diarrhea types, classification, IMNCI, management, diarrhea in immunocompromised

1. Acute diarrheal
diseases including
Cholera
Dr. Shalli
JR CCM
1

2. Outline
Definition
Burden
Causes
Management
Vaccine
Cholera
IMNCI validation in India
Diarrhea in immunocompromised
2

3. Definition
 Diarrhoea is defined by WHO as the passage of 3 or more loose or
liquid stools per day, or more frequently than is normal for the
individual
 It is usually a symptom of gastro intestinal infection
 It is the change in consistency rather than number of stools which is
important
3

4. Types
 Acute watery diarrhoea: which lasts several hours or days: the main
danger is
dehydration
 weight loss also occurs if feeding is not continued
 Dysentery: the main dangers are
 damage of the intestinal mucosa,
 sepsis and malnutrition;
 dehydration
 Persistent diarrhoea (which lasts 14 days or longer: the main danger is
 malnutrition
 serious non-intestinal infection
 dehydration may also occur
4

5. Global Burden
 Diarrhoea is a leading killer of children, accounting for 9 per cent of all deaths
among children under age 5 worldwide in 2015
 Most deaths from diarrhoea occur among children less than 2 years of age living in
South Asia and sub-Saharan Africa
 Even though the total annual number of deaths from diarrhoea among children
under 5 decreased by more than 50 per cent – from over 1.2 million to half a
million in the past decade
 Many more children could be saved through basic interventions.
http://www.who.int/healthinfo/global_burden_disease/en/acessed on 21st march 2017
5

6. Global Burden
https://data.unicef.org/topic/child-health/diarrhoeal-disease/acessed on 21st march 2017
6

7. 7

8. Burden in India
 India has made steady progress in reducing deaths in children younger than 5
years, with total deaths declining from 2.5 million in 2001 to 1.5 million in 2012
 Even though the deaths among children under-5 years have declined, the
proportional mortality accounted by diarrheal diseases still remains high.
 Diarrhea is the third most common cause of death in under-five children,
responsible for 13% deaths in this age-group, killing an estimated 300,000 children
in India each year
Lakshminarayanan S, Jayalakshmy R. Diarrheal diseases among children in India: Current scenario and future perspectives. Journal of Natural Science, Biology, and
Medicine. 2015;6(1):24-28. doi:10.4103/0976-9668.149073.
8

9. Child death statistics for India
Total
Neonatal
Deaths
Total Post-
neonatal
Deaths
Neonatal
Deaths Due To
Diarrhoea
Postneonatal
Deaths Due To
Diarrhoea
Underfive
Deaths Due
To Diarrhoea
Neonatal
Death Rate
From
Diarrhoea
(Per 1000
Livebirths)
Postneonatal
Death Rate
From
Diarrhoea
(Per 1000
Livebirths)
Underfive
Death Rate
From
Diarrhoea
(Per 1000
Livebirths)
% Neonatal
Deaths Due
To Diarrhoea
% Post-
neonatal
Deaths Due
To Diarrhoea
% Under-five
Deaths Due
To Diarrhoea
6,95,852 5,05,146 4,962 1,12,323 1,17,285 0 4 5 1% 22% 10%
Estimate of child causes of death 2015
10

10. Causal pathway
 Agent factors
 Host factors
 Environmental factors
11

11. Agent factors
Bacteria
• Shigella
• Escherichia coli
• Salmonella
• Campylobacter jejuni
• Yersinia
enterocolitica
• Staphylococcus
• Vibrio
parahemolyticus
• Clostridium difficile
Viruses
• Rotavirus
• Adenoviruses
• Caliciviruses
• Astroviruses
• Norwalk agents
andNorwalk-like
viruses
Parasites
• Entameba
histolytica
• Giardia lamblia
• Cryptosporidium
• Isospora
12

