Evaluation of the HIV-infected patient with diarrhea
- C Mel Wilcox, MD
C Mel Wilcox, MD
- Professor of Medicine
- University of Alabama at Birmingham
- Christine A Wanke, MD
Christine A Wanke, MD
- Professor of Medicine and Public Health
- Tufts University School of Medicine
Diarrhea can cause significant morbidity in HIV-infected patients and can be due to a multitude of etiologies from infectious pathogens to malignancy to medications. Diarrhea is also an independent predictor of reduced quality of life and, in the case of advanced HIV disease, increased mortality .
The approach to the evaluation of diarrhea will be discussed here. For detailed information about specific pathogens, please see appropriate topic reviews. (See "AIDS-related cytomegalovirus gastrointestinal disease" and "Mycobacterium avium complex (MAC) infections in HIV-infected patients".)
●United States – Prior to the use of potent antiretroviral therapy (ART) in the United States, chronic diarrhea (defined as four or more weeks of diarrhea) was responsible for 17 percent of the new AIDS diagnoses reported to the Centers for Disease Control and Prevention (CDC) . (See "The natural history and clinical features of HIV infection in adults and adolescents", section on 'AIDS and advanced HIV infection'.)
However, with the widespread use of ART, the incidence of infectious causes of diarrhea in HIV-infected patients with low CD4 counts (<200 cells/microL) has declined . Experience at a single center between 1995 and 1997 found that, while the incidence of diarrhea remained constant, infectious etiologies declined from 53 to 13 percent . In another study that followed a cohort of approximately 600 patients in the Boston area after the introduction of potent ART, chronic diarrhea was reported in 28 percent and severe diarrhea (defined as more than six stools per day) in 3 percent . In this study, stool pathogens were found in only 12 percent of the population.
Although the incidence of infectious diarrhea has decreased, antiretroviral-associated diarrhea may occur in up to 50 percent of patients, depending on the ART regimen (see 'Exposures' below). Medication-induced diarrhea is a leading diagnostic consideration when diarrhea is the sole complaint , particularly when there is a temporal association. In addition, when an infectious etiology is not ascertained in advanced disease, then HIV-associated enteropathy needs to be considered.
Subscribers log in hereTo continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:Literature review current through: Jul 2017. | This topic last updated: Mar 15, 2017.References
- Siddiqui U, Bini EJ, Chandarana K, et al. Prevalence and impact of diarrhea on health-related quality of life in HIV-infected patients in the era of highly active antiretroviral therapy. J Clin Gastroenterol 2007; 41:484.
- Bartlett JG, Belitsos PC, Sears CL. AIDS enteropathy. Clin Infect Dis 1992; 15:726.
- Ledergerber B, Egger M, Erard V, et al. AIDS-related opportunistic illnesses occurring after initiation of potent antiretroviral therapy: the Swiss HIV Cohort Study. JAMA 1999; 282:2220.
- Call SA, Heudebert G, Saag M, Wilcox CM. The changing etiology of chronic diarrhea in HIV-infected patients with CD4 cell counts less than 200 cells/mm3. Am J Gastroenterol 2000; 95:3142.
- Knox TA, Spiegelman D, Skinner SC, Gorbach S. Diarrhea and abnormalities of gastrointestinal function in a cohort of men and women with HIV infection. Am J Gastroenterol 2000; 95:3482.
- Reijers MH, Weigel HM, Hart AA, et al. Toxicity and drug exposure in a quadruple drug regimen in HIV-1 infected patients participating in the ADAM study. AIDS 2000; 14:59.
- Wanke CA, Cohan D, Thummakul T, et al. Diarrheal disease in patients infected with human immunodeficiency virus in Bangkok, Thailand. Am J Trop Med Hyg 1999; 60:871.
- Colebunders R, Francis H, Mann JM, et al. Persistent diarrhea, strongly associated with HIV infection in Kinshasa, Zaire. Am J Gastroenterol 1987; 82:859.
- Thea DM, St Louis ME, Atido U, et al. A prospective study of diarrhea and HIV-1 infection among 429 Zairian infants. N Engl J Med 1993; 329:1696.
- Mayer HB, Wanke CA. Diagnostic strategies in HIV-infected patients with diarrhea. AIDS 1994; 8:1639.
- Wanke CA. Gastrointestinal infections in AIDS. In: Infectious Disease Teaching Atlas, 2nd ed, Mildvan D, Mandell GL (Eds), Churchill Livingstone, Philadelphia 1997. p.9.2-9.8.
- Weber R, Ledergerber B, Zbinden R, et al. Enteric infections and diarrhea in human immunodeficiency virus-infected persons: prospective community-based cohort study. Swiss HIV Cohort Study. Arch Intern Med 1999; 159:1473.
- Mayer HB, Wanke CA. Enteroaggregative Escherichia coli as a possible cause of diarrhea in an HIV-infected patient. N Engl J Med 1995; 332:273.
- Wanke CA, Mayer H, Weber R, et al. Enteroaggregative Escherichia coli as a potential cause of diarrheal disease in adults infected with human immunodeficiency virus. J Infect Dis 1998; 178:185.
- Durrer P, Zbinden R, Fleisch F, et al. Intestinal infection due to enteroaggregative Escherichia coli among human immunodeficiency virus-infected persons. J Infect Dis 2000; 182:1540.
