AIDS Associated Arteriopathy as Etiology of Non-Infectious Recto-Colonic Ulcerations in an Adult

Abstract

AIDS associated arteriopathy (AAA) of the gastrointestinal tract in adults has not been previously reported. We report the case of a young adult with AIDS and non-infectious recto-colonic ulcerations and postulate that the ulcerations may constitute a complication of AAA. Case Report: A 35 yo male with history of HIV with AIDS, non-Hodgkin's lymphoma, and MAI presented with fever, rectal pain and bleeding. Four months prior to admission, the patient underwent excision of a rectal ulcer, which revealed thick walled vessels with medial hypertrophy and intimal fibrosis within the granulation tissue. A few beaded acid-fast rods, consistent with Nocardia species were noted in adjacent crypts. Follow up colonoscopy revealed multiple ulcerations throughout the colon characterized microscopically as Candida associated colitis. The patient was treated for Nocardia and had complete resolution of his symptoms. 10 weeks later, he presented with diffuse abdominal pain and hematochezia. A repeat colonoscopy revealed a large, irregular fungating, friable cecal mass with biopsy changes similar to those in the rectal ulcer as well as luminal obliteration by organizing thrombi and no inflammation in the adjacent non-ulcerated cecal mucosa. Infectious, inflammatory and neoplastic etiologies were ruled out. The patient underwent a right hemicolectomy with ileo-colonic anastomosis with complete resolution of his pain. Microscopically, the cecal mass had vascular changes similar to those of the biopsy. AAA was the presumed etiology. Discussion: AAA is characterized by intimal fibrosis and fragmentation of the elastic fibers of medium sized arteries as well as fragmentation and calcification of the internal elastic membrane, with luminal narrowing. These changes have been described in children in organs such as the heart, lung, kidney, intestine, brain and spleen. Isolated cases complicated by coronary artery aneurysm, esophageal stricture and colonic perforation have been reported. Increased exposure to endogenous and exogenous elastases resulting from multiple infections secondary to the immunodeficiency in AIDS have been postulated as the pathogenetic mechanism. We report the first case of these vascular changes in the gastrointestinal tract of an adult with AIDS.