Intestinal parasite isolates in AIDS patients with chronic diarrhea in Gondar Teaching Hospital, North west Ethiopia.

Chronic diarrhea is one of the major AIDS-defining illnesses in WHO Classification and occurs in 60-90% of HIV-infected patients in Africa. We did a case series study on parasite isolation in stool samples of AIDS patients with chronic diarrhea using wet-mount, Formol-Ether concentration technique and Modified Acid-Fast staining method in Gondar Teaching Hospital between January and September 2000. Seventy AIDS patients with chronic diarrhea were included in the study. Wasting syndrome was the clinical presentation in (97%) almost all AIDS patients who had chronic diarrhea. Intestinal parasites were detected in 41 out of 70 diarrheal specimens in AIDS patients. Multiple parasitic injections were detected in three diarrheal specimens. Intracellular parasite, (29%) Cryptosporidium parvum, and mucosal parasite, (17%) Strongyloides stercoralis were the frequently isolated parasites in diarrheal specimens of AIDS patients, accounting for 80% diarrhaegen pathogens among positive specimens. Cryptosporidium parvum, under-estimated cause of chronic diarrhea in immunocompetent adults, was found to be the prominent diarrheagen in AIDS patients in this study, similar with other studies in different African countries.

AIDS-associated diarrhea and wasting in Northeast Brazil is associated with subtherapeutic plasma levels of antiretroviral medications and with both bovine and human subtypes of Cryptosporidium parvum.

Advanced HIV infection is frequently complicated by diarrhea, disruption of bowel structure and function, and malnutrition. Resulting malabsorption of or pharmacokinetic changes in antiretroviral agents might lead to subtherapeutic drug dosing and treatment failure in individual patients, and could require dose adjustment and/or dietary supplements during periods of diarrheal illness. We determined the plasma levels of antiretroviral medications in patients that had already been started on medication by their physicians, in an urban infectious diseases hospital in northeast Brazil. We also obtained blood samples from patients hospitalized for diarrhea or AIDS-associated wasting, and we found reduced stavudine and didanosine levels in comparison with outpatients without diarrhea or wasting who had been treated at the same hospital clinic. There was a predominance of the protozoal pathogens Cryptosporidium and Isospora belli, typical opportunistic pathogens of AIDS-infected humans, in the stool samples of inpatients with diarrhea. We conclude that severe diarrhea and wasting in this population is associated with both protozoal pathogens and subtherapeutic levels of antiretroviral medications.

AIDS-associated diarrhea and wasting in northeast Brazil is associated with subtherapeutic plasma levels of antiretroviral medications and with both bovine and human subtypes of Cryptosporidium parvum

Advanced HIV infection is frequently complicated by diarrhea, disruption of bowel structure and function, and malnutrition. Resulting malabsorption of or pharmacokinetic changes in antiretroviral agents might lead to subtherapeutic drug dosing and treatment failure in individual patients, and could require dose adjustment and/or dietary supplements during periods of diarrheal illness. We determined the plasma levels of antiretroviral medications in patients that had already been started on medication by their physicians in an urban infectious diseases hospital in northeast Brazil. We also obtained blood samples from patients hospitalized for diarrhea or AIDS-associated wasting, and we found reduced stavudine and didanosine levels in comparison with outpatients without diarrhea or wasting who had been treated at the same hospital clinic. There was a predominance of the protozoal pathogens Cryptosporidium and Isospora belli, typical opportunistic pathogens of AIDS-infected humans, in the stool samples of inpatients with diarrhea. We conclude that severe diarrhea and wasting in this population is associated with both protozoal pathogens and subtherapeutic levels of antiretroviral medications

Macronutrient intake and malabsorption in HIV infection: a comparison with other malabsorptive states.

BACKGROUND: Wasting is a major complication of HIV infection. The role of malabsorption in wasting is controversial. AIMS: To assess oral intake and malabsorption in a cohort of weight losing HIV infected patients, with or without chronic diarrhoea. METHODS: A prospective study using a predefined protocol for HIV infected patients was performed in a gastroenterology and nutrition unit in a university hospital. A retrospective comparison was made with HIV negative patients with malabsorption due either to small bowel disease or resection. Body weight and height, serum albumin, oral intake of macronutrients, faecal weight, and faecal fat were measured. RESULTS: Seventy nine weight losing HIV infected patients were studied. Among the 66 patients with more than 5% lipid malabsorption, wasting was significantly greater in patients with cryptosporidiosis (n = 22) than in patients with microsporidiosis (n = 18) who exhibited significantly more wasting than patients with no identified enteropathogen (n = 26) (body mass index 16.8 (14.0-20.7), 18.9 (16.5-21.3), 19.7 (15.9-23), respectively). When controlling for the level of lipid malabsorption, HIV infected patients had a significantly lower energy intake than HIV negative patients with chronic malabsorption. In HIV infected patients, but not in other categories of malabsorbers, body mass index correlated significantly with energy intake (r = 0.33, 95% confidence intervals 0.12 to 0.51). CONCLUSION: In weight losing HIV infected patients, reduced energy intake is superimposed on malabsorption and significantly contributes to wasting.

