Is this AIDS Patient Suffering from Intestinal Tuberculosis or Lymphoma?
Year: 2024
Type: article
Study design: Case Report
Abstract: Acquired immunedeficiency syndrome (AIDS) patients are easily complicated with various opportunistic infections and tumors, requiring differential diagnosis in clinical practice. The symptoms of some diseases are atypical or mixed, and the diagnosis is difficult. Here, we present a patient with abdominal pain, diarrhea, and fever whose abdominal computerized tomography (CT) and colonoscopy findings suggested intestinal tuberculosis or lymphoma. However, these two diagnoses were ultimately incorrect after a series of verifications. Case Description A 29-year-old male patient was admitted to our hospital due to “abdominal pain and diarrhea for 10 days.” The pain site was mainly around the umbilicus and left lower abdomen, which was persistent, and accompanied by diarrhea, approximately 3 times/day. The patient was treated with oral drugs (probiotics) in the outpatient department, but there was no relief. The patient felt fatigue accompanied by night sweats and slight sweats in the afternoon. Recently, he lost 3 kg in weight. No other chronic diseases, alcohol use, family history, or suspected drug use were reported. The physical examination indicated a body temperature of 98.2°F, pulse of 93 beats per minute, respirations of 20 beats per minute, and blood pressure of 125/79 mmHg. The abdomen was soft on palpation, with tenderness and rebound pain around the umbilical cord and lower abdomen. The rest of the physical examination showed no abnormalities. Routine blood tests showed elevated neutrophils, high-sensitivity C-reactive protein (CRP), D-dimer (D-D), and erythrocyte sedimentation rate (ESR). No abnormalities were found in routine urine tests or routine stool tests. AIDS antibodies were suspiciously positive, and CD4+ T lymphocytes and CD4/CD8 were both decreased. No abnormalities were found in the thyroid function/tumor markers, antinuclear antibody profile, or antineutrophil cytoplasmic antibody (ANCA) series. The patient began to develop high fever on the 3rd day after admission, with the highest body temperature exceeding 102.2°F. During this period, he did not have chills, cough, frequent urination, urgent urination, or pain. The procalcitonin (PCT), endotoxin, respiratory virus triple, Coxsackie virus (IgM), Epstein‒Barr virus antibody (IgM), rubella virus antibody, herpes simplex virus type II, herpes simplex virus type I, cytomegalovirus (CMV) antibody, toxoplasmosis antibody, Mycoplasma pneumoniae antibody-IgM, and chlamydia pneumoniae antibody-IgM were normal. Lung CT showed multiple nodules in both lungs, with larger nodules located in the upper lobe of the right lung, prone to inflammatory granulomatous lesions. Abdominal enhanced CT indicated thickening of the ileocecal intestinal wall; multiple lymph node enlargements in the posterior peritoneum, mesenteric root and right lower abdomen; spleen enlargement; a few pelvic effusions; and lesions considered tuberculosis or lymphoma (Figure 1).FIGURE 1.: Abdominal enhanced CT of the patient. The ileocecal intestinal wall was uniformly thickened with significant enhancement, and no significant stenosis was observed in the lumen. Multiple enlarged lymph nodes of different sizes were observed in the posterior peritoneum, mesenteric root and right lower abdomen, some of which were fused, and the superior mesenteric artery and hepatic portal vein were embedded in them. After enhancement, the above lesions showed uneven and obvious enhancement and some obvious ring enhancement. (A) Abdominal CT scan, transverse position; (B) Abdominal enhanced CT, arterial phase, transverse position; (C) Abdominal enhanced CT, portal venous phase, transverse position. CT = computed tomography. The patient was most likely to have AIDS combined with intestinal tuberculosis or lymphoma, and further examination was carried out. TB antibody, T-SPOT, and PPD tests were all negative. Colonoscopy revealed multiple ulcers and proliferative changes at the end of the ileum, ileocecal region, and ascending colon (Figure 2). Pathology suggested chronic mucosal ulcers accompanied by inflammatory