The HIV infected global traveller. David Lalloo Liverpool School of Tropical Medicine

Transcription

1 The HIV infected global traveller David Lalloo Liverpool School of Tropical Medicine

2 The patient A 33 year old HIV positive Caucasian patient returns to your clinic after a four year absence He has been working in East Africa for the UN, with basic living conditions on occasion Generally well- occasional febrile illnesses and diarrhoea Viral load fully suppressed, CD4 count 370 On tenofovir, FTC and efavirenz for two years. Nadir CD4 180; previously took combivir and efavirenz

3 The patient Past history: eczma as a child and mild asthma Major current complaints are of intermittent loose stools Routine investigations show: Eosinophil count 1.0 x 10 9 /l Stool culture negative Stool OCP- giardia cysts and blastocystis

4 Which of these is LEAST likely to account for the eosinophilia? 1. Drug toxicity 2. Strongyloidiasis 0% 3. History of atopy 3% 13% 4. Schistosomiasis 5. Giardiasis 33% 51%

5 Eosinophilia Practically defined as > 0.5 x 10 9 /l Multiple causes Up to 10% of individuals may have eosinophilia prior to travelling eczma / asthma Drugs: NSAIDs, dapsone haematological, hypoadrenalism, pulmonary diseases invasive helminth infections Requires investigation

6 Causes of eosinophilia 262 patients presenting to HTD (non-hiv) 64% helminth identified 15% atopy alone 21% cause not identified 57 patients with HIV of African origin 55% had parasitic cause Both studies suggest likelihood of parasite is related to degree of elevation of eosinophil count Whetham J infect 2003, Sarner 2007

7 Initial assessment Clinical examination is unremarkable Urine dipsticks show a trace of protein only Schistosomal serology is performed- positive with a medium level titre

8 What is the next best action? 1. Empirical treatment with albendazole 11% 13% 18% 2. CXR to assess for pulmonary eosinophilia 3. Filtration of midday urine 4. Empirical treatment with praziquantel 26% 32% 5. Further stool examination for ova, cysts and parasites

9 Making an egg diagnosis is important False positive schistosomal serology occurs Defines species and potential likely complications Indicates degree of further assessment that is necessary May be able to follow success of treatment

10 Progress Schistosomal eggs are found in the semen and on urine filtration Species identified as S. haematobium He remains well with no urinary symptoms Praziquantel is given (40mg/kg) in two divided doses

11 Progress Seen one month after treatment Eosinophilia still present Urine filter shows no evidence of S. haematobium Schistosomal serology unchanged Repeat stool x 3 for ova cyst parasites normal

12 What is your next course of action? 1. Review eosinophil count in a further month 0% 15% 2. Strongyloides stool culture 15% 22% 3. Repeat praziquantel treatment at higher dose 4. Arrange for day and night filarial blood films 5. Serology for filaria and strongyloides 48%

13 17% of patients investigated for eosinophilia had more than one helminth species found Whetham 2003

14 Investigation of eosinophilia Stool OCP (x2) Strongyloides stool culture Strongyloides serology Urine microscopy for schistosoma (Africa) Schistosomal ELISA (Africa, S America) Filarial ELISA (W. Africa) Night day blood for microfilariae (W Africa) Sputum for Strongyloides, hookworm, paragonimiasis if resp symptoms Skin snips if symptoms Whetham et al 2002

15 Strongyloides and HIV Systemic infection surprisingly rare in HIV Brazil: serological prevalence 4.5 v 1.5% in HIV/non-HIV infected Increasing recognition of importance of hyperinfection syndrome as manifestation of IRIS HIV positive patients may be at risk if given corticsteroids Asymptomatic infection should be treated Brown 2006

16 Conclusions Eosinophilia in any HIV patient with a history of overseas travel needs to be investigated Careful travel history can help to determine extent of investigation Multiple causes may exist in those with significant overseas exposure

17 Diarrhoea in an HIV infected traveller ALASTAIR MILLER MA FRCP DTM&H Consultant Physician Tropical & Infectious Disease Unit (3Z) Royal Liverpool University Hospital Honorary Fellow Liverpool School of Tropical Medicine

