably associated with symptoms of gastroenteritis. Coronaviruses can occasionally be cultured from enteric specimens, but most detection is accomplished with genetic amplification technologies. Excretion of viral RNA in stool can extend for a prolonged period. Culture‐positive stool samples have been found to exceed a fourteen day period after onset of infection for some coronaviruses. Virus can also sometimes be cultured from patients' respiratory samples during the late incubation period. Relatively asymptomatic patients may excrete virus. Both viable and nonviable virus can be found in the immediate environment of the patient, the health care worker, and less often the public. These lessons from the past study of animal and human coronaviruses can be extended to presumptions for severe acute respiratory syndrome coronavirus 2. Already, the early reports from the coronavirus disease‐2019 pandemic are confirming some concerns. These data have the cumulative potential to cause us to rethink some current and common public health and infection control strategies. coronaviruses are variably found in human enteric samples during the course of infection. abdominal and intestinal illnesses are associated with coronavirus infections. enteric excretion of live virus and viral RNA have been confirmed. occasionally, live virus can be found in stool samples to exceed a fourteen day period after disease onset, and virus can also be cultured from these samples during the late incubation period or from asymptomatic individuals.
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Affiliation(s)
- Nevio Cimolai
- Department of Pathology and Laboratory Medicine, Faculty of Medicine, Children's and Women's Health Centre of British Columbia, The University of British Columbia, Vancouver, British Columbia, Canada
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Coronaviruses, Including Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS). MANDELL, DOUGLAS, AND BENNETT'S PRINCIPLES AND PRACTICE OF INFECTIOUS DISEASES 2015. [PMCID: PMC7151770 DOI: 10.1016/b978-1-4557-4801-3.00157-0] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
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Shim JO. Differential diagnosis of acute diarrheal disorders in children. JOURNAL OF THE KOREAN MEDICAL ASSOCIATION 2012. [DOI: 10.5124/jkma.2012.55.6.516] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Affiliation(s)
- Jung Ok Shim
- Division of Gastroenterology, Hepatology and Nutrition, Department of Pediatrics, Korea University Guro Hospital, Seoul, Korea
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Frequent detection of human adenovirus from the lower gastrointestinal tract in men who have sex with men. PLoS One 2010; 5:e11321. [PMID: 20593015 PMCID: PMC2892480 DOI: 10.1371/journal.pone.0011321] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2010] [Accepted: 05/01/2010] [Indexed: 12/19/2022] Open
Abstract
Background The association between baseline seropositivity to human adenovirus (HAdV) type 5 and increased HIV acquisition in the Step HIV Vaccine Study has raised questions concerning frequency of acquired and/or persistent Adenovirus infections among adults at high risk of HIV-1 infection. Methodology To evaluate the frequency and pattern of HAdV shedding from the lower GI tract, we retrospectively tested rectal swabs for HAdVs in a cohort of 20 HSV-2 positive HIV-positive Peruvian men who have sex with men (MSM) undergoing rectal swabbing three times/week for 18 consecutive weeks, in a prospective study of HSV-2 suppression in HIV infection. Viral DNA was extracted and amplified using a sensitive multiplex PCR assay that detects all currently recognized HAdV types. Molecular typing of viruses was performed on selected samples by hexon gene sequencing. Baseline neutralizing antibody titers to HAdVs −5, −26, −35 and −48 were also assessed. Principal Findings 15/20 individuals had HAdV detected during follow up. The median frequency of HAdV detection was 30% of samples (range 2.0% to 64.7%). HAdV shedding typically occurred on consecutive days in clustered episodes lasting a median of 4 days (range 1 to 9 days) separated by periods without shedding, suggesting frequent new infections or reactivation of latent infections over time. 8 of the 15 shedders had more than one type detected in follow-up. 20 HAdV types from species B, C, and D were identified, including HAdV-5, −26 and −48, HAdV types under development as potential vaccine candidates. 14/20 subjects were seropositive for HAdV-5; 15/20 for HAdV-26; 3/20 for HAdV-35; and 2/20 for HAdV-48. HAdV shedding did not correlate with CD4 count, plasma HIV-1 viral load, or titers to HAdV-5 or HAdV-35. The sole individual with HAdV-5 shedding was HAdV-5 seropositive. Conclusions HAdV shedding was highly prevalent and diverse, including types presently under consideration as HIV vaccine vectors. Subclinical HAdV infection of the GI tract is common among MSM in Peru; the prevalence of HAdV in the enteric tract should be evaluated in other populations. The association between ongoing recent enteric HAdV and the immune response to recombinant HAdV vaccines should be evaluated.
