Maria A. Ovalles P.

Residente de primer nivel

• Países desarrollados: 30 a 50%• Países subdesarrollados: 90%• Síntoma inicial: 51 a 72%• Mas común en homosexuales

Girardi E,. Impact of the HIV epidemic on the spread of other diseases. AIDS 2000; 14(Suppl 3):S47–56.

• Incrementa a mayor inmunodeficiencia• Contaje de linfocitos T CD4+ > 200 cel/mm3

Miller V, et al. Relations among CD4 lymphocyte count nadir, antiretroviral therapy, and HIV-1 disease progression: results from the EuroSIDA study. Ann Intern Med 1999; 130:570–7.

PAÍSES EN DESARROLLO PAÍSES DESARROLLADOS

Citomegalovirus (45%)Salmonella sp (25%)E. Histolytica (25%)Cryptosporidium (15%)Giardia lamblia (15%)Campylobacter jejuni (10%)Mycobacterium avium (5%)Herpes simple (5%)

Cryptosporidium (45%)Blastocystis hominis (34%)Isospora belli (15%)Giardia lamblia (4 – 13%)E. Histolytica

Ponce, S. SIDA. Aspectos clínicos y terapeuticos. 2000

• Diarreas con múltiples agentes (85%)• Diarreas sin patógeno detectado (15 – 44%)

Etiology of Chronic Diarrhea in Antiretroviral-Naïve Patients with HIV Infection Admitted to Norodom Sihanouk Hospital, Phnom Penh, Cambodia. Clinical Infectious Diseases 2006; 43:925–32

Patrón:• Agudo• Intermitente• Crónico

Practice Guidelines for the Management of Infectious Diarrhea. Clinical Infectious Diseases 2001; 32:331–50

PROTOZOOS

•Inflamación •Atrofia y fusión de las vellosidades• Enterotoxinas

•Atrofia de las vellosidades•Hiperplasia de las criptas

VIRUS

• Patogenia• Vasculitis de capilares de la submucosa

• Trombosis e isquemia focal• Reactivación viral con invasión masiva de la mucosa

BACTERIAS

• Contaje Linfocitos CD4+ en 60 cel/mm3

• HIV-1 RNA en plasma > 100.000 copias/mL• Lesión duodenal• Clínica: fiebre, diaforesis nocturna, perdida de peso, diarrea, dolor abdominal, malabsorción y anemia.

• Prevalencia 20 veces mayor• Recurrencia de bacteriemia 80%• Gastroenteritis autolimatada

• Tinción Kinyoun: Ooquistes (Isospora, Cryptosporidium)

• Inmunofluorescencia con anticuerpos monoclonales (Cryptosporidium)

• Epifluorescencia en Microscopia de contraste de fase (Cyclospora)

•

• Tinción Tricrómica: Esporas (Microsporas)

• Quimiofluorescenca (Microsporas)

• Enzyme Immunoassay (EIA)/Enzyme-Linked Immunosorbent Assay (ELISA) (sensibilidad 95%)• PCR (identificación genotipica)

Treating Opportunistic Infections among HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. Clinical Infectious Diseases 2005;40:S131–S235

• Cryptosporidium• Estudio comparativo: Ziehl Neelsen, azul de metileno-zafranina, ELISA y PCR

• Especificidad de ELISA 92-94%• Especificidad de PCR 100%

Kaushik, K. (2007) Evaluation of staining techniques, antigen detection and nested PCR for the diagnosis of cryptosporidiosis in HIV seropositive and seronegative patients Clin Infec Dis.

• Hemocultivo con Bactec (M. avium, Salmonella)• M.avium

• CIM >32 μg/mL para claritromicina • O >256 μg/mL para Azitromicina

• IgM y PCR para CMV• Detección de antígeno Herpes Virus• Serologia para hongos• Coprocultivo

Clinical Chemistry 51: 2415-2418, 2005.

1. Citomegalovirus vs Salmonella• Lesiones úlceradas, hemorragicas• Placas adheridas de verde amarillentas, bordes hiperémicos• Pseudotumores

2. Herpes simple (rectosigmoidoscopia)

• Cryptosporidium: • Proyección hacia la luz• Intracelular- extracitoplasmatica• Basofilicos (hematoxilina-eosina)

• Microsporidium:• Giemsa, hematoxilina-eosina, Brown-Hopps Gram, acid-fast o Cromotrope 2A

• Citomegalovirus• Intranuclear- intracitoplasmatica

Weiss LM, Vossbrinck CR. Microsporidiosis: molecular and diagnostic aspects. Adv Parasitol 1998; 40:351–95.

•Cryptoporidium Heces•Cryptococcus Antígeno Suero

•Cuantificación de ADN de CMV por PCR a tiempo real.•Detección de ADN de M. tuberculosis y M. avium•Otros

• Primera consideración • CD4+ >100cel/mm3

Dore GJ, Li Y; McDonald A; Ree H, et al. Impact of highly active antiretroviral therapy on individual AIDS-defining illness incidence and survival in Australia. J AIDS 2002; 29:388–95.