12. Agent factors
 Four pathogens are significantly associated with moderate-to-severe diarrhoea:
rotavirus, Cryptosporidium, Shigella, and ST-ETEC
 Rotavirus had the highest number of cases compared to any pathogen during infancy
 The estimated incidence of moderate-to-severe diarrhoea is highest in India
 Moderate-to-severe diarrhoea was common in the paediatric populations studied, producing
more than 20 episodes per 100 child-years during each of the first 2 years of life
 Cryptosporidium was a significant pathogen at all sites regardless of HIV prevalence
Burden and aetiology of diarrhoeal disease in infants and young children in developing countries (the Global Enteric Multicenter Study, GEMS): a
prospective, case-control study Kotloff, Karen L et al.The Lancet , Volume 382 , Issue 9888 , 209 - 222
13

13. Host factors
 Diarrhea is most common in children 6 months to 2 years of age
 Highest incidence in 6-11 months which is period of weaning
 Low level of maternally acquired Abs
 Lack of active immunity in infants
 Introduction of contaminated food
 Direct contact to human and animal faeces when infant crawls
 Malnutrition
 Poverty
 Lack of personal and domestic hygiene
 Incorrect feeding practices
14

14. Environmental factors
 Seasonal pattern
 Tropical areas- rotavirus throughout the year and bacteria in summers
 Temparate areas- bacterial in summer and tropical in winters
Mode of Transmission
• Feco-oral
15

15. Clinical features
 E. coli-
 Watery stools
 Vomiting is common
 Dehydration moderate to severe
 Fever– often of moderate grade
 Mild abdominal pain
 Rotavirus –
 Insidious onset
 Prodromal symptoms, including fever, cough, and vomiting precede diarrhea
 Stools are watery or semi-liquid; the color is greenish or yellowish– typically
looks like yoghurt mixed in water
 Mild to moderate dehydration
 Fever– moderate grade
16

16. Clinical features
 Shigellosis
 Frequent passage of scanty amount of stools, mostly mixed with blood and mucus
 Moderate to high grade fever
 Severe abdominal cramps
 Tenesmus– pain around anus during defecation
 Usually no dehydration
 Amoebiasis
 Offensive and bulky stools containing mostly mucus and sometimes blood
 Lower abdominal cramp
 Mild grade fever
 No dehydration
17

17. Assessment of dehydration
18

18. IMNCI Classification19

19. Laboratory diagnosis
 Stool microscopy
 Stool cultures
 ELISA for rotavirus
 Immunoassays, bioassays or DNA probe tests to identify E. coli strains
20

20. Management
Main components
are
Rehydration
Zinc
supplementation
Nutrients rich food
21

21. Oral rehydration salt solution(ORS)
 Dehydration was the major cause of death in 1829 pandemic of cholera
 I/V fluids were the major and standard line of therapy for Dehydration
 Robert A phillip attempted to create an effective ORT solution but his
solution was extensively hypertonic
 In early 1960s, biochemist Robert K. Crane described the described the
sodium glucose co transport mechanism and its role in intestinal glucose
absorption
Ruxin JN. Magic bullet: the history of oral rehydration therapy. Medical History.
1994;38(4):363-397
22

22. Oral rehydration salt solution(ORS)
 In 1967-1968, Norbert Hirschhorn and Nathaniel F. Pierce showed that people
with severe cholera can absorb glucose, salt and water
 In 1968 David R. Nalin reported that in adults with cholera, given an oral
glucose-electrolyte solution in volumes equal to that of the diarrhea losses,
reduced the need for IV fluid therapy by eighty percent
 In 1971, during the Bangladesh liberation war, an epidemic of cholera
happened
 Dr. Dilip Mahalanabis, a physician orderd use of ORS in refugees and it was
seen that mortality rate was 3.6% in those who received ORS and 30% in those
with I/V fluid therapy
23

