A Classic Case of Diarrhea in a Severely Immune-compromised Patient

Abstract

Purpose: A classic presentation of an exceedingly rare entity. Case Report: A 28-year-old African-American female with HIV/AIDS most recent CD4 1, VL 600,000 copies/mL who is non-compliant with HAART therapy presented to the emergency department with complaints of profuse watery non-bloody diarrhea for three weeks associated with abdominal cramping and night sweats. She also had 10-pound unintentional weight loss over the three weeks. She denied nausea and vomiting. She denied sick contacts and recent travel. Her past medical history also includes: oral/esophageal candidiasis, pneumocystis jirovecii pneumonia and molluscum contagiosum. On examination, she was found to have a fever of 103.8F, hypotension and tachycardia. She appeared severely cachectic and listless. Her abdomen was scaphoid with hyperactive but normo-pitched bowel sounds, soft and non-tender. The stool was liquid, brown mixed with mucous; there was no bright red blood or melena. Labs were significant for profound iron deficiency anemia, thrombocytosis and electrolytes disturbance. The liver function tests were within normal limits. Stool studies and culture were negative. Rectal swab viral culture was also negative. CAT scan of the abdomen and pelvis revealed hepatomegaly, splenomegaly with multiple hypoattenuated lesions in the spleen and multiple mesenteric lymph nodes. Flexible- sigmoidoscopy was normal and the pathology on random biopsies showed chronic non-specific inflammation. Esophagogastroduodenoscopy revealed thickening pale nodular duodenal folds interdigitated with atrophic friable mucosa (Figure 1). Pathology was significant for numerous histiocytes within the lamina propria with PAS and AFB stain positive revealing numerous intracellular organisms morphologically consistent with Mycobacterium avium-intracellulare complex. Subsequently, blood cultures returned positive for Mycobacterium avium-intracellular complex as well. She was started on ethambutol, clarithromycin, and rifabutin, and her symptoms resolved.Figure