Gut 1992;33: 1080-1084

Gastrointestinal symptoms in patients infected withhuman immunodeficiency virus: relevance ofinfective agents isolated from gastrointestinal tract

R Ullrich, W Heise, C Bergs, M L'age, E 0 Riecken, M Zeitz

AbstractThe correlation of gastrointestinal symptomsand infections in 186 consecutive patientswith human immunodeficiency virus (HIV)infection undergoing diagnostic endoscopy(oesophagogastroduodenoscopy, n=124;colonoscopy, n=37; both, n=25) was investi-gated. Biopsy and stool samples were exam-ined for infective agents. Only weight loss(p=0.003) and dysphagia (p=0.027) were morecommon in patients at stage CDC IV com-pared with earlier stages. In three of 27patients at stage II/III and in 93 of 159 patientsat stage IV an infective agent was identified instool or gastrointestinal biopsy specimen(p<O.OOl). Cytomegalovirus (n=35), Candidasp (n=28), M avium complex (n=10), andCryptosporidium (eight) were the most fre-quent agents detected. At stage IV, diarrhoeawas more frequent in infected compared withnon-infected patients (p=0.006); however, aninfective agent was also' found in 39 of 82patients at stage IV without diarrhoea. Thefrequency of gastrointestinal symptoms wasnot consistently increased in patients harbour-ing specific infective agents compared withnon-infected patients. Our findings indicatethat the pathogenic relevance of a gastro-intestinal infection in HIV infected patientshas to be verified and indirectly support theexistence of an HIV associated enteropathy.(Gut 1992; 33: 1080-1084)

because of ethical reasons. Therefore, we haveinvestigated the presence and absence ofdifferent gastrointestinal symptoms in patientswith and without intestinal infections.

Methods

PATIENTSWe studied 186 consecutive patients undergoingdiagnostic endoscopy of the gastrointestinal tractin two major referral based hospitals in WestBerlin over two years. Clinical data of 45 patientshave been reported previously.2 Symptomsincluded weight loss (defined as an unintendeddecrease of body weight of more than 5% in sixmonths), diarrhoea (defined as more than threeloose bowel movements a day), epigastric andabdominal pain, nausea, vomiting, dysphagia,and fever of unknown origin. The classificationof the Centers for Disease Control14 5was used todetermine the disease stage of each patient: 16patients were at stage II, 11 at stage III, 13 atstage IVa, 82 at stage IVcl, 26 at stage IVc2, 26 atstage IVd, and 12 at stage IVcl/IVd. Thepatients ranged in age from 19 to 68 years(median 36). One hundred and twenty six menwere homosexual or bisexual, five women and 21men were intravenous drug abusers, one womanand three men had received blood transfusions;in 30 men no risk factor could be ascertained.

Department of Medicine,Klinikum Steglitz, FreeUniversity of Berlin,Berlin FRGR UllrichC BergsE 0 RieckenM Zeitz

Department of Medicine,Auguste-ViktoriaHospital, Berlin-Sch8neberg, Berlin FRGW Heise,M L'ageCorrespondence to:Dr Martin Zeitz,Medical Clinic,Dept Gastroenterology,Klinikum Steglitz,Hindenburgdamm 30,D-1000 Berlin 45,Federal Republic of Germany.Accepted for publication28 November 1991

The pathogenesis of gastrointestinal symptomsin patients with the acquired immunodeficiencysyndrome (AIDS) is still under debate. Recentreports have stressed the importance of extensivemicrobiological evaluation of stool samples andintestinal biopsy specimens, however, there isalways a considerable proportion of sympto-matic patients without an identifiable intestinalpathogen.1 This observation has led to thehypothesis of a human immunodeficiency virus(HIV) induced enteropathy which has beenconfirmed recently by the finding of smallbowel atrophy with hyporegeneration andimpaired enterocyte maturation in patientsinfected with HIV.' 3 The possibility ofHIV itself being an intestinal pathogen chal-lenges the pathogenic relevance of other infect-ious agents recovered from the gastrointestinaltract of HIV infected patients. The causal relev-ance of an agent would be optimally confirmed ifit was detected in symptomatic but not inasymptomatic patients. Thorough examinationincluding endoscopy with biopsy of asympto-matic patients, however, is hardly conceivable

