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642 PART 5: Infectious Disorders

cardiac output, and hypotension. The clinical approach to management with a high prevalence of AIDS patients, active peer support groups may
98
is similar to that for other critically ill patients, detailed in Chap. 64. The be extremely helpful. In addition, family physicians and referring spe-
evaluation of adrenal insufficiency and use of corticosteroids for septic cialists who have long-term care relationships with patients can provide
shock are relevant; furthermore, patients with PJP or suspected PJP valuable support to the critical care team.
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should be treated with hydrocortisone, as discussed earlier.
Enteropathy, malnutrition, and weight loss are very common gastroin- ICU ELIGIBILITY OF AIDS PATIENTS
testinal problems in AIDS patients. Up to 30% of AIDS patients have mul-
tiple gastrointestinal pathogens. The causes of common gastrointestinal The two fundamental issues determining ICU eligibility in a patient
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problems in AIDS patients are listed in Table 69-7. Esophagitis may be with AIDS are the patient’s prognosis and the patient’s wishes regarding
caused by Candida, CMV, and herpes simplex virus (HSV). Candida life support. Concerning prognosis, it is necessary to assess both the
esophagitis usually presents with dysphagia, but marked odynophagia prognosis of the acute illness necessitating life support and the prognosis
suggests either HSV or CMV esophagitis. Oropharyngeal and esopha- of the underlying HIV disease. Prior to the development of AIDS, the
geal Candida infection rarely gives rise to deep visceral involvement or prognosis of HIV disease generally was dictated by the CD4 count and
disseminated candidiasis. Antifungal treatment options for esophagitis the remaining antiretroviral treatment options available.
include fluconazole or echinocandins, while management of candidemia As in any other critical illness, it is of utmost importance to involve
and other invasive forms of candidiasis include echinocandins, flucon- the patient or those close to the patient, whenever possible, in discus-
azole, lipid formulations of amphotericin B, and amphotericin B. AIDS sions regarding the appropriateness of ICU admission and life support.
patients with esophageal symptoms and thrush may be treated empiri- Often the issue of life support has been considered previously, and the
cally with fluconazole 100 to 200 mg daily. If there is no response, then patient has already made his or her wishes known to primary physi-
178
esophagoscopy and biopsy should be performed. Diarrhea occurs in cians, friends, or relatives. ICU admission and life support gener-
about 50% of AIDS patients and is caused by gastrointestinal infections, ally are inappropriate for patients with life-threatening complications
AIDS-associated enteropathy, and much less commonly, gastrointestinal for which there is no particularly effective therapy (eg, high-grade
neoplasms. Gastroenteritis may be secondary to Cryptosporidium, lymphoma). It is reasonable, however, to offer ICU admission and life
Giardia, Isospora, Salmonella, MAC, and CMV. Cryptosporidium and support to patients with an acceptable quality of life who have a potent-
Microsporidia may cause severe diarrhea, and although specific anti- ially reversible acute illness. 179
microbial therapy for cryptosporidiosis has not been proved effective, In every instance, clear goals of ICU admission should be established
clinical and microbiologic resolution has been reported anecdotally in with the patient, family, and treating physicians. Obviously, a lucid, well-
association with ART-induced immune reconstitution. Enterocolitis may informed patient and his or her family may refuse life support. Finally, it
be the result of infection with Shigella, Campylobacter, Entamoeba histo- must be emphasized that the outlook of AIDS and its related conditions
lytica, and CMV. Finally, sexually transmitted proctitis caused by gonor- has improved considerably. For this reason, rigid policies regarding ICU
rhea, syphilis, Chlamydia, or HSV may produce severe rectal symptoms admission are undesirable, and detailed evaluation of each situation on
accompanied by frequent small-volume stools associated with blood and a case-by-case basis is required. For patients who still have antiretrovi-
mucus. Clostridium difficile colitis should also be considered in patients ral therapy options and in whom there is some expectation of partial
treated recently with antibacterial agents. Others have diarrhea caused immune reconstitution, there is no CD4 count that by itself would be
by AIDS-associated enteropathy, which may represent an unidentified considered justification for exclusion of the patient from admission to
175
infectious cause, possibly HIV or an autoimmune disorder. the ICU. It should also be noted that the initiation of ART may be associ-
Investigation of diarrhea includes examination of stool for ova and ated with clinical improvement in patients with opportunistic diseases
parasites, stool culture, and C difficile toxin assay, and occasionally, for which there is no proven specific effective therapy (eg, microspo-
flexible sigmoidoscopy and upper gastrointestinal endoscopy. The ridiosis, cryptosporidiosis, PML, and macrolide-resistant disseminated
176
treatment of critically ill AIDS patients who have diarrhea includes MAC infection).
bowel rest, standard antimicrobial therapy for isolated pathogens, 174,177
intravenous fluid and electrolytes, symptomatic antidiarrheal therapy,
and nutritional therapy. Antimotility agents should be avoided when
certain enteric pathogens (eg, Salmonella, Shigella, E histolytica, and C
difficile) are suspected. Total parenteral nutrition may be necessary in KEY REFERENCES
critically ill patients who have significant diarrhea because enteral nutri- • Akgun KM, Pisani M, Crothers K. The changing epidemiology of
tion frequently exacerbates the diarrhea. Malnourished AIDS patients HIV-infected patients in the intensive care unit. J Intensive Care
who are critically ill and do not have diarrhea often respond adequately Med. 2011;26:151-164.
to enteral nutrition supplemented as appropriate with potassium, mag- • Akgun KM, Tate JP, Pisani M, et al. Medical ICU admission diag-
nesium, calcium, and phosphate. noses and outcomes in human immunodeficiency virus-infected
AIDS patients, family, and friends may also suffer important emotional and virus-uninfected veterans in the combination antiretroviral
and psychological problems that require counseling, psychological sup- era. Crit Care Med. 2013;41(6):1458-1467.
port, and the empathy of health care workers. In many communities
• el-Sadr W, Simberkoff MS. Survival and prognostic factors in
severe Pneumocystis carinii pneumonia requiring mechanical
ventilation. Am Rev Respir Dis. 1988;137:1264-1267.
• Hall HI, Hughes D, Dean HD, Mermin JH, Fenton KA. HIV
TABLE 69-7 Causes of Common Gastrointestinal Problems in AIDS Patients Infection - United States, 2005 and 2008. MMWR Surveill Summ.
Problem Organisms 2011;60(suppl):87-89.
Esophagitis Candida, CMV, HSV • Havlir DV, Kendall MA, Ive P, et al. Timing of antiretroviral
therapy for HIV-1 infection and tuberculosis. N Engl J Med.
Gastroenteritis Cryptosporidium, Microsporidium, Giardia lamblia, Isospora 2011;365:1482-1491.
belli, Salmonella, MAC, CMV
• Huang L, Quartin A, Jones D, Havlir DV. Intensive care of patients
Enterocolitis Shigella, Campylobacter, Entamoeba histolytica, CMV, with HIV infection. N Engl J Med. 2006;355:173-181.
Cryptosporidium, MAC, Clostridium difficile
• Hull MW, Phillips P, Montaner JS. Changing global epidemiology of
Sexually transmitted proctitis N gonorrhea, Chlamydia trachomatis, Treponema pallidum, HSV
pulmonary manifestations of HIV/AIDS. Chest. 2008;134:1287-1298.
CMV, cytomegalovirus; HSV, herpes simplex virus; MAC, Mycobacterium avium complex.

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