23. Oral rehydration salt solution(ORS)
 The World Health Organization in 1978 launched the global diarrheal
diseases control program with ORS and a short-term objective of
reducing mortality due to diarrhea1
 During the 1980s, UNICEF launched the 'child survival and development
revolution', concentrating its efforts on four potent methods of saving
children's lives -- growth monitoring, breastfeeding, immunization, and
the use of oral rehydration salts (ORS)
 The British medical journal The Lancet has described ORS as "potentially
the most important medical advance of this century“2
1. Bhattacharya SK. History of development of oral rehydration therapy. Indian J Public Health. 1994 Apr-Jun;38(2):39-43. PubMed PMID: 7530695
2. 2. www.unicef.org/sowc96/joral.htm
24

24. Composition of ORS

25. Coverage of ORS in the world26

26. Treatment plan A
 Incase of No dehydration treatment A is to be followed
 Give the child as much ORS as he can take after each loose stool
 children under 2 years of age: 50-100 ml (a quarter to half a large cup) of fluid
 children aged 2 up to 10 years: 100-200 ml (a half to one large cup)
 older children and adults: as much fluid as they want
 Zinc supplementation
 Nutrient intake
27

27. Treatment plan B28

28. Treatment plan C29

29. ResoMal
 ReSoMal (oral rehydration salts or ORS for severely malnourished children) is used in in-
patient centres for the treatment of children with severe acute malnutrition (SAM)
 It contains a mixture of salts and minerals specially designed to correct deficiencies of
potassium, magnesium, zinc and copper and to address high levels of sodium in children
with SAM
 Children with SAM and who have some or severe dehydration but no shock should
receive 5 mL/kg ReSoMal every 30 min for the first 2 h. Then, if the child is still
dehydrated, 5–10 mL/kg/h ReSoMal should be given in alternate hours with F-75, up to a
maximum of 10 h
 Signs of improved hydration status and overhydration should be checked every half hour for the first
2 h, then hourly
1. https://www.unicef.org/supply/files/Resomal.pdf
2. http://www.who.int/elena/titles/full_recommendations/sam_management/en/index5.html
30

30. ResoMal vs ORS
 ReSoMaL has a large beneficial effect on
potassium status compared with standard
ORS. However, ReSoMaL therapy may result
in symptomatic hyponatremia and seizures in
patients with severe diarrhea*
*Efficacy and safety of a modified oral rehydration solution (ReSoMaL) in the treatment of severely malnourished children with watery diarrhea
Alam, N.H et al. The Journal of Pediatrics , Volume 143 , Issue 5 , 614 - 619

31. Zinc supplementation
 Zinc benefits children with diarrhoea because it is a vital micronutrient essential for
1
 protein synthesis,
 cell growth and differentiation,
 immune function, and
 intestinal transport of water and electrolytes
 Zinc is also important for normal growth and development of children
 Zinc deficiency is associated with an increased risk of gastrointestinal infections,
adverse effects on the structure and function of the gastrointestinal tract, and
impaired immune function2
 Dietary deficiency of zinc is especially common in low-income countries because of
a low dietary intake of zinc-rich foods3
1.Patel AB, Dhande LA, Rawat MS. Therapeutic evaluation of zinc and copper supplementation in acute diarrhea in children: double blind randomized trial. Indian
Pediatrics. 2005; 42(5):433–42
2.Bhatnagar S, Natchu UC. Zinc in child health and disease. Indian Journal of Pediatrics. 2004; 71(11):991–5
3.Aggarwal R, Sentz J, Miller MA. Role of zinc administration in prevention of childhood diarrhea and respiratory illnesses: a meta-analysis. Pediatrics. 2007; 119(6):1120–
30
32

32. Zinc
supplementation
 Zinc supplementation
significantly reduces the severity
and duration of diarrhoea in
children less than 5 years of age
 It is now recommended that zinc
(10-20 mg/day) be given for 10
to 14 days to all children
 It reduces the risk of diarrhoea
for 3-4 months

33. Feeding
 The infant usual diet should be continued during diarrhoea and food should never be
withheld
 In case of breast feeding child, Breastfeeding should always be continued
 When food is given, sufficient nutrients are usually absorbed to support continued
growth and weight gain
 Continued feeding also speeds the recovery of normal intestinal function, including
the ability to digest and absorb nutrients
34

