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HIV-Associated Enteropathy

HIV Enteropathy

Gastrointestinal (GI) disorders, mainly diarrhea, are a defining feature of human immunodeficiency virus (HIV) infection. Persistent diarrhea in the absence of infectious pathogens other than HIV itself is classified as HIV enteropathy. Thus, HIV enteropathy is defined and also identified in HIV-infected patients by excluding other organisms as the cause of persistent diarrhea.


Presentation

HIV infection presents in the majority of cases with diarrhea and associated complaints, which are either due to opportunistic organisms or HIV itself. The introduction of highly active antiretroviral therapy (HAART) has had a striking effect on all aspects of HIV infections, among which has been a decline in intestinal colonization by opportunistic pathogens. Nevertheless, such infections still occur and cause diarrhea.

Intestinal pathogen-negative HIV enteropathy also persists in spite of HAART. The presentation, in addition to diarrhea, the most common symptom, includes a variety of features such as dysphagia, nausea, and abdominal pain. The anomalies observed in the GI tract in HIV enteropathy, such as inflammation, elevated permeability, malabsorption of some substances, villous atrophy and crypt hyperplasia account for the symptoms. HIV may be responsible for some of the GI pathologies was suggested early on by the observation that the virus could directly infect gastrointestinal cells in the crypts and lamina propria [1].

A variety of mechanisms have been suggested to account for the direct and indirect effects of the HIV virus on intestinal physiology:

  • HIV proteins (Tat and gp120) were shown to have toxic effects on enterocytes [2] [3]
  • HIV was found adjacent to abnormal enterocytes indicating that it could influence differentiation pathways [4]
  • Stimulation of the local immune system of the GI tract was demonstrated by the presence of proinflammatory molecules [5]
  • Also, the lymphoid tissue of the gut is known to be an early location for HIV replication [4] [6].
Collapse
  • This structural relationship in the crypt/villus unit indicates that crypt elongation encroaches on villous height, or that villous collapse stimulates crypt hyperplasia.[journals.lww.com]
  • […] is a rapid event after lamina propria T cell activation, and it precedes villous atrophy. 29 30 This time course of events casts doubt on the alternative model of crypt hyperplastic villous atrophy, which suggests that enterocyte shedding and villous collapse[gut.bmj.com]
Intestinal Disease
  • It is believed that HIV enteropathy may be due to the virus (HIV) itself which causes small intestinal disease either directly or indirectly.[healthhype.com]
  • Diseases HIV Enteropathy All MeSH Categories Diseases Category Immune System Diseases Immunologic Deficiency Syndromes HIV Infections HIV Enteropathy[ncbi.nlm.nih.gov]
  • Diseases HIV Enteropathy Gastrointestinal Diseases Digestive System Diseases HIV Infections Lentivirus Infections Retroviridae Infections RNA Virus Infections Virus Diseases Sexually Transmitted Diseases, Viral Sexually Transmitted Diseases Immunologic[clinicaltrials.gov]
Foul Smelling Stool
  • ., leading to obstruction) Fat malabsorption (pancreatic exocrine insufficiency) Weight loss, abdominal bloating, steatorrhea, foul-smelling stools, flatulence Can occur at any count — Quantitative: 72-hour stool fat analysis, fecal elastase Qualitative[aafp.org]
Nocturnal Diarrhea
  • . † GI symptom questionnaire assessed cramping, urgency, incontinence, and nocturnal diarrhea with a possible score of 0 to 24, with 2 being normal. ‡ Using a scale of 1 (formed) to 6 (watery). References Asmuth D, Netanya S.[enteragam.com]
Failure to Thrive
  • HIV enteropathy Most common symptoms of gastrointestinal involvement are chronic or recurrent diarrhea, abdominal pain, dysphagia and failure to thrive. Secondary and opportunistic infection are incriminated in most of the cases.[hivinchildren.org]
Recurrent Diarrhea
  • HIV enteropathy Most common symptoms of gastrointestinal involvement are chronic or recurrent diarrhea, abdominal pain, dysphagia and failure to thrive. Secondary and opportunistic infection are incriminated in most of the cases.[hivinchildren.org]
Vascular Disease
  • A quantitative assessment of plasma homocysteine as a risk factor for vascular disease: probable benefits of increasing folic acid intake. ‏[books.google.com]
Flushing
  • Correspondence to: Nyabilondi Ebama, MD, New York Hospital Queens, Internal Medicine Residency Program, 56-45 Main St, Flushing, NY 11355. E-mail: ebamanya@hotmail.com.[journals.lww.com]
Sexual Dysfunction
  • Covers sexual dysfunction in both men and women and the basics of human sexual behavior and sexual health. Section Editors and Contributors from all continents of the world have made this a truly global reference book.[books.google.com]
Urinary Incontinence
  • Your recognised location is United States (US) More: Guidance Urinary incontinence in women Source: Finnish Medical Society Duodecim This article is freely available only to users in the UK.[evidence.nhs.uk]

Workup

Careful recording of the patient’s history will reveal whether diarrhea perceived by the patient is indeed present according to clinical standards [7] and whether it may be due to food allergies, or medications. Among the medications are components of the HAART regimens, which in themselves may be the cause of GI symptoms. Some of the protease inhibitors are especially problematic in this respect [8] [9].

