DIAGNOSTIC STRATEGIES IN HIV-INFECTED PATIENTS WITH DIARRHEA

Infectious disease specialists have proposed guidelines on diagnostic evaluation of HIV infected patients with diarrhea. They are based on using clues from a careful history, physical examination, and evaluation of known laboratory data. Early on, clinicians must differentiate between small and large bowel diarrhea to properly evaluate any patient with diarrhea. If available, they should use the patient's absolute CD4 count, duration of diarrhea, frequency and characteristics of stools, degree of weight loss, and exposure history (e.g., residence and water supply). When conducting the patient history, clinicians should ask about recent antibiotic or antiretroviral use, previous opportunistic infections, and other illnesses or hospitalizations. The physical exam should include height and weight, orthostatic blood pressure, and degree of wasting. Abnormalities of skin and mucous membrane may indicate nutrient deficiencies (e.g., vitamin B deficiency = stomatitis). The disease specialists provide us with an algorithm to the diagnostic evaluation of HIV infected patients with diarrhea using the CD4 cell count and the type of diarrhea (small or large bowel) as the defining factors. For example, clinicians should request stool cultures for Salmonella, Campylobacter, and Yersinia and examination with saline and iodine for the presence of ova and parasites for patients with CD4 counts greater than 200 cells x 1 million/l and small bowel diarrhea. If the patient also has a fever, blood cultures should be done to test for Salmonella. If all these tests are negative and the patient still has symptoms, modified acid-fast staining should be done to look for cryptosporidium oocysts. If this test is negative and symptoms continue, upper endoscopy with biopsy is warranted. This strategy should result in a less time-consuming and more directed diagnostic strategy that may improve quality of life.