Journal of Clinical Virology 49 (2010) 219–222
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Chronic norovirus infection in an HIV-positive patient with persistent diarrhoea: A novel cause Tom Wingﬁeld a,∗ , Chris I. Gallimore b , Jacqueline Xerry b , Jim J. Gray b , Paul Klapper c , Malcolm Guiver d , Tom J. Blanchard a a
The Monsall Unit, Infectious Diseases and Tropical Medicine Department, North Manchester General Hospital, Manchester, UK Enteric Virus Unit, Virus Reference Department, Centre for Infections, Health Protection Agency, Colindale, London, UK Central Manchester Foundation Trust, Department of Virology, Manchester, UK d Molecular Diagnostics Department, Health Protection Agency North West, Manchester Royal Inﬁrmary, Manchester, UK b c
a r t i c l e
i n f o
Article history: Received 2 June 2010 Received in revised form 26 July 2010 Accepted 30 July 2010 Keywords: HIV Chronic Norovirus Immunoglobulin AIDS
1. Why this case is important We describe the ﬁrst recorded case of chronic norovirus infection in a patient with HIV. Our patient had poor compliance with antiretroviral therapy and subsequent profound immunosuppression. He was admitted due to chronic, non-bloody diarrhoea and multiple stool samples were found to contain norovirus for a total of 15 months. He posed both a clinical – and infection control – challenge receiving a trial of immunoglobulin therapy in an attempt to control his diarrhoeal symptoms. We aim to explore the signiﬁcance of the chronic norovirus in his stool and to elaborate on current knowledge surrounding diagnosis, quantiﬁcation and management of norovirus infection while contrasting it with the unique presentation of our case.
2. Case description In April 2009, a 36-year-old HIV-positive man was admitted to hospital due to persistent chronic diarrhoea.
∗ Corresponding author. E-mail addresses: tom.wingﬁ[email protected]
, tomwingﬁ[email protected]
(T. Wingﬁeld). 1386-6532/$ – see front matter © 2010 Elsevier B.V. All rights reserved. doi:10.1016/j.jcv.2010.07.025
He had not been compliant with antiretrovirals (ARVs) despite various regimens since his diagnosis 13 years previously. He took no medications and had no drug allergies. He was a gay male but was not in a current relationship and denied any sexual intercourse over the past 5 years. He described chronic diarrhoea that had persisted for over 6 months. It was watery, profuse, and up to 20 times per day. It was associated with abdominal colic, occasional vomiting and unintentional weight loss of 3-stone. A lactose-free diet had not had any appreciable effect on symptoms. On admission, he had a CD4 count of 19 cells/l (4%) and an HIV viral load of 38,362 copies/ml (log 4.58). Over the previous 5 months (November 2008–May 2009), his stool samples had all tested positive by polymerase chain reaction (PCR) for norovirus, genotype II-4 (G II-4). On admission, examination was essentially normal apart from patches of oropharyngeal candida, signs of dehydration and a 5 mm × 5 mm patch of Kaposi’s sarcoma (conﬁrmed by biopsy) on his left shin. Initial blood tests revealed a lymphopenia and an Hb of 11.6 g/dl (MCV 100). Liver, renal and thyroid function tests were normal (of note, a normal albumin) apart from a low magnesium and potassium. He had two negative serum tissue transglutaminase samples and normal faecal elastase levels. An oesophagoduodenoscopy (OGD) was macroscopically normal but duodenal (D2) biopsies revealed a degree of villous atrophy, felt to
T. Wingﬁeld et al. / Journal of Clinical Virology 49 (2010) 219–222 Table 2 Norovirus PCR crossing threshold (CT) and viral burden estimates.
Table 1 CD4 count and HIV viral load (VL) of our patient 2008–2010. Date
Absolute CD4 (cells/l)
Oct 08 Dec 08 Mar 09 May 09 Jun 09 July 09 Oct 09 Dec 09 Jan 10 Mar 10 Jun 10 July 10
35 36 19 19 7 6 2 16 65 57 30 40
HIV VL (copies/ml) 20,033 38,362 44 44