Mwachari C, Batchelor B I, Paul J, Waiyaki P G, Gilks C F
Kenya Medical Research Institute, Nairobi.
J Infect. 1998 Jul;37(1):48-53. doi: 10.1016/s0163-4453(98)90561-8.
Chronic diarrhoea and wasting are well recognized features of AIDS in Africa. However, because of resource constraints few comprehensive aetiological studies have been conducted in sub-Saharan Africa which have included a broad range of microbiological investigations. We undertook a prospective cross-sectional study of adult patients admitted to a government hospital in Nairobi, Kenya, to determine possible bacterial, mycobacterial, parasitic and viral causes of diarrhoea; to consider which may be treatable; and to relate microbiological findings to clinical outcome.
Stool specimens from 75 consecutive HIV-seropositive patients with chronic diarrhoea admitted to a Nairobi hospital were subjected to microbiological investigation and results were compared with clinical findings and outcome. Stool samples were cultured for bacteria and mycobacteria and underwent light and electron microscopy; lawns of Escherichia coli were probed for pathogenic types and aliquots were tested for the presence of Clostridium difficile cytotoxin. Blood cultures for mycobacteria and other bacterial pathogens were performed as clinically indicated.
Thirty-nine (52%) patients yielded putative pathogens, the most common being Cryptosporidium sp. (17%), Salmonella typhimurium (13%), and Mycobacterium tuberculosis (13%). Of 41 patients investigated for pathogenic Escherichia coli, enteroaggregative E. coli and diffusely adherent E. coli were each found in four patients. Thirty-one (41%) patients died. Detection of cryptosporidium cysts was the single most significant predictor of death (X2 = 5.2, P<0.05). Many patients did not improve (21; 28%) or self-discharged whilst still sick (5; 7%) but five (7%) were diagnosed ante mortem with tuberculosis and treated and a further 13 (17%) showed improvement by time of discharge.
HIV-infected patients with chronic diarrhoea in Nairobi have a poor outcome overall, and even with extensive investigation a putative pathogen was identified in only just over half the patients. The most important step is to exclude tuberculosis; and the most useful investigation appears to be Ziehl-Neelsen staining. Other potentially treatable gram-negative bacterial pathogens, S. typhimurium, Shigella sp. and adherent E. coli were, however, common but require culture facilities which are not widely accessible for definitive identification. Further studies focussing on simple ways to identify sub-groups of patients with treatable infections are warranted.
慢性腹泻和消瘦是非洲艾滋病患者广为人知的特征。然而，由于资源限制，撒哈拉以南非洲地区很少开展全面的病因学研究，这些研究涵盖广泛的微生物学调查。我们对肯尼亚内罗毕一家政府医院收治的成年患者进行了一项前瞻性横断面研究，以确定腹泻可能的细菌、分枝杆菌、寄生虫和病毒病因；考虑哪些病因可能是可治疗的；并将微生物学结果与临床结局相关联。
对在内罗毕一家医院连续收治的75例慢性腹泻的HIV血清阳性患者的粪便标本进行微生物学调查，并将结果与临床发现和结局进行比较。粪便样本进行细菌和分枝杆菌培养，并进行光镜和电镜检查；对大肠杆菌菌苔进行致病类型检测，并对等分试样检测艰难梭菌细胞毒素的存在。根据临床指征进行分枝杆菌和其他细菌病原体的血培养。
39例（52%）患者检出可能的病原体，最常见的是隐孢子虫属（17%）、鼠伤寒沙门菌（~13%）和结核分枝杆菌（13%）。在41例接受致病性大肠杆菌调查的患者中，肠聚集性大肠杆菌和弥漫性黏附性大肠杆菌各在4例患者中被发现。31例（41%）患者死亡。隐孢子虫囊肿的检测是死亡的唯一最重要预测因素（X2 = 5.2，P<0.05）。许多患者没有好转（21例；28%）或在仍患病时自行出院（5例；7%），但有5例（7%）在死前被诊断为结核病并接受治疗，另有13例（17%）在出院时病情有所改善。
内罗毕慢性腹泻的HIV感染患者总体预后较差，即使进行了广泛调查，也仅在略超过一半的患者中鉴定出可能的病原体。最重要的步骤是排除结核病；最有用的检查似乎是萋-尼染色。然而，其他潜在可治疗的革兰氏阴性细菌病原体，如鼠伤寒沙门菌、志贺菌属和黏附性大肠杆菌很常见，但需要培养设施来进行明确鉴定，而这些设施并非广泛可用。有必要开展进一步研究，重点关注识别可治疗感染患者亚组的简单方法。