granulation tissue hyperplasia, a small number of eosinophilic granulocytes, heterogeneous lymphoid cells and foam-like histiocyte infiltration, and focal tissue crush injury. Detection of drug resistance and mutation of Mycobacterium tuberculosis was negative. Special staining results revealed: acid-fast staining (−), periodic Schiff (PAS) (−), silver periodic (PAM) (−), and Regge (−). Immunohistochemistry showed polyclonal hyperplasia, suggesting reactive hyperplasia. Other results were CD20 (+ 30%) oven, CD3 (+ 30%), CD30 (−), CD56 (−), CD138 (+ 20%), CD163 (+ 20%), Ki67 (+ 30%), and CK (−).FIGURE 2.: Colonoscopic findings of the patient. (A) At the end of the ileum, the local mucosa was thickened and raised, the central ulcer was formed and covered with white moss, and the biopsy was tough. (B) In the ileocecum, there are multiple ulcers covered with pus white moss. (C) Obvious ileocecal valve congestion swelling and ulcer formation that is covered with white moss. In the ascending colon, multiple ulcers are formed and covered with white moss. PET-CT examination results showed the possibility of hematologic disease (lymphoma) or inflammation and infection. Lymph node biopsy (left cervical lymph node puncture) revealed reactive hyperplasia of the lymph node. Finally, metagenomic next-generation sequencing (mNGS) of blood samples suggested Talaromyces marneffei (TM), and further blood mycobacterium, fungal culture and identification suggested TM. Sputum culture: a few filamentous fungi. The Aspergillus antigen test and cryptococcus antigen test were negative. Experientially, TM infection is thought to cause clinical symptoms, intestinal ulcers, abdominal imaging findings, and lung lesions in patients. This patient had received antifungal treatment with voriconazole. After antifungal therapy for less than 2 weeks, the patient’s condition improved, and abdominal pain and diarrhea were relieved. After antifungal therapy and anti-HIV treatment for 12 weeks, he returned to the local hospital for follow-up treatment. Discussion TM, formerly known as Penicillium marneffei (PM), is a conditional pathogen that easily infects AIDS and other immunedeficiency patients. TM can cause systemic disseminated infection, but only a few cases involve the digestive tract. TM intestinal infection has occult symptoms, atypical clinical manifestations, and different endoscopic manifestations, making diagnosis difficult and easy to confuse with intestinal tuberculosis, lymphoma, etc. (Wang et al., 2023). The clinical manifestations of TM infection can be divided into localized and disseminated types according to the site and characteristics of the disease. The localized type only causes disease of individual organs. The clinical manifestations are mainly primary symptoms, such as local subcutaneous nodules and subcutaneous abscesses. AIDS with TM infection is mostly disseminated, invading blood, bone marrow, skin, lymph nodes, digestive tract, etc., with fever, rash, cough, diarrhea, weight loss, liver, and spleen lymph node enlargement as the main manifestations. There is an associated a high fatality rate (Peng et al., 2022). The gastrointestinal tract of AIDS patients with TM infection show no specificity, and the most common symptoms are fever, abdominal pain, abdominal distention, diarrhea, and lymphadenectasis in the abdominal cavity. The colon has various manifestations, which are easily misdiagnosed and missed (Xie et al., 2022). Common colonic mucosal findings include: (1) The ulcer is flat, the central base covered with yellow‒white moss, and surrounded by erythema, congestion, and erosion; (2) The ulcer is centrally depressed, covered with white moss, surrounded by swelling, and the mucosa between the lesions is normal; (3) The intestinal tract has discontinuous flat erosions with obvious surface congestion, and the interlesion mucosa is normal; (4) The erosive lesions are umbilical-concave or verrucous, with central depression and elevated surrounding mucosa; (5) The intestinal mucosal folds show mass-like uplift with erosion. The intestinal pathological manifestations of TM infection are ulcer and/or erosion, chronic mucosal inflammatory changes, more lymphocytes, plasma