Case 13/2012: Chronic diarrhoea in HIV jeanette

http://www.uonbi.ac.ke/projects/pace/index.php?option=com_kunena&func=view&catid=4& id=2011&Itemid=2

By the end of this case, you should be able to:

Define chronic diarrhoea Identify the aetiologies of chronic diarrhoea Carry out diagnostic tests in a case ofchronic diarrhoea

OFFLINE Moderator Case AB, a 30 year old HIV positive male, is visiting the CCC for his regular checkup. He informs his doctor that he has been having abdominal pain and a running stomach for three weeks. The doctor requests for a CD4 cell count, Full Blood Count (FBC), Stool Microscopy (ova and cysts) and Stool Culture. These were the results: CD4 cell count: 94 cells/ mm3 FBC: Hb 9g/dL (13 18) g/L HCT 28% (40 -54%) RBC 2.9 x 1012/ L (4.5 6.5 x 1012 / L) WBC 15 x 109 /L ( 3.5 10 x 109/ L) Neutrophils 58% ( 40 75%) Lymphocytes 24% ( 20 45%) Monocytes 3% ( 2 10%) Eosinophils 15% ( 0 7%) Platelets 400 x 109/ L (150 400 x 109/L) MCV, MCH and MCHC: Normal Stool Culture: No pathogens isolated Stool microscopy: No ova, cysts or trophozoites seen (direct and iodine preparation. A stool smear stained with Modified Ziehl-Nielsen Stain showed the following: Refer to the figure in email Figure 1: Modified Ziehl-Nielsen stain Questions: 1. Based on the laboratory results above, what is causing the diarrhoea? How do the CD4 cell and Full Blood Counts support your answer? 2. An individual walks into your laboratory and requests for a stool microscopy test because he keeps having recurrent diarrhoea. The results show nothing abnormal. This individual then intimates to you that they are really worried because they are HIV positive. In light of this new information, what steps of action would you recommend to this person and why?

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3. Define chronic diarrhoea. What are the causes of chronic diarrhoea? Suggested Reading: "Gastrointestinal Manifestations of HIV Infection." In National Manual for the Management of HIV-Related Opportunistic Infections and Conditions: A Healthcare Worker's manual, by Sylvia Ojoo, 51-58. Nairobi: Baltech Equipments Ltd, 2008. "Examination of Fecal Specimens." In District Laboratory Practice in Tropical Countries Part 2, by Monica Cheesbrough, 97-105. New York: Cambridge University Press, 2008. "Human Intestinal Coccidia: Isospora belli, Cryptosporidium parvum, Cyclospora cayetanensis." In District Laboratory Practice in Tropical Countries Part 1, by Monica Cheesbrough, 205-208. New York: Cambridge University Press, 2008. Submitted and moderated by: Partnership for Advanced Clinical Education (PACE) team REPLY QUOTE Re: Case 13/2012: Chronic diarrhoea in HIV 6 months, 3 weeks ago#2160

jeanette

Answers: 1. Based on the laboratory results above, what is causing the diarrhoea? How do the CD4 cell and Full Blood Counts support your answer? The aetiology of the infection is Cryptosporidium species. Though it causes selflimiting diarrhoea in those who are HIV-negative, it can cause debilitating chronic diarrhoea in PLWHA especially in those with a CD4 cell count of 100 cells/ mm3 and below. 2. An individual walks into your laboratory and requests for a stool microscopy test because he keeps having recurrent diarrhoea. The results show nothing abnormal. This individual then intimates to you that they are really worried because they are HIV positive. In light of this new information, what steps of action would you recommend to this person and why? The right thing to do is to recommend the individual to a Comprehensive Care Clinic (CCC) for comprehensive management. 3. Define chronic diarrhoea. What are the causes of chronic diarrhoea? The gastrointestinal (GI) tract is a common site for opportunistic infections and malignancies in patients with HIV infection. Chronic diarrhoea is defined as diarrhoea that has persisted for 2 or more weeks. Often, patients with chronic diarrhoea will have had symptoms for much longer than this. This type of diarrhoea is much more common in PLHA when compared to HIV-uninfected people.

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The most common bacterial causes of chronic diarrhoea include Salmonella typhi, Mycobacteria Avium Complex (MAC) and Mycobacterium tuberculosis. Cryptosporidium parvum, Giardia lamblia, Isospora belli, Entamoeba histolytica and microsporidia are the common causes of protozoal chronic diarrhoea. The most common parasite known to cause chronic diarrhoea is Strongyloides stercoralis. Cytomegalovirus is the commonest cause of viral chronic diarrhoea. Physiological conditions such as malabsorption also cause acute diarrhoea.

Submitted and moderated by: Partnership for Advanced Clinical Education (PACE) team