Valley Hospital Medical Center Las Vegas, NV, United States
Thomas Ilustrisimo, DO, Alexis Serrano, DO, Rebecca Salvo, DO, Dipesh Banker, MD Valley Hospital Medical Center, Las Vegas, NV
Introduction: Despite advancements in HAART therapy, AIDS cholangiopathy (AC) remains a fatal illness affecting those with significant immunosuppression. Here we describe a case of a male with undiagnosed HIV who presented with abdominal pain and bloody diarrhea which lead to the diagnosis of AIDS cholangiopathy.
Case Description/Methods: 39 yo male with no MHx presented with abdominal pain and bloody diarrhea associated with 20lb weight loss. CE-CT abdomen showed periportal edema, 8mm CBD with enhancement, intrahepatic biliary ductal dilatation, thickened rectal wall with perirectal hyperemia. He underwent colonoscopy which identified 4cm punched out rectal ulcer with surrounding erythematous polypoid heaped up tissue. Ulcer margin biopsies were obtained which were positive for CMV. GI PCR resulted with Cryptosporidium. Due to concern for HIV, he was tested and was HIV1+ with CD4 count 13. Patient was also found to have alk phosph of 601. MRCP with biliary dilatation and possible small distal CBD stone. Therefore EUS/ERCP was performed which revealed 1cm CBD dilatation, negative for any obvious stricture or stone. The combination of opportunistic infections and cholestatic transaminitis without any other identified cause confirmed AIDS cholangiopathy. Due to his persistent pain, sphincterotomy was performed. ID administered IV Valcyclovir and Paromomycin and initiated HAART. He was eventually discharged without issues.
Discussion: Prior to HAART, AC prevalance ranged between 26-46%, and is now more commonly seen in developing countries. However, certain populations remain at risk within the US including men who have sex with men, medically nonadherent, undiagnosed individuals, and those with resistant HIV. Pathophysiology involves infection related biliary strictures leading to obstruction and cholestatic damage. It is associated with CD4 < 100, opportunistic infections, with CMV and cryptosporidium being the two most common. Patients may be asymptomatic or present with abdominal pain, nausea, or diarrhea. Clinical findings include cholestatic transaminitis and biliary dilatation. Cholangiography demonstrates papillary stenosis with a smoothly tapered stricture at the distal CBD. Management is symptomatic as eradicating the opportunistic infections do not halt the disease progression, which includes sphincterotomy and ursodeoxycholic acid. Survival is poor due to advanced stages of immunosuppression and the presence of multiple opportunistic infections and possibly be complicated with cholangiocarcinoma.
Figure: Pictured is the patient's dilated extrahepatic and intrahepatic biliary tree with smooth tapering at the distal CBD.
Disclosures: Thomas Ilustrisimo indicated no relevant financial relationships. Alexis Serrano indicated no relevant financial relationships. Rebecca Salvo indicated no relevant financial relationships. Dipesh Banker indicated no relevant financial relationships.
Thomas Ilustrisimo, DO, Alexis Serrano, DO, Rebecca Salvo, DO, Dipesh Banker, MD. P2181 - AIDS Cholangiopathy Presenting With Ongoing CMV Colitis and Cryptosporidium-Related Diarrhea, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.