cell infiltration and partial neutrophil infiltration, inflammatory granuloma, and mild epithelial gland hyperplasia (Huang et al., 2020). Pathological biopsy, immunohistochemistry, and special staining are helpful for diagnosis. The diagnostic criteria are typical dachshund-like spores found in the pathological tissue of colon mucosa, but few TMs in the intestine can be identified by histopathology or cultured from intestinal tissue. mNGS is considered to be highly specific and sensitive and can be used for rapid diagnosis of talaromicosis (Mao et al., 2022). AIDS patients easily suffer from intestinal tuberculosis or lymphoma, and the symptoms include abdominal pain, diarrhea, stool, fever, and swollen lymph nodes, which are similar to the merger of TM intestinal infection. The manifestations of intestinal ulcers in this patient were consistent with the colonoscopy findings of TM infection, and the pathological findings showed that the ulcers were accompanied by inflammatory granulation tissue, heterogeneous lymphoid cells, and foam histopathocyte infiltration, which was highly consistent with the pathological findings of TM. Although no typical dachshund-like spores were found in the pathology, etiological evidence was obtained by mNGS, and the symptoms improved rapidly after treatment, which reconfirmed the diagnosis of the patient. At the same time, patients with CD4+ T lymphocytes less than 100/μL are likely to develop the disease. The CD4+ T lymphocyte count in this patient was 18/μL, which directly indicated that the patient’s immunity was very poor and susceptible to pathogens. Moreover, the inflammatory granulomatous lesions suggested by lung CT are also one of the manifestations of TM infection. Combined with the patient’s clinical manifestations and initial imaging findings, the possibility of AIDS complicated with intestinal tuberculosis or lymphoma was considered. Intestinal tuberculosis is prone to occur in the ileocecal region, where mucosal congestion and edema, ulcer formation, inflammatory polyps of different sizes and shapes, and intestinal cavity narrowing can be observed under endoscopy. Finding acid-fast bacilli in pathological biopsy is helpful for diagnosis, and caseous granuloma can be confirmed (Ganesan et al., 2023; Osei Bonsu et al., 2023). Because there is no direct evidence, according to the results of tuberculosis-related tests, the diagnosis of intestinal tuberculosis was not valid for this patient. Lymphoma occurs most frequently in patients with advanced AIDS. The most common CT manifestation of intestinal lymphoma is intestinal wall thickening with aneurysmal dilatation of the intestinal cavity. The thickened intestinal wall was uniform and slightly less dense, and the enhanced scan showed uniform mild to moderate delayed enhancement. Diagnosis is confirmed by tissue biopsy (deep biopsy) (Mwazha et al., 2020). The immunohistochemical results of the patient’s intestinal mucosa showed reactive hyperplasia, and the biopsy of the left cervical lymph node also suggested reactive hyperplasia, so the diagnosis of lymphoma was inconclusive. Finally, the patient’s response to treatment confirmed the diagnosis of AIDS with TM infection. Conclusion This case reminds all healthcare providers, including doctors and nurses, that for patients with immunodeficiency such as AIDS, it is necessary to always pay attention to the investigation of various specific or non-specific infections. Providers of AIDS patients need to think comprehensively to make accurate diagnoses of complications, understand various complications, and quickly target pathogenic bacteria to facilitate timely and effective treatment of patients. While helping patients with clear diagnosis and treatment, it is necessary to pay attention to preventing nosocomial infection, contact isolation, and droplet isolation, which need to be carried out simultaneously. This complex management is a challenge for patient care and requires joint response by healthcare staff.
Source: Gastroenterology Nursing
Authors: Liyuan Tao, Fang Chen, Linlin Shi, Dongya Chen
Language: English
Subfield: Surgery
Field: Medicine
Domain: Health Sciences
Open Access status: hybrid
OpenAlex ID: W4403947130