- Flanigan T, Whalen C, Turner J, et al. Cryptosporidium infection and CD4 counts. Ann Intern Med 1992; 116:840.
- Asmuth DM, DeGirolami PC, Federman M, et al. Clinical features of microsporidiosis in patients with AIDS. Clin Infect Dis 1994; 18:819.
- Barakat SS, Campbell WN. Refractory diarrhea in a patient with HIV infection. Clin Infect Dis 2009; 48:213; 257.
- Horsburgh CR Jr. Mycobacterium avium complex infection in the acquired immunodeficiency syndrome. N Engl J Med 1991; 324:1332.
- Asmuth DM, Hammer SM, Wanke CA. Physiological effects of HIV infection on human intestinal epithelial cells: an in vitro model for HIV enteropathy. AIDS 1994; 8:205.
- Lambl BB, Federman M, Pleskow D, Wanke CA. Malabsorption and wasting in AIDS patients with microsporidia and pathogen-negative diarrhea. AIDS 1996; 10:739.
- Connolly GM, Forbes A, Gazzard BG. Investigation of seemingly pathogen-negative diarrhoea in patients infected with HIV1. Gut 1990; 31:886.
- Angulo FJ, Swerdlow DL. Bacterial enteric infections in persons infected with human immunodeficiency virus. Clin Infect Dis 1995; 21 Suppl 1:S84.
- Koehler JE, Cederberg L. Intra-abdominal mass associated with gastrointestinal hemorrhage: a new manifestation of bacillary angiomatosis. Gastroenterology 1995; 109:2011.
- Blanshard C, Collins C, Francis N, Gazzard BG. Invasive amoebic colitis in AIDS patients. AIDS 1992; 6:1043.
- Corazza GR, Ginaldi L, Furia N, et al. The impact of HIV infection on lactose absorptive capacity. J Infect 1997; 35:31.
- Rabeneck L, Crane MM, Risser JM, et al. Effect of HIV transmission category and CD4 count on the occurrence of diarrhea in HIV-infected patients. Am J Gastroenterol 1993; 88:1720.
- Guest JL, Ruffin C, Tschampa JM, et al. Differences in rates of diarrhea in patients with human immunodeficiency virus receiving lopinavir-ritonavir or nelfinavir. Pharmacotherapy 2004; 24:727.
- Brinkman K, Kakuda TN. Mitochondrial toxicity of nucleoside analogue reverse transcriptase inhibitors: a looming obstacle for long-term antiretroviral therapy? Curr Opin Infect Dis 2000; 13:5.
- Sanchez TH, Brooks JT, Sullivan PS, et al. Bacterial diarrhea in persons with HIV infection, United States, 1992-2002. Clin Infect Dis 2005; 41:1621.
- Harper KN. HIV-altered gut microbiome may be driving disease progression. AIDS 2017; 31:N1.
- Dinh DM, Volpe GE, Duffalo C, et al. Intestinal microbiota, microbial translocation, and systemic inflammation in chronic HIV infection. J Infect Dis 2015; 211:19.
- Chioralia G, Trammer T, Kampen H, Seitz HM. Relevant criteria for detecting microsporidia in stool specimens. J Clin Microbiol 1998; 36:2279.
- Wilcox CM, Schwartz DA, Cotsonis G, Thompson SE 3rd. Chronic unexplained diarrhea in human immunodeficiency virus infection: determination of the best diagnostic approach. Gastroenterology 1996; 110:30.
- Dieterich DT, Rahmin M. Cytomegalovirus colitis in AIDS: presentation in 44 patients and a review of the literature. J Acquir Immune Defic Syndr 1991; 4 Suppl 1:S29.
- Kearney DJ, Steuerwald M, Koch J, Cello JP. A prospective study of endoscopy in HIV-associated diarrhea. Am J Gastroenterol 1999; 94:596.
- Didier ES, Orenstein JM, Aldras A, et al. Comparison of three staining methods for detecting microsporidia in fluids. J Clin Microbiol 1995; 33:3138.
- Wei SC, Hung CC, Chen MY, et al. Endoscopy in acquired immunodeficiency syndrome patients with diarrhea and negative stool studies. Gastrointest Endosc 2000; 51:427.
- Sharpstone D, Gazzard B. Gastrointestinal manifestations of HIV infection. Lancet 1996; 348:379.
- Fulyzaq (crofelemer) prescribing information. http://www.accessdata.fda.gov/drugsatfda_docs/label/2012/202292s000lbl.pdf (Accessed on January 14, 2013).
- US Food and Drug Administration. FDA News Release. FDA approves first anti-diarrheal drug for HIV/AIDS patients. http://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm333701.htm (Accessed on January 14, 2013).
- Nwachukwu CE, Okebe JU. Antimotility agents for chronic diarrhoea in people with HIV/AIDS. Cochrane Database Syst Rev 2008; :CD005644.
- Cárcamo C, Hooton T, Weiss NS, et al. Randomized controlled trial of zinc supplementation for persistent diarrhea in adults with HIV-1 infection. J Acquir Immune Defic Syndr 2006; 43:197.
- Regional involvement
- - Small bowel involvement
- - Large bowel involvement
- - Anorectal involvement
- PHYSICAL EXAMINATION
- LABORATORY TESTING
- DIAGNOSTIC STUDIES
- Stool examination
- Blood cultures
- EMPIRIC THERAPY
- SUMMARY AND RECOMMENDATIONS