34. Chemotherapy
35

35. Vitamin A and Diarrhoea
 Diarrhoea reduces the absorption of vitamin A
 It is a problem when diarrhoea occurs during or shortly after measles, or in
children who are already malnourished1
 Hence, children with diarrhoea should be examined routinely for corneal
clouding and conjunctival lesions
 Oral vitamin A should be given at once and again the next day: 200 000
units/dose for age 12 months to 5 years, 100 000 units for age 6 months to 12
months, and 50 000 units for age less than 6 months.
 Mothers should also be taught routinely to give their children foods rich in
carotene like yellow or orange fruits or vegetables, and dark green leafy
vegetables 2
1. Nalin DR, Russel R. Vitamin A, xerophthalmia and diarrhea. Lancet 1980, ii: 1411
2. World Health Organization. A Manual for the Treatment of Diarrhea. Geneva, WHO, 1990, pp 5-26
36

36. Key measures to prevention
Access to safe drinking-water
Use of improved sanitation
Hand washing with soap
Exclusive breastfeeding for the first six months of life
Good personal and food hygiene
Health education about how infections spread
Rotavirus vaccination
37

37. Rotavirus Vaccination
 Rotavirus vaccine should be considered a priority particularly in countries with high rotavirus
gastroenteritis (RVGE) associated fatality rates, such as in South and South- Eastern Asia, and sub-
Saharan Africa
 The first oral rotavirus vaccine was licensed in the USA (Rotashield®, Wyeth)
 However, Rotashield® was withdrawn nine months after introduction due to an increased risk of
intussusception associated with the vaccine
 This was a major setback in efforts to reduce the global burden of rotavirus disease
 Recently developed rotavirus vaccines (Rotarix®, GSK and Rotateq®, Merck) have been shown to
be safe and effective in placebo- Controlled clinical trials, each of which included >60 000 infants
1. Joensuu et al., 1997; Perez-Schael et al., 1997; Bresee et al., 1999
2. Centers for Disease Control and Prevention, 1999; Prevention, 1999; Murphy et al., 2001; Bines, 2005; Justice et al., 2005; Bines, 2006)..
38

38. Administration of vaccine
 Rotarix® (RV1) should be administered orally in a 2-dose schedule at the time of DTP/penta1
and DTP/penta2 contacts, with an interval of at least 4 weeks between doses.
 RotaTeq® (RV5) should be administered orally in a 3-dose schedule at the time of the
DTP/penta1, DTP/penta2, and DTP/penta3 contacts, with an interval of at least 4 weeks
between doses
 Rotavirus vaccination of children >24 months of age is not recommended
 Rotavirus vaccinations can be administered simultaneously with other vaccines in the infant
immunization schedule
 Phased introduction, at present in Andhra Pradesh, Haryana, Himachal Pradesh and Orissa from
2016
39

39. Contraindications
 Severe allergic reaction (e.g. anaphylaxis) after a previous
dose, and severe immunodeficiency including severe
combined immunodeficiency (SCID).
 History of intussusception or intestinal malformations, chronic
gastrointestinal disease, and severe acute illness.
 Ongoing acute gastroenteritis or fever with moderate to
severe illness
40

40. Cholera
41

41. Introduction
Cholera is an acute
diarrhoeal infection caused
by ingestion of food or water
contaminated with the
bacterium Vibrio cholera
01
Cholera remains a global
threat to public health and
an indicator of inequity and
lack of social development
02
Every year, there are roughly
1.3 to 4.0 million cases, and
21 000 to 143 000 deaths
worldwide due to cholera
03
Ali M, Nelson AR, Lopez AL, Sack DA. Updated Global Burden of Cholera in Endemic Countries. Remais JV, ed. PLoS
Neglected Tropical Diseases. 2015;9(6):e0003832. doi:10.1371/journal.pntd.0003832.
42