18

19

20 Case - 38 year old MSM 3 months ago self referred for HIV test No previous HIV-related illness HIV test positive, CD4 86 Currently Taking Truvada/Kaletra & cotrimoxazole CD4 160, VL <40 Wants to go to Kenya for 4 weeks Beach + safari

21 1 4 Do you More than one answer possible 1. Advise him not to go (yet)? Start him on ciprofloxacin prophylaxis? 3. Give him ciprofloxacin self treatment 4. Give him rifaximin prophylaxis 5. Advise him on enteric precautions 33

22 Clinic 2 weeks after return He had intermittent diarrhoea whilst abroad but it was not severe Now has several bulky, offensive motions a day Foul smelling, difficult to flush away and with no mucus or blood He feels nauseated and a bit bloated but does not have a fever

23 What sort of diarrhoea is he describing? 1. Secretory due to preformed toxin 3% 2. Secretory due to enterotoxin 8% 3. Malabsorptive 4. Colitic (dysentery) 86% 3%

24 5 What diagnostic steps do you take? More than one answer possible 1. Send stool for routine culture Send stool for microscopy (OCP) 3. Do serological tests for typhoid 4. Refer for upper GI endoscopy 5. Refer for flexible sigmoidoscopy 40

25 Routine stool exam negative He returns 2 weeks later He is increasingly concerned Thinks he has lost 2-3 kg since his holiday Now opening his bowels 4 times a day CD4 count 2 weeks ago was 196 Stool results are negative to date

26 Do you More than one answer possible 1. Send more stool Treat empirically with ciprofloxacin 3 3. Treat empirically with rifaximin 3 4. Treat empirically with metronidazole (or tinidazole) 5. Treat empirically with nitazoxanide 1 35

27 What are the likely causes of his diarrhoea? 1. Salmonella 0% 2. Cryptosporidium 2% 3. Giardia 4. Tropical sprue 7% 10% 5. Ritonavir 81%

28 Giardiasis Association with MSM noted as part of gay bowel syndrome in California late 1970s Not more common in HIV or other similar immunocompromised patients, but possibly more severe Persisting problem in inherited agammaglobulinaemia (Bruton s)

29 Giardia lamblia Faeces (iodine) Duodenal fluid

30 Diarrhoea in HIV infected traveller: pre travel Avoid travel if CD4 < 200 Advise Peel it, cook it, boil it or forget it Ice, teeth cleaning etc Instructions on rehydration Self treatment Ciprofloxacin, azithromycin Possible prophylaxis rifaximin, fluoroquinolone

31

32

33

34

35 Assessment of diarrhoea Hydration status?bacteraemic Acute/chronic Exposure history Blood cultures Stool culture/ocp

36 General approach to diagnosis of HIV diarrhoea Verify presence of diarrhoea Baseline stool microscopy and culture Blood cultures (including mycobacteria) 1, 3 or 6 stools for parasitology FEA concentration ZN Microsporidial stains Sigmoidoscopy and histology for most parasites & mycobacteria, but will miss right-sided CMV Consider jejunal biopsy (not duodenal) for microsporidia but EM preferred microscopy method

37 Common Pathogens Campylobacter C difficile C perfringens E histolytica E coli Giardia Salmonella Shigella Staph aureus Vibrios Yersinia Opportunistic Pathogens Adenovirus Cryptosporidia Cyclospora Isospora belli Microspora Encephalitozoon intestinalis Enterocytozoon bieneusi HSV Histoplasma MAC and M.Tb CMV

38 Summary of treatments Farthing MJG. Nature Clin Pract Gastroenterol Hepatol 2006; 3:

39 Empirical management (tropics) Treat pathogens that are easy Metronidazole for giardiasis Cotrimoxazole for isosporiasis Antibiotics for persistent bacterial infections (cipro, azithro) Improve patient condition HAART If not, symptomatic Rx and home support Role of thalidomide untested in this setting in tropics Cryptosporidiosis Paromomycin/azithromycin Nitazoxanide especially if CD4 >100 Microsporidiosis Albendazole for E. intestinalis? Fumagillin or nitazoxanide for E. bieneusi

40 Summary Diarrhoea a common problem in HIV Diarrhoea a common problem in travel Precautions before travel Careful clinical and laboratory assessment on return Empirical treatment for giardia

41

42

43

44

45

46

47

48