Treatment and Management of Diarrhea in HIV Infected Individuals - Assignment Example

EXPLORE THE AETIOLOGY, MANIFESTATION, MANAGEMENT AND TREATMENT OF DIARRHOEA WHICH MAY AFFECT INDIVIDUALS WITH HIV. 1st DRAFT Introduction This paper is going to explore aetiology, manifestation, treatment and management of diarrhea in HIV infected individuals. Diarrhea has been a common problem in patients with advanced HIV. Up to two-thirds of patients have suffered with this symptom at some time during the course of their illness. (Crotty et al, 1996) Symptoms arise from a wide range of pathogens.(Sharpstone et al, 1996) Protozoa infections such as cryptosporidia (cryptosporidium pavum) and microsporidia (Enterocytozoon bieneusi and Encephalitozoon Intestinalis) were among the most common causative organisms and contributed to the significant morbidity and mortality seen in advanced stages of HIV illness. (Blanshard et al, 1992) The UNAIDS and WHO statistics released in 2003 , it is seen that an estimated 70 million people world wide are HIV Positive, with 14,000 new infections incurred by HIV patients daily. Of this about 95% is found to be contributed by the developing countries as new medical treatment is not readily available to them.(Dolan etal,2003). In the African countries AIDS is still the leading factor causing death. The grave part is that almost globally there are 2.1 – 2.9 million children infected with HIV. At present the figure has grown to till more alarming rate. The UNAIDS/WHO AIDS update shows that by the end of 2007 there are 30.8 million adults and 2.5 million children living with HIV , with 95% population seen in developing countries. The sub-Saharan Africa is the morst affected part with 68% of HIV population- a population of 2.5 million HIV infected adult and children living there. (UN AIDS update,2007)The AIDS patients have a suppressed immune system owing to which they suffer from number of other infection. Of AIDS suffering patient, globally almost 50% of them are found to have acute or chronic diarrhea.(Kotler ,2005) In some it tends to be severe leading to loss of life. Of that only in 30% the aetiology is understood and is treatable with antibiotics. The occurrence of diarrhea in HIV infected patient is about 42 – 90% in the developing nations owing to poor sanitation, hygiene and drinking water quality. In UK and European countries, a raise is seen from 1995 but in African country the condition is very worse as 1700 new cases of HIV detected each day and the incidence of diarrhea among them is as high ,with more rural population succumbing to the condition. (Sharpstone and B Gazzard,1996). In the given backdrop, this essay tends to analyze the pathogenesis, aetiology, manifestation and treatment of diarrhea in HIV infected patients. The essay particularly tends to focus on the sub-Saharan – African population. I would suggest that you should end the introduction with an outline of how the assignment is to progress. Remember that the reader should be able to tell what they are going to read in the whole piece by examining the introduction. Diarrhea in HIV infected person – pathogenesis: Generally diarrhea may be defined as a passage of abnormal stool consistency or the urgency in defecation or increased frequency of motion.(AGA,1999) Chronic diarrhea in the term of gastroenterologist is increased frequency of defecation at a rate of 200g / day for minimum of a month. (AGA,1999)In general diarrhea may occur due to any reason as poor reabsorbtion of osmotic solute or deranged intestinal motility, loss of absorptive capacity or infection. Diarrhea in HIV patient is seen as widely as 90% HIV positive being afflicted by diarrhea may occur due to a number of causes as infection due to conventional and opportunistic pathogens, enteropathy, and malignancy or even due to the treatment, thus proving to be multifactoral in aetiogenesis. (AGA, 1999) The pathogenesis of diarrhea is not that fairly understood. In HIV patients there could be seen a presence any on of the features as malabsorption characterestics or villous atrophy or impairment in gut absorbability . The role of cytokines released as result of invasion of pathogen causing increased secretion of chloride and water is debated.( Chui & Owen,1994) The inflammations in intestine and malabsorption of fat and carbohydrate are also found to be the reasons.