42. History
 The first cholera pandemic occurred in the Bengal region of India,
near Calcutta starting in 1817

 The disease dispersed from India to Southeast Asia, the Middle East,
Europe, and Eastern Africa through trade routes
 The second pandemic occurred in 1827 and particularly affected
North American and Europe
 The third pandemic erupted in 1839, persisted until 1856, extended
to North Africa, and reached South America,
43

43. History
 The fourth pandemic lasted from 1863 to 1875 spread from
India to Naples and Spain
 The fifth pandemic was from 1881-1896 and started in India
and spread to Europe, Asia, and South America
 The sixth pandemic started 1899–1922
 The seventh pandemic originated in 1961 in Indonesia and is
marked by the emergence of a new strain, nicknamed El Tor,
which still persists today in developing countries
44

44. History
 Dr. John Snow demonstrated how cases of cholera that broke out in
a district of central London could all be traced to a single source of
contaminated drinking water
 He discovered that cholera was waterborne
45

45. Epidemiology
 Cholera can be endemic or epidemic
 A cholera-endemic area is an area where confirmed cholera
cases were detected during 3 out of the last 5 years with
evidence of local transmission (meaning the cases are not
imported from elsewhere)
 A cholera outbreak/epidemic is defined by the occurrence of
at least 1 confirmed case of cholera with evidence of local
transmission in an area where there is not usually cholera
46

46. Etiology
 Drinking contaminated and inadequately sterilized water or eating
undercooked seafood
 Risk Factor: antacids and achlorhydria
 Gastric acid production is reduced will allow easier entrance of the bacteria to the
small interstines
 Based on agglutination of antiserum against O1 (LPS) antigen
 O1 and non-O1 strains
 V. cholerae O1 and O139 associated with epidemics
 Produce cholera toxin
 Non-O1, non-O139 serotypes
 Cause diarrheal disease identical to classical cholera but does not cause large outbreaks of diseas
47

47. Cholera strains
 There are many serogroups of V. cholerae, but only two – O1 and
O139 – cause outbreaks
 V. cholerae O139 – first identified in Bangladesh in 1992 – caused
outbreaks in the past, but recently has only been identified in sporadic
cases.
 This epidemic expansion probably resulted from a single source after a
lateral gene transfer (LGT) event that changed the serotype of an
epidemic V. cholerae O1 El Tor strain to O139
48

48. Risk factors
 Ingestion of contaminated water
 Replicates in fresh and low-salt-containing water
 Drinking unsterile water and ice in developing countries
 Ingestion of contaminated food sources
 Shelfish, clams, oysters and crabs and its products or food handlers
 High poverty
 Urban slums, refugee camps, conflict zones, natural disasters and prisons where sanitation
facilities may not exist
 Periods of flooding
 People using tube-wells that become contaminated with fecal contents from the poo-
quality sanitation.
49

49. Clinical features
 Onset begins 2-3 days after ingestion of bacteria
 Copious Watery Diarrhea
 Diarrhea >1 liter/hour is most likely cholera if sustained
 >20 mL/kg during a 4-hour observation period
 Evidence of Volume Depletion (WHO Criteria)
 Mild (<5% volume depletion) = alert, but increased HR, dry mucous
membranes and small postural BP drop (<20 mmHg)
 Moderate (5% to 10%) = irritability, sunken eyes, dry mouth, decreased skin
turgor significant (>20 mmHg) postural BP drop.
 Severe (>10% volume depletion) = lethargy or coma, circulatory collapse
(systolic BP< 80 mmHg
 Family History of recent, severe cholera outbreak
 Family clusters due to secondary cases or due to a common source
50

50. Diagnosis
 CBC- raised hct/neutrophilia
 Serum Electrolyes – low potassium
 Antisera- serotype confirmation
 Darkfield Phase contrast microscopy of stool – large quantity of bacteria
 Culture
51

