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26 Case Study: Tsegenet ? Tsegenet is a 48 year-old woman who presents with a new genital lesion noted 4 days ago by her sex partner. 28 Case Study: Tsegenet (3) A.What additional information do you wish to know about this patient?
Bleeding Bleeding With Feces Mixed (proximal to sigmoid colon) On the surface (Distal to sigmoid Colon) Without Feces Separate from feces (follow defecation or Not) On toilet paper (anal skin) The color of blood –Bright red ? anal or rectum –Dark ? proximal lesion in the large bowel or higher. Investigations Proctoscope Proctoscope Inspect (10-12 cm) Biopsy can be taken Sigmoidoscope Sigmoidoscope Lighted tube 2 cm in diameter.
Anorectal Abscess Definition: Infection in one or more of anal spaces, usually is bacterial infection of blocked anal gland at dentate line. Fissure-in-ano (anal fissure) Definition: Acute & chronic Longitudinal split in the skin of the anal canal. Working group membership included practicing RN(C)s and Nurse Leaders from each health authority and Options for Sexual Health. Non-certified STI nursing practices fall within sections 6 and 7 of the Nurse Registered, Nurse Practitioner Regulation.
STI Certified Practices in Reproductive Health fall under Section 8 of the Nurse Registered, Nurse Practitioner Regulation.  The certified practice (CP) STI DSTs are hosted on the CRNBC website. A complete review of Certified Practice STI DSTs was completed in 2013.  This was followed by a review of Non-Certified Practice STI DSTs, which was initiated in March 2014. In October 2014, 2013 CRNBC STI DST Revision and 2014 Non-Certified DST Revisions - Updates was presented as a continuing nursing education (CNE) session on the VCH PHSA Mediasite by Cheryl Prescott and Dr. This year, another CNE session will be hosted on the VCH PHSA Mediasite on September 9, 2015. By subscribing to the STI Updates Blog, my email address will be collected by Feedburner and will be stored outside of Canada.
Emergency numbersCompliments & ComplaintsHealthlink BCPHSA improves the health of British Columbians by seeking province-wide solutions to specialized health care needs in collaboration with BC health authorities and other partners.
In the past three decades, studies have elucidated a variety of HIV-associated inflammatory, infectious, and neoplastic GI diseases, often with specific predilection for various sites. Provider-centered Approach to Care ? What are the key differences between the patient- and provider-centered approaches to care?
B.Based on the history you have and the appearance of the lesion, what does your differential diagnosis include? DST revisions were facilitated by the BCCDC CPS Education and Clinical Leadership Teams in collaboration with monthly PWG Member teleconferences.
This DST will be published in Chapter 5 of the BCCDC CD Manual once final edits are completed. Facilitated by Cheryl Prescott, this session will summarize highlights of the 2014 BCCDC non-certified practice STI DST review.  The upcoming session will be announced through the STI DST Provincial Working group prior to the September presentation. HIV-associated esophageal disease, for example, commonly includes candidiasis, cytomegalovirus (CMV) and herpes simplex virus (HSV) infection, Kaposi's sarcoma (KS), and idiopathic ulceration. The session offered a review of the 2013 CP STI DST revisions, an overview of the 2014 non-certified STI DST revisions to-date and a review of the new Syphilis Enzyme Immune-Acid (EIA) testing platform implemented by the BC Public Health Microbiology Reference Lab in August 2014.
Gastric disease, though less common than esophageal disease, frequently involves CMV, Mycobacterium avium-intracellulare (MAI), and neoplasia (KS, lymphoma). The gastrointestinal (GI) tract is a major site of disease in HIV infection: almost half of all HIV-infected patients present with GI symptoms, and almost all patients develop GI complications [1].
GI symptoms such as anorexia, weight loss, dysphagia, odynophagia, abdominal pain, and diarrhea are frequent and usually nonspecific among these patients.
