Most patients with AIDS (50 to 98 percent) either present with or later develop diarrhea that is often life-threatening. Gastrointestinal disease in immunocompromised patients is often due to Cryptosporidium, Isospora, Microsporidium, and Cyclospora.
The diagnosis of Cryptosporidium is made with a modified Ziehl-Neelsen acid-fast stain or Kinyoun stain of the stool. Many antimicrobial and antidiarrheal agents have been tried without much success in the treatment of cryptosporidiosis. The high rate of recurrence and relapse of this disease is probably related to the underlying immunodeficiency. Isospora belli is another protozoan that can cause significant gastrointestinal disease. As with Cryptosporidium, infection with Isospora occurs after ingestion of oocysts in contaminated food or water and following sexual contact. Symptoms may vary from acute gastroenteritis in immunocompetent individuals to severe, protracted diarrhea in the immunocompromised. Characteristic oocysts can be detected in the stool with acid-fast stains. Treatment is with trimethoprim-sulfamethoxazole.
Microsporidium is an obligate intracellular protozoan that is becoming more commonly recognized as a pathogen in patients with AIDS and the immunocompetent. Most patients present with diarrhea and a wasting syndrome, but hepatitis, peritonitis, and keratitis have been described. Diagnosis by stool examination is difficult due to the small spore size. Immunologic detection of spores with polyclonal serum has been attempted. Definitive diagnosis usually requires intestinal biopsy and detection with transmission electron microscopy. Treatment is difficult. Patients who do not respond to standard antidiarrheal therapy can be tried on octreotide, albendazole, or metronidazole.
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