Management of severe diarrhea in an AIDS patient with inflammatory bowel disease with Short Bowel Syndrome

Abstract

Introduction: The human immunodeficiency virus (HIV) can lead to a loss of lymphoid tissue through the intestinal mucosa, making the intestine susceptible to infections and inflammation. As a result, the patient may present with Crohn's Disease (CD), a chronic inflammatory bowel disease (IBD). Short Bowel Syndrome (SBS) results from loss of bowel absorption capacity after extensive bowel resection and is associated with several complications. Objective: To report the case of a patient presenting with acute chronic diarrhea, of probable multifactorial etiology, secondary to HIV, CD, and SBS. Methods: The information contained in this report was obtained through a review of the medical record and a review of the literature. Case Report: This is the report of E. F. C, male, 49 years old, who was admitted to the ICU of Hospital Ernesto Dornelles, in Porto Alegre, from 12/04/2020 to 01/07/2021, with HIV, CD, and SBS. The patient was admitted complaining of diarrhea that had started 15 days ago, which had worsened in the last 7 days, with loss of appetite, vomiting episodes, and mental confusion. Using empirical Lamivudine, Zidovudine, Tenofovir, Ciprofloxacin and Metronidazole, Methotrexate and Prednisone. On physical examination, he was sleepy, afebrile, with a normotensive abdomen, severe dehydration, and edema 3+/4+. From anthropometry, the measured weight of 50 kg, reported height of 1.70 m, and BMI of 17 kg/m2. On laboratory tests, he had severe pancytopenia and electrolyte disturbances. Although the cause of diarrhea was not clarified, bowel rest and the use of glutamine and enteral symbiotic were chosen, while treating HIV and CD, to improve enterocyte nutrition and reduce bacterial translocation capable of causing septic conditions. Despite this, diarrhea was untreatable, mean greater than 1,000 ml/day, with indication, but without the possibility of total parenteral nutrition, due to thrombocytopenia. On 12/06, E. F. C was in poor general condition, anasarca, tachycardic, hypotensive, treating septicemia caused by Candida tropicalis. On 12/07, he presented no spontaneous breathing, absence of central pulses and pupillary reflexes, opted not to institute invasive measures, and died. Final Considerations: The report highlights the need to cover IBD and opportunistic infections in the differential diagnosis of diarrhea in AIDS patients with CD and SBS. It also demonstrates the challenge of nurturing the patient who does not have conditions for enteral and/or parenteral nutrition, with a high risk of malnutrition due to the catabolism of such pathologies.