Small bowel biopsies and intestinal aspirates from HIV-infected patients often show HIV enteropathy, MAI, protozoa (Giardia, Isospora, Cryptosporidia, amebae, Microsporidia), and helminths (Strongyloides stercoralis). GI symptoms, such as anorexia, weight loss, dysphagia, odynophagia, abdominal pain, and diarrhea, are common and usually non-specific in this population. Every 5 years beginning at age 50 is the current endoscopic screening method recommended for asymptomatic persons at average risk for colorectal carcinoma. Endoscopy is the diagnostic test of choice for most HIV-associated GI diseases, as endoscopic and histopathologic evaluation can render diagnoses in patients with non-specific symptoms.
Colorectal biopsies demonstrate viral (CMV, HSV), bacterial (Clostridia, Salmonella, Shigella, Campylobacter), fungal (cryptococcosis, histoplasmosis), and neoplastic (KS, lymphoma) processes. Herein, we review HIV-associated GI pathology, with emphasis on common endoscopic biopsy diagnoses. Pathologic evaluation of endoscopic biopsy specimens includes light and electron microscopy, special stains, immunohistochemical techniques, fluorescent in situ hybridization (FISH), and polymerase chain reaction (PCR) [2]. Skinner, et al., “Diarrhea and abnormalities of gastrointestinal function in a cohort of men and women with HIV infection,” American Journal of Gastroenterology, vol.
Light microscopy, with hematoxylin and eosin (H & E) staining, is often sufficient to suggest or confirm a diagnosis. Electron microscopy may be used to identify protozoan infections of the small bowel, as small organisms such as Cryptosporidia and microsporidia are more readily apparent with this technique.
Herein, we review HIV-associated GI pathology, with emphasis on common endoscopic biopsy diagnoses.2. Images were selected from archives in the Departments of Pathology and Gastroenterology at a large academic hospital.3.
Endoscopically, candidiasis appears as white or yellow plaques with surrounding mucosal erythema, on otherwise intact esophageal mucosa (Figure 1).
Histopathologic features of candidiasis include pseudomembranes and neutrophilic infiltrates; the fungi appear as budding yeast forms and pseudohyphae (Figure 2). CMV is the most common opportunistic agent in HIV-infected patients, and, while it can affect the entire GI tract, it frequently involves the esophagus and the colon [4]. CMV typically presents with distal esophageal ulceration, which may range from small, discrete, and superficial to extremely large and deep, such that only infected granulation tissue is evident (Figure 1).
Rarely, CMV may present as a mass lesion, or inflammatory pseudotumor, causing luminal obstruction. Biopsies from the ulcer base are more likely to demonstrate characteristic CMV inclusions, which are usually seen in stromal and endothelial cells, as compared to HSV infection, which manifests in squamous cells [3].
Necrotizing vasculitis and regenerative mucosal hyperplasia may also be present (Figure 2) [2]. Histopathologic features of HSV are more evident in biopsies from ulcer edges, as opposed to ulcer bases, and include necrosis, acute and chronic inflammation, and diagnostic nuclear changes (Figure 2). HSV cytopathic effect encompasses (i) homogenous ground-glass nuclei with margination of chromatin, (ii) nuclear molding, (iii) multinucleation, and, rarely, (iv) Cowdry type A nuclear inclusions [5].

Moreover, HSV-induced ulceration exhibits an inflammatory infiltrate rich in neutrophils and histiocytes, the presence of which should prompt a thorough search for viral cytopathic changes [2].HIV-associated idiopathic esophageal ulceration refers to large, irregular, mid esophageal and distal esophageal ulcers with no identifiable etiologic agent. Endoscopically, idiopathic ulcers resemble CMV-induced ulcers, but are more often solitary and deep [6]. Kazanjian, “Discrete gastrointestinal mass lesions caused by cytomegalovirus in patients with AIDS: report of three cases and review,” Clinical Infectious Diseases, vol.
Biopsy reveals a nonspecific mixed inflammatory infiltrate, with prominent eosinophils and granulation tissue [5].
Other esophageal diseases in HIV-infected patients include gastroesophageal reflux disease (GERD) with esophagitis or peptic strictures, pill-induced esophagitis, carcinoma, tuberculosis, histoplasmosis, cryptosporidiosis, Kaposi’s sarcoma, and Pneumocystis infection [3].
