CHRONIC DIARRHOEA IN HIV PATIENTS WHO ARE NON COMPLIANT

CHRONIC DIARRHEA IN HIV PTS

1. CHRONIC
DIARRHOEA
IN HIV.
OTUNDO BARBARA
H31/43137/2017

2. Introduction
Diarrhoea is the occurrence of more than 3 loose stools a day.
It is common in HIV infected individuals with both advanced and no Advanced HIV disease.
Diarrhoea in these patients can be due to:-
●Non-infectious:- ARV-related side effects eg:-lopinavir and ritonavir may cause Diarrhoea /or
●Infectious:-As a result of immunosuppression, the patient is predisposed to infection.
Diarrhoea is classified into two:-
1.Acute diarrhoea - lasting less than 2 weeks
2.Chronic diarrhoea - lasting more than 2 weeks

3. Causative organisms
Acute Diarrhoea
●Bacterial:- E.coli, Salmonella, Shigella ,
Cholera, Campylobacter, clostridium
difficile etc
●Viral :- rotavirus, adenovirus, hepatitis
virus
●Protozoan:- Giardia lamblia, Entamoeba
histolytica
●Medications, Inflammatory Bowel dx
Chronic Diarrhoea
●All acute causes plus
●Protozoa:- Cryptosporidium parvum,
Microsporidia spp.
●Mycobacterium:- Mycobacterium Avium
Complex
●Others:- CMV, lymphoma
These organisms cause GIT- related
opportunistic infections and should be evaluated
whenever a patient with advanced HIV presents
with Diarrhoea.

4. Approach to a HIV patient presenting
with Diarrhoea.
History and physical examination
-Onset of Diarrhoea
-Duration of Diarrhoea
-Frequency of the Diarrhoea
-Characteristic of stool:- Bloody or non bloody:- (causative organisms for bloody Diarrhoea in Advanced HIV disease:-Shigella,
salmonella, E.coli, Campylobacter , Amoeba histolytica and CMV)
-Associated symptoms :- N, V, Abdominal pain , weight loss,fever
-Rule out non HIV causes such as:- hx of travel, hx of contact with anyone with diarrhoea, sanitation
-Enquire about time of HIV diagnosis, ART regimen, compliance to ARVs, last viral load.
On physical examination:-
-General nutrition status:- adequate , wasted
-General examination:- Hydration status, oral candidiasis , malaise
-Vitals :- BP, RR, HR, SPO2, Temp
-Abdominal exam :- IPPA

5. Laboratory investigations
1.Stool microscopy, culture and sensitivity:- ova , cysts, leukocytes
2.Fecal occult blood test
3.Acid fast smears:- mycobacterium, cryptosporidium, isospora
4.Full hemogram
-Hb level:- signs of anaemia
-WBC count to rule out infection
1.UECs:- urea and creatinine levels :- risk of AKI due to dehydration
2.Colonoscopy :- rule out colitis
3.CD4 count
4.HIV Viral load

6. MANAGEMENT
Assess for emergency symptoms and signs:-
1.Tachycardia
2.Tachypnoea
3.Temperature >37.5 degrees
4.Blood pressure for signs of hypotension
Determine level of hydration then classify and correct dehydration and electrolyte
imbalance

7. Classification of dehydration
Hydration statusSigns and symptomsSevere dehydrationLethargy, confusion, altered state of confusion,inability
to drink or feed appropriately, skin pinch returns very
slowly, radial pulse weak or not palpable
Moderate dehydrationSunken eyes, thirsty, drinks eagerly, skin pinch goes
back slowly
Mild dehydrationVitals are normal . Patient may be thirsty

8. REHYDRATION THERAPY
For mild or no obvious dehydration (ORS to take home and drink plus extra fluids .1 cup for every loose stool.
For moderate determine the amount of ORS required in the first 4 hours based on age or weight.
For severe dehydration give IV 100mls/kg I of RL/NS divided as follows then hourly.reviews. Start ORS 5ml/kg once
able to drink(4hourly for children, 1-2 hourly in adults.
Age5-14 yrs(20-30kg)>15yrs(>30kg)Amount of fluid1000-2200 mls2200-4000 mls
AgeGive 30 ml/kg in the first:Then give 70ml/kg in:Infants<12 months1hr (repeat once if radial
pulse is undetectable
5 hoursChildren>12m, adolescents
and adults
30 min(repeat once if radial
pulse is undetectable)
2.5 hours

9. Prevention
Vitamin A supplementation is recommended for all HIV infected and exposed
infants and children aged 6months to 5 years in doses given every 6
months(100000 IU for those aged
6-12 months and 200000 IU for those >12months
Give supplemental Zinc (10mg<6 months, 20mg>6months) to the child every day
for 10-14 days
Continue to feed the child:- prevent malnutrition.

10. CauseTreatment
Not determined or due to medication(no other symptoms)Loperamide 4 mg stat then 2mg after each loose stool(up to 16mg/day) Not determined.Other s/s present:- fever, bloody Diarrhoea,PMN in
stool
Ciprofloxacin 500mg BD for 5-10 days(or until symptoms improve)
+\-Metronidazole 500mg TDS for 5-10 days
CampylobacterErythromycin 500mg QDS*5 days. Or ciprofloxacinNon-typhi salmonellaCiprofloxacin * 10-14d. May be longer if symptoms persist.Enterohemorrhagic E. ColiAntibiotics C/IOther E.coliCiprofloxacin 500 BD for 3 daysShigellaCiprofloxacin 500BD for 3 daysPatient on cotrimoxazole prophylaxisMetronidazole + Albendazole. Add Ciprofloxacin if patient is febrilePatient not on cotrimoxazoleMetronidazole + Albendazole CTX 960 mg BD for 10 daysIsospora belliCTX 960 mg BD for 10 daysEntamoeba Histolytica Metronidazole 500mg TDS for 10 daysGiardia LambliaMetronidazole 250 mg TDS for 10 daysCryptosporidium ART; nutritional support ; anti- Diarrhoea
Duration of
diarrhoea
Acute
Diarrhoea
Chronic
Diarrhoea

11. REFERENCES
1.Zambia AHD Guidelines 2022
2.WHO recommendations of the management of Diarrhoea in HIV infected
infants and children 2010
3.HIV and AIDS infections and invasions[PubMed]