INVESTIGATIONSAll patients had a complete physical examinationand their medical history was recorded usinga standardised protocol. In 150 patients thenumber of CD4+ lymphocytes per microlitreand the CD4/CD8 ratio in the peripheral bloodwas determined within two weeks before or afterendoscopy. Oesophagogastroduodenoscopy wasperformed in 124 patients, flexible colonoscopyin 37 patients, and 25 patients had both examina-tions. Ifno lesions were seen, seven biopsies eachof the stomach and duodenum in upper, and ofdifferent parts of the large intestine in lowerendoscopy were taken: two for histopatho-logical, three for microbiological, and two forvirological examination. An additional sevenbiopsies were taken from visible lesions. At leastthree stool samples per patient were examined byculture for enteropathogenic Salmonella spp,Shigella spp, Campylobacter spp, Yersiniaspp, Streptococcus spp, Staphylococcus spp,Clostndium spp, and mycobacteria. In addition,stools were examined by microscopy for ova andparasites, including Cryptosporidium and Isopora.

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Gastrointestinal symptoms in patients infected with human immunodeficiency virus: relevance ofinfective agents isolatedfrom gastrointestinal tract

TABLE I Gastrointestinal symptoms in patients with HIV infection correlated with the stage ofdisease and risk group

Stage ofdisease

II or III IV

Homosexual risk* Homosexual risk*

Negative Positive Total Negative Positive Total

Dysphagia 0 (0%) 1 (8%) 1(4%) 5 (26%) 27 (24%) 36 (23%)tNausea 1 (10%) 3 (23%) 5 (19%) 5 (26%) 42 (37%) 51(32%)Vomiting 2 (20%) 3 (23%) 6(22%) 4 (21%) 25 (22%) 33 (21%)Pain

Epigastric 4(40%) 4(31%) 9(33%) 7 (37%) 34 (30%) 46 (29%)Abdominal 2 (20%) 2 (15%) 4(15%) 1(5%) 40 (35%)t 46 (29%)

Weight loss§ 0 (0%) 2 (15%) 2 (7%) 3 (16%) 52 (46%)11 58 (36%)¶Diarrhoea** 5 (50%) 3 (23%) 10 (37%) 11(58%) 57 (50%) 77 (48%)Total number 10 13 27 19 114 159

*30 patients in which no risk factor could be ascertained were excluded; tp=0-014 compared withpatients at stage II/III; tp=0.005 compared with non-homosexual patients at stage IV; §Defined as'decrease in body weight of more than 5% in six months; 1p=0.012 compared with non-homosexualpatients at stage IV; ¶p=0-001 compared with patients at stage II/III; **Defined as more than threeloose bowel movements a day.

Paraffin sections of formaldehyde fixed biopsieswere stained with various histochemical stainsincluding haematoxylin and eosin, Ziehl-Neelsen acid fast, Grocott, Giemsa, periodic acidSchiff, and Gram stain. Sections were examinedby light microscopy for bacterial, protozoal,fungal, and viral enteric pathogens. Biopsieswere also cultured for enteropathogenic bacteriaincluding mycobacteria. Rectal swabs were cul-tured for chlamydia. Investigations for viralpathogens were done by electron microscopicalexamination of stool samples (identification ofrota, corona, and adenoviruses), and cultures ofstool samples and intestinal biopsies on threedifferent cell lines were observed for character-istic cytopathic effects. In addition, biopsiesfrom lesions were examined for the presence ofcytomegalovirus by immunohistology.

STATISTICAL ANALYSISMeasurement results were described as mediansand range, and the two tailed Mann-Whitney Utest was used to evaluate comparative statisticalsignificance. The frequency of symptoms orpathogens in different groups of patients wascompared by Fisher's exact test. The criticalhypotheses to be tested in our study were ratherthat there are no differences between groupsthan that there are differences. Therefore, inorder to minimise the risk of falsely rejecting anexisting difference, p values less than 0.05 wereconsidered as significant although multiple testswere carried out on the same data.

Results

CLINICAL FINDINGSAll patients in this study presented with gastro-intestinal complaints. Gastrointestinal symp-toms were correlated with the stage of diseaseand risk group (Table I). Dysphagia and weightloss were the only symptoms found significantlymore frequently in patients at stage IV comparedwith patients at stages II or III. No significantdifferences were observed in the frequencyof gastrointestinal symptoms when comparinghomosexual and non-homosexual patients atstage II/III, at stage IV abdominal pain andweight loss were more frequent in homosexualcompared with non-homosexual patients.