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Zingg W. Die virale Gastroenteritis. DER GASTROENTEROLOGE 2007; 2:179-185. [PMID: 32288844 PMCID: PMC7104389 DOI: 10.1007/s11377-007-0078-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Lee PO, Tsui PT, Tsang TY, Chau TN, Kwan CP, Yu WC, Lai ST. Severe acute respiratory syndrome: clinical features. CORONAVIRUSES WITH SPECIAL EMPHASIS ON FIRST INSIGHTS CONCERNING SARS 2005. [PMCID: PMC7122834 DOI: 10.1007/3-7643-7339-3_3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Abstract
PURPOSE OF REVIEW Since Kapakian first identified a virus in the stool of a patient with diarrhoea in 1972, many viruses have been described that cause diarrhoea directly or indirectly. It is now appreciated that viruses are the most common cause of diarrhoeal illness worldwide. Although bacteria and other pathogens cause significant numbers of gastroenteritis, it is the viruses that are dealt with in this review. The viruses responsible will be discussed individually. RECENT FINDINGS Rotavirus remains the leading cause of diarrhoeal disease overall, with the newly designated calicivirus family causing the most outbreaks in the industrialized nations. As diagnostic techniques improve, however, the importance of astrovirus and other previously under-reported pathogens is becoming more apparent and the number of viruses associated with gastroenteritis continues to increase. The emergence of severe acute respiratory syndrome coronavirus, arguably the most important emerging infection of recent years and a cause of significant gastrointestinal disease, is also discussed. SUMMARY No effective treatments have been developed for viral gastroenteritis. Current efforts are targeted at the development of suitable vaccines and the implementation of infection control measures.
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Affiliation(s)
- Benjamin Clark
- Department of Infection and Tropical Medicine, Royal Hallamshire Hospital, Sheffield S10 2JF, UK.
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Guest JL, Ruffin C, Tschampa JM, DeSilva KE, Rimland D. Differences in Rates of Diarrhea in Patients with Human Immunodeficiency Virus Receiving Lopinavir-Ritonavir or Nelfinavir. Pharmacotherapy 2004; 24:727-35. [PMID: 15222662 DOI: 10.1592/phco.24.8.727.36071] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVE To determine and compare rates of diarrhea in patients receiving an antiretroviral regimen containing lopinavir-ritonavir versus nelfinavir and in patients who received these drugs sequentially. DESIGN Retrospective cohort analysis. SETTING Hospital-based human immunodeficiency virus (HIV) clinic. PATIENTS Four hundred one participants in the HIV Atlanta VA Cohort Study who were prescribed lopinavir-ritonavir or nelfinavir from 1996-2002. MEASUREMENTS AND MAIN RESULTS Chart review identified episodes of diarrhea that potentially were associated with an antiretroviral agent. Data collected included antidiarrheal agents dispensed, baseline viral load and CD4+ cell counts, demographic variables, and previous therapy Diarrhea associated with an antiretroviral regimen occurred in 175 (49%) of 354 patients receiving nelfinavir and 17 (17%) of 99 patients receiving lopinavir-ritonavir (p < 0.001). Treatment for the diarrhea occurred in 118 (33%) of 354 patients receiving nelfinavir and 9 (9%) of 99 receiving lopinavir-ritonavir (p < 0.001). Patients in the lopinavir-ritonavir group were more likely to have received highly active antiretroviral therapy and azithromycin than patients receiving nelfinavir, and they had lower baseline CD4+ cell counts (p < or = 0.01 for each comparison). The average number of months/person-year of diarrhea treatment was 2.0 for the nelfinavir group and 0.13 for the lopinavir-ritonavir group. Of the 10 antiretroviral-naive patients who received lopinavir-ritonavir, none needed treatment for diarrhea, whereas 78 (36%) of 217 antiretroviral-naive patients who received nelfinavir required treatment for diarrhea. Of the 52 patients who had been taking nelfinavir and were switched to lopinavir-ritonavir, they were more likely to start antidiarrheal treatment while taking nelfinavir (14 [27%]) than while receiving lopinavir-ritonavir (3 [6%]) (p = 0.004). CONCLUSIONS Patients receiving lopinavir-ritonavir were significantly less likely to have diarrhea or to require treatment for diarrhea than patients receiving nelfinavir. The same results occurred when the drugs were given to the same patients sequentially (nelfinavir followed by lopinavir-ritonavir). The diarrhea associated with lopinavir-ritonavir was less frequent, less severe, and shorter in duration than diarrhea associated with nelfinavir.