Many opportunistic GI diseases have decreased in frequency since the introduction of effective antiretroviral therapy, but Helicobacter pylori infection and GERD have apparently increased in frequency [7].
This may be attributed, in part, to alleviation of the gastric hypochloridia often seen in severely immunocompromised patients.While upper GI symptoms, such as epigastric pain, nausea, and vomiting, are often reported by HIV-infected patients, gastric disease is relatively uncommon [3].
In HIV-infected patients, CMV is the most frequent opportunistic gastric infection and may be the most commonly identified cause of ulcer disease in symptomatic patients [8, 9].
Endoscopically, CMV gastritis appears as patchy erythema, erosions, or multiple small ulcers.
Unlike intestinal biopsy specimens, gastric biopsies often show CMV inclusions in epithelial cells. Clayton, “Gastrointestinal pathology in HIV-infected patients,” Gastroenterology Clinics of North America, vol.
CMV-infected cells are markedly enlarged with amphophilic nuclear inclusions and abundant granular basophilic cytoplasm (Figure 2) [5]. Mycobacterium-avium intracellulare (MAI) is the most common mycobacterial infection in severely immunocompromised patients, and disseminated infection often causes mesenteric lymphadenitis with diffuse abdominal pain, weight loss, fever, or diarrhea. Endoscopically, MAI commonly presents with multiple raised nodules or normal-appearing mucosa. Less common findings include ulceration, erythema, edema, friability, reduced mucosal vascularity, stricture, and aphthous erosions [10]. Definitive diagnosis is established by biopsy, with demonstration of acid-fast bacilli in tissue specimens; blood and stool cultures may also reveal MAI infection [3].
Gastrointestinal Kaposi’s sarcoma is often asymptomatic, but gastric involvement may result in pyloric obstruction, pain, or upper GIT bleeding [3]. Schwartz, “Endoscopic characterization of idiopathic esophageal ulceration associated with human immunodeficiency virus infection,” Journal of Clinical Gastroenterology, vol.
Its subtle, submucosal presentation often results in false-negative endoscopic biopsy results. Histologically, KS is composed of spindle cells and irregular, jagged, slit-like spaces lined by atypical endothelial cells; extravasated red cells, hemosiderin, and eosinophilic round cytoplasmic globules are also often evident (Figure 2) [5].
Moreover, human herpesvirus 8 (HHV8) immunostains may aid in diagnosis, as the virus has been implicated in the pathogenesis of KS. In contrast to KS, gastric lymphoma is frequently symptomatic, as it is typically advanced (stage IV) at presentation, and causes epigastric pain or symptoms of gastric outlet obstruction [3]. HIV-Associated DiarrheaDiarrhea is the most common GI symptom in HIV-infected patients, affecting up to 90% of patients, and increases in frequency and severity as immune function deteriorates [12]. The most common HIV-associated diarrheal pathogens include Cryptosporidium, nontubercular mycobacteria, microsporidia, bacteria (Salmonella, Shigella, Campylobacter, and E. Buset, “Upper gastrointestinal endoscopic findings in the era of highly active antiretroviral therapy,” HIV Medicine, vol. HIV enteropathy, for example, causes ileal dysfunction, altered bowel motility, and bacterial overgrowth. Direct HIV infection of intestinal mucosa results in chronic inflammation, infection of enterochromaffin cells, gp120 interation with VIP receptors, antiproliferative effects, and enterocyte dysfunction. If diagnostic doubt remains, duodenal biopsies may be useful, especially in patients with lower CD4 counts [13]. The organisms most commonly found on duodenal biopsies include CMV, Cryptosporidium, microsporidia, and Giardia [3]. As in gastric infection (see above), CMV causes intestinal inflammation, erosion, and ulceration, with characteristic CMV inclusions in stromal and endothelial cells. Intestinal MAI causes subtle macroscopic changes, such as thickened or edematous mucosal folds with occasional yellow patches, which can become confluent [3]. Lin, “Low prevalence of Helicobacter pylori but high prevalence of cytomegalovirus-associated peptic ulcer disease in AIDS patients: comparative study of symptomatic subjects evaluated by endoscopy and CD4 counts,” Journal of Gastroenterology and Hepatology, vol. Both Cryptosporidia and microsporidia are often missed on routine biopsies, as their subtle appearance is better appreciated with electron microscopy. If microsporidia spores are not identified in stool samples or duodenal aspirates, Brown-Brenn stains may aid in visualization. Moreover, microsporidia can be reliably diagnosed using a modified trichrome stain, PCR analysis of stool specimens, or FISH. Enteric isosporiasis, secondary to opportunistic Isospora belli infection, is more common in HIV-infected patients in developing countries than in the United States or in Europe. Isosporiasis localizes to the small bowel, but can spread to the colon and regional lymph nodes. Diagnosis is facilitated by identification of (i) oocysts in stool samples or duodenal aspirates, or (ii) merozoites on light or electron microscopy.