GASTROINTESTINAL INFECTIONSGastrointestinal pathogens were investigated in186 HIV infected patients by endoscopy withbiopsy and microbiological examination of biop-sies and repeated stool samples. In 96 patients(52%) an infectious agent was identified in stoolor biopsy: in three (11%) of 27 patients at stageII/III and in 93 (58%) of 159 patients at stage IV(p<0 0001). In 25 patients (26% ofinfections) anagent was recovered only from stool samples, in58 patients (60% of infections) an agent wasidentified only in biopsy, in 23 patients (24% ofinfections) an agent was detected in both stooland biopsy. There were two patients harbouringthree and 18 patients harbouring two differentinfectious agents in the gastrointestinal tract(Table II). Five patients, all with a gastro-intestinal infection, had intestinal Kaposi'ssarcoma, four in the duodenum and one in therectum. In 90 patients (48%) no potential patho-gen was found. At stage II Chlamydia trachomatiswas detected in rectal biopsies of two homo-sexual men (one had fever and weight loss, theother had abdominal pain), and Staphylococcusaureus in stool specimens of one non-homosexualman with epigastric pain and diarrhoea. In noneofthe patients at stage III was an infectious agentisolated from the gastrointestinal tract. At stageIV 72 (63%) of 114 homosexual and eight (42%)of 19 non-homosexual patients had a gastro-intestinal infection (p=0.070, not significant).Intestinal infections, however - that is, ifcandida oesophagitis was excluded, were foundmore commonly in 58 (51%) of 114 homosexual,compared with four (2 1%) of 19 non-homosexualpatients at stage IV (p=0014).

TABLE II Multiple gastrointestinal infections in HIV infected patients*

Candida Crypto- E histo- Adeno- Campylo- Chlamy- Shigella Corona- Spiro- M tuber-CMVt sp MACt sporidium lytica virus bacter sp dia sp sp virus chetes culosis Coinfection5

Cytomegalovirus # 711 3 ¶ 1¶ 1 1 1 1 13/35 (37%)Candida sp 7 2 1 9/28 (32%)M avium complex 3 ¶ 211 1¶ 1 5/10 (50%)Cryptosporidium 1 1/8 (13%)E histolytica 1¶ 1¶ 1/6 (17%)Adenovirus 1 1 1 1 4/5 (80%)Campylobacter sp 1 1/3 (33%)Chlamydia sp 2 2/5 (40%)Shigella sp 2 2/3 (67%)Goronavirus 1 1 2/2 (100%)Spirochetes 1 1/2 (50%)M. tuberculosis 1 1/1(100%)

*20 of 186 patients were multiply infected, 76 patients were monoinfected; t CMV=Cytomegalovirus; tMAC=M avium complex; §Patients with coinfection/infectedpatients (%); l|One patient had CMV, MAC, and candida infection; ¶One patient had CMV, MAC, and E histolytica infection.

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1082 ~~~~~~~~~~~~~~~~~~~~~~~~~~~Ullri'ch,Heise, Bergs, L'age, Ri'ecken, Zeitz

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Frequency ofgastrointestinal symptoms in 159 HIV infected patients at stage IV in correlationto the presence ofa gastrointestinal infection. Infectious agents were recovered from stool orbiopsy in 93 patients (closed bars), in 66 patients no infectious agent was identified (open bars).The number ofpatients with the symptoms indicated is given below the horizontal axis. Thefrequency ofdysphagia (p =0 042) and diarrhoea (p =0 003) was increased in infectedcompared with non-infected patients.

The frequency of gastrointestinal symptomswas compared in infected and non-infectedpatients at stage IV (Figure); earlier stages wereexcluded to avoid bias because of the smallproportion of infected patients at stages HIL/lOnly two of the seven symptoms investigatedwere found to occur more frequently in thepresence of identifiable infectious agents -

namely, dysphagia which was found in 15% ofnon-infected and in 28% of infected patients(p=0O042), and diarrhoea which was found in35% of non-infected and in 58% of infectedpatients (p=0003). Diarrhoea was present in 44(59%) of 74 patients with intestinal infection -

that is, if candida oesophagitis was excluded, andthus also more common compared with non-infected patients. Of note, infectious agents werealso detected in 39 (48%) of 82 patients at stageIV without diarrhoea (Table III), 30 (37%) ofwhom had intestinal infection.