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Affiliation(s)
- Jodie L Guest
- Infectious Disease Section, Atlanta Veterans Affairs Medical Center, Decatur, Georgia, USA
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Leung WK, To KF, Chan PKS, Chan HLY, Wu AKL, Lee N, Yuen KY, Sung JJY. Enteric involvement of severe acute respiratory syndrome-associated coronavirus infection. Gastroenterology 2003; 125. [PMID: 14517783 PMCID: PMC7126982 DOI: 10.1016/j.gastro.2003.08.001] [Citation(s) in RCA: 378] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND AND AIMS Severe acute respiratory syndrome (SARS) is a recently emerged infection from a novel coronavirus (CoV). Apart from fever and respiratory complications, gastrointestinal symptoms are frequently observed in patients with SARS but the significance remains undetermined. Herein, we describe the clinical, pathologic, and virologic features of the intestinal involvement of this new viral infection. METHODS A retrospective analysis of the gastrointestinal symptoms and other clinical parameters of the first 138 patients with confirmed SARS admitted for a major outbreak in Hong Kong in March 2003 was performed. Intestinal specimens were obtained by colonoscopy or postmortem examination to detect the presence of coronavirus by electron microscopy, virus culture, and reverse-transcription polymerase chain reaction. RESULTS Among these 138 patients with SARS, 28 (20.3%) presented with watery diarrhea and up to 38.4% of patients had symptoms of diarrhea during the course of illness. Diarrhea was more frequently observed during the first week of illness. The mean number of days with diarrhea was 3.7 +/- 2.7, and most diarrhea was self-limiting. Intestinal biopsy specimens obtained by colonoscopy or autopsy showed minimal architectural disruption but the presence of active viral replication within both the small and large intestine. Coronavirus was also isolated by culture from these specimens, and SARS-CoV RNA can be detected in the stool of patients for more than 10 weeks after symptom onset. CONCLUSIONS Diarrhea is a common presenting symptom of SARS. The intestinal tropism of the SARS-CoV has major implications on clinical presentation and viral transmission.
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Affiliation(s)
- Wai K Leung
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Prince of Wales Hospital, Shatin, Hong Kong.
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Abstract
This chapter discusses the causative viral agents, pathophysiology, and immunology of gastroenteritis. Acute gastroenteritis is among the most common illnesses of humans and is caused by a variety of agents, including bacteria, viruses, parasites, toxins, and chemicals. The clinical spectrum ranges from asymptomatic or mild infection to severe dehydrating illness with a fatal outcome; the latter occurs primarily in young children and in the elderly. The chapter concludes with a discussion on the prevention and treatment of gastroenteritis. For the prevention of epidemic viral gastroenteritis, efforts need to be focused on caliciviruses. No specific antiviral therapy is recommended for childhood viral gastroenteritis, emphasizing the importance of distinguishing it from the selected forms of bacterial and parasitic gastroenteritis that require treatment. Other than pertinent epidemiologic information, certain clinical features of illness may provide etiologic clues, but they are not highly discriminating. Standard therapy of viral enteric infections relies on maintenance of adequate hydration and electrolyte balance. Oral rehydration therapy (ORT) is the main treatment.
