Creighton University/St. Joseph's Medical Center Phoenix, AZ, United States
Shehroz Aslam, MD1, Zaid Ansari, MD2, Mustafa Alani, MD3, Brett Hughes, MD2, Indu Srinivasan, MD4, Keng-Yu Chuang, MD2 1Creighton University, Dignity Health St. Joseph's Medical Center, Phoenix, AZ; 2Creighton University School of Medicine Phoenix Program, Phoenix, AZ; 3Creighton University/St. Joseph's Medical Center, Phoenix, AZ; 4Creighton University/Valleywise Health, Phoenix, AZ
Introduction: Chronic diarrhea is a common complication in patients with human immunodeficiency virus (HIV) resulting in significant morbidity and mortality. Identifying the pathogen and improving the CD4 count is the key to managing these patients. Here we present a case of a middle-aged female with poorly controlled HIV and persistent Cystoisospora belli enteritis.
Case Description/Methods: A 49-year-old African female with limited English proficiency and past medical history of acquired immunodeficiency syndrome (AIDS), non-compliant with ART presented with a 3-month history of watery, non-bloody diarrhea, abdominal pain, and weakness. Physical exam revealed diffuse abdominal tenderness with no peritoneal signs. Labs showed a CD4 count of 190 cells/microL and HIV viral load of 15, 617 copies/ml. No eosinophilia was detected. A CT scan of the abdomen and pelvis showed diffuse mucosal hyperenhancement of small and large bowel consistent with enteritis/colitis (Figure 1). Stool studies including ova and parasites were negative. Endoscopic evaluation of the small intestine and colon was normal but random biopsies revealed Cystoisospora belli in the small intestine. She improved with one course of Bactrim but was re-hospitalized multiple times with recurrent diarrhea. Repeat endoscopy with small bowel biopsy showed persistent infection.
Discussion: Cystoisosporiasis is an opportunistic infection causing severe enteritis, chronic diarrhea, malabsorption, and weight loss in HIV patients. Though found worldwide it is uncommon in North America and hence should be suspected when routine diagnostic tests are negative. The diagnosis is made by detecting oocysts in the feces which often require modified acid-fast stain. Imaging is usually unremarkable though in our patient mucosal hyperenhancement of the intestines was seen. Parasites may also be detected in intestinal biopsy and hence endoscopy should be considered even with negative stool studies. In patients with a CD4 count of less than 200 cells/microL, secondary prophylaxis should be continued after the initial treatment course until the patient develops a sustained increase in their CD4 count for at least 6 months. Compliance with this treatment course can be challenging which leads to the high incidence of recurrent symptoms.
Figure: Figure 1: Computed tomography image showing mucosal hyperenhancement of the small and large bowel (red arrow)
Disclosures: Shehroz Aslam indicated no relevant financial relationships. Zaid Ansari indicated no relevant financial relationships. Mustafa Alani indicated no relevant financial relationships. Brett Hughes indicated no relevant financial relationships. Indu Srinivasan indicated no relevant financial relationships. Keng-Yu Chuang indicated no relevant financial relationships.
Shehroz Aslam, MD1, Zaid Ansari, MD2, Mustafa Alani, MD3, Brett Hughes, MD2, Indu Srinivasan, MD4, Keng-Yu Chuang, MD2. P3023 - Chronic Cystoisosporiasis in an Immunocompromised Host: A Diagnostic and Treatment Challenge, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.