Giardia lamblia is a flagellated enteric protozoan, which is typically waterborne, but is also transmitted person-to-person through fecal-oral spread [2, 15].
Giardia causes acute and chronic diarrhea worldwide; in the USA, it is the most commonly identified intestinal parasite.
Acute giardiasis causes diarrhea, cramps, bloating, and flatulence; chronic infection results in malabsorption, steatorrhea, malaise, weight loss, and diffuse abdominal discomfort. Initially transmitted as a cyst, Giardia forms a trophozoite that adheres to intestinal epithelium.
The trophozoites are pearshaped and binucleate, but may appear sickle-shaped in sagittal sections, and mistaken for detached enterocytes (Figure 2).
In the absence of cysts of trophozoites in stool specimens, upper endoscopy and duodenal biopsy may confirm the diagnosis. HIV-infected patients show a decreased antibody response to Giardia, but their clinical manifestations are similar to those of immunocompetent hosts [15].
Metronidazole is effective in the treatment of giardiasis, but is not recommended for pregnant patients due to potential teratogenicity.

Strongyloides stercoralis is a parasitic nematode with a predilection for the small intestine [2]. Lower GI Pathology (Tables 1 and 2; Figures 1 and 2)The endoscopic appearance of viral colitis in HIV-infected patients is highly variable [18]. Evaluation of the colon may reveal (i) normal mucosa, (ii) characteristic features of viral infection (such as nuclear inclusions involving surface epithelium), or (iii) severe ulceration (such as in CMV colitis). Chadburn, “Lymphadenopathy and the lymphoid neoplasms associated with the acquired immune deficiency syndrome,” in Neoplastic Hematopathology, D. Viral inclusions are most often present in the endothelial cells of the deeper layers of the bowel wall, thus multiple biopsies may be necessary for identification. Katabira, “Epidemiology and management of diarrheal disease in HIV-infected patients,” International Journal of Infectious Diseases, vol. As in CMV infection elsewhere in the GI, the etiologic role of CMV in the cellular inclusions can be confirmed by immunoperoxidase staining, FISH, or PCR.
Symptomatic treatment of CMV colitis includes intravenous ganciclovir, foscarnet, or cidofovir, but none of these agents improve mortality [23].Bacterial colitis can result from (i) anomalous growth of intestinal flora, (ii) bacterial infections (including Salmonella, Shigella, and Campylobacter), or (iii) opportunistic pathogens (such as atypical mycobacteria) [2]. Endoscopically, bacterial colitis appears as epithelial necrosis, abscesses, erosions, ulceration, and focal hemorrhage. Histopathologic features of bacterial colitis include mucosal epithelial changes: degeneration, necrosis, cellular atypia, regeneration, and fissures. The severity of immunodeficiency and bacterial infection determines the degree of mucosal damage. On H&E staining, bacterial forms appear as small, basophilic cocci, bacilli, or coccobacilli. MAI may also affect the colon, causing diarrhea, malabsorption, flattened mucosa on endoscopic examination, and a dense histiocytic infiltrate in the lamina propria.
As in upper GI MAI infection, acid-fast staining will reveal mycobacterial organisms.HIV-related cryptococcosis commonly affects the colon and the esophagus, while the stomach and terminal ileum are rarely involved [24].