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Affiliation(s)
- Umesh D Parashar
- Viral Gastroenteritis Section, Respiratory and Enteric Viruses Branch, Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
| | - Roger I Glass
- Viral Gastroenteritis Section, Respiratory and Enteric Viruses Branch, Division of Viral and Rickettsial Diseases, National Center for Infectious Diseases, Centers for Disease Control and Prevention, Atlanta, GA 30333, USA
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Abstract
Chronic HIV-associated diarrhea is currently a field in flux. Improved noninvasive diagnostic tests, improved pathogen-specific regimens, and better empiric therapies may change some of the assumptions used to select algorithms for diagnostic evaluation and management. Any shift in the cause of diarrhea from pathogen-associated to idiopathic or a reduction in the overall incidence of diarrhea would have considerable impact. It is unclear how significant the problem of pathogen relapse in previous responders will become. Existing studies reviewed in this article show that the high diagnostic yield of endoscopy when stool tests are negative, coupled with significantly better outcomes when pathogens are identified, support the current practice of routine endoscopic evaluation. There currently are scant data on the economic impact of HIV-associated diarrhea as it relates to pathogen-specific and empiric therapy in the era of protease inhibitors. Such data would be integral to future evaluation of the impact of diagnostic and therapeutic strategies.
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Affiliation(s)
- J Cohen
- Division of Gastroenterology, Department of Medicine, New York University School of Medicine, New York, New York, USA
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Orenstein JM, Dieterich DT. The histopathology of 103 consecutive colonoscopy biopsies from 82 symptomatic patients with acquired immunodeficiency syndrome: original and look-back diagnoses. Arch Pathol Lab Med 2001; 125:1042-6. [PMID: 11473454 DOI: 10.5858/2001-125-1042-thoccb] [Citation(s) in RCA: 85] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To compare the primary diagnoses assigned by general surgical pathologists on a series of 103 consecutive colon biopsies from individuals infected with human immunodeficiency virus (HIV) with diagnoses rendered by a pathologist with extensive experience in gastrointestinal pathology in HIV/acquired immunodeficiency syndrome. DESIGN New sections were cut from paraffin blocks of 103 consecutive colon biopsies taken during colonoscopies of 82 different HIV-infected patients; all new sections were stained with hematoxylin-eosin. These individuals either had negative stool studies or had failed to respond to therapy and had chronic large bowel symptoms, such as frequent small volume-type diarrhea, tenesmus, and/or bright red blood per rectum. Immunohistochemistry for cytomegalovirus (CMV) was performed on 18 of 22 specimens originally diagnosed with CMV colitis. RESULTS The initial study yielded 70 (68%) negative or nonspecific diagnoses, 22 (21%) cases of CMV colitis, 5 (5%) Cryptosporidium diagnoses, 2 cases each of adenomatous polyps and Kaposi sarcoma, and 1 case each of spirochetosis and squamous cell carcinoma of the anorectum. Review of the recuts yielded 64 (62%) negative or nonspecific diagnoses, 12 (12%) new adenovirus infections (3 combined with CMV), and 11 (11%) lone CMV infections. Three attaching and effacing bacterial infections were diagnosed, 1 with adenovirus coinfection. A total of 4 spirochetosis cases were found on review. Seven (7%) of the biopsies showed at least 1 coinfection. Nine biopsies had features suggestive of inflammatory bowel disease. CONCLUSIONS Colonoscopy with biopsy after negative stool studies or failure to respond to therapy yielded a high proportion of negative or nonspecific diagnoses. Adenovirus and enteropathogenic bacterial infections had been totally overlooked on initial examination. It takes particular experience to evaluate gastrointestinal biopsies from HIV-infected patients.
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Affiliation(s)
- J M Orenstein
- Department of Pathology, George Washington University Medical Center, 2300 Eye Street NW, Washington, DC 20037, USA.
