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Gastrointestinal manifestations of AIDS Janez Tomažič

Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

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Page 1: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Gastrointestinalmanifestations of AIDS

Janez Tomažič

Page 2: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

GIT manifestations

Gastrointestinal and hepatobiliary disorders are amongthe most frequent complaints in patients with HIVdisease

Effective ART and chemoprophylaxis (PCP, MAC, andCMV) has significantly reduced the occurrence ofGIT opportunistic infections

Page 3: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Decreased incidence of opportunistic infections afterintroduction of HAART. Emerg Infect Dis 2004;10:1713-20.

Page 4: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

GIT and AIDS defining diseasesClinical Category C

Candidiasis: esophagealCryptosporidiosis: chronic intestinal (>1 month)CMV: other than liver, spleen, nodesHistoplasmosis: disseminated, extrapulmonaryIsosporiasis: chronic (>1 month)Kaposi sarcomaLymphoma: Burkitt, immunoblasticM. avium or M. kansasii : extrapulmonaryM. tuberculosisSalmonella: bacteremia, reccurentWasting syndrome

Page 5: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

GIT & HIV - Clinical Category B

Candidiasis: oropharyngeal

Constitutional: diarrhea >1 month

Page 6: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Oral manifestations

Candida:

Thrush is presented by white painless plaques on oral mucosa that can easily be scarped off

Page 7: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 8: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 9: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 10: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 11: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 12: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Oral manifestations

Oral hairy leukoplakia (EBV) is a raised, white lesion of the oral mucosa, usually seen on the lateral margin of the tongue that can not be scraped off and that not respond to antifungal therapy

Page 13: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 14: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Oral manifestations

The cause of aphthous ulcers is unknown In dd HSV, CMV and drug-induced ulcers should be considered

Page 15: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 16: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Oral manifestations

Anaerobic bacteria cause gingivitis:from linear gingival erythema, necrotizing gingivitis, necrotizing peridontitis to necrotizing stomatitis

Page 17: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 18: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 19: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Oral manifestations

Other oral lesions:Kaposi sarcoma (purple-red lesions)non-Hodgkin lymphoma (either swelling or ulcers)oral wartssalivary glands may be enlarged by infiltration with CD8+ cells

Page 20: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

KaposiKaposi’’s s SarcomaSarcoma in Oral in Oral CavityCavity

Page 21: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Oral manifestations

Other oral lesions:Kaposi sarcoma (purple-red lesions)non-Hodgkin lymphoma (either swelling or ulcers)oral wartssalivary glands may be enlarged by infiltration with CD8+ cells

Page 22: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 23: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 24: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 25: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Oral manifestations

Other oral lesions:Kaposi sarcoma (purple-red lesions)non-Hodgkin lymphoma (either swelling or ulcers)oral wartssalivary glands may be enlarged by infiltration with CD8+ cells

Page 26: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 27: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Esophageal disease causing dysphagia and/or odynophagia

Candida: most common cause of esophageal symptomsinfrequently associated with feverempiric dg (trush, odynophagia, CD4 <100)

CMV:usually focal pain associated with fever

dg: biopsy of erithema, erosions or ulcers

Page 28: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 29: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Esophageal disease causing dysphagia and/or odynophagia

HSV: often associated with oral manifestationsusually focal pain with inferquent feverdg: brush, biopsy or culture of erithema, erosions or ulcers

Aphtous ulcers:usually focal pain, infrequently associated with fever

dg: negativ tests for Candida, CMV, HSV and other infections

Page 30: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Diarrhea

Diarrhea is the most common GIT symptom in patients with HIV,occurs in up to 80% of patients with AIDS

Bacterial, viral, protozoal and fungal organisms may cause diarrhea inpatients with AIDS

An infectious cause can be identified in 60-80% of cases

Pathogen-negative diarrhea: motility disorders, bacterialovergrowth, HIV-enteropathy

Page 31: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Diarrhea

Bacterial Infections– Mycobacterium avium complex– Salmonella– Shigella– Campylobacter sp.– Clostridium difficile– Small-bowel overgrowth– Vibrio parahaemolyticus