Fifteen different infectious agents wereisolated from the gastrointestinal tract of HIVinfected patients at stage IV of the disease, themost frequent agent was cytomegalovirus (TableIV). The most common result of the microbio-

TABLE III Infective agents detected in stool or gastrointestinalbiopsy, of82 HIV infected patients at stage IV withoutdiarrhoea*t

Agents detected Patients (n)

Candzda sp 9CMVt 7Candida sp, CMV 4MACS 4Cryptosponridum 3E hzstolytica 2Adenovirus 1Adenovirus, Candida sp 1Adenovirus, Coronaviruis 1MAC, CMV 1Campvlobacter sp 1Cperfrzngens 1CMV, SpirochetesG lamblia 1Salmonella spSpirochetesTotal 39

*Diarrhoea= more than three loose bowel movements a day;tin addition, C trachomatns was detected in two of 17 patients atstage Il/Ill without diarrhoea; 4:CMV =Cytomegalosvirus;SMAC=M avium complex.

logical examinations, however, was negative(42%), and this was true for patients with everysymptom except dysphagia and abdominal pain,who had candida oesophagitis and cytomegalo-virus infection, respectively, as the most frequentfindings. Cytomegalovirus was the only agentdetected more frequently in homosexual com-pared wth non-homosexual patients. Comparedwith patients without detectable infective agentsdysphagia, abdominal pain, weight loss, anddiarrhoea were more frequent in patients withcytomegalovirus infection. Candida sp wasfound only in oesophageal biopsies, and candidaoesophagitis correlated significantly with thepresence of dysphagia. Patients with M aviumcomplex infection had more frequent dys-phagia, vomiting, and epigastric pain, patientswith salmonella infection vomiting and abdomi-nal pain, and patients with shigella or chlamydiainfection diarrhoea compared with non-infectedpatients. No other significant associationbetween gastrointestinal symptoms and aspecific organism was found. Four agents weredetected in less than three patients each, how-ever, and could therefore not be tested at 5%significance level. Both patients with corona-virus infection had weight loss, one with cyto-megalovirus coinfection had diarrhoea too. Inone patient with diarrhoea M tuberculosis andcytomegalovirus was found. Two patients withintestinal spirochetosis and one patient withC perfringens infection had fever as the onlysymptom.The number of CD4 positive cells per micro-

litre and the CD4/CD8 ratio in the peripheralblood was reduced in patients at stage IV com-pared with patients at stage 11/111, and - at stageIV - in patients with gastrointestinal infectionscompared with non-infected patients (data notshown). Both values were not significantlydifferent in homosexual compared with non-homosexual patients (data not shown).

DiscussionThe absence of identifiable pathogens in a con-siderable proportion of HIV infected patientswith gastrointestinal symptoms and thedetection of intestinal pathogens in asympto-matic patients6 raise doubts about the pathogenicrelevance of secondary infections and malig-nancies.' We have therefore investigated gastro-intestinal symptoms in correlation to thedetection of infective agents in stool or gastro-intestinal biopsies of patients at different stagesof HIV infection.Compared with patients at earlier stages of

HIV infection, we found a significantly increasedrate of gastrointestinal infections in patients atstage IV. This is not merely an artifact caused bythe classification system but probably resultsfrom progressive immune dysfunction asindicated by a decrease of CD4' cells and of theCD4/CD8 ratio in the peripheral blood correlat-ing with the stage of disease and the presence ofgastrointestinal infections. Only two gastro-intestinal symptoms were more common inadvanced stages of the disease, however, dys-phagia which was strongly associated withcandida oesophagitis leading to a stage IV classi-

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Gastrointestinal symptoms in patients infected with human immunodeficiency virus: relevance ofinfective agents isolatedfrom gastrointestinal tract

TABLE IV Detection ofinfective agents in stool orgastrointestinal biopsyfrom 159 HIV infected patients at stage IVofthedisease correlated with gastrointestinal symptoms and risk group

Homosexual nisktEpigastric Abdominal Weight

Agents Total Dysphagia Nausea Vomiting pain pain loss* Diarrhoeat Positive Negative