Symptoms accompanying the diarrhea are helpful in localizing the affected segment of the GI tract: cramps and bloating indicate the small bowel, whereas hematochezia and tenesmus suggest the involvement of the large bowel. The two sections of the GI tract are colonized by different opportunistic organisms. Some of the organisms in the upper tracts (small bowel) are protozoa and fungi (cryptosporidia, cyclosporidia, and microsporidia), while some of those in the colon are bacteria and viruses (such as campylobacter, clostridium difficile and cytomegalovirus). CD4 cell counts should be determined to assess the competence of the immune system: opportunistic infections do not usually occur if the immune system is not too compromised (CD4 counts greater 200 cells/microliter) [10].

Culturing of the stool and its examination in the microscope for cysts, ova, and parasites are early diagnostic tests mandatory for deciding whether or not the diarrhea is due to opportunistic organisms. [9] The polymerase chain reaction and immune assays are also used to identify some of the organisms. If the stool samples do not contain identifiable organisms, and if diarrhea seriously impacts the quality of life, invasive methods, such as endoscopy, sigmoidoscopy, or colonoscopy are used to isolate opportunistic organisms and to examine the GI tract. In several studies, colonoscopy and endoscopy together with tissue biopsy identified opportunistic pathogens in about a quarter to half of the patients whose stool samples were pathogen free [11].

If none of these methods show opportunistic pathogens, the diagnosis of HIV enteropathy can be made, bearing in mind that with advances in technology new pathogens are being discovered, such as atypical viruses [12].

In general, the diagnostic effort should concentrate on finding treatable conditions to lessen the detrimental effect of diarrhea on the quality of life [7].

Treatment

  • Review the latest developments in the field and get up-to-date clinical information on hot topics like polyps, capsule endoscopy, and pancreatic treatments.[books.google.com]
  • Is this possible, if so is their a treatment? Response from Dr. Henry HIV enteropathy is unusual in the setting of good viral control and high CD4 cell counts.[thebody.com]
  • Co-infections require appropriate specific treatment. (See Chapter on HIV and Opportunistic Infections) HIV and Pancreas Pancreas is one of the many organs that may be affected by HIV.[hivinchildren.org]
  • There is currently no effective treatment. We conducted a secondary analysis of a randomised controlled trial of high dose multiple micronutrient (MM) supplementation on small bowel architecture in EE in participants with or without HIV infection.[ncbi.nlm.nih.gov]
  • They may be other non-specific gastrointestinal symptoms like : abdominal pain nausea vomiting (rare) bloating excessive belching abdominal distention Treatment of HIV Enteropathy There is no specific treatment for HIV enteropathy and it may occur even[healthhype.com]

Prognosis

  • […] literature on this behalf revealed a distinct pathological pattern for disseminated MAC; that it may exacerbate HIV entheropathy and eventually worsening the malabsorption syndrome in a disseminated/terminal stage of HIV infection, predicting an ominous prognosis[repositorio.ul.pt]
  • It would be logical to assume that patients with a direct HIV-1 enteropathy and increased HIV-1 activity in the gut have a worse prognosis.[journals.plos.org]
  • The prognosis is poor. ICD-10-CM C86.2 is grouped within Diagnostic Related Group(s) (MS-DRG v 36.0): 820 Lymphoma and leukemia with major o.r. Procedure with mcc 821 Lymphoma and leukemia with major o.r.[icd10data.com]
  • Prognosis A retrospective study by John et al indicated that the survival rate has increased for patients who develop protein-losing enteropathy as a complication of the Fontan procedure, an operation for the treatment of several types of congenital heart[emedicine.medscape.com]
  • Given the absence of any clearly effective regimens and the questionable impact of HCV infection on the overall prognosis of patients coinfected with HIV, aggressive treatment cannot be recommended at the present time.[hivinsite.ucsf.edu]

Etiology

  • Although great progress has been made in understanding epidemiology and etiology of the syndrome, much about the syndrome remains mysterious.[books.google.com]
  • Abstract Abstract To investigate the etiology of chronic diarrhea associated with human immunodeficiency virus (HIV) infection in Lusaka, we studied 63 HIV-positive patients and 36 seronegative controls clinically and endoscopically.[ajtmh.org]
  • Bockus Gastroenterology, 5th ed, p1155) Year introduced: 1996 PubMed search builder options Subheadings: analysis anatomy and histology blood classification complications diagnosis diagnostic imaging diet therapy drug therapy economics epidemiology etiology[ncbi.nlm.nih.gov]
  • Etiology The chain of events of how HIV infects an individual is as follows: The virus enters the body through infected fluids or blood transmitted during sexual intercourse, blood transfusions, needle-prick injuries, or through intravenous drug use.[xpertdox.com]
  • However, as they are at a higher risk to acquiring infectious diseases, and because these symptoms do rarely point to a specific etiology, the diagnosis is challenging.[repositorio.ul.pt]