(Chui &Owen,1994) Aetiology The HIV patients suffer from incapacitated immune system, and are at a greater risk of infections. The diarrhea is an infection seen in adults and most commonly in children due to poor sanitation and drinking water quality. The causes are mainly attributed to the infectious microorganism. Topping the list is HIV only, which is believed to cause diarrhea as it replicates in the intestinal mucosa. (Hodgkinson, 1994). Other causes of chronic diarrhea are opportunistic enteric infections with common organisms like Candida, Cryptosporidium, Cytomegalovirus, Giardia, Isosporabelli and Salmonella. These infections cause a dysfunctional immunity at the lamina propria of the gut that in turn leads to a decreased secretary IgA, the principal protective immunoglobulin. The reduced helper T-cell function results in the decrease of mucosal immune system of the gut as result of persistent infection, leading to prolonged diarrhea with malabsorption and malnutrition. (Hodgkinson, 1994) Also the Highly Active Anti-Retroviral Therapy HAART treatment is found to cause diarrhea due to the highly active chemical used in the therapy. Fat malabsorption is commonly found symptom arising due to unknown cause., aetiology might be HAART treatment or due to HIV itself. The cause in some cases couldn’t be affirmed, leading to abstract knowledge. Thus the causes are multifactoral.(Joseph etal.,2007) Many studies undertaken in different geographical location shows different causative organism. For instance a cross sectional study undertaken in Nairobi, Kenya found that S. typhimurium, Shigella sp. and adherent E. coli were common causative organism of diarrhea in the HIV affected patients there. This study was conducted in 1213 individuals and examined the CD4 cells count and stool sample for diagnosis. They further concluded that there was less protozoan infection. Their study compounded the fact that Diarrhea was common and most strongly associated with low CD4 counts and over two-thirds of diarrhea episodes were undiagnosed. (Mwachari etal.,2002). When analyzed literature for this study it could be found that many times diarrhea seen in HIV patients are attributed to unknown reason. In another study conducted in American HIV affected population study published in the December 1st edition of Clinical Infectious Diseases., Clostridium difficile was found to be the most common cause of bacterial diarrhea in HIV-positive patients,. They studied over 44,000 HIV-positive patients between 1992 and 2002. (Sanchez etal.,2002). This helps us understand the fact the causative organism varies with different geographical location. This study is found to argue its point strongly with its winning sample size and period of study. In general, three Campylobacter spp. are known to be the prevailing causative organism of causing diarrhea in HIV infected patients. In pediatric cases four species of campylobacter is identified as causative organism..( Liesenfeld etal.,1993). In the HIV/AIDS patients studied was by Tee and Mijch, (1998) and Sorvillo et al.(1991) who reported that campylobacter enteritis and campylobacter bacteraemia were more common in patients with AIDS than in the general public. They made this statement after analyzing the particular geographical locations diarrhea population with the HIV infected diarrhea population. Another study by Sanchez et al, (2002 conducted on 147 HIV 1 patients with persistent diarrhea , analyzed their clinical , demographic, CD4 lymphocyte and fecal sample showing that Cryptosporidium species was the most frequent pathogen.Giardia lamblia [Giardia duodenalis], Aeromonas species, Campylobacter species, and rotavirus were all significantly associated with diarrhoea. Another study conducted in Nigeria in adult HIV infected individuals with chronic diarrhea took a sample size of 101 and showed a prevalence of Cryptosporidium parvum ,Enterocytozoon bieneusi/Encephalitozoon intestinalis ,Cyclospora cayetanensis ,Isospora belli , Entamoeba histolytica , Giardia lamblia , Hookworm , Trichuris trichiura , Ascaris lumbricoides , Strongyloides stercoralis , Schistosoma mansoni and Dicrocoelium dendriticum , Candida species as causative organism. This study confirmed a high prevalence of intestinal parasitosis in HIV-infected adults with chronic diarrhoea. (Smith, 2002). This study though was not repeated after that and owing to small sample size couldn’t be given much weightage. After a review of the literature it could be generalized that the causative organism of diarrhea in HIV patient might be HIV itself or bacterial , fungal, or protozoan organism. Namely Clostridium, campylobacter. I am concerned that this section tends to offer a list of a variety of organisms. It would be useful for the reader if you could provide a short summary of what you think are the key organisms of concern. This will then help when you come to discuss the management of the diarrhoea. Manifestation: The condition of diarrhea manifests itself as acute to chronic with increased severity. The patients suffering from diarrhea shows presence of pathogens in 99% cases with invariably reduced CD 4 Lymphocytes count. (Smego ,1999)The affected group mostly is children. The diagnosis is mainly stool analysis, done under light microscope and culture. Modified stains as Ziehl Nielsen, trichome stain and Calcoflour are used to identify the microorganism.