None 66 10 25 15 17 14 22 23 42 11Cytomegalovirus 35 10 9 5 11 1711 17§ 2211 32¶ 0Candida sp 28 141 9 8 11 7 6 14 22 4M avium complex 10 5 4 5§ 7** 3 5 5 9 1Cryptosporidium 8 1 2 1 1 2 3 5 7 0E histolytica 6 2 0 0 1 2 1 4 3 1Adenovirus 5 1 2 2 1 2 4 2 4 0Salmonella sp 4 1 2 2§ 1 2§ 3 3 2 1Campylobacter sp 3 0 1 0 0 2 2 2 1 1Chlamydia sp 3 0 1 2 2 1 1 3§ 1 0G lamblia 3 0 0 0 1 1 1 2 2 0Shigella sp 3 0 0 2 2 1 1 3§ 1 0Coronavirustt 2 0 0 0 0 0 2 1 1 0Spirochetestt 2 0 0 0 0 0 0 0 2 0C perfringenstt 1 0 0 0 0 0 0 0 1 0Mtuberculosistt 1 0 0 0 0 0 0 1 1 0Total 159 36 51 33 46 46 58 77 114 19

*Defined as decrease in body weight ofmore than 5% in six months; tDefined as more than three loose bowel movements a day;t30 patients in which no risk factor could be ascertained were excluded; §p<005 compared with non-infected patients; IIp<O005compared with non-infected patients; ¶p<0O005 compared with non-homosexual patients; **p<0.01 compared with non-infectedpatients; ttAgents found in less than three patients could not be tested at 5% significance level.

fication, and weight loss which did not correlatewith gastrointestinal infections at stage IV. Tworecent studies exclusively involving patients withdiarrhoea similarly reported the absence ofpotential pathogens in most patients with AIDSrelated complex while in most patients withAIDS a potential cause of diarrhoea wasdetected7 8; as the abnormalities detected inAIDS patients were obviously not necessary toproduce diarrhoea at earlier stages of the disease,their causative relevance is doubtful.

Intestinal infections were more common inhomosexual compared with non-homosexualpatients at stage IV, which is in contrast with thereport by Rene and coworkers9 and probablyresults from the inclusion of non-homosexualpatients from Africa and Haiti in their study.Despite the higher rate of intestinal infectionshomosexual patients had a higher frequency ofabdominal pain and weight loss only, while thefrequency of diarrhoea or other symptoms wasnot different.

In the present study, in 42% (95% confidenceinterval: 38% to 46%) of patients at stage IV withgastrointestinal symptoms no potential pathogenwas detected in stool or gastrointestinal biopsy.Diarrhoea was the only symptom occurring morefrequently in infected compared with non-infected patients at stage IV which is in accord-ance with two previous studies.9 '0 No infectiousagent was found in 30% (95% confidenceinterval: 25% to 36%) of 77 patients at stage IVwith diarrhoea and furthermore, nearly 50% ofthe patients without diarrhoea harboured aninfective agent in their gastrointestinal tract.These agents obviously did not cause diarrhoeaat the time of study, although their presencemight represent chronic or convalescent carriageafter earlier symptomatic infection.The frequency of agents found in our patients

was similar to those reported in earlier studiesfrom Western Europe and the USA,` exceptfor cryptosporidium which was detected in 5% ofour patients, in about 10% of patients in theUSA,68 '` but in more than 20% of patients inGreat Britain7 and France.9 These differencesmight result from epidemiological differences inthe populations studied. We confirmed the clear

correlation of histologically proven candidainfection, which was always confined to theoesophagus, with the presence of dysphagia.'2Patients infected with cytomegalovirus hadsignificantly more frequent dysphagia, abdomi-nal pain, weight loss, and diarrhoea, and asignificant association with diarrhoea can also beinferred from two earlier studies.9' No correla-tion ofintestinalM avium complex infection withgastrointestinal symptoms has been shown pre-viously. We found an increased frequency ofdysphagia, vomiting, and epigastric pain inpatients infected with M avium complex whilethe frequencies of weight loss or diarrhoea werenot different. Neither diarrhoea nor the othersymptoms investigated were more common inpatients with cryptosporidiosis compared withnon-infected patients in our study. In fact, asignificant association of cryptosporidiosis withdiarrhoea can be inferred from only one9 ofprevious studies, and Janoff and coworkers'3recently reported asymptomatic colonisation ofthe digestive tract by Cryptosporidium. Isolationrates of other agents isolated from the gastro-intestinal tract of our patients at stage IV werebelow 4% each which limits an estimation oftheir pathogenic relevance based on the associa-tion with gastrointestinal symptoms. Nosymptomatic improvement ofdiarrhoea in AIDSpatients, however, has been observed by othersafter eradication of E histolytica, Salmonella,Campylobacter sp, or G lamblia.7 0 Therapeuticstudies on intestinalM avium complex infectionare missing and an effective therapy for crypto-sporidiosis is not available at present. In con-trast, improvement of gastrointestinal symptomsafter specific treatment with ganciclovir is welldocumented in cytomegalovirus infection70'which is in accordance with the significantassociation this agent has with the gastro-intestinal symptoms reported here. Nonetheless,it should be noted that cytomegalovirus waspresent in 13 of our patients without diarrhoea.