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Abstract
GASTROENTROLOGY 2001;120:607-621
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Key Words
- aids, acquired immunodeficiency syndrome
- cmv, cytomegalovirus
- haart, highly active antiretroviral therapy
- hiv, human immunodeficiency virus
- ifn-α, interferon α
- mac, mycobacterium avium complex
- nnrti, nonnucleoside reverse-transcriptase inhibitor
- nrti, nucleoside reverse-transcriptase inhibitor
- pi, protease inhibitor
- rti, reverse-transcriptase inhibitor
- siv, simian immunodeficiency virus
- tmp-smx, trimethoprim-sulfamethoxazole
- zdv, zidovudine
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Affiliation(s)
- E N Janoff
- Mucosal and Vaccine Research Center, Infectious Disease Section, Department of Medicine, Veterans Affairs Medical Center and University of Minnesota School of Medicine, Minneapolis, Minnesota, USA
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Gassama A, Sow PS, Fall F, Camara P, Guèye-N'diaye A, Seng R, Samb B, M'Boup S, Aïdara-Kane A. Ordinary and opportunistic enteropathogens associated with diarrhea in Senegalese adults in relation to human immunodeficiency virus serostatus. Int J Infect Dis 2001; 5:192-8. [PMID: 11953215 PMCID: PMC7128624 DOI: 10.1016/s1201-9712(01)90069-4] [Citation(s) in RCA: 69] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES A survey was conducted in Dakar, Senegal, to identify major types and prevalences of bacteria, parasites, fungi, and Rotaviruses associated with diarrhea in relation to human immunodeficiency virus (HIV) serostatus with the goal to provide guidance to physicians for case management. METHODS Etiologic agents were identified in a case control study: cases were HIV-infected patients with diarrhea (HIV+ D+) and HIV seronegative patients with diarrhea (HIV D+); controls were HIV-infected patients without diarrhea (HIV+ D ) and seronegative controls without diarrhea (HID D ). Ordinary enteric pathogens were identified by conventional methods. Different Escherichia coli pathotypes were characterized by polymerase chain reaction (PCR), identification of HEp-2 cell adherence pattern, Sereny test, GM1-ELISA, and the suckling mouse assay. Opportunistic parasites, such as Cryptosporidium and Microsporidium, were identified by the Kinyoun method and trichromic stain of Weber, respectively. Rotaviruses were identified with a commercial latex agglutination kit. Antimicrobial susceptibility testing was carried out by the disk diffusion method. RESULTS Among the 594 patients examined, 158 were HIV+ D+, 121 were HIV2 D+, 160 were HIV+ D , and 155 were HIV D . The main etiologies of diarrhea were different according to HIV serostatus of patients. In immunocompetent adults the main causes of diarrhea were Shigella sp (12.4%), Entamoeba histolytica(10.7%), Salmonella enterica (6.6%), and Giardia (4.9%). In the immunocompromised host the more frequent pathogens were enteroaggregative E. coli (19.6%), Microsporidium (9.4%), Cryptosporidium sp (8.2%), Rotavirus (8.2%), Shigella sp (7.6%), Candida albicans (7.6%), E. histolytica (5.1%), S. enterica (4.4%), and Isospora belli (4.4%). Also, Blastocystis hominis has to be considered as an opportunistic parasite, because it was identified only in HIV-infected patients, with higher prevalence in adults with diarrhea (2.5% in HIV+ D+ patients; 0.6% in HIV+ D patients). High level of asymptomatic carriage of Ascaris lumbricoides and Trichuris trichiura and some cases of multiple infections were observed. Fungi, Cryptosporidium sp and Microsporidium sp, were often identified in patients with low CD4 counts (range, 79 250 cells/mL). Independently from HIV-serostatus, CD4 count was lower in diarrheic persons, suggesting that diarrhea is a debilitating illness and that effective management of diarrhea can prevent immunosuppression. Isolated enteropathogenic strains displayed high resistance to most antibiotics used in Senegal for treating diarrhea (ampicillin, tetracycline, cotrimoxazole); they were susceptible to amikacin, gentamicin, and norfloxacin. CONCLUSION These epidemiologic data suggest that guidelines for the management of diarrhea during HIV infection in Dakar should be updated.
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Abstract
HIV-related diarrhoea is an important cause of morbidity and mortality in HIV infection. Cytomegalovirus is a well-established cause of diarrhoea, but the role of other enteric viruses is less clear and will be discussed here. The clinical manifestations, disease mechanisms, diagnostic techniques and current treatments for the management of these infections are reviewed.
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Affiliation(s)
- R C Pollok
- Digestive Diseases Research Centre, St Bartholomew's and the Royal London School of Medicine and Dentistry, Turner St, London, UK E1 2AT.