(Smego,1999). Now newer polymerase test are also available to pin point the causative microorganism. Also gut colonoscopy is undertaken at times to find out the underlying cause when stool samples shows negative.(Smego,1999) Management For most of the causes of diarrhea, the clinical signs are non-specific, and the laboratory diagnostic workup is neither easy nor fast.(Khoo,1995).For management of diarrhea in the initial stage of HIV patients, the primary goal is to identify and provide exact treatment. History of illness also helps in management, with less severe diarrhea and CD4 count above 200 cells / micro liter the condition will resolve by itself. When causative organism is identified and CD 4 count is less than 200 cells / micro liter then treatment is initiated (Mitra et al, 2001) Compared to HIV-1-infected adults, survival times are considerably shorter for children who acquire the virus perinatally or during infancy. Opportunistic infections in adults are often secondary to reactivation of pathogens acquired before HIV infection. In contrast opportunistic infections in infants and children with vertical infection may reflect primary acquisition of host pathogens during ongoing HIV replication and advancing immunosuppression, and contrast clinically in children compared to adults. (Levin, 2002) Acute diarrhea in HIV-infected children is treated like in their HIV-negative counterparts, using the Integrated Management of Child Health ( IMCI ) guidelines, with the focus on the management of dehydration, the continuation of feeding as well as on counseling the mother about the danger signs of dehydration. (World Health Organization, 2003) .The oral rehydration solution (ORS) is to be periodically given. If this treatment is unsuccessful, intravenous rehydration can be given .Generally anti diarrheal agents are not beneficial in children when diagnosed in the initial stage as they have severe adverse effects.(Lew etal.,1996) Persistent diarrhea is indistinguishable from other episodes of acute gastroenteritis, but then the diarrhea does not resolve due to factors like mucosal damage of the gut, bacterial overgrowth and/or persistent or new infections of the gut. The management consists of, Oral rehydration solution to prevent dehydration; continuing breastfeeding should not be stopped. Stool-microscopy and -culture are to be done and assessment for other infections is done.( National Department of Health, South Africa, 2004) In adults in severe acute conditions; management requires antibiotic therapy, as they shorten the duration of diarrhea. The antibiotic profile varies for different pathogens. Treatment: The World Health Organization’s (WHO) 1991 guidelines for the management of persistent diarrhea in HIV-positive patients in resource limited countries recommend co-trimoxazole prophylaxis for persistent diarrhea in HIV-positive patients. However, US and Peruvian investigators found that only 24% of the pathogens causing diarrhea were susceptible to co-trimoxazole, but that ciprofloxacin, doxycycline and erythromycin were all widely effective. Most bacterial pathogens found by them were found to be susceptible to ciprofloxacin. Immunoglobulins from bovine colostrum (Lactobin, Biotest, Dreieich, and FRG) are found to have high titers of antibodies against a wide range of bacterial, viral and protozoal pathogens as well as against various bacterial toxins. They have proven to be effective when given in children as a boost to immunity (Carcamo etal.,2005) Of the bacterial pathogens (Aeromonas, Campylobacter, Salmonella, and Vibrio species and enterotoxigenic Escherichia coli), only 24% were susceptible to co-trimoxazole, whereas 90% were susceptible to ciprofloxacin this was established with the study based on Peruvian population. Another study showed that enteric bacterial isolates were susceptible to nalidixic acid, gentamicin, and ciprofloxacin but were resistant to ampicillin, tetracycline, chloramphenicol, streptomycin, and cephalothin. (Andrea Tramin et al., 2004) (Brian Gazzard, 2006) From the studies it could be understood that Ciproflaxin, genatmycin and nalidixic acid could be effective managing agents. Recommendation for future use: Thus the problem of diarrhea in HIV patients as we have seen is more in the developing country. The problem can be managed in two ways, first by looking into prevention and then treatment. The problem of diarrhea as a common complication of HIV infection is further compounded by lack of a potable water supply and lack of good hygienic practices in most developing countries for example Africa. (Von Schirnding et al., 1993) Many such countries people still drink water from stream, pond and river