Abdominal Pain in Newly Diagnosed HIV Patient: More Serious Than You Think

Abstract

Multicentric Castleman Disease (MCD) is a lymphoproliferative disorder that happens more in Human Herpes Virus-8 (HHV-8) positive HIV patients. We are reporting a unique case of rapidly progressive Multicenteric Castleman disease in patient with acute retroviral syndrome admitted for abdominal pain. Our patient was a 40 year old male presented with fevers, chills and persistent abdominal pain. He was recently diagnosed with HIV. On presentation he was febrile. Physical examination demonstrated cervical lymphadenopathy with hepatosplenomegaly and normal bowel sounds. His labs were significant for pancytopenia (WBC of 4.1 thousand/mcL; HgB 6.1 gm/dL; MCV 82 fL; Platelet 78 thousand/mcL), hyponatremia (131 mmol/L), and elevated creatinine (1.5 mg/dL). In addition, his CRP was 23.4 mg/L. Chest X-Ray (CXR) was not impressive and his EKG was normal sinus rhythm. A working diagnosis of acute retroviral syndrome was made, although the anemia was too severe to be secondary to HIV only and was attributed to possible gastrointestinal losses. He received blood transfusions, but there was minimal improvement in hemoglobin. CT Abdomen/pelvis was done and showed hepatosplenomegaly with enlarged lymph nodes. Interestingly, lymph node biopsy was consistent with HHV-8 associated MCD. Accordingly, he was started on Anti-Retroviral Therapy for HIV and Gancyclovir and Rituxamab for MCD. During his admission, his hemoglobin continued to drop requiring additional blood transfusions. On day 7, His platelets continued to drop significantly (Platelet 42 thousand/mcL), and his clinical condition continued to worsen despite all attempts of aggressive management. On day 8, he developed severe respiratory distress requiring transfer to Medical Intensive Care Unit (MICU). On the following day, he developed acute hypoxemic respiratory failure. Accordingly he was ventilated due to severe Acute Respiratory Distress Syndrome (ARDS) resulting in respiratory failure, and shortly thereafter his condition continued to deteriorate. Despite all efforts, the patient eventually succumbed to his illness and passed away. In conclusion, we believe that presentation of abdominal pain and anemia in patients with acute retroviral syndrome can be the initial manifestation of a very serious uncommon subtype of Castleman disease which has a very poor prognosis and physicians should be aware of such an unusual presentation.Figure 1