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20
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Abstract
BACKGROUND AND AIMS The role of non-cytomegalovirus (CMV) enteric viral infection in causing diarrhoea in patients with human immunodeficiency virus (HIV) is poorly understood. We aimed to investigate the prevalence of these infections in acute and chronic diarrhoea. METHODS Stool specimens from 377 HIV-infected patients presenting with diarrhoea were studied prospectively for evidence of non-CMV enteric viral infection. Patients with diarrhoea underwent investigation for gastrointestinal pathogens, including electron microscopic examination of stool for enteric viruses. We collected data on patients in whom enteric virus was identified and examined the association of enteric virus infection with diarrhoeal symptomatology. RESULTS Eighty-nine (10.3%) stool specimens from 60 (15.9%) HIV+ individuals were positive for coronavirus (n = 13, 22%), rotavirus (n = 11, 18%), adenovirus (n = 30, 50%) and small round structured viruses (n = 5, 8%) or dual infection (n = 2, 3%). Thirty-four of 52 (65%) patients available for analysis had acute diarrhoea, and 18/52 (35%) had chronic diarrhoea. Twenty-three of 52 (44%) patients had a concurrent gut pathogen. After exclusion of concurrent pathogens enteric viral infections were found to be significantly associated with acute as opposed to chronic diarrhoea (P = 0.004). The presence of adenovirus colitis was significantly more likely to be associated with chronic diarrhoea (15/21 cases) than adenovirus isolated from stool alone (9/23 cases) (P = 0.03). There was a trend towards an association between adenovirus colitis and colonic cytomegalovirus infection (P = 0.06). CONCLUSION Enteric viral infection is strongly associated with acute diarrhoea in patients with HIV. Light microscopic examination of large bowel biopsies can identify adenovirus colitis which is significantly associated with chronic diarrhoea, and in addition may facilitate gastrointestinal co-infection with CMV.
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Affiliation(s)
- P D Thomas
- Department of HIV/GUM Medicine, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK
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21
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Abstract
Gastrointestinal infections are a frequent and important complication of immunodeficiency diseases and immunosuppressive therapy. Such infections may be severe, prolonged, or even fatal, whereas the same infections are typically mild and transient in immunocompetent persons. In this regard, the strong association between HIV-induced immunosuppression and the increased prevalence of severe enteric infections is strong evidence of the link between immune function and defense against enteric pathogens. Because gastrointestinal infections in immunocompromised persons are frequently severe and life-threatening, a vigorous approach to the diagnostic evaluation and therapeutic management is advocated by many clinical investigators. In this review, we summarize the important new developments, particularly during the past year, regarding gastrointestinal infections in immunocompromised persons.
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Affiliation(s)
- G Meng
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Alabama at Birmingham School of Medicine and the VA Medical Center, University of Alabama Station, Birmingham, AL 35294, USA
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Abstract
The small intestine, coming in direct contact with ingested potential pathogens, depends on active mucosal immunity to withstand invasion and damage. In patients with AIDS and severe impairment of immunoregulatory lymphocytes, proliferation of protozoal, viral, bacterial, and fungal pathogens produces diarrhea and malabsorption. When noninvasive tests of stool and blood fail to identify responsible organisms, endoscopy can reveal mucosal lesions which are suggestive if not diagnostic. Cryptosporidium, cf2E. intestinalis, cf1CMV, MAC, and other infections can be identified by intestinal biopsy quicker and often at lower overall cost than they can be by culture.
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Affiliation(s)
- Johannes Koch
- From the Division of Gastroenterology, Hepatology, and Clinical Nutrition, San Francisco General Hospital, San Francisco, California,The Department of Medicine, University of California, San Francisco, San Francisco, California
| | - Robert L. Owen
- Sections of Gastroenterology and Infectious Diseases, Veterans Affairs Medical Center, San Francisco, San Francisco, California,The Department of Medicine, University of California, San Francisco, San Francisco, California,Address reprint requests to: Robert L. Owen, MD, Cell Biology and Aging Section (151E), VA Medical Center, 4150 Clement Street, San Francisco, CA 94121
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Abstract
The colon is a frequent site of gastrointestinal complications in patients with HIV infection, and these colonic disorders increase in frequency as immunodeficiency worsens. The most common clinical manifestations of colonic disease in AIDS are diarrhea, lower gastrointestinal bleeding, and abdominal pain. Toxic megacolon, intussuseption, typhlitis, idiopathic colonic ulcer, and pneumatosis intestinalis also have been described. In the HIV-infected patient with preserved immunity, the most common cause of colitis is bacterial, but as the degree of immunodeficiency worsens, opportunistic pathogens (CMV, protozoa, mycobacteria, fungi) and neoplasms become more frequent. The frequent use of antibiotics, chemotherapeutic agents, and frequent hospitalization increase the susceptibility to cf2Clostridium difficule cf1colitis. Endoscopy plays an integral role in the management of many colonic disorders in AIDS.