contaminated with faces that serve as important vehicles for the transmission of waterborne diseases exemplified by diarrhea. Steps are to be taken to avoid this condition world wide. New medication and treatment discovered across the world should be e made available to all the countries immediately, that could help to keep diarrhea in check, preventing it from developing into a life taking situation. In case of children, ample information could be given to the care takers and parents regarding the preventive steps to be taken and the symptoms to be looked after.I am surprised not to see any recommendations regarding children as you cite these as being a particular risk group. Conclusion: Thus from the essay the aetiology, management and treatment option of diarrhea in HIV affected individuals could understood. Diarrhea has now developed into a major life threatening situation in HIV infected individuals. Further research is needed to bring out still more generalized and effective treatment. It could be understood that the condition is worse in developing country like Africa than in developed countries, there mainly the causes being poor sanitation and health measures. Steps should be taken to create awareness among people there .You conclusion should include your key messages form your assignment. I think that this would really help here. References: You do jnot need to number your references as they are presented in alphabetical order. American Gastroenterological association, (1999)AGA Technical review of evaluation and management of chronic diarrhea, Gastroenterology, , 116:1464- 1486. [My paper] Andrea Tramarin, Association between diarrhea and quality of life in HIV-infected patients receiving highly active antiretroviral therapy. Qual Life Res. 2004 Feb ;13 (1):243-50 15058804 Brian Gazzard, 2006Medicine , Volume 33, Issue 6, 1 June 2005, Pages 24-26 HIV and AIDS AIDS. 17(14):2124-2126, September 26, 2003. Carcamo C et al. Etiologies and manifestations of persistent diarrhea in adults with HIV-1 infection: a case control study in Lima, Peru. J Infect Dis 191 (on-line edition), 2005. Chui W, Owen RL. AIDS and the gut. J Gastroenterol Hepatol 1994; 9: 291-303 Dolan R, Mazur H and Sag MS, (2003) AIDS therapy, Churchill Livingstone, Edinburgh Hodgkinson, N. 1994. Research disputes epidemic of Aids. Sunday Times. London, May 22nd, p24 Joseph H. Sellin, Bincy Abraham. (2007) Drug-induced diarrhea. Current Gastroenterology Reports 9:5, 365 Kotler. K.J, (2005)Gastrointestinal manifestations of human immunodeficiency virus infection, Adv Intern Med 40 , pp. 197–242. Khoo SH. Journal of Infectious Diseases 172(3):629-37, September 1995. Lew E, Poles M, Dieterich D. HIV-associated diarrhea. PAACNOTES 5(10):406-410, October 1996. Liesenfeld 0, Weinke T, Hahn H. Three-year prevalence of enteropathogenic bacteria in an urban patient population in Germany. Infection 1993; 21: 101-5. Levin L. Antiretroviral therapy in children. Clinical guidelines of the Southern African HIV Clinicians Society. The Southern African Journal of HIV medicine, Oct. 2002, p23 – 33. Mwachari C, Batchelor BI, Paul J, Waiyaki PG, Gilks CF. Chronic diarrhoea among HIV-infected adult patients in Nairobi, Kenya.Journal of Infection Volume 45, Issue 2, August 2002, Pages 99-106. Mitra A.K. Hernandez C.D.; Hernandez C.A.1; Siddiq Z., Management of diarrhoea in HIV-infected patients , International Journal of STD & AIDS, Volume 12, Number 10, 1 October 2001 , pp. 630-639(10) National Department of Health, South Africa, 2004: National Antiretroviral Treatment Guideline. Integrated management of childhood illness. South Africa (Department of Health), World Health Organization (Division of Child Health), Unicef. Jan 2003. Sharpstone D and Gazzard B (1996) Gastrointestinal manifestations of HIV infection, Lancet 348 pp. 379–383. Sanchez TH et al. Bacterial diarrhea in persons with HIV infection, United States, 1992 – 2002. Clin Infect Dis 41: 1621 – 1627, 2005. Sorvillo FJ, Lieb LE, Waterman SH. Incidence of campylobacteriosis among patients with AIDS in Los Angeles County. J AIDS 1991; 4: 598-602 Smith, S I,  Otuonye, M N,  Omonigbehin, E A,  Nkoth, A,  Et al,2002, Prevalence of campylobacter species among HIV/AIDS patients in Nigeria,British Journal of Biomedical Science . Smego RA. HIV/AIDS–problems, progress and direction. Southern Afr J Epidemiol Infect 1999;14:90-1. Tee W, Mijch A. Campylobacter jejuni bacteraemia in human immunodeficiency virus (HIV)-infected and non-HIV-infected patients: comparison of clinical features and review. Clin Infect Dis 1998; 26: 91-6. Von Schirnding I, Yeah D, Mathee A. Health aspects of sanitation with special reference to South Africa.J Compr Health 1993;4:73-9 2007 AIDS epidemic update ,http://www.unaids.org/en/KnowledgeCentre/HIVData/EpiUpdate/EpiUpdArchive/2007/. Read More