Histopathologic features include fungal colonies of spherical to oval yeast-like pleomorphic cells, which are often surrounded by a clear halo corresponding to the mucinous capsule (Figure 2). Despite frequent GI involvement, the symptoms are typically non-specific or absent [26, 27].
Lu, “Pathophysiology of HIV-associated diarrhea,” Gastroenterology Clinics of North America, vol. In HIV-infected patients, histoplasmosis is most likely to affect the ileocecal region, with marked morphologic heterogeneity [28]. The following pathologic features may be seen: (i) grossly unremarkable mucosa, despite marked histiocytic infiltration of the lamina propria, (ii) infected macrophages causing plaques and pseudopolyps, and (iii) ulceration with tissue necrosis. In HIV infection and men who have sex with men, proctitis may occur secondary to HSV, Neisseria gonorrhea, Chlamydia trachomatis, or Treponema pallidum infection [29]. Rectal biopsies may reveal typical intranuclear inclusion bodies or multinucleated giant cells.
Blaser, “Acute antibody responses to Giardia lamblia are depressed in patients with AIDS,” Journal of Infectious Diseases, vol.
HIV-Associated GI BleedingWith increasing immunosuppression, HIV-infected patients with GI bleeding may have unique lesions related to HIV disease and should be evaluated endoscopically [3].
Kaposi’s sarcoma and gastroduodenal lymphoma are the most common causes of HIV-related upper GI bleeding in advanced HIV infection.
Upper endoscopy with biopsy facilitates diagnosis of both entities, and endoscopic therapy may temporarily control bleeding, but the definitive therapy is often surgical resection [3].
Lower GI bleeding in advanced HIV infection may result from CMV colitis or Kaposi’s sarcoma [3].
ConclusionsDespite widespread use of HAART in HIV infection, the GI tract is still frequently affected by HIV-associated disease processes. HIV-infected patients often present with non-specific GI symptoms, and the diagnostic workup requires consideration of both individual risk factors and common HIV-associated GI diseases.
Therefore, identification of one pathologic entity should not forestall the search for concomitant disease processes. Endoscopy and biopsy, with histopathologic and microbiologic analysis, are frequently required to identify and treat GIT disease in HIV-infected patients.Numerous studies over the past three decades have elucidated a variety of HIV-associated inflammatory, infectious, and neoplastic diseases of the GI tract, often with specific predilection for various sites.
HIV-associated esophageal disease, for example, commonly includes candidiasis, CMV and HSV infection, Kaposi’s sarcoma, and idiopathic ulceration.
Gastric disease, though less common than esophageal disease, frequently involves CMV, Mycobacterium avium intracellulare (MAI), and neoplasia (KS, lymphoma). Emery, “Investigation of CMV disease in immunocompromised patients,” Journal of Clinical Pathology, vol. Rahmin, “Cytomegalovirus colitis in AIDS: presentation in 44 patients and a review of the literature,” Journal of Acquired Immune Deficiency Syndromes, vol.
Schwartz, “Cytomegalovirus colitis in acquired immunodeficiency syndrome: a clinical and endoscopic study,” Gastrointestinal Endoscopy, vol.
Cutait, “Cytomegaloviral colitis in HIV positive patients: endoscopic findings,” Arquivos de Gastroenterologia, vol. Katlama, “Treatment of AIDS-associated gastrointestinal cytomegalovirus infection with foscarnet and ganciclovir: a randomized comparison,” Journal of Infectious Diseases, vol. Hyslop, “Spectrum of Cryptococcus neoformans infection in 68 patients infected with human immunodeficiency virus,” Reviews of Infectious Diseases, vol. Mariuz, “Gastrointestinal histoplasmosis in patients with AIDS: case report and review,” Clinical Infectious Diseases, vol.
Milligan, “Gastrointestinal histoplasmosis presenting as hematochezia in human immunodeficiency virus-infected hemophilic patients,” American Journal of Hematology, vol. Kent, “Etiology of clinical proctitis among men who have sex with men,” Clinical Infectious Diseases, vol.
Miller, “Gastrointestinal histoplasmosis in an HIV-infected patient living in a non-endemic area,” International Journal of STD and AIDS, vol.

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