Empiric treatment of diarrhea in patient with HIV infection: a case report


  • Lisa A. Susanto Department of Internal Medicine, Wangaya Regional Hospital, Denpasar, Bali
  • I. Made Bayu S. Dana Department of Internal Medicine, Wangaya Regional Hospital, Denpasar, Bali
  • Ketut Suryana Department of Internal Medicine, Wangaya Regional Hospital, Denpasar, Bali




Diarrhea, HIV, Metronidazole


Diarrhea is common opportunistic infection in patient with Human immunodeficiency virus (HIV) infection. Diarrhea in patient with HIV infection that contributes the negatively to quality of life. The etiology of diarrhea in patient with HIV infection is multifactorial include infectious, non-infectious, ART-association diarrhea. In addition, this diarrhea can be associated with empiric therapy. This article a 31 years old male patient with 3 days fatigue and diarrhea. Physical examination dry mucous membranes, abdominal pain especially in in the upper abdomen and increase small bowel peristalsis. Stool examination test doesn’t have blood, parasites, and fungi. Stool cultures for Salmonella, Shigella, Campylobacter organisms no presence. The treatment metronidazole oral 500 mg every 8 hours was again performed. Metronidazole is available for the management of diarrhea in patient with HIV that can’t be treated with other antibiotics.

Author Biographies

Lisa A. Susanto, Department of Internal Medicine, Wangaya Regional Hospital, Denpasar, Bali

department of internal medicine

I. Made Bayu S. Dana, Department of Internal Medicine, Wangaya Regional Hospital, Denpasar, Bali

department of internal medicine

Ketut Suryana, Department of Internal Medicine, Wangaya Regional Hospital, Denpasar, Bali

department of internal medicine


Elfstrand L, Florén CH. Management of chronic diarrhea in HIV-infected patients: current treatment options, challenges and future directions. HIV/AIDS - Research and Palliative Care. 2010;2:219-24.

Miskin JP, Kemiskinan G, Kemiskinan IK, Kemiskinan IK, Provinsi M. Statistics Indonesia. (Number and Percentage of Poor people,, the Poverty Line, Poverty Gap Index (P1), and Poverty Severity Index (P2). Jakarta: Badan Pusat Statistik. 2013. Available from : https://www.bps.go.id/linkTabelStatis/view/id/1489. Last accessed on 01 November, 2020.

Simadibrata M, Akut DD. In: Setiati S, Alwi I, Sudoyo AW, Simadibrata M, Setiyohadi B, eds. Buku ajar ilmu penyakit dalam. 6 th ed. Jakarta: Interna publishing. 2014;1899.

Dikman AE, Schonfeld E, Srisarajivakul NC, Poles MA. Human immunodeficiency virus-associated diarrhea: still an issue in the era of antiretroviral theraphy. Nature public health emergency collection. 2015;60(8):2236-24.

Rossit AR, Gonçalves AC, Franco C, Machado RL. Etiological agents of diarrhea in patients infected by the human immunodeficiency virus-1: a review. Rev Inst Med Trop Sao Paulo. 2009;51:59-65.

Krones E, Hogenauer C. Diarrhea in the immunocompromised patient. Gastroenterol Clin North Am. 2012;41:677-701.

Sanchez TH, Brooks JT, Sullivan PS. Bacterial diarrhea in persons with HIV infection, United States, 1992–2002. Clin Infect Dis. 2005;41:1621-627.

Wilcox CM, Schwartz DA, Cotsonis G, Thompson SE. Chronic unexplained diarrhea in human immunodeficiency virus infection: determination of the best diagnostic approach. Gastroenterol. 1996;110:30-37.

Anton PA, Elliott J, Poles MA. Enhanced levels of functional HIV-1 co-receptors on human mucosal T cells demonstrated using intestinal biopsy tissue. AIDS. 2000;14:1761-765.

Chun TW, Nickle DC, Justement JS. Persistence of HIV in gut-associated lymphoid tissue despite long-term antiretroviral therapy. J Infect Dis. 2008;197:714-20.

Blanshard C, Francis N, Gazzard BG. Investigation of chronic diarrhoea in acquired immunodeficiency syndrome. A prospective study of 155 patients. Gut. 1996;39:824-32.

Weber R, Ledergerber B, Zbinden R, Altwegg M, Pfyffer GE, Spycher MA et al. Enteric infections and diarrhea in human immunodeficiency virus-infected persons: prospective community-based cohort study. Swiss HIV Cohort Study. Arch Intern Med. 1999;159:1473-480.

Cotte L, Rabodonirina M, Piens MA, Perreard M, Mojon M, Trepo C. Prevalence of intestinal protozoans in French patients infected with HIV. J Acquir Immune Defic Syndr. 1993;6:1024-029.

Karp CL, Neva FA. Tropical infectious diseases in human immunodeficiency virus-infected patients. Clin Infect Dis. 1999;28:947-63.

Lanjewar DN, Anand BS, Genta R, Maheshwari MB, Ansari MA, Hira SK et al. Major differences in the spectrum of gastrointestinal infections associated with AIDS in India versus the west: an autopsy study. Clin Infect Dis. 1996;23:482-85.

