Baylor Scott & White Health Round Rock, TX, United States
Pardeep Singh, DO Baylor Scott & White Health, Round rock, TX
Introduction: HIV late presenters with advanced AIDS are known to have multiple opportunistic infections (OI). Late presentation has been exacerbated by the COVID19 pandemic. Treatment is complicated by many unidentified OIs exhibiting similar symptoms and clinical progress is delayed. The following case presents a newly diagnosed HIV patient with chronic diarrhea. The patient was ultimately diagnosed with GI OIs of Shigella, Microsporidia, Cryptococcus, CMV enteritis/colitis, Candida esophagitis, and Kaposi sarcoma of the stomach. These are all contributors to HIV wasting syndrome. The patient required bacterial, fungal, protozoal, and viral therapy, while antiretroviral therapy was delayed to avoid IRIS.
Case Description/Methods: A 47-year-old male with recently diagnosed HIV with AIDS was admitted for cryptococcal meningitis treatment. He showed symptoms of sore throat and diarrhea, and he reported unintentional weight loss of 100lb over eight months with no prior workup. On admission, the patient weighed 85lb and had a BMI of 12.2. He exhibited bitemporal wasting on exam, as well as sacral ulceration.
Stool PCR was positive for Shigella and ova and parasite (O&P) testing was positive for Microsporidia. However, he did not respond to Bactrim and albendazole therapy. Diarrhea complicated ulcer healing, requiring rectal tube placement. EGD with biopsies identified Kaposi sarcoma in the stomach body, candida in the esophagus, and cryptococcus in the duodenum. Colonoscopy with biopsies showed ulcerations throughout the terminal ileum and the ascending, descending, and sigmoid colon, which confirmed CMV enteritis/colitis. The patient was receiving amphotericin and flucytosine on admission for cryptococcal meningitis and was started on valganciclovir for CMV. His diarrhea improved and the rectal tube was removed once his incontinence resolved. He experienced weight gain of 3lb over the hospital course.
Discussion: Typically noninvasive treatment and further investigation if symptoms don’t resolve is standard practice. Patients such as this warrant aggressive evaluation because multiple OIs may occur concurrently, contributing to a common symptom. Quality of life suffers when diarrhea is prolonged. Hospitalization provided the means for monitoring therapy and rapidly advancing evaluative measures. Endoscopy, O&P testing, and stool PCR were necessary to identify the contributors to this patient’s wasting.
Figure: Figure 1: Endoscopy findings
Pardeep Singh indicated no relevant financial relationships.
Pardeep Singh, DO. P0436 - Thoroughly Investigating HIV Late Presenters With Wasting Syndrome, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.