Electron microscopy of intestinal biopsies wasnot done in our study, thus we cannot rule outthe possibility that microsporidia were present.An ongoing study revealed microsporidia in onlyone (3%) of 39 HIV-infected patients investi-

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1084 Ullrich, Heise, Bergs, L'age, Riecken, Zeitz

gated so far, however,'4 (and unpublishedresults), thus the prevalence of microsporidiosisseems to be rather low in Berlin. It is thereforeunlikely that microsporidia were responsible forthe symptoms in a relevant proportion of thepatients reported here, especially those at earlydisease stages and those without detectablesecondary infection, as intestinal micro-sporidiosis is apparently associated with lowCD4 counts in the peripheral blood.'5Thus we have shown a high frequency of

gastrointestinal symptoms including diarrhoeaand weight loss in non-infected patients whichwas not consistently increased in patientsharbouring specific infective agents. Further-more diarrhoea or weight loss were absent in aconsiderable proportion of infected patients.Extensive microbiological evaluation obviouslyincreases the number of abnormalities detected;however, these may or may not be of pathogenicrelevance as also indicated by the persistence ofsymptoms after eradication of several infectiveagents reported by others. Thus, further control-led studies are clearly needed to define the truerole of the various secondary infective agentsdetectable in the intestine of HIV infectedpatients. Apart from the mere detection of anagent in stool or biopsy additional criteria have tobe established which differentiate asymptomaticcarriers from those patients with infection in thestrict sense - that is, with related signs of illness.Nonetheless we recommend a thorough diag-nostic evaluation of HIV infected patients withgastrointestinal symptoms because specifictherapy especially of cytomegalovirus infectionmay indeed lead to symptomatic improvement.The high proportion of symptomatic patients

without detectable pathogens especially at earlystages of HIV infection, and furthermore thepoor correlation of infections and symptomsmight be explained by an enteropathogenic roleof HIV itself. HIV infection of the intestinalmucosa is found in about 40% of patients withgastrointestinal symptoms and thus the mostfrequent infective agent detected in this popula-tion.' 2 16 As for most of the secondary infectiousagents a clear correlation between intestinal HIVinfection and gastrointestinal symptoms has notbeen established so far. Mucosal HIV infection,however, is associated with defects in enterocytematuration and hyporegenerative villusatrophy2 16 which are less pronounced in pitientsreceiving zidovudine. '7 Thus HIV probablycauses gastrointestinal dysfunction; furthermoreHIV is the only intestinal pathogen which isfrequently found even at stages II or II2 6 andcould therefore account for the occurrence ofgastrointestinal symptoms and mucosal abnor-malities at early stages of the disease when otherpotential causes are rarely detected.2 6 6 AnHIV enteropathy would probably worsen withdisease progression, and our study shows thatother intestinal infections are of uncertain rele-vance; however, it is tempting to assume asynergistic effect of HIV with other infectiousagents to explain the progressive gastrointestinaldysfunction seen with the advancement of thedisease. The recent report by Connolly et alof diarrhoea and malabsorption being moresevere in the presence of detectable secondary

infections supports this hypothesis.2" In fact,such synergy has been shown between HIV andcytomegalovirus," an agent which is unequivo-cally found to cause gastrointestinal symptoms.

In conclusion, our findings show that gastro-intestinal symptoms are not generally explainedby secondary infections as the pathogenicrelevance of most agents detected in HIVinfected patients is doubtful. Thus the propor-tion of patients with unexplained symptoms is infact even larger than recognised so far whichindirectly supports an enteropathogenic role ofHIV itself.

We thank the staff of the gastroenterological departments and ofthe endoscopical units of the Klinikum Steglitz and of the AugusteViktoria Hospital, and all study participants for their cooperation.The studies were supported by grants FKZ II-048-88 and III-008-91 from the Bundesminister fur Forschung and Technologie.This study was presented in part at the International Congress ofVirology in Berlin, 1990.