Scott GB. Management of acute illness in HIV-infected children. In: HIV/AIDS Primary Care Guide. Editors: Lawrence M, Tierney. Education and Training University of Florida, Florida. 2002;283-89.

Cello JP, Day LW. Idiopathic AIDS enteropathy and treatment of gastrointestinal opportunistic pathogens. Gastroenterology. 2009;136(6):1952-65.

Batman PA, Miller AR, Forster SM, Harris JR, Pinching AJ, Griffin GE. Jejunal enteropathy associated with human immunodeficiency virus infection: quantitative histology. J Clin Pathol. 1989;42:275-281.

Batman PA, Kotler DP, Kapembwa MS. HIV enteropathy: crypt stem and transit cell hyperproliferation induces villous atrophy in HIV/Microsporidia-infected jejunal mucosa. AIDS. 2007;21:433-39.

Maresca M, Mahfoud R, Garmy N, Kotler DP, Fantini J, Clayton F. The virotoxin model of HIV-1 enteropathy: involvement of GPR15/Bob and galactosylceramide in the cytopathic effects induced by HIV-1 gp120 in the HT-29-D4 intestinal cell line. J Biomed Sci. 2003;10:156-66.

Rufo PA, Lin PW, Andrade A. Diarrhea-associated HIV-1 APIs potentiate muscarinic activation of Cl-secretion by T84 cells via prolongation of cytosolic Ca2+ signaling. Am J Physiol Cell Physiol. 2004;286:C998-1008.

Bode H, Lenzner L, Kraemer OH. The HIV protease inhibitors saquinavir, ritonavir, and nelfinavir induce apoptosis and decrease barrier function in human intestinal epithelial cells. Antivir Ther. 2005;10:645-55.

MacArthur RD, DuPont HL. Etiology and pharmacologic management of noninfectious diarrhea in HIV-infected individuals in the highly active antiretroviral therapy era. Clin Infect Dis. 2012;55:860-67.

Morpeth SC, Thielman NM. Diarrhea in patients with AIDS. Curr Treat Options Gastroenterol. 2006;9:23-37.

MacArthur RD. Clinical Focus: Evolving Options for Managing Noninfectious Diarrhea in HIV-Infected Patients. Clinical Care Options® HIV. 2013. http://www.clinicaloptions.com/HIV/Treatment%20Updates/Noninfectious%20Diarrhea/CCO%20Slideset/Slideset.aspx. Last accessed on 01 November, 2020.

Morpeth SC, Thielman NM. Diarrhea in patients with AIDS. Curr Treat Options Gastroenterol. 2006;9:23-37.

Nwachukwu CE, Okebe JU. Antimotility agents for chronic diarrhoea in people with HIV/AIDS. Cochrane Database Syst Rev. 2008;8:CD005644.

Sherman DS, Fish DN. Management of protease inhibitor-associated diarrhea. Clin Infect Dis. 2000;30:908-14.

Imodium A-D, and Imodium multi-symptom relief (loperamide and loperamide-simethicone) [package insert]. Fort Washington, PA: McNeil Consumer Healthcare. 2005.

Cottreau J, Tucker A, Crutchley R, Garey KW. Crofelemer for the treatment of secretory diarrhea. Expert Rev Gastroenterol Hepatol. 2012;6:17-23.

Matheson AJ, Noble S. Racecadotril. Drugs. 2000;59:829-35.

MacArthur RD, Hawkins TN, Brown SJ. Efficacy and safety of crofelemer for noninfectious diarrhea in HIV-seropositive individuals (ADVENT trial): a randomized, double-blind, placebo-controlled, two-stage study. HIV Clin Trials. 2013;14:261-73.

Golden P, Mathis A, Chu H. Population pharmacokinetic (PK) analysis demonstrates no drug-drug interactions (DDI) between crofelemer, a novel treatment for noninfectious diarrhea in HIV+ individuals, and antiretroviral therapy (ART). Presented at: 53rd Interscience Conference on Antimircobial Agents and Chemotherapy. 2013.

Wilcox CM. Gastrointestinal consequences of infection with human immunodeficiency virus. In: Gas- trointestinal and liver disease. Feldman M, Friedman LS, Brandt LJ (editors). Elsevier Saunders. 2010;526-30.

Gordon SN, Cervasi B, Odorizzi P. Disruption of intestinal CD4 1 T cell homeostasis is a key marker of sys- temic CD4 1 T cell activation in HIVinfected individuals. J Immunol.

Deshpande A, Pasupuleti V, Rolston DD. Diagnostic accuracy of real-time polymerase chain reaction in detection of Clostridium difficile in the stool samples of patients with suspected Clostridium difficile infection: a meta-analysis. Clin Infect Dis. 2011;53(7):e81-90.

Krones E, Högenauer Ch. Diarrhea in the immuno- compromised patient. Gastroenterol Clin North Am. 2012;41(3):677-701.

Pankuch GA, Jacobs MR, Appelbaum PC. Susceptibilities of 428 gram-positive and -negative anaerobic bacteria to Bay y3118 compared with their susceptibilities to ciprofloxacin, clindamycin, metronidazole, piperacillin, piperacillin-tazobactam, and cefoxitin. Antimicrob Agents Chemother. 1993;37(8):1649-54.






Case Reports