51. Cholera vaccine
Currently there are 3 WHO pre-qualified oral cholera
vaccines: Dukoral®, Shanchol™, and Euvichol®
All 3 vaccines require 2 doses for full protection
Dukoral® is administered with a buffer solution that, for
adults, requires 150 ml of clean water. Dukoral® provides
approximately 65% protection against cholera for 2 years
52

52. Cholera vaccine
 Shanchol™ and Euvichol® are essentially the same vaccine produced
by 2 different manufacturers
 They do not require a buffer solution for administration, which makes
them easier to administer to large numbers of people in emergency
contexts. There must be a minimum of 2 weeks delay between each
dose of these 2 vaccines
 Individuals vaccinated with Shanchol™ or Euvichol® have
approximately 65% protection against cholera for up to 5 years
following vaccination in endemic areas
53

53. 54

54.  The goal is to end childhood deaths due from pneumonia and diarrhoea by 2025
 The action plan –
 Various interventions for controlling pneumonia and diarrhoea in children less
than five years of age as:
protecting children by establishing and promoting good health practices
preventing children from becoming ill from pneumonia and diarrhoea by
ensuring universal coverage of immunization, HIV prevention and healthy
environments
Treating children who are ill from pneumonia and diarrhoea with appropriate
treatment.
55

55. Why diarrhea and pneumonia together?
56

56. Coverage targets
By end 2025
 90% full-dose coverage of each relevant
vaccine (with 80% coverage in every
district);
 90% access to appropriate pneumonia and
diarrhoea case management (with 80%
coverage in every district);
 at least 50% coverage of exclusive
breastfeeding during the first 6 months of
life;
 virtual elimination of paediatric HIV
By end 2030
 universal access to basic drinking-
water in health care facilities and
homes;
 universal access to adequate
sanitation in health care facilities by
2030 and in homes by 2040;
 universal access to handwashing
facilities (water and soap) in health
care facilities and homes;
 universal access to clean and safe
energy technologies in health care
facilities and homes
57

57. Improving mother and child health
58

58. Framework
59

59. IMNCI validation in India(upto 2 months age
group)
 Objective: To check the validity of Integrated Management of Neonatal and
Childhood Illness (IMNCI) algorithm for young infants (0-2 months)
 Study Design: Prospective observational study
 Setting: The outpatient department and emergency room of a medical college
attached hospital.
60

60. Methodology
 Recruitment period- April 2005 to February 2006
 The study was spread over 11 months duration to minimize the seasonal variation in
morbidities

 The subjects were enrolled as and when they came in contact with study group both in OPD
and Emergency
 A total of 419 outborn young infants (0-2 months), who presented to OPD or emergency
room of the treating unit for a fresh episode of illness formed the study group.
61

61. Methodology
 These subjects were managed according to the protocol of treating
unit under the supervision of the senior faculty.
 All relevant investigations were performed as indicated
 As per the hospital policy, a birthweight of 1.5 kg or less (very low
birth weight) was also a criterion for admission even if the baby was
otherwise well
 The decision of treating unit regarding diagnosis and treatment was
considered as the ‘Gold Standard’
62

62. Methodology
 For all cases, all the particulars and signs listed in IMNCI
algorithm were recorded in the predesigned proforma
 The treatment Steps were also identified according to IMNCI
algorithm and recorded.
 The actual diagnosis and therapy was determined by the
admitting and treating unit
 Parental consent for inclusion in the study and for follow up
visit was taken in every case
63

63. Methodology
 The study subjects were either admitted or sent home after initial
evaluation, depending upon nature and severity of illness
 Dietary therapy/advice was given to every child with low birth weight or
those with feeding problem
 Every unimmunized or incompletely immunized child was immunized
 The study subjects were divided into 0-7 days and 7 days to 2 months
 The efficacy of IMNCI was evaluated in terms of sensitivity and specificity
64

64. Operational definitions
 Under-diagnosis - cases where one or more illness recorded as per the gold
standard was not covered by IMNCI a d/or would not be referred using IMNCI
algorithm though needed hospitalization
 Over-diagnosis- cases where morbidity recorded as per IMNCI was not confirmed by
the gold standard and or those which would have been referred using IMNCI
algorithm but did not need hospitalization
 Diagnostic mismatch -If there was a difference in diagnosis between ‘Gold Standard’
and IMNCI (e.g. hypocalcemic seizures vs. Possible Serious Bacterial Infection (PSBI),
meconium aspiration syndrome vs. PSBI
65

65. Results
66

66. Results
 Majority of the diagnosis (80%) made were either totally or
partially covered by the algorithm with
 Sensitivity- 88.5%
 Specificity- 57.4%
 IMNCI criteria in correctly identifying infants needing referral
for 0-7, 7-2 months and 0-2 months
 Sensitivity - 97%, 94% and 95%, and
 Specificity -85%, 87% and 87%
67

67. Diagnostic difference between gold standard and
IMNCI algorithm68

68. Discussion
 The study found that algorithm for young infants performed well in appropriately identifying cases
for referral among both 0-7 days and 7 days-2 months age group
 Majority (80%) of diagnoses made by the treating units were either totally or partially covered by
the algorithm.
 There was complete agreement of diagnoses between IMNCI and the gold standard in about 50%
of subjects
 Complete diagnostic mismatch due to difference of diagnosis was present in 19% subjects

69

69. Conclusion
 IMNCI approach in young infants has good sensitivity and
specificity for referring children with severe illness along with
provision for preventive services of immunization and feeding
counselling
 Diagnostic mismatch observed highlights the need for having
a different strategy for the management of sick young infants
in the facility once they have been identified and referred
using IMNCI algorithm
70

70. Diarrhoea in immunocompromised
 Diarrhea is a common problem in patients with immunocompromising conditions.
 The etiologic spectrum differs significantly from patients with diarrhea who have a
normal immune system
 In Africa, HIV infection was formerly called “slim disease” because of watery
diarrhea, weight loss, malnutrition, and a wasting away followed by death1
 Diarrhea in HIV-infected patients is most frequently caused by opportunistic
infections due to alterations in the mucosal immune system2
 Diarrhea in patients with AIDS can be caused by neoplasms (eg, lymphoma, Kaposi
sarcoma) or pancreatic disease3
1. Kartalija M, Sande MA. Diarrhea and AIDS in the era of highly active antiretroviral therapy. Clin Infect Dis 1999;28:701–5.
2. Cello JP, Day LW. Idiopathic AIDS enteropathy and treatment of gastrointestinal opportunistic pathogens. Gastroenterology 2009;136:1952–65.
3.Feasey NA, Healey P, Gordon MA. Review article: the aetiology, investigation and management of diarrhoea in the HIV-positive patient. Aliment
Pharmacol Ther 2011;34:587–603.
71

71. Diarrhea in immunocompromised
 Diagnostic management of diarrhea in immunocompromised conditions includes
clinical assessment, drug history, microbiological stool examination, and
endoscopy4
 Clostridium difficile is the most common bacterial pathogen causing diarrhea in
patients infected with human immunodeficiency virus and in other
immunocompromised patients
 Idiopathic AIDS enteropathy improves with highly active antiretroviral therapy and
increasing CD4 counts
 Cytomegalovirus disease is a major cause of morbidity and mortality in
immunocompromised patients and may be confirmed by endoscopic biopsy and
histologic analysis, including immunologic staining
 Intestinal graft-versus-host disease is primarily treated with glucocorticoids5
4.Feasey NA, Healey P, Gordon MA. Review article: the aetiology, investigation and management of diarrhoea in the HIV-positive patient. Aliment Pharmacol
Ther 2011;34:587–603.
5. Diarrhea in the Immunocompromised Patient ArticleinGastroenterologyclinicsofNorthAmerica·September2012
DOI:10.1016/j.gtc.2012.06.009·Source:PubMed
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74. Thankyou
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