Howard University Hospital Washington, DC, United States
Abdullahi Musa, MBBS1, Temitayo Gboluaje, MD1, Joseph Asemota, MD1, Walid Ali, MD1, Rachel Gordezky, MD2, Adeyinka Laiyemo, MD, MPH2, Hassan Ashktorab, PhD2, Farshad Aduli, MD2 1Howard University Hospital, Washington, DC; 2Howard University College of Medicine, Washington, DC
Introduction: Opportunistic infections in HIV patients have declined after the introduction of Anti-retroviral therapy (ART). However, patients who are not adherent to therapy or developed resistance to ART will be susceptible to opportunistic infections. Mycobacterium avium complex (MAC) is a rare opportunistic infection in patients with CD4 count less than 50. Here we present a case of disseminated MAC diagnosed by small bowel and liver biopsies.
Case Description/Methods: A 33-year-old female with known history of HIV AIDS with CD4 count of 46 cell/uL, not on ART, presented to our tertiary care center with complaint of abdominal pain, chronic diarrhea and intermittent melena. Physical examination was remarkable for generalized muscle wasting and RUQ tenderness. Laboratory workup revealed iron deficiency anemia and cholestatic pattern of elevation in liver associated enzymes. Stool work up was negative for an infectious etiology. Esophagogastroduodenoscopy was notable for normal duodenum. Histopathology of duodenal biopsies revealed foamy macrophages with positive periodic acid-Schiff (PAS) staining with clusters of rod-shaped bacterial organism suggestive of Whipple disease (Fig. A). Other hepatic related workup with in a normal range, including viral hepatitis panel, ANA, ALKM-Ab and Ceruloplasmin. Ultrasound of the abdomen was notable for hepatosplenomegaly with no biliary dilatation. Liver biopsy revealed non-necrotizing granuloma with positive staining for acid fast bacilli suggestive of MAC infection (Fig. C).The diagnosis of hepatic MAC infection instigated a second review of the duodenal biopsies and was found to be consistent with acid fast bacilli (Fig. B) therefore, the patient was managed as disseminated MAC infection. The patient was started on Azithromycin and Ethambutol with significant improvement in symptoms observed, as well as normalization of her liver associated enzymes. Patient was discharged from the hospital with outpatient follow up.
Discussion: Incidence of disseminated MAC infection in HIV patients has declined due to ART. The Gastrointestinal tract, in particular the small bowel is a common site for opportunistic MAC infection. Endoscopic evaluation of the small bowel is an important tool in making a diagnosis. However, in patients with normal endoscopic evaluation, biopsies should be obtained for histopathology. Disseminated MAC can cause cholestatic liver disease and should always be considered as a differential diagnosis in patients with poorly controlled HIV infection.
Figure: Fig.A: Aggregate of foamy macrophages. Fig.B: AFB stain highlighting organisms. Fig.C: Granuloma in liver parenchyma and AFB stain highlighting organisms.
Abdullahi Musa indicated no relevant financial relationships.
Temitayo Gboluaje indicated no relevant financial relationships.
Joseph Asemota indicated no relevant financial relationships.
Walid Ali indicated no relevant financial relationships.
Rachel Gordezky indicated no relevant financial relationships.
Adeyinka Laiyemo indicated no relevant financial relationships.
Hassan Ashktorab indicated no relevant financial relationships.
Farshad Aduli indicated no relevant financial relationships.
Abdullahi Musa, MBBS1, Temitayo Gboluaje, MD1, Joseph Asemota, MD1, Walid Ali, MD1, Rachel Gordezky, MD2, Adeyinka Laiyemo, MD, MPH2, Hassan Ashktorab, PhD2, Farshad Aduli, MD2. P3039 - Disseminated Mycobacterium Avium Complex Infection in an HIV Patient; Small Bowel and Liver Involvement, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.