• Reposición hídrica• Correcciones electrolíticas• Soporte nutricional• Uso de probioticos

Practice Guidelines for the Management of Infectious Diarrhea. Clinical Infectious Diseases 2001; 32:331–50

•Uso de probioticos• Mejora contaje de CD4• Disminuye diarrea, flatulencias, nauseas• Lactobacillus rhamnosus y reuteri

Kingsley C. Yogurt Containing Probiotic Lactobacillus rhamnosus GR-1 and L. reuteri RC-14 Helps Resolve Moderate Diarrhea and Increases CD4 Count in HIV/AIDS Patients. J Clin Gastroenterol 2008;42:239–243)

• Malabsorción de Ácidos Biliares • Colestiramina: 4 a 16 g/día VO

• Diarreas intensas• Difenoxilato de atropina o loperamida (BIII)

• Niveles de Polipéptido intestinal vasoactivo• Octreótido 50 mcg/8 h SC dosis respuesta hasta 500 mcg/8 h por 7 días (DII)

Recommendations from CDC, the National Institutes of Health, and

the HIV Medicine Association/Infectious

Diseases Society of America

ANTIMICROBIANOSATB DOSIS ALTERNATIVA

Cryptosporidium Sintomático Nitrazoxanida 500mg BID (CIII)

Paromicina 25mg/Kg (CIII)

Microsporidium Albendazol 400 mg BID 4 semanasCD4 > 200

cel

Nitrazoxanida Itraconazol

Fumagilin 60mg OD

IsosporaCyclospora

Trimetoprim-Sulfametoxazol

(AII)

160 mg /800 mg

QID 10 días luego BID

por 3 semanas

Ciprofloxacina

Treating Opportunistic Infections among HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. Clinical Infectious Diseases 2005;40:S131–S235

ATB DOSIS OPCIÓN

M. avium Claritromicina (AI)

500 mg BID Azitromicina (AII)

Etambutol (AI) 15 mg/Kg QID Rifabutin (CI)Fluoroquinolonas o amikacina (CIII)

Salmonella Fluoroqunolona: Ciprofloxacina

(AIII)

500-750 mg BID 7-14 dias

CD4 < 200cel: 4-6 sem

TMP-SMXCefalosporinas de

3 era (BIII)

ANTIMICROBIANOS

Treating Opportunistic Infections among HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. Clinical Infectious Diseases 2005;40:S131–S235

ATB DOSIS

Citomegalovirus Ganciclovir 5 mg/kg/12 h EV 14

Foscarnet 60 mg/kg/8 h o 90 mg/kg/12 h, EV por 14 a

21 días a 21 días

ANTIMICROBIANOS

Treating Opportunistic Infections among HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. Clinical Infectious Diseases 2005;40:S131–S235

ATB DOSIS ALTERNATIVA

Cryptococcus Inducción: Anfotericina B

0,7mg/Kg (liposomal: 4mg/Kg) IV

2 semanas

Fluconazol

Consolidación: Fluconazol 400 - 800mg VO-IV

OD

8 semanas

Itraconazol 200mg VO BID

ANTIMICROBIANOS

Treating Opportunistic Infections among HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. Clinical Infectious Diseases 2005;40:S131–S235

Prophylaxis against Opportunistic Infections in Patients with Human Immunodeficiency Virus Infection. N Engl J Med 2000;343(9):672.

• Altos costos• Asociada a resistencia de Candida a

fluconazol

The Impact of Primary Prophylaxis for Cryptococcosis on Fluconazole Resistance in Candida SpeciesJ Acquir Immune Defic Syndr Volume 47, Number 5, April 15, 2008

VIRUS DE INMUNODEFICIENCIA

HUMANA

• Patogenia• Atrofia de bajo grado del intestino delgado• Defecto de maduración de enterocitos

• Malabsorción• Amerita diagnóstico de exclusión

• Diarrea crónica• Bien establecida (> 1 mes de duración)• No se determina otra causa infecciosa• Evaluación completa que incluye biopsia intestinal

OTRAS CAUSAS

• Linfomas Gastrointestinales• Sarcoma de Kaposi• Carcinoma Anorrectal

REFENCIAS BIBLIOGRAFICAS• Treating Opportunistic Infections among HIV-Infected Adults and Adolescents: Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. Clinical Infectious Diseases 2005;40:S131–S235• Kingsley C. Yogurt Containing Probiotic Lactobacillus rhamnosus GR-1 and L. reuteri RC-14 Helps Resolve Moderate Diarrhea and Increases CD4 Count in HIV/AIDS Patients. J Clin Gastroenterol 2008;42:239–243)• The Impact of Primary Prophylaxis for Cryptococcosis on Fluconazole Resistance in Candida SpeciesJ Acquir Immune Defic Syndr Volume 47, Number 5, April 15, 2008• Dore GJ, Li Y; McDonald A; Ree H, et al. Impact of highly active antiretroviral therapy on individual AIDS-defining illness incidence and survival in Australia. J AIDS 2002; 29:388–95.• Miller V, Mocroft A, Reiss P, et al. Relations among CD4 lymphocyte count nadir, antiretroviral therapy, and HIV-1 disease progression: results from the EuroSIDA study. Ann Intern Med 1999; 130:570–7.• Girardi E,. Impact of the HIV epidemic on the spread of other diseases. AIDS 2000; 14(Suppl 3):S47–56.• Travis, H.Bacterial Diarrhea in Persons with HIV Infection, United States, 1992–2002. Clinical Infectious Diseases 2005; 41:1621–7• Etiology of Chronic Diarrhea in Antiretroviral-Naïve Patients with HIV Infection Admitted to Norodom Sihanouk Hospital, Phnom Penh, Cambodia. Clinical Infectious Diseases 2006; 43:925–32• Practice Guidelines for the Management of Infectious Diarrhea. Clinical Infectious Diseases 2001; 32:331–50• Enzyme Immunoassay (EIA)/Enzyme-Linked Immunosorbent Assay (ELISA) Clinical Chemistry 51: 2415-2418, 2005

GRACIAS