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González GG, Pujol FH, Liprandi F, Deibis L, Ludert JE. Prevalence of enteric viruses in human immunodeficiency virus seropositive patients in Venezuela. J Med Virol 1998; 55:288-92. [PMID: 9661837 DOI: 10.1002/(sici)1096-9071(199808)55:4<288::aid-jmv6>3.0.co;2-x] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The prevalence of enteric viruses associated with gastroenteritis was determined in 125 stool samples from patients infected with the human immunodeficiency virus (HIV), with or without diarrhea. Diagnostic assays included enzyme immunoassays for the identification of rotavirus, adenovirus, and Norwalk virus; polyacrylamide gel electrophoresis for atypical rotaviruses and picobirnaviruses and polymerase chain reaction for astrovirus. Enteric viruses were detected in 6.4% (8 of 125) of the stools collected: five (4.0%) samples positive for adenoviruses, and three (2.3%) samples positive for picobirnaviruses were detected. No rotavirus, astrovirus, or Norwalk virus were observed. Only one of the viruses identified (adenovirus) was found in a sample from a patient with diarrhea. Viruses were detected in 10% of the patients with AIDS, 14% of the symptomatic patients, and none of the asymptomatic persons. These results do not support a major role for enteric viruses in the diarrhea suffered by HIV-infected patients.
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Affiliation(s)
- G G González
- Centro de Microbiología y Biología Celular, Instituto Venezolano de Investigaciones Científicas, Caracas, Venezuela
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Stockmann M, Fromm M, Schmitz H, Schmidt W, Riecken EO, Schulzke JD. Duodenal biopsies of HIV-infected patients with diarrhoea exhibit epithelial barrier defects but no active secretion. AIDS 1998; 12:43-51. [PMID: 9456254 DOI: 10.1097/00002030-199801000-00006] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES To characterize diarrhoeal mechanisms in HIV-infected patients, epithelial transport and barrier function of the duodenal mucosa was investigated in vitro. PATIENTS Twenty-one HIV-seropositive patients (13 asymptomatic and eight with diarrhoea) and 12 controls from an urban referral-based tertiary care centre in Berlin who underwent duodenoscopy. METHODS A new miniaturized Ussing chamber allowed measurements on duodenal forceps biopsies. Epithelial barrier function was characterized by alternating current impedance analysis, which allows differentiation of epithelial and subepithelial resistance and by 3H-lactulose and 3H-mannitol flux measurements. Na+-glucose cotransport was quantified as phlorizin-sensitive short circuit current (Isc) and active ion secretion by baseline and bumetanide-sensitive Isc. RESULTS Duodenal biopsies from asymptomatic HIV-infected patients were no different from controls, whereas biopsies from HIV-infected patients with diarrhoea showed a decrease in epithelial resistance from 21.2+/-1.9 to 12.9+/-1.3 omega cm2 (P<0.01). Concomitantly, mucosal-to-serosal lactulose flux increased from 0.29+/-0.02 to 0.40+/-0.03 micromol (hcm2) (P<0.01). Phlorizin-sensitive Isc indicating Na+-glucose cotransport, as well as baseline and bumetanide-sensitive Isc indicating active electrogenic chloride secretion were not different between the three groups. CONCLUSIONS A miniaturized Ussing device was developed for electrophysiological investigations of duodenal forceps biopsies, which allowed characterization of active ion transport mechanisms and epithelial barrier function. Duodenum of HIV-infected patients with diarrhoea showed no evidence for active ion secretion or Na+-glucose malabsorption, but showed an impaired epithelial barrier function, which could contribute to diarrhoea by a leak flux mechanism.
