Morning report today focused on an HIV+/HBV coinfected man with a CD4 count of 7, presenting with diarrhea, cachexia, and cirrhosis following travel, ultimately diagnosed with Salmonella enteriditis bacteremia.
Salmonella infections can be classified as typhoid fever, or those caused by Salmonella typhi or paratyphi, and other non-typhoidal salmonella (NTS) infections. NTS clinical syndromes can take 4 forms:
1) diarrheal disease (colitis)
2) invasive bacteremia
3) focal or suppurative infection
4) asymptomatic carriage in stool.
HIV+ patients are at much higher risk for invasive NTS bacteremia when compared to HIV negative populations, and are much more likely to have recurrence of disease. Recurrent often occurs with the same strain and is thought to be related to reticuloendothelial persistence. The presentation can be quite non-specific and may not include any diarrhea at all.
Treatment is typically with fluoroquinolones. Plasmid-mediated resistance does exist, but in relatively few isolates in the US - our patient was successfully treated with cipro as well. See here for a study about this if bugs and drugs are your thing!
Lots more to discuss: differential diagnosis of esophageal ulcers in and HIV+ patient, differential diagnosis of diarrhea in HIV+ patients, and HBV/HIV coinfection, but I'll have to save those for future blogs! Thanks to Dr. Vellend for being our guest.
Why not, as my vacation comes to an end, and since I miss all of you, I thought why not actually comment on Malika's wonderful blog!
ReplyDeleteMaybe I shall take the differential diagnosis of diarrheal disease in HIV+ patients.
All of the creatures causing diarrheal disease in immunocompetent patients can be found in immunocompromised patients, but there are indeed some others that you should think about in your differential diagnosis including cryptosporidium, microsporidium, isospora belli, and cyclospora
As I once mentioned, and I thought I should re-itterate it again about empiric treatment of bloody diarrhea, E. coli O157:H7 and Shigella should not be treated with antibiotics as it would release verotoxin and shigatoxin, respectively, which can cause hemolytic-uremic sundrome!
I hope that helps a bit, and if anyone would like to add to the list, as there is a myriad of bugs, please feel free to do so
Gianni Lorello :-)