Maliha Naseer, MD1, Prashant Mudireddy, MD2; 1East Carolina University, Greenville, NC; 2Vidant Medical Center/ECU Brody School of Medicine, Greenville, NC
Introduction: Hepatobiliary tuberculosis (TB), lymphoma and HIV cholangiopathy are frequently reported causes of obstructive jaundice in HIV/ AIDS patients. We are presenting a rare case of obstructive jaundice due to extrinsic compression of the common hepatic duct from mycobacterial avium (MAC) adenitis of the porta hepatis associated with immune reconstitution inflammatory syndrome (IRIS).
Methods: A 55-years-old male with history of HIV/ AIDS, disseminated MAC, colon cancer and hypertension admitted with 2 weeks history of jaundice and itching. Patient denied abdominal pain, nausea, vomiting, fever, chills, weight loss, recent travel history, over the counter or herbal supplements. Medications include ethambutol, rifabutin and HAART started few months ago. Examination significant for scleral icterus otherwise unremarkable. His initial lab work-up revealed total bilirubin 30, alkaline phosphatase 1600, AST 164, ALT 78 and CD 4 count of 150. Patient underwent abdominal CT scan and MRCP which showed a 3.2 cm mass/ adenopathy at porta hepatis with malignant appearing stricture in the mid common duct with resultant moderate biliary ductal dilatation along with enlarged mediastinal, retroperitoneal and mesenteric nodes. Lymphoma, cholangiocarcinoma and metastatic disease were in the differentials. Further work up with EUS and ERCP revealed a 3.8 x 2.2 cm irregular heterogenous and poorly defined mass in the perihepatic/periportal space causing CHD stenosis. FNA was obtained. ERCP with spyglass showed a severe stricture (Bismuth I) in the CHD which appeared to be secondary to extrinsic compression. Plastic stents were placed in the RHD. Following stent placement, jaundice gradually resolved. FNA samples showed granulomatous inflammation with acid-fast mycobacterium. Decision was made to continue with current MAC and HAART treatment. Discussion: IRIS is defined as a reactivation of previously treated opportunistic infections after starting antiretroviral therapy. It is more likely to occur in AIDS patients with CD4 count < 100 cells/mm. Disseminated MAC is one of the most common opportunistic infections associated with this paradoxical clinical worsening. Though some obstructive jaundice cases caused by abdominal tuberculous lymphadenitis have been reported. There have been no reports of biliary obstruction caused by the worsening of lymph node swelling due to IRIS. Endoscopic or percutaneous drainage in addition to anti-mycobacterial treatment needed.
Image 1: EUS showing periportal/ perihepatic mass causing compression of common hepatic duct
Image 2: Fluoroscopy showing severe stenosis in the middle bile duct (Bismuth I)
Image 3: Spyglass showing severe stenosis from extrinsic compression in the common hepatic duct
Disclosures: Maliha Naseer indicated no relevant financial relationships. Prashant Mudireddy indicated no relevant financial relationships.