Page 32: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Diarrhea

Viral Infections– Cytomegalovirus– Herpes simplex– Adenovirus– Picornavirus– HIV

Page 33: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Diarrhea

Protozoal/Helminth Infections– Cryptosporidium– Microsporidium– Isospora belli– Leishmania donovani– Giardia– Cyclospora– Entamoeba histolytica– Strongyloides stercoralis

Page 34: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Diarrhea

Fungal Infections– Candida albicans– Histoplasma capsulatum

Neoplasms– Lymphoma, Kaposi's sarcoma

Idiopathic– “HIV-enteropathy"

Page 35: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

DiarrheaMedications: a common cause ("early" HIV disease),especially PIs. Often self-limited, lasting for2-4 weeks from initiation of medication

Small bowel overgrowth:may cause diarrheaand malabsorption of fat, vitamin B12, andcarbohydrates. The prevalence of small bowelbacterial overgrowth with HIV-associateddiarrhea is 38%

Page 36: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
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Cholangiopathy

- relatively rare diseases, seen primarily inlate stage AIDS

- most common identified microbial cause:Crytposporidium, Microsporidia, CMV andCyclospora

Page 39: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Endoscopic retrograde cholangiopancreatogram, demonstrating diffuse intrahepatic strictures of

both the intrahepatic and extrahepatic bile ducts

Page 40: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Pancreatitis

- NRTIs: ddI or ddI + d4T (mitochondrial toxicity)- PIs (hypertriglyceridemia)- opportunistic infections (CMV, non-tuberculous

and tuberculous mycobacteriosis, cryptosporidiosis)- conditions that cause pancreatitis in general

population (especially alcoholism; less common gallstones and hypertriglyceridemia)

Page 41: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Hepatic abnormalities

- quite common - viral hepatitis- HIV-related opportunistic infections- medication toxicity (all ART)- alcohol, nonalcoholic fatty liver disease - malignancy (Kaposi sarcoma, non-Hodgkin

lymphoma, hepatocellular carcinoma)

Page 42: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

HCV and HIV

- higher HCV RNA loads - more rapid progression of HCV-related liverdisease

- major cause of hospital admissions and deaths- effective HCV treatment strategies are needed- pegINFα + ribavirin: may be effective- early monitoring of HCV RNA response atweeks 4 and 12 identify persons with virologic nonresponse preventing unnecessary exposure toxicity

- liver transplantation

Page 43: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

HBV and HIV

- HIV infection can accelerate progression of HBV

- treatment for all HBV/HIV-coinfectedpatients is recommended

- tenofovir + emtricitabine or lamivudine- HBV vaccination

Page 44: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Abdominal pain

right upper quadrant pain: thickening or dilatationof the bile duct (AIDS related sclerosing cholangitis)

epigastric pain: peptic ulcer, Kaposi sarcoma, lymphoma,CMV infection of the distal oesophagus

lower abdominal pain: sever constipation (opiate use)

difusse abdominal pain: bacterial or CMV causes ofdiarrhea

loin pain: indinavir (4% of patients taking this drug haverenal stones)

Page 45: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

GIT bleeding

upper GIT bleeding: more common (~50% areattributed to HIV-related conditions: esophagitis, ulcers, Kaposi sa, lymphoma)

lower GIT bleeding: less common (~70% areattributed to HIV-related conditions: CMV colitis, idiopathic colon ulcers, Kaposi sa, lymphoma, MAC)

Page 46: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Bowel perforation

in AIDS patients, the most common cause of life-threating abdominal pain is peritonitis from smallbowel or colon perforation (CMV enteritis, Kaposi sa,lymphoma, MAC)

Page 47: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

Wasting syndrome

involuntary loss of at least 10% of originalbody weight accompanied by:

- persistent diarrhea (at least to bowelmovements daily for more than 30 days)or

- extreme fatigue and/or fever withoutapparent infectious etiology

Page 48: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 49: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis
Page 50: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis

“May HIV flow from our blood intohistory books ?”

~ Bill Clinton, 2005 ~

Page 51: Gastrointestinal manifestations of AIDS - Dr. Falk Pharma · –Isospora belli –Leishmania donovani –Giardia –Cyclospora –Entamoeba histolytica –Strongyloides stercoralis