Enteropathy in Zambians with HIV related diarrhoea: regression modelling of potential determinants of mucosal damage.

BACKGROUND: AIDS is characterised by small intestinal mucosal damage, but its aetiopathogenesis is poorly understood. Enteric infections in Africa differ from those in northern countries, where protozoan infections have been associated with severe enteropathy in AIDS patients. AIMS: To characterise enteropathy in Zambian AIDS patients compared with local controls, and to assess relative contributions of enteric infection, nutritional impairment, and immune dysfunction. METHODS: Computer aided mucosal morphometry of small intestinal biopsy specimens from 56 HIV infected Zambians with persistent diarrhoea and 26 diarrhoea free controls, followed by regression modelling. RESULTS: Patients with HIV related diarrhoea had reduced villous height and increased crypt depth compared with controls. There was no difference between HIV positive and negative controls. In regression models applied to AIDS mucosal measurements, villous height and crypt depth were related to nutritional parameters and to serum soluble tumour necrosis factor receptor p55 concentration. Crypt depth was also related to lamina propria plasma cell count. Intestinal infection was found in 79%, which consisted predominantly of microsporidia in 34%, Isospora belli in 24%, and Cryptosporidium parvum in 21%, but detection of these enteropathogens was not related to severity of enteropathy. CONCLUSIONS: Nutritional and immune disturbances were associated with enteropathy, accounting for over one third of the variation in mucosal morphometric parameters.

PIP: The relative contributions of enteric infection, nutritional impairment, and immune dysfunction to AIDS-related enteropathy were investigated in a comparative study of small intestinal biopsy specimens from 56 HIV-positive patients from Lusaka, Zambia, with persistent diarrhea and 26 diarrhea-free controls. Compared with both HIV-positive and HIV-negative controls, patients with HIV-related diarrhea had a 40% reduction in mean villous height and a 19% increase in mean crypt depth. In regression models applied to AIDS mucosal measurements, villous height and crypt depth were related to nutritional parameters and to the serum soluble tumor necrosis factor receptor p55 concentration. Crypt depth also was related to lamina propria plasma cell count. Intestinal infection, primarily microsporidia, was detected in 79% of cases; however, the presence of enteropathogens was not related to the severity of enteropathy. These findings suggest that nutritional and immune disturbances account for more than 33% of the variation in mucosal morphometric parameters in AIDS-related enteropathy.

Malabsorption and wasting in AIDS patients with microsporidia and pathogen-negative diarrhea.

OBJECTIVE: To define the clinical syndrome, nutritional status and malabsorptive status in patients with HIV and chronic diarrhea and either microsporidia or no identified pathogen. PATIENTS: HIV-positive patients from an urban, hospital-based infectious disease clinic with chronic diarrhea who had undergone exhaustive gastrointestinal and stool studies for enteric pathogens and were found to have either microsporidia or no pathogen. METHODS: Patients were evaluated for clinical history, physical, body composition, nutritional and malabsorptive studies including D-xylose, Schilling test, determinations of 24 h stool fat, weight and nitrogen, and 24 h urea nitrogen. RESULTS: Ten patients with microsporidia were studied, four of whom were infected with Septata intestinalis, six with Enterocytozoon bieneusi; nine patients had no identified pathogen. Patients in both groups were comparable in stage of HIV disease, and demonstrated abnormal nutritional status and malabsorptive parameters. Patients with no pathogen had significantly longer duration of symptoms prior to presentation; however, patients with microsporidia had significantly greater malabsorption of fat, D-xylose, vitamin B12, and significantly lower serum levels of zinc. Nutritional status and malabsorption were similarly depressed in patients infected with either species of microsporidia. CONCLUSION: HIV-infected patients with chronic diarrhea associated with either microsporidial infection or with no identified pathogen had abnormal parameters of absorption and malnutrition, and those infected with microsporidia demonstrated more severe malabsorption.