Introduction: Patients with immunosuppressed states such as uncontrolled HIV are at increased risk for opportunistic infections including acute infectious diarrhea. Here, we present a case of a noncompliant HIV patient who presented with a complaint of acute diarrhea with resulting weight loss. Work-up was significant for co-infection with giardia and campylobacter as a result of receptive anal sexual intercourse.
Case Description/Methods: A 45-year-old transgender male to female patient with a past medical history of poorly controlled HIV infection not actively on antiviral therapy and chronic Hepatitis B (HBV) infection presented with initial complaint of acute diarrhea for one week with accompanying weight loss. The patient concurrently complained of a diffuse, painful, pruritic rash for five days. A thorough history revealed the patient had just returned from Miami, where she reported multiple sexual partners with recent unprotected oral and anal intercourse. On initial presentation, the patient was tachycardic and febrile to 104.8, with generalized abdominal tenderness and a diffuse macular rash involving scalp, torso, genitals, and extremities, including palms and soles.
The patient was admitted and started on acyclovir, vancomycin and ceftriaxone. A comprehensive stool panel was positive for both campylobacter and giardia. The patient was also noted to have CMV viremia, a HIV viral load of 38,000, and a positive rapid plasma reagin. The infectious disease team was consulted and the patient was treated with a single dose of tinidazole and two doses of metronidazole followed by a 7-day course of ciprofloxacin. Her acute diarrhea resolved, at which point she restarted antiretroviral therapy, and completed a 14-day course of penicillin for her syphilis. She was discharged home with close follow up with her infectious disease specialist.
Discussion: This case highlights the increased risk of opportunistic infections in the setting of poorly controlled HIV and unprotected sexual intercourse as highlighted by this patient’s co-infection with both giardia and campylobacter. Campylobacter and giardia are two commonly associated foodborne illnesses, however they can be transmitted via unprotected oral-anal sex. In addition to compliance with HIV treatment, patients should consider barrier methods during receptive sex to prevent fecal-oral transmission. In sum, our case highlights the importance of keeping a broad differential of infectious causes of diarrhea, especially in the immunocompromised population.
