Clinical Manual for Management of the HIV-Infected ... - myCME.com

6–22 | Clinical Manual for Management of the HIV-Infected Adult/2006
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If cholangitis is suspected, consider abdominal
ultrasound to detect biliary ductal dilatation, and
endoscopic retrograde cholangiopancreatography
(ERCP).
Check electrolytes; conduct liver function studies
including alkaline phosphatase and bilirubin.
If fever is present, obtain blood cultures.
Conduct other diagnostic testing as indicated by the
history and physical examination (eg, evaluation for
CMV, MAC, and other infectious causes of diarrhea
or cholangitis) (see chapter Diarrhea).
Treatment
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Provide supportive care and symptomatic relief
(this may require hospitalization in cases of severe
dehydration), including the following:
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Aggressive fluid and electrolyte replacement as
needed
Oral rehydration (solutions containing glucose,
sodium bicarbonate, potassium, magnesium,
and phosphorus); in severe cases, intravenous
hydration may be required
Antidiarrheal agents: atropine/diphenoxylate
(Lomotil), loperamide (Imodium), tincture of
opium (Paregoric)
Antispasmodics
Antiemetics
Topical treatment for the anorectal area, as
needed (Tucks pads, sitz baths)
No antiparasitic therapy has been proven to
cure or prevent cryptosporidiosis. Most patients
experience symptom improvement or resolution
with immune reconstitution achieved by effective
antiretroviral therapy (ART), especially if the CD4
count increases to >100 cells/µL. All patients with
cryptosporidiosis should be treated with ART,
unless it is contraindicated, as early in the course of
cryptosporidiosis therapy as possible (see chapter
Antiretroviral Therapy).
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Antiparasitic agents have not been proven effective,
but are sometimes used. These include:
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Paromomycin (Humatin), which may result in
initial response, although its efficacy remains
unclear. The usual adult dosage is 500 mg orally 4
times daily or 1,000 mg twice daily, with meals.
Paromomycin in combination with azithromycin.
One study found substantial short-term benefit
from this combination, although cure rates were
low.
Nitazoxanide (Cryptaz), 500 mg orally twice
daily. This agent is approved for use in children
with diarrhea caused by C parvum. Its usefulness
in adults and those with immunodeficiency has
not been demonstrated consistently.
For patients with weight loss, nutritional
supplementation is usually an important aspect of
treatment. In some cases, partial or total parenteral
nutrition may be necessary while patients are
awaiting clinical improvement in response to ART
or other therapies. Consult or refer to a dietitian or
nutritionist, if available. If not, assess food intake
and counsel the patient about increasing caloric and
nutritional intake.
Cryptosporidiosis in Resource-Limited Settings
Cryptosporidium infection in HIV-uninfected
populations is more common in countries with
overcrowding and poor sanitary conditions. The disease
is also associated with rainy seasons and is frequent in
children