Epidemiology

  • Although great progress has been made in understanding epidemiology and etiology of the syndrome, much about the syndrome remains mysterious.[books.google.com]
  • ., Bockus Gastroenterology, 5th ed, p1155) Year introduced: 1996 PubMed search builder options Subheadings: analysis anatomy and histology blood classification complications diagnosis diagnostic imaging diet therapy drug therapy economics epidemiology[ncbi.nlm.nih.gov]
Sex distribution
Age distribution

Pathophysiology

  • In this small study, there was a clear difference in response depending on HIV status, suggesting that EE with superimposed HIV enteropathy may be a distinct pathophysiological condition.[ncbi.nlm.nih.gov]
  • […] etiological agent Essential features Gastrointestinal tract is a major site for HIV replication; virus localizes in gastric mucosal tissue and depletes CD4 T cells ICD coding AIDS (related complex) B20 Sites Can occur anywhere in gastrointestinal tract Pathophysiology[pathologyoutlines.com]
  • It is not a single disease, but an atypical manifestation of other diseases. [2] Pathophysiology The pathophysiology of this disorder is directly related to the excessive leakage of plasma proteins into the lumen of the gastrointestinal tract.[emedicine.medscape.com]

Prevention

  • There are several targets for intervention; blockage of residual mucosal virus replication, preventing antigen uptake, modulating the microbiome, improving T cell recovery, combining therapies aimed at mucosal integrity, augmenting mucosal immunity, and[ncbi.nlm.nih.gov]
  • Elsevier Health Sciences, 10 Feb 2014 - Medical - 1422 pages Covers all aspects (historical, epidemiological, diagnostic, clinical, preventative, public health and medico-legal) of STIs in complete detail with a special emphasis on STIs in special groups—migrants[books.google.com]

References

Article

  1. Nelson JA, Wiley CA, Reynolds-Kohler C, Reese CE, Margaretten W, Levy JA. Human immunodeficiency virus detected in bowel epithelium from patients with gastrointestinal symptoms. Lancet. 1988 Feb 6;1(8580):259-262.
  2. Canani RB, De Marco G, Passariello A, et al. Inhibitory effect of HIV-1 Tat protein on the sodium-D-glucose symporter of human intestinal epithelial cells. AIDS. 2006 Jan 2;20(1):5-10.
  3. Maresca M, Mahfoud R, Garmy N, Kotler DP, Fantini J, Clayton F. The virotoxin model of HIV-1 enteropathy: involvement of GPR15/Bob and galactosylceramide in the cytopathic effects induced by HIV-1 gp120 in the HT-29-D4 intestinal cell line. J Biomed Sci. 2003 Jan-Feb;10(1):156-166.
  4. Heise C, Dandekar S, Kumar P, Duplantier R, Donovan RM, Halsted CH. Human immunodeficiency virus infection of enterocytes and mononuclear cells in human jejunal mucosa. Gastroenterology. 1991 Jun;100(6):1521-1527.
  5. Olsson J1, Poles M, Spetz AL, et al. Human immunodeficiency virus type 1 infection is associated with significant mucosal inflammation characterized by increased expression of CCR5, CXCR4, and beta-chemokines. J Infect Dis. 2000 Dec;182(6):1625-1635.
  6. Dandekar S. Pathogenesis of HIV in the gastrointestinal tract. Curr HIV/AIDS Rep. 2007 Feb;4(1):10-15.
  7. 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 May-Jun;41(5):484-490.
  8. Hill A, Balkin A. Risk factors for gastrointestinal adverse events in HIV treated and untreated patients. AIDS Rev. 2009 Jan-Mar;11(1):30-38.
  9. Feasey NA1, Healey P, Gordon MA. Review article: the aetiology, investigation and management of diarrhoea in the HIV-positive patient. Aliment Pharmacol Ther. 2011 Sep;34(6):587-603.
  10. Cello JP, Day LW. Idiopathic AIDS enteropathy and treatment of gastrointestinal opportunistic pathogens. Gastroenterology 2009; 136:1952–1965.

  11. Kearney DJ, Steuerwald M, Koch J, Cello JP. A prospective study of endoscopy in HIV-associated diarrhea. Am J Gastroenterol. 1999 Mar;94(3):596-602.
  12. Cunningham AL, Grohman GS, Harkness J, et al. Gastrointestinal viral infections in homosexual men who were symptomatic and seropositive for human immunodeficiency virus. J Infect Dis 1988;158:386–391.

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Last updated: 2019-06-28 12:22