1 Riecken EO, Zeitz M, Ullrich R. Non-opportunistic causes ofdiarrhoea in HIV infection. Baillieres Clin Gastroenterol1990; 4: 385-403.

2 Ullrich R, Zeitz M, Heise W, L'age M, Hoffken G, RieckenEO. Small intestinal structure and function in patientsinfected with human immunodeficiencv virus (HIV):Evidence for HIV-induced enteropathy. Ann Intern Med1989; 111: 15-21.

3 Cummins AG, LaBrooy JT, Stanley DP, Rowland R,Shearman DJ. Quantitative histological study of entero-pathy associated with HIV infection. Gut 1990; 31: 317-2 1.

4 Centers for disease control. Classification system for human T-lymphotropic virus type III/lymphadenopathv-associatedvirus infections. MMWR 1986; 35: 334-9.

5 Leads from the MMWR (Morbidity and Mortality WeeklyReport), Supplement 15. Revision of the CDC surveillancecase definition for acquired immunodeficiency syndrome.J3AMA 1987; 258: 1143-54.

6 Laughon BE, Druckman DA, Vernon A, et al. Prevalence ofenteric pathogens in homosexual men with and withoutacquired immunodeficiency syndrome. Gastroenterologv1988; 94: 984-93.

7 Connolly GM, Shanson D, Hawkins DA, Webster JN,Gazzard BG. Non-cryptosporidial diarrhoea in humanimmunodeficiency virus (HIV) infected patients. Gut 1989;30: 195-200.

8 Kotler DP, Francisco A, Clayton F, Scholes JV, OrensteinJM. Small intestinal injury and parasitic disease in AIDS.Ann Intern Med 1990; 113: 444-9.

9 Rene E, Marche C, Regnier B, et al. Intestinal infections inpatients with acquired immunodeficiency syndrome.DigDisSci 1989; 34: 773-80.

10 Smith PD, Lane HC, Gill VJ, et al. Intestinal infections inpatients with the acquired immunodeficiency syndrome(AIDS). Etiology and response to therapy. Ann Intern Med1988; 108: 328-33.

11 Heise W, Mostertz P, Skorde J, L'age M. Gastrointestinalebefunde bei der HIV-infektion. Dtsch Med Wochenschr 1988;113: 1588-93.

12 Raufman JR. Odynophagia/dysphagia in AIDS. GastroenterolClin North Am 1988; 17: 599-614.

13 Janoff EN, Limas C, Gebhard RL, Penley KA. Crypto-sporidial carriage without symptoms in the acquiredimmunodeficiency syndrome (AIDS) [Letter]. Ann InternMed 1990; 112: 75-6.

14 Ullrich R, Zeitz M, Bergs C, Janitschke K, Riecken EO.Intestinal microsporidiosis in a German patient with AIDS.Klin Wochenschr 1991; 69: 443-5.

15 Eeftinck Schattenkerk JKM, van Gool T, van Ketel RJ, et al.Clinical significance of small-intestinal microsporidiosis inHIV-1-infected individuals. Lancet 1991; 337: 895-8.

16 Ullrich R, Zeitz M, Heise W, et al. Mucosal atrophv isassociated with loss of activated T cells in the duodenalmucosa of human immunodeficiency virus (HIV)-infectedpatients. Digestion 1990; 46 (suppl 2): 302-7.

17 Ullrich R, Heise W, Bergs C, L'age M, Riecken E-O, Zeitz M.Effects of zidovudine treatment on the small intestinalmucosa in patients infected with HIV. Gastroenterology 1992;102: 1483-92.

18 Miller ARO, Griffin GE, Batman P, et al. Jejunal mucosalarchitecture and fat absorption in male homosexuals infectedwith human immunodeficiency virus. Q J Med 1988; 69:1009-19.

19 Batman PA, Miller AR, Forster SM, Harris JR, Pinching AJ,Griffin GE. Jejunal enteropathy associated with humanimmunodeficiency virus infection: quantitative histology.J Clin Pathol 1989; 42: 275-81.

20 Connolly GM, Forbes A, Gazzard BG. Investigation ofseemingly pathogen-negative diarrhoea in patients infectedwith HIV1. Gut 1990; 31: 886-9.

21 Skolnik PR, Kosloff BR, Hirsch MS. Bidirectionalinteractions between human immunodeficiency vtirus type 1and cytomegalovirus.JZ Infect Dis 1988; 157: 508-14.

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