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Affiliation(s)
- M Stockmann
- Department of Gastroenterology, Universitätsklinikum Benjamin Franklin, Freie Universität Berlin, Germany
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Schmidt W, Schneider T, Heise W, Schulzke JD, Weinke T, Ignatius R, Owen RL, Zeitz M, Riecken EO, Ullrich R. Mucosal abnormalities in microsporidiosis. AIDS 1997; 11:1589-94. [PMID: 9365763 DOI: 10.1097/00002030-199713000-00007] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine the prevalence of microsporidiosis in HIV-infected patients with and without diarrhoea and to characterize alterations in mucosal architecture and brush border enzyme activities in patients with microsporidiosis. PATIENTS A total of 259 HIV-infected patients undergoing oesophago-gastroduodenoscopy because of diarrhoea (n = 123) or other symptoms (n = 136) were studied. METHODS Patients were evaluated for the presence of microsporidia by electron microscopy of duodenal biopsies. Brush border enzyme activities were measured by histochemistry and mucosal architecture was determined by three-dimensional morphometry in biopsies from patients with microsporidiosis and compared with biopsies from a subgroup of HIV-infected patients with or without other enteropathogens. RESULTS Enterocytozoon bieneusi was detected in 17 patients and Encephalitozoon intestinalis was detected in two patients. Microsporidiosis was significantly more frequent in patients with chronic diarrhoea (19.1%; P < 0.0001) or in patients with acute diarrhoea (7.2%; P = 0.04) than in patients without diarrhoea (1.5%). Microsporidiosis was associated with lactase deficiency (P = 0.03) and a reduced activity of alkaline phosphatase (P = 0.028) and alpha-glucosidase (P = 0.025) at the basal part of the villus compared with brush border enzymes in patients without enteropathogens. Patients with microsporidia had reduced villus height (P = 0.043) and a villus surface reduced by 40% (P = 0.004) compared with patients with enteropathogens other than microsporidia. CONCLUSIONS Our study confirms the association between microsporidia and diarrhoea. The pathophysiologic mechanism by which microsporidia cause diarrhoea appears in part to be malabsorption, caused by a reduction of absorptive mucosal surface and impairment of enterocyte function.
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Affiliation(s)
- W Schmidt
- Department of Medicine, Universitätsklinikum Benjamin Franklin, Free University of Berlin, Germany
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Wilcox CM, Mönkemüller KE. Review article: the therapy of gastrointestinal infections associated with the acquired immunodeficiency syndrome. Aliment Pharmacol Ther 1997; 11:425-43. [PMID: 9218066 PMCID: PMC7159661 DOI: 10.1046/j.1365-2036.1997.00159.x] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Although there have been dramatic strides in the therapy of human immunodeficiency virus infection over the last few years, the number of infected people world-wide is tremendous and, at least in developing countries, continues to expand. Complications which involve the gastrointestinal tract are common in these patients, because the gut is a major site for involvement by opportunistic infections and neoplasms in patients with the acquired immunodeficiency syndrome. It is important to recognize the clinical spectrum of gastrointestinal diseases, as well as the appropriate and most cost-effective diagnostic strategies, as therapies for a number of these disorders are both widely available and high effective. This review summarizes the major gastrointestinal infections which are seen in patients with the acquired immunodeficiency syndrome, and their treatment.
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Affiliation(s)
- C M Wilcox
- Department of Medicine, University of Alabama of Birmingham 35294-0007
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Wilcox CM. Chronic unexplained diarrhea in AIDS: approach to diagnosis and management. AIDS Patient Care STDS 1997; 11:13-7. [PMID: 11361724 DOI: 10.1089/apc.1997.11.13] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- C M Wilcox
- Department of Medicine, University of Alabama at Birmingham, USA
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Schneider T, Ullrich R, Zeitz M. Immunopathology of human immunodeficiency virus infection in the gastrointestinal tract. SPRINGER SEMINARS IN IMMUNOPATHOLOGY 1997; 18:515-33. [PMID: 9144868 DOI: 10.1007/bf00824056] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Affiliation(s)
- T Schneider
- Medical Clinic II, University of the Saarland, Homburg/Saar, Germany
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