Additional consideration for common gastrointestinal presentations- thinking outside the guidelines

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Introduction

A 52-year-old woman presented with 3 stone weight loss and diarrhoea for 4 months. She had multiple investigations over a 6 month period including OGD with duodenal biopsies for coeliac disease and giardiasis, colonoscopy with biopsy and blood tests including coeliac serology which were within normal limits. Her symptoms progressed so hospital admission was arranged. At time of hospitalisation she had now had further weight loss (8stone), increasing diarrhoea (up to 8 times a day), vomiting and shortness of breath on exertion. Examination revealed hair loss, bibasal crepitations and evidence of dramatic weight loss. A CT scan revealed two separate areas of intussusceptum within the jejunum and increased interstitial markings in the lungs, particularly at the bases, with the impression of some patchy ground-glass change. Respiratory opinion was sought and the patient was booked for bronchoscopy. HIV testing was performed at this point given the multisystem nature of her disease –it was positive with a viral load of 27202Iu/ml. Throat swab testing for PCP was positive a a titre of 3.3×106 cop/ml. She was commenced on co-trimoxazole but her oxygen requirements increased and she was transferred to infectious diseases in the regional centre. She continued to deteriorate and required ICU input but unfortunately died 9 days after transfer.

Conclusion

This case highlights that HIV presents in a variety of ways –patients may present initially to a gastroenterologist with unexplained chronic diarrhoea or weight loss. HIV guidelines recommend testing for HIV in these circumstances but GI guidelines do not.