Idiopathic AIDS enteropathy and treatment of gastrointestinal opportunistic pathogens

John P Cello, Lukejohn W Day, John P Cello, Lukejohn W Day

Abstract

Diarrhea in patients with acquired immune deficiency syndrome (AIDS) has proven to be both a diagnostic and treatment challenge since the discovery of the human immunodeficiency virus (HIV) virus more than 30 years ago. Among the main etiologies of diarrhea in this group of patients are infectious agents that span the array of viruses, bacteria, protozoa, parasites, and fungal organisms. In many instances, highly active antiretroviral therapy remains the cornerstone of therapy for both AIDS and AIDS-related diarrhea, but other targeted therapies have been developed as new pathogens are identified; however, some infections remain treatment challenges. Once identifiable infections as well as other causes of diarrhea are investigated and excluded, a unique entity known as AIDS enteropathy can be diagnosed. Known as an idiopathic, pathogen-negative diarrhea, this disease has been investigated extensively. Atypical viral pathogens, including HIV itself, as well as inflammatory and immunologic responses are potential leading causes of it. Although AIDS enteropathy can pose a diagnostic challenge so too does the treatment of it. Highly active antiretroviral therapy, nutritional supplementation, electrolyte replacements, targeted therapy for infection if indicated, and medications for symptom control all are key elements in the treatment regimen. Importantly, a multidisciplinary approach among the gastroenterologist, infectious disease physician, HIV specialists, oncology, and surgery is necessary for many patients.

Figures

https://www.ncbi.nlm.nih.gov/pmc/articles/instance/7094677/bin/grr1_lrg.jpg
John P. Cello
https://www.ncbi.nlm.nih.gov/pmc/articles/instance/7094677/bin/grr2_lrg.jpg
Lukejohn W. Day
Figure 1
Figure 1
Biopsy of small bowel from a patient with AIDS and pathogen-negative diarrhea. Note the prominent villus atrophy, crypt architectural distortion, decrease in crypt/villus ratio, and the significant influx of lymphocytes within the lamina propria. Figure courtesy of Dr James P. Grenert from the Department of Pathology, University of California, San Francisco.
Figure 2
Figure 2
Comparison of (A) mean villus/crypt ratio, (B) mean villus/height ratio, (C) and mean crypt depth among AIDS patients with and without diarrhea and normal controls. arc, AIDS-related complex. Reprinted with permission from Greenson JK et al. AIDS enteropathy: occult enteric infections and duodenal mucosal alterations in chronic diarrhea. Ann Intern Med 1991;141:366–327.
Figure 3
Figure 3
Association between gastrointestinal infections as a result of a specific pathogen and CD4+ T-cell count ranges in HIV-positive patients.
Figure 4
Figure 4
Proposed treatment algorithm for patients with AIDS and chronic diarrhea.
Figure 5
Figure 5
Change in stool weight of patients with AIDS and refractory diarrhea using octreotide vs placebo in a double-blind phase and open-label phase clinical trial. Reprinted with permission from Simon et al.

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