Correspondence

Enteroaggregative Escherichia coli As a Possible Cause of Diarrhea in an HIV-Infected Patient

N Engl J Med 1995; 332:273-274January 26, 1995

Article

To the Editor:

Chronic diarrhea is being recognized with increasing frequency in patients with human immunodeficiency virus (HIV) infection, and it contributes to morbidity in this population. Up to 30 percent of patients with this problem have no identifiable pathogen even after intensive evaluation.1 In an attempt to identify another potential cause in pathogen-negative diarrhea, Kotler and Orenstein reported visualizing bacteria adherent to a colonic-biopsy specimen from a 33-year-old man with AIDS, three months of unexplained diarrhea, and weight loss that responded to ciprofloxacin.2 These bacteria were not characterized further. Enteroaggregative Escherichia coli have been recognized as a cause of persistent diarrhea in children in the developing world and have recently been reported to be a potential cause of persistent diarrheal disease in HIV-infected children in Zaire.3,4 We report the presence of enteroaggregative E. coli in an adult patient with HIV and chronic unexplained diarrhea.

A 43-year-old man with hemophilia and HIV infection had had a CD4 count below 200 cells per cubic millimeter since May 1992. He had had no documented opportunistic infection but reported chronic intermittent diarrhea and weight loss for the past three years. During this period, his weight decreased from 158 to 133 lb (71.7 to 60.3 kg). Multiple cultures of the stool and tests for Clostridium difficile, ova, and parasites, including cryptosporidium and microsporidium by the modified trichrome stain, were negative. Upper and lower endoscopy with duodenal aspiration for quantitative culture, examination for parasites, and culture for Mycobacterium avium complex and cytomegalovirus were performed in 1992; upper endoscopy was repeated in 1993. No gross lesions were visible, and all cultures and aspirates were unrevealing.

During an exacerbation of diarrhea in April 1994, we reevaluated the patient's stools by culture and examination for parasites and elected to screen E. coli recovered during routine stool culture for strains consistent with either enteropathogenic or enteroaggregative E. coli, using the HeLa-cell tissue-culture assay.5 The classic aggregative phenotype, with cascades of bacteria adherent to tissue-culture cells and the background of the slide, was seen. The patient received 500 mg of oral ciprofloxacin twice a day for 10 days. The diarrhea resolved but subsequently recurred. The patient was treated again, and his diarrhea has remained quiescent for six weeks at this writing. His weight is currently stable at 141 lb (64.0 kg); his most recent CD4 count was 20 cells per cubic millimeter. We have screened E. coli from stools from an additional seven HIV-infected patients with chronic diarrhea and found one more enteroaggregative strain. This strain was present in a patient who also had cryptosporidium, which was demonstrable only on duodenal aspiration and biopsy.

Because enteroaggregative E. coli would be a treatable pathogen in this population, controlled studies to evaluate the role of these organisms in the pathogenesis of chronic pathogen-negative diarrhea in patients infected with HIV are warranted.

Howard B. Mayer, M.D.
Christine A. Wanke, M.D.
New England Deaconess Hospital, Boston, MA 02215

5 References

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Citing Articles (15)

Citing Articles

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   Fabiola Avelino, Zeus Saldaña, Sohidul Islam, Valerio Monteiro-Neto, Monique Dall’Agnol, Carlos A. Eslava, Jorge A. Girón. (2010) The majority of enteroaggregative Escherichia coli strains produce the E. coli common pilus when adhering to cultured epithelial cells. International Journal of Medical Microbiology 300:7, 440-448
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   B. M. Sobieszczańska, J. Osek, D. Waśko-Czopnik, E. Dworniczek, K. Jermakow. (2007) Association of enteroaggregative Escherichia coli with irritable bowel syndrome. Clinical Microbiology and Infection 13:4, 404-407
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   A. Sonnevend, K. Al Dhaheri, T. Mag, M. Herpay, J. Kolodziejek, N. Nowotny, A. Usmani, F. A. Sheikh, T. Pal. (2006) CTX-M-15-producing multidrug-resistant enteroaggregative Escherichia coli in the United Arab Emirates. Clinical Microbiology and Infection 12:6, 582-585
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   David B. Huang, Hoonmo Koo, Herbert L. DuPont. (2004) Enteroaggregative Escherichia coli: An emerging pathogen. Current Infectious Disease Reports 6:2, 83-86
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   David B. Huang, Pablo C. Okhuysen, Zhi-Dong Jiang, Herbert L. DuPont. (2004) Enteroaggregative Escherichia coli: An Emerging Enteric Pathogen. The American Journal of Gastroenterology 99:2, 383
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   Iruka N Okeke, James P Nataro. (2001) Enteroaggregative Escherichia coli. The Lancet Infectious Diseases 1:5, 304-313
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   Christine A. Wanke. (2001) To Know Escherichia coli Is to Know Bacterial Diarrheal Disease. Clinical Infectious Diseases 32:12, 1710-1712
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   Amy Gassama, Papa Salif Sow, Fatou Fall, Pathé Camara, Hovette Philippe, Aïssatou Guèye-N'diaye, Rémonie Seng, Badara Samb, Souleymane M'Boup, Yves Germani, Awa Aïdara-Kane. (2001) Ordinary and opportunistic enteropathogens associated with diarrhea in senegalese adults in relation to human immunodeficiency virus serostatus. International Journal of Infectious Diseases 5:4, 192-198
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   Markku Keskimäki, Marjut Eklund, Heidi Pesonen, Tarja Heiskanen, Anja Siitonen. (2001) EPEC, EAEC and STEC in stool specimens: prevalence and molecular epidemiology of isolates. Diagnostic Microbiology and Infectious Disease 40:4, 151
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    Ted S. Steiner, James P. Nataro, Celeste E. Poteet-Smith, Jeffrey A. Smith, Richard L. Guerrant. (2000) Enteroaggregative Escherichia coli expresses a novel flagellin that causes IL-8 release from intestinal epithelial cells. Journal of Clinical Investigation 105:12, 1769-1777
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    Mikael Staaf, Felipe Urbina, Andrej Weintraub, Goran Widmalm. (1999) Structure elucidation of the O-antigenic polysaccharide from the enteroaggregative Escherichia coli strain 62D1. European Journal of Biochemistry 262:1, 56-62
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    Sain Sain Lu. (1997) PATHOPHYSIOLOGY OF HIV-ASSOCIATED DIARRHEA. Gastroenterology Clinics of North America 26:2, 175-189
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    Stuart R. Framm, Rosemary Soave. (1997) AGENTS OF DIARRHEA. Medical Clinics of North America 81:2, 427-447
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    Christine A. Wanke, Douglas Pleskow, Paola C. Degirolami, Barbara B. Lambl, Kimberly Merkel, Salim Akrabawi. (1996) A medium chain triglyceride-based diet in patients with HIV and chronic diarrhea reduces diarrhea and malabsorption: A prospective, controlled trial. Nutrition 12:11-12, 766-771
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