University of Iowa Hospitals and Clinics Iowa City, IA
Katelin M. Durham, MD1, Scott Albright, DO1, Xiaocen Zhang, MD2, Aditi Reddy, MD3, Hye Yeon Jhun, MD1 1University of Iowa Hospitals and Clinics, Iowa City, IA; 2University of Iowa Hospitals & Clinics, Iowa City, IA; 3UIHC, Iowa City, IA
Introduction: Diarrhea in patients with human immunodeficiency virus (HIV) can be due to a variety of etiologies including infection, malignancy, and antiretroviral therapy (ART). With increased use of ART, diarrhea due to opportunistic infections has become less common. Here we report a rare case of chronic diarrhea due to Mycobacterium avium complex (MAC) infection involving the duodenum, colon, and rectum of a patient with advanced HIV.
Case Description/Methods: A 41-year-old man with HIV infection diagnosed two years earlier presented with progressively worsening diarrhea. Two months prior, his CD4 count was stable at 50 cells/uL and his HIV level was undetectable while on dolutegravir/lamuvidine. He had history of MAC mycobacteremia under treatment with ethambutol, azithromycin, and rifabutin. He also had cytomegalovirus (CMV) viremia treated with valganciclovir. He reported compliance with the above medications.
He had eight-month history of frequent, watery diarrhea associated with malaise, nausea, bloating, abdominal pain, and weight loss. He was hospitalized for severe malnutrition and electrolyte abnormalities. Evaluation of his diarrhea included negative C. difficile toxin, enteric pathogen panel, and ova and parasite exam. CMV was detected in the blood at 17,000 IU/mL and HIV viral load was 6,166 IU/mL. Esophagogastroduodenoscopy was performed and revealed diffuse erythema and edema affecting the mucosa of the entire duodenum with associated villous blunting and fissuring (Figure 1A). Flexible sigmoidoscopy revealed normal appearing mucosa to the level of the ascending colon. Pathology from duodenal biopsies showed extensive histiocytic inflammation with presence of acid-fast bacillus organisms (Figures 1B, 1C). Random biopsies from the colon and rectum showed similar findings and no evidence of CMV. Acid-fast bacillus blood cultures grew Mycobacterium avium-intracellulare. His MAC treatment was changed to amikacin, linezolid, rifampin, and ethambutol with subsequent improvement in his diarrhea.
Discussion: Gastrointestinal tract involvement by MAC is usually part of a disseminated MAC infection in patients with advanced HIV, especially those with CD4 lymphocyte counts < 50 cells/uL. The duodenum is most often affected, followed by the rectum. We report this case to raise awareness that MAC enterocolitis remains an important etiology of chronic diarrhea in patients with advanced HIV.
Figure: Figure 1A. EGD showing duodenal involvement by MAC causing diffuse erythema and edema with villous blunting and fissuring. Figure 1B. H&E stain of duodenal mucosa with extensive histiocytic inflammation. Figure 1C. Ziehl-Neelsen stain of duodenal mucosa with acid-fast bacillus positive organisms consistent with Mycobacterium avium complex.
Disclosures:
Katelin Durham indicated no relevant financial relationships.
Scott Albright indicated no relevant financial relationships.
Xiaocen Zhang indicated no relevant financial relationships.
Aditi Reddy indicated no relevant financial relationships.
Hye Yeon Jhun indicated no relevant financial relationships.
Katelin M. Durham, MD1, Scott Albright, DO1, Xiaocen Zhang, MD2, Aditi Reddy, MD3, Hye Yeon Jhun, MD1. D0659 - Enterocolitis Caused by Mycobacterium Avium Complex in an HIV-Infected Patient, ACG 2022 Annual Scientific Meeting Abstracts. Charlotte, NC: American College of Gastroenterology.
