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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