Splenic Infarcts Associated with Immune Reconstitution Inflammatory Syndrome

Abstract

A 28-year-old white man presented with fever, rash, and sudden onset of left upper quadrant abdominal pain. Three months prior, he had been diagnosed with AIDS and disseminated Mycobacterium avium complex (MAC) infection, and was started on highly active antiretroviral therapy, rifabutin, ethambutol, and azithromycin. His viral load decreased to undetectable levels and his CD4 count increased from 88 to 252 cells/mm3. On arrival, computed tomography (CT) of the abdomen demonstrated new splenic infarcts (Fig. 1, arrows) and mesenteric lymphadenopathy (Fig. 2, asterisks). Laparoscopic lymph node biopsy showed granulomatous lymphadenitis with multiple acid-fast bacilli. He was treated with oral steroids with improvement in his symptoms. Figure 1. CT of abdomen showing new splenic infarcts (arrows). Figure 2. CT of abdomen showing mesenteric lymphadenopathy (asterisks). Splenic infarcts can present as acute abdomen in patients with atheroembolism, malignancies, trauma, pancreatitis, splenic torsion, and hematologic dyscrasias (sickle cell disease, thrombophilia, polycythemia vera, essential thrombocythemia, myeloid metaplasia). This patient had splenic infarcts thought to be due to immune reconstitution inflammatory syndrome (IRIS)—an association that has not been previously reported.1 The physiopathology of the presumed arterial thrombosis may be explained by the marked local inflammatory response and hypercoagulability in patients with AIDS.