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A 27-year-old HIV-positive man comes to the office due to a 4-day history of low-grade
fever, profuse watery diarrhea, and abdominal cramps. He has had no bloody stools or
dizziness. The patient has continued to eat and drink well but has been more fatigued
than usual. He has had no recent sick contacts or travel. The patient has been on
antiretroviral therapy for the past 8 months after presenting with Pneumocystis jirovecii
pneumonia, but his current CD4 count is unknown. Temperature is 37.9 C (100.2 F),
blood pressure is 105/70 mm Hg, pulse is 102/min, and respirations are 14/min. The
patient is anicteric, and his lung fields are clear to auscultation. Abdominal examination
reveals minimal tenderness diffusely with deep palpation and no rebound or guarding.
What is the most appropriate next step in the management of this patient?

o A. Abdominal CT scan
o B. Colonoscopy with biopsy of the colonic mucosa
o C. Loperamide and lactose-free diet until diarrhea subsides
0 D. Start empiric treatment for cytomegalovirus
0 E. Stool examination studies including ova and parasites
o F. Stop antiretroviral therapy

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0. ld : 2269
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GJIIA)
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A 27-year-old HIV-positive man comes to the office due to a 4-day history of low-grade
fever, profuse watery diarrhea, and abdominal cramps. He has had no bloody stools or
dizziness. The patient has continued to eat and drink well but has been more fatigued
than usual. He has had no recent sick contacts or travel. The patient has been on
antiretroviral therapy for the past 8 months after presenting with Pneumocystis jirovecii
pneumonia, but his current CD4 count is unknown. Temperature is 37.9 C (1 00.2 F),
blood pressure is 105/70 mm Hg, pulse is 102/min, and respirations are 14/min. The
patient is anicteric, and his lung fields are clear to auscultation. Abdominal examination
reveals minimal tenderness diffusely with deep palpation and no rebound or guarding.
What is the most appropriate next step in the management of this patient?

A Abdominal CT scan [3%)

B. Colonoscopy with biopsy of the colonic mucosa [3%)
C. Loperamide and lactose-free diet until diarrhea subsides [1%)
D. Start empiric treatment for cytomegalovirus [1 8%)
E. Stool examination studies including ova and parasites [74%)
F. Stop antiretroviral therapy [1%)

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Explanation: User
This patient with HIV has acute onset, nonbloody diarrhea with low-grade fevers,
suggesting an infectious etiology. Common infectious causes of AIDS-related diarrhea
include Cryptosporidi um, Mycobacterium avium complex (if CD4 count <50/mm'),
microsporidia, Giardia, or Isospora belli. The absence of colitis (eg, bloody diarrhea)
makes infection with many of the non-oppcrtunistic pathogens (eg, Salmonella,
Campylobacter, Entamoeba, Shigella) less likely. The first step in diagnosis would be to
perform a stool examination for culture, ova/parasites, Clostridi um difficile antigen,
and an acid-fast stain (for Cryptosporidium).
(Choice A) An abdominal CT scan is generally not useful in patients with diarrhea
unless toxic megacolon/complications are suspected. Although this scan can show
colitis, mucosal biopsy is often required for specific diagnosis in patients with HIV. This
patient, who is hemodynamically stable and has frequent watery diarrhea, has no
indication for an urgent CT scan and can be evaluated with stool studies first.
(Choice B) Colonoscopy and biopsy of mucosa and/or ulcers are reserved for patients

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Explanation: User
This patient with HIV has acute onset, nonbloody diarrhea with low-grade fevers,
suggesting an infectious etiology. Common infectious causes of AIDS-related diarrhea
include Cryptosporidium, Mycobacterium avium complex (if CD4 count <50/mm>),
microsporidia, Giardia, or Isospora belli. The absence of colitis (eg, bloody diarrhea)
makes infection with many of the non-opportunistic pathogens (eg, Salmonella,
Campylobacter, Entamoeba, Shigella ) less likely. The first step in diagnosis would be to
perform a stool examination for culture, ova/parasites, Clostridium difficile antigen,
and an acid-fast stain (for Cryptosporidium) .
(Choice A) An abdominal CT scan is generally not useful in patients with diarrhea
unless toxic megacolon/complications are suspected. Although this scan can show
colitis, mucosal biopsy is often required for specific diagnosis in patients with HIV. This
patient, who is hemodynamically stable and has frequent watery diarrhea, has no
indication for an urgent CT scan and can be evaluated with stool studies first.
(Choice B) Colonoscopy and biopsy of mucosa and/or ulcers are reserved for patients
with persistent diarrhea and negative initial workup (eg, stool examination).
(Choice C) In a patient whose diarrhea is likely infectious, use of an antidiarrheal agent
may cause more organisms or toxin to remain in the intestine, which could lead to toxic
megacolon.

(Choice 0) Cytomegalovirus (CMV) colitis often presents with bloody diarrhea and
usually develops in patients with CD4 count <50/mm>. Due to the toxic profile of
anti-CMV agents, specific therapy should be instituted once the diagnosis is established.
(Choice F) This patient has been on antiretroviral therapy for an extended period. As a
result, it is more likely that an infective organism, not an antiretroviral medication, is
causing the diarrhea.
Educational objective:
HIV-associated diarrhea has many potential causes. CD4 count, chronicity, and the
presence or absence of symptoms of colitis help narrow the differential diagnoses.
Work-up typically involves sending the stool for several tests including culture, ova and
parasites, acid-fast stain, and Clostridi um difficile antigen.

Time Spent: 1 seconds Copyright © UWorld Last updated: [10/17/2016)

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