Diarrhoea and malabsorption in acquired immune deficiency syndrome: a study of four cases with special emphasis on opportunistic protozoan infestations.

Abstract

SUMMARY Chronic diarrhoea is frequent in acquired immune deficiency syndrome (AIDS) but has been poorly investigated so far. We report four patients with AIDS in whom diarrhoea and malabsorption were outstanding features, and who underwent extensive digestive investigations. Diarrhoea was a presenting symptom in all subjects and was of secretory type in three of them. D-xylose and vitamin B12 were malabsorbed in all cases; steatorrhea was found in the two patients who could ingest significant amounts of fat. Faecal cU-antitrypsin clearance was increased in all subjects. Search for digestive pathogens showed unusual protozoans in all patients: in case 1, optical and electron microscopy revealed the presence in the cytoplasm of villous enterocytes of Microsporidia protozoans still unreported in AIDS. Stool and jejunal fluid examination showed Isospora belli in case 2 and Cryptosporidium in cases 3 and 4. On histological and ultrastructural study the former was localised in the cytoplasm of a few enterocytes and the latter was scattered throughout the villus and crypt brush border. Otherwise small intestinal histology only showed minor non-specific changes and the enterocytes were ultrastructurally normal. In patient 3 the slow marker intestinal perfusion technique showed a profuse fluid secretion in the duodenum and proximal jejunum. All patients needed prolonged total parenteral nutrition. Cryptosporidium and Microsporidia could not be eradicated despite multiple drug trials. Isospora belli was transiently cured by pyrimethamine-sulphadiazine. Only patient 2 is presently at home, and patients 1, 3, and 4 died after two, six, and nine months of total parenteral nutrition, respectively.

Intestinal Coinfection with Enterocytozoon bieneusi and Cryptosporidium in a Human Immunodeficiency Virus-Infected Child with Chronic Diarrhea

“…The microsporidian protozoan organism Enterocytozoon bieneusi, first reported in 1985 [1,2], has been recognized as a human immunodeficiency virus (HIV)-associated intestinal opportunistic pathogen [1][2][3][4][5][6][7][8][9]. Preliminary epidemiological studies have indicated that it may be present in 10%-30% of severely immunodeficient HIV-infected adults with chronic diarrhea [3][4][5][6]9].…”

'Protozoan' Infections in the Immunocompromised Patient--The Parasites and their Diagnosis

“…Whilst infection may be asymptomatic, symptoms in immunocompromised patients, and especially in AIDS patients, may be severe and prolonged (Whiteside et al, 1984). In such patients a clinical picture similar to that found in cryptosporidiosis may occur and it is of interest that concomitant infection with both coccidians is not uncommon (Modigliani et al, 1985;Gelb and Miller, 1986). I. belli has been found in 15% of Haitian AIDS sufferers (de Hovits et al, 1986).…”

“…These authors suggest that the homosexual or bisexual activity of oro-anal intercourse accounts for the relatively high prevalence (4.2%) of cryptosporidiosis in such patients compared with heterosexual male and female AIDS patients (2.1%). In immunocompromised patients, and particularly in AIDS patients, symptoms are prolonged with profuse watery diarrhoea which can be life-threatening (Malebranche et al, 1983;Modigliani et al, 1985;Gelb and Miller, 1986). Cryptosporidium spp.…”

Modification of the clinical course of intestinal microsporidiosis in acquired immunodeficiency syndrome patients by immune status and anti-human immunodeficiency virus therapy.

“…The clinical entity of Enterocytozoon bieneusi-related diarrhea first characterized by Modigliani and others 1 and Desportes and others 2 was originally considered to be a relentless, progressive, wasting condition with significant morbidity and mortality seen in severely immunosuppressed patients with CD4 cell counts generally less than 100 cells/ mm 3 . [1][2][3] Parasite eradication using metronidazole, albendazole, and thalidomide was considered problematic.…”

“…[1][2][3] Parasite eradication using metronidazole, albendazole, and thalidomide was considered problematic. [4][5][6] Recent observations suggest that the clinical course of E. bieneusi-associated gastrointestinal infection has changed from its original description.…”