Chronic Diarrhea in HIV: Case Presentation and Management

REPUBLIC OF THE PHILIPPINES REPUBLIC OF THE PHILIPPINES DEPARTMENT OF HEALTH DEPARTMENT OF HEALTH DR. JOSE R. REYES MEMORIAL MEDICAL CENTER DR. JOSE R. REYES MEMORIAL MEDICAL CENTER Medical Grand Rounds Double Trouble: Chronic diarrhea in HIV Moderator: Dr. Higinio Mappala Reactor: Dr. Mario Panaligan Dr. Darshan Kumar Gurung Dr. Madelle De Leon Dr. Nawli Manandhar

Objectives: To present a case of chronic diarrhea in HIV patient. To discuss the approach to diagnosis and management of HIV patients with chronic diarrhea. To present the epidemiology of HIV and AIDS in the Philippines. To present the fast tract approach to target sustainable developmental goal in HIV/ AIDS patients in the Philippines.

General data L.G. 26-year old Male Single Bulacan City

Chief complaint loose watery stools

History of present illness Diarrhea Abdominal pain Nausea Loss of appetite Fever Body malaise 1month Admitted: Dx: amoebiasis Tx: metronidazole Discharged improved ( decrease in frequency of diarrhea) 18days

History of present illness Recurrence of loose watery stool and fever productive cough Admission Dx: pneumonia and patient was for THOC but opted to go home 15days

History of present illness Persistence of loose watery stool, fever and body malaise Few hours ADMISSION

Review of systems General (+) Weight loss 7kg over 1 month HEENT (-) headache (-) blurring of vision (-) hearing loss (-) otalgia (-) tinnitus (-) dysphagia (-) odynophagia (-) epistaxis (-) hoarseness Cardiac (-) dyspnea (-) palpitations (-) chest pain Gastrointestinal (-) hematemesis (-) melena (-) hematochezia Muscuoskeletal (-)limitation of movement (-) edema Endocrine (-) polyuria (-) polydipsia (-) polyphagia (-) heat or cold intolerance Hematologic (-) easy bruising Neurologic (-) seizures, (-) paralysis (-) memory loss

Past Medical History Non-hypertensive Non- diabetic No history of PTB Non-asthmatic No history of blood transfusions, tattoos No known food and drug allergies

Family history (-) hypertension (-) Diabetes (-) cancer (-) stroke

Personal social history non-smoker occassional alcoholic beverage drinker denies illicit drug abuse occupation: respiratory technician sexual history: Multiple male partners

Physical Examination General survey Conscious, coherent, not in cardio-respiratory distress Vital signs: BP: 90/60mmHg HR: 102bpm RR: 20cpm T: 39.2 C BMI: 19.5 No jaundice, no rashes Skin and integumentary HEENT Pink palpebral conjunctiva, anicteric sclera, no nasoaural discharge, no tonsillopharyngeal congestion, no lymphadenopathy, no neck vein engorgement, whitish plaque in buccal mucosa, dry lips

Physical examination Chest and lungs Symmetrical chest expansion, no retractions, no lagging, clear breath sounds Cardiovascular Adynamic precordium,tachycardic, no heaves, no thrills, apex beat at 5th ICS MCL, no murmur Abdomen Flat, soft, hyperactive bowel sounds , no masses palpated, no organomegaly, (-) fluid wave Extremities No edema, no deformities, no cyanosis, pulses full and equal

Salient features 26M chronic watery stool, abdominal pain, loss of appetite and fever weight loss 7kg over 1 month Multiple Male sexual partners Febrile Tachycardic at 102bpm Dry lips, Whitish plaque buccal mucosa Flat, soft, hyperactive bowel sounds

Initial Impression: Chronic diarrhea of undetermined etiology with mild dehydration.

COURSES IN THE WARD

1st hospital day NA K CREA ALT ALB LDH AST BUN CBC 9/23 Fecalysi s 140.30 3.62 74.40 Hb HCT MCV Consisten cy MCH MCHC WBC Pus NEU LYM PLT color RBC mucus Ova and parasite intermittent fever Loose watery diarrhea Diagnostics: CBC Na, K creatinine fecalysis urinalysis Treatment: Paracetamol 300mg IV q 4 hrs for fever Nystatin 100,000 IU/ml 5ml qid Referred to ID service 9/22 58.80 20.70 9/22 9/21 9/22 10.3 30.8 83 27.8 33.4 10.48 None 77.7 9.4 333 None Brown 81.20 Soft None Mucoid 2.95 9/16 9/14 Green Soft 137.30 None None Non- mucoid none 411 137.70 9/20 9/15 7.6 23.5 85.1 27.5 32.3 15.46 82 5.2 319 3.70 9/15 9/14 130 3.72 75.80 9.1 29.3 88.5 27.5 31.1 14.33 81.8 7.7 258

2nd hospital day IDS: Impression: Immunocompromising conditions with multiple opportunistic infections: Oral Candidiasis Chronic diarrhea TB and PCP Hepatitis B infection Piptazo 4.5mg IV q6 TMP-SMX 160/800mg 1 tablet OD Continue Nystatin

2nd hospital day Rapid plasma regain Non reactive Additional labs were requested such as Hepatitis profile blood CS mycobacterial blood C/S RPR, VDRL serum CALAS modified acid fast stool PPD COPT HbsAg Reactive HCV Non-reactive Anti-Hbe Non reactive HbeAg Reactive CALAS (cryptococcal antigen) negative negative

4th hospital day intermittent fever diarrhea occasional cough INH 300mg/tab 1 tab q24h Azithromycin 500mg/tablet 2 & tablet every Saturdays

5th hospital day episodes of vomiting hypotensive episodes 70/40 Fluid challenge of 1L

10th hospital day Sent home with following meds: Levofloxacin 750mg/tab OD for 6days TMP-SMX 160/800MG 2tabs three times a day for 2 weeks then OD Azithromycin 500mg/tab 2and tab q weekly (every Friday) till follow up INH 300mg/tab 1tab q24 for 9 months Multivitamin 1 tab OD Nystatin 100,000 units/ml 5ml TID for till follow up

Diarrhea passage of abnormally liquid or unformed stools at an increased frequency stool weight >200 g/d

Acute <2weeks Persistent 2-4weeks Chronic >4weeks

Diarrhea Chronic >4 weeks Steatorrheal Osmotic Osmotic Secretory Secretory Dysmotile Inflammatory chronic

Chronic infectious Parasites: G. lamblia, E. histolytica AIDS related: Viral: CMV Bacterial: C. difficile, Mycobacterium avium complex Protozoal: microsporidia (cryptosporidium, isospora belli,enterocytozoon bieneusi)

Inflammatory conditions Idiopathic inflammatory bowel disease Crohn s and chronic ulcerative colitis Malignancy lymphoma Adenocarcinoma Radiation enteritis HIV Enteropathy

Final diagnosis HIV enteropathy